ChanBeDu/relevant_section_length · Datasets at Hugging Face

62,389

124,507

5786

Discharge summary

report

Admission Date: [**2158-5-10**] Discharge Date: [**2158-5-16**] Date of Birth: [**2113-1-29**] Sex: M Service: MEDICINE Allergies: Latex Attending:[**First Name3 (LF) 2751**] Chief Complaint: tachypnea, hypotension, respiratory distress Major Surgical or Invasive Procedure: Tracheal intubation History of Present Illness: 45 M w metastatic RCC (papillary vs clear cell) to lungs & L pleural effusions s/p multiple chemo regimens (most recently cycle 10 of bevacizumab + erlotinib on [**2158-4-13**]), presents after a recent admission to [**Hospital1 18**] for PNA with fevers, tachypnea, cough, SOB. . The patient was most recently admitted from [**2158-4-10**] to [**2158-4-14**] for similar symptoms. He was started on a 14-day course of unasyn & doxycycline but was ultimately discharged on augmentin. He did not, however, complete a 14-day course; opting to stop antibiotics on [**4-18**] in hopes of being considered for a clinical trial. . Subsequent to his penultimate admission, he was screened for a clinical trial for a novel anti-PDL1 antibody that required him to hold his tarceva for 3 weeks. During this time, he appears to have clinically deteriorated. His current symptoms include dyspnea on exertion, chills, night sweats, extremely poor PO intake. He notes that he woke from sleep two days earlier gasping for breath. During this time, his friends have been giving him IVF fluids. Yesterday, he was set up with 5L home oxygen by face mask and he states that he has been sleeping comfortably. . The patient also reports several days of crampy abdominal pain & diarrhea. . Today, the patient presented to heme/onc clinic for a follow up appointment with shaking chills and fevers. His oxygen saturation was noted to be 89% on RA. He was started on 5L oxygen via FM and his oxygen subsequently rose to 97%. BP was noted to be 81/39 with HR 117, temp 100.6. He denied dizziness and lightheadedness. he was given 1 L NS but his BP persisted in the 80s/40s. Given his clinical picture he was referred to the ED for further evaluation. . In the ED, the patient was given a total of 4L of IVF. He was given 125 mg PO vanco, 500 mg IV flagyl, 750 mg IV levofloxacin. He had a CXR and CT that showed enlarged pleural effusion on the left. As such, IP was called and a thoracentesis was performed. 250 cc of serous fluid was drained. . Vital signs at the time of transfer: 97.4 108 99/56 27 94/RA . On arrival to the ICU, the patient states that he is thirsty but that his breathing has improved dramatically. . REVIEW OF SYSTEMS: (+): As per HPI. Also feels slight wheeze. Coughing. (-): SOB, chest pain, nausea, vomiting Past Medical History: PAST ONCOLOGIC HISTORY - Renal Cell Carcinoma ---> [**2154**]: Microscoping hematuria ---> CT A/P: 4.5 cm L adrean & periadrenal mass ---> MRI: L periaortic mass 4.6 cm ---> PET CT: lingular nodule, RP lesion adjacent to L adrenal - [**11/2154**]: underwent resection of mass & L adrenal nodule ---> Pathology revealved metastatic adenocarcinoma of unknown origin ---> Prominent papillary architecture w abundant eosinophilic or clear cytoplasm & high-grade nuclear features - PET [**2-6**]: interval increase in size & update of pulmonary nodules - [**3-9**]: 6 cycles carboplatin & Taxotere ---> PET CT: improvement in L lung lesions - [**9-7**]: Enrolled in phase 1 trial of MET/ALK inhibitor ---> PET CT: Progression of disease in L adrenalectomy bed & lungs ---> Taken off trial - THEROS CancerType ID molecular classification test revealed 90.9% probability that cancer is of kidney origin based on 92 gene expression profile - [**11-7**]: Sunitinib ---> Post-CT: Partial regression of adrenal bed lesion & stability in pulmonary nodules. ---> Progressed after 6 cycles of sunitinib - [**8-8**]: Everolimus - [**9-8**]: Taken off everolimus for disease progression - [**9-8**]: Cyberknife radiation for mass invading psoas muscle ---> Recovery c/b severe pain [**3-2**] inflammation ---> Fevers to 100-102, SOB, R-sided CP. - [**10-9**]: Bronch revealed malignant cell ---> No ABPA - [**10-9**]: Started pazopanib - [**3-11**]: Disease progression; taken off pazopanib - [**4-10**]: s/p 10 cycles bevacizumab & erlotinib . PAST MEDICAL HISTORY: - Nephrolithiasis (bilateral) - Mitral valve prolapse - Colon polyp - Dysplastic nevus x3 - Necrotic LN in left neck (never biopsied/cultured) Social History: - Anesthesiologist at [**Hospital6 **] - Married with two young children. - Lives in [**Location **]. - Denies ETOH/tobacco/illicits. Family History: - Father: Died in his 60s from brain aneurysm. Hypoplastic kidney - Mother: Alive in her 70s. - All 3 sisters healthy. Physical Exam: ADMISSION EXAM: GEN: Thin, NAD. NECK: No JVD. Supple. No LAD COR: +S1S2, RRR. PULM: Coarse BS L > R. Dullness bilbasilarly. Wheeze L > [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]: +NABS in 4Q. Soft, TTP in LLQ. No rebound or guarding EXT: WWP. 2+ DP pulses bilaterally. No edema. NEURO: MAEE. Pertinent Results: ADMISSION LABS: [**2158-5-10**] 02:35PM BLOOD WBC-8.6 RBC-3.21* Hgb-8.4* Hct-27.3* MCV-85 MCH-26.0* MCHC-30.6* RDW-18.4* Plt Ct-566* [**2158-5-10**] 08:05PM BLOOD PT-19.3* PTT-29.6 INR(PT)-1.8* [**2158-5-10**] 02:35PM BLOOD UreaN-13 Creat-0.7 Na-134 K-4.6 Cl-96 HCO3-25 AnGap-18 [**2158-5-10**] 02:35PM BLOOD UreaN-13 Creat-0.7 Na-134 K-4.6 Cl-96 HCO3-25 AnGap-18 [**2158-5-10**] 02:35PM BLOOD ALT-114* AST-134* AlkPhos-143* TotBili-0.7 [**2158-5-10**] 08:05PM BLOOD Lipase-10 [**2158-5-10**] 08:05PM BLOOD Albumin-1.6* Calcium-7.0* Phos-2.5*# Mg-1.6 [**2158-5-10**] 08:31PM BLOOD Lactate-1.6 [**2158-5-10**] 05:15PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015 [**2158-5-10**] 05:15PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-NEG [**2158-5-10**] 05:15PM URINE RBC-0 WBC-1 Bacteri-FEW Yeast-NONE Epi-0 [**2158-5-10**] 05:15PM URINE Mucous-MOD [**2158-5-11**] 04:08AM BLOOD Hapto-500* [**2158-5-11**] 04:08AM BLOOD Ret Aut-1.8 MICROBIOLOGY: Blood cultures 4/11: pending Pleural fluid culture [**5-10**]: --gram stain with 1+ polys, no microorganisms --culture pending C diff [**5-12**] negative Legionella negative Blood culture [**5-11**]: pending Blood culture [**5-12**]: pending IMAGING: CXR [**5-10**]: Increasing opacity in the left lower lung, concerning for worsening consolidation and effusion. Extensive metastatic disease within the chest. Refer to subsequent CT for further details. CTA Chest/Abd/Pelvis [**5-10**]: 1. Extensive metastatic disease within the chest, including mediastinal and hilar lymphadenopathy and extensive pulmonary nodularity and both hilar and perihilar consolidations. Increased consolidations in the left lower lobe, lingula and right lower lobe likely account for acute symptoms of tachypnea. Slight increase in left loculated pleural effusion and interval development of a small right pleural effusion. 2. Metastatic disease burden in the abdomen appears overall stable with retroperitoneal lymphadenopathy. Small volume ascites is new from prior exam with mild bowel wall thickening along the distal colon, likely indicative of colitis (inflammatory versus infectious, versus ischemic). 3. No central PE identified. CXR [**5-12**]: Tip of the new left PIC line projects over the low SVC. Severe consolidation in most of the left lower lung and in a smaller region of the right lower lung has improved slightly on the left, worsened slightly on the right. Previous pulmonary edema has improved. Extensive pleural mass surrounds the left lung and small pleural effusion and is collected in a nondependent fashion, probably unchanged in overall volume since the earlier study. Small right pleural effusion layers dependently. Heart size is normal, but mediastinal contours and the enlarged left hilum reflect extensive central lymph node enlargement. [**2158-5-13**] 8:18 pm STOOL CONSISTENCY: SOFT Source: Stool. **FINAL REPORT [**2158-5-15**]** FECAL CULTURE (Final [**2158-5-15**]): NO ENTERIC GRAM NEGATIVE RODS FOUND. NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2158-5-15**]): NO CAMPYLOBACTER FOUND. FECAL CULTURE - R/O VIBRIO (Final [**2158-5-15**]): NO VIBRIO FOUND. FECAL CULTURE - R/O YERSINIA (Final [**2158-5-15**]): NO YERSINIA FOUND. FECAL CULTURE - R/O E.COLI 0157:H7 (Final [**2158-5-15**]): NO E.COLI 0157:H7 FOUND. Cryptosporidium/Giardia (DFA) (Final [**2158-5-15**]): NO CRYPTOSPORIDIUM OR GIARDIA SEEN. [**2158-5-12**] 3:00 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT [**2158-5-13**]** C. difficile DNA amplification assay (Final [**2158-5-13**]): Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). Brief Hospital Course: REASON FOR ICU ADMISSION: 45 M with metastatic RCC s/p multiple chemo regimens p/w fevers, cough, SOB, hypotension as well as abdominal pain with diarrhea x 2-3 days. HOSPITAL COURSE: # Acute respiratory failure, with post obstructive pneumonia and progressive tumor burden, and pleural effusion: Dr. [**Known lastname 22998**] presented with increased shortness of breath, with CT scan that revealed significant disease progression in his left lung, but no pulmonary embolism. He had been recently admitted for pneumonia, with bronchoscopy that was negative for pathogen, and he self-truncated his antibiotics course in order to be evaluated for a clinical trial. Given his recent hospitalization and evidence of new L-lung consolidation, he was treated empirically for HCAP. However, the findings on his chest CT were possibly infectious, but also most likely related to incresed tumor burden. He was seen by interventional pulmonology, with no recommendation for bronchoscopic treatment given distal nature of obstruction. He was also treated with small volume thoracentesis in the ED. His effusion met criteria for exudate in nature. Pt was started on vanc/cefepime plan for an 8 day course. Cultures from thoracentesis showed no growth. He was moved to Levofloxacin (also got Flagyl) and will complete 3 more days. # Colitis: The patient had abdominal pain for the past several days as well as diarrhea. His CT showed evidence of distal descending & sigmoid colitis. Given recent hospitalization and antibiotic administration there was c/f C.Diff and he was started on IV flagyl and PO vancomycin. However he had decreased stool output, and ultimately C.Diff PCR was negative, so po vancomycin was discontinued. CT abdomen showed some mild bowel wall thickening along the distal colon, likely indicative of colitis (report said inflammatory vs infectious vs ischemic). It was felt this was not ischemic colitis. He was treated with flagyl, and cefepime was moved to Levofloxacin, for presumed infectious colitis. Other stool studies were negative. # Renal Cell Carcinoma: The patient is on daily tarceva. He is now s/p multiple rounds of chemotherapy with progression of disease. Home oxycodone 5-10 mg Q4H prn and dilaudid for breakthrough pain were continued, and his Oxycodone was renewed on discharge with #90 tablets. Outpatient NP was contact[**Name (NI) **] and per her direction he was continued on tarceva while in house. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (primary oncologist) was contact[**Name (NI) **] and saw patient prior to discharge. He will arrange f/u on [**2157-5-21**] (Monday) for further treatment. I suggested to Dr. [**Last Name (STitle) **] that he consider offering further psychosocial support to patient who is dealing with a devastating disease while trying to support his family (wife and two children). # Anemia: Pt's hematocrit 24.3 (was in the 30s in [**3-12**]). No obvious source of bleeding. Other cell lines are not involved, arguing against myelophistic process. Could also be due to terceva. On [**5-11**] Pt was transfused 1unit pRBCs with appropriate bump in HCT up to 32, though this returned to baseline of mid-20s. # Transaminitis/LFT Abnormality: Pt with evidence of transaminitis in 100s on admission. Alk phos also elevated. No elevation in bilirubin. Could be med side effect vs. acute illness vs. hepatitis. LFTs trended down prior to Discharge [**2158-5-14**]: ALT AST AlkPhos TotBili 55* 79* 102 0.4. # Coagulopathy: INR 1.8; pt not on coumadin. Could be due to sepsis, acute illness, malignancy, poor nutritional Vit K intake. INR was trended down when pt left the [**Hospital Unit Name 153**] (1.6). # Tachycardia; patient with borderine tachycardia that was fluid responsive prior to discharge. He was stable on ambulation and instructed to keep adequate fluid intake in. Is at risk for volume depletion with decreased PO intake. Patient indicated a desire to go home. Medications on Admission: - Oxycodone 5 mg Q6H PRN pain - Tarceva 150 mg QD Discharge Medications: 1. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for Constipation. 2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*90 Tablet(s)* Refills:*0* 3. erlotinib 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. loperamide 2 mg Capsule Sig: Two (2) Capsule PO ONCE (Once). 5. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain or fever. 6. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 3 days. Disp:*3 Tablet(s)* Refills:*0* 7. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 3 days. Disp:*9 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Pneumonia Renal cell cancer w/ metastasis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted with respiratory failure, likely related to both post obstructive pneumonia and progressive metastatic disease to your lungs, as well as the pleural effusion. You have been moved to oral antibiotics (Levofloxacin) and continue without fever. Your CT scan showed mild colitis affecting the distal descending and sigmoid colon. Stool studies were negative for infection. You were empirically treated with Flagyl and should complete 1 week on [**2158-5-19**]. Please continue supplemental Ensure plus to support your nutrition. Followup Instructions: With your Oncologist -- Dr. [**Last Name (STitle) **] will arrange to see you next Monday afternoon [**2158-5-22**]. His office should be contacting you with information.

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Discharge summary

report

Admission Date: [**2151-5-21**] Discharge Date: [**2151-5-25**] Date of Birth: [**2079-12-14**] Sex: F Service: Medicine HISTORY OF PRESENT ILLNESS: This is a 71-year-old woman with a chief complaint of hematemesis. The patient with a history of chronic obstructive pulmonary disease and peptic ulcer disease 40 years ago; who, on the morning of admission, felt nauseous upon waking up. Improved with eating breakfast; however, around noon the patient felt nauseated and weak. At 12:10 p.m. the patient suddenly vomited a large amount of bright red blood. She has had no recent illness. No chest pain. Status post vomiting, she started feeling weak and short of breath. She was brought into Emergency Department. She had melanotic stool in the Emergency Department. On arrival to the Emergency Department, her temperature was 98.1, blood pressure was 126/44, heart rate was 99, respiratory rate was 28, and oxygen saturation was 100% on room air. Nasogastric tube suctioning showed coffee-grounds emesis. She had been Prevacid orally and then given intravenous famotidine. Subsequently, several hours later, the patient was given intravenous Protonix 40 mg. PAST MEDICAL HISTORY: 1. She had peptic ulcer disease 40 years ago. 2. Chronic back pain (In [**2145**], she had a spinal cord stimulator placed). 3. Chronic obstructive pulmonary disease (on home oxygen at 2 liters at baseline). 4. Myocardial infarction in [**2122**] and [**2130**]; status post coronary artery bypass graft in [**2140**] and [**2143**]. 5. Hypertension. 6. Hypercholesterolemia. 7. She had an aortobifemoral bypass and a right renal artery bypass in [**2147**]. 8. She is status post cholecystectomy. 9. Status post appendectomy. 10. She has congestive heart failure (with an ejection fraction of 30% in [**2146**]). MEDICATIONS ON ADMISSION: (Her medications on admission included) 1. Azmacort 4 puffs inhaled twice per day. 2. Aspirin 81 mg p.o. once per day. 3. Norvasc. 4. Albuterol 2 puffs inhaled twice per day. 5. [**Doctor First Name **] 60 mg p.o. once per day. 6. Lisinopril 5 mg p.o. once per day. 7. Soma 350 mg p.o. four times per day as needed (for pain). 8. Darvocet one tablet p.o. four times per day as needed. 9. Colace. 10. Famotidine 20 mg p.o. q.h.s. 11. Prozac 20 mg p.o. once per day. 12. Lasix 20 mg p.o. once per day. 13. Atrovent 2 puffs inhaled four times per day. 14. Sublingual nitroglycerin as needed. ALLERGIES: Allergy to ATIVAN (she gets anaphylaxis) and MORPHINE (she gets nausea). She also has an allergy to VALIUM, HALDOL, TAPE, SULFA, and CODEINE. SOCIAL HISTORY: She lives alone. Her nephew [**Name (NI) **] (telephone number [**Telephone/Fax (1) 1585**]) is her health care proxy. She is a 100-pack-year smoker; one quarter of a pack per day currently. She is do not resuscitate/do not intubate. REVIEW OF SYSTEMS: On review of systems, she was fully independent at baseline. She drives and goes grocery shopping by herself without difficulty. She gets chest pressure once every few months and takes sublingual nitroglycerin as needed. PHYSICAL EXAMINATION ON PRESENTATION: On examination, her temperature was 98.1, blood pressure was 126/44, and heart rate was in the 80s. In general, she was a thin elderly woman in no apparent distress. She appeared slightly uncomfortable and anxious. Head, eyes, ears, nose, and throat examination revealed the oropharynx was dry. No blood was visible. Chest examination revealed breath sounds were distant. She had no wheezes, rhonchi, or rales. Cardiovascular examination revealed a regular rate and rhythm. Normal first heart sounds and second heart sounds. No murmurs. The abdomen was soft, nontender, and nondistended. Positive bowel sounds. Extremities were warm and well perfused. No edema. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on admission revealed her white blood cell count was 8.3, hematocrit was 27.1 (repeat hematocrit was 25.7 three hours later), and platelets were 250. Differential with 71% neutrophils, 24% lymphocytes, and 4% monocytes. Her Chemistry-7 was unremarkable other than an elevated blood urea nitrogen of 61 and a creatinine of 0.9. Creatine kinase was 79. Troponin was less than 0.3. PERTINENT RADIOLOGY/IMAGING: A chest x-ray showed no infiltrates. No pneumothorax. HOSPITAL COURSE BY ISSUE/SYSTEM: The patient was admitted to the Medical Intensive Care Unit from [**5-21**] to [**5-24**]. 1. GASTROINTESTINAL ISSUES: On the evening of admission, she had emergent esophagogastroduodenoscopy which showed an active pumping arterial bleeding vessel in the fundus 5 cm distal to the gastroesophageal junction. Epinephrine and electrocautery were attempted to stop the bleed, but this failed. She was then subsequently sent to Interventional Radiology who injected the celiac axis to localize the bleed, but no bleed was found. They attempted to embolize the left gastric artery but failed secondary to its tortuosity. The bleed appeared to have stopped. In the Medical Intensive Care Unit she received 48 hours of octreotide, given intravenous Protonix 40 mg twice per day (which was changed to 40 mg p.o. twice per day), and her diet was advanced to clears. She had received 4 units of packed red blood cells and one bag of platelets while on the Unit. The platelets were given because the patient had been on aspirin, but she was not thrombocytopenic. She was then transferred out to the floor after her hematocrit had been stable on [**2151-5-24**]. Her hematocrit was 36 status post transfusion and remained at this level over a 72-hour period. Her diet was continually advanced, and she had brown stools by the time she left the hospital. She was to follow up with Dr. [**First Name8 (NamePattern2) 1586**] [**Name (STitle) **] on [**2151-7-5**] for a repeat esophagogastroduodenoscopy. 2. CHRONIC OBSTRUCTIVE PULMONARY DISEASE ISSUES: She was stable on home oxygen. She was continued on her inhalers. 3. CORONARY ARTERY DISEASE ISSUES: The patient was ruled out for a myocardial infarction given her dyspnea. Her antihypertensives were held given the possibility of becoming hypotensive, and her aspirin was also discontinued given her risk of bleeding. She was to follow up with her primary care physician; at which point he will decide on restarting her antihypertensives. She also has congestive heart failure which was stable. Previously on Lasix 20 mg p.o. once per day; but this has also been held and was to be restarted by her primary care physician. 4. BACK PAIN ISSUES: She has chronic back pain. She was to continue on her home medications including her Soma and Darvocet. 5. ANEMIA ISSUES: The patient was worked up as an outpatient including a bone marrow biopsy which was normal. Her hematocrit was stable for 72 hours status post transfusion on [**5-21**]. 6. CODE STATUS: Her code status is do not resuscitate/do not intubate. DISCHARGE STATUS: The patient was discharged to home with [**Hospital6 407**] for blood pressure monitoring. DISCHARGE DIAGNOSES: (Her discharge diagnoses included) 1. Upper gastrointestinal bleed. 2. Status post transfusion of four units of packed red blood cells and one bag of platelets. 3. Gastric ulcer with arterial bleed. 4. Hypertension. 5. Coronary artery disease. 6. Peptic ulcer disease. 7. Chronic obstructive pulmonary disease. 8. Hypercholesterolemia. 9. Congestive heart failure (which is stable). 10. Anemia. MAJOR SURGICAL/INVASIVE PROCEDURES: 1. Esophagogastroduodenoscopy with electrocautery. 2. Epinephrine injection. 3. Interventional Radiology embolectomy attempt. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was discharged to home with [**Hospital6 1587**] to continue blood pressure monitoring. 2. The patient was advised to return to the hospital right away with any signs of bleeding; including bright red blood per rectum, vomiting, coffee-grounds emesis, black stools, red stools, lightheadedness, chest pain, shortness of breath, or dizziness. 3. The patient was to stop aspirin and all nonsteroidal antiinflammatory drugs. 4. The patient was to hold her blood pressure medications for now including her Norvasc and lisinopril and to be restarted by Dr. [**Last Name (STitle) 1588**]. The patient was also to hold her Lasix; also to be restarted by Dr. [**Last Name (STitle) 1588**]. 5. The patient had a follow-up appointment with Dr. [**Last Name (STitle) 1588**] on [**2151-6-26**] at 12 noon. 6. The patient had a follow-up appointment with Dr. [**First Name8 (NamePattern2) 1586**] [**Name (STitle) **] in Gastroenterology for a repeat esophagogastroduodenoscopy to follow up her gastric ulcer on [**2151-6-5**]. 7. Helicobacter pylori was added to her laboratories on the day of discharge; which were still pending. MEDICATIONS ON DISCHARGE: (Her discharge medications included) 1. Atrovent 2 puffs inhaled twice per day. 2. Azmacort 4 puffs inhaled twice per day. 3. Albuterol 2 puffs inhaled twice per day and q.4-6h. as needed. 4. Protonix 40 mg p.o. q.12h. 5. Soma 350 mg p.o. four times per day as needed. 6. Fluoxetine 20 mg p.o. once per day. 7. Nitroglycerin 0.4-mg tablet p.o. as needed. 8. Colace 100 mg p.o. twice per day. 9. [**Doctor First Name **] 60 mg p.o. once per day. 10. Darvocet one tablet p.o. four times per day as needed (for pain). [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1589**], M.D. [**MD Number(1) 1590**] Dictated By:[**Name8 (MD) 1020**] MEDQUIST36 D: [**2151-5-25**] 14:25 T: [**2151-5-29**] 02:37 JOB#: [**Job Number 1591**]

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icd9cm

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Discharge summary

report

Admission Date: [**2167-11-1**] Discharge Date: [**2167-11-6**] Date of Birth: [**2137-3-18**] Sex: M Service: MEDICINE Allergies: Bactrim Attending:[**First Name3 (LF) 32198**] Chief Complaint: Tingling in legs Major Surgical or Invasive Procedure: Endoscopy with banding of varices History of Present Illness: Pt is a 32 yo male, recently diagnosed with metastatic gallbladder ca, who presented to the ED with LE numbness and weakness. Pt was diagnosed with poorly differentiated gallbladder cancer in [**8-29**] after he presented with painless jaundice and 10 lb weight loss. Found to have cancer, with a pancreatic mass, gallbladder fundus mass, and several liver lesions as well as retroperitoneal lymphadenopathy on imaging. Pt is getting palliative chemotherapy with gemcitabine (100 mg/m2) and cisplatin (20 mg/m2), three weeks on, one week off. Pt began second cycle of chemotherapy on Thursday. Since chemo, pt says that he has lower extremity pain. Today he points to above his right knee and it is hard for him to describe exactly what it feels like. Of note, upon arrival to the floor, pt was found to have a 5 point Hct drop over 3 days. He also had melanotic stools on the floor. He was transfused 2 units of pRBCs, NG lavaged (cleared after 200 cc) and transferred to the [**Hospital Unit Name 153**]. Past Medical History: 1. anemia- low mcv with nml iron - likely anemia of chronic disease 2. Malaria; multiple infections in past 3. s/p Appendectomy 4. H. Pylori- treated 5. UTI [**2163**] 6. Hepatitis B - low viral load; evidence of varices in lower [**12-27**] of esophagus Social History: Pt is from [**Country **]. Moved to [**Location (un) 86**] 5 years ago. Worked at 7-eleven though not any more. No tobacco. No drugs. No EtOH for many months. Family History: Positive for DM--both parents. No cancer, heart disease. Ten siblings - none with cancer Physical Exam: VS: T: 98.8; BP: 148/81; HR: 76; RR: 20; O2: 100% on RA Gen: black male, appears nervous, in NAD. HEENT: PERRLA; EOMI. OP clear without exudate. No blood. CV: RRR S1S2. No M/R/G Lungs: CTA b/l. Good air entry. Abd: +BS. SOft, nt, nd Ext: DP 2+. No edema. Neuro: CN II-XII tested and intact. MS [**4-29**]. Sensation to soft and sharp on LE was intact. Lower extremity: abduction, adduction, hip flexion and extension all [**4-29**]. Patella no pain to deep palpation. Pertinent Results: Labs on admission: CBC/Coags: [**2167-11-1**] 08:00AM BLOOD WBC-3.2* RBC-2.89* Hgb-6.4* Hct-21.8* MCV-75* MCH-22.0* MCHC-29.3* RDW-17.2* Plt Ct-268 [**2167-10-31**] 06:30PM BLOOD Neuts-84.7* Lymphs-8.8* Monos-6.0 Eos-0.5 Baso-0.1 [**2167-11-1**] 08:00AM BLOOD PT-14.6* PTT-25.8 INR(PT)-1.3 Chemistries: [**2167-11-1**] 08:00AM BLOOD Glucose-90 UreaN-10 Creat-0.5 Na-135 K-3.7 Cl-104 HCO3-24 AnGap-11 [**2167-11-1**] 08:00AM BLOOD Calcium-8.7 Phos-3.4 Mg-1.5* ___________________________________ Labs on discharge: [**2167-11-6**] 03:10PM BLOOD WBC-6.3 RBC-3.82* Hgb-9.1* Hct-27.7* MCV-73* MCH-23.8* MCHC-32.9 RDW-18.2* Plt Ct-136* [**2167-11-6**] 03:10PM BLOOD CK(CPK)-32* [**2167-11-6**] 06:40AM BLOOD Calcium-8.8 Phos-2.7 Mg-1.4* ____________________________________ Urine: [**2167-10-31**] 07:22PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.014 Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG RBC-0 WBC-0 Bacteri-OCC Yeast-NONE Epi-0 Creat-344 Na-77 Osmolal-702 _____________________________________ Brief Hospital Course: Upon arrival to the floor, pt was found to have melanotic stools with a 5 point HCT drop over previous few days, >10 points from baseline. Because of known esophageal varices, hepatitis B, and antral gastritis, he was NG Lavaged which cleared after 200 cc. He was then transferred to the [**Hospital Unit Name 153**] while getting transfused pRBCs (HCT 21) normal mid-30s. 1. GI bleed- Pt had an EGD where he was found to have multiple grade II varices with erythema and oozing of blood. Gastroenterology placed 5 bands successfully. He was started on an octreotide drip x 5 days. He also started IV PPI,nadolol, and sucralfate. In the ICU, pt was started on ciprofloxacin for SBP prophylaxis because he had small amount of free fluid on previous CT. However, when pt was transferred back to the regular floor, upon discussion with GI, that was discontinued. In the ICU, Hct was checked and pt was transferred back to the floor when he was stable. Hct remained stable after the banding procedure. 2. Anemia- The acute anemia was from GIB. However, also likely to have anemia of chronic disease from cancer. Usual Hct is mid-30s. 3. Oncology - Pt will receive palliative chemo on day of discharge. Pt's oncologist will consider d/cing cisplatin secondary to neuro symptoms, though quite atypical. Will defer to primary oncology team. 4. LE pain- The lower extremity pain was difficult to ascertain what was happening. On PE sensation and strength were fully intact. Pt was seen in ED initially by neurology and no focal deficits were seen. His pain is not classical for cisplatin neuropathy but could be related. In speaking with pt's oncology, Dr. [**Last Name (STitle) 150**], there appears to be a cultural communication issue, in that it is difficult to really tell what the patient was describing. At times, he described it as "soft." Pt was started on gabapentin [**Hospital1 **] with relief. 5. F/E/N- Diet was slowly advanced post-procedure as tolerated. Electrolytes were checked and repleted as necessary. Magnesium needed to be repleted every day. 6. [**Name (NI) 946**] Pt was hyponatremic on the two days prior to discharge (131-->126-->125). Urine lytes with Na 77 and Osm >700. Suggesting sodium wasting vs. new SIADH which was unlikely. Fluid restriction and sodium tablets were tried. 7. Prophylaxis: IV protonix, pneumoboots. Pt was ambulating. 8. Code- Full code. Primary oncology is broaching the subject. Medications on Admission: 1. dilaudid 4mg tid 2. fentanyl 25mcg q3d 3. ativan prn 4. compazine prn 5. cisplatin 6. gemcitabine Discharge Medications: 1. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 2. Zolpidem Tartrate 5 mg Tablet Sig: 1-2 Tablets PO HS (at bedtime) as needed for sleep: Take as needed when you have insomnia. Disp:*30 Tablet(s)* Refills:*0* 3. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*1* 4. 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:*1* 5. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). Disp:*10 Patch 72HR(s)* Refills:*1* 6. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*1* Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Upper gastroentestinal bleed Lower extremity pain Secondary diagnosis: gallbladder cancer Discharge Condition: [**Name (NI) 14658**] Pt is without leg pain. His hematocrit is stable after the banding procedure. His bowel movements do not have blood in them. His sodium and magnesium are low. Discharge Instructions: -You will be going to chemotherapy on [**Hospital Ward Name **] 9 pm at 10 am today. -Please call your doctor or go to the emergency room if you have leg weakness, feel dizzy, fevers, worsening of pain, or any other health concern. Followup Instructions: You have an appointment with the gastroenterologists for a repeat EGD on [**11-17**] on the [**Hospital Ward Name **] of [**Hospital3 **]. It will be at 9:30 am but you should show up at 8:30 am. You will receive instructions in the mail how to prepare. Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3281**], RN Where: [**Hospital6 29**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2167-11-12**] 11:30 Provider: [**Name Initial (NameIs) 4426**] 21 Date/Time:[**2167-11-12**] 11:30 Provider: [**Name10 (NameIs) 831**],[**Name11 (NameIs) **] HEMATOLOGY/ONCOLOGY-CC9 Where: [**Hospital 273**] HEMATOLOGY/ONCOLOGY Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2167-11-12**] 11:30 [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 32201**]

[ "070.32", "456.20", "537.89", "285.1", "197.7", "156.0", "357.6", "E933.1" ]

icd9cm

[ [ [] ] ]

[ "42.33", "99.04" ]

icd9pcs

[ [ [] ] ]

6903, 6909

3521, 5957

286, 322

7063, 7245

2424, 2429

7526, 8378

1830, 1921

6108, 6880

6930, 6930

5983, 6085

7269, 7503

1936, 2405

230, 248

2940, 3498

350, 1359

7021, 7042

6949, 7000

2443, 2920

1381, 1638

1654, 1814

61,809

193,297

8065

Discharge summary

report

Admission Date: [**2112-8-27**] Discharge Date: [**2112-8-30**] Date of Birth: [**2077-7-18**] Sex: M Service: MEDICINE Allergies: Haldol Attending:[**First Name3 (LF) 3853**] Chief Complaint: "etoh withdrawal." Major Surgical or Invasive Procedure: none History of Present Illness: 35 yo M with h/o polysubstance abuse (etoh, cocaine, previous heroin), h/o etoh withdraw, presents to the ED after binge drinking [**12-20**] gallon a day for a week. After binge drinking this past 2 days, also verbalizing that he wants to die. He does not recall last drink. Denies other substances. Reports depression without SI. No medical complaints. Has history of DTs on withdrawal. Pt did verbalize when calling 911 that he wanted to die, though he denies it here. Unclear about last drink- oriented to name, place, day of week but unlcear about time of day. . In ED, arrival 97.9 110 126/85 18 98%. Exam was significant for tachycardia. Labs were significant for Serum EtOH 302, WBC of 11. He was given Lorazepam (1mg IV), Diazepam x2 (15mg IV total). He was admitted to MICU for frequent CIWA [**Doctor Last Name **] of q1h. Recommend Psych eval if still suicidal once sober (denying it X 2 here). . On the floor, stable and drunk. . Review of systems: (+) Per HPI . Past Medical History: Borderline personality disorder Schizoaffective d/o PTSD Polysubstance abuse (patient adamantly denies history of IVDU) ADHD (on Ritalin as a child) Anxiety d/o Hepatitis C Ab positive (patient adamantly denies) Social History: MI in father at 35 (fatal), grandfather died of MI at early age. Mother lung cancer 38 (deceased). -Etoh: [**12-20**] gallon of vodka daily, alcohol use at age 12, daily use at age 16. Prior dx of alcohol hallucinosis. AA support in past, attending meetings occassionaly currently. Used to live in sober house. History of DTs. Last drink today. -Tobacco: 1.5 ppd -Illicit Drug Use: Ongoing MJ use. Denies other drug use currently, although tox screen pos for benzos and amphetamines in past. Use of marijuana, LSD in past per OMR. Used heroin in [**2099**] per OMR. -has 2 children in DSS custody, lives with girlfriend [**Name (NI) **] who "babysits" him. -no pets in home. -works as a chef, but has not worked for over a year due to right hand injury. Family History: MI in father at 35 (fatal), grandfather died of MI at early age. Mother lung cancer 38 (deceased). Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 98 BP: 117/70 P:112 R: 18 O2: 95% 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 . DISCHARGE EXAM: VSS (patient left AMA but last recorded vitals were stable) General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, very minimal tremors to full extension of hands, no asterixis, no fasciculations Pertinent Results: At admission: [**2112-8-27**] 08:00PM BLOOD WBC-11.7* RBC-4.89 Hgb-16.2 Hct-44.9 MCV-92 MCH-33.1* MCHC-36.1* RDW-14.3 Plt Ct-296 [**2112-8-27**] 08:00PM BLOOD Neuts-81.2* Lymphs-15.8* Monos-2.2 Eos-0.6 Baso-0.3 [**2112-8-28**] 02:12AM BLOOD PT-12.5 PTT-25.2 INR(PT)-1.0 [**2112-8-27**] 08:00PM BLOOD Glucose-75 UreaN-13 Creat-0.9 Na-140 K-5.3* Cl-96 HCO3-16* AnGap-33* [**2112-8-27**] 08:00PM BLOOD ALT-34 AST-53* AlkPhos-121 TotBili-0.6 [**2112-8-28**] 02:12AM BLOOD Lipase-62* [**2112-8-28**] 02:12AM BLOOD Albumin-4.1 Calcium-8.5 Phos-1.7*# Mg-1.4* [**2112-8-27**] 08:00PM BLOOD ASA-NEG Ethanol-302* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . Discharge labs: [**2112-8-30**] 06:35AM BLOOD WBC-6.0 RBC-4.35* Hgb-14.6 Hct-41.2 MCV-95 MCH-33.5* MCHC-35.3* RDW-13.6 Plt Ct-221 [**2112-8-30**] 06:35AM BLOOD Glucose-105* UreaN-13 Creat-0.8 Na-140 K-3.9 Cl-106 HCO3-24 AnGap-14 [**2112-8-30**] 06:35AM BLOOD Phos-5.2*# Mg-1.5* . MICRO: [**2112-8-28**] URINE URINE CULTURE-FINAL INPATIENT . IMAGING: NONE Brief Hospital Course: This is a 35 year old male with history of polysubstance abuse (alcohol, cocaine, previous heroin), with history of complicated alcohol withdraw including delirium tremens (DT) who presents after binge drinking [**12-20**] gallon a day for a week. . ACTIVE PROBLEMS BY ISSUE: # Alcohol (EtOH) abuse: Patient presented to the hospital for the purpose of withdrawal. Patient was admitted to the ICU due to a history of withdrawl seizures. While in the ICU he received Valium 40mg PO overnight [**8-27**] from midnight, then 30mg from 7am to 2pm. He had no evidence of seizure or DTs while in the unit. Once transfered to the floor he received 30 mg valium overnight [**8-29**] then did not require valium during the day of [**8-30**] based upon CIWA scores. Social work was consulted to help him cope with EtOH but he declined further assistance including set-up with substance abuse programs and pain management clinic. He left against medical advice (AMA) without medications. . # Right Hand injury: The patient had a chronic injury with history of traumatic osteomyelitis and status post about 7 surgeries. His inflammatory markers were well within normal limits. He was offered acetaminophen and ibuprofen for pain but was still asking for narcotic pain medications. He did not have narcotics prescribed for him as an outpatient previously. When told that he was not going to be discharged with narcotics but that we would set him up with the pain clinic so that he could sign a narcotics contract, he insisted instead on leaving AMA. . # Psych/suicide ideation: Patient had a history of post-traumatic stress disorder and personality disorders. Psychiatry was consulted and recommended that we restart home medications. He did not qualify for an inpatient detox program and per psych he was clear to make his own decisions, including the decision to leave AMA. . INACTIVE PROBLEMS BY ISSUE: # Hepatitis C Viral (HCV) Infection: Patient had a history of HCV infection but was not on treatment. He was told that he can follow-up as an outpatient for further management. . TRANSITIONAL ISSUES: - This patient should have follow-up established with a therapist and case worker to assist him with alcohol dependence - He should also have follow-up for chronic pain - He should have a follow-up appointment for his HCV infection when he has stopped drinking Medications on Admission: Medications: (per patient) - Oxcarbazepine 600 mg Tablet PO TID (last picked up in [**5-/2112**], likely not taking) - Quetiapine 800 mg Tablet PO QHS . Allergies: Haldol Discharge Medications: Left AMA Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: Alcohol withdrawal and dependence Chronic pain . SECONDARY DIAGNOSIS: Hepatitis C chronic infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 2520**], . You were admitted to the hospital because you were withdrawing from alcohol. You were monitored and your withdrawal symptoms were improving. You were going to be given one more week of medications (chlordiazepoxide) for alcohol withdrawal. . You were also having chronic pain from your hand surgeries in the past. We have arranged for you to have a follow-up appointment with a pain management clinic and a hand surgeon to help with this pain. Unfortunately, we cannot give you pain medications without an outpatient doctor who will be willing to prescribe these for you. The pain management clinic and new primary care doctors [**Name5 (PTitle) **] get to know you and become your prescribers for pain medications in the future. . You left against medical advice before discharge arrangements could be provided to you. Followup Instructions: Left AMA

[ "070.54", "303.91", "291.81", "300.00", "295.70", "301.83", "285.9", "535.30", "577.1", "314.01" ]

icd9cm

[ [ [] ] ]

[ "94.62" ]

icd9pcs

[ [ [] ] ]

7272, 7278

4648, 6732

286, 292

7441, 7441

3616, 4269

8479, 8491

2333, 2434

7239, 7249

7299, 7299

7041, 7216

7592, 8456

4285, 4625

2474, 2986

3002, 3597

6753, 7015

1290, 1306

228, 248

320, 1271

7388, 7420

7318, 7367

7456, 7568

1328, 1542

1558, 2317

273

158,689

8712

Discharge summary

report

Admission Date: [**2141-4-19**] Discharge Date: [**2141-4-20**] Date of Birth: [**2107-8-10**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 338**] Chief Complaint: Cocaine and heroine overdose Major Surgical or Invasive Procedure: Right internal jugular vein central line placement Intubation and extubation on [**2141-4-19**] History of Present Illness: The patient is a 33 year old African-American male with a history of polysubstance abuse who was found by the police in his car with a needle in his antecubital vein, incoherent and combative. He was subsequently brought to [**Hospital1 18**] where he admitted to cocaine, heroin and marajuana use but denied ETOH. The patient was initially extremely combative and required up to 20 mg IV haldol and 4 + mg ativan for sedation. After receiving sedation, he then became somnolent with an inability to manage his own secretions and was intubated for airway protection. His serum tox in the ED was negative with a urine tox positive for cocaine and opiates. Past Medical History: L meniscal tear chylamydia heroin/cocaineHCV gential herpes anxiety eczema Social History: The patient smokes 1.5 packs of cigarettes per day. He recently has used 30 to 50 bags of heroine in the past. Low alcohol. Positive cocaine use. Positive crack use. Positive heroine drug abuse. The patient claims about 3 g a day for cocaine use in past history. Family History: The patient claims mother and father are alive and healthy. The patient has no siblings. Physical Exam: Tc=97.9 P=100 BP=170/100 RR=18 100% O2 on RA Gen - Intubated, sedated HEENT - PERLA Heart - RRR, No M/R/G Lungs - CTAB (anteriorly) Abdomen - Soft, NT, ND, + BS, no hepatosplenomegaly Ext - No C/C/E, + 2 d. pedis bilaterally Skin - Tattoos, needle marks evident throughout upper extremities Pertinent Results: [**2141-4-19**] 03:29PM CK(CPK)-663* [**2141-4-19**] 03:29PM WBC-8.1 RBC-4.80 HGB-12.2* HCT-37.3* MCV-78* MCH-25.4* MCHC-32.7 RDW-13.0 [**2141-4-19**] 03:29PM PLT COUNT-204 [**2141-4-19**] 02:43PM TYPE-ART PO2-131* PCO2-49* PH-7.38 TOTAL CO2-30 BASE XS-3 INTUBATED-NOT INTUBA [**2141-4-19**] 01:13PM TYPE-ART PO2-71* PCO2-52* PH-7.34* TOTAL CO2-29 BASE XS-0 [**2141-4-19**] 01:00PM TYPE-ART RATES-[**11-13**] TIDAL VOL-600 O2-50 PO2-179* PCO2-55* PH-7.34* TOTAL CO2-31* BASE XS-2 -ASSIST/CON INTUBATED-INTUBATED [**2141-4-19**] 06:26AM TYPE-ART PO2-347* PCO2-57* PH-7.32* TOTAL CO2-31* BASE XS-1 [**2141-4-19**] 05:00AM URINE HOURS-RANDOM [**2141-4-19**] 05:00AM URINE HOURS-RANDOM [**2141-4-19**] 05:00AM URINE GR HOLD-HOLD [**2141-4-19**] 05:00AM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS cocaine-POS amphetmn-NEG mthdone-NEG [**2141-4-19**] 05:00AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.023 [**2141-4-19**] 05:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-1 PH-5.0 LEUK-NEG [**2141-4-19**] 02:30AM GLUCOSE-93 UREA N-10 CREAT-1.0 SODIUM-144 POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-25 ANION GAP-20 [**2141-4-19**] 02:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG ECG Study Date of [**2141-4-19**] 10:01:34 AM Sinus rhythm. Since the previous tracing of [**2141-4-19**] the rate has decreased. The mild J point and ST segment elevation are now back to a pattern similar to that of [**2138**]. CHEST (PORTABLE AP) [**2141-4-19**] 3:15 AM IMPRESSION: No definite acute cardiopulmonary process. Brief Hospital Course: Impression: The patient is a 33 year old male with h/o PSA who presented after cocaine/heroine intoxication s/p intubation post sedation now extubated and AOX3. 1. Polysubstance abuse: - The patient clearly overdosed on heroine and cocaine. On further questioning, the patient was unable to provide more details regarding the event. - Addiction consult was placed but patient did not want to participate in referral. - The patient exhibited no further symptoms of withdrawal throughout his stay. 2. Respiratory status: - As mentioned, the patinet required intubation secondary to sedation and inability to clear his secretions. - The patient was given lasix in the ED for what they thought was flash pulmonary edema. His CXR showed ?RL infiltrate but was felt not to be significant given his clinical picture. - He self-extubated himself and continued to sat well off of O2. 3. ID- ?RL infiltrate - Patient did not spike fevers with no WBC with questionable RL infiltrate on CXR. There was no evidence to support a pneumonia and thus the patient was not treated with antibiotics. 4. Hepatitis C: - The patient has received no prior treatment and his LFTs were within normal limits. 5. Mental status change: - The patient arrived to the FICY very sedated. This was most likely due to the 20 mg IV haldol and 4 mg Ativan the patient received in the ED. The patient was not fully cooperative on physical exam but alert and oriented times three. The patient was discharged from the [**Hospital Unit Name 153**] with no further events once he remained stable and was able to tolerate PO intake and asked to follow up with his primary care physician. Medications on Admission: None. Discharge Medications: None. Discharge Disposition: Home Discharge Diagnosis: Heroin and cocaine overdose. Discharge Condition: Stable. Discharge Instructions: Please return to the ER if you feel more confused or develop more shortness of breath. Followup Instructions: Please call ([**Telephone/Fax (1) 1300**] to schedule an appointment with your primary care doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1557**].

[ "E850.0", "070.30", "518.81", "E854.1", "304.31", "970.8", "304.01", "428.0", "969.6", "965.01", "305.1", "E854.3", "070.70", "E849.8", "304.21", "292.0" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71", "94.65" ]

icd9pcs

[ [ [] ] ]

5332, 5338

3594, 5246

343, 441

5411, 5420

1946, 3571

5555, 5733

1526, 1617

5302, 5309

5359, 5390

5272, 5279

5444, 5532

1632, 1927

275, 305

469, 1127

1149, 1226

1242, 1510

27,911

197,635

31408

Discharge summary

report

Admission Date: [**2120-8-19**] Discharge Date: [**2120-8-23**] Date of Birth: [**2096-10-25**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5880**] Chief Complaint: s/p 20 ft Fall Major Surgical or Invasive Procedure: None History of Present Illness: 23 yo male s/p fall at work on a construction site fell 20 ft onto concrete on his back; he was wearing a hard hat at the time. No reported LOC. He was transported from the scene to [**Hospital1 18**] for further care. `` Past Medical History: Asthma Family History: Noncontributory Physical Exam: T: BP:140/90 HR:109 R 21 O2Sats 99 Gen: WD/WN, comfortable, NAD. HEENT: Pupils: [**4-5**] reactive EOMs full Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert Orientation: Oriented X2 (no date) Motor: D B T FE FF IP Q AT [**Last Name (un) 938**] G R 5 5 5 5 5 3 3 5 L 5 5 5 5 5 3 3 5 5 5 Sensation: Intact to light touch Reflexes: B T Br Pa Ac Right 2+============== Left 2+============== Propioception intact Toes downgoing bilaterally Rectal exam normal sphincter control No saddle anesthesia Pertinent Results: [**2120-8-19**] 09:32PM HCT-33.9* [**2120-8-19**] 02:09PM GLUCOSE-138* LACTATE-2.7* NA+-143 K+-3.7 CL--109 TCO2-25 [**2120-8-19**] 01:08PM UREA N-13 CREAT-0.9 [**2120-8-19**] 01:08PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2120-8-19**] 01:08PM WBC-8.3 RBC-4.44* HGB-14.0 HCT-40.2 MCV-91 MCH-31.6 MCHC-34.9 RDW-13.8 [**2120-8-19**] 01:08PM PLT COUNT-291 [**2120-8-19**] 01:08PM PT-12.7 PTT-25.4 INR(PT)-1.1 CT C-SPINE W/O CONTRAST FINDINGS: There is no disc, vertebral, or paraspinal abnormality identified. There is no sign of fracture or abnormal alignment. Please note CT is not able to provide intrathecal detail comparable to MRI. The visualized outline of the thecal sac appears unremarkable. Please note there is mild narrowing of the C4/5 intervertebral disc space with the appearance suggesting this may be congenital in etiology, v. isolated degenerative disease. Incompletely visualized lung fields reveal a possible tiny left apical tiny pneumothorax. IMPRESSION: No acute abnormality of the cervical spine on CT. CT HEAD W/O CONTRAST FINDINGS: History did not specify the location of any visible trauma, including whether the patient fell on his head. Upon further questioning, the point of impact was the back. FINDINGS: There is no visible intracranial hemorrhage, mass effect, shift of normally midline structures, minor or major vascular territorial infarction. The density values of the brain parenchyma are within normal limits. The surrounding osseous and soft tissue structures also appear unremarkable. CONCLUSION: No definite signs of extra or intracranial post-traumatic pathology. We have placed a note on the emergency room dashboard for you to contact this office to discuss this case, regarding its clinical findings, in detail. A subsequent conversation by telephone provided the additional history needed (i.e. point of impact). CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST IMPRESSION: 1. Multiple splenic lacerations with intraparenchymal hematoma and hemoperitoneum in the upper abdomen, left greater than right. 2. Mild pulmonary ground-glass opacities mostly on the left, compatible with pulmonary contusion without evidence of hemothorax or pneumothorax. 6-mm lung nodule in the left upper lobe, probably related to trauma. However, follow up is recommended. 3. Left 9th posterior non-displaced rib fracture and L1-L4 left transverse process fracture. 4. Well-corticated defect along the left acetabular roof likely congenital or disequilibrium prior trauma. Please note that this scan was obtained on delayed phase, which limits evaluation for solid organ injury. Brief Hospital Course: He was admitted to the Trauma Service. Neurosurgery/Spine was consulted because of the spine fractures; these were nonoperative. Pain control was initially an issue, he was on PCA Dilaudid and later switched to oral Dilaudid which has been helpful. Serial abdominal exams and hematocrits were followed given his splenic injury; this was also non operative. His Hct remained stable at 29.1. He continued to have posterior cervical pain despite negative CT spine imaging; flexion/extension films were obtained and were negative for any fracture. Physical therapy was consulted and he has been cleared for discharge home. Social work was consulted for emotional support. Discharge Medications: 1. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**2-6**] Puffs Inhalation Q4H (every 4 hours) as needed for shortness of breath or wheezing. Disp:*1 * Refills:*0* 2. Hydromorphone 2 mg Tablet Sig: 2-3 Tablets PO every 4-6 hours as needed for pain. Disp:*90 Tablet(s)* Refills:*0* 3. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. Disp:*20 Tablet(s)* Refills:*0* 4. Tylenol Extra Strength 500 mg Tablet Sig: Two (2) Tablet PO every six (6) hours. Discharge Disposition: Home Discharge Diagnosis: s/p 20 ft Fall L1-L4 Lumbar vertebrae transverse process fractures Left posterior 9th rib fracture Grade 2 splenic laceration Discharge Condition: Stable Discharge Instructions: Return to the nearest Emergency room if you develop any feelings of dizziness; faintness; lightheadedness asthese may be possible signs of bleeding relating to the injury to your spleen. Avoid any contact sports for the next 8 weeks. If you experience any other symptoms that are concerning to you because of your injuries, such as fevers, headache, numbness/weakness in any of your extremities; and/or any other symptoms that are concerning to you please return to the Emergency room. Followup Instructions: Follow up with Dr. [**Last Name (STitle) **] in Trauma Clinic in [**3-9**] weeks, call [**Telephone/Fax (1) 6429**] for an appointment. Follow up with Dr. [**Last Name (STitle) 548**], Spine Surgery if needed for any concerns related to your spine fractures. Call [**Telephone/Fax (1) 1669**] if an appointment is needed. Completed by:[**2120-8-23**]

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Discharge summary

report

Admission Date: [**2140-4-21**] Discharge Date: [**2140-4-24**] Date of Birth: [**2088-7-4**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2751**] Chief Complaint: Dog Bite, Hyponatremia Major Surgical or Invasive Procedure: Suturing of multiple wounds from dog bites Placement and removal of a central line History of Present Illness: 51 y/o M transferred from OSH after sustaining multiple bite wounds on torso from pitbull. According to patient he was bending over to open a drawer and his brother's pitbull bite him. He states the dog is at baseline aggressive and showed no recent concerning behaviour. He was sent to OSH where he received Unasyn and transferred to [**Hospital1 18**] for plastic surgery eval due to extensive wound. On arrival to our ED T 98.2, BP 130/50, HR 84, RR 18, O2 98% RA. Patient with multiple bite wounds on bilateral axilla, neck, chest, and back - right axilla wound down to muscle. Plastic surgery irrigated right axilla with normal saline, wound edges closed via a V-Y advancement flap. Other wounds closed by ED. Patient was given unasyn 4.5 g IV, valium 10 gram IV, maalox 30 mg po, magnesium 4 mg IV and 80 total potassium (40 po and 40 IV) and morphine 4 mg IV. He was admitted to the ICU for hyponatremia. Patient reports he is up to date on tetanus. He reports his last drink was Sunday - typically he drinks 8-14 beers/day. Denies any toxic alcohol injestions. Denies recent drug use. Reports significant vomiting while drinking - 3-4x/day (last episode of vomiting on Monday). Denies blood in vomit. Denies abdominal pain or diarrhea. Limited po intake - last ate yesterday at lunch. Otherwise patient his usual state of health, denies chest pain. Describes intermittent chronic SOB and ? recent subjective fevers. Otherwise extensive review of systems is negative. According to the dog's vet he was not uptodate on rabies vaccination. Past Medical History: Liver Disease (related to alcohol - for the last 2 years) COPD ? Low Potassium Has not seen a physician in several years No history of DTs/seizues from ETOH withdrawal Social History: Lives with brother or sister. Smokes 1 pack/day for several years. Drinks 8-14 beers per day for several years. Denies recent drug use or history of IV drug use. Family History: Mother passed age 70 due to MI. Father passed age 60 ? unknown. Physical Exam: Tmax: 37.2 ??????C (99 ??????F) Tcurrent: 37.2 ??????C (99 ??????F) HR: 86 (81 - 104) bpm BP: 144/116(120) {133/66(82) - 144/116(120)} mmHg RR: 14 (13 - 24) insp/min SpO2: 97% Heart rhythm: SR (Sinus Rhythm) Height: 69 Inch GEN: pleasant, comfortable, NAD, oriented x 3 HEENT: PERRL, EOMI, anicteric, dryMM, op without lesions, no jvd RESP: CTA b/l with good air movement throughout CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly, no fluid wave EXT: no c/c/e SKIN: right axilla deep wound, 3 incisions on neck, deep scratch left posterioir NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. No pass-pointing on finger to nose. 2+DTR's-patellar and biceps Pertinent Results: Admission labs: [**2140-4-21**] 02:50AM BLOOD WBC-10.5 RBC-3.23* Hgb-11.2* Hct-29.8* MCV-92 MCH-34.6* MCHC-37.5* RDW-12.3 Plt Ct-53* [**2140-4-21**] 02:50AM BLOOD PT-14.5* PTT-24.8 INR(PT)-1.3* [**2140-4-21**] 01:16PM BLOOD Glucose-167* UreaN-33* Creat-1.2 Na-119* K-3.3 Cl-79* HCO3-36* AnGap-7* [**2140-4-21**] 09:43PM BLOOD Na-126* K-3.5 Cl-83* [**2140-4-22**] 10:13AM BLOOD Glucose-292* UreaN-28* Creat-1.0 Na-128* K-3.9 Cl-85* HCO3-37* AnGap-10 [**2140-4-22**] 03:50PM BLOOD Glucose-135* UreaN-25* Creat-1.0 Na-131* K-4.0 Cl-89* HCO3-36* AnGap-10 [**2140-4-21**] 02:50AM BLOOD ALT-64* AST-135* LD(LDH)-283* AlkPhos-81 TotBili-1.3 [**2140-4-21**] 05:45PM BLOOD VitB12-644 Folate-8.8 [**2140-4-21**] 09:30AM BLOOD Osmolal-266* [**2140-4-21**] 02:50AM BLOOD ASA-NEG Ethanol-109* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2140-4-21**] 01:16PM URINE RBC-2 WBC-2 Bacteri-NONE Yeast-NONE Epi-1 TransE-<1 [**2140-4-21**] 01:16PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [**2140-4-21**] 01:16PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.006 MICROBIOLOGY: [**4-21**] BCx x 2: NGTD Brief Hospital Course: 51 year-old male with history of COPD, liver disease, and alcohol abuse who was admitted to the MICU on [**4-21**] due to hyponatremia and for IV antibiotics due to dogbites. The [**Hospital 228**] hospital course has been complicated by alcohol withdrawal. # Electrolyte Abnormalities (Hyponatremia): Based on history of poor PO intake, patient's hyponatremia and hypochloremia were most consistant with beer potomania, with compensatory metabolic alkalemia. No IVF was given and full diet was introduced. Sodium and electrolytes corrected gradually over the next 36 hours at reasonable rate of ~0.5 mEq/h. Phosphorous levels decreased with re-introduction of food, felt likely to refeeding; repleted IV and PO as required. By time of discharge his sodium and potassium with within normal limits. # Dog bite: Multiple bite wounds on bilateral axilla, neck, chest, and back suffered from brother's pitbull. Right axilla wound down to muscle consequently sewn up by plastics. Unfortunately dog not up to date on rabies. Received Unasyn in ED and was continued on IV while inpatient. [**Location (un) 3844**] animal control and public health officials notified. Pitbull was noted to have been aggressive in past, previously wounding patient. While neck bites are at high risk for transmission or rabies, health officials recommended not initiating prophylaxis rabies treatment. Pitbull quarantined to crate at home for 10 days prior to family plan to euthanize animal. Follow-up with plastics arranged. He was discharged on augmentin to complete a 10 day course. Blood cultures were still pending at time of discharge. # Alcohol abuse/withdrawal: Patient denied other toxic ingestions. Placed on CIWA scale on admission and received diazepam as necessary. He required several doses of diazepam due to symptoms of withdrawal. Repleted thiamine/folic/MVI orally to avoid administering extra fluid in setting of hyponatremia. He was counseled to avoid alcohol use in the future. # Acute on chronic renal failure: Resolved with IV fluids. Likely prerenal from hypovolemia. # Hyperglycemia: The patient had no history of diabetes, but was found to have elevated BS and covered with SSI while hospitalized. He was not started on an oral medication due to his risk of hypoglycemia when not eating and concern for alcoholic ketoacidosis making metformin not an idea drug. . # Thrombocytopenia: Most likely related to liver disease and alcohol abuse, [**Name (NI) 653**] [**Name (NI) **] [**Name (NI) **] for baseline labs, but not recieved. Thrombocytopenia stable, no sign of bleeding. . # Anemia: Most likely related to alcohol abuse and mixed nutritional deficiencies. Hct in mid 20's this admission with unknown baseline. Vitamin B12 WNL and folate low/nl. No clinical evidence of bleeding, but does have history of "liver disease" possibly cirrhosis, so could be at risk for varices and should have an EGD as an outpatient. Also needs a screening colonoscopy. He was empirically started on omeprazole 40 mg daily as he is at high risk of gastritis due to his recent alcohol use. He was given folic acid oral repletion and multivitamin. He was instructed to stop drinking, and do everything possible in this regard. He declined detox or rehab referrals. . # Liver Disease: Related to alcohol use. INR 1.3. No evidence of encephalopathy or chronic liver disease. . # COPD: Not on home inhalers. Plans to quit smoking. No PFTs in our system. He was started on a nicotine patch. He will need outpatient follow up/PFTs (if not recently done) and consideration of starting a long-acting bronchodilator as he appears to be symptomatic reporting dyspnea on exertion at baseline. . # CODE: Full code # CONTACT: Sister [**Name (NI) **] [**Name (NI) 88792**] [**Telephone/Fax (1) 88793**], Brother [**Name (NI) **] [**Telephone/Fax (1) 88794**] Medications on Admission: None Discharge Medications: 1. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:*30 Patch 24 hr(s)* Refills:*2* 2. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. 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 Discharge Diagnosis: Primary: Dog bites Hyponatremia Alcohol withdrawal Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital due to multiple dog bites. You were also found to have an extremely low sodium level which was likely caused by your drinking. It is very important that you stop drinking as you will continue to develop health problems due to alochol use. Your hospital course was complicated by alcohol withdrawal and you were treated with a medication to stop the withdrawal. You were also found to have very low levels of phosphorus due to your lack of food intake prior to admission. It is very important that you eat food (other then alcohol) every day. You were also diagnosed with diabetes during this admissionyou likely need a medication to treat your elevated blood sugars. WE did not start this medication while you were in the hospital but you should follow up with your primary care doctor regarding your diabetes and starting this medication. You were also found to have low blood counts. You had no evidence of bleeding, but you will need a colonoscopy and upper endoscopy to look for evidence of blood loss. You were started on a medication to decrease inflammation in you stomach likely caused by alcohol use. You decided to quit smoking and were started on a nicotine patch. It is important that if you start smoking again, you stop using the nicotine patch. Medication changes: START augmentin twice daily for 7 more days (it is very important you do not miss a dose of this medication) (this treats your wounds) START nicotine patch daily START thiamine daily START folic acid daily START multivitamin daily Followup Instructions: You will need to follow up with your primary doctor within the next week. The plastic surgeons (the doctors [**First Name (Titles) 1023**] [**Last Name (Titles) 88795**] your wounds) want you to follow up with them on Friday [**4-29**]. Please call their clinic at [**Telephone/Fax (1) 4652**] to confirm and check on the time of your appointment. Their clinic is located at the [**Hospital **] Medical Office Building on [**Hospital Unit Name 11610**] [**Location (un) 86**], [**Numeric Identifier 88796**]. You also need to see a doctor [**First Name (Titles) 1023**] [**Last Name (Titles) 14903**] in liver disease. Please discuss who you should see with your primary doctor. Completed by:[**2140-4-24**]

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Discharge summary

report

Admission Date: [**2119-8-13**] Discharge Date: [**2119-8-30**] Date of Birth: [**2044-10-4**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 689**] Chief Complaint: status-post fall Reason for MICU admission: anemia, hyperkalemia, acute renal failure Major Surgical or Invasive Procedure: none History of Present Illness: Pt is a 74 yo male from nursing facility with a h/o schizoaffective disorder, HTN, DM II, CRF, anemia, and prior CVA in [**2109**] who was brought to the ED s/p an unwitnessed fall today with laceration on his left forehead. Pt reports fall precipitated by vertigo, which he has had episodically for several years. These are often associated with tinnitis and last for minutes, up to a half hour; not positional. Poor historian but denies any chest pain preceding this episode. Does describe urinary incontinence after fall. Unclear whether he had any loss of consciousness or confusion. Denies any tonic clonic movements. Review of records shows prior admission in [**2-1**] for dizziness more suggestive of lightheadedness. On Neuro f/u, EEG at that time not notable for seizure activity, consistent with a remote history of occipital stroke. . In the ED, initial VS were: T 96.7, P 41, BP 88/40, RR 16, O2sat 97RA. Pt was given atropine 0.5mg IV on arrival with improvement to SBP 100 and HR 50s. On exam, he was initially oriented only to self, hospital, and year but improved to [**Hospital1 18**] and month when higher BP. Exam notable for slightly larger left pupil; neuro exam otherwise intact. Guaiac negative. Labs notable for Hct 23 from baseline 27 in [**7-4**], Na 133, K 8.3, FSG 468. No anion gap but lactate 3.3. No ketonia. EKG without signs of hyperkalemia. CT head and c-spine unremarkable. CT abdomen/pelvis without evidence of bleed. Pt received a total of 3L IV fluids with improvement in Na to 136. Also given calcium gluconate and kayexalate 60mg for hyperkalemia with improvement to K 6.9. Given 10 units of regular insulin and started on insulin gtt at 5 units/hr with improvement to FSG 243. One unit of pRBC hung prior to transfer to MICU. VS on transfer: T 98, HR 56, BP 135/52, RR 17, O2sat 100. . On the floor, pt currently complaining of pain at site of laceration as well as mild vertigo. . Review of sytems: (+) Per HPI (-) Denies fever, chills, night sweats. Denies rhinorrhea or congestion. Denies cough, shortness of breath. Denies chest pain or tightness. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No dysuria. Has polyuria and polydipsia. Denies arthralgias or myalgias. Past Medical History: Schizoaffective disorder s/p Geripsych admission [**12-1**] w/ paranoia, impulsivity, & threatening behavior R posterior cerebellar artery infarct [**8-/2109**] Vascular dementia Hypertension Hypertriglyceridemia Type 2 DM (A1c 7.7 in [**7-4**]) Chronic anemia Chronic kidney disease (baseline 1.1-1.2) GERD Social History: Per prior d/c summary, born and raised in the [**Location (un) 86**] area with two brothers and one sister, all of whom are now deceased. He worked as a roofer for 30 years. He never married and has no children. Prior to his stroke in [**2109**], he lived alone in an apartment; currently in a nursing home. Drank 3 beers a day for years but none since stroke. Denies any history of tobacco and illicits. Family History: Unable to obtain. Parents, 2 brothers, and 1 sister all deceased. Next of [**Doctor First Name **] is [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 8360**] ([**Telephone/Fax (1) 23904**]) Physical Exam: Vitals: T 96.4, HR 60, BP 133/54, RR 15, O2sat 95% RA General: Alert, perseverative with child-like thought process, no acute distress HEENT: Superficial laceration over left forehead, sclera anicteric, MMM, oropharynx clear Neck: Supple, JVP not elevated, no LAD, left carotid bruit Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular, bradycardic, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Distended but soft, bowel sounds present, no rebound tenderness or guarding, no organomegaly by percussion GU: No foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Chronic rash on nape of neck Neuro: AAO x 2 (person, [**Hospital1 18**]), left pupil 4mm, right pupil 3mm; both reactive, CN II-XII otherwise grossly intact without nystagmus, strength 5/5, no pronator drift or tremor, not cooperative with finger-to-nose testing or [**Last Name (un) **]-Hallpike, patellar reflexes symmetric, toes downgoing on Babinski, gait not assesssed. . Physical on Discharge: tmax: 98 Tc: 98 HR: 58 BP: 134/64 General: Well appearing gentleman in no acute distress Neck: Supple, no JVD CV: Regular rate and rhythm; normal S1 and S2; no murmurs, rubs, or gallops Abdomen: +BS, soft/non-tender, non-distended Ext: Warm and dry; no edema Skin: Scaly and dry Neuro: Very uncooperative with exam; refused further testing this morning Pertinent Results: Admission labs: [**2119-8-13**] WBC-9.7# Hgb-6.8*# Hct-23.0*# MCV-73*# RDW-17.1* Plt Ct-289 [**2119-8-14**] PT-13.9* PTT-26.7 INR(PT)-1.2* [**2119-8-13**] Neuts-82.3* Lymphs-13.9* Monos-3.0 Eos-0.3 Baso-0.4 [**2119-8-13**] Glucose-382* UreaN-27* Creat-2.4*# Na-131* K-8.3* Cl-103 HCO3-18* AnGap-18 [**2119-8-13**] Calcium-8.7 Phos-3.8 Mg-2.1 [**2119-8-13**] ALT-18 AST-18 LD(LDH)-182 CK(CPK)-94 AlkPhos-56 TotBili-0.3 [**2119-8-13**] Lipase-138* . Discharge labs: [**2119-8-23**] 06:00AM BLOOD WBC-6.7 RBC-3.42* Hgb-8.3* Hct-27.2* MCV-79* MCH-24.1* MCHC-30.4* RDW-19.9* Plt Ct-221 [**2119-8-30**] 06:10AM BLOOD Glucose-112* UreaN-48* Creat-1.8* Na-142 K-4.6 Cl-108 HCO3-23 AnGap-16 . CXR [**2119-8-13**]: No acute intrathoracic process. Limited study. . CXR [**2119-8-14**]: There is interval development of right lung consolidation, mostly involving the right lower lobe, but also affecting the right upper lobe, extensive and given its rapid development might be consistent with interval aspiration. The left lung is clear. Cardiomediastinal silhouette is unremarkable. . CXR [**2119-8-16**]: There is interval improvement in the right basilar opacity which currently right perihilar lower lung abnormality demonstrated that might be consistent with resolution of massive aspiration giving complete absence of the abnormalities on [**8-13**], [**2119**], radiograph and its rapid development on [**2119-8-14**] radiograph. The left lung is clear as well as the right upper lung. Healed fractures of the left ribs are unchanged in appearance. There is no appreciable pleural effusion or pneumothorax. . CXR [**2119-8-20**]: There is improved aeration bilaterally. There is no focal infiltrate. There is a small right effusion. . CT abd/pelvis [**2119-8-13**]: 1. No retroperitoneal hematoma. 2. Trace free pelvic fluid, of uncertain etiology. 3. Vascular atherosclerotic calcifications. 4. Fatty infiltration of the liver. . CT head [**2119-8-13**]: 1. No intracranial hemorrhage or edema. No fracture. 2. Mucosal thickening of the right maxillary sinus and partial opacification of the left mastoid air cells. . CT cervical spine [**2119-8-13**]: 1. No fracture or malalignment of the cervical spine. Multilevel degenerative changes. 2. Subcutaneous cystic lesion of the posterior left neck - ? sebacious cyst. Brief Hospital Course: 1. Syncope s/p fall: The patient presented to the hospital after syncopizing, falling, and hitting his head. Non-contrast head CT showed no evidence of bleed. CT C-spine showed no fracture or malalignment. The patient's syncopal episode occurred in the setting of dizziness/vertigo. Given the patient's known vertebrobasilar disease and the left carotid bruit observed on exam, the question of vertebrobasilar insufficiency was raised. Differential diagnosis included Meniere's disease, vasovagal, orthostasis (in the setting of dehydration), or arrhythmia (in the setting of hyperkalemia). The patient was monitored on telemetry, which initially showed bradycardia to 30s. Followed correction of hyperkalemia, telemetry showed normal sinus rhythm with frequent premature ventricular contractions. Echocardiogram showed preserved ejection fraction, with no evident structural cause of syncope. Cardiac enzymes were negative. The patient should consider repeat MRI/MRA as an outpatient for evaluation of the cerebral circulation (last examined in [**2117**]). . 2. Acute on chronic renal failure: The patient presented with a creatinine of 2.4, up from baseline 1.1. The etiology of the patient's acute on chronic renal failure was unclear. The most likely etiology is pre-renal, as the patient;s renal function rapidly improved with the administration of IV fluids. A Foley catheter was placed in the emergency department, but was discontinued prior to discharge. The patient was able to void well without the catheter. At the time of discharge, the patient's creatinine was between 1.0 to 1.2. The patient will need to have his creatinine monitored weekly after discharge from the hospital. . 3. Hyperkalemia: The patient presented with a potassium of 8.3, in the setting of acute renal failure, hyperglycemia, and lisinopril use. The patient was treated with calcium, insulin, and kayexylate, with improvement of his potassium. Lisinopril was initally held, but was subsequently restarted, along with chlorthalidone. The patient's potassium was monitored closely and remained in the normal range. The patient will need his potassium checked weekly following discharge from the hospital. . 4. Bradycardia: In the ED, the patient had bradycardia to 30s, which improved with atropine and normalization of hyperkalemia. . 5. Hypertensive emergency: In the medical intensive care unit, the patient had flash pulmonary edema in the setting of agitation and hypertension to 220s/110s. The patient was treated with Lasix, labetalol, and BiPap, with improvement in his respiratory status. Echocardiogram showed preserved ejection fraction. Lisinopril was restarted for improved blood pressure control, and was dosed in the evening, as the patient tended to be most hypertensive at night. At the time of discharge, the patient's lisinopril dose was 20 mg each night. Metoprolol was added but then discontinued due to bradycardia. Chlorthalidone was started and titrated up to 50 mg daily. At the time of discharge, the patient's blood pressure control was improved. The patient will need blood pressure monitored closely following discharge from the hospital. . 6. Fever with ?pneumonia: The patient had fever in the medical intensive care unit. Chest x-ray showed a right lower lobe infiltrate, although it was not clear if this was a true infiltrate or if it was pulmonary edema in the setting of hypertensive emergency. The patient was treated empirically cefamine and vancomycin, which was subsequently narrowed to levofloxacin, for a 5-day course. By the time of discharge, the patient's fevers had resolved, his chest x-ray had improved, and his lung exam had normalized. . 7. Anemia: The patient presented with hematocrit 23. For this, he received 1 unit of packed red cells in the emergency department. Guiaic was repeatedly negative. Further evaluation revealed microcytosis and severe iron deficiency (ferritin 5). There was no evidence of hemolysis. B12 and folate were normal. UPEP/SPEP did not show a monoclonal gammopathy. The patient was treated with erythropoietin, vitamin C, and IV iron in the intensive care unit. His hematocrit remained stable throughout the admission. The patient was discharged or oral iron supplementation. He should follow up with his primary care provider for further evaluation of his iron deficiency anemia. . 8. Diabetes mellitis: On admission, the patient's blood glucose was elevated to greater than 400. Oral hypoglycemics were discontinued given acute renal failure, and the patient's blood sugar was managed with insulin. Glyburide was retarted but then discontinued. The [**Last Name (un) **] diabetes service was consulted to help manage the patient's hyperglycemia. The patient was treated with Lantus and a Humalog sliding scale, with improved glucose control. He was was discharged on 9 of Lantus and a Humalog sliding scale (please see attached). Sliding scale can be adjusted as necessary at [**Hospital3 537**]. He will need frequent insulin checks (4x/day) and insulin administration throughout the day. . 9. Left carotid bruit: Bruit observed on exam. Consider further evaluation (carotid ultrasound vs. MRI) as outpateint. This has not been an urgent issue during this admission. . 10. Schizoaffective disorder - The patient had some agitation, leading to hypertensive emergency. At that time, the patient's risperdal dose was increased to 1 mg twice daily. The patient's Celexa and trazodone were continued, with no dosage change. . 11. Sebhorreic dermatitis: The patient had erythematous plaques, with greasy scaling, on his forehead, occiput, and beard area, consistent with seborrheic dermatitis. He was treated with selenium shampoo and ketaconazole cream. He can continue this treatment after discharge, until the dermatitis resolves. . 12. Vascualar dementia: The patient's dementia was stable throughout the admission. His hypertension was treated as above. . 13. Hyperlipidemia: Stable, continued Welchol and Lipitor. Medications on Admission: Fish oil 1000mg daily Vitamin C 500mg daily Citalopram 60mg daily Lipitor 20mg daily Glyburide 5mg daily Lisinopril 10mg daily Cyanocoabalamine 1000mcg injection qmonth ASA 325mg daily Mom[**Name (NI) 6474**] 0.1 cream daily to eyebrows and nose Ammonium lac [**Hospital1 **] to back Docusate 100mg [**Hospital1 **] Risperidone 0.5mg [**Hospital1 **] Welchol 1250mg [**Hospital1 **] Lamisil Cream [**Hospital1 **] to affected area Mi-acid 30mL [**Hospital1 **] Meclizine 25mg tid Metformin 750mg tid Ayr saline nasal gel tid to nostrils Trazodone 50mg qhs Ranitidine 150mg qhs Senna 8.6mg 2 tabs qhs Artificial tears [**1-27**] gtt ou qid prn Blephamide S.O.P. ointment qhs to eyelid margins prn crusting Albuterol inh 1-2 puffs [**Hospital1 **] prn Milk of magnesia 30 ml daily prn constipation Tylenol 650mg q4h prn Discharge Medications: 1. Omega-3 Fatty Acids Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Colesevelam 625 mg Tablet Sig: Two (2) Tablet PO bid (). 6. Meclizine 12.5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**1-27**] Drops Ophthalmic QID (4 times a day). 11. Sulfacetamide-Prednisolone 10-0.2 % Ointment Sig: [**1-27**] Ophthalmic HS (at bedtime) as needed for eye crusting. 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever or pain. 13. Simethicone 80 mg Tablet, Chewable Sig: [**1-27**] Tablet, Chewables PO QID (4 times a day) as needed for bloating. 14. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 16. Risperidone 0.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 18. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing, shortness of breath. 20. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: [**1-27**] Inhalation Q6H (every 6 hours) as needed for sob/wheezing. 21. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 22. Selenium Sulfide 2.5 % Suspension Sig: One (1) ML Topical DAILY (Daily) as needed for seborrheic dermatitis. 23. Ketoconazole 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 24. Chlorthalidone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 25. Ondansetron 4 mg IV Q8H:PRN nausea 26. Humalog 100 unit/mL Solution Sig: One (1) Subcutaneous four times a day: See attached sliding scale for administration. 27. Lantus 100 unit/mL Solution Sig: Nine (9) Subcutaneous once a day: One dose every morning. Discharge Disposition: Extended Care Facility: [**Hospital3 537**]- [**Location (un) 538**] Discharge Diagnosis: Primary diagnoses: 1. acute renal failure 2. hyperkalemia 3. hypertensive emergency 4. diabetes mellitis, type 2 . Secondary diagnoses: 1. history of stroke 2. schizoaffective disorder Discharge Condition: hemodynamically stable, tolerating oral diet, no respiratory difficulties, improved blood pressure control, improved glycemic control Discharge Instructions: You came to the hospital after losing consciousness and hitting your head. You had a CT scan of your head and neck, which did not show any damage from the fall. It is unclear exactly why you lost consciousness. Your loss of consciousness could be related to your history of dizziness, or to your history of poor circulation to parts of your brain. It could also have been related to dehydration. Another possibility is that you had an abnormal heart rhythm due to your potassium level, which was dangerously high at the time of admission. . When you got to the hospital, your were found to have decreased kidney function and very high glucose and potasssium levels. Your kidney function, glucose, and potassium improved with treatment. You were admitted to the intensive care unit for close monitoring. There, your blood pressure became very elevated one night, causing you to have difficulty breathing. This improved with treatment of your blood pressure. While in the intensive care unit, you also had some fevers, and you were treated with antibiotics for possible pneumonia. . As your condition improved, you were transferred from the intensive care unit to the medical floor. There your blood pressure medicines were adjusted for improved control. In addition, you were seen by the [**Last Name (un) **] Diabetes service, who helped adjust your insulin level in order to improve your glucose control. . You have a rash on your scalp and face, which is due to a condition called sebhorreic dermatitis. This condition is not dangerous. You are being treated with a selenium shampoo and a creme. You should continue these treatments until the rash improves. . Several changes have been made to your medicines. (1) You are now on two types of insulin for your diabetes. You should no longer take glyburide or metformin. (2) Your risperdal dose has been increased to 1 mg twice daily. (3) Your blood pressure medicines now include lisinopril 20 mg at night and a new medicine called chlorthalidone 50 mg daily. . You will have to have your blood drawn about once per week to check your electrolytes and kidney function. You should take all of your medicines as prescribed. . You should return to the emergency room if you develop fever, chills, lightheadedness, loss of consciousness, chest pain, difficulty breathing, changes in your vision, nausea, vomiting, or other symptoms that are concerning to you. Followup Instructions: -Nephrology appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4883**] on Thursday, [**10-5**] at 11:00AM. You are being discharged to an extended care facility. You will need weekly lab drawns to check your electrolytes (particularly potassium) and kidney function (creatinine). You will need to be seen by the doctor at the extended care facility on a regular basis. Your creatinine was elevated when you left this hospital, but not significantly above your baseline. If your creatinine continues to be high (>2), the healthcare providers at your new facility might decide to stop your new medication, lisinopril.

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icd9cm

[ [ [] ] ]

[ "99.04" ]

icd9pcs

[ [ [] ] ]

16735, 16806

7400, 13438

400, 406

17035, 17171

5059, 5059

19641, 20297

3440, 3645

14306, 16712

16827, 16942

13464, 14283

17195, 19618

5523, 7377

3660, 4670

16963, 17014

4684, 5040

275, 362

2376, 2670

434, 2358

5075, 5507

2692, 3002

3018, 3424

25,326

183,216

4924

Discharge summary

report

Admission Date: [**2118-9-26**] Discharge Date: [**2118-10-4**] Date of Birth: [**2058-5-23**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1973**] Chief Complaint: Seizure Major Surgical or Invasive Procedure: None History of Present Illness: 60 year old male with h/o seizure disorder, ESRD on HD, nonischemic cardiomyopathy (EF40-45%), remote h/o MI and CVA, and hepatitis B who presented to the ED after a witnessed seizure today. He apparently left AMA from his rehab facility on Friday in order to be the guest speaker at a conference in [**Hospital1 789**] on Saturday. He had lived at the rehab since [**5-2**]. He left without any prescriptions and reports not taking his anti-epileptics for the last 4 days. Today he went to HD and then was planning to go to the pharmacy to pick up his medications. However, on the way he reportedly had a seizure and a bystander called EMS (he doesn't remember the incident). Does endorse that he is "getting over a cold." Also reports not eating anything today at all. In the ED, initial vitals were BP 100/60 HR 109 RR 18. He arrived "post-ictal" and had two further seizures ("generalized tonic clonic and focal right-sided motor seizures" per ED records). Fingerstick glucose was 44. He was given 1 amp D50, Ativan 1mg x 1 then 2mg x 1. CT head and C-spine showed no acute process (final reads pending). He was placed in a c-collar. He initially had BP of 80's/50's and was given 1L IVF with subsequent normal BP. He then had recurrent hypotension to 70's/40's with MAPs in the 50's and was given another 1L of IV fluid. ECG showed a LBBB. He also was noted to have a laceration of the right eyebrow that did not require suturing. Neuorology was consulted and recommended keppra 1g IV x 1 and to resume his home meds when able to take oral medications. They also recommended medicine admit with neurology consult to follow. He was also given a dose of levaquin as he may have aspirated during his seizure. Vitals on transfer were BP 102/58 HR 102 99%3L. Review of systems: Denies any recent fever, chills, shortness of breath, chest pain, dizziness, cough, abdominal pain, diarrhea, urinary symptoms. Denies peripheral edema, PND, orthopnea. Does endorse constipation at times. Also states has had left knee swelling since a fall 6 weeks ago. He was last admitted to [**Hospital1 18**] in [**7-2**] with seizures in the setting of medication noncompliance. Past Medical History: - Seizure disorder since mid [**2097**]'s after starting dialysis - MSSA HD line infection with septic lung emboli [**9-1**] with left pleural effusion - H/o Hepatitis B, treated - Non-ischemic cardiomyopathy, last EF 40-45% - MI [**2086**] per pt - CVA [**2086**] per pt (?residual LE weakness) - ESRD on hemodialysis [**1-25**] HTN. EDW 80 kg as of [**2118-1-3**]. - Multiple thrombectomies in LUE and R thigh AV fistula - Graft excision for infected thigh graft [**2117-5-26**] - Hungry bone syndrome status post parathyroidectomy - Pituitary mass - Anemia of chronic disease - s/p PEG tube placement [**2117-10-29**] Social History: Retired piano and organ teacher. Has 2 PhDs (history and music) and prefers to be called "Dr. [**Known lastname 2026**]." Walks with a walker at baseline. Never smoker, no other drug use. Drinks 1 drink/week. Has 2 sisters that live out of state, son died 3 years ago ("was shot to death"). Family History: Father with DM, mother died at age 41 of renal failure. Physical Exam: VS: 98, 59, 124/77, 20, 99%RA GEN: Tall, thin, African American male with slightly disheveled appearance HEENT: Pupils equal and reactive to light, EOMI, anicteric, MMM, OP without lesions. RESP: lungs clear bilaterally CV: Normal S1/S2, no murmurs, rubs, or gallops Abd: Soft, BS+, not tender or distended. Ext: Extremities WWP, no clubbing, cyanosis, or edema. Left groin HD line without tenderness or erythema. Neuro: A+Ox3, CN II-XII intact. Strength and sensation grossly intact throughout. Decreased ability to dorsiflex ankles. Reflexes symmetric and 1+. Pertinent Results: Admission Labs: [**2118-9-26**] 01:10PM WBC-7.3 RBC-4.11* HGB-11.4* HCT-37.2* MCV-91 MCH-27.6 MCHC-30.5* RDW-16.2* [**2118-9-26**] 01:10PM NEUTS-78.9* LYMPHS-12.9* MONOS-3.8 EOS-3.8 BASOS-0.6 [**2118-9-26**] 01:10PM PT-13.9* PTT-68.3* INR(PT)-1.2* [**2118-9-26**] 01:10PM PLT COUNT-324 [**2118-9-26**] 01:10PM ASA-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2118-9-26**] 01:10PM DIGOXIN-0.4* [**2118-9-26**] 01:10PM TSH-1.7 [**2118-9-26**] 01:10PM CALCIUM-9.7 PHOSPHATE-2.9 MAGNESIUM-1.7 [**2118-9-26**] 01:10PM ALT(SGPT)-18 AST(SGOT)-19 CK(CPK)-78 ALK PHOS-169* TOT BILI-0.3 [**2118-9-26**] 01:10PM LIPASE-71* [**2118-9-26**] 01:10PM GLUCOSE-289* UREA N-31* CREAT-5.7* SODIUM-144 POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-28 ANION GAP-17 Imaging: [**9-26**] ECG: Sinus tachycardia. Since the previous tracing there is no significant change in previously noted findings. [**9-26**] CT head: 1. No evidence of acute intracranial process. 2. Generalized atrophy. [**9-26**] CT C-spine: 1. No evidence of acute fracture or malalignment. 2. Enlarged heterogeneous thyroid with calcifications. Correlation with prior imaging and clinical history recommended. [**9-26**] CXR: No definite signs of pneumonia in this limited radiograph. Brief Hospital Course: 60 year old male with h/o seizure disorder, ESRD on HD, nonischemic cardiomyopathy (EF40-45%), remote h/o MI and CVA, and hepatitis B who presented to the ED after a witnessed seizure. #. Seizure Disorder: Admitted to the MICU after multiple seizures. It was felt that his seizures were due to noncompliance in the setting of leaving rehab AMA without prescriptions. He was loaded with Keppra IV 1g IV in the ED and restarted on his home medications. There was no evidence of infection. He did not have any additional seizures while in the hospital. His blood sugar was also noted to be low at 44 on presentation. Pt denies history of low blood sugar or diabetes. A1c was normal. He did not have any additional episodes of hypoglycemia. #. Hypotension: He had transient hypotension in the ED, responsive to small boluses of IV fluids. It was felt that he was intravascularly volume depleted in the setting of recent dialysis. His lisinopril was also held. His blood pressure improved as well with oral hydration. He again had an episode of hypotension after his next session of HD, during which he remained asymptomatic. BP improved with gentle IV fluids. He had no further episodes of hypotension while on the floor. #. Left groin + skin culture: Pt has indwelling left femoral catheter for HD. Renal was concerned about the appearance of the catheter, and sent skin cultures, which grew out VRE and staph. Pt given a dose of vanc at HD on Monday. Pt has no complaints of pain at the site. Per renal, antibiotics (vanc) were continued at dialysis through [**2118-10-7**] (felt that VRE likely contaminant). Blood cultures show no growth to date but will need final follow up. #. ESRD on HD: Continued to be dialyzed on MWF, and continued on sevelamer, calcium acetate, lanthanum. #. Non-ischemic cardiomyopathy and h/o MI: No complaints of chest pain. Continue home ASA and statin, held ACE-I initially due to hypotension. #. Anemia: Hematocrit at recent baseline. Continued on home folic acid and ferrous sulfate. #. Thyroid abnormality: Incidentally found to have enlarged left thyroid with calcificaitons. Also has had parathyroidectomy in the past. TSH was normal, and pt advised that he should have a thyroid ultrasound after discharge for further evaluation. #. Disposition: When he was medically ready for discharge, Mr [**Known lastname 2026**] came up with a plan to stay at a local hotel until he is able to secure his own apartment at the end of this week. Although there was initially some concern about the safety of this plan, pt was AOx3 and deemed to be competent to make his own decisions regarding his medical care and disposition. He was also able to ambulate independently with a walker, indicating that he did not need rehab-level of care. His home medications were obtained for him before discharge. He will continue to arrange transportation to dialysis through "the Ride". At the time of discharge, pt was afebrile, with stable vital signs, alert and oriented, tolerating PO intake, and able to walk independently with a walker. Medications on Admission: Allopurinol 100mg po daily Calcium acetate 667mg - 4 tabs po tid with meals Digoxin 125mcg po every other day Folic acid 1mg po daily Acetaminophen 325mg po q6h prn pain/fever Bisacodyl 10mg po daily prn constipation Ferrous sulfate 300mg po daily Lanthanum 500mg po bid Lisinopril 10mg po daily Omeprazole 20mg po daily Senna 8.6mg po qhs prn constipation Sevelamer 400mg - 4 tabs po tid with meals Gabapentin 200mg po daily Oxcarbazepine 300mg po tid, plus additional dose after HD Levetiracetam 500mg po tid, plus additional dose after HD ASA 81mg po daily Discharge Medications: 1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day as needed for Constipation. Disp:*60 Tablet(s)* Refills:*2* 3. calcium acetate 667 mg Capsule Sig: Four (4) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*330 Capsule(s)* Refills:*2* 4. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). Disp:*60 Tablet, Chewable(s)* Refills:*2* 7. sevelamer HCl 400 mg Tablet Sig: Four (4) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*330 Tablet(s)* Refills:*2* 8. gabapentin 100 mg Capsule Sig: Two (2) Capsule PO Q24H (every 24 hours). Disp:*60 Capsule(s)* Refills:*2* 9. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 10. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO MWF (Monday-Wednesday-Friday). Disp:*30 Tablet(s)* Refills:*2* 11. oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*150 Tablet(s)* Refills:*2* 12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 13. oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO MWF (Monday-Wednesday-Friday). Disp:*50 Tablet(s)* Refills:*2* 14. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*70 Tablet(s)* Refills:*2* 15. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 16. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). Disp:*30 Tablet(s)* Refills:*2* 17. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). Disp:*30 Tablet(s)* Refills:*2* 18. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 19. vancomycin 1,000 mg Recon Soln Sig: One (1) dose Intravenous once for 1 doses: please give last dose of vanc at dialysis on wed [**10-5**]. 20. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: seizure, intermittent hypotension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were treated at [**Hospital1 18**] for seizures after you were unable to take your seizure medications for several days. You were also found to have a low blood sugar at that time. Your hemoglobin A1C (a test of your long-term blood sugar) was normal. You were also treated with fluid bolus for intermittent low blood pressure, usually after your hemodialysis treatments, which was asymptomatic. You should resume your home medications. Due to your heart failure, you should weigh yourself every morning, and [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. You were found to have an enlarged left thyroid on CT scan. Your TSH was normal. You should follow up with your primary doctor for further evaluation with an ultrasound. You should make an appointment with your neurologist for the next 1-2 weeks. If you are unable to make this appointment, you have been given an appointment at the neurology clinic as seen below. It is very important that you keep your appointments at dialysis on Monday, Wednesday, and Friday. Please arrange your ride service to get you to these appointments. Followup Instructions: Department: [**Hospital3 249**] When: MONDAY [**2118-10-10**] at 3:45 PM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage *Dr [**Last Name (STitle) **] is your new physician at [**Name9 (PRE) 191**]. Dr. [**Last Name (STitle) **] works closely with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**First Name3 (LF) **] both will be involved in your care. Department: NEUROLOGY When: MONDAY [**2118-10-17**] at 1 PM With: DRS. [**Name5 (PTitle) **] & [**Doctor Last Name **] [**Telephone/Fax (1) 3294**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2118-10-5**]

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icd9cm

[ [ [] ] ]

[ "39.95", "38.95" ]

icd9pcs

[ [ [] ] ]

11663, 11669

5463, 8552

323, 329

11747, 11747

4171, 4171

13067, 13940

3516, 3573

9162, 11640

11690, 11726

8578, 9139

11930, 13044

3588, 4152

2155, 2543

276, 285

357, 2136

5099, 5440

4187, 5090

11762, 11906

2565, 3187

3203, 3500

43,671

176,657

41922

Discharge summary

report

Admission Date: [**2122-12-10**] Discharge Date: [**2122-12-15**] Date of Birth: [**2066-8-6**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 165**] Chief Complaint: throat pain Major Surgical or Invasive Procedure: [**2122-12-10**] Cardiac Catheterization [**2122-12-11**] Coronary Artery Bypass x3(Free LIMA/off SVG-LAD, SVG-PDA, SVG-OM) History of Present Illness: Ms. [**Location (un) 91020**] is a 56 year old woman without a prior CAD history who was admitted to [**Hospital6 **] on [**2122-9-3**] with an acute MI. She had been at work and was experiencing lower back pain, a headache and throat discomfort. She did not have chest pain. Per report, at [**Hospital1 112**] she had anterior and inferior ST elevation, with some anterior R wave loss. . Cath at [**Hospital1 112**] revealed a small LM (smaller than the 6F guide). The LAD had a 99% stenosis in the mid vessel with TIMI 2 flow. The mid Cx had a 90% stenosis and the dominant RCA had a 90% stenosis. Surgery was consulted for potential CABG. Subsequent LV gram showed severe anterior wall hypokinesis. Based upon this and poor R wave progression on her EKG, she was turned down for CABG. The decision was made for PCI and the LAD was treated with DES. . In [**2122-10-1**] the patient underwent surveillance stress testing. Imaging revealed a moderate zone of ischemia involving the LV apex and anterior apical region. There was also a probable small anterior septal apical region that was fixed. LVEF was 62% with anterior hypokinesis, and apical dyskinesis/akinesis. As the patient was asymptomatic at the time, medical management was continued. . The patient had been in cardiac rehab since then. Last thursday while on the stationary bicycle she developed throat discomfort similar to what she experienced at the time of her MI. SL nitroglycerin relieved her pain. On [**2122-12-8**] the patient had similar discomfort while walking in her house, resolving with relaxation. She was therefore admitted for elective cardiac cath. Cath this morning revealed: LMCA: diffusely small with at least 70% at bifurcation LAD: mid stent widely patent LCX: sequential 80% proximal and mid lesions RCA: 60% mid; 80% lesion before bifurcation She is now being admitted for workup prior to CABG. . On arrival to the floor, patient denies any pain or SOB. . REVIEW OF SYSTEMS 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, or hemoptysis. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: Coronary Artery Disease, s/p CABG x 3 on [**2122-12-11**] PMH: Hyperlipidemia [**2122-8-31**]: Anterolateral MI, s/p LAD stenting (known 90% Cx and RCA disease untreated) Occasional rectal bleeding d/t hemorrhoids Psoriasis Past Surgical History: C-section x 2 Hernia repair Social History: - Tobacco: Patient smoked about 1 ppd x 17 years. Quit [**Month (only) 216**], [**2122**] - ETOH: None - Illicits: Denies - Patient is separated with two children, ages 19 and 17. She lives alone. - Works in an administrative position for Youth Services. Family History: Mother with CABG in her late 60's. Physical Exam: On Admission: VS: 96.9 125/41 56 16 100% on RA GENERAL: WDWN female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple without 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. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: Plaques on extensor surfaces of elbows and knees consistent with psoriasis. Right femoral cath site clean with intact dressing. No tenderness, hematoma, or bruit. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: Admission Labs: [**2122-12-10**] 11:30AM BLOOD WBC-7.3 RBC-4.16* Hgb-12.1 Hct-36.1 MCV-87 MCH-29.2 MCHC-33.6 RDW-14.7 Plt Ct-284 [**2122-12-10**] 11:30AM BLOOD PT-12.8 PTT-32.0 INR(PT)-1.1 [**2122-12-10**] 11:30AM BLOOD Glucose-118* UreaN-15 Creat-0.9 Na-137 K-3.9 Cl-103 HCO3-24 AnGap-14 [**2122-12-10**] 11:30AM BLOOD ALT-17 AST-17 CK(CPK)-55 AlkPhos-71 Amylase-110* TotBili-0.1 [**2122-12-11**] 03:50AM BLOOD CK-MB-1 cTropnT-<0.01 [**2122-12-10**] 11:30AM BLOOD Albumin-4.1 [**2122-12-10**] 11:30AM BLOOD %HbA1c-5.8 eAG-120 . Discharge Labs: [**2122-12-15**] 05:45AM BLOOD WBC-10.1 RBC-3.14* Hgb-9.5* Hct-27.8* MCV-89 MCH-30.2 MCHC-34.1 RDW-14.2 Plt Ct-281 [**2122-12-14**] 05:02AM BLOOD WBC-12.5* RBC-3.06* Hgb-9.2* Hct-27.3* MCV-89 MCH-30.1 MCHC-33.7 RDW-14.3 Plt Ct-199 Intra-op TEE [**2122-12-11**] Conclusions PRE-CPB:1. The left atrium is normal in size. No thrombus is seen in the left atrial appendage. 2. No atrial septal defect is seen by 2D or color Doppler. 3. Right ventricular chamber size and free wall motion are normal. 4. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. There are simple atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. 6. Mild (1+) mitral regurgitation is seen. During a period of iscemia, with PA pressures of 75/45, the mitral regurgitation increased to 2+. After nitroglycerine therapy, the MR was trace. Dr. [**Last Name (STitle) **] was notified in person of the results.] POST-CPB: On infusions of phenylephrine and nitroglycerine. A-pacing. Preserved systolic function from precpb. LVEF = 45%. Anteroseptal and anterior hypokinesis. MR, AI are 1 +. There was one episode of elevated PA pressures following a volume transfusion that resulted in transient 2+ MR, which responded to nitroglycerine. The aortic contour is normal post decannulation Brief Hospital Course: The patient was brought to the operating room on [**12-11**] where the patient underwent a [**2122-12-11**] CABG x3(Free LIMA/off SVG-LAD, SVG-PDA, SVG-OM). 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. She developed nausea and was treated with Reglan and Zofran. There was no ileus on KUB. Narcotics were discontinued. Plavix was resumed for previous stents and poor targets. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged home with VNA in good condition with appropriate follow up instructions. Medications on Admission: CAPTOPRIL 6.25 mg TID, CLOPIDOGREL 75 mg Daily, METOPROLOL SUCCINATE 50 mg Daily, NITROGLYCERIN 0.4 mg SL PRN, OMEPRAZOLE 20 mg Daily, ROSUVASTATIN 20 mg Daily, ASPIRIN 325 mg Discharge Medications: 1. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 7. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. Disp:*40 Tablet(s)* Refills:*0* 8. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*0* 9. 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* Discharge Disposition: Home With Service Facility: [**Hospital1 **] VNA [**Location (un) 5087**] Discharge Diagnosis: Coronary Artery Disease, s/p CABG x 3 on [**2122-12-11**] PMH: Hyperlipidemia [**2122-8-31**]: Anterolateral MI, s/p LAD stenting (known 90% Cx and RCA disease untreated) Occasional rectal bleeding d/t hemorrhoids Psoriasis Past Surgical History: C-section x 2 Hernia repair Discharge Condition: DISCHARGE CONDITION: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Edema: trace to 1+ 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: Dr.[**Name (NI) 11272**] office will call you with the following appointments: Wound Check: Surgeon: Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] - [**Telephone/Fax (1) 170**] Cardiologist: Dr. [**First Name (STitle) **] [**First Name8 (NamePattern2) **] [**Doctor Last Name **] Please call to schedule the following: Primary Care in [**5-5**] weeks. Name: [**Last Name (LF) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Address: [**Street Address(2) 4472**],[**Apartment Address(1) 24519**], [**Hospital1 **],[**Numeric Identifier 9331**] Phone: [**Telephone/Fax (1) 18325**] Fax: [**Telephone/Fax (1) 18324**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2122-12-15**]

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Discharge summary

report

Admission Date: [**2179-9-29**] Discharge Date: [**2179-10-22**] Date of Birth: [**2102-1-6**] Sex: M Service: MEDICINE Allergies: Iodine Attending:[**First Name3 (LF) 1055**] Chief Complaint: 77M with history of CAD, AF, esophageal adenocarcinoma s/p XRT, resection and chemotherapy who initially presented with tachypnea [**12-30**] pericardial and pleural effusions and transferred to MICU after thoracentesis, pericardiocentesis and pericardial window with chest tube for pneumothorax. Stable respiratory status since transfer to floor. Major Surgical or Invasive Procedure: Pericardiocentesis Right Anterior Mini Thoracotomy and Pericardial Window Bronchoscopy Right heart catheterization PICC placement History of Present Illness: Admitted to [**Location (un) **] from [**Hospital **] Rehab with tachypnea and hypoxia. Per OSH records, patient had been experiencing shortness of breath, with O2 sats in the high 60's, RR in 40's. O2 sats improved with Lasix up to 90% on 2L, BP 98-109/40-60s, HR 70-80s. Pt was given cefepime and levaquin for R-sided infiltrate seen on CXR and underwent a US guided thoracentesis for R-sided effusion. 1 liter of serous fluid removed, post-procedure CXR showed 10% R apical pneumothorax. In addition, patient went into a-fib w/ hr into 160's. Patient given dig, amiodarone (loaded and drip x 6 hours) and diltiazem drip. Patient underwent echo which showed large pericardial effusion, sent to [**Hospital1 18**] for evaluation/pericardiocentesis. . Of note, patient recently discharged from [**Hospital3 **] after 2 week hospitalization for bilateral pleural effusions and pneumonia. . On admission, patient states that he been feeling progressively SOB for the past week, and has noticed increased swelling of his lower extremities, making it difficult to walk. Denies any current chest pain, reports currently breathing comfortably. No F/C/N/V. H/o productive cough. + orthopnea. Past Medical History: HTN, lung disease, pleural tap 1L on right [**9-29**], COPD exacerbation, esophageal cancer- Barrett's, stage II, T1, N1, MO adenocarcinoma, s/p resection, chemo and radiation (completed approx. 2 months ago), J-tube in place for supplemental nutrition, PAF on coumadin (saw Mirbach for tachy thought to be a-fib/flutter after adenosine x1), h/o cardioversion, anemia, h/o kidney stones, "trigger finger", cataract surgery Social History: married w/ two sons, lives w/ wife [**Name (NI) 382**]. Former manager of phone company. + 60 pack year tob history, quit 6 months ago. +h/o ETOH, quit 6 months ago. Family History: Mom deceased at 78 from MI, Dad deceased from MS at 44. Brother w/ quad bypass 78. Physical Exam: 97.0/ 72/ 28/ 111/72 85kg/ 93% on 5L NC GEN:pale, awake, alert, sitting up in bed, breathing comfortably HEENT:atraumatic, anicteric sclerae, clear OP NECK:no carotid bruits, JVP about 10cm CV:muffled and distant HS, no murmurs appreciated, +pleural rub, +femoral pulses, faint but +DP and PT pulses. Pulsus of 9. LUNGS:diminished on R, crackles at bases, deeply productive cough ABDOMEN: soft, j-tube in place, site CDI, NABS, nt EXT:[**1-29**]+ pitting edema bilaterally on LE, UE edema bilaterally, + clubbing of nails, resting tremor of R leg NEURO:A/O X3, spontaneous movement x4. no focal deficits Pertinent Results: EKG: a-fib, low voltage in precordial and limb leads, no ST changes or TWI . Cath ([**9-30**]): Right heart catheterization demonstrated elevated right atrial and right ventricular end diastolic pressures which were approximately equal to pericardial pressures (12 mmHg0 suggestive of early tamponade. After pericardiocentesis, pericardial pressures returned to 0 mmHg. Cardiac output calculated using the Fick method demonstrated moderate to severely diminished cardiac index of 2.0L/min/m2 prior to pericardiocentesis, with improvement to 2.6L/min/m2 after pericardiocentesis. PA sat improved 48 to 58. . Echo ([**10-11**]): approximately 1 cm wide partially echo dense region around the heart (most prominent anteriorly) consistent with probable somewhat organized pericardial effusion and pericardial thickening. No definite echocardiographic signs of tamponade are identified but views are technically suboptimal. Echo ([**10-6**]): moderate sized pericardial effusion. No right ventricular diastolic collapse is seen. There is sustained right atrial collapse, consistent with low filling pressures or early tamponade Echo ([**10-2**]): moderate pericardial effusion, anterior to RA and RV, consistent with loculation Echo ([**9-30**]): anterior space fat pad, but possible loculated anterior pericardial effusion Echo ([**9-29**]): large pericardial effusion with increased intrapericardial pressure, EF 50-60% . CXR ([**10-11**], 14:26): Probable small right apical pneumothorax. Status post placement of small bore chest tube. Moderate right and small left pleural effusions. CXR ([**10-11**], 10:30): Worsening atelectasis in the right lung. Lucency at right lung apex, without definitive visceral pleural line identification. Status post esophagectomy and pullup procedure. Improving left pleural effusion and enlarging right pleural effusion CXR ([**10-10**]): Bilateral pleural effusions and associated atelectases in both lower zones. No pneumothorax. CXR ([**10-2**]): mild pulmonary edema, moderate bilateral pleural effusions (R>L) CXR ([**9-29**]): bilateral pleural effusions (L>R), pulmonary edema on right side, RLL collapse . Cytology [**10-11**] - bronchial brushings - reactive bronchial epithelial cells. . Chest U/S [**10-12**] - bilateral pleural effusions . CT-Chest/abd/pelvis - [**10-13**] - Interval decrease in pericardial effusion and right-sided pleural effusion with left-sided pleural effusion, not significantly changed. Interval increase in size of right-sided pneumothorax compared to prior chest CT. Compressive atelectasis in both lungs with no specific evidence for aspiration. No evidence of GI or bowel obstruction. Cholelithiasis. Small nonobstructing stones in the right kidney. Low attenuation lesion in the left kidney that likely represents a cyst, that is not fully characterized on this noncontrast study. . [**2179-9-29**] 07:26PM GLUCOSE-128* UREA N-25* CREAT-0.6 SODIUM-140 POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-29 ANION GAP-12 [**2179-9-29**] 07:26PM CK(CPK)-13* [**2179-9-29**] 07:26PM CK-MB-NotDone cTropnT-<0.01 [**2179-9-29**] 07:26PM ALBUMIN-2.3* CALCIUM-7.4* PHOSPHATE-3.2 MAGNESIUM-1.5* IRON-28* [**2179-9-29**] 07:26PM calTIBC-212* VIT B12-933* FOLATE-14.0 FERRITIN-347 TRF-163* [**2179-9-29**] 07:26PM WBC-12.6* RBC-2.83* HGB-9.2* HCT-27.3* MCV-96 MCH-32.5* MCHC-33.7 RDW-15.8* [**2179-9-29**] 07:26PM RET AUT-2.8 [**2179-9-29**] 07:26PM PT-17.8* PTT-33.5 INR(PT)-2.2 [**2179-9-29**] 07:26PM BLOOD calTIBC-212* VitB12-933* Folate-14.0 Ferritn-347 TRF-163* [**2179-10-1**] 01:35AM BLOOD Type-ART Temp-37.1 pO2-66* pCO2-54* pH-7.40 calHCO3-35* Base XS-6 [**2179-9-30**] 10:45AM OTHER BODY FLUID WBC-444* Hct,Fl-2* Polys-22* Lymphs-10* Monos-7* Eos-1* Mesothe-1* Macro-59* [**2179-9-30**] 10:45AM OTHER BODY FLUID TotProt-3.6 Glucose-99 LD(LDH)-343 Amylase-16 Albumin-2.0 [**2179-10-13**] 02:26PM PLEURAL TotProt-2.1 LD(LDH)-88 Albumin-1.1 [**2179-10-13**] 02:26PM PLEURAL WBC-17* RBC-510* Polys-39* Lymphs-26* Monos-25* Meso-8* Macro-2* [**2179-10-7**] 06:06AM BLOOD WBC-8.8 RBC-3.16* Hgb-10.3* Hct-29.5* MCV-93 MCH-32.5* MCHC-34.8 RDW-16.5* Plt Ct-245 [**2179-10-8**] 05:11AM BLOOD WBC-12.1* RBC-3.27* Hgb-10.7* Hct-30.5* MCV-93 MCH-32.6* MCHC-35.0 RDW-16.4* Plt Ct-235 [**2179-10-9**] 05:00AM BLOOD WBC-13.8* RBC-3.12* Hgb-10.1* Hct-30.2* MCV-97 MCH-32.4* MCHC-33.4 RDW-16.1* Plt Ct-266 [**2179-10-11**] 05:15AM BLOOD WBC-8.6 RBC-2.71* Hgb-8.8* Hct-27.0* MCV-100* MCH-32.4* MCHC-32.5 RDW-15.9* Plt Ct-245 [**2179-10-12**] 04:15AM BLOOD WBC-10.3 RBC-2.80* Hgb-9.0* Hct-26.0* MCV-93 MCH-32.3* MCHC-34.7 RDW-16.2* Plt Ct-318 [**2179-10-14**] 03:52AM BLOOD WBC-9.6 RBC-3.40*# Hgb-10.9*# Hct-30.3*# MCV-89 MCH-32.1* MCHC-36.0* RDW-16.0* Plt Ct-225 [**2179-10-9**] 05:00AM BLOOD PT-15.0* PTT-32.3 INR(PT)-1.5 [**2179-10-10**] 06:51AM BLOOD PT-14.4* PTT-50.4* INR(PT)-1.4 [**2179-10-10**] 07:45AM BLOOD PT-14.3* PTT-32.8 INR(PT)-1.4 [**2179-10-12**] 04:15AM BLOOD PT-16.2* PTT-108.1* INR(PT)-1.8 [**2179-10-13**] 04:12AM BLOOD PT-15.1* PTT-74.0* INR(PT)-1.6 [**2179-10-14**] 03:52AM BLOOD PT-14.3* PTT-28.9 INR(PT)-1.4 [**2179-10-7**] 06:06AM BLOOD Glucose-83 UreaN-21* Creat-0.5 Na-140 K-4.8 Cl-100 HCO3-35* AnGap-10 [**2179-10-9**] 05:00AM BLOOD Glucose-128* UreaN-16 Creat-0.5 Na-139 K-4.3 Cl-99 HCO3-34* AnGap-10 [**2179-10-12**] 04:15AM BLOOD Glucose-100 UreaN-22* Creat-0.4* Na-140 K-4.0 Cl-98 HCO3-37* AnGap-9 [**2179-10-14**] 03:52AM BLOOD Glucose-71 UreaN-18 Creat-0.5 Na-143 K-4.2 Cl-98 HCO3-33* AnGap-16 [**2179-10-2**] 02:16PM BLOOD ALT-10 AST-8 LD(LDH)-126 AlkPhos-66 TotBili-0.3 [**2179-10-13**] 04:12AM BLOOD TotProt-4.7* Calcium-8.2* Phos-3.3 Mg-1.5* [**2179-10-11**] 02:51PM BLOOD Type-ART Rates-/28 FiO2-100 pO2-194* pCO2-91* pH-7.26* calHCO3-43* Base XS-10 AADO2-450 REQ O2-75 Intubat-NOT INTUBA [**2179-10-11**] 09:48PM BLOOD Type-ART Temp-37.7 pO2-76* pCO2-54* pH-7.47* calHCO3-40* Base XS-13 Intubat-INTUBATED [**2179-10-12**] 12:18AM BLOOD Type-ART Temp-37.4 Rates-20/26 Tidal V-450 PEEP-5 FiO2-50 pO2-102 pCO2-54* pH-7.46* calHCO3-40* Base XS-12 -ASSIST/CON Intubat-INTUBATED [**2179-10-13**] 04:12AM BLOOD Type-ART Temp-36.9 Rates-/24 PEEP-5 FiO2-50 pO2-73* pCO2-58* pH-7.43 calHCO3-40* Base XS-11 Intubat-INTUBATED Vent-SPONTANEOU [**2179-10-13**] 01:43PM BLOOD Type-ART Temp-37.8 Rates-/72 FiO2-40 pO2-103 pCO2-75* pH-7.37 calHCO3-45* Base XS-13 Intubat-NOT INTUBA Comment-NEBULIZER [**2179-10-14**] 05:56AM BLOOD Type-ART Temp-36.7 FiO2-50 pO2-81* pCO2-61* pH-7.39 calHCO3-38* Base XS-8 [**2179-10-14**] 03:45PM BLOOD Type-ART Temp-36.7 pO2-118* pCO2-62* pH-7.37 calHCO3-37* Base XS-8 . Discharge Labs: [**2179-10-22**] 07:05a Na 137 Cl 98 BUN 18 Glc 114 K 4.6 Bicarb 33 Cr 0.5 Ca: 7.9 Mg: 1.6 P: 3.6 PT: 13.9 PTT: 62.7 INR: 1.3 ----------- [**10-22**] 12AM heparin dose: 1180 PTT: 60.8 ---------- [**2179-10-21**] 5:05p heparin dose: 1180 PTT: 65.2 ----------- [**2179-10-21**] 09:05a heparin dose: 1120 PT: 13.9 PTT: 53.8 INR: 1.3 Brief Hospital Course: 77 y/o male w/ long history of smoking, a-fib, htn, COPD, and esophageal cancer rx w/ chemo, surgery, and radiation; s/p thoracentesis, who presents with hypoxia, tachypnea, concern for tamponade on echo done at OSH. 1. Cardiac In terms of his vessels, he was stable, with no acute concerns to suggest ischemia. The patient had negative cardiac enzymes on admission. He was restarted on his beta blocker once his blood pressure was able to tolerate it, and was titrated up to a dose of metoprolol 25mg TID. In terms of his pump, the patient underwent a repeat echo immediately upon admission which showed a large circumferential effusion, with an estimated EF >55%. He underwent a pericardiocentesis on [**9-30**] with removal of over 300 cc of bloody exudative fluid. Cultures from the fluid were negative, and the preliminary report on the cytology of the fluid is negative for malignancy. The patient underwent subsequent repeat echoes which showed a stable, persistent anterior effusion. Thoracic surgery was consulted to evaluate patient for a pericardial window, felt that procedure would carry a higher risk given past surgery for esophageal cancer. Patient would need risk stratification prior to surgery. The patient had an echo on the day of discharge, which showed an increase in the pericardial effusion (loculated) w/ RA collapse and evidence of constrictive pericarditis as well. The decision was made for patient to undergo a pericardial window, and was taken to the OR on [**10-7**]. Will need to follow up on fluid cytology, pathology, and culture results. Report was negative for malignant cells. In addition, the patient had a history of atrial fibrillation, and underwent both electro cardioversion and chemical conversion with ibutilide at the OSH. Although in NSR on admission, the patient subsequently developed an atrial tachycardia/a-flutter rhythm with a heart rate up to 140's. Rate control was attempted with IV calcium channel blocker, IV metoprolol, and IV amiodarone; but ultimately required conversion again with ibutilide. The patient remained in NSR with effective rate control on amiodarone and metoprolol. Patient currently on TID Amiodarone but can be switched to once daily Amiodarone on [**11-1**]. The patient was restarted on heparin after an occluding thrombus was seen in his left cephalic vein. He is being transferred to rehab on heparin drip for bridge to coumadin. His goal PTT is 60-80 and his goal INR is [**12-31**]. Patient will need to have his INR followed closely as an outpatient once discharged from extended care facility. . 2. Pulmonary- the patient was admitted with hypoxia/tachypnea, likely secondary to bilateral effusions and ? infiltrate/infection seen on chest x-ray. The patient was placed on oxygen with a goal saturation in low-mid 90's given his history of COPD, with continuation of his Advair/Atrovent/spiriva/Xopenex. The OSHs were contact[**Name (NI) **] for results from his thoracentesis-->which were c/w a transudative fluid, all cultures negative, however it was unclear as to whether any sample was sent for cytology. The patient underwent a chest CT, which showed significant consolidation on the right, a right hydropneumothorax from the prior tap at the OSH, bilateral pleural effusions, and changes consistent with pneumonitis form XRT. Given that the patient had recently been treated with Levaquin at the OSH, the patient was started on ceftriaxone to complete a ten day course, and azithromycin. Pulmonary was consulted, and they recommended completing the course of antibiotics and felt that further thoracentesis would be low yield, but that the patient should have a repeat CT in a few weeks to evaluate for resolution of his effusions. The patient underwent a repeat CT prior to pericardial window procedure, which showed an increase in his effusions bilaterally, thus pleural fluid was also removed during the procedure with samples sent for cytology/path/culture. The patient's breathing and oxygen saturation remained stable throughout his hospitalization, and his cough lessened in severity. The patient became acutely hypoxic and tachypneic on am of [**10-11**], requiring transfer back to CCU for intubation. CXR showed R apical pneumothorax, dart chest tube placed by thoracic service w/out much improvement on repeat CXR. Pulmonary reconsulted, decided patient will need bronch and that primary issues were no longer cardiac but rather pulmonary. Decision made to transfer patient to MICU team. While on the MICU service the pt's minichest tube was pulled on [**10-14**]. F/U CXR revealed a stable PTX. The pt was extubated on [**10-14**] and continued to do well from a respiratory standpoint with chest PT and pulmonary toilet. However post extubation pt continued to have recurrent atrial tach. Patient cardioverted on [**10-2**] w/ ibutilide (1.6 mg) and is now on amiodarone, rhythm mostly sinus with freq PACs. Beta blocker was re-added once his hypotension resolved. He was back in afib/flutter [**10-15**], unresponsive to IV metop and dilt drip, converted by EP with ibutilide. The pt is now stable in NSR on amiodarone. His respiratory status has been stable since transfer to the floor. His O2 sats are 94-96 on 2L NC. Patient can be weaned off supplemental O2 as tolerated. Patient started on standing Lasix for prevention of volume overload. . 3. ID- The patient was started on ceftriaxone and azithromycin for pneumonia, showed some improvement in his productive cough while on antibiotics and completed course. Cultures from his pericardial fluid were negative, cultures from pleural fluid negative from [**10-13**] following "very low numbers" of coagulase negative staphylococcus on [**10-7**]. Patient remained afebrile without a leukocytosis during remainder of his admission. . 4. Anemia- likely iron deficiency anemia in addition to element of anemia of chronic disease secondary to malignancy. The patient was transfused 2 units of PRBCs with appropriate increases in his HCT during admission. Iron studies were sent, which were c/w iron deficiency anemia, vitamin B12 and folate were normal. The patient had several episodes of guaiac positive brown stool, and although he states that he has had a colonoscopy within the past five years, he will likely need a GI workup as an outpatient. Although kidney function appeared normal with a creatinine of .5, the patient would likely benefit from iron/Epogen supplementation as an outpatient. Would recommend starting weekly Epoen injections. . 5. FEN- The patient was restarted on TF through his j-tube per nutrition recommendations. Evaluated with bedside speech and swallow evaluation as well as video swallow. He can have thin liquids and pureed consistency solids as per their recs. He MUST take small, single sips of thin liquids by cup or straw. He was noted to have a metabolic alkalosis, with an initial bicarb of 34 that rose to 37. This was thought to be secondary to contraction alkalosis as patient received some Lasix, in addition to a compensatory alkalosis for a respiratory acidosis from his COPD, and resolved without specific intervention. Bicarb 33 at time of discharge. Would monitor closely as patient started to standing Lasix to prevent volume overload. Patient required aggressive magnesium supplementation and should have his electrolytes monitored closely. . 6. Oncology- the patient was recently treated for Stage II esophageal cancer, s/p resection, chemo and XRT with intended cure. Heme/onc was consulted and recommended that patient undergo restaging with a PET scan as an outpatient. The patient did not show signs of metastasis on CT done here, and the preliminary cytology report from his pericardial fluid was negative for malignancy, however it was noted that this does not rule out a malignant effusion given the low sensitivity of cytology. The patient stated that he wants to continue his oncology care through [**Hospital3 2358**], and has a follow-up appointment scheduled with his oncologist for [**2179-11-18**]. . 7. Dispo: The patient was seen by PT/OT prior to discharge, and the patient should see his PCP after leaving extended care facility so that a follow-up echo can be arranged, in addition to Coumadin management and monitoring of his QT interval, as many of his medications cause a prolonged QT. Medications on Admission: Admit meds from OSH: Amiodarone gtt at 0.5mg/min Diltiazem gtt Furosemide 40mg daily Advair KCl Metoprolol 100mg tid Dulcolax MOM Albuterol [**Name (NI) 10687**] MVI Reglan Coumadin Levofloxacin Cefepime Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Terbinafine 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) for 3 weeks. 3. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q4H (every 4 hours). 4. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. [**Hospital1 10687**] 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 11. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 12. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 14. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: One (1) sliding scale Intravenous ASDIR (AS DIRECTED): Please continue heparin sliding scale w/ PTT goal 60-80 until INR therapeutic at 2-3. 15. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO three times a day: Please continue this dose for 10 days through [**2179-11-1**] and then switch to 200mg once daily. 16. Epogen 20,000 unit/mL Solution Sig: One (1) injection Injection once a week. 17. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital6 19504**] of [**Hospital1 189**] Discharge Diagnosis: pericardial effusion pleural effusion COPD a-flutter/a-fib s/p chemical conversion hypertension esophageal adenocarcinoma Discharge Condition: Stable Discharge Instructions: Please take all of your other medications as instructed. Please maintain your follow-up appointments as listed below. Please call your doctor or return to the hospital if you develop shortness of breath, chest pain, fever or chills. Please have a follow-up echo in about 4 weeks. Followup Instructions: 1. You have an appointment scheduled with your oncologist for [**2179-11-18**] at 9AM at the [**Hospital3 **] with Dr.[**Last Name (STitle) **] at [**Telephone/Fax (1) 66282**]. 2. Please follow up with your primary care doctor within [**11-29**] weeks of discharge from rehab facility. 3. Please contact Dr.[**Last Name (STitle) **] with any questions by paging him at [**Telephone/Fax (1) 8717**], pager #[**Numeric Identifier 9522**]. Completed by:[**2179-10-22**]

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icd9cm

[ [ [] ] ]

[ "99.69", "96.04", "37.0", "38.93", "34.91", "37.12", "96.6", "33.24", "96.71", "38.91", "99.07", "99.04", "37.21", "34.04", "99.29" ]

icd9pcs

[ [ [] ] ]

20626, 20697

10318, 18668

616, 748

20863, 20872

3344, 9933

21201, 21671

2619, 2704

18924, 20603

20718, 20842

18694, 18901

20896, 21178

9950, 10295

2719, 3325

228, 578

776, 1972

1994, 2419

2435, 2603

3,917

184,678

5970

Discharge summary

report

Admission Date: [**2102-8-29**] Discharge Date: [**2102-9-6**] Date of Birth: [**2055-7-29**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1973**] Chief Complaint: L foot pain, alcohol withdrawl Major Surgical or Invasive Procedure: none History of Present Illness: patient is a 47 y/o M with a history of alcohol abuse/withdrawl, hypothyroidism and cocaine abuse who presented to the ED with a complaint of foot pain. He reports that he fractured his foot about 5 weeks ago and over the last week his foot pain has increased. He attributes this to his girlfriend kicking him in the foot during her sleep. In the ED an xray confirmed an old fracture and the patient was going to be discharged home, however he was noted to be hypertensive and complained of shaking and was observed for alcohol withdrawl. He noted his last drink was about 9:30pm on [**8-28**] right before coming to the emergency room. He reports that he was recently admitted to [**Hospital1 18**] for alcohol withdrawl, however he left AMA and has continued to drink 1L of vodka/day since then. He currently reports that he feels achy all over, tremulous and has pain in his L foot. He reports that he has had seizures from alcohol withdrawl in the past. . In the ED his BP was noted to be elevated to 180/100. He received 30mg IM toradol for foot pain, 5mg diazepam PO, 45mg valium IV over 4 hours, and was then started on an ativan drip at 0.5mg/hr. He also was given 2L NS and a banana bag. Labs notable for Na of 146 and EtOH of 232. Past Medical History: - EtOH abuse with multiple admissions for w/d - h/o withdrawl seizures - Alcoholic Dilated Cardiomyopathy (last [**Hospital1 18**] records indicated an EF of 40-45% with mild global HK) [**5-8**] - cocaine abuse - hypothyroidism: TSH 10 on [**2102-8-22**] -does not take prescribed levothyroxine - h/o head and neck cancer s/p resection and radiation in [**2093**] - bilateral cavitary lung lesions; bx demonstrated Aspergillous fumigatus and [**Female First Name (un) 564**] albicans [**2-/2102**]. Multiple r/o for TB negative. Pt did not comply with course of anti-fungals, had 3 AFB smears here which were nagative - h/o C. diff colitis - h/o IVDA per OSH records (pt notes only cocaine iv) - HBV (core Ab, surface Ab positive [**2102-6-23**]) - HCV ([**2102-6-23**]) - HIV negative [**2102-6-23**] Social History: Social History: Tobacco, unable to say how long, [**1-3**] PPD currently. Prior to that he smoked 1 ppd. Heavy EtOH use, currently 1L vodka daily. Sober x10 years, started drinking again 2 years ago. Also reports cocaine and marijuana. Sexually active with his girlfriend Family History: Mother - CAD. Sister - h/o CVA. Reports his father was the "[**Location (un) 86**] [**Location (un) 23530**]," and that he and his mother changed their names after his arrest, etc. Physical Exam: VS: Tc 98.5 BP 241/138 HR 112 RR 21 Sat 98% RA Gen: Thin, disheveled man who appears anxious HEENT: MMM, sclera anicteric, chin erythematous with 4mm pustule Neck: no LAD, JVD about 6 cm, left neck with post surgical and radiation changes Resp: bibasilar rales, no wheezes/rhonchi CV: regular rhythm but tachycardic, nl S1S2, No M/R/G Abd: soft, NT/ND, +BS, no masses Ext: no cyanosis/clubbing/edema, 2+ DP/PT pulses bilaterally Neuro: A&Ox3, hyperreflexic in lower extremities bilaterally (patellar reflexes spread), strength testing limited by "stiffness" - seems to be patient discomfort at moving limbs. Pertinent Results: Left foot AP/Lat/Obl: Early healing of fracture through the base of the second metatarsal. [**2102-9-6**] 05:15AM BLOOD WBC-5.2 RBC-3.66* Hgb-12.9* Hct-36.4* MCV-99* MCH-35.3* MCHC-35.5* RDW-16.0* Plt Ct-315 [**2102-9-5**] 06:50AM BLOOD PT-12.3 PTT-25.3 INR(PT)-1.1 [**2102-9-5**] 06:50AM BLOOD Glucose-113* UreaN-20 Creat-1.0 Na-136 K-4.5 Cl-98 HCO3-31 AnGap-12 [**2102-8-29**] 05:38PM BLOOD ALT-23 AST-40 LD(LDH)-200 AlkPhos-84 Amylase-23 TotBili-0.6 [**2102-8-29**] 05:38PM BLOOD Lipase-65* [**2102-9-5**] 06:50AM BLOOD Calcium-9.9 Phos-3.4 Mg-2.1 [**2102-9-5**] 06:50AM BLOOD Digoxin-0.5* [**2102-9-4**] 06:35AM BLOOD Digoxin-0.3* [**2102-8-30**] 05:56AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [**2102-8-29**] 08:45AM BLOOD Ethanol-232* LEFT FOOT, THREE VIEWS: Again seen is the oblique fracture through the base of the left second metatarsal. There remains minimal lateral displacement of the distal fracture fragment. There is a small amount of new periosteal bone formation consistent with interval healing. The fracture line remains evident. No other fractures are identified. The joint spaces are preserved. IMPRESSION: Early healing of fracture through the base of the second metatarsal. Brief Hospital Course: A/P: 47yoM with chronic EtOH use complicated by dilated cardiomyopathy, cocaine use, hypothyroidism, hypertension and medication nonadherence, presenting with foot pain and EtOH withdrawal. Following issues addressed on this admission: 1. Alcohol withdrawal: - Patient admitted to [**Hospital Unit Name 153**] [**8-29**] - Initially 45mg iv valium in er and then ativan drip. Required very large doses of valium for withdrawal over [**8-30**] and [**8-31**]. By [**8-31**], more stable, transferred to floor and maintained on q2 hour CIWA. This was gradually titrated off by [**9-4**]. - patient has a concominant anxiety disorder, which causes his CIWA to be more positive that it probably is from alcohol withdrawal. 2. Alcohol dependence: - Patient expressed desire for abstinence - SW and addictions consult services have been involved on patient's previous admissions. - SW provided patient with multiple resources for help with abstinence. Patient did not qualify for dual diagnosis inpatient admission given patient was detoxed on medical service -discussed with psychiatry on call. - Patient is making an appointment for structured outpatient program - Maintained on thiamine, folate. 3. Chronic Systolic HEart Failure: - Alcoholic Cardiomyopathy: maintained on digoxin, lisionopril. - Dig level checked on [**9-4**] and within normal limits. - However, given his poor compliance, am choosing to stop digoxin, as it is really just for symptomatic relief and prevention of admissions, rather than change in mortality, and failure to comply with therapy safely is more dangerous vs. the benefits - No beta blocker given history of cocaine abuse. 4. Benign Hypertension: - Maintained on lisinopril, - Normotensive 5. Hypothyroidism: - maintained on levothyroxine 75 6. Foot pain: - due to old fracture - Maintained on oxycodone - Patient refused to wear soft cast while in house. 7. Smoking: - Nicotine patch in house - Counseling on cessation provided, cessation advised. Medications on Admission: Medications: per d/c summary from [**2102-7-27**]-patient states not taking any medications at home. Levothyroxine 75 mcg PO DAILY Digoxin 125 mcg Tablet PO DAILY Famotidine 20 mg Tablet PO Q12H Hydrochlorothiazide 25 mg daily Metoprolol Tartrate 25 mg PO BID Seroquel 50 mg PO TID and 25 mg PO BID PRN anxiety Buspar 5 mg PO qam and 10 mg PO qpm Celexa 20 mg PO daily Discharge Medications: 1. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Buspirone 5 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). Disp:*30 Tablet(s)* Refills:*2* 4. Buspirone 10 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). Disp:*30 Tablet(s)* Refills:*2* 5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: 1. Alcohol withdrawal 2. Alcohol Dependence 3. Anxiety Secondary: 1. Left foot fracture 2. Chronic Systolic Heart Failure Discharge Condition: Stable Discharge Instructions: Follow up as below. Continue to abstain from alcohol. You have been provided multiple resources to help you with your abstinence, and you should have made an outpatient appointment for a structured outpatient program. If you develop any chest pain, shortness of breath, fevers or any other new concerning symptoms, contact your doctor or go to the emergency room. Take all medications as prescribed. Followup Instructions: Follow up with your primary care doctor within the next few weeks.

[ "291.81", "303.01", "300.00", "E849.9", "729.5", "304.31", "428.22", "905.4", "304.21", "V10.89", "244.9", "E989", "428.0", "401.1", "V15.81", "425.5", "070.70" ]

icd9cm

[ [ [] ] ]

[ "94.68" ]

icd9pcs

[ [ [] ] ]

8011, 8017

4840, 6838

346, 352

8183, 8191

3592, 4817

8643, 8712

2765, 2947

7258, 7988

8038, 8162

6864, 7235

8215, 8620

2962, 3573

275, 308

380, 1633

1655, 2460

2492, 2749

52,529

147,569

53801

Discharge summary

report

Admission Date: [**2184-4-4**] Discharge Date: [**2184-4-21**] Date of Birth: [**2112-5-28**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 594**] Chief Complaint: fevers, hypoxia Major Surgical or Invasive Procedure: central venous line placement - [**4-4**] arterial line placement - [**4-4**] left BKA - [**4-6**] revision amputation - [**4-8**] History of Present Illness: 71 M with history of HTN, HL, OSA, s/p unrestrained MVC rollover on [**2184-3-9**] with TBI, L open ankle fracture, R closed ankle fracture and dislocation, scalp laceration discharged with hospital course complicated prolonged intubation, PEA arrest and apnea post-op requiring tracheostomy placement on [**2184-3-18**]. Underwent PEG placement on [**2184-3-24**] for long term nutritional needs. Discharged to rehab on [**4-2**] with external fixator in place on left ankle and open left calcaneal wound s/p debridement on kefzol and trach collar. At rehab, spiked temperature to 102 this morning and ? desaturation to 89%. Sent to [**Hospital1 18**] ED for concern of PNA on CXR versus sepsis. . In the ED, patient desated to 84% and improved with bagging and suction. Concern for mucus plugging. Underwent CXR, CTA chest and x-ray of right foot. CTA chest did not show evidence of PNA, PE. Patient required paralyzation with vec for CT scan and subsequently required vent. Started on zosyn/vanc/levofloxacin for concern of wound infection and ? PNA. Because of ventilatory need, patient was admitted to the MICU. Prior to leaving the ED, SBP dropped to 80s and patient was started on levophed 0.18 with good effect and SBPs up to 112. . On arrival to the MICU, patient's VS - T 98.6, HR 85, BP 184/88, RR 14, O2sat 100% on CMV through trach. Patient is sedated, but in NAD . Review of systems: (+) Per HPI (-) unable to fully assess at this time Past Medical History: HTN Hypercholesterolemia OSA s/p MVC with TBI s/p tracheostomy [**2184-3-18**] s/p PEG placement [**2184-3-24**] s/p ex-fix L ankle; closure scalp lac [**2184-3-9**] s/p ORIF R ankle, washout L ankle [**2184-3-11**] s/p Debridement L foot/heel. Longer trach [**2184-3-26**] Social History: married, has daughter, occasional EtOH Family History: NC Physical Exam: Admission Physical Exam: Vitals: T 98.6, HR 85, BP 184/88, RR 14, O2sat 100% on CMV through trach General: sedated, on ventilator, in NAD HEENT: PERRL, trach in place with well healed stoma, no surrounding erythema no drainage Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding, PEG in place without drainage or erythema GU: no foley Ext: Large skin defect on left calcaneous probing to bone with surrounding purulent appearing drainage. Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: sedated and paralyzed for CT scan Discharge Physical Exam: VS: T:98.3, HR:76, BP150/70, RR17, O2sat: 92% on 40%trach mask General: responsive and conversant, mild confusion HEENT: PERRL, trach in place with well healed stoma, no surrounding erythema no drainage, seborrhea on face improving Neck: supple, no LAD CV:RRR, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally on anterior exam, no wheezes, rales, rhonchi , transmitted bronchial breathsounds Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding, PEG in place without drainage or erythema GU: foley in place Ext: Left leg BKA with dressing in place and knee immobilizer, dressing c/d/i, right LLE with cast, digits warm and well perfused Neuro: A&O to person and hospital. Responds to commands and answers question Pertinent Results: Admission Labs: [**2184-4-4**] 07:30AM BLOOD WBC-7.7 RBC-3.65* Hgb-10.6* Hct-32.8* MCV-90 MCH-28.9 MCHC-32.1 RDW-15.1 Plt Ct-266 [**2184-4-4**] 07:30AM BLOOD Neuts-81.8* Lymphs-7.9* Monos-7.6 Eos-2.4 Baso-0.4 [**2184-4-4**] 07:30AM BLOOD PT-12.8* PTT-29.1 INR(PT)-1.2* [**2184-4-4**] 07:30AM BLOOD Glucose-135* UreaN-20 Creat-0.7 Na-137 K-4.1 Cl-98 HCO3-29 AnGap-14 [**2184-4-4**] 07:30AM BLOOD ALT-14 AST-32 AlkPhos-266* TotBili-0.8 [**2184-4-4**] 07:30AM BLOOD Lipase-59 [**2184-4-4**] 07:30AM BLOOD Albumin-3.7 Calcium-8.8 Phos-3.5 Mg-2.1 [**Hospital3 **]: [**2184-4-4**] 07:30AM BLOOD ESR-68* [**2184-4-4**] 07:30AM BLOOD cTropnT-<0.01 [**2184-4-4**] 07:30AM BLOOD CRP-35.3* [**2184-4-5**] 03:15AM BLOOD VitB12-1194* [**2184-4-5**] 03:15AM BLOOD TSH-3.9 [**2184-4-6**] 04:48AM BLOOD Vanco-16.9 Urine: [**2184-4-4**] 07:35AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.025 [**2184-4-4**] 07:35AM URINE Blood-SM Nitrite-NEG Protein-100 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR [**2184-4-4**] 07:35AM URINE RBC-16* WBC-7* Bacteri-NONE Yeast-NONE Epi-0 TransE-1 Discharge Labs: Microbiology: [**2184-4-4**] 7:40 am BLOOD CULTURE-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE, STAPHYLOCOCCUS EPIDERMIDIS}; Aerobic Bottle Gram Stain-FINAL; Anaerobic Bottle Gram Stain-FINAL [**2184-4-5**] 3:15 am RAPID PLASMA REAGIN TEST (Final [**2184-4-6**]): NONREACTIVE. Blood cultures ([**4-4**], [**4-5**], [**4-6**], [**4-7**], [**4-8**], [**4-9**], [**4-10**]) pending, NGTD Urine culture ([**4-4**], [**4-9**]) negative MRSA screen ([**4-4**]) negative Sputum culture ([**4-5**], [**4-6**]) contaminated Left leg tissue culture (1st amputation, [**4-7**]) - GRAM STAIN-FINAL (cancelled by lab, possible path lab contamination); TISSUE-FINAL {[**Female First Name (un) **] ALBICANS, PRESUMPTIVE IDENTIFICATION}; ANAEROBIC CULTURE-PRELIMINARY Left leg tissue culture (2nd amputation, [**4-8**]) - GRAM STAIN 1+ PMNs, no MICROORGANISMS SEEN; TISSUE (Preliminary): NO GROWTH; ANAEROBIC CULTURE (Preliminary): NO GROWTH. Mini-BAL ([**4-8**]) GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL . Imaging: CXR [**4-4**] PORTABLE AP CHEST RADIOGRAPH: Tracheostomy tube is noted. Right-sided PICC line tip projects over the expected region of the distal SVC. Prominence of the pulmonary vasculature consistent with pulmonary edema is improved since the prior exam. Left pleural effusion cannot be completely excluded. Bilateral low lung volumes with crowding of bronchovascular markings are noted. Cardiac silhouette is accentuated by low lung volumes. XR Left Foot [**4-4**] FINDINGS: No localizing information was provided with regards to the site of the patient's infection; however, soft tissue irregularity is seen along the plantar aspect of the heel but is incompletely imaged on the lateral. Hardware obscures the plantar surface of the calcaneus, limiting assessment for osteomyelitis in this location. Oblique fractures are seen along the bases of the second, third, fourth and fifth metatarsal. Fracture through the tuft of the great toe is also seen. There is no evidence of hardware-related complication for the external fixation. The internal fixation devices about the ankle are not as well seen. IMPRESSION: 1. Limited study with re-demonstration of the fractures and external fixation hardware but poor evaluation of the site of soft tissue infection which is presumed to be the plantar surface of the heel. If continued clinical concern, consider alternate imaging modalities. 2. Possible fracture of the tuft of the great toe. CTA Chest [**4-4**]: 1. Improvement in the previously described bilateral opacities with a single rounded peripheral right upper lobe opacity, which may reflect atelectasis or infectious process. 2. Central bilateral ground-glass opacities could be due to edema, though infection cannot be excluded. 3. Dense bibasilar atelectasis and simple effusions as before. 4. Anterior third through sixth bilateral rib fractures CT Head [**4-4**]: FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or infarction. Prominent ventricles and sulci suggest age-related involutional changes or atrophy. Periventricular white matter hypodensities are consistent with chronic small vessel ischemic disease. The basal cisterns appear patent and there is preservation of [**Doctor Last Name 352**]-white differentiation. No fracture is identified. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. No facial or cranial soft tissue abnormalities are present. IMPRESSION: No evidence of acute intracranial process. CXR [**4-4**]: 1. No pneumothorax. 2. Worsened opacities likely due to edema without change to atelectasis and effusion as on chest CT. Concomitant infectious process would be difficult to exclude. CXR [**4-5**]: FINDINGS: Since the prior radiograph, there has been improvement in bilateral pulmonary opacities, likely improvement in pulmonary edema. There is no definite focal consolidation. There is mild blunting of the left costophrenic angle, likely a small pleural effusion. Cardiac silhouette is enlarged, but stable. There is no pneumothorax. Tracheostomy tube is in place. Right PICC line catheter is unchanged in position. IMPRESSION: Improvement in bilateral pulmonary opacities, likely representing improved pulmonary edema. Stable small left pleural effusion. [**2184-4-12**]: MRI Head: IMPRESSION: 1. Two foci of restricted diffusion are redemonstrated in the left cerebral hemisphere, likely consistent with subacute ischemic changes, measuring less than 1 cm in size. No new lesions are identified since the most recent study. 2. Unchanged areas of high signal intensity in the subcortical and periventricular white matter, which are nonspecific and may reflect chronic microvascular ischemic disease. 3. Unchanged mucosal thickening at the sphenoid sinus and mild improvement in the pattern of pneumatization in the maxillary sinuses bilaterally. Persistent opacities at the mastoid air cells. [**2184-4-14**]: IMPRESSION: 1. Successful uncomplicated placement of a new gastrojejunostomy tube. The catheter can be used after 24 hours. 2. Successful uncomplicated placement of a 42 cm 5 French dual-lumen PICC in through the right arm with the tip in the distal SVC. The catheter is ready to use. EEG [**2184-4-9**]: IMPRESSION: This is an abnormal continuous ICU monitoring study because of a severe diffuse encephalopathy. There were subtle features of greater right hemisphere pathology, i.e. suppression of electrical activity broadly across the right hemisphere. There were no interictal discharges identified nor were there any periods that suggest electrographic seizures. Compared to the prior day's recording, there were no significant changes. Radiology Report CHEST (PORTABLE AP) Study Date of [**2184-4-18**] 10:52 PM IMPRESSION: Slight interval progression of mild pulmonary edema. Discharge Labs: [**2184-4-21**] 03:27AM BLOOD WBC-9.2 RBC-2.78* Hgb-8.2* Hct-25.3* MCV-91 MCH-29.4 MCHC-32.3 RDW-14.6 Plt Ct-382 [**2184-4-19**] 04:00AM BLOOD Neuts-76.9* Lymphs-10.4* Monos-5.3 Eos-7.2* Baso-0.3 [**2184-4-21**] 03:27AM BLOOD Glucose-118* UreaN-34* Creat-1.3* Na-138 K-3.6 Cl-101 HCO3-27 AnGap-14 [**2184-4-19**] 04:00AM BLOOD ALT-43* AST-60* LD(LDH)-368* AlkPhos-265* TotBili-0.5 [**2184-4-19**] 04:00AM BLOOD Lipase-75* [**2184-4-21**] 03:27AM BLOOD Calcium-8.2* Phos-4.0 Mg-2.0 Brief Hospital Course: PRIMARY REASON FOR HOSPITALIZATION: Patient is a 71yo male s/p MVC with TBI, L open ankle fracture, R closed ankle fracture with hospital course complicated by need for tracheostomy and PEG placement who was recently discharged and re-presented from rehab with fever and ? PNA and wound infection. He was sent to MICU for mechanical vent requirement, and hospital course notable for L BKA and prolonged AMS. With completion of abx course and holding of sedating medications, patient's mental status gradually cleared to the point where he was performing limited ADL's and easily directable. He was discharged to a long-term acute care facility for continued recovery. ACUTE CARE: 1. Fever - Patient presented with temperature to 102 at OSH and 101.6 in ED. There was concern for PNA on OSH CXR, though CXR here unremarkable and CTA chest showed likely resolving PNA, possibly developing brochiectasis. A left leg ulcer with purulent drainage probing down to bone which was felt to be the most likely source. He was started on Vancomycin and Zosyn to cover both wound and HCAP. Wound cultures were unrevealing, blood cultures grew coagulase-negative staph, but unclear if this was a contaminant or not. He had a PICC line from his prior hospitalization which was removed. ID was consulted and given nature of injury, felt polymicrobial coverage would be warranted and rec'd continuing vanco/zosyn for 7 days after. He underwent BKA on [**4-6**] and revision on [**4-8**] where 10 more cm were removed. He continued to spike intermittent fevers, particularly after procedures, including IR for PICC and advancement of GJ tube. His cultures remained negative and he was afebrile throughout the remainder of his stay after his final procedure. . 2. Altered mental status - Pt was somnolent, nonverbal, unable to follow commands, and intermittently agitated throughout admission. There was concern that his AMS might reflect acute delirium (as family understood from last admission) vs underlying post-traumatic/post-PEA arrest neurologic injury. Per family, during last admission he had been able to speak in short sentences using passe-muir valve, follow simple commands, identify family members, and read simple words, so AMS on admission this time was acutely worse. They also noted that he did have difficulty with orientation (when and where) and was very agitated at night, requiring up to 400 mg Seroquel daily. This was difficult to differentiate. Possible contributors to delirium would include infection and pain, so these were carefully monitored and treated as best possible (limited by pt's inability to communicate and therefore inability to report any localizing symptoms). There was no evidence of anoxic brain injury on MRI during previous hospitalization, but given PEA arrest, this was an ongoing concern. He had been started on Keppra during previous admission for epileptiform changes on EEG, so this was continued. Seroquel was restarted but had minimal effect on agitation. Neurology was consulted - they recommended restarting EEG monitoring. Continuous EEG showed 'moderately-severe to severe diffuse encephalopathy,' with poor neurological prognosis. Family was updated about pt poor mental status frequently. Patient's mental status improved as he was weaned from the mechanical ventilator and sedation. On [**4-15**] patient began responding to commands and appropriately communicating. Mental status improved throughout the remainder of his stay to the point of being conversant and performing ADL's although confused. Several family meetings over the recuperative course of his hospitalization were held, and his tenuous clinical status (with a significant risk for future complications) was emphasized, along with his uncertain neurologic recovery. His family endorsed understanding of this, and understood that it may take several months to determine the degree of neurologic improvement he can achieve with time and dedicated rehabilitation. . 3. LLE wound - Based on evaluation by Orthopedics and Plastics consult teams, who had followed the patient closely during last admission, the lower extremity wound was felt to be non-salvagable on presentation. He underwent BKA on [**4-6**] and revision on [**4-8**] where 10 more cm were removed. His LLE wound was felt to be the most likely source of systemic infection, although no microorganism could be identified by microbiology/pathology. He was continued on antibiotics for 7 day course after L BKA revision and completed course on [**2184-4-14**]. . 4. Hypoxic respiratory failure Patient underwent tracheostomy during last admission given persistent vent requirement. He required CMV mode ventilation on admission. This was weaned to CPAP following operative procedures and eventually off of mechanical ventilation doing well with trach collar. 5. [**Last Name (un) **] - Patient came in with Cr of 0.7. He received a CTA in the ED for concern of PE which was negative. Following the study, his creatinine increased to 2.1. It was felt that his [**Last Name (un) **] was related to CIN that progressed to ATN. He became very volume overloaded and was given lasix to help with forced diuresis. His creatinine slowly downtrended over the course of his hospital stay and was 1.3 on discharge to LTAC. His length of stay fluid balance was positive 984cc on discharge. 6. Hypotension/sepsis - Patient had tachycardia, fever and hypotension concerning for sepsis in the setting of an open L leg ulcer. CTA showed no evidence of PE. He required intermittent pressor support in the perioperative period, but was able to be weaned off all pressors by [**4-10**]. He was continued on vanc/zosyn for 7 days total after the revision of his L BKA and completed the course on [**2184-4-14**]. 7. HTN - Patient on lisinopril, diltiazem, metoprolol and clonidine as outpatient. These were held in the setting of sepsis. As patient was weaned from sedation, he became increasingly hypertensive. Patient was originally started on labatelol drip, clonidine and enapril IV as sedation was weaned. He was transitioned to PO labetalol and uptitrated to effect and home lisinopril that was eventually increased to effect. He was also started on amlodipine 10mg instead of diltiazem for better BP control, and clonidine PO by discharge with adequate BP control. . 8. Erythema - The patient developed generalized skin erythema on [**4-4**], concerning for infusion reaction from vancomycin. He was provided Benadryl and the infusion time was slowed which improved his skin reaction. Erythema dissipated after completion of antibiotic course. . TRANSITIONS IN CARE: 1. Code Status: Full Code, confirmed 2. CONTACTS: [**Name2 (NI) **] Home Phone: [**Telephone/Fax (1) 110408**] [**Doctor First Name **] - DAUGHTER [**Telephone/Fax (1) 110409**] 3. Medication Changes: 1. START amlodipine 10mg by mouth daily 2. START labetalol 800mg by mouth three times daily 3. START glycerin suppository 1 PR daily as needed for constipation 4. START miralax 17gm PO daily asd needed for constipation 5. START lansoprazole 30mg tablet by mouth daily 6. START calcium carbonate 500mg by mouth three times daily Please keep all follow-up appointments. 7. START quetiapine 100mg by mouth three times daily 8. STOP taking diltiazem 9. STOP taking metoprolol tartrate 10. STOP taking cefazolin 11. STOP taking ferrous sulfate for now 12. CHANGE levetiracetam to 1500mg by mouth twice daily 13. CHANGE lisinopril to 40mg by mouth daily 14. CHANGE clonidine to 0.3mg by mouth twice daily 15 CHANGE trazodone to 25mg by mouth nightly as needed for insomnia 4. Outstanding Clinical Issues: -titration of blood pressure medication IF BP meds need to be decreased, with clohnidine, go down to 0.2mg [**Hospital1 **], wait three days and if indicated, go down to 0.1mg [**Hospital1 **], wait three days, and if indicated, stop the medication. After the clonidine, the labetalol can be decreased. -management of hyperlipidemia -LLE stump suture removal [**2184-4-29**] in orthopedics follow-up -final results of bone culture follow-up -patient had glucose levels stably in the 100s with only minimal amounts of insulin so his insulin sliding scale was stopped. If he is significantly hyperglycemic, the insulin sliding scale can be restarted. He does not [**First Name7 (NamePattern1) 4540**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of diabetes. Medications on Admission: Medications on discharge [**4-2**]: 1. bisacodyl 10 mg DAILY PRN constipation 2. senna syrup 8.8 mg [**Hospital1 **] 3. insulin regular human 100 unit/mL Solution per sliding scale 4. heparin 5,000 unit SC TID 5. albuterol sulfate 90 mcg/actuation 6 Puff Q4H PRN wheezing 6. ipratropium bromide 17 mcg/actuation 6 puff QID 7. acetaminophen solution 650 mg Q6H PRN pain/fever 8. miconazole nitrate 2 % Powder Topical [**Hospital1 **] PRN rash 9. docusate sodium liquid 100mg [**Hospital1 **] 10. camphor-menthol 0.5-0.5 % Lotion Topical QID PRN itching 11. diltiazem HCl 60 mg QID 12. levetiracetam solution 100 mg [**Hospital1 **]: Continue until follow-up with neurology. 13. metoprolol tartrate 150 mg TID 14. trazodone 25 mg HS PRN insomnia 15. lisinopril 20 mg DAILY 16. clonidine 0.2 mg TID 17. ferrous sulfate liquid 300 mg (60 mg iron) DAILY 18. cefazolin solution for IV 10 gram Q8H Discharge Medications: 1. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 2. bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2) Tablet, Delayed Release (E.C.) PO once a day as needed for constipation. 3. senna 8.8 mg/5 mL Syrup [**Hospital1 **]: One (1) tablet PO twice a day. 4. heparin (porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) Injection TID (3 times a day). 5. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler [**Hospital1 **]: 2-4 Puffs Inhalation Q6H (every 6 hours) as needed for SOB. 6. ipratropium bromide 17 mcg/actuation HFA Aerosol Inhaler [**Hospital1 **]: Two (2) Puff Inhalation QID (4 times a day). 7. acetaminophen 325 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain: do not take more than 4 gm of acetaminophen daily. 8. miconazole nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical QID (4 times a day) as needed for rash. 9. docusate sodium 50 mg/5 mL Liquid [**Hospital1 **]: One (1) PO twice a day. 10. camphor-menthol 0.5-0.5 % Lotion [**Hospital1 **]: One (1) Appl Topical QID (4 times a day) as needed for itching. 11. levetiracetam 100 mg/mL Solution [**Hospital1 **]: 1500 (1500) mg PO BID (2 times a day). 12. lisinopril 20 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 13. clonidine 0.1 mg Tablet [**Hospital1 **]: Three (3) Tablet PO BID (2 times a day). 14. amlodipine 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 15. labetalol 200 mg Tablet [**Hospital1 **]: Four (4) Tablet PO TID (3 times a day). 16. glycerin (adult) Suppository [**Hospital1 **]: One (1) Suppository Rectal PRN (as needed) as needed for constipation. 17. polyethylene glycol 3350 17 gram Powder in Packet [**Hospital1 **]: One (1) Powder in Packet PO DAILY (Daily) as needed for constipation. 18. trazodone 50 mg Tablet [**Hospital1 **]: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 19. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 20. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable PO TID (3 times a day). 21. quetiapine 100 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO three times a day: hold for sedation, please give at 8am, 2pm, 10pm. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 8957**] Discharge [**Location (un) 9687**]: PRIMARY: Left tibia deep infection with massive skin loss. SECONDARY: Delirium, hypertension, acute kidney injury, respiratory failure Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [**Known lastname 19442**], It was a pleasure taking part in your care. You were admitted to the hospital because your left leg was infected. Treatment required a course of antibiotics and amputation. In the course of your stay, you experienced difficulty breathing and confusion, which gradually improved. You were discharged to a rehab hospital to continue recovery. Please make the following changes to your medications: 1. START amlodipine 10mg by mouth daily 2. START labetalol 800mg by mouth three times daily 3. START glycerin suppository 1 PR daily as needed for constipation 4. START miralax 17gm PO daily asd needed for constipation 5. START lansoprazole 30mg tablet by mouth daily 6. START calcium carbonate 500mg by mouth three times daily Please keep all follow-up appointments. 7. START quetiapine 100mg by mouth three times daily 8. STOP taking diltiazem 9. STOP taking metoprolol tartrate 10. STOP taking cefazolin 11. STOP taking ferrous sulfate for now 12. STOP insulin 13. CHANGE levetiracetam to 1500mg by mouth twice daily 14. CHANGE lisinopril to 40mg by mouth daily 15. CHANGE clonidine to 0.3mg by mouth twice daily 16. CHANGE trazodone to 25mg by mouth nightly as needed for insomnia Please keep all follow-up appointments made for you and have the rehab facility arrange for you to see your PCP when discharged from there. Please take other medications as prescribed. Followup Instructions: Department: ORTHOPEDICS When: THURSDAY [**2184-4-29**] at 8:00 AM With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ORTHOPEDICS When: THURSDAY [**2184-4-29**] at 8:20 AM With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: COGNITIVE NEUROLOGY UNIT When: TUESDAY [**2184-5-4**] at 3:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 658**], M.D. [**Telephone/Fax (1) 1690**] Building: Ks [**Hospital Ward Name 860**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage

[ "958.3", "V44.0", "272.4", "276.69", "995.92", "486", "518.81", "287.5", "E930.8", "785.4", "V15.52", "891.1", "707.13", "V44.1", "V12.53", "695.9", "584.9", "038.9", "348.39", "401.9", "293.0", "327.23", "E929.0" ]

icd9cm

[ [ [] ] ]

[ "84.15", "89.19", "84.3", "33.24", "96.72", "44.32", "96.6", "38.93" ]

icd9pcs

[ [ [] ] ]

23270, 23518

11446, 18269

319, 452

23539, 23539

3985, 3985

25149, 26092

2312, 2316

20807, 23247

19891, 20784

23717, 24123

10941, 11423

2356, 3123

24153, 25126

1887, 1941

18289, 19865

263, 281

480, 1868

4001, 5086

6019, 10924

23554, 23693

1963, 2239

2255, 2296

3149, 3966

16,194

104,187

3147

Discharge summary

report

Admission Date: [**2167-12-8**] Discharge Date: [**2167-12-30**] Date of Birth: [**2096-4-28**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1973**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: Central line placement Arterial line placement History of Present Illness: Ms. [**Known lastname **] is a 71 morbidly obese, ARF, ho of multiple UTIs (ESBL Klebsiella in past), hypoglycemia (similar in the past). Came in at 80's systolic and got vanco 1 gm and levofloxacin 750 mg x 1. K and Mag repleted in ED along with 3 L NS. Despite increasing initially, her CVP remained low [**7-29**]. She is guiaic positive and had a HCT drop. Admitted to ICU for low urine output and BP refractory to 3 L NS. On arrival to [**Hospital Unit Name 153**], BP difficult to obtain secondary to body habitus, ranging from 80's-120/50-70. Intubated. Judged to be urosepsis and pneuomonia. Eventually recovered from sepsis. Sent to floor. Had ATN/ARF from her sepsis. Pt was made DNR/DNI. Past Medical History: MRSA Right Femur Fx S/P ORIF ([**10/2165**]: Tripped Over Commode) HTN Hyperlipidemia DMII Peripheral Neuropathy CKD with baseline creat 1.5 Obesity Anemia if chronic disease, bl 30 IBS (Chronic Constipation, Abdominal Pain and Intermittent Diarrhea) Chronic LBP/Sciatica (Osteoporisis, DJD/OA, Spinal Stenosis) Depression/Anxiety Panic Disorder Parotid Gland Tumor S/P Resection S/P Multiple Falls H/O Herpes Zoster S/P CCY B/L Cataract Removal. Social History: She lives with her daughter, who is very involved with her care. She had 11 children, and one passed away. She was a homemaker. She quit smoking 20 years ago and had between [**4-28**] py. She uses ETOH rarely (<1x/month). Family History: Her mother had DM. She knows nothing of her father. [**Name (NI) **] sister died of [**Name (NI) **] at 60. Physical Exam: Vitals: 97.5, 115/70, 80's, 14, 97%2L Gen: slightly confused, easily arousable, oriented to place HEENT: dry MMM, unable to assess JVP, Card: RRR no MRG Chest: CTA Abd: NT, soft, no rebound Ext: no edema Skin: no rash, RUE skin breakdown, sacral decubitus stage 1 Pertinent Results: [**2167-12-30**] 03:58AM BLOOD WBC-7.7 RBC-3.02* Hgb-8.8* Hct-27.1* MCV-90 MCH-29.3 MCHC-32.6 RDW-15.8* Plt Ct-232 [**2167-12-26**] 03:15PM BLOOD Neuts-62.8 Lymphs-27.1 Monos-6.8 Eos-2.9 Baso-0.4 [**2167-12-30**] 03:58AM BLOOD UreaN-10 Creat-1.0 Na-145 K-3.5 HCO3-33* [**2167-12-23**] 05:00AM BLOOD ALT-8 AST-11 AlkPhos-84 TotBili-0.4 [**2167-12-14**] 05:54AM BLOOD Lipase-57 [**2167-12-19**] 05:35AM BLOOD CK-MB-2 cTropnT-0.05* [**2167-12-30**] 03:58AM BLOOD Phos-3.2 Mg-1.2* [**2167-12-22**] 04:10PM BLOOD Cortsol-34.5* [**2167-12-22**] 05:57AM BLOOD Vanco-16.3 ECHO: Conclusions: 1. The left atrium is mildly dilated. 2.There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The aortic valve leaflets are mildly thickened. No aortic regurgitation is seen. 5.The mitral valve leaflets are mildly thickened. No mitral regurgitation is seen. 6.There is an anterior space which most likely represents a fat pad. Brief Hospital Course: Pt completed course of antibiotics. ARF resolved. Anasarca was treated with diuresis. Pt improved clinically, however was markedly delerious. This was felt to be multifactorial due to narcotics and sedating meds. These were decreased with improvement to mental status back to baseline. Pt developed sacral decubitus during admission. She also had a PICC line in the RUE which developed skin breakdown. Both of these were addressed with the wound care team. Discharge Medications: 1. Oxycodone 20 mg Tablet Sustained Release 12HR Sig: Three (3) Tablet Sustained Release 12HR PO Q12H (every 12 hours). Disp:*180 Tablet Sustained Release 12HR(s)* Refills:*0* 2. Oxycodone 15 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*224 Tablet(s)* Refills:*0* 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 6. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Olanzapine 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Mupirocin Calcium 2 % Cream Sig: One (1) Appl Topical TID (3 times a day) as needed. Disp:*1 tube* Refills:*4* 11. Oxycodone 5 mg Tablet Sig: Six (6) Tablet PO Q6H (every 6 hours) as needed for pain. 12. Nystatin-Triamcinolone 100,000-0.1 unit/g-% Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. Disp:*1 tube* Refills:*3* 13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for antifungal. Disp:*1 bottle* Refills:*3* 14. Double Guard Cream Sig: One (1) appl Topical twice a day. Disp:*1 tube* Refills:*2* 15. Aloe Vesta 2-n-1 Antifungal 2 % Ointment Sig: One (1) appl Topical twice a day. Disp:*1 tube* Refills:*2* Discharge Disposition: Home With Service Facility: VNA of [**Location (un) 86**] Discharge Diagnosis: Sepsis Urinary Tract Infection Respiratory Failure Due to Nosocomial Pneumonia Diastolic Congestive Heart Failure Perirectal Ulcer Anxiety Morbid Obesity Discharge Condition: stable Discharge Instructions: Please make sure you take your medications as listed below. Please make sure you follow up with Dr. [**Last Name (STitle) **] in the next week. Please call your doctor if you experience fever/chills/shortness of breath/or confusion/or any other concerning symptoms. Followup Instructions: 1. Please call for an appointement to follow up with Dr. [**Last Name (STitle) **] in the next week.

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icd9cm

[ [ [] ] ]

[ "96.72", "38.93", "99.04", "96.04", "00.17", "96.6", "38.91" ]

icd9pcs

[ [ [] ] ]

5483, 5543

3433, 3891

331, 379

5740, 5748

2244, 3410

6062, 6166

1835, 1944

3914, 5460

5564, 5719

5772, 6039

1959, 2225

277, 293

407, 1107

1129, 1578

1594, 1819

4,798

190,043

9308

Discharge summary

report

Admission Date: [**2195-12-28**] Discharge Date: [**2196-1-6**] Date of Birth: [**2136-12-11**] Sex: M HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] was a 58-year-old male who had end-stage renal failure and underwent a living donor kidney transplant in [**2195-5-1**] which was complicated by a severe case of post transplant lymphoma. He underwent an had a prolonged hospital course with mental status changes likely secondary to an intracranial extension of the post transplant lymphoma. His course, although prolonged, finally led to his discharge on [**12-22**] to rehabilitation. He had a right internal jugular dialysis catheter which was placed during his admission for which he was receiving his dialysis, and the patient was discharged on [**12-22**] to a antibiotics secondary to a superinfection of his intracranial lymphoma. The patient returned on [**12-28**] with the chief complaint of dysfunctional right internal jugular Perm-A-Cath. On further questioning, the family indicated that his blood pressure was "low" at the rehabilitation center. HOSPITAL COURSE: On [**12-29**], the patient was taken to the operating room for replacement of a new right internal jugular Perm-A-Cath dialysis catheter. He was at his baseline functional status with a conversant mental status at the time of going to the operating room for this Perm-A-Cath. The surgery went well with a good functional Perm-A-Cath being placed intraoperatively with no complications. However, postoperatively he was found to be hypotensive and septic in appearance. The patient continued to progress with his sepsis and was admitted to the Intensive Care Unit intubated and placed on pressor support for his hypotension. A source for his sepsis was not found despite pan culturing. He was on Levophed as well as dopamine and dobutamine to maintain his blood pressure above a systolic of 90. His Perm-A-Cath measurements clearly showed a hypermetabolic process consistent with sepsis. The patient was placed on broad spectrum antibiotics, and a discussion was had with the family regarding the grave nature of his illness. The patient's blood pressure was very dependent on fluids, and he received several liters of fluids in addition to his pressor requirements to maintain his end-organ perfusion. However, after one week of hospitalization he showed slow and steady improvement. His oxygenation improved on the ventilator. His blood cultures were always negative, and his blood pressure improved to the point that his pressor agents were weaned considerably from what they had been on admission to the Intensive Care Unit. However, he had a sudden episode on the evening of [**1-5**] (the early morning of [**1-6**]) where he became hypertensive and then had a cardiac arrest. It is unclear as to the cause of this sudden arrest; however, despite protocol CPR efforts, the Intensive Care Unit team was not able to resuscitate him. The family was notified and a discussion was had with the patient's wife regarding the patient's demise. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3598**], MD [**MD Number(1) 3599**] Dictated By:[**Last Name (NamePattern1) 31856**] MEDQUIST36 D: [**2196-1-25**] 10:49 T: [**2196-1-25**] 15:39 JOB#: [**Job Number 31857**]

[ "202.80", "324.0", "038.9", "518.5", "996.73", "263.9", "427.1", "585", "V42.83" ]

icd9cm

[ [ [] ] ]

[ "96.04", "99.15", "38.95", "38.91", "96.72", "99.10" ]

icd9pcs

[ [ [] ] ]

1109, 3336

148, 1091

48,184

197,111

39522

Discharge summary

report

Admission Date: [**2102-7-26**] Discharge Date: [**2102-8-9**] Date of Birth: [**2036-4-15**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 613**] Chief Complaint: Dehydration, UTI Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname **] is a 66 yoM with supranuclear palsy and chronic contractures living at [**Hospital 169**] Center of [**Location (un) 745**], who was brought to the ED after routine labs showed elevated Na to 152 and Cr bump. This is in the background of several weeks of poor PO intake, and he is being considered for a feeding tube. He is non-verbal, moans and is contracted at baseline, and has severe constipation problems requiring manual disimpaction at his last admission. . The patient was recently admitted from [**6-6**] - 28/10 for ARF (mixed pre-renal and obstructive from unclear etiology), left hydronephrosis with forniceal rupture, and left nephrostomy placement. He was then readmitted on admitted from [**6-16**]- [**2102-6-20**] for removal of left nephrostomy tube under IR guidance; on that admission, he was found to have a massively dilated bladder and had developed a right hydroureter. He was given a voiding trial overnight after his foley was pulled prior to discharge; he failed and was discharged with instructions for TID straight caths. The etiology of his urinary retention remains uncertain but may be related to his SNP and he was also started on terazosin after Ct showed an enlarged prostate. Of note, urine cultures from these admissions were negative. Per family foley was last changed on [**7-25**], but I am not certain when a foley catheter was initially placed after his last discharge. . In the ED, VS were T 99.2, P 83, BP 126/74, RR 18, O2 100%. He received 6L NS for concern for sepsis and hypotension (lowest BP 95/65 with HR 78). BP on discharge from last admission was 107/77 and his SBP was noted to run 100-140's. He received IV levofloxacin for UTI. . Past Medical History: 1. Supranuclear palsy, non-verbal, followed by Dr. [**First Name (STitle) **] at [**Hospital1 2177**]. has progressively been declining 2. Dementia 3. HLD 4. s/p TKR and shoulder surgery 5. Recent admission from [**Date range (1) 87286**] after p/w ARF (pre-renal and obstructive), left hydronephrosis c/b forniceal rupture (had 2 days IV abx), and nephrostomy placement (was capped prior to discharge with plan to remove in 1 week). Social History: Previous lived with wife prior to [**Name (NI) 205**] admission who provided all his care with help of his children. Now cared for in a nursing home. Used to work on the [**Location (un) 41649**], now on disability. Family History: Non-contributory Physical Exam: VS: 97.3, 132/84-89, 60s, 18-20@100%(RA) GENERAL: thin and chronically ill appearing; occasional moaning; non verbal HEENT: poor dentition, atraumatic, PERRLA, EOM difficult to assess LUNGS: seemingly CTAB (anteriorly), but unable to cooperate CARDIO: RRR, no murmurs appreciated ABD: + BS, soft, ND, NT SKIN: Sacral decub over coccyx, stage 4 Ext: WWP, no cyanosis or clubbing. Trace LE edema. Distal pulses radial 2+, DP 2+. NEURO: Non-verbal. Minimal tracking to voices. Occasionally follows commands to squeeze fingers or open mouth. Withdraws to pain. Pertinent Results: ADMISSION LABS: [**2102-7-26**] 06:30PM BLOOD WBC-9.3 RBC-3.96* Hgb-10.8* Hct-34.5* MCV-87 MCH-27.4 MCHC-31.4 RDW-15.1 Plt Ct-213 [**2102-7-26**] 06:30PM BLOOD Neuts-78.3* Lymphs-18.4 Monos-2.5 Eos-0.6 Baso-0.2 [**2102-7-26**] 06:30PM BLOOD PT-13.0 PTT-27.9 INR(PT)-1.1 [**2102-7-26**] 06:30PM BLOOD Glucose-114* UreaN-32* Creat-0.8 Na-153* K-3.8 Cl-114* HCO3-28 AnGap-15 [**2102-7-27**] 04:24AM BLOOD Albumin-2.5* Calcium-7.1* Phos-2.3* Mg-1.9 [**2102-7-26**] 06:56PM BLOOD Lactate-2.8* [**2102-7-28**] 05:37AM BLOOD Lactate-1.6 URINALYSIS: [**2102-7-27**] 12:04AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.031, Blood-MOD Nitrite-POS Protein-25 Glucose-1000 Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD, RBC-[**10-7**]* WBC-21-50* Bacteria-MANY Yeast-NONE Epi-0-2, URINE CastHy-[**4-27**]* MICROBIOLOGY: [**2102-7-26**] Blood Cultures: NGTD [**2102-7-26**] Urine Cultures: URINE CULTURE (Final [**2102-7-29**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMIKACIN-------------- <=2 S AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 8 I TRIMETHOPRIM/SULFA---- <=1 S [**2102-7-26**] C DIFF: negative IMAGING: [**2102-7-25**] CT ABD/PELVIS with contrast: 1. Interval removal of left nephrostomy tube. No evidence of hydronephrosis. Multiple large renal cysts bilaterally could mimic appearance of hydronephrosis in non-contrast study. 2. Interval development of decubitus ulceration in the midline sacrococcygeal region. Small pocket of subcutaneous fluid and air. Concerning for developing osteomyelitis and/or abscess. Recommend direct inspection of the affected area. 3. Moderate fecal loading. No evidence of colitis. ADMISSION CXR: No evidence of pneumonia. DISCHARGE LABS: [**2102-8-8**] 10:10AM BLOOD WBC-3.8* RBC-3.72* Hgb-10.2* Hct-31.2* MCV-84 MCH-27.4 MCHC-32.6 RDW-14.7 Plt Ct-195 [**2102-8-8**] 05:48AM BLOOD Glucose-93 UreaN-2* Creat-0.4* Na-138 K-3.7 Cl-107 HCO3-26 AnGap-9 [**2102-8-8**] 05:48AM BLOOD Albumin-2.6* Calcium-8.4 Phos-2.4* Mg-1.9 Brief Hospital Course: Mr. [**Known lastname **] is a 66 yo man with supranuclear palsy and end stage dementia with worsening PO intake over last few weeks, new large sacral decub ulcer and UTI/urosepsis, admitted to the MICU for acute management of hypernatremia. . #. HYPERNATREMIA: The patient has poor PO intake over the last few weeks while at rehab with progression of his underlying neurologic disease and inability to swallow. Sodium of 153 on admission corrected with aggressive fluid rehydration in the ICU. Regarding future hydration and nutrition, multiple family meetings were held in order to evaluate goals of care. Electrolytes were trended throughout the hospitalization, and no further hypernatremia was noted. IV fluids were given as necessary. . #. GOALS OF CARE: Pt has had poor PO intake for months, and acutely worsened over last few weeks. Pt initially admitted with intention of PEG placement, though with expressions of desire for "comfort care," PEG placement was postponed. Palliative care was consulted, and first family meeting addressed decubitus ulcer and malnutrition. Following this first meeting, these topics were addressed further while team attempted to better define family's goals of care. Even though patient's family is not pursuing strict CMO measures at this point, they have the patient's comfort in mind. It is for these reasons that the patient's family ultimately decided to pursue a PEG placement, as they feel that state of dehydration is uncomfortable to patient. The family struggles with feeling of "abandoning " patient, and feel that to not hydrate and/or feed is abandoning patient. They are very educated on patient's prognosis, and are not pursuing feeding tube in effort to extend lifespan. . #. MALNUTRITION WITH ALBUMIN OF 2.5, DECREASED PO INTAKE: difficult to fully assess given pt's baseline non-verbal state from SNP, but SNP and end-stage dementia likely contributing. Speech/swallow saw patient and determined that pt should be NPO except ice chips and evaluate for other means of nutritional supplementation. GI was consulted after numerous meetings regarding goals of care, and pt had PEG placed on [**8-7**]. Post-PEG check was within normal limits, and water flushes and nutrition started on [**8-8**]. While not taking any nutrition, bowel regimen was on hold. Will need to re-evaluate after patient at goal TF intake. . #. UTI, UROSEPSIS: Pyruia on admission UA, in context of hypotension. Elevated lactate at admission --> tissue hypoperfusion. Given pt's past medical history, he was started empirically on ceftriaxone for UTI. Blood cultures were negative and he was hemodynamically stable with IVF, never needing pressors in the ICU. Pt was called out of the MICU on [**2102-7-28**], and completed his antibiotic course on the floor. Urine cultures grew E. coli sensitive to ceftriaxone, and pt completed a 7-day course. . #. SACRAL DECUB ULCER: Pt had a large sacral decubitus ulcer that was managed by the wound nurse. It did probe to bone, though he was not started on antibiotics for osteomyelitis given goals of care. Medications on Admission: (per recent discharge summary): 1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 2. Polyethylene Glycol 3350 17 gram/dose Powder Sig: Two (2) packets PO DAILY (Daily). 3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 5. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Dulcolax 10 mg Suppository Sig: One (1) Rectal once a day as needed for constipation. 7. Milk of Magnesia 400 mg/5 mL Suspension Sig: Thirty (30) mL PO once a day as needed for constipation. 8. Fleet Enema 19-7 gram/118 mL Enema Sig: One (1) Rectal once a day as needed for constipation. 9. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO three times a day. 10. Bisacodyl 10 mg/30 mL Enema Sig: One (1) Rectal once a day as needed for constipation. Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Morphine 100 mg/4 mL Solution Sig: 1-2 mg Intravenous With wound dressing changes as needed for pain. Discharge Disposition: Extended Care Facility: Highgate Manor Discharge Diagnosis: Primary: -Urinary tract infection -Malnutrition, severe -Hypernatremia Secondary: -Supranuclear palsy -Dementia Discharge Condition: Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Mental Status: Confused - always. At baseline, patient does not interact; occasionally groans and tracks to voice. Discharge Instructions: Mr. [**Known lastname **], You were hospitalized at [**Hospital1 18**] with decreased oral intake and malnutrition, high sodium levels in your blood (hypernatremia), and a urinary tract infection. While you were here, we had our speech/swallow therapists see you, and they observed that it was very dangerous for you to have anything (liquid or food) orally. We treated your urinary tract infection with IV antibiotics, gave you fluids through an IV, and addressed your nutrition status with your loving family members. [**Name (NI) **] had a PEG tube placed for nutrition/hydration needs. We had several family meetings addressing your care, and you are being discharged to a skilled nursing facility. The following changes were made to your medications: -STOP all medications that you used to take orally: Docusate, Miralax, multivitamin, Tamsulosin, Senna, Milk of Magnesia, oral Tylenol. If these medications are to be continued, they will have to be given via your PEG tube. -You can resume suppository and enema medications to help with bowel movements after having tube feeds for >24-48 hours Followup Instructions: Per family desire; can call to schedule appointments. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

[ "294.9", "344.89", "041.4", "784.3", "599.0", "564.09", "707.03", "272.4", "728.85", "261", "276.0", "707.24" ]

icd9cm

[ [ [] ] ]

[ "43.11", "96.6" ]

icd9pcs

[ [ [] ] ]

10209, 10250

5955, 9050

330, 337

10407, 10483

3414, 3414

11757, 11935

2799, 2817

9991, 10186

10271, 10386

9076, 9968

10625, 11734

5650, 5932

2832, 3395

274, 292

365, 2090

3430, 5634

10498, 10601

2112, 2548

2564, 2783

74,894

179,438

55018

Discharge summary

report

Admission Date: [**2168-6-16**] Discharge Date: [**2168-7-12**] Date of Birth: [**2121-1-20**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3984**] Chief Complaint: sepsis Major Surgical or Invasive Procedure: Endotracheal intubation ([**Date range (1) 112325**]) [**6-23**] tracheostomy [**6-23**] PEG TEE ([**6-21**], [**6-30**]) Paracentesis [**6-30**] History of Present Illness: 47F w/ unknown PMHx found by EMS conscious but nonverbal, sitting on doorstep. Initially noted to be in narrow-complex tachycardia 220 w/ no radial pulses. She was given adenosine 6, 12 and slowed to sinus tach at 140 w/occasional PACs. Appeared hypovolemic per EMS. Upon arrival in [**Last Name (LF) **], [**First Name3 (LF) **] "old" tampon was removed from her vagina by RN staff. After 2L of fluid her Mental status improved. She complained of pain "everywhere". She reported that she takes amitryptiline at baseline and uses heroin but otherwise did not provide any history. In the ED, initial VS were: T 97.9 HR 158 BP 82/49 RR 35 Sa 100% on 3L. VBG in ED (10:00AM) 7.37/33/49/20 Her BP went as low as 80s in the ED, remained at 90 despite a total of 5.5L NS. She given vanc/ceftriaxone/flagyl. MS decreased again, was tachypneic to 45 and was therefore intubated. A central line was placed and levophed was started. Urine tox was positive for opiates and benzodiazepines. On arrival to the MICU, patient's VS were: T 102.7 HR 149 BP 138/113 RR 36 Sa 98% on Ventilator at 40% FiO2 Vent: Assist/Rate 20/450mL/PEEP 5/FiO2 40%. Breathing at 30s-40. Past Medical History: Hep. C not treated, being followed at [**Hospital1 2177**] Asthma Emphysema Vit. D deficiency Chronic HA Social History: Currently separated from wife for 3 weeks prior to admission because of patient's polysubstance abuse. Pt actively using heroine, MJ, BZ, ?cocaine. approximately 35 pack year smoking hx. Two sons (24, 16). Two grandchildren Family History: Father deceased lung Ca brother deceased ALL Uncle deceased [**Name2 (NI) **] Ca + COPD son bladder Ca Physical Exam: Exam at [**Hospital Unit Name 153**] admission: General: Overweight female intubated and sedated on midazolam and fentanyl infusion, completely unresponsive to examination maneuvers, appears to be in 30s or 40s. HEENT: Sclera slightly icteric, conjunctivae pale. No ecchymoses, no LAD. Pupils constricted. Neck: Supple, no LAD. JVP not elevated. CV: Sinus rhythm, irregular. Hyperkinetic with palpable sternal heave. S1 + S2, no murmurs, rubs, gallops. Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi. Abdomen: No scars, wounds, or ecchymoses. Tense, cannot adequately assess organomegaly. Bowel sounds absent. GU: Foley Ext: Hands and feet cool and pale with 1+ pulses bilaterally. No clubbing, cyanosis, or edema. Numerous macular ecchymoses on palms and soles, consistent with [**Last Name (un) 1003**] lesions. Splinter hemorrhage of R 3rd digit. Dark ecchymotic macules in cubital fossae. Neuro: Unresponsive to exam maneuvers. DISCHARGE EXAM VS: 98.7, 124, 112/78, 19, 100% on 35% trach mask Gen: NAD, Alert, nods/shakes head to yes/no questions CV: RRR, S1+S2, [**2-23**] HSM loudest at apex Pulm: clear on anterior auscultation. No increased work of breathing. Abd: Soft, distended, no TTP. +BS. Extr: Hands bandaged+splinted. PICC site non-tender, non-erythematous. Feet with stable dry gangrene. Pertinent Results: Admission Labs: [**2168-6-16**] 09:55AM WBC-8.6 RBC-4.73 HGB-14.7 HCT-43.5 MCV-92 MCH-31.0 MCHC-33.7 RDW-12.5 [**2168-6-16**] 09:55AM PLT COUNT-51* [**2168-6-16**] 09:55AM PT-21.4* PTT-32.0 INR(PT)-2.0* [**2168-6-16**] 09:55AM FIBRINOGE-371 [**2168-6-16**] 09:55AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2168-6-16**] 09:55AM ALBUMIN-2.7* [**2168-6-16**] 09:55AM LIPASE-8 [**2168-6-16**] 09:55AM ALT(SGPT)-25 AST(SGOT)-44* LD(LDH)-288* CK(CPK)-243* ALK PHOS-83 TOT BILI-2.4* [**2168-6-16**] 09:55AM UREA N-28* CREAT-1.5* [**2168-6-16**] 10:00AM freeCa-1.02* [**2168-6-16**] 10:00AM GLUCOSE-147* LACTATE-5.0* NA+-132* K+-3.4 CL--103 TCO2-18* [**2168-6-16**] 10:00AM TYPE-[**Last Name (un) **] PO2-49* PCO2-33* PH-7.37 TOTAL CO2-20* BASE XS--4 [**2168-6-16**] 10:20AM URINE WBCCLUMP-RARE MUCOUS-RARE [**2168-6-16**] 10:20AM URINE AMORPH-RARE [**2168-6-16**] 10:20AM URINE HYALINE-9* [**2168-6-16**] 10:20AM URINE RBC-7* WBC-47* BACTERIA-MANY YEAST-NONE EPI-<1 TRANS EPI-1 [**2168-6-16**] 10:20AM URINE BLOOD-LG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-SM UROBILNGN-4* PH-5.5 LEUK-LG [**2168-6-16**] 10:20AM URINE COLOR-DkAmb APPEAR-Cloudy SP [**Last Name (un) 155**]-1.014 [**2168-6-16**] 10:20AM URINE bnzodzpn-POS barbitrt-NEG opiates-POS cocaine-NEG amphetmn-NEG mthdone-NEG [**2168-6-16**] 10:20AM URINE UCG-NEGATIVE OSMOLAL-394 [**2168-6-16**] 10:20AM URINE HOURS-RANDOM UREA N-256 CREAT-30 SODIUM-70 POTASSIUM-49 CHLORIDE-86 [**2168-6-16**] 12:18PM TYPE-ART PO2-362* PCO2-46* PH-7.19* TOTAL CO2-18* BASE XS--10 [**2168-6-16**] 05:46PM HBsAg-NEGATIVE HBs Ab-POSITIVE HBc Ab-POSITIVE [**2168-6-16**] 05:46PM HCV Ab-POSITIVE* DISCHARGE LABS [**2168-7-12**] 04:31AM BLOOD WBC-10.8 RBC-2.53* Hgb-8.1* Hct-25.0* MCV-99* MCH-31.9 MCHC-32.2 RDW-21.4* Plt Ct-233 [**2168-7-4**] 04:50AM BLOOD Neuts-82.3* Lymphs-10.8* Monos-3.5 Eos-3.2 Baso-0.3 [**2168-7-9**] 05:11AM BLOOD PT-15.5* PTT-39.7* INR(PT)-1.5* [**2168-7-12**] 04:31AM BLOOD Glucose-115* UreaN-9 Creat-0.6 Na-138 K-3.3 Cl-103 HCO3-25 AnGap-13 [**2168-7-7**] 03:34AM BLOOD ALT-22 AST-38 AlkPhos-81 TotBili-1.3 [**2168-7-12**] 04:31AM BLOOD Calcium-8.0* Phos-3.0 Mg-1.6 PERTINENT LABS [**2168-6-17**] 06:03AM BLOOD FDP-80-160* [**2168-7-3**] 07:04AM BLOOD Ret Aut-5.3* [**2168-6-17**] 02:01PM BLOOD ESR-35* [**2168-6-25**] 04:12AM BLOOD Lipase-186* [**2168-6-16**] 05:46PM BLOOD CK-MB-8 cTropnT-0.21* [**2168-6-17**] 01:35AM BLOOD CK-MB-10 MB Indx-2.7 cTropnT-0.31* [**2168-6-17**] 06:03AM BLOOD CK-MB-14* MB Indx-1.9 cTropnT-0.41* [**2168-6-17**] 09:52PM BLOOD CK-MB-5 cTropnT-0.29* [**2168-7-3**] 03:40AM BLOOD calTIBC-150* Hapto-<5* Ferritn-487* TRF-115* [**2168-6-22**] 02:36PM BLOOD Osmolal-325* [**2168-6-18**] 05:40AM BLOOD Cortsol-51.8* [**2168-6-16**] 09:55AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2168-6-16**] 05:46PM BLOOD HCV Ab-POSITIVE* [**2168-6-16**] 05:46PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-POSITIVE Imaging [**7-11**] Video swallow IMPRESSION: No evidence of aspiration or penetration. For full details, please see speech pathology report in webOMR. CXR (5 done):--Mild pulmonary vascular congestion. --In comparison with the earlier study of this date, there has been placement of an endotracheal tube with its tip approximately 2.5 cm above the carina. Nasogastric tube extends well into the stomach, beyond the lower margin of the image. --In comparison with the earlier study of this date, there has been placement of a right IJ catheter that extends to about the level of the cavoatrial junction. No evidence of pneumothorax. --[**6-19**]: IMPRESSION: Orogastric tube ends in the distal stomach. ET tube in standard placement. Previous vascular engorgement and mild pulmonary edema has cleared in the upper lungs, but consolidation in the lower lungs, particularly the right has worsened, though this could be atelectasis, is more concerning for extensive pneumonia. --[**6-21**]: FINDINGS: As compared to the previous radiograph, the pre-existing parenchymal opacities at the right lung base and in the left perihilar area have substantially decreased in extent and severity. As a consequence, the lung parenchyma is more transparent and lucent than before. The image shows no evidence of newly appeared parenchymal opacities. The size of the cardiac silhouette is constant and normal. No pulmonary edema. The monitoring and support devices are in unchanged position. --[**7-1**]: There are new bilateral alveolar consolidations that could be compatible with multifocal pneumonia. --[**7-3**]: Unchanged tracheostomy tube, unchanged left PICC line. No evidence of pneumothorax. --[**7-10**]: Decreasing effusions with persistent consolidation on the right and volume loss in the left lower lobe. CT Head [**6-16**]: Ill-defined non-territorial hypodensities in left cerebellum and right vertex concerning for infarction, possibly embolic or venous in etiology. Infection cannot be excluded. Equivocal hyperdensities within Preliminary Reportbilateral sulci may represent blood products. MR with and without contrast is recommended for further evaluation. CT Head [**6-18**]: IMPRESSION: Persistent hypodensities in bilateral cerebellar hemispheres and right vertex, concerning for infarcts, however, other underlying conditions, cannot be completely excluded, correlation with MRI of the brain with and without contrast is recommended. No evidence for new acute intracranial hemorrhage. MR [**Name13 (STitle) 430**] [**6-20**]: IMPRESSION: 1. Numerous, diffuse acute infarcts without mass effect or hydrocephalus. The findings are compatible with septic embolic infarcts, some of which have microhemorrhages. In the setting of septic emboli, there is a substantial risk this patient may have a mycotic aneurysm, which may be a further contraindication to anticoagulation. We do not see a mycotic aneurysm on this study, but these are frequently distal and the infarcts are distal. If clinically indicated, an MRA of the more distal vessels could be performed (from the vertex to the supraclinoid ICA) to evaluate for a more distal mycotic aneurysm. TEE [**6-17**]: 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 ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 40 cm from the incisors. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve and there does not appear to be involvement of the intervalvular fibrous area or the aortic root. No aortic regurgitation is seen. There is a large vegetation on the mitral valve, predominantly on the posterior leaflet, that measure 2.4x1.4cm, with leaflet abscess suggested (and possibly posterior annulus early abscess). There is a significant mobile elements to the vegetation. At least moderate (2+) mitral regurgitation is seen, though this may be underquantified due to the large vegetation. No masses or vegetations are seen on the tricuspid or pulmonic valve. IMPRESSION: Large mitral valve vegetation measuring 2.4x1.4cm with leaflet abscess and at least moderate mitral regurgitation. No other valvular or root involvement. TEE [**6-30**]: The left atrium is dilated. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. There are filamentous strands on the aortic leaflets consistent with Lambl's excresences (normal variant). No aortic valve abscess is seen. No aortic regurgitation is seen. There is a moderate-sized (1.3 cm x 0.9 cm) vegetation on the posterior leaflet of the mitral valve. There is an abscess cavity seen adjacent to the mitral valve along the posterior annulus. Moderate (2+) mitral regurgitation is seen. IMPRESSION: Moderate sized mitral valve vegetation measuring 1.3 cm x 0.9 cm with leaflet abscess, likely mitral annular (posterior) abscess and moderate mitral regurgitation. No other valvular or root involvement Compared with the prior study (images reviewed) of [**2168-6-21**], the vegetation is significantly smaller than prior study when it measured 2.4x1.4cm. The posterior annulus abscess appears similar. RUQ U/S [**6-21**]: IMPRESSION: Tumefactive sludge and stones without the gallbladder without specific findings to suggest cholecystitis. Trace ascites. CT Chest/Abd/Pelvis [**6-29**]: IMPRESSION: 1. Small bilateral pleural effusions with compressive atelectasis. 2. Large abdominal ascites. 3. Nodular liver contour suggestive of cirrhosis. 4. Large volume splenic infarct and bilateral renal infarcts, compatible with history of endocarditis and septic emboli. 5. Anasarca. Brief Hospital Course: 47F with PMH of hep. C cirrhosis, IVDU, who was found down possibly in the setting of heroin use, now intubated and in septic shock with etiology concerning for endocarditis. #Refractory Septic shock: [**1-21**] MSSA bacteremia from endocarditis: Upon ED admission she was hypotensive to 80s, refractory to fluid resuscitation; during her first 24hrs in the hospital she required levo/vasopressin/neo to maintain MAP>60. Neo was d/c'd after the first day, and vasopressin several days later. She was continued on levo infusion until [**6-24**], and did not require pressors for the duration of her ICU admission. # MSSA endocarditis - TTE and TEE ([**6-17**], [**6-21**], [**6-30**]) revealed large mitral valve vegetation with abscess. No progression was observed during the hospitalization. Patient was initially covered on vanc/zosyn, subsequently narrowed to nafcillin after cultures grew MSSA. All blood cx after [**6-16**] were sterile. CT surgery deferred mitral valve replacment surgery initially as patient was too hemodynamically unstable. Once stabilized, surgery was deferred because of lack of progression of endocarditis as evidenced by TEE, her fever defervesced, and blood cx were sterile. The patient was seen by ID, and will received a 6-week course of nafcillin starting on [**2168-6-17**]. # Respiratory Failure: Patient was initially intubated on AC, later weaned to CPAP/PSV and then to T-mask. Bedside tracheostomy was performed [**6-23**] due to prolonged ventilator use and poor progress towards extubation. Initially tachypneic to 40s, subsequently to 20s-30s; thought to be a combination of primary central cause plus respiratory compensation for metabolic acidosis. Passe-Muir valve was fitted [**6-30**] in order to allow patient to speak. While she had pneumonia, she required ventilator support as she became tachypnic. Once her pneumonia resolved, she was able to be weaned from ventilator support and tolerated trach mask well. # Pneumonia - Patient had change in amount and character of secretions, became febrile, tachypnic, and CXR concerning for multi-focal pna. Sputum cx growing GNR speciated as Klebsiella Pneumonia. She was treated with cefepime, once sensitivities were obtained she was changed to levofloxacin, completing an 8 day course. She required ventilator support during her pneumonia. Clinically she improved and was able to tolerate trach mask without need for ventilator. # AMS/head CT abnormalities: Lesions on head CT may represent septic emboli, possibly contributing to AMS. Additionally, the patient was hyperthermic to 107 while in septic shock, which most likely contributes to her altered mental status. Brain MR was performed without contrast due to [**Initials (NamePattern4) 228**] [**Last Name (NamePattern4) **]; contrast is necessary to identify mycotic aneurysms. EEG performed revealed mostly (slow) delta activity, triphasic waves, and no epileptiform discharges suggesting diffuse cerebral dysfunction. Since the patient has biopsy proven cirrhosis, hepatic encephalopathy was thought to be a component of her AMS as triphasic waves seen on EEG. However, her AMS did not clear after being treated with lactulose, making hepatic encephalopathy unlikely. Once pt improved clinically and she was able to be weaned from ventilator, she was able to communicate with physicians/nurses with use of her passe-muir valve. She was alert and oriented. # Hand/foot necrosis: Patient was admitted with [**Last Name (un) 1003**] lesions to hands and feet; after the first 24hrs in [**Hospital Unit Name 153**] areas of necrosis and "dry gangrene" were seen that subsequently covered multiple fingers and distal 50% of both feet. The most likely etiology is septic emboli in addition to the need for extensive pressor use while she was in septic shock. Vascular surgery was consulted and recommended debridement of feet in [**12-22**] months. Hand surgery was consulted and recommended maintaining hands in splints/dressings with betadine and allowing fingers to auto-amputate. # SBP: Patient developed new ascites with increasing abdominal distention after one week and ascites was confirmed on CT [**6-29**]. Paracentesis of peritoneal fluid on [**7-1**] revealed >400 PMN's with SAAG>2 with FATP <2.5 (suggesting hepatic source for the ascites), but no organisms on Gram stain, but consistent with SBP. She was started on CTX and albumin was administered. Peritoneal fluid cx demonstrated yeast, and she was started on micafungin. Given the most likely source of yeast is intra-abdominal, flagyl was added as she is at increased risk for anaerobic infection also. Pt completed 8 day course of micafungin for [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 29361**] and glabrata. # [**Last Name (un) **]: Cr peaked at 3.1 (baseline unknown), later down to 1.1 two weeks after admission. Fena was initially 2.5%; thought due to ATN from prolonged hypotension. # Mixed anion/non anion gap acidosis: Her metabolic derangements initially included (i) primary anion gap acidosis (AG=13 but with Ca=6.3, thus ULN for AG is 8.6); (ii) primary respiratory alkalosis (pCO2=26 vs. 30.5 predicted by winter's formula); (iii) primary non-anion-gap acidosis (HCO3 down by 24-15=9 vs. AG increased by 13-8.6 = 4.4). Likely etiology for non-gap acidosis is dilutional effect of boluses. # Hepatitis C cirrhosis: Records were obtained from [**Hospital1 2177**] where she receives her care indicating that she was diagnosed with biopsy proven hep. c cirrhosis and has never received interferon therapy. Upon admission AST 45 with direct Bili 2.7; her transaminases and bilirubin subsequently normalized. # Coagulopathy/thrombocytopenia: Pt had thrombocytopenia (as low as Plt 12) with coag factor deficiency (INR as high as 2.4). Likely secondary to infection, possibly also liver disease. Peripheral smear found no schistocytes making TTP unlikely. Platelets and INR subsequently returned to [**Location 213**]-range two weeks after admission. #Pancreatitis - lipase to 186 on [**6-25**] in the setting of increased abdominal pain on exam. Adominal ultrasounds were unremarkable. She received morphine for pain and tube feeds were held for two days, after which symptoms resolved. #UTI - completed 7 day course of cipro for complicated UTI. Transitional Issues: -------------------- -continue Nafcillin for 6 week course until [**2168-7-29**] -will recommend oxycodone 5 mg prn for pain control for now, expect to discontinue after resolution of acute illness -As per ID, weekly Chem 7, CBC, and LFTs with results faxed to [**Hospital **] clinic -hand necrosis - follow up with hand surgeon should be arranged -foot necrosis - follow up with orthopedic -should recheck TEE in mid-[**Month (only) 216**] (~[**8-1**]) -pt known IVDU tolerance currently is not known and concern for opiate dependence to develop -Nutrition calorie count as may not need TPN Medications on Admission: Advair Singulair Proventil Amitriptyline Discharge Medications: 1. Outpatient [**Name (NI) **] Work Pt must obtain weekly: CBC with diff Chem 7 LFTs ESR CBC These results should be faxed weekly to Dr. [**First Name (STitle) **] [**Name (STitle) **], [**Hospital **] clinic at [**Telephone/Fax (1) 1419**] 2. Albuterol Inhaler [**1-23**] PUFF IH Q4H:PRN wheeze 3. Acetaminophen 650 mg PO Q6H pain Do not exceed 4g in one day 4. Artificial Tears 1-2 DROP BOTH EYES PRN dry eyes 5. Docusate Sodium (Liquid) 100 mg PO BID Hold for loose stools. 6. Heparin 5000 UNIT SC TID 7. Nafcillin 2 g IV Q4H endocarditis 8. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain in feet 9. Quetiapine Fumarate 25 mg PO HS:PRN agitation, insomnia 10. Senna 1 TAB PO BID:PRN constipation 11. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 12. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 13. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH [**Hospital1 **] Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: MSSA endocarditis Respiratory Failure Pneumonia Acute tubular necrosis Pancreatitis Hand/foot necrosis Fungal peritonitis Urinary tract infection Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of bed with assist Discharge Instructions: Dear Ms. [**Known lastname 112326**], It was a pleasure caring for you at the [**Hospital1 827**]. You were admitted after being found unconscious. You required intubation and eventual tracheostomy. You were found to have an infection growing on your heart valves and this infection spread to other parts of your body affecting many organs. While you were admitted you were also treated for a pneumonia, damage to your kidneys, a urinary tract infection and a yeast infection in your belly. Because you were so seriously ill, a number of changes were made to your medications, including a need to complete at least 6 weeks of antibiotics for your heart infection. Followup Instructions: Department: ORTHOPEDICS When: TUESDAY [**2168-7-19**] at 9:40 AM With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ORTHOPEDICS When: TUESDAY [**2168-7-19**] at 10:00 AM With: HAND CLINIC [**Telephone/Fax (1) 3009**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: VASCULAR SURGERY When: MONDAY [**2168-7-25**] at 1:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD [**Telephone/Fax (1) 2625**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: INFECTIOUS DISEASE When: TUESDAY [**2168-7-26**] at 11:30 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: CARDIAC SURGERY When: THURSDAY [**2168-8-4**] at 1:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8583**], MD [**Telephone/Fax (1) 170**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 551**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

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icd9cm

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icd9pcs

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153,098

21706

Discharge summary

report

Admission Date: [**2180-4-8**] Discharge Date: [**2180-4-14**] Date of Birth: [**2113-7-19**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 9002**] Chief Complaint: Syncope Major Surgical or Invasive Procedure: Esophageogastroduodenal (EGD) endoscopy (twice) Embolization of gastroduodenal artery History of Present Illness: The patient is a 66 year old male two weeks out from cystectomy/prostatectomy and hernia repair/ileal loop who presented to the ED after experiencing a syncopal episode and passing bloody bowel movements. Following his recent surgery, he had been in his usual state of health until yesterday morning, when he started feeling lightheaded. He had had several bowel movements during the day, some of which contained red-brown liquid. In the afternoon, he felt progressively weaker, and crawled to the bathroom to have another bowel movement. At this point, he suddenly lost consciousness completely, fell forward, and hit his chin. He had continued to feel lightheaded, but does not recall any prodrome of chest pain, dyspnea, nausea, or vomiting. He was home by himself at the time. His wife later found him on the ground in the bathroom. He estimates he was on the ground up to 30 minutes. He called EMS to bring him to the hospital. . In the ED, the patient was asymptomatic. His initial VS were: 98.7, 80, 90/51, 18, 100% on 4LNC. Exam was notable for melanotic stool and a 4 cm chin laceration, which was sutured. Labs showed leukocytosis with left shift, anemia, and thrombocytosis. Chemistry panel revealed hyponatremia and mild elevation of BUN/creatinine to 44/1.3. Initial lactate of 2.4 trended up to 3.3, then improved to 2.0. CT head was negative. CTAP showed no dehiscence of his ileal conduit. The patient was given Ceftriaxone and a tetanus shot. GI was consulted, and recommended IVF, NG lavage (not performed), RBC transfusion if Hct < 30, and IV PPI (given). Urology was also contact[**Name (NI) **]. [**Name2 (NI) **] signs prior to transfer were 98.2, 57, 109/46, 16, 100% RA. . On arrival to the floor, the patient feels exhausted but does not have any lightheadedness. He had another bloody bowel movement soon after arrival. He denies chest pain, dyspnea, abdominal pain, nausea/vomiting, hematuria, dysuria, fevers or chills. . ROS: As per HPI. Furthermore, he denies night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, or cough. Past Medical History: # Bladder cancer and prostatic urethral cancer -- s/p TURBT ([**12/2179**]) -- s/p robotic radical cystoprostatectomy, laparoscopic bilateral pelvic lymph node dissection, bilateral partial nerve-sparing ([**2180-3-24**]) -- s/p creation of ileal conduit ([**2180-3-24**]) # Hypertension # Plantar fasciitis # Erectile dysfunction Social History: He is a nonsmoker, quit 40 years ago. He drinks six to seven drinks per week. He does work out regularly. He is married, has been with his current partner for 16 years, but has been married with her for six. He has two daughters. [**Name (NI) **] is monogamous. He is semi-retired but works as a consultant. Family History: Father alive at age [**Age over 90 **] with history of eye cancer, which was excised. Mother passed away at age 87 after complications of a stroke postoperatively from a bowel lesion. Youngest daughter with GI issues, she is 25. Physical Exam: Physical Exam On Admission: VS: 99.0, 121/61, 84, 18, 99% RA GENERAL - well nourished adult male in NAD, appears fatigued HEENT - NC/AT, PERRLA, no conjunctival pallor, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no JVD, no carotid bruits LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored HEART - RRR, no MRG, nl S1-S2 ABDOMEN +ileal loop ostomy with yellow urine, no surrounding erythema or induration, abd soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses SKIN - ruddy complexion, no pallor NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**6-15**] throughout, sensation grossly intact throughout, cerebellar exam intact, gait assessment deferred given recent syncope . Physical Exam on Discharge: Vitals: T: 99.0 BP: 112-126/59-77 P: 78-85 R: 20 O2: 98% RA General: Alert, pale, oriented, pleasant, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, no LAD, bandage on R IJ c/d/i Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: S1, S2, no murmurs auscultated Abdomen: Soft, non-tender, non-distended, +ileal loop ostomy with yellow urine, no surrounding erythema or induration at ostomy site, no rebound/guarding Ext: warm, well perfused, 2+ pulses Pertinent Results: Lab Results On Admission: [**2180-4-7**] 08:45PM BLOOD WBC-16.5*# RBC-2.82* Hgb-8.9* Hct-25.8* MCV-92 MCH-31.5 MCHC-34.4 RDW-12.8 Plt Ct-568*# [**2180-4-7**] 08:45PM BLOOD Neuts-91.8* Lymphs-5.5* Monos-1.9* Eos-0.5 Baso-0.3 [**2180-4-7**] 08:45PM BLOOD PT-13.3 PTT-20.9* INR(PT)-1.1 [**2180-4-7**] 08:45PM BLOOD Glucose-164* UreaN-44* Creat-1.3* Na-129* K-4.4 Cl-94* HCO3-25 AnGap-14 [**2180-4-7**] 08:55PM BLOOD pH-7.44 Comment-GREEN TOP [**2180-4-7**] 08:55PM BLOOD Glucose-158* Lactate-2.4* Na-129* K-4.0 Cl-94* calHCO3-26 [**2180-4-7**] 08:55PM BLOOD Hgb-9.2* calcHCT-28 [**2180-4-7**] 08:55PM BLOOD freeCa-1.08* . Urinalysis: [**2180-4-8**] 03:00AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.042* [**2180-4-8**] 03:00AM URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2180-4-8**] 03:00AM URINE RBC-[**7-21**]* WBC-[**4-15**] Bacteri-MANY Yeast-NONE Epi-0 [**2180-4-8**] 12:02PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.026 [**2180-4-8**] 12:02PM URINE Blood-SM Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [**2180-4-8**] 12:02PM URINE RBC-[**4-15**]* WBC-[**7-21**]* Bacteri-MOD Yeast-NONE Epi-0-2 [**2180-4-8**] 12:02PM URINE Hours-RANDOM UreaN-867 Creat-73 Na-65 K-33 Cl-69 [**2180-4-8**] 12:02PM URINE Osmolal-577 . Lab Results On Discharge: Discharge labs: [**2180-4-14**] 07:25AM BLOOD WBC-8.1 RBC-3.90* Hgb-11.9* Hct-33.9* MCV-87 MCH-30.4 MCHC-34.9 RDW-15.0 Plt Ct-233 [**2180-4-14**] 07:25AM BLOOD PT-12.9 PTT-23.7 INR(PT)-1.1 [**2180-4-14**] 07:25AM BLOOD FactVII-77 [**2180-4-14**] 07:25AM BLOOD Glucose-107* UreaN-9 Creat-0.8 Na-137 K-4.1 Cl-102 HCO3-27 AnGap-12 [**2180-4-14**] 07:25AM BLOOD Calcium-8.4 Phos-3.2 Mg-2.0 [**2180-4-9**] 01:00PM BLOOD Lactate-1.0 [**2180-4-11**] 02:25AM BLOOD freeCa-1.15 [**2180-4-13**] 03:40PM BLOOD Hct-34.0* [**2180-4-13**] 07:55AM BLOOD WBC-6.5 RBC-3.79* Hgb-11.5* Hct-33.7* MCV-89 MCH-30.3 MCHC-34.2 RDW-14.9 Plt Ct-224 [**2180-4-12**] 08:22PM BLOOD Hct-31.1* [**2180-4-12**] 12:19PM BLOOD Hct-32.0* . ................................................................ Microbiology: . URINE CULTURE (Final [**2180-4-11**]): CITROBACTER AMALONATICUS. >100,000 ORGANISMS/ML.. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ CITROBACTER AMALONATICUS | ENTEROCOCCUS SP. | | AMPICILLIN------------ <=2 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 32 S <=16 S TETRACYCLINE---------- <=1 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S VANCOMYCIN------------ 2 S [**2180-4-8**] Blood Cx: NGTD [**2180-4-8**] Serum H. pylori: negative [**2180-4-9**] Stool Cx: negative URINE CULTURE (Final [**2180-4-13**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. ................................................................ Imaging / Studies: # CHEST (PORTABLE AP) ([**2180-4-7**] at 10:07 PM): FINDINGS: The lungs are clear. There are no pleural effusions or pneumothorax. The cardiomediastinal and hilar contours are normal. Pulmonary vascularity is normal. There is no pneumoperitoneum. IMPRESSION: Normal chest. No signs of pneumoperitoneum. . # CT HEAD W/O CONTRAST ([**2180-4-7**] at 11:24 PM): FINDINGS: There is no acute intracranial hemorrhage, edema, mass effect or major vascular territorial infarcts. The ventricles and sulci are prominent, but remain symmetric, likely represent age-related global atrophy. There is no shift of normally midline structures. The [**Doctor Last Name 352**]-white matter differentiation is well preserved. There is no acute fracture. Tiny fluid is noted in the bilateral mastoid air cells. The left maxillary sinus demonstrates minimal mucosal thickening. The remaining paranasal sinuses are otherwise clear. IMPRESSION: No evidence of acute intracranial traumatic injury. . # CT ABD & PELVIS WITH CONTRAST ([**2180-4-7**] at 11:25 PM): CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The lung bases are clear with no focal consolidations, pleural effusions, or pulmonary nodules. There are two subcentimeter hypodensities in the liver in segment VIII and segment V, too small too characterize, stable since [**2179-11-10**]. The gallbladder, spleen, pancreas, both adrenal glands, both kidneys, and ureters are unremarkable, and ureters are demonstrated with ureteral jets within the ileal conduit (series 2, image 7). No high-attenuation material is demonstrated within the abdomen to suggest leakage of excreted contrast. The visualized portions of intra-abdominal small and large bowel are unremarkable. There is no mesenteric or retroperitoneal lymphadenopathy. The ileal conduit is unremarkable. CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: There is a small amount of pelvic fluid and stranding within post-surgical limits. This layers freely. The rectum is normal. The bladder is removed. There is sigmoid diverticulosis without evidence of diverticulitis. BONE WINDOWS: The visualized osseous structures are unremarkable with no suspicious lytic or sclerotic foci. There are multilevel degenerative changes, most prominent at the level of L4-L5 with retrolisthesis of L4 on L5, a prominent disc bulge and loss of intravertebral disc height. IMPRESSION: Unremarkable appearance of the ileal conduit demonstrating excreted contrast within it, and no evidence of excreted contrast leakage into the abdomen. A small amount of pelvic fluid and stranding, within post-surgical limits. . [**2180-4-10**] Interventional Radiology IMPRESSION: 1. There was conventional anatomy with no evidence of active arterial extravasation on celiac axis, SMA, GDA, and inferior pancreaticoduodenal artery angiograms. 2. Successful prophylactic embolization of the GDA with no evidence of retrograde filling from the inferior pancreaticoduodenal artery. . [**2180-4-13**] EKG: Sinus rhythm. Normal tracing. Compared to the previous tracing of [**2180-4-7**] no diagnostic interim change. Brief Hospital Course: The patient is 66 year old male with recent cystectomy/prostatectomy with ileal conduit who presented with syncope and GI bleeding. . # GI bleeding: His Hct on admission was 25.8 down from 29.1 on recent discharge [**2180-3-27**]. It was not initially clear whether the source was upper or lower GI. The patient described the blood as bright red, but also described dark brown diarrhea, and had melanotic stools in the ED. He denied any hematemesis. Given his recent surgery, there was also concern for a post-operative bleed at his intestinal anastomosis. Screening colonoscopy in [**2174**] showed diverticular disease and grade I hemorrhoids. No family history of colon cancer. He does take NSAIDs as outpatient for chronic back pain. He was transfused 2 units of PRBCs overnight and an additional unit the next morning, with an appropriate increase in Hct. He was kept NPO pending GI evaluation and planned endoscopy after the weekend. He was continued on Pantoprazole 40 mg IV Q12H. On the morning of [**2180-4-9**], he was transfused one unit of PRBCs for Hct 28.3 with goal Hct >30, and appeared well on morning rounds. Later that morning, he was found on the floor with significant leakage of melena after getting up to go to the bathroom. Code blue was called. He maintained a pulse, quickly regained consciousness, and was transferred to the ICU. EGD showed a large bleeding duodenal ulcer, which was clipped and injected. Patient transfused additional 5 units pRBCs, without appropriate rise in HCT. Repeat EGD [**4-10**] showed re-bleeding from ulcer and clip was no longer present, therefore patient went for IR coiling of gastroduodenal artery. Tolerated procedure well. Was transfused additional 5 units pRBCs, to bring total to 13 units pRBCs this admission. Patient's HCT stabilized, and he remained hemodynamically stable. He was transitioned from a PPT gtt to IV PPI [**Hospital1 **], and will be discharged on oral PPI. H. pylori antigen testing negative; ulcer felt to be secondary to chronic NSAID use. During his stay on the medicine floor, his hematocrit remained stable. He had several bowel movements that were dark, but not as dark as previously, and loosely formed. He transitioned to regular diet without complication. He also tolerated his PPI as PO medication. He denied any pain or lightheadedness. . # Syncope: Given his several hours of lightheadedness, known blood loss, and hypotension in ED triage, his syncopal episode was almost certainly due to hypovolemia. A vasovagal component is also likely given that it occurred during a bowel movement and with the patient seeing blood in the toilet bowel. He has no known cardiac history to suggest dysrhythmias and no seizure history. His symptoms initially improved after receiving blood and IV fluids. He subsequently had another syncopal episode from a large bleed as described above, though had no further episodes follwing transfusions and coiling of artery. His EKG was not suggestive of a cardiac event. . # Leukocytosis: His initial CBC showed WBC 16.5 and a significant left shift with no bandemia. He received a single dose of Ceftriaxone in the ED, but antibiotics were not continued on the floor. His WBC count decreased to 13.0 the next morning and 9.1 by that afternoon. The differential includes an infectious etiology vs a stress reaction from his blood loss and trauma. He was afebrile in the ED, with no subjective fevers or chills, and remained afebrile during his stay. He was hypotensive on arrival but this is almost certainly due to his blood loss, with little evidence of sepsis. Given concern for possible UTI, patient was later continued on ceftriaxone, and urine culture was positive for pan-sensitive citrobacter and also enterococcus. The ceftriaxone was then transitioned to ciprofloxacin, for which he will complete a 7-day course. . # Hyponatremia: On admission he had new hyponatremia with Na 129, which remained stable at 128 overnight. He has not had any altered MS [**First Name (Titles) **] [**Last Name (Titles) 54422**]. He appeared somewhat hypovolemic on initial exam, and his Na improved after receiving blood and fluids, suggesting hypovolemia as the most likely cause for his initial hyponatremia. His sodium levels were within the normal limits during his stay on the medicine floor. . # GU Surgery History: He was recently diagnosed and treated for bladder cancer. On [**2180-3-24**], he had a laparoscopic radical cystectomy, prostatectomy, pelvic node dissection, periumbilical hernia repair, and ileal conduit creation with urostomy. On admission, his urostomy appeared to be functioning well with good urine output and no evidence of hematuria or obstruction. UA did show bacteria and some WBCs, but this is common with an ileal conduit and does not necessarily represent a UTI. However, as above, given urine culture grew citrobacter and then enterococcus, patient was treated for presumed infection, initially with ceftriaxone. He was moved to PO ciprofloxacin, for which he will complete a 7-day course. His follow-up urine culture was negative, and he had no leukocytosis or fever upon discharge. . # Hypertension: His BP was low on arrival but stabilized with IVF and his PRBC transfusions. He was on Lisinopril 10 mg PO daily at home, which was held on admission. He was normotensive during his stay on the medicine floor. . # Chin Laceration: He fell during his syncopal episode and had a significant laceration on his chin, which was sutured in the ED. Standard wound care procedures were performed. The external sutures were removed prior to transfer to the floor. The internal sutures are dissolvable. . Medications on Admission: Lisinopril 10 mg PO daily Hydrochlorothiazide 25 mg PO daily Percocet 5-325 1-2 tabs PO Q4H PRN Acetaminophen 325 mg PO Q6H PRN Ibuprofen PRN Cepacol Sore Throat + Coating 15-5 mg Lozenge MM QID PRN Omega-3 fatty acids PO daily Cyanocobalamin (vitamin B-12) 500 mcg PO daily Discharge Medications: 1. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 1 days. Disp:*2 Tablet(s)* 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. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Duodenal ulcer and hemorrhage Facial laceration Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname **], . It was a pleasure participating in your care at [**Hospital1 771**]. . You were treated for bleeding that developing from your duodenum, which is a part of your small intestine just past your stomach. You had so much bleeding that you required many transfusions of blood. To try to stop the hemorrhage, two endoscopies were performed. The bleeding could be seen, but injection and thermal treatment were not sufficient to prevent continued bleeding. You then underwent a procedure (embolization) to cut off the blood supply to your duodenal ulcer. That procedure appears to have worked. Since that embolization, you have not required any additional blood transfusions. Your blood counts have remained stable since that time. You also have been able to eat without difficulty. . During your stay, you were also treated for your facial lacerations. The stitches that were required have since been removed. . To prevent the formation of new ulcers, you should take pantoprazole 40mg twice a day and follow up with the GI doctors (appointments below). Some bacteria were also isolated in your urine, so you should finish a seven-day course of the antibiotic ciprofloxacin. . START pantoprazole 40 mg by mouth twice daily. START ciprofloxacin 500 mg by mouth twice daily for one more day. . Do NOT take any NSAIDs (aspirin, ibuprofen, naproxen, etc.). For pain, take Tylenol or medicines that Dr. [**Last Name (STitle) **] provides. . Please call [**Company 191**] to determine when your follow-up appointment with Dr. [**Last Name (STitle) **] should be. Please follow-up with your urologist. Followup Instructions: Department: GASTROENTEROLOGY When: FRIDAY [**2180-5-12**] at 9:00 AM With: [**Name6 (MD) 81**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1983**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Patient will call for appointment with Dr. [**Last Name (STitle) **]. He reports he already has follow-up with his urologist.

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icd9cm

[ [ [] ] ]

[ "44.44", "86.59", "44.43" ]

icd9pcs

[ [ [] ] ]

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42300

Discharge summary

report

Admission Date: [**2130-11-8**] Discharge Date: [**2130-11-10**] Date of Birth: [**2074-2-21**] Sex: M Service: MEDICINE Allergies: No Allergies/ADRs on File Attending:[**First Name3 (LF) 613**] Chief Complaint: ?TCA overdose, AMS Major Surgical or Invasive Procedure: extubation [**2041-11-7**] (intubated prior to arrival) History of Present Illness: 56y/o male with a PMH of possible ETOH abuse, gastric bypass who is transferred from OSH for further management of AMS and likely overdose. Per OSH report, he was found slumped over a picnic table by friends unresponsive after partying. Arrived to OSH with decoriticate posturing. There, he received CT head which was negative. Alcohol level 25. Received zosyn, rocephin, and bicarb gtt for prolonged QRS on EKG to 126. Transferred intubated and sedated to [**Hospital1 18**] ED. . At [**Hospital1 18**] ED, a toxicology panel tested positive for serum tricyclics, but negative for Serum ASA, EtOH, Acetmnphn, Benzo, Barb. Urine was positive for benzos but was negative for Barbs, Opiates, Cocaine, Amphet, Mthdne. QRS was initially wide on arrival (120s), so toxicology was consulted. They agreed upon treating as a likely TCA overdose with bicarb gtt, though serum tox for TCA has low specificity and may detect benadryl, seroquel, carbamazepine, and other meds. Due to spontaneous narrowing of the QRS, ED discontinued bicarb gtt. Neuro involved for ?seizures and AMS, recommended a CTA head and neck which revealed no new pathology, as well as an EEG. He remained afebrile and hemodynamically stable with BP in the 130s, sats in 100s on the vent, and HR in the 80s. Psych consulted -- pt denied SI initially but may be endorsing to certain member of conuslting teams. Per psych note [**11-8**], patient's partner is concerned re multiple comments about suicide, patient was upset at partner. [**Name (NI) **] sister pt seemed fine earlier in the day. . MICU course notable for: [**11-8**] > extubated, active SI; seen by psych and section 12'd, stayed in unit to monitor for withdrawl; placed on ciwa as well as home klonipin. . In transfer to floor, patient denied suicidal ideation during time of Transfer. Vitals 96.3 (ax), 108, 130/81, 17, 97% on RA. Past Medical History: pancreatitis gallstones gastric bypass alcohol abuse and withdrawal Social History: Social history: youngest of 6, lives with partner [**Name (NI) 401**], lost 11 year job as bus driver, worked in the past as hairdresser and lived in [**Location **]. Parents deaceased. Family History: Family psych hx; sister with bipolar disorder, otherwise noncontributory. Physical Exam: EXAM ON TRANSFER TO FLOOR: Vitals: Vitals 96.3 (ax), 108, 130/81, 17, 97% on RA. General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: crackles at bases B/L, mild expiratory wheezes CV: regular, tachycardic Abdomen: soft, non-tender, non-distended, no rebound tenderness or guarding GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission Labs: [**2130-11-8**] 10:21AM TYPE-ART RATES-14/4 TIDAL VOL-500 PEEP-5 O2-100 PO2-353* PCO2-43 PH-7.43 TOTAL CO2-29 BASE XS-4 AADO2-322 REQ O2-59 [**2130-11-8**] 09:27AM TYPE-ART TEMP-36.3 RATES-14/4 TIDAL VOL-500 PEEP-5 O2-100 -ASSIST/CON [**2130-11-8**] 09:27AM VoidSpec-QNS TO RUN [**2130-11-8**] 03:11AM GLUCOSE-111* LACTATE-3.5* NA+-142 K+-3.9 CL--102 TCO2-26 [**2130-11-8**] 03:09AM TYPE-ART PO2-146* PCO2-45 PH-7.37 TOTAL CO2-27 BASE XS-0 COMMENTS-SPECIMEN R [**2130-11-8**] 03:05AM UREA N-6 CREAT-0.6 [**2130-11-8**] 03:05AM estGFR-Using this [**2130-11-8**] 03:05AM ALT(SGPT)-30 AST(SGOT)-42* LD(LDH)-175 CK(CPK)-740* ALK PHOS-69 TOT BILI-0.4 [**2130-11-8**] 03:05AM LIPASE-15 [**2130-11-8**] 03:05AM CK-MB-20* MB INDX-2.7 [**2130-11-8**] 03:05AM ALBUMIN-4.0 [**2130-11-8**] 03:05AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-POS [**2130-11-8**] 03:05AM WBC-8.0 RBC-3.80* HGB-13.7* HCT-38.6* MCV-101* MCH-36.1* MCHC-35.6* RDW-14.8 [**2130-11-8**] 03:05AM PLT COUNT-154 [**2130-11-8**] 03:05AM PT-12.5 PTT-24.3 INR(PT)-1.1 [**2130-11-8**] 03:05AM FIBRINOGE-195 [**2130-11-8**] 02:49AM URINE HOURS-RANDOM [**2130-11-8**] 02:49AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2130-11-8**] 02:49AM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.005 [**2130-11-8**] 02:49AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG CXR [**2130-11-8**]: The endotracheal tube terminates approximately 4.5 cm above the carina. There is no pneumothorax or large pleural effusion. Linear opacity in the lung bases are compatible with bibasilar atelectasis. There is no definite focal airspace consolidation. The cardiomediastinal silhouette, hilar contours, and pulmonary vasculature are within normal limits. Multilevel degenerative changes are mild-to-moderate. IMPRESSION: The endotracheal tube terminates approximately 4.5 cm above the carina. CTA HEAD NECK [**2130-11-8**] 1. No evidence of acute intracranial hemorrhage or acute territorial infarction. 2. No evidence of focal flow-limiting stenosis, occlusion, or aneurysm greater than 3 mm in arteries of neck. 3. A small protuberance is noted along the superior aspect of anterior communicating artery. However, no discrete aneurysm is identified. Brief Hospital Course: Patient is a 56YO M found down with decorticate posturing at OSH and + TCA on serum tox at [**Hospital1 18**], intubated and sedated with QRS widening on EKG. . #. ALTERED MENTAL STATUS: Patient arrived intubated and sedated on a bicarbonate gtt with suspicion for polysubstance abuse including TCA overdose based on a positive blood serum screen and an initially prolonged QRS segment on OSH EKG. Toxicology was consulted in the ED, who felt that in the abscense of the typical hemodyanmic compromise that accompanies these patients, his TCA screen was possibly a false positive induced by substances like benadryl, flexeril, and others. By the time of arrival, his QRS was normal and remained closed on repeat EKG, so bicarbonate was not restarted. His mental status was not clearing with sedation holiday in the ED, prompting neuro consult. CTA of the head and neck showed no structural or vascular causes for his AMS. He cleared considerably in the MICU and was promptly extubated with return to his baseline mental status. #. ?SUICIDE ATTEMPT: Psychiatry consulted upon extubation, per their interview: Pt has no recollection of what happened the day PTA. He reports that he went to visit his sister, he had lunch with her. His sister says that he was fine forward looking, and did not drink at lunch. Pt went home. Per the sister pt partner not there, the pt had made dinner, but when the partner called and spoke with his pt, the partner [**Name (NI) 91660**] that he was already slurring his speech. The partner went home, so the pt slumped over the picnic table still breathing, and then the partner watched him, about two hour laters he noted that the pt had stopped breathing, he called 911 and went to the outside hospital. Reportedly the alcohol level was not very high 26, the ct of the head was negative, and the patient was sent here for concern re stroke. Pt QRS was wide at the time. Pt sister doesn't think he was suicidal, appeared forward looking. Pt partner reports several months of very heavy drinking and several months of worry abou this work. 11 days ago the patient lost his job driving a bus because of 4 minor accidents in a year. Since that time and before per the partner the patient made statements suggestive of suicide. About a month ago, made statements to partner suggestive of intending to end his life. His partner has been upset about the patient's drinking. He was placed on a section 12 with plan for psychiatric hospitalization following medical stabilization. [**Hospital1 18**] Psych ulimately felt him safe for home with close watching by his partner and they reversed their section 12 statement that so that he could go home to follow up with his outpatient psychiatrist. . #. ALCOHOL WITHDRAWAL: An escalating pattern of intoxication emerged through multiple conversations with his sister and partner. [**Name (NI) **] was placed on CIWA scale with occasional diazepam requirement only during his first hospital night. . # Anxiety/Depression: continued clonazapam, held triazolam. Continued citalopram. . # ?GERD: continued protonix . # Hypothyroid: continued levothyroxine. . # Hypertension: contintued carvedolol . # Hyperlipidemia: continued lipitor. . Transitions of care: substance abuse counseling with outpatient psych. Medications on Admission: citalopram levothyroxine; lisinopril; clonazepma 1mg tid; tirazola 2mg 3 at hs; pantoprazole percocet Discharge Medications: 1. clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 3. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO 2X/WEEK (TU,TH). 4. lisinopril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Testim 50 mg/5 gram (1 %) Gel Sig: Two (2) tubes Transdermal once a day. 8. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Home Discharge Diagnosis: Primary: Respiratory failure Substance overdose . Secondary: Anxiety / Depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname **]: . You were admitted to [**Hospital1 69**] with concern for a drug overdose. You were initially admitted to the ICU but were subsequently transferred to the medicine floor once you were stabilized. The psychiatry service saw you as an inpatient and felt that you were safe to return home. It is very important that you follow up with your outpatient psychiatrist. It is also very important that you do not drink alcohol or while your are taking benzodiazepines (Clonazepam and Triazolam). . The following changes were made to your medications: - You did not receive Triazolam during this hospitalization. You should NOT resume taking this medication after discharge. We strongly encourage you to stop taking this medication. - You also did not receive Oxycodone-Acetaminophen (Percocet) during this hospitalization. Please do not take this medication until you follow up with your primary care doctor. - You did not receive Flexeril (Cyclobenzaprine) during this hospitalization. Please do not take this medication until you follow up with your primary care physician. . The reason many of these medications were held or discontinued is because of the potential for interaction between the drugs and with alcohol and their side-effects, especially sedation. Followup Instructions: Please followup with your primary care physician [**Name Initial (PRE) 176**] [**8-20**] days regarding the course of this hospitalization. . Please call your outpatient psychiatrist on Monday, [**2130-11-13**], to schedule an appointment. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2130-11-13**]

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icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

9689, 9695

5530, 5702

305, 362

9821, 9821

3123, 3123

11280, 11673

2563, 2639

8971, 9666

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390, 2251

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12,365

125,302

48241

Discharge summary

report

Admission Date: [**2135-6-3**] Discharge Date: [**2135-6-7**] Date of Birth: [**2054-8-17**] Sex: M Service: MEDICINE Allergies: Fentanyl / adhesive bandage / surgical tape / cefepime Attending:[**First Name3 (LF) 10593**] Chief Complaint: fever, hypotension Major Surgical or Invasive Procedure: Dialysis Central line placement and removal History of Present Illness: 80M CKD, CAD s/p CABGx3, atrial fibrillation, DM2, systolic heart failure (last EF 40-45%), valvular heart disease, ESRD on HD (M,W,F) with right brachiocephalic fistula, PVD with venous stasis ulceration that presented to ER after experiencing fever at dialysis. He was triggered for hypotension on arrival for SBP 70. He was dialyzed today with 3 L taken off. He went home and family felt he was warm and called 911. He received tylenol and 300 mL prior to arrival. Per records, [**First Name3 (LF) **] pressure normally 90s/40s, and upon presentation in the ER, his BP was 70s/40s. The patient was unable to provide a significant amount of history. It is unclear when his fever started and if it was associated with HD. Per Dr.[**Name (NI) 9388**] last note dated [**2135-4-1**], it was noted that he had low [**Year/Month/Day **] pressure in clinic (VS documented around 90/60), and it was decided that he should remain on atenolol for rate control. In the ED, initial VS were: 20:46 101.1 110 SBP 70 pOx 97%. Patient was triggered for hypotension on arrival to SBP 70 (baseline in 90s). Exam revealed a patient that was mentating well with stable cardiopulmonary exam, distended abdomen, and + guiaic. Bilateral lower extremities are warm and swollen with ? cellulitis vs. venous stasis change. Labs were performed: - Chemistry panel with Cr 2.2, Glc 130; Mg 1.4, Ph 1.3 - CBC WBC 5.8, Hgb 10.1, MCV 109, Plt 69 with differential of N77, Atyps 1, Metas 2 - lactate 1.3 - Troponin 0.08 - INR 1.6 Bedside US was performed with no pericardial effusion. IVC was unable to be visualized. There was ? abdominal ascites. Patient was 2 L IVF without improvement of [**Year/Month/Day **] pressure, which remained 70s/40s. An LIJ was placed with an infusion of levophed at 0.09 started with improvement of [**Year/Month/Day **] pressure to 89/51, HR 102. He was started on vancomycin, cefepime, and flagyl. He was also given tylenol for fever. CXR showed no acute process. ECG was performed showing atrial fibrillation with RVR with PVCs at 109 bpm, IVCD (QRS 124 ms), leftward axis. Non-specific lateral changes. VS on transfer were not given. On arrival to the MICU, patient's VS were BP 94/57 on levophed 0.12, HR 93, pOx 88 for which he was placed on 2 L NC with improvement to 98 %. Patient was very somnolent upon arrival and difficult to awake. He would open his eyes briefly and [**Doctor Last Name **] somewhat intelligible statements. ABG was performed showing pH 7.38 pCO2 58 pO2 159 HCO3 36. His repeat lactate was within normal limits. ScVO2 was 87. His pressor requirement increased from 0.1 --> 0.14. His initial CVP was 18. NICOM was utilized - SVI increased by 19 % with passive leg raise suggesting fluid responsiveness (patient was still down 2 kg from baseline weight recently). Past Medical History: - ESRD on HD, MWF, since [**4-/2134**], has right brachiocephalic fistula created [**2134-11-30**]. - GI bleed in [**2128**], massive GI bleed [**2129**], now off coumadin and ASA - CAD s/p CABG x3 in [**2115**] and cath with 1 graft down (SVG to CX) - Atrial fibrillation, not on coumadin [**3-3**] GI bleed - Anemia - normocytic, normochromic attributed to chronic disease and mild renal insufficiency; patient gets iron infusions - Chronic hematuria -- likely from renal cysts - CHF: EF 40 - 45 % on [**2134**], ECHO with moderate to severe (3+) MR - DM2: Followed at [**Last Name (un) **] - Hypertension - Hyperlipidemia - PVD with venous stasis ulceration - Chronic back pain from disc disease/spinal stenosis/nerve root compression on oxycontin and gabapentin - s/p hip replacements x2 - s/p CCY - Colonic polyps with adenoma on path on c-scope [**2124**] with neg EGD in [**2126**] - Gout - GERD - BPH Social History: He lives is divorced and lives by himself in [**Location (un) **]; one daughter who lives in [**Name (NI) 620**]. - 80 pack-year hx smoking (quit since [**2109**]) - rare EtOH - denies drug use Family History: unknown -- family died in Holocaust Physical Exam: General: AAOx2, sleepy at times but can arouse to voice. HEENT: Sclera anicteric, MM dry, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: no foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. Discharge exam: T 98.6 BP: 79/45-95/52 HR 90s, max 110 GEN: well NAD RESP: diminished breath sounds through out, with rhonchi, crackles at bases. CARD: s1s2 irregularly irregular, 2/6 systolic murmur heard best at left sternal border with respiratory variation ABD: soft non-tender, non-distented, no suprapubic pain. EXT: Pitting edema bilaterally with chronic venous changes in legs, erythematous and scabbed over. Fistula in RUE with good thrill. Pertinent Results: Admission Labs: [**2135-6-3**] 09:00PM [**Year/Month/Day 3143**] WBC-5.8 RBC-3.03* Hgb-10.1* Hct-32.9* MCV-109* MCH-33.3* MCHC-30.7* RDW-16.9* Plt Ct-69* [**2135-6-3**] 09:00PM [**Year/Month/Day 3143**] PT-16.6* PTT-36.4 INR(PT)-1.6* [**2135-6-3**] 09:00PM [**Year/Month/Day 3143**] Glucose-130* UreaN-11 Creat-2.2* Na-140 K-3.7 Cl-101 HCO3-33* AnGap-10 [**2135-6-3**] 09:00PM [**Year/Month/Day 3143**] ALT-13 AST-28 AlkPhos-73 TotBili-1.3 [**2135-6-3**] 09:00PM [**Year/Month/Day 3143**] cTropnT-0.08* [**2135-6-4**] 06:02AM [**Year/Month/Day 3143**] CK-MB-1 cTropnT-0.08* [**2135-6-3**] 09:00PM [**Year/Month/Day 3143**] Lipase-38 [**2135-6-3**] 09:00PM [**Year/Month/Day 3143**] Albumin-2.9* Calcium-8.3* Phos-1.3* Mg-1.4* Discharge Labs: [**2135-6-7**] 07:55AM [**Year/Month/Day 3143**] WBC-3.9* RBC-3.36* Hgb-11.1* Hct-37.6* MCV-112* MCH-33.0* MCHC-29.6* RDW-17.4* Plt Ct-64* [**2135-6-7**] 07:55AM [**Year/Month/Day 3143**] Glucose-85 UreaN-19 Creat-2.9* Na-140 K-4.1 Cl-105 HCO3-25 AnGap-14 [**2135-6-5**] 03:34AM [**Year/Month/Day 3143**] ALT-15 AST-28 LD(LDH)-170 AlkPhos-61 TotBili-0.8 [**2135-6-7**] 07:55AM [**Year/Month/Day 3143**] Calcium-8.4 Phos-2.2* [**2135-6-5**] 03:34AM [**Year/Month/Day 3143**] TSH-1.8 [**2135-6-5**] 11:30AM [**Year/Month/Day 3143**] Cortsol-18.4 Micro: ALL [**Year/Month/Day 3143**] CULTURES NGTD [**2135-6-4**] [**Numeric Identifier 3143**] CULTURE [**Numeric Identifier **] Culture, Routine-PENDING INPATIENT [**2135-6-4**] [**Numeric Identifier 3143**] CULTURE [**Numeric Identifier **] Culture, Routine-PENDING INPATIENT [**2135-6-4**] MRSA SCREEN NEGATIVE [**2135-6-3**] [**Numeric Identifier 3143**] CULTURE [**Numeric Identifier **] Culture, Routine-PENDING EMERGENCY [**Hospital1 **] [**2135-6-3**] [**Numeric Identifier 3143**] CULTURE [**Numeric Identifier **] Culture, Routine-PENDING . Radiology: [**2135-6-3**]: SINGLE AP PORTABLE VIEW OF THE CHEST: Patient is status post median sternotomy. Cardiomediastinal silhouette is mildly enlarged and there is vascular engorgement. Lungs are clear of focal opacities concerning for infectious process. No pleural effusion or pneumothorax. CVC has been removed since the prior study. IMPRESSION: Pulmonary vascular congestion without other acute cardiopulmonary process. [**2135-6-3**]: HISTORY: Right IJ central line. FINDINGS: There is a new right IJ central line with tip in the distal SVC. There continues to be moderate cardiomegaly with pulmonary vascular redistribution, without focal infiltrate or effusion. Sternotomy wires are again seen. There is no pneumothorax. [**6-5**] CXR: Compared to the study from the prior day, there is no significant interval change. There continues to be volume loss in the lower lobes with retrocardiac opacity and some focal areas of obscuration of the left hemidiaphragm. It is unclear if this is due to volume loss or early infiltrate. The heart continues to be moderately enlarged with mild pulmonary vascular redistribution. The right IJ line with tip in the distal SVC is again visualized. [**6-6**] Echo: The left atrium is moderately dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with focal dyskinesis of the basal inferior wall. The remaining segments contract normally (LVEF = 55 %). Right ventricular chamber size and free wall motion are normal. There is abnormal septal motion/position. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. An eccentric, inferolaterally directed jet of moderate (2+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Mild symmetric left ventricular hypertrophy with regional systolic dysfunction c/w CAD. Moderate eccentric jet of mitral regurgitation. Pulmonary artery hypertension. Biatrial enlargement. Compared with the prior study (images reviewed) of [**2134-5-6**], the severity of mitral regurgitation and the estimated PA systolic pressure are slightly reduced. Brief Hospital Course: 80M CKD, CAD s/p CABGx3, atrial fibrillation, DM2, systolic heart failure (last EF 40-45%), valvular heart disease, ESRD on HD (M,W,F) via right brachiocephalic fistula, PVD with venous stasis ulceration who presented to ER for fever after HD and was admitted to ICU for sepsis and hypotension requiring pressor support, also found to have acute encephalopathy. # Possible Sepsis Patient presented with fever & tachycardia with presumed infection although uncertain source. Labs were significant for normal WBC but with left shift on differential. CXR on [**6-5**] revealed equivocal pneumonia and patient's only localizing symptom was dry cough. [**Month/Day (4) **] cultures were negative to date. He was started on vancomycin, cefepime, and flagyl with discontinuation of IV abx on [**6-6**] and transition to levofloxacin. Most likely, pt had transient bacteremia from dialysis as pt uses "button-hole" method for access which has higher rates of infectious complications. The patient was well without fevers while on levofloxacin and given cough and question of pneumonia on chest x-ray, pt will be covered for 5 more days on levofloxacin for coverage of [**Hospital 101654**] health care associated pneumonia. . # Hypotension Patient's baseline BP is SBP 70s-90s per notes and patient history. He presented with SBP 70 that was not responsive to 2 L NS, so was started on levophed. Given coincident fevers, there was concern for sepsis. Serial lactates within normal limits suggested good perfusion. Levophed was able to be weaned off and SBPs remained in his normal 70-90 range, with intermittent hypotension while sleeping which self-corrected to >70 systolic immediately when pt was awake. Mentation remained intact. Echo showed improved heart function compared to previous. # Acute encephalopathy Seemed to be related to patient being drowsy on admission. He improved markedly the morning after admission, mentated well thereafter. # Chronic systolic and diastolic heart failure Echo revealed improvement of heart function with LVEF >55% in setting of likely diastolic failure and some regional systolic wall motion abnormalities. The pt was switched from atenolol to metoprolol. Given his good EF and low [**Hospital **] pressures, ACE was deferred. Pt volume overloaded [**3-3**] to heart failure and ESRD. Pt is anuric. Will need to continue to take off volume at dialysis. Reported baseline weight is 84kg. # Elevated INR Likely from poor nutrition/poor PO intake. Not on anticoagulation, no other LFT abnormalities. # ESRD on HD (M,W,F) Continued on same schedule. Pt's sevelamer was discontinued due to low phosphorous. # Atrial fibrillation ECG with atrial fibrillation on admission. Not on coumadin or aspirin secondary to massive GIB in [**2129**]. Switched to metoprolol 25mg [**Hospital1 **] for rate control. Can continue to uptitrate as tolerated for goal rates <90. . # CAD s/p CABGx3 Stable, continued on home meds. . # Normocytic, normochromic anemia Stable. Hct at baseline, 30-32, most likely from CKD. . # Thrombocytopenia Stable, pt possibly with MDS. Can defer workup to outpatient setting. . # Diabetes Mellitus type 2 Last A1c 6.5 on [**2134-4-12**]. Pt did not require any ISS while here. . # Hyperlipidemia Continued statin. LFTs wnl. . # PVD with venous stasis ulceration . # Chronic back pain Secondary to disc disease/spinal stenosis/nerve root compression. Held oxycontin, oxycodone, gabapentin on arrival while somnolent. Then restarted home meds without issue. . # Gout Continued allopurinol. . # Rash: Maculopapular and pruritic with prominence over back and thighs. Occurred after starting cefepime and vancomycin. Felt most likely to be from cefepime. Not c/w redman syndrome given distribution. Treated with sarna lotion and hydroxyzine with some improvement. No anaphylactic symptoms. TRANSITIONAL ISSUES - Continue rate control. - Pt's baseline pressures are 80-90 systolic. - Monitor and workup thrombocytopenia. Medications on Admission: - oxycontin 10 mg PO QID - gabapentin 100 mg PO BID - nephrocaps PO qD - oxycodone 5 mg prn - simvastatin 20 mg Po qD - allopurinol 200 mg Po qD - atenolol 25 mg PO qD - folic acid 1 mg PO qD - Vitamin B12 250 mcg PO qD - vitamin C 500 mg PO qD - chondroitin/glucosamine 1200/1500 mg Po qD - prilosec 20 mg PO qD - renvela 800 mg PO qD Discharge Medications: 1. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO Q6H (every 6 hours). 2. gabapentin 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for breakthrough pain. 5. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. allopurinol 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Hold for SBP<80. 8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. hydroxyzine HCl 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for itching. 10. Vitamin B-12 250 mcg Tablet Sig: One (1) Tablet PO once a day. 11. Vitamin C 500 mg Tablet Sig: One (1) Tablet PO once a day. 12. Glucosamine-Chondroitin DS 500-400 mg Tablet Sig: Three (3) Tablet PO once a day. 13. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 14. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching,rash. 15. Doxercalciferol 0.5 mcg IV QHD 16. levofloxacin 250 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 4 days: End on [**6-11**]. Discharge Disposition: Extended Care Facility: [**Hospital 11851**] Healthcare & Rehabilitation Center - [**Location (un) 620**] Discharge Diagnosis: Primary: Transient bacteremia vs pneumonia Secondary: systolic CHF, atrial fibrillation, ESKD on dialysis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [**Known lastname 79024**], It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted for low [**Hospital1 **] pressure and fevers and it was thought that this was most likely due to a transient bacterial bloodsteam infection from dialysis. However, it is also possible that you have a pneumonia. You were treated with intravenous antibiotics and then this was decreased to oral antibiotics. Your [**Hospital1 **] pressures have stabilized and your have had no more fevers. The following changes were made to your medications: START Levofloxacin for infection STOP Atenolol START Metoprolol STOP Sevelamer START Nephrocaps Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Department: ADVANCED VASC. CARE CNT When: TUESDAY [**2135-8-2**] at 1 PM With: [**Name6 (MD) 5536**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 5537**] Building: [**Street Address(2) 7298**] ([**Location (un) 583**], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: CARDIAC SERVICES When: TUESDAY [**2135-9-27**] at 2:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**Telephone/Fax (1) 127**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2135-6-7**]

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icd9cm

[ [ [] ] ]

[ "38.95", "39.95" ]

icd9pcs

[ [ [] ] ]

15531, 15639

9803, 13787

333, 379

15789, 15789

5538, 5538

16745, 17399

4381, 4418

14173, 15508

15660, 15768

13813, 14150

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15804, 15948

3241, 4153

4169, 4365

77,913

195,298

44464

Discharge summary

report

Admission Date: [**2114-12-23**] Discharge Date: [**2114-12-28**] Service: MEDICINE Allergies: Lisinopril / Aspirin / Diovan / Ultram / Nsaids Attending:[**First Name3 (LF) 8104**] Chief Complaint: Blood in stool Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **] yo F with the history of diverticulosis, diastolic CHF, CAD, hypertension who presented to the ER this AM. The patient and son report that this AM at approximately 2:30 AM the patient had several episodes of bright red blood per rectum. After approximately 3-4 episodes of bleeding (initially stool mixed with blood and then frank blood). After these episodes the patient became presyncopal and 911 was called. The patient had been in her usual state of health until yesterday and had no complaints of pain, dyspnea or chest discomfort prior to or during the episodes at home. In the ED, She received 1 L NS, 2 large bore IVs. There is some report of mild dyspnea while in the ED, but the patient denies this. . The patient was admitted to 11Reisman and found to have several episodes of BRBPR with decrease in her BP to the 90s. She was not tachycardic. Given the persistent bleeding and hypotension the patient was transferred to the [**Hospital Unit Name 153**]. . On arrival to the [**Hospital Unit Name 153**] the patient was asymptomatic and no longer hypotensive. The patient has no pain, dizziness, lightheadedness, dyspnea. . . Past Medical History: 1. Hypertension. 2. GI bleeding [**2-3**] pancolonic diverticula 3. Arthritis of both knees 4. Hypothyroidism. 5. Angioedema from ACE inhibitors, shrimp. 6. Diastolic CHF (see study below from [**2-7**]) 7. CAD, s/p MI in [**2076**] but normal pharm stress in [**2110**] 8. Right hip pain 9. Colonoscopy [**10-5**] with adenoma 10: Osteoporosis 11. Spinal stenosis LBP, followed by pain clinic 12. Left shoulder pain, followed by pain clinic 13. s/p cholecystectomy [**20**]. s/p hysterectomy 15. hx of Syphilis Neither patient nor son know of any lung disease and do not recall why she is on the advair . Social History: She is a retired factory worker. Husband died 2 years ago. Lives with her son and grand-son. [**Name (NI) **] lots of family in the area, all of whom are very involved in her care. She is functional at home, does her own ADLs though her son gives her her medications. She walks w/ a walker. Family History: NC Pertinent Results: [**2114-12-23**] 06:00AM WBC-6.9 RBC-3.44* HGB-10.4* HCT-31.3* MCV-91 MCH-30.2 MCHC-33.2 RDW-14.1 [**2114-12-23**] 06:00AM NEUTS-58.2 LYMPHS-34.9 MONOS-4.2 EOS-2.3 BASOS-0.3 [**2114-12-23**] 06:00AM PLT COUNT-169 [**2114-12-23**] 06:00AM PT-13.8* PTT-26.8 INR(PT)-1.2* [**2114-12-23**] 06:00AM GLUCOSE-113* UREA N-23* CREAT-1.1 SODIUM-146* POTASSIUM-4.0 CHLORIDE-109* TOTAL CO2-27 ANION GAP-14 [**2114-12-23**] 06:00AM ALT(SGPT)-10 AST(SGOT)-21 CK(CPK)-108 ALK PHOS-78 TOT BILI-0.5 [**2114-12-23**] 06:00AM CK-MB-5 cTropnT-0.03* [**2114-12-23**] 06:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-1 PH-6.5 LEUK-NEG [**2114-12-23**] 06:15AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.016 [**2114-12-23**] 06:15AM URINE GR HOLD-HOLD [**2114-12-23**] 06:15AM URINE HOURS-RANDOM [**2114-12-23**] 06:20AM freeCa-1.07* [**2114-12-23**] 06:20AM HGB-10.2* calcHCT-31 [**2114-12-23**] 06:20AM GLUCOSE-107* LACTATE-1.5 NA+-143 K+-3.9 CL--104 [**2114-12-23**] 10:14AM HCT-24.8* [**2114-12-23**] 06:17PM HCT-33.6*# [**2114-12-24**] 12:00AM HCT-31.3* [**12-23**] GI Bleeding scan: No evidence of gastrointestinal bleeding. CXR: FINDINGS: Again seen is bilateral hilar prominence and moderate cardiomegaly. There is no new infiltrate or effusion. Brief Hospital Course: Plan: 1. GI bleeding/hypotension: Given history of diverticuli, brisk lower bleed and significant hct drop, the most likely cause of bleeding is the sigmoid diverticuli. The patient was admitted to the ICU and was transfused 2 U PRBC on the day of admission. NG lavage was negative. She underwent a RADIOPHARMACEUTICAL tagged RBC scan that was negative for an acute bleed. She was monitored in the intensive care unit and on HD#3 was noted to have a recurrence of melena. A repeat bleeding scan was negative. She received additional blood transfustions. Her hematocrit remained stable and she was transferred to the general medical floor the next day. On the floor, she had an additional episode of hematochezia with small amounts of blood. Given the low volume of blood, another RBC scan was not performed. She was monitored in the hospital for another 36 hours. She had no recurrent bleeding and her hematocrit remained stable. The primary team on the floor had a discussion with the patient and her son. The patient again reiterated that she would not want to have a colonscopy or surgery, and thus no further evaluation was undertaken during this admission. She would however consider angiography should she have recurrent bleeding in the future. Given the likelihood of recurrent bleeding and the patient'd desire for hospitalization, transfusions, and possible angiographic intervention, she was instructed to return to the hospital should she have episodes of blood on or in the stool or bright red blood per rectum. Both the patient and her son had good understanding of this. I encouraged the patient to continue ongoing discussions with her primary care giver about these issues. The patient and son were also educated about the discontinuation of ASA. . 2. dCHF: Patient with grade II diastolic dysfunction. Has not had event of decompensation in approx 1 year. She received lasix with some of the blood transfusions and remained euvolemic. . 3. Allergy history: the patient has history of multiple allergies including shellfish. Thus would require pretreatment with solumedrol, benadryl and famotidine should she require an angiography procedure in the future. . 4. Vaginal bleeding: Patient had an episode of vaginal bleeding during this hospitalization. She was seen by OB-GYN who noted a pocket from a previous suture, but no evidence of bleed. . 5. Hypothyroidism- continued home meds . 6. Osteoporosis: continued calcium when taking POs. Vitamin D was initiated. . # Code: DNR/I. This was confirmed several times during this hospitalization. Patient clearly had capacity to make medical decisions. . Medications on Admission: Medications: ADVAIR DISKUS - 250-50MCG Disk with Device - TAKE 1-2 PUFFS TWICE A DAY FUROSEMIDE [LASIX] - 40 mg Tablet - 1 Tablet(s) by mouth daily HYDRALAZINE - 50 mg Tablet - 1 Tablet(s) by mouth three times a day LEVOTHYROXINE - 25 mcg Tablet - 1 Tablet(s) by mouth daily with 200mcg tablet LEVOTHYROXINE [LEVOXYL] - 200 mcg Tablet - one Tablet(s) by mouth daily with 25mcg tablet POTASSIUM CHLORIDE - 20 mEq Packet - (NOT TAKING PER SON) [**Name (NI) 95306**] (D3) [CALCIUM 500 + D] - 500 mg-200 unit Tablet - 1 Tablet(s) by mouth three times a day COLACE - 100 mg Capsule - 1 Capsule(s) by mouth twice a day CYANOCOBALAMIN [VITAMIN B-12] - 100 mcg Tablet - 1 Tablet(s) by mouth once a day LORATADINE [CLARITIN] - 10 mg Tablet - 1 Tablet(s) by mouth daily Aspirin daily . Allergies: Son and patient recall no allergies, but there is a documented history of ACE/[**Last Name (un) **] angioedema, possible reaction to ultram/nsaids and GI bleeding to Aspirin Discharge Medications: 1. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 2. Calcium 500 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* 3. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 4 days. Disp:*8 Tablet(s)* Refills:*0* 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Cyanocobalamin 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO three times a day. 7. Levothyroxine 200 mcg Tablet Sig: One (1) Tablet PO once a day. 8. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO once a day. 9. Potassium Chloride 20 mEq Packet Sig: One (1) PO once a day. Discharge Disposition: Home Discharge Diagnosis: 1) Lower GI bleed 2) Diastolic heart failure 3) Urinary Tract Infection 4) Vaginal bleeding Discharge Condition: Good/stable Discharge Instructions: You were admitted with a lower GI bleed. You should return to the hospital if you have have large amounts of dark tarry stool or bright red blood on or in your stool. Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name12 (NameIs) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2115-1-7**] 3:30 Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**] Date/Time:[**2115-2-12**] 1:00 If you would like ob/gyn follow-up for your vaginal bleeding, please call [**Telephone/Fax (1) 2664**] to make an appointment. The Ob/Gyn Offices are located in [**Hospital Ward Name 23**] Building, [**Location (un) **] of the [**Hospital Ward Name 5074**] of [**Hospital1 18**].

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icd9cm

[ [ [] ] ]

[ "99.04" ]

icd9pcs

[ [ [] ] ]

8206, 8212

3795, 6419

272, 279

8348, 8362

2442, 3772

8578, 9154

2419, 2423

7430, 8183

8233, 8327

6445, 7407

8386, 8555

218, 234

307, 1465

1487, 2094

2110, 2403

42,438

105,247

40252

Discharge summary

report

Admission Date: [**2161-10-16**] Discharge Date: [**2161-10-16**] Date of Birth: [**2093-7-29**] Sex: F Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 2817**] Chief Complaint: unresponsiveness Major Surgical or Invasive Procedure: none History of Present Illness: 68F h/o metastatic RCC and a history of depression found unresponsive by family this AM with open pill bottles. Patient was last seen in her normal state last night. Family initiated CPR (of note patient always had a pulse) and called EMS. EMS found her to be hypothermic and hypotensive but with a pulse. They gave her 2mg Narcan, 1L NS, and brought her to [**Hospital3 **]. On arrival at [**Hospital3 **] she was hypotensive and hypothermic. Pupils fixed and dilated. Rectal temp was 90.1. Foley inserted, stiff neck collar placed, intubated with a #7 ETT, OG #18 inserted. An acetaminophen level was 140. Combined CCB and acetaminophen overdose was felt to be the most likely diagnosis. She was intubated and given 1 amp of calcium gluconate, 1 mg of glucagon, started on NAC, and started on triple pressors (dopamine, norepinephrine, vasopressin). At [**Hospital3 **] the patient, received 1 amp of calcium gluconate, glucagon 1mg, 10mg of decadron, and started on NAC therapy. She was then sent by [**Location (un) **] to [**Hospital1 18**] for further evaluation and transfer. On the flight she received 10mg of decadron. On arrival at the [**Hospital1 18**] ED her initial vital signs were 70s/40s and HR in 100s, rectal temp 90.2. Found to be intubated, not sedated, flaccid, 4-5 mm dilated fixed post surgical pupils. Her blood sugars rose from 290s to 300s and she was started on an insulin gtt. EKG showed an incomplete RBBB QRS 134. Some bicarb was given to test to see if she had any component of a sodium channel blockade but her QRS did not significantly improve. An echo showed a globally hypokinetic heart and a FAST ultrasound showed a large GB with sludge and wall distention felt likely [**12-30**] to her large fluid resuscitation. CT of chest showed no PE but possible aspiration PNA and she was started on vanc/zosyn. Past Medical History: renal cell carcinoma s/p nephrectomy and lobectomy hypertension hyperlipidemia h/o CVA GERD asthma anxiety depression Social History: lives with husband Family History: NC Physical Exam: VS: 78/49 hr 105 rr 20 sat 100%/FiO2 100% Vent Settings: CMV 500 x 20 PEEP 6 FiO2 100% GEN: nonresponsive HEENT: intubated, vomit on face PULM: coarse CARD: tachy regular ABD: soft EXT: cold, no edema NEURO: nonresponsive, no gag reflex, pupils fixed dilated, no caloremic reflex Pertinent Results: [**2161-10-16**] 10:47AM BLOOD WBC-11.7* RBC-3.17* Hgb-10.2* Hct-32.4* MCV-102* MCH-32.2*# MCHC-31.5# RDW-13.4 Plt Ct-454* [**2161-10-16**] 08:48AM BLOOD WBC-16.4* RBC-4.01* Hgb-11.7* Hct-41.8 MCV-104* MCH-29.1 MCHC-27.9* RDW-13.6 Plt Ct-502* [**2161-10-16**] 10:47AM BLOOD Neuts-90.3* Lymphs-8.4* Monos-0.7* Eos-0.3 Baso-0.2 [**2161-10-16**] 08:48AM BLOOD Neuts-88.7* Lymphs-9.0* Monos-1.9* Eos-0.2 Baso-0.2 [**2161-10-16**] 10:47AM BLOOD Plt Ct-454* [**2161-10-16**] 10:47AM BLOOD PT-15.0* PTT-30.0 INR(PT)-1.3* [**2161-10-16**] 08:48AM BLOOD Plt Ct-502* [**2161-10-16**] 08:48AM BLOOD PT-13.8* PTT-22.8 INR(PT)-1.2* [**2161-10-16**] 10:47AM BLOOD Glucose-293* UreaN-11 Creat-0.9 Na-143 K-2.6* Cl-113* HCO3-16* AnGap-17 [**2161-10-16**] 08:48AM BLOOD Glucose-310* UreaN-12 Creat-1.0 Na-137 K-3.6 Cl-108 HCO3-16* AnGap-17 [**2161-10-16**] 10:47AM BLOOD ALT-11 AST-8 LD(LDH)-111 CK(CPK)-18* AlkPhos-49 TotBili-0.1 [**2161-10-16**] 10:47AM BLOOD Albumin-2.3* Calcium-6.1* Phos-3.8# Mg-1.2* [**2161-10-16**] 08:48AM BLOOD Calcium-7.5* Phos-5.5* Mg-1.6 [**2161-10-16**] 08:48AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-67* Bnzodzp-NEG Barbitr-POS Tricycl-NEG [**2161-10-16**] 12:52PM BLOOD Type-ART pO2-271* pCO2-58* pH-7.06* calTCO2-17* Base XS--14 [**2161-10-16**] 11:52AM BLOOD Type-ART Temp-33.5 Rates-20/ Tidal V-500 PEEP-5 FiO2-100 pO2-257* pCO2-44 pH-7.15* calTCO2-16* Base XS--13 AADO2-434 REQ O2-73 -ASSIST/CON Intubat-INTUBATED [**2161-10-16**] 10:39AM BLOOD Type-ART Temp-33 Tidal V-500 FiO2-100 pO2-292* pCO2-50* pH-7.11* calTCO2-17* Base XS--14 AADO2-393 REQ O2-67 Intubat-INTUBATED Vent-SPONTANEOU Comment-CORE [**2161-10-16**] 12:52PM BLOOD Lactate-4.2* K-2.1* [**2161-10-16**] 11:52AM BLOOD Lactate-3.7* K-2.1* [**2161-10-16**] 10:39AM BLOOD Lactate-3.7* [**2161-10-16**] 09:06AM BLOOD Lactate-3.6* [**2161-10-16**] 11:52AM BLOOD O2 Sat-97 [**2161-10-16**] 10:39AM BLOOD O2 Sat-97 [**2161-10-16**] 12:52PM BLOOD freeCa-1.31 [**2161-10-16**] 11:52AM BLOOD freeCa-1.55* [**2161-10-16**] 10:39AM BLOOD freeCa-1.05* Brief Hospital Course: 68F metestatic RCC found unresponsive after suspected toxic ingestion of multiple medications including amdlodipine, tylenol and ativan. # Shock: distributive, [**12-30**] toxic metabolic ingestion of multiple medications most significant for CCB. Treated with four pressors including norepinephrine, dopamine, vasopressin and neosynephrine with MAPs of ~60. Given a total of 16L of IVF. Lactates continued to trend up. She was terminally extubated as below. # Toxic Overdose: suspected CCB +/- tylenol and benzos. Unclear if intentional, suspected based on history of depression and patient's known metastatic renal cell carcinoma. Toxicology consulted. HIE insulin gtt started and blood sugars monitored q15min. Given aggressive IVF with NS and then D5W + 150meq HCO3. Intralipid rescue therapy was started, and the 21-hour NAC protocol started as well. Calcium chloride was given to maintain a normal ionized calcium in the setting of a CCB overdose. A dose of flumazenil was given with concern for a benzo component of her overdose. She remained nonresponsive with fixed dilated pupils and no corneal reflex - higher doeses were planned but not pursued based onconversations with famiy re goals of care . # Aspiration PNA: seen on CT scan, patient found with vomitus on face. Hypothermic. Treated with vanc/zosyn. # Goals of Care and Expiration: discussions with the family (including her granddaughter who is her HCP) it was agreed that she would not want extraordinary measures taken and that she would not want to be kept alive on machines. Social work was brought in to the discussion and the services of the clergy were offered but declined. Two additional family meetings were held to discuss her situation and her grandaughter who was the HCPO stated that her grandmother would never want aggressive [**Last Name (un) 28015**] if there was even a chance she would not be able to return home to a normal life. She was adamant and in fact made her grandtr and not her husband the HCP because she trusted her to carry out these wishes. We discussed that there were other tests we could do including brain imaging to evaluate extent of damage to try to be sure extent of injury, but family stated it was not needed and that we had already gone past want Mrs [**Known lastname 61078**] [**Name (STitle) 88360**] have wanted. After the family had the opportunity to say goodbye she was made comfort measures only and her pressors, fluids and antibiotics were stopped. She was terminally extubated and started on a morphine drip. She expired at 3:45pm surrounded by her two granddaughters. Case reported to ME's office due to possible suicidal ingestion (though family felt unlikely) and death in less than 24 admission and case was accepted. Medications on Admission: amlodipine ativan lunesta lisinopril tylenol butalbital paroxetine Discharge Medications: N/A Discharge Disposition: Expired Facility: [**Hospital1 69**] Discharge Diagnosis: PRIMARY: 1. Toxic Overdose 2. Respiratory Failure 3. Distributive Shock 4. Aspiration Pneumonia SECONDARY: 1. Renal Cell Carcinoma Discharge Condition: expired Discharge Instructions: N/A Followup Instructions: N/A

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icd9cm

[ [ [] ] ]

[ "38.93", "96.71" ]

icd9pcs

[ [ [] ] ]

7654, 7693

4753, 7508

315, 321

7868, 7877

2711, 4730

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2391, 2395

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7714, 7847

7534, 7603

7901, 7906

2410, 2692

259, 277

349, 2197

2219, 2339

2355, 2375

55,973

175,862

4031

Discharge summary

report

Admission Date: [**2182-4-12**] Discharge Date: [**2182-4-19**] Date of Birth: [**2120-10-31**] Sex: F Service: MEDICINE Allergies: Penicillins / Imuran / Cephalosporins / Sulfa (Sulfonamide Antibiotics) / Reglan / Ampicillin / Lactose / Neomycin / metoclopramide / Doxepin Attending:[**First Name3 (LF) 1242**] Chief Complaint: sepsis Major Surgical or Invasive Procedure: Left femoral CVL [**4-13**] History of Present Illness: 61F with DM1, ESRD on PD, s/p pancreatic transplant, CAD with [**Month/Year (2) **] [**10-3**] s/p CABG in [**2-3**], p/w rigors and fever to 103. Pt reports being n her USOH until she developed diarrhea two nights ago X 3 BMs, none since. On the morning of admission she developed chills that became severe and quickly developed a temp of 101. She was sent to the ED. . In our ED, Temp was 103.5 at triage. She was noted to have RLE erythema, warmth and tenderness consistent with cellulitis. She was evaluated by transplant surgery who supported diagnosis of cellulitis and recommended avoidance of central line if possible. Renal was also made aware. Hct 23, lactate 2.2. Blood culture and peritoneal cultures were sent. CXR with LLL opacity worse than prior. Peritoneal WBC 24 with no left shift. Patient was started empirically on Vanco/Meropenem/Flagyl for coverage of cellulitis and posible Cdiff. During her ED course systolic blood pressures dropped to 70s despite receiving 3L NS, so she was transferred to the ICU for management of sepsis. Access 2 PIVs. Vital signs on transfer were: BP 83/36 HR 101 RR 19 O2 sat 100%. . Of note patient has history of relative hypotension since her cardiac surgery with blood pressures usually in the low 100s on midodrine. Ocassionally pressures drop to the 70s at her rehab and quickly improve after small gatorade bolus. She also has a history of multidrug resistant organisms including VRE. . On the floor, she looks tired, but answering questions appropriately. She reports feeling better, still has RLE pain. . Review of systems: as above. Denies cough, sore throat, abdominal pain, further diarrhea, blood in stools, change in urinary output, dysuria, any other skin changes, feeling confused. Past Medical History: #CHF; EF 25% in [**2182-1-23**] # h/o severe MR s/p repair in [**2181**] # NSTEMI [**7-/2181**], s/p [**Year (4 digits) **] to LAD [**9-/2181**] # CABGX5 vessel [**1-/2182**] # s/p renal transplant ([**2157**]) -- c/b chronic rejection -- second renal transplant ([**2160**]) # s/p pancreas transplant -- with allograft pancreatectomy ([**5-/2174**]) -- redo pancreas transplant ([**6-/2175**]) -- admission for acute rejection ([**7-/2180**]), resolved with increased immunosupression # Diabetes mellitus type I -- c/b neuropathy, retinopathy, dysautonomia -- no longer requires regular insulin after the pancreas transplant, but has been given SS while on high-dose prednisone in house # Autonomic neuropathy # Sleep disordered breathing -- Unable to tolerate CPAP; uses oxygen 2L NC at night # Osteoporosis # Hypothyroidism # Pernicious anemia # Cataracts # Glaucoma # Anemia of CKD, on Aranesp in the past # R foot fracture c/b RLE DVT # Chronic LLE edema # Recurrent E. coli pyelonephritis # s/p anal polypectomy ([**5-/2176**]) # s/p bilateral trigger finger surgery ([**8-/2178**]) # s/p left [**Year (4 digits) 6024**] ([**8-/2179**]) Social History: Child psychiatrist, on disability. Has been in and out of hospitals in the last 8 months. Was longest at [**Hospital3 **], most recently at [**Location (un) **] in [**Location (un) **]. Mobile with wheelchair but unable to do transfers. - Tobacco: Denies - Alcohol: Denies - Illicits: Denies Family History: Father with MI at 57. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION EXAM: . General: Alert, oriented, drowsy, responding appropriately to questions HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: supple, JVP flat, no LAD Lungs: Few rales at LL base, but otherwise clear. CV: Normal rate and regular rhythm, 2/6 SEM at USB Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. Peritoneal [**Last Name (un) **] in place, no skin changes or tenderness surrounding the site. GU: No foley [**Last Name (un) **]: 2+ edema, warm, well perfused, no clubbing. RLE with erytehma warmth and tenderness, no crepitus. Neuro: CNII-XII in tact. Grossly in tact Discharge PE: Vitals: 98.5 110/60 (110-128/60-74) 83 (69-84) 18 99CPAP Gen: NAD, pleasant woman laying comfortably in bed, well-appearing chest: old HD line site, clean/dry, no tenderness to palpation or erythema HEENT: angular cheliosis b/l improving, + thrush on tongue, improving CVS: ?soft SEM heard at USB, no m/r/g PULM: bibasilar crackles, L>R, improving, with slightly decreased breath sounds at the bases b/l ABD: soft, nontender, distended, no tenderness to palpation around PD site extremities: L [**Last Name (un) 6024**], RLE erythema continues to improve Pertinent Results: ADMISSION LABS: . [**2182-4-12**] 09:50PM BLOOD WBC-5.0 RBC-2.22* Hgb-7.2* Hct-23.3* MCV-105*# MCH-32.3* MCHC-30.8* RDW-22.7* Plt Ct-251 [**2182-4-12**] 09:50PM BLOOD Neuts-94.6* Lymphs-4.1* Monos-0.8* Eos-0.3 Baso-0.2 [**2182-4-12**] 09:50PM BLOOD PT-27.7* PTT-32.1 INR(PT)-2.7* [**2182-4-12**] 09:50PM BLOOD Glucose-81 UreaN-56* Creat-5.9*# Na-136 K-4.0 Cl-96 HCO3-26 AnGap-18 [**2182-4-12**] 09:50PM BLOOD ALT-21 AST-33 AlkPhos-65 TotBili-0.2 [**2182-4-12**] 09:50PM BLOOD Albumin-2.7* Calcium-7.3* Phos-3.7 Mg-1.1* [**2182-4-12**] 10:06PM BLOOD Lactate-2.2* . CXR [**4-12**]: 1. Bilateral pleural effusions, improved on the right compared to the prior examination, but worsened on the left. Increased opacification at the left lung base may represent underlying infection. 2. Low lung volumes with crowding of bronchovascular markings and minimal increased pulmonary vascular engorgement. . LENI'S [**4-13**]: TECHNIQUE: Doppler son[**Name (NI) **] of right common femoral, superficial femoral, deep femoral, popliteal and proximal calf veins were performed. There is normal compressibility, flow and augmentation throughout. Mild subcutaneous edema is seen in the right calf. Left common femoral vein waveforms could not be obtained due to the overlying dresing. IMPRESSION: No evidence of DVT in the right lower extremity. Discharge labs: [**2182-4-19**] 05:55AM BLOOD WBC-4.7 RBC-2.77* Hgb-8.8* Hct-28.0* MCV-101* MCH-31.7 MCHC-31.4 RDW-21.8* Plt Ct-133* [**2182-4-19**] 05:55AM BLOOD PT-13.8* PTT-27.5 INR(PT)-1.3* [**2182-4-19**] 05:55AM BLOOD Glucose-86 UreaN-45* Creat-5.1* Na-137 K-3.5 Cl-97 HCO3-30 AnGap-14 [**2182-4-19**] 05:55AM BLOOD ALT-16 AST-20 AlkPhos-66 TotBili-0.2 [**2182-4-19**] 05:55AM BLOOD Albumin-2.1* Calcium-8.3* Phos-3.5 Mg-1.6 [**2182-4-19**] 05:55AM BLOOD Vanco-17.3 [**2182-4-19**] 05:55AM BLOOD tacroFK-9.7 [**2182-4-13**] 11:57AM BLOOD Lactate-2.4* Brief Hospital Course: 60 year old female with a complicated past medical history including DMI, on peritoneal HD, s/p pancreas transplant, CHF who presents with cellulitis of RLE who later developed enteroccocus sepsis. . # enterococcus sepsis: Most likely etiology is RLE cellulitis given clinical findings on exam. Blood cultures growing enterococcus from 1/4 bottles. She was maintained on pressors overnight of admission and was eventually weaned off with stable BPs. CXR also showed some suggestion of opacification at left long base so was was covered broadly with meropenem/linezolid to start, but the linezolid was changed to daptomycin on [**4-13**]. LFTs/CK subsequently increased, so she was changed back to linezolid. Urine and peritoneal cultures were pending, but no sign of SBP on cell count. No diarrhea to suggest c.diff. She was put onto stress dose steroids on admission, but was tapered back to her home dose of prednisone 5mg daily. Cellulitis was trended with marked borders and improved. The patient's HD line was pulled given her bacteremia, and she was switched to PD Vanc. The patient also had TTE and TEE, both of which were negative. . The patient will continue PD vanc for 2 weeks after negative culture (first negative culture [**2182-4-13**]); end date of abx [**4-27**]. As per ID, the patient should have Vancomycin 1000 grams q4days with random vanc levels checked two times per week, with trough goal of 15-20. . # RLE cellulitis: The patient was found to have RLE cellulitis, which was potentially the source of her sepsis, though unclear. She was initially treated with meropenem/linezolid which was ultimately switched to vancomycin. Of note, the patient still has some slight RLE erythema. This will have to be followed as an outpatient. . # Anemia: HCT on admission down to 23 from baseline of about 30, with an increased MCV of 105, now s/p 1 unit of PRBC's with a stable HCT of 25. No evidence of hemolysis. Retic count 3.6. The patient was given one more unit of blood prior to her discharge. She will continue her EPO as an outpatient. . # Transaminitis/Elevated CK: Thought to be secondary to daptomycin. Was changed back to linezolid given this. Ultimately liver enzymes downtrended after dapto was stopped, and CK also normalized. The patient's atorvastatin was held during this time, but was restarted upon discharge. . # ESRD s/p renal transplant: The patient continued on PD, phos binders, and nephrocaps while in patient. The patient was continued on her home dose of prednisone, after initially receiving stress dose steroids in the ED. Tacrolimus and MMF were restarted on [**2182-4-15**]. Daily tacro levels were followed and dose changed as per transplant recs. #. DM1 s/p pancreas transplant: Maintained on immunosuppression as above . # sCHF: The patient was maintained on PD while in patient, in order to help maintain euvolemia. # afib: The patient was in sinus; coumadin was initially held in the unit, and then restarted at a small dose. INR was trended daily, and the patient's coumadin dose was changed accordingly. INR will have to be followed as an outpatient, as the patient's INR upon discharge was 1.3. Caution will have to be taken with coumadin dosage, as the patient is on many other drugs and antibiotics that can interact with her INR. . # presumed esophageal [**Female First Name (un) **]/thrush: The patient was found to have oral thrush, as well as symptoms of dysphagia (was getting harder for her to swallow pills). Given her history of esophageal [**Female First Name (un) **], the patient was started on fluconazole for treatment of thrush and presumed esophageal [**Female First Name (un) **]. The patient's tacro levels were closely followed, as fluconazole can interact with her tacro. . # CAD s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **] and CABG: The patient was contined on ASA while in patient. He statin was held while the patient had elevated LFTs. It was restarted upon discharge. Of note, the patient was also not getting Plavix (s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **]). This was restarted this admission, as per her outpatient cargiologist, Dr. [**Last Name (STitle) 171**]. . # Hypothyroidism: Continue home levothyroxine . # Glaucoma: Continue home eye drops. . Transitional Issues: - The patient will continue PD vanc for 2 weeks after negative culture (first negative culture [**2182-4-13**]); end date of abx [**4-27**]. As per ID, the patient should have Vancomycin 1000 grams q4days with random vanc levels checked two times per week, with trough goal of 15-20. Please fax trough results to [**Telephone/Fax (1) 697**] attn: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 7749**]. . - The patient has INR of 1.3, getting daily coumadin. Given antibiotics and other medications, will continue coumadin 1 mg daily. Will have to check INRs daily until therapeutic. . - Of note, the patient still has some slight RLE erythema. This will have to be followed as an outpatient. Medications on Admission: acyclovir 200 mg [**Hospital1 **] amiodarone 200mg daily aspirin 81mg dialy brimonide tartrate tid calcum carbonate 1250mg [**Hospital1 **] cellcept 500mg [**Hospital1 **] after meals cosopt daily coumadin 1mg daily creon [**Numeric Identifier 890**] units tid before meals epogen 10000munits weekly (wed) folic acid 1mg daily lanthanum carbonate 500mg tid before meals imodium 2mg [**Hospital1 **] prn artificial tears prn lactaid 3000units tid before meals lipitor 80mg qhs midodrine 15mg tid nephrocaps daily neurontin 100mg daily nystatin swish and spit qid prednisone 5mg daily prilosec 20mg daily restasis [**Hospital1 **] synthroid 100mg Tuesday, [**Hospital1 5929**], Sun; 112mcg MWFSaturday Tacrolimus 4mg [**Hospital1 **] Tucks pads APAP 650 tid prn Xalatan qhs Zofran 4mg q8h prn Discharge Medications: 1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 2. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 5. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. fluconazole 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 10. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 11. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 12. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 13. Epogen 10,000 unit/mL Solution Sig: One (1) Injection once a week: every Wednesday. 14. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 15. lanthanum 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a day: please take before meals. 16. Imodium A-D 2 mg Tablet Sig: One (1) Tablet PO twice a day as needed for diarrhea. 17. Artificial Tears Drops Ophthalmic 18. Lactaid 3,000 unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a day: before meals. 19. Lipitor 80 mg Tablet Sig: One (1) Tablet PO at bedtime. 20. midodrine 5 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 21. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 22. Neurontin 100 mg Capsule Sig: One (1) Capsule PO once a day. 23. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 24. cyclosporine 0.05 % Dropperette Sig: One (1) Dropperette Ophthalmic [**Hospital1 **] (). 25. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO 3X/WEEK ([**Doctor First Name **],TU,TH). 26. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO 4X/WEEK (MO,WE,FR,SA). 27. tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 28. ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for nausea. 29. Xalatan 0.005 % Drops Sig: One (1) Ophthalmic at bedtime. 30. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO three times a day as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital **] LivingCenter - [**Hospital1 8218**] - [**Location (un) **] Discharge Diagnosis: primary diagnosis: enterococcal sepsis cellulitis secondary diagnosis: coronary artery disease glaucoma diabetes kidney failure renal and pancreas transplant Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: Dear Ms. [**Known lastname 17759**], It was a pleasure taking care of you while you were hospitalized at [**Hospital1 18**]. You were admitted to the hospital because you were having fevers at the rehab; you were found to have an infection of your skin, and found to have bacteria in your blood. We treated your infection with antibiotics. You will have to continue taking antibiotics until [**4-27**]. We made the following changes to your medications: INCREASE acyclovir to 400 mg [**Hospital1 **] CONTINUE Plavix 75 mg daily START Fluconazole 200 mg daily DECREASE Tacrolimus to 2 mg [**Hospital1 **] START vancomycin Followup Instructions: Department: TRANSPLANT When: MONDAY [**2182-4-22**] at 4:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4861**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: CARDIAC SERVICES When: WEDNESDAY [**2182-4-24**] at 2:40 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: TRANSPLANT CENTER When: MONDAY [**2182-5-13**] at 4:00 PM With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Completed by:[**2182-4-21**]

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icd9cm

[ [ [] ] ]

[ "38.93", "00.14", "54.98", "88.72" ]

icd9pcs

[ [ [] ] ]

15511, 15612

7041, 11407

410, 439

15815, 15815

5128, 5128

16599, 17524

3725, 3863

12986, 15488

15633, 15633

12170, 12963

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467, 2044

15705, 15794

5144, 6459

15652, 15684

15830, 15926

2252, 3398

3414, 3709

68,797

145,714

42127

Discharge summary

report

Admission Date: [**2134-12-11**] Discharge Date: [**2134-12-30**] Date of Birth: [**2074-5-11**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2291**] Chief Complaint: Fall Major Surgical or Invasive Procedure: [**2134-12-16**] ACS service: I/D bilateral IV site abcesses History of Present Illness: The patient is a right handed 60-year-old insulin-dependent diabetic man tarnsfered to [**Hospital1 18**] on [**12-10**] after suffererd an unwitnessed fall while walking his dog around 7pm. The amount of ETOH he admitted to drinking varied between [**1-18**] beverages. The patient does not recall the circumstances around the fall but he thinks that he was told by someone that he "tripped." He recalls waking up in [**Hospital3 91383**] where he was found to be in Afib with RVR and head CT revealed R frontal subdural hematoma with contusion. He was transferred here for further care. Past Medical History: 1. DM - insulin dependent Social History: He is a right handed enigineer. He reports to tobacco use but up to three alcoholic beverages daily. He has a girlfriend. Family History: unknown Physical Exam: On admission: PHYSICAL EXAM: O: T: BP: 133/100 HR: 130 R: 14 O2Sats: 99% RA Gen: Smells of EtOH; NAD. HEENT: Clear oropharynx Lungs: Clear Cardiac: Rapid and irregular Abd: Soft, NT, BS+ Extrem: Multiple plaque-like rash over the extremities. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, [**Hospital1 756**]&Woman and date. Inattentive: Keep thinking that its [**Hospital1 112**] and unable to [**First Name8 (NamePattern2) **] [**Doctor Last Name 1841**] backwards. Language: Speech fluent. No dysarthria. Cranial Nerves: II: Pupils equally round and reactive to light, 3 to 2mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**5-20**] throughout. No pronator drift. No asterixis. Sensation: Intact to light touch. Vibration felt for 5 seconds in both big toes. Reflexes: B T Br Pa Ac Right 2 2 2 0 0 Left 2 2 2 0 0 Toes downgoing bilaterally Coordination: Normal on finger-nose-finger. Gait: Deferred At discharge: Pertinent Results: [**2134-12-10**] 10:30PM FIBRINOGE-314 [**2134-12-10**] 10:30PM PT-15.1* PTT-31.2 INR(PT)-1.3* [**2134-12-10**] 10:30PM PLT COUNT-117* [**2134-12-10**] 10:30PM WBC-5.6 RBC-3.85* HGB-13.8* HCT-40.5 MCV-105* MCH-35.9* MCHC-34.1 RDW-14.0 [**2134-12-10**] 10:30PM ASA-NEG ETHANOL-253* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2134-12-10**] 10:30PM CK-MB-1 [**2134-12-10**] 10:30PM cTropnT-<0.01 [**2134-12-10**] 10:30PM LIPASE-90* [**2134-12-10**] 10:30PM CK(CPK)-97 [**2134-12-10**] 10:30PM estGFR-Using this [**2134-12-10**] 10:30PM UREA N-8 CREAT-0.9 [**2134-12-10**] 10:52PM freeCa-1.05* [**2134-12-10**] 10:52PM HGB-14.6 calcHCT-44 O2 SAT-67 CARBOXYHB-2 MET HGB-0 [**2134-12-10**] 10:52PM GLUCOSE-198* LACTATE-4.0* NA+-141 K+-3.2* CL--98 [**2134-12-10**] 10:52PM PO2-42* PCO2-41 PH-7.38 TOTAL CO2-25 BASE XS-0 CXR [**2134-12-10**] Single supine AP portable view of the chest was obtained. Underlying trauma board and other overlying external artifact partially obscure the view. Given this, no focal consolidation, pleural effusion, or evidence of pneumothorax is seen. The cardiac silhouette is top normal. Slight prominence of the superior mediastinum is likely accentuated by supine, AP technique. No displaced fracture is seen. CT head [**2134-12-10**] 1. Right frontotemporal subdural hematoma. 2. Subarachnoid hemorrhage within the right frontal vertex. 3. Multiple foci of hemorrhage within bilateral hemispheres have increased in size since the most recent prior examination approximately two hours earlier, with some new hyperacute foci noted. 4. Early 2mm leftward shift of normally midline structures noted. 5. Large left occipital subgaleal hematoma. CT c-spine [**2134-12-10**] No evidence of acute fracture. Multilevel degenerative changes noted. CT head [**2134-12-11**] 1. Interval increase in size of a right frontotemporal subdural and intraparenchymal hematoma, with increased moderate effacement of the anterior [**Doctor Last Name 534**] of the right lateral ventricle. 2. Slight increase in mild leftward shift of anterior midline structures. 3. The quadrigeminal and suprasellar cisterns remain preserved. 4. Slight increase in size of the left temporal hematoma. 5. Redistribution of blood products along the right tentorial leaflet and subarachnoid regions within the right temporal and frontal lobes. 6. No definite new hemorrhagic focus. CT Head [**12-13**] 1. Interval enlargement of largest expansile collection of parenchymal hemorrhage in the right frontal lobe with more extensive surrounding edema causing further subfalcine herniation and increased leftward shift of midline structures now 6.5 mm from 2.0 mm two days ago. 2. Enlarging areas of subarachnoid hemorrhage suggestive of diffuse axonal injury. Liver UA [**2134-12-13**] 1. Heterogeneous hepatic echotexture without focal lesion. Echogenicity of the liver suggests fatty deposition though other forms of liver disease including advanced hepatic fibrosis/cirrhosis cannot be excluded. 2. Borderline splenomegaly. CXR [**2134-12-14**] No evidence of pneumonia/aspiration Right shoulder imaging [**2134-12-15**] - No fracture or dislocation is detected involving the right shoulder. Artifact obscures the base of the coracoid on the axillary view. If clinically indicated, a repeat view can be obtained at no additional charge to the patient. ECG [**12-16**] - Sinus rhythm with ventricular premature beats and premature atrial contractions. Diffuse ST-T wave changes raise concern for anterior ischemia. Compared to the previous tracing of [**2134-12-10**] the rhythm appears to be sinus and there are ST-T wave changes in the early precordial leads raising concern for ongoing anterior ischemia. Brief Hospital Course: Mr. [**Name13 (STitle) 30922**] was transfered to [**Hospital1 18**] on [**12-10**]. A scalp lacertion was suturedin the Ed. He was admitted to the TSICU. . Cardiology consult was colled for rapid Afib and he was put on a diltiazem drip. Cardiac enzymes were unconcerning for acute MI. He was loaded with Keppra for seizure prophylaxis and this was continued and titrated up to 750 on [**12-11**]. . His cervical collar was cleared with imaging in the ED. He had a repeat CT head on [**12-11**] with expected blossoming of right frontal and left CP angle contusions and minimal midline shift. He developed confusion and signs of ETOH withdrawal on [**12-12**]. He would not allow team members to clean his scalp wound due to combativeness and agitation. . He was in sinus rhythm with intermittent tachycardia associated with agitation. We also illicited a history from the patient and his girlfriend of intermittent palpitations prior to admission. The cardiology teamrecommended an TTE for further evaluation. LVEF was 55%. There was no abnormal finding. They also recommended ASA when cleared from a neurosurgery standpoint. . He had a repeat CT head on [**12-13**] that showed slight increase in size of contusion with minimal increase in midline shift. He was transferred to the stepdown unit on the CIWA protocol for ETOH withdrawal. He was more alert and appropriate on [**12-15**] but he remained confused. He complained of righ shoulder pain since his fall and X-rays imaging was done and showed no fracture or dislocation. His diet was advanced to regular with thin liquids by Speach/Swallow team. He no longer required a CIWA scale. . The ID team followed him for persistent fevers starting [**12-12**]. Fever work up yielded a finding of bacteremia in [**12-13**] blood cultures. These cultures showed a polymicrobial infection with MSSA and beta Strep Group G. The source of the infection was unclear, but one possibility was a skin infection from the scalp laceration that was persistently erythematous and bleeding due to patient thrashing in bed and casuing irritation. Anther possible source is the pustular lesion in his right arm, where a previous peripheral line was in place. An intra-abdominal source is also possible since Strep G is mainly a bowel organism; a contained ruptured viscous post trauma should be considered in case bacteremia persist or patient developes abdominal symptoms. The acute nature of the bacteremia and the negative TTE rule out endocarditis. . On [**12-15**], they recommened changing Vancomycin to nafcillin and asked to repeat blood cultures until negative. They were also concerned about his right arm abcess and asked for general surgery input. They were called on [**12-16**]. The patient continued to remove his head dressings, even when restrained. Large head wraps were repeatedly placed. The scalp hematoma looked larger on [**12-16**]. IT was cleaned and redressed. He has bilateral infected IV sites that appeared to be abcesses. There were gettin glarge, the right was worse than the left. He Tmax on [**12-16**] waw 101.1F and responded to tylenol. . He continued to have rising Total Bilifrom 1.8 to now 5.9 on [**12-19**]. As a result, hepatology was consulted for furhter management. They recommended acute hepatitis panel and repeat INR. He contineud to be febrile on [**12-20**] as a result PICC line was held. A dobhoff was placed as his albumin and poor oral intake. CXR confirmed placement. Nutrition consulted and Tubefeeds were initiated. . On [**12-19**] he was deemed to have no further neurosurgical needs and was transferred to the medicine service. What follows is an itemized list of his active problems at time of discharge, their course of treatment and status on day of discharge . #1) [**Last Name (un) **]: Patient Cr reached a peak of 1.5 from a base line of 1.0. FeNa was 0.9% suggesting a prerenal etiology. IV fluids were increased and his Cr corrected to normal. . #2) Bacteremia: MSSA and Group G strep from [**12-13**]. Patient was transferred on nafcillin however he cholestatis was thought to be atributed to the nafcillin and this was switched to vancomycin. He will continue to receive IV Vancomycin 1000mg Daily. Last day on [**2135-1-25**]. Follow up in ID clinc with outpatient lab monitoring as detailed below. . #3) Monomorphic ventricular tachycardia: Prior to transfer the patient has several <1min runs of asymptomatic v tach. Work up was negative for any acute ischemic event, structural abnormality or electrolye abnormality. Cardiology was consulted and felt this was secondary to his acute illness. He was continued on his metoprolol 50mg Q6 hours and loaded with amiodarone. He had no further events for the rest of his stay. He will need to follow up with Cardiology as detailed below. . # Afib: patient was seen and evaluated by surgery at the time of his admission and felt to have new onset afib as a result of his acute illness and increased sympathetic tone in the setting of a recent head bleed. He eventually converted to NSR (see above) and was discharged on metoprolol and amiodarone (see above). He is not currently a candidate for anticoagulation given his recent head trauma. . # Hyperglycemia: Patient had difficult to contolr sugars while in house as a result of his acute illenss and continuous tube feeds. He was [**First Name9 (NamePattern2) **] [**Male First Name (un) **] [**Hospital1 **] NPH and regular insulin sliding scale and shoudl be continued on this at the time of discharge. Continue current insulin regimen with on tube feeds. If tube feeds are turned off at any time or dophoff falls out his insulin shoudl be held and readjusted to fit his intake at that time. . # Abdominal pain and LFT abnormalities: LFTs initially presented as [**Last Name (un) **] t-aminitis AST>ALT suggestive of ETOH-hepatitis. Hyperbilirubinemia developed and rose to peak of 5.9 also suggestive of EtOH hepatitis. Patient's lipase rose transiently and in the setting of right upper quadrant pain and right shoulder pain (? referred) and fever have to consider cholangitis or possible recent passage of gall stone. RUQ U/S unrevealing. His abdminal pain and lipase resolved spontaneously. Switched from Nafcillin to vacnomycin with subsequent improvement in Bilirubin levels. On the day of discharge his LFTs have normalized and are now showing a slight AST elevation. This is likley [**2-17**] his ongoing tubefeeds. . # Encephalopathy/delirum: DDX includes post traumatic, infectious and toxic metabolic. Initially concern for hepatic encephalopathy however lactulose and rifaximin had little effect on him. Also felt that it could all represent drug and etoh withdrawl however despite almost 2 weeks od sobriety he remined altered. Infectious work up was negative with the exception of the bacteremia currently being treated. He was seen by neruology who reccomended a head CT on [**12-24**] which showed interval worsenign of his cerebral edema and significant midline shift. After urgent neurosurgical and neurological evaluation it was agreed that this was likley resolving edema that had accumulated in the interim between head CTs'. His exam continued to impove and follow up head CT on [**12-27**] showed mild improvement of his symptoms. . *****TRANSITIONAL ISSUES******** # Weekly labs to be follow by OPAT: BMP, CBC, Vanc trough All laboratory results should be faxed to Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**]. All questions regarding outpatient antibiotics should be directed to the infectious disease R.Ns. at . # Will need adjustment of his amiodarone dose. He is being discharged on 400mg Amiodarone [**Hospital1 **]. On [**1-6**] this will need to be reduced to 200mg daily. Will need to follow up with caridology as listed below. Discuss need for continued amiodarone. . #Insulin needs will need to be assessed frequently based on his diet . # Please avoid hypotonic IV solutions for one week following discharge and keep free water flushes of his tubefeeds to a minimum given his cerebral edema . # Maintain HOB >30% . Medications on Admission: Insulin Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 7. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 8. levetiracetam 750 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO twice a day. 10. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 11. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. chlorhexidine gluconate 0.12 % Mouthwash Sig: Five (5) ML Mucous membrane TID (3 times a day). 13. potassium chloride 20 mEq Packet Sig: One (1) Packet PO BID (2 times a day). 14. NPH insulin human recomb 100 unit/mL Suspension Sig: Eighteen (18) unITS Subcutaneous twice a day. 15. insulin regular human 100 unit/mL Solution Sig: 2-14 UNITS Injection QACHS: per sliding scale. 16. vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous once a day for 18 days: last day of therapy is to be [**2135-1-25**]. Discharge Disposition: Extended Care Facility: [**Hospital3 4339**] Discharge Diagnosis: Cerebral Conutsion SDH ETOH withdrawal new onset Afib Skin Abcess Bacteremia UTI Hyperbilirubinemia Fever malnutrition scalp abscess cellulitis premature ventricular contractions premature atrial contractions Discharge Condition: . Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to [**Hospital1 18**] after you fell and suffered a bleed into your head. You were evauated by the neurosurgery team who deemed that you did not need surgery. You were transferred to the internal medicine service for management of your care. . While you were here we made the following changes to your medications: We STARTED you on senna We STARTED you on docusate We STARTED you on thiamine We STARTED you on multivitamin We STARTED you on folic acid We STARTED you on tylenol We STARTED you on heparin subcutaneous We STARTED you on levetiracetam We STARTED you on amiodarone We STARTED you on famotidine We STARTED you on chlorhexidine We STARTED you on potassium We STARTED you on insulin NPH We STARTED you on insulin regular . Instructions for Follow up for Subdural, Epidural or Subarachnoid Hemorrhages Non-Surgical Dr. [**Last Name (STitle) 24275**] [**Name (STitle) 739**] ?????? Take your pain medicine as prescribed if needed. You do not need to take it if you do not have pain. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? DO not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. until follow up. ?????? You can not take blood thinning medication until you are seen in follow up in one month ?????? ***You have been discharged on Keppra (Levetiracetam) for anti-seizure medicine, you will not require blood work monitoring. ?????? Do not drive until your follow up appointment. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion, lethargy or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? New onset of the loss of function, or decrease of function on one whole side of your body. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 4676**] to schedule an appointment with Dr. [**Last Name (STitle) 739**], to be seen in 4 weeks. ??????You will need a CT scan of the brain without contrast prior to your appointment. This can be scheduled when you call to make your office visit appointment. ??????We recommend you see Dr [**First Name (STitle) **] in the Traumatic Brain Injury (TBI) clinic the phone number is [**Telephone/Fax (1) 6335**]. If you have any problems booking this appointment please ask for [**First Name8 (NamePattern2) 16367**] [**Last Name (NamePattern1) 16368**]. . Your insurance records are incomplete- please call our registration department at ([**Telephone/Fax (1) 22161**] before your first appointment. Department: RADIOLOGY When: WEDNESDAY [**2135-2-2**] at 10:00 AM With: CAT SCAN [**Telephone/Fax (1) 327**] Building: [**Hospital Ward Name 517**] CC CLINICAL CENTER [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: NEUROSURGERY When: WEDNESDAY [**2135-2-2**] at 11:00 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1669**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Suite B Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: CARDIAC SERVICES When: WEDNESDAY [**2135-1-12**] at 10:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Infectious disease follow up appointments: Opat attending visit: [**2135-1-13**] 02:30p ID,[**Doctor Last Name 1413**] [**Doctor First Name 1412**] ID WEST (SB) . Fellow visit: [**2135-1-28**] 11:30a ID,[**Doctor Last Name 13125**] [**Last Name (LF) **],[**First Name3 (LF) **] LM [**Hospital Ward Name **] BLDG ([**Doctor First Name **]), BASEMENT ID WEST (SB)

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Discharge summary

report

Admission Date: [**2179-2-11**] Discharge Date: [**2179-2-22**] Date of Birth: [**2120-6-4**] Sex: M This is summary of [**Hospital 228**] hospital course from [**2179-2-11**] to [**2179-2-19**]. HISTORY OF PRESENT ILLNESS: The patient is a 58-year-old multifactorial pulmonary disease on 4 liters home nasal cannula oxygen who presents with a three day history of increasing weakness and shortness of breath. Two days prior to admission VNA recorded blood pressure of 50/30 (normal systolic blood pressure 80-90). The patient was alert and oriented with this blood pressure. [**Name (NI) **] wife reports no history of fevers, chills, nausea, vomiting, diarrhea, cough, cough productive of white sputum. In addition, patient has sacral decubitus ulcer which has been improving. The patient was treated for left lower extremity toe cellulitis approximately two weeks ago with course of Keflex. Of note, wife reports patients friends visited the patient three days prior to admission and are known to give patient Benzodiazepines and narcotics. At hemodialysis the patient's systolic blood pressure was 82. Blood pressure dropped to 77 and patient received 200 cc of IV fluids with increase in systolic blood pressure to 85. The patient was noted to be sedated and Narcan 0.8 mg was given with some increase in responsiveness. Blood cultures and EKG were done and patient was given Vancomycin 1 gm and Gentamycin 80 mg for empiric treatment of sepsis. In the Emergency Room patient's temperature was 96.3, blood pressure 96/61, sat 83% on room air. The patient was poorly responsive with blood pressure decreased to 60's. Dopamine was started at this time. O2 sats at 100% non rebreather mask decreased to the 80's and chest x-ray was obtained which was consistent with CHF. An additional Narcan 0.4 mg was given with minimal effect. ABG was obtained which showed 6.93/133/72 and patient was intubated for hypoxic hypercarbic respiratory failure and Neo-Synephrine was started. The patient was then taken to the MICU. PAST MEDICAL HISTORY: 1) AIDS diagnosed in [**2159**], no opportunistic infections except for a question of candidal esophagitis. CD4 count stable in the 130's. Toxo titers negative. 2) Hepatitis C and hepatitis B virus. 3) End stage renal disease on hemodialysis. 4) History of DVT and pulmonary embolus in [**2168**] on Coumadin. 5) History of positive PPD. 6) Multifactorial pulmonary disease with history of PE and COPD on 4 liters O2 nasal cannula at home. 7) History of pancreatitis. 8) History of pneumonia requiring intubation. 9) History of IV drug use on Methadone. 10) History of HIV cardiomyopathy. 12) History of VT in [**10-24**], status post ablation on Amiodarone. MEDICATIONS: On admission, Methadone 50 mg po q a.m., Amiodarone 200 mg po q d, Captopril 6.25 mg po bid, Coumadin 2 mg po q h.s., Diazepam 5-10 mg po tid prn anxiety, Epogen 9,000 units three times per week given at dialysis, Fentanyl patch 50 mcg per hour q 72 hours, Folic Acid 1 mg po q d, Lactulose 15 cc q 6 hours prn constipation, Lamivudine 25 mg po q d, Lopressor 12.5 mg po bid, Megace 20 mg po q d, Neurontin 100-200 mg po tid for neuropathy, Prevacid 30 mg po q d, Percocet 1-2 tabs qid as needed for pain, no more than 6 tablets per day, Sertraline 50 mg po q d, then Stavudine 20 mg po q d, Bactrim DS one tablet po three times a week. ALLERGIES: Haldol causes a rash. Thorazine anaphylaxis. History that H2 blockers cause thrombocytopenia. Clindamycin, rash. Codeine, rash. Stelazine, rash. SOCIAL HISTORY: The patient lives at home with his wife. History of IV drug use, Cocaine and Marijuana use, 120 pack year smoker, quit alcohol 10 years ago. LABORATORY DATA: On admission, WBC 10.8, INR 3.9, platelet count 128,000. Electrolytes within normal limits. Creatinine 5.1, BUN 40. LFTs, ALT 24, AST 35, alkaline phosphatase 181, total bilirubin 0.6, CPK 39. Tox screen positive for Benzodiazepine. ABG on admission, 6.93/131/72. Lactate 1.0. MICROBIOLOGY: Blood cultures 3-21 and [**2-12**] show no growth to date. Fundal blood culture and AFB blood culture show no fungus or macrobacteria isolated. Sputum culture [**2-13**], sparse growth of MRSA. RADIOGRAPHIC IMAGING: Chest x-ray [**2-11**], moderate CHF. Chest x-ray [**2179-2-13**], hazy bilateral lung opacities which are improved from previous exam, subsegmental atelectasis of the left base. PHYSICAL EXAMINATION: On admission, in general, somnolent, poorly arousable, pupils 3 mm bilaterally reactive. HEENT: No scleral icterus, conjunctiva pale, oropharynx clear, moist mucus membranes. Neck supple with no lymphadenopathy. CV, regular rate with no murmurs, rubs or gallops. No erythema or fluctuants. Pulmonary, diffuse rales bilaterally, poor air movement, poor inspiratory effort. Abdomen, nontender, non distended, normal bowel sounds, no masses. Extremities, no edema, no lesions, no rashes. Neuro, non verbal, reflexes 2+ throughout. HOSPITAL COURSE: [**2179-2-11**] to [**2179-2-19**]: The patient is a 58-year-old male with AIDS, end stage renal disease on hemodialysis, multifactorial pulmonary disease on home O2 use with history of hypercarbic respiratory failure who presents with three day history of increasing fatigue and shortness of breath. The patient was found to be in hypocarbic respiratory failure with hypotension. Differential diagnosis on admission was sepsis vs overdose of Benzodiazepines or narcotics. 1. Pulmonary: The patient has long history of multifactorial pulmonary disease including history of pulmonary embolism and COPD, who presents with increasing fatigue and shortness of breath. In the Emergency Room, patient's O2 sats decreased to 80's on 100% on rebreather. ABG showed 6.93/133/72 on 100% non rebreather, consistent with a primary respiratory acidosis with mild metabolic acidosis. The patient was subsequently intubated. Etiology o hypercarbic respiratory failure included overdose of narcotics or Benzodiazepines causing decreased central drive vs obstruction from infectious process. The patient did have a small response to administration of Narcan in the Emergency Room. The patient was subsequently extubated on hospital day #2. ABG done post extubation on four liters nasal cannula showed PH 7.20, PCO2 60, PO2 65 which is thought to represent patient's baseline pulmonary status. Following extubation, patient's O2 saturation remained stable on four liters of nasal cannula oxygen which is patient's baseline O2 requirement. Of note, patient is not taking any MDIs or nebulizers for history of COPD, as patient states he does not like the way they make him feel. During this admission the patient's Methadone was continued but other narcotics and Benzodiazepines were initially held. The patient was started on Percocet one tablet po q 4 hours for pain. 2. Infectious Disease: Following intubation, patient spiked a temperature to 101.6 associated with leukocytosis with white count of 10.8. In the Emergency Room the patient became hypotensive with systolic blood pressures in the 60's and patient was started on Vancomycin, Gentamycin and Levaquin for empiric treatment of sepsis. Blood cultures, fungal cultures and AFB cultures drawn on admission all showed no growth to date. Sputum cultures grew MRSA and chest x-ray showed bilateral lung opacities consistent with a pneumonia. Whether pneumonia was a primary event causing respiratory failure or result of aspiration following intubation is unclear. On hospital day #2 Levaquin and Gentamycin were discontinued and patient was kept on Vancomycin for 14 day course of antibiotics for treatment of MRSA pneumonia. Of note, patient does have baseline productive cough which slightly worsened during this admission. The patient was continued on Stavudine and Lamivudine for HIV. In addition, patient is on Bactrim DS one tablet three times a week for PCP [**Name Initial (PRE) 1102**]. 3. Cardiovascular: Patient presents with history of HIV, dilated cardiomyopathy with EF of 30-40% in [**2178-1-22**]. In addition, patient has a history of VT in [**2178-10-24**] status post ablation, now on Amiodarone. In the Emergency Room the patient was found to be hypotensive with systolic blood pressures in the 60's (of note, patient's baseline systolic blood pressure is 80-90). Chest x-ray was consistent with CHF. The patient was started on Neo-Synephrine for hypotension. Differential diagnosis of hypotension included sepsis vs overdose of Benzodiazepines and narcotics. A repeat echocardiogram was obtained to ascertain if patient had decreased systolic function leading to worsening CHF. Echocardiogram showed an EF of 70%. TR gradient was greater than 44 mmHg. Left ventricular systolic function was normal with mild symmetric left ventricular hypertrophy. The RV free wall was hypertrophied with severe global RV free wall kinesis. Compared to previous study of [**1-22**], the left ventricular ejection fraction is now significantly increased with RV contractile function remaining significantly reduced. Due to hypotension with normal EF, the patient's Lopressor and Captopril were held. Of note, due to history of low blood pressure, Cortisol level was sent and was normal at 21. 4. Hematology: The patient presents with history of DVT and PE on lifetime anticoagulation. Coumadin was continued at 2 mg po q h.s. 5. Renal: The patient has end stage renal disease thought to be secondary to membranoproliferative glomerulonephritis vs IgA nephropathy. The patient was continued on Epogen for history of anemia. For hyperphosphatemia the patient is currently taking RenaGel 3200 mg po tid and TUMS three tablets po tid. 6. Prophylaxis: The patient was continued on Protonix, Colace and Coumadin. CODE STATUS: The patient is full code. [**First Name11 (Name Pattern1) 4283**] [**Last Name (NamePattern4) 4284**], M.D. [**MD Number(1) 7551**] Dictated By:[**Last Name (NamePattern1) 1297**] MEDQUIST36 D: [**2179-2-19**] 15:25 T: [**2179-2-19**] 17:42 JOB#: [**Job Number **]

[ "482.41", "070.54", "799.4", "425.8", "042", "518.81", "428.0", "585", "070.32" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

5014, 10133

4459, 4996

246, 2055

2078, 3561

3578, 4436

45,407

188,328

38915

Discharge summary

report

Admission Date: [**2158-2-27**] Discharge Date: [**2158-3-3**] Date of Birth: [**2115-3-1**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1973**] Chief Complaint: Coffee-ground emesis Major Surgical or Invasive Procedure: Endoscopy [**2158-2-27**] History of Present Illness: Mr. [**Known lastname **] is a 42yo M w/hx of alcohol abuse, HCV cirrhosis, esophageal varices, DM2 and multiple admissions for variceal banding who presents with coffee-ground emesis. He was recently admitted [**Date range (3) 86337**] for an upper GI bleed and had grade III varices banded on [**2158-2-21**]. On discharge he was given prescriptions and money for his medications but did not pick them up. He reports that he left the hospital and was on the street. He drinks > 10 beers per day. He was scheduled to see Dr. [**Last Name (STitle) 497**] on the day of admission for repeat banding which he did not show for. He was admitted to [**Hospital 4199**] Hospital yesterday after being in a fight and discharged today. He reports drinking alcohol starting at 2pm today, then having 4 episodes of coffe-ground emesis. He went to an OSH ED where NG lavage showed 100ml of coffee-ground emesis. At the OSH ED, he was given Morphine 2mg IV x 2 Protonix 40mg IV x 1 and started on an octreotide gtt, then sent here. HCT was reportedly 45 at [**Hospital 4199**] Hospital. . In the ED, initial vs were: T99.2 106 138/90 16 96%. He was put on an octreotide and protonix drips. Attempt was made to repeat the NG lavage but this failed. His HCT was 38. . On the floor, he complains of [**7-4**] epigastric pain radiating to the back. He states that it feels like someone is punching him in the stomach. It is similar to prior episodes of abdominal pain. He reports nausea. Denies melena or BRBPR. Otherwise ROS is negative. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: EtOH Abuse Cirrhosis Hepatitis C: No prior treatment Diabetes Mellitus 2 - 20 + years Tobacco Use Depression Hypertension GERD Pancreatitis Diverticulitis Hemorrhoids Atypical chest pain Social History: - Tobacco: 1 ppd x 20+ years - Alcohol: 6-12 beers daily (none x 3 days) - Illicits: None Family History: No history of bleeding disorders or abdominal bleeding. Both parents still living. Physical Exam: Vitals: T: 98.5 BP: P: R: 18 O2: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, bruising over right eye, NG tube in place 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, epigastric tenderness without rebound, 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: Labs on Admission: [**2158-2-27**] 06:45PM PT-14.8* PTT-31.1 INR(PT)-1.3* [**2158-2-27**] 06:45PM PLT COUNT-157# [**2158-2-27**] 06:45PM NEUTS-44.4* LYMPHS-49.2* MONOS-4.7 EOS-0.7 BASOS-1.0 [**2158-2-27**] 06:45PM WBC-7.3# RBC-4.65 HGB-13.3* HCT-38.8* MCV-83 MCH-28.6 MCHC-34.3 RDW-14.6 [**2158-2-27**] 06:45PM ASA-NEG ETHANOL-147* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2158-2-27**] 06:45PM LIPASE-31 [**2158-2-27**] 06:45PM ALT(SGPT)-175* AST(SGOT)-249* LD(LDH)-227 ALK PHOS-127 TOT BILI-0.9 [**2158-2-27**] 06:45PM estGFR-Using this [**2158-2-27**] 06:45PM GLUCOSE-117* UREA N-9 CREAT-0.6 SODIUM-143 POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-27 ANION GAP-16 [**2158-2-27**] 10:05PM HCT-37.3* Labs on Discharge: [**2158-3-2**] 06:20AM BLOOD WBC-5.2# RBC-4.58* Hgb-13.2* Hct-38.6* MCV-84 MCH-28.8 MCHC-34.3 RDW-14.4 Plt Ct-107* [**2158-3-2**] 06:20AM BLOOD Glucose-181* UreaN-6 Creat-0.7 Na-135 K-3.7 Cl-99 HCO3-27 AnGap-13 [**2158-3-2**] 06:20AM BLOOD ALT-160* AST-244* Studies: Endoscopy [**2158-2-27**]: 3 cords of grade II varices with ulcerations were seen in the distal esophagus; one with intact band. Other Blood clot in the stomach, no gastric varices. Otherwise normal EGD to pylorus Brief Hospital Course: Mr. [**Known lastname **] is a 42yo M w/hx of alcohol abuse, HCV cirrhosis, DM2 who presented with coffee-ground emesis in the context of EtOH intoxication. . # Acute Blood Loss Anemia due to Esophageal Varices with Bleeding: The patient presented with UGIB likely from bleeding varices as this patient has a known history of esophageal varices and multiple banding procedures. No active varices seen on EGD, but evidence of ulceration in the area of previous banding was noted. The EGD also noted 250cc of blood in the stomach, so further episodes of hematemesis were expected but did not occur. The patient was maintained on an octreotide drip as well as a protonix drip while in the MICU. Serial hematocrits were monitored and reached a nadir of 34 from an admission hematocrit of 38. His hemodynamics were monitored closely without any instability. The patient was also treated with ciprofloxacin [**Hospital1 **] for prophylaxis for gut translocation after EGD. His Hct remained stable thereafter and he did not require any blood transfusions. He was transitioned to oral PPI, restarted on home dose nadolol and diet advanced as tolerated. He had no further evidence of GI bleeding during his admission, and he was discharged with a plan for repeat EGD to be performed [**3-14**]. . # Alcohol Dependence/Withdrawal: Pt with active EtOH abuse, but would like to stop drinking and would ideally like treatment to maintain his sobriety. The patient was maintained on thiamine, folate, and multivitamin. He was initially treated with diazepam on a CIWA scale, but required minimal dosing of benzodiazepines. His CIWA was discontinued on [**2158-3-3**] and he had no evidence of ongoing withdrawal. He was . # Type 2 Diabetes Uncontrolled with Complications: The patient was maintained on his home dose of Lantus and humalog sliding scale. . # S/P Fight: Multiple bruises but no evidence of intra-abdominal bleeding. . # Abdominal pain: Felt to be multifactorial from splenomegaly and gut spasm from bleed. He was treated with tramadol prn for pain, and his gabapentin titrated up. . # Cirrhosis due to Alcohol, Chronic Hepaititis: No signs of decompensated cirrhosis during this admission. Patient was continued on nadolol as noted above. . # Benign Hypertension: Restarted on home dose Lisinopril after Hct stabilized. . # Tobacco Use: Active use. Pt did not require a nicotine patch during this admission. Provided counseling on smoking cessation. . # Depression: Restarted on prior outpatient doses paroxetine and quetiapine. Medications on Admission: (from prior d/c summary, but patient not taking) Nadolol 20mg PO qday Thiamine 100mg PO qday Folic Acid 1mg PO qday Lisinopril 5mg PO qday Pantoprazole 40mg PO q12H Sucralfate 1gm PO QID Gabapentin 300mg PO TID Quetiapine SR 300mg PO qday Paroxetine 30mg PO qday Vitamin D3 400IU PO qday Lantus 60 units PO qAM Humalog sliding scale Discharge Medications: 1. Lantus 100 unit/mL Solution Sig: Sixty (60) Subcutaneous qAM. 2. Humalog 100 unit/mL Solution Sig: ASDIR Subcutaneous four times a day: Please see sliding scale. 3. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*2* 8. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). Disp:*90 Capsule(s)* Refills:*2* 9. Quetiapine 300 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 10. Paroxetine HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Vitamin D-3 400 unit Tablet Sig: One (1) Tablet PO once a day. 12. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 13. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 1 days. Disp:*2 Tablet(s)* Refills:*0* 14. 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* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: Upper GI bleed EtOH Abuse and intoxication Facial contusion . Secondary Diagnoses: Cirrhosis, secondary to EtOH and HCV Hypertension Diabetes Mellitus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You have a diagnosis of cirrhosis, and were admitted to the hospital because of bleeding from your GI tract. This bleeding is most likely related to your alcohol use, and you need to stop drinking alcohol completely. If you do not stop drinking, you will likely have another bleed that could result in death. . We made the following changes to your home medications: -INCREASE Gabapentin to 400 mg three times daily -START Ciprofloxacin - take twice daily for another 1 day -CHANGE pantoprazole to Omeprazole 40 mg twice daily Please restart your prior home medications. Take all medications as prescribed. Followup Instructions: You have an appointment for repeat banding, detailed below. It is very important that you do not eat or drink from midnight the night before this procedure. Department: DIGESTIVE DISEASE CENTER When: TUESDAY [**2158-3-14**] at 1 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 463**] Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3202**] Campus: EAST Best Parking: Main Garage Department: ENDO SUITES When: TUESDAY [**2158-3-14**] at 1 PM

[ "571.2", "250.02", "577.1", "303.01", "305.1", "070.54", "311", "572.3", "285.1", "401.9", "V65.49", "456.20" ]

icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

9122, 9128

4661, 7204

334, 362

9342, 9342

3404, 3409

10127, 10738

2716, 2800

7587, 9099

9149, 9230

7230, 7564

9493, 9844

2815, 3385

9251, 9321

9862, 10104

1950, 2382

274, 296

4152, 4638

390, 1931

3423, 4133

9357, 9469

2404, 2592

2608, 2700

17,760

194,497

47118

Discharge summary

report

Admission Date: [**2156-9-9**] Discharge Date: [**2156-9-13**] Service: [**Hospital Unit Name 196**] Allergies: Oxacillin Attending:[**First Name3 (LF) 2901**] Chief Complaint: Sudden onset of chest pain Major Surgical or Invasive Procedure: Cardiac catheterization with 2 stents placed in RCA History of Present Illness: 87 y/o with history of HTN, atrial fibrillation, and hyperlipidemia presents with sudden onset of CP at 2am . It radiated to his neck and back. No dyspnea, diaphoresis at OSH. He was found to have inferior ST elevations and complete heart block w/BP 96/53, HR=43, RV4 w/ST elev. He was sent to [**Hospital1 **] w/transcutaneous pacing, started on hep gtt, integrilin, ASA, MSO4, guiac - by ED note. Received 2.5L IVF. In cath lab, he was found to have RCA totally occluded in mid section w/prox stenosis as well, and a tight OM1. RCA got 2 heparin coated stents w/good result. Pressures: RA=16, PA=42/24, PCWP=24, PA sat=49%. He also got atropine in cath lab on presentation. Currently asymptomatic. Past Medical History: 1.HTN 2. AF 3. PVD (MRA BLE [**5-/2156**] showed 90% stenosis of superficial femoral artery on right, 70-80% stenosis of prox popiteal artery on left, severe stenosis of right ant tibial artery and occlusion of bilat peroneal arteries) 4. COPD 5. Blind in R eye [**3-15**] chol emboli 6. Hypercholesterolemia 7. CN 6 paralysis 8. GIB [**6-/2156**] with EGD showing 2 small duodenal ulcers, prior gastric ulcer 9. Depression 10. Cervical laminectomy Social History: Lives alone in independent living facility. Smoked for 15 years, but stopped 40 years ago. Family History: Not known to be contributory Physical Exam: BP=101/42, HR=69, RR=20, 99% on 4LNC. Gen: Elderly, alert, oriented, lying flat comfortably. HEENT: EOMI, PERRLA, dilated equally, MM dry Neck:No bruits, no LAD CV:Distant heart sounds, RRR, nL S1,S2. No MRG, No carotid bruits. Chest:Bibasilar rales anteriorly and laterally. Abdomen:NT/ND, NABS, No organomegaly, Soft Ext:No edema, cyanosis, clubbing, DP pulses are dopplerable. Pertinent Results: [**2156-9-9**] 10:45AM BLOOD WBC-7.3 RBC-3.80* Hgb-11.4*# Hct-35.2* MCV-93 MCH-30.0 MCHC-32.4 RDW-14.0 Plt Ct-166 [**2156-9-9**] 05:06PM BLOOD Hct-33.7* Plt Ct-169 [**2156-9-10**] 01:00AM BLOOD Hct-33.8* [**2156-9-11**] 06:30PM BLOOD WBC-7.7 RBC-3.85* Hgb-11.8* Hct-35.2* MCV-91 MCH-30.6 MCHC-33.4 RDW-14.0 Plt Ct-148* [**2156-9-12**] 05:40AM BLOOD WBC-6.3 RBC-3.55* Hgb-10.7* Hct-32.9* MCV-93 MCH-30.3 MCHC-32.6 RDW-13.9 Plt Ct-176 [**2156-9-9**] 10:45AM BLOOD Neuts-85.9* Lymphs-9.8* Monos-3.5 Eos-0.5 Baso-0.4 [**2156-9-12**] 05:40AM BLOOD Plt Ct-176 [**2156-9-9**] 10:45AM BLOOD PT-13.7* PTT-33.5 INR(PT)-1.2 [**2156-9-9**] 10:45AM BLOOD Glucose-119* UreaN-35* Creat-1.7* Na-141 K-4.8 Cl-111* HCO3-24 AnGap-11 [**2156-9-9**] 05:06PM BLOOD K-3.8 [**2156-9-10**] 01:00AM BLOOD Glucose-130* UreaN-29* Creat-1.6* Na-139 K-4.1 Cl-106 HCO3-24 AnGap-13 [**2156-9-11**] 06:30PM BLOOD Glucose-168* UreaN-32* Creat-1.7* Na-141 K-4.0 Cl-106 HCO3-24 AnGap-15 [**2156-9-12**] 05:40AM BLOOD Glucose-98 UreaN-34* Creat-1.8* Na-142 K-4.4 Cl-108 HCO3-24 AnGap-14 [**2156-9-11**] 06:30PM BLOOD ALT-50* AST-92* AlkPhos-114 TotBili-0.4 [**2156-9-9**] 10:45AM BLOOD CK(CPK)-697* [**2156-9-9**] 05:06PM BLOOD CK(CPK)-1443* [**2156-9-10**] 01:00AM BLOOD ALT-58* AST-223* CK(CPK)-1345* AlkPhos-104 TotBili-0.5 [**2156-9-9**] 10:45AM BLOOD CK-MB-124* MB Indx-17.8* cTropnT-2.27* [**2156-9-9**] 05:06PM BLOOD CK-MB-225* MB Indx-15.6* [**2156-9-10**] 01:00AM BLOOD CK-MB-170* MB Indx-12.6* [**2156-9-9**] 10:45AM BLOOD Calcium-8.3* Phos-3.3 Mg-1.9 Cholest-131 [**2156-9-10**] 01:00AM BLOOD Calcium-8.0* Phos-2.9 Mg-1.9 [**2156-9-12**] 05:40AM BLOOD Mg-2.2 [**2156-9-9**] 10:45AM BLOOD Triglyc-61 HDL-47 CHOL/HD-2.8 LDLcalc-72 [**2156-9-11**] 06:30PM BLOOD TSH-2.8 Cardiac Cath: COMMENTS: 1. Selective coronary angiography revealed a right-dominant system with 3-vessel coronary disease. The LMCA was a short vessel with no angiographically apparent disease. The LAD was heavily calcified and diffusely diseased in the mid-vessel up to 70%. The LCx was diffusely diseased in the mid-vessel with a long lesion up to 80%. A large OM1 branch had a 50-60% proximal stenosis. The RCA was calcified with a total occlusion in the proximal vessel. 2. Resting hemodynamics revealed moderately elevated right- and left-sided filling pressures (mean RA 16 mmHg, mean PCW 22 mmHg). There was moderate pulmonary artery hypertension (mean PA 32 mmHg). The cardiac index was severely depressed at 1.6 L/min/m2. 3. The patient entered the lab in complete heart block with an escape rate of 40 bpm. A 5 French temporary pacing wire was placed in the right ventricle with successful capture and pacing at 60 bpm. The patient's heart block resolved and the pacing wire was was removed at the end of the case. 4. Successful stenting of the mid RCA was performed with overlapping 3.0 x 18 mm and 3.5 x 18 mm Hepacoat stents. 5. Successful closure of the right groin was performed with a 6Fr Angioseal device. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Elevated filling pressures. 3. Acute inferior MI, terminated by primary PCI. 4. Angioseal of the groin. Echo: Conclusions: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Resting regional wall motion abnormalities include inferior akinesis and inferolateral hypokinesis. The right ventricular cavity is dilated. Right ventricular free wall is not fully visualized but systolic function appears depressed. The aortic root is moderately dilated. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (tape reviewed) of [**2152-12-29**], regional wall motion abnormality is new and estimated pulmonary artery systolic pressure is now higher. CXR: IMPRESSION: 1. Patchy right lower lobe opacity, likely represent atelectasis. 2. The previously described hazy opacity overlying the right hemithorax is less apparent on the current study. 3. Small left pleural effusions. 4. Emphysema. Brief Hospital Course: Mr [**Known lastname **] was admitted from the cath lab after stenting of his RCA to treat his ST elevation inferior MI and complete heart block. He recovered well from his MI and heart block and was discharged to acute rehab due to deconditioning and recent issues with falling/loss of balance. Problems addressed included: 1. CAD: Initially was transcutaneously paced before cath. Did not require pacing afterwards. His MI was inferior and appears to involve the RV. He was initially given ASA, Plavix, and 18 hours of integrilin. His lipitor was increased to 80 mg qd. He was slowly started on an ACE-I as his BP would tolerate. A beta-blocker was then added and increased to his current dose of metoprolol 25 mg [**Hospital1 **]. He tolerated these well. No additional chest pain during the admission. His enzymes were cycled, and his CK peaked at 1443. 2. Pump issues: He had an echo which showed an EF=45-50%, with some akinetic areas. His ACE-I was continued for afterload reduction. It was decided not to anticoagulate him due to recent history of large GIB. He had [**Last Name **] problem maintaining his BP during admission. 3.EP/cardiac rhythm: He initially had a prolonged PR interval and RBBB. Also has h/o A fib. Again, was decided that we would not restart coumadin due to GIB risk. He developed both frequent NSVT and went into a fib while here. He was started on amiodarone (loading with 400 [**Hospital1 **] x7d, then 400 qd x7d, then 200 qd ongoing)and kept on his B-blocker. This will address both arrhythmias effectively in someone who is not likely a candidate for an ICD if the NSVT continues. Baseline LFTs and TFTs were obtained prior to amio. He will need close follow-up of this NSVT to determine effectiveness of amiodarone. It was asymptomatic while he was here. He will have a Holter monitor for 24 hours in several weeks after his amio load is complete, and will then follow-up with EP to have this reevaluated and further treatment prescribed. 4. CRI: He has CRI of unknown etiology. His Cr was high, but stable in 1.7 range. It was followed closely as was his UOP, which remained adequate. His Flomax and Detrol were also continued. 5. COPD: He had some wheezing during admission. He was also on O2 for much of the time, with reported SOB when he got up without it. He responded well to prn albuterol and atrovent MDIs. On discharge, he was maintaining adequate O2 sats off of O2 and his wheezing was absent most of the time. He was sent out on atrovent MDI for this. 6. ? lung infiltrate: A "hazy opacity" was initially seen on portable CXR. Repeat PA/lateral reported that the "previously described hazy opacity overlying R hemithorax was now less apparent". This will need to be followed with a repeat Pa/lateral as an outpatient in 1 month to determine significance and whether it needs to be further worked up. No cough. 7. He was discharged to rehab for acute conditioning. He has also been having increased number of falls and reports feeling unsteady when walking. This can be addressed at rehab. Does not sound like an acute event (stroke), but rather a chronically progressive issue for him. 8.Follow-up: Needs to be seen for a follow-up CXR in about 1 month to evaluate his "hazy opacity" for changes. Also needs to follow-up with EP to evaluate his improvement after a full amiodarone load. We will try to schedule a Holter monitor for a few days before this visit (after full load complete) so they have information about his current rhythm. Medications on Admission: 1.Coumadin 4 mg qd 2. Zoloft 150 qd 3. Norvasc 5 qd 4. Cozaar 25 qd 5. Lipitor 40 qd 6. Flomax 4 qd 7. Detrol 4 qd 8. Vioxx 25 qd 9. Combivent 2 puffs qid Discharge Medications: 1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD (once a day). 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QD (once a day). 3. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO QD (once 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. 6. Sertraline HCl 50 mg Tablet Sig: Three (3) Tablet PO QD (once a day). 7. Tolterodine Tartrate 2 mg Tablet Sig: One (1) Tablet PO QD (once a day). 8. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 9. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 10. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed). 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO QD (once a day). 13. Amiodarone HCl 200 mg Tablet Sig: as directed Tablet PO as directed: Take 400 mg twice a day for 5 days, then take 400 mg/day for 7 days, then take 200 mg/day ongoing. 14. Atrovent 18 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation four times a day. Discharge Disposition: Extended Care Facility: [**Location (un) 582**] Of [**Location (un) 620**] Discharge Diagnosis: 1.Inferior ST elevation Myocardial Infarction 2.Atrial fibrillation 3.COPD 4.Chronic Renal Insuffciency 5.GI BLEED Discharge Condition: Pt was stable without any chest pain.He did have some SOB with activity and some unsteadiness when attempting to walk.Eating well and no issues with cognition. Discharge Instructions: Please call your doctor or return to the hospital if you experience new chest pain or shortness of breath. Several new medications were started. Please take notice of these. Most importantly, do not stop your Plavix medication for at least 30 days as it is important for keeping your cardiac stents from becoming blocked. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], M.D. Where: [**Hospital6 29**] NEUROLOGY Phone:[**Telephone/Fax (1) 1694**] Date/Time:[**2156-9-14**] 4:00 Department of Cardiology: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**]- [**Telephone/Fax (1) 285**]- [**2156-10-11**] at 11 AM. [**Telephone/Fax (1) 3104**]- Holter Lab- [**2156-10-6**]- at 11AM Please schedule an appointment to follow-up with your PCP [**Last Name (NamePattern4) **] 1 week of discharge from rehab. You will need a repeat chest X-ray in [**4-15**] weeks as described in your discharge summary. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]

[ "414.01", "410.41", "401.9", "427.31", "593.9", "427.1", "496", "272.0" ]

icd9cm

[ [ [] ] ]

[ "37.23", "99.20", "88.56", "36.06", "36.01", "37.78" ]

icd9pcs

[ [ [] ] ]

11412, 11489

6391, 9926

263, 316

11648, 11809

2090, 5074

12181, 12977

1643, 1673

10131, 11389

11510, 11627

9952, 10108

5091, 6368

11833, 12158

1688, 2071

197, 225

344, 1045

1067, 1518

1534, 1627

78,551

194,101

6286

Discharge summary

report

Admission Date: [**2126-3-6**] Discharge Date: [**2126-3-13**] Date of Birth: [**2064-9-2**] Sex: M Service: NEUROSURGERY Allergies: Morphine Attending:[**First Name3 (LF) 1835**] Chief Complaint: Lower extremity weakness Major Surgical or Invasive Procedure: T1 to T8 lamenectomies for tumor debulking History of Present Illness: Mr. [**Known lastname 24399**] [**Known lastname 24400**] is a 61 yo M with widely metastatic prostate CA who preents with 2 days of progressive lower extremity weakness. The patient had been ambulating normally 2 days prior, then yesterday he required assistance, and was leaning on furniture to stand. Today, he was completely unable to stand, walk and could not move his legs. He denies any neck or back pain. He denies headache. At baseline he ambulates independently, and has used a cane infrequently for long distances. The patient endorses numbness in the legs for 2 days as well. He endorses an altered sensation in the groin area, but states it is not completely numb. He had incontinence of urine today. He was not able to feel himself urinating at first, and then became aware but was unaware to get himself to the bathroom. He has not moved his bowels in several days, and has not had the urge to do so. He c/o chest pain for 1 week, likely due to bony mets, and cough for 1 month. Past Medical History: Metastatic prostate Ca, with diffuse skeletal mets, initially diagnosed in [**2112**] s/p radical prostatectomy and penile prostheses, s/p hormone therapy and chemotherapy, on Lupron and a clinical phase I trial of MDV3100 (selective androgen receptor modulator) -HTN -GERD -Hyperlipidemia -Glaucoma Social History: Drinks 2-12 glasses wine/day, currently smokes 1pp x 40 years, denies illicits. Lives in Northern NH with his wife and son. Retired from transportation. Family History: Both parents died of complications related to alcoholism. No FHx of cancers. Physical Exam: O: T: 98.5 HR 98 BP 109/61 RR 24 02 92% RA Gen: WD/WN, uncomfortable with movement, NAD. HEENT: Pupils: EOMs Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused, 2+ pitting edema bilaterally Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Motor: normal tone D B T WE WF IP Q H AT [**Last Name (un) 938**] G R 5- 5 5 5 5 3 2 3 3 2 1 L 5 5 5 5 5 3 2- 3- 3 2 1 Sensation: Decreased sensation to light touch at right lateral and anterior thigh. Reflexes: B T Br Pa Ac Right 2 2 2 1 1 Left 2 2 2 1 1 3 beats clonus on R Toes R upgoing, L downgoing Rectal exam normal tone, sensation intact On Discharge: Motor exam improved to 5/5 strength. Pertinent Results: [**3-6**] MRI spine: IMPRESSION: 1. Widespread extensive metastatic bone infiltration throughout the spine. 2. Mildly enhancing extramedullary and intradural lesion extending from T1 to T6 narrowing the canal and mildly compressing the cord, consistent with a metastatic process. 3. Multilevel degenerative changes in the cervical spine with canal narrowing as described above. Dural enhancement from the posterior fossa extends down the posterior cervical canal due to metastatic process. 4. Lumbar spine demonstrates multilevel degenerative changes and moderate-to-severe canal narrowing at multiple levels due to predominantly epidural fat and combination of other degenerative factors. Small enhancing epidural lesion involving the right L2 pedicle and deforming the thecal sac. [**3-6**] MRI Brain: IMPRESSION: 1. Interval development of a new extra-axial metastatic lesion in the left anterior temporal region and a small lesion in the left cerebellum and interval increase in minor dural enhancement on the right. New FLAIR signal changes from vasogenic edema in the left temporoparietal lobe and left cerebellum. 2. Marked reduction in the size of extra-axial enhancing mass in the left frontoparietal region. 3. No acute infarction. [**3-7**] CT Torso:IMPRESSION: 1. Increase in size of right lateral chest wall metastases with new right pleural-based pleural effusion. 2. New right hepatic metastases. 3. Extensive sclerosis involving the entire appendicular and axial skeleton. New pathological fracture of the right lateral 5th rib adjacent to the enlarging chest wall lesion. The degree of cord compression in the thoracic spine, as seen on prior MRI, is difficult to fully visualise on this non-dedicated CT. [**3-7**] CT T-Spine: IMPRESSION: Status post T1 - T8 laminectomy with post-surgical changes in the spinal canal and posterior soft tissue with drain in place. No large fluid collections seen. Please note evaluation of the spinal canal is suboptimal. Brief Hospital Course: Mr. [**Known lastname 24399**] [**Known lastname 24400**] was admited thru the ED to the neurosurgical service after an MRI showed an epidural mass at T1 to T8 with cord compression. The patient went to the ICU and was started on Steroids which improved his motor exam. He was taken to the Operating room on HD#2 for a thoracic decompression and tumor debulking. Intraoperatively he recieved four units of PRBCs and two units of FFP to correct his coagulopathy. He had a 1200cc blood loss. He was taken to the ICU intubated and extubated in the evening. A post operative CT did not reveal any evidence of an epidural hematoma. Upon transfer to the floor, the patient was seen by PT and OT..... On [**3-9**] drains and PCA were discontinued. Foley trial was initiated. Lung sounds revealed crackles bilaterally at bases. Pt stated that he was on Advair at home so this was started and had nebs prn. His drain was discontinued. On [**3-10**] his foley was discontinued but he failed 2 voiding trials and a Foley was replaced in the evening on [**3-12**]. At the time of discharge on [**3-13**] he is tolerating a regular diet, ambulating with an assistive device, afebrile with stable vital signs. Medications on Admission: BIMATOPROST [LUMIGAN] - (Prescribed by Other Provider) - Dosage uncertain CITALOPRAM - 40 mg Tablet - 1 Tablet(s) by mouth daily HYDROMORPHONE - 2 mg Tablet - 1 or 2 Tablet(s) by mouth every 3 hours as needed for pain IRBESARTAN [AVAPRO] - (Prescribed by Other Provider) - Dosage uncertain LEUPROLIDE (3 MONTH) [LUPRON DEPOT (3 MONTH)] - 22.5 mg Syringe - IM every three months LORAZEPAM [ATIVAN] - 1 mg Tablet - 1 Tablet(s) by mouth take one or two pills as needed as needed for for anxiety or sleep MORPHINE - 30 mg Tablet Extended Release - 1 or 2 Tablet(s) by mouth three times a day OMEPRAZOLE [PRILOSEC] - 20 mg Capsule, Delayed Release(E.C.) - take one day in the am Capsule(s) by mouth take one a day in the am PEGFILGRASTIM [NEULASTA] - 6 mg/0.6 mL Syringe - inject into skin every three weeks two days after chemotherapy PRAVASTATIN [PRAVACHOL] - (Prescribed by Other Provider) - Dosage uncertain PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth as needed every 6 hours as needed PSA TEST - - PSA test monthly starting [**7-29**] please give results to patient and fax to Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 24401**] WARFARIN [COUMADIN] - 1 mg Tablet - 1 Tablet(s) by mouth daily ZOLEDRONIC ACID [ZOMETA] - 4 mg/5 mL Solution - iv every three months to six months Medications - OTC LOPERAMIDE [IMODIUM A-D] - (Prescribed by Other Provider) - Dosage uncertain Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain fever. 2. insulin regular human 100 unit/mL Solution Sig: Sliding Scale Injection ASDIR (AS DIRECTED). 3. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 4. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 8. loperamide 2 mg Capsule Sig: One (1) Capsule PO DAILY (Daily) as needed for loose stool. 9. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 10. morphine 30 mg Tablet Extended Release Sig: Three (3) Tablet Extended Release PO Q8H (every 8 hours). 11. gabapentin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 12. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 14. losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for shoulder pain / Left. 16. dextromethorphan poly complex 30 mg/5 mL Suspension, Extended Rel 12 hr Sig: One (1) PO Q12H (every 12 hours) as needed for cough. 17. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 18. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 19. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. furosemide 20 mg Tablet Sig: One (1) Tablet PO 5 PM (). 21. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 22. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 23. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 24. morphine 15 mg Tablet Sig: 3-4 Tablets PO Q6H (every 6 hours) as needed for pain. 25. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 26. warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 27. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 28. dextrose 50% in water (D50W) Syringe Sig: One (1) Intravenous PRN (as needed) as needed for hypoglycemia protocol. 29. Valium 5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for Spasm. 30. dexamethasone 1 mg Tablet Sig: Two (2) Tablet PO every eight (8) hours for 1 days: on [**3-13**]. 31. dexamethasone 1 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 1 days: on [**3-14**], then stop dexamethasone on [**3-15**]. Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 24402**], ME Discharge Diagnosis: Spinal metastasis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: ?????? Do not smoke. ?????? Keep your wound(s) clean and dry / No tub baths or pool swimming for 14 days from your date of surgery. - ?????? You have Staple and desolveable sutures. The staples can be removed at 14 days postop however the sutures shoult NOT be removed. They will desolve in 6 weeks. You may shower after seven days and get your wound wet. ?????? No pulling up, lifting more than 10 lbs., or excessive bending or twisting. ?????? Limit your use of stairs to 2-3 times per day. ?????? Have a friend or family member check your incision daily for signs of infection. ?????? Take your pain medication as instructed; you may find it best if taken in the morning when you wake-up for morning stiffness, and before bed for sleeping discomfort. ?????? Increase your intake of fluids and fiber, as pain medicine (narcotics) can cause constipation. We recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? Pain that is continually increasing or not relieved by pain medicine. ?????? Any weakness, numbness, tingling in your extremities. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, and drainage. ?????? Fever greater than or equal to 101?????? F. ?????? Any change in your bowel or bladder habits (such as loss of bowl or urine control). Followup Instructions: Follow Up Instructions/Appointments - No Radiation therapy for at least 2 weeks postop to allow for wound healing. - Do NOT remove sutures, they will dissolve on their own. Staples will need to be removed at 14 days postop. ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **] to be seen in [**4-3**] weeks. ??????You will need a Thoracic spine MRI with and without contrast prior to your appointment. Completed by:[**2126-3-13**]

[ "530.81", "788.20", "198.5", "336.3", "197.0", "198.3", "272.4", "V10.46", "401.9" ]

icd9cm

[ [ [] ] ]

[ "03.4" ]

icd9pcs

[ [ [] ] ]

10655, 10733

4904, 6112

296, 341

10795, 10795

2898, 4881

12531, 13020

1876, 1955

7572, 10632

10754, 10774

6138, 7549

10978, 12506

1970, 2234

2841, 2879

232, 258

369, 1365

10810, 10954

1387, 1689

1705, 1860

75,798

149,915

53081

Discharge summary

report

Admission Date: [**2186-3-14**] Discharge Date: [**2186-4-4**] Date of Birth: [**2138-12-13**] Sex: M Service: MEDICINE Allergies: Ciprofloxacin Attending:[**Doctor First Name 2080**] Chief Complaint: Elective Spinal Surgery Major Surgical or Invasive Procedure: Spinal Surgery x2 Endotracheal intubation History of Present Illness: (History gathered from notes as patient is unable to give a history due to delerium). This is a 47-year-old gentleman with hepatitis C, chronic low back pain, migraines, GERD, who was admitted for elective spinal surgery for chronic low back pain, had his first procedure on [**3-14**] (anterior approach) and is supposed to go back to surgery tomorrow for the posterior approach. On admission, patient admitted to drinking [**6-15**] vodka drinks per day. He was put on a CIWA scale and started to become confused and aggitated on [**3-15**] (presumably approx 24-48 hours after his last drink). He was given 1mg IV ativan x 3 on [**3-15**] and progressively became worse today. Was given 6 IV ativan between 6 am and 2pm, then 2mg IV haldol at 2PM and 4PM and 10mg PO diazepam at 17:00. His CIWA has been between 10 an 16. . On eval, the patient is tachycardic, delerius- thought he was on a street, was constantly trying to get out of bed. He was given another 10mg PO Diazepam without effect. He then had a code purple called due to grabbing a nurse. He was given 10mg IV valium and put in 4 point restraints and the MICU was called. Past Medical History: 1. Chronic low back pain. 2. Chronic hepatitis C.-of note the patient had AST/ALT elevation 219/115 in [**2186-1-10**]. 3. Migraines. 4. GERD. 5. Tobacco abuse. 6. Herpes simplex virus manifest as cold sores on lips. Social History: The patient works as a house painter, but has recently found it difficult to get work. The patient lives in [**Location 47**] with his girlfriend with whom he has a monogamous relationship. The patient has smoked one pack a day tobacco for 20 years. He quit tobacco "cold [**Country 1073**]" last year for about three months. However, he has since resumed smoking. The patient also drinks about [**3-15**] glasses of beer or hard liquor per night. The patient is hesitant to cut down his alcohol use even though he knows it is not good for his liver. The patient used to use cocaine and believes that he contracted hepatitis C from "sharing straws." Family History: Dad died of pancreatic cancer 11 years ago. Mother with hypertension and colitis. The patient denies any other history of cancer in the family or history of diabetes, high cholesterol or heart disease. The patient has five brothers and sisters who are in good health. Physical Exam: Gen: Lying in bed, asking me to leave. HEENT: Sclera anicteric. PERRL. Neck: Supple, JVP not elevated. CV: tachycardic, no murmur. Chest: Resp were unlabored, CTAB on anterior exam. Abd: Soft, NTND. No HSM or tenderness. Ext: No c/c/edema. Skin: No stasis dermatitis, ulcers, scars. Neuro: Alert and oriented x 3, 5/5 strength in upper and lower extremities bilaterally, CNs II-XII grossly intact Pertinent Results: Admission labs: [**2186-3-16**] 10:03PM BLOOD WBC-16.1*# RBC-4.18* Hgb-13.6* Hct-38.5* MCV-92 MCH-32.5* MCHC-35.3* RDW-13.0 Plt Ct-194 [**2186-3-16**] 10:03PM BLOOD PT-12.2 PTT-25.0 INR(PT)-1.0 [**2186-3-16**] 10:03PM BLOOD Glucose-119* UreaN-9 Creat-0.7 Na-129* K-4.0 Cl-96 HCO3-23 AnGap-14 [**2186-3-16**] 10:03PM BLOOD ALT-94* AST-58* CK(CPK)-360* AlkPhos-63 TotBili-1.1 [**2186-3-16**] 10:03PM BLOOD Albumin-3.6 Calcium-9.1 Phos-2.1*# Mg-1.7 [**2186-3-17**] 03:53AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-POS Barbitr-NEG Tricycl-NEG [**2186-3-17**] 06:43PM BLOOD Type-ART Tidal V-507 PEEP-5 FiO2-42 pO2-173* pCO2-43 pH-7.41 calTCO2-28 Base XS-2 -ASSIST/CON Intubat-INTUBATED [**2186-3-27**] 03:13AM BLOOD TSH-1.2 Micro data: [**2186-3-31**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2186-3-30**] URINE URINE CULTURE-FINAL [**2186-3-29**] BLOOD CULTURE Blood Culture, Routine-FINAL [**2186-3-27**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST-FINAL-NEGATIVE [**2186-3-25**] URINE URINE CULTURE-FINAL [**2186-3-25**] BLOOD CULTURE Blood Culture, Routine-FINAL [**2186-3-25**] BLOOD CULTURE Blood Culture, Routine-FINAL [**2186-3-25**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL GRAM STAIN (Final [**2186-3-25**]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2186-3-27**]): SPARSE GROWTH Commensal Respiratory Flora. [**2186-3-22**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL GRAM STAIN (Final [**2186-3-22**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [**2186-3-24**]): MODERATE GROWTH Commensal Respiratory Flora. [**2186-3-20**] URINE URINE CULTURE-FINAL [**2186-3-19**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL GRAM STAIN (Final [**2186-3-19**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Final [**2186-3-21**]): HEAVY GROWTH Commensal Respiratory Flora. [**2186-3-17**] IMMUNOLOGY HCV VIRAL LOAD-FINAL HCV VIRAL LOAD (Final [**2186-3-17**]): 2,120,000 IU/mL. [**2186-3-16**] MRSA SCREEN MRSA SCREEN-FINAL-NEGATIVE Pathology: [**3-14**] Disc: Fibrocartilage with degenerative changes Radiology: 2/2 L-Spine: Localizer marker indicates the L4-5 interspace. Normal vertebral body height is preserved. Intervertebral body spacer placed at the L5-S1 interspace with second disk prosthesis at the L4-5 level. For further details, please see operative note from the same date. [**3-17**] ECG: Sinus tachycardia. Diffuse non-specific ST-T wave changes. Compared to the previous tracing of [**2183-6-3**] heart rate is significantly faster. [**3-17**] CXR: As compared to the previous examination, the lung volumes have minimally decreased. As a consequence, the basal aspect of the lung is slightly denser than before. Although this leads to the visualization of air bronchograms in the retrocardiac lung areas, there is no safe evidence for the presence of pneumonia or aspiration. No overhydration. No pleural effusions. Normal aspect of the hila and the mediastinum. [**3-17**] CT L-spine: Status post anterior lumbar instrumentation and anterior fusion from L4 through S1 levels as described in detail above. The alignment and configuration of the lumbar vertebral bodies are maintained with no evidence of spondylolisthesis or distraction. There is no evidence of loosening of the orthopedic hardware, allograft bone material is noted anterior to the vertebral body at L4/L5 and L5/S1. No fluid collections or hematomas are detected. [**3-22**] CXR: ET tube is in the standard position. NG tube tip is in the stomach. Cardiac size is top normal. Left perihilar opacities have minimally increased. Attention should be paid in these area to exclude a developing infectious process. The retrocardiac atelectasis has improved. The left lateral CP angle was not included on the film. There is no evidence of pneumothorax or enlarging pleural effusions. [**3-24**] CXR: 1. Right-sided PICC tip projects over the distal SVC with no pneumothorax. 2. No interval change since prior chest radiograph on the same day. [**3-27**] CXR: FINDINGS: In comparison with the study of [**3-25**], there is some poorly defined areas of increased opacification at the bases. It is unclear whether this could represent some atelectatic change or early elevation of pulmonary venous pressure, or be a manifestation of developing bilateral consolidations as suggested by the clinical history. Discharge labs: COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2186-4-4**] 06:45AM 10.9 3.40* 11.0* 31.6* 93 32.5* 34.9 13.5 674* RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2186-4-4**] 06:45AM 891 9 0.7 136 4.4 100 29 11 ENZYMES ALT AST LD(LDH) CK(CPK) AlkPhos Amylase TotBili DirBili [**2186-4-2**] 07:10AM 51* 42* 142* 0.3 CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron [**2186-4-4**] 06:45AM 9.8 3.7 2.0 Brief Hospital Course: ****MICU Course/Medical Floor: 47 yo M with PMH of EtOH abuse, chronic hep C, spinal stenosis, spinal DJD, GERD, migraine admitted for elective spinal surgery who became acutely agitated likely [**3-14**] EtOH withdrawal post-surgery. #. Delirium/Altered Mental status: The patient was believed to be in acute alcohol withdrawal, given the timing of the onset of his delirium, tachycardia, hypertension. He was oriented only to self. He received Q10 minute doses of valium for his withdrawal and his mental status did not improve, despite high & frequent dosing. His delirium was later thought to be potentially due to benzo toxicity. Toxicology screen was otherwise unrevealing. He was intubated on [**3-17**] for altered mental status. While intubated, he was treated with multiple sedatives when he appeared agitated. He was extubated on [**3-25**] but continued to require occasional sedatives. His mental status only slowly improved and he required TPN. His delirium was likely exacerbated by pain, given his multiple spine surgeries, and he was treated with PRN IV narcotics. He continued to be tachycardic and hypertensive for the majority of his time in the MICU, and he was started on a clonidine patch, in addition to his withdrawal medications. He was frequently re-oriented to person place and time, and a social work consult was ordered for alcohol abuse. Upon stabilization he was transfered to the medical floor where he continued to have improving delirium but still requiring occasional sedatives. His delirium resolved on [**3-31**], he was able to tolerate a regular diet, and TPN was stopped. His MS has been his baseline since. # Urinary retention: Patient had a Foley catheter placed at the time of surgery. This remained in place for ~2 weeks while the patient was intubated and during his prolonged delirium. Once his MS was back to baseline the catheter was taken out but the patient was unable to void and was found to be retaining urine. The catheter was then replaced and this was intented on 3 different occasions but the patient failed to void during all even after starting treatment with Flomax. The patient should keep the catheter in place until [**4-10**] (per surgery recs) at which time a voiding trial should be done. If at this time he fails to void, the patient should be seen by Urology. # Spinal Stenosis: The patient underwent anterior and posterior spinal surgeries. He remained in the MICU following his second surgery. His pain was treated as above during his MICU dose but these medication were changed to PO once his mental status was improved and patient able to take PO. His hemovac was pulled by surgery on [**3-20**], without complications. Of note, the patient fell out of bed (while in the MICU) in between his two surgeries; CT of the L-spine revealed no acute complications or distortion of prior instrumentation/surgical changes. - Needs to follow up with Dr. [**Last Name (STitle) 363**] 2 weeks after discharge # VAP: The patient had fevers and CXR concerning for ventilator-associated pneumonia, and he was started on vancomycin and cefepime on [**3-22**]. Cefepime was later changed to meropenem on [**3-25**], given the patient's rising WBC count. He remained afebrile throughout his medical floor course, was continued on vanc/[**Last Name (un) 2830**] until the day of discharge (received a total 13 day antibiotic course). # GERD: The patient was continued on his home PPI # Leukocytosis: Patient was found to have a persistent leukocytosis that ranged from [**12-26**]. He was ruled out for C.diff, UA, UCx and BCx were negative. This was thought to be due to a combination of VAP, surgery and pain. # Thrombocytosis: Patient presented with a platelet count of 194, it continued to trend up throughout his hospitalization to a max of 777. This was thought to be due to a combination of VAP, surgery and pain. He had no complications due to this and it was trending down on discharge. # Chronic Hepatitis C: Untreated, had transaminitis [**1-18**] with normal bili. Last seen here in Liver center [**2180**] by Dr. [**Last Name (STitle) 7033**]. Last viral load [**2182**] was 39,400,000. Was referred back to GI at PCP appt in [**2186-1-10**] but has not yet seen. HCV viral load was > 2 million, but LFTs were only mildly elevated. # HTN, benign/Tachycardia: Patient developed HTN and tachycardia during his hosptialization. This was thought to be due to a combination of pain and aggitation. He was treated with antihypertensive and nodal blocking agents. This subsequently resolved and patient was weaned off these medications. Medications on Admission: DOXEPIN - 50 mg Capsule - 1 (One) Capsule(s) by mouth three times a day FLUTICASONE - 50 mcg Spray, Suspension - 1 (One) spray each nostril once a day OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg Tablet - 1 Tablet(s) by mouth q6 hours as needed for as needed for pain OXYCODONE-ACETAMINOPHEN [PERCOCET] - 5 mg-325 mg Tablet - 1 (One) Tablet(s) by mouth q6 prn PANTOPRAZOLE - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once per day 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. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Tablet(s) 3. OxyContin 10 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO twice a day for 7 days. 4. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours for 7 days. 5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day: until urinary retention resolves. 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily) as needed for constipation. 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at [**Hospital6 1109**] - [**Location (un) 1110**] Discharge Diagnosis: Spinal Surgery VAP Alcohol withdrawal AMS/Delirium GERD Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - requires assistance or aid (walker or cane) Discharge Instructions: You were admitted for elective spinal surgery. You post-operative course was complicated by alcohol withdrawal, the need for intubation, ventilator associated pneumonia and acute mental status changes. This was all treated and resolved after several days of treatment and your mental status returned to [**Location 213**]. Due to your long hospital course, the complications that arose and you being in bed for a long time you developed weakness. This will improve with physical therapy that you will also need for recovery after back surgery. Due to the need of bladder catheterization throughout you hospitalization you developed bladder motility problems. [**Name (NI) **] should keep the catheter until [**4-10**] and then be re-evaluated. If at this point you are still unable to urinate you will need to make an appointment with urology. Medication changes: Start: Tamsulosin 0.4mg until you are able to void without a Foley catheter Start: Oxyconting twice a day for pain for 1 week Start: Oxycodone up to every 6 hours for breakthrough pain for 1 week Start: Nicotine Patch 14mg for 3 more weeks, then you can decrease to 7 mg patch Start: Colace, Senna, Bisacodyl and Miralax prn while taking narcotics for constipation No other changes were made to your medications Followup Instructions: Appointment #1 MD: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] Specialty: Orthopaedics Date/ Time: Wednesday [**2186-4-12**] at 11:30 AM Location: [**Hospital1 18**] [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Building [**Location (un) 551**], [**Location (un) **], [**Location (un) 86**], MA Phone number: ([**Telephone/Fax (1) 11061**] Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 7128**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2186-4-12**] 10:30

[ "722.52", "070.44", "238.71", "291.0", "788.20", "530.81", "285.8", "564.09", "997.5", "305.1", "401.1", "997.31", "303.91", "721.3", "346.90", "288.60", "E878.8", "E939.4", "276.1" ]

icd9cm

[ [ [] ] ]

[ "96.72", "81.06", "96.6", "57.95", "38.93", "81.08", "96.04", "84.51", "81.62", "99.15", "80.99", "84.52" ]

icd9pcs

[ [ [] ] ]

14727, 14872

8516, 8772

299, 343

14972, 14972

3139, 3139

16451, 16993

2435, 2706

13620, 14704

14893, 14951

13154, 13597

15149, 15994

8020, 8493

2721, 3120

16014, 16428

236, 261

371, 1511

3155, 8004

14986, 15125

1533, 1752

1768, 2419

27,300

110,085

43505

Discharge summary

report

Admission Date: [**2180-12-16**] Discharge Date: [**2180-12-23**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 30**] Chief Complaint: Right frontal hematoma Major Surgical or Invasive Procedure: none History of Present Illness: This is a 84 y/o female with HTN, chronic hyponatremia (of unclear etiology), who presented s/p fall 1 week ago and MS changes. History obtained from patient's daughter: patient sustained a fall at home approximately 1 week ago and was found on the floor at home by her son, who came in to check on her. She was conscious but altered - patient was unable to specify how the fall occured. She was able to ambulate easily after the fall and was taken to the [**Hospital1 392**] ER that day. Per report, CT head demonstrated bilateral subdural hygromas and generalized cerebral atrophy. A CXR showed a possible PNA and urine reportedly was dirty. She was admitted for MS changes and had intermittent worsening periods of confusion during her hospital course. She is normally AO x 3 and interactive at baseline, but after the fall has been AO x [**1-18**] with lucid periods intermittently. She was treated with both ciprofloxacin for a presumed UTI and azithromycin for possible bronchitis at the OSH. Her daughter noted that 1-2 days into her hospital course, she had a small bruise on the back of her head. The patient improved slightly on her own and was discharged to a [**Hospital1 1501**] on Thursday night. However, she continued to be confused at the [**Hospital1 1501**] and it was noted that the occipital bruise had increased in size, so she was sent to the [**Hospital1 392**] ER on Saturday for re-evaluation. Repeat head CT was read as a right front epidural hematoma and she was transferred to [**Hospital1 18**] for further managment. . In the ED, initial VS were T 97, BP 144/58, HR 65, RR 20, SaO2 98%/RA. A repeat head CT was done and she was seen by neurosurgery - CT showed a small right extraaxial bleed (no intraventricular or intraparenchymal bleed, no mass effect). She received 2 L NS for her low Na of 121. She also received 10 mg IV labetolol x 1 and 1" NTP for a BP of 170/60, with improvement to the 140's systolic. . Currently the patient denies any concerns or complaints. She is comfortable. Past Medical History: HTN PMR - on prednisone Hypothyroidism Hyponatremia - baseline Na low 120s (unclear etiology) Left eye macular degeneration Right eye s/p corneal transplant - 1 month ago Baseline leukocytosis (14.2 on [**2180-10-16**] per routine labs with PCP) Social History: Lives alone, normally performs ADLs, interactive. Most recently at [**Hospital1 1501**] since last Thursday. No tobacco, EtOH. Daughter and son involved in care and check on patient frequently. Family History: Non contributory Physical Exam: Tc 98.1, BP 136/68, HR 85, RR 16, SaO2 98%/RA General: pleasant, elderly female in NAD, AO x 1 (to self), hard of hearing HEENT: NC/AT, +corneal opacity in right eye. Left pupil 3mm->2mm. MMM, OP clear Neck: supple, no LAD or TMG Chest: CTA-B, no w/r/r CV: RRR s1 s2 normal, no m/g/r Abd: soft, NT/ND, NABS Ext: no c/c/e, wwp Neuro: AO x 1, speech fluent but nonsensical at times. CN II-XII intact, MS [**5-20**] throughout, sensation to light touch intact grossly. Normal FTN. Pertinent Results: [**2180-12-16**] CXR - Two views with no comparisons. There is borderline LV enlargement, but no pulmonary vascular congestion, significant pleural effusion, or other evidence of CHF. No focal consolidation is seen. There is atherosclerosis involving the thoracic aorta, and dense calcification of the mitral annulus. Incidentally noted is evidence of chronic left rotator cuff disease. . [**2180-12-16**] CT head - Bilateral small extraxial fluid follections and small acute right extraxial hematoma, measuring 4 mm from the inner table. Negligible mass effect. . [**2180-12-16**] EKG - NSR at 65 bpm with nl axis. PR prolongation at 200 ms. [**Name13 (STitle) **] acute ST or T wave changes. No prior available for comparison. . Repeat Ct head [**12-17**]: A small 4-mm extra-axial hematoma is unchanged in size and appearance compared to one day prior. Left greater than right bilateral low-density extra-axial collections are also unchanged. There is no new hemorrhage, and no evidence of infarction. Osseous structures and soft tissues are unremarkable. Air- fluid levels are again noted within the sphenoid sinus. IMPRESSION: 1. Unchanged small right extra-axial hematoma. 2. Unchanged bilateral extra-axial fluid collections, which may represent chronic subdural hematomas. These findings were discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at 10:00 p.m. on [**2180-12-17**]. . ECHO [**12-18**]: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). No masses or thrombi are seen in the left ventricle. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. Right ventricular systolic function is normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. . CT head [**12-20**]: FINDINGS: Comparison is made to [**2174-12-18**] and [**2180-12-16**]. Again seen are hypodense bilateral subdural collections over the frontal convexities which appear minimally decreased in size compared to the prior study. Again seen is a hyperdense component over the right frontal lobe measuring approximately 1.9 by approximately 0.4 cm, which is not significantly changed in size. This may represent a more acute subdural hematoma component or alternatively an incidental meningioma. There are no intracranial hemorrhages. The [**Doctor Last Name 352**]/white matter differentiation is maintained. The ventricles and extraaxial CSF spaces are marginally prominent as before. There is a moderate degree of white matter hypodensities consistent with chronic microangiopathic changes. The visualized orbits are normal. Vascular calcifications are seen. There is a mucous retention cyst within the left sphenoid air cell. Not significantly changed since the prior studies is a nondisplaced fracture of the left occipital bone with no underlying intracranial hemorrhage or swelling of the overlying scalp. IMPRESSION: Minimal decrease in size of hypodense collections over the frontal lobes bilaterally. No significant change in size of the hyperdense component over the right frontal lobe which may represent an acute subdural hematoma versus a meningioma. Nondisplaced left occipital bone fracture. [**2180-12-22**] Sodium 130 Brief Hospital Course: 84 y/o female with HTN, chronic hyponatremia, s/p recent fall, p/w extraaxial bleed and MS changes. . # Right frontl hematoma/Bilateral frontal fluid collections Small in size, no evidence of mass effect. Unclear if was blood or fluid collection. Thought secondary to recent fall and trauma. On review of records from outside hospital, patient had a CT of the head which showed no evidence of extra-axial collections on [**12-11**]. These collections were first noted on a CT head from the outside hospital on [**12-16**]. Neurosurgery was consulted upon arrival to [**Hospital1 18**] and felt that there was minimal contribution of fluid collection to current clinical situation. A CT head was repeated the following day which showed stability in extraaxial bleed. Neuro checks remained stable and nonfocal throughout. In the setting of persistent disorientation in the MICU, a CT head was again repeated 3 days later which showed slight improvement in L sided fluid collection and otherwise unchanged head CT. A non-displaced L Occipital bone fracture was noted for the first time on this head CT but was then retrospectively seen on prior head CTs and was reportedly unchanged. There was no underlying bleeding or other intracranial abnormality. Neurosugery recommended repeat CT head in 4 weeks to reassess extra-axial collections. . # Syncope Patient was found down at home, unclear cause,unwitnessed. Syncope considered as a possible cause. She had no events on telemetry during her hospital course to suggest arrhythmia. She had an echo performed which showed mild LVH and diastolic dysfunction but no significant valvular abnormalities. She had a CTA of her head on [**2180-12-12**] at the outside hospital which showed atherosclerotic calcified plaques of the internal carotid arteries but no evidence of hemodynamically significant stenosis or other vascular abnormalities. No further workup indicated at this time. . # MS changes Per patients family, she was different from normal baseline. However, MS had been worse since her previous admission to the outside hospital. Her subdural fluid collections were possibly contributing given the temporal correlation of her fall, the development of the fluid collections, and the onset of her delerium. However, the collections were small and improved over time so it was also considered that the patient was delerius from prolonged hospitalization including prolonged MICU course. Patient remained pleasant throughout MICU course with only mild sundowning responsive to reorientation. She required soft wrist restraints once to prevent her from getting out of bed and responded to 5 mg of zyprexa. Her hyponatremia was a chronic problem and was not thought to be contributing. She had a thorough infectious work up as well which was unremarkable, Zyprexa was discontinued prior to discharge due to questionable effectiveness. Her mental status continues to wax and wane. . # Hyponatremia Patient with long-standing history of hyponatremia in the low 120's at baseline of unclear etiology. Received 2 L NS in the ED, Na 121->128 over 8 hours. Response to fluid suggested some evidence of hypovolemic hyponatremia. However, after stabilization, serum osms were low, urine osms were high, and urine sodium was elevated suggesting SIADH. Patient was managed with fluid restriction throughout her course with stable Na throughout. At discharge fluid restriction will not be mantained. Reasoning is that her baseline sodium is in the low 120s and she has not been on any prior fluid restriction. Given her age the decision was made to opt for quality of life and not restrict her fluid intake unnecessarily. . # Leukocytosis WBC 14 with left shift with 90% PMN's. Baseline WBC was 14.2 on routine blood work per her PCP's office, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 93632**]. Thought secondary to chronic prednisone therapy. Recently on treatment for UTI and bronchitis. While here infectious work up was unremarkable. She developed a thrombocytosis during her MICU stay which was also suggestive of infection. However, repeat infectious work up continued to be unremarkable. Baseline hematocrit 34 and platelets 430 on last lab slip on [**2180-10-16**] at PCP's office. . # HTN Continued on atenolol, lisinopril, cardizem. . # PMR Continued on prednisone 8mg daily. . # F/E/N Regular diet. Fluid restriction of 1000cc. . # PPx Heparin SQ . # Communcation - with daughter, HCP, [**Name (NI) **] [**Name (NI) 10113**] (c)[**Telephone/Fax (1) 93633**], (h)[**Telephone/Fax (1) 93634**], (w) [**Telephone/Fax (1) 93635**] . # Code - Full Code (confirmed with HCP) Medications on Admission: 1. ASA 81 mg daily 2. Atenolol 100 mg daily 3. Diltiazem CR 240 mg daily 4. Cipro 250 mg daily - recently started 5. Colace 100 mg daily 6. Calcium carbonate 1000 mg daily 7. Prednisone 8 mg daily 8. Lisinopril 40 mg daily 9. Levothyroxine 50 mcg daily 10. Prednisolone eye gtt 11. Erythromycin eye gtt 12. Azithromycin 250 mg daily - recently started 13. Vitamin D 800 units daily Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Atenolol 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 4. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day) as needed. 8. PredniSONE 5 mg/5 mL Solution Sig: Eight (8) ml PO DAILY (Daily). 9. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic TID (3 times a day). 12. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic TID (3 times a day). 13. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed). Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary: 1. Intracranial extra-axial bleed 2. Traumatic nondisplaced occipital bone fracture 3. Delirium 4. Syncope NOS Secondary: 1. Hypertension 2. Hypothyroidism 3. Polymyalgia rheumatica 4. Chronic SIADH Discharge Condition: Stable, mental status waxes and wanes Discharge Instructions: You were admitted for concern of a bleed in your head after the fall you experienced. You were seen by neurosurgery who did not believe any surgical intrvention was indicated. You had repeat CT scan of your head which showed minimal resolution of the pocket of fluid. You will have a repeat scan of your head in [**Month (only) 404**] which will be reviewed by neurosurgery. Your sodium level was low, this has been a chronic issue and is not overly concerning, there is no need to restrict your fluid intake given this has been a chronic issue and you have not been on fluid restriction prior to admission. Please continue to take all medications as prescribed. Please continue to follow a 1.5 L fluid restriction. Please have a head CT without contrast repeated on [**2180-1-24**] to assess for resolution of the fluid collections under your skull. This will be on the same day you follow up with Dr. [**Last Name (STitle) **] of Neurosurgery. Please follow up with your PCP as below. Please call your doctor or return to the hospital for feversm, chills, chest pain, shortness of breath, lightheadedness, confusion, numbness, weakness, or any other concerns. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] of Neurosurgery on [**2180-1-24**] 1:45 pm. You should have a CT of your head repeated before your appointment. Phone: ([**Telephone/Fax (1) 11314**] Please follow up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in [**2-19**] weeks. Dr. [**Name (NI) 93636**] office will call to schedule a follow up appointment. Phone: ([**Telephone/Fax (1) 93637**]

[ "401.9", "V42.5", "433.10", "E888.9", "725", "780.2", "780.09", "244.9", "801.26", "396.3", "253.6" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

13405, 13484

7224, 11889

285, 291

13737, 13777

3373, 7201

14993, 15428

2841, 2859

12321, 13382

13505, 13716

11915, 12298

13801, 14970

2874, 3354

223, 247

319, 2344

2366, 2613

2629, 2825

3,210

132,516

7170

Discharge summary

report

Admission Date: [**2196-5-28**] Discharge Date: [**2196-6-12**] Date of Birth: [**2135-11-17**] Sex: F Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 4748**] Chief Complaint: ABF graft infection Major Surgical or Invasive Procedure: Bed side wound I&D [**2196-5-29**] History of Present Illness: Hospitalized [**2-20**] for sepsis and klebsella pneumonia. Underwent a cardiac cath for angina. Developed a rt, groin wound infection and rt. limb of ABF grafgt infection. [**Month/Year (2) 22925**] to [**Hospital1 8482**] s/p rt. axillo-[**Doctor Last Name **] bpg and treated with antibiotics. Wound VAC and antibiotics at d/c in [**3-21**] for total of IV x 14days and po x 10days. Vac d/c [**2196-5-2**]. Onset of fever and rt. groin pain over the following week with progression of groin pain, fever and chills7/13. Admitted from ER for further care . Past Medical History: history of DM2, insulin dependant history of hyperlipdemia history of PVD s/p ABF graft, s/p rt. ax-[**Doctor Last Name **] bpg with PTFE [**3-21**] history of klebsella pneumonia with sepsis [**2-20**] histroy of rt. ABF limb graft infection,s/p wound debridment and VAC dressing history of diverticulitis [**2180**] history of bilateral oophrectomy [**2180**] Family History: not applicable Physical Exam: Tc 102.2 HR 103 BP 108/99 RR 20 O2sat 97RA Genl: NAD CV: RRR Resp: CTA-B Abd: obese, s/nt/nd; RLE fem/[**Doctor Last Name **]/DP/PT 1+/palp graft pulse/1+/0 appearance: groin has granulation tissue, no discharge LLE fem/[**Doctor Last Name **]/DP/PT 2+/biph/1+/biph appearance: no swelling Pertinent Results: [**2196-5-28**] 06:35PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.008 [**2196-5-28**] 06:35PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2196-5-28**] 05:25PM PT-33.4* PTT-34.6 INR(PT)-3.6* [**2196-5-28**] 04:55AM GLUCOSE-57* UREA N-13 CREAT-0.6 SODIUM-137 POTASSIUM-3.6 CHLORIDE-109* TOTAL CO2-21* ANION GAP-11 [**2196-5-28**] 04:55AM CALCIUM-8.5 PHOSPHATE-2.4* MAGNESIUM-1.7 [**2196-5-28**] 04:55AM WBC-8.2 RBC-3.22* HGB-9.3* HCT-28.5* MCV-89 MCH-29.0 MCHC-32.8 RDW-15.4 [**2196-5-28**] 04:55AM PLT COUNT-240 [**2196-5-28**] 04:55AM PT-30.2* PTT-36.4* INR(PT)-3.2* [**2196-5-27**] 09:11PM GLUCOSE-77 LACTATE-1.2 K+-3.9 [**2196-5-27**] 09:00PM GLUCOSE-72 UREA N-16 CREAT-0.8 SODIUM-131* POTASSIUM-3.9 CHLORIDE-94* TOTAL CO2-25 ANION GAP-16 [**2196-5-27**] 09:00PM estGFR-Using this [**2196-5-27**] 09:00PM WBC-12.9*# RBC-3.83* HGB-11.3* HCT-33.5* MCV-88 MCH-29.6 MCHC-33.9 RDW-15.2 [**2196-5-27**] 09:00PM PLT COUNT-325 [**2196-5-27**] 09:00PM PT-29.3* PTT-34.3 INR(PT)-3.1* Brief Hospital Course: [**2196-5-28**] [**First Name9 (NamePattern2) 22925**] [**Last Name (un) 834**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] to our emergency room andmitted to vascular service for infected rt. groin wound and ABF graft.IV Vanco and meropenum began after wound and blood c/s obtained.VICU status. [**2196-5-29**] Right groin I&D [**2196-5-30**] ID consulted.Patient continued on Vancomycin and meropenum. Blood c/s sent without growth. Local wound care continued. IV heparin gtt continued. [**2196-5-31**] [**Month/Day/Year 22925**] to floor. [**Date range (1) 26632**] awaitng speciation of GNR. plan left ax fem [**6-6**], followed by removal of ABF graft [**6-7**]. IV antibiotic,wound care and heparin continued. [**6-6**] Went to OR for left axillofemoral bypass graft in preparation for removal of infected aortobifemoral bypass graft [**6-7**] Patient developed a right ischemic foot with nondopplerable signals and change in temperature. She was taken to the operating room for an exploration of right axillopopliteal bypass graft, thrombectomy, graft to anterior tibialis jump graft with reversed saphenous vein graft. [**6-8**] Patient taken to the operating room for removal of infected aortobifem bypass graft, which was complicated by a full-thickness laceration of the duodenum secondary to adherent graft. Patient remained intubated secondary to hemodynamic instability. [**6-9**] Patient returned to the operating room emergently for cold right foot and loss of previously dopplerable signals over right-sided bypass. Thrombectomies were performed with return of blood flow through axillopopliteal bypass. [**6-10**] Despite continued anticoagulation and multiple surgical interventions, patient again developed signs of right lower extremity ischemia. Patient was again returned to the operating room for an open thrombectomy of the right axillopopliteal PTFE bypass graft, right lower extremity arteriogram, angioplasty and stenting of the above to below-the-knee popliteal vein bypass graft and 4 compartment right lower extremity fasciotomies. Patient was returned to the ICU for continuing monitoring, ventilator and vasopressor support. [**6-11**] Patient began to develop acute renal failure, rising LFT's and increasing vasopressor requirement. After prolonged discussion with the team, social work, hospital ethics committee, legal affairs and patient's next of [**Doctor First Name **], decision was made to withdraw support. Patient expired at 2:25am on [**6-12**]. Medications on Admission: coumadin 1mg PO daily, Diovan 160mg PO daily, pletal 100mg PO BID, lantus 48units qPM, humalog SS Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: infected ABF graft perpheral vascular disease,s/p ABF [**2187**] Right limb ABF graft infection post cardiac cateterization,s/p rt. ax -[**Doctor Last Name **] bpg with PTFE [**3-21**] history of Dm2,insulin dependant history of hyperlipdemia history of klebsella pneumonia-treated,gram negative sepsis [**2-20**] history of diverticulitis [**2180**] respiratory insufficiency hemodynamic collapse multisystem organ failure Discharge Condition: Deceased Discharge Instructions: None Followup Instructions: None

[ "V45.81", "518.5", "996.74", "998.2", "038.9", "570", "729.72", "420.90", "682.2", "041.09", "250.00", "995.92", "511.8", "996.62", "427.31", "V45.3", "E879.8", "584.9", "V58.67", "274.9" ]

icd9cm

[ [ [] ] ]

[ "34.04", "00.48", "00.41", "39.49", "99.04", "39.50", "83.09", "37.0", "39.90", "89.64", "99.07", "88.48", "96.72", "88.72", "39.29", "99.62", "46.71" ]

icd9pcs

[ [ [] ] ]

5465, 5474

2773, 5288

292, 329

5941, 5951

1662, 2750

6004, 6011

1317, 1333

5436, 5442

5495, 5920

5314, 5413

5975, 5981

1348, 1643

233, 254

357, 916

938, 1301

54,768

110,889

40129

Discharge summary

report

Admission Date: [**2131-12-9**] Discharge Date: [**2131-12-14**] Date of Birth: [**2049-5-21**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 922**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2131-12-10**] 1. Mitral valve replacement with a 27-mm St. [**Male First Name (un) 923**] Epic bioprosthesis, reference number [**Serial Number 87003**], serial number [**Serial Number 88164**]. 2. Resection of left atrial appendage. 3. Repair transected/avulsed azygos vein. History of Present Illness: 82 year old female with known mitral regurgitation followed by serial echocardiograms. Her most recent echocardiogram revealed now severe mitral regurgitation. She has noted peripheral edema which has worsened over the past year. She underwent a cardiac catheterization in preparation for surgery which showed no significant coronary artery disease. She is referred today for evaluation for mitral valve surgery. Past Medical History: Atrial fibrillation (Presented 5-7 years ago) Mitral regurgitation Hypertension Past Surgical History: Bilateral TKR Resection of left arm Basal cell cancer Hammer toe surgery Social History: Lives with: Husband. [**Name2 (NI) **], MA Occupation: Retired Tobacco: Never ETOH: Social/rare use Family History: Mother and father died of heart disease in their 70's/80's. Sister with heart disease in her 70's. Physical Exam: Pulse: 82 AF Resp: 18 O2 sat: 95% B/P Right: 144/60 Left: Height: 64" Weight: 156 General: [**Last Name (un) 664**] 82 yo in NAD Skin: Warm[X] Dry [X] intact [X] HEENT: NCAT[X] PERRLA [X] EOMI [X] Neck: Supple [X] Full ROM [X] No JVD Chest: Lungs clear bilaterally [X] Heart: Irregular rhythm, Nls1-S2, III/VI holosystolic murmur Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] 1+ LE Edema Varicosities: Left below knee with varicosities. Mild RLE varicosities. Neuro: Grossly intact Pulses: Femoral Right:2 Left:2 DP Right:2 Left:2 PT [**Name (NI) 167**]:1 Left:1 Radial Right:2 Left:2 Carotid Bruit Transmitted vs Bruit Pertinent Results: Pre-op: [**2131-12-9**] 08:57PM PT-17.6* PTT-24.5 INR(PT)-1.6* [**2131-12-9**] 08:57PM PLT COUNT-337 [**2131-12-9**] 08:57PM WBC-12.5* RBC-4.33 HGB-12.8 HCT-38.2 MCV-88 MCH-29.5 MCHC-33.4 RDW-15.1 [**2131-12-9**] 08:57PM %HbA1c-6.4* eAG-137* [**2131-12-9**] 08:57PM CALCIUM-9.7 PHOSPHATE-3.7 MAGNESIUM-2.1 [**2131-12-9**] 08:57PM LIPASE-36 [**2131-12-9**] 08:57PM ALT(SGPT)-19 AST(SGOT)-22 ALK PHOS-90 AMYLASE-56 TOT BILI-0.5 [**2131-12-9**] 08:57PM GLUCOSE-104* UREA N-13 CREAT-0.7 SODIUM-144 POTASSIUM-4.0 CHLORIDE-105 TOTAL CO2-29 ANION GAP-14 [**2131-12-9**] 09:00PM cTropnT-<0.01 [**2131-12-9**] 09:30PM URINE RBC-0-2 WBC-[**3-16**] BACTERIA-OCC YEAST-NONE EPI-0-2 [**2131-12-9**] 09:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-SM Discharge: [**2131-12-14**] 04:35AM BLOOD Hgb-10.1* Plt Ct-309 [**2131-12-13**] 04:40AM BLOOD WBC-15.3* RBC-3.48* Hgb-10.3* Hct-31.3* MCV-90 MCH-29.4 MCHC-32.8 RDW-15.2 Plt Ct-252 [**2131-12-14**] 04:35AM BLOOD Plt Ct-309 [**2131-12-14**] 04:35AM BLOOD PT-19.9* INR(PT)-1.8* [**2131-12-14**] 04:35AM BLOOD UreaN-18 Creat-0.6 Na-138 K-4.1 Cl-102 [**2131-12-13**] 04:40AM BLOOD Glucose-78 UreaN-19 Creat-0.5 Na-137 K-4.1 Cl-102 HCO3-26 AnGap-13 [**2131-12-10**]-echo PRE-BYPASS: The left atrium is dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. The right atrium is dilated. No atrial septal defect is seen by 2D or color Doppler. Right ventricular chamber size and free wall motion are normal. There are focal calcifications in the aortic arch. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is partial anterior mitral leaflet flail. An eccentric, posteriorly directed jet of Moderate to severe (3+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). Moderate [2+] tricuspid regurgitation is seen. TA in 4 chamber view is 3.1 cm in end systole.The IVC is dilated to 25mm. There is no pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the results on [**Known firstname **] [**Known lastname **] prior to surgery. All the ECHO findings were also done, interpreted and conveyed to surgeon by Dr.[**First Name8 (NamePattern2) 6506**] [**Name (STitle) 6507**] as well. POST-BYPASS: There is a bioprosthesis sitting in the mitral position. It is stable and functioning well. There is valvular or perivalvular leak seen. The transmitral gradient was 7mm of Hg mean with cardiac output of 5.0 L/min.The thoracic aorta is intact. Normal RV systolic function. LVEF 55%. Radiology Report CHEST (PORTABLE AP) Study Date of [**2131-12-12**] 12:57 PM [**Hospital 93**] MEDICAL CONDITION: 82 year old woman s/p MVR tissue Final Report: In comparison with study of [**10-10**], all of the monitoring and support devices have been removed. No evidence of pneumothorax. Substantial enlargement of the cardiac silhouette with bibasilar effusions and atelectasis. Brief Hospital Course: The patient was brought to the operating room on [**2131-12-10**] where the patient underwent Mitral Valve Replacement (27mm tissue) and Left Atrial Appendage Ligation. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. Within 24 hours she was weaned from sedation, awoke neurologically intact and extubated. She was hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. Coumadin was resumed for atrial fibrillation. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued per cardiac surgery protocol without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on post-op day four the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to Pleasant [**Hospital **] Nursing and Rehab in [**Location (un) 23638**], MA. in good condition with appropriate follow up instructions. Medications on Admission: Digoxin 250mcg daily **Coumadin 5mg daily**-last dose 4 days ago Evista 60mg daily Calcium and Vitamin D 400-600mg tab twice daily Lisinopril 30mg daily Vitamin B 12 1000mcg Inj monthly Fluocinonide Topical 0.05% PRN Cardizem CD 120mg daily Lasix 40mg daily Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 7. lisinopril 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 2 weeks. 9. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 2 weeks. 10. Evista 60 mg Tablet Sig: One (1) Tablet PO daily (). 11. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 12. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever, pain. 13. warfarin 1 mg Tablet Sig: as directed Tablet PO DAILY (Daily): Target INR 2-2.5 for Afib 5 mg on [**12-14**]. Discharge Disposition: Extended Care Facility: Pleasant Bay Nursing & Rehabilitation Center - [**Location (un) 23638**] Discharge Diagnosis: Mitral Regurgitation Atrial Fibrillation s/p Mitral Valve Replacement and Left Atrial Appendage Ligation PMH: Hypertension Past Surgical History: Bilateral TKR Resection of left arm Basal cell cancer Hammer toe surgery Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with percocet Sternal Incision - healing well, no erythema or drainage Edema: [**1-13**]+ pedal edema bilat LE 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**] [**Telephone/Fax (1) 170**] Tuesday [**12-25**] @ 2:00 pm Cardiologist Dr. [**First Name8 (NamePattern2) 4115**] [**Last Name (NamePattern1) **] [**1-2**] @ 1:15 pm Please call to schedule the following: Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 88165**] in [**4-16**] 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 Coumadin for Atrial fibrillation Goal INR 2-2.5 First draw day after discharge [**2131-12-15**] Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as required Upon discharge from rehab, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] should be contact[**Name (NI) **] to follow Coumadin and INR Completed by:[**2131-12-14**]

[ "998.2", "424.2", "428.0", "429.3", "427.31", "V10.83", "782.3", "V14.0", "V43.65", "424.0", "285.9", "E870.0", "402.91", "V15.08", "V58.61", "790.29", "V17.49" ]

icd9cm

[ [ [] ] ]

[ "39.61", "37.36", "39.32", "35.23", "39.31" ]

icd9pcs

[ [ [] ] ]

8297, 8396

5557, 6779

298, 578

8658, 8847

2229, 5225

9718, 10691

1352, 1452

7087, 8274

5262, 5534

8417, 8540

6805, 7064

8871, 9695

8563, 8637

1467, 2210

239, 260

606, 1020

1042, 1122

1235, 1336

28,142

168,657

51857

Discharge summary

report

Admission Date: [**2117-6-14**] Discharge Date: [**2117-6-14**] Date of Birth: [**2037-10-5**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3561**] Chief Complaint: hypotension, respiratory distress Major Surgical or Invasive Procedure: central line placement CPR History of Present Illness: 79 yo female with h/o CAD s/p CABG and PTCA in the past, HTN, afib, systolic HF EF 20-25%, presents to ED with MS changes- lethargy, and complaints of diarrhea and nausea. The stool was guiaic negative per patient report. She denied fever or chills while in the ED. Further history was unable to obtained at the time of admission since patient was intubated and family was not immediately available. In the ED, vitals were 33.4 rectal, 86, 115/76, 16, 100%. Her ED course was complicated and included developing respiratory distress which eventually required intubation. She also developed a wide complex tachycardia, which was evaluated by cardiology who felt it was likely secondary to her acidosis. During placement of her central line, she went into a pulseless VT, and was given 200J shoch with return of her pulses. Given her diarrhea, abdominal pain, severe acidosis and elevated lactate, there was a concern for ischemic bowel. Both non-contrast, and contrast CTs were obtained, without obvious evidence of ischemia or pneumatosis. She also had a dirty UA, and there was a concern for urosepsis. During her course, she received 6L IVFs, and a right IJ was also placed. She did at one point become hypotensive SBP to 80s despite IVFs, and she was started on levophed since CVP was 12. The granddaughter, who is the decision maker, was initially in the ED with the patient. A pastor was called to the bedside, but at the time of transfer to the MICU, the patient was FULL CODE. Past Medical History: 1 CAD s/p CABG [**2100**], s/p PTCA in [**2106**] w stents 2 ANEMIA with OB positive stools in the past 3 HTN 4 h/o of rapid afib not on coumadin 5 CHF: TTE in [**2-11**]: EF 20-25%. The left atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated with severe global and inferior akinesis. Right ventricular chamber size is normal with moderate global free wall hypokinesis. 6 s/p mitral valve annuloplasty 7 h/o H Pylori gastritis 8 Rh negative 9 HCV + [**2114-11-8**] 10 colonoscopy [**2-11**]: Aphthae in the proximal ascending colon, 2 Polyps in the distal descending colon, 1 of which was adenomatous 11 EGD [**2-11**]: Erythema and nodularity in the stomach body and fundus Polyp in the second part of the duodenum 12 Hypothyroidism Social History: Social History: The patient lives in Mission [**Doctor Last Name **]. She lives with her son and granddaughter currently. She has about a 20 pack year history and is currently smoking 1 ppd. Does not drink or use any illicit drugs. Pts son is imprisoned Family History: No family history of breast, lung, colon ca Physical Exam: VS: 97.8 140/55 63 17 93% on AC 400/20/5 GEN: elderly female, very ill appearing, intubated HEENT: ET tube in place; RIJ in place, no SOI around site CV: difficult to appreciate heart sounds LUNGS: rhonci bilaterally; coarse breath sounds ABDOMEN: soft, normal BS EXT: chronic venous stasis change; no edema, 2+ DP/radial pulses NEURO: sedated, intubated, no response to voice Pertinent Results: [**2117-6-14**] 06:07AM BLOOD WBC-26.1* RBC-4.18* Hgb-12.7 Hct-39.7 MCV-95 MCH-30.4 MCHC-32.0 RDW-16.3* Plt Ct-141* [**2117-6-14**] 06:07AM BLOOD PT-26.3* PTT-59.4* INR(PT)-2.6* [**2117-6-13**] 09:00PM BLOOD PT-16.1* PTT-32.9 INR(PT)-1.4* [**2117-6-14**] 06:07AM BLOOD FDP-160-320* [**2117-6-14**] 06:07AM BLOOD Fibrino-178 [**2117-6-14**] 06:07AM BLOOD Glucose-76 UreaN-26* Creat-1.1 Na-147* K-4.1 Cl-112* HCO3-18* AnGap-21 [**2117-6-14**] 06:07AM BLOOD ALT-1328* AST-1588* LD(LDH)-3555* AlkPhos-72 TotBili-1.2 [**2117-6-13**] 09:00PM BLOOD ALT-22 AST-44* CK(CPK)-134 AlkPhos-89 TotBili-1.0 [**2117-6-14**] 01:55AM BLOOD CK-MB-60* MB Indx-7.9* [**2117-6-13**] 09:00PM BLOOD cTropnT-0.08* [**2117-6-14**] 06:07AM BLOOD Calcium-7.2* Phos-5.4* Mg-1.6 [**2117-6-14**] 01:55AM BLOOD Albumin-2.7* UricAcd-8.7* [**2117-6-14**] 08:08AM BLOOD Lactate-10.0* [**2117-6-13**] 09:12PM BLOOD Glucose-86 Lactate-10.7* Na-146 K-3.7 Cl-103 calHCO3-17* [**2117-6-14**] 12:02AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.017 [**2117-6-14**] 12:02AM URINE Blood-SM Nitrite-POS Protein-TR Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-4* pH-5.0 Leuks-NEG [**2117-6-14**] 12:02AM URINE RBC-[**2-10**]* WBC-[**2-10**] Bacteri-MANY Yeast-NONE Epi-[**2-10**] Blood Culture, Routine (Final [**2117-6-19**]): NO GROWTH. AP CHEST X-RAY: An endotracheal tube terminates 4 cm above the carina. An enteric catheter courses through the esophagus to terminate in the mid stomach. The median sternotomy wires, prosthetic valve and mediastinal clips are unchanged. Heart size is markedly enlarged, unchanged. Bilateral lung hyperinflation and prominent interstitium is unchanged. increased interstitial prominence and Kerley B lines is new since [**Month (only) **]. There is no consolidation, pneumothorax or effusion. IMPRESSION: Stable severe cardiomegaly with mild fluid overload that has increased since [**Month (only) **] with satisfactory position of lines and tubes. CT ABDOMEN WITHOUT IV CONTRAST: The lung bases demonstrate bibasilar atelectasis. Moderate cardiomegaly is unchanged. There is no pericardial effusion. Trace pleural effusions are noted. On this non-contrast examination, the liver, and spleen are unremarkable. A mildly atrophic right kidney is noted. there is no evidence of hydronephrosis or mass. Small bilateral; adrenal nodules with Hounsfield measurments less than 10 are unchanged. There is a 5 mm gallstone without evidence of intrahepatic or extrahepatic biliary dilatation to suggest acute cholecystitis. Pancreatic head and body atrophy are unchanged. Periportal edema is moderate. Two small subcentimeter well circumscribed lesions in the right kidney likely represent cysts, although are too small to characterize. CT PELVIS WITHOUT CONTRAST: The rectum, uterus, adnexa and pelvic loops of bowel are unremarkable. There is a trace amount of free fluid noted. Foley and rectal catheters are noted. Bone windows demonstrate no suspicious lytic or blastic lesions. IMPRESSION: 1. Fluid filled small bowel without evidence of obstruction or inflammatory change. 2. Small bilateral stable adrenal adenomas. 3. Cholelithiasis without evidence of cholecystitis. 4. Extensive abdominal atherosclerotic changes. NON-CONTRAST CT HEAD: There is no evidence of hemorrhage, mass, mass effect or shift of normally midline structures. The [**Doctor Last Name 352**]-white matter differentiation is preserved throughout without evidence of recent infarct. Bilateral subcortical and periventricular white matter hypodensities represent chronic microvascular ischemia, unchanged. Calcification along the cavernous carotid arteries as well as the basal ganglia is unchanged. A small osteoma near the right coronal suture is unchanged. The paranasal sinuses and mastoid air cells are clear. IMPRESSION: No acute intracranial process. CT ABDOMEN: There are small bilateral effusions and associated relaxation atelectasis. The right kidney demonstrates patchy hypodensities which may represent acute to subacute infarcts as the right kidney is moderatley decreased in size but not grossly atrophic. The left kidney is unremarkable. The liver demonstrates patchy enhancement which is likely related to right heart failure. The spleen is unremarkable. There is moderate perihepatic and periportal ascites, unchanged. This may be seen in patients recieving hydration. The mesenteric venous and venous structures appear patent. The intra- abdominal loops of small and large bowel are grossly unremarkable, without evidence of pneumatosis, free air or obstruction. The pancreatic head and body are atrophic, unchanged. Bilateral adrenal nodules measuring less than 10 Hounsfield units are consistent with adenomas, unchanged. A 6 mm gallstone in the gallbladder is unchanged. CT PELVIS WITHOUT CONTRAST: There is trace pelvic free fluid. The rectum, uterus, adnexa and appendix are normal. foley and rectal tube are again noted. Bone windows demonstrate no suspicious lytic or blastic lesions. Extensive aortic and iliac calcifications are noted. IMPRESSION: 1. Right kidney infarcts are likely secondary to vascular insult and may be acute or subacute. 2. Extensive abdominalaortic, SMA and celiac arterial calcifications without evidence of bowel ischemia. 3. Small bilateral adrenal adenomas are unchanged. 4. cardiomegaly which includes rithe heart failure. The study and the report were reviewed by the staff radiologist. Brief Hospital Course: A/P: 79 yo female with h/o CAD, chronic systolic HF, presents with fevers, respiratory distress, hypotension, found to be in septic shock with multiorgan involvement, s/p intubation #. Sepsis: Patient meets sepsis criteria (leukocytosis, tachypnea, tachycardia, possible source), requiring intubation, then despite IVFs and CVP 12, still SBP in the 80s requiring Levophed initiation. She has a significant acidosis, with a significantly elevated lactate. Possible sources include pulmonary, GU, GI. Further workup did not reveal specific source except potential abdominal cause. On admission to MICU, she once again when into a pulseless VT and a code blue was called. The patient was stabilized after the code on 5 pressors, but there was no neuro function noted, with fixed pupils and dolls eyes. After multiple discussions with the granddaughter who was the closest relative we could discuss with at the time (patient's son was out of the country), a decision by the family was made to withdraw care and make the patient CMO. The patient expired from respiratory arrest likely secondary to sepsis. #. DIC: INR slowly increasing, as well as PTT, especially with elevating LFTs. The patient likely had evidence of DIC secondary to sepsis. #. Respiratory Distress: patient intubated [**1-9**] respiratory distress. CXR with ? infiltrate in RML. Patient remained intubated until made CMO and ventilatory support was removed per family request. #. Wide Complex Tachycardia: likely in the setting of septic heart; currently with many episodes of ectopy/NSVT. This eventually likely lead to her cardiac arrest and subsequent code blue. #. CONTACT: granddaughter [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 107393**] Medications on Admission: atorvastatin 40 mg daily Lasix 20 mg daily levothyroxine 88 mcg daily lisinopril 10 mg daily Toprol-XL 50mg daily sertraline 25 mg daily Prilosec 20 mg daily. Ensure 1 can daily. Discharge Medications: expired Discharge Disposition: Expired Discharge Diagnosis: Sepsis Expired secondary to cardiac arrest Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: expired

[ "311", "V12.72", "427.5", "244.9", "530.81", "427.31", "401.9", "414.00", "294.8", "276.4", "V45.82", "070.54", "785.52", "V45.81", "428.22", "272.0", "995.92", "535.50", "286.9", "285.9", "038.9", "496", "569.3", "428.0", "427.1", "V45.89", "305.1", "518.81" ]

icd9cm

[ [ [] ] ]

[ "96.71", "99.62", "99.60", "96.04" ]

icd9pcs

[ [ [] ] ]

10948, 10957

8949, 10686

349, 377

11044, 11053

3477, 6727

11109, 11119

3018, 3063

10916, 10925

10978, 11023

10712, 10893

11077, 11086

3078, 3458

276, 311

405, 1892

6736, 8926

1914, 2729

2761, 3002

31,183

130,947

47355

Discharge summary

report

Admission Date: [**2137-8-14**] Discharge Date: [**2137-9-9**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1145**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Cardiac Catheterization with BMS to LCx and OM1, PTCA of PL History of Present Illness: Mr. [**Known firstname **] [**Known lastname 1557**] is an 83 year-old male with type II diabetes, hypertension, coronary artery disease s/p STEMI in [**2137-1-25**] with BMS to the LAD and in-stent thrombosis managed by PTCA who presents from [**Hospital 100**] Rehab with worsening shortness of breath. He reports that he had been doing well at rehab until recently. He was seen in the office on [**2137-5-1**]. At that time he reported persistent fatigue and dyspnea on exertion. His blood pressures at rehab had been lower than usual and his lasix had been held with resulting lower extremity edema, dyspnea on exertion and orthopnea. On the morning of the 10th he was satting 98% on 2L nasal NC. He had a CXR which showed modest congestive heart failure which was worse compared to 1 month prior. He slept well the night of the 10th. On the morning of the 11th he was noted to be more uncomfortable with worsening shortness of breath. He had significant difficulty breathing when ambulating to the bathroom. He received 80 mg PO lasix. His shortness of breath persisted and his oxygen saturation decreased to 92% on 6L NC. He was transferred to the emergency room. . In the emergency room his initial vitals were T: 98.7 HR: 77 BP: 124/64 RR: 20-30 O2: 100% on NRB. His initial EKG was a poor baseline tracing but shows likely sinus rhythm, normal axis, normal intervals, no acute ST segment changes compared to prior from [**2137-3-16**]. He had a chest xray which showed signs of pulmonary edema. His BNP was elevated at 22,059. His first set of cardiac enzymes was notable for a troponin of 0.08. He initially required BIPAP but was transitioned to nasal cannula. He received aspirin 325 mg, ativan 0.5 mg x 1, lasix 40 mg IV x 1 and was placed on a nitroglycerin drip. His blood pressures were decreased on the nitroglycerin drip and this was discontinued. He was transferred to the floor for further management. . On review of systems he denies lightheadedness, dizziness, chest pain. He reports his shortness of breath is significantly improved since this morning. He denies chest pain, nausea, vomiting, abdominal pain, diarrhea, constipation, dysuria, hemuaturia or leg pain. He endorses worsening lower extremity edema, orthopnea and PND over the past week. All other review of systems negative in detail. Past Medical History: # Myocardial Infarction [**1-/2137**], s/p cath with PTCA and 2 stents placed in proximal LAD. C/b cardiogenic shock and VT requiring defibrillation/pacing for heart block # Myocardial Infarction with two stents placed in the RCA in [**2127**]. # RLE DVT [**3-1**] # Diabetes: HA1c 6.4% on [**11-30**]. High grade proteinuria X 1 yr. # Hypertension # Hypercholesteremia # Asthma # Stage IV Chronic Kidney Disease (baseline creatinine 2.5 to 2.8) Social History: Social history is significant for a long standing history of smoking prior to his myocardial infarction. He is now residing at [**Hospital 100**] Rehab and is not currently smoking. He does not use alcohol. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: PHYSICAL EXAMINATION AT ADMISSION: VS: T: 98.6 BP: 118/64 (right) HR: 59 RR: 25 O2: 99% on 5L NC Gen: Eldlerly male, lying in bed, mild respiratory distress, oriented x 3, 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 10 cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. + S4 Chest: No chest wall deformities, scoliosis or kyphosis. Resp were mildly labored with evidence of abdominal respiratory movements. Exam with decreased breath sounds throughout, crackles diffusely. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: 2+ edema in feet, no clubbing or cyanosis, trace DP pulses bilaterally. Pertinent Results: LABS AT ADMISSION: [**2137-8-14**] 06:52PM CK(CPK)-46 [**2137-8-14**] 06:52PM CK-MB-NotDone cTropnT-0.09* [**2137-8-14**] 10:55AM LACTATE-1.6 [**2137-8-14**] 10:40AM GLUCOSE-129* UREA N-98* CREAT-2.8* SODIUM-140 POTASSIUM-4.0 CHLORIDE-93* TOTAL CO2-36* ANION GAP-15 [**2137-8-14**] 10:40AM estGFR-Using this [**2137-8-14**] 10:40AM ALT(SGPT)-15 AST(SGOT)-20 LD(LDH)-209 CK(CPK)-44 ALK PHOS-80 TOT BILI-0.3 [**2137-8-14**] 10:40AM cTropnT-0.09* [**2137-8-14**] 10:40AM CK-MB-NotDone proBNP-[**Numeric Identifier **]* [**2137-8-14**] 10:40AM WBC-9.9 RBC-3.95* HGB-9.3* HCT-31.1* MCV-79* MCH-23.5* MCHC-29.8* RDW-16.4* [**2137-8-14**] 10:40AM NEUTS-81.2* LYMPHS-12.5* MONOS-4.8 EOS-1.4 BASOS-0.1 [**2137-8-14**] 10:40AM PLT COUNT-401 [**2137-8-14**] 10:40AM PT-32.3* PTT-40.5* INR(PT)-3.4* [**2137-8-14**] 10:32AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.011 [**2137-8-14**] 10:32AM URINE BLOOD-TR NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM [**2137-8-14**] 10:32AM URINE RBC-0-2 WBC-[**2-27**] BACTERIA-NONE YEAST-NONE EPI-0-2 [**2137-8-14**] 10:32AM URINE HYALINE-0-2 .. SELECTED RADIOGRAPHIC STUDIES: . RUQ U/S ([**2137-8-27**]) The gallbladder is collapsed, demonstrating numerous shadowing stones. No gallbladder wall edema evident. No pericholecystic or perihepatic fluid identified. Limited imaging of the liver is unremarkable. IMPRESSION: No evidence of biloma. . CT [**Last Name (un) **]/PEL ([**2137-8-30**]) IMPRESSION: 1. No evidence of retroperitoneal bleeding. 2. Unchanged abdominal aortic aneurysm. 3. Biliary stent. 4. Large bilateral pleural effusions. 5. Fluid-fluid levels in the small bowel. Correlate for GI bleeding. These may also represent vicarious excretion of contrast material from the recent catheterization procedure where contrast was administered. 6. Persistent contrast within the renal cortex may be related to patient's renal failure and recent contrast administration. . R-SIDED DEDICATED RIB FILM ([**2137-9-4**]) A single non-oblique view shows no gross evidence of fracture or pneumothorax. .. ECHOCARDIOGRAPHY: TTE ([**2137-8-15**]) The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. There is severe regional left ventricular systolic dysfunction with akinesis of the anterior, septal walls and the distal [**12-27**] of the ventricle (multivessel CAD). There is hypokinesis of the remaining segments (LVEF = 10-15%). A left ventricular mass/thrombus cannot be excluded. The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Moderate to severe (3+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Dilated left ventricle with severe regional and global systolic dysfunction. Moderate to severe mitral regurgitation. Moderate tricuspid regurgitation. Moderate pulmonary hypertension. Compared with the prior study (images reviewed) of [**2137-6-10**], the findings are similar. .. THALLIUM REST TEST ([**2137-8-22**]): INTERPRETATION: Following injection of of Thallium Chloride while the patient was at rest, static and gated SPECT images were obtained and analyzed. This study was interpreted using the 17-segment myocardial perfusion model. The image quality is limited, with suboptimal signal to noise. The left ventricular cavity size again demonstrates moderate to severe dilation. Resting perfusion images at 20 minutes and 4 hours reveal moderate to severe perfusion defects involving the distal anterior, anteroseptal, and anteroapical walls. The 24 hour images show no evidence of tracer redistribution. Compared with the study of [**2137-3-19**], there appears to have been no change. IMPRESSION: 1. Stable moderate to severe perfusion defects in distal anterior, anteroseptal and anterolateral walls without evidence of delayed tracer redistribution to suggest myocardial viability. 2. Stable moderate to severe ventricular dilation. .. CORONARY ANGIOGRAPHY ([**2137-8-29**]): COMMENTS: 1. Selective coronary angiography of this codominant system revealed 2 vessel CAD. The LMCA had no angiographically obstructive lesion. The LAD was diffusely diseased with a patent stent. The LCX had a proximal 70% stenosis and gave rise to two OM branches. The OM1 was a large branch with an 80% mid vessel stenosis. The PL had an 80% stenosis. The RCA was not engaged. 2. Limited resting hemodynamics revealed normal to low systemic pressure. 3. Left ventriculography was deferred. 4. Successful PTCA and stenting of the mid OM1 with a 2.5 x 15 mm VISION BMS at 16 ATM. Successful PTCA of the PL with a 2.0 and then a 2.25 x 20 mm voyager balloon at 12 and 8 ATM respectively. Successful PCI of the proximal LCX with a 3.0 x 15 mm VISION BMS at 16 ATM. Final angiography revealed no residual stenosis in the stents and a 20-30% residual in the PL, no dissection and TIMI III flow. (See PTCA comments) FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Successful stenting of the LCX and the OM1. 3. Successful PTCA of the PL. Brief Hospital Course: In summary, this is an 83-year old male with type II diabetes, hypertension, coronary artery disease s/p STEMI in [**2137-1-25**] with BMS to the LAD and in-stent thrombosis managed by PTCA who presents from [**Hospital 100**] Rehab with worsening shortness of breath found to have evidence of congestive heart failure now with significant improvement after aggressive diuresis. .. # PUMP / ACUTE ON CHRONIC HEART FAILURE: He has stage IV congestive heart failure and presented from rehab with an acute exacerbation. A TTE performed at admission revealed unchanged EF of [**10-9**]% with severe regional and global left ventricular dysfunction. He was diuresed aggressively with Lasix gtt as well as chlorthiazide. Unfortunately his breathing and hypercarbia worsened to the point that he required intubation and [**Hospital **] transfer from [**8-15**] to [**8-20**]. . After extubation, he underwent thallium rest study to investigate whether he might benefit from reperfusion in the setting of known CAD and LV systolic dysfunction. The thallium study, performed on [**8-22**], showed a possible area of myocardial viability in the distribution of OM1, and it was felt that he would benefit from coronary angioplasty and revasularization. He thus went to the cath lab on [**8-29**] after sufficient time to allow his creatinine to return to baseline, and after pre-treatment with N-acetylcysteine and adequate IV hydration. The full cath report is above: BMS were placed to his OM1 and his LCx with balloon angioplasty of the PL. . After the catheterization and likely d/t the contrast given during, he developed acute on chronic renal failure for which he was diuresed aggressively with IV Lasix drip and chlorthiazide twice daily. Five days post-procedure his urine output improved and oxygen requirements decreased to current mid to high 90s on 2-4L O2 by nasal cannula, depending on his activity level and position. For his heart failure, he was started on hydralazine and nitro paste. The hydralazine was uptitrated as BP tolerated to a dose of 10 mg four times daily at time of discharge. The nitro paste was switched to PO isosorbide dinitrate 10 mg to be taken three times daily. .. # ISCHEMIA / CORONARY ARTERY DISEASE: He is s/p STEMI in [**Month (only) 956**] complicated by in-stent thrombosis, VT/VF requiring cardioversion and pacing. Upon admission, he was continued on [**Month (only) **] 325, Plavix 75, and atorvastatin 80. His ACEI was held for concern of acute on chronic renal failure, and his BB was held in the setting of acute decompensated HF. These have both been stopped. Current heart failure medical regimen is described above. .. # RHYTHM / HISTORY OF VT/VF AND ATRIAL FIBRILLATION: At presentation, he was in normal sinus rhythm, being treated with BB, amiodorone and coumadin. As above, his BB was held for acute decompensated heart failure. He was switched to heparin drip in anticipation of coronary angiography, and was subsequently maintained on heparin gtt for acute renal failure and anticipated need of tunneled line placement for HD. When it became clear that his kidneys were recovering from the contrast-dye insult and there would be no indication for urgent hemodialysis, his warfarin was restarted. At time of discharge he has therapeutic INR for over two days. . Throughout the hospital course, he was monitored on telemetry and continued on his outpatient amiodorone. .. # RESPIRATORY DISTRESS: As above, he developed hypercarbic respiratory failure and was intubated from [**8-15**] to [**8-20**]. After extubation and stabilization on 4L NC, he was transferred to the floors. However, post cath procedure, he again developed volume overload (likely d/t his contast-related nephropathy and ARF) and was re-transferred to the CCU, where he was placed on NRB overnight. With diuresis and bronchodilator therapy, he was quickly weaned off NRB to NC. His urine output gradually increased and he was transitioned back to 2-4L NC and transferred back to the floors on [**9-5**]. . Bronchospasm was treated with alb/ipra nebulizers as needed. There was never concern of pneumonia or infectious pulmonary process. Serial CXRs showed bilateral pleural effusions, and although the idea of thoracentesis was entertained, this was never acted upon d/t the liklihood that the effusions would re-accumulate and that the most effective approach remained aggressive diuresis. . At time of discharge he is back on his home regimen of ipratropium inh four times daily. He is on O2 by NC, 2-4L to maintain O2 sats above 92%. .. # HISTORY OF ACUTE CHOLECYSTITIS: At time of presentation, he had a percutaneous cholecystostomy tube which was intermittently draining small amounts of fluid. There were no complications until the night of [**8-26**], at which time he became agitated and pulled out the bilary catheter. A RUQ U/S was performed which showed collapse of the gallbladder with no intra or peri-cholecystic fluid, no fat-stranding and no evidence of bilary duct dilatation. Surgery was consulted regarding possible replacement of the biliary catheter, but as there was no target to aim for (i.e. a collapsed gallbladder) and no signs on physical exam or laboratory data to suggest active infection, we decided on watchful waiting. There were no further complications during hospital course. The site of the previous cholecystostomy tube healed well and his transaminases remained WNL. .. # URINARY TRACT INFECTION: He had two separate urine cultures on [**8-31**] and [**9-2**] that showed >100,000 colonies of MRSA and pan-sensitive enterococcus. This was in the setting of normal UA, no symptoms, and no fevers. Because he had a persistent low-grade leukocytosis ([**12-8**]), non-resolving, we decided to begin a seven day course of vancomycin. He completes this on the day of discharge. .. # ACUTE ON CHRONIC RENAL FAILURE: His creatinine at admission was 3.8 from a baseline of 2.6 to 2.8. The presumed cause was poor renal perfusion given his acute decompensated CHF. After diuresis, his creatinine improved to baseline such that we were comfortable proceeding with coronary cath. Post-procedure, his creatinine trended up to peak at 4.9, at which point it stabilized and began decreasing. Simultaneously his urine output began to come back on a Lasix gtt and [**Hospital1 **] chlorthiazide. Renal was consulted but d/t improving renal function there was never a need for urgent HD. Hyperkalemia was treated with kayexalate prn. . # TYPE II DIABETES MELLITUS: Oral agents were held at admission. He was kept on regular insulin sliding scale. At time of discharge he is started back on home glipizide. . # ANEMIA: Baseline hematocrit of 30-35. There was concern when his hematocrit dropped to mid 20s post-cath that he may have internal bleeding. A CT [**Last Name (un) 103**]/pelvis was then performed which was completely negative for occult bleed. Stool guaiac was also negative. His hematocrit remained stable in the mid to high 20s. Per renal recs, he was started on erythropoietin, in addition to the iron supplement on which he presented, for anemia related to stage IV CKD. . # ANXIETY / DEPRESSION: He is an anxious man at baseline requiring regular nursing and physician [**Name Initial (PRE) 2176**]. Certainly this baseline anxiety was exacerbated by his acute illness and hospitalization. Psychiatry was consulted for recommendations regarding management while in house. Per their recommendations he was started on Zyprexa both standing and PRN doses. This helped significantly with his agitation. Meanwhile, he was continued on home Celexa for his h/o depression. Trazadone and lorazepam were held. His discomfort associated with breathing distress and back pain (see below) was treated with morphine 0.5-1mg q4h prn, from which he also derived considerable benefit. At time of discharge, his anxiety disorder is being treated with standing and prn Zyprexa. His citalopram has been continued. His discomfort associated with shortness of breath can be treated with morphine liquid. If he becomes agitated, family in the past has hired overnight companions to stay with patient. . # PAIN: He intermittently complained of left and right-sided shoulder to back pain, as well as right-sided rib pain that was reproducible with palpation. CXR and dedicated rib films were repeatedly negative for acute fracture. Shoulder joint exams were unremarkable. We believed the pain to be d/t musculoskeletal strain and/or inflammation resulting from inactivity and the strain of lying on his back and side in bed for such a prolonged period of time. We treated the pain with tramadol, morphine, and lidocaine patches. . # BPH: Currently not being treated. . # He was kept on a cardiac, diabetic diet. DVT prophylaxis was not an issue as he was anticoagulated on heparin gtt or coumadin during entirety of hospital course. GI prophylaxis with famotidine and bowel regimen. His code status, which was addressed with both son [**Name (NI) **] and patient, remained full code throughout. Medications on Admission: Atorvastatin 80mg daily Carvedilol 3.125mg [**Hospital1 **] Flomax 0.4mg hs Clopidogrel 75mg daily Citalopram 20mg daily Aspirin 325mg daily Lorazepam 0.5mg hs PRN Lasix 80mg qAM, 40mg qPM Digoxin 0.125mg daily Amiodarone 200mg daily Glipizide 2.5mg daily Trazodone 25mg daily Ferrous sulfate 324mg daily Coumadin 5mg daily Gabapentin 200mg TID Metolazone 2.5mg [**Hospital1 **] Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Glipizide 2.5 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO once a day. Tab,Sust Rel Osmotic Push 24hr(s) 8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Calcium Carbonate 500 mg Tablet, Chewable Sig: [**12-26**] Tablet, Chewables PO BID PRN as needed for heartburn. 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 12. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). Adhesive Patch, Medicated(s) 13. Tramadol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for pain. Tablet(s) 14. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 15. Hydralazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours): Hold for SBP <80. 16. Chlorothiazide 250 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 17. Furosemide 40 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 18. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): Hold for SBP <80. 19. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO BID (2 times a day) as needed. 20. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO BID (2 times a day). 21. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)). 22. Morphine 10 mg/5 mL Solution Sig: 0.5-1 mL PO q4H PRN as needed for shortness of breath or anxiety. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary Diagnosis: -------------------- Congestive Heart Failure with EF of around 15% Coronary Artery Disease CKD w/ [**Last Name (un) **] probably due to contrast nephropathy Acute choleycystitis s/p choleycystotomy tube . Secondary Diagnoses: Atrial Fibrillation Hypertension Hyperlipidemia Dyslipidemia Anxiety/Depression Benign Prostatic hypertrophy Discharge Condition: Vital signs stable. O2 sats mid 90s on 4L. Weight 66.4 kg. Discharge Instructions: You were admitted because you were short of breath and were having problems with your thinking. We believe this was because your heart failure had worsened. We attempted to remove fluid to help your breathing and you also had a blocked vessel reopened in your heart. Your kidneys temporarily failed after the catheterization procedure, probably due to the contrast dye, but then recovered on their own. You are being discharged to rehab to complete your recovery. . Your heart medications have been changed. We have started you on two new medicines to help your heart. These are isosorbide dinitrate and hydralazine. We have also started you on two medicines to help you urinate and decrease the amount of fluid in your body. These are Lasix and chorathiazide. . During this hospitalization, you were diagnosed with anxiety disorder. This condition may cause you to become restless and worried at times. This has been treated with reassurance and alteration in some of your medications. Ativan and trazadone were stopped. Olanzepine was started at a standing dose, which you should take regularly throughout the day, and at an as needed dose, which you should take when you become anxious. . Please keep all scheduled follow-up appointments as these are important to maintain your health. . > 3 lbs. Please adhere to a 2 gm of sodium per day and 1.5 liter of fluid per day diet. Please call your doctor or report to the emergency room if you have fevers to >101, increased shortness of breath, chest pain, inability to tolerate food by mouth, or any other concerning changes to your health. Followup Instructions: Cardiology: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 62**] Date/time: [**9-16**] at 4:20pm. . Nephrology: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone: [**Telephone/Fax (1) 60**] Date/time: [**9-26**] at 9am. Completed by:[**2137-9-9**]

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39992

Discharge summary

report

Admission Date: [**2124-6-26**] Discharge Date: [**2124-7-9**] Date of Birth: [**2096-2-3**] Sex: M Service: CARDIOTHORACIC Allergies: Advil / Aspirin Attending:[**First Name3 (LF) 165**] Chief Complaint: Intermittent bradycardia, hypoxia, chest pain with TWI and trop leak in setting of infective endocarditis Major Surgical or Invasive Procedure: [**2124-7-2**] 1. Aortic valve replacement with a size 23-mm St. [**Male First Name (un) 923**] mechanical valve. 2. Mitral valve replacement with a size 31 St. [**Male First Name (un) 923**] mechanical valve. History of Present Illness: 28 yo M with PMH of IVDU, and aortic valve infective endocarditis admitted with infective endocarditis. He is transferred to the CCU for more monitoring in setting of worsened hypoxia, altered mental status and intermittent hypotension/bradycardia thought to be vagal in nature. . He was admitted here on [**6-26**] after a 3 day stay at an OSH. The day prior to that he presented to his PCP and found to have a 7 point hct drop 31--->24 and was referred to an OSH ED. There, he has no elevation if WBC but had a 7% bandemia and blood cultures grew out strep. He was positive for cocain as well. After his blood cultures turned positive, he was transferred here for further care as there had been plan for valve replacement with Dr. [**Last Name (STitle) 65483**]. . Of note, his last episode of infective endocarditis was in the fall of [**2123**] and was treated with 3 months of iv antibiotics (unknown type). He had previously been on IV abx (unclear which kind for 3 months . Since admission here, he has been doing well and had been treated with ceftriaxone and gentamycin. ID has been following. Blood cultures here have been negative. . He has been continued on his cardiac medications and received diuresis for fluid overload with lasix thought to be from his severe MR. Repeat echo here showed 4+ MR, 4+ AI, EF 65% with 1cm vegetations on both the aoritic and mitral valves. There was also a likely vegetation attached to the left atrial wall in the region of the warfarin ridge. Finally, the aortic root appeared thickened concerning for an abscess/phlegmon. . CT surgery was consulted given wide open MV and AV on echo. Though there is CT surgery note from this admission, per intern notes, recommendation was antibiotics, out pt drug rehab and goal of being drug free for 6 months prior to consideration for valve replacement. . He had been doing well since admission until last night at 10pm when he became anxious, reported chest pain. Also had 2 episodes of bradycardia to high 30's which resolved without intervention and tele showed ? junctional rhythm. EKG showed TWI in the precordial leads. The overnight team spoke with the cardiology fellow who felt that this was unlikely to be heart block as it resolved with no intervention. Felt to be vagal and likely related to anxiety and he received ativan 1mg iv and he felt better. Cardiac enzymes were sent and trop was 0.37 and CK/MB were normal. Felt to likely be a coronary septic emboli and systemic anticoagulation is not favored given high risk of CNS emboli and converstion to hemorrhage. CT head was negative though MRI was recommended for complete rule out of emboli. . At 6am this morning, he triggered for tachypnia, hypoxia to mid 80's on room air. He noted to be diaphoretic and with chest pain. See trigger note for full details. He was again bradycardic, with BP's in the 100's, hypoxia to mid 80's on room air which reoslved to 2L nc. EKG showed deeper TWI in precordial leads and TWI in inferior leads. Repeat trop down trended to 0.32 and CK/MB normal. Cr increased to 1.6 and Na down to 130. Lactate was 3. There was concern that he had friends visiting the evening before and that he could have used an illicit drug. A room search was done and suboxone/naloxone combo pills were found. Pill count showed an appropriate number of pills. Urine and serum tox were negative. Cardiac surgery consulted for urgent surgical correction. Past Medical History: Aortic and mitral valve endocarditis s/p Aortic and Mitral valve replacement Past medical history: Viridin streptococcal endocarditis PICC line infection - Stenotrophomonas/Enterobacter cloacae Anxiety Depression Asthma surgery for pilonidal cyst s/p Hernia repair Social History: -Tobacco: 1 ppd -ETOH: Denies -Illicit drugs: Denies, but cocaine postive at OSH Family History: Father died at age 57 of an abdominal aortic aneurysm (heavy smoker). Mother had [**Name2 (NI) 499**] cancer with a colectomy, GF died of asbestos Physical Exam: VS: Tc 99.2 BP 96/53 HR 65 RR 18 100% RA GENERAL: diaphoretic male in NAD. Oriented x3. Mood, affect appropriate. HEENT: Eyebrown ring above left eyebrow. No evidence of focal hemmorage. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink NECK: Supple without JVD CARDIAC: [**3-12**] soft systolic murmur best heart at the mitral position, LUNGS: CTAB ABDOMEN: Soft, NTND. No HSM or tenderness EXTREMITIES: 2+ lower extremity edema, non-pitting. Left toe between digits 4 and 5 is torn with scab formation. SKIN: Multiple tattos, but no signs of osler's nodes or [**Last Name (un) **] lesions. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Pertinent Results: [**2124-6-26**] 11:44PM BLOOD WBC-13.0* RBC-3.77* Hgb-9.6* Hct-30.1* MCV-80* MCH-25.5* MCHC-31.9 RDW-18.0* Plt Ct-460* [**2124-6-26**] 11:44PM BLOOD Neuts-83.2* Lymphs-9.2* Monos-3.5 Eos-3.1 Baso-0.9 [**2124-6-26**] 11:44PM BLOOD PT-14.9* PTT-22.9 INR(PT)-1.3* [**2124-6-26**] 11:44PM BLOOD Glucose-129* UreaN-26* Creat-1.5* Na-130* K-4.1 Cl-90* HCO3-28 AnGap-16 [**2124-6-27**] 05:49AM BLOOD ALT-16 AST-24 LD(LDH)-208 AlkPhos-112 TotBili-0.5 DirBili-0.3 IndBili-0.2 [**2124-6-26**] 11:44PM BLOOD Calcium-8.4 Phos-5.0* Mg-2.2 [**2124-6-27**] 05:49AM BLOOD calTIBC-268 Hapto-309* Ferritn-282 TRF-206 [**2124-6-27**] 05:49AM BLOOD CRP-50.9* [**2124-6-26**] 11:45PM BLOOD HIV Ab-NEGATIVE . Echo [**6-30**]: The left atrium is dilated. Left ventricular wall thicknesses are normal. The right ventricular cavity is dilated with depressed free wall contractility. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets are mildly thickened with probable vegetation (~1cm diameter). The aortic root is irregularly thickened consistent with aortic phelgmon/abscess. Severe (4+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened with large perforation of the anterior leaflet. There is a large (~1.7 cm) vegetation on the mitral valve attached to the anterior leaflet in the region of the perforation. Severe (4+) mitral regurgitation is seen. There is a moderate sized vegetation (~1.2 cm) attached to the left atrial wall in the region of the warfarin ridge. The tricuspid valve leaflets are mildly thickened. There is severe pulmonary artery systolic hypertension. The pulmonic valve leaflets are thickened. There is a very small pericardial effusion. In addition to the above vegetations, at least one additional vegetation (~0.6 cm diameter) is noted attached to the anterior mitral valve leaflet. Compared with the prior report (images unavailable) of [**2124-6-27**], findings are similar. The mitral valve vegetation appears slightly larger. [**2124-7-2**] TEE Conclusions Prebypass No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. There is a small vegetation seen on the coumadin ridge. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is mildly depressed (LVEF=45-50%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] The right ventricular cavity is dilated with mild global free wall hypokinesis. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. There is a moderate-sized vegetation on the aortic valve. No aortic valve abscess is seen. Severe (4+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is partial anterior mitral leaflet flail. There is a moderate-sized vegetation on the mitral valve. Severe (4+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is a small pericardial effusion. Post bypass Patient is in sinus rhythm and receiving an infusion of Norepinephrine, Vasopressin and Milrinone. LVEF= 40%. Mechanical valve seen in the aortic position. It appears well seated and the lealfets move well. Peak gradient across the aortic valve is 26 mm Hg and the mean gradient is 13 mm Hg. Washing jets typical for this type of valve are seen. Mechanical valve seen in the mitral posiiton. It appears well seated and the leaflets move well. The mean gradient across the mitral valve is 3 mm Hg and the peak gradient is 5 mm Hg. Washing jets typical for this type of valve are also seen. Trivial tricuspid regurgitation seen. Aorta is intact post decannulation. Brief Hospital Course: MEDICINE COURSE: 28 yo M with hemodynamically significant strep endocarditis in setting of likely [**Hospital 15254**] transferred to CCU after decompensation with worsening heart failure, hypoxia, chest pain with EKG changes and troponin leak concerning for coronary emboli now s/p temporary pacer placement with plan for surgical intervention on [**7-2**] . # Bradycardia: On [**6-30**] patient with episodes of intermittent symptomatic bradycardia to high 30 to low 40's. At that time tele with wide complex rhythm, poor baseline thus difficult to assess for p waves though appears to have some p waves on strip, appear to be non-conducting at an atrial rate of ~60 and a ventricular rate of ~40 consistent with intermittent heart block in setting of endocarditis/aortic wall abscess. Patient was subsequently hemodynamically stable with temporary pacer in place. Transfered to OR for surgical treatment of his endocarditis . # Hypoxia: Likely decompensation in setting of wide open MV and AV as result of infective endocarditis. Clinically volume up. # Streptococcus Infective Endocarditis: Has vegetations on MV, AV and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **]. High concern for emboli given increase in trop, change in mental status though CT was negative. Clinically has decompensated in spite of maximum medical therapy with appropriate antibiotics, treatment for heart failure. After extensive discussion plan to forge head with surgical intervention. # Chest Pain: Occurs with his heart block likely precipitating cardiac ischemia. EKG with worsening TWI initially in precordial leads and now in inferior leads as well. Trop bump peak at 0.37, down to 0.32. Per literature review, 40% of patients with IE have troponin leak. Also concern for coronary emboli though ischemic from CHB most likely. No role for systemic anticoagulation or cath in this setting. - temporary pacer in place. # Acute Renal Failure: New in last 24 hours, likely in setting of worsening heart failure and poor forward flow. In setting of aggressive diuresis creatinine stable but elevated at 1.7 with adequate UOP. # elevated lactate: likely [**3-8**] to poor forward flow and likely peripheral ischemia . # Drug Dependance and Abuse: Cocaine positive at OSH though patient denied. POST-OP COURSE: The patient was brought to the Operating Room on [**2124-7-2**] where the patient underwent AVR (23mm St. [**Male First Name (un) 923**] mechanical), MVR (31mm St. [**Male First Name (un) 923**] mechanical) with Dr. [**First Name (STitle) **]. 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 by POD 2. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. Coumadin was initiated for mechanical valves, with a heparin bridge. Initial gram stain from OR tissue grew gram negative rods. ID continued to follow for antibiotic management. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD #7 he was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to [**Hospital **] rehab in good condition with appropriate follow up instructions. Medications on Admission: Buprenorphine-nalaxone 8 mg-2mg sublingually [**Hospital1 **] Klonoprin 0.25 mg Daily Furosemide 80 mg daily Lisinopril 10 mg daily Potassium 20 mEq daily Discharge Medications: 1. metoprolol tartrate 25 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO BID (2 times a day). 2. potassium chloride 10 mEq [**Hospital1 8426**] Extended Release Sig: Two (2) [**Hospital1 8426**] Extended Release PO Q12H (every 12 hours). 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. ranitidine HCl 150 mg [**Hospital1 8426**] Sig: One (1) [**Hospital1 8426**] PO BID (2 times a day). 5. aspirin 81 mg [**Hospital1 8426**], Delayed Release (E.C.) Sig: One (1) [**Hospital1 8426**], Delayed Release (E.C.) PO DAILY (Daily). 6. warfarin 1 mg [**Hospital1 8426**] Sig: [**Name8 (MD) **] MD [**First Name (Titles) 8426**] [**Last Name (Titles) **] DAILY (Daily): INR goal=2.5-3.5 for mechanical AVR/MVR . 7. acetaminophen 325 mg [**Last Name (Titles) 8426**] Sig: Two (2) [**Last Name (Titles) 8426**] PO Q4H (every 4 hours) as needed for pain/fever. 8. oxycodone-acetaminophen 5-325 mg [**Last Name (Titles) 8426**] Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 9. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 10. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 11. benzocaine 20 % Paste Sig: One (1) Appl Mucous membrane QID (4 times a day) as needed for oral sores. 12. ceftriaxone in dextrose,iso-os 2 gram/50 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours): Start date: [**2124-7-2**] Stop date: [**2124-7-29**] (4 weeks as of surgery) . 13. gentamicin 40 mg/mL Solution Sig: 4.5 Injection Q24H (every 24 hours): Start date: [**2124-7-2**] Stop date: [**2124-7-15**] (2 weeks as of surgery) . 14. sodium chloride 0.9 % 0.9 % Syringe Sig: Ten (10) ML Injection once a day as needed for line flush: & PRN. 15. warfarin 2 mg [**Month/Day/Year 8426**] Sig: One (1) [**Month/Day/Year 8426**] PO once for 1 doses: administer at 4PM . 16. furosemide 10 mg/mL Solution Sig: Four (4) Injection [**Hospital1 **] (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital1 **]-[**Hospital1 8**] Discharge Diagnosis: Aortic and mitral valve endocarditis s/p Aortic and Mitral valve replacement Past medical history: Viridin streptococcal endocarditis PICC line infection - Stenotrophomonas/Enterobacter cloacae Anxiety Depression Asthma surgery for pilonidal cyst s/p Hernia repair Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Percocet Incisions: Sternal - healing well, no erythema or drainage Edema- 2+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 170**] Date/Time:[**2124-7-31**] 1:45 Cardiologist: Dr. [**Last Name (STitle) 23097**] [**8-8**] at 2:35pm [**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2124-7-24**] 10:30 Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) 67391**] in [**5-9**] weeks [**Telephone/Fax (1) 87956**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? indication: Mechanical Aortic and Mitral Valves Goal INR 2.5-3.5 First draw [**2124-7-10**] Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by MD *****ANTIBIOTIC REGIMEN AND PROJECTED DURATION: [**Doctor Last Name **] and DOSE: Ceftriaxone 2gmQ24h Start date: [**2124-7-2**] Stop date: [**2124-7-29**] (4 weeks as of surgery) Gentamicin 180mg IV Q24 Start date: [**2124-7-2**] Stop date: [**2124-7-15**] (2 weeks as of surgery) REQUIRED LABORATORY MONITORING: LAB TESTS: CBCdiff, BUN, CREA, LFTs, Vanco trough, Gent trough, ESR, CRP FREQUENCY: Qweekly All laboratory results should be faxed to Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**] FOLLOW UP APPOINTMENTS SCHEDULED: [**2124-7-24**] 10:30a ID,[**Doctor Last Name **],[**Doctor First Name **] LM [**Hospital Unit Name **], BASEMENT ID WEST (SB) All questions regarding outpatient antibiotics should be directed to the infectious disease R.Ns. at ([**Telephone/Fax (1) 1354**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2124-7-9**]

[ "790.7", "041.85", "421.0", "041.09", "424.1", "999.31", "428.0", "276.1", "V02.54", "584.9", "300.4", "285.29", "426.0", "304.20", "493.90", "E879.8", "416.8", "V45.89", "685.1", "V16.0", "424.0", "428.21" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.22", "38.91", "99.69", "35.24" ]

icd9pcs

[ [ [] ] ]

15352, 15413

9410, 13099

386, 598

15723, 15890

5319, 9387

16813, 18602

4472, 4620

13306, 15329

15434, 15512

13126, 13283

15914, 16790

4635, 5300

240, 348

626, 4065

15534, 15702

4372, 4456

20,169

147,155

27235

Discharge summary

report

Admission Date: [**2192-11-14**] Discharge Date: [**2192-11-29**] Date of Birth: [**2123-12-22**] Sex: F Service: MEDICINE Allergies: Naproxen / Ultram / Captopril / Codeine Attending:[**First Name3 (LF) 1580**] Chief Complaint: unresponsive, AMS Major Surgical or Invasive Procedure: abdominal paracentesis with 6L removed History of Present Illness: 64 yo F with h/o cirrhosis thought to be [**3-15**] NASH s/p s/p large volume 6L paracentesis on [**2192-11-14**] and subsequently found unresponsive. Patient was hypotensive SBP 60s, hypoglycemic FS 42 as well as hypothermic. Given 1 am D50 with improvement in FS to 240. Given aggressive IVFs in ED, SBP 70->100's. Guaiac neg. . Recently admitted [**11-3**] to [**11-6**] with chills and rigors, tap not c/w SBP however. Blood, urine and peritoneal fluid cultures all negative. Vancomycin, ceftriaxone were started empirically then d/ced and sent home on SBP ppx with Bactrim and Cipro. . In the ED VS T 95.6 HR 87 BP 69/47-->104/60 RR 26 100% RA. BS 20 in ED given another amp D50. Total 5.5 L given in ED. Albumin given, 200 cc then 50 g. Given Ceftrixone 1 g and Vanco 1 g, lactulose and rifaximin. . Past Medical History: 1. Cirrhosis- diagnosed by bx in [**Country 4194**] in [**2190**], developed ascites and edema 5 months ago, likely due to NASH, Hep B and C negative ([**6-16**]), now with ascites and grade II varices (EGD [**7-17**]); s/p TIPS 2. DM2- on glipizide 3. Low blood pressure 4. Depression 5. s/p TAH 6. Schistosoma Ab positive [**6-16**] Social History: Originally from [**Country 4194**] but now lives with her family in [**Hospital1 3494**]. Speaks Portuguese only. She does not drink ETOH or smoke. No hx of IVDU. Had a blood transfusion 25 yrs ago following a TAH. Family History: no hx of liver disease, cancer, heart disease Physical Exam: VS: 97.9, 102/74, 82, 20, 100% RA, FS 198 Gen: lethargic, but arouses to name Skin: spider telangiectasias on face, +jaundice Heent: dry mmm, icteric, PERRL, EOMI Chest: CTA no wheezing/rales CVS: nl S1 S2, RRR, no m/r/g appreciated Abd: distended, soft, +ascites, + BS, NT Ext: warm, 1+ edema in upper and lower ext, multiple eccymoses Neuro: lethargic, able to follow simple commands, oriented to self, moving all 4 ext. Pertinent Results: [**2192-11-13**] 01:40PM PT-15.5* PTT-34.6 INR(PT)-1.4* [**2192-11-13**] 01:40PM WBC-9.2 RBC-3.63* HGB-10.7* HCT-31.4* MCV-87 MCH-29.4 MCHC-34.0 RDW-17.0* [**2192-11-13**] 01:40PM GLUCOSE-52* UREA N-37* CREAT-1.4* SODIUM-126* POTASSIUM-5.8* CHLORIDE-91* TOTAL CO2-25 ANION GAP-16 [**2192-11-13**] 02:51PM ASCITES WBC-65* RBC-315* POLYS-2* LYMPHS-41* MONOS-19* ATYPS-1* MACROPHAG-36* OTHER-1* [**2192-11-13**] 10:30PM ALT(SGPT)-89* AST(SGOT)-144* ALK PHOS-448* AMYLASE-71 TOT BILI-2.1* [**2192-11-13**] 10:49PM LACTATE-2.7* [**2192-11-14**] 08:23AM CORTISOL-19.9 [**2192-11-14**] 10:20AM AMMONIA-38 [**2192-11-29**] 09:00AM BLOOD WBC-5.4 RBC-2.91* Hgb-9.1* Hct-26.9* MCV-92 MCH-31.2 MCHC-33.8 RDW-18.8* Plt Ct-161 [**2192-11-29**] 09:00AM BLOOD Plt Ct-161 [**2192-11-29**] 09:00AM BLOOD Glucose-105 UreaN-18 Creat-0.5 Na-131* K-4.2 Cl-99 HCO3-25 AnGap-11 [**2192-11-28**] 06:58AM BLOOD ALT-146* AST-272* AlkPhos-692* TotBili-4.0* [**2192-11-29**] 09:00AM BLOOD Calcium-8.3* Phos-2.7 Mg-2.1 CT head [**11-18**] FINDINGS: There is no evidence of hemorrhage, mass effect, shift of normally midline structures, hydrocephalus, or acute major vascular territorial infarction. The ventricles and sulci are normal in size. The [**Doctor Last Name 352**]-white matter differentiation is preserved. Again seen are atherosclerotic calcifications within the visualized vertebral arteries and along the falx and tentorium cerebelli. The surrounding osseous and soft tissue structures are unremarkable. The visualized paranasal sinuses are well aerated. IMPRESSION: No intracranial hemorrhage or mass effect. Stable appearance of the brain since [**2192-10-18**]. DUPLEX DOPP ABD/PEL [**2192-11-20**] 10:33 AM LIVER OR GALLBLADDER US (SINGL; -59 DISTINCT PROCEDURAL SERVIC Reason: eval patency of TIPS IMPRESSION: 1. Persistent large amount of ascites surrounding liver. 2. Decrease in TIPS velocities. Peak velocity in the distal TIPS currently 78 cm/sec (previously 120 cm/sec). SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA RIGHT [**2192-11-22**] 3:51 PM FINDINGS: There is a fracture involving the surgical neck of the right proximal humerus. Several butterfly fragments are seen. There is bridging callus. However, the fracture line is still well seen. There is marked varus angulation and internal rotation of the humeral head at the fracture site since the previous study. The humeral shaft is displaced anteriorly in relation to the humeral head. Brief Hospital Course: A/P: 68 yo F with cirrhosis [**3-15**] presumed NASH, s/p large volume paracentesis on [**11-13**] presents with hypotension, hypothermia and hypoglycemia. #AMS: Upon arrival to [**Hospital Unit Name 153**], patient hypothermic to 95.0, hypotensive SBP in 90s, FS dropped to 20's. Patient started on D5 gtt, bolused NS with improvement. Her FS dropped to nadir of 3 and required dextrose drips, D20 and D50 boluses. It was felt this was due to glyburide that was recently started and its interaction with ciprofloxacin (unclear if she ever got cipro, per family) vs. bactrim (which she was definitely taking). FS normalized on [**2192-11-18**]. Her FS are now in the mid 100's off glucose drips. Her mental status was still poor after FS normalized and was given flumazenil empirically (last dose AM of [**2192-11-19**]) as she had been given benzos one week prior for ?seizure in setting of hypoglycemia. She did perk up after the flumazenil [**Name8 (MD) **] RN. CT head was negative on [**2192-11-18**]. She was continued on home rifaxamin and lactulose doses, and after ativan wore, off her MS [**First Name (Titles) **] [**Last Name (Titles) 5348**] until d/c. . Her BP normalized with fluids and albumin. She did have some low UO during her stay in ICU. Initial concern was for HRS versus abd compartment syndrome. Bladder pressures were WNL. She was started on empiric tx for HRS with midodrine and octreotide. This was discontinued on [**2192-11-18**]. # Hypoglycemia - Resolved. Felt to be secondary to glyburide interacting with ciprofloxacin. Holding glyburide. [**Last Name (un) **] consulted and didn't believe she was a candidate for oral hypoglycemics given liver dz. and response to glyburide. the decision was made to allow more permissive glucose control given the risks and benefits of tight control given recent episode of hypoglycemia and her poor longterm prognosis and inability to qulaify for ongoing VNA teaching. - she was started on lantus and HISS d/c'd prior to discharge - she was given diabetic insulin administration teaching for her family in hospital as does not qualify for VNA as well as nutrition consult for diabetes. - She should avoid all oral hypoglycemics as well as bactrim in the future. It is unclear if she should avoid ciprofloxacin in the future as well. . # Cirrhosis. Unclear etiology, likely NASH, dependent on frequent large volume paracentesis, SBP r/out multiple times. received 6L tap yesterday. - cont. lactulose, rifaximin - She had a therapeutic paracentesis on [**2192-11-19**]. - restarted on diuretics 20mg lasix, with increased dose of 100mg aldactone to improve diuresis as she has had refractory ascites. - she was not placed on SBP ppx given possible hypoglycemia induced by cipro vs. bactrim and since she has no h/o of SBP that we could identify in her chart. . # Hyponatremia: pt. hyponatremic on admit, thought to be [**3-15**] hypervolemic hyponatremia, resolving by discharge on diuretics as above . # ?UTI: Culture from [**11-13**] with 10,000-100,000 VRE, repeat u/a and ucx negative on [**11-17**] but u/a on [**11-18**] had 21 WBC with 1000 RBC. - Urine Cx. negative, so will not treat with abx now. . # Heme: Platelets lower now than previously but stable. Likely secondary to cirrhosis. Will cont to monitor. Hematocrit around bl of 30 and stable. She had no signs of bleeding, hct stable during admission Medications on Admission: - Lactulose [**Hospital1 **] - Simethicone 80 0.5 daily - Citalopram 20 mg po daily - Pantoprazole 40 mg daily - Metoclopramide 10 mg PO QIDACHS - Oxycodone 5 mg PO Q4-6H - Furosemide 20 mg po daily - Spironolactone 25 mg po daily - Glyburide 5 mg po daily - Bactrim DS 160-800 mg PO twice a day for 5 days. Discharge Medications: 1. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 2. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO QID (4 times a day): titrate to 6 bowel movements/day. Disp:*3600 ML(s)* Refills:*2* 3. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Insulin Glargine 100 unit/mL Solution Sig: Four (4) units Subcutaneous HS (at bedtime). Disp:*1 qs* Refills:*2* 5. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Simethicone 80 mg Tablet, Chewable Sig: .5 Tablet, Chewable PO once a day as needed for gas. Disp:*15 Tablet, Chewable(s)* Refills:*2* 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 9. Lancets Misc Sig: One (1) lancet Miscell. twice a day: check your blood sugars twice a day, once in the mornign before you eat and once at night. Disp:*2 boxes* Refills:*2* 10. One Touch Ultra Test Strip Sig: One (1) strip Miscell. twice a day: check your sugars twice daily, once before you eat in the morning and once before you go to bed. Disp:*2 boxes* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Hypoglycemia Diabetes Mellitus Liver Cirrhosis Recurrent Ascites Discharge Condition: good, tolerating POs, ambulating with assist, satting well on RA Discharge Instructions: Please return if you develop increased abdominal girth, abdominal pain, nausea, or decreased urine output. Also seek medical attention if your glucose measurements are low, or if you experience dizziness, nausea, or changes in your mental status. Please take all medications exactly as prescribed. You will be taking 20mg lasix once a day and 100mg spironolactone once a day. You should also take lactulose [**4-14**] times a day, titrating to 6 loose bowel movements per day. You have also been started on insulin shots. you will be taking 4 units of insulin each night as shown to you by your nurses. Followup Instructions: follow up at the following appts: [**Doctor First Name 10079**] [**Doctor First Name 10080**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2192-12-6**] 2:00 in [**Hospital Ward Name **] center, [**Location (un) **], south suite for an electrolyte check. Come 1 hour before the appointment in order to have your labs drawn before the appointment. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2192-12-14**] 11:00 in the [**Hospital Unit Name **] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1583**] MD, MSC, MPH[**MD Number(3) 1584**]

[ "V02.59", "E931.9", "571.5", "458.29", "280.0", "E932.3", "719.41", "570", "276.1", "287.5", "572.2", "789.5", "780.39", "572.3", "456.21", "250.30" ]

icd9cm

[ [ [] ] ]

[ "54.91", "99.04", "38.93", "96.6" ]

icd9pcs

[ [ [] ] ]

9909, 9966

4796, 8185

321, 362

10075, 10142

2312, 4773

10799, 11498

1806, 1853

8544, 9886

9987, 10054

8211, 8521

10166, 10776

1868, 2293

264, 283

390, 1199

1221, 1557

1573, 1790

4,113

196,584

4895

Discharge summary

report

Admission Date: [**2144-7-5**] Discharge Date: [**2144-7-10**] Date of Birth: [**2103-6-23**] Sex: F Service: MEDICINE Allergies: Codeine / Amoxicillin / Blood-Group Specific Substance Attending:[**First Name3 (LF) 3624**] Chief Complaint: nausea/vomiting Major Surgical or Invasive Procedure: insertion of R IJ central line History of Present Illness: 41 y/o f with h/o DM1, CAd s/p CABG, ESRD s/p renal tx, on HD, PVD, legal blindness, who p/w severe DKA. Patient was discharged from [**Hospital1 18**] [**6-24**] after p/w DKA, NSTEMI, esophageal candidiasis, and pneumonia. Patient noted onset of nausea vomiting day prior to admission. She was unable to tolerate pos and was not able to take any of her medications. She denies any fevers/chills/abd pain/dysuria/CP/or SOB. She reports taking her usual doses of insulin including her 16 units of glargine at bedtime and her sliding scale humalog, but said her blood sugars were persistently >500. She has been using an insulin device that clicks so she can tell how much insulin she is administering as she is legally blind. She does not believe there have been any mistakes in how much insulin she has been administering. She also has chronic dry gangrene of her R toes, for which she is followed by podiatry. She was also treated for pneumonia 2 months ago. In the ED her blood sugar was >500, with a serum bicarb of 5, and a SAG of >30. She was started on an insulin gtt, had a RIJ placed for difficult IV access, and was admitted to the [**Hospital Unit Name 153**] overnight for treatment of her DKA. She has now been ruled out for MI, and there has been no discovered precipitant for her DKA. [**Last Name (un) **] was consulted and there was some concern that perhaps her insulin administration system was not working well for her. She has been off insulin gtt for 24 hours now and has started eating and is being administered long acting insulin with a closed SAG. Past Medical History: 1.ESRD s/p living related donor [**10-31**] 2.Diabetes Mellitus type I with retinopathy, gastroparesis and neuropathy 3.CAD s/p CABG [**5-2**] (LIMA-LAD, SVG-PDA, OMI-Diag). (Echo at [**Hospital1 **] [**First Name (Titles) **] [**2143-8-1**] showed mild symmetric LVH with a normal EF of greater than 55%. There were subtle apical, anterior, and lateral areas of hypokinesis. There was also moderate 2+ mitral regurg and moderate pulmonary artery hypertension. She had a stress test and exercise MIBI in [**2144-1-1**] that showed reversible defects in the territory ofthe LAD and left circumflex similar in appearance to a prior study in [**2142-5-31**]. A normal ejection fraction of 51% was reported.) 4.PVD s/p bypass fem-[**Doctor Last Name **] 5.CHF EF = 45-50% 6.HTN 7.Chronic ulcers 8. Sarcoidosis 9. Depression 10. Blindness bilaterally. L eye prosthesis. . Social History: Lives with her mother in [**Name (NI) **]. Quit tobacco 3 months ago; prior, smoked 1/2ppd - 1 ppd for about 15 years. No alcohol or IVDU. Family History: no diabetes "heart trouble" in father and mother of unknown type F - MI at 74y/o M - HTN Physical Exam: In ED: T 97.2 HR 105 BP 121/60 R 26 sat 98% RA gen: mild resp distress, A+OX3 HEENT: dry mm, EOMI CV: tachycardic, regular, holosystolic murmur at LLSB pulm: CTAb abd: s/nt/nd +BS no HSM ext no edema, dry gangrene of R toes, old AV graft LUE Pertinent Results: [**2144-7-5**] 05:45PM URINE UCG-NEGATIVE [**2144-7-5**] 05:23PM GLUCOSE-107* UREA N-15 CREAT-1.1 SODIUM-139 POTASSIUM-3.9 CHLORIDE-109* TOTAL CO2-19* ANION GAP-15 [**2144-7-5**] 05:23PM CALCIUM-8.1* PHOSPHATE-2.9 MAGNESIUM-2.0 [**2144-7-5**] 02:00PM CK(CPK)-78 [**2144-7-5**] 02:00PM CK-MB-NotDone cTropnT-<0.01 [**2144-7-5**] 11:10AM OSMOLAL-318* [**2144-7-5**] 08:15AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.020 [**2144-7-5**] 08:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE->1000 KETONE->80 BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0 LEUK-NEG [**2144-7-5**] 08:15AM URINE RBC-0 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0-2 TRANS EPI-<1 [**2144-7-5**] 08:05AM GLUCOSE-598* LACTATE-2.0 K+-6.1* [**2144-7-5**] 07:55AM ALT(SGPT)-18 AST(SGOT)-25 LD(LDH)-476* CK(CPK)-133 ALK PHOS-90 AMYLASE-64 TOT BILI-0.2 [**2144-7-5**] 07:55AM LIPASE-24 [**2144-7-5**] 07:55AM WBC-6.4 RBC-3.87* HGB-11.2* HCT-35.9* MCV-93# MCH-28.9 MCHC-31.1 RDW-12.8 [**2144-7-5**] 07:55AM NEUTS-74.5* LYMPHS-19.2 MONOS-4.8 EOS-0.9 BASOS-0.5 [**2144-7-5**] 07:55AM PLT COUNT-359 [**2144-7-5**] 07:55AM PT-13.0 PTT-24.0 INR(PT)-1.1 Brief Hospital Course: 1. DKA: h/o multiple admissions for DKA, no clear precipitant for this episode other that possible misadministration of home insulin; treated successfully with insulin gtt in the [**Hospital Unit Name 153**], restarted on home dose glargine and humalog SS, started eating again, called out to floor. [**Last Name (un) 20424**] consulted and followed on the floor with still difficult to control BS with occaisional low BS. Humalog SS was adjusted. Patient will need to follow up with urgent care at [**Last Name (un) **] the day after discharge to arrange a new insulin administartation system, possibly with preloaded insulin pens, to make administartion easier in light of her blindness. 2. DM1: c/b retinopathy (legally blind), neuropathy, nephropathy (ESRD), and gastroparesis; [**Last Name (un) **] consulted, Humalog SS adjusted, will follow up with urgent care at [**Last Name (un) **] for new administartion system and teaching, f/u with Dr. [**Last Name (STitle) 10088**] as well. 3. ID: Continued fluconazole treatment for her past esophageal candidiasis. No evidence of PNA this admission, has been treated in the past. Remained afebrile. 4. CAD: s/p CABG, recent NSTEMI 2 months ago, ruled out for MI, continued on ASA/BB/statin/ACEI. 5. ESRD: s/p living related transplant, Cr [**Last Name (STitle) **] to 1.8 on admission, likely prerenal in etiology as dehydrated from DKA, improved back to baseline 1.3 on discharge. Follow up with Dr. [**Last Name (STitle) **] after discharge. Continued on tacrolimus 2 mg [**Hospital1 **], siromlimus 2 mg daily, and prednisone 4 mg daily. 6. PVD: chronic dry gangrene of R toes, f/u podiatry, no evidence of active infection. 7. FEN: DM, renal diet 8. Code: Full 9. [**Hospital1 **]: SC heparin, PPI 10: dispo: to home, given information to arrange personal care assistant, declined home VNA Medications on Admission: 1. Tacrolimus 2 mg po bid 2. Sirolimus 3 mg po daily 3. metoprolol 50 mg tid 4. plavix 75 mg daily 5. ASA 81 mg daily 6. Ramipril 5 mg daily 7. lipitor 80 mg daily 8. CaCO3 1250 mg po bid 9. Cholecalciferol 400 units daily 10. Bactrim DS one tab M/W/F 11. Prednisone 4 mg daily 12. Glargine 16 units sc hs 13. reglan 10 mg po qidachs 14. citalopram 40 mg daily Discharge Medications: 1. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 2. Sirolimus 2 mg Tablet Sig: One (1) Tablet PO once a day: Please skip dose on [**7-11**] and start taking [**7-12**]. Disp:*30 Tablet(s)* Refills:*2* 3. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Calcium Carbonate 1,250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Citalopram Hydrobromide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Metoclopramide HCl 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 9. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 12. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 13. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 14. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 15. Amlodipine Besylate 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 16. Insulin Glargine 100 unit/mL Solution Sig: Eighteen (18) UNITS Subcutaneous qam. Disp:*qs 1 month* Refills:*2* 17. Insulin Lispro (Human) 100 unit/mL Solution Sig: per sliding scale per sliding scale Subcutaneous four times a day: per sliding scale. Disp:*qs 1 month* Refills:*2* 18. Sodium Citrate-Citric Acid 500-334 mg/5 mL Solution Sig: Ten (10) mg PO TID (3 times a day). Disp:*qs 1 month* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Diabetic Ketoacidosis Discharge Condition: stable Discharge Instructions: Please do not take your sirolimus tomorrow [**7-11**], then resume at 2 mg daily dose. Please have your labs checked on Monday. Please follow up with Dr. [**Last Name (STitle) **] in 2 weeks. Please go to your urgent care [**Last Name (un) **] appointment to have teaching on how to use an insulin pen. Please stop taking your bactrim and start taking bicitra 10 mg three times daily. Please also follow up with your PCP. [**Name10 (NameIs) **] your doctor [**First Name (Titles) **] [**Last Name (Titles) **] blood sugars >300 or any low blood sugars. Followup Instructions: 1. Please go to your [**Last Name (un) **] urgent care appointment Tues [**7-14**] with Nurse Educator, Katey [**Doctor Last Name **], at 3:30pm, [**Location (un) **] [**Last Name (un) **] Center, to have teaching on how to use an insulin pen. 2. Please have your labs checked including CBC, chem 10, and rapamycin and FK506 levels on Monday [**7-13**]. 3. Please follow up with Dr. [**Last Name (STitle) **] [**7-14**] at 10:30 am, [**Location (un) **] [**Hospital Unit Name **], you can call [**Telephone/Fax (1) 673**] to reschedule or if you have questions. 4. Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) **] in next 1-2 weeks. Please also discuss with Dr. [**First Name (STitle) **] having a diagnostic mammogram for nodularities in both breasts. [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**]

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icd9cm

[ [ [] ] ]

[ "38.93", "99.04" ]

icd9pcs

[ [ [] ] ]

8721, 8727

4575, 6431

330, 363

8793, 8802

3406, 4552

9403, 10333

3034, 3124

6842, 8698

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13,033

196,337

42983

Discharge summary

report

Admission Date: [**2186-4-11**] Discharge Date: [**2186-4-15**] Date of Birth: [**2148-4-23**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 348**] Chief Complaint: headache, blurry vision, nausea, vomiting Major Surgical or Invasive Procedure: HD History of Present Illness: 37M who is well known to [**Hospital1 18**] with type I DM c/b ESRD and severe autonomic dysfunction who presented to the ED on [**4-11**] with abdominal pain, vomiting, and inability to take his BP meds. His abdominal pain and vomiting felt similar to his past exacerbations of gastroparesis. Before presentation to the ED, he developed headache and blurry vision. He reports his SBP has been 170s over the last week. Per the Renal note, he had missed HD on Saturday and UF on Tuesday. In the ED, his BP was 240s/120s, and he was given given labetalol 20 x2, hydralazine 20 x1, dilaudid 2x3, ativan 2x3, with SBP decreasing to 190s. He was then given clonidine PO 0.1, clonidine PO 0.2 and his SBP decreased to 120s. He was admitted to the floor for further management. He has had numerous similar admissions in the past. Past Medical History: 1. DM type I 2. ESRD on hemodialysis started [**2-/2184**] on Tu, Th, Sat 3. Severe autonomic dysfunction with multiple hospitalizations for hypertensive emergency, gastroparesis, and orthostatic hypotension. 4. History of esophageal erosion, MW tear 5. CAD with 1-vessel disease (50% stenosis D1 in [**7-/2181**]), normal stress [**11/2182**] 6. hx of Foot Ulcer 7. h/o clot in AV graft x2 ([**Month (only) 958**] and [**2185-8-13**]) Social History: Denies alcohol or tobacco use. Endorses occassional marijuana use. Lives with his [**Hospital1 **] mother and their three children. Family History: His father recently died of ESRD and diabetes. His mother is in her 50s and has hypertension. He has two sisters, one with diabetes, and six brothers, one with diabetes. Physical Exam: Vitals- Tc 98, Tm 99, BP 118/80 (94-174/46-107), HR 98 (81-135), RR 12 O2 sat 99% on RA General- chronically ill-appearing young man, in NAD, alert and answers questions appropriately HEENT- proptosis, muddy sclerae, pupils equal at 3mm and reactive, OP clear Neck- supple, no JVD Chest- R SC portacath without surrounding erythema or tenderness Pulm- CTAB, good air movement CV- RRR, 2/6 SEM heard best at RUSB/LUSB Abd- +BS throughout, soft, nondistended, mild epigastric TTP with no rebound or guarding Extrem- no LE edema, DP pulses 1+ b/l, L AV fistula with palpable thrill Pertinent Results: LABS ON ADMISSION: [**2186-4-11**] 04:44PM WBC-6.9 RBC-4.23* HGB-11.7* HCT-34.5* MCV-82 MCH-27.6 MCHC-33.9 RDW-18.7* [**2186-4-11**] 04:44PM NEUTS-49.6* LYMPHS-33.3 MONOS-11.7* EOS-4.6* BASOS-0.7 [**2186-4-11**] 04:44PM PLT COUNT-222 [**2186-4-11**] 04:44PM GLUCOSE-231* UREA N-27* CREAT-8.8* SODIUM-137 POTASSIUM-3.7 CHLORIDE-94* TOTAL CO2-24 ANION GAP-23* . EKG- NSR at 88bpm, normal axis and intervals, early repolarization changes, no significant change from prior study on [**2186-4-6**] Brief Hospital Course: 37M with DMI c/b gastroparesis and severe autonomic dysfunction who was admitted in the setting of hypertensive urgency and nausea/vomiting. . # Hypertensive urgency: Was given IV labetalol and IV hydralazine as well as po clonidine with a decrease of SBPs from 240s to 120s in the ED. On presentation to the floor, teh pt was placed on his home BP medication regimen and dialyzed. The following day, it was noted that the pt was vomiting and not tolerating his BP meds again. He was triggered for BP 220s/110s and was given IV lopressor X 2 with subsequent decrease in SBPs to 140-150s. Several hours later, it was again noted that his SBPs > 200. He was transferred to the MICU given nursing needs and concerns where he was started on standing IV lopressor q4h and continued on his clonidine patch. The following day, the pt was tolerating his po medications without difficulty and was called out to the floor. Overnight, he again vomited X 2 and was triggered the following morning for SBPs 220s/110s and increased confusion. He was given IV lopressor, IV hydralazine, and IV dilaudid and ativan with subsequent decrease in BPs to 120-130s. By the time of discharge, the pt remained at BP goal for 36 hrs and was discharged home on his prior outpt BP regimen. During the hospital course, he was also evaluated by Dr. [**Last Name (STitle) **] for a possible kidney transplant, which will hopefully help improve his labile BPs. Hepatitis serologies and HIV testing were sent on this admission. He will need a stress test on an upcoming admission for further pre-transplant evaluation. . # Abdominal pain/nausea: Symptoms c/w prior exacerbations of gastroparesis. Missed HD appointments may have resulted in this exacerbation. Has been refractory to maximal medical therapy, h/o G-tube that had to be removed [**3-17**] infection. Pt has been refusing 2nd attempt at G-tube. He was continued on standing reglan along with other prn anti-emetics and prn dilaudid. As above, the pt was evaluated by the transplant surgery for a possible kidney and pancreas transplant during this admission. . # ESRD: On HD TThSat. Missed recent HD and UF appointments as above. Was followed by renal and dialyzed with UF removed and had subsequent improvement in BPs. . # DM: Continued on low dose qhs lantus, HISS, and [**Doctor First Name **] diet. . # H/o AV graft clot: Has had multiple graft clots in the past s/p thrombectomies, most recently in [**8-18**]. Was continued on [**Date Range **] 1.5 mg qhs for goal INR [**3-18**]. . # Code status: FULL CODE . # Communication: Proxy name: [**First Name4 (NamePattern1) 450**] [**Last Name (NamePattern1) **] (Baby's mother), [**Telephone/Fax (1) 92670**] . By the time of discharge, the pt was tolerating his [**Doctor First Name **] diet without difficulty, his BPs remained stable > 36 hrs, and was otherwise feeling well. Medications on Admission: Metoclopramide 10 Q6H Metoprolol Tartrate 75 TID Calcium Acetate 667 mg Capsule TID W/MEALS Ativan 1 mg Q6H prn agitation/nausea Hydromorphone 4 PO Q3-4H prn Clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QFRI (every Friday). Clonidine 0.2 TID Warfarin 1.5 QHS Nifedipine 30 mg SR QD Pantoprazole 40 QD Aspirin 81 mg QD Humalog 100 unit/mL sc QID prn ISS Insulin NPH Human Recomb 100 unit/mL, 2 units sc BID Discharge Medications: 1. Clonidine 0.3 mg/24 hr Patch Weekly Sig: Three (3) Patch Weekly Transdermal QFRI (every Friday). Disp:*12 Patch Weekly(s)* Refills:*2* 2. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO three times a day: For total of 75 mg three times a day. Disp:*90 Tablet(s)* Refills:*2* 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO three times a day: for total of 75 mg three 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 Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Warfarin 1 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). Disp:*45 Tablet(s)* Refills:*2* 7. 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* 8. Nifedipine 30 mg Tab,Sust Rel Osmotic Push 24HR Sig: One (1) Tab,Sust Rel Osmotic Push 24HR PO once a day. Disp:*30 Tab,Sust Rel Osmotic Push 24HR(s)* Refills:*2* 9. Ativan 1 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for nausea, agitation, anxiety. Disp:*45 Tablet(s)* Refills:*0* 10. Reglan 10 mg Tablet Sig: One (1) Tablet PO qachs. Disp:*120 Tablet(s)* Refills:*2* 11. Calcium Acetate 667 mg Tablet Sig: One (1) Tablet PO tid w/ meals. Disp:*90 Tablet(s)* Refills:*2* 12. Dilaudid 4 mg Tablet Sig: One (1) Tablet PO q3-4 h as needed for abd pain. Disp:*30 Tablet(s)* Refills:*0* 13. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Hypertensive Urgency Gastroparesis Autonomic Dysfunction DM type I ESRD on HD Discharge Condition: Good, ambulating, breathing well on room air, eating [**Doctor First Name **] diet. Discharge Instructions: You were admitted for elevated blood pressures and persistent nausea and vomiting, which have since resolved. During your admission, you were also evaluated for a possible kidney and pancreatic transplant. It is very important to take all of your medications as prescribed and to keep all of your dialysis appointments. Please call your doctor or return to the emergency room if you experience any of the following: severe headache, blurry vision, shortness of breath, chest pain, severe abdominal pain, and persistent nausea and vomiting. Followup Instructions: Please follow-up with your PCP [**Name Initial (PRE) 176**] 1 week. Please keep all of your appointments for dialysis sessions. Completed by:[**2186-4-17**]

[ "414.01", "250.43", "250.63", "337.1", "403.01", "536.3", "585.6" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

8218, 8224

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356, 361

8346, 8432

2628, 2633

9022, 9182

1842, 2013

6505, 8195

8245, 8325

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2028, 2609

275, 318

389, 1215

2648, 3131

1237, 1676

1692, 1826

60,104

112,160

20927+57208

Discharge summary

report+addendum

Admission Date: [**2141-5-24**] Discharge Date: [**2141-6-4**] Date of Birth: [**2080-10-2**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1384**] Chief Complaint: Wound infection Major Surgical or Invasive Procedure: [**2141-5-24**]: - Extensive debridement of complicated wound, including multiple abscesses. - Component separation of the anterior abdominal wall with fascial dissection and reconstruction. - Repair of large incisional hernia with mesh. - Lysis of adhesions [**2141-5-29**] PICC line placement History of Present Illness: 60 y/o male status post liver transplant. Subsequent to his liver transplant, he developed a mycobacterial infection of the skin. Despite aggressive attempts at antibiotics and local debridement, he was not able to clear his mycobacterial infection. After consultation with multiple providers including hernia experts and infectious disease, it was elected to take him back to the operating room to completely clean out his anterior abdominal wound, place a mesh, and close the wound. Past Medical History: PAST MEDICAL HISTORY: - metabolic bone disease - hepatitis C cirrhosis s/p OLT [**2-14**] c/b poor wound healing, as below. - interstitial lung disease - dx 2y ago, no pulmonary follow-up, does not use home inhalers presently. - GERD - chronic pain - abdominal and B LE (neuropathy) - chronic BLE edema - psoriasis - DM2 - dx over past year, on insulin. - h/o B LE burns [**2-7**] trauma in fire. . - denies CVA, CAD, HTN, CKD, PE/DVT, malignancy. . PAST SURGICAL/PROCEDURAL HISTORY [**2138**] RFA of liver lesion [**2132**] lung biopsy [**2131**] Extensive burns&#[**Numeric Identifier 25684**];skin graft surgeries [**2140-2-28**] liver transplant with repair of chronic diaphragmatic hernia. [**2140-3-1**] Exploratory laparotomy, repair of ventral hernia with mesh and liver biopsy. Social History: Currently smoking [**1-7**] ppd, denies etoh, ivdu. History of IVDA and ETOH abuse. He has abstained from both since transplant. Family History: Mother, 85: No known illness Father, dead 76: Liver cancer Twin brother, dead 18: Murdered Brother, 35: No known illness Brother, 46: No known illness Physical Exam: VS: 98.6, 79, 123/65, 24, 98% 5L General: Initially receiving ketamine drip and dilaudid IV for pain management post op Card: Nl S1S2, RRR Lungs: Few crackles bilater bases Abd: Soft, mild distention, initial dressing left on for 5 days to protect initial incision. POst op the incision has remained intact, without erythema or drainage. 1 JP drain with serosanguinous fluid Extr: No edema, venodynes in place Pertinent Results: On Admission: [**2141-5-25**] WBC-23.0*# RBC-3.47* Hgb-10.9* Hct-33.2* MCV-96 MCH-31.4 MCHC-32.8 RDW-15.4 Plt Ct-127*# PT-15.3* PTT-33.0 INR(PT)-1.3* Glucose-197* UreaN-24* Creat-1.0 Na-135 K-5.5* Cl-106 HCO3-24 AnGap-11 ALT-71* AST-78* AlkPhos-127 TotBili-1.7* Albumin-2.8* Calcium-7.6* Phos-2.7 Mg-1.8 At Discharge: [**2141-6-2**] WBC-7.1 RBC-2.96* Hgb-9.2* Hct-28.6* MCV-97 MCH-30.9 MCHC-32.0 RDW-16.5* Plt Ct-123* Glucose-146* UreaN-52* Creat-1.4* Na-130* K-5.9* Cl-101 HCO3-24 AnGap-11 ALT-50* AST-71* AlkPhos-293* TotBili-1.6* Calcium-7.8* Phos-4.5 Mg-1.5* tacroFK-5.8 Brief Hospital Course: 60 y/o male with complicated post liver transplant surgery course. Since last year his course has been complicated by recurrent hernias requiring debridements and infection with Mycobacterium abscesses. (MYCOBACTERIUM ABSCESSUS/MASSILIENSE/BOLLETII GROUP) He was taken to the OR with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] for Extensive debridement of complicated wound, including multiple abscesses, Component separation of the anterior abdominal wall with fascial dissection and reconstruction, Repair of large incisional hernia with mesh, Lysis of adhesions times 1 hour and Repair of wound more than 30 cm. This was an ext4ensive surgery, which the patient tolerated well. Due to past hsitory of narcotic tolerance, the patient was initially managed on a ketamine drip in addition to dilaudid and his baseline methadone. Over the course of the hospitalization the regimen now includes Home Oxycontin and methadone, breakthrough oxycodone and IV Morphine for breakthrough also. The initial dressing was taken down at 5 days per Dr [**Last Name (STitle) 15283**] instructions, and the incision has remianed intact, with no erythema or drainage noted. The small wound from the previous attempt at debridement has been intact as well. Per ID recommendations, who were following prior to this surgery, initial antibiotics were amikacin, tigecycline and vancomycin. After further consideration, the Vanco was stopped and azithromycin was added. ID continued to follow during this admission, and when the creatinine was noted to be increasing, the amikacin was stopped and Linezolid was added. The patient received 4 days of lasix in an attempt to diurese. He remains about 5 Liters above his admission weight, no further lasix has been attempted, creatinine has leveled at 1.4 (baseline around 1) On POD 8 he had a large amount of ascitic appearing fluid drain Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 2. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 3. Methadone 10 mg Tablet Sig: Eleven (11) Tablet PO DAILY (Daily): Home dose. 4. Insulin Regular Human 100 unit/mL Solution Sig: per sliding scale Injection ASDIR (AS DIRECTED). 5. Sulfamethoxazole-Trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). 7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal Once daily PRN constipation as needed for distention. 10. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 11. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 12. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 13. Oxycodone 40 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours): This is patients home dose. 14. Tigecycline 50 mg Recon Soln Sig: Fifty (50) mg Intravenous Q12H (every 12 hours). 15. Azithromycin 500 mg Recon Soln Sig: Five Hundred (500) mg Intravenous Q24H (every 24 hours). 16. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. 17. Sodium Chloride 0.9 % 0.9 % Parenteral Solution Sig: Ten (10) ML Intravenous PRN (as needed) as needed for line flush. 18. Morphine Sulfate 1-4 mg IV Q4H:PRN breakthrough pain 19. Linezolid 600 mg/300 mL Parenteral Solution Sig: Six Hundred (600) mg Intravenous Q12H (every 12 hours). 20. Tacrolimus 0.5 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours): needs tacrolimus levels q wk. Disp:*180 Capsule(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital - [**Hospital1 8**] Discharge Diagnosis: Complex abdominal wound with multiple abscesses, necrotizing infection, and large hernia Narcotic tolerance Liver transplant [**2-/2140**] Discharge Condition: Stable/Fair A+Ox3 Poor ambulatory state, needs extensive rehabilitation Discharge Instructions: please call the transplant clinic at [**Telephone/Fax (1) 673**] for fever, chills, nausea, vomiting, increased abdominal pain, increased drainage from the JP bulb or area around the JP drain insertion. There is a pouch covering the JP drain insertion site due to some leaking. Drain and record JP drain output twice daily and more often as needed. Please call the transplant clinic if the drainage increases rgeatly, develops a foul odor or becomes bloody in appearance. No heavy lifting Continue labwork q Monday/Thursday with results faxed to transplant clinic. CBC, Chem 10, AST, ALT, Alk Phos, T bili, Trough Prograf Continue antibiotics via PICC line Wear abdominal binder at all times Followup Instructions: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2141-6-8**] 10:40 [**Name6 (MD) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2141-6-12**] 8:00 [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2141-6-15**] 8:00 Name: [**Known lastname 10436**],[**Known firstname **] Unit No: [**Numeric Identifier 10437**] Admission Date: [**2141-5-24**] Discharge Date: [**2141-6-4**] Date of Birth: [**2080-10-2**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2648**] Addendum: In the previously completed discharge summary, the patient was coded as having impaired renal function when in fact he was in acute renal failure Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital - [**Hospital1 15**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2649**] MD [**MD Number(2) 2650**] Completed by:[**2141-7-3**]

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icd9cm

[ [ [] ] ]

[ "53.61", "54.3", "54.59", "54.72", "38.93" ]

icd9pcs

[ [ [] ] ]

9277, 9505

3323, 5218

329, 634

7511, 7585

2724, 2724

8325, 9254

2126, 2279

5241, 7234

7349, 7490

7609, 8302

2294, 2705

3042, 3300

274, 291

662, 1152

2738, 3028

1196, 1962

1978, 2110

22,578

177,351

48669

Discharge summary

report

Admission Date: [**2178-9-29**] Discharge Date: [**2178-10-11**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1572**] Chief Complaint: fever, abdominal pain Major Surgical or Invasive Procedure: JP drain placement History of Present Illness: HPI: 81 year old male, CP, A fib hx,L DVT in femoral vein, started to develop GIB, , s/p IVC filter RA on MTX and prednisone, recently admitted for worsening hip pain and inability to walk, and recent CT of abd/hip that revealed diverticular abscess [**3-4**] to perforated diverticulum and s/p drainage and drain removed on [**9-28**]. CT scan noted abscess well drained. He was d/c back to rehab Vanc/Levo/Flagyl. levaquin 500 qd x 3, ticarcillin 3.1 gm IV He is was noted to have spiking over past 24-48 hrs (101.8-103.8) with highest 103. 8 at 10pm on [**9-28**]. CXR -> LLL infiltrate . He was examed by HO at 9pm on [**9-28**] He did not have any complaints to HO at rehab. He denies any abd pain, SOB or SOB, no diarrhea. No cough or sputum. He was given vanco X 1. On exam, CV: tachy, abd: no pain on deep palp, no rebound, Resp: scattered rales, Ext: + pain w/ flexor of L hip He c/o [**9-9**] CP this AM at 9am. He was given asa, sub lingual nitro, BP 100/60, P 132-> 5 mins post 162/88 P 192 A fib and 2nd sublingual nitro given-> 10 mins post, BP 172/88 P 192, 2nd nitro sl given-> 9am 5 mg lopressor, HR down to 130s.CP disspiated at 945am. BP normalized in 100/60 at 10am. He was admitted to [**Hospital1 18**] where sepsis protocal was initiated in the ED after CT abd showed marked increase in the size of the LLQ abscess associated with ileopsoas muscle and extending into the thigh. Bilateral residual pulmonary emboli were also noted Pt had fevers/sepsis on admission which was from diverticular abscess but also concern for about PICC line infection. PICC line was d/c on [**9-29**] - no growth from tip. Blood culture from [**9-29**] grew [**Female First Name (un) **] parapsilosis ([**2-3**]). Blood cultures are negative to date subsequent. A drain was placed by IR on [**10-1**] by CT guidance. Colorectal surgery has been following. Abscess culture from [**10-1**] grew entrococcus (vanc/amp/levo/pcn resistant) and yeast (likely c. albicans). Pt covered linezolid (hx VRE), meropenem (for GNR and anaerobes) and caspofungin (fungemia) . Infectious disease team has been following. Right IJ line was d/c and tip showed no growth. Pt has been afebrile for past 48 hours. His WBC count has improved from 14K to 6k since admission. Pt blood pressure runs in SBP 90-100. HR is controlled with QID metoprolol. Today the MICU team is attempting gentle diuresis for volume overload Past Medical History: 1) Perforated diverticulum with pelvic abscess [**Hospital1 18**] admission, his CT pelvis which revealed a large left pelvic abscess (7.3 x 11.1 x 14.4 cm), felt likely secondary to perforated diverticulum. He underwent CT-guided drainage of his abscess on [**9-3**] in IR, and was started on emipiric abx with Levo/Flagyl. Vanco added following an episode of hypotension responsive to IVF, D/C'd [**9-7**]. He was also started on Heparin on [**9-3**] with initial bolus for PE, and Coumadin started on [**9-4**]. On [**2178-9-7**], Mr. [**Known lastname 50388**] had an episode of BRBPR, initially with BM described as 3 "coinsized clots", then 2 further episodes with clots without stools. Hct drop 34 last night-->27 this AM, transfused an additional unit of PRBCs. Hemodynamically stable overnight, but this AM BP drop to 84/60, with spontaneous recovery. PTT intermittently supratherapeutic (101, 108, 143) in past days, INR 2.5 this AM. Still on heparin, last Coumadin on [**9-6**]. Last C-scope in [**2172**] with diverticulosis. Only prior history of occasional blood on toilet paper after straining. 2) CAD since [**2138**], s/p IMI in [**2145**]. Stress thallium in [**2163**] with redistributing posterolateral and inferior defect. 3) Hypertension 4) Hyperlipidemia 5) Rheumatoid arthritis, recently diagnosed, on Prednisone 5 mg PO BID and Methotrexate 10 mg Qwk 6) Diverticulosis, last colonoscopy in [**2172**] 7)VRE but unclear sources 8)RLL PE ([**2178-9-28**]), bilat DVT 9) GI bleed on last admission, coumadin and hep held -> filter placed by IR s/p IVC filter (removable) Social History: No etoh, no tob, was at [**Hospital **] rehab since d/c from [**9-25**], previously lived w/ wife ( who is unofficial HCP) Family History: Noncontributory Physical Exam: VS: T98.9 BP110-138/60-90 HR84-90 RR20-22 o2sat: 94-98%RA Is/Os 1750/4200cc over 24 hrs FS99-247 HEENT: O/P clear. Anicteric sclera. Neck: Supple. CV: Regular, occasional irreg beats. Nml s1,s2. No s3 or murmur Resp: CTAB with occasional crackles at the bases. Abd: Soft. NTND. +BS. No TTP over LLQ. No HSM. No rebound or gurading. No erythema or TTP over JP drain site. Ext: [**2-1**]+ edema to mid-shins bilat. GU: no CVA tenderness Neuro: AAOx3, moves all extremities Pertinent Results: [**2178-10-9**] 05:40AM BLOOD WBC-8.8 RBC-3.59* Hgb-10.7* Hct-32.2* MCV-90 MCH-29.8 MCHC-33.2 RDW-16.7* Plt Ct-210 [**2178-10-9**] 05:40AM BLOOD Plt Ct-210 [**2178-10-9**] 05:40AM BLOOD Glucose-78 UreaN-22* Creat-1.0 Na-139 K-3.8 Cl-102 HCO3-27 AnGap-14 [**2178-10-8**] 05:35AM BLOOD ALT-30 AST-27 LD(LDH)-173 AlkPhos-66 TotBili-0.2 [**2178-10-9**] 05:40AM BLOOD Calcium-8.5 Phos-3.0 Mg-1.5* [**2178-9-21**] 1:30 pm ABSCESS Source: LLQ drain. **FINAL REPORT [**2178-9-27**]** GRAM STAIN (Final [**2178-9-21**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). FLUID CULTURE (Final [**2178-9-25**]): Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup is performed appropriate to the isolates recovered from the site (including a screen for Pseudomonas aeruginosa, Staphylococcus aureus and beta streptococcus). CITROBACTER FREUNDII COMPLEX. MODERATE GROWTH. Trimethoprim/Sulfa sensitivity available on request. ENTEROCOCCUS SP.. SPARSE GROWTH. YEAST. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ CITROBACTER FREUNDII COMPLEX | ENTEROCOCCUS SP. | | AMPICILLIN------------ =>32 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CHLORAMPHENICOL------- 8 S GENTAMICIN------------ 4 S IMIPENEM-------------- <=1 S LEVOFLOXACIN---------- 0.5 S =>8 R MEROPENEM-------------<=0.25 S PENICILLIN------------ =>64 R PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ 4 S VANCOMYCIN------------ =>32 R ANAEROBIC CULTURE (Final [**2178-9-27**]): BACTEROIDES FRAGILIS GROUP. SPARSE GROWTH. BETA LACTAMASE POSITIVE. **FINAL REPORT [**2178-10-5**]** AEROBIC BOTTLE (Final [**2178-10-3**]): REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Doctor Last Name 17975**] ON [**2178-10-1**] @ 10:10AM. [**Female First Name (un) **] PARAPSILOSIS. ANAEROBIC BOTTLE (Final [**2178-10-5**]): NO GROWTH. Brief Hospital Course: A/P: 81 year old, CAD, HTN, recent admission w/ diverticular abscess, s/p drainage, hosp course c/b PE/DVT and GIB likely [**3-4**] anticoagulation, d/c to [**Hospital1 **] for rehab, re-presented with hx of 24-48 hx of fever and CP, with a 5 day stay in the MICU s/p IVF, [**Last Name (un) **]/Caspo/Linezolid, pRBC, never required pressors or intubation. * 1. Fever Patient with recurrant LLQ intraabdominal abscess as seen on abd CT, s/p drainage. Cx's have grown VRE, C.parapsilosis, Citrobacter, Bacteroides at various times of drainage. -Pt afebrile, without leukocytosis, appears resolving today. Continues to have minor pus drainage from JP drain, <50cc/day. Cont to flush drain with 10cc twice daily, and monitor for patency. -ID following, appreciate recs -Cont Levaquin 500mg po qD, Flagyl 500mg po q8, Diflucan 400 mg po qD, Linezolid 600 PO qD. - Will check repeat CT abd in 2 weeks to look for resolution of abscess. -Surgery following, who believes that surgical intervention is not required at the present time. Pt to continue to have drain in place, to follow up with Dr. [**Last Name (STitle) **] in 2 weeks to reevaluate surgical candidacy. -PICC line pulled on [**9-29**] -R IJ pulled on [**10-1**] -> tip sent for cx, (-) on cx. -Pt with hx of onchomycosis predating diverticular abscess, candidemia. No need for ECHO, r/o endocarditis at this time. Cont diflucan. * 2. CP - now resolved. -unclear etiology, resolved since admission -No new PE per reread of CTA -admission EKG notable for a fib but resolved to sinus on admission s/p fluid boluses -3 sets of CKs flat, trop peaked 0.44 on [**9-30**] -monitor clinically for now * 3. A fib - now resolved -initial a fib likely in setting of sepsis but resolved to sinus on admission -no anticoag per hx of GIB, IVC filter in place. -returned to a fib on [**9-30**], lopressor IV given x 3 this AM -continue on lopressor 25mg [**Hospital1 **] * 4. CAD -Cont ASA, Lopressor increased to 25mg [**Hospital1 **] (originally held with GIB, sepsis) -d/c'ed Zetia, Atorvastatin due to risk of LFT abnormalities. Restart under direction of Dr. [**Last Name (STitle) **], PCP. * 5. CHF Patient currently volume overloaded, with 2+ pitting edema, but improving on Lasix and increased mobilization with PT. -Cont Lasix 20mg PO qD, putting out good UOP to this dose -Goal -1L per day. * 5. PE/DVT - No new PE on reread of CTA on [**9-29**]; residual PE remains from before, femoral DVTs bilaterally remain. Pt not a candidate for coumadin d/t GI bleed hx. -IVC filter in place. Cont to hold anticoagulation. * 6. Anemia -baseline 31-32, currently at baseline. -goal hct>27 -daily hct, transfuse as needed. * 7. ARF - now resolved -initially 1.3 up from 0.9-1.0 but resolved to baseline 0.9 s/p fluid boluses -likely [**3-4**] to shock/ATN, now resolved. * 8. Adenopathy on abd CT - f/u abd CT as outpt * 9. RA Pt complaining of worsening R shoulder and R elbow pain. Patient in past had RA mostly in bilat knee, but has had shoulder pain in past. Patient has been off MTX x4 weeks, and at a lower dose of prednisone due to infection/sepsis. -Consulted rheum , will cont pred at dose of 5mg po qd today - pt more comfortable. If continues to have escalating pain, will consider increasing to [**Hospital1 **], although in lieu of systemic infection, will not increase steroid dose unless absolutely necessary. No joints appear septic at this time - will continue to closely monitor. -Hold off MTX for now due to infection risk. No NSAIDs due to GI bleed. -Cont pain medicine as tolerated. * 10. FEN: -continue cardiac/low residue diet * 11. PPX: IVC filter, hep sc, holding coumadin d/t GIB hx. C.dif (-) x2. * 12. Hyperglycemia No hx of DM. In light of infection, will attempt to control sugars while currently infected. - Cont NPH 4mg SQ qAM with breakfast, and Insulin SS with regular insulin throughout day to prevent high sugars leading to worsening infection. * 13. Code: full * 14. Drain: JP drain in place. Please flush with 10cc NS [**Hospital1 **] - tid and ensure that are removing amount flushed to ensure patency. Drain was noted to be out of place on [**10-9**], and patient was taken down to CT to have his drain re-placed in the abscess. * 15. DISPO: Pt is being discharged to Rehab today. Pt continues to have drain in place, which will remain in place for a minimum of 2 weeks, until has a repeat CT scan of abdomen in 2 weeks to evaluate for resolution of his abscess. Continue pt on 4 ABx regimen (Linezolid, Levaquin, Flagyl, Diflucan PO) for a minimum of 2 weeks, and do not stop unless instructed by ID fellow, Dr. [**Last Name (STitle) 4334**]. Pt is tolerating PO diet, and ambulating with assistance of walker. Please continue to improve his functional status with rehab, along with proper drain maintainence. Please refer to the numbers below for his continued follow up. * * Consults PCP [**Name Initial (PRE) **] [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] ([**Telephone/Fax (1) 16148**] ID- Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4334**] ([**Telephone/Fax (1) 457**] Gen Surgery - Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 1483**] Medications on Admission: Insulin SS Linezolid 600 mg IV Q12H Aspirin 325 mg PO DAILY Atorvastatin 20 mg PO DAILY Meropenem 1000 mg IV Q8H Metoprolol 12.5 mg PO QID Caspofungin 50 mg IV Q24H Ezetimibe 10 mg PO DAILY Pantoprazole 40 mg PO Q24H Folic Acid 1 mg PO DAILY Furosemide 20 mg IV Prednisone 5 mg PO DAILY Heparin 5000 UNIT SC TID Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 5. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 9. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 13. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 14. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 15. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 16. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) Unit Injection TID (3 times a day). [**Telephone/Fax (1) **]:*[**Numeric Identifier 31034**] Unit* Refills:*2* 18. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: Scale as below Insulin Scale Subcutaneous four times a day: FS 150-200 Give 2 Units FS 200-250 Give 4 Units FS 250-300 Give 6 units FS 300-350 Give 8 Units FS 350-400 Give 10 Units FS >400 Call physician. [**Name Initial (NameIs) **]:*300 Insulin Scale* Refills:*2* 19. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Four (4) Units Subcutaneous qBreakfast. [**Name Initial (NameIs) **]:*10 mL* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: 1. Diverticular Abscess 2. Hypertension 3. Coronary Artery Disease. Discharge Condition: Stable to be discharged to rehab. Discharge Instructions: 1. Please continue all medications as prescribed. Please continue all antibiotics until your next ID appointment. Please schedule a follow up appointment with Dr. [**Last Name (STitle) **] in 2 weeks after discharge. Please call ([**Telephone/Fax (1) 1483**] to schedule that appointment. . 2. Please have abdominal CT scan on [**2178-10-15**]. . 3. The JP drain should remain in place until follow up with ID (Dr. [**Last Name (STitle) 4334**], and Dr. [**Last Name (STitle) **]. Followup Instructions: CT Scan of abdomen. Where: [**Hospital Ward Name 452**] 3 ([**Hospital Ward Name 516**]). When: [**2178-10-15**] at 8:45 am. You must not eat or drink anything after 4am on [**2178-10-15**]. . Provider: [**Name10 (NameIs) 12082**] CARE ID Where: LM [**Hospital Unit Name 4337**] DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2178-10-22**] 2:00 . Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Where: LM [**Hospital Unit Name 4337**] DISEASE Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2178-11-5**] 11:30 . Provider: [**Name10 (NameIs) **] WEST,ROOM FOUR GI ROOMS Where: GI ROOMS Date/Time:[**2178-10-28**] 10:00 . Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],MD Where: [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **] COMPLEX) Phone:[**Telephone/Fax (1) 1983**] Date/Time:[**2178-10-28**] 10:00 .

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icd9cm

[ [ [] ] ]

[ "00.14", "83.95", "99.15", "00.17", "99.04" ]

icd9pcs

[ [ [] ] ]

15096, 15175

7496, 12688

293, 314

15287, 15323

5062, 7473

15853, 16721

4527, 4544

13050, 15073

15196, 15266

12714, 13027

15347, 15830

4559, 5043

232, 255

342, 2753

2775, 4371

4387, 4511

42,794

143,264

53593

Discharge summary

report

Admission Date: [**2127-4-30**] Discharge Date: [**2127-5-6**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3151**] Chief Complaint: SOB Major Surgical or Invasive Procedure: intubated History of Present Illness: Mr. [**Known lastname 110111**] is a 88 yo M w/ AS, CHF here with incr SOB, chest congestion and cough productive of blood tinged sputum x1 day. Pt was visited by VNA on [**4-29**] who also found him to have O2 sat 80s on RA, a slight wheeze and who supplied him with supplemental oxygen. This relieved his symptoms. No fever, CP. CXR with PNA, U/A with UTI, trop indeterminate with baselinee Cr 2.9, BNP lower than baseline. Pt was originally on facemask in the ED with sats mid 90s with tachypneic to 30s. He was at first wheezy but later was rhonchorous. Around 2am, vitals were P79 BP153/70 R24 O2 SAT 97% on FM 15L. Just prior to planned transfer to the ICU, pt experiences resp decompensation. He was intubated with succinylcholine, etomodate, fentanyl and midazolam and soon after dropped his pressures ? [**1-21**] incr intrathoracic pressure with AS and was started on levo, placed RIJ. In total in the ED, he got 6mg of midazolam and 200mcg fentanyl. He was also bolused with total 1L fluid. He also recieved ASA 325mg, Azithromycin 500mg IV, ceftriaxone 1gm IV, Lasix 20 IV and urojet. . On arrival to the ICU, the pt is intubated and sedated. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: - Hypertension 2. CARDIAC HISTORY: - Severe Aortic Stenosis (peak vel 5m/s, mean grad 72, [**Location (un) 109**] 0.9 cm2) - Diastolic heart failure (LVEF 70-80%) - Pulmonary Hypertension (moderate, PASP >55) - moderate LVH (1.6cm) 3. OTHER PAST MEDICAL HISTORY: - Stage IV CKD (Baseline Cr~3) - Gastritis - Trigeminal neuralgia - Bladder cancer - BPH s/p TURP - Iron deficiency anemia (HCT mid 30s) - Vitamin B12 deficiency - RCC s/p nephrectomy [**2119**] - chronic mycobacterium avium intracellular infection positive sputum in [**2126-2-17**] (pulm follows) had three negative sputums in [**2126-11-19**] Social History: Patient lives alone in [**Location (un) **]. He was lieutenant colonel in Russian Army during WWII, and his entire family killed in war. After end of war went to medical school and became a dermatologist and practiced for 43 yrs. He moved to the US 18 years ago to be near his sons, in [**Name (NI) 86**]/SF who are in computers. He no longer practices but enjoys going to dermatology grand rounds at [**Hospital1 2025**] and BIMDC. He smoked until age 25. Rare alcohol use. He denied illicits/herbals. Family History: Father died from lung CA at age 45, though he worked in a tobacco store. Mother, siblings were all killed at a young age in WWII. He says his sons have no medical issues. Physical Exam: On Admission to ICU: On Transfer to Floor: afebrile, hr 67 bp 132/57 sat 97/2L General: NAD, alert, unclear level of orientation [**Name (NI) 4459**]: MMM Neck: RIJ, no JVD appreciated Cards: RRR, [**3-25**] blowing systolic murmur across precordium Resp: mostly clear, sparse crackles Abdomen: soft, NT/ND, +BS, no R/G Extremities: trace edema Pertinent Results: Labs on Admission: [**2127-4-29**] 11:30PM BLOOD WBC-7.4 RBC-3.27* Hgb-9.5* Hct-29.5* MCV-90 MCH-28.9 MCHC-32.1 RDW-14.5 Plt Ct-356 [**2127-4-29**] 11:30PM BLOOD Neuts-67.2 Lymphs-23.2 Monos-5.2 Eos-3.5 Baso-0.9 [**2127-4-29**] 11:30PM BLOOD Plt Ct-356 [**2127-4-29**] 11:30PM BLOOD Glucose-129* UreaN-54* Creat-2.9* Na-137 K-4.8 Cl-105 HCO3-22 AnGap-15 [**2127-4-29**] 11:30PM BLOOD CK(CPK)-42* [**2127-4-29**] 11:30PM BLOOD CK-MB-NotDone proBNP-[**Numeric Identifier 110112**]* [**2127-4-30**] 06:12AM BLOOD Calcium-7.3* Phos-4.4 Mg-2.2 [**2127-4-29**] 11:37PM BLOOD Lactate-1.0 [**2127-4-30**] 12:05AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.012 [**2127-4-30**] 12:05AM URINE Blood-SM Nitrite-NEG Protein-75 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD [**2127-4-30**] 12:05AM URINE RBC-[**2-21**]* WBC->50 Bacteri-MOD Yeast-NONE Epi-0-2 Labs on Transfer to Floor: [**2127-5-4**] 02:59AM BLOOD WBC-7.4 RBC-3.26* Hgb-9.7* Hct-28.4* MCV-87 MCH-29.8 MCHC-34.2 RDW-14.7 Plt Ct-312 [**2127-5-4**] 02:59AM BLOOD Plt Ct-312 [**2127-5-4**] 02:59AM BLOOD Glucose-96 UreaN-42* Creat-2.9* Na-141 K-4.2 Cl-106 HCO3-24 AnGap-15 [**2127-5-4**] 02:59AM BLOOD Calcium-9.0 Phos-3.9 Mg-2.1 [**2127-5-4**] 06:13AM BLOOD Vanco-21.6* MICRO: [**2127-4-29**] 11:40 pm BLOOD CULTURE x2: NO GROWTH. [**2127-4-30**] 6:38 am SPUTUM Source: Endotracheal. GRAM STAIN (Final [**2127-4-30**]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2127-5-2**]): RARE GROWTH Commensal Respiratory Flora. ACID FAST SMEAR (Final [**2127-5-1**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): FINAL REPORT [**2127-5-3**]** Respiratory Viral Culture (Final [**2127-5-3**]): No respiratory viruses isolated. Culture screened for Adenovirus, Influenza A & B, Parainfluenza type 1,2 & 3, and Respiratory Syncytial Virus.. Detection of viruses other than those listed above will only be performed on specific request. Please call Virology at [**Telephone/Fax (1) 6182**] within 1 week if additional testing is needed. Respiratory Viral Antigen Screen (Final [**2127-5-1**]): Respiratory viral antigen test is uninterpretable due to the lack of cells. Refer to respiratory viral culture for further information. REPORTED BY PHONE TO [**First Name8 (NamePattern2) 1112**] [**Last Name (NamePattern1) **] [**Numeric Identifier **] [**2127-5-1**] 11:55AM. URINE CULTURE (Final [**2127-5-1**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. [**2127-4-30**] 12:05 pm URINE LEG ADDED TO ACC#0048K. **FINAL REPORT [**2127-5-1**]** Legionella Urinary Antigen (Final [**2127-5-1**]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, in infected patients the excretion of antigen in urine may vary. [**2127-4-30**] 1:09 pm URINE Source: Catheter. **FINAL REPORT [**2127-5-1**]** URINE CULTURE (Final [**2127-5-1**]): NO GROWTH. IMAGING: CHEST (PORTABLE AP) [**2127-4-29**] 10:16 PM AP UPRIGHT RADIOGRAPH OF THE CHEST: There is increasing faint opacity in the left mid lung, suggestive of an infectious process. There is a large retrocardiac hiatal hernia. There is bibasilar atelectasis. A small left pleural effusion is also new. There is no pneumothorax or pulmonary edema. Cardiac silhouette is mildly enlarged in size, unchanged. IMPRESSION: 1. Left mid lung pneumonia. A followup radiograph to document resolution is recommended. Small left pleural effusion. 2. Large hiatal hernia. CHEST (PORTABLE AP) [**2127-5-1**] 2:39 PM AP single view of the chest has been obtained with patient in sitting semi-upright position. Analysis is performed in direct comparison with the next preceding similar study obtained 10 hours earlier during the same day. The patient remained intubated, the tube in unchanged position. The same holds for the previously described right internal jugular approach central venous line. On previous chest examinations observed perivascular haze ([**4-30**], 3:44 hours and [**5-1**], 4:57 hours) has regressed, thus less evidence of CHF. No new parenchymal infiltrates are identified. No pneumothorax has developed. Observed that patient was difficult to examine and left lateral chest wall is not completely included in image field. IMPRESSION: Improvement of pulmonary congestive pattern in comparison with next preceding chest examinations. ECHO [**2127-5-2**]: The left atrium is mildly dilated. There is asymmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Left ventricular systolic function is hyperdynamic (EF 80%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is a mild resting left ventricular outflow tract obstruction. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Mild to moderate ([**12-21**]+) aortic regurgitation is seen. The severity of aortic regurgitation may be underestimated. The mitral valve leaflets are moderately thickened. There is no mitral valve prolapse. An eccentric, anteriorly directed jet of mild to moderate ([**12-21**]+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. Compared with the findings of the prior study (images reviewed) of [**2127-3-14**], the left ventricle is slightly less hyperdynamic, and the cavity is slightly larger. Brief Hospital Course: # Respiratory failure: Pt p/w PNA on CXR and increased work of breathing in ED for which he was intubated. Pt was felt to be volume overloaded and extubated successfully after diuresis. Breathing comfortably on room air at time of discharge. # Pneumonia complicated by sepsis: hypotensive in ED in setting of PNA and +UA and required levophed initially. After treatment with antibiotics, we were able to wean levophed quickly. Pt was broadly covering with vancomycin and zosyn. Urine culture was mixed flora c/w contamination and reculture showed no growth. Sputum was obtained by BAL and was negative for bacteria and acid fast bacilli. Blood cultures were also checked on admission and were no growth. On discharge pt is day [**6-26**] for his pneumonia treatment (however, he will not require any additional vancomycin doses as he gets vancomycin q48h and got vanc on the day of discharge). # Hemoptysis: Pt has had longstanding occasional sm volume hemoptysis. This is felt to possibly be [**1-21**] MAC (isolated from prior BAL specimen), however, decision was made not to treat. Pt also has pulmonary nodules that will require f/u in [**7-29**]. # Pulm nodules noted [**1-29**]: Pt had 4mm pulm nod noted on CT chest in [**1-29**]. Pt to get repeat CT chest at 6 mos ([**7-29**]). -PLEASE ORDER PT FOR [**Name (NI) **] CT CHEST FOR [**2127-7-20**] # CKD: Cr remained at baseline of ~2.8. Pt's calcitriol was recently increased and was continued at current dose of 4x daily. # diastolic CHF with acute exacerbation: Diuresed aggressively in the MICU and then placed back on home regimen of 20 lasix M,W,F. Currently euvolemic s/p diuresis prior to extubation. Pt was continued on atorvastatin and aspirin. PER PT'S CARDIOLOGIST, IDEAL BP IS 140-150, LASIX HELD FOR SBP <140. # Severe AS: s/p valvuloplasty [**2-26**]. Pt likely still somewhat preload dependent. PER PT'S CARDIOLOGIST, IDEAL BP IS 140-150, LASIX HELD FOR SBP <140. # Aspiration: initial concern for aspiration, S/Sw evaluated after intubation with poor results, on re-evaluation pt had improved and was able to tolerate normal diet and thin liquids. . # anemia: pt had recent iron studies, b12, folate. Repletion continued. Per pt's nephrologist, pt likely has some anemia [**1-21**] CKD. Medications on Admission: ATORVASTATIN [LIPITOR] - 80 mg daily CALCITRIOL - 0.25 mcg Capsule Sunday,Monday, Wednesday, and Friday FINASTERIDE - 5 mg daily FUROSEMIDE - 20 mg monday, wednesday, and friday PRN LORAZEPAM - 0.5 mg qhs prn METOPROLOL SUCCINATE - 100 mg DAILY OMEPRAZOLE - 20 mg DAILY OXCARBAZEPINE [TRILEPTAL] - 600 mg DAILY TOLTERODINE [DETROL LA] - 4 mg, Sust. Release DAILY ACETAMINOPHEN - 325 -650MG q 6 PRN PAIN ASPIRIN - 81 mg DAILY CYANOCOBALAMIN DOCUSATE SODIUM - 100 mg [**Hospital1 **] FERROUS GLUCONATE - 325 mg DAILY Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 2. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO 4X/WEEK ([**Doctor First Name **],MO,WE,FR). 8. Oxcarbazepine 600 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. Lasix 20 mg Tablet Sig: One (1) Tablet PO M,W,F: HOLD FOR SBP <140. 11. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 12. Tolterodine 4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours as needed for pain. 14. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day: please hold for sbp <140. 15. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 2 days: LAST DOSE [**2127-5-7**] IN THE EVENING. Discharge Disposition: Extended Care Facility: [**Hospital1 599**] of [**Location (un) 55**] Discharge Diagnosis: PRIMARY: 1. PNA 2. Respiratory Failure 3. Sepsis SECONDARY: 1. Severe AS Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: It was a pleasure taking care of you during your admission at [**Hospital1 69**]. You were admitted for pneumonia. You had a breathing tube in and needed medicines to raise your blood pressure. You improved with antibiotics. Please get a current medication list from your rehab when you are discharged. In brief, your toprol was decreased from 100mg daily to 50mg daily. Your lorazepam was stopped. Followup Instructions: *** PLease arrange for f/u with pt's pcp (Dr [**Last Name (STitle) 665**] within 1 week of discharge*** (phone number below) Please transport pt to the following appointments: Department: SLEEP UNIT NEUROLOGY When: THURSDAY [**2127-6-12**] at 11:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6855**], M.D. [**Telephone/Fax (1) 6856**] Building: [**Hospital6 29**] [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 249**] When: TUESDAY [**2127-7-1**] at 12:00 PM With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1114**], M.D. [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES When: WEDNESDAY [**2127-8-20**] at 11:00 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN [**Telephone/Fax (1) 721**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2127-5-6**]

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Discharge summary

report

Admission Date: [**2201-11-11**] Discharge Date: [**2201-11-18**] Date of Birth: [**2135-3-5**] Sex: F Service: ORTHOPAEDICS Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / Optiray 300 / Prochlorperazine Attending:[**First Name3 (LF) 4277**] Chief Complaint: Left thigh pain Major Surgical or Invasive Procedure: [**2201-11-11**]: Prophylactic intramedullary fixation of left proximal femur lesion History of Present Illness: Ms. [**Known lastname 23333**] is a 66 year old female with Renal Cell Carcinoma. She has had metastatic lesions to her left femur and brain and most recently has developed pain in her left thigh. She is a minimal ambulator, primarily only with transfers, however has developed much more pain requiring increasing amounts of Dilaudid. Further examination revealed a lesion in the intertrochanteric region of the left femur susceptible to impending fracture. Past Medical History: # Renal Cell Carcinoma s/p nephrectomy with multiple metastases which is slowly progressing despite chemotherapy # CAD with STEMI and 2 BMS to LAD placed [**2-14**] # Hypertension # chronic systolic CHF (EF 45-50%) # atrial fibrillation, now off coumadin afer ambulatory monitoring failed to show significant AF burden # pathologic R femur fracture s/p IM nail, then nonunion and revision in [**2197**] # CKD # osteoarthritis # gout # hypothyroidism Past Oncologic history: 1. [**1-11**]: CT scan revealed 7-cm left renal mass. Underwent left nephrectomy. 2. [**4-12**]: Complained of right hip pain. X-ray revealed lytic lesion with biopsy positive for renal cell carcinoma 3. [**1-13**]: T10 erosion noted 4. [**5-15**]: SRS to T10 5. [**7-15**]: embolization with RFA and cementation of T10; cryoablation of lesion in left iliac crest 6. [**9-14**]: fixation and cementation of right femoral tumor 7. [**12-15**]: MRI of right hip at outside facility revealed large right thigh soft tissue density concerning for progressive metastatic disease. 8. [**2199-3-13**]: Signed consent for trial 08-219, phase III trial of Sutent vs Pazopanib. Randomized to the Sutent arm. 10. [**2200-11-6**] MRI head (at outside facility) with unchanged left pareital bone lesion but development of contiguous dural enhancement enveloping the left frontal convexity. Pelvis with right iliac bone lesion with increase in extraosseous soft tissue component to 2.5 cm. 11. [**2200-11-12**]: Taken off 08-219 because of clinical disease progression. Started everolimus on [**2200-12-4**]. 12. On [**2201-1-28**] noted new dyspnea, possibly related to everolimus-induced pneumonitis. Everolimus held (and subsequently never restarted because of disease progression) and brief steroid course started with improvement in symptoms. 13. [**2201-3-4**] MRI brain with significant interval increase in left parietal bone metastasis, now 3.7x4.5x2.6 from 3.3x3.3x1.5 cm. MRI chest with possible new 1.4 cm right T8 vertebral lesion. [**2201-3-6**] MRI abdomen/pelvis with new 2.3 cm left adrenal mass, increase in left intertrachanteric femoral lesion, 4.0x2.2x2.3 from 2.8x1.7x1.7 cm, new 11 mm lesion within tip of left iliac crest, stable large lesion to right iliac [**Doctor First Name 362**]. [**2201-3-9**] MRI right femur with interval increase in lesion medial to prior pathologic mid-femoral shaft fracture, now 4.8 cm from 3.0 cm. - Most recent zometa [**2201-3-18**] - pazopanib started on [**2201-4-8**] Social History: she has two children. She is not a smoker. She drinks very occasionally. She lives at home in [**Doctor Last Name **]. Used to work as a sculptor, was on the original design team for the GI [**Doctor First Name **]. Ambulates with a walker or uses a scooter for shopping. Family History: uncle had a GI cancer of unknown type. The great aunt on her father's side of the family had either a colon cancer or an ovarian cancer. Physical Exam: Admission Physical Exam: VS: 98.6 HR 126 BP 107/43 RR 19 98% 2L Gen: Caucasian female resting in bed, NAD HEENT: EOMI, PERRL, MMM, OP clear Neck: JVD difficult to appreciate given body habitus CV: irregularly irregular, rapid Resp: unlabored respirations, CTA anteriorly GI: soft NTND no HSM, +BS Ext: +pneumoboots in place Neuro: CNII- CNXII intact, strength and sensation intact throughout Psych: A&OX3, appropriate Discharge Physical Exam: Afebrile HR 70-80s BP 130-150/60-80s RR 16-18 96-98% RA Gen: Obeses female resting in bed, NAD CV: RRR Resp: unlabored, CTA anteriorly GI: obese, soft, NTND Ext: WWP, difficulty in appreciating edema, palpable radial and DP LLE: dressings c/d/i over left thigh, some surrounding ecchymosis, sensation intact, full strength about knee and ankle Psych: AAOx3 Pertinent Results: URINE CULTURE (Final [**2201-11-12**]): <10,000 organisms/ml. CBC: [**2201-11-14**] 04:00AM BLOOD WBC-6.2 RBC-2.75* Hgb-9.0* Hct-27.3* MCV-99* MCH-32.6* MCHC-32.9 RDW-14.8 Plt Ct-228 INR: [**2201-11-18**] 06:24AM BLOOD PT-25.1* INR(PT)-2.4* [**2201-11-17**] 06:10AM BLOOD PT-25.0* INR(PT)-2.4* [**2201-11-16**] 07:10AM BLOOD PT-23.4* INR(PT)-2.2* [**2201-11-15**] 06:38AM BLOOD PT-22.3* INR(PT)-2.1* [**2201-11-14**] 04:00AM BLOOD PT-22.1* PTT-41.2* INR(PT)-2.0* LFT: [**2201-11-17**] 06:10AM BLOOD ALT-17 AST-19 LD(LDH)-196 AlkPhos-116* TotBili-0.4 Brief Hospital Course: The patient is a 66F with a history of metastatic renal cell carcinoma previously on pazopanib, CAD with STEMI and 2 BMS to LAD, HTN, CHF (EF 45-50%), prior atrial fibrillation, CKD, and hypothyroidism who was found to have a lesion in the left proximal femur with impending pathologic fracture and was admitted for prophylactic intramedullary fixation. She started on Pazopanib in [**2201-4-7**] and this has been complicated labile blood pressures, ranging from 100s to 200 systolic, requiring increasing anti-hypertensive medications. However, since stopping pazopanib in mid [**Month (only) **] her blood pressures have typically run 120s to 130s systolic. She continues to take lisinopril, metoprolol, and diltiazem. She has tapered down and this past week discontinued the hydralazine. She takes lasix as needed for lower extremity edema, typically two to three times per week. The medicine consult service was requested regarding her new post-op atrial fibrillation, and had recommended that she stop her home metroplol, lisinopril, and diltizaem secondary to low blood presures. On the floor, upon awaking from a nap, she was noted to have Afib with RVR, which she was not in previously; she said she was in [**6-16**] pain in her LLE, but denied any chest pain, shortness of breath, she endorsed a headache, but was without any breathing difficulties. She was AAOx3, and was given lopressor 5 mg x 3 between 2 PM and 3 PM, and then between 3 and 4 PM was given a total of 25 mg of IV Diltiazem, without any improvement in her atrial fibrillation, with continued rates in the 130s. She was given 100 mg PO Metoprolol around 1 PM, and was noted at one point after an IV Dilt bolus to have her pressures down to the 88s systolic. She was then transfered to the ICU for rate control and further monitoring. The etiology of her Afib was felt to be secondary to a combination of hypovolemia, pain and the discontinuation of her metoprolol and dilt. She was started on amiodarone (bolus followed by drip) and converted to normal sinus rhythm. Her blood pressures responded to IV fluids. She was transitioned to po amiodarone and transferred back to the floor. On the floor she continued to work with physical therapy, able to transfer to chair with lift only. Her wound continued to look good. She was stable, tolerating a regular diet with bowel movement. Pain was controlled with oral Dilaudid. She was voiding without difficulty. Medications on Admission: Home Medications: ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth once a day CLONAZEPAM - 0.5 mg Tablet - 0.5 (One half) Tablet(s) by mouth prn anxiety COLCHICINE - (Prescribed by Other Provider) - 0.6 mg Tablet - 1 Tablet(s) by mouth takes 2 at first signs of flare and then one daily prn until resolution DILTIAZEM HCL - 120 mg Capsule, Ext Release 24 hr - 1 Capsule(s) by mouth daily Hold drug with HR < 50 FENTANYL - 75 mcg/hour Patch 72 hr - apply 1 patch to skin every 3 days FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth PRN HYDROMORPHONE - 12 mg Tablet - 1 Tablet(s) by mouth every [**3-12**] hours as needed for pain LEVOTHYROXINE - 50 mcg Tablet - One Tablet(s) by mouth daily Avoid taking Calcium and the magnesium one hour before and after. LISINOPRIL - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth once daily METOPROLOL TARTRATE - (Dose adjustment - no new Rx) - 50 mg Tablet - 3 Tablet(s) by mouth twice a day OMEPRAZOLE - (Dose adjustment - no new Rx) - 20 mg Capsule, Delayed Release(E.C.) - One Capsule(s) by mouth daily ONDANSETRON - (Prescribed by Other Provider) - 4 mg Tablet, Rapid Dissolve - [**2-8**] Tablet(s) by mouth three times a day as needed for nausea SERTRALINE [ZOLOFT] - (Prescribed by Other Provider) - 100 mg Tablet - 2 Tablet(s) by mouth q am SOD PHOS,DI & MONO-K PHOS MONO [PHOSPHA 250 NEUTRAL] - 250 mg Tablet - 3 Tablet(s) by mouth daily. ZOLEDRONIC ACID [ZOMETA] - (Prescribed by Other Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4613**], MD; Dose adjustment - no new Rx) - 4 mg/5 mL Solution - 3.3 mg IV every 28 days ZOLPIDEM - (Prescribed by Other Provider; Dose adjustment - no new Rx) - 5 mg Tablet - 1 Tablet(s) by mouth PRN insomnia ASPIRIN - (Prescribed by Other Provider; Dose adjustment - no new Rx) - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day MULTIVIT-IRON-MIN-FOLIC ACID [CENTRUM] - (Prescribed by Other Provider) - Dosage uncertain Discharge Medications: 1. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Anxiety. 2. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: Please draw INR and adjust dose for INR between [**3-12**]. Managing Provider: [**Name Initial (NameIs) 7274**]: [**Last Name (LF) **],[**First Name3 (LF) **] Address: 1672 [**Location (un) **] TRAIL, [**Apartment Address(1) 3882**], [**Location (un) 63167**],[**Numeric Identifier 67221**] Phone: [**Telephone/Fax (1) 64624**] Fax: [**Telephone/Fax (1) 67222**] 3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. hydromorphone 4 mg Tablet Sig: 2-3 Tablets PO Every 3 hours as needed for pain: [**Month (only) 116**] give an additional dose prior to PT or transfers. Disp:*120 Tablet(s)* Refills:*0* 5. fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal q72h (). Disp:*10 Patch 72 hr(s)* Refills:*2* 6. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 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 every eight (8) hours as needed for fever or pain. 10. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 11. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: 400 mg 3 times/day for 2 additinal days, then 400 mg/day for 1 month, then 200 mg/day until further follow-up. Disp:*72 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Location (un) 11792**] Nursing and Rehab Center Discharge Diagnosis: Left intertrochanteric femoral pathologic lesion status post femoral cepholomedullary nail. 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: Activity: Touchdown weight bearing of the right lower extremity, Full weight bearing of the left lower extremity. Transfer/mobilize with assistance Wound Care: Replace dry, sterile gauze and cover with tegaderm for an additional one week. Incisions may get wet but do not submerge in water. Diet: Regular Anticoagulation: You are being discharged on Coumadin for anticoagulation. Your INR goal is [**3-12**] and will be followed by Dr. [**Last Name (STitle) 67220**]. Physical Therapy: Activity: Activity: Activity as tolerated tid Right lower extremity: Touchdown weight bearing (healing fracture with previously placed IMN) Left lower extremity: Full weight bearing Right upper extremity: Full weight bearing Left upper extremity: Full weight bearing Treatments Frequency: Wound care: Site: left thigh x 3 Type: Surgical Comment: change daily for 5 additional days with dry sterile dressing and Tegaderm Followup Instructions: Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2201-11-30**] 10:35 Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2201-11-30**] 11:30 Provider: [**First Name11 (Name Pattern1) 4224**] [**Last Name (NamePattern4) 4225**], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2201-11-30**] 2:00 Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Location (un) 50955**], [**Location (un) 50909**], RI Date/Time:[**12-23**] 12:45pm Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 67223**], XRT, [**Location (un) 50909**] RI - Pending Date/Time (midweek) Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], [**Telephone/Fax (1) 64624**] Pending Date/Time

[ "244.9", "585.9", "198.7", "278.00", "198.5", "412", "427.31", "428.0", "414.01", "403.90", "274.9", "428.22", "V85.43", "V45.82", "V10.52" ]

icd9cm

[ [ [] ] ]

[ "78.55" ]

icd9pcs

[ [ [] ] ]

11497, 11574

5314, 7761

360, 447

11710, 11710

4734, 5291

12838, 13675

3758, 3898

9833, 11474

11595, 11689

7787, 7787

11886, 12034

3938, 4332

12375, 12654

12678, 12678

7805, 9810

305, 322

12691, 12815

475, 936

11725, 11862

958, 3448

3464, 3742

4357, 4715

19,506

174,695

3219

Discharge summary

report

Admission Date: [**2174-9-20**] Discharge Date: [**2174-9-22**] Date of Birth: [**2120-10-27**] Sex: M Service: [**Hospital1 139**] HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 53-year-old male with a history of chronic obstructive pulmonary disease (not requiring home oxygen), coronary artery disease, and diabetes admitted directly to the Medical Intensive Care Unit on [**9-20**] for hypoxemic and hypercapnic respiratory failure. Mr. [**Known lastname **] was in his usual state of health until the morning of [**9-20**] when he developed progressive shortness of breath not relieved by his usual inhalers. Prior to the onset of this dyspnea, he relates experiencing a runny nose and a sore throat for several days. However, he denies experiencing chest pain, palpitations, nausea, vomiting, fevers, chills, or a productive cough. After several hours of worsening shortness of breath, tachypnea and diaphoresis, the patient called Emergency Medical Service and was taken to [**Hospital1 190**] for evaluation and treatment. In the Emergency Department, the patient was noted to be in severe respiratory distress; only able to speak 1-word sentences. His vital signs were as follows; temperature was 97.9, blood pressure was 239/159, heart rate was 124, respiratory rate was 36, and oxygen saturation of 83% on 100% nonrebreather. The patient was then intubated, placed on a nitroglycerin drip for blood pressure, started on steroids, antibiotics, and nebulizers and admitted to the Medical Intensive Care Unit. In the Medical Intensive Care Unit, the patient was placed on ventilator assist-control mode. He was intubated for less than 24 hours. On the morning following his admission to the Medical Intensive Care Unit, the patient was weaned off the ventilator. His nitroglycerin drip was stopped. His oxygen saturations were found to be greater than 95% on 5 liters nasal cannula, and his blood pressure was well controlled with a systolic blood pressure of 160. The patient was then called out to the floor for further observation. During the Intensive Care Unit stay, the patient was ruled out for a myocardial infarction with cycled enzymes and electrocardiogram. PAST MEDICAL HISTORY: 1. Coronary artery disease; 3-vessel disease, status post coronary artery bypass graft in [**2168**]. 2. Hypertension. 3. Diabetes mellitus; complicated by nephropathy. 4. Chronic obstructive pulmonary disease; not requiring home oxygen, unknown pulmonary function tests. Multiple admissions for chronic obstructive pulmonary disease exacerbations including one in [**2172**] which required intubation. MEDICATIONS ON ADMISSION: Home medications were albuterol, aspirin, Flovent, NPH insulin, Atrovent, levofloxacin, Ativan, Protonix. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient is a long-time smoker with greater than a 40-pack-year history; smoking half a pack per day. He admits to occasional alcohol use; four beers on the weekends, but denies any intravenous drug use. He lives alone in [**Location 8391**] and has a girlfriend. REVIEW OF SYSTEMS: Review of systems as above. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs on the floor were as follows; temperature was 98.1, blood pressure was 150/80, heart rate was 86, respiratory rate was 22, saturating 98% on 5 liters nasal cannula. The patient's physical examination in general revealed the patient was a well-developed and well-nourished male, in bed, appeared comfortable, in no acute distress. Head, eyes, ears, nose, and throat revealed pupils were equal, round, and reactive to light. Sclerae were anicteric. His oropharynx was clear with poor dentition and dry mucous membranes. Neck revealed the patient had no jugular venous distention, no lymphadenopathy, and his neck was supple. Cardiovascular revealed the patient's heart was regular in rate and rhythm. A soft 2/6 systolic murmur at the left lower sternal border. No rubs or gallops. Lungs revealed the patient had decreased breath sounds at the bases, diffuse rhonchi most prominently anteriorly in the right lung, and expiratory wheezes in the right lung. His abdomen was obese, soft, nontender, and nondistended, with good bowel sounds. Extremities revealed the patient's extremities were notable for clubbing, tar stains, and cyanosis; but no edema. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories revealed complete blood count was as follows; white blood cell count was 11.1, hematocrit was 40.4, and platelet count was 234. His Chemistry-7 revealed sodium was 140, potassium was 4.1, chloride was 104, bicarbonate was 25, blood urea nitrogen was 20, creatinine was 0.8, blood glucose was 190. Calcium was 8.9, magnesium was 1.5, and phosphorous was 4.4. His last arterial blood gas in the Unit prior to transfer to the floor was on 4 liters of oxygen by nasal cannula with a pH of 7.4, PCO2 was 48, and an O2 of 84. RADIOLOGY/IMAGING: A chest x-ray from [**9-20**] (on the date of admission) showed cardiomegaly, but no overt congestive heart failure. No consolidations or effusions. HOSPITAL COURSE: 1. PULMONARY: As previously mentioned, the patient was intubated in the Emergency Department, started on Solu-Medrol and levofloxacin, and rapidly weaned off the ventilator to room air on which he was saturating 95% to 98% on discharge. The patient was also treated with albuterol, Atrovent, and Flovent during his stay in the Intensive Care Unit. Sputum culture were sent but were pending at the time of discharge. 2. CARDIOVASCULAR: The patient was markedly hypertensive on presentation to the Emergency Department. He was started on a nitroglycerin drip with resolution of the hypertension. The patient was then switched to his regular doses of captopril and Lopressor with eventual blood pressures of 160 to 150/80 on discharge. 3. ENDOCRINE: The patient was kept on a regular insulin sliding-scale during his stay, and blood sugars were generally between 150 and 300. CONDITION AT DISCHARGE: Condition on discharge was good. DISCHARGE DIAGNOSES: 1. Chronic obstructive pulmonary disease. 2. Coronary artery disease. 3. Diabetes mellitus. 4. Hypertension. MEDICATIONS ON DISCHARGE: 1. Albuterol meter-dosed inhaler 2 puffs q.6h. as needed for shortness of breath. 2. Prednisone 60 mg p.o. q.d. times two days; then 40 mg p.o. q.d. times two days; then 20 mg p.o. q.d. times two days. 3. Levofloxacin 250 mg p.o. q.d. (times seven days). 4. Flovent 110 mcg meter-dosed inhaler 4 puffs q.a.m. 5. Atrovent meter-dosed inhaler 4 puffs q.i.d. 6. Zestril 10 mg p.o. q.d. 7. Atenolol 10 mg p.o. q.d. 8. NPH insulin 25 units q.a.m. and 8 units q.p.m. 9. Regular insulin 10 units q.a.m. DISCHARGE FOLLOWUP: The patient was arranged for a [**Hospital 702**] clinic appointment at his usual clinic (which is the [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9464**] Health Center in [**Location (un) 538**]) for Tuesday, [**9-27**], at 2:15 p.m. with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] where he was to receive education regarding his asthma and his asthma medications; particularly his meter-dosed inhalers. [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 15074**] Dictated By:[**Last Name (NamePattern1) 11801**] MEDQUIST36 D: [**2174-9-22**] 17:00 T: [**2174-9-28**] 13:16 JOB#: [**Job Number 15075**]

[ "493.22", "414.01", "V45.81", "518.81", "401.9", "250.00" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

6108, 6222

6248, 6754

2681, 2826

5143, 6038

6053, 6087

3133, 5125

6775, 7534

178, 2223

2245, 2654

2843, 3113

18,754

180,992

22656

Discharge summary

report

Admission Date: [**2197-1-2**] Discharge Date: [**2197-1-12**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 281**] Chief Complaint: 80 year old female s/p fall from her wheelchair on coumadin with right hemothorax. Developed increased SOB and presented to [**Hospital 1562**] Hospital. CXR complete white out on right-mediastinal shift transferred to [**Hospital1 18**]. Major Surgical or Invasive Procedure: Rigid bronchoscopy [**2197-1-3**]. [**Hospital1 **]-valve cast to left lower extremity. History of Present Illness: 80 yr old female s/p fall from wheelchair (on coumadin for subclav DVT 3yrs ago). Developed increased SOB. Presented to [**Hospital 1562**] Hospital. CXR w/ right hemothorax, medialstinal shift. Chest CT w/ large right effusion. Transfered to [**Hospital1 18**] for management via Med Flight. Past Medical History: Childhood polio- wheelchair bound. Left subclavian DVT 3 yrs ago from chronic crutch walking. Mainatined on coumdain per PCP d/t relative risk from immobility. Social History: Lives w/ husband in [**Name (NI) 1562**]. Wheelchair bound but does transfer. Family History: Strong Family history of cancer. Mother and sister w/ breast cancer. Brother w/bowel cancer. Physical Exam: General appearance: Frail, cachetic 80 yr old female with c/o SOB and left knee pain. HEENT: eccymosis over left orbital area; no facial tenderness. PERRL. Hearing intact. MMM. Native dentition in poor condition. Has partial dentures. Neck: Supple, NT, no JVD. No C-Spine tenderness. Chest: Symmetrical. CXR w/ right lung field white out. Tracheal shift to left. Heart: RRR S1, S2; no mumur. ABD: Soft, NT, +BS. Extrem: No clubbing or edema. Right fingers noted to be cyanotic w/ capillary refill<2sec. left knee tenderness. Neuro: A+Ox3. Pertinent Results: [**2197-1-2**] 11:30PM TYPE-ART PO2-108* PCO2-63* PH-7.28* TOTAL CO2-31* BASE XS-0 [**2197-1-2**] 11:30PM GLUCOSE-108* K+-3.7 [**2197-1-2**] 04:38PM CK-MB-12* MB INDX-3.3 cTropnT-0.11* [**2197-1-2**] 04:38PM CALCIUM-8.2* PHOSPHATE-3.0 MAGNESIUM-1.7 [**2197-1-2**] 04:38PM WBC-9.9 RBC-3.73* HGB-10.7* HCT-32.3* MCV-87 MCH-28.8 MCHC-33.2 RDW-15.7* [**2197-1-2**] 04:38PM PT-16.5* PTT-31.5 INR(PT)-1.7 Brief Hospital Course: 80 yr old famle admitted to [**Hospital1 18**] on [**2197-1-2**] from [**Hospital 1562**] Hospital via Med Flight for right lung field white out w/ left tracheal shift and assoc'd SOB s/p fall from wheelchair on coumadin. Admitted to the Thoracic Surgical Service in the CSRU for monitoring. A right chest tube was placed and immed drained 2.5 liters of serosang fluid. Taken to the OR on [**2197-1-3**] -intubated for Rigid Bronchcoscopy, Flex Bronch, for evacuation of clot and confirmation of right upper lobe/ mainstem tumor seen on chest CT scan. Tumor was confirmed and debulked and sent for pathology. Pt was stable post-OR and transferred back to the CSRU. Was extubated on [**2197-1-3**] and maintained on 3L NP w/ sats mid 90's. Pt was transferred from the ICU to the floor for cont'd management and rehab. Swallow study was done post extubation w/o evidence of aspiration. [**Last Name (un) **] mech soft diet w/ boost supplements d/t malnutrition. Chest tube w/ mod serosang raiange to SXN. Sent for head CT to r/o Mets- neg scan. Left knee xray was done d/t c/o left knee pain. Was found to have left supracondylar femoral fracture. Orthopedics was consulted and a [**Hospital1 **]-valve cast was placed. Pt is non weight bearing to the left lower extremity. Medications on Admission: Coumadin 2.5 mg, vit E Discharge Medications: 1. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 2. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 3. Warfarin Sodium 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Enoxaparin Sodium 60 mg/0.6mL Syringe Sig: One (1) 50mg Subcutaneous Q12H (every 12 hours). Discharge Disposition: Extended Care Discharge Diagnosis: Right upper lung tumor -pathology pending. Left supracondylar femoral fracture. Discharge Condition: good. Discharge Instructions: Discharge to rehab for continued reconditioning and rehab for left supracondylar femoral fracture. Follow up w/ PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] 1-[**Telephone/Fax (1) 58710**] upon d/c from rehab. Followup Instructions: Oncology follow up at [**Hospital1 1562**] once pathology known. Follow up with Dr. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 2637**] (orthopedic)4 weeks post discharge [**Telephone/Fax (1) 24832**]. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**] Completed by:[**2197-1-20**]

[ "286.9", "790.7", "E884.3", "518.84", "V58.61", "599.0", "V12.51", "860.4", "162.8", "198.89", "518.0", "821.23", "197.1", "V12.02" ]

icd9cm

[ [ [] ] ]

[ "99.15", "96.6", "96.04", "00.17", "38.91", "32.01", "34.92", "99.04", "96.72", "93.59", "33.22", "34.04", "38.93" ]

icd9pcs

[ [ [] ] ]

4052, 4067

2310, 3588

499, 589

4191, 4198

1875, 2287

4514, 4854

1206, 1300

3661, 4029

4088, 4170

3614, 3638

4222, 4491

1315, 1856

221, 461

617, 912

934, 1095

1111, 1190

73,242

124,644

2595

Discharge summary

report

Admission Date: [**2117-9-22**] Discharge Date: [**2117-9-26**] Service: SURGERY Allergies: MD-76 R Attending:[**First Name3 (LF) 371**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [**2117-9-23**]: Laparoscopic cholecystectomy - Dr. [**Last Name (STitle) **] History of Present Illness: Patient is an 88 year old male with multiple medical problems including CAD s/p CABG in [**2099**], prostate cancer s/p xrt and HLD presenting to the ED with abdominal pain. Patient has been in the ED for greater than 12 hours when our service was consulted. Per preexisting reports by emergency department patient presented with epigastric pain versus chest pain and was ruled out for an MI. He continued to have back pain as well as epigastric pain thus the CTA of the torso was obtained to rule out aortic dissection. Patient underwent a non-contrast CT scan prior to the CTA. He continued to have some abdominal pain versus discomfort and received a total of morphine IV 15 mg by the time ACS surgery was called to examine the patient. At the time of our exam patient was very sleepy and minimally engaged. He was difficult to arouse. He was able to answer questions appropriately, but was unable to recall some history information. Past Medical History: PMH: HLD, CAD (IMI/CABG [**2099**]), Prostate CA (XRT [**2105**]) PSH: 4-vessel CABG [**2099**], PTCA/stent LCX [**2104**], repair RFA pseudoaneurysm Social History: lives at home denies tobacco, denies EtOH Family History: NC Physical Exam: Admission: VS: 98 110 94/64 20 96% RA patient examined in the ED, very drowsy and difficult to wake up, keeps falling asleep during the interview and exam, has been receiving morphine IV for multiple hours RRR CTA b/l abdomen is soft, thin, minimally distended, tender in the RLQ and RUQ, minimal tympany, no rebound tenderness, no guarding Pertinent Results: [**2117-9-22**] CTA torso - No pulmonary embolism, acute aortic process, or ischemic colitis. Distended gallbladder with small pericholecystic fluid and cholelithiasis. This appearance may be related to a third-spacing state, but given the suggestion of hyperemia in the gallbladder fossa and a possible cystic duct stone, symptoms should be correlated clinically. If indicated, HIDA scan may be obtained for further evaluation. US may assess for a possible cystic duct stone. Large fecal load. Increased displacement of left inferior and superior pubic ramus fractures without significant interval bony callus formation. Moderate-sized hiatal hernia Brief Hospital Course: Mr. [**Known lastname 13099**] is an 88M who presented to the [**Hospital1 18**] ED complaining of lower abdominal pain. He was worked up for MI in the ED and eventually underwent a CTA of his torso which demonstrated possible cholecystitis. He became increasingly tachycardic and hypotensive during his ED course and was started on levophed prior to admission to the MICU. A right IJ was placed in the ED. After further evaluation, Mr. [**Known lastname 13099**] was taken to the OR for laparoscopic cholecystectomy, which he tolerated without difficulty. He was admitted to the TSICU postoperatively for hemodynamic monitoring given his initial decompensation in the ED. On [**9-23**], Mr. [**Known lastname 13099**] was noted to be increasingly hypercarbic and had a significant respiratory acidosis, and was intubated. He required levophed with propofol, both of which were weaned off. His ventillator support was weaned. On [**9-24**] He was transferred to the floor and advanced to a regular diet. On [**9-25**] his foley was discontinued and he voided. His platelets were shown to be trending down at a nadir of 49 so a HIT panel was sent, heparin was stopped and fondaparinux was restarted. His antibiotics were also changed to po augmentin. His Blood cultures grew back pansenstive Ecoli so we continued him on that regimen. He was also shown to be fluid overloaded, without respiratory compromise so we gave him 10 Iv lasix, which he responded well. His home meds were also restarted. On [**9-26**] he was dischrged home on PO augmentin. Medications on Admission: - aspirin 162 mg po qdaily - tamsulosin 0.4 mg mg po qhs - lisinopril 2.5 mg po qdaily - simvastatin 60 mg po qdaily Discharge Medications: 1. Acetaminophen 650 mg PO Q6H 2. Amoxicillin-Clavulanic Acid 875 mg PO Q12H RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by mouth twice a day Disp #*14 Tablet Refills:*0 3. Aspirin 162 mg PO DAILY 4. Docusate Sodium 100 mg PO BID RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice a day Disp #*100 Capsule Refills:*0 5. HYDROmorphone (Dilaudid) 2-4 mg PO Q4H:PRN pain RX *hydromorphone [Dilaudid] 2 mg [**12-28**] tablet(s) by mouth Every 4-6 hours Disp #*60 Tablet Refills:*0 6. Tamsulosin 0.4 mg PO HS 7. Simvastatin 40 mg PO DAILY 8. Lisinopril 2.5 mg PO DAILY Discharge Disposition: Home Discharge Diagnosis: Acute Cholecystitis s/p Laparoscopic Cholecystectomy 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 with acute cholecystitis. You were taken to the operating room and had your gallbladder removed laparoscopically. You tolerated the procedure well and are now being discharged home to continue your recovery with the following instructions. During your stay, you received lasix for fluid overload, as you had edema in your extremities and groin. Please f/u with your PCP for further diuretic management. Your platelets were trending down so we got a HIT panel which is still pending. Your blood cultures grew Ecoli at admission so we started you on Unasyn while you were here. You are being discharged on Augmentin for 7days. Please follow up in the Acute Care Surgery clinic. You need to call [**Telephone/Fax (1) 11173**] ACTIVITY: o Do not drive until you have stopped taking pain medicine and feel you could respond in an emergency. o You may climb stairs. o You may go outside, but avoid traveling long distances until you see your [**Telephone/Fax (1) 5059**] at your next visit. o Don't lift more than [**10-11**] lbs for 4 weeks. (This is about the weight of a briefcase or a bag of groceries.) This applies to lifting children, but they may sit on your lap. o You may start some light exercise when you feel comfortable. o You will need to stay out of bathtubs or swimming pools for a time while your incision is healing. Ask your doctor when you can resume tub baths or swimming. HOW YOU [**Month (only) **] FEEL: o You may feel weak or "washed out" for a couple of weeks. You might want to nap often. Simple tasks may exhaust you. o You may have a sore throat because of a tube that was in your throat during surgery. o You might have trouble concentrating or difficulty sleeping. You might feel somewhat depressed. o You could have a poor appetite for a while. Food may seem unappealing. o All of these feelings and reactions are normal and should go away in a short time. If they do not, tell your [**Month (only) 5059**]. YOUR INCISION: o Tomorrow you may shower and remove the gauzes over your incisions. Under these dressing you have small plastic bandages called steri-strips. Do not remove steri-strips for 2 weeks. (These are the thin paper strips that might be on your incision.) But if they fall off before that that's okay). o Your incisions may be slightly red around the stitches. This is normal. o You may gently wash away dried material around your incision. o Avoid direct sun exposure to the incision area. o Do not use any ointments on the incision unless you were told otherwise. o You may see a small amount of clear or light red fluid staining your dressing or clothes. If the staining is severe, please call your [**Month (only) 5059**]. o You may shower. As noted above, ask your doctor when you may resume tub baths or swimming. YOUR BOWELS: o Constipation is a common side effect of narcotic pain medications. If needed, you may take a stool softener (such as Colace, one capsule) or gentle laxative (such as milk of magnesia, 1 tbs) twice a day. You can get both of these medicines without a prescription. o If you go 48 hours without a bowel movement, or have pain moving the bowels, call your [**Month (only) 5059**]. PAIN MANAGEMENT: o It is normal to feel some discomfort/pain following abdominal surgery. This pain is often described as "soreness". o Your pain should get better day by day. If you find the pain is getting worse instead of better, please contact your [**Name2 (NI) 5059**]. o You will receive a prescription for pain medicine to take by mouth. It is important to take this medicine as directed. o Do not take it more frequently than prescribed. Do not take more medicine at one time than prescribed. o Your pain medicine will work better if you take it before your pain gets too severe. o Talk with your [**Name2 (NI) 5059**] about how long you will need to take prescription pain medicine. Please don't take any other pain medicine, including non-prescription pain medicine, unless your [**Name2 (NI) 5059**] has said its okay. o If you are experiencing no pain, it is okay to skip a dose of pain medicine. o Remember to use your "cough pillow" for splinting when you cough or when you are doing your deep breathing exercises. If you experience any of the following, please contact your [**Name2 (NI) 5059**]: - sharp pain or any severe pain that lasts several hours - pain that is getting worse over time - pain accompanied by fever of more than 101 - a drastic change in nature or quality of your pain MEDICATIONS: Take all the medicines you were on before the operation just as you did before, unless you have been told differently. If you have any questions about what medicine to take or not to take, please call your [**Name2 (NI) 5059**]. Followup Instructions: [**Hospital 2536**] Clinic- Please call [**Telephone/Fax (1) 11173**] to make your appointment for 7-10days. PCP-[**Name10 (NameIs) 357**] follow up with your Primary care Physician this week. Urology Provider: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. Phone:[**Telephone/Fax (1) 277**] Date/Time:[**2118-1-19**] 10:00

[ "038.42", "428.0", "276.69", "V45.81", "575.0", "785.52", "272.4", "428.22", "401.9", "414.8", "995.92", "V10.46" ]

icd9cm

[ [ [] ] ]

[ "38.97", "51.23" ]

icd9pcs

[ [ [] ] ]

4926, 4932

2585, 4142

228, 307

5029, 5029

1908, 2562

9959, 10322

1525, 1529

4310, 4903

4953, 5008

4168, 4287

5180, 9936

1544, 1889

174, 190

335, 1274

5044, 5156

1296, 1449

1465, 1509

12,902

163,024

45347

Discharge summary

report

Admission Date: [**2171-1-24**] Discharge Date: [**2171-1-28**] Date of Birth: [**2126-8-23**] Sex: M Service: CARDIOTHORACIC Allergies: Erythromycin Base / Doxycycline / Betadine / Iodine / Percocet Attending:[**First Name3 (LF) 1505**] Chief Complaint: S/P IMI/Fatigue Major Surgical or Invasive Procedure: [**2171-1-24**] - CABGx3 (Lima->left anterior descending artery, SVG->Diagonal, SVG->Ramus) History of Present Illness: Mr. [**Known lastname 96835**] is a 44-year-old male with worsening anginal symptoms. He underwent cardiac catheterization that showed disease in his right coronary and left main disease. The cardiology service stented his right coronary artery back in [**Month (only) **] and he elected to wait for his cardiac surgery. He is presenting for revascularization. Past Medical History: Diabetes type II Hypertension Hyperlipidemia Hypothyroid Diabetes mellitus type II Fatty liver Migraine Obesity Proteinuria Psoriasis Colitis Sleep apnea Social History: tobacco 25 pack year history currently smokes, +coccaine in past last use in the 80s. +social etOH. Family History: grandfather with mi at 42, mother with cva at 68, a. fib. Physical Exam: Vitals: BP 90-110/40, HR 68, General: well developed male in no acute distress HEENT: oropharynx benign Neck: supple, no JVD Heart: regular rate, normal s1s2 +s4, I-II/VI systolic ejection murmur Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, no edema, no varicosities Pulses: 2+ distally Neuro: nonfocal Pertinent Results: [**2171-1-28**] 07:00AM BLOOD Hct-27.2* [**2171-1-27**] 05:37AM BLOOD WBC-5.9 RBC-3.26* Hgb-8.8* Hct-24.8* MCV-76* MCH-26.8* MCHC-35.3* RDW-15.1 Plt Ct-150 [**2171-1-27**] 05:37AM BLOOD Plt Ct-150 [**2171-1-28**] 07:00AM BLOOD UreaN-16 Creat-0.7 K-3.8 [**2171-1-24**] ECHO Pre bypass: The left atrium is normal in size. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. There is no aortic valve stenosis. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Cardiac output calculated 6.6 l/min by continuity. Post bypass: Preserved biventricular function lvef >55% no change in wall motion. No change in valvular findings. Aortic contours preserved without visible dissection. Remaining exam unchanged. [**2171-1-25**] CXR Right internal jugular venous access catheter terminates in upper SVC. The pulmonary artery catheter has been removed. The endotracheal tube and nasogastric tube have been removed. Two mediastinal drains and left-sided chest tube in unchanged position. The mediastinal contours are unchanged. The cardiac silhouette is largely obscured by newly increased atelectasis within the right and left lower lobes. There is no evidence of pulmonary edema and no pneumothorax. [**2171-1-24**] EKG Sinus rhythm Inferior infarct - age undetermined Borderline first degree AV block No change from previous Brief Hospital Course: Mr. [**Known lastname 96835**] was admitted to the [**Hospital1 18**] on [**2171-1-24**] for surgical management of his coronary artery disease. He was taken directly to the operating room where he underwent coronary artery bypass grafting to three vessels. He tolerated the procedure well and postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. On postoperative day one, Mr. [**Known lastname 96835**] [**Last Name (Titles) 26228**] neurologically intact and was extubated. Beta blockade, aspirin and a statin were resumed. His drains and wires were removed without complication. On postoperative day two, he was transferred to the step down unit for further recovery. Mr. [**Known lastname 96835**] was gently diuresed towards his preoperative weight. The physical therapy service worked with him daily to increase his postoperative strength and mobility. Mr. [**Known lastname 96835**] maintained a normal sinus rhythm throughout his postoperative course. He continued to make steady progress and was discharged home on postoperative day four. He will follow-up with Dr. [**Last Name (STitle) **], his cardiologist and his primary care physician as an outpatient. Medications on Admission: Synthroid 250mcg daily Atenolol 25mg daily Diovan 80mg daily Lipitor 10mg daily Plavix 75mg daily Protonix 40mg daily Aspirin 325mg daily Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*4* 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Synthroid Oral 7. Levothyroxine 125 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 8. Glipizide 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2H (every 2 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Take while taking pain medication. [**Month (only) 116**] discontinue when off pain medicine. Disp:*30 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: care group Discharge Diagnosis: CAD HTN MI NIDDM Hypercholesterolemia Obstructive sleep apnea s/p RCA stent Hypothyroid Migraine Headaches Fatty liver Proteinuria Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. 2) Report any fever greater then 100.5. 3) Report any weight gain of greater then 2 pounds in 24 hours or 5 pounds in 1 week. 4) No driving for 1 month. 5) No lifting greater then 10 pounds for 10 weeks. 6) No lotions, creams or powders to wounds until they have healed. 7) Call with any questions or concerns. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] in 1 month. Follow-up with cardiologist Dr. [**Last Name (STitle) **] in [**12-3**] weeks as well on [**2171-5-21**] at 4:30PM. Phone:[**Telephone/Fax (1) 5003**] Follow-up with primary care physician [**Last Name (NamePattern4) **]. [**First Name (STitle) **] in 2 weeks. Completed by:[**2171-1-28**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

5846, 5887

3235, 4440

345, 439

6062, 6069

1585, 3212

6521, 6870

1144, 1204

4628, 5823

5908, 6041

4466, 4605

6093, 6498

1219, 1566

290, 307

467, 832

854, 1009

1025, 1128

30,188

163,152

50350

Discharge summary

report

Admission Date: [**2104-5-4**] Discharge Date: [**2104-5-6**] Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 2297**] Chief Complaint: ? malaise Major Surgical or Invasive Procedure: Central venous line placement Intubation Plasmapheresis History of Present Illness: [**Age over 90 **] M c HTN, spinal stenosis, BPH, aortic stenosis c AVR, hypercholesterolemia, CAD. He presented to [**Hospital6 1597**] on [**5-3**] with few days of progressive malaise. No change in MS as per family, no recent illness, no fevers, or chills. On admission he was found to have plt count 12, WBC 7.56, HCT 32, LDH 1500, T Bili 2.0, retic 1.9, fib 356, d-dimer 558, LDH 1825, the initial smear did not have schistocytes and the pt. was treated for ITP with prednisone. He had a head CT that showed interval development of low-attenuation focus in the left cerebellar hemisphere. On [**5-4**] pt. developed MS changes and a repeat smear showed schistocytes precipitating transfer for pheresis for possible TTP. He had a headt CT and head MRI that showed bilateral "embolic" cerebellar CVA (based on wet read). Significant labs that day were as follows; WBC 12, Plt 13, D-dimer 733, t-bili 2.1, LDH 2498 Of note, Tn I 0.65, 0.54, 0.46, CPK, 68, 64. Ferritin 558 Past Medical History: HTN Arthritis Spinal stenosis BPH Peripheral neuropathy Aortic stenosis s/p porcine AVR [**7-31**]. CAD Hypercholesterolemia Fall [**1-/2104**] c/b L orbital fracture and cerebral hemorrhage Social History: Nonsmoker, rare EtOH, no hx IVDU. Retired music teacher. Lives in [**Hospital1 **] with wife and son. Family History: Brother c CHF, sarcoid, no premature CAD in family. Physical Exam: VS- T 96.0, HR 72, BP 189/90, RR 24, O2 sat 96%ra GEN-elderly man, lying in bed HEENT-pupils round and reactive, CN II-XII intact, poor effort LUNGS-crackles bilaterally HEART-RRR, S1, S2, systolic click ABDOM-soft, NT, +BS EXTRE-no edema NEURO-oriented times two, not cooperating with exam, somnolent, generalized weakness, bilateral upgoing Babinski, right lower extremity weakness>left lower extremity weakness SKIN-petechiae on bilat feet, anterior tibial area, chest Pertinent Results: Admission labs: [**2104-5-4**] 09:17PM WBC-12.7*# RBC-3.99* HGB-11.8* HCT-34.3* MCV-86 MCH-29.5 MCHC-34.3 RDW-15.7* [**2104-5-4**] 09:17PM NEUTS-86.5* LYMPHS-10.5* MONOS-2.8 EOS-0.1 BASOS-0.1 [**2104-5-4**] 09:17PM PLT SMR-RARE PLT COUNT-17*# [**2104-5-4**] 09:17PM GLUCOSE-168* UREA N-49* CREAT-1.5* SODIUM-135 POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-24 ANION GAP-11 [**2104-5-4**] 09:17PM ALBUMIN-3.7 CALCIUM-9.1 PHOSPHATE-3.1 MAGNESIUM-2.4 IRON-241* [**2104-5-4**] 09:17PM ALT(SGPT)-31 AST(SGOT)-65* LD(LDH)-1116* ALK PHOS-59 TOT BILI-2.8* [**2104-5-4**] 09:17PM PT-12.8 PTT-29.9 INR(PT)-1.1 [**2104-5-4**] 09:17PM FIBRINOGE-373 D-DIMER-2356* [**2104-5-4**] 09:17PM RET AUT-2.5 [**2104-5-4**] 09:17PM calTIBC-311 HAPTOGLOB-LESS THAN FERRITIN-748* TRF-239 . Studies: CT HEAD W/O CONTRAST [**2104-5-4**] IMPRESSION: 1. Multiple hypodensities within the cerebellum, left greater than right, consistent with areas of infarction seen on MRI from the same day from [**Hospital6 2561**]. 2. Prominent ventricles, unchanged compared to prior CT and MRI from the same day. NOTE ADDED AT ATTENDING REVIEW: The outside studies are not available for comparison. Therefore I cannot comment on the comparison that was made at the time of the preliminary report. The cerebellar hypodensities suggest subacute infarction on the left, perhaps with older infarction as well. The right cerebellar lesions might represent old or recent infarction. Correlation with the MR would be helpful. . CTA HEAD W&W/O C & RECONS [**2104-5-5**] IMPRESSION: 1. Large acute infarct within the left superior cerebellar artery territory without definite stenosis or thrombosis of the left superior cerebellar artery. 2. Additional more chronic-appearing infarcts in both cerebellar hemispheres, though age is indeterminant, and correlation with outside hospital MRI or repeat MRI is recommended. 3. Stenosis and occlusion of the right vertebral artery, also age indeterminant. Vertebral artery dissection cannot be excluded. 4. Moderate-to-severe atherosclerotic disease within the right M1 segment of the MCA. . TTE (Complete) Done [**2104-5-5**] The left atrium is elongated. There is severe symmetric left ventricular hypertrophy with normal/small cavity size and low normal systolic function (LVEF 50-55%). Regional left ventricular wall motion is normal. The right ventricular free wall is hypertrophied. Right ventricular chamber size is normal. with mild global free wall hypokinesis. The aortic root is mildly dilated at the sinus level. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet motion and transvalvular gradients. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is severe mitral annular calcification. There is mild valvular mitral stenosis (area 1.6cm2). Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The pulmonary artery systolic pressure could not be determined. There is a trivial/physiologic pericardial effusion. IMPRESSION: Severe symmetric left ventricular hypertrophy with normal/small cavity size and low normal systolic function. Right ventricular free wall hypokinesis. In the absence of a history of systemic hypertension, an infiltrative process (e.g., amyloid) should be considered. Normal functional aortic valve bioprosthesis. . CHEST (PORTABLE AP) [**2104-5-6**] FINDINGS: In comparison with the study of [**5-5**], there is increased opacification in the left mid and lower lung zone with obscuration of the hemidiaphragm. This would be consistent with a sequela of the recent aspiration event. Suggestion of some volume loss in the left lung, some of which may be due to angulation of the patient. Nevertheless, the possibility of volume loss in the left lower lobe secondary to mucus plug should be seriously considered. There has been placement of a central catheter with its tip in the mid SVC just below the level of the carina. Brief Hospital Course: [**Age over 90 **]-year-old male with a past medical history significant for hypertension, spinal stenosis, BPH, aortic stenosis with prosthetic AVR, and coronary artery disease who presented to OSH with generalized weakness, low platelets, developed mental status changes, petechiae, schistocytes and was found to have a left cerebellar stroke, concerning for TTP. . Pt's acute mental status worsened the following morning of admission to the point that he was minimally arousable to painful stimuli. In this setting, an aspiration event was witnessed and he was found to have built up secretions in his mouth. He was intubated AM of [**5-5**]. After the witnessed aspiration event, CXR showed signs of possible aspiration with a leukocytosis. Pt was started on vanc/unasyn. . For his stroke, Neurology and Neurosurgery were consulted. Neurology was concerned about an embolic phenomenon v. thrombotic phenomenon in the setting of low platelets. CTA showed: 1. Large acute infarct within the left superior cerebellar artery territory without definite stenosis or thrombosis of the left superior cerebellar artery. 2. Additional more chronic-appearing infarcts in both cerebellar hemispheres, though age is indeterminant, and correlation with outside hospital MRI or repeat MRI is recommended. 3. Stenosis and occlusion of the right vertebral artery, also age indeterminant. Vertebral artery dissection cannot be excluded. 4. Moderate-to-severe atherosclerotic disease within the right M1 segment of the MCA. Echocardiogram was performed and did not reveal source of embolism. Labs for vasculitis work-up was sent and included neg. ANCA, positive [**Doctor First Name **] with pending titers, ESR of 35, and CRP of 3.9. Per Neurology, BP was kept at 140-180 with levophed to increase cerebral perfusion. Per Neurosurgery, there were no surgical indications. . Given his low platelets, increasing schistocytes, mental status changes that Neurology felt was unrelated to L cerebellar stroke, and worsening renal function, there was great concern for TTP causing the thrombotic stroke. Heme/Onc was consulted. Pt was initiated on plasmapheresis in evening of [**5-5**]. However, his blood pressure did not tolerate plasmapheresis well and the session was shortened. ADAMTS13 ACTIVITY AND INHIBITOR was sent and is pending. While treatment for TTP was initiated, pt continued treatment for ITP with methylprednisolone 30mg q8hr. G6PD was also checked, which was within normal limits. . On AM of [**5-6**], his neurologic exam was very concerning for acute decline as pt had no ocular reflexes, no gag reflexes. Pt then developed signs of autonomic dysfunction concerning for brainstem injury, including labile temperatures and blood pressure. His pupils were later noted to be fixed and dilated. His blood pressure remained in the 60s despite maximal pressor support, and he then became bradycardic and arrested. He was DNR. Medications on Admission: 1. Darvocet 1-2 tabs PRN 2. Coreg 10 mg daily 3. Avodart 0.5 mg daily 4. Stool softener [**Hospital1 **] 5. Crestor - had been taking for 3 weeks prior to this presentation; previously on Zocor 6. Lisinopril 5 qhs 7. Miralax Discharge Medications: N/C Discharge Disposition: Expired Discharge Diagnosis: Cerebellar stroke Acute mental status changes TTP Acute renal failure Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A

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icd9cm

[ [ [] ] ]

[ "96.04", "96.6", "96.71", "99.71", "38.93" ]

icd9pcs

[ [ [] ] ]

9559, 9568

6314, 9255

251, 308

9681, 9690

2225, 2225

9742, 9748

1664, 1717

9531, 9536

9589, 9660

9281, 9508

9714, 9719

1732, 2206

202, 213

337, 1314

2241, 6291

1336, 1529

1545, 1648

54,923

120,306

38106

Discharge summary

report

Admission Date: [**2122-6-10**] [**Month/Day/Year **] Date: [**2122-6-29**] Date of Birth: [**2103-5-27**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 759**] Chief Complaint: Tylenol ingestion Major Surgical or Invasive Procedure: Intubation History of Present Illness: Of note, patient not willing to discuss much at the time of initial examination. Most of the history was obtained from review of minimal available records. The patient is a 19 y/o M with unknown PMHx who was transferred to [**Hospital1 18**] from an OSH for management of acetaminophen overdose. Per the patient, he took approximately 100 extra strength Tylenols 3 days ago. Per report, the patient was ultimately brought to the ED by his mother because of several days of vomiting. Pertinent OSH labs included APAP 73 ug/mL, Salicylic acid <4 mg/dL, AST/ALT = 661/824, Tbili 7.4, INR 2.0. Utox was positive for acetaminophen and THC. WBC remarkable for 21.1. He was given loading dose of IV NAC and transferred to [**Hospital1 18**] ED. Per report, the patient also reported that he had taken several other medications but would not give further details other than a list of home medications (see below). In the ED at [**Hospital1 18**], serum tox and urine tox were negative. Acetaminophen level was 39. He was seen by Toxicology in the ED, who recommended continuing the NAC treatment and obtaining a Lithium level. Hepatology also saw the patient in the ED and final recommendations were pending at the time of transfer. When asked about his actions, the patient stated that he was trying to end his life. Psychiatry attempted to speak with the patient, but he refused, citing his Scientology beliefs. Prior to transfer from the ED, the patient's VS were: 100.0 91 143/57 18 100%RA. . On arrival to the floor, the patient's VS were T: 99.4 BP: 147/63 P: 89 R: 19 O2: 96% on RA. He complained of some abdominal pain. He also complained of numbness/weakness in his legs and his left arm. He also complained of feeling swollen. He was not cooperative with any further questioning. . After initial evaluation on arrival to the MICU, the patient began to refuse care. He would not let nursing place additional IV's and refused lab draws. He stated that he wanted to be left to die. His case was discuss with psychiatry and with the ethics service ([**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]) and the hospital legal service. It was determined that the patient did not have the capacity to make these decisions. The decision was made to sedate and intube the patient to allow for further management of his serious medical condition. Past Medical History: ? Asthma ? Psychiatric Condition Social History: Lives with parents. Denies alcohol, tobacco and IVDU. Family History: Mother has known hypertension Physical Exam: PHYSICAL EXAM UPON ADMISSION: Vitals: T: 99.4 BP: 147/63 P: 89 R: 19 O2: 96% on RA General: Alert, Non-cooperative, Oriented x 1. HEENT: NC/AT. Pupils dilated but equal and reactive. EOMI. Neck: supple Lungs: CTA anteriorly; No wheezes, rhonchi, or rales noted. CV: RRR, No r/g, 2/6 systolic murmur loudest at the LUSB Abdomen: soft, non-distended, reports right-sided abdominal pain with palpation, no rebound or guarding noted GU: foley in place Ext: warm, well perfused, 2+ pulses Neuro: PERRL, EOMI, face symmetric, exhibits weakness on eyelid closure and reports generalized decreased sensation in the face bilaterally, reports weakness and numbness in the LUE, reports weakness in the bilateral LE's and numbness in the distal LE's (from the knees distally) . PHYSICAL EXAM UPON [**Last Name (NamePattern1) 894**]: VS: 100 162/80 range (144-180/74-90) 78 18 95% RA GENERAL: NAD. Oriented x3. Clothes are sweaty on exam. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. NECK: Left central removed, site is clean,dry, intact non-tender. CARDIAC: RR, normal S1, S2. No m/r/g. No S3 or S4. LUNGS: CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: Warm. No c/c/e. No femoral bruits. 2+ pulses LE/UE b/l SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. NEURO: CN intact, no focal deficits. Pertinent Results: Labs upon admission: . [**2122-6-10**] 03:20PM BLOOD WBC-17.0* RBC-4.83 Hgb-15.7 Hct-44.9 MCV-93 MCH-32.5* MCHC-35.0 RDW-12.9 Plt Ct-304 [**2122-6-10**] 03:20PM BLOOD Neuts-92.0* Lymphs-6.0* Monos-1.5* Eos-0.2 Baso-0.2 [**2122-6-10**] 03:20PM BLOOD PT-25.7* PTT-33.9 INR(PT)-2.5* [**2122-6-10**] 10:46PM BLOOD PT-41.0* PTT-40.3* INR(PT)-4.3* [**2122-6-12**] 11:05AM BLOOD Fibrino-291 [**2122-6-10**] 03:20PM BLOOD Glucose-95 UreaN-17 Creat-1.0 Na-139 K-3.9 Cl-106 HCO3-21* AnGap-16 [**2122-6-10**] 03:20PM BLOOD ALT-1891* AST-1664* CK(CPK)-223 AlkPhos-95 TotBili-5.5* DirBili-1.9* IndBili-3.6 [**2122-6-10**] 10:46PM BLOOD ALT-7533* AST-7567* LD(LDH)-5805* AlkPhos-84 TotBili-3.6* [**2122-6-11**] 12:34PM BLOOD ALT-[**Numeric Identifier 85039**]* AST-7838* AlkPhos-125 TotBili-3.9* [**2122-6-10**] 03:20PM BLOOD Albumin-4.2 Calcium-8.8 Phos-2.9 Mg-2.1 [**2122-6-10**] 03:20PM BLOOD Ammonia-17 [**2122-6-12**] 05:47AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-POSITIVE [**2122-6-10**] 03:20PM BLOOD Lithium-<0.2 [**2122-6-10**] 03:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-39* Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2122-6-11**] 04:18AM BLOOD Acetmnp-13 [**2122-6-11**] 12:34PM BLOOD Acetmnp-7* [**2122-6-11**] 07:08PM BLOOD Acetmnp-NEG [**2122-6-10**] 04:57PM BLOOD Type-[**Last Name (un) **] pO2-117* pCO2-31* pH-7.45 calTCO2-22 Base XS-0 Comment-GREEN TOP [**2122-6-10**] 11:54PM BLOOD Type-ART Temp-36.6 Rates-14/ Tidal V-500 PEEP-5 FiO2-40 pO2-192* pCO2-39 pH-7.36 calTCO2-23 Base XS--2 -ASSIST/CON Intubat-INTUBATED [**2122-6-12**] 06:27AM BLOOD Lactate-0.8 [**2122-6-13**] 11:44PM BLOOD O2 Sat-84 [**2122-6-10**] 11:54PM BLOOD freeCa-1.07* . Labs upon [**Month/Day/Year **]: . [**2122-6-24**] 06:30AM BLOOD WBC-9.9 RBC-3.41* Hgb-10.9* Hct-30.5* MCV-90 MCH-32.1* MCHC-35.8* RDW-13.7 Plt Ct-695* [**2122-6-18**] 03:54AM BLOOD Neuts-64.1 Lymphs-23.7 Monos-8.1 Eos-3.4 Baso-0.7 [**2122-6-23**] 07:30AM BLOOD PT-16.3* PTT-30.4 INR(PT)-1.4* [**2122-6-24**] 06:30AM BLOOD Glucose-83 UreaN-25* Creat-1.9* Na-137 K-4.7 Cl-100 HCO3-23 AnGap-19 [**2122-6-24**] 06:30AM BLOOD ALT-128* AST-53* CK(CPK)-109 AlkPhos-77 TotBili-1.7* [**2122-6-24**] 06:30AM BLOOD CK-MB-4 cTropnT-0.04* [**2122-6-24**] 06:30AM BLOOD Calcium-9.3 Phos-5.6* Mg-2.0 [**2122-6-24**] 06:30AM BLOOD Cortsol-12.9 [**2122-6-23**] 07:33AM BLOOD Vanco-11.4 [**2122-6-19**] 06:11AM BLOOD Lactate-0.6 [**2122-6-29**]: WBC: 8.6 Hgb:11.7 HCT 33.8 PLT 582 [**2122-6-29**]: CR: 1.2 NA: 139 K 3.8 CL 104 HCO3 24 [**2122-6-29**]: AST 64 ALT 36 ALK PO4 79 TBili 1.3 . ECHOCARDIOGRAM [**2122-6-16**]: The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. The mitral valve leaflets are mildly thickened. There is no pericardial effusion. . CXR: [**2122-6-19**] (MOST RECENT TO [**Month/Day/Year 894**]): In comparison with the study of [**6-18**], the monitoring and support devices are unchanged. The lungs are essentially clear without vascular congestion or pleural effusion. . CT HEAD: [**2122-6-22**]: There is no evidence of hemorrhage, edema, mass or midline shift or infarction. Sulci are normal in caliber and configuration. Slight asymmetry of ventricles, unchanged from prior exam, possibly positional in nature. Basilar cisterns are patent. No fracture is identified. . LUE US: [**2122-6-19**]: Thrombosis of left basilic vein. No deep venous thrombosis in left upper extremity. . RENAL ARTERY ULTRASOUND WITH DOPPLER: [**2122-6-24**]: 1. No son[**Name (NI) 493**] findings to suggest renal artery stenosis. 2. Diffusely increased cortical echogenicity noted bilaterally. These findings are suggestive of possible diffuse parenchymal process. 3. Trace amount of free fluid adjacent to the left kidney. 4. Mild circumferential wall thickening of the bladder, of uncertain etiology. . EKG [**2122-6-11**]: Sinus rhythm. Low inferolateral lead T wave amplitude. ST-T wave configuration also suggests early repolarization pattern. Findings are non-specific. Brief Hospital Course: [**Known firstname **] [**Known lastname 1001**] is a 19 year old man admitted after presenting to and outside hospital with nausea and vomitting after reported ingestion of 100 extra strength tylenol. He was initially refusing medical care and causing self-harm and was intubated after consultation with ethics. . The patient's acute hepatitis was secondary to APAP ingestion. He was intubated for protection as was refusing medical care on admission, as well as riping out IV lines. He was treated with NAC until tylenol level was undetedtable. Hepatology consulted and followed closely. Transplant surgery evaluated and deemed him not a transplant candidate given underlying psychiatric conditions and suicide attempt. Patient monitored with labs and transaminiases peaked in 10,000's. They trended down as did INR and Tbili. A CT scan of his head showed no evidence of cerebral edema. . The patient suffered hypoxic respiratory failure several hours after attempted extubation upon completion of NAC. He developed hypoxia and frothy pink secretions consistent with flash pulmonary edema. He was reintubated and diuresed as below. He grew out MSSA from sputum and was treated with 8 days of cefepime and 2 weeks of vancomycin (last dose [**2122-6-22**]) for a ventilator acquired pneumonia. Note he was initially treated with nafcillin but developed acute renal failure secondary to acute interstitial nephritis. After diuresis he was extuabted without difficulty. . His acute renal failure was thought to be secondary to APAP toxicity and possibly acute interstitial nephritis secondary to nafcillin use. Renal was consulted and recommended a lasix drip. He diuresed well and the lasix drip was stopped. He has since maintained good urine output and his creatinine has remained stable at 1.9 for several days approaching [**Month/Day/Year **]. . The patient was hypertensive on the medical floor with systolic blood pressures ranging from 140-180. Considering his age, positive family history and recent history of flash pulmonary edema, an initial work up for secondary causes of hypertension was begun. Renal artery ultrasound with doppler showed no evidence of renal artery stenosis, but did show diffuse parenchymal disease consistent with his APAP toxicity and is likely the cause of what may be transient hypertension. Morning fasting cortisol was within normal limits. Should his hypertension persist despite normalization of his creatinine and kidney function, we recommend further outpatient work up for secondary causes of hypertension including primary hyperaldosteroism and pheochromocytoma. He was started on amlodipine 5mg daily on [**2122-6-23**]. . The patient complained of chest pressure the morning of [**2122-6-24**]. ECG was checked and had non-specific T wave changes in the lateral leads along with early repolarization, consistent with prior ECGs. One set of cardiac enzymes revealed normal CK and CKMB. His chest pressure resolved without intervention and there was no suspicion for acute coronary syndrome. . The patient developed low grade fevers while on the medical floor. An extensive workup was completed which included negative blood cultures, negative culture from the tip of his removed central venous line, negative urine and sputum cultures and recently clear chest x-ray. His fevers may be due to a resolving subcaspsular kidney hematoma noticed on CT abdomen or due to resolving acute liver or kidney injury. Upon [**Date Range **] to psychiatry, we have very little suspicion of underlying infection and consider him medically stable for transfer. . The patient attempted suicide with tylenol overdose. He recently broke with pregnant girlfriend, which was thought to be an inciting event. Per his family, he has had prior history of psychiatric problems. Psych was consulted and felt he has major depressive disorder with possible psychotic features. He will be [**Date Range **] to inpatient psychiatry for full evaluation and management. . It is recommended the patient establish regular care with a new primary care physician upon [**Date Range **] who can monitor his liver and renal function as well as his hypertension and newly started amlodipine. . He should have his CBC, LFTs and chem 10 checked weekly while in the psychiatry unit. . The patient was full code for this admission. Medications on Admission: Unknown; however, pt reportedly did bring with him a list of medications, including the following: Bactrim [**2121-2-12**] Seroquel Clarithromycin [**2120-11-11**] Ranitidine "Amox" [**12-20**] oxycodone lithium [**8-19**] prilosec cephalexin ASA Proair The patient also presented a bag of medications, including bottles of seroquel, oxycodone/APAP, lithium, clarithromycin, bactrim, amoxicillin, cefalexin, tylenol, ibuprofen, ranitidine, omeprazole, as well as a proair inhaler. [**Month/Year (2) **] Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 6. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO DAILY (Daily). 7. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**12-13**] puff Inhalation every four (4) hours as needed for shortness of breath or wheezing. [**Month/Day (2) **] Disposition: Extended Care Facility: [**Hospital1 69**] - [**Location (un) 86**] [**Location (un) **] Diagnosis: Primary Diagnoses: Suicide Attempt Acetaminophen overdose Acute Liver Failure Acute Renal Failure Ventilator acquired pneumonia Secondary Diagnoses: Major Depressive Disorder with possible psychotic features Hypertension [**Location (un) **] Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. [**Location (un) **] Instructions: You were admitted for tylenol overdose. You developed acute liver failure, acute renal failure, and pneumonia and were intubated in the intensive care unit. Your acute liver failure improved over the course of treatment and your renal function stabilized. Your pneumonia was successfully treated with antibiotics. While on the medical floor, your blood pressure was elevated and a new medication was started to lower it. Your medical issues are stable and you are now ready for full psychiatric evaluation and care. . Please take the medications: -Start amlodipine 5mg by mouth daily for high blood pressure. -Start Senna 8.6 mg twice daily as needed for constipation. -Start Multivitamin 1 tab daily -Start Folic Acid 1 mg daily -Start Thiamine 100mg daily -Start Docusate Sodium 100 mg twice daily as needed for constipation -Start Olanzapine 5 mg daily -Start Albuterol Inhaler 1-2 puffs every 4 hours as needed for shortness of breath or wheezing. . Please establish care with a primary care doctor upon your [**Location (un) **] from the psychiatric unit in order to monitor your liver function and renal function. Additionally, your blood pressure should be monitored and if it returns to normal, your new medication (amlodipine) may be able to be stopped. . It was a pleasure taking care of you. Followup Instructions: We recommend the patient establish care with a primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] from the psychiatric unit. He was found to be hypertensive on the medical floor and will need further work up as an outpatient for secondary causes of hypertension if his blood pressure does not normalize. His new primary care doctor can adjust his amlodipine as necessary. Completed by:[**2122-6-29**]

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icd9cm

[ [ [] ] ]

[ "96.72", "94.62", "38.93", "96.71", "38.91", "96.04" ]

icd9pcs

[ [ [] ] ]

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344, 356

4294, 4301

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133,653

711+712

Discharge summary

report+report

Admission Date: [**2106-6-10**] Discharge Date: [**2106-6-17**] Date of Birth: [**2032-5-3**] Sex: F Service: CARDIOTHORACIC Allergies: Aspirin / Penicillins / Sulfa (Sulfonamides) / Latex / Keflex Attending:[**First Name3 (LF) 1267**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Aortic Valve Replacement (19mm Mosaic Poricine) [**2106-6-10**] History of Present Illness: 74 y/o female with known Aortic Stenosis who presented to ED with chest pain intermittently x 2 weeks. Repeat Echo revealed worsening AS. Referred for elective valve surgery. Past Medical History: Aortic Stenosis, Hypertension, Hypercholesterolemia, Hypothyroidism, Asthma, Peripheral Vascular/Carotid Disease, Meneire's Disease, Osteoarthritis, s/p bilat. cataract surgery, s/p hysterectomy, s/p bladder suspension, s/p hemerrhoidectomy, s/p cholecystectomy, s/p appendectomy, s/p hand surgery Social History: Patient is married and lives at home. Denies any history of smoking, EtOH or recreational drug use. Family History: Non contributory Physical Exam: VS: Afebrile p-70's BP 126/54 General: NAD, WD/WN HEENT: Sclera nonicteric, EOMI, PERRL Neck: Supple, -JVD, +carotid bruit bilat Lung: Rales L base Heart: RRR w/ 4/6 SEM Abd: Soft, NT/ND, +BS Ext: -C/C/E good pulses throughout Pertinent Results: Echo [**6-10**]: PRE-CPB: Left ventricular wall thicknesses and cavity size are normal. Overall left ventricular systolic function is normal (LVEF>55%). The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. The aortic root is mildly dilated. There are simple atheroma in the ascending aorta. There are three aortic valve leaflets. No masses or vegetations are seen on the aortic valve. There is moderate aortic valve stenosis. There is moderate mitral stenosis. POST: Preserved biventricular systolic function. Bioprosthesis in aortic position/Well seated and mechanically stable/good leaflet excursion. No AI. No other change in valve structure and function. Head CT [**6-11**]: No evidence acute intracranial hemorrhage or mass effect. Punctate hypodensities in the right basal ganglia, and in the left parietal lobe. If there is concern for embolic phenomenon, an MRI with diffusion-weighted imaging is recommended. Stable prominent perivascular spaces in the superior frontal lobes bilaterally. Neck CT [**6-12**]: No hemodynamically significant stenosis identified. EEG [**6-12**]: This is an abnormal portable EEG obtained in drowsiness progressing to stage II of sleep with brief periods of wakefulness due to the presence of multifocal mixed theta and delta frequency slowing. This finding suggests multifocal bilateral subcortical dysfunction and is nonspecific, but could be consistent with vascular insufficiency. The background slowing indicates a beginning, mild widespread encephalopathy or represents a drowsy state. There were no clear epileptiform abnormalities recorded. CXR [**6-14**]: Persistent left basilar atelectasis/effusion. Resolution of right apical pneumothorax. [**2106-6-10**] 10:38AM BLOOD WBC-15.5*# RBC-2.97*# Hgb-8.6*# Hct-25.0*# MCV-84 MCH-28.8 MCHC-34.2 RDW-15.9* Plt Ct-490* [**2106-6-15**] 06:50AM BLOOD WBC-9.5 RBC-3.17* Hgb-9.3* Hct-27.0* MCV-85 MCH-29.4 MCHC-34.6 RDW-16.0* Plt Ct-639* [**2106-6-10**] 10:38AM BLOOD PT-18.5* PTT-35.4* INR(PT)-1.7* [**2106-6-15**] 06:50AM BLOOD PT-12.8 PTT-26.8 INR(PT)-1.1 [**2106-6-10**] 12:00PM BLOOD UreaN-18 Creat-0.5 Cl-113* HCO3-24 [**2106-6-15**] 06:50AM BLOOD Glucose-106* UreaN-18 Creat-0.7 Na-138 K-4.4 Cl-99 HCO3-30 AnGap-13 [**2106-6-14**] 02:40AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.3 [**2106-6-14**] 08:33AM URINE Blood-TR Nitrite-POS Protein-NEG Glucose-NEG Ketone-150 Bilirub-SM Urobiln-1 pH-5.0 Leuks-NEG [**2106-6-14**] 08:33AM URINE RBC-0-2 WBC-[**2-28**] Bacteri-MANY Yeast-NONE Epi-0 Brief Hospital Course: Ms. [**Known lastname **] was electively admitted on [**2106-6-10**] for valve replacement. She was brought to the operating room this day where she underwent an aortic valve replacement (tissue). Please see operative report for surgical details. Following the procedure she was transferred to the CSRU for invasive monitoring in stable condition. Later on op day she was weaned from sedation, awoke neurologically intact and extubated. Chest tubes were removed on post-op day one. Beta blockers and diuretics were started and she was gently diuresed towards her pre-op weight. Later on this day she appeared to be doing well was transferred to the telemetry floor. Later on post-op day one she appeared to have decreased mental status. She was transferred back to the CSRU and a CT was performed and Stroke team consulted. CT was questionable for left CVA. On post-op day two she underwent a neck CT and EEG (please see pertinent results). Her epicardial pacing wires were removed on post-op day three. Her mental status and extremity weakness slowly improved and on post-op day four she was transferred back to the step-down floor. It appeared on this day she had a UTI and cultures were still pending at time of discharge. She was empirically started on antibiotics. Her medications were titrated for maximum BP and HR control. Physical therapy worked with pt during entire post-op course for strength and mobility. She appeared to be doing well with stable labs and vital signs and was discharged to rehab facility on post-op day six. Medications on Admission: Plavix 75mg qd, HCTZ 25mg qd, Lipitor 5mg qd, Toprol XL 50mg qd, Synthroid 50mcg qd, Colace 100mg [**Hospital1 **], Heparin 5000u SC TID Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 days. 7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital **] Rehab Center for the Aged Discharge Diagnosis: Aortic Stenosis s/p Aortic Valve Replacement Post-op Stroke PMH: Hypertension, Hypercholesterolemia, Hypothyroidism, Asthma, Peripheral Vascular/Carotid Disease, Meneire's Disease, s/p bilat. cataract surgery, s/p hysterectomy, s/p bladder suspension, s/p hemerrhoidectomy, s/p cholecystectomy, s/p appendectomy, s/p hand surgery Discharge Condition: Good Discharge Instructions: Can take shower. Wash incision with water and gentle soap. Gently pat dry. Do not take bath. Do not apply lotions, creams, ointments or powders to incision. Do not drive for 1 month. Do not lift greater than 10 pounds for 2 months. If you develop a fever or notice redness or drainage from chest incision, please contact office immediately. Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks Dr. [**First Name (STitle) **] in [**1-29**] weeks Dr. [**Last Name (STitle) 2903**] in [**12-28**] weeks [**Hospital 409**] clinic in 2 weeks Completed by:[**2106-6-16**] Admission Date: [**2106-6-10**] Discharge Date: [**2106-6-17**] Date of Birth: [**2032-5-3**] Sex: F Service: CSU ADDENDUM: While Ms. [**Known lastname **] did have some changes in her mental status perioperatively there was no evidence either by radiographic imaging or physical examination that she suffered a perioperative stroke. Her change in mental status was most likely related to pain medication. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1714**], [**MD Number(1) 1715**] Dictated By:[**Last Name (NamePattern1) 5297**] MEDQUIST36 D: [**2106-7-26**] 07:04:33 T: [**2106-7-26**] 09:00:10 Job#: [**Job Number 5298**]

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icd9cm

[ [ [] ] ]

[ "39.61", "35.21" ]

icd9pcs

[ [ [] ] ]

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338, 403

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30216

Discharge summary

report

Admission Date: [**2185-12-22**] Discharge Date: [**2186-1-22**] Date of Birth: [**2117-5-22**] Sex: M Service: MEDICINE Allergies: Morphine Sulfate / Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 3556**] Chief Complaint: Left hip drainage MICU transfer for c diff colitis sepsis Major Surgical or Invasive Procedure: [**2185-12-23**]: I&D left hip with VAC placement [**2185-12-27**]: I&D left hip with VAC change/placement [**2186-1-2**]: I&D left hip with VAC change/placement [**2186-1-5**]: I&D left hip with VAC change/placement [**2186-1-9**]: I&D left hip with VAC change/placement [**2186-1-12**]: I&D left hip with VAC change/placement [**2186-1-15**]: VAC change at bedside [**2186-1-18**]: VAC change at bedside History of Present Illness: This is a 68 yo male with a past medical history of CAD s/p stents, HTN, CVA, hyperlipidemia admitted initially to the ortho service about 1 month ago for a left girdlestone procedure, course complicated by infection s/p multiple washouts, on cefepime, now with C. diff colitis and delirium. He was started on PO flagyl the day prior to transfer, but the patient refused the medication, so it was switched to IV. This morning, his wbc increased from 16 to 33 and became tachycardic to 130's. He was started on PO vanco, but refused this as well. He remains delirious. His labs were notable for evidence of hemoconcentration and a new thrombocytosis. ECG revealed sinus tach. Prior to transfer to the MICU, the patient was seen by surgery in consultation who did not feel he needed surgery at this time. . Patient denies CP, SOB, cough, pain in his hip or abdominal pain, N/V but is a poor historian given his delerium. . Past Medical History: CAD s/p stent x3 [**88**] years ago CVA [**2180**] with L hemiparesis LLE DVT [**2180**] HTN Hypercholesterolemia LLE venous stasis Left hip ORIF [**3-/2185**] L hip removal of hardware/girdlestone [**10-24**] s/p numerous washouts now with vac dressing in place Social History: unknown Family History: n/a Physical Exam: Upon admission per ortho: . Alert and oriented Cardiac: Regular rate rhythm Chest: Lungs clear bilaterally Abdomen: Soft non-tender non-distended Extremities: LLE Incision with large amount of drainage, sutures intact, sensation/movement at baseline. . . on transfer to MICU VS: Temp: 99.8 BP: 133/78 HR: 126 RR: 17 O2sat 98% RA GEN: ill appearing but NAD HEENT: PERRL, EOMI, right ptosis, anicteric, MM dry, op without lesions NECK: no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits RESP: CTA b/l with moderate air movement throughout CV: tachycardic, S1 and S2 wnl, no m/r/g ABD: minimal distention, soft, marked ttp diffusely, but more in the epigastrium and right side. Involuntary guarding present, but no evidence of rebound. EXT: no c/c/e, cool distally. Venous stasis changes on LLE SKIN: no rashes/no jaundice NEURO: disoriented, knew he was in a hospital but not where. He was not oriented to time. He repeated questions repeatedly, not clear he was comprehending questions. Left sided hemiparesis. DTR's wnl. Pertinent Results: pertinent labs: Wbc trended to 77,000 on [**2186-1-21**] Lactate 4.2 Creatinine trended to 1.7 . C diff positive on [**2186-1-18**] Brief Hospital Course: Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2185-12-22**] via direct transfer from the orthopaedic clinic due to left hip drainage in presence of an infection. On [**2185-12-23**] he was prepped, consented, and then taken to the operating room for an I&D of his left hip with VAC placement. He tolerated the procedure well, was extubated, transferred to the recovery room, and then to the floor. He was continued on his Cipro and started postoperatively on Vancomycin. Infectious Disease was consulted for antibiotic coverage and management. On [**2185-12-25**] his vancomycin dose was adjusted due to a high trough. On [**2185-12-27**] he returned to the operating room for an I&D of his left hip with change and replacement of a VAC sponge. He tolerated the procedure well, was extubated, transferred to the recovery room and then to the floor. He was started on cefepime per ID recommendations. On [**2185-12-28**] he was transfused with 2 units of packed red blood cells due to acute post operative anemia. On [**2185-12-30**] he again returned to the operating room for another I&D with VAC change. On [**2186-1-2**] he again returned to the operating room for another I&D with VAC change. On [**2186-1-3**] his vancomycin was discontinued and he remained only on cefepime. On [**2186-1-5**] he again returned to the operating room for an I&D with VAC change. He tolerated the procedure well. On [**2186-1-9**] he again returned to the operating room for an I&D with VAC change. On [**2186-1-10**] he was transfused with 2 units of packed red blood cells due to acute post operative anemia. On [**2186-1-11**] he underwent an MRI of his L spine for evaluation of his lumbar stenosis. On [**2186-1-12**] he was again taken to the OR for an I&D with VAC change. Also his amlodipine was increased to 5mg daily. On [**2186-1-15**] he tolerated a VAC change at the bedside. On [**2186-1-18**] he again tolerated a VAC change at the bedside. On [**2186-1-18**] he had an MRI of his T spine to evaluate a mass noted on the first MRI that needed further imaging. This MRI demonstrated an atypical hemangioma involving the right side of the T10 vertebral body and a smaller typical hemangioma at the left side of the T11 vertebral body. Based on this finding he was started on tizanidine per chronic pain service recommendations. On [**2186-1-19**] the patient was found to have c. difficile colitis, for which he was started on a course of p.o. flagyl. . The patient became tachycardic, oliguric and had a marked leukocytosis in the setting of a known c diff colitis on [**2186-1-21**]. He met the criteria for sepsis. He was hemodynamically stable upon transfer initially, but was quite dehydrated both on physical exam and as evidenced by his lab data which showed hyperchloremia and borderline hypernatremia with hemoconcentration on CBC. Aggressive fluid resuscitation was initiated, with a total of 16 Liters positive by 4am on [**2186-1-21**]. Despite these aggressive efforts, the family reconfirmed the patient's DNR/DNI status, and he expired on [**2186-1-22**] at 0630 AM. Medications on Admission: HYDROmorphone (Dilaudid) 0.125 mg IV Q6H:PRN pain MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Duration: 14 Days Acetaminophen 1000 mg PO QID Multivitamins 1 CAP PO DAILY Amlodipine 5 mg PO DAILY Ondansetron 4 mg IV Q8H:PRN nausea Atorvastatin 20 mg PO DAILY OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain Bisacodyl 10 mg PR EVERY 3 DAYS Oxycodone SR (OxyconTIN) 20 mg PO BID Calcium Carbonate 500 mg PO Q 8H Pantoprazole 40 mg PO Q12H CefePIME 2 gm IV Q12H Prochlorperazine 10 mg IV Q6H:PRN nausea Citalopram Hydrobromide 40 mg PO DAILY Senna 2 TAB PO HS Clopidogrel Bisulfate 75 mg PO DAILY Enoxaparin Sodium 40 mg SC DAILY Sorbitol 15 ml PO BID Ferrous Gluconate 300 mg PO DAILY Tizanidine HCl 2 mg PO HS Fluticasone-Salmeterol (250/50) 1 INH IH [**Hospital1 **] Vancomycin Oral Liquid 250 mg PO Q6H (Day 1 [**1-21**]) Fluticasone Propionate NASAL 1 SPRY NU [**Hospital1 **] Vitamin D 800 UNIT PO DAILY Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Left hip infection Acute post operative anemia c diff colitis leading to septic shock Discharge Condition: expired Discharge Instructions: none Followup Instructions: none [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3559**] MD, [**MD Number(3) 3560**]

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icd9cm

[ [ [] ] ]

[ "86.04", "86.28", "99.04", "93.59" ]

icd9pcs

[ [ [] ] ]

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359, 775

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2075, 3124

262, 321

803, 1726

3160, 3277

1748, 2013

2029, 2039

26,477

147,033

27951

Discharge summary

report

Admission Date: [**2187-5-17**] Discharge Date: [**2187-5-20**] Date of Birth: [**2134-6-3**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1436**] Chief Complaint: 52 yo f s/p anterolateral STEMI Major Surgical or Invasive Procedure: Cardiac catheterization with ostial LAD stent placement History of Present Illness: This is a 52 yo f with a PMH significant for DM1 (insulin dependent), peripheral edema, chronic renal insufficiency with a baseline Cr of 2.0, who went to an OSH with chest pain that had started several weeks prior and had just worsened the day of admission. ECG performed demonstrated ST elevations in the anteroseptal leads with small Q waves in II, III, F, V1 and V2. Patient was then transferred to [**Hospital1 18**] for emergent cath after being started on Plavix 600mg, [**Hospital1 **] 81, Lopressor 2 IV, integrillin gtt, SLNTG and morphine. Cardiac Cath revealed a PCWP of 26, RA 21, AO 92/51, PA 49/25, and RV of 45/15 with a CO of 3.11 and a CI of 2.42. Coronary angio revealed 90% ostial with mild diffuse disease in the LAD, mild diffuse disease in the LCX and a RCA 40% ostial and 50% mid nondominant. Drug eluting stent was placed in the ostial LAD with the proximal edge of the stent in the distal left main. On transfer into the SICU, patient was stable vitals in NSR in the 60's. She then began to complain of [**5-28**] chest pain, repeat ECG showed ST elevations in V4-V5, ECG at 0/10 pain showed the same changes. Past Medical History: DM1 PVD CRI Cr 2.0 nephrolithiasis Hx of Anorexia Social History: 30 pack-year history tobacco, current; 1 Etoh/wk; works in a doctor's office. No children. Family History: CAD, MI in both parents Physical Exam: Vitals - 96.8 96/50 60 13 General AA&Ox3, NAD HEENT no bruits, JVP not elevated Heart RR no m/r/g Lungs CTAB with bronchial breath sounds. Abd soft, ND/NT +BS Ext Right groin - sheath removed. No hematoma. 2+DP pulses equal bil. Pertinent Results: [**2187-5-17**] GLUCOSE-129* UREA N-53* CREAT-2.5* SODIUM-139 POTASSIUM-3.0* CHLORIDE-109* TOTAL CO2-14* ANION GAP-19 [**2187-5-17**] WBC-13.0*# RBC-4.18* HGB-12.6 HCT-37.1 MCV-89 MCH-30.1 MCHC-34.0 RDW-14.30 [**2187-5-17**] 10:03PM CK(CPK)-340* [**2187-5-17**] 10:03PM CK-MB-20* MB INDX-5.9 cTropnT-2.63* [**2187-5-17**] 02:52PM CK(CPK)-571* [**2187-5-17**] 02:52PM CK-MB-42* MB INDX-7.4* [**2187-5-17**] 04:32AM CK(CPK)-583* [**2187-5-17**] 04:32AM CK-MB-58* MB INDX-9.9* cTropnT-2.12* Brief Hospital Course: Briefly, this is a 52 yo F s/p septal STEMI who underwent emergent cath with stent placement in the ostial LAD. . Plan: 1. Cardiac - Ischemia - the patient has had a septal STEMI as evidenced by ST elevations on ECG and CE of Trp 10 and CK of 550. She underwent revascularization with stent placement in the ostial LAD before arrival to the CCU. Post cath, she received 18 hours of integrillin and post cath hydration and was started on Plavix 75mg [**Last Name (LF) 244**], [**First Name3 (LF) **] 325mg QD and Atorvastatin 80mg QD. Her SBP remained in the 80-90 range, which was corrected with fluid administration and therefore she wasn't able to be started on captopril until [**2187-5-19**]. She was titrated up and switched to Lisinopril 5mg QD for discharge. This should be continued to be titrated up as an outpatient for optimal cardioprotection in a diabetic patient. Pump - Echo showed apical akinesis following cath and therefore, the patient will require 3 months of anticoagulation with follow up echo at that time. She was bridged to coumadin and was therapeutic by [**2187-5-19**] with an INR of 3.1. SBP has been in the 110's since repleting fluids. Rhythm- NSR in the 60's with no events on telemetry during admission. . 2. Renal insufficiency - the patient has a baseline Cr 2.0. Post cath, the Cr did bump to 2.5 which was most likely due to the large dye load which may have contributed to non-gap acidosis. Will need to monitor Cr and renally dose all meds for discharge. . 3. DM1 - Insulin standing doses restarted as per outpatient regimen which should be continued upon discharge. . 4. Counseling: Smoking cessation and diet counseling provided. . Medications on Admission: Lantus 15 Units QAM NPH 1 unit before breakfast, lunch, dinner Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(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. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). 6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day: Please start this medication on Wednesday, [**2187-5-23**]. You will need to have your INR checked and followed by your PCP at this time. Disp:*30 Tablet(s)* Refills:*2* 8. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Sublingual once a day as needed for chest pain: Please take one tab for severe chest pain if pain is not relieved in 5 mins repeat and call 911. . Disp:*20 * Refills:*2* 9. Outpatient Lab Work INR and PTT on Wednesday [**2187-5-23**] Discharge Disposition: Home Discharge Diagnosis: anterolateral STEMI Discharge Condition: Stable, afebrile, ambulating. Discharge Instructions: Please return to the hospital if you experience chest pain, shortness of breath, palpitations, severe headache, dizziness or severe back pain. Please do not stop taking your Plavix for any reason without confirming with your Cardiologist, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please take all of your medications as directed. Followup Instructions: Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5311**] [**Telephone/Fax (1) 5317**] on Monday for INR and chem 7 check. Please follow up with your cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 2 weeks.

[ "272.4", "458.29", "414.01", "410.01", "250.01", "593.9", "276.2", "401.9", "305.1", "998.2", "780.6" ]

icd9cm

[ [ [] ] ]

[ "99.04", "88.56", "37.23", "00.40", "00.46", "00.66", "36.07" ]

icd9pcs

[ [ [] ] ]

5653, 5659

2584, 4271

346, 404

5723, 5755

2056, 2561

6163, 6489

1767, 1792

4384, 5630

5680, 5702

4297, 4361

5779, 6140

1807, 2037

275, 308

432, 1570

1592, 1643

1659, 1751

28,780

142,716

32917

Discharge summary

report

Admission Date: [**2135-2-1**] Discharge Date: [**2135-2-5**] Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1271**] Chief Complaint: right upper extremity numbness and weakness, right facial droop, word finding difficulty Major Surgical or Invasive Procedure: evacuation of left subdural hematoma via burr holes History of Present Illness: [**Age over 90 **] year old female with right upper extremity numbness and weakness since Saturday [**1-29**]. She went to ED at OSH Saturday and they told her it was secondary to arthritis and cervical DJD. Saturday afternoon she began having word finding difficulty, where she "can't get the words out", which improved in the evening and then started again later that night. Family spoke with PCP who suggested follow up in the office on Monday [**1-31**]. Sunday night her family noticed she had a slight right facial droop and today her family noticed she had 1 sentence which was completely jumbled and did not make sense. She visited her PCP [**Name Initial (PRE) 3011**] ([**1-31**]) who sent her to [**Hospital3 **] ED for eval. Head CT done there showed a L SDH and she was transferred to [**Hospital1 18**] for further eval. Reports fall 3 months ago where she hit her head, no CT done per patient and family. No headache, no complaints other than left leg pain which is baseline due to neuropathy and right upper extremity numbness. Past Medical History: CHF, DM, spinal stenosis, arthritis, PVD, atrial fibrillation, diabetic neuropathy Social History: lives alone Family History: father-stroke, MI, mother-DM,CAD Pertinent Results: [**2135-1-31**] 05:00PM PT-26.6* PTT-30.4 INR(PT)-2.6* [**2135-2-1**] 02:44AM PT-14.4* PTT-26.5 INR(PT)-1.3* CT HEAD W/O CONTRAST [**2135-1-31**] 5:13 PM FINDINGS: There is a large left frontoparietal extra-axial fluid collection predominantly hyperdense, within a largely hypodense background, likely representing subdural hematoma. This measures 13 mm in maximal thickness at the level of the lateral ventricles. There is slight rightward shift of the septum pellucidum, measuring roughly 4mm. There is effacement of the occipital [**Doctor Last Name 534**] of the left lateral ventricle. There is no evidence of uncal herniation. [**Doctor Last Name **]-white matter differentiation is preserved. There is no evidence to suggest acute major vascular territorial infarction. The visualized paranasal sinuses and mastoid air cells are clear, and no skull fracture is seen. IMPRESSION: 1. Large left frontoparietal subdural hematoma with mixed hypo- and hyper- dense material, with a laminar and compartmentalized appearance, consistent with acute-on-more chronic hemorrhage, likely from internal fibrovascular strands; there is no "swirl" sign to suggest hyperacute hemorrhage. 2. Mild rightward shift of midline structures, no evidence of herniation. CT HEAD W/O CONTRAST [**2135-2-1**] 6:24 PM FINDINGS: There has been interval placement of two burr holes located within the left frontal cortex. Multiple staples are present in the subcutaneous tissues at this level. There are several foci of pneumocephalus present throughout the left subdural space and more medially within the left cerebral hemisphere/subarachnoid space. There is a new large area of subarachnoid hemorrhage centered within the left frontal lobe superiorly. There is shift of normally midline structures to the right by approximately 5 mm . Aside from effacement of the sulci within the frontal lobe, there is no other significant mass effect. A persistent mixed density subdural hematoma overlying the left cerebral convexity appears slightly smaller in size when compared to the examination from eight hours prior. There is no intraventricular blood. There is no hydrocephalus. The visualized portions of the paranasal sinuses and mastoid air cells are clear. IMPRESSION: Status post two burr holes placed in the left frontal cortex for evacuation of subdural hematoma. New interval confluent subarachnoid hemorrhage centered within the superior left frontal lobe compared to examination from eight hours earlier. Multiple foci of intracranial pneumocephalus as described. CT HEAD W/O CONTRAST [**2135-2-4**] 10:37 AM [**Hospital 93**] MEDICAL CONDITION: [**Age over 90 **] year old woman with new seizure activity FINDINGS: New low attenuation within the left MCA distribution is most prominent within the left anterior temporal lobe, and left parietotemporal lobe. This finding is concerning for subacute infarction. The patient is status post evacuation of a left subdural hematoma via two burr holes within the superior left frontal and parietal lobes. Remaining subdural hematoma is stable in size, measuring up to 1 cm in maximum dimension. There has been a slight interval decrease in postoperative pneumocephalus. A large amount of left frontoparietal subarachnoid hemorrhage and adjacent focal edema is unchanged. Left-to-right midline shift at the level of the septum pellucidum is unchanged at 4 mm. The ventricles and right cerebral hemisphere are unchanged. IMPRESSION: New low attenuation within the left MCA territory, including the left anterior temporal and left parietotemporal lobes concerning for evolving infarct. Brief Hospital Course: Mrs. [**Known lastname 76607**] was admitted from the ED to the ICU by the neurosurgical service. She was given a loading dose of Dilantin in the ED and continued on Dilantin in the ICU for seizure prophylaxis. She was given FFP to reverse the INR and her neurologic status was closely monitored. A CT head was repeated in the morning on [**2-1**] and surgical treatment of the SDH was recommended. The patient and family agreed to evacuation via burr holes and she was consented and prepared for the OR. She underwent evacuation via burr holes on [**2-1**] and it was noted post operatively that she had some right sided hemiparesis, expressive aphasia and right facial droop. A stat head CT was done which showed new left frontal intracerebral hemorrhage. A repeat CT head on [**2-2**] was stable and she was treated for hypernatremia with a Na of 146. On [**2-3**] she had worsening mental status including not following commands and a repeat head CT was done which was stable. She also had increasing creatinine and decreased urine output which was responsive to IV fluid boluses. A discussion was had with her family and she was made DNR/DNI. On [**2-4**], her creatinine continued to increase with a low urine output and low urine output. She was started on phenylephrine for low urine output. She had multiple seizures and a repeat head CT was done which showed new low attenuation within the left MCA territory, including the left anterior temporal and left parietotemporal lobes concerning for evolving infarct. A discussion was had with the patient's family and Dr. [**Last Name (STitle) 739**] in the afternoon on [**2-4**] and it was decided to begin comfort care only. The patient expired at 1:50 am on [**2135-2-5**]. Her family was with her when she died and they did not want an autospsy performed. Medications on Admission: cymbalta 60mg qd, Coumadin, novolin 70/30 28 units in AM, 12 units dinner, zaroxolyn 5mg one tab twice weekly, lasix 80mg [**Hospital1 **], reglan 5mg prn, simvastatin 40mg qd, prilosec 20mg qd, atentolol 12.5mg qd, captopril 50mg TID, elavil 25mg qHS, allopurinol 100mg qd, celexa 10mg qd, imdur 60mg qd, buspar 5mg TID, meclizine 25mg TID prn, KCl 10mEq 3tabs [**Hospital1 **], nitroglycerin SL prn, percocet prn Discharge Disposition: Expired Discharge Diagnosis: left subdural hematoma left intracerebral hemorrhage acute renal failure Discharge Condition: expired Followup Instructions: NA [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2135-2-5**]

[ "443.9", "428.0", "357.2", "401.9", "584.9", "V85.23", "342.90", "276.0", "780.39", "V58.61", "250.60", "V66.7", "784.3", "432.1", "431", "781.94", "427.31" ]

icd9cm

[ [ [] ] ]

[ "01.31", "99.07" ]

icd9pcs

[ [ [] ] ]

7646, 7655

5348, 7180

353, 407

7772, 7781

1694, 4302

7804, 7931

1640, 1675

4339, 5325

7676, 7751

7206, 7623

225, 315

435, 1488

1510, 1595

1611, 1624

22,856

138,134

51792

Discharge summary

report

Admission Date: [**2138-5-15**] Discharge Date: [**2138-5-17**] Date of Birth: [**2063-1-7**] Sex: M Service: [**Company 191**] CHIEF COMPLAINT: Dizziness and dark stools. HISTORY OF PRESENT ILLNESS: This is a 75-year-old male with a nonischemic dilated cardiomyopathy with an ejection fraction of less than 20%, chronic renal insufficiency with a baseline creatinine of roughly 2, and atrial fibrillation diagnosed in [**2137-12-7**], who was in his usual state of fair health until the last several when he started noticing that he was dizzy with orthostatic symptoms. In the last one to two weeks prior to developing this dizziness the patient had been noticing dark stools, but he had also begun taking iron and attributed the darkened stools to the iron. He says his stool at the time of admission had progressed to the point of becoming black and tarry. The patient describes no abdominal pain, constipation, or bright red blood per rectum. In addition to dizziness, he also reports some mild exertional dyspnea and palpitations, but no chest pain. Of note, the patient was using Aleve twice a day over the last several weeks for a flare of gouty arthritis in his foot. His Coumadin dose otherwise has been stable. PAST MEDICAL HISTORY: 1. Dilated cardiomyopathy with an ejection fraction of 20%, clean coronary arteries, 1+ mitral regurgitation. 2. Chronic renal insufficiency (with a baseline creatinine of around 2, has been rising recently). 3. Hypertension. 4. Gout. 5. Iron deficiency anemia. 6. History of gastrointestinal bleed. Last esophagogastroduodenoscopy on [**2137-9-2**], which showed antral gastritis. 7. Last colonoscopy on [**2138-2-7**], showed five sigmoid polyps and grade II internal hemorrhoids; also diverticulosis. 8. History of cerebrovascular accident versus transient ischemic attack in [**2128**]. 9. History of atrial fibrillation; now in normal sinus rhythm. ALLERGIES: Allergy possibly to ISORDIL and ZAROXOLYN. MEDICATIONS ON ADMISSION: 1. Toprol-XL 75 mg p.o. q.d. 2. Lasix 80 mg p.o. q.d. 3. Digoxin 0.125 mg p.o. q.d. 4. Coumadin. 5. Allopurinol 200 mg p.o. q.d. 6. Hydralazine 10 mg p.o. q.i.d. 7. Iron sulfate 325 mg p.o. q.d. 8. Prilosec 20 mg p.o. q.d. 9. Amiodarone 200 mg p.o. q.d. SOCIAL HISTORY: The patient occasionally drinks alcohol. There is no tobacco use. He lives alone. FAMILY HISTORY: No colon cancer. PHYSICAL EXAMINATION ON PRESENTATION: Admission physical examination revealed vital signs with a temperature of 96, pulse of 73, blood pressure of 150/70, heart rate of 19, oxygen saturation of 100% on room air. Head, eyes, ears, nose, and throat revealed pupils were equal, round, and reactive to light. Extraocular movements were intact. Sclerae were anicteric, but bilateral arcus senilis was noted. Conjunctivae were pale. Mucous membranes were moist. Neck was supple, no lymphadenopathy, and no jugular venous distention. Lungs were clear to auscultation bilaterally. Cardiovascular examination revealed a regular rhythm, normal rate. Normal first heart sound and second heart sound. No third heart sound or fourth heart sound. A [**2-12**] holosystolic murmur at the left lower sternal border radiating to the apex. Abdomen was soft, nontender, and nondistended, normal active bowel sounds. Extremities revealed no clubbing, cyanosis or edema. Rectal examination was heme-positive, black/tarry stool. Normal digital examination. Neurologic examination, alert and oriented times three. Cranial nerves II through XII were grossly intact. PERTINENT LABORATORY DATA ON PRESENTATION: Admission laboratories revealed a white blood cell count of 9.9, hematocrit of 16, and platelets of 255. PT of 43.7, PTT of 45, INR of 13.3. AST of 29, ALT of 36, LDH of 209, amylase of 88, total bilirubin of 0.2. SMA-7 revealed sodium of 139, potassium of 4.2, chloride of 105, bicarbonate of 24, blood urea nitrogen of 51, creatinine of 2.2, blood sugar of 134. Digoxin level of 1. RADIOLOGY/IMAGING: Chest x-ray showed no infiltrates or opacifications. No pneumothorax or effusions. Electrocardiogram revealed a normal sinus rhythm at a rate of 73. Intervals were normal. Flattened T waves in V4 through V6, I, and L. No change from [**2138-2-11**]. HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit with acute blood loss anemia and an elevated INR. He received 3 units of packed red blood cells, and his anticoagulation was reversed with vitamin K 5 mg intravenously and 5 mg subcutaneous times one. An esophagogastroduodenoscopy was performed on [**5-15**] which revealed a moderate reducible hiatal hernia but a normal stomach and duodenal mucosa. After the patient's 3 units of packed red blood cells, his hematocrit was stable at 26, and he had no further melenic stools. The patient's INR came down to 1.2 over the first 48 hours. Iron studies sent one month prior to admission showed the following: An iron of 36, a TIBC of 472, and ferritin of 19. A thyroid-stimulating hormone had been done in [**2137-5-7**] which was 2. On the evening of [**2138-5-16**], the patient was called out from the Intensive Care Unit to the floor for further monitoring. Overnight, the patient was stable with no complaints; and, again, no further bloody stool production. He was able to ambulate the halls as was tolerating p.o. well. His hematocrit remained stable at 26, and his INR was stable at 1.2. The patient's Diovan was restarted after his creatinine had come down to 1.8 (which was in his baseline range). He was seen by Gastrointestinal and felt to be stable for discharge on [**2138-5-17**]. DISCHARGE DIAGNOSES: Clinical history consistent with upper gastrointestinal bleed; source unclear after esophagogastroduodenoscopy. Lower gastrointestinal workup pending. MEDICATIONS ON DISCHARGE: (No Coumadin and no Aleve) 1. Toprol-XL 75 mg p.o. q.d. 2. Lasix 80 mg p.o. q.d. 3. Digoxin 0.125 mg p.o. q.d. 4. Allopurinol 200 mg p.o. q.d. 5. Hydralazine 10 mg p.o. q.i.d. 6. Iron sulfate 325 mg p.o. q.d. 7. Prilosec 20 mg p.o. q.d. 8. Amiodarone 200 mg p.o. q.d. DISCHARGE FOLLOWUP: The patient was to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2138-5-20**] at 2:30 p.m. This appointment has been arranged. The patient will need to arrange an appointment for a small-bowel follow-through; and after those results are obtained an appointment will need to be arranged with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17185**] of Gastroenterology for further followup. DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-983 Dictated By:[**Name8 (MD) 2653**] MEDQUIST36 D: [**2138-5-17**] 10:05 T: [**2138-5-17**] 10:29 JOB#: [**Job Number 72957**]

[ "401.9", "578.9", "553.3", "425.4", "428.0", "280.9", "427.31", "274.9", "593.9" ]

icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

2401, 4286

5692, 5845

5873, 6150

2018, 2282

4304, 5669

163, 191

6171, 6847

220, 1248

1270, 1992

2299, 2383

29,219

147,435

46044

Discharge summary

report

Admission Date: [**2177-4-13**] Discharge Date: [**2177-4-30**] Date of Birth: [**2109-5-15**] Sex: F Service: MEDICINE Allergies: Ampicillin / Penicillins / Bactrim / Lisinopril / Shellfish Attending:[**First Name3 (LF) 5552**] Chief Complaint: Chest pain, shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: Ms [**Known lastname 50416**] is a 67F with a PMH s/f pulmonary hypertension, sarcoidosis and colon cancer on chemotherapy (s/p C3D15 of cetuximab/rinotecan on [**4-8**]) who is presenting with a [**2-16**] day history of chest pain. The pain is described as substernal, pleuritic, sharp, radiating to her back, unchanged quality from prior. Pain initially [**10-24**] in severity. Associated symptoms include dyspnea, the patient denies diaphoresis, nausea or vomiting. No F/C, denies [**Month/Year (2) **]. . In the ED, initial VS were T: 97.2F, BP: 142/92, HR: 102, RR: 20, 100% 4L NC (on 3L NC at home). An EKG showed NSR with nnormal axis and intervals and no ischemic ST or T-wave changes. Initial CK was flat at 50, with troponin slightly elevated to 0.1, from a recent baseline around 0.8. A CTA was negative for pulmonary embolism and demonstrated a new RUL opacity tracking along the fissure, and thought by radiology to most likely reflect plate-like atelectasis related to her history of sarcoidosis. She was, however, given a dose of levofloxacin 750mg IV. Lower extremity dopplers were negative for DVTs. Her labs were otherwise normal except for her baseline elevated bicarbonate. She was given Morphine IR 2mg IV x 3 for chest pain, with some effect. Incidentally, patient has not taken any of her antihypertensives today. Past Medical History: ONCOLOGIC HISTORY: 1. Sigmoid colon cancer -Mucinous adenocarcinoma (>50%), pT3, pN2, and M1 (stage IV) with mets to the omentum and peritoneum, s/p sigmoid resection on [**2175-6-9**] -s/p 5 cycles of FOLFOX -irinotecan started on [**2176-5-24**] c/b hypercapnic respiratory failure on the first day of her sixth cycle ([**2176-10-8**]) and was admitted to the ICU and required intubation, on [**2176-10-18**] she received another dose of irinotecan which was c/b a SBO -C3D15 of cetuximab/rinotecan on [**4-8**] . OTHER PMH 1. Asthma 2. HTN 3. Sarcoidosis/Pulm HTN -Home O2 at 4L -Inhaled iloprost and prednisone 4. Osteopenia 5. Hypercholesterolemia 6. s/p thyroid adenoma resection Social History: Lives with daughter. Former [**Name2 (NI) 1818**], quit smoking 25 yrs ago (10 pack years). No ETOH/drugs. Family History: Negative for any colon, uterine, or any other type of malignancy. . Physical Exam: T: 98.5F BP: 167/92 HR: 97 RR: 24 O2: 97% 3.5L NC . PHYSICAL EXAM GENERAL: Pleasant, well appearing female, lying comfortably in NAD, speaking in full sentences HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. 2+ SEM at LUSB radiating to the carotids, no rubs or gallops. JVP=~9cm LUNGS: scattered fine rales throughout all lung fields, good air movement biaterally. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: [**1-15**]+ LLE edema, no calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [**1-15**]+ reflexes, equal BL. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: = = = = = = = = = = = ================================================================ RADIOLOGY Final Report CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2177-4-13**] 2:35 PM CTA CHEST W&W/O C&RECONS, NON- Reason: eval for PE [**Hospital 93**] MEDICAL CONDITION: 67 year old woman with SOB, pleuritic chest pain, metastatic cancer and edematous left leg with hypoxia on room air in the 70s REASON FOR THIS EXAMINATION: eval for PE CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 67-year-old woman with known sarcoidosis, metastatic colon cancer, now with dyspnea. COMPARISON: CTA of the chest from [**2177-3-28**] and CT of the torso from [**2177-3-11**]. TECHNIQUE: Multidetector CT scanning of the chest was performed before and following intravenous contrast administration. Multiplanar reformations were obtained. FINDINGS: There are no central or segmental filling defects within the tortuous and enlarged pulmonary arteries, whose appearance is unchanged compared to prior studies. The heart size is stable with atherosclerotic calcifications noted within the coronary arteries as well as within the thoracic aorta. There is no significant pericardial effusion. No lymphadenopathy is appreciated. The thyroid remains heterogeneous with isthmic and right-sided hypodensities suggestive of nodules. Within the lungs, again noted is fibrosis and traction bronchiectasis involving primarily the upper lobes. In addition, there is a newly apparent more consolidative opacity in the right upper lobe, tracking along the fissure and to a lesser extent in the left upper lobe also along the fissure. There are no pleural effusions. The central airways are patent. In the visualized upper abdomen, note is made of an incompletely evaluated large hypodense left upper quadrant mass whose appearance is similar to the prior studies, measuring upwards of 9 cm. A calcified retrocrural lymphadenopathy is also noted and unchanged. A hypodense posterior right lobe of the liver lesion is stable. IMPRESSION: 1. New opacity tracking along the major fissures bilaterally in the upper lobes is suspicious for superimposed infection in the setting of chronic changes due to sarcoid. 2. No evidence of central or segmental pulmonary embolism. 3. Enlarged pulmonary arteries, unchanged. 4. Large left upper quadrant abdominal mass and retrocrural calcified lymphadenopathy, similar to prior studies and compatible with metastatic disease. 5. Heterogeneous thyroid. [**2177-4-14**] 12:00AM GLUCOSE-63* UREA N-16 CREAT-1.0 SODIUM-131* POTASSIUM-4.7 CHLORIDE-85* TOTAL CO2-39* ANION GAP-12 [**2177-4-14**] 12:00AM CK(CPK)-56 [**2177-4-14**] 12:00AM CK-MB-3 cTropnT-0.07* [**2177-4-14**] 12:00AM ALBUMIN-3.6 CALCIUM-8.9 PHOSPHATE-3.7 MAGNESIUM-1.2* [**2177-4-14**] 12:00AM WBC-7.5 RBC-3.04* HGB-9.0* HCT-27.7* MCV-91 MCH-29.6 MCHC-32.5 RDW-15.4 [**2177-4-14**] 12:00AM PLT COUNT-287 [**2177-4-13**] 02:15PM GLUCOSE-84 UREA N-14 CREAT-0.9 SODIUM-133 POTASSIUM-4.3 CHLORIDE-83* TOTAL CO2-40* ANION GAP-14 [**2177-4-13**] 02:15PM CK(CPK)-50 [**2177-4-13**] 02:15PM cTropnT-0.10* [**2177-4-13**] 02:15PM CK-MB-NotDone proBNP-755* [**2177-4-13**] 02:15PM WBC-8.4 RBC-3.56* HGB-10.2* HCT-31.9* MCV-90 MCH-28.7 MCHC-32.0 RDW-15.1 [**2177-4-13**] 02:15PM NEUTS-78.6* BANDS-0 LYMPHS-12.4* MONOS-3.3 EOS-5.0* BASOS-0.8 [**2177-4-13**] 02:15PM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+ SCHISTOCY-OCCASIONAL STIPPLED-OCCASIONAL TEARDROP-OCCASIONAL [**2177-4-13**] 02:15PM PLT COUNT-380 [**2177-4-13**] 02:15PM PT-13.0 PTT-24.2 INR(PT)-1.1 Brief Hospital Course: The patient initially presented for admission with shortness of breath and persistent chest pain on [**2177-4-13**]. Initial evaluation was generally unremarkable with LENIs negative for DVT, CTA not suggestive of PE. She was diuresed with lasix prn. She also had her pain medications uptitrated and in the setting of her new pain regimen, she developed hypercarbic and hypoxic respiratory distress on [**2177-4-14**], necessitating transfer to the [**Hospital Unit Name 153**] and NIPPV. At that time, her initial ABG was notable for PCO2 of 132. Patient improved significantly after receiving BiPap and was called out to the floor. Again on the floor she developed increased confusion on [**4-18**] with slow response to questions and PCO2 of 97. She received NIPPV overnight and improved and was called out to floor. On the floor she received BIPAP at night. Received 500cc [**4-21**] for hypovolemic hyponatremia and 1000cc on [**4-22**], and 1 unit PRBCs on [**4-23**]. Developed increased RR on [**4-23**] to 26-30 and CXR was c/w volume overload. She received 20 IV lasix on [**4-23**]. During her course her O2 was again increased to 97-100% and she developed progressive somnolence. ABG was 7.26/99/32, placed in BIPAP without improvement (7.22/107/62). She was given 40 IV lasix and transferred to the [**Hospital Unit Name 153**] for noninvasive ventilation. In the [**Hospital Unit Name 153**], she was started on bipap. Respiratory therapy was consulted and she transitioned to bipap at night only. Her mental status and O2 sats improved and she remained on 3L nasal canula during the daytime. Again 2 days later the patient developed mild confusion with slow response to questions. ABG at that time was notable for PCO2 97. She was then transferred to the [**Hospital Unit Name 153**] for initiation of NIPPV. During her hospital course patient had numerous transfers to the ICU for mental status changes and respiratory failure, which became increasingly difficult to control, she was DNR/DNI and remained BiPAP dependant. On [**4-30**] her respiratory status did not respond to NIPV and she died in hypercarbic respiratory failure. Remaining hospital course by issues: . #. Hypercarbic Respiratory Distress: pt c/o SOB, O2 2L with O2 sat of 92% and initial improvement of her symptoms. Etiology of patient's propensity towards hypercarbic distress was likely her multiple primary pulmonary pathologies, including pulmonary hypertension, sarcoidosis, diastolic dysfunction, and presumed obstructive sleep apnea. These, coupled with narcotic use for pain related to malignancy require careful management to prevent inappropriately high bicarbonate levels. Treated with BiPAP 8/5/30%, aimed to avoid further sedating medications, continued hydroxychloroquine and prednisone for sarcoidosis, continued sildenafil for pulmonary hypertension and albuterol prn. . #. Hyponatremia: presentation and urine lytes c/w SIADH in the setting of pulmonary disease. Fluid restriction of 1.5L, and continued salt tabs. TSH cortisol normal and less likely to include in the differential. . #. Anemia: stable, continued ferrous sulfate. #. Hypothyroidism: Continue Levothyroxine 25mcg PO daily . #. Anxiety: low-dose ativan PRN. . #. Hypertension: continued nifedipine and metoprolol . #. Pain control: Acute Pain consult requested by ICU team prior to transfer. Fentanyl TD increased from 12 to 25 mcg/hour. Patient refused morphine PCA, as recommended. Continued fentanyl TD at increased dose, continue standing acetaminophen 1 g q6 hours, oxycodone PRN, Neurontin 300 mg qHS. - f/u Pain Service recs . #. PPx: bowel regimen, PPI, lovenox SC regimen . #. COMM: [**Name (NI) **] & Daughter [**Name (NI) 440**]: [**Telephone/Fax (1) 97995**], [**Telephone/Fax (1) 97996**]. Medications on Admission: 1. Hydroxychloroquine 200 mg [**Hospital1 **] 2. Ferrous Sulfate 325 mg daily 3. Levothyroxine 25 mcg daily 4. Nifedipine sustained release 30mg daily 5. Prednisone 10 mg daily 6. Docusate Sodium 100 mg [**Hospital1 **] 7. Senna 8.6 mg [**Hospital1 **] prn 8. Pantoprazole 40 mg daily 9. Metoprolol Tartrate 75mg [**Hospital1 **] 10. Oxycodone 5 mg q4H prn 11. Sildenafil 25 mg TID 12. Home oxygen 13. Lasix 20mg daily 14. Lorazepam 0.5mg q6-8h 15. Oxycontin 10mg [**Hospital1 **] Discharge Disposition: Expired Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: . Discharge Condition: . Discharge Instructions: . Followup Instructions: .

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icd9cm

[ [ [] ] ]

[ "38.93", "99.25" ]

icd9pcs

[ [ [] ] ]

11581, 11654

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352, 359

11699, 11702

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2580, 2650

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11726, 11729

2665, 3605

281, 314

4048, 7248

387, 1731

1753, 2440

2456, 2564

878

155,816

3235

Discharge summary

report

Admission Date: [**2136-6-6**] Discharge Date: [**2136-6-11**] Date of Birth: [**2061-8-17**] Sex: F Service: MEDICINE Allergies: Lasix / Diuril / Keflex / Iodine Attending:[**First Name3 (LF) 689**] Chief Complaint: Shortness of breath. Major Surgical or Invasive Procedure: None. History of Present Illness: Mrs. [**Known lastname **] is a 74 yo woman with pulmonary fibrosis and COPD on transtracheal home oxygen (3-4L) and chronic prednisone (10mg po daily) who was admitted to the MICU on [**2136-6-6**] for worsening dyspnea and hypoxia after elective bronchoscopy earlier that day. She was admitted in [**Month (only) 958**] (~6 wks prior to this admission) to an OSH for exacerbation of her shortness of breath and was discharged to a rehab facility. Previously, she had been the primary caretaker for her ill husband, and reports being able to perform household chores and climb the stairs in her house, though believes this "wore her out." . Because of the six weeks of worsening dyspnea and two days of increased cough productive of prurulent sputum (which coincided with an episode of prolonged epistaxis c/w prior history, though patient denies any link to her SOB), she was scheduled for elective bronchoscopy on day of admission. Per IP notes, there was no bloody secretions in the airways, minimal clear secretions and no endobronchial lesions. Pt was monitored post procedure without event and was transferred back to the rehab where she and her husband have been living for the last 2 months. On return to rehab, husband was concerned that she was increasingly SOB and O2 sats dipped into the 70s. Husband spoke with Dr. [**Last Name (STitle) **] who recommended returning to the ED for evaluation. . In the ED, initial vs were: T 100.1 P 101 BP 141/54 R 24 O2 sat 96%. Patient underwent a CXR which was essentially unchanged with possible retrocardiac opacity. She was given Vanc/Levofloxacin, Albuterol and Ipratropium for possible PNA. Cultures/Coags were not sent as she was a difficult stick. Hct was notably down from recent baseline and was positive with brown stool. Pt denied any BRBPR or hematemesis and was given IV PPI. She was cross matched for blood and GI was notified. Pt was ultimately admitted to the ICU for tachypnea and O2 requirement. . On arrival to the ICU, pt was tachypneic but completing full sentences and not appearing to be in any distress. There were no events and she was transferred to the floor the next day. On the floor, she is resting comfortably on 4L, speaking full sentences, though becoming SOB with minimal exertion (such as sitting forward for lung exam) and with occasional cough. She denies any dizziness, chest pain, palpitations, nausea, or vomiting. . Review of sytems: She was denying CP, palpitations, PND, orthopnea, lightheadedness, tingling, numbness, nausea, vomiting, diarrhea or BRBPR. She has baseline dark stools due to iron replacement and this remains unchanged. She denies fevers, URI or congestion but reports general decline in resp status over the last 6 wks and feels SOB has gradually worsened with some increased cough with scant hemoptysis since episode of epistaxis. Past Medical History: #s/p nasal embolization for refractory epistaxis [**6-30**] #s/p mechanical MVR in '[**25**] due to acute MR #Sinus node dysfunction s/p DDD pacemaker placement in [**2125**] #Aflutter s/p ablation in [**2-/2132**] and cardioversion [**11-3**] (maintained on dofetilide, followed by [**Doctor Last Name **]) #CHF: Last echo [**3-5**] LVEF 40-45%, 4+ TR #COPD: On 2-4L O2 at home via transtracheal oxygen cath #Idiopathic pulmonary fibrosis on chronic prednisone 10mg daily #CRI; baseline creatinine 1.3-1.6 #Anemia due to MVR and CRI; baseline HCT 30-35 #Hypertension #Hypercholesterolemia #Hypothyroidism #Meniere??????s disease (HOH) #Spinal arthritis #Breast cancer treated with radical mastectomy of right breast in [**2095**]. No chemo or XRT. Partial left [**2097**]. #s/p hysterectomy [**2101**] Social History: Since mid [**Month (only) 547**] she has been in rehab, sharing a room with her husband. She has two step- children. She smoked for ~ 36 years, but quit in [**2111**]. Social alcohol. No IVDU. Prior to hospitalization in [**Month (only) 958**] (patient has been in rehab since that time): Housekeeper 2x /week. Peapod for groceries. HHA twice a week since discharge along with HHA for assitance with showers. Husband does [**Name2 (NI) 14994**]. Since entering rehab, patient requires assistance with all ADLs, IADLs and uses walker at baseline. No falls + Visual aides - Dentures - Hearing Aides Family History: Parents are deceased, father had polymyositis, mother with metastatic bone CA. Her mother died of metastatic bone disease. Her father died of coronary artery disease. She has no siblings. She has several cousins with breast cancer. Physical Exam: ON ADMISSION: General: NAD, mildly tachypneic, oriented HEENT: Sclera anicteric, MMM, exopthalmos Neck: supple, no LAD Lungs: dry velcro rales at bases bilaterally, no congestion, rhonchi or wheezes CV: Regular rate and rhythm, gr 3 SEM over RUSB Abdomen: soft, NT/ND, NABS, no rebound or guarding Ext: warm, 2+ pulses, no edema ON TRANSFER TO FLOOR: Vitals: T: 95.8 BP: 130/70 P: R: 20 O2: 100% General: Alert, oriented, no acute distress, sitting watching television and eating breakfast HEENT: Sclera anicteric, MMM Neck: supple, JVP 7-8 cm, no LAD Lungs: Decreased air entry throughout, dry crackles bilaterally, more pronounced at bases. CV: Regular rate and rhythm, accentuated S1, S2, no murmurs, rubs, gallops appreciated Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: On Admission: [**2136-6-5**] 09:40PM WBC-14.0* RBC-2.79*# HGB-8.1*# HCT-26.2*# MCV-94 MCH-28.9 MCHC-30.8* RDW-17.5* [**2136-6-5**] 09:40PM NEUTS-92.0* LYMPHS-5.8* MONOS-1.4* EOS-0.6 BASOS-0.4 [**2136-6-5**] 09:40PM PLT COUNT-323# [**2136-6-5**] 09:40PM GLUCOSE-182* UREA N-36* CREAT-1.7* SODIUM-140 POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-29 ANION GAP-15 [**2136-6-5**] 10:03PM HGB-8.7* calcHCT-26 [**2136-6-5**] 10:03PM GLUCOSE-178* LACTATE-2.6* K+-4.0 [**2136-6-6**] 01:35AM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 [**2136-6-6**] 01:35AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2136-6-6**] 01:35AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013 [**2136-6-6**] 04:31AM CK-MB-NotDone cTropnT-0.09* [**2136-6-6**] 04:31AM CK(CPK)-62 . ECHO The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 45 %). There is no ventricular septal defect. The right ventricular cavity is mildly dilated with depressed free wall contractility. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. A bileaflet mitral valve prosthesis is present. The mitral prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [**2134-11-19**], the LVEF is slightly lower. . CT CHEST: 1)Severe emphysema combined with pulmonary fibrosis is most likely due to the syndrome of combined pulmonary fibrosis and emphysema (CPFE)with no acute pathology. 2)Stable enlarged mediastinal lymph nodes and severe cardiomegaly Brief Hospital Course: ***Discharged to Rehab and she can be reached at [**Location (un) 169**] [**Location (un) 1411**] [**Telephone/Fax (1) 15122**]*** 74 y/o F with PMHx of end stage lung disease who presents with subacute worsening in baseline hypoxia and anemia. # Dyspnea: The etiology of Mrs.[**Known lastname 670**] acute worsening of her chronic dyspnea was not clear, but the differential at admission included bronchospasm s/p bronch, ACS, respiratory infection, IPF flare, acute anemia, and CHF. She was weaned back to baseline O2 within an hour in ICU. She was clinically euvolemic with TTE unchanged, troponin peak 0.09, which trended down; EKG changes in absence of symptoms thought to be due to LVH with strain in the setting of acute hematocrit drop. Given the history of increased cough and sputum production with no acute process on chest CT, sputum positive for GPC and GNR (likely colonization, but possibly bronchitis), she was treated empirically for COPD exacerbation with levofloxacin (completed 6 day course) and rapid prednisone taper to chronic 10mg dose. We would recommend a discussion regarding goals of care and long-term progression of her disease with her primary team during follow-up. . # Anemia: Hematocrit 24.7 on admission. Patient is maintained on chronic ferrous sulfate and epoetin for anemia of chronic disease with a history of transfusion requirements at times of bleeding, including epistaxis. Stools were guaiac positive, but there was no evidence of active bleeding on admission, the patient was hemodynamically stable, and she has no history of brisk GI bleed. Given poorly compensated resp status, she was transfused 1 RBC unit in the ICU, and she bumped 24-->27. Stable coags. She was seen by ENT, who felt there was no need for intervention and recommended nasal saline. She was also seen by GI, but declined EGD and colonoscopy to evaluate for source of bleeding. During the admission there was no evidence of active bleeding and her Hct remained stable at 25, with slow upward trend. Epoetin was due (but not given) [**6-8**]. . # Anticoagulation (s/p mechanical MVR in 99): INR was 2.3 on admission. Baseline warfarin dose is 5mg. ICU re-started coumadin at 2.5 mg given that patient received levofloxacin in the ED. On the floor, the patient was covered with LMWH given subtherapeutic INR, and warfarin dose was increased to baseline 5mg. Dofetilide was continued at home-dose. . # AF/Aflutter s/p PCM for sick sinus node: Pt followed by Dr. [**Last Name (STitle) **], maintained on Dofetilide, anticoagulated with coumadin. Her heart rate remained ~80 throughout the admission. . # Systolic CHF: baseline EF 40-45%, though denies any symptoms of volume overload and appears clinically dehydrated on exam with mildly elevated creatinine. Continued spironolactone and held Bumex initially given that patient was hypovolemic-euvolemic on exam. Patient continued to appear euvolemic throughout admission, and Bumex was restarted at 2mg po BID upon discharge. . # Hypertension: Amlodipine 5mg daily was continued and patient remained normotensive throughout admission. . # Hypercholesterolemia: Atorvastatin was continued at 20mg daily. . # Hypothyroidism: Levothyroxine 112mcg daily was continued. . # Code: FULL Medications on Admission: ALBUTEROL inhaled AMLODIPINE 5mg daily BUMEX 3mg [**Hospital1 **] DOFETILIDE 125mcg [**Hospital1 **] EPOETIN ALFA 20,000 weekly FEXOFENADINE 60mg [**Hospital1 **] FLUTICASONE inhaled [**Hospital1 **] LEVOTHYROXINE 112 mcg daily LIPITOR 20MG Tablet daily MORPHINE 3-5mg prn SOB PREDNISONE 10mg daily SALMETEROL 50 mcg [**Hospital1 **] SPIRONOLACTONE 50mg daily TIOTROPIUM 18 mcg daily WARFARIN Vitamin D Colace Ferrous Sulfate 325mg daily Mucinex MIV TUMS [**Hospital1 **] Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Warfarin 2 mg Tablet Sig: 2.5 Tablets PO Once Daily at 4 PM: This should be adjusted based on your INR. 3. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 6. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing. 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 10. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Dofetilide 125 mcg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 12. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 14. Morphine 10 mg/5 mL Solution Sig: 2.5 PO Q4H (every 4 hours) as needed for SOB. 15. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 16. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Please confirm that this is patient's baseline dose (before hospitalization). If not, please adjust to prehospitalization dose. 17. Bumetanide 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 18. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Guaifenesin 600 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO bid (). 20. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed for SOB. 21. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous Q 24H (Every 24 Hours): Please discontinue once INR is therapeutic between 2.5-3.5 for at least 2 days. 22. weight Please obtain weight Monday, Wednesday, Friday at same time each day. If weight changes >3lbs, please notify MD; Bumex dose may need to be adjusted. 23. Outpatient Lab Work Please check INR every 2 days and adjust warfarin dose as needed to maintain INR between 2.5-3.5. 24. Epoetin Alfa 20,000 unit/mL Solution Sig: One (1) Injection once a week: Please adjust dose recommended by Dr. [**Last Name (STitle) **] before hospitalization. 25. Outpatient Lab Work Please check hematocrit, sodium, potassium, BUN, and creatinine weekly. 26. Insulin Sliding Scale Please monitor patient's blood sugars and manage with Humalog insulin on a sliding scale. The scale used in the hospital is included in the discharge paperwork. Discharge Disposition: Extended Care Facility: [**Location (un) 169**] [**Location (un) 1411**] Discharge Diagnosis: Primary: COPD exacerbation Secondary: Idiopathic pulmonary fibrosis Chronic obstructive pulmonary disease Anemia Chronic kidney disease Heart failure, systolic dysfunction Atrial flutter Hypertension Hyperlipidemia Hypothyroidism Discharge Condition: Hemodynamically stable, satting 99-100% on 4L transtracheal. Ambulating with O2 sats >90% on 6L. Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the ICU and then the medicine floor at [**Hospital1 1535**] for your worsened shortness of breath. The bronchoscopy and chest CT did not show any evidence of pneumonia or any new changes. You were treated with bronchodilators, steroids, and antibiotics. You were also transfused 1 unit of red blood cells because your red blood cell count was low (Hct 24.7) on admission. *You should continue your medications from before hospitalization and should see your cardiologist and pulmonologist, as listed below. The only change to your medication is to: CONTINUE Bumex 2mg twice a day. If you start to drink more fluids, gain more than 3lbs, or notice significant swelling in your legs, you should talk to Dr. [**Last Name (STitle) **] or Dr. [**Last Name (STitle) **] about increasing the dose. *Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. Followup Instructions: Dept: Cardiology Dr. [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **] [**Hospital1 **] Hospital - [**Location (un) 620**] [**Street Address(2) 3001**] [**Location (un) 620**] [**Numeric Identifier 3002**] Phone: ([**Telephone/Fax (1) 8937**] When: Wednesday [**2136-6-27**] at 3:30 PM Dept: Pulmonary [**Hospital1 **] Hospital- [**Location (un) 86**] [**Location (un) 830**], [**Location (un) 86**] [**Numeric Identifier 718**] Phone: ([**Telephone/Fax (1) 513**] Someone will call you about an appointment with Dr. [**Last Name (STitle) **]. If you don't hear from someone within 2-3 days, you should call the number above. DR. [**First Name11 (Name Pattern1) 275**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2136-10-4**] 11:40 Completed by:[**2136-6-12**]

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icd9cm

[ [ [] ] ]

[ "55.23" ]

icd9pcs

[ [ [] ] ]

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1714

Discharge summary

report

Admission Date: [**2152-2-29**] Discharge Date: [**2152-3-2**] Date of Birth: [**2091-4-15**] Sex: M Service: CCU HISTORY OF PRESENT ILLNESS: Mr. [**Known firstname 9818**] [**Known lastname 9723**] is a 60-year-old gentleman with a history of severe end-stage ischemic cardiomyopathy, status post coronary artery bypass grafting, status post biventricular pacemaker, on home milrinone who presents for tailored congestive heart failure therapy. In the Catheterization Laboratory, he had resting hemodynamics performed to assess response to escalating doses of inotropic afterload reduction. His home milrinone was supposedly at a dose of 0.3 mcg/kg/min with a response to this in the Catheterization Laboratory with cardiac output and index of 3.91 and 2.37; respectively. In the Catheterization Laboratory, he had a slight increase in cardiac output and index in response to increasing doses of milrinone; however, he had the most significant result with 0.9 mcg/kg/min of milrinone and 0.01 mcg/kg/min of Natrecor with a cardiac output and index of 5.32 and 3.23; respectively. He was subsequently transferred to the Coronary Care Unit for further therapy. At the time of admission to the Coronary Care Unit, he denied any chest pain or shortness of breath and actually admitted that he had no change in symptoms at home prior to admission. PAST MEDICAL HISTORY: 1. Status post biventricular pacemaker and automatic internal cardioverter-defibrillator placement. 2. Chronic renal insufficiency. 3. Anemia. 4. Coronary artery disease; status post coronary artery bypass graft. 5. Severe end-stage ischemic cardiomyopathy. 6. Diabetes mellitus. SOCIAL HISTORY: The patient is originally from [**Country 9819**]. He formerly as a cashier. He denies any tobacco, alcohol, or drug use. FAMILY HISTORY: Family history was noncontributory. ALLERGIES: The patient has no known drug allergies. MEDICATIONS ON ADMISSION: (Current home medications included) 1. Plavix 75 mg by mouth once per day. 2. Aspirin 81 mg by mouth once per day. 3. Lipitor 30 mg by mouth once per day. 4. Colace 100 mg by mouth twice per day. 5. Carvedilol 6.25 mg by mouth twice per day. 6. Digoxin 0.125 mg by mouth once per day. 7. Repaglinide 1 mg by mouth three times per day. 8. Epogen 10,000 units subcutaneously three times per week. 9. Colchicine 0.3 mg by mouth once per day. 10. Lasix 40 mg by mouth twice per day. 11. Lisinopril 2.5 mg by mouth once per day. 12. Milrinone 0.75 mcg/kg/min. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs on admission revealed the patient's heart rate was 72 (which was paced), his blood pressure was 111/54, his respiratory rate was 12, and his oxygen saturation was 99% on room air. In general, the patient was alert and oriented times three. He was pleasant and in no acute distress. Head, eyes, ears, nose, and throat examination revealed the pupils were equal, round, and reactive to light. The extraocular muscles were intact. The oropharynx was moist and without lesions or exudates. Neck examination revealed a right internal jugular with Swan placement. His lungs had fine bibasilar crackles. His heart was regular. Normal first heart sounds and second heart sounds. There were no murmurs, rubs, or gallops. The abdomen was soft, nontender, and distended. There were normal active bowel sounds. Extremity examination revealed his extremities were thin and cool. He had 2+ dorsalis pedis and posterior tibialis pulses. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratories on admission with a complete blood count which revealed his white blood cell count was 6.4, his platelets were 309, and his hematocrit was 33.5. The patient had a sodium of 135 potassium was 4.3, chloride was 98, bicarbonate was 26, blood urea nitrogen was 97, and his creatinine was 1.8. His magnesium was 2.5. CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: 1. CARDIOVASCULAR ISSUES: The patient has a history of coronary artery disease. He was continued on his aspirin, Plavix, Lipitor, ACE inhibitor, and beta blocker while admitted. (a) Pump0: With regard to his pump function, he obviously had end-stage ischemic cardiomyopathy and was admitted for tailored hemodynamic therapy. He was continued on Natrecor 0.1 mcg/kg/min and milrinone 0.6 mcg/kg/min on the floor with very effective diuresis and maintenance of good cardiac output and index. His goal on admission was a wedge pressure of less 20; which was obtained approximately five hours after admission. The original plan was to wean the milrinone and Natrecor and try the patient on dopamine in order to obtain a wedge pressure of less than 20; however, this was obtained with milrinone and Natrecor on admission. There were several discussions regarding a heart transplant and possible transfer to [**Hospital 4415**] for workup for a heart transplant, which the patient stated he was not interested in. However, after multiple discussions with his family he eventually decided that he would like to undergo further evaluation for a heart transplant. He was to be transferred to [**Hospital 4415**] to pursue this further. (b) Rhythm: With regard to his rhythm, the patient has a biventricular pacemaker with an automatic internal cardioverter-defibrillator. His pacemaker was functioning fine throughout this admission. He had occasional ectopy; however, not significant. 2. ENDOCRINE ISSUES: The patient has a history of diabetes mellitus and was continued on his repaglinide at 1 mg three times per day. He had four times per day fingerstick checks and was covered with a regular insulin sliding-scale. 3. RENAL ISSUES: The patient has a history of chronic renal insufficiency with a baseline creatinine of 1.3 to 1.5. His last creatinine prior to admission was 2.2. At the time of admission, his creatinine was 1.8 and improved slightly with diuresis. There was some concern considering his milrinone was not at a renal dose; however, his creatinine was falling with further diuresis. The milrinone was maintained at 0.6 mcg/kg/min. 4. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient was continued on a cardiac, diabetic, and renal diet. 5. DISCHARGE DISPOSITION ISSUES: The original plan once the patient refused further workup for a heart transplant was to pull the Swan and continue him on milrinone, and monitor him on the floor, and then send him home at a dose of 0.6 mcg/kg/min with further followup. However, he had decided he was interested in a heart transplant and was to be transferred to [**Hospital 4415**] for further workup. DISCHARGE DIAGNOSES: 1. Congestive heart failure. 2. Coronary artery disease; status post coronary artery bypass graft. 3. Chronic renal insufficiency. 4. Diabetes mellitus. 5. Status post biventricular pacemaker and automatic internal cardioverter-defibrillator placement. CONDITION AT DISCHARGE: At the time of discharge, the patient was without complaints. He denied any chest pain or shortness of breath and was extremely stable. MEDICATIONS ON DISCHARGE: 1. Plavix 75 mg by mouth once per day. 2. Aspirin 81 mg by mouth once per day. 3. Lipitor 30 mg by mouth once per day. 4. Colace 100 mg by mouth twice per day. 5. Carvedilol 6.25 mg by mouth twice per day. 6. Digoxin 0.125 mg by mouth once per day. 7. Repaglinide 1 mg by mouth three times per day. 8. Epogen 10,000 units subcutaneously three times per week. 9. Colchicine 0.3 mg by mouth once per day. 10. Lasix 40 mg by mouth twice per day. 11. Lisinopril 2.5 mg by mouth once per day. 12. Milrinone 0.6 mcg/kg/min. 13. Natrecor 0.01 mcg/kg/min. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was to be transferred to the [**Hospital 8503**] for further evaluation for a heart transplant. 2. The patient was instructed to follow up in the Heart Failure Clinic by Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 2031**] and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4582**], M.D. [**MD Number(1) 4992**] Dictated By:[**Last Name (NamePattern1) 9820**] MEDQUIST36 D: [**2152-3-2**] 17:17 T: [**2152-3-2**] 17:33 JOB#: [**Job Number 9821**]

[ "414.00", "414.8", "V45.02", "250.00", "285.9", "V45.81", "428.42", "428.0", "593.9" ]

icd9cm

[ [ [] ] ]

[ "00.13", "37.21" ]

icd9pcs

[ [ [] ] ]

1841, 1932

6661, 6930

7110, 7680

1959, 3919

7713, 8330

3953, 6640

6945, 7083

164, 1372

1394, 1681

1698, 1823

14,376

178,762

5579

Discharge summary

report

Admission Date: [**2173-4-14**] Discharge Date: [**2173-4-21**] Date of Birth: [**2104-7-14**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 14964**] Chief Complaint: SOB Major Surgical or Invasive Procedure: s/p Coronray Artery Bypass Graft x 2 (LIMA to LAD, SVG to Ramus) on [**2173-4-14**] History of Present Illness: 68 y/o female w/ h/o HTN, ^Chol, DM, CHF w/ cc of SOB and recent +ETT. Referred for cardiac cath which revealed 2 vessel disease. Past Medical History: Hypertension Hypercholesterolemia Diabtes Mellitus Congestive Heart Failure GERD Colon CA s/p coloectomy on 5FU and leucovorin Anemia DJD-neck h/o GI Bleed (negative EGD/colonoscopy) Thrombophlebitis R Leg Anxiety s/p C-sectionx4 s/p Cataract surgery s/p T&A Social History: Lives w/ husband. -ETOH/Tobacco She is a retired teacher who lives with her husband and cat. She denies alcohol or smoking history. Family History: non-contributory Physical Exam: VS: 57SR 119/70 20 100%2L 5'[**77**]" 130lbs General: Lying in Bed, NAD Neuro: A&Ox3, MAE, Follows commands, non-focal HEENT: PERRLA, EOMI Neck: Supple, -JVD, -Bruits, Wears soft collar for DJD Chest: CTAB -w/r/r Heart: RRR +S1S2 -c/r/m/g Abd: Soft NT/ND/NABS well-healed midline incision Ext: Warm, well-perfused -c/c/c Pulses: Carotids/Radials/Fem Bilat. 2+, DP 1+ Pertinent Results: [**2173-4-14**] 11:33AM BLOOD WBC-4.2 RBC-2.43*# Hgb-7.4*# Hct-21.8*# MCV-90 MCH-30.5 MCHC-33.9 RDW-13.7 Plt Ct-93*# [**2173-4-20**] 05:19AM BLOOD WBC-11.6* RBC-3.71* Hgb-11.0* Hct-33.2* MCV-90 MCH-29.6 MCHC-33.1 RDW-15.2 Plt Ct-284 [**2173-4-14**] 11:33AM BLOOD PT-19.7* PTT-48.7* INR(PT)-2.6 [**2173-4-17**] 03:26AM BLOOD PT-13.1 PTT-26.4 INR(PT)-1.1 [**2173-4-14**] 01:15PM BLOOD UreaN-13 Creat-0.5 Cl-108 HCO3-22 [**2173-4-18**] 03:23AM BLOOD Glucose-277* UreaN-11 Creat-0.6 Na-130* K-4.0 Cl-96 HCO3-28 AnGap-10 [**2173-4-20**] 05:19AM BLOOD Glucose-127* UreaN-13 Creat-0.7 Na-134 K-4.1 Cl-96 HCO3-30* AnGap-12 [**2173-4-15**] 12:54AM BLOOD Calcium-8.4 Phos-3.2 Mg-1.5* [**2173-4-20**] 05:19AM BLOOD Calcium-9.5 Phos-3.6 Mg-1.5* [**2173-4-14**] 09:17AM BLOOD freeCa-1.23 [**2173-4-19**] 03:06AM BLOOD freeCa-1.18 Brief Hospital Course: As mentioned in the HPI, pt. had cath on [**2173-3-17**] which revealed 2 VD (LAD 80%, LCx 80%) and was a same day admit on [**2173-4-14**] for bypass surgery. Once in the OR, pt underwent a CABGx2 after general anesthesia. Please see op note for full surgical report. Pt tolerated the procedure well with a total bypass time of 38 minutes and cross clamp time of 21 minutes. She was transferred to CSRU in stable condition with a MAP of 68, CVP 4, HR of 80 A-paced and being titrated on Neo, Propofol, and an Insulin gtt. Later on op day, pt was weaned from propofol and mechanical ventilation and was successfully extubated. He was awake, alert, MAE and following commands. She remained hypotensive throughout the night and received Neo and also 1 unit PRBCs with improvement. On POD #2 chest tubes were removed. Pt. remained stable and slowly improved but still required Neo for pressure support. Diuretics started per protocol. POD #3 pt. still remained on Neo and was transfused 2 units of PRBCs (HCT 24). Insulin started at 1/2 home dose and foley removed. Pt. remained stable through POD #4, started on B-blockade and was getting OOB and ambulating well. His epicardial pacing wires and central line were removed on POD #5. His exam was unremarkable and besides extended pressure support via Neo had uncomplicated post-op course. Transferred to telemetry floor on POD #5 and on POD #6 appeared very well and at level 5. On POD#7 she was ready for discharge. Her physical exam was unremarkable besides some pedal edema. She was alittle above her pre-op wt and lasix would be continued at home. Medications on Admission: 1. Atenolol 50mg qd 2. Lisinopril 10mg qd 3. Lipitor 10mg qd 4. Insulin NPH 25 units AM 3 PM 5. RISS 6. FeSO4 7. Lorazepam 1mg PRN 8. Tylenol PRN 9. TUMS PRN Discharge Medications: 1. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 3. 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:*1* 4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 weeks. Disp:*14 Tablet(s)* Refills:*0* 5. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 7. 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* 8. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 1 weeks. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 9. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twenty Five (25) units Subcutaneous qAM: And 3 units qPM. Disp:*7 units* Refills:*2* 10. Insulin Regular Human 100 unit/mL Solution Sig: [**12-2**] units Injection once a day as needed for blood glucose: Take as directed by PCP (sliding scale based on blood glucose). Disp:*1 * Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Coronary Artery Disease s/p Coronray Artery Bypass Graft x 2 Hypertension Hypercholesterolemia Diabtes Mellitus Congestive Heart Failure GERD Colon CA s/p coloectomy on 5FU and leucovorin Anemia DJD-neck h/o GI Bleed (negative EGD/colonoscopy) Thrombophlebitis R Leg Anxiety s/p C-section s/p Cataract surgery s/p T&A Discharge Condition: Good Discharge Instructions: Can take shower. Wash incisions with warm water and mild soap. Gently pat dry. Do not take bath or swim. Do no apply lotions, creams, or ointments to incisions. Do not lift greater then 10 pounds for 2 months. Do not drive for 1 month. Make/keep all follow-up appointments. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) 70**] in 6 weeks. Follow-up with Dr. [**Last Name (STitle) 9006**] in [**11-29**] weeks. Follow-up with Dr. [**Last Name (STitle) **] in [**12-31**] weeks.

[ "250.00", "428.0", "272.0", "285.9", "530.81", "721.0", "300.00", "414.01", "V10.05", "V58.67", "401.9" ]

icd9cm

[ [ [] ] ]

[ "36.15", "99.04", "36.11", "88.72", "39.61" ]

icd9pcs

[ [ [] ] ]

5580, 5635

2280, 3881

326, 412

5996, 6002

1439, 2257

6324, 6523

1019, 1037

4089, 5557

5656, 5975

3907, 4066

6026, 6301

1052, 1420

283, 288

440, 571

593, 853

869, 1003

25,655

130,554

16940

Discharge summary

report

Admission Date: [**2180-1-12**] Discharge Date: [**2180-1-15**] Date of Birth: [**2135-1-14**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 30**] Chief Complaint: Etoh intoxication Major Surgical or Invasive Procedure: Intubation and mechanical ventilation History of Present Illness: 44 yo white male with h/o etoh abuse and CAD was found down at the [**Location (un) **] Mall. He was speaking but was slow to respond. He took an unknown amount of valium/clonipin and ETOH. His fingerstick at the time was 361. Per family pt has had a problem with alcohol on and off, pain meds since approx five years. He also abuses klonipin and valium. Family denies any history of withdrawl seizures or DTs. . On arrival to the ED, he was tachycardic (p100) and hypertensive (150/90). 4.8mg of narcan was given with little effect and he was intubated for airway protection. He also received charcoal. His BP improved to 113/56 after intubation. Past Medical History: CAD s/p anterior MI with stent to LAD- [**4-3**] at BUMC c/b pericarditis. Hypertension Hypercholesterolemia Gastroesophageal reflux disease Depression ETOH and drug abuse . PSHX: Status post right knee surgery Status panniculectomy [**2173**] Social History: ETOH and drug abuse. H/o tobacco- many years tobacco, denies current use. Moved out of mother's house last week. lives in [**Company **] now. Family History: Unknown Physical Exam: PE: t97.4, 118/63, 89, 15, 99% AC: TV 650x14, 5, 100% Unresponsive to name and rub. Intubated, large while male. PERRL 4-->3, +corneal reflex Neck supple. Nl s1/s2- but transmitted upper airway sounds make exam difficult. CTA- transmitted sounds, no rales large, soft, +bs no edema, well perfused, difficult to elicit dtrs, no [**Name2 (NI) 6954**] . Post-extubation, PE on transfer to floor: Tm- 99.6 99.6 126/73 90 23 99% RA Gen- Obese man resting on the bed. Alert and oriented. NAD. Does have difficulty giving details of the history. HEENT- NC AT. EOMI. Anicteric sclera. MMM. No lesions in the oropharynx. Cardiac- RRR. S1 S2. No m,r,g. Pulm- Faint crackles in the left base. Abdomen- Obese. Soft. NT. ND. POsitive bowel sounds. Extremities- Warm. No c/c/e. 1+ DP pulses bilaterally. Pertinent Results: Labs on admission: Tox screen: +benzos, +barbituates, +etoh (175) WBC 6, Hct 40.4, Plt 298 Na 143, K 4.7, Cl 103, HCO3 24, BUN 12, Cr 0.9, Glu 145, AG 16 Ca 9, Ph 4.3, Mg 2 ALT 64*, AST 41*, LD(LDH) 251*, AlkPhos 94, TBili 0.1 INR 2.6 CPK 368, MB 5 ABG: 7.38/43/101 .. UA: [**2180-1-12**] 07:21PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.016 [**2180-1-12**] 07:21PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG . URINE TOX benzo-POS barb-POS opiates-NEG cocaine-NEG amph-NEG mthdone-NEG . Repeat UA [**2180-1-13**]: Cloudy, straw colored, USG 1.030, Blood-SM, Nitr-NEG, Prot-NEG, Glu-NEG, Ket-NEG, Bili-NEG, Urobiln-NEG, pH-5.0, LE-NEG, RBC 141*, WBC 2, Bact NONE, Yeast NONE, Epi 0, AmorphX MOD . Cardiac enzymes: [**2180-1-12**] 05:15PM BLOOD CK(CPK)-368* CK-MB-5 cTropnT-<0.01 [**2180-1-13**] 04:22AM BLOOD CK(CPK)-250* CK-MB-3 cTropnT-<0.01 . [**2180-1-14**] ALT 36, AST 21 . Labs on discharge: WBC 11.6*, Hgb 13.1*, Hct 37.9*, MCV 92, Plt 220 Na 143, K 3.9, Cl 105, HCO3 22, BUN 11, Cr 0.7, Glu 99 Ca 8.5, Phos 3.8, Mg 1.8 . UA: Yellow, clear, USG 1.020, Blood-NEG, Nitr-NEG, Prot-NEG, Glu-NEG, Ket-TR, Bili-NEG, Urobil-NEG, pH-5.0, LE-NEG . MICRO: [**2180-1-13**]: urine cx x2 NO GROWTH . IMAGING: [**2180-1-12**] EKG: ST@100bpm, nl axis, nl intervals, evidence of old anterior mi( qs v1-v3), poor r-wave progression, precordial Ts- more upright than previous- compared to [**5-3**] . [**2180-1-12**] CXR: ET tube is in standard placement. Nasogastric tube passes to the lower stomach and out of view. Lungs are low in volume but clear. Pulmonary vasculature is engorged. Mediastinal widening is probably due to combination of supine positioning, vascular engorgement and fat deposition. The radiographic appearance is not concerning. There is no pleural effusion or indication of pneumothorax. . [**2180-1-12**] CXR: There is an endotracheal tube with the tip located at the level of the medial clavicles. The heart size appears within normal limits. The mediastinum may be widened. The hilar regions are not fully seen. The pulmonary vasculature appears within normal limits. There are curvilinear opacities adjacent to the left side of the aortic arch as well as adjacent to the right mediastinum, which could represent atelectasis. No pneumothorax is seen. There are no pleural effusions. The osseous structures appear unremarkable. IMPRESSION: Possible widening of the mediastinum. Endotracheal tube with tip at level of the medial clavicles. . [**2180-1-13**] CXR: The heart is borderline normal. The pulmonary vasculature is engorged. There are no pleural effusions. There is no pneumothorax. IMPRESSION: Low lung volumes. Mild CHF. . [**2180-1-13**] CT head: 1. No evidence of intracranial hemorrhage. 2. Sinus mucosal thickening and retention cyst. Brief Hospital Course: 44 y/o man with PMH significant for CAD s/p anteior MI, HTN, ETOH abuse, and drug abuse admitted to [**Hospital1 18**] [**2180-1-12**] with a multi drug overdose. Intubated for airway protection. . # Overdose: Mr. [**Known lastname **] presented with acute ETOH intoxication in addition to being positive for benzos and barbituates on his tox screen. He was initially intubated for airway protection, but was able to be extubated w/o complications after 24 hrs. He was given a banana bag for IVF in the [**Hospital Unit Name 153**], as well as MVI, thiamine, and folate. He was on propofol once intubated, but when extubated, he was put on a diazepam CIWA scale and monitored closely for signs of withdrawal and/or DTs. He was seen by social work for addictions consult, but the patient states that he preferred to follow-up with his EtOH abuse group at [**Hospital 882**] Hospital. . # CAD: Mr. [**Known lastname **] has a significant history of CAD s/p MI and stent to his RCA. He remained CP free throughout his admission and was continued on his cardiac regimen, including ASA, beta blocker, ACE-i, and statin. Cardiac enzymes were checked x2 as his CK was elevated, but troponins and CK-MB remained flat, at <0.01 and <5 respectively. He has been on coumadin in the past for a low EF, but because he is considered a fall risk and is still actively drinking, his coumadin was held and further recommendations as to coumadin use will be deferred to his outpatient PCP. . # Hypercholesterolemia: He was continued on lipitor and zetia. . # Hematuria: Mr. [**Known lastname **] developed hematuria, with significant RBCs on his UA. It was most likely secondary to foley trauma. A UA was repeated on [**1-15**] once the foley catheter had been removed and it showed resolution of his hematuria. . # Elevated LFTs: Mr. [**Known lastname **] had elevated transaminases on admission, felt to be secondary to either his EtOH use (although AST << ALT) or from his statin. His transaminitis was transient, however, and his LFT's had normalized by discharge. . # Elevated CK: Mr. [**Known lastname **] was found to have an elevated CK on admission, likely due to muscle injury after being found down. Troponins were also checked and were negative, so it was an isolated CK elevation. His CK trended down during his admission. . # Seizure history: He was continued on his outpatient dose of depakote. . # Psych hx: He was continued on sertraline, mirtazapine at his outpatient doses. . # HTN: He was continued on his beta blocker and ACE-i. . # FEN: He was given a regular, cardiac diet. IVF while in the [**Hospital Unit Name 153**], stopped once he was tolerating adequate POs. Electrolytes were checked regularly and repleted prn. . # PPX: SC heparin; Bowel regimen; PPI; CIWA scale; Fall precautions. . # Code: Full . # Dispo: To his mother's home, with f/u at [**Hospital 882**] Hospital. . Medications on Admission: 1. ASA 325 mg daily 2. Atenolol 100 mg daily 3. Lisinopril 20 mg daily 4. Lipitor 80 mg daily 5. Zetia 10 mg daily Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Mirtazapine 15 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 5. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO TID (3 times a day). 7. Sertraline 100 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. Ibuprofen 400 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for knee pain. 9. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 11. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: EtOH intoxication and withdrawal Altered mental status Coronary artery disease Transaminitis Discharge Condition: Stable, tolerating PO's. Discharge Instructions: Follow-up with your PCP at [**Name9 (PRE) 882**] Hospital. All medications as prescribed. Return if you have any fevers, or any new concerning symptoms. Refrain from using alcohol. Followup Instructions: With your PCP at [**Name9 (PRE) 882**] Hospital. With your support group at [**Hospital 882**] Hospital

[ "599.7", "V45.82", "291.81", "E850.2", "530.81", "414.01", "965.09", "305.01", "412", "401.9", "305.41" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

9407, 9413

5204, 8095

332, 372

9550, 9577

2338, 2343

9806, 9913

1502, 1511

8260, 9384

9434, 9529

8121, 8237

9601, 9783

1526, 2319

3130, 3295

274, 294

3314, 5079

400, 1059

5088, 5181

2357, 3113

1081, 1326

1342, 1486

24,029

163,575

20551

Discharge summary

report

Admission Date: [**2165-4-26**] Discharge Date: [**2165-5-3**] Date of Birth: [**2091-6-24**] Sex: F Service: CSU HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This is a 73-year-old female who has known mitral valve prolapse since [**2158**] and has begun to experience increasing fatigue and shortness of breath times 3 months. The patient was seen by her cardiologist, Dr. [**Last Name (STitle) 25833**] and had an echocardiogram which revealed 2 plus AI, moderate mitral valve prolapse with a torn chorda and a flail leaflet, 4 plus mitral regurgitation, and [**1-22**] plus tricuspid regurgitation. The patient had a cardiac catheterization on [**3-13**] which showed severe mitral regurgitation, normal left ventricular function, and no coronary artery disease. The patient was referred to Dr. [**Last Name (Prefixes) **] for mitral valve repair. PAST MEDICAL HISTORY: 1. Mitral valve prolapse, mitral regurgitation. 2. Glaucoma. 3. Status post left total hip replacement in [**2161**]. 4. Status post bilateral vein stripping in [**2124**]. PREOPERATIVE MEDICATIONS: 1. Timolol eye drops. 2. Enteric-coated aspirin 81 mg po qd 3. Multivitamin 4. Citracal. ALLERGIES: NKDA. LABORATORY DATA: The patient had a carotid ultrasound preoperatively which showed no significant carotid or vertebral artery disease. HO[**Last Name (STitle) **] COURSE: The patient was admitted [**2165-4-26**] and taken to the operating room with Dr. [**Last Name (Prefixes) **] for a mitral valve repair with resection of flail segment of the posterior leaflet and placement of a 28 mm [**Doctor Last Name 405**] annuloplasty band. Please see operative note for full details. Total cardiopulmonary bypass time 65 minutes. Cross clamp time 45 minutes. The patient was transported to the intensive care unit in stable condition. Shortly after arrival in the intensive care unit, the patient developed rapid atrial fibrillation. Cardioversion was attempted times 2 unsuccessfully. The patient was loaded with amiodarone, and again cardioverted to sinus bradycardia and was atrially paced. The patient's hemodynamics during this time were stable. The patient was weaned and extubated from mechanical ventilation on the first postoperative day with an adequate cardiac index. On postoperative day 1, the patient's hematocrit was 24.3. She was transfused 1 unit of packed red blood cells. On postoperative day 2, the patient again developed atrial fibrillation. An electrophysiology consult was obtained. As the patient's atrial fibrillation was alternating with sinus bradycardia and junctional rhythm, electrophysiology recommended low-dose oral amiodarone and slow addition of low- dose beta blocker. As patient had had multiple episodes of bradycardia, they recommended following patient closely. There was also concern at the time as the patient had developed some elevated filling pressures that the patient might possibly have a pericardial effusion and therefore, an echocardiogram was obtained which showed preserved left ventricular ejection fraction, no mitral regurgitation, no pericardial effusion. The patient's chest tubes remained in as they continued to have a high amount of output. Also, on postoperative day 2, a chest x-ray showed that the patient had right lower lobe atelectasis and collapse. The patient underwent aggressive chest physiotherapy with subsequent chest x-ray showing significant improvement. The patient continued to have episodes of rapid atrial fibrillation alternating with sinus bradycardia. The patient tolerated these episodes well. On postoperative day 2, the patient's chest tubes were removed without incident. The patient began working with physical therapy. On[**Last Name (STitle) 14810**]perative day 5, the patient was transferred from the intensive care unit to the regular part of the hospital. Upon arrival to the floor, the patient was in sinus bradycardia, and evening of postoperative day 5 the patient was noted to have sinus bradycardia to the 40s. At this time, the Lopressor and amiodarone were discontinued. Electrophysiology was again consulted and recommended holding both the Lopressor and the amiodarone. Over the course of the next day, the patient's heart rate increased into the 50s and 60s at rest and increasing to the 80s with ambulation. A discussion was had with electrophysiology at this time. The decision was made to hold the amiodarone and the Lopressor, and discharge the patient to home with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor to monitor for any signs of atrial fibrillation. The patient had been started on Coumadin, and after 2 doses of Coumadin the patient's INR had risen to 2.8. This was discussed with Dr. [**Last Name (Prefixes) **], and as the patient had been in sinus rhythm-sinus bradycardia for several days, the decision was made to hold the anticoagulation with the [**Doctor Last Name **] of Hearts monitor. If the patient had any further atrial fibrillation , the anticoagulation would be restarted. The patient's pacing wires had been removed without incident, and the patient ambulated with physical therapy, and by postoperative day 6, the patient had been cleared for discharge to home. The patient was discharged to home on postoperative day 7. DISCHARGE CONDITION: T-max 98.3, pulse 56, sinus bradycardia, blood pressure 127/78, respiratory rate 16, room air oxygen saturation 96%. White blood cell count 9.0, hematocrit 27.5, platelet count 215, potassium 4.7, BUN 18, creatinine 0.8. The patient's weight on [**5-3**] was 63.9 kg. The patient weighed 60 kg preoperatively. Chest x-ray on [**5-2**] showed no CHF and a small right effusion and a mildly elevated left hemidiaphragm. Neurologically, the patient is awake, alert, oriented x 3. Cardiovascular - regular rate and rhythm without rub or murmur. Respiratory - breath sounds are clear bilaterally. GI - positive bowel sounds, soft, nontender, nondistended, tolerating a regular diet. Sternal incision - Steri-Strips are intact. Incision is clean and dry. There is no erythema. No drainage. Extremities - trace edema. DISCHARGE DIAGNOSES: 1. Mitral valve prolapse/mitral regurgitation. 2. Status post mitral valve repair. 3. Postoperative atrial fibrillation . 4. Postoperative sinus bradycardia. DISCHARGE MEDICATIONS: 1. Lasix 20 mg po qd times 7 days. 2. Potassium chloride 20 mEq po qd times 7 days. 3. Colace 100 mg po bid. 4. Protonix 40 mg po qd. 5. Dilaudid 2 mg po q 6 h prn. 6. Motrin 400 mg po q 6 h. 7. Enteric-coated aspirin 81 mg po qd. DISCHARGE STATUS: The patient is to be discharged to home in stable condition. The patient is to have [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor for 2 weeks with asymptomatic daily recordings transmitted, as directed, to be read by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73**]. FO[**Last Name (STitle) 996**]P: 1. The patient is to follow-up with her cardiologist, Dr. [**Last Name (STitle) 25833**], in [**12-21**] weeks. 2. The patient is to follow-up with Dr. [**Last Name (Prefixes) **] in [**2-21**] weeks. [**Doctor Last Name **] [**Last Name (Prefixes) **], MD 2351 Dictated By:[**Last Name (NamePattern4) 8524**] MEDQUIST36 D: [**2165-5-3**] 13:18:42 T: [**2165-5-3**] 15:21:03 Job#: [**Job Number **]

[ "428.0", "424.0", "518.0", "997.1", "427.31", "365.9", "427.89", "V43.64", "E878.8" ]

icd9cm

[ [ [] ] ]

[ "96.71", "88.72", "89.64", "38.93", "89.62", "99.07", "99.04", "99.62", "39.61", "38.91", "96.04", "96.07", "35.12" ]

icd9pcs

[ [ [] ] ]

5360, 6182

6203, 6364

6387, 7437

1105, 5338

904, 1079

14,389

115,608

24364

Discharge summary

report

Admission Date: [**2182-4-24**] Discharge Date: [**2182-4-29**] Date of Birth: [**2126-2-28**] Sex: FEMALE Service: CARDIOTHORACIC SURGERY HISTORY OF PRESENT ILLNESS: This is a 56-year-old woman, with a history of tetralogy of Fallot status post a left- sided Blalock-Taussig shunt at age 19 months, with subsequent transannular repair at age 16. She had no documented sustained arrhythmias. She was a patient of [**Location (un) 86**] adult congenital heart service, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], at [**Hospital3 18242**]. She was referred to Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] for RV outflow repair and evaluation of her pulmonic valve. Sh[**Last Name (STitle) **] originally by Dr. [**Last Name (Prefixes) **] in the office on [**2182-4-18**]. She had increasing symptoms of dyspnea on exertion and recent cardiac MRA showed a severe pulmonic regurgitation, mild aortic insufficiency. Her previous tetralogy of Fallot repair dilated the ascending aorta 4.3 cm and RV dilatation. Please refer to the official report date [**2182-3-5**]. She had cardiac catheterization performed on [**2182-3-28**], which showed normal coronary arteries, and was referred for RV outflow tract reconstruction and pulmonic valve replacement versus repair. MEDICATIONS: Lo/Ovral birth control pill. ALLERGIES: Bactrim; Augmentin; ketorolac producing hives. PAST MEDICAL HISTORY: 1. Tetralogy of Fallot. 2. Chronic lower back and neck pain. 3. Bell palsy 10 years ago with mild paresis of the right side of her face. 4. Question of a bleeding episode, origin undetermined. PAST SURGICAL HISTORY: Repair of tetralogy of Fallot in [**2126**] and corrective repair again in [**2142**], and tonsillectomy and adenoidectomy in [**2132**] and [**2139**]. FAMILY HISTORY: Her father had a question of a myocardial infarction at age 53. SOCIAL HISTORY: She lives with her husband. [**Name (NI) 1403**] as emergency medical services. Had no tobacco or alcohol history. No use of IV drugs. EXAM: Her heart rate was regular in rate and rhythm, a rate of 84, blood pressure 198/90 on the right and 140/90 on the left, height 5'5" tall, weight 151 pounds. No obvious lesions. She appeared her stated age and was in no apparent distress. Her EOMs were intact. Pupils were equally round, reactive to light and accommodation. Neck was supple with no thyromegaly or obvious lymphadenopathy. Chest was clear to auscultation bilaterally with a well-healed midline sternal incision with no murmur, rub or gallop, with a regular rate and rhythm, S1, S2 tones with a grade III/VI diastolic murmur, and a grade II/VI systolic murmur. Abdomen was soft, round, nontender, nondistended, with positive bowel sounds. Extremities were warm and well-perfused with no clubbing, cyanosis or edema. Right lower extremity calf had some tenderness with a negative [**Last Name (un) 4709**] sign. The patient had bilateral spider veins in the lower extremities. Cranial nerves II through XII were grossly intact with a nonfocal neuro exam. NEUROLOGIC EXAM: The patient was moving all extremities. The patient had bilateral 2+ femoral, DP, PT and radial pulses, and no carotid bruit was present. PREOP LAB WORK: White count 6.8, hematocrit 41.8, platelet count 250,000. When the patient was admitted on the 24th, preoperatively PT 12, PTT 24.0, INR 1.1. Urinalysis was negative with a trace amount of blood present. ALT 15, AST 19, alkaline phosphatase 60, total bilirubin 0.9, total protein 7.1, albumin 4.4, globulin 2.7. Additional preop labs showed sodium 140, K 3.3, chloride 106, bicarbonate 21, BUN 13, creatinine 0.9, with a blood sugar of 102. HO[**Last Name (STitle) **] COURSE: The patient obtained dental clearance prior to operation and was readmitted to our service on [**4-23**], the evening before her corrective repair. On the following morning, on [**4-24**], the patient underwent repair of a right ventricular outflow tract with reconstruction and pulmonic valve replacement with a 25 mm [**Last Name (un) 3843**]-[**Doctor Last Name **] Magna ThermaFix pericardial valve. In addition, the patient also underwent right ventriculorrhaphy by Dr. [**Last Name (Prefixes) **] and Dr. [**Doctor Last Name 61313**] of [**Hospital3 1810**] and Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] of [**Hospital3 1810**]. The patient was transferred to cardiothoracic ICU in stable condition on a propofol drip of 20 mcg/kg/min and a Neo-Synephrine drip of 0.3 mcg/kg/min. On the day of operation, the patient had been extubated by 6:30 in the evening, and was awake and alert on a nitroglycerin drip. Gentle diuresis was begun. On postoperative day 1, the patient remained on nitroglycerin drip at 1.25 mcg/kg/min. Sternum was stable. Heart was regular in rate and rhythm. White count 11.0, hematocrit 32, platelet count 158,000, PT 14, PTT 31, INR 1.4, BUN 9, creatinine 0.7. The patient had decreased breath sounds at bilateral lung bases. Beta blockade was begun. The patient was seen by case management and evaluated, and seen everyday by the adult congenital service from [**Hospital3 1810**], with the patient's attending, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. On postoperative day 2, the patient began aspirin. Beta blockade was increased to metoprolol 50 b.i.d. The patient was received p.o. Percocet for pain management, and was satting 98% on room air, in sinus rhythm at 77, maintaining good blood pressure of 132/83. The patient continued to receive diuresis for a weight of 87.6 kg. Lopressor was increased to 75 b.i.d. Foley was removed later in the day. The patient was encouraged to increase her activity level and was transferred out to the floor on the 26th. She was seen and evaluated by physical therapy, and continued to make excellent progress. On postoperative day 3, she spiked a temp to 101.2. Blood cultures were drawn, but the patient continued to do extremely well. She had been pancultured. The following day, had a blood pressure of 146/66, remaining in sinus rhythm. Pacing wires were removed on postoperative day 3. K was repleted at 3.8, and Lopressor was increased the following morning operating table 100 mg p.o. b.i.d., and discharge planning was begun. On[**Last Name (STitle) 14810**]perative day 4, the patient was alert and oriented, nonfocal. Lungs were clear bilaterally. Heart was regular in rate and rhythm, with a blood pressure of 126/58, satting 97% on room air. Her sternal incision was clean, dry and intact with trace peripheral edema. Her central venous line had already been removed. She continued to work with the physical therapists, and continued to improve, and was cleared for discharge on the 30th, postoperative day 5, with an unremarkable exam, and was also seen by cardiology from [**Hospital1 **] before discharge, was ambulating well, her volume status appeared stable, and she was discharged to home with visiting nurses on [**4-29**] with the following discharge instructions: To follow-up with Dr. [**Last Name (STitle) 10747**], her primary care physician, [**Last Name (NamePattern4) **] [**12-2**] weeks post discharge; follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 61710**] in [**1-3**] weeks post discharge, and follow-up with Dr. [**Last Name (Prefixes) **], her cardiac surgeon, for postop surgical visit in the office in [**2-1**] weeks. DISCHARGE MEDICATIONS: 1. Potassium chloride 20 mEq p.o. once a day for 10 days. 2. Lasix 20 mg p.o. once a day for 10 days. 3. Aspirin, enteric-coated, 81 mg p.o. once a day. 4. Percocet 5/325, 1-2 tablets p.o. p.r.n. q. 4 h. for pain. 5. Metoprolol 100 mg p.o. b.i.d. 6. Colace 100 mg p.o. t.i.d. 7. Ranitidine 150 mg p.o. b.i.d. DISCHARGE DIAGNOSES: 1. Status post right ventricular outflow tract repair with ventriculorrhaphy and pulmonic valve replacement with [**Last Name (un) 3843**]-[**Doctor Last Name **] pericardial valve. 2. Status post tetralogy of Fallot with repair in [**2126**] and corrective repair again in [**2142**]. 3. Chronic low back and neck pain. 4. Bell palsy with mild paresis of the right side of her face. Again, the patient was discharged to home in stable condition with VNA service on [**2182-4-29**]. [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2182-6-26**] 11:17:04 T: [**2182-6-26**] 12:05:30 Job#: [**Job Number 61711**]

[ "438.83", "564.00", "V15.1", "745.2", "724.2", "401.9" ]

icd9cm

[ [ [] ] ]

[ "35.25", "35.72", "35.39", "39.61" ]

icd9pcs

[ [ [] ] ]

1847, 1912

7825, 8574

7493, 7804

1676, 1830

189, 1432

3107, 7470

1454, 1652

1929, 3090

23,825

122,250

48778+48779

Discharge summary

report+report

Admission Date: [**2120-10-28**] Discharge Date: [**2120-11-2**] Service: [**Company 191**] REASON FOR ADMISSION: Hematocrit drop from 38 to 30 and maroon stools. HISTORY OF PRESENT ILLNESS: 81-year-old female with multiple medical problems, to include dementia, pulmonary fibrosis, well as a history of GI bleeding, admitted due to a hematocrit drop from 38 to 30. In [**2120-9-17**], the patient was admitted to [**Hospital1 18**] and had a hematocrit of 26 with hem-positive stool. A CT of the abdomen revealed diverticula. The patient was unable to tolerate a barium enema study. Due to her pulmonary disease, she was not felt to be a good candidate for colonoscopy. The patient received on [**2120-10-22**]. She is currently a resident of the [**Hospital3 52663**] Home and was observed this morning passing a maroon stool. Her hematocrit was found to be 30. Her systolic blood pressure decreased from 120 to 100. The patient denies abdominal pain, chest pain, shortness of breath, lightheadedness, dizziness. PAST MEDICAL HISTORY: 1. Breast cancer diagnosed 1-1/2 years ago. 2. Type 2 diabetes mellitus. 3. Anemia. 4. History of GI bleed. 5. Dementia. 6. Pulmonary fibrosis on steroids. 7. Thrombocytopenia. 8. Depression. 9. Sigmoid diverticula. 10. Urinary tract infection with MRSA. 11. Nephrolithiasis. 12. Osteoporosis. MEDICATIONS: 1. Glyburide 1.25 q.d. 2. Prednisone 10 q.o.d. 3. Faslodex 1 gram IM q.month. 4. Regular insulin, sliding scale. 5. Acidophilus. 6. Colace. 7. Protonix 40 mg a day. 8. Risperdal 0.5 mg b.i.d. 9. Iron sulfate 325 mg a day. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient is a resident at [**Hospital3 52663**] Home. FAMILY HISTORY: Positive family history of colon cancer in two cousins. PHYSICAL EXAMINATION: GENERAL: Elderly female calling out "[**Doctor First Name **]". HEENT: Ecchymosis of her left eye. PERRL. EOMI. Mucous membranes moist. Oropharynx clear. NECK: Supple. No carotid bruits. CVS: Regular rate and rhythm, normal S1 and S2. No murmurs, rubs or gallops. Lungs clear to auscultation bilaterally. Abdomen soft, nontender, nondistended. Positive bowel sounds. No hepatosplenomegaly. EXTREMITIES: 2+ lower extremity edema. 2+ DP pulses. RECTAL: Per E.D., brown with flecks of blood. NEURO: Alert and oriented to self. Cranial nerves II - XII grossly intact. Moves all extremities. LABORATORY DATA: On admission white count was 6, hematocrit of 30, platelet count of 87. Chem-7 showed a sodium of 140, potassium of 4, chloride of 105, bicarb 25, BUN 18, creatinine 0.7, glucose 173. PT was 13.7, PTT was 26.2, INR was 1.3. HOSPITAL COURSE: The patient was admitted to [**Company 191**] for further management. She was transfused 2 units of packed red blood cells on [**2120-10-28**]. She tolerated the transfusion without incident. Post-transfusion, her hematocrit increased to 39.8. Outside lab results indicated that the patient has a normal EPO level. She was found to be H. pylori positive and was started on a 2-week course of pantoprazole, amoxicillin, and clarithromycin. The patient was seen by the GI consult service. It was decided that the patient would undergo colonoscopy. She was administered Golytely per NG tube times two days. On [**2120-11-1**], the patient underwent colonoscopy. Colonoscopy results showed polyps in the cecum. The patient underwent biopsy and polypectomy. The GI service recommended that the patient undergo repeat colonoscopy in three to six months. She should avoid anticoagulants such as aspirin, NSAIDs, and Coumadin for ten days following discharge. She should also continue on a PPI. Her INR should be maintained less than 1.3, and her platelet count should be monitored. During her hospitalization, the patient continued on her prednisone 10 mg q.o.d. for her pulmonary fibrosis. For her dementia, her Risperdal was increased (the p.m. dose) from 0.5 to 0.75. She continued to take 0.5 mg in the morning. The patient's glyburide was held and she was maintained on a regular insulin sliding scale. The rest of her hospitalization will be covered in an additional discharge summary. DIAGNOSIS: 1. GI bleed due to colonic polyps. 2. Diabetes, type 2. 3. Dementia. 4. Pulmonary fibrosis. 5. Thrombocytopenia. 6. UTI with MRSA. 7. Breast cancer. [**First Name11 (Name Pattern1) 2671**] [**Last Name (NamePattern4) 2672**], M.D. [**MD Number(1) 2673**] Dictated By:[**Last Name (NamePattern1) 5092**] MEDQUIST36 D: [**2120-11-2**] 13:58 T: [**2120-11-2**] 13:56 JOB#: [**Job Number 46069**] Admission Date: [**2120-10-28**] Discharge Date: [**2120-11-15**] Service: [**Company 191**] Please note a dictation exists for the first few days of this admission, however, given the complexity and extended course of this hospitalization, this dictation will cover the time period between [**2120-10-28**] until discharge on [**2120-11-15**]. REASON FOR ADMISSION: Hematocrit drop from 38 to 30 and maroon stools. HISTORY OF PRESENT ILLNESS: The patient is an 81 year-old female with multiple medical problems (see below), including dementia, diabetes type 2, breast cancer, pulmonary fibrosis and a history of intermittent GI bleeding, is admitted due to patient was admitted to [**Hospital1 69**] and had a hematocrit of 26 with heme positive stool. A CAT scan of the abdomen at that time revealed diverticulosis. The patient was unable to tolerate a barium enema study. Due to her pulmonary disease she was not felt to be a good candidate for a colonoscopy. The patient received transfusions as an outpatient with hematocrit increased to 38 on [**2120-10-22**]. She is currently a resident of [**Hospital3 41599**] Home and was observed on the day of admission to passing maroon stool. Her hematocrit was found to be 30. Her systolic blood pressure had decreased from 120 to 100. The patient denied abdominal pain, chest pain, shortness of breath, lightheadedness, dizziness. PAST MEDICAL HISTORY: 1. Breast cancer diagnosed [**2119-10-19**]. Tamoxifen treatment initiated. Was noted to be an excisional candidate, however, given improvement and Tamoxifen, a noninvasive measures were pursued. Left breast mass has been stable as of her last CAT scan in [**2120-10-18**]. She is status post Femora treatment. Her CEA in [**2119-12-19**] was 89, in [**2120-9-17**] was 15. Her CA125 was 15 in [**2119-12-19**]. Her CA 27.29 was 29 in [**2109-12-18**] and 92 in [**2120-9-17**]. 2. Type 2 diabetes mellitus. 3. Anemia iron deficiency and anemia of chronic disease. 4. History of gastrointestinal bleeds. 5. Diverticulosis. 6. Dementia, Alzheimer's. 7. Hypersensitivity pneumonitis with subsequent pulmonary fibrosis on Prednisone and oxygen. 8. Thrombocytopenia, admission [**2120-9-17**]. 9. Depression. 10. Urinary tract recurrent infections recently with MRSA. 11. Nephrolithiasis. 12. Osteoporosis. 13. Status post total hysterectomy and bilateral salpingo-oophorectomy. 14. Esophagogastroduodenoscopy with tertiary contractions and spasms of esophagus. 15. History of right humeral fracture. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Glyburide 1.25 mg q.d. 2. Prednisone 10 mg q.o.d. 3. Regular insulin sliding scale. 4. Acidophilus. 5. Colace. 6. Protonix 40 mg a day. 7. Risperdal 0.5 mg b.i.d. 8. Iron sulfate 325 mg a day. SOCIAL HISTORY: The patient is a resident of [**Hospital3 52663**] Home. No tobacco use. No alcohol use. FAMILY HISTORY: Positive family history of colon cancer in two cousins. PHYSICAL EXAMINATION ON ADMISSION: General, elderly female calling out "[**Doctor First Name **]." HEENT ecchymosis of her left eye. Pupils are equal, round and reactive to light. Extraocular movements intact. Mucous membranes are moist. Oropharynx clear. Neck supple, no carotid bruits. Cardiovascular regular rate and rhythm. Normal S1 and S2. No murmurs, rubs or gallops. Pulmonary clear to auscultation bilaterally. Abdomen soft, nontender, nondistended, normoactive bowel sounds, no hepatosplenomegaly. Extremities 2+ lower extremity edema. 2+ dorsalis pedis pulses. Rectal per Emergency Department brown with flecks of blood. Neurological alert and oriented to self. Cranial nerves II through XII are grossly intact. Moving all extremities. LABORATORY DATA ON ADMISSION: White blood cell count 6, hematocrit 30, platelets count 87, chem 7 showed a sodium of 140, potassium 4, chloride 105, bicarbonate of 25, BUN 18, creatinine 0.7, glucose 173. PT was 13.7, PTT 26.2, INR 1.3. ASSESSMENT: The patient is an 81 year-old female with dementia, breast cancer, diabetes type 2, pulmonary fibrosis, admitted with recurrent lower gastrointestinal bleed. Her hospital course was complicated by discovery of a large colonic mass found to be adenocarcinoma of the colon. Also complicated by removal of bleeding polyps in the cecum. Polypectomy was complicated by rebleed requiring repeat colonoscopy for injection and clipping. This was followed by interventional radiology embolization of ileocolic artery. Also hospital course complicated by need for transfusions of 21 units of packed red blood cells since [**2120-10-18**]. Course also complicated by MRSA bacteremia and multidrug resistant Klebsiella urinary tract infection. Course also complicated by congestive heart failure secondary to massive blood product requirement. Also complicated by disseminated intravascular coagulopathy. HOSPITAL COURSE: 1. Lower gastrointestinal bleed: Gastrointestinal Service was consulted for this admission. [**11-1**] colonoscopy biopsy demonstrated fragments of adenoma with focal high grade dysplasia. [**11-5**], repeat colonoscopy demonstrated bleeding at the cecum that was controlled with epinephrine and clipping. A mass was also noted at the ascending colon with a biopsy consistent with adenocarcinoma. Biopsy also demonstrated bleeding from the previous polypectomy sites. [**11-7**] interventional radiology consulted for possible embolization. Contrast radiography demonstrated active extravasation originating from a third order branch arising off the SMA, a branch of the ileocolic artery. This was successfully embolized with a 3 mm coil and two 2 cm straight coils. Follow up angiography showed no active extravasation. The procedure was complicated by a drop coil down the right leg arterial system with no further sequela. The patient was given a fourteen day course of Flagyl for potential ischemic colitis secondary to massive epinephrine use. The patient had two mild episodes of hematochezia subsequent to her embolization. Her hematocrit, however, remained stable and was 33.7 on [**11-13**]. The patient's post procedural course was complicated by abdominal pain that was presumed secondary to the multiple abdominal manipulations during this admission. A KUB was unrevealing on [**11-14**] as were liver function tests and amylase studies. After discussion with her family, it was decided to focus care on comfort, with no futher replacement of blood products, minimal lab draws, and continuation of IV antiboitics as long as she maintained IV access; if access was lost, it would not be replaced. 2. Disseminated intravascular coagulopathy: Likely secondary to multiple infections (see below) and underlying malignancies. Treated with aggressive antibiotics and blood product support. Status post 5 units of platelets transfused, status post 7 units of fresh frozen platelets transfused. No evidence of active bleeding by the day of discharge. Platelets on admission were 87 and stable on [**11-13**] at 59. The patient's INR was 1.3 on admission and 1.4 on [**11-13**]. Fibrinogen was 84 on [**11-13**]. 3. MRSA bacteremia: The patient had a low grade temperature on [**11-7**]. Otherwise hospital was afebrile. Blood cultures for this admission are [**11-5**] no growth times two bottles. [**11-6**] MRSA times two bottles. [**11-8**], no growth times four bottles. [**11-11**] and [**11-12**] no growth to date times four bottles. The patient was started on Vancomycin and resumed on this medication secondary to positive blood cultures on [**11-6**]. Surveillance cultures have been negative times six bottles since. A PICC line was placed on [**11-13**]. The patient is day number ten of fourteen on [**11-15**]. Blood cultures should be rechecked times two on day thirteen or fourteen. If they are negative then Vancomycin should be discontinued. If there is any evidence of MRSA then the patient should complete an additional two week course. 4. Klebsiella urinary tract infection: The patient has a history of recurrent urinary tract infections and yeast colonization. A urinalysis was unrevealing on [**11-5**] and culture demonstrated moderate yeast. On [**11-8**] multidrug resistant Klebsiella species greater then 100,000 was demonstrated on urine culture. The patient was started on Imipenem and completed a seven day course with repeat urine cultures on [**11-12**] with no growth final. Foley catheter was replaced on [**11-14**]. 5. Pain secondary to multiple abdominal procedures: The patient was maintained on morphine sulfate at .5 to 2 mg intravenous q 2 hours prn pain. 6. Anemia secondary to lower gastrointestinal bleed: Also has iron deficiency and anemia of chronic disease. Blood product transfusions as above. 7. Congestive heart failure: In [**2118-9-18**] the patient had abnormal echocardiogram with a preserved ejection fraction. Her hospital course this admission was complicated by congestive heart failure in the setting of massive blood product requirement with subsequent increase supplemental oxygen requirement. The patient was diuresed appropriately and euvolemic by the day of discharge. 8. Atypical chest pain: [**11-11**] the patient's CK equaled 60, troponin equaled less then 0.3. No electrocardiogram changes. Atypical pain felt to be secondary to multiple abdominal procedures. 9. Pulmonary: Pulmonary fibrosis, maintained on prednisone. Supplemental O2 requirement 4 liters nasal cannula. 10. Diabetes mellitus: Glyburide was held on this admission. She was maintained on regular insulin sliding scale. 11. Sacral pressure ulcer: Pressure dressings applied. 12. Dementia: Per the family's report it was slightly worse then baseline on this admission and continued at the time of discharge. The patient's Risperdal was increased from .5 mg po b.i.d. to 1 mg po b.i.d. Much of her agitation and dementia on this admission was felt to be secondary to the setting of hospitalization including multiple procedures and an Intensive Care Unit stay. 13. Fluids, electrolytes and nutrition: The patient was tolerating a regular diet on the day of discharge. Chem 7 demonstrated a sodium of 140, potassium of 4.0, creatinine of 0.6, BUN 11, calcium 8.0, magnesium of 1.9 on [**2120-11-13**]. 14. Code status: The patient is DNR/DNI, no pressors. CONDITION ON DISCHARGE: Stable. DISCHARGE DIAGNOSES: 1. Lower gastrointestinal bleed, status post two colonoscopies, status post cecal polypectomy, status post ileocolic artery embolization. 2. Colonic adenocarcinoma. 3. Diverticulosis. 4. Disseminated intravascular coagulopathy secondary to infection/malignancy. 5. MRSA bacteremia (on Vancomycin, surveillance cultures negative times six bottles). 6. Klebsiella urinary tract infection (status post seven day course of Imipenem). 7. Congestive heart failure (preserved EF secondary to volume overload. 8. Anemia. 9. Breast cancer. 10. Diabetes mellitus. 11. Dementia. 12. Pulmonary fibrosis. 13. DNR/DNI code status. MEDICATIONS ON DISCHARGE: 1. Vancomycin 100 mg intravenous q 24 hours ([**11-15**] is day number 10 of 14). 2. Flagyl 500 mg intravenous q 8 hours ([**11-15**] is day number 10 of 14). 3. Risperidone 1 mg po b.i.d. 4. Senna two tabs po q day. 5. Morphine sulfate 0.5 to 2 mg intravenous q 12 hours prn pain. 6. Protonix 40 mg po or intravenous q 24 hours. 7. Prednisone 10 mg po q.o.d. 8. Acetaminophen 500 to 1000 mg po q 4 to 6 hours prn pain. 9. Regular insulin sliding scale (finger sticks between 61 to 250, do nothing. Start insulin at finger sticks greater then 250). 10. Iron sulfate 325 mg po q day. DISPOSITION: The patient will be discharged to a new extended care facility, [**Hospital3 537**], as her previous facility would not take her back. DISCHARGE INSTRUCTIONS: 1. Continue antibiotics through PICC line. Includes Vancomycin and Flagyl as above. 2. Supplemental oxygen via nasal cannula to keep O2 sat greater then 90%. 3. Regular insulin sliding scale, see page one. Also insulin not to be used unless finger sticks greater then this medication. 4. Check temperature daily and monitor for signs and symptoms of infection. 5. Wound care along her sacrum pressure ulcer. 6. Foley catheter care. 7. Regular diet. 8. Bacitracin application to left forearm wound. 9. Morphine sulfate as needed for pain/distress. CODE STATUS: DNR/DNI no pressors. Will not hospitalize again. FAMILY CONTACT: The patient's daughter [**Name (NI) **] telephone number [**Telephone/Fax (1) 102517**], the patient's son [**Name (NI) **] [**Telephone/Fax (1) 102518**]. [**First Name11 (Name Pattern1) 2671**] [**Last Name (NamePattern4) 2672**], M.D. [**MD Number(1) 2673**] Dictated By:[**Doctor Last Name 25109**] MEDQUIST36 D: [**2120-11-15**] 07:24 T: [**2120-11-15**] 09:41 JOB#: [**Job Number 102519**]

[ "599.0", "280.0", "515", "790.7", "286.6", "428.0", "578.9", "998.11", "153.8" ]

icd9cm

[ [ [] ] ]

[ "88.47", "45.42", "99.29", "45.25", "39.79", "38.93", "96.33", "45.43" ]

icd9pcs

[ [ [] ] ]

7603, 7681

15126, 15758

15785, 16538

7267, 7477

9593, 15071

16563, 17650

1818, 2673

5104, 6049

8454, 9575

6072, 7240

7494, 7586

15096, 15105

66,311

138,253

54762

Discharge summary

report

Admission Date: [**2157-7-15**] Discharge Date: [**2157-7-21**] Date of Birth: [**2070-10-18**] Sex: F Service: MEDICINE Allergies: IV Dye, Iodine Containing Contrast Media Attending:[**First Name3 (LF) 2901**] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: left heart catheterization History of Present Illness: HISTORY OF PRESENTING ILLNESS: Ms. [**Known lastname 13304**] is an 86 y/o female with a history of chronic afib (refusing warfarin) and stable angina who presented to [**Hospital6 8283**] on [**7-13**] with 3-4 days of progressive cough and shortness of breath. She also had some left sided chest discomfort that was associated with exertion. At the OSH her EKG was reportedly normal however troponin trend was 0.04>0.18>0.08. Chest X-ray showed findings concerning for pneumonia and she was started on levofloxacin. An echo done on [**2157-7-14**] revealed an LV thrombus and EF 27% (prior 62% on Persantine ST [**2157-4-28**]). Thus, the patient was transferred to [**Hospital1 18**] for cardiac catheterization. Vital Signs prior to transfer were Temp 98.1, BP 118/84, HR afib 80-90's at rest, 130-140's with stimulation, RR 22-24, O2sat 95-98% on 2L NC. . When she arrived to the cath lab she was noted to be very dyspneic and was felt to be volume overloaded. She was transferred to the CCU for further management and diuresis. . On arrival to the floor, patient was comfortable and in NAD. She notes that she is feeling better. She denied having any pain. She notes that her breathing has improved. . REVIEW OF SYSTEMS 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, 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 paroxysmal nocturnal dyspnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: PAST MEDICAL HISTORY: 1. CARDIAC RISK FACTORS: + Diabetes, Dyslipidemia, + Hypertension 2. CARDIAC HISTORY: -CABG: -PERCUTANEOUS CORONARY INTERVENTIONS: -PACING/ICD: 3. OTHER PAST MEDICAL HISTORY: -longstanding angina typically brought on by mod-heavy exertion and relieved by sl NTG or rest -chronic afib (declines warfarin) -Borderline T2DM (diet-controled) -HTN -s/p umb hernia repair -s/p bowel obstruction resulting in colectomy/colostomy/reversal 7 yrs ago . Social History: She lives with her husband who has [**Name (NI) 2481**]. She functions independently -Tobacco history: negative -ETOH: negtive -Illicit drugs: negative Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Admission GENERAL: patient was comfortbale and in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 12 cm. CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: Crackles noted bilaterally throughout lungs, no wheezes or rhonchi ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ Neuro: CN2-12 intact, 5/5 strength bilaterally both upper and lower extremities Discharge: GENERAL: NAD, NT/ND sitting at bedside. HEENT: NCAT. Sclera anicteric. EOMI. NECK: Supple with JVP of [**6-16**] cm. CARDIAC: irregularly irregular, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: Rales R >> L, worse at bases, no rhonchi, wheeze. No amu, speaks in full sentences. ABDOMEN: Soft, NTND. No HSM or tenderness. ? seroma palpable. EXTREMITIES: Hematoma improved since yesterday and less painful to touch. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Difficult to assess accurately with TEDs, but DPs equal. Neuro: Fluent, appropriate, linear and prompt. Moves all 4 freely without apparent weakness or tremor. Pertinent Results: [**2157-7-15**] 02:00PM PT-13.9* INR(PT)-1.3* [**2157-7-15**] 07:55PM PT-13.2* PTT-30.8 INR(PT)-1.2* [**2157-7-15**] 07:55PM PLT COUNT-206 [**2157-7-15**] 07:55PM WBC-9.3 RBC-4.62 HGB-14.5 HCT-42.1 MCV-91 MCH-31.5 MCHC-34.5 RDW-13.9 [**2157-7-15**] 07:55PM CALCIUM-8.8 PHOSPHATE-2.7 MAGNESIUM-1.8 [**2157-7-15**] 07:55PM estGFR-Using this [**2157-7-15**] 07:55PM estGFR-Using this [**2157-7-15**] 07:55PM GLUCOSE-151* UREA N-22* CREAT-1.0 SODIUM-139 POTASSIUM-3.3 CHLORIDE-99 TOTAL CO2-29 ANION GAP-14 Discharge [**2157-7-21**] 07:22AM BLOOD WBC-11.8* RBC-3.72* Hgb-11.6* Hct-33.5* MCV-90 MCH-31.0 MCHC-34.5 RDW-13.9 Plt Ct-323 [**2157-7-18**] 02:06AM BLOOD Neuts-65.2 Lymphs-26.1 Monos-6.3 Eos-2.1 Baso-0.3 [**2157-7-21**] 07:22AM BLOOD Plt Ct-323 [**2157-7-21**] 07:22AM BLOOD Glucose-132* UreaN-41* Creat-1.1 Na-128* K-3.9 Cl-88* HCO3-30 AnGap-14 [**2157-7-21**] 07:22AM BLOOD CK(CPK)-988* [**2157-7-20**] 03:55PM BLOOD CK(CPK)-1366* [**2157-7-20**] 07:07AM BLOOD CK(CPK)-1282* [**2157-7-19**] 09:00PM BLOOD CK(CPK)-1130* [**2157-7-20**] 07:07AM BLOOD CK-MB-6 cTropnT-<0.01 [**2157-7-15**] 07:55PM BLOOD CK-MB-6 cTropnT-0.07* [**2157-7-21**] 07:22AM BLOOD Calcium-9.3 Phos-3.7 Mg-2.1 [**2157-7-16**] 05:41AM BLOOD %HbA1c-6.7* eAG-146* [**2157-7-16**] 05:41AM BLOOD TSH-7.6* Brief Hospital Course: Ms. [**Known lastname 13304**] is an 86 y/o female with a history of chronic afib and stable angina who presented to [**Hospital6 8283**] on [**7-13**] with 3-4 days of progressive cough and shortness of breath and new dilated cardiomyopathy transferred to [**Hospital1 18**] for consideration for catheterization noted to be volume overloaded. ACUTE ISSUES # Acute Systolic Heart Failure: She had a reported EF of 60% on [**2157-4-28**] which was 27% on TTE done at OSH. With her chronic angina, we suspected coronary artery disease as likely etiology. The differential also included infectious cardiomyopathy, toxic cardiomypathy, endocrine dysfunction and stress induced cardiomypathy. Patient was initially diuresed with lasix and metolazone and put out adequate urine. She was transiently hypotensive so further diuresis was held. Given there was a troponin leak at the OSH (and small elevation initially here), a cardiac cath was considered to look for CAD as the trigger for her CHF. However, there was concern in regards to viability of her left ventricle, and also as to whether there was a thrombus present so a cardiac MRI was obtained. This study found no LV thrombus and did find viable cardiac tissue. She was then prepped for cath with IV steroids and benadryl given her previous contrast allergy. Her cath results from [**2157-7-19**] showed no coronary disease, etiology of acute CHF likely stress cardiomyopathy/embolism from A fib to coronary/myocarditis. With improved EF improved 40% making stress cardiomyopathy the likely etiology of her actue CHF The patient went home on Lisinopril Metoprolol XL . She was given 5 pills of 20 mg lasix IN CASE she starts gaining weight in the interim before her follow up appointment with Dr. [**Last Name (STitle) 10543**]. #R lower ext pain: Pt began complaining of R LE pain after transfer to the floor. She described it as diffuse and worse upon lifting her leg. Her CPK was originally 233 on [**7-18**] and uptrended to 1366 on [**7-18**]. We had initially started her on atorvastatin 80 mg daily in house, but d/ced the medication once she was symptomatic. Also taken down for LENIs and ABI and found to have completely intact arterial and venous flow. On further examination, a large right upper leg hematoma was discovered. CPK downtrended to the 500s and her heparin was d/ced. # CORONARIES: She has a history of chronic stable angina however appears to have been getting progressively worse. With slight elevation of cardiac enzymes concern for NSTEMI however no EKG changes were noted. Likely etiology of enzymes are demand in the setting of extreme volume overload. We continued aspirin 325mg daily, ACE-i, statin # RHYTHM: She has a history of atrial fibrillation which is currently rate controlled. She declined being on coumadin. CHADS2 is at least 4 with CHF, HTN, Age and diabetes. She would benefit from anticoagulation however given recent though bleed we felt that she would benefit from starting anticoagulation in an outpatient setting. # Hyponatremia: Paitent had a low Na down into 125. This resolved during hospital stay. CHRONIC ISSUES # Hypertension: was well controlled on current regimen. . # Type 2 Diabetes: Patient is apparently diet controlled. There is no A1c in our system. TRANSITIONAL ISSUES: -starting anticoagulation for AFib given CHADS2 4. -f/u on acute CHF, will likely need an echo when she follows up with her cardiologist in outpatient setting -f/u A1C -f/u thigh hematoma to see if it is resolving Medications on Admission: HOME MEDICATIONS: Metoprolol XL 50mg Isosorbide 20mg [**Hospital1 **] ASA 325mg Discharge Medications: 1. Metoprolol Succinate XL 100 mg PO DAILY RX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*3 2. Lisinopril 5 mg PO DAILY RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*3 3. Aspirin 325 mg PO DAILY RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*3 4. Furosemide 20 mg PO DAILY Only take if weight goes up 3 Kg. RX *furosemide 20 mg 1 tablet(s) by mouth daily Disp #*10 Tablet Refills:*0 Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Primary diagnosis: Acute systolic heart failure: Stress cardiomyopathy Secondary diagnoses: hyponatremia (euvolemic, high urine Osm) Hematoma to upper right medial thigh Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 13304**], It was a pleasure taking care of you during your stay at the [**Hospital1 69**]. You were transferred to the [**Hospital3 **] from [**Hospital3 4298**] because of several days of shortness of breath. It had been determined that your heart was not contracting as forcefully as is normal. This caused fluid to back up into your lungs and in turn caused your shortness of breath. We gave you medications to get rid of this excess fluid and help you breathe more easily. Furthermore, you received a catheterization later in your hospital course that showed that the contractility of your heart had improved. Because you have been laying down in the hospital for so long and in addition because you have fluid in your lungs, you will go home with a physical therapist scheduled to work with you to help regain your strength. In addition, imaging of your leg to look at the size of your bruise showed a fluid collection next to your hernia. You and your primary care physician can discuss this on an office visit. Your sodium level was temporarily low, but this resolved with fluid restriction. Several of your medications have changed. You can refer to the medication discharge list attached to this form, but in brief: START: Metoprolol XL 100mg - this is a medication to help your heart. You were previously taking a lower dose. Please increase it to 100mg daily. Furosemide (Lasix) 20mg daily by mouth only as needed IF your daily weight increases 3kg from your weight at discharge from the hospital or if you become short of breath. If you have to take these pills, call Dr.[**Name (NI) 41631**] office to see if he can see you sooner than your regularly scheduled appointment on [**7-28**] (see below). Lisinopril 5mg daily- this is a medication to help your heart STOP: Isosorbide 20mg twice daily CHANGE: Metoprolol XL 50mg daily to Metoprolol XL 100mg by mouth daily When you see your phyisician, please discuss the idea of taking coumadin. We feel this is very important for your rhythm, to prevent clots. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] B. Specialty: Primary Care/Cardiology Location: [**Hospital3 **] INTERNAL MEDICINE ASSOCIATES Address: [**Street Address(2) 4472**], [**Apartment Address(1) 4473**], [**Hospital1 **],[**Numeric Identifier 9331**] Phone: [**Telephone/Fax (1) 4475**] When: Thursday, [**7-28**] at 3:15pm [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**]

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icd9cm

[ [ [] ] ]

[ "88.56" ]

icd9pcs

[ [ [] ] ]

9700, 9771

5544, 8834

322, 351

9985, 9985

4226, 5521

12214, 12684

2760, 2876

9202, 9677

9792, 9792

9097, 9097

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9884, 9964

2216, 2274

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8855, 9071

263, 284

379, 2086

9811, 9863

10000, 10112

2305, 2575

2130, 2196

2591, 2744

43,128

126,743

52710

Discharge summary

report

Admission Date: [**2130-1-11**] Discharge Date: [**2130-2-9**] Date of Birth: [**2085-8-31**] Sex: F Service: MEDICINE Allergies: Haldol Attending:[**First Name3 (LF) 348**] Chief Complaint: Violent behavior Major Surgical or Invasive Procedure: None History of Present Illness: Ms [**Known lastname 108741**] is a 44 year old woman with history of psychosis, polysubstance abuse, and chronic transverse myelitis c/b paraplegia, as well as stage IV decubitus ulcers transferred on a section 12 from her rehab for violent behavior in the setting of cocaine use. Notably, she was recently discharged [**2129-12-22**] for osteomyelitis treated with meropenem and vancomycin. On day PTA, when confronted by rehab staff for concern for recent cocaine use, pt became aggressive. Cigarettes and a crack pipe found in room. Per report, she had witnessed crack use 1 hour prior to transfer. . In the ED, she was tachycardic to the 150s on arrival which improved to 120s w/one dose of Ativan. Her other vitals: T 98.5 BP 149/97 RR 20 sat 100% on room air. She received Lorazepam 2mg IV x 3, Vancomycin 1g IV x 1 and Meropenem 500 mg IV x 1. Past Medical History: - Psychotic disorder, has guardian; unable to make own medical decisions - Sacral osteomyelitis: Admitted in [**2129-8-11**] treated with 6wks of meropenem and vancomycin - Admitted [**Date range (1) 108746**] for ankle osteomyelitis, currently getting 6 weeks of meropenem and vancomycin - Removal ([**10-23**]) of ??????ex-fix?????? tibio-talar fusion of L ankle - Paraplegia due to transverse myelitis - Multiple complications from pressure wounds - Depression with suicidal ideation, treated at [**Hospital1 **] - Borderline hypertension Social History: Jehovah's Witness belief and should not be transfused with any blood products. Patient was born and raised in MA, with 10 siblings. Graduated highschool and went to [**University/College **] College (liberal arts major). Patient reportedly has worked in the past x 20 years, in various jobs, including working as a substitute teacher at Kindercare learning center. Patient has been living most recently alone with the support witha 3 "PCAs." Patient is currently supported with SSDI. Her sister was named her guardian during patient's most recent medical admission. Tob: 1pack every few days for 10 years. EtOH: Denies. Illicit drugs: has tested positive for cocaine in the past, denies current use. Family History: Noncontributory. Physical Exam: T: 97.8 BP: 102/72 HR: 107 RR: 22 O2 100% RA Gen: sleepy, NAD HEENT: AT/NC, PERRL, EOMI, anicteric, no conjuctival pallor, MMM, clear oropharynx, no erythema, no exudates no rhinorrhea/ discharge, no sinus tenderness NECK: supple, trachea midline, no LAD LUNG: CTAB, no RRW CV: RRR, nl S1, S2, no MRG ABD: obese, soft, +BS, NT/ND, no rebound/rigidity/guarding EXT: multiple ulcers on feet, largest on bilateral heels, no drainage SACRUM: Patient refused exam SKIN: No rashes noted NEURO: Alert and Oriented x 3 PSYCH: Appropriate, but accusatory. Denies any substance abuse. Pertinent Results: [**2130-1-11**] 05:48PM SED RATE-70* [**2130-1-11**] 05:48PM PLT SMR-HIGH PLT COUNT-542* [**2130-1-11**] 05:48PM NEUTS-68.9 LYMPHS-20.3 MONOS-4.0 EOS-5.5* BASOS-1.2 [**2130-1-11**] 05:48PM WBC-11.5* RBC-5.08 HGB-10.7* HCT-33.9* MCV-67* MCH-21.1* MCHC-31.6 RDW-19.2* [**2130-1-11**] 05:48PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2130-1-11**] 05:48PM CRP-97.3* [**2130-1-11**] 05:48PM CALCIUM-10.1 PHOSPHATE-3.5 MAGNESIUM-2.0 [**2130-1-11**] 05:48PM estGFR-Using this [**2130-1-11**] 05:48PM GLUCOSE-96 UREA N-8 CREAT-0.4 SODIUM-137 POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-23 ANION GAP-15 [**2130-1-11**] 05:57PM LACTATE-1.8 [**2130-1-11**] 08:25PM URINE cocaine-NEG [**2130-1-11**] 08:25PM URINE HOURS-RANDOM . CXR: A left-sided PICC catheter is noted to be in place with its tip terminating in the mid-to-distal aspect of the left brachiocephalic vein. Lungs display unchanged appearance to small calcified granuloma in the peripheral right base with no other focal consolidations identified. No edema, effusions, or pneumothorax is appreciated. Cardiomediastinal silhouette and hilar contours are stable as are degenerative changes of the spine and underlying scoliosis. [**2130-2-4**] 09:20AM BLOOD WBC-11.4* RBC-4.70 Hgb-9.5* Hct-30.2* MCV-64* MCH-20.2* MCHC-31.4 RDW-16.9* Plt Ct-689* [**2130-1-28**] 09:35AM BLOOD WBC-10.4 RBC-4.64 Hgb-9.6* Hct-30.3* MCV-65* MCH-20.7* MCHC-31.7 RDW-17.7* Plt Ct-663* [**2130-2-4**] 09:20AM BLOOD Neuts-64.9 Lymphs-23.8 Monos-3.0 Eos-7.6* Baso-0.7 [**2130-1-28**] 09:35AM BLOOD Plt Smr-VERY HIGH Plt Ct-663* [**2130-2-4**] 09:20AM BLOOD Plt Ct-689* [**2130-1-21**] 05:02AM BLOOD Plt Smr-HIGH Plt Ct-544* [**2130-1-11**] 05:48PM BLOOD ESR-70* [**2130-1-21**] 05:02AM BLOOD ESR-81* [**2130-1-28**] 09:35AM BLOOD ESR-82* [**2130-2-4**] 09:20AM BLOOD ESR-87* [**2130-2-4**] 09:20AM BLOOD Glucose-101 UreaN-8 Creat-0.4 Na-138 K-4.2 Cl-104 HCO3-23 AnGap-15 [**2130-1-28**] 09:35AM BLOOD Glucose-56* UreaN-11 Creat-0.4 Na-139 K-4.4 Cl-104 HCO3-24 AnGap-15 [**2130-2-4**] 09:20AM BLOOD ALT-9 AST-13 [**2130-2-4**] 09:20AM BLOOD Calcium-9.0 Phos-3.5 Mg-2.0 [**2130-1-11**] 05:48PM BLOOD CRP-97.3* [**2130-1-21**] 05:02AM BLOOD CRP-73.7* [**2130-1-28**] 09:35AM BLOOD CRP-113.3* [**2130-2-4**] 09:20AM BLOOD CRP-96.0* [**2130-1-19**] 04:32PM BLOOD Vanco-19.8 [**2130-1-21**] 05:02AM BLOOD Vanco-17.0 [**2130-1-11**] 05:48PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2130-1-11**] 05:57PM BLOOD Lactate-1.8 Brief Hospital Course: 44 year old woman with history of psychosis, polysubstance abuse, and transverse myelitis c/b paraplegia, as well as multiple severe pressure ulcers admitted for violent behavior in the setting of cocaine use. # Violent behavior. Patient has history of paranoid psychosis and was admitted on section XII. The patient has previously been discharged home with VNA but she has refused to allow them to see her due to her paranoia and she has demonstrated a marked inability to care for herself. Thus, guardianship was pursued and awarded to her sister, [**Name (NI) **], with a [**Name (NI) 7474**] treatment plan in place. She was begun on Risperdal Consta IM injections in addition to oral risperdal for continued treatment of her psychosis. The oral risperdal was then changed to oral Zyprexa as she was not responding to the risperdal as well we hoped. Her pyschosis is proving difficult to treat and she still retains significant paranoia and delusions. However, she has exhibited no further violent or disruptive behavior. She has occasionally refused a variety of therapies for different reasons. Per her guardian and her treatment plan, she may not refuse treatment. If she refuses oral Zyprexa, it may be administered IM. She will continue to receive further psychiatric treatment at [**Hospital1 **] State hospital. # Sacral Decubitus Ulcer: Pt with Stage IV sacral decubitus with fistulus tract to vulva. MRI of her pelvis on [**12-17**] without clear evidence of osteo. Further evaluation of the ulcer was deferred given patient refusal and discomfort. Patient was treated previously empirically with 6 week course of vancomycin and meropenem. Plastic surgery was consulted and made extensive wound care recs to allow the wounds to heal. They have no plans for operative repair. She will follow up with plastic surgery as an outpatient for further management. Wound care recommendations are outlined in her page 1. # Left Ankle/4th and 5th metatarsal Osteomyelitis: This was diagnosed on a prior hospitalization via plain films. She completed another full 6 week course of Vancomycin and Meropenem. Finished on [**2130-1-24**]. Per infectious disease consult, she was then begun on a suppressive regimen of PO doxycycline to be continued indefinitely. She will follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (ID) as an outpatient with weekly labs faxed to her. # Anemia: Beta-thalassemia trait along with anemia of chronic disease per iron studies. She is a Jehovah's witness so she does not desire any transfustions. She was continued on her outpatient iron supplementation and her HCT remained stable. # Neurogenic Bladder and Urinary Incontinence: Due to spinal injury from transverse myelitis. Continued oxybutynin. Foley in place. # Thrombocytosis: Likely reactive [**2-20**] chronic inflammation. Improved from prior hospitalization. No further workup required. # Fever: Patient spiked fever to 101 on [**2130-2-7**], workup showed UTI growing Proteus, started on cefpodoxime 200mg PO BID for 7 days # FAMILY: [**Name (NI) **] sister and guardian [**Name (NI) **] (hearing for permanent guardianship is scheduled for [**2130-1-10**]. [**Telephone/Fax (1) 108742**] (home) or [**Telephone/Fax (1) 108744**] (work). - Psychiatry obtained additional legal documentation of guardianship - [**Name2 (NI) **] informed consent goes through this guardian # FEN: Regular diet. # Prophylaxis: Lovenox daily, ; bowel regimen. # CODE: Full code. No blood products. Medications on Admission: - Vancomycin 1250 mg IV Q 12H (Day #1 [**12-14**]; last day [**2130-1-24**]) - Meropenem 500 mg IV Q6H (Day #1 [**12-14**]; last day [**2130-1-24**]) - Aspirin 325 mg PO DAILY - Risperidone 2 mg PO BID:PRN [patient receives depot risperidone as outpatient] - Acyclovir Ointment 5% 1 Appl TP ASDIR - Lorazepam 1-2 mg IV Q4H:PRN - Famotidine 20 mg PO Q12H - Bisacodyl 10 mg PO/PR DAILY:PRN - Ferrous Sulfate 325 mg PO DAILY - FoLIC Acid 1 mg PO DAILY - Heparin 5000 UNIT SC TID - Senna 8.6mg [**Hospital1 **] PRN - Oxybutynin 10mg [**Hospital1 **] - Olanzapine 5mg IM / Ativan 2mg IV / Cogentin 1mg IM PRN refusing to take antibiotics, risperdal, exams Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 3. Acyclovir 5 % Ointment Sig: One (1) Appl Topical ASDIR (AS DIRECTED). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 9. Oxybutynin Chloride 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 11. Doxycycline Hyclate 100 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 12. Risperidone Microspheres 37.5 mg/2 mL Syringe Sig: One (1) Syringe Intramuscular Q2W (WE): Next dose to be given [**2130-2-15**]. 13. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) syringe Subcutaneous DAILY (Daily). 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 15. Olanzapine 2.5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 16. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Alum-Mag Hydroxide-Simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for heartburn, nausea. Discharge Disposition: Extended Care Facility: [**Hospital1 **] State Hospital Discharge Diagnosis: Psychosis Osteomyelitis of ankle Secondary: History of transverse myelitis complicated by paraplegia Discharge Condition: Stable, afebrile Discharge Instructions: You were admitted for agitation and violent behavior at rehab. You were initially in the ICU and were then transferred to the floor. You received IV antibiotics for your osteomyelitis and will need to continue to take oral antibiotics to keep the infection suppressed. . Please keep all of your follow up appointments as scheduled, and take all of your medications as prescribed. If you develop worsening pain, shortness of breath, chest pain, or other concerning symptoms, please seek medical attention immediately. Followup Instructions: Please call ([**Telephone/Fax (1) 7138**] to schedule a follow up appointment with plastic surgery in 2 weeks. Please call ([**Telephone/Fax (1) 4170**] to schedule an infectious disease follow up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in 1 month Completed by:[**2130-2-9**]

[ "041.6", "344.1", "707.06", "788.20", "707.07", "V58.62", "326", "788.30", "619.1", "599.0", "282.49", "707.03", "707.24", "285.29", "297.8", "238.71", "401.9", "V12.04", "305.60", "596.54", "730.17", "311", "786.59" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11344, 11402

5653, 9169

282, 289

11547, 11566

3102, 5630

12131, 12457

2472, 2490

9871, 11321

11423, 11526

9195, 9848

11590, 12108

2505, 3083

226, 244

317, 1171

1193, 1738

1754, 2456

21,097

128,446

14512

Discharge summary

report

Admission Date: [**2137-5-2**] Discharge Date: [**2137-5-3**] Date of Birth: [**2073-11-11**] Sex: F Service: CCU HISTORY OF PRESENT ILLNESS: Patient is a 63-year-old female admitted for elective carotid stent. Patient is referred by Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] carotid stenting. The patient has had serial carotid ultrasounds for several years due to a strong family history of CVA. Patient's carotid ultrasounds have been stable until recently when a carotid study was done on [**2137-3-13**], which showed a 70-90% right ICA stenosis and a 70-80% stenosis involving the left proximal ICA. Patient denied chest pain or shortness of breath. She also denied any lightheadedness or dizziness. She denied any visual changes, heat intolerance, weight loss, headaches, incontinence, diarrhea, fever or chills. PAST MEDICAL HISTORY: 1. Hypertension. 2. Neuropathy. 3. Myopathy. 4. Migraines. 5. Hypercholesterolemia. 6. Bilateral carotid artery stenosis. 7. Colon cancer in [**2127**] status post chemotherapy and XRT, status post resection. 8. Status post bilateral axillary sweat gland surgery for removal. 9. Tonsillectomy. 10. Thyroid nodule. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Clonidine 0.2 b.i.d. 2. Triamterene 35/25 q.d. 3. Plavix 75 q.d. 4. Aspirin 325 q.d. 5. Multivitamin. 6. Vitamin E. 7. Folic acid. 8. Fish oil. SOCIAL HISTORY: The patient is employed at [**Hospital3 **] Eye Associates. She is married. She denies tobacco use. She drinks alcohol socially. FAMILY HISTORY: The patient has a mother with vascular disease at age 75 and a brother who is status post CABG at age of 50 with a redo CABG at the age of 58. PHYSICAL EXAM ON ADMISSION: Patient is a well-appearing female in no acute distress. Cardiac was regular, rate, and rhythm, normal S1, S2. Lungs were clear to auscultation bilaterally. Abdomen was soft, nontender, nondistended, good bowel sounds. There is no edema in the extremities. She has good pulses bilaterally. SUMMARY OF HOSPITAL COURSE: 1. Carotid stenosis: Patient is status post a right internal carotid stent. She tolerated this procedure well without complications. The patient was continued on her aspirin and Plavix. During this procedure, the patient was started on phenylephrine for blood pressure control to maintain a systolic blood pressure in the 140s. Patient was monitored in the Cardiac Intensive Care Unit overnight. The patient received fluid boluses approximately 1 liter, and was able to be successfully weaned from the phenylephrine. Patient's blood pressure remained stable throughout the remainder of her hospitalization. 2. Blood pressure: The patient was originally hypotensive at the time of carotid stenting and transiently on phenylephrine for blood pressure control. With fluid boluses, the patient's pressure came up. The patient's blood pressure rose in the morning of discharge in the setting of having her antihypertensives held. The patient had a blood pressure of 170s systolic that morning and was instructed to take clonidine 0.1 mg on the night following discharge. After that, the patient will resume clonidine b.i.d. per Dr. [**First Name (STitle) **]. The patient will follow up with Dr. [**First Name (STitle) **] for blood pressure check in the days following discharge, and he will resume further antihypertensives as blood pressure tolerates. 3. Neurologic: The patient was evaluated by Neurology during the carotid stenting as well as prior to discharge. She had no neurologic events, and was neurologically intact at the time of discharge. She had no complaints. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: To home. DISCHARGE DIAGNOSIS: Carotid stenosis. MEDICATIONS ON DISCHARGE: 1. Aspirin 325 q.d. 2. Plavix 75 q.d. 3. Clonidine b.i.d. FOLLOW-UP PLANS: The patient will follow up with her primary care physician within two weeks. She will call Dr. [**First Name (STitle) **] on the Monday following discharge with a blood pressure check, and he will restart antihypertensives as tolerated. In addition, the patient will follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of Neurology in one month's time. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3184**], M.D. [**MD Number(1) 23649**] Dictated By:[**Name8 (MD) 12502**] MEDQUIST36 D: [**2137-5-8**] 21:38 T: [**2137-5-9**] 05:04 JOB#: [**Job Number 42873**]

[ "443.9", "433.30", "V10.05", "272.0", "356.9", "V17.1", "401.9", "V17.3" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

1562, 1720

3735, 3754

3780, 3839

2059, 3650

3857, 4508

160, 859

1735, 2031

881, 1395

1412, 1545

3675, 3713

2,385

104,824

10141

Discharge summary

report

Admission Date: [**2107-3-21**] Discharge Date: [**2107-4-4**] Date of Birth: [**2041-7-11**] Sex: F Service: VASCULAR CHIEF COMPLAINT: Left leg ischemia and cellulitis. HISTORY OF PRESENT ILLNESS: This is a 65-year-old female with severe bilateral lower extremity inflow and outflow disease who was scheduled for an aorto-bifemoral bypass on [**3-25**] with Dr. [**Last Name (STitle) **] with prior three-week history of left foot pain with ambulation. She requires wheelchair for ambulation. Prior to that, she ambulated independently without claudication symptoms. There was a painful cut on the left lateral foot which progressed to weeping and pain over the last three days. She was started on Augmentin two days prior to admission. She denied constitutional symptoms. The patient also has a history of carotid disease and stated that she was to have carotid endarterectomy prior to her aorto-bifemoral. She denied any symptoms. The patient was admitted for further vascular evaluation and treatment. PAST MEDICAL HISTORY: History of Hodgkin's lymphoma 13 years ago. Status post splenectomy and thoracic lymph node dissection. Status post radiation to the chest and mediastinum. History of hypercholesterolemia. History of hypertension. History of dementia, Alzheimer's type. History of hypothyroidism. History of asthma; she has not been intubated, no history of hospitalizations, or steroid use for her asthma. Status post cerebrovascular accident without residual. Peripheral vascular disease. SOCIAL HISTORY: She has greater than 103 pack-year smoking history. Nondrinker. ALLERGIES: NO KNOWN DRUG ALLERGIES. MEDICATIONS: Lipitor 20 mg q.d., Aricept 5 mg q.d., Euthyroid 75 mg q.d., Pulmicort 1 q.d., Augmentin 500 mg b.i.d., Albuterol p.r.n. PHYSICAL EXAMINATION: Vital signs: 97.4, 101, 205/76, 18, 98% on room air. Blood pressure rechecked was 166/58. General: This was a pleasant but difficult to understand white female in no acute distress. She was oriented to person and place but not time. HEENT: Unremarkable. She had a left carotid bruit. Lungs: Clear to auscultation but diminished throughout. Heart: Irregular rate and rhythm. There was a 2/6 systolic ejection murmur at the right upper sternal border. Abdomen: Nontender and nondistended. There was a well-healed median abdominal incision. She has a palpable liver edge. Atympanic. Rectum: Unremarkable. Guaiac negative. No abdominal aortic aneurysm. Extremities: Pulse exam showed palpable femorals bilaterally. The dorsalis pedis and posterior tibial with Dopplerable signals only bilaterally. The left foot with diffuse streaky erythema and edema. There was a 1 cm diameter draining wound. There were small fissures along the lateral aspect of the left foot near the heel. There was no drainage or active bleeding. Neurological: Cranial nerves II-XII grossly intact. Left foot motor was intact with diminished sensation to light touch. Extremity strength was symmetrical without deficits. LABORATORY DATA: CBC with a white count of 19.2, hematocrit 40.9, differential with polys of 74, lymphs 17, no bands; electrolytes with a BUN of 21, creatinine 1.0, potassium 4.9, glucose 129. Electrocardiogram was normal sinus rhythm with inverted Ts in II, III, and AVF. There were no changes from previous electrocardiogram of [**2107-3-10**]. Chest x-ray showed no active cardiopulmonary disease. There was a small mediastinal irregular opacity without change from prior chest x-ray. Other studies included an arteriogram which showed extensive infrarenal aortic disease, left common iliac occluded, left internal iliac reconstructed by right collaterals from the external iliac, left common femoral profunda with multifocal SFA disease proximally, distal SFA and popliteal were patent, there was disease of the tibial, proximal posterior tibial, and peroneal arteries, the left AT is in major runoff vessel but diseased proximally and mid portions. Foot fed by collaterals. The right common iliac and external iliac diseased. The right common femoral profunda, SFA, popliteal were patent. There was two-vessel runoff via the posterior tibial and the dorsalis pedis on the right. A MIBI stress test on [**3-17**] showed no wall motion abnormalities, ejection fraction was calculated at 54%. The ultrasound of the carotid showed left internal carotid artery stenosis of 85-90%, right internal carotid stenosis of 60-70% at the origins, right internal carotid artery subvalvular stenosis of 85% 2 cm above the bifurcation. The left vertebral was totally occluded. The right vertebral was patent. The ultrasound of the carotids showed a 70-79% bilateral internal carotid artery stenosis with nonvisualized left vertebral artery. HOSPITAL COURSE: The patient was admitted to the Vascular Service. She was placed on Metoprolol 25 mg b.i.d., Levofloxacin 500 q.24, and Flagyl 500 mg q.8. Subcue Heparin was begun for DVT prophylaxis. She was continued on her preadmission medications. Dressings were normal saline wet-to-dry dressings b.i.d. with multi-podis boot of the affected foot. She was placed on a house diet. She was placed on bedrest with the leg elevated. She was allowed to receive Percocet tablets 5/325 one-half to one q.4-6 hours p.r.n. for pain. Vancomycin 1 g IV q.12 hours was begun with peak and trough levels with third dose. Lopressor was increased to 50 mg b.i.d. hospital day #2. Vancomycin was discontinued on [**3-24**], and Oxacillin 1 g q.6 hours IV was begun for MSSA. The patient underwent on [**3-25**] a left carotid endarterectomy. She tolerated the procedure well, and she was transferred to the PACU in stable condition. The patient was intubated, alert, and responded to commands. She was without chest pain. Her vitals signs were stable. She was hemodynamically stable. Her neck dressing was clean, dry, and intact. There was no hematoma. She was extubated in the PACU and transferred to the VICU for continued monitoring and care. Nitroglycerin was weaned off on postoperative day #1. She required reintubation in the PACU secondary to sedation. She was afebrile. Her hematocrit was 29.6. Her electrolytes remained stable. Her exam showed bilateral lung wheezing with generalized edema. She was diuresed. She received nebulizations around the clock. Stool for C-diff was sent. Her diet was advanced as tolerated. Her Foley was continued to monitor urinary output, and she remained in the VICU. Her Lopressor was dosed at 37.5 b.i.d. and required decreased dosing strength secondary to bronchospasm. Her chest x-ray showed mildly improved interstitial edema. Her hematocrit remained stable. Her wheezing was still present on auscultation of her lungs but diminished from prior exam. We continued aggressive pulmonary toiletry and physical therapy. Ambulation in the chair was begun. Diuresis was continued. The patient remained in the VICU. On postoperative day #3, the patient received a total of 40 Lasix IV during the previous 24 hours. She remained afebrile and hemodynamically stable. She was negative 2600. Her hematocrit remained stable at 33.2, although her white count remained elevated at 24. Chest x-ray was unremarkable. CPKs were obtained; total CPK peaked at 236, with an MB of 5, and a troponin less than 0.3. Her respiratory status seemed much improved. She continued on the current management. Narcotics were discontinued. She remained in the VICU. Because of the persistent white count elevation, Infectious Disease was consulted. Sputum culture from [**3-28**] showed greater than 25 polys, with 40 epithelials, but 1+ ................. consistent with oropharyngeal flora. A chest x-ray was pending. Urinalysis C&S was no growth. The foot swab gram was with no polys, 2+ gram positive cocci, pairs, chains, and clusters. It grew out MSSA. The blood cultures were no growth. The abdominal ultrasound showed normal liver with moderate distended gallbladder with no stones, no wall thickening, no dilated ducts. Chest x-ray showed resolved congestive failure with a left lower lobe atelectasis. The foot film showed no evidence of osteomyelitis. She was begun on Ceftriaxone for her left lower lobe infiltrate, and she was continued on Oxacillin. The Levofloxacin and Flagyl were discontinued. She remained in the VICU. On postoperative day #5, she was transferred out of the VICU. She remained afebrile. She did have some end expiratory wheezing, but otherwise the lungs were unremarkable. The left foot erythema was nearly gone. The white count was at 22.3. Her neutrophils were 68, lymphs 22, and monos 7. The patient continued to progress. Repeat x-ray was unremarkable, and the Ceftriaxone was discontinued. Recommendations of Infectious Disease were to continue her Oxacillin through her anticipated bifemoral surgery and then to continue antibiotics two weeks postsurgery. On [**2107-4-11**], the patient underwent a right axillo-bilateral femoral artery bypass with 8 mm [**Doctor Last Name 4726**]-Tex graft. She tolerated the procedure well. She required 1 U packed red blood cells intraoperatively and was transferred to the PACU in stable condition. Her immediate postoperative check revealed her to be stable. She was on Nitroglycerin at 3 mg/kg/min. Her hematocrit was 32. Chest x-ray was unremarkable. The patient was neurologically intact. Groin was without hematomas bilaterally, and she had palpable dorsalis pedis and posterior tibial on the right and Dopplerable dorsalis pedis and posterior tibial on the left. The patient continued to remain stable. She was continued on around-the-clock nebulizations and was transferred to the VICU for continued monitoring and care. She still required her Nitroglycerin to maintain her systolic below 110. Her exam was unremarkable. Her Nitroglycerin was weaned, and oral medications were begun. Fluids were Hep-Locked. Diet was advanced as tolerated. She was continued on subcue heparinization for DVT prophylaxis. On postoperative day #2, she continued to do well. Her hematocrit remained stable at 31.1. Her white count peaked at 28.3. Her electrolytes were unremarkable. Her CVL was discontinued, and a peripheral line was placed. The Foley was maintained. She otherwise did well. On postoperative day #3, there were no overnight events, and the hematocrit remained stable at 31.9, and the white count was decreased to 25.7. The right groin was mildly erythematous. There was no hematoma. The right dorsalis pedis and posterior tibial were palpable. The left dorsalis pedis and posterior tibial remained Dopplerable. Chest exam was unremarkable. A PICC line was placed for continued for continued antibiotic therapy. Physical Therapy was requested to see the patient and begin assessment for rehabilitation placement. The Foley was discontinued. The patient was discharged in stable condition. DISCHARGE MEDICATIONS: Aspirin 325 mg q.d., Tylenol 650 mg q.4 hours p.r.n., Flovent 2 puffs b.i.d., Lopressor 25 mg b.i.d., hold for systolic blood pressure less than 100, heart rate less than 60, subcue Heparin 5000 U t.i.d., Synthroid 75 mcg q.d., Oxacillin 1 g IV q.6 hours, this is to be continued for a total of two weeks from [**4-1**], to [**4-15**], Albuterol nebulizer q.4 hours p.r.n., Aricept 5 mg q.d., Lipitor 20 mg q.d. DISCHARGE DIAGNOSIS: 1. Bilateral carotid disease status post left carotid endarterectomy. 2. Left foot ischemic ulcerations with cellulitis, status post axillo-bifemoral bypass. 3. Asthma with exacerbation, treated. 4. Congestive heart failure, resolved. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], M.D. [**MD Number(1) 6223**] Dictated By:[**Last Name (NamePattern1) 1479**] MEDQUIST36 D: [**2107-4-4**] 10:29 T: [**2107-4-4**] 10:41 JOB#: [**Job Number 33875**]

[ "917.2", "433.10", "V10.79", "440.23", "272.0", "682.7", "331.0", "428.0", "401.9" ]

icd9cm

[ [ [] ] ]

[ "39.29", "38.93", "96.04", "86.22", "96.71", "38.12" ]

icd9pcs

[ [ [] ] ]

10986, 11399

11420, 11943

4807, 10962

1823, 4789

157, 192

221, 1037

1060, 1543

1560, 1800

9,163

172,763

53624

Discharge summary

report

Admission Date: [**2147-11-26**] Discharge Date: [**2147-11-30**] Service: CCU HISTORY OF PRESENT ILLNESS: This is an [**Age over 90 **]-year-old woman with a history of hypertension and no known coronary artery disease presented to [**Hospital3 8834**] with several hours of indigestion. She became unresponsive in the Emergency Department, with a ventricular fibrillation arrest. She was shocked with 100 joules and converted to a normal sinus rhythm. She was also briefly on a lidocaine drip. Her electrocardiogram showed 2-mm to 3-mm ST elevations in leads II, III, and aVF and 1-mm ST elevations in V4-R. She was started on aspirin, heparin, a 2B3A inhibitor, and metoprolol and was transferred to [**Hospital1 69**] for catheterization. In the catheterization laboratory, the patient had a right atrial pressure of 11, and pulmonary arterial pressure of 38/21. She had an extensively calcified right-dominant system. Her left main coronary artery had a 10% lesion. Her left anterior descending artery had a 40% medial and an 80% small first diagonal lesion. Her left circumflex had a 40% medial lesion and a 60% first obtuse marginal lesion. Her right coronary artery had diffuse 50% ostial and 40% proximal and 90% medial lesions. She underwent percutaneous transluminal coronary angioplasty/stent of her medial right coronary artery lesion after great difficulty engaging the lesion. She was hypotensive after inflation of the balloon and was initiated on dopamine until an intra-aortic balloon pump was placed. PAST MEDICAL HISTORY: 1. Hypertension. 2. No known history of hypercholesterolemia, coronary artery disease, diabetes, or renal disease. MEDICATIONS ON ADMISSION: Medications on admission were unknown. SOCIAL HISTORY: Social history is negative for smoking. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on admission revealed temperature was 98.2, heart rate was 73, blood pressure was 104/68, respiratory rate was 16, oxygen saturation was 98% on 4 liter nasal cannula. In general, the patient was drowsy and agitated when stimulated on admission. Head, eyes, ears, nose, and throat examination reflected dry mucous membranes. Neck examination revealed jugular venous pressure at approximately 7 cm. Heart was regular, with normal first heart sound and second heart sound, and a mild diastolic murmur at the right upper sternal border. Lung examination revealed scattered rhonchi. The abdominal examination revealed an obese, soft, and nontender abdomen with normal sounds and no bruits. Extremity examination revealed no edema and 2+ dorsalis pedis pulses. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on admission from outside hospital revealed the patient had a white blood cell count of 18.5, hematocrit was 35, platelets were 335. Creatine kinase was 82, MB was 3. Sodium was 138, potassium was 2.9, chloride was 99, bicarbonate was 21, blood urea nitrogen was 33, creatinine was 1.5, and blood glucose was 203. HOSPITAL COURSE BY SYSTEM: 1. CARDIOVASCULAR SYSTEM: (a) Coronary arteries: After her catheterization, the patient did not have symptoms of coronary artery disease for the remainder of her admission. She had a peak creatine kinase of 1657 with a peak MB of 396, and a MB index was 23.9. Thereafter, her enzymes trended downward. She had a cholesterol panel that revealed high-density lipoprotein was 45, low-density lipoprotein was 92, and triglycerides were 145. She was placed on aspirin, Plavix, Lipitor, as well as a beta blocker and an ACE inhibitor. The beta blocker and ACE inhibitor were titrated up as her blood pressure and pulse allowed. (b) Pump: The patient had an echocardiogram on day two of admission. The echocardiogram revealed an left ventricular ejection fraction of 45%, mildly depressed left ventricular systolic function with inferior and posterior hypokinesis, and depressed right ventricular systolic function. The patient denied symptoms of heart failure and was weaned to room air, maintaining good oxygen saturations. (c) Rhythm: The patient remained in sinus rhythm with occasional premature ventricular contractions while monitored on telemetry. 2. RENAL SYSTEM: The patient had a decrease of her creatinine from 1.5 at the outside hospital to 1.1 and subsequently 0.9 at [**Hospital1 69**]. Her renal function remained good throughout her admission. 3. HEMATOLOGY: The patient was noted to be anemic on presentation with a hematocrit of 29. Her red blood cells were normal in size, and iron studies revealed a decreased iron and decreased total iron-binding capacity. Her stool was guaiac-negative. Her hematocrit decreased to a level of 27 on [**11-29**], and she was transfused one unit of packed red blood cells with an increase to 31. She is a candidate for further workup of this anemia on an outpatient basis. 4. NEUROLOGIC SYSTEM: The patient was noted to be agitated and disoriented on the day of catheterization. Her mental status subsequently cleared, and she remained alert throughout her admission. Per her son, the patient had impaired memory relative to her baseline. Her neurologic examination revealed intact strength and sensation bilaterally, and no focal deficits. She is a candidate for further workup of her possible memory deficit on an outpatient basis. DISCHARGE DIAGNOSES: 1. Acute inferior myocardial infarction. 2. Status post right coronary artery stent. 3. Hypertension. CONDITION AT DISCHARGE: Condition on discharge was fair. MEDICATIONS ON DISCHARGE: (Discharge medications were) 1. Metoprolol-XL 100 mg p.o. q.d. 2. Lisinopril 10 mg p.o. q.d. 3. Aspirin 325 mg p.o. q.d. 4. Plavix 75 mg p.o. q.d. (for a 30-day course). 5. Lipitor 10 mg p.o. q.d. DISCHARGE STATUS: Discharge status was to home. DISCHARGE FOLLOWUP: To follow up in one week with her cardiologist. She was to participate in Dr. [**First Name (STitle) **] [**Name (STitle) 110145**] study of electrophysiology risk stratification for implantable cardioverter-defibrillator placement status post myocardial infarction. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 15176**], M.D. [**MD Number(1) 15177**] Dictated By:[**Last Name (NamePattern1) 5596**] MEDQUIST36 D: [**2147-12-1**] 13:16 T: [**2147-12-2**] 05:34 JOB#: [**Job Number **]

[ "427.41", "401.9", "414.01", "458.2", "410.41" ]

icd9cm

[ [ [] ] ]

[ "36.06", "88.56", "37.22", "37.61", "36.01", "88.53", "99.20" ]

icd9pcs

[ [ [] ] ]

5372, 5488

5564, 5817

1710, 1750

3034, 5351

5503, 5537

5838, 6383

118, 1543

1565, 1683

1767, 3006

7,489

195,033

27312

Discharge summary

report

Admission Date: [**2182-4-29**] Discharge Date: [**2182-5-7**] Date of Birth: [**2118-11-25**] Sex: F Service: SURGERY Allergies: Clonidine Attending:[**First Name3 (LF) 1481**] Chief Complaint: MVC Major Surgical or Invasive Procedure: s/p exploratory laparotomy with repair of liver laceration and mesenteric artery tear History of Present Illness: The patient is a 63 year old female restrained driver involved in a motor vehicle crash (car vs. tree), +LOC prior to accident. Airbag deployed and struck pt in chest. BIBEMS, complaining of R sided chest pain with breathing, R ankle pain, and abdominal pain. Past Medical History: 1. HTN 2. DM2 3. Hypothyroidism 4. Urinary incontinence 5. Bipolar depression 6. Chronic renal insufficiency Social History: Lives with husband, no [**Name2 (NI) **], no EtOH Family History: N/C Physical Exam: VS: 99.8 63 164/74 18 96% RA A&O x 3 NC/AT, PERRL, EOMI, nl TMs no c-spine TTP s1s2 RRR CTAB no TLS spine TTP Abd obese, soft, NT/ND, + TTP ruq no pelvic instability rectal nl tone, guaiac neg MAE FAST exam negative Pertinent Results: [**2182-4-29**] 11:37PM TYPE-ART TEMP-37.4 PO2-187* PCO2-31* PH-7.29* TOTAL CO2-16* BASE XS--10 [**2182-4-29**] 11:37PM freeCa-0.96* [**2182-4-29**] 08:31PM HCT-29.1* [**2182-4-29**] 07:33PM TYPE-ART PO2-186* PCO2-37 PH-7.28* TOTAL CO2-18* BASE XS--8 [**2182-4-29**] 07:33PM LACTATE-1.7 [**2182-4-29**] 07:33PM freeCa-1.10* [**2182-4-29**] 06:36PM TYPE-ART PO2-191* PCO2-37 PH-7.26* TOTAL CO2-17* BASE XS--9 [**2182-4-29**] 06:36PM GLUCOSE-142* [**2182-4-29**] 05:11PM TYPE-ART PO2-211* PCO2-36 PH-7.24* TOTAL CO2-16* BASE XS--11 [**2182-4-29**] 05:11PM O2 SAT-99 [**2182-4-29**] 03:46PM TYPE-ART PO2-327* PCO2-52* PH-7.15* TOTAL CO2-19* BASE XS--11 [**2182-4-29**] 03:46PM GLUCOSE-221* LACTATE-1.9 [**2182-4-29**] 03:46PM O2 SAT-98 [**2182-4-29**] 03:46PM freeCa-1.17 [**2182-4-29**] 03:40PM GLUCOSE-238* UREA N-57* CREAT-2.0* SODIUM-137 POTASSIUM-5.0 CHLORIDE-112* TOTAL CO2-17* ANION GAP-13 [**2182-4-29**] 03:40PM AMYLASE-96 [**2182-4-29**] 03:40PM LIPASE-116* [**2182-4-29**] 03:40PM CALCIUM-7.6* PHOSPHATE-4.4 MAGNESIUM-1.6 [**2182-4-29**] 03:40PM WBC-15.9* RBC-2.88* HGB-8.9* HCT-26.7* MCV-93 MCH-31.0 MCHC-33.4 RDW-17.3* [**2182-4-29**] 03:40PM PLT COUNT-213 [**2182-4-29**] 03:40PM PT-14.2* PTT-23.7 INR(PT)-1.3* [**2182-4-29**] 03:40PM FIBRINOGE-128* [**2182-4-29**] 02:18PM TYPE-ART PO2-427* PCO2-39 PH-7.28* TOTAL CO2-19* BASE XS--7 INTUBATED-INTUBATED [**2182-4-29**] 02:18PM GLUCOSE-189* LACTATE-1.6 NA+-137 K+-3.8 CL--114* [**2182-4-29**] 02:18PM HGB-6.9* calcHCT-21 O2 SAT-98 [**2182-4-29**] 02:18PM freeCa-1.07* [**2182-4-29**] 02:10PM PT-15.5* PTT-27.0 INR(PT)-1.4* [**2182-4-29**] 12:14PM GLUCOSE-122* LACTATE-1.7 NA+-140 K+-5.5* CL--107 TCO2-20* [**2182-4-29**] 12:08PM URINE HOURS-RANDOM [**2182-4-29**] 12:08PM URINE HOURS-RANDOM [**2182-4-29**] 12:08PM URINE GR HOLD-HOLD [**2182-4-29**] 12:08PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG [**2182-4-29**] 12:08PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.007 [**2182-4-29**] 12:08PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2182-4-29**] 12:08PM URINE RBC-0 WBC-0 BACTERIA-0 YEAST-NONE EPI-0 [**2182-4-29**] 12:07PM UREA N-69* CREAT-2.5* [**2182-4-29**] 12:07PM UREA N-69* CREAT-2.5* [**2182-4-29**] 12:07PM ASA-NEG ETHANOL-NEG ACETMNPHN-5.3 bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2182-4-29**] 12:07PM WBC-13.3* RBC-3.59* HGB-11.7* HCT-35.1* MCV-98 MCH-32.5* MCHC-33.3 RDW-13.3 [**2182-4-29**] 12:07PM PLT COUNT-308 [**2182-4-29**] 12:07PM PT-11.4 PTT-18.5* INR(PT)-1.0 [**2182-4-29**] 12:07PM FIBRINOGE-256 Brief Hospital Course: The patient was taken for imaging and the following studies were obtained: . CXR/pelvis: 1) Chest -- left-sided rib fractures with left lower lobe atelectasis and probable small left effusion. A tiny pneumothorax would be difficult to exclude. 2) Chest -- Small amount of soft tissue density at the left apex. ? chronic pleural thickening, but a small amount of left apical pleural capping cannot be excluded. 3) Pelvis--no acute fracture detected. 4) Osteopenia and degenerative changes of the thoracic and lumbar spine. . Head CT: IMPRESSION: 1. No evidence of intracranial hemorrhage. 2. Slight prominence of the left cavernous sinus- differential diagnosis includes tortuous carotid artery versus cavernous carotid aneurysm. 3. Moderate enlargement of lateral ventricles only without prominence of sulci. This raises possibility of communicating hydrocephalus. Please correlate clinically. . CT c-spine: IMPRESSION: Multilevel degenerative changes as described. No evidence of acute fractures . CT C/A/P: IMPRESSION: 1) Large 6.3 x 5.8 cm mesenteric hematoma with high attenuation central focus, 245 H. The findings are highly concerning for mesenteric injury. 2) High attenuation material, 234 H, surrounding the bladder and tracking into the mesentery peritoneum. These findings are highly concerning for intraperitoneal bladder rupture or ureteral tear. 3) Multiple areas of liver laceration/contusion in segments 7, 6, and 4B of the liver. There is an area of active extravasation seen in segment VII of the liver. There is a perfusion abnormality in segment VII. 4) Multiple displaced bilateral rib fractures, more on the right than the left. There is no evidence of pneumothorax. 5) No evidence of pelvic fracture. 6) Polycystic kidneys. 7) Calcified splenic artery aneurysm. 8) Right adrenal gland nodule which cannot be further evaluated on this examination. . The patient's blood pressure dropped to a systolic in the 70s during the initial resuscitation and the patient was taken emergently to the OR for an ex lap (see separate operative note for details). The liver laceration and mesenteric tear were repaired and the pt was transferred to the TSICU, was extubated, did well, and was transferred to the floor. There were no significant events on Telemetry. The hematocrit trended down but then stabilized ~ 25, she received a total of 7 U pRBCs between the OR, TSICU and floor ; the anemia was thought to be [**1-31**] mobilization of resuscitation fluid volume. Her diet was advanced, with good bowel function and brisk urine output, and she worked with PT/OT and was cleared for discharge home with services on HD 9. The abdominal staples were removed prior to discharge. She will follow up with Trauma Clinic in 2 weeks as well as her PCP. [**Name10 (NameIs) **] findings on the head CT were discussed with Neurosurgery and she should follow up with Dr. [**First Name (STitle) 23161**] for further evaluation. Medications on Admission: Lithium, Diovan, Ditropan, Synthroid, HCTZ, Norvasc, Prilosec, Tylenol, ASA, Tramadol, Quinine, Diflunisal Discharge Medications: 1. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Levothyroxine 75 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Lithium Carbonate 300 mg Capsule Sig: One (1) Capsule PO QD (). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). Disp:*60 Tablet(s)* Refills:*2* 7. Codeine Sulfate 30 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*45 Tablet(s)* Refills:*0* 8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: 1. Motor vehicle crash 2. Liver laceration 3. Mesenteric artery tear 4. Rib fractures Discharge Condition: Good Discharge Instructions: Call your doctor or go to the ER for any of the following: increased pain, nausea/vomiting, unable to move bowels, fever > 101.4, signs of infection from the wound (redness/drainage), or other troubling concerns. Follow up in Trauma Clinic in 2 weeks, call for appointment: [**Telephone/Fax (1) **]. Take all of your medications as prescribed. Resume your home medications as previously prescribed. Take tylenol and codeine as needed for pain. Follow up with your primary care doctor regarding your previous medical issues/medications. Your doctor should follow up on the results of your head CT and may wish to order an MRI to further evaluate the blood vessels in your brain. You can also follow up with Dr. [**First Name (STitle) 23161**] in Neurosurgery: ([**Telephone/Fax (1) 88**]. Followup Instructions: As above.

[ "401.9", "863.89", "807.04", "864.05", "585.9", "E816.0", "244.9", "250.00", "902.20", "296.7" ]

icd9cm

[ [ [] ] ]

[ "39.31", "50.61", "38.93" ]

icd9pcs

[ [ [] ] ]

7713, 7784

3835, 4359

273, 361

7914, 7921

1125, 3812

8761, 8774

865, 870

6924, 7690

7805, 7893

6793, 6901

7945, 8738

885, 1106

230, 235

389, 650

4368, 6767

672, 782

798, 849

70,675

104,160

38867+58238

Discharge summary

report+addendum

Admission Date: [**2103-3-27**] Discharge Date: [**2103-4-3**] Date of Birth: [**2053-3-20**] Sex: M Service: SURGERY Allergies: Aspirin Attending:[**First Name3 (LF) 1234**] Chief Complaint: Sent from home by VNA for blood pressure control Major Surgical or Invasive Procedure: none History of Present Illness: Type B dissection aorta. History Present Illness: 50 year old male known type B aortic dissection, diagnosed in [**2103-1-15**] at [**Hospital6 **]; transferred here per patient request. Was in house for a few days for control of blood pressure. He was seen by VNA today found to have a BP of of 160s so was sent to the ED. He had no complaints of abdominal or chest pain, No SOB. Past Medical History: Hypertension Chronic Renal Insufficiency Sickle Cell Trait Social History: Currently not working. He currently lives his mother. [**Name (NI) **] alcohol. No tobacco. He is single with no children. Family History: No premature coronary disease. Hypertension; Brother Diabetic. Physical Exam: Vitals: 98.3 61 143/79 18 100%RA Gen: A&Ox3, NAD CV: RRR Lungs: CTA-B Abd: Soft, NTND, no palpable anurysm ext: good distal pulses, no edema Pertinent Results: [**2103-3-29**] 06:05PM BLOOD Glucose-145* UreaN-25* Creat-1.6* Na-136 K-4.0 Cl-100 HCO3-25 AnGap-15 Brief Hospital Course: Mr [**Known lastname **] was admitted on [**2103-3-27**] for management of his blood pressure. Initially he was started on a nitro drip to control his blood pressure and was observed in the ICU. On HD3 the patient was weaned completely off drips and transferred to the floor. While in house his blood pressure was controlled with several anti-hypertensives which were quickly titrated up due to the inability to lower his blood pressure. While in house the patient remained hemodynamically stable. He tolerated a regular diet and ambulated daily. He was kept on subcutaneous heparin for DVT prophylaxis. He should follow-up with his primary care doctor 1-2 weeks for continued blood pressure management. At the time of discharge his blood pressure was ranging in the mid 130s. He is being discharged in stable condition Medications on Admission: Amlodpine 10mg, Clonidine 0.2mg TID, Labetolol 900mg TID, Lisinopril 40mg, Hydralazine 100mg TID Discharge Medications: 1. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 3. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 tabs* Refills:*2* 4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Clonidine 0.2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 6. Hydralazine 25 mg Tablet Sig: Four (4) Tablet PO Q6H (every 6 hours). Discharge Disposition: Home Discharge Diagnosis: descending aortic dissection Discharge Condition: stable, ambulating and mentating normal Discharge Instructions: You were seen and evaluated for your elevated blood pressure. The most important thing for you to do when you get home is check your blood pressure and record it twice a day. You should bring these recordings to your primary care doctor at your next appointment. Your primary care doctor will be responsible for managing your blood pressure Please follow the general discharge instructions below: Activity: no strenuous activity or heavy lifting Diet: please limit the salt in your diet, this will help your blood pressure. Medications: Some of your medications have changed while in the hospital. Please only take the medications that have been prescribed to you while in the hospital. Followup Instructions: You should follow-up with Dr. [**Last Name (STitle) **] in [**2-15**] weeks. Please call his office for that appointment. ([**Telephone/Fax (1) 2867**] You should schedule an appointment with your primary care doctor for management of your blood pressure medications. Please make arrangements to see them in the next 1-2 weeks (Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 250**]) Name: [**Known lastname 13647**],[**Known firstname 13648**] M. Unit No: [**Numeric Identifier 13649**] Admission Date: [**2103-3-27**] Discharge Date: [**2103-4-3**] Date of Birth: [**2053-3-20**] Sex: M Service: SURGERY Allergies: Aspirin Attending:[**First Name3 (LF) 270**] Addendum: Mr. [**Known lastname **] was not discharged on [**2103-4-1**] due to continued hypertension. His medications were adjusted and a repeat ct scan and renal artery ultrasound were done on [**4-2**]. The CT and ultrasound were essentially unchanged from prevoius studies. Mr. [**Known lastname 13650**] blood pressure remained under better control and on [**4-3**] he was deemed stable for discharge to home with home monitoring of his bp's and close follow up with his pcp and the [**Month/Year (2) **] team. [**2103-4-2**] CTA chest/ abdomen/ pelvis 1. Aortic dissection flap extending from just distal to the left subclavian artery inferiorly into the right external iliac artery. The extent of dissection is overall unchanged from [**2103-2-4**], though there is increased compression of the true lumen and increased opacification of the false lumen compared to the prior study. As detailed above, the major mesenteric and renal arteries are normally opacified, without evidence for visceral perfusion abnormality. 2. Multiple bilateral renal cysts. 3. Small bilateral fat-containing inguinal hernias. DUPLEX DOPP ABD/PEL and Renals Study Date of [**2103-4-2**] 1:04 PM 1. Multiple bilateral renal cysts. A single cyst in the lower pole of the left kidney does demonstrate a vascularized internal septation. There is no further nodularity or complexity identified involving the renal cyst. 2. Delayed systolic upstroke identified in the bilateral main renal arteries, similar in appearance to [**2103-3-16**]. This involves both the main renal arteries and intrarenal renal arteries. This may be secondary to renal artery stenosis, or the presence of a dissection flap within the aortic lumen. 3. More focal increased velocity identified at the ostia of the left main renal artery. Reviewing the CT torso, may reflect the origin of the left main renal artery in the close approximation to the aortic dissection flap. Medications on Admission: Amlodpine 10mg, Clonidine 0.2mg TID, Labetolol 900mg TID, Lisinopril 40mg, Hydralazine 100mg TID Discharge Medications: 1. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 tabs* Refills:*2* 2. Clonidine 0.2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*2* 3. Hydralazine 25 mg Tablet Sig: Four (4) Tablet PO Q6H (every 6 hours). 4. Labetalol 200 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). Disp:*360 Tablet(s)* Refills:*2* 5. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 6. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: type B aortic dissection hypertension - uncontrolled Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were seen and evaluated for your type B Aortic Dissection and elevated blood pressure. The most important thing for you to do when you get home is check your blood pressure and record it twice a day. You should bring these recordings to your primary care doctor at your next appointment. Your primary care doctor will be responsible for managing your blood pressure. The goal blood pressure is 120/80 or less. Please follow the general discharge instructions below: Activity: you may drive. you should walk daily and get into a habit of doing cardiovascular exercise on a regular basis. No lifting >70lbs Diet: please limit the salt in your diet, this will help your blood pressure. Medications: Some of your medications have changed while in the hospital. Please only take the medications that have been prescribed to you while in the hospital. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 272**], MD Phone:[**Telephone/Fax (1) 283**] Date/Time:[**2103-5-1**] 9:45 Provider: [**Name10 (NameIs) 282**] LAB Phone:[**Telephone/Fax (1) 283**] Date/Time:[**2103-5-1**] 8:45 Provider: [**Name10 (NameIs) 112**] POST [**Hospital **] CLINIC Phone:[**Telephone/Fax (1) 23**] Date/Time:[**2103-4-6**] 9:30 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 272**] MD [**MD Number(1) 273**] Completed by:[**2103-4-3**]

[ "593.2", "403.00", "550.92", "282.5", "285.9", "441.02", "585.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7126, 7132

1341, 2171

315, 322

7229, 7229

1216, 1318

8260, 8796

974, 1039

6516, 7103

7153, 7208

6395, 6493

7380, 8237

1054, 1197

227, 277

350, 733

7244, 7356

755, 816

832, 958

16,757

173,108

24741

Discharge summary

report

Admission Date: [**2166-9-25**] Discharge Date: [**2166-9-30**] Date of Birth: [**2115-8-13**] Sex: F Service: SURGERY Allergies: Cyclosporine / Ceclor / Penicillins / Plaquenil / Cytoxan / Sulfa (Sulfonamides) / Ace Inhibitors / Vioxx Attending:[**Last Name (NamePattern1) 15344**] Chief Complaint: dislodged G tube ?necrotizing fasciitis Major Surgical or Invasive Procedure: Replacement of gastrostomy tube Placement of left subdural drain History of Present Illness: 51F s/p debilitating stroke [**2164**], s/p PEG, who presents from OSH with dislodged G tube, redness & crepitus about G tube site, as well as mental status changes & leukocytosis. Past Medical History: hepatitis C infection s/p subarachnoid hemorrhage chronic sudbural hematoma s/p PEG [**2164**] interstitial lung disease arthritis polymyositis Social History: h/o polysubstance abuse Family History: noncontributory Physical Exam: 97.9 P 119 BP 138/89 RR 20 99% 2L Wt 62kg Alert, not oriented, agitated, chronically ill appearing L frontal craniotomy site C/D/I CN 2-12 intact, moving all extremities, 5/5 strength Tachy, no murmurs CTA bilat Soft, nondistended, Diffuse tenderness, worst at G tube site, assoc erythema & crepitus, +purulent drainage Pertinent Results: [**9-25**] CT head: Subacute to chronic left subdural hemorrhage causing moderate amount of mass effect in the left hemisphere and shift of normally midline structures to the right (approximately 5 mm). There is probably also mild right ventricular dilatation. [**9-25**] CT abdomen: The Foley catheter balloon and tip are within the stomach. There is no evidence of leak of air or contrast to the peritoneum or to the subcutaneous tissues. There is a small amount of contrast and air exiting the stomach through the G-tube tract. Inflammatory changes around the G-tube in the subcutaneous tissues without evidence of fluid collections. Large amount of air in subcutaneous tissues is similar to when compared to the CT performed earlier in the same day. 2. Low-attenuation area with calcifications in the walls in the mid pole of the right kidney likely representing a cyst with thin calcifications in the wall versus a calyceal diverticulum with milk of calcium. 3. Atelectatic changes of the lungs. [**9-29**] G tube check: Percutaneous gastrostomy tube with distal tip within the stomach. No extraluminal contrast identified. [**9-25**] wound culture: MRSA, CORYNEBACTERIUM SPECIES (DIPHTHEROIDS), PROBABLE ENTEROCOCCUS, LACTOBACILLUS SPECIES, YEAST [**9-25**] stool culture: C diff+ WBC: 18.9 to 15 to 12.6 [**2166-9-29**] [**Month/Day/Year **]-10.2 (trough) & 32.6 (peak) Brief Hospital Course: In ED, G tube site showed subcutaneous air but no fluid collections or fascial involvement to necessitate emergent surgery. Admitted to SICU for close monitoring. NEURO: neurosurgery consulted. subdural drain placed on HD2 with release of high pressure fluid. mental status subsequently improved & drain was DC'd. per neurosurgery, no need for dilantin at this point. wean decadron per protocol. neurosurgery at southern NH can follow. Her mental status improved over time and she was less agitated. CARDS: initial tachycardia improved with hydration. DC'd on atenolol for BP control. RESP: prn nebs FEN: G tube site erythema gradually improved & G tube was replaced without complication, and sutured to the skin and an abdominal binder placed to prevent the pt. from pulling the tube out. It was confirmed placement in the stomach with a G-tube study. Tube feeds restarted & tolerated before discharge. HEME: hepSC ID: WBC 18 on admission, improved by discharge. Found to be C diff positive, receiving flagyl x 2 wks. Wound culture polymicrobial. It was felt on reviewing the patient's clinical course, careful examination of the patient and examination of her outside CT scan and repeat CT scan here that she did not have necrotizing fasciitis and that the subcutaneous air was related to escape of gastric air into the subcutaneous tissues. Also her stomach was anchored to the abdominal wall likely from scar from a previous G-tube with a well-established tract, such that there was no intraabdominal infection. Thus, she did not require surgery. Her WBC was felt to be related also to the c-diff and UTI which were treates. She remained hemodynamically stable and without fever, and with decreasing WBC and resolution of the minimal erythema at the tube site. A new G-tube was placed within the stomach. ENDO: decadron wean. RISS. HCP: husband [**Name (NI) 449**] [**Telephone/Fax (1) 62388**] Medications on Admission: dilantin 100"', lidoderm patch, nystatin powder, haldol 2.5"', risperdol 0.5', avolox 400', HISS, duoneb", zinc 220', prevacid 30', mannitol 15"", decadron 6"", novadipine 60 """", vancomycin 1000", ciprofloxacin 400', clindamycin Discharge Medications: 1. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram Intravenous Q 12H (Every 12 Hours) for 1 weeks. Disp:*14 gram* Refills:*0* 2. Metronidazole in NaCl (Iso-os) 500 mg/100 mL Piggyback Sig: Five Hundred (500) mg Intravenous Q8H (every 8 hours) for 10 days: for c diff colitis. Disp:*30 doses* Refills:*0* 3. Prevacid 30 mg Susp,Delayed Release for Recon Sig: One (1) dose PO once a day. Disp:*30 doses* Refills:*2* 4. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 5. Haldol 5 mg/mL Solution Sig: One (1) mg Injection three times a day. Disp:*30 mg* Refills:*2* 6. Hydromorphone 2 mg/mL Syringe Sig: One (1) mg Injection Q3-4H (Every 3 to 4 Hours) as needed for pain. Disp:*30 mg* Refills:*3* 7. Lorazepam 2 mg/mL Syringe Sig: 1-2 mg Injection Q4H (every 4 hours) as needed for anxiety. Disp:*30 mg* Refills:*0* 8. Risperidone 0.5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO DAILY (Daily). Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*2* 9. Albuterol Sulfate 0.083 % Solution Sig: One (1) treatment Inhalation Q4-6H (every 4 to 6 hours) as needed. Disp:*15 neb* Refills:*2* 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. Disp:*15 neb* Refills:*3* 11. Nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). Disp:*30 applications* Refills:*2* 12. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). Disp:*90 ml* Refills:*2* 13. Decadron 4 mg Tablet Sig: One (1) Tablet PO four times a day: wean per protocol. Disp:*60 Tablet(s)* Refills:*2* 14. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. Disp:*qs container* Refills:*3* 15. Insulin sliding scale Fingersticks QID. Administer regular insulin as follows: 0-70, [**12-29**] amp D50; 121-160, 2 units; 161-200, 5 units; 201-240, 8 units; 241-280, 11 units; 281-320, 14 units; over 320, 15 units & contact MD. 16. Outpatient Lab Work Serial CBC, chem-10 [**Name8 (MD) **] MD. [**First Name (Titles) **] [**Last Name (Titles) **] trough q48 until stable dose. Discharge Disposition: Extended Care Facility: [**State 20192**] Center Discharge Diagnosis: hepatitis C infection s/p subarachnoid hemorrhage chronic sudbural hematoma s/p PEG [**2164**] interstitial lung disease arthritis polymyositis urinary tract infection c difficile colitis Discharge Condition: improved Discharge Instructions: Tube feeding as ordered. Continue your antibiotics & other prescribed medications as written. Followup Instructions: You are having your care transferred back to the [**Hospital 28448**] Center. Call with any questions. Completed by:[**2166-9-30**]

[ "599.0", "008.45", "536.41", "682.2", "432.1", "070.54", "515", "438.89" ]

icd9cm

[ [ [] ] ]

[ "01.09", "97.02" ]

icd9pcs

[ [ [] ] ]

7086, 7137

2710, 4629

414, 481

7369, 7380

1303, 1314

7523, 7658

916, 933

4910, 7063

7158, 7348

4655, 4887

7404, 7500

948, 1284

335, 376

509, 691

1323, 2687

713, 858

874, 900

46,227

144,943

37915

Discharge summary

report

Admission Date: [**2158-10-17**] Discharge Date: [**2158-10-19**] Date of Birth: [**2103-10-15**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7651**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Cardiac catheterization with intravenous ultrasound History of Present Illness: 55yo M hx [**Hospital **] transferred from OSH s/p DES to LAD now with residual chest pain for IVUS. The pt has been troubled by occasional episodes of chest pressure while exercising for the past year. He characterized the discomfort as substernal chest pressure, [**2159-3-29**] and relieved after 5min with rest. He only experienced this chest pressure ~5 times until [**Month (only) 205**]-[**Month (only) 216**] of this year when he went to his PCP to get it evaluated. He had an exercise stress test in [**Month (only) 216**] which was repeated a week later with nuclear imaging and both tests showed excellent functional capacity with exercise duration of 14 min and no evidence of ischemia. . On the morning on admission ([**2158-10-17**]) the pt developed gradual onset of substernal chest pain while riding on the elliptical treadmill. He rested for 5 minutes and the pain resolved. He then went back on the elliptical and CP returned within 1 minute. He then decided he was going to the ER to get this pain evaluated, but decided to shower first. While exiting the shower he developed excrusciating central chest pressure and heaviness, rater [**9-4**] and radiated to his neck/throat and down the inside of both arms. He also noticed some diaphoresis but denied SOB, HA, lightheadedness, nausea or vomiting. The ambulance was called and pt was given [**Month/Year (2) **] and nitro en route to the hospital. Nitro spray did not change discomfort, nitro SL did improve pain in ED. Vitals on admission were 97.2, 164/98, 87, 16, 99% on RA. Initial EKG showed TWI in 3, AVR, V1. CEs were negative with Troponin T <0.03, CK 141, CKMB 3.9, BNP 59. . Cardiac cath was done which showed prox LAD 80-90% lesion and 40% occlusion of RCA. Plaques were also found in an LAD ramus and diag. During cath the pt developed 4/10 chest pain with ST elevations in the inferior leads. Drug eluting stent was placed to the prox LAD. Proximal portion of the stent looked hazy so pt was transferred to [**Hospital1 18**] for IV ultrasound. At OSH he received [**Last Name (LF) **], [**First Name3 (LF) **], Plavix 600, Nitro gtt, Atorvastatin 80, Metoprolol 12.5 po x1, Lisinoprol 2.5 x1. Post-cath CK 321, MB 45.9, Index 14.3, TnT 0.33. . Upon transfer the pt had [**2-4**] residual substernal chest pain. The pain has been waxing and [**Doctor Last Name 688**], does not radiate and has no associated symptoms. On review of systems, he denies fevers, chills, HA, lightheadedness, SOB, n/v, abd pain, orthopnea, dyspnea on exertion, PND, ankle swelling, palpitations, syncope or presyncope. Rest of the review of systems is negative in detail. He is scheduled with Dr. [**Last Name (STitle) 14334**] tomorrow morning for IVUS for stent evaluation. Past Medical History: 1. CARDIAC RISK FACTORS: HTN 2. CARDIAC HISTORY: -CABG: none. -PERCUTANEOUS CORONARY INTERVENTIONS: [**2158-10-17**] cath wtih drug eluting stent to prox-LAD -PACING/ICD: none. 3. OTHER PAST MEDICAL HISTORY: tonsillectomy Social History: software developer for health company -Tobacco history: 1-2packs per year for 20 years. Quit 17yrs ago. -ETOH: [**3-7**] drinks per week -Illicit drugs: none. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Father died of lung cancer/asbestosis, mother died of stroke. Physical Exam: VS: T= BP=142/72 HR=67 RR=16 O2 sat= 98% on 2L GENERAL: AAOx3. NAD. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP of *** cm. CARDIAC: RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. Normoactive BS. EXTREMITIES: No c/c/e. R femoral cath site CDI no oozing, induration or bruits. 2+ DP pulses bilaterally. Pertinent Results: On Admission: [**2158-10-17**] 11:57PM GLUCOSE-138* UREA N-12 CREAT-0.8 SODIUM-139 POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-21* ANION GAP-16 [**2158-10-17**] 11:57PM WBC-11.4* RBC-4.54* HGB-13.3* HCT-38.9* MCV-86 MCH-29.4 MCHC-34.2 RDW-13.0 [**2158-10-17**] 11:57PM PLT COUNT-270 [**2158-10-17**] 11:57PM CALCIUM-8.8 PHOSPHATE-3.7 MAGNESIUM-2.1 [**2158-10-17**] 11:57PM PT-13.6* PTT-32.0 INR(PT)-1.2* [**2158-10-17**] 11:57PM CK-MB-60* MB INDX-14.1* cTropnT-0.61* [**2158-10-17**] 11:57PM CK(CPK)-426* [**2158-10-18**] 06:25AM BLOOD CK(CPK)-450* [**2158-10-18**] 06:25AM BLOOD CK-MB-58* MB Indx-12.9* cTropnT-1.14* [**2158-10-18**] 04:10PM BLOOD CK(CPK)-292* [**2158-10-18**] 04:10PM BLOOD CK-MB-30* MB Indx-10.3* . CARDIAC CATHETERIZATION [**2158-10-18**]: 1. Selective coronary angiography of this right dominant system demonstrated minimal plaque in the LMCA. The LAD had ostial faint haziness that likely appeared to be mock effect froma small side branch. The proximal stent was widely patent with moderate mid LAD disease up to 40-50% stenosis. The distal LAD had mild disease and the diagonal arteries were patent. The ramus branch had mild to moderate proximal disease. The LCX had mild diffuse disease. 2. IVUS of the proximal and mid LAD demonstrated moderate plaque of the mid LAD up to 40% with CSA of 8mm2. The proximal LAD tsent was widely patent and well apposed on the vessel wall with CSA Of 9mm2. The ostial LAD was widely patent with mild plaque and the ostium of the ramus and LCx were free of disease. The LMCA had very mild plaque. FINAL DIAGNOSIS: 1. NO angiographically apparent flow limiting coronary artery disease. 2. Patent LAD stent. . On Discharge: [**2158-10-19**] 06:38AM BLOOD WBC-10.4 RBC-4.41* Hgb-13.7* Hct-38.1* MCV-86 MCH-30.9 MCHC-35.8* RDW-12.9 Plt Ct-254 [**2158-10-19**] 06:38AM BLOOD Plt Ct-254 [**2158-10-19**] 06:38AM BLOOD Glucose-105 UreaN-12 Creat-0.9 Na-136 K-4.3 Cl-103 HCO3-24 AnGap-13 Brief Hospital Course: 55 year old male with a history of [**Hospital **] transferred from [**Hospital **] with NSTEMI status post drug eluting stent to LAD for intravascular ultrasound. . # CORONARIES: Per the patient's history he likely has a history of stable angina with NSTEMI on the day of admission. At the outside hospital a cardiac catheterization was done which showed prox LAD 80-90% lesion and a drug eluting stent was placed to proximal LAD. There was concern at the outside hospital over the patency of the stent. He was transferred here for intravascular ultrasound which showed widely patent stent. Previous concern was likely [**Last Name (un) **] effect. No re-intervention was done. Peak CK 450, MB 58, TnT 1.14. Aspirin 325 po qday, Atorvastatin 80 po qday, Plavix 75 po qday were started. Nitro sublingual tabs were given prn for chest pain. . # PUMP: There was no previous history of heart failure or heart failure symptoms. LV gram at the outside hospital showed hypokinesis of anterior wall and apex. Lisinopril 10 po qday and Metoprolol 37.5 po bid were started. . # RHYTHM: The patient has no history of abnormal rhythms. No events were seen on telemetry during admission. ECGs have been showing slightly slurred upstroke of R wave in precordial leads - possible delta waves concerning for accessory pathway. . #Discharge: On [**2158-10-19**], after a thorough workup revealed no ongoing coronary ischemia, and the patient was asymptomatic, he was discharged to home from [**Hospital1 771**] in good, ambulatory conditions, with stable vital signs. Prior to discharge, post myocardial infarction education was reviewed with the patient including reduction of risk for coronary disease, appropriate exercise after myocardial infarction, and a review of his discharge medications. Medications on Admission: Amlodipine 2.5 po qday Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Do not stop taking unless your cardiologist tells you to. . Disp:*30 Tablet(s)* Refills:*11* 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. Disp:*60 Tablet, Sublingual(s)* Refills:*0* 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Metoprolol Succinate 50 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* Discharge Disposition: Home Discharge Diagnosis: Non-ST elevation myocardial infarction, with patent drug-eluting stents placed at [**Hospital3 1280**] Hospital Discharge Condition: Good, ambulatory, vital signs stable Discharge Instructions: You were admitted to [**Hospital1 69**] from [**Hospital3 1280**] Hospital, for evaluation of coronary blood flow using an ultrasound device. A thorough examination, including a cardiac catheterization demonstrated that the stent that was recently placed in your coronary arteries at [**Hospital3 1280**] Hospital was widely patent with good blood flow. You are being discharged to home in good condition, with stable vital signs, with appropriate outpatient follow-up at [**Hospital3 1280**] Hospital arranged for you. . Please [**Hospital3 10836**] immediately to the Emergency Room with any new or concerning symptoms including, chest pain, shortness of breath, palpitations, fainting, dizzyness, or nausea or vomiting. Please call your doctor [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the Emergency Room if you notice changes in your groin from the sites where a catheter was enterred. Changes may include new bruising, pain, hardening of the skin, or numbness or tingling. . You may resume normal activities, including driving, upon discharge. Please limit exertional activities over the next two weeks including exercise and sexual intercourse. Please refrain from lifting heavy objects or from straining over the next [**2-28**] weeks. Followup Instructions: -Please follow-up with Dr. [**Last Name (STitle) 32255**] or Dr. [**Last Name (STitle) 14334**] at the Heart Center of [**Hospital1 **] in the next 1-2 weeks. You have an appointment scheduled with Dr. [**Last Name (STitle) 32255**] on Friday [**2158-10-26**]. - Please follow-up with your primary care doctor in the next [**1-27**] weeks

[ "V45.82", "401.9", "414.01", "410.71" ]

icd9cm

[ [ [] ] ]

[ "88.56", "00.24", "37.22" ]

icd9pcs

[ [ [] ] ]

8959, 8965

6314, 8098

329, 382

9121, 9160

4343, 4343

10472, 10814

3590, 3739

8171, 8936

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3223, 3351

6032, 6291

279, 291

410, 3152

4357, 5907

3382, 3397

3174, 3203

3413, 3574

9,248

169,997

21411

Discharge summary

report

Admission Date: [**2173-1-8**] Discharge Date: [**2173-1-13**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 783**] Chief Complaint: 80y/o M presented to ED with dizziness, exertional chest pain, lightheadedness x3 days. Major Surgical or Invasive Procedure: right femoral line blood transfusion (three units) History of Present Illness: Pt presented to OSH with dizziness and chest pain x3 days. Chest pain: pt went to move luggage, felt chest pain and also dizziness. Chest pain with some improvement with lying down. Has had multiple episodes of similar pain lasting 2-3 hours, sometimes associated with activity. Reports dizziness, lightheadedness, ringing in his ears. No vertigo. Denies fever/chills, + mild SOB with activity. No [**Location (un) **], reports good appetite, denies N/V. + left neck pain. Reports a [**3-19**] week history of diarrhea prior to admission, nonbloody, about [**3-19**] bowel movements/day. No sick contacts, no different food. Denies associated abdominal pain, cramping, or vomiting. Reports that he did feel thirsty during that time. OSH course ([**Hospital3 4298**]): Pt was found to have Cr of 3.7 and K 6.8, digoxin 1.5; was started on dopamine gtt, given digibind, aspirin, atropine 0.5mg x2, and 1 U PRBC. Transferred to [**Hospital1 18**] for question of 3rd degree heart block. Here, Pt with sinus brady (HR to 30s), BP 160/44, given Kayexalate, insulin, D50, lasix, bicarb, and transferred to MICU. At this time, pt feels fairly well, is still with minor dizziness but reports much improvement. Reports improvement in his diarrhea, and denies dysuria, LE edema, or orthopnea. Past Medical History: 1. CAD: cath [**11-19**] with LMCA, LCx, RCA patent; LAD with 90% ostial in stent restenosis; LCx with proximal stent. Mild pulm HTN, s/p successful stenting of ostial LAD in stent restenosis. 2. PVD 3. ?COPD: 20-30 pack-yr hx; chronic AM cough 4. ?PAfib: on coumadin. 5. h/o CVA - CT [**5-19**] with chronic white matter infarctions 6. AAA 5 cm seen on CT [**11-19**] 7. h/o EtOH w/d at last admission 8. PTSD 9. depression Social History: TOB: quit 2 months ago, reports 2ppd x 52 years EtOH: "quite a bit" in past but denies any use x 2 mos Lives alone. 2 children in area. Family History: M died when he was a child Physical Exam: on admission: VS 95.5 160/44 30 20 Gen: resting in bed, NAD HEENT: NC/AT, OP clear CV: bradycardic, regular rhythm, no murmurs Pulm: clear bilaterally, no wheezes or crackles Abd: soft, NT, + BS, no rebound or guarding Ext: no clubbing, cyanosis, or edema Neuro: A&O x3 Pertinent Results: [**1-8**] CXR: Mild congestive heart failure. [**1-9**] CXR: CHEST, SINGLE AP VIEW: No central line is identified at this time. No pneumothorax is detected. There is moderately severe cardiomegaly. There is perihilar vascular blurring, consistent with CHF and alveolar edema. No effusion is identified. CHF findings are slightly improved compared with 1 day earlier. [**1-9**] renal ultrasound: RENAL ULTRASOUND: The right and left kidneys measure 12.4 and 14.1 cm, respectively. There is a 2 cm simple cyst visualized in the upper pole of the left kidney. A 4.5 cm cyst is also visualized in the lower pole of the left kidney. The right kidney is unremarkable. There are no stones, masses, or hydronephrosis. IMPRESSION: No evidence of hydronephrosis. [**2172-11-21**] renal ultrasouund: R kidney 11.4cm, L kidney 13.6cm, patent artery/vein bilaterally, simple renal cysts Admission labs: [**2173-1-8**] 04:20PM WBC-8.6 RBC-2.76* HGB-9.1* HCT-27.4* MCV-99* MCH-33.2* MCHC-33.4 RDW-13.3 [**2173-1-8**] 04:20PM NEUTS-85.8* BANDS-0 LYMPHS-8.8* MONOS-3.1 EOS-2.1 BASOS-0.1 [**2173-1-8**] 04:20PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL [**2173-1-8**] 04:20PM PLT COUNT-167 [**2173-1-8**] 04:20PM PT-12.5 PTT-23.7 INR(PT)-1.0 [**2173-1-8**] 04:20PM CALCIUM-9.8 PHOSPHATE-4.7* MAGNESIUM-2.5 [**2173-1-8**] 04:20PM GLUCOSE-148* UREA N-51* CREAT-3.7*# SODIUM-140 POTASSIUM-7.6* CHLORIDE-107 TOTAL CO2-23 ANION GAP-18 [**2173-1-8**] 04:20PM CK(CPK)-57 [**2173-1-8**] 04:31PM cTropnT-0.04* [**2173-1-8**] 05:50PM DIGOXIN-1.5 [**2173-1-8**] 04:39PM K+-7.8* [**2173-1-8**] 04:39PM HGB-9.1* calcHCT-27 [**2173-1-8**] 07:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-500 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2173-1-8**] 07:15PM URINE OSMOLAL-423 [**2173-1-8**] 07:15PM URINE HOURS-RANDOM CREAT-135 SODIUM-82 POTASSIUM-44 CHLORIDE-43 [**2173-1-8**] 08:38PM K+-6.6* [**1-9**]: K 4.7, Na 143, Cl 105, bicarb 27, BUN 44, Cr 3.3, Mg 1.8 Discharge labs: [**2173-1-12**] 05:15AM BLOOD WBC-6.8 RBC-3.49* Hgb-11.5* Hct-33.7* MCV-96 MCH-32.8* MCHC-34.1 RDW-13.9 Plt Ct-182 [**2173-1-12**] 05:15AM BLOOD Glucose-73 UreaN-49* Creat-2.8* Na-142 K-4.0 Cl-102 HCO3-29 AnGap-15 [**2173-1-12**] 05:15AM BLOOD Calcium-9.7 Phos-3.2 Mg-1.8 [**2173-1-12**] 05:15AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-POSITIVE [**2173-1-12**] 05:15AM BLOOD ANCA-NEGATIVE [**2173-1-12**] 05:15AM BLOOD [**Doctor First Name **]-NEGATIVE [**2173-1-10**] 01:48PM BLOOD PEP-HYPOGAMMAG IgG-571* IgA-221 IgM-67 [**2173-1-12**] 05:15AM BLOOD C3-151 C4-36 [**2173-1-10**] 05:07AM BLOOD Digoxin-1.1 [**2173-1-12**] 05:15AM BLOOD HCV Ab-NEGATIVE Micro data: [**1-10**] stool culture negative, C diff negative Brief Hospital Course: 1. symptomatic bradycardia - Pt was likely bradycardic due to digoxin toxicity. Digibind was given to the patient at the outside hospital, and there was no indication for acute dialysis. The precipitating factors of digoxin toxicity were thought to be diarrhea and dehydration-induced renal failure, causing decreased clearance of dignoxin. Digoxin was stopped, as was his beta blocker. Pt's heart rate increased to 70s-80s and he was hemodynamically stable. His digoxin was discontinued. He was tried again on his beta blocker prior to discharge, but this again resulted in bradycardia into the low 50s. 2. acute on chronic renal failure - Pt's chronic renal failure was thought to be due to long-standing hypertensive disease; pt was also taking continual NSAIDs. Renal consult was called. Acute renal failure was thought likely to be due to ATN due to the course of recovery and post-ATN diuresis; ATN developed most likely in the setting of long-standing dehydration, with NSAID use. FENa was 1.5%. A smear for urine eosinophils was negative. Pt's renal ultrasound showed somewhat enlarged kidneys, raising the concern for multiple myeloma; SPEP and UPEP were sent. Of note, pt had nephrotic range proteinuria on 2 different urine samples (5.4g/day and 6.5g/day); the etiology for this is unclear, but could be due to minimal change disease. Pt will follow up in nephrology clinic. During the course of his hospitalization, pt's renal function was in the direction of recovery (Cr on admission 3.7, on discharge 2.8, baseline about 1.3). Pt had good urine output during his stay and did not require dialysis. 3. hyperkalemia - Hyperkalemia was thought to be due primarily to acute renal failure, but also with ACE inhibitor and triamterene use. These drugs were held. Pt's potassium was 7.6 on admission. He was treated with lasix, Kayexalate, D50, and insulin. Pt's potassium was better controlled by HD #2 and remained stable throughout the rest of his hospitalization. This was likely due to renal failure and reolved with improvement of renal function. 4. diarrhea - Pt's diarrhea had resolved by HD #2. Stool studies were sent, which were negative for C diff, Salmonella, and Shigella. 5. hypertension - Pt's SBP was around 160s-170s on transfer to the floor. His baseline per clinic notes seemed to be around 160s. This may be a contributing factor to his chronic kidney disease. Pt's ACE I was held in the setting of acute renal failure; BB was held in the setting of symptomatic bradycardia; diuretics were held in the setting of acute renal failure. Therefore, pt was ultimately begun on amlodipine 10mg the day prior to discharge, and his SBP over the course of that day ranged from 140s-160s systolic. 6. anemia - Pt was guaiac negative. His Hct was 27.4 on admission. He received 2 units PRBC with appropriate bump in Hct. Iron studies revealed a slightly low TIBC (259), a normal iron (60) and a normal ferritin (274). Pt's Hct remained stable through the rest of his hospitalization and was 33.7 on the day of discharge. 7. depression/anxiety - Pt was continued on Zoloft and buspirone during his hospital stay. There were no acute issues. 8. dizziness - pt complained of a couple of episodes of transient dizziness during the last few days of admission. During these episodes, 12-lead EKGs were normal, he was not orthostatic, and his glucose and other electrolytes were stable. He was not unstable on his feet. He was somewhat confused at the start of one episode, but this resolved within [**10-30**] minutes. Pt reports that he has had multiple episodes of this in the past. He may need further workup as an outpatient. 9. history of CAD - Pt had recent cardiac catheterization. He was maintained on his aspirin and Plavix, as well as his statin. He may need to be restarted on his beta blocker at some future date, but he likely has nodal disease, as the beta blocker caused significant bradycardia. 10. FEN/GI - Pt was maintained on a renal, cardiac diet. He was given IV fluids as needed. 11. Code - full Medications on Admission: aspirin 325mg po daily plavix 75mg po daily zoloft 100mg po daily triamterene 75mg po daily felodipine 5mg po daily metoprolol 50mg po daily digoxin 0.125mg po daily terazosin 2mg po qHS folate 1mg po daily lipitor 40mg po daily naproxen 550mg po bid vit B12 daily buspirone 10mg po tid Discharge Medications: 1. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Sertraline HCl 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Atorvastatin Calcium 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Buspirone HCl 15 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Amlodipine Besylate 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) **] Nursing Association Discharge Diagnosis: Primary: 1. digoxin toxicity 2. symptomatic bradycardia 3. acute renal failure Secondary: 1. chronic kidney disease 2. chronic obstructive pulmonary disease 3. coronary artery disease 4. hypertension 5. abdominal aortic aneurysm Discharge Condition: stable, ambulating, tolerating po Discharge Instructions: Please take all of your medications as prescribed. You should not take digoxin. You should not take lisinopril or triamterene until a doctor tells you to start taking them again. You should stop using ibuprofen and naprosyn. If you have pain, Tylenol is your best option. It is likely that this has hurt your kidneys. If you notice dizziness, chest pressure or pain, shortness of breath, or any other symptom that is concerning to you, please call your primary care doctor or go to the emergency room. You have been started on a new medication, amlodipine, since metoprolol made your heart rate too low. You will have your blood pressure checked by the visiting nurse. Followup Instructions: You have an appointment with Dr. [**Last Name (STitle) 19751**] on Monday at 3:30PM. Please keep this appointment, as some of your blood pressure medications may need to be changed. Provider: [**Name10 (NameIs) 706**] MRI Where: [**Hospital6 29**] [**Hospital6 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2173-2-16**] 9:15 Provider: [**Name10 (NameIs) 706**] MRI Where: [**Hospital6 29**] [**Hospital6 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2173-2-22**] 3:45 Appointment with nephrologists: Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 720**], M.D. Where: [**Hospital6 29**] MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2173-2-23**] 2:30 [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

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icd9cm

[ [ [] ] ]

[ "38.91", "99.04" ]

icd9pcs

[ [ [] ] ]

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28,004

146,015

16514

Discharge summary

report

Admission Date: [**2160-11-12**] Discharge Date: [**2160-11-14**] Date of Birth: [**2078-11-16**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2145**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: none History of Present Illness: 81 yo Cantonese speaking female with a past medical history significant for ESRD on HD was admitted initially to the MICU with altered mental status and hypotension. . Per report, patient was at HD on Tuesday [**11-11**] when her HD was stopped early due to hypotension. Then on Wednesday [**11-12**], she was noted by her nursing home to be still hypotensive and with altered mental status. The NH reports that she had no fevers, no chills, no dyspnea in the days prior to transfer. They note that at baseline she knows her name and knows where she is but is forgetful and disoriented. Upon arrival to [**Hospital1 18**], her BP was 87/44 but improved to 110/45 with 1L NS. CXR demonstrated pneumonia and she developed a leukocytosis - WBC 5.8->12.7. She was started on broad spectrum antibiotics with ceftriaxone, levofloxacin, and vancomycin and admitted to the ICU. Past Medical History: ESRD on HD (R avf) Pulmonary Fibrosis on O2NC 2L s/p CVA h/o SVT Gout Hypothyroidism Anemia HTN h/o TB h/o colon ca DM2 Osteoporosis h/o falls/gait disorder Social History: Home: lives in [**Hospital6 1643**] [**Telephone/Fax (1) **] ; supportive family with son and daughter who lives locally ?? EtOH, Tobacco, or drug use . Family History: n/c Physical Exam: Gen: NAD HEENT: [**Last Name (un) 17066**] OP NECK: Supple, No LAD, unable to assess JVD at present time CV: RR, NL rate. NL S1, S2. No murmurs, rubs or gallops LUNGS: coarse crackles bilaterally throughout her lungs but no respiratory distress, no accessory muscle use ABD: Soft, NT, ND. NL BS. No HSM EXT: No edema in LE. rubbing left leg, right arm swollen with some bruising - IV in place in rt hand SKIN: No lesions NEURO: AOx1, mumbling, no coherant speech, unable to follow commands but makes eye contact sporadically and responds to very basic questions Pertinent Results: [**2160-11-11**] UA - 0-2 RBCs, 3-5 WBCs, rare bacteria, no yeast, 0-2 epis . MICROBIOLOGY [**2160-11-11**] Blood Cx negative . STUDIES: - [**2160-11-11**] CXR 1. Right lower lobe and retrocardiac opacities that are concerning for pneumonia. 2. Bilateral pleural effusions. - [**2160-11-11**] Head CT 1. No hemorrhage or mass effect. 2. Chronic paranasal sinus mucosal disease. 3. Soft tissue lesion within the external auditory canal with scutal and mastoid air cell erosion. The findings are suggestive of an external auditory canal cholesteatoma. Further evaluation with temporal bone CT is recommended - [**2160-11-11**] CT C spine - 1. No fracture. 2. Diffuse osseous sclerosis likely reflecting underlying renal osteodystrophy. 3. Grade 1 anterolisthesis of C3 on C4 and C4 on C5 likely degenerative. - [**2160-11-11**] AP Pelvis - No fracture or abnormal alignment. - [**2160-11-11**] Right Shoulder XR - No fracture or abnormal alignment. - [**2160-11-13**] Chest XR - Large right pleural effusion is enlarging. Mild pulmonary edema in the perihilar left lung is new. Left lower lobe atelectasis unchanged. No pneumothorax. Graft tubing projects from the right upper arm to the mediastinum, presumably the ascending thoracic aorta. - [**2160-11-13**] CXR - The heart size is moderately enlarged but stable.There is gradual development of left mid lung consolidation, which is consistent for developing aspiration and/or pneumonia. The extensive opacities in the right lung did not change significantly and might be attributable to the patient known IPF. Bilateral pleural effusions are present, which did not change significantly over these two days. . CBC: [**2160-11-11**] 09:00PM BLOOD WBC-6.6 RBC-3.00* Hgb-10.4* Hct-32.6* MCV-109* MCH-34.5* MCHC-31.9 RDW-18.3* Plt Ct-182 [**2160-11-12**] 04:38AM BLOOD WBC-5.8 RBC-2.76* Hgb-9.6* Hct-30.0* MCV-109* MCH-34.8* MCHC-32.0 RDW-18.1* Plt Ct-198 [**2160-11-13**] 06:09AM BLOOD WBC-12.7*# RBC-3.27* Hgb-11.2* Hct-35.3* MCV-108* MCH-34.1* MCHC-31.7 RDW-18.1* Plt Ct-208 [**2160-11-13**] 07:50PM BLOOD WBC-26.8*# [**2160-11-13**] 11:50PM BLOOD WBC-26.6* [**2160-11-13**] 06:09AM BLOOD Neuts-91.4* Bands-0 Lymphs-2.7* Monos-5.6 Eos-0.1 Baso-0.3 . Chem 7 [**2160-11-11**] 09:00PM BLOOD Glucose-100 UreaN-19 Creat-4.1* Na-145 K-5.7* Cl-100 HCO3-36* AnGap-15 [**2160-11-12**] 04:38AM BLOOD Glucose-77 UreaN-17 Creat-3.4* Na-149* K-3.1* Cl-111* HCO3-29 AnGap-12 [**2160-11-13**] 06:09AM BLOOD Glucose-116* UreaN-23* Creat-4.7*# Na-143 K-4.9 Cl-102 HCO3-27 AnGap-19 . LFT's [**2160-11-11**] 09:00PM BLOOD ALT-27 AST-61* CK(CPK)-110 AlkPhos-83 Amylase-39 TotBili-0.4 [**2160-11-11**] 09:00PM BLOOD Lipase-22 . Cardiac Enzymes [**2160-11-11**] 09:00PM BLOOD CK-MB-4 cTropnT-0.39* [**2160-11-12**] 04:38AM BLOOD CK-MB-NotDone cTropnT-0.28* [**2160-11-13**] 06:09AM BLOOD CK-MB-NotDone cTropnT-0.28* [**2160-11-12**] 04:38AM BLOOD CK(CPK)-60 [**2160-11-13**] 06:09AM BLOOD CK(CPK)-99 . ABG [**2160-11-13**] 08:25PM BLOOD Type-ART pO2-62* pCO2-48* pH-7.48* calTCO2-37* Base XS-10c . MISC [**2160-11-11**] 09:00PM BLOOD Calcium-10.6* Phos-3.5 Mg-1.9 [**2160-11-12**] 04:38AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.5* [**2160-11-13**] 06:09AM BLOOD Calcium-10.8* Phos-4.2 Mg-1.8 [**2160-11-13**] 06:40PM BLOOD PTH-823* [**2160-11-12**] 04:38AM BLOOD HBsAg-NEGATIVE [**2160-11-12**] 04:38AM BLOOD HCV Ab-NEGATIVE [**2160-11-13**] 08:25PM BLOOD Lactate-1.5 Brief Hospital Course: 81 yo Cantonese speaking female with a past medical history significant for ESRD on HD, Pulmonary Fibrosis, TB and Colon CA who presented with hypotension, altered mental status and possible PNA. She was admitted to the ICU where her mental status and hypotension briefly improved. She did fairly well on the floor without hypotension until after hemodialysis. After HD, she was hypotensive, hypoxic and in respiratory distress, with marked elevation of her WBC. She was restarted on broad spectrum antibiotics. The family was contact[**Name (NI) **] given her poor prognosis. They confirmed her wished to be DNR/DNI and indicated that she would not want BiPap or agressive treatment. They further stated that the primary goal should be make her comfortable. She was maintained on broad specturm antibiotics but started on Dilauded PRN dyspnea and was not transfered to the ICU. She died on [**2160-11-14**]. The family and PCP were notified. Medications on Admission: HOME MEDICATIONS: Levothyroxine 100mcg PO qdaily Amiodarone 200mg qdaily Megestrol 40mg qdaily Protonix 40mg qdaily Docusate Renagel 800mg TID Nephrocaps 1mg qdaily Hydromorphone 1mg PO q6h prn pain, usually needs 2mg daily Hydromorphone 2mg PO every HD Fentanyl patch 50 mcg q72h started [**8-/2160**] Lactulose 20ml qdaily MOM Bisacodyl [**Name (NI) 10687**] Trazadone 50mg qhs Neurontin 300mg [**Hospital1 **] . TRANSFER MEDICATIONS: Tylenol 325-650mg PO q6h prn Amiodarone 200mg PO daily Bisacodyl prn Docusate 100mg PO bid Heparin 5000 units SC tid Lactulose 30 mL PO daily Levothyroxine 100mcg PO daily Levofloxacin 250mg IV daily Megestrol acetate 40mg PO daily Nephrocaps 1 capsule PO dialy Pantoprazole 40mg IV q24h Sevelamer 800mg PO tid with meals [**Hospital1 10687**] 1 tab PO bid prn Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: Pneumonia Sepsis Discharge Condition: expired Discharge Instructions: N/A Followup Instructions: N/A [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]

[ "403.91", "995.91", "244.9", "515", "486", "250.00", "285.9", "038.9", "585.6" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

7468, 7477

5645, 6591

340, 346

7537, 7546

2216, 5622

7598, 7696

1612, 1617

7440, 7445

7498, 7516

6617, 6617

7570, 7575

1632, 2197

6635, 7032

279, 302

7054, 7417

374, 1245

1267, 1426

1442, 1596

1,701

174,844

51632

Discharge summary

report

Admission Date: [**2165-4-13**] Discharge Date: [**2165-4-18**] Date of Birth: [**2117-2-25**] Sex: F Service: TRANSPLANT SURGERY HISTORY OF PRESENT ILLNESS: The patient is a 40 year old female known to transplant service, who has been evaluated prior for a kidney transplant, who presented to the [**Hospital1 1444**] Emergency Department with acute onset of left lower quadrant pain. The patient said the pain began at around 9:00 p.m. the night of admission and included nausea and vomiting. The patient denies any fever, chills, melena, bright red blood per rectum, shortness of breath or chest pain. She had her last hemodialysis on Friday. On review of systems, she does report having a history of constipation and takes soft softeners at baseline. PAST MEDICAL HISTORY: 1. End stage renal disease. 2. Diabetes mellitus. 3. Coronary artery disease. 4. Cerebrovascular accident. PAST SURGICAL HISTORY: 1. Coronary artery bypass graft in [**2158**]. 2. Bilateral femoral popliteal bypass graft. 3. Status post cesarean section times two. MEDICATIONS ON ADMISSION: 1. Atenolol 25 mg p.o. q.o.d. 2. Dilantin 300 mg p.o. q.h.s. 3. Celexa 10 mg p.o. q.h.s. 4. Remeron 45 mg q.h.s. 5. Wellbutrin 200 mg p.o. twice a day. 6. Pamelor 70 mg p.o. once daily. 7. Levoxyl 0.2 mg p.o. once daily. 8. Reglan 10 mg p.o. twice a day. 9. Allopurinol 100 mg p.o. once daily. 10. Nephrocaps once daily. 11. Epogen 5000 units subcutaneous q.Monday, Wednesday and Friday. 12. Prevacid 50 mg p.o. once daily. 13. Klonopin 4 mg p.o. q.p.m. 14. Insulin pump. 15. Aspirin. ALLERGIES: Penicillin, shellfish and gadolinium. SOCIAL HISTORY: The patient denies ETOH use, quit tobacco several years ago and lives at home. PHYSICAL EXAMINATION: On admission, examination revealed a temperature of 98.3, heart rate 62 and blood pressure 134/54. She appeared comfortable in no acute distress. Chest was clear bilaterally. The heart was regular. The abdomen was soft, with tenderness in the left lower quadrant, with a palpable mass, no rebound or guarding. Rectal was guaiac negative with stool in the vault. There was palpation of the posterior tibial bilaterally and the dorsalis pedis only on the right side. There was a skin graft which showed a positive thrill. LABORATORY DATA: On admission, white blood cell count was 9.2, hematocrit 36.0. Potassium 5.0, blood urea nitrogen 30 and creatinine 4.6. INR 1.1. All other laboratories were within normal limits. CT of the abdomen demonstrated a complete small bowel obstruction with an abnormal segment in the distal jejunum which was consistent with closed loop obstruction. Electrocardiogram on admission showed normal sinus rhythm, no ischemic changes. HOSPITAL COURSE: The patient was immediately taken to the operating room. Prior to going to surgery, the patient had a pulmonary artery catheter placed which immediately demonstrated adequate cardiac output and index and good intravascular volume resuscitation. After hemodynamics were established and found to be adequate, she was taken to the operating room where exploratory laparotomy was performed and lysis of adhesions was performed on a band which had caused a closed loop obstruction. After the completion of the lysis of adhesions, all the bowel was found to be viable and the patient was closed and taken to the Post Anesthesia Care Unit in stable condition. The details of the surgery are found in the operative note. Postoperatively, the patient remained in stable condition with good hemodynamics from the pulmonary artery catheter. Electrocardiogram showed no changes. The patient was ruled out with cardiac enzymes times three. She then spent the night in the Post Anesthesia Care Unit and postoperative day number one her pulmonary artery catheter was changed to a central venous line and she was transferred to the floor for continuation of her care. Postoperative day number two, the patient remained afebrile and reported flatus and her nasogastric tube was discontinued. During her postoperative course, she was followed by [**Hospital **] Clinic for her diabetes mellitus for which she was on insulin pump and her insulin was kept in good control. She was also followed by the renal fellow and she continued on her hemodialysis as an inpatient without incident. On postoperative day number three, she was started on some clears, had minimal nausea and was continued on hemodialysis. On postoperative day number four, the patient was advanced. Nausea had subsided. On postoperative day number five, the patient reported bowel movement, tolerating diet, ambulating and is now ready for discharge. The patient was seen by [**Last Name (un) **] and renal and will follow-up with them as appropriate. DISCHARGE DIAGNOSES: 1. Status post exploratory laparotomy, lysis of adhesions for complete small bowel obstruction. 2. Diabetes mellitus. 3. End stage renal disease on hemodialysis. 4. Coronary artery disease. 5. History of cerebrovascular accident. MEDICATIONS ON DISCHARGE: 1. Reglan 10 mg p.o. twice a day. 2. Nortriptyline 70 mg p.o. q.h.s. 3. Bupropion 200 mg p.o. twice a day. 4. Clonazepam 2 mg p.o. once daily. 5. Protonix 40 mg p.o. once daily. 6. Allopurinol 100 mg p.o. once daily. 7. Mirtazapine 45 mg p.o. q.h.s. 8. Synthroid 200 mcg p.o. once daily. 9. Phenytoin 100 mg p.o. three times a day. 10. Atenolol 25 mg p.o. once daily. 11. Percocet one to two p.o. q4hours p.r.n. 12. Aspirin 81 mg p.o. once daily. 13. Insulin pump [**First Name8 (NamePattern2) **] [**Hospital **] Clinic. 14. Colace 100 mg p.o. once daily. 15. Senna p.r.n. FOLLOW-UP: The patient will follow-up with Dr. [**First Name (STitle) **] next week in clinic and will call for an appointment. The patient will follow-up with the renal team and [**Hospital **] Clinic as appropriate and will call them also in the morning for follow-up appointments. The patient of note was going to have a coronary angiography to evaluate for coronary artery disease. She will call Dr. [**Last Name (STitle) **] and arrange for an angiography at a future date after her follow-up appointment with Dr. [**First Name (STitle) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1331**] Dictated By:[**Last Name (NamePattern1) 3835**] MEDQUIST36 D: [**2165-4-18**] 16:10 T: [**2165-4-21**] 11:02 JOB#: [**Job Number 106987**]

[ "414.01", "560.2", "585", "V45.81", "557.1", "250.41", "493.20", "780.39" ]

icd9cm

[ [ [] ] ]

[ "54.59", "46.80" ]

icd9pcs

[ [ [] ] ]

4797, 5033

5059, 6468

1100, 1646

2759, 4776

935, 1074

1766, 2741

176, 778

800, 912

1663, 1743

40,236

187,307

8477+55949

Discharge summary

report+addendum

Admission Date: [**2181-5-14**] Discharge Date: [**2181-5-24**] Date of Birth: [**2098-1-8**] Sex: F Service: SURGERY Allergies: Fosamax Attending:[**First Name3 (LF) 2836**] Chief Complaint: abdominal pain, rectal bleeding and abdominal distension Major [**First Name3 (LF) 2947**] or Invasive Procedure: Subtotal colectomy and splenectomy. History of Present Illness: 83 year old female with past medical history of CAD with MI in [**Month (only) 956**], atrial fibrillation (not on anticoagulation), Crohns disease and diabetes mellitus who had a recent admission [**5-7**] - [**5-11**] after a fall with an intertrochanteric femur fracture which was repaired with a hip screw on [**5-8**]. She is weight bearing on that leg. She did not have any cardiac events. She was treated for a uti. She was discharged to rehab on lovenox. She has had abd distension for 3 days. She was disimpacted yesterday and treated with Miralax. She says she had many bms and was passing flatus. Today she developed bleeding per rectum and increased abd pain and was brought here. Currently not c/o SOB or chest pain. Past Medical History: -Coronary Artery Disease status post MI in [**2180-12-24**] (3VD on cardiac cath but managed non-operatively) -Depression -Anxiety -Atrial Fibrillation (not on anticoagulation) -Crohn's Disease -Chronic obstructive pulmonary disease -distant history of tonsillectomy and adenoidectomy Social History: Lives alone on [**Hospital3 4298**]. Quit tobacco [**1-1**] after 68 pk years No ETOH in 30 years Family History: She reports multiple family members with heart problems. Physical Exam: Physical Exam: VS: T 95.6, BP 125/56, P 60, RR 14, O2 98% RA Gen: in distress HEENT: dry mucous membranes CV: Irregular rhythm Pulm: CTAB Abd: distended, soft, diffusely tender, no abd scars Extrem: Warm and well perfused, no edema Neuro: A and O*3 Pertinent Results: [**2181-5-14**] 01:35PM WBC-7.3 RBC-3.62* HGB-10.7* HCT-31.8* MCV-88 MCH-29.6 MCHC-33.7 RDW-17.2* [**2181-5-14**] 01:35PM NEUTS-24* BANDS-48* LYMPHS-14* MONOS-5 EOS-0 BASOS-0 ATYPS-0 METAS-9* MYELOS-0 [**2181-5-14**] 01:35PM GLUCOSE-102 UREA N-46* CREAT-1.9* SODIUM-118* POTASSIUM-4.8 CHLORIDE-87* TOTAL CO2-23 ANION GAP-13 [**2181-5-14**] Abdominal CT:1. Pneumatosis of the cecal wall without evidence of portal venous gas. Mild dilatation of the large and small bowel loops without evidence of discrete transition point. No pneumoperitoneum. Limited evaluation for bowel wall ischemia and vessel patency in the absence of IV contrast. 2. Dilated right renal collecting system suggestive of ureteropelvic obstruction. No obstructing stone identified. 3. Cholelithiasis without evidence of acute c [**2181-5-15**] TEE: The left atrium is moderately dilated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%. . The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic regurgitation is seen. Mild to moderate ([**11-24**]+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen.Overall right ventricular function is depressed [**2181-5-22**] Left Hip: IMPRESSION: Left intertrochanteric femur fracture with DHS fixation. Notable backing-out of the dynamic screw compared to intra-operative radiograph Brief Hospital Course: Mrs. [**Known lastname 29878**] as admitted to the hospital and had an abdominal CT which showed pneumatosis around the cecum and soon became hypotensive requiring fluid resuscitation and pressors. She developed peritoneal signs on exam and was urgently taken to the Operating Room where she underwent a subtotal colectomy and splenectomy. She returned to the SICU in stable condition but remained intubated and required some pressor support and fluids post op. She had some brief sinus bradycardia to the 30's on post op day #1 and then developed atrial fibrillation. Cardiac enzymes were flat x 3 but she had a prolonged qtc on her EKG. Cardiology was consulted and recommended TEE which was done on [**2181-5-15**] which revealed an EF >55% and no wall motion abnormalities. Continuation of her amiodarone was recommended and she had no further episodes of bradycardia. She was extubated on post op day #3 and did well. She underwent vigorous pulmonary toilet including chest PT and incentive spirometry and was able to remain free of any pulmonary complications post op. Following extubation she was sent to the [**Date Range **] floor for further monitoring where she continued to make slow progress. She gradually began a clear liquid diet and was eventually increased to regular without difficulty. She did have a speech and swallow evaluation which showed no evidence of aspiration. Prior to her hospitalization she was taking Ensure supplements and she continues to do so. Her incision was healing well and she was seen by the ostomy nurse for instructions and caring for her ileostomy. She was followed by the orthopedic service post op for evaluation after her recent left hip surgery and she was also seen daily by the Physical Therapist. Her activity status was touch-down weight bearing. She did have left hip films done on [**2181-5-22**] which showed some backing out of the intertrocanteric screw. These were reviewed by orthopedics and her activity status will remain the same. They will follow her with serial xrays and a follow uo appointment in 6 weeks. Due to a persistent leukocytosis post op multiple cultures were done including B blood, urine and stool for CDiff. All were negative and she remained afebrile without bandemia however her WBC was in the 20-26K range. Ms. [**Known lastname 29878**] was very discouraged during her hospitalization because of her recent setback after hip surgery. Through intervention with the staff including our social worker , encouragement was given and she wanted to be able to eventually go back to the [**Location (un) **] and be able to take care of herself. She was discharged to rehab with the [**Known firstname **] of returning home in a month or so and she will follow up with Dr. [**First Name (STitle) **] and [**Location (un) **] for further evaluation. Medications on Admission: 1. Amiodarone 200 (once a day (in the morning)). 2. Aspirin 325 DAILY (Daily). 3. Captopril 12.5 (3 times a day). 4. Furosemide 40 (once a day (in the morning)). 5. Atorvastatin 80 once a day. 6. Lorazepam 0.5 mg [**Hospital1 **] 7. Lorazepam 1 PO HS (at bedtime) 8. Multivitamin DAILY (Daily). 9. Metoprolol Tartrate 6.25 twice a day 10. Docusate Sodium 100 [**Hospital1 **] (2 times a day). 11. Bisacodyl 10 DAILY (Daily) as needed for constipation. 12. Enoxaparin 40 mg/0.4 mL Syringe Sig: 0.4 ml Subcutaneous Q 24H 13. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H 14. Acetaminophen 325 PO Q6H (every 6 hours) Discharge Medications: 1. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: 2.5 mg Inhalation Q6H (every 6 hours) as needed for wheezing. 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for SBP<100. 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Enoxaparin 40 mg/0.4 mL Syringe Sig: Forty (40) mg Subcutaneous DAILY (Daily). 6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety, aggitation. 8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for anxiety. 11. Metoprolol Tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2 times a day): Hold for HR<60 SBP<100. 12. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 13. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day). 14. Ipratropium Bromide 0.02 % Solution Sig: One (1) inh Inhalation Q6H (every 6 hours) as needed for wheezing. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Gangrene of the cecum through transverse colon and of the left colon. Discharge Condition: stable Discharge Instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**4-1**] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash [**Month/Year (2) **] incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Followup Instructions: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (orthopedics) ([**Telephone/Fax (1) 29879**]) Call for an appointment in 6 weeks Call Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 29822**]) for an appointment for follow up after you are discharged from rehab. Provider: [**Name10 (NameIs) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SPECIALTIES CC-3 (NHB) Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2181-6-6**] 1:15 Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2181-6-14**] 10:20 Provider: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 1228**] Date/Time:[**2181-6-14**] 10:40 Completed by:[**2181-5-24**] Name: [**Known lastname 5219**],[**Known firstname **] Unit No: [**Numeric Identifier 5220**] Admission Date: [**2181-5-14**] Discharge Date: [**2181-5-24**] Date of Birth: [**2098-1-8**] Sex: F Service: SURGERY Allergies: Fosamax Attending:[**First Name3 (LF) 3149**] Addendum: Ms. [**Known lastname **] remained afebrile, all cultures were negative, wounds were healing without any erythema and the leukocytosis was deemed secondary to her spleenectomy. Discharge Disposition: Extended Care Facility: [**Hospital3 14**] & Rehab Center - [**Hospital1 15**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2000**] MD [**MD Number(2) 3151**] Completed by:[**2181-5-24**]

[ "250.00", "557.0", "820.21", "496", "584.9", "427.31", "275.2", "567.89", "276.1", "562.10", "414.01", "412", "569.89", "300.4", "569.3" ]

icd9cm

[ [ [] ] ]

[ "45.82", "41.5", "38.91", "88.72", "46.20", "99.04" ]

icd9pcs

[ [ [] ] ]

11792, 12030

3408, 6254

8395, 8404

1929, 3385

10430, 11769

1585, 1643

6933, 8179

8302, 8374

6280, 6910

8428, 9885

9901, 10407

1673, 1910

227, 380

408, 1146

1168, 1454

1470, 1569

10,302

119,529

43477

Discharge summary

report

Admission Date: [**2151-7-17**] Discharge Date: [**2151-7-25**] Service: MEDICINE Allergies: Iodine Attending:[**First Name3 (LF) 2485**] Chief Complaint: Respiratory failure Major Surgical or Invasive Procedure: none History of Present Illness: 85 y/o M h/o CAD s/p CABG, dCHF, CRI, AFib on coumadin, CHB s/p pacer, [**Hospital **] transferred from [**Male First Name (un) 1056**] s/p tracheostomy for management of respiratory failure and septic shock. According to reports he was in St. [**Doctor Last Name **] with his wife where they live part of the year when he suffered a fall. Following that he had progressive dyspnea. He presented to the local hospital [**2151-6-29**] where he had a chest xray that showed complete white out of the left lung. He was seen by the surgical consultant in the ED who performed a thoracotomy and chest tube placement with a small amount of red blood. CT scan was reportedly suggestive of a hemothorax. His VS at that time were T 97 BP 85/49 WBC 5.2 Hgb 8.6 PLT 106 PTT 28.2 INR 1.49 Na 136 K4.2 AST 22 ALT 32 CKMB 1.6 Trop <0.05 ABG 7.5 pCO2 32.7 PO2 63, BUN 25 creat 2.4. Chest CT from [**2151-7-1**] reportedly with complete opacification of the left lung with air bronchograms. Findings suggestive of extensive pneumonic consolidation vs malignancy. According to physician notes felt most likely to be hemothorax [**1-30**] pneumonia with supratheraputic INR of 4.4. . He was subsequently transferred to a hospital in [**Male First Name (un) 1056**] on [**2151-6-30**] for treatment by a pulmonologist. He was treated with levophed, imipenem/cilastin, vancomycin, Intropin?. He was mechanically ventilated with settings CMV 50% 500 20 7. During his course he had bronchoscopy which showed LL atelctasis and pneumonia. He had an Echo [**2151-7-7**] which showed EF 60%, dilated left atrium, mild MR, trivial TR, calcific aortic valve, severe LV diastolic dysfunction, no pericardial effusion, no intracardiac thrombus. On [**2151-7-13**] he had tracheostomy given severity of underlying lung process. Levophed was weaned starting on [**2151-7-13**]. CXR from [**2151-7-15**] reportedly showed bilateral perihilar and basal opacities with obscuration of the diaphragm and costophrenic angles most likely pleural effusion. On [**2151-7-16**] he was transfused 10 units platelets. Sputum CX from [**7-13**] with [**Female First Name (un) **] albicans, urine culture from [**7-17**] with 10,000 [**Female First Name (un) **]. Blood culture [**7-14**] with no growth. Labs on [**7-15**] with Vanco T 29.6, [**7-17**] WBC 15.2 HCT 26.3 PLT 55, creatinine 1.4, BUN 85, Na 149, CL 129, CO2 19. . During his [**Hospital **] transfer to [**Hospital1 18**] his V/S were stable with blood pressure 112/46 - 135/69, uneventful per report. . Past Medical History: CAD s/p CABG [**2146**] CHB s/p pacemaker dCHF (EF 55% in [**5-5**]) AFib Tachy-brady syndrome CLL CRI b/l Cr 1.5 Anemia b/l Hct 30-32% HTN COPD Hyperlipidemia s/p hernia repair s/p tonsillectomy BPH Social History: Lives with wife, split time in [**Name (NI) 86**]/St. [**Doctor Last Name **]; quit smoking ~50 yrs ago, drinks ETOH socially; 3 kids; worked in the transportation business . Family History: unknown Physical Exam: V/S T 97.5 HR 86 BP 94/45 RR 18 96% on AC 500/20/5/40% CVP 9 GEN: intubated, sedated HEENT: PERRL, poor dentition; NGT NECK: tracheostomy; R subclavian CV: RRR nl S1S2 no m/r/g PULM: asymmetric chest wall with sunken-appearing left hemithorax; absent BS on left, coarse BS with scattered end-exp wheeze on right ABD: soft, NTND +BS EXT: warm, dry; DP pulses + with doppler; extensive bandages cover all 4 ext SKIN: multiple areas of skin breakdown, friability, ecchymosis; 2 cm R lateral arm ulceration NEURO: withdraws to painful stimuli Pertinent Results: CXR: near-complete white-out of left hemithorax with some aeration of LUL field; RLL field with mild interstitial markings . EKG: V-paced HR 60, underlying rhythm is AFib; old TWI in I,L; old J-point elevation in anterior precordial leads . TTE [**5-5**] - The left and right atria are markedly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Regional left ventricular wall motion is normal. Transmitral Doppler and tissue velocity imaging are consistent with Grade II (moderate) LV diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. IMPRESSION: Symmetric LVH with preserved global and regional biventricular systolic function. Moderate diastolic dysfunction. Moderate mitral regurgitation. Mild pulmonary hypertension. Brief Hospital Course: 85 y/o M h/o CAD s/p CABG, dCHF, CRI, AFib on coumadin, CHB s/p pacer, CLL, s/p tracheostomy transferred for management of respiratory failure and septic shock. On admission patient was s/p tracheostomy. The records incomplete but suspect hypoxic resp failure in the setting of septic shock, airway collapse. A bronchoscopy revealed friable airways, bronchomalacia, mucous, and old blood consistent with severe hemorrhagic aspiration PNA. Patient's repiratory status was supported with mechanical ventilation. A chest CT was performed which showed a loculated pleural effusion concerning for emphyema. The patient's family decided not to persue thoracocentesis to drain abscess. The patient septic shock did not improve after several days of pressors and fluid boluses. The patient was treated with broad spectrum antibiotics. Given the patient's poor overall prognosis the family eventually decided to make the patient CMO. He passed away peacefully and his family was notified of the patient's passing. Medications on Admission: amlodipine 2.5 mg daily norvasc 7.5 mg daily metoprolol 25 mg [**Hospital1 **] spironolactone 25 mg daily lasix 60 mg qAM, 20 mg qPM coumadin 2.5 mg daily ASA 81 mg daily lipitor flomax 0.4 mg daily finasteride zantac 150 mg [**Hospital1 **] vit D 1000 U daily FeSO4 B12 1000 mcg citracel dulcolax MVI Discharge Medications: NONE Discharge Disposition: Expired Discharge Diagnosis: Septic Shock likely secondary to aspiration PNA Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired Completed by:[**2151-7-25**]

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icd9cm

[ [ [] ] ]

[ "96.6", "96.72", "38.91", "38.93" ]

icd9pcs

[ [ [] ] ]

6437, 6446

5042, 6056

234, 240

6537, 6546

3831, 5019

6602, 6640

3246, 3256

6408, 6414

6467, 6516

6082, 6385

6570, 6579

3271, 3812

175, 196

268, 2814

2836, 3037

3054, 3230

21,781

139,158

11633

Discharge summary

report

Admission Date: [**2194-6-23**] Discharge Date: [**2194-7-23**] Date of Birth: [**2124-4-26**] Sex: M Service: MEDICINE Allergies: Penicillins / Tetracyclines / Iodine Attending:[**First Name3 (LF) 3913**] Chief Complaint: left leg deep venous thrombosis and shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: CC: shortness of breath and DVT in left lower extremity HPI: 70 y/o CM with h/o AML dx [**12-8**] s/p allo-BMT [**5-9**] c/b GVHD of the lungs (bronchiolitis obliterans) and the lichen-planus version of GVHD of the skin, transferred from OSH with left LE DVT extending up to groin. He went to [**Hospital3 **] ER with shortness of breath, tachycardia, and lower extremity edema. He was in atrial fibrillation with rapid ventricular response at the OSH and ruled in by cardiac enzymes for non-ST elevation MI. He was in pulmonary edema and diuresed with lasix. His metoprolol was titrated up, but not on aspirin upon transfer. He was started on Lovenox for anti-coagulation and 2 doses of coumadin were given to bridge prior to tranfer. V/Q scan low probability for PE, as IV Contrast could not be used (allergy to contrast). He has been constipated in the past few weeks and attributes this to oxycodone use (for history of spinal compression fracture). In the past 3 days, however, he has had several small, loose stools/day. No abdominal pain. ROS: No fevers, chills, nausea, vomiting. Skin unchanged. Past Medical History: Past Oncologic History: Pt was diagnosed with AML MO subtype in [**2192-12-5**] after 2 months of progressively worsening fatigue and dyspnea on exertion. He was treated with idarubicin and ARA-C (7+3). Induction was complicated by typhlitis. In [**2-9**] he received HiDAC consolidation, which was well tolerated. Marrow examination [**4-9**] showed no evidence of leukemia. He was subsequently admitted on [**2193-6-4**] for busulfan/cytoxan followed by allogeneic sibling matched transplant. . His post transplant course was complicated by GVHD of the lungs and skin. The pt developed BOOP, bronchiolitis obliterans, for which he is on chronic steroid therapy, inhalers. His last set of PFTs was FEV1 1.58, FVC 2.47, on [**2194-1-31**]. He also developed GVHD of the skin, lichen planus subtype, for which he has received 2 doses of rituxan with benefit. . Past Medical History: 1. Hypertension 2. Type 2 Diabetes Mellitus 3. Paroxysmal Atrial Fibrillation- off coumadin since [**1-9**] 4. Coronary Artery Disease --s/p echo [**2193-5-14**] LVEF 50% Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. --s/p Stress Test [**5-8**]-IMPRESSION: Borderline EKG evidence of myocardial ischemia at peak exercise in the absence of anginal symptoms at the achieved level of work (unchanged from prior stress in [**2185**]). --s/p Coronary catheterization following abnormal stress test in [**2185**] showing up-sloping ST depressions with normal Thallium image. Showed non- flow limiting disease with a tapering LAD 5) type II diabetes (diet and oral [**Doctor Last Name 360**] controlled) 6) h/o salivary duct stone 7) CRI: BL Cr 1.7 - ? [**2-6**] to cyclosporine . Admission Meds: acyclovir 400mg [**Hospital1 **] azithromycin 250mg qday bactrim DS 160mg qM/W/F Cellcept 750mg qam 500mg qnoon 750mg qhs Cipro 500mg po bid cozaar 25mg po qday lasix 60mg po qday magnesium 750mg po qday Toprol 50mg po qday (just increased) prednisone 35 mg po qday protonix 40 mg po bid singulair 10mg po qday voriconazole 200mg po bid Lantus 10u qhs, RISS prn Senna tobramycin inh qday advair [**Hospital1 **] Social History: Marital Status: Divorced and remarried with three children, lives with his wife. Occupation: Engineer AGFA, retired purchasing [**Doctor Last Name 360**]. Tobacco: No current use. quit 38 years ago, previous 30 yr h/o [**1-8**] ppd. Alcohol: none currently, previously [**4-12**]/week. Illicits: none Toxins: No exposures Family History: Mother: died at age [**Age over 90 **] with h/o HTN, Afib Father: MI in 40s Brother: premature CAD, recent dx prostate CA. No family history of cancer/leukemia/lymphoma Physical Exam: Vitals: 96.9F HR 74 BP 134/86 RR 20 97%/2.5L General: alert and oriented, no acute distress, speaking in full sentences HEENT: PERRL EOMI anicteric sclera, MMM, OP clear without lesions or thrush Neck: No JVD Lungs: bilateral crackles and wheezes heard with rhoncorous sounds throughout CV: RRR S1 and S2 audible without m/r/g Abd: Soft, NT, ND NABS, No masses. No HSM Ext: warm, well-perfused, 2+ DP pulses b/l. No edema. Skin: hyperpigmented scaly plaques, patches. Pertinent Results: [**2194-6-23**] 05:25PM BLOOD WBC-7.9 RBC-3.49* Hgb-12.0* Hct-33.5* MCV-96 MCH-34.3* MCHC-35.7* RDW-17.9* Plt Ct-110* [**2194-6-23**] 05:25PM BLOOD Neuts-88.9* Lymphs-6.1* Monos-4.9 Eos-0.1 Baso-0 [**2194-6-23**] 05:25PM BLOOD PT-16.1* PTT-44.4* INR(PT)-1.5* [**2194-6-23**] 05:25PM BLOOD Glucose-140* UreaN-22* Creat-1.0 Na-127* K-4.3 Cl-89* HCO3-30 AnGap-12 [**2194-6-23**] 05:25PM BLOOD Calcium-8.1* Phos-3.1 Mg-2.1 UricAcd-3.9 [**2194-6-23**] 05:25PM BLOOD ALT-20 AST-23 LD(LDH)-331* CK(CPK)-PND AlkPhos-145* TotBili-0.6 [**2194-6-23**] CXR: Portable AP chest radiograph compared to [**2194-6-11**]. The heart size is normal. The aorta is tortuous with no focal dilatation. The lungs are clear. The pleural surfaces are smooth. There is no pleural effusion. IMPRESSION: No acute cardiopulmonary process EKG: unchanged from prior. HR 60's. Sinus rhythm, left bundle branch block, left axis deviation. [**2194-6-24**] CT Chest without contrast CT OF THE CHEST: IMPRESSION: 1. New multifocal peribronchiolar and peripheral ground-glass opacities. The appearance suggests infectious process, most likely due to RSV in the setting of bone marrow transplant, although infectious etiologies and COP are also possible. 2. Minimal diffuse bronchial dilation, a finding that may be seen with obliterative bronchiolitis. Expiratory images were not performed to demonstrate potential air trapping. 3. T7 and T9 compression fractures, new since the prior CT but unchanged from [**6-11**] chest x-ray. . [**2194-7-8**] Portable CXR Vascular catheter remains in standard position. Heart size is normal. There are three subtle poorly defined rounded areas of opacity present in the right upper lobe, right infrahilar region and left retrocardiac region. This could be due to an early bronchopneumonia, septic emboli, or multifocal aspiration. Brief Hospital Course: A/P: 70 year old male with AML s/p Allo BMT complicated by GVHD of lungs and skin transferred from an outside hospital with DVT, NSTEMI in the setting of Afib with RVR, and worsening shortness of breath. Mr. [**Known lastname 1007**] had a very long and complicated course that ended in his death over a month after his admission. Briefly Mr. [**Known lastname 1007**] was admitted on his home regimen of medications and was started on lovenox to treat his DVT. His VQ scan did not show evidence of pulmonary embolus. He had severe dyspnea on admission which was likely multifactorial, for the most part being secondary to his bronchiolitis obliterans/GVHD of the lungs with an element of congestive heart failure secondary to his NSTEMI. He was diuresed and his heart failure was treated. With regards to his [**Last Name **] problem: lung GVHD, Ms. [**Known lastname 1007**] and Dr. [**First Name (STitle) 1557**] decided to procede with a new therapy called photopheresis which had been discussed on an outpatient basis. His lovenox was held fo a day prior to placement of his photopheresis catheter, but unfortunately Mr. [**Known lastname 1007**] [**Last Name (Titles) **] profusely and became further hypoxic in the setting of the catheter placement. He was sent to the MICU, placed on CPAP and diuresed for his hypoxia. He was kept off anticoagulation and was transfused numerous units of pRBCs. He was stabilized and sent back to the floor. There continued to be problems controlling his anticoagulation (although his bleeding subsided) and was eventually placed on a low-goal, no bolus heparin nomogram. He received 2x photopheresis treatments but these were abandoned because his general deconditioning, the ambulance transfer required for the procedure, and the large dose of heparin needed for the treatment were considered to risky for him. Also with regard to his GVHD of the lungs, he was on mycophenolate and methylprednisolone on admission. His mycophenolate had to be decreased secondary to thrombocytopenia and he was begun on tacrolimus 1mg po bid. He was unfortunately found to have worsening [**Last Name (Titles) **] status and a toxic level of tacrolimus (22-25), so this medication was stopped. His chronic restrictive lung disease was very difficult to manage and he remained dyspneic with a 2-4L N/C oxygen requirement despite maximal diuresis. With regard to infection: he was on chronic voriconazole for concern of a + sputum culture for aspergillus (not fumigatus) as an outpatient. He was also on chronic acyclovir and bactrim. A CXR on [**7-8**] showed an ill-defined density concerning for a fungal infx so he recieved a 14d course of caspofungin with resolution of this radiographic finding. As part of his thrombocytopenia work-up he was found to have a positive CMV viral load and was started on gancicyclovir. This level was followed and increased. He was afebrile this admission, but became hypothermic near the end of his course. Blood and urine cultures were persistently negative for bacterial infection. Toward the end of his course Mr. [**Known lastname 25817**] [**Last Name (Titles) **] status declined with increasing somnolence. Head CT was negative. He did not have focal neurologic symptoms. His wife refused MRI, LP, and ABG. His tacrolimus level was found to be 25 and this medication was held. He was progressively uremic without a cause which may have contributed Overall Mr. [**Known lastname 1007**] was terribly deconditioned with [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 36901**] and weeping arms. He likely had steroid myopathy as well as profound wasting from non-use. In the end Ms. [**Known lastname 1007**] had multiple discussions with various providers about her husbands [**Name (NI) **] clinical picture and poor prognosis. The decision was made to change the goals of care to comfort measures. he was begun on a morphine drip with a scopolamine patch with ativan for respiratory comfort. He passed away peacefully with his wife at his side. His body was delivered directly to the funeral home as per his wife's wishes. He was a wonderful man and a pleasure to take care of. I wish and [**Doctor Last Name 501**] (his wife) all the best in his absence. Medications on Admission: acyclovir 400mg [**Hospital1 **] azithromycin 250mg qday bactrim DS 160mg qM/W/F Cellcept 750mg qam 500mg qnoon 750mg qhs Cipro 500mg po bid cozaar 25mg po qday lasix 60mg po qday magnesium 750mg po qday Toprol 50mg po qday (just increased) prednisone 35 mg po qday protonix 40 mg po bid singulair 10mg po qday voriconazole 200mg po bid Lantus 10u qhs, RISS prn Senna tobramycin inh qday advair [**Hospital1 **] Discharge Disposition: Home with Service Discharge Diagnosis: AML bronchiolitis obliterans DVT NSTEMI Discharge Condition: stable

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icd9cm

[ [ [] ] ]

[ "99.07", "99.28", "38.93", "99.88", "99.04", "99.05", "93.90", "99.15" ]

icd9pcs

[ [ [] ] ]

11324, 11343

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353, 360

11426, 11436

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4225, 4699

258, 315

388, 1509

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28,619

153,223

47014

Discharge summary

report

Admission Date: [**2160-9-29**] Discharge Date: [**2160-10-2**] Date of Birth: [**2103-5-27**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 301**] Chief Complaint: Bright red blood per rectum, with associated dizziness and lightheadedness and believes he syncopized on the way to the hospital (corroborated by his wife). Major Surgical or Invasive Procedure: Fluid resuscitation with tagged RBC scan History of Present Illness: . HPI: 57 yo M with a history of diverticulosis and recurrent lower GI bleed admitted with BRBPR. . The patient was in his usual state of health until approximately 3PM on the day of admission when he noted a small amount of BRBPR. At 7PM the patient had a massive bloody stool followed by another one approximately 20-30 minutes later. The stool was entirely red blood. He noted associated dizziness and lightheadedness and believes he syncopized on the way to the hospital (corroborated by his wife). He denies any chest pain or shortness of breath. The patient was driven to the ED by his wife. On presentation to the ED, 110 100/59 16 100% RA. In the ED, the patient had 2 16g IV's placed. NG lavage was negative. He received 2L NS and was started on a 3rd L with resolution of his tachycardia and improved bp to 76 124/68. He was sent for a stat tagged RBC scan in accordance with GI recs. He received ondansetron and promethazine for nausea. Past Medical History: Diverticulosis, recurrent lower GI bleeding DM, poorly controlled Bronchitis GERD HTN S/p bilateral knee surgery Social History: Lives with his wife in [**Name (NI) 1474**]. Works as a supervisor at NSTAR. No tobacco or drug use. Rare EtOH. Family History: Denies a family history of GI bleeding or diverticulosis. Mother died at age 76 of lung CA. Father alive at age 82 with HTN and DM. Physical Exam: VS: 76 125/76 18 100%RA. Gen: NAD. Comfortable. HEENT: PERRL. CV: RRR. Normal S1 and S2. No M/R/G. Pulm: CTA bilaterally. Abd: Obese, soft, nontender, no palpable organomegaly. Ext: No lower extremity edema. Neuro: A&Ox3. Appropriate mood and affect. . Labs: See below. Remarkable for BUN/Cr 19/1.9, Hct 35.3, platelets 207, INR 1.1, PTT 20.6. . EKG: Sinus tachycardia at 102. Normal axis and intervals. <1mm T elevation in V2. No acute ST or T wave changes. Pertinent Results: [**2160-9-29**] 08:20PM HGB-12.5* calcHCT-38 [**2160-9-29**] 08:10PM GLUCOSE-432* UREA N-19 CREAT-1.9* SODIUM-135 POTASSIUM-3.6 CHLORIDE-100 TOTAL CO2-22 ANION GAP-17 CXR ([**2160-9-29**]): No acute cardiopulmonary process. [**2160-10-1**] 03:58AM BLOOD WBC-7.3 RBC-3.45* Hgb-9.5* Hct-28.1* MCV-82 MCH-27.6 MCHC-33.9 RDW-17.4* Plt Ct-131* Tagged RBC scan - IMPRESSION: Finding consistent with a lower GI bleeding, with the origin in recto-sigmoid. Recommend repeat study in the lateral projection. EGD ([**2160-4-18**]): A single sessile 5 mm polyp of benign appearance was found in the ascending colon. Multiple diverticula were seen in the whole colon and more pronounced in the cecum and ascending colon. Diverticulosis appeared to be severe. . Pathology: Polyp Tissue ([**2160-4-18**]): Normal colonic mucosa. Brief Hospital Course: This is a 57 year old male with recurrent lower GI bleeds from diverticulosis. His past medical history is also significant for diabetes mellitus, GERD, bronchitis, hypertension, and bilateral knee surgery. Admitted [**2160-9-26**] with bright red blood from rectum and syncope. Resusciatated with fluid. Tagged RBC scan done. #1 - Lower GI bleed - Presumed secondary to diverticular disease. Tagged RBC scan weakly positive in recto-sigmoid area. HD 2 the bleeding had stopped and he was having guiac negative stool. #2 - Elevated Cr. Improving with volume rescucitation. last creatinine 1.4 #3 - DM. Poorly controlled. - Insulin sliding scale. Hold oral hyperglycemic agents. - [**Last Name (un) **] consult called to Dr. [**Last Name (STitle) 3617**] on [**2160-10-1**] recommended to continue Metformin 500mg [**Hospital1 **] and begin glyburide as well. Patient will follow-up with [**Hospital **] Clinic. #4 - Rising PSA. PCP reports PSA rising from 1.9->4.8. - Send UA to evaluate for prostatitis. - Outpatient follow-up for further evaluation. Appointment made with Dr. [**Last Name (STitle) 770**] [**11-10**], at 2:10 pm [**Location (un) 470**] [**Hospital Ward Name 23**] building. #5 - GERD. PPI therapy. #6 - HTN. Will resume antihypertensives at home. Medications on Admission: Metformin 500 (2) twice daily Cardizem 360mg daily Enalapril 10mg daily Famotidine 40mg daily Atenolol 25mg daily Aspirin 81mg daily Discharge Medications: 1. GlyBURIDE 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*0* 2. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Cardizem 120 mg Tablet Sig: Three (3) Tablet PO once a day. 4. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO once a day. 5. Famotidine 40 mg Tablet Sig: One (1) Tablet PO once a day. 6. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: S/P Recurrent lower gastrointestinal bleed from diverticulosis Discharge Condition: stable Discharge Instructions: Return to the emergency room or notify your physician if you have any of the following: Bloody stools Lightheadedness/dizziness Abdominal pain Nausea/vomiting Or any other symptoms that are concerning to you Followup Instructions: Please call Dr. [**Last Name (STitle) **] office to make an appointment for next week. # [**Telephone/Fax (1) 2723**] Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4653**], MD Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2160-11-10**] 2:10 Completed by:[**2160-10-5**]

[ "530.81", "250.02", "585.9", "403.90", "790.93", "562.12" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5169, 5175

3252, 4533

470, 512

5281, 5289

2403, 3229

5546, 5847

1774, 1907

4717, 5146

5196, 5260

4559, 4694

5313, 5523

1923, 2384

274, 432

540, 1492

1514, 1629

1645, 1758

4,199

101,689

8582

Discharge summary

report

Admission Date: [**2135-5-18**] Discharge Date: [**2135-6-17**] Date of Birth: [**2062-1-21**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1556**] Chief Complaint: Fall with facial abrasions and neck pain Major Surgical or Invasive Procedure: Halo placement [**2135-5-26**], with revision [**2135-6-9**] GJ tube placement [**2135-5-26**], with revision [**2135-6-4**] Tracheostomy [**2135-5-26**] EGD x2 [**2135-5-28**], [**2135-6-3**] Cystoscopy [**2135-6-10**] History of Present Illness: Patient was trasfer from an OSH, he presented s/p fall at home with facial abrasions and neck pain after an unknown period of LOC. Patient was drinking heavily prior to fall. Past Medical History: Type 2 DM Rheumatic Heart Disease Aortic Mechanical Valve AI, MR, Afib Prostate CA Iron deficency Anemia LV failure s/p pacer/defibrillator Emphysema Depression Gout Social History: EtOH+ Denies Cocaine, Heroine Family History: denies Physical Exam: On admission: VS: 97, 116, 140/77, 15 93% Gen: Alert+O x3, NAD HEENT: antreior face abrasions Cardiac: irregularly irregular Chest: CTAB Abd: Soft, NT/ND +BS Ext: no c/c/e, no deformity Neuro: 5/5 strength UE/LE, sensation intact Pertinent Results: [**2135-6-17**] 05:38AM BLOOD WBC-8.3 RBC-3.06* Hgb-9.3* Hct-27.5* MCV-90 MCH-30.2 MCHC-33.6 RDW-14.9 Plt Ct-237 [**2135-6-16**] 05:15AM BLOOD WBC-8.1 RBC-3.18* Hgb-9.7* Hct-28.8* MCV-91 MCH-30.4 MCHC-33.6 RDW-14.9 Plt Ct-223 [**2135-5-24**] 02:54PM BLOOD WBC-9.4 RBC-2.77* Hgb-9.2* Hct-26.3* MCV-95 MCH-33.3* MCHC-35.1* RDW-13.1 Plt Ct-181 [**2135-5-18**] 07:38PM BLOOD WBC-7.9 RBC-3.83* Hgb-12.6* Hct-35.9* MCV-94 MCH-32.8* MCHC-35.0 RDW-13.7 Plt Ct-198 [**2135-6-17**] 05:38AM BLOOD PT-12.7 PTT-49.2* INR(PT)-1.1 [**2135-6-16**] 07:00PM BLOOD PT-12.9 PTT-50.1* INR(PT)-1.1 [**2135-6-16**] 04:15PM BLOOD PT-13.0 PTT-54.6* INR(PT)-1.1 [**2135-5-18**] 07:38PM BLOOD PT-17.1* PTT-29.1 INR(PT)-1.9 [**2135-5-19**] 01:09AM BLOOD PT-17.7* PTT-52.0* INR(PT)-2.1 [**2135-5-19**] 08:26AM BLOOD PT-18.3* PTT-150* INR(PT)-2.2 [**2135-6-17**] 05:38AM BLOOD Glucose-182* UreaN-27* Creat-1.1 Na-135 K-3.8 Cl-98 HCO3-26 AnGap-15 [**2135-6-16**] 05:15AM BLOOD Glucose-137* UreaN-28* Creat-1.2 Na-136 K-4.2 Cl-99 HCO3-26 AnGap-15 [**2135-5-19**] 01:09AM BLOOD Glucose-167* UreaN-8 Creat-0.6 Na-130* K-3.5 Cl-97 HCO3-21* AnGap-16 [**2135-5-18**] 07:38PM BLOOD Glucose-186* UreaN-10 Creat-0.7 Na-135 K-4.4 Cl-100 HCO3-20* AnGap-19 [**2135-5-29**] 03:11AM BLOOD ALT-24 AST-26 LD(LDH)-294* AlkPhos-67 Amylase-30 TotBili-4.3* [**2135-5-28**] 01:00PM BLOOD ALT-21 AST-29 AlkPhos-60 Amylase-23 TotBili-4.1* [**2135-5-18**] 07:38PM BLOOD CK(CPK)-97 Amylase-40 [**2135-5-29**] 03:11AM BLOOD Lipase-40 [**2135-5-19**] 03:59PM BLOOD Lipase-23 [**2135-5-31**] 12:20PM BLOOD CK-MB-NotDone cTropnT-0.01 [**2135-5-18**] 07:38PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2135-6-17**] 05:38AM BLOOD Calcium-9.2 Phos-3.7 Mg-1.9 [**2135-6-16**] 05:15AM BLOOD Calcium-9.2 Phos-5.2* Mg-2.0 [**2135-5-19**] 01:09AM BLOOD Calcium-6.1* Phos-2.5* Mg-2.2 [**2135-5-18**] 07:38PM BLOOD Calcium-9.8 Phos-2.6* Mg-2.5 [**2135-5-19**] 03:59PM BLOOD TSH-0.29 [**2135-6-12**] 08:30AM BLOOD PSA-0.2 [**2135-5-19**] 01:19PM BLOOD Type-ART pO2-338* pCO2-39 pH-7.35 calHCO3-22 Base XS--3 Psych Consult ([**6-13**]): ASSESSMENT: 73 y/o man presented s/p C2 traumatic neck fracture following fall 6 weeks ago. He is s/p Halo, trach, and PEG placement ([**5-26**]) with readjustment during this admission. In the past weeks, his mental status diminished to the point where he could not make medical decisions, so his proxy (son) served as a surrogate decision-maker. At this time, he is able to weigh benefits of risks of treatment, and in general is very accepting to continued medical treatment. He has capacity to medical decisions regarding his care. His current CODE status is DNR/DNI PLAN: reverse DNR/DNI status to FULL CODE approach pt re: medical decisions during this hospitalization make clear to son that his role as proxy is to represent patient's wishes if pt. were able to convey them Cytology on Cystoscopy ([**6-10**]): ATYPICAL. Atypical urothelial cells, present singly and in clusters. Squamous cells, anucleate squames, histiocytes, neutrophils and red blood cells. EGD: [**2135-6-3**]: Diffuse erosive esophagitis with active oozing of blood noted throughout the entire esophagus ECHO (TTE) [**5-30**]: Conclusions: 1. The left atrium is mildly dilated. 2. The left ventricular cavity is mildly dilated. There is severe global left ventricular hypokinesis. Overall left ventricular systolic function is severely depressed. 3. The right ventricular cavity is dilated. Right ventricular systolic function appears depressed. 4. The aortic root is moderately dilated. The ascending aorta is moderately dilated. 5. A bileaflet aortic valve prosthesis is present. The aortic prosthesis leaflets appear to move normally. The transaortic gradient is normal for this prosthesis. Trace aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. EGD ([**5-28**]) A single non-bleeding erosion was noted in the antrum, near the gastrostomy site. RUQ U/S ([**5-28**]) IMPRESSION: Normal right upper quadrant ultrasound without evidence for intrahepatic or extrahepatic biliary ductal dilatation or cholecystitis CT of Cspine [**2135-5-19**] IMPRESSION: 1) Fracture of C2, with posteriorly displaced odontoid fracture fragments causing spinal canal narrowing and cord compression at C1/2. 2) Anterior subluxation of C3 on C4, a finding that, in the setting of trauma, could indicate disruption of the joint capsule at the facet joints, and may be indicative of ligamentous instability. 3) No other fractures identified within the cervical spine. Brief Hospital Course: Pt is a 72 yo man with a significant PMH of Afib, LVF with pacer/defibrillator, Aortic Mechanical valve requiring anticoagulation, Rheumatic Heart Disease, MR, AI, DM, Emphysema, Gout, and Depression who presented to an OS s/p fall where he was found to have an unstable dens fracture. The patient was taken to the OR where a Halo was placed, tracheostomy was performed and open GJ tube was placed. The patient, did well post procedure but developed coffee ground emesis as anticoagulation was restarted, an EGD was performed finding a single non-bleeding 2cm, clean based ulcer in the gastroesophageal junction, a RUQ US was also performed which was normal, the patients Hcts remained stable. Subsequently, the patient developed leakage of gastric contents around the GJ tube and increased G tube output around the GJ site. The patient also developed some hematuria and Heme positive gastric secretions at this time. The Patients Hematocrits continued to drop so much so that Transfusions were required. At this point the decision was made to perform a follow up EGD which showed diffuse erosive esophagitis with active oozing of blood noted throughout the entire esophagus. This occurred despite antiulcer regimens, Heparin was stopped and the patient was brought back to the OR for repositioning of the GJ tube. After this procedure, gastric secretions around the GJ Tube decreased significantly, and the Pts Hct stabilized, the patient was restarted on Heparin, but hematuria persisted, Urology consult was obtained who did cystoscopy and found only an irritated portion of the bladder that was most likely from foley trauma. Bladder irrigation was performed and the patient's urine cleared, anticoagulation was restarted, and the patient's hematocrits remained stable. The patient did have continued episodes of hematuria, but hematocrits remained stable and events always subsided and were often after foley manipulation. In addition, during the course of his stay, the patient had episodes of Confusion and agitation which mostly occurred in the ICU and step down units. Once moved to the floor, the patient cleared considerably and Psych consult deemed the patient to have decision making capacity. Through out the patients stay, his Afib was rate controlled. Medications on Admission: Allopurinol Lasix Coumadin Lexapro Glyburide HCTZ Topral Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed for pain. 3. Docusate Sodium 150 mg/15 mL Liquid Sig: [**12-5**] PO BID (2 times a day). 4. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 5. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed. 6. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) Injection Q4H (every 4 hours) as needed for aggitation. 8. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 9. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 10. Escitalopram Oxalate 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY (Daily). 17. B-Complex with Vitamin C Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 20. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 21. Heparin Sod (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: One (1) Intravenous ASDIR (AS DIRECTED): 1200 units/hr. 22. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): SSI:0-50 mg/dL [**12-5**] amp D50 51-120 mg/dL 0 Units 121-140 mg/dL 3 Units 141-160 mg/dL 7 Units 161-180 mg/dL 11 Units 181-200 mg/dL 15 Units 201-220 mg/dL 19 Units 221-240 mg/dL 23 Units > 240 mg/dL Notify M.D. . Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: C2 odontoid fracture, status post halo fixation and revision GE junctional nonbleeding ulcer Diffuse erosive esophagitis Hematuria Discharge Condition: Stable Discharge Instructions: Return to the Emergency room if you develop high fevers, abdominal Pain, weakness, sensory changes, or other concerns. Take medications as prescribed, follow up as indicated below. Halo must be on for 6-8 weeks, be sure to follow up with Orthopaedic spine regarding removal. Followup Instructions: Follow up with: Ortho Spine: Dr. [**Last Name (STitle) 363**], follow up lateral C-spine x-ray in 10 days, call ([**Telephone/Fax (1) 11061**] for appointment and eval of x-ray. Urology: Call ([**Telephone/Fax (1) 5278**] for appointment Gastroenterology: Dr. [**First Name (STitle) 2643**], follow up in 2 wks, call ([**Telephone/Fax (1) 26817**] for appointment Your Primary Care Doctor, Dr. [**Last Name (STitle) 12982**] ([**Telephone/Fax (1) 30118**], as needed Your Primary Cardiologist, Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 22764**], as needed

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icd9cm

[ [ [] ] ]

[ "57.32", "96.6", "44.13", "96.04", "89.49", "31.1", "96.72", "02.94", "44.39", "45.13", "97.02", "93.41", "38.93" ]

icd9pcs

[ [ [] ] ]

10512, 10582

5918, 8202

355, 577

10757, 10765

1309, 5895

11088, 11658

1035, 1043

8309, 10489

10603, 10736

8228, 8286

10789, 11065

1058, 1058

275, 317

605, 782

1072, 1290

804, 972

988, 1019

9,231

144,023

24759

Discharge summary

report

Admission Date: [**2139-8-14**] Discharge Date: [**2139-8-19**] Date of Birth: [**2075-7-15**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 348**] Chief Complaint: CC:[**CC Contact Info 62412**] Major Surgical or Invasive Procedure: Left IJ central line placed. History of Present Illness: 64 yo man with rectal cancer (all details unknown) presented to ED from [**Hospital3 328**] w/ rigors, fever, hypotension during chemotherapy today (unsure what chemo he is getting). He was briefly unresponsive by report w/ ?seizure activity vs. severe rigoring. He was given 1 g cefepime at [**Company 2860**]. He has minimal recollection of the event but remembers waking up on a stretcher on the way to the [**Hospital1 18**], feeling "cold." "They told me I seized." Finger stick 140 upon arrival. In ED, BP 130/90 HR 130 (sinus tach), resp 44, sat 97% on nasal cannula ?liters, temp 103.7. BP recheck 86/39, HR 124. Given 4L NS, UOP 400 on ED note, L IJ placed, Levophed started. Given cefepime and vanco and diflucan 400 mg IV x 1. Head CT negative. CXR negative except for small nodular density over lung base. U/a positive for UTI. Started on sepsis protocol. K,Mg repleted. BP's improved to 119/59 upon arrival to [**Hospital Unit Name 153**]. Patient reports feeling somewhat better currently. He is alert, pleasant, and has no discomfort currently. He said he hasn't felt "right" for approximately one week. His "legs haven't been steady" and he has had a decreased appetite and fatigue with his ongoing chemotherapy. Dr [**Last Name (STitle) 62413**] is his primary oncologist. He has a chronic foley x ?1 year. Patient is unsure why he has this, but he has had radiation to rectum which may have led to incontinence. . Patient reports having shaking chills last week-- went to [**Hospital1 **] as chronic foley was "blocked." Denies getting abx and was sent home after foley flushed. Past Medical History: PMH: 1. Rectal ca [**2133**] w/ colostomy, has had xrt, cryotherapy, and various chemo regimens per patient. He is unsure of names but thinks he may have had leucovorin and 5 FU. He is currently undergoing "supplemental" chemo, but cannot elaborate. . 2. DVT [**3-10**] on lovenox "my leg swelled up" chronic foley x 1 year . 3. ortho procedure on LLE after fracture . Denies other PMH . 4. pancreatitis . 5. AAA Social History: SOCIAL: lives w/ mother; son helps out; able to do own ADL's, used to work in bakery as a frozen shipper; couple drinks/week or none- denies h/o withdrawal--last drink more than one week ago; quit smoking 5 years ago but smoked 3 ppd for many years. Family History: noncontributory Physical Exam: PE: T 95 P 57 R 16 100% 4L BP 100/53 Gen: comfortable, ill-appearing man, conversant HEENT: no oral lesions, Dry MM, dentures in place, NC in place Neck: no JVD CHEST: CTA with faint crackles at bases; right sided port-a-cath w/o erythema or induration CV: RRR no m/r/g ABD: soft, obese, multiple well healed scars, ostomy in place draining brown, liquid stool; nabs, non tender, no erythema over ostomy site NEURO: poor historian but conversant, a+o x 3; follows all commands, good tone in extrem EXTRM: cool, clammy, diaphoretic, 2+ DP and radial pulses bilaterally. scant edema . Pertinent Results: Admission Labs: GLUCOSE-237* UREA N-13 CREAT-0.7 SODIUM-141 POTASSIUM-5.0 CHLORIDE-118* TOTAL CO2-15* CALCIUM-7.7* PHOSPHATE-0.9* MAGNESIUM-1.5* WBC-7.6 RBC-3.74* HGB-9.4* HCT-29.5* MCV-79* MCH-25.2* MCHC-31.9 RDW-15.6* PLT COUNT-150 UA: moderate blood, moderate leuk esterase, pH 9.0, WBC [**10-25**], many bact Urine Cx: [**2139-8-14**] pansensitive Proteus mirabilis; [**8-15**] and [**8-17**] no growth day of admission urine(data from [**Hospital1 112**]): Serratia sensitive to levofloxacin Blood Cx: [**8-14**], [**8-15**], [**8-17**] no growth day of admission blood (data from [**Hospital1 112**]) pansensitive Proteus mirabilis CXR: No radiographic evidence of pneumonia. Small rounded nodular density projecting over the right lateral extreme lung base. Comparison with outside studies if available is recommended. When clinically feasible, this may be further evaluated with a repeat [**MD Number(3) 25633**] x- ray with shallow oblique views. CT head: no hemorrhagic or mass effect. Brief Hospital Course: Mr. [**Known lastname **] is a 64 yo man w/ rectal ca (stage unknown to this hospital) and a chronic indwelling foley catheter who presented with urosepsis. He states that he no longer sees his old PCP, [**Name10 (NameIs) **] is frequently seen by his oncologist Dr. [**Last Name (STitle) 62414**] of [**Hospital 10596**] Cancer Institute, nad his urologist Dr. [**Last Name (STitle) **] of [**Hospital1 **]. For this particular hospitalization he was diverted to [**Hospital1 18**] because [**Hospital1 112**] was full at that time. 1. Urosepsis: Mr. [**Known lastname **] presented in sepsis with a UA consistent with UTI. He was admitted to the ICU and began sepsis protocol. He required pressors only for a few hours, after which his pressure responded well to fluid boluses overnight. Urine culture quickly grew out pansensitive Proteus mirabilis and the pt was started on ampicillin and gentamycin due to a report of "2 GNRs" from the [**Hospital1 112**] microbiology laboratory with further ID pending. Later confirmation with the [**Hospital1 112**] lab showed a blood culture with pansensitive proteus only, and a urine culture with serratia. The patient was changed to PO levofloxacin and will discharged with this as well to complete a 14 day antibiotic course. His foley catheter was changed during this hospitalization and subsequent urine cultures x 3 were all negative. 2. Rectal ca: The pt is seen by Dr. [**Last Name (STitle) 62414**] at [**Company 2860**] for chemotherapy. He has a follow up appointment with Dr. [**Last Name (STitle) 62414**] on Friday [**8-21**] at 12:45 pm. The pt has a R sided Hickman portacath which appeared clean and intact during his stay here. The pt also has an colostomy, which was cared for by nursing during his stay here. The patient's pain, which he describes as in his rectum or back, was well controlled with his usual regimen of MS Contin 15 [**Hospital1 **] and oxycodone 5mg PO q4hrs prn for breakthrough. 3. h/o DVT [**3-10**]: The pt continued on his usual regimen of lovenox [**Hospital1 **] during his stay here. 4. Glucose intolerance in setting of sepsis: The pt has no known history of DM, however while he was in the MICU he repeatedly had high FS. Upon transfer to the floor, when the pt was stable, his FS were in normal range. He did not receive steroids during his stay. This should be followed up on as an outpt insofar as he is likely at increased risk for the development of diabetes later on. 5. Nodule on CXR: As described, there was a "small rounded nodular density projecting over the right lateral extreme lung base" on CXR. As no other films were available for comparison, we recommend viewing of pt's past CXR or performing another CXR as an outpt for comparison and follow up by his usual caregivers. 6. Health Coverage: The patient believed that he did not have health coverage, however our case manager revealed that he does, in fact, have Medicare. His medications are given to him from the Free Care Pharmacy at [**Hospital1 112**] and [**Company 2860**], and he received free levo from our Free Care pharmacy as well on discharge. 7. Home services: The pt was offered VNA services at home in particular to aid with colostomy care, his portacath site, his foley catheter, and medications, however he repeatedly refused this stating that he did not want someone coming into his home in this capacity. 8. Access: During his stay, a Left IJ central line was placed and removed without event. The pt has a right sided hickman portacath. 9. Chronic indwelling foley catheter and UTI risk: The pt stated that he used to straight cath himself, but has been sleeping many hours per day and had overflow incontinence on many occasions. He has, therefore, had an indwelling cathether for the last year. This may be followed and discussed as an outpt with his usual urologist as to whether this is the best option for the pt, given the infection risk, versus the convenience of a foley. The pt does not believe he has had other UTIs in this time period and may therefore be quite good at maintaining his foley. 10. code: full Medications on Admission: oxycodone 5 mg prn q4 hr pain MS contin 15 mg [**Hospital1 **] lovenox 80 mg sc qd imodium 2 mg qd prochlorperazine 10 mg q6 hr potassium 20 mg qd ditropan 5 mg qd . Chemo as per Dr. [**Last Name (STitle) 62415**] at [**Hospital1 112**]. Discharge Medications: 1. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. 2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 3. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) injection of syringe Subcutaneous Q24H (every 24 hours). 4. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 10 days. Disp:*10 Tablet(s)* Refills:*0* 5. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. 7. Loperamide 2 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: UTI, sepsis Discharge Condition: stable Discharge Instructions: Please continue to take your antibiotic, Levofloxacin, one pill per day until you have finished all of the pills. Take the first pill tomorrow. If you have fever, abdominal pain, increased weakness, or lightheadedness, or if your urine looks very cloudy (or infected) please call Dr. [**Last Name (STitle) 62414**] or come to the emergency room. Followup Instructions: Please keep your appointment with Dr. [**Last Name (STitle) 62414**] on Friday at 12:45. Completed by:[**2139-8-20**]

[ "599.0", "V10.06", "276.2", "995.92", "V44.3", "996.64", "785.52", "038.9" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

9503, 9509

4396, 8513

344, 375

9565, 9574

3367, 3367

9970, 10090

2727, 2744

8801, 9480

9530, 9544

8539, 8778

9598, 9947

2759, 3348

275, 306

403, 2007

4341, 4373

3384, 4332

2029, 2443

2459, 2711

2,297

168,565

5521

Discharge summary

report

Admission Date: [**2114-12-24**] Discharge Date: [**2115-1-3**] Date of Birth: [**2065-9-23**] Sex: F Service: OMED HISTORY OF PRESENT ILLNESS: 49-year-old female with metastatic breast cancer diagnosed in 10/98 noted to be infiltrating ductal carcinoma with ER positive and HER-2/neu positive, node negative. She received four cycles of Adriamycin, and Cytoxan and radiation therapy and had relapse with metastases in [**11/2112**] to bone, liver, and lung. She is now status post her second Arimidex with progression of disease and status post Taxotere, Adriamycin, and Navelbine. She is currently on Xeloda, Zometa, and Herceptin and relatively stable since [**14**]/[**2113**]. The patient was in her usual state of health until one week prior to admission, when she began noticing facial swelling, neck and hand swelling. The patient also noticed some dyspnea with lying flat as well as with any activity. This is a new finding for the patient. Patient denies any pain, denies any stridor, denies any other chest pain, denies bony pain, denies passing out, denies cough, denies fever or chills. PAST MEDICAL HISTORY: 1. Breast cancer, as described, diagnosed in 10/98 with left partial mastectomy Grade 2 infiltrating ductal carcinoma, node negative, ER positive, HER-2/neu positive. Adriamycin, Cytoxan four cycles plus radiation therapy and Tamoxifen changed to Herceptin and Arimidex in 12/[**2111**]. In [**1-/2113**] the patient received Taxotere, Adriamycin, Navelbine, and Herceptin in that year and currently on Xeloda, Zometa, and Herceptin. She has metastatic disease to her lung, liver, and bones. She had malignant pleural effusions in 12/[**2112**]. 2. Cervical cancer at age 20 status post cone removal. ALLERGIES: No known drug allergies. MEDICATIONS: 1. Effexor 75 mg q. day. 2. Ativan q. h.s. 3. Herceptin. 4. Xeloda. 5. Tylenol as needed. 6. Ibuprofen as needed. 7. Fentanyl 100 mcg patch q. 72 hours. 8. Nexium. 9. Femara 2.5 q. day. 10. Epogen 60,000 q. week. SOCIAL HISTORY: She is married; occupational therapist. No tobacco. Occasional alcohol. FAMILY HISTORY: No family history of breast cancer. PHYSICAL EXAMINATION: Vital signs: Temperature 98.6, blood pressure 110/50, heart rate 66, respirating at 12, 95% on room air. In general, pleasant, no acute distress. HEENT: Anicteric. Oropharynx is clear. Pupils equal, round, reactive to light. Extraocular muscles intact. Facial plethora noted with periorbital edema and erythema. Her neck is supple with distended neck veins. Heart is regular rate and rhythm; no murmurs, rubs, or gallops. Lungs: Clear to auscultation bilaterally. Abdomen: Soft, nontender, nondistended; positive bowel sounds. Extremities: She has right greater than left upper extremity diffuse swelling; non-pitting edema; no cyanosis; 2+ distal pulses. Neuro exam: Cranial nerves II-XII intact; awake, alert, and oriented times three; 5/5 strength upper and lower extremities; lower extremities show no calf tenderness; no swelling of her lower extremities. PERTINENT LABORATORY DATA OR STUDIES ON ADMISSION: White count 5.0, hematocrit 35.1, platelets 231, Chem-7 unremarkable. Chest x-ray showed no consolidation, no widening of the mediastinum, no effusion, no lymphadenopathy noted. CTA showed no evidence of pulmonary embolus but showed a 3 cm SVC thrombus with retrograde flow through azygous and lumbar veins returning to the heart via the inferior vena cava. No evidence of pulmonary consolidation. CT head also done in the Emergency Department showed no evidence of metastatic disease. BRIEF SUMMARY OF HOSPITAL COURSE: 49-year-old female with metastatic breast cancer to lungs, liver, and bone apparently on Xeloda and Herceptin being admitted for superior vena cava syndrome secondary to thrombus. 1. Superior vena cava clot: The patient was noted to have a 3 cm clot in her superior vena cava likely related to her Port-A-Cath which was involved with the clot, according to Radiology secondary report. The patient was immediately placed on a Heparin drip, and consideration for thrombectomy versus other Interventional Radiology procedures was considered. Given the patient's significant symptoms of dyspnea as well as facial swelling, she was started on a TPA infusion for a total of 24 hours. The TPA infusion was per an Interventional Radiology protocol, and the patient was monitored in the Intensive Care Unit during this infusion period. The patient was monitored for signs of bleeding. During the infusion the patient's Heparin drip was decreased, and she was closely monitored for neurologic, bleeding, or other signs of bleeding. The TPA was infused through her Port-A-Cath. The infusion was 1 mg per hour times eight hours then 0.5 mg per hour times 16 hours. [**Name (NI) **] PT, INR, fibrinogen, platelets, and hematocrits were followed during this infusion. If her fibrinogen was less than 150, her TPA dose would be decreased by half, and if it was less than 100 her TPA would be discontinued completely. The patient's fibrinogen remained stable throughout, and her TPA was tolerated well. The repeat CTA showed complete clearance of clot along wall of the superior vena cava and a very small filling defect. There was a fibrin sheath or residual clot--it was unclear--along the terminal portion of the Port-A-Cath just above tip. Given the small filling defect and likely fibrin sheath on the Port-A-Cath, further intervention was considered with Interventional Radiology as well as Surgery. The consideration included balloon angioplasty and/or catheter stripping through Interventional Radiology versus a surgical advancement of the catheter tip for improved placement. There was thought that the current catheter placement was likely causing some vessel wall injury which led to the clot formation. A final decision was made to have the patient fully anticoagulated on Coumadin for a goal INR of between 2 and 3. After approximately one month of full anticoagulation, Dr. [**Last Name (STitle) **], who is the Surgical consult, agreed to advance the catheter into the right atrium to avoid further vessel injury and likely further clot formation. A total of six months of anticoagulation was recommended by Dr. [**Last Name (STitle) **] and the interventional radiologists. In addition, Dr. [**Last Name (STitle) **] recommended to avoid sclerosing agents to be used in the Port-A-Cath, which may cause additional vessel wall injury and possible clot formation. The patient remained in hospital until her INR became therapeutic on Coumadin while on her Heparin drip until her INR was between 2 and 3. She received two days of 10 mg of Coumadin and was transitioned to 5 mg q. day as an outpatient. She will have an INR checked in one day upon discharge and will be adjusted by Dr. [**First Name (STitle) **] and then again in two days, in which Dr. [**Last Name (STitle) 2244**] will adjust her Coumadin dosing. 2. Oncology: The patient received two Herceptin treatments while in hospital, continuing with her weekly Herceptin, without any complications. She was also continued on her daily Xeloda treatment and her Femara. The patient's blood counts were followed closely without any evidence of neutropenia or anemia. The patient had an MRI of her pelvis done to evaluate her persistent hip pain. The MRI results were pending upon her discharge. The patient's pain was fairly well controlled with her Fentanyl patch and p.r.n. Tylenol. The patient received Xeloda 1000 mg p.o. q. a.m. and 1500 mg p.o. q. p.m. for 14 days. She is on a two-week on and one-week off schedule. 3. Code status: Patient preferred not to have heroic measures done and instructed the house status to make her Do Not Resuscitate/Do Not Intubate, as well as she provided a health care proxy form, which is her husband, [**Name (NI) **] [**Name (NI) **]. DISPOSITION: To home. DISCHARGE CONDITION: Good status post TPA infusion and therapeutic INR of 2.2 upon discharge. DISCHARGE DIAGNOSES: 1. Superior vena cava clot with associated superior vena cava syndrome. 2. Metastatic breast carcinoma. 3. Anxiety. DISCHARGE MEDICATIONS: 1. Fentanyl patch 100 mcg q. 72 hours. 2. Lorazepam 1 mg q. h.s. as needed. 3. Effexor 75 mg q. day. 4. Protonix 40 mg q. day. 5. Colace 100 b.i.d. 6. Senna, one tab, q. day. 7. Coumadin 5 mg q. h.s. to be adjusted by Dr. [**First Name (STitle) **]. DISCHARGE INSTRUCTIONS: 1. Outpatient laboratory work: Patient is to have her INR checked on [**2115-1-4**] and fax results to Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) 22294**]. She is also to have her INR checked during the weekend of [**2115-1-5**] and to have Dr. [**Last Name (STitle) 2244**] paged with the results and given her pager number. 2. She is to have a follow-up appointment with Dr. [**Last Name (STitle) **] in approximately four to six weeks, and they are to call her to set up that appointment. She was also given the number to set up that appointment. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 16520**] Dictated By:[**Last Name (NamePattern1) 3480**] MEDQUIST36 D: [**2115-1-3**] 15:34 T: [**2115-1-3**] 20:35 JOB#: [**Job Number 22295**]

[ "197.7", "459.2", "V10.41", "197.0", "E879.8", "198.5", "174.8", "996.74", "790.92" ]

icd9cm

[ [ [] ] ]

[ "99.10" ]

icd9pcs

[ [ [] ] ]

7967, 8041

2138, 2175

8062, 8182

8205, 8463

8487, 9296

3654, 7945

2198, 3113

162, 1125

3128, 3625

1147, 2029

2046, 2121

6,147

116,516

43302

Discharge summary

report

Admission Date: [**2178-7-22**] Discharge Date: [**2178-8-3**] Date of Birth: [**2118-12-13**] Sex: F Service: SURGERY Allergies: Percocet / Ceftriaxone / Flagyl / Levofloxacin / Iodine Strong / Unasyn / Bactrim / Vancomycin Attending:[**First Name3 (LF) 668**] Chief Complaint: Left Abdomen Cellulitis of 5 days duration Weight loss and anorexia x 1 month Major Surgical or Invasive Procedure: Incision and drainage of abdominal abcess Small bowel resection secondary to fistula in communication with abcess History of Present Illness: Patient with known Hep C Cirrhosis (last paracentesis 4 months ago) presents with 4-5 day history of Left side abdominal cellulitis. Denies nausea or vomiting, although she notes weight loss and anorexia over the last month. Denies abdominal pain, no change in bowel habits. Past Medical History: 1. Hepatitis C: She is followed in liver clinic, but declined any interventions. She has evidence of cirrhosis and ascites. This is believed to have resulted from transfusion 20 years ago following an ectopic pregnancy 2. Hypertension 3. Cryoglobinemia diagnosed in [**3-23**] 4. Varicose veins status post stripping in [**5-27**] and [**12-29**] 5. Vasculitis: Leukocytoblastic diagnosed on biopsy from [**2-21**] following 3 year history of difficulty walking and leg pain and swelling. 6. Hypothyroidism 7. Cholecystectomy in [**2174**] that is thought to be due to chronic vasculitis from untreated Hepatitis C. Social History: She came to the US from [**Country 532**] about 15 years ago. She lives with her ex-husband, son, and daughter. She requires assistance in walking to the bathroom and ADLs. She denies alcohol or tobacco use. Family History: Her mother died of coronary arterty disease and hypertension at the age of 72 Physical Exam: On Admission: VS: 101 HR 120's, BP100/50 Cardiac: Tachy Lungs: clear bilaterally Abd: Distended with ascites. NT, Left side of abdomen with cellulitis, desqaumation. Pertinent Results: Labs on Admission: [**2178-7-22**] 03:55AM GLUCOSE-87 UREA N-16 CREAT-0.5 SODIUM-131* POTASSIUM-3.4 CHLORIDE-97 TOTAL CO2-19* ANION GAP-18 ALT(SGPT)-11 AST(SGOT)-30 ALK PHOS-79 AMYLASE-60 TOT BILI-1.4 LIPASE-28 ALBUMIN-2.3* CALCIUM-7.6* PHOSPHATE-3.3 MAGNESIUM-1.3* WBC-16.2*# RBC-3.90* HGB-9.4* HCT-28.4* MCV-73* MCH-24.0* MCHC-33.0 RDW-16.8* NEUTS-94.2* BANDS-0 LYMPHS-4.1* MONOS-1.5* EOS-0.1 BASOS-0 PLT COUNT-171# LACTATE-2.9* FreeCa-1.29 PT-19.8* PTT-50.3* INR(PT)-1.9* Brief Hospital Course: 59 y/o female with known history of Hep C/cirrhosis and ascites requiring intermittent paracentesis presents with 4-5 day duration of abdominal cellulitis. CT of abdomen/pelvis revealed a large left anterior abdominal subcutaneous abscess. She also has a large amount of ascites, as well as moderate right and small left pleural effusions. Surgical drainage of the abcess and exploratory laparotomy was performed on [**7-22**] and was complicated by the need for a small bowel resection due to an intracutaneous fistula. Patient also underwent lysis of adhesions and ileoileostomy with repair of abdominal wall defect. Initially the patient had 2 abdominal JPs and was started on Vanco and Aztreonam. These were D/C'd and Meropenem started, then Vanco re-added as well as Fluconazole. Patient extubated on [**7-24**]. Patient continued to require RBC's, PLts and FFP. (History of cryoglobulinemia) Wound Vac started on [**7-25**] to abdominal wound. Strep Viridans isolated from the abdominal wound. Biopsy of Segments of small bowel taken during surgery showed Focal necrotizing arteritis. Focal perforation with surrounding necrosis, acute inflammation, and serosal reaction, as well as focal villous flattening with architectural distortion and metaplastic change consistent with chronic injury. TPN was started for nutritional support. On [**7-28**] patient experienced approxiamtely 50 cc BRBPR, receiving platelets and PRBCs. Hct as low as 23%, on discharge Hct 24.8%, platelets 146 Wound VAC remained in place, being changed q 3 days. Wound is reported to be free of any S&S of infection and granulation tissue is noted. Patient required detailed explanations of any procedure or medication she was to receive, and this was better managed with the use of the Russian interpreter. Patient had not been taking any medications at home, and used limited ones while at the hospital. Initially PT was refused, however patient has been encouraged by many disciplines of the importance of ambulating, and being OOB. Psych consult was obtained, and the recommendation to have a translator available when reviewing procedures and need for medications was made. Treatable etiologies of dementia were ruled out, and patient was encouraged to follow up with Social work or other mental health provider to work out issues of trust with medical system. TPN continued until discharge, patient should be given supplements to PO intake with breakfast lunch and dinner. Appointments as indicated. Medications on Admission: None, refuses to take Discharge Medications: 1. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 3. Nadolol 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Hydromorphone 2 mg/mL Syringe Sig: One (1) Injection Q3-4H (Every 3 to 4 Hours) as needed. 6. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours). Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Focal necrotizing arteritis S/P small bowel resection intracutaneous fistula, abdomen Discharge Condition: Stable Discharge Instructions: Please call [**Telephone/Fax (1) 673**] to notify if patient experiences fever, chills, change in abdominal wound, difficulty with wound vac, or other problems concerning to you Followup Instructions: Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **]/[**Doctor Last Name **] Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2178-8-6**] 8:00 Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2178-8-13**] 4:00 Call [**Telephone/Fax (1) 673**] for follow up appointment with surgeon Completed by:[**2178-8-3**]

[ "244.9", "578.9", "789.5", "571.5", "446.0", "682.2", "276.51", "569.81", "446.29", "401.9", "070.54", "511.9" ]

icd9cm

[ [ [] ] ]

[ "54.0", "99.05", "99.04", "93.59", "45.62", "99.15" ]

icd9pcs

[ [ [] ] ]

5582, 5661

2515, 5004

431, 546

5791, 5800

2016, 2021

6026, 6426

1736, 1815

5076, 5559

5682, 5770

5030, 5053

5824, 6003

1830, 1830

314, 393

574, 850

2035, 2492

872, 1491

1507, 1720

47,993

198,686

43886+58665

Discharge summary

report+addendum

Admission Date: [**2152-4-1**] Discharge Date: [**2152-4-20**] Date of Birth: [**2077-10-8**] Sex: M Service: CARDIOTHORACIC Allergies: Morphine / Dilaudid / ionic contrast Attending:[**First Name3 (LF) 1406**] Chief Complaint: Dyspnea and chest pain Major Surgical or Invasive Procedure: [**2152-3-31**] cardiac catheterization [**2152-4-10**] 1. Re-do sternotomy. 2. Coronary artery bypass grafting x2 with reverse saphenous vein graft to the posterior left ventricular branch artery and the second diagonal artery. History of Present Illness: 74 year old male with dyspnea and chest discomfort, now referred for a cardiac catheterization. Had increasing shortness of breath since [**2152-1-12**]. The dyspnea occurs while walking around the house. Occasionally the he will experience chest pain with exertion and requires one nitroglycerin SL for relief. These episodes of dyspnea and chest pain have increased since his follow up appointment with Dr. [**Last Name (STitle) 911**] in [**2152-1-12**]. Past Medical History: CAD multiple POBA's to mlad in [**2133**] and DES to RCA and Cx in [**2146**] Atrial fibrillation Hypertension DM Arthritis of knees CRI since [**2148**] [**12-18**]: 7 month hospitalization for sepsis/infected knee prostheses following puncture of hand with a drill bit. Patient was vented and trached for an extended time, had knee replacements removed and eventually replaced. GERD BPH s/p bilateral knee replacements in [**Month (only) 547**]/[**2148-6-11**] s/p CABG x 4 [**2142**] (svg-D1, SVG-Cx- occluded, SVG- PDA- occluded) Social History: Lives with:wife Occupation:retired Tobacco: stopped about 50 years ago; ETOH: occasional Family History: Mother had "heart issues", passing away in her 60's Physical Exam: Pulse:71 Resp:16 O2 sat: 95/RA B/P Right:188/63 Left:184/64 Height:6' Weight:203 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] well healed sternotomy incision Heart: RRR [] Irregular [x] Murmur 3/6 systolic ejection murmur with radiation to the left carotid area. Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] no Edema no Varicosities: None; vein harvest site from the right leg; bilateral knee incisions. Neuro: Grossly intact Pulses: Femoral Right: 2+ Left: 2+ DP Right: 1+ Left: 1+ PT [**Name (NI) 167**]: 0 Left: 0 Radial Right: 2+ Left: 2+ Carotid Bruit Right:no Left: soft murmur; likely radiating heart murmur Pertinent Results: [**2152-4-10**] ECHO PRE BYPASS The left atrium is dilated. Mild spontaneous echo contrast is seen in the body of the left atrium. Moderate to severe spontaneous echo contrast is present in the left atrial appendage. A left atrial appendage thrombus is not clearly see but cannot be completely excluded. The right atrium is dilated. No atrial septal defect is seen by 2D or color Doppler. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is severe regional left ventricular systolic dysfunction with severe hypokinesis of the lateral, anterolateral, and inferolateral walls. The rest of the segments are moderately globally depressed. Overall left ventricular systolic function is severely depressed (LVEF= 20 %). The right ventricle displays moderate global free wall hypokinesis. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is severe aortic stenosis by Doppler however there is likely an element of pseudo-aortic stenosis. Likely there is mild to moderate aortic stenosis. There is trace aortic to mild aortic regurgitation. The mitral valve leaflets are moderately thickened. Mild to moderate ([**2-13**]+) mitral regurgitation is seen. Dr. [**Last Name (STitle) **] was notified in person of the results in the operating room at the time of the procedure. POST BYPASS The patient is being AV paced. The patient is receiving norepinephrine and milrinone by infusion. The right ventricle displays improved systolic function and is now borderline normal. The left ventricle also displays improved systolic performance with mild global hypokinesis with continued severe lateral, anterolateral, and inferolateral hypokinesis. Overall EF now about 40%. The aortic valve area has improved to 1.6 cm2 consistent with mild to moderate aortic stenosis. The rest of valvular function is unchanged. The thoracic aorta is intact after decannulation. Brief Hospital Course: Transferred in for cardiac evaluation, after presenting to outside hospital for chest pain and ruled in for non ST elevation myocardial infarction. He underwent a cardiac Catheterization that revealed significant coronary disease and cardiac surgery was consulted. Post cardiac catheterization he had an acute kidney injury with peak creatinine to 3.2. He was monitored and underwent preoperative workup. On [**2152-4-10**] he was brought to the operating room and underwent redo sternotomy and coronary artery bypass graft surgery. See operative report for further details, of note he required bougie for intubation. (see anesthesia report) He received cefazolin and vancomycin for perioperative antibiotics. He was transferred to the intensive care unit for post operative management on levophed for hypotension and milirone for systolic failure. He was also started on vasopressin and with in the first twenty four hours he was weaned off levophed and vasopressin. Postoperative day one he was weaned and extubated without complications and milirone was slowly tapered off. That night he had increasing oxygen requirements with volume overload and was treated with diuretics with no response. Postoperative day two he was placed on non invasive ventilation for hypoxia with good response, renal was consulted for acute kidney failure and he was started on CVVH for volume overload. He improved with volume removal and remained in the intensive care unit for monitoring. On [**4-15**] CVVH was stopped and he was restarted on diuretics with good response. He was restarted on coumadin for atrial fibrillation. He continued to progress well and was transferred to the floor on postoperative day 7 for further recovery. Physical therapy worked with him on his strength and mobility. His renal function continued to improve. Lasix was stopped. His intake and output should be monitored while at rehab along with every other day labs to include renal function and electrolytes. In the even that his output diminishes, lasix should be dosed or resumed as needed. Mr. [**Known lastname 94219**] continued to make steady progress and was ready for discharge to Masconomet rehabiltation on post operative day 10. He will follow-up with Dr. [**Last Name (STitle) **], Dr. [**Last Name (STitle) 911**] and his primary care physician as an outpatient. Medications on Admission: CALCITRIOL 0.25 mcg every other day CLOPIDOGREL 75 mg once a day DIGOXIN 125 mcg once a day DILTIAZEM HCL 300 mg Ext Release once a day FUROSEMIDE 20 mg every other day if weight gain is greaterthan [**3-16**] lbs on a daily basis HYDRALAZINE 50 mg twice a day LEVOTHYROXINE 75 mcg once a day METOPROLOL SUCCINATE 100 mg daily RANITIDINE HCL 300 mg once a day SIMVASTATIN 20 mg every evening TAMSULOSIN 0.4 mg Ext Release once a day WARFARIN 5 mg Tablet - 1-1.5 Tablet(s) by mouth every evening ASPIRIN 81 mg daily VITAMIN D 400 unit twice a day NPH INSULIN 25-35 units twice a day Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 3. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. simvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 5. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO EVERY OTHER DAY (Every Other Day). 6. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 9. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 12. warfarin 5 mg Tablet Sig: Dose for goal INR of 2.0-2.5 for atrial fibrillation Tablets PO ONCE (Once): Goal INR 2.0-2.5. 13. Insulin Please refer to insulin standing dose and slidiing scale 14. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. Discharge Disposition: Extended Care Facility: [**Hospital 12414**] Healthcare Center - [**Location (un) 12415**] Discharge Diagnosis: Coronary Artery disease s/p CABG Atrial fibrillation Acute systolic heart failure Non ST elevation myocardial infarction Acute kidney injury secondary to acute tubular necrosis Chronic kidney disease Diabetes Mellitus Dyslipidemia Hypertension Arthritis Gartroesophageal reflux disease Benign prostatic hypertrophy arthritis of knees s/p bilateral knee replacements Hypothyroid Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with tylenol Incisions: Sternal - healing well, no erythema or drainage Leg Left EVH - healing well, no erythema or drainage. Trace Edema Discharge Instructions: 1) 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 2) Please NO lotions, cream, powder, or ointments to incisions 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart 4) 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 5) No lifting more than 10 pounds for 10 weeks 6) Please monitor PT/INR and dose coumadin accordingly. Goal INR is 2.0-2.5 for atrial fibrillation. 7) Please monitor renal function and electrolytes every other day. Please resume lasix if not making sufficient urine. Monitor input and output (I/O's) daily. 8) Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on Phone: [**Telephone/Fax (1) 170**] Date/Time:[**2152-5-17**] 1:15 Cardiologist: Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**] Phone: [**Telephone/Fax (1) 62**] Date/Time:[**2152-5-31**] 2:40 and also on [**2152-10-4**] 1:40 [**Telephone/Fax (1) 62**] Please call to schedule appointments with your Primary Care Dr [**Last Name (STitle) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 1105**] [**Telephone/Fax (1) 80429**] in 4 weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Labs: PT/INR for Coumadin ?????? indication- Atrial fibrillation Goal INR 2-2.5 First draw Please check INR monday and wednesday and friday for two weeks and as needed then decrease to twice weekly until on stable dose Rehab physician to dose coumadin based on INR results - please set up follow up when discharged from rehab Completed by:[**2152-4-20**] Name: [**Known lastname 14904**],[**Known firstname **] S Unit No: [**Numeric Identifier 14905**] Admission Date: [**2152-4-1**] Discharge Date: [**2152-4-20**] Date of Birth: [**2077-10-8**] Sex: M Service: CARDIOTHORACIC Allergies: Morphine / Dilaudid / ionic contrast Attending:[**First Name3 (LF) 135**] Addendum: His intake and output should be monitored while at rehab along with every other day labs to include renal function and electrolytes. In the event that his output diminishes, lasix should be dosed or resumed as needed. Added to Page 1 was to have rehab check BUN/CREATINIE/POTASSIUM every other day until renal function improves. Discharge Disposition: Extended Care Facility: [**Hospital 12776**] Healthcare Center - [**Location (un) 12777**] [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 137**] MD [**MD Number(2) 138**] Completed by:[**2152-4-20**]

[ "584.5", "428.0", "410.71", "585.9", "785.51", "E879.0", "428.21", "427.31", "584.9", "600.00", "250.00", "530.81", "403.90", "V58.67", "272.4", "997.5", "414.05" ]

icd9cm

[ [ [] ] ]

[ "36.12", "39.95", "39.61" ]

icd9pcs

[ [ [] ] ]

12684, 12934

4734, 7093

325, 564

9453, 9676

2654, 4711

10793, 12661

1737, 1791

7725, 8915

9052, 9432

7119, 7702

9700, 10770

1806, 2635

263, 287

592, 1055

1077, 1614

1630, 1721

51,267

174,972

50215

Discharge summary

report

Admission Date: [**2121-11-12**] Discharge Date: [**2121-11-26**] Service: SURGERY Allergies: Lopressor / Niacin / Cardura Attending:[**First Name3 (LF) 148**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: Right hemicolectomy PPM placement due to tachy-brady syndrome History of Present Illness: This is a [**Age over 90 **] year old male who presented initially to Neurology with 2 days of a dull headache. He has a history of artrial fibrillation and was on coumadin for a-fib. He reported falling at home in the bathroom and striking his head 2 days prior to presentation. He was found to have an acute right subdural hematoma. He was admitted and due to his SDH his coumadin was disontinued. One day after his admission to Neurology, he reported an acute onset of generalized, diffuse abdominal pain. He denied any nausea and emesis. Past Medical History: 1. Lumbar L3 compression fracture; status post fall in [**Month (only) **] of [**2115**] with multiple falls since that point. 2. Delirium. 3. Coronary artery disease; S/P 4 vessel CABG [**2105**] with a left internal mammary artery to left anterior descending artery, saphenous vein graft to posterior descending artery, and saphenous vein graft to first obtuse marginal and 3rd obtuse marginal. Catheterization in [**2114-8-9**] demonstrated patency of the grafts. An echocardiogram in [**2116-1-9**] with mild LVH, left ventricular ejection fraction of greater than 55%, 1 to 2+ mitral regurgitation, and moderate pulmonary artery systolic hypertension. 3. Hypertension; refractory (on multiple agents). 4. Paroxysmal atrial fibrillation (on Coumadin). 5. Abdominal aortic aneurysm. 6. Chronic renal insufficiency 7. Bilateral renal artery stenosis. 8. Bilateral carotid artery stenosis. 9. Gastroesophageal reflux disease. 10. Lumbar spinal stenosis. 11. Status post cholecystectomy in [**2071**]. 12. Status post transurethral resection of prostate in [**2096**]. 13. History of hernia repair in [**2110**]. 14. Chronic obstructive pulmonary disease. Social History: -Tobacco history: quit 50 yrs ago -ETOH: remote alcohol use -Illicit drugs: none Family History: Father and brother had diabetes mellitus. The patient's brother is deceased after myocardial infarction x2. Physical Exam: on admission: PE: 102.9, 119, 156/68, 21, 95% on room air Gen: mild distress, alert and oriented x 3 HEENT: PERRL, EOMI, anicteric, mucus membranes dry Neck: supple Chest: tachycardic, lungs clear, sternotomy scar Abdomen: soft, distended, tender to palpation diffusely but mainly focused in RLQ, no rebound Rectal: loose stool, guaiac negative, no masses Ext: palpable pedal pulses bilaterally, no edema on discharge: PE: 98.7, 72, 130/62, 20, 100/2L Gen: alert and oriented, somewhat tired and drowsy HEENT: PERRL, EOMI, anicteric, MMM NECK: supple , no LAD, no JVD Chest: lungs clear, decreased breath sounds on bases Abdomen: soft, incisional tenderness,+BS incision c/d/i with steri strips in place Extremities: +1 edema Pertinent Results: [**2121-11-12**] 08:37AM CK(CPK)-63 [**2121-11-12**] 08:37AM CK-MB-NotDone cTropnT-0.02* [**2121-11-12**] 08:37AM TSH-2.2 [**2121-11-12**] 03:45AM GLUCOSE-115* UREA N-34* CREAT-1.5* SODIUM-141 POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-24 ANION GAP-14 [**2121-11-12**] 03:45AM CALCIUM-8.9 PHOSPHATE-3.2 MAGNESIUM-2.0 [**2121-11-12**] 03:45AM HCT-27.3* [**2121-11-12**] 03:45AM PT-15.7* PTT-31.8 INR(PT)-1.4* [**2121-11-12**] 01:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2121-11-12**] 01:00AM URINE RBC-0 WBC-0 BACTERIA-FEW YEAST-NONE EPI-0 [**2121-11-11**] 11:22PM GLUCOSE-106* NA+-139 K+-5.0 CL--102 TCO2-23 [**2121-11-11**] 11:15PM UREA N-38* CREAT-1.8* [**2121-11-11**] 11:15PM estGFR-Using this [**2121-11-11**] 11:15PM CK(CPK)-62 [**2121-11-11**] 11:15PM CK-MB-NotDone [**2121-11-11**] 11:15PM WBC-6.6 RBC-3.79* HGB-11.9* HCT-35.4* MCV-93 MCH-31.4 MCHC-33.6 RDW-14.2 [**2121-11-11**] 11:15PM NEUTS-73.8* LYMPHS-16.3* MONOS-8.3 EOS-1.2 BASOS-0.4 [**2121-11-11**] 11:15PM PT-26.0* PTT-35.8* INR(PT)-2.5* [**2121-11-11**] 11:15PM PLT COUNT-196 [**2121-11-11**] 11:15PM FIBRINOGE-476* CT head ([**2121-11-17**]) NON-CONTRAST HEAD CT: Again demonstrated is the relatively acute right subdural hematoma, with maximal thickness of 13 mm layering over the right temporoparietal convexity (2:17), not significantly changed since the most recent exam. There is also blood layering in the right suboccipital region, over the right tentorial leaflet, extending anteriorly. Blood is also seen in the temporal [**Doctor Last Name 534**] of the right lateral ventricle, grossly unchanged. There is no significant shift of the midline structures. Prominence of the ventricles and sulci is stable and consistent with age- appropriate volume loss. There is asymmetric decreased size of the right lateral ventricle and effacement of the right-sided cerebral sulci likely secondary to mass effect from the right subdural hematoma, also grossly stable. No lytic or blastic osseous lesion is seen. The visualized mastoid air cells are clear. There is mucosal thickening and air-fluid level in the right and a mucus retention cyst in the left maxillary sinus; the air-fluid level in the right maxillary sinus appears new over the series of studies. IMPRESSION: 1. Unchanged right subdural hematoma, with only slight mass effect on the right lateral ventricle and effacement of the subjacent sulci, and no significant shift of midline structures. 2. No new hemorrhage. 3. Worsening right maxillary sinus mucosal sinus disease with new air-fluid level; clinical correlation for evidence of acute sinusitis is suggested. ECHO ([**2121-11-20**]) Findings LEFT ATRIUM: Moderate LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size and regional/global systolic function (LVEF>55%). [Intrinsic LV systolic function likely depressed given the severity of valvular regurgitation.] No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. AORTIC VALVE: Moderately thickened aortic valve leaflets. No AS. Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MVP. Moderate mitral annular calcification. Moderate (2+) MR. TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Moderate [2+] TR. Moderate PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. 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%). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Moderate mitral and tricuspid regurgitation. Moderate pulmonary hypertension. Brief Hospital Course: This [**Age over 90 **]-year-old gentleman was admitted to the General Surgical Service for evaluation and treatment of abdominal pain. He recently fell at home and suffered a subdural hematoma and was initially admitted to the neurosurgical service. Two days after his admission, he had an acute onset of abdominal pain following reversal of his anticoagulation for atrial fibrillation. A CT scan, as well as physical exam and history all pointed towards an ischemic colon with portal venous gas evident on the imaging. This was a situation that was deteriorating fast. After a detailed and fair and balanced assessment of the risk profile, the patient decided to pursue an operative approach and we decided to proceed emergently with a exploratory laparotomy. Postoperatively, the patient was transferred to the intensive care unit. A stat head CT ordered as per neurology didn't show any interval change. The patient remained intubated overnight, sedated on propofol gtt. hemodynamically stable. He was extubated on POD1 without any incident and transferred to the floor. Neuro: s/p fall with R SDH, he had a simple partial seizure in the ED where he received 2 mg of ativan and was loaded with keppra. Repeated head CTs showed an unchanged right subdural hematoma, with mass effect, but no shift of midline structures or herniation. The patient remained stable without any focal nuerological deficits. CV: The patient has a history of a-fib, hypertension, hypercholesterolemia and carotid stenosis. In the first postoperative days he remained stable hemodynamically with rate control home medications atenolol and nifidepine. He triggered [**2121-11-20**] at 0230 for chest pain associated with SOB and diaphoresis. An ECG showed ST-segment depressions in V4/V5. Given 2 mg morphine, SL NTG x1, metoprolol 10 mg IV, furosemide 20 mg IV. Pt had resolution of sx and ST-segment depressions. BP then 140/80.Trop peaked at 0.13. The mild elevation in troponin likely represented demand ischemia given recent stressors and surgery. In the following days he had intermittent Afib alternating with episodes of sinus bradycardia with long conversion pauses. Cardiology was consulted and it was felt that he would benefit form PPM placement, which would allow for better control of his ventricular rate in atrial fibrillation. A permanent pacemaker was placed. The patient did well after the procedure. He had some hypertensive episodes in the following days. His Valsartan dose was increased from 120 to 160mg)and he was restarted on the beta blocker. He might require further titration and adjustment of his blood pressure medications. Pulmonary: The patient remained stable from a pulmonary standpoint; vital signs were routinely monitored. Good pulmonary toilet and incentive spirometry were encouraged throughout hospitalization. GI/GU/FEN: s/p right colectomy, large midline incision. Post-operatively, the patient was made NPO with IV fluids. Diet was advanced when appropriate, which was well tolerated. Patient's intake and output were closely monitored, and IV fluid was adjusted when necessary. Electrolytes were routinely followed, and repleted when necessary. Docusate was given for bowel regimen. The patient failed two voiding trials (most recent one on [**2121-11-24**]). A foley was put back and remained in place. Prophylaxis: The patient received subcutaneous heparin and venodyne boots were used during this stay; was encouraged to get up and ambulate as early as possible, but is not back to his baseline level yet. He will still need long term anticoagulation, although this is currently being held due to recent subdural hemorrhage. He will follow up with Neurosurgery on [**2121-12-3**]. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet and pain was well controlled. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: Furosemide 20 mg daily Simvastatin 40 mg daily Aspirin 325 mg daily Vit C 250mg [**Hospital1 **] MVI daily Terazosin 10 mg Atenolol 25 mg Nifedipine 90 mg Valsartan 120 mg Omeprazole daily Warfarin 4 mg (T/Th/Sa/[**Doctor First Name **]) and 3mg (M/W/F) Alendronate 35mg qweek Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Ascorbic Acid 250 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 5. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 8. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for Breakthrough pain. 9. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 10. Hydralazine 20 mg/mL Solution Sig: One (1) Injection Q2HRS () as needed for prn SBP > 160. 11. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 12. Valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Atenolol 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: Subdural hemorraghe Focal ischemia of the right colon Discharge Condition: stable Discharge Instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**5-18**] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Followup Instructions: Please call the office of Dr. [**First Name (STitle) **] / neurosurgeon to be seen in 2 weeks ( on or about [**2121-12-3**] ) with a CT scan of the brain to evaluate your sub dural collection. [**Telephone/Fax (1) **] thank you Provider: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], M.D. Phone:[**Telephone/Fax (1) 1694**] Please follow up with General Surgery (Dr. [**Last Name (STitle) **] in 3 weeks after discharge. Call [**Telephone/Fax (1) 1231**] for an appointment. Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2121-12-1**] 2:00 Completed by:[**2121-11-26**]

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Discharge summary

report

Admission Date: [**2137-4-13**] Discharge Date: [**2137-8-8**] Date of Birth: [**2111-9-19**] Sex: M Service: MEDICINE Allergies: Cefepime Attending:[**First Name3 (LF) 3963**] Chief Complaint: Fever, neck pain. Major Surgical or Invasive Procedure: PICC Placement CVL placement Tongue Biopsy Lingular artery embolization Intubation Bone Marrow Biopsy Skin biopsy History of Present Illness: 25 yo man with hypoplastic MDS, transfusion-dependent chronic pancytopenia, chronic mouth sores, and h/o peri-rectal abscess, who presents with 2 days of right-sided neck pain. He was seen in the outpatient clinic today and was noted to have a fever to 100.3 and pancytopenia, so he is being admitted for transfusions as well as further evaluation of his neck pain out of concern for an abscess. He denies any subjective fevers or chills, tooth pain, or dysphagia. No SOB or difficulty breathing. Has has good PO intake. He denies any peri-rectal pain and states that the abscess has completely healed. . ROS: (+) As noted above (-) Denies any headache, dizziness, visual disturbances, chest pain, SOB, cough, abdominal pain, nausea, vomiting, diarrhea, blood in stool, dysuria, hematuria, myalgias, arthralgias, or rash. Past Medical History: ONCOLOGIC HISTORY: Admitted to [**Hospital1 18**] in [**10/2136**] with fatigue, subjective fevers, weakness, palpitations, found to be pancytopenic. Viral workup was negative. Bone marrow biopsy on [**2136-11-15**] demonstrated a hypocellular marrow with cytogenetic abnormalities consistent with hypoplastic MDS (deletion 7q and 13). HLA typing is underway for future Allo transplant. . OTHER PAST MEDICAL HISTORY: - Hypoplastic myelodysplastic syndrome (initially presented [**10/2136**] with malaise and weakness, found to be pancytopenic, bone marrow biopsy results from [**2136-11-15**] c/w hypoplastic MDS - HAV Ab +, HBsAb, HBcAb, HBsAg neg, HCV Ab neg, HIV Ab + VL neg - Strongyloides Ab neg, CMV IgG +, EBV VCA IgG and EBNA + - H/o C. difficile infection [**10/2136**] - H/o pericoronitis s/p extraction 4 teeth [**2137-1-24**] - H/o buccal lesions - H/o peri-rectal abscess s/p drainage [**2137-2-27**] - H/o periodic transaminitis of unclear etiology, though possibly due to iron load from frequent transfusions; has been evaluated by hepatology and is scheduled for liver biopsy Social History: The patient moved from [**Country **] 1 year ago. He lives with sister, brother-in-law, and their 2 children. He has no pet exposures. He previously worked in warehouse packing boxes, has not worked since [**35**]/[**2136**]. He has a history of working for an oil company in [**Country **], though per reports worked mainly in office and had only occasional exposure to factory environment. He is not currently sexually active. No significant tobacco history. Occasional alcohol use (1-2 times per month). No illicit drug use or history of IVDU. Family History: Father died at age 73, per reports had "illness" and progressive weakness. Mother died of stroke at age 60. No known family history of cancer or bleeding disorders. Has 6 siblings who are healthy. Physical Exam: ADMISSION EXAM: VITALS: 100.3, 124/80, 86, 18, 100% on RA GEN: Appears very tired but in NAD HEENT: PERRL, EOMI, MMM, poor dentition, erythematous patch in posterior oropharynx on the right, ulceration in inner lip on the right LYMPH NODES: No anterior/posterior cervical, submandibular, or occipital LAD CV: RRR, nml S1/S2, no M/R/G LUNGS: CTAB ABDOM: NABS, NTND, no HSM appreciated GU: External hemorrhoid, no fissures or abscess EXTREM: WWP, no edema Neuro: A&Ox3, CN II-XII intact, strength and sensation intact, gait normal RECTUM: at 8 o'clock there is a tender, small 1 cm closed lesion. Surrounding area with no erythema or warmth. No evidence of fluctulence or findings concerning for fluid collection. Derm: No rashes or petechiae Pertinent Results: ADMISSION LABS: [**2137-4-13**] 09:15AM BLOOD WBC-1.4* RBC-2.70* Hgb-8.0* Hct-20.8* MCV-77* MCH-29.6 MCHC-38.3* RDW-12.0 Plt Ct-13*# [**2137-4-13**] 09:15AM BLOOD Neuts-14.5* Bands-0 Lymphs-82.2* Monos-2.4 Eos-0.2 Baso-0.8 [**2137-4-13**] 09:15AM BLOOD Gran Ct-203* [**2137-4-13**] 09:15AM BLOOD Glucose-121* UreaN-11 Creat-0.9 Na-136 K-3.8 Cl-97 HCO3-29 AnGap-14 [**2137-4-13**] 09:15AM BLOOD ALT-45* AST-26 AlkPhos-91 TotBili-0.7 DirBili-0.1 IndBili-0.6 [**2137-4-13**] 09:15AM BLOOD Calcium-9.6 Phos-4.4 Mg-2.0 . DISCHARGE LABS: [**2137-8-8**] 12:00AM BLOOD WBC-2.8* RBC-2.22* Hgb-6.8* Hct-19.4* MCV-87 MCH-30.5 MCHC-34.9 RDW-16.3* Plt Ct-31* [**2137-8-8**] 12:00AM BLOOD Neuts-34* Bands-2 Lymphs-30 Monos-32* Eos-0 Baso-0 Atyps-0 Metas-2* Myelos-0 [**2137-8-8**] 12:00AM BLOOD PT-13.7* PTT-34.3 INR(PT)-1.2* [**2137-8-8**] 12:00AM BLOOD Glucose-117* UreaN-16 Creat-1.2 Na-134 K-4.0 Cl-105 HCO3-17* AnGap-16 [**2137-8-8**] 12:00AM BLOOD ALT-82* AST-60* LD(LDH)-157 AlkPhos-196* TotBili-0.5 [**2137-7-24**] 12:00AM BLOOD GGT-126* [**2137-8-8**] 12:00AM BLOOD Calcium-8.5 Phos-3.8 Mg-1.7 [**2137-7-25**] 12:00AM BLOOD Ferritn-[**Numeric Identifier 87410**]* ................................................................ MICROBIOLOGY: [**4-13**] - [**2137-4-22**] Blood Cx: No Growth [**2137-4-13**] Mouth Ulcer Cx: mixed orpharyngeal growth, no growth on viral HSV / VZV culture [**2137-4-14**], [**2137-4-17**] UCx: No Growth [**2137-4-16**] Monospot negative [**2137-4-16**] Throat Culture: GAS and respiratory culture negative [**2137-4-16**] Respiratory Viral Culture: No Growth [**2137-4-17**] CMV VL: Negative [**2137-4-17**] Blood: AFB and fungal culture pending [**2137-4-17**] Beta-glucan negative [**2137-4-17**] Galactomannan negative [**2137-4-17**] Bartonella serologies negative [**2137-4-18**] EBV PCR: pending [**2137-4-19**] HHV-6 PCR Negative [**2137-4-19**] R inner lip mouth sore tissue biopsy: [**2137-4-20**] toxoplasma serologies negative ....................................................... IMAGING: [**2137-4-14**] CXR: normal . [**2137-4-14**] CT Neck W/Contrast: Status post lower teeth removal without evidence of surrounding abscess or bony lytic lesion; prominent right cervical lymph nodes, although none meet pathologic size criteria; no evidence of abscess. . [**2137-4-20**] CT Neck W/Contrast: There are no fluid collections concerning for abscess formation. There are multiple prominent cervical chain lymph nodes demonstrated bilaterally, the largest demonstrated as a level 2 lymph node (series 2: image 28) measuring up to 7 mm in short axis. The lung apices are clear. The cervical vessels enhance symmetrically. The visualized inferior brain is unremarkable. Soft tissues of the neck are unremarkable. The submandibular and parotid glands are symmetric. Redemonstrated is removal of two lower teeth within the mandible. There is no periapical lucency. There are no lytic or sclerotic lesions within the visualized osseous structures. IMPRESSION: 1. No abscess. 2. Prominent cervical chain lymph nodes bilaterally by quantity, though none meet pathologic size criteria. . [**2137-4-21**] MRI OF THE PELVIS WITH IV CONTRAST: Arising 2 cm above the anal verge, there is an enhancing fistulous tract which begins at the 1 o'clock position and travels in the intersphincteric space, draining into the left perineum (5:24 through 27 and 4:42-45). At the 12 o'clock position, at the level of the origin of the fistulous tract, there is an additional 5-mm peripherally enhancing focus within the intersphincteric space which extends slightly inferiorly and may represent a tiny abscess or a small sinus tract (702:22). There is associated enhancing inflammatory tissue within the left perineum measuring 2.2 x 1.3 cm. There is no drainable abscess. The rectum is normal. There are no abnormal or enhancing lymph nodes within the pelvis. There are several T1 hypointense bony abnormalities within midline sacrum, left iliac [**Doctor First Name 362**], and the right acetabulum, all of which demonstrate mild enhancement and are likely related to the patient's myelodysplastic syndrome. The largest lesion in the left ilium measures 14 x 9 mm (4:9). None of these lesions have anatomic correlate on the prior CT examinations. IMPRESSION: 1. Intersphincteric fistula extending from 1 o'clock, 2 cm above the anal verge to the left perineum. Additional tiny 5 mm enhancing focus in the intersphincteric space may represent a tiny abscess or small sinus tract. Associated inflammatory tissue in the left perineum. 2. Several enhancing T2 hypointense lesions within the bony pelvis, likely related to the patient's myelodysplastic syndrome. . MRI head FINDINGS: There have been no significant changes since the prior study. Again seen is an area of tissue loss in the body of the left caudate nucleus, he significance is uncertain. The location would be appropriate for an old lacunar infarction if the patient has appropriate risk factors. The diffusion study is of limited quality due to artifacts. However, there are no findings to suggest acute infarction. There is no evidence of hemorrhage or masses. CONCLUSION: No change since the study of [**2137-5-23**]. Focal tissue loss in the body of the left caudate nucleus as discussed above. No evidence of hemorrhage or recent infarction. . MR neck IMPRESSION: The previous region of mass-like enhancement of the right tongue base is significantly reduced in size consistent with the history of surgical resection. There remains diffuse enhancement of the right tongue base which is nonspecific and may be postoperative, inflammatory or infectious in origin. There is one focus of non-enhancement of the right tongue base measuring 7 mm in greatest dimension which may represent residual necrosis or variation of enhancement, not likely a fluid collection. . [**Doctor First Name **] renal US . Echocardiogram The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 70%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. A linear echodensity is seen in juxtaposition to the right atrium/right ventricle, most likely representing acoustic artifact emanating from the PICC line. Compared with the findings of the prior study (images reviewed) of [**2137-5-8**], the findings are similar. MRI neck [**7-18**] IMPRESSION: Persistent post-operative changes of the base of tongue with no suspicious interval change to suggest recurrent infection. GI biopsies Gastrointestinal mucosal biopsies: A. Stomach, body: Fundic mucosa, no diagnostic abnormalities recognized. B. Stomach, antrum: Antral mucosa, no diagnostic abnormalities recognized. C. Duodenum: Duodenal mucosa, no diagnostic abnormalities recognized. Brief Hospital Course: *BMT COURSE ([**2137-6-3**] - [**2137-8-8**]) 25 yo man with hypoplastic MDS, transfusion-dependent chronic pancytopenia, chronic mouth sores, and h/o peri-rectal abscess, who presented with fever and right-sided neck pain. # Hypoplastic MDS: The patient presented with neutropenic fever. Exam was significant for sore on the R inner lip mucosa. Tenderness in the anterior cervical lymph chain, and continued presence of tender peri-rectal lesion (now closed). Initial negative including a chest x-ray and CT of the neck with contrast showed no evidence of infection. Urine and blood cultures were negative. ID was consulted. Thorough ID work-up including CMV VL, monospot, EBV PCR, Bartonella serologies, Toxoplasma serologies, throat culture for GAS and Arcanobacterium, R lip wound culture, respiratory viral culture, beta-glucan, galactomannan, were all negative. He was empirically treated with Vancomycin, Zosyn, and treatment dose Acyclovir. He continued to spike fevers and received micafungin for fluconazole resistant candidal esophagitis. He continued on prophylactic dose fluconazole. He continued to spike fevers so the CT of the neck was repeated which again failed to show an abscess. An EGD showed no evidence of esophagitis. An MRI of the pelvis showed an intersphincteric fistula extending from 1 o'clock, 2 cm above the anal verge to the left perineum and an additional tiny 5 mm enhancing focus in the intersphincteric space which may represent a tiny abscess or small sinus tract. He was found to have a tongue mass. This was complicated by a 3 liter bleed and intubation. While intubted he underwent tongue biopsy and right lingular artery embolization. The bleeding ceased and he was found to have a tongue mucor infection on pathology. He was started on Posaconazole and Ambisome for the mucor infection. He remained afebrile on Ambisome and Meropenem. ANC uptrended to >500 and team had discussion with ID who recommended repeat MRI on [**7-18**] which was stable. Pt was taken off posaconazole and continued on ambisome. Meropenem and vancomycin were also discontinued on [**7-18**] given ANC and adequate period of coverage for VRE bacteremia that was diagnosed on [**2137-7-2**]. He spiked a low grade temp 100.6 on [**7-19**] w c/o dysuria and mild nausea. Chest xray was negative for pna and showed atelectasis. Blood and urine cx were negative. Cdiff was negative. Symptoms resolved overnight wo intervention and abx cont'd to be withheld. Chest xray was notable for atelectasis and pt used incentive spirometer. BK virus checked and megative. He was kept in the hospital for ongoing nausea/vomiting with concern for GVH. EGD with biopsies were negative and a one time dose of steroids did not alleviate his symptoms. He was started on [**Hospital1 **] compazine with relief of his nausea and vomiting. He continued to have loose stool <500cc/day. On [**8-5**] he developed low grade temps and was found to have a positive CMV viral load at 2900 (repeat VL was 3490). ID was reconsulted and recommended checking adenovirus pcr, urine cmv culture, BK virus, mycolytic blood culture. BK viral load returned significantly elevated (above threshold). Mycolytic blood culture and CMV studies pending at time of discharge. Adenovirus pcr was negative. He was started on valganciclovir for CMV with plan for repeat CMV vl on [**8-10**]. He will be seen daily in the oncology clinic for ambisome, tacrolimus and tranfusion requirements immediately after discharge. Prior to discharge a family meeting was held to update recent hospital course and new medications. #Oral Mucor infection- treated with Posaconazole and Ambisome. Was able to tolerate soft foods and swallow on BMT floor. Before transplant process began was discontinued from Posaconazole which was later restarted. Given uptrend of LFTs and stable evaluation of mucor, the posaconazole was discontinued (as well as other broad spectrum abx) given non-neutropenic status. He was continued on ambisome w plans to continue w monitoring MRIs to document resolution. He will continue ambisome at home w infusion services. The dose was decreased to 400mg QOD per ID recs and he was discharged on this dose. He was given 500cc boluses post-ambisome infusion. # Myelodysplastic syndrome/pancytopenia: The patient was transfused as needed to keep Hct>24 and platelets>20. Was found to have cord match after siblings refused to be biopsied because of religous reasons, underwent cord BMT on [**2137-6-24**]. He was started on tacrolimus and MMF. Prophylaxis was acyclovir, atovaquone and he was continued on ambisome for mucor infection. His platelets continued to be low at time of discharge and he will require close follow up in the oncology clinic w regular platelet transfusions until his counts recover. He was advised to continue eating soft foods and chewing carefully. Monitored w weekly CMV vl, EBV, HHV-6, beta glucan, and galactomannan. # Transaminitis: Patient has a h/o intermittent transaminitis which has been evaluated by hepatology. Possibly secondary to iron overload from from numerous transfusions. Though most likely multifactorial as Posaconazole also causes transaminitis. This did not delay the transplant as LFT's began to trend down with the discontinuation of Posaconazole pre transplant. After transplant posaconazole was restarted and his LFTs slowly uptrended as well. These downtrended with discontinuation of meropenem, vancomycin and posaconazole. These normalized at time of discharge. *ICU COURSE* Pt was transferred to [**Hospital Unit Name 153**] after ENT removal of pedunculated and bleeding tongue mass. Tissue was sent from OR for microbiology and cytological studies to work-up malignancy vs infectious etiology. . # Respiratory status: Pt arrived to [**Hospital Unit Name 153**] intubated with [**Last Name (un) **]-tracheal tube from the OR on propofol sedation. Pt has had post-operative laryngeal edema in past requiring steroids. He was started on methylprednisolone in anticipation of trial extubation pending hemostasis of ENT surgical site. Pt was extubated sucessfully on [**2137-5-15**] and steroids were tapered off on [**2137-5-16**]. . # Oral mass: The patient underwent excision of a mass at the base of his tongue by ENT that was diagnosed as mucor. He was continued on broad antimicrobials (Zosyn, Flagyl, Bactrim, Ambisome, Acyclovir) and his pathology from the neck was consistent with fungal forms. . # MDS: The patient remains pancytopenic and is transfusion dependent. His siblings are not eligible and the search remains underway for a matched unrelated donor. He was transfused 3 units of platelets in OR and post-operative platlets >100. He was given 2 uits of pRBC post operatively with a post-transfusion goal to keep Hct >20. . # Transaminitis: Patient has a h/o intermittent transaminitis which has been evaluated by hepatology. Liver bx recommended pending current ENT w/u. LFTs were trended daily. Plan for close outpatient follow up and consideration for referral to liver clinic per primary oncologist management . # H/o Peri-rectal Abscess: Drainage in 01/[**2137**]. None seen on examination today but continue abx. He was covered broadly with the above regimen. . [**Hospital Unit Name 153**] [**Date range (1) 72430**]: Code Blue was called for hypotension and respiratory distress in the setting of acute large volume blood loss from his mouth and nose. He was immediately intubated and transferred to the [**Hospital Unit Name 153**], where the massive transfusion protocol was activated and he received 6u pRBC, 3u plts, and 2u FFP. He was also started on Levophed for pressure support. He was transferred to the [**Hospital Ward Name 12837**] for IR embolization of the culprit bleeding vessel. . MICU [**Location (un) **] [**5-24**]- [**6-3**]: Pt had lingual artery embolized and maintained on intubation with oropharynx packed. ENT removed packing after 4 days. He required intermittent PRBC and platlet transfusion throughout course. [**5-29**] rigid bronch in OR which showed only mucus and clot which was suctioned and clear lower airways. Also friable mucosa with clot (non-obstructing) in post oropharynx. He was extubated [**5-30**] without event. He was maintained on broad spectrum antibiotics acyclovir, ambisome, meropenem and vancomycin. Zosyn was discontinued early in MICU course for a question of allergic reaction of erythematous [**Doctor Last Name **], blanching skin rash. [**6-3**] MRI brain showed no evidence of stroke and mental status noted to be much improved. # MUCORMYCOSIS/OP BLEED: Patient s/p exision of basilar tongue mass which grew mucor on culture, with subsequent large tongue bleed requiring coiling. Patient was successfully extubated without further bleeding. He is on ambisome 10mg/kg maximal dose since [**5-22**]. Also on posiconazole which cannot be given without fatty enteral diet, so will need a NGT/dobhoff. ID will request MRI of [**Last Name (un) **] pharynx next week to assess progress of mucor treatment. # SOMNOLENCE: Patient less somnolent. He is now attempting to speak and while he shakes his head in response to questions. Part of this is possibly from his major depression, though his failure to manage secretions is concerning. His head MRI did not show evidence of anoxic brain injury . . # DESATURATIONS: decreasing 02 requirements . # WEAKNESS: likely highly deconditioned from hospital stay. Will try to encourage activity this PM. # NEUTROPENIC FEVER: Remains on broad spectrum antibiotics for neutropenic fever, though temps continue to run in 99s. We started broad spectrum antibiotics with meropenem/vanc/ambisone, acyclovir. . # RASH: Has resolved, suspecting likely drug rash from ?zosyn. . # MDS: Patient is transfusion dependent with hypoplastic MDS. Cord blood is available for transplant, though patient needs further stabilization and control of mucor/neutropenic fever first. Will look to BMT about defining eligibility goals to proceed with transplant. For now, will treat with prn transfusions. Medications on Admission: 1. Acyclovir 400 mg QID 2. Ciprofloxacin 500 mg [**Hospital1 **] 3. Metronidazole 500 mg TID 4. Fluconazole 200 mg daily 5. Neupogen 480 mcg 2-3x/week 6. Colace 100 mb TID Discharge Medications: 1. atovaquone 750 mg/5 mL Suspension Sig: Ten (10) ml PO DAILY (Daily): Take this medication with food. Disp:*300 ml* Refills:*2* 2. ursodiol 300 mg Capsule Sig: One (1) Capsule PO QAM (once a day (in the morning)). Disp:*30 Capsule(s)* Refills:*2* 3. ursodiol 300 mg Capsule Sig: Two (2) Capsule PO qPM. Disp:*60 Capsule(s)* Refills:*2* 4. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 5. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 6. multivitamin Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 7. fluoride rinse Sig: Five (5) ml once a day. 8. Heparin Flush 10 unit/mL Kit Sig: Two (2) ml Intravenous once a day as needed for line flush PICC: flush w 10ml normal saline following by heparin as above and prn per lumen. 9. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 10. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Take one tablet at 10:00AM. Take one half tablet at 5:00PM prior to evening medications. . Disp:*60 Tablet(s)* Refills:*2* 11. Ambisome 400 mg IV Q48H Start: In am Please space by 2 hours from platelet transfusions. Based on 5mg/kg dosing. 12. valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 13. tacrolimus 0.5 mg Capsule Sig: Nine (9) Capsule PO Q12H (every 12 hours). Disp:*540 Capsule(s)* Refills:*2* Discharge Disposition: Home with Service Discharge Diagnosis: Primary Diagnosis: Mucormycosis, VRE bacteremia, Myelodysplastic Syndrome Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure taking care of you during your stay here at [**Hospital1 18**]. You were admitted to the hospital with fever and neck pain. Your white count was abnormally low and you were found to have a condition called Myelodysplastic Syndrome. Your neck pain was found to be caused by a fungal infection called mucor. You underwent a bone marrow transplant which was complicated by a blood stream infection. The following changes were made to your medications: STARTED Valganciclovir for CMV infection STARTED Atovaquone STARTED Ambisome STARTED Mycophenolate mofetil STARTED Tacrolimus STARTED Omeprazole STARTED fluoride rinse, ok to brush your teeth with a VERY SOFT toothbrush STARTED folic acid, multivitamin STARTED Compazine, antinausea medication Followup Instructions: The following appointments were made for you: Department: BMT/ONCOLOGY UNIT When: FRIDAY [**2137-8-9**] at 8:00 AM [**Telephone/Fax (1) 447**] Building: Fd [**Hospital Ward Name 1826**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3971**] Campus: EAST Best Parking: Main Garage Department: BMT/ONCOLOGY UNIT When: SATURDAY [**2137-8-10**] at 11:30 AM [**Telephone/Fax (1) 447**] Building: Fd [**Hospital Ward Name 1826**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3971**] Campus: EAST Best Parking: Main Garage Department: BMT/ONCOLOGY UNIT When: SUNDAY [**2137-8-11**] at 8:00 AM [**Telephone/Fax (1) 447**] Building: Fd [**Hospital Ward Name 1826**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 3971**] Campus: EAST Best Parking: Main Garage

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icd9pcs

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4026

Discharge summary

report

Admission Date: [**2181-8-17**] Discharge Date: [**2181-9-7**] Date of Birth: [**2120-10-31**] Sex: F Service: MEDICINE Allergies: Penicillins / Imuran / Cephalosporins / Sulfa (Sulfonamide Antibiotics) / Reglan / Latex / Ampicillin / Lactose / Soy, Lentals, Beans Attending:[**First Name3 (LF) 5037**] Chief Complaint: dyspnea, shortness of breath . Reason for MICU transfer: Dyspnea, Respiratory Distress Major Surgical or Invasive Procedure: [**2181-8-23**] - Cardiac catheterization History of Present Illness: This is a pleasant 60-year old Indian female with a complicated past medical history significant for type 1 IDDM (s/p revision renal and pancraes transplants, [**2160**] and [**2174**]), diastolic CHF (Echo 35-40%, [**7-/2181**]), sleep-disordered breathing (on 2L home oxygen at night) who presented on [**2181-8-17**] with dyspnea and evidence of bilateral pleural effusions. . Of note, the patient was most recently admitted ([**Date range (1) 17771**]) with complaints of weakness and dyspnea. She was found to be inurosepsis and was treated empirically with Meropenem and Vancomycin (she has a history of prior urosepsis in [**6-/2180**], speciating MDR E.coli). She was again found to have E.coli in her urine as a source, and was treated with Meropenem IV and switched to Ertapenem on discharge. She also had an NSTEMI with positive tropoinin of 0.36 on admission (MB 10.6) which peaked at 1.11 on HD#3, thought to be related to demand ischemia. Her prior EKG had evidence of LBBB. ETT was obtained, showing a likely distal LAD lesion, not cardiomyopathy, distal septal akinesis, 3+ MR which may have been associated with volume. She was aggressively diuresed with a Lasix gtt given her acute CHF exacerbation and transitioned to Lasix 60 mg IV BID, likely triggered by urosepsis. She was also treated with empirically for C.diff with PO Vancomycin to end on [**2181-8-21**]. . In the ED, VS BP 102-125 systolic, MAPs mid 50-60s, HR 63, RR 27, 98% 2L; the patient was hypoxic to the 90s on 2L. Bedside ultrasound showed bilateral pleural effusions. IP was consulted for possible thoracentesis, and diuresis was recommended. She was given 60 mg IV Lasix. Her troponin was 0.38. BNP 24,918. Levofloxacin 750 mg IV and Vancomycin 1g IV x 1 were given; Lactate 0.6. She has a RUE PICC line. . She was admitted to MICU due to low MAPs to the 50s-60s in the ED and oxygen saturations in the low 90s on 2 liters. In the MICU, she was started on a Lasix gtt and metolazone was added. She is LOS: -3.2 Liters. VS prior to transfer: 95.6 141/67 91 14 98% on 2L NC. Notably had visual hallucinations and started on seroquel. . On the floor, she appears fatigued, but is in no acute distress. She denies chest pain or trouble breathing. She denies palpitations, lightheadedness, and feels only mildly dizzy when standing. She denies headaches or vision changes. She has no nausea or vomiting and has been tolerating diet. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea. She does have some edema in her right leg; but she denies palpitations, syncope. Past Medical History: PAST MEDICAL & SURGICAL HISTORY: 1. diastolic CHF (preserved EF 35-40%, moderate regional systolic dysfunction, [**7-/2181**]) 2. s/p renal transplant ([**2157**], complicated by chronic rejection, second transplant [**2160**]) 3. s/p pancreas transplant (with allograft pancreatectomy [**5-/2174**], redo transplant [**6-/2175**], acute rejection [**7-/2180**] which resolved with increased immunosuppresion) 4. diabetes mellitus type I (complicated by neuropathy, retinopathy, dysautonomia, no longer requires regular insulin after pancreas transplant) 5. autonomic neuropathy 6. sleep-disordered breathing (on 2L NC nighttime, unable to tolerate CPAP) 7. osteoporosis 8. hypothyroidism 9. pernicious anemia 10. cataracts 11. glaucoma 12. anemia from chronic kidney disease (on Aranesp previously) 13. Right foot fracture, complicated by RLE DVT 14. chronic LLE edema 15. Reucrrent MDR E.coli pyelonephritis 16. s/p anal polypectomy ([**5-/2176**]) 17. s/p bilateral trigger finger surgery ([**8-/2178**]) 18. s/p left [**Year (4 digits) 6024**] ([**8-/2179**]) Social History: Child psychiatrist, on disability. Lives alone in [**Hospital1 8**], MA. Has a PCA 8 hours/day. Ambulatory with a prosthesis for left leg. Was at [**Hospital3 **] prior to this admission. Denies tobacco use or alcohol use; no recreational substance use. Family History: Father with MI at 57 year old; denies family history of arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ON ADMISSION (to floor): VITALS: 97.3/97.3 122 98/52 20 98% 2L NC GENERAL: Appears in no acute distress, but is fatigued. Alert and interactive. HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear. Mucous membranes appear dry. No xanthalesma. NECK: supple without lymphadenopathy. JVD 6-7 cm. CVS: irregularly irregular, [**1-28**] harsh, systolic murmur at base and holosystolic murmur at apex, normal S1-S2. No S3 or S4. RESP: Respirations unlabored, no accessory muscle use. Decreased breath sounds at bases with bilateral inspiratory crackles to mid-lung fields. No wheezing, rhonchi. Stable inspiratory effort. ABD: soft, non-tender, non-distended, with normoactive bowel sounds. No palpable masses or peritoneal signs. Abdominal aorta not enlarged to palpation, no bruit. EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses RLE; LLE [**Month/Day (4) 6024**] well-healed DERM: No stasis dermatitis, ulcers, scars, or xanthomas. NEURO: CN II-XII intact throughout. Alert and oriented x 3. DTRs 2+ throughout, strength 5/5 bilaterally (limited effort), sensation grossly intact. Gait deferred. PULSE EXAM: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ ON DISCHARGE: Vitals: 98.6, 123/71 69 20 98% on 2L General: chronically ill appearing, alert and oriented Heart: RRR no m/r/g Lungs: decreased at the bases R>L Abdomen: soft, NT, ND, +BS Extremities: 2+ edema, left [**Month/Day (4) 6024**] Pertinent Results: Admission Labs [**2181-8-17**] 12:10PM BLOOD WBC-3.3* RBC-3.31* Hgb-9.6* Hct-29.6* MCV-90 MCH-29.0 MCHC-32.5 RDW-15.4 Plt Ct-179 [**2181-8-17**] 12:10PM BLOOD Neuts-65.9 Lymphs-21.2 Monos-6.0 Eos-5.9* Baso-1.0 [**2181-8-17**] 12:10PM BLOOD Glucose-88 UreaN-96* Creat-2.1* Na-130* K-5.8* Cl-98 HCO3-23 AnGap-15 [**2181-8-17**] 12:10PM BLOOD ALT-12 AST-34 AlkPhos-96 TotBili-0.2 [**2181-8-17**] 12:10PM BLOOD proBNP-[**Numeric Identifier **]* [**2181-8-17**] 12:10PM BLOOD cTropnT-0.38* [**2181-8-17**] 12:57PM BLOOD pO2-92 pCO2-47* pH-7.27* calTCO2-23 Base XS--5 [**2181-8-17**] 12:24PM BLOOD Lactate-0.6 . EKG ([**2181-8-17**]): Sinus rhythm. Left atrial abnormality. A-V conduction delay. Left bundle-branch block. No significant change compared to the tracing of [**2181-8-1**]. . 2D-ECHOCARDGIOGRAM ([**2181-8-1**]): The left atrium is mildly dilated. The left atrium is elongated. Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. There is moderate regional left ventricular systolic dysfunction with akinesis of the apex and hypokinesis of the distal segments of the LV. The remaining segments contract normally (LVEF = 35-40 %). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid regurgitation jet is eccentric and may be underestimated. There is moderate pulmonary artery systolic hypertension. There is a trivial physiologic pericardial effusion. There are no echocardiographic signs of tamponade. . [**2181-8-17**] CXR - Interval enlargement of bilateral pleural effusions. The adjacent bibasilar opacity is likely in part due to the effusion and atelectasis; however, early developing infiltrate in either or both areas is not excluded. Mild interstitial prominence may indicate edema. . [**2181-6-22**] STRESS/P-MIBI - Mild to moderate reversible defect of the distal anteroseptal and apical walls. Severe left ventricular enlargement with mild systolic dysfunction. LVEF of 41%. The patient was administered 0.142 mg/kg/[**Month/Day/Year **] of Persantine over four minutes. No chest, neck, back, or arm discomforts were reported by the patient throughout the study. Palpitations were reported in the setting of PSVT. Post-infusion, ~0.5 mm of horizontal ST segment depression was noted in leads V5-6, resolving by minute 12 post infusion. The rhythm was sinus with 2 runs of 7 and 11 beat PSVT (~130 bpm) and one apb throughout the study. Appropriate hemodynamic response to the infusion. (0-4 minutes 0.142MG/ KG/[**Month/Day/Year **] vitals 73 126/60 RPP 9198 - total exercise time 4 [**Month/Day/Year **], % max HR achieved: 46%) . [**2181-8-23**] CARDIAC CATH: Selective coronary angiography in this right dominant system demonstrated three vessel disease. The LMCA had no angiographically apparent disease. The LAD had a proximal 90% stenosis, 90% D! and a long 40% mid LAD and diffuse mild disease. The LCx had a mid 60% stenosis and 80% stenosis small OM1. The RCA had a proximal 70% stenosis, mid 50% and 70% distal. Resting hemodynamics revealed elevated right and left sided filling pressures with RVEDP of 15 mmHg and PCW 32 mmHg. There was moderate pulmonary artery systolic hypertension with PASP of 60 mmHg. The cardiac index was preserved at 3.9 L/[**Month/Day/Year **]/m2. There was normal systemic arterial systolic and diastolic central pressures at the aortic level. Left ventriculography was deffered due to elevated filling pressures. . [**2181-8-24**] BLADDER U/S - No evidence of mobile debris in bladder to suggest fungus ball as questioned. Thickened posterior bladder wall, which could relate to known history of cystitis. As other etiologies for bladder wall thickening cannot be entirely excluded, suggest correlation with urine cytology. . [**2181-8-25**] CT HEAD NON-CONTRAST - No acute intracranial process. . [**2181-8-26**] EEG - This is an abnormal EEG because of diffuse background slowing and bursts of generalized delta slowing. These findings are indicative of a mild to moderate diffuse encephalopathy which is etiologically non-specific. No epileptiform features were seen. . [**2181-8-27**] CXR PA & LATERAL - There are bilateral pleural effusions. There is pulmonary vascular re-distribution. There is volume loss at both bases. An underlying infectious infiltrate cannot be excluded in these regions. Compared to the prior study the pulmonary edema is worse and the PICC line position has changed [**2181-8-30**] MRI HEAD - Suboptimal MRI study secondary to patient motion. Within these limitations, unremarkable MRI of the head. [**2181-9-3**] RUE U/S - 1. Non-occlusive thrombus in the right axillary and subclavian veins. 2. Right-sided PICC line terminating in the right axillary vein with thrombus in the basilic vein around the line. DISCHARGE LABS [**2181-9-7**] 04:40AM BLOOD WBC-2.1* RBC-3.30* Hgb-9.6* Hct-29.6* MCV-90 MCH-29.1 MCHC-32.4 RDW-15.1 Plt Ct-149* [**2181-9-7**] 04:40AM BLOOD PT-22.9* PTT-99.0* INR(PT)-2.1* [**2181-9-7**] 04:40AM BLOOD Glucose-135* UreaN-91* Creat-2.3* Na-137 K-4.0 Cl-95* HCO3-31 AnGap-15 [**2181-9-7**] 04:40AM BLOOD Amylase-96 [**2181-9-7**] 04:40AM BLOOD Lipase-29 [**2181-9-7**] 04:40AM BLOOD Calcium-8.8 Phos-2.8 Mg-1.7 [**2181-9-5**] 04:20AM BLOOD rapmycn-7.0 [**2181-9-5**] 04:20AM BLOOD tacroFK-7.2 Brief Hospital Course: 60F with PMH significant for type 1 IDDM (s/p revision renal and pancraes transplants, [**2160**] and [**2174**]), systolic CHF (Echo 35-40%, [**7-/2181**]), sleep-disordered breathing (on 2L home oxygen at night) who presented on [**2181-8-17**] with dyspnea and evidence of bilateral pleural effusions consistent with acute CHF exacerbation. . # CHF - The patint has known systolic CHF with a 2D-echo showing mild LV cavity dilatation, moderate LV dysfunction with akinesis of the apex and hypokinesis of the distal segment; LVEF 35-40% - admitted with dyspnea and fatigue attributed to volume overload in the setting of acute CHF exacerbation, likely due to inadequate diuresis. Put on a lasix drip while in the MICU, then transferred to cardiology. The patient continued to demonstrate evidence of CHF exacerbatio with 1+ pitting edema of the right LE, B/L faint inspiratory crackles on exam, and CXR consistent with pleural effusions. She was diuresed with IV lasix up to 80mg IV BID, and then transitioned to torsemide 80mg PO daily. Continued to be net negative about 1L daily. Her torsemide was decreased to 40mg daily on discharge. ACE-I was avoided given her acute kidney injury. Medically optimized with beta-blocker and diuretics. # ACUTE ON CHRONIC RENAL INSUFFICIENCY - The patient had renal insufficiency in the setting of known renal transplant (with redo) and remained on chronic immune suppresion with Prednisone, Tacrolimus and Sirolimus. She had acute kidney injury that was assumed to be prerenal vs. contrast induced nephropathy. Her Cr peaked at 3.1 post-cardiac cath before slowly downtrending to 2.3 even with continued diuresis. Baseline is about 1.5 to 1.9. Her hyperphosphatemia was managed with calcium acetate with meals TID which was discontinued after electrolyte normalization. Prednisone continued was continued at 5mg daily. Her tacrolimus was decreased to 1.5mg q12 and sirolimus was decreased to 1mg qAM given her [**Last Name (un) **] on admission. These doses were continued as an outpatient as her levels were around 7. # RUE DVT - On [**9-3**], she was found to have swelling in her right upper extremity. A ultrasound noted clot in the axillary and subclavian, as well as clot surrounding the midline in the basilic vein. She was started on a heparin drip to bridge her coumadin. She was started on 5mg of warfarin on [**9-3**], and became therapeutic at INR of 2.1 on [**9-7**]. She was given 7.5mg of coumadin on [**7-6**], but this was unlikely to be responsible for her therapeutic INR, so she was reduced to 5mg and discharged. Heparin drip was stopped and midline PICC was removed prior to discharge. She will need to complete a 3 mth course of anticoagulation. # s/p pancreatic transplant: continued on home immunosuppressants although dose of tacrolimus and sirolimus were downtitrated due to [**Last Name (un) **]. On day of discharge, fasting blood glucose was mildly elevated to 135 although amylase/ lipase within normal limits. Labs will need to be followed closely as an outpatient to ensure that there is no evidence of rejection # ATRIAL FIBRILLATION - The patient was admitted and transferred from MICU with a stable rhythm that was normal sinus, but on MICU trasnfer was noted to have new onset A.fib with no prior history. On HOD#3 she had some evidence of rapid ventricular reponse with a rate in the 110s (130 maximum), which responded to diuresis. This was attributed to atrial stretch from volume overload, and once diuresis ensued, her rhythm spontaneously converted to sinus. The patient had no symptoms of palpitations or chest pain, she only noted mild fatigue and dizziness which eventually resolved. She was anticoagulated with a heparin gtt given her paroxysmal A.fib, and maintained with a PTT goal of 50-80. We monitored her closely with telemetry and optimized her electrolytes, and her rhythm remained sinus following these issues. We initiated Metoprolol 25 mg PO twice daily for rate control and given her CAD. Her telemetry showed no further concerns regarding her rhythm and she remained sinus. Of note, coumadin was started due to RUE DVT and she will not need to continue anticoagulation for provoked episode of afib unless further evidence of arrhythmia arises. . # CAD - The patient has documented ischemic cardiomyopathy with evidence of a mild to moderate reverisble defect of the distal anteroseptal and apical walls on P-MIBI from [**6-/2181**] with an LVEF 41%. She had a 2D-Echo with an of EF 35-40% as well. She developed non-specific ST depression and PVST during the study. On a prior admission she had an NSTEMI with troponin peak of 1.11 which was treated conservatively. This admission her troponin was 0.38 -> 0.26 which was thought to be residual from her prior NSTEMI (given evidence of [**Last Name (un) **] and chronic renal insufficiency). On admission she denied chest pain, nausea or palpitations. She was therefore medically optimized with Aspirin, Metoprolol and a statin. She was also on a heparin gtt briefly (discontinued on [**2181-8-25**]) for A.fib concerns. Given the history of coronary disease and the P-MIBI findings from [**Month (only) 205**] [**2180**] in the setting of her CHF exacerbation, she was taken to the cardiac cath lab on [**2181-8-23**] which showed extensive disease involving three-vessels. Specifically, the LMCA had no angiographically apparent disease. The LAD had a proximal 90% stenosis and a long 40% mid LAD and diffuse mild disease. The LCx had a mid 60% stenosis and 80% stenosis small OM1. The RCA had a proximal 70% stenosis, mid 50% and 70% distal. Resting hemodynamics revealed elevated right and left sided filling pressures with RVEDP of 15 mmHg and PCW 32 mmHg. There was moderate pulmonary artery systolic hypertension with PASP of 60 mmHg. The cardiac index was preserved at 3.9 L/[**Date Range **]/m2. There was normal systemic arterial systolic and diastolic central pressures at the aortic level. Left ventriculography was deffered due to elevated filling pressures. The Cardiac surgery team evaluated the patient, but given the medical problems noted, CABG was not recommended until her other medical issues stabilize. In the meantime, she was continued on Aspirin, Atorvastatin, and Metoprolol. She was without chest pain following admission. # URINARY TRACT INFECTION - The patient was noted to have a positive U/A which grew yeast from urine cultures on [**8-15**]. This was treated with IV Fluconazole 100 mg IV daily (started on [**2181-8-25**]). This was continued for 5-days. She had a bladder U/S showing no evidence of a fungal ball. She also had no WBC or fevers, although she was immunosuppressed. Her mental status changes were attributed to the UTI and yeast infection. She was restarted on suppressive therapy with fosfomycin following discharge. . # NORMOCYTIC ANEMIA - The patient had a hematocrit that was trending down this admission, with no obvious source of bleeding identified - likely her renal insufficiency was contributing to this normocytic anemia. Stool guaiac was negative x 2. She did have some evidence of right thigh swelling with concern for hematoma given her recent cardiac catheterization via the right femoral access point. She was monitored with serial HCTs and required a single unit of packed red cells, with adequate response. A basic hemolysis panel was obtained to rule out a hemolytic component to her anemia, this was negative and reassuring. She remained hemodynamically stable and required no further transfusions. . # LEUKOPENIA - The patient was admitted with leukopenia in the setting of chronic immune suppression with Tacro and Sirolmus with chronic steroid use. Her acyclovir was held given her immune suppression and renal insufficiency. She had blood, mycolytic and urine cultures repeatedly drawn given some intermittent hypotension episodes and given her mental status changes (noted below). With the exception of yeast in her urine, her cultures were unrevealing. She remained afebrile this admission. . # HALLUCINATIONS vs. DELIRIUM - The patient was noted to have visual hallucinations which began in the MICU on admission. She was given Seroquel at nighttime for concerns of ICU delirium and sleep deprivation. Her mental status issues continued despite removal of Seroquel and on transfer to the cardiology floor. She always remained alert and oriented but had hallucinations of tribal warrior visitors, a plethora of feline visitors and a Chinese family. An infectious source was suspected, given her yeast in the urine, which was treated with Fluconazole. Her blood cultures were negative and she was afebrile. A head CT was negative on [**2181-8-25**]. A neurology consult was obtained, noting the above hallucinations with mild myoclonus. Toxic metabolic encephalopathy was suspected vs. infectious etiology. We started low dose Trazodone, stopped her Doxepin and Seroquel given her renal function and AMS. Her visual hallucinations resolved with all of these measures and Neuro consult signed off on [**2181-8-29**]. MRI head performed on [**8-30**] due to continued lethargy was also without acute pathology. Mental status slowly resolved as azootemia and CHF exacerbation resolved. On discharge, she remained off doxepin, seroquel and all other CNS altering meds. . # SLEEP DISORDERD BREATHING - The patietn was noted to utilize 2L NC supplemental oxygen in the evening given a diagnoses of sleep-disordered brathing; she cannot tolerate non-invasives; O2 sats > 95% on this admission. She was continued on pulse oximetry, she was maintained on 2L nasal cannula at night. She was given ipratropium and albuterol nebs. She had no further issues this admission. . # EMPIRIC C.DIFF COVERAGE - The patient was recently treated with Meropenem IV for urosepsis with E.coli (MDR) on a prior admission. She was treated empirically with PO Vancomycin given some frequent stools and leukopenia noted from her immune suppresion. This admission, the patient remained afebrile, and completed the PO Vanc course on [**2181-8-21**] with no further issues of frequent stooling. She is also gluten-intolerant and required diet adjustment. A C.diff on [**2181-8-28**] was negative. . # GLAUCOMA - The patient was continued on her home regimen of Cyclosporin, Dorzolamide/Timolol, Brimonodine and Latanoprost ophthalamic drops for her known chronic glaucoma. Methazolamide was initially held because of concerns it was contributing to renal failure. It was restarted for glaucoma and also for her elevated bicarb. . # HYPOTHYRODISM - Her previous TSH was 0.7 in [**7-/2181**] and given her intermittent A.fib as noted above, we checked her TSH which was stable. We continued her Levothyroxine 110-112 mcg PO daily. TRANSITIONS OF CARE: # CHF exacerbation: - daily weights/ monitor ins and outs - diuresing well with torsemide (dose reduced from 80mg to 40mg on discharge) - adhere to low salt diet - medical management of CAD # DVT: midline pulled, INR therapeutic at 2.1 - monitor PT/INR and adjust coumadin accordingly - maintain on anticoagulation x 3 mths # s/p renal and pancreatic transplant - cont sirolimus/ tacrolimus - monitor amylase/lipase, fasting glucose and renal function twice weekly Medications on Admission: 1. fosfomycin tromethamine 3 gram: 1 packet PO QWeek: dissolve in [**2-23**] ounces of water. Can be taken with or without food. 2. acyclovir 400 mg Tablet: 1 Tab PO Q12H 3. doxepin 10 mg Caps: 1 Capsule PO HS 4. doxazosin 1 mg Tab: 2 Tabs PO DAILY 5. levothyroxine 100 mcg Tab: 1 Tab PO EVERY OTHER DAY 6. levothyroxine 112 mcg Tab: 1 Tab PO EVERY OTHER DAY 7. aspirin 81 mg Tab: 1 Tab PO DAILY 8. methazolamide 50 mg Tab: 1 Tab PO TID 9. prednisone 5 mg Tab: 1 Tab PO DAILY 10. atorvastatin 40 mg Tab: 2 Tabs PO DAILY 11. folic acid 1 mg Tab: 1 Tab PO DAILY 12. albuterol sulfate 0.083 Nebs: 1 INH Q6H prn 13. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 14. ipratropium bromide 0.02%: 1 INH Q6H prn 15. teriparatide 20 mcg/dose Pen Injector: 1 ML Subcutaneous daily 16. sirolimus 1 mg Tab: 2 Tab PO DAILY administered at 6am. 17. carvedilol 12.5 mg Tab: 1 Tab PO BID 18. tacrolimus 0.5 mg Cap: 4 Caps PO Q12H 19. furosemide 20 mg Tab: 1 Tab PO BID 20. senna 8.6 mg Tab: 1 Tab PO BID 21. acetaminophen 325 mg Tab: 1-2 Tabs PO Q6H prn fever, pain. 22. gabapentin 100 mg Cap: 1 Cap PO DAILY 23. gabapentin 100 mg Cap: 2 Caps PO HS 24. lisinopril 5 mg Tab: 0.5 Tab PO HS (at bedtime) 25. cyclosporine 0.05 % Drops: 1 Drop Ophthalmic daily 26. brimonidine 0.15 % Drops: 1 Drop Ophthalmic Q8H 27. latanoprost 0.005 % Drops: 1 Drop Ophthalmic HS 28. lipase-protease-amylase 12,000-38,000 -60,000 unit Cap: 1 Cap PO TID with meals 29. dorzolamide-timolol 2-0.5 % Drops: 1 Drop Ophthalmic [**Hospital1 **] 30. oxygen 1-2L PRN SOB or sats <91% 31. Calcium 500 + D 500 mg(1,250mg) -400 unit Tab: 1 Tab PO daily 32. Aranesp 60 mcg/mL: 1 mL Inj once a month 33. vancomycin 125 mg Cap: 1 Cap PO Q6H until [**2181-8-21**]. 34. pentamidine 300 mg INH: 1 INH once a month. . Discharge Medications: 1. fosfomycin tromethamine 3 gram Packet Sig: One (1) packet PO once a week. 2. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO 3X/WEEK ([**Doctor First Name **],TU,TH). 3. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO 4X/WEEK (MO,WE,FR,SA). 4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. methazolamide 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) inh Inhalation Q6H (every 6 hours) as needed for sob/wheeze. 10. ipratropium bromide 0.02 % Solution Sig: One (1) inh Inhalation Q6H (every 6 hours) as needed for sob/wheeze. 11. teriparatide 20 mcg/dose - 600 mcg/2.4 mL Pen Injector Sig: One (1) injection Subcutaneous once a day. 12. sirolimus 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): at 6am. 13. tacrolimus 0.5 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours). 14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 15. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/fever. 16. cyclosporine 0.05 % Dropperette Sig: One (1) drop Ophthalmic [**Hospital1 **] (2 times a day). 17. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours). 18. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 19. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO three times a day: with meals. 20. dorzolamide-timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 21. Calcium 500 + D 500 mg(1,250mg) -400 unit Tablet Sig: One (1) Tablet PO once a day. 22. Aranesp (polysorbate) 60 mcg/mL Solution Sig: One (1) injection Injection once a month: most recent dose [**2181-9-7**]. 23. pentamidine 300 mg Recon Soln Sig: One (1) inhalation Inhalation once a month. 24. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 25. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 26. torsemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 27. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Primary Diagnoses: 1. acute CHF exacerbation 2. diastolic heart failure 3. acute on chronic renal insufficiency Secondary Diagnoses: 1. pancreas and renal transplant patient (on immunosuppression) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Ms. [**Known lastname 17759**], You were admitted to the hospital due to worsening of your congestive heart failure. You were initially admitted to the ICU, then the Cardiology service, and lastly the Kidney service. We gave you diuretics to help reduce the extra fluid in your lungs and legs. . CHANGES IN YOUR MEDICATION RECONCILIATION: You should START: torsemide 40mg daily for diuresis You should START: warfarin 5mg daily for anti-coagulation You should START: aspirin 325mg daily for heart disease You should START: metoprolol 25mg twice a day for blood pressure and heart disease * The following medications were DISCONTINUED on admission and you should NOT resume: DISCONTINUE: doxepin DISCONTINUE: doxazosin DISCONTINUE: furosemide (this has been replaced by torsemide) DISCONTINUE: gabapentin DISCONTINUE: carvedilol (this has been replaced by metoprolol) DISCONTINUE: lisinopril (until your renal function has improved) * You should continue all of your other home medications as prescribed, unless otherwise directed above. Followup Instructions: Department: CARDIAC SERVICES When: WEDNESDAY [**2181-9-12**] at 2:20 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: TRANSPLANT CENTER When: TUESDAY [**2181-9-25**] at 9:40 AM With: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**Name6 (MD) 2105**] [**Name8 (MD) 2106**] MD [**MD Number(2) 5038**]

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icd9cm

[ [ [] ] ]

[ "93.90", "37.23", "88.56" ]

icd9pcs

[ [ [] ] ]

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41044

Discharge summary

report

Admission Date: [**2124-12-25**] Discharge Date: [**2125-1-2**] Date of Birth: [**2084-1-31**] Sex: F Service: NEUROSURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 78**] Chief Complaint: Worst headache of life Major Surgical or Invasive Procedure: Coiling of LMCA Coiling of basilar tip and ACA aneurysms. History of Present Illness: 40yoF, previously healthy, transferred from [**Hospital **] [**Hospital 1459**] Hospital with CT scan demonstrating non-traumatic SAH. Reportedly was at work when she experienced acute onset of severe headache, which originated posteriorly. The headache was associated with dizziness and 1 syncopal episode. However, she denied fever, nausea/vomiting, visual changes, or photophobia. No h/o migraines, headaches, or similar symptoms. Of note, cousin recently died of brain aneurysm. Upon CT finding, she was transferred to [**Hospital1 18**] for further evaluation and management Past Medical History: None Social History: Not married Family History: Cousin who died in [**Month (only) 1096**] of a cerebral aneursym Physical Exam: GCS 15 O: T: 97.8 BP:150/80 HR:60 RR:16 O2Sat:100%RA Gen: WD/WN, comfortable, NAD HEENT: Pupils: 3-to-2mm bilaterally, EOMs intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. No C/C/E. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [**1-25**] objects at 5 minutes. 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, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to finger rub bilaterally. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**3-29**] throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements Exam on Discharge: Intact Pertinent Results: [**2124-12-26**] 06:03AM BLOOD WBC-6.5 RBC-3.73* Hgb-11.2* Hct-32.2* MCV-86 MCH-30.0 MCHC-34.7 RDW-12.8 Plt Ct-199 [**2124-12-25**] 06:45PM BLOOD Neuts-78.7* Lymphs-18.4 Monos-2.2 Eos-0.1 Baso-0.5 [**2124-12-26**] 06:27AM BLOOD PT-12.8 PTT-59.0* INR(PT)-1.1 [**2124-12-26**] 06:03AM BLOOD Glucose-107* UreaN-12 Creat-0.6 Na-134 K-3.6 Cl-104 HCO3-23 AnGap-11 [**2124-12-26**] 06:03AM BLOOD Calcium-7.9* Phos-3.3 Mg-1.7 [**2124-12-26**] 06:03AM BLOOD Phenyto-9.5* CTA Head [**2124-12-25**]: IMPRESSION: 1. Subarachnoid hemorrhage, unchanged since the recent prior CT with no evidence of hydrocephalus. 2. Three aneurysms arising from the ACOM, left MCA and right superior cerebellar arteries as described above, with the left MCA aneurysm being liekly ruptured given the sentinel clot appearance at this focus. Pl. see the subsequent conventional angiogram report for details. Renal Ultrasound [**2124-12-27**]: IMPRESSION: No son[**Name (NI) 493**] evidence of polycystic kidney disease. 8-mm echogenic focus in left kidney may represent crystals in caliceal diverticulum or nonshadowing, nonobstructing stone. Brief Hospital Course: Ms [**Known lastname 89506**] was taken emergently to the neurointerventional suite and had a coiling of a right mca aneursym that appeared to be the cause of her bleed. 2 additional aneursyms were also found: 5x3AComm and 4x3R PCA. Those were not treated initially. She was admitted directly to the ICU with Q1 neurochecks, she was started on Nimodipine, her SBP was kept less than 160.She was neurologically intact. On [**12-27**] she went back to the neurointerventional suite and undewent a coiling of the ACA and basilar tip aneurysm. Post-angio she did well. She underwent a renal ultrasound to rule out polycystic kidney disease- which was negative. On [**12-28**] she had TCDs which showed R MCA - moderate vasospasm but asymptomatic and did not require any intervention other than close neurochecks and IV fluids. Her IV fluids were decreassed over a three day period, her Dilantin was discontinued and she was transferred to neuroscience floor. She has remained neurologically stable throughout her stay. A CTA was negative for spasm. She was discharged on [**2125-1-2**], her headaches were well controlled. She will continue on Nimodipine at home. Medications on Admission: None Discharge Medications: 1. nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4 hours) for 11 days. Disp:*132 Capsule(s)* Refills:*0* 2. nimodipine 30 mg Capsule Sig: Two (2) Capsule PO every four (4) hours for 1 days. Disp:*12 Capsule(s)* Refills:*0* 3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation: Use while on Dilaudid. Disp:*60 Capsule(s)* Refills:*1* Discharge Disposition: Home Discharge Diagnosis: Multiple Intracranial Aneurysms with rupture of LMCA Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Take Aspirin 325mg (enteric coated) once daily. ???????????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort. What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs. ?????? You may shower (let the soapy water run over groin 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 or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal). ?????? After 1 week, you may resume sexual activity. ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate. ?????? No driving until you are no longer taking pain medications Followup Instructions: Follow up in 4 weeks with Dr. [**First Name (STitle) **] with an MRI/MRA. When you call to make your appointment we will arrange this study for you. Call [**Telephone/Fax (1) 4296**]. Completed by:[**2125-1-2**]

[ "437.3", "435.9", "305.1", "430", "496", "401.9" ]

icd9cm

[ [ [] ] ]

[ "39.76" ]

icd9pcs

[ [ [] ] ]

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150,445

8931

Discharge summary

report

Admission Date: [**2187-2-27**] Discharge Date: [**2187-3-7**] Date of Birth: [**2109-1-9**] Sex: M Service: SURGERY Allergies: Atenolol Attending:[**First Name3 (LF) 2597**] Chief Complaint: Asymptomatic abdominal aortic aneurysm Major Surgical or Invasive Procedure: [**2187-2-27**] Resection and repair of abdominal aortic aneurysm with 20 mm Dacron tube graft History of Present Illness: Mr. [**Known lastname **] is a very pleasant 78-year-old patient referred by [**First Name4 (NamePattern1) 2174**] [**Last Name (NamePattern1) 2912**] for an abdominal aortic aneurysm. His primary physician is [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 31022**]. He was undergoing an evaluation for hypertension and had a CT scan which showed a left adrenal mass which is probably not malignant or active, but was found quite incidentally to have a 5.5-cm aneurysm of the infrarenal abdominal aorta. He denies any abdominal or back pain. There is a family history of aneurysm. His father had a femoral aneurysm which was never treated. He has also a family history of coronary artery disease. The patient himself also has coronary artery disease. He was having exertional angina about three years ago. He had a positive stress test and ultimately [**Last Name (NamePattern1) 1834**] cardiac catheterization and coronary angioplasty and stenting. He reports that his most recent stress test in this past fall however was reasonably good, although he does not have specific details. Past Medical History: CAD, HTN, ^ chol, s/p RCA 3.0 x 8 mm Cypher DES [**7-/2184**] Syncope, AAA, PUD as result of large of ibuprofen, s/p cauterization, GERD PSH: Tonsillectomy, Appy, Bilateral cataract surgery Social History: He is married and lives with his wife. [**Name (NI) **] is a retired business executive. He is very active and continues to play golf quite regularly and walks and carries his clubs. Family History: Father - femoral artery aneurysm Physical Exam: On physical exam, he is well-appearing gentleman in no acute distress. Blood pressure was 140/90 in the left right arm and 138/86 on the right. He had no cervical bruits. Chest was clear. Heart was in regular rhythm. Pulse was 60 and regular. His abdomen was soft and nontender. He had very prominent pulsating mid abdominal mass was evident, which was nontender. He had palpable femoral, popliteal, and posterior tibial pulses bilaterally with no suggestion of peripheral aneurysm. Pertinent Results: [**2187-2-27**] 12:54PM WBC-12.3*# RBC-3.82* HGB-12.0* HCT-35.6* MCV-93 MCH-31.5 MCHC-33.7 RDW-13.6 [**2187-2-27**] 12:54PM GLUCOSE-111* UREA N-23* CREAT-0.9 SODIUM-139 POTASSIUM-4.1 CHLORIDE-109* TOTAL CO2-22 ANION GAP-12 [**2187-2-27**] 12:54PM CALCIUM-7.6* PHOSPHATE-4.3 MAGNESIUM-1.2* [**2187-2-27**] 12:54PM CK-MB-4 cTropnT-0.03* [**2187-2-27**] 12:54PM CK(CPK)-165 [**2187-2-27**] 01:19PM LACTATE-3.7* ***** OPERATIVE REPORT [**2187-2-27**] Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 31023**] Service: VSU Date: [**2187-2-27**] Date of Birth: [**2109-1-9**] Sex: M Surgeon: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD 2287 PREOPERATIVE DIAGNOSIS: Abdominal aortic aneurysm. POSTOPERATIVE DIAGNOSIS: Abdominal aortic aneurysm. PROCEDURE: Resection and repair of abdominal aortic aneurysm with 20 mm Dacron tube graft. ASSISTANT: [**First Name4 (NamePattern1) 11805**] [**Last Name (NamePattern1) 29316**], M.D. ANESTHESIA: General endotracheal and epidural. ESTIMATED BLOOD LOSS: [**2178**] mL. COMPLICATIONS: None. INDICATIONS: This 78-year-old gentleman was recently found to have a 5.5 cm aneurysm of the infrarenal abdominal aorta - not involving the iliacs, with ectasia of his aorta proximally and with the visceral segment being about 3 cm. He did not have a neck that was suitable for endovascular repair, and he was advised to have an open repair. DESCRIPTION OF PROCEDURE: Under adequate general endotracheal anesthesia and with an epidural in place, the patient was placed on a bean bag in the modified right lateral decubitus position. The kidney rest was raised and the table broken, and the flank, abdomen, and groins were prepped and draped in usual sterile fashion. An oblique incision was made across the flank, extending to the edge of the rectus muscle, off the tip of the eleventh rib. The incision was actually extended posteriorly onto the eleventh rib for a short distance. The oblique muscles of the abdomen and intercostal muscles between the eleventh and tenth ribs were divided down to the level of the rectus sheath, which was left intact. The retroperitoneal space was entered. Using sharp and blunt dissection, the peritoneum and its contents were swept out of the iliac fossa, towards the right side, raising the kidney as well. Dissection was carried over to the lateral surface of the aorta, exposing the left common iliac artery. The [**Last Name (un) 24412**] retractor was then placed. Working proximally, the lumbar branch of the left iliac vein was encountered and this was carefully ligated and divided. The vein was allowed to reflect superiorly. The left renal artery was dissected free and exposed. The retroperitoneal tissues over the anterolateral surface of the aorta were then divided down to the left common iliac artery, which was also exposed. Dissection was then carried along the anterior surface of the aorta, dividing the inferior mesenteric artery flush with the aorta, allowing the peritoneum to sweep further to the right. The left ureter was swept up with the peritoneum. The right common iliac artery was dissected free as well. Dissection was then carried proximally, exposing the entire neck of the aorta inferior to the left renal artery. We divided the crus of the diaphragm to look more superiorly, feeling that the aorta was somewhat ectatic at the level of the renal arteries, in hopes of clamping the aorta above the renals and allowing us to sew more closely to the renal arteries. It was apparent, however, that the aorta here was thin-walled and ectatic with early aneurysmal changes, and I was uncomfortable with the thought of clamping it, even though I knew there was no thrombus present within it. We decided to clamp below the renal arteries. A vessel loop was placed around the left renal artery to prevent embolization into the renal when clamping the aorta close to it. We knew the right renal artery was more proximal. After the patient was fully heparinized, we clamped the left and right iliac arteries first, and then the neck of the aorta. A longitudinal aortotomy was then made and this was T'd off proximally and distally. A large amount of thrombus and atheromatous debris was removed from the aortic sac. The wall was thin-walled and fragile. Multiple lumbar branches were suture ligated with figure-of-eight 2-0 silk suture ligatures. Some calcific plaque at the aortic bifurcation was carefully removed transversely, giving a good sewing ring distally. Proximally, the aorta was extremely friable, and I was concerned about using the standard graft inclusion technique because of the fragile nature of the aortic wall. We, therefore, divided the aortic wall completely proximally and excised it back to a relatively short stump of about 1 cm long where the quality was better. I then took a strip of felt and took a 20 mm woven Dacron graft. We then did an end-to-end anastomosis between the graft and the proximal aorta using a running continuous felted technique such that the strip of felt was buttressing the outside of the aortic wall. Once this was completed, the graft was clamped and the anastomosis was tested. A couple of small bleeding points were found on the right corner of the anastomosis and these were repaired with interrupted horizontal pledgeted mattress sutures of 3-0 Prolene. Once this anastomosis was hemostatic, attention was turned to the distal end. The distal portion of the aorta was quite smaller than the proximal end and it was clear that there was a size discrepancy between the graft and the aorta. To deal with this, the aortotomy was extended onto the lateral side of the left common iliac artery. We then took the graft and trimmed it to an appropriate length, and a second end-to-end anastomosis was fashioned between the graft and distal aorta with a running continuous suture of 2-0 Prolene using the standard graft inclusion technique. Prior to completing this anastomosis, the arteries and graft were flushed copiously to be sure there was no residual thrombus present within. We then finished the anastomosis and restored flow in a sequential fashion. The left femoral artery was compressed in the groin. Flow was reestablished into the left iliac system, directing all flow into the pelvis. The patient did drop his blood pressure to about 80 mmHg, but this responded rapidly to volume replacement. Once the blood pressure had stabilized, flow was reestablished into the left leg without any difficulties. We then completed restoration of flow to the right lower extremity in identical fashion as described on the left. Once this was done, hemostasis was secured. One or two bleeding points in the distal anastomosis were encountered and these were repaired similarly with horizontal pledgeted mattress sutures of 3-0 Prolene. The activated clotting time was checked, and the heparin was then fully reversed with protamine. We then removed all retractors and packs. The kidney rest was lowered and the table unbroken. A single pericostal stitch of #1-PDS was used posteriorly. The internal oblique and transversus abdominis muscles were closed in a single layer with a running continuous suture of double-stranded #1-PDS, and the external oblique was closed with a separate running continuous suture of double-stranded #1-PDS. Some subcutaneous sutures of 3-0 Vicryl were used to line up the skin properly, and the skin was closed with skin staples. A dry sterile dressing was applied. The patient tolerated the procedure well and was taken to the recovery room in stable condition. All counts were reported correct. Brief Hospital Course: Mr. [**Known lastname **] [**Last Name (Titles) 1834**] open excision and repair of abdominal aortic aneurysm on [**2187-2-27**]. See operative report for full details of the procedure. Postoperatively he remained intubated and was transferred to the cardiovascular ICU with an epidural and a small amount of pressors. He was extubated successfully overnight. He was started on a CIWA scale for agitation. On POD 3 his platelets count dropped to 75 so his heparin was stopped and anti-heparin antibody was found to be negative. Epidural was DC'd. He was found to be anemic and hypotensive so was transfused a total of 3 units of blood with suboptimal response. He received an additional 2 units on POD 4, and this time his hematocrit bumped appropriately and subsequently remained stable. He was also febrile and was started on Cipro empirically. All cultures were negative. On POD 5 the patient was transferred to the VICU in stable condition. He had a 14 beat run of VTach on POD 6 so cardiology consult was called, and he was ruled out for MI. He complained of abdominal distension and constipation, so was started on a bowel regimen with good result. He received several doses of lasix and diuresed well. On POD 8 he was voiding well, ambulating, and pain was well controlled, so was discharged home. Medications on Admission: ASA 325 mg daily, HCTZ 25 mg daily, Lipitor 40 mg daily, Lisinopril 20 mg daily, Plavix 75 mg daily. Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 3. Atorvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 doses. 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. 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* 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Abdominal aortic aneurysm Retroperitoneal bleed HTN CAD s/p stenting GERD Discharge Condition: Good. Discharge Instructions: What to expect when you go home: 1. It is normal to feel weak and tired, this will last for [**5-6**] 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! 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 [**12-31**] 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: Followup with your primary care physician for blood pressure control. Provider: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2187-3-22**] 11:45 Completed by:[**2187-3-7**]

[ "287.4", "285.9", "998.11", "401.9", "998.89", "564.09", "V45.82", "427.1", "997.1", "780.6", "458.29", "272.0", "414.01", "441.4" ]

icd9cm

[ [ [] ] ]

[ "99.04", "38.93", "38.44" ]

icd9pcs

[ [ [] ] ]

12608, 12614

10263, 11583

305, 402

12732, 12740

2531, 10240

15370, 15628

1973, 2007

11734, 12585

12635, 12711

11609, 11711

12764, 14917

14943, 15347

2022, 2512

227, 267

430, 1540

1562, 1754

1770, 1957

5,544

105,241

485+486

Discharge summary

report+report

Admission Date: [**2114-4-3**] Discharge Date: [**2114-4-13**] Date of Birth: [**2047-10-15**] Sex: M Service: Cardiac Surgery CHIEF COMPLAINT: Unstable angina. HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 23**] is a 66-year-old male with a past medical history of coronary artery disease, type 2 diabetes mellitus, hypertension, and hypercholesterolemia who came to [**Hospital1 190**] with unstable angina. He was in his usual state of health and doing well with cardiac rehabilitation until about one week ago when he had two episodes of chest pain. He cardiologist had increased his Zestril from 2.5 mg to 5 mg, and his atenolol to 150 mg p.o. q.d. The patient continued with cardiac rehabilitation until the a.m. of admission (which was [**2114-4-3**]) when he had two episodes of resting angina at 1:15 a.m. and at 3 a.m., relieved by one sublingual nitroglycerin. He was referred to cardiac catheterization for his unstable angina. PAST MEDICAL HISTORY: (His past medical history includes) 1. Coronary artery disease. He had a cardiac catheterization in [**2113-12-19**] with percutaneous transluminal coronary angioplasty and stent of the left anterior descending artery and the first obtuse marginal. He had a catheterization in [**2114-1-19**] with percutaneous transluminal coronary angioplasty of first obtuse marginal in-stent stenosis and subsequent brachy treatment with stents placed distal and proximal to the first obtuse marginal. 2. Type 2 diabetes mellitus; he was diagnosed 10 years ago. 3. Hypertension. 4. Hypercholesterolemia. 5. Erectile dysfunction. MEDICATIONS ON ADMISSION: His medications on admission included amitriptyline 25 mg p.o. at bedtime, atenolol 150 mg p.o. q.d., lisinopril 5 mg p.o. q.d., enteric-coated aspirin 325 mg p.o. q.d., Lipitor 10 mg p.o. q.d., metformin 1000 mg p.o. b.i.d., Glucovance 500 p.o. b.i.d., insulin 40 units q.d., Humalog sliding-scale, Claritin p.r.n. ALLERGIES: The patient is allergic to TETRACYCLINE AND ITS DERIVATIVES. He is allergic to ALMONDS, PEACHES, POLLEN, and OAK TREES. SOCIAL HISTORY: The patient lives with his wife at home. He does not smoke and does not drink any alcohol. FAMILY HISTORY: The patient's father died of lung cancer. His mother had hypertension, hypercholesterolemia, and died of died of brain cancer. REVIEW OF SYSTEMS: On admission he denied fevers, chills, nausea, vomiting, dizziness, or cough. He denied bright red blood per rectum. He denied melena. He denied urinary symptoms. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed temperature of 98, blood pressure of 140/84, pulse of 54, respiratory rate of 18, oxygen saturation of 96% on room air. In general, a pleasant male in no acute distress. Head, eyes, ears, nose, and throat revealed anicteric. Cardiovascular examination revealed a regular rate and rhythm. First heart sound and second heart sound. A [**1-24**] murmur consistent with mitral regurgitation. Pulmonary revealed clear breath sounds anteriorly and laterally. The abdomen was soft, nontender, and nondistended, positive bowel sounds. Extremities revealed right groin site was clean, dry, and intact; no bruits. Pulses were 2+ bilaterally. Neurologically alert and oriented times three, mentating well. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on admission revealed a white blood cell count of 8.2, hematocrit of 38.7, platelets of 285. INR of 1.1, PTT of 29, PT of 12.4. Sodium of 137, potassium of 4.5, chloride of 100, bicarbonate of 27, blood urea nitrogen of 20, creatinine of 1.1, blood sugar on admission was 333. Creatine kinase was 71. Troponin I was less than 0.3. RADIOLOGY/IMAGING: The patient underwent a cardiac catheterization; please see full report for complete results. Briefly, the patient had 50% in-stent restenosis of the left anterior descending artery, 90% ostial stenosis of the circumflex. Right coronary artery with no significant obstructive disease. He also underwent an echocardiogram; please see full report for complete details. Briefly, the patient had no wall motion abnormalities noted. He had mild aortic stenosis seen. Atrial septal defect secondary to evidence of right-to-left flow. The atrial septal defect was small. His ejection fraction was 55%. HOSPITAL COURSE: On [**4-5**], the patient was taken to the operating room and he underwent a coronary artery bypass graft times three; left internal mammary artery to left anterior descending artery, saphenous vein graft to obtuse marginal, left radial to ramus intermedius. Please see the Operative Note for full details. The patient was told the operation went well and was transferred from the operating room to the Cardiothoracic Intensive Care Unit. At the time of transfer the patient was in normal sinus rhythm. He had an arterial line, a central venous pressure right atrial catheter, two ventricular pacing wires, two atrial pacing wires, two mediastinal chest tubes, and one pleural chest tube. Intravenous drips included "cariporide" (study drug), nitroglycerin, and propofol. Shortly after being in the Cardiothoracic Intensive Care Unit, the patient was started on Nipride for increased blood pressure and an insulin drip for a blood sugar of greater than 194. The patient did well in the immediate postoperative period. He was weaned off his sedation, and he was weaned from the ventilatory and extubated successfully. On postoperative day one, the patient was weaned off Nipride drip. He continued on the insulin drip, and he was restarted on half of his dose of Lantus insulin. He continued to do well. On postoperative day two, the patient became confused. He was given Haldol, and after approximately 24 hours his confusion resolved. He was restarted on his Nipride for hypertension. On postoperative day three, the patient went into a rapid atrial fibrillation which converted to normal sinus rhythm as the amiodarone bolus and drip was started. His temperature spike on that day was 101.8, and he was found to have a urinary tract infection; for which he was started on a 5-day course of Levaquin 500 mg p.o. q.d. On postoperative day four, the patient again went into atrial fibrillation at a rate of 100 to 130. He received an additional amiodarone bolus and was started on p.o. amiodarone. He then converted to normal sinus rhythm. A heparin drip was started on that day. On postoperative day five, the patient was transferred to [**Hospital Ward Name 121**] Six. By this time, the insulin drip, Nipride drip, and amiodarone drip had been weaned off. He was on p.o. amiodarone, and he had been started on Imdur on [**4-7**] for his arterial graft site. Once transferred to the floor, the patient's Lopressor dose and Imdur dose had been increased due to hypertension and also frequent episodes of atrial fibrillation. He continued on his p.o. dose of amiodarone as well. On postoperative day six, the patient was noted to have increased blood sugars and was also noted to have right arm thrombophlebitis in the antecubital area. The patient was started on Ancef 1 g intravenously q.8h., and the patient's blood sugars were being covered by a sliding-scale insulin. Also the patient was being followed by the [**Hospital **] Clinic. On a daily basis the patient had been seen by Physical Therapy. His activity level had increased with the assistance of Physical Therapy and the nursing staff. The patient was due to be discharged from the hospital on postoperative day seven after 24 hours of antibiotics for his thrombophlebitis and reassessment of the patient's blood sugars. PHYSICAL EXAMINATION ON DISCHARGE: Vital signs revealed temperature of 98.1, heart rate of 98 (atrial fibrillation), respiratory rate of 18, blood pressure of 151/67. Blood sugar at this time was 300. Skin revealed right antecubital thrombophlebitis, erythematous. Chest incision was intact with slight redness in the lower pole of the incision. Left radial artery incision was intact with slight redness with clear drainage in the distal end. Cardiovascular examination revealed irregularly irregular with a blowing murmur heard best at the apex. Chest was clear to auscultation. Abdomen was soft, positive bowel sounds. Extremities revealed palpable pulses in the bilateral arms and feet. Bilateral fingers were cool. Feet were warm. Neurologically, alert and oriented times three. Pupils were equal, round, and reactive to light. He had a right facial droop (which is his baseline). COMPLICATIONS/SIGNIFICANT EVENTS: 1. Postoperative atrial fibrillation; being treated with amiodarone and Coumadin; also on Lopressor. 2. Postoperative thrombophlebitis of the right arm; being treated with intravenous Ancef. 3. Postoperative urinary tract infection; has been on a 5-day course of p.o. Levaquin. 4. Hyperglycemia; being treated with sliding-scale as well as his regular insulin regimen of Glargin 52 units subcutaneous q.h.s. and Humalog insulin sliding-scale. MEDICATIONS ON DISCHARGE: (Medications on discharge included) 1. Metoprolol 75 mg p.o. b.i.d. 2. Docusate sodium 100 mg p.o. b.i.d. 3. Enteric-coated aspirin 325 mg p.o. q.d. 4. Isosorbide mononitrate 90 mg p.o. q.d. 5. Amiodarone 400 mg p.o. t.i.d. (through [**4-15**]; then amiodarone 400 mg p.o. q.d.). 6. Ferrous gluconate 324 mg p.o. t.i.d. 7. Glargin insulin 52 units subcutaneous q.h.s. 8. Metformin 100 mg p.o. b.i.d. 9. Humalog insulin sliding-scale. 10. Vitamin C 500 mg p.o. b.i.d. 11. Percocet one to two tablets p.o. q.4h. p.r.n. for pain. 12. Acetaminophen 650 mg p.o. q.4h. p.r.n. for pain. DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Status post coronary artery bypass graft times three. 3. Type 2 diabetes mellitus. 4. Hypertension. 5. Hypercholesterolemia. 6. Erectile dysfunction. CONDITION AT DISCHARGE/DISPOSITION: Condition on discharge was pending; as he will be discharged on [**4-13**] pending blood glucose control and a 24-hour course of intravenous antibiotics for his thrombophlebitis. He will be discharged to home at that time with [**Hospital6 407**] services for INR checks, as he will be on Coumadin. Dose of Coumadin was pending. DISCHARGE FOLLOWUP: The patient was to follow up with Dr. [**Last Name (STitle) 70**] in two weeks. He was to follow up with his primary care physician in two weeks, and he was to follow up with the [**Hospital **] Clinic for insulin adjustments on [**5-1**]. He also had another follow-up appointment at [**Hospital **] Clinic on [**5-16**]. The patient was also to follow up in the [**Hospital 409**] Clinic in two weeks. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Last Name (NamePattern1) 4060**] MEDQUIST36 D: [**2114-4-12**] 12:27 T: [**2114-4-12**] 15:30 JOB#: [**Job Number 4061**] Admission Date: [**2114-4-3**] Discharge Date: [**2114-4-13**] Date of Birth: [**2047-10-15**] Sex: M Service: Cardiac Surgery CHIEF COMPLAINT: Unstable angina. HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 23**] is a 66-year-old male with a past medical history of coronary artery disease, type 2 diabetes mellitus, hypertension, and hypercholesterolemia who came to [**Hospital1 190**] with unstable angina. He was in his usual state of health and doing well with cardiac rehabilitation until about one week ago when he had two episodes of chest pain. He cardiologist had increased his Zestril from 2.5 mg to 5 mg, and his atenolol to 150 mg p.o. q.d. The patient continued with cardiac rehabilitation until the a.m. of admission (which was [**2114-4-3**]) when he had two episodes of resting angina at 1:15 a.m. and at 3 a.m., relieved by one sublingual nitroglycerin. He was referred to cardiac catheterization for his unstable angina. PAST MEDICAL HISTORY: (His past medical history includes) 1. Coronary artery disease. He had a cardiac catheterization in [**2113-12-19**] with percutaneous transluminal coronary angioplasty and stent of the left anterior descending artery and the first obtuse marginal. He had a catheterization in [**2114-1-19**] with percutaneous transluminal coronary angioplasty of first obtuse marginal in-stent stenosis and subsequent brachy treatment with stents placed distal and proximal to the first obtuse marginal. 2. Type 2 diabetes mellitus; he was diagnosed 10 years ago. 3. Hypertension. 4. Hypercholesterolemia. 5. Erectile dysfunction. MEDICATIONS ON ADMISSION: His medications on admission included amitriptyline 25 mg p.o. at bedtime, atenolol 150 mg p.o. q.d., lisinopril 5 mg p.o. q.d., enteric-coated aspirin 325 mg p.o. q.d., Lipitor 10 mg p.o. q.d., metformin 1000 mg p.o. b.i.d., Glucovance 500 p.o. b.i.d., insulin 40 units q.d., Humalog sliding-scale, Claritin p.r.n. ALLERGIES: The patient is allergic to TETRACYCLINE AND ITS DERIVATIVES. He is allergic to ALMONDS, PEACHES, POLLEN, and OAK TREES. SOCIAL HISTORY: The patient lives with his wife at home. He does not smoke and does not drink any alcohol. FAMILY HISTORY: The patient's father died of lung cancer. His mother had hypertension, hypercholesterolemia, and died of died of brain cancer. REVIEW OF SYSTEMS: On admission he denied fevers, chills, nausea, vomiting, dizziness, or cough. He denied bright red blood per rectum. He denied melena. He denied urinary symptoms. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed temperature of 98, blood pressure of 140/84, pulse of 54, respiratory rate of 18, oxygen saturation of 96% on room air. In general, a pleasant male in no acute distress. Head, eyes, ears, nose, and throat revealed anicteric. Cardiovascular examination revealed a regular rate and rhythm. First heart sound and second heart sound. A [**1-24**] murmur consistent with mitral regurgitation. Pulmonary revealed clear breath sounds anteriorly and laterally. The abdomen was soft, nontender, and nondistended, positive bowel sounds. Extremities revealed right groin site was clean, dry, and intact; no bruits. Pulses were 2+ bilaterally. Neurologically alert and oriented times three, mentating well. PERTINENT LABORATORY DATA ON PRESENTATION: Laboratories on admission revealed a white blood cell count of 8.2, hematocrit of 38.7, platelets of 285. INR of 1.1, PTT of 29, PT of 12.4. Sodium of 137, potassium of 4.5, chloride of 100, bicarbonate of 27, blood urea nitrogen of 20, creatinine of 1.1, blood sugar on admission was 333. Creatine kinase was 71. Troponin I was less than 0.3. RADIOLOGY/IMAGING: The patient underwent a cardiac catheterization; please see full report for complete results. Briefly, the patient had 50% in-stent restenosis of the left anterior descending artery, 90% ostial stenosis of the circumflex. Right coronary artery with no significant obstructive disease. He also underwent an echocardiogram; please see full report for complete details. Briefly, the patient had no wall motion abnormalities noted. He had mild aortic stenosis seen. Atrial septal defect secondary to evidence of right-to-left flow. The atrial septal defect was small. His ejection fraction was 55%. HOSPITAL COURSE: On [**4-5**], the patient was taken to the operating room and he underwent a coronary artery bypass graft times three; left internal mammary artery to left anterior descending artery, saphenous vein graft to obtuse marginal, left radial to ramus intermedius. Please see the Operative Note for full details. The patient was told the operation went well and was transferred from the operating room to the Cardiothoracic Intensive Care Unit. At the time of transfer the patient was in normal sinus rhythm. He had an arterial line, a central venous pressure right atrial catheter, two ventricular pacing wires, two atrial pacing wires, two mediastinal chest tubes, and one pleural chest tube. Intravenous drips included "cariporide" (study drug), nitroglycerin, and propofol. Shortly after being in the Cardiothoracic Intensive Care Unit, the patient was started on Nipride for increased blood pressure and an insulin drip for a blood sugar of greater than 194. The patient did well in the immediate postoperative period. He was weaned off his sedation, and he was weaned from the ventilatory and extubated successfully. On postoperative day one, the patient was weaned off Nipride drip. He continued on the insulin drip, and he was restarted on half of his dose of Lantus insulin. He continued to do well. On postoperative day two, the patient became confused. He was given Haldol, and after approximately 24 hours his confusion resolved. He was restarted on his Nipride for hypertension. On postoperative day three, the patient went into a rapid atrial fibrillation which converted to normal sinus rhythm as the amiodarone bolus and drip was started. His temperature spike on that day was 101.8, and he was found to have a urinary tract infection; for which he was started on a 5-day course of Levaquin 500 mg p.o. q.d. On postoperative day four, the patient again went into atrial fibrillation at a rate of 100 to 130. He received an additional amiodarone bolus and was started on p.o. amiodarone. He then converted to normal sinus rhythm. A heparin drip was started on that day. On postoperative day five, the patient was transferred to [**Hospital Ward Name 121**] Six. By this time, the insulin drip, Nipride drip, and amiodarone drip had been weaned off. He was on p.o. amiodarone, and he had been started on Imdur on [**4-7**] for his arterial graft site. Once transferred to the floor, the patient's Lopressor dose and Imdur dose had been increased due to hypertension and also frequent episodes of atrial fibrillation. He continued on his p.o. dose of amiodarone as well. On postoperative day six, the patient was noted to have increased blood sugars and was also noted to have right arm thrombophlebitis in the antecubital area. The patient was started on Ancef 1 g intravenously q.8h., and the patient's blood sugars were being covered by a sliding-scale insulin. Also the patient was being followed by the [**Hospital **] Clinic. On a daily basis the patient had been seen by Physical Therapy. His activity level had increased with the assistance of Physical Therapy and the nursing staff. The patient was due to be discharged from the hospital on postoperative day seven after 24 hours of antibiotics for his thrombophlebitis and reassessment of the patient's blood sugars. PHYSICAL EXAMINATION ON DISCHARGE: Vital signs revealed temperature of 98.1, heart rate of 98 (atrial fibrillation), respiratory rate of 18, blood pressure of 151/67. Blood sugar at this time was 300. Skin revealed right antecubital thrombophlebitis, erythematous. Chest incision was intact with slight redness in the lower pole of the incision. Left radial artery incision was intact with slight redness with clear drainage in the distal end. Cardiovascular examination revealed irregularly irregular with a blowing murmur heard best at the apex. Chest was clear to auscultation. Abdomen was soft, positive bowel sounds. Extremities revealed palpable pulses in the bilateral arms and feet. Bilateral fingers were cool. Feet were warm. Neurologically, alert and oriented times three. Pupils were equal, round, and reactive to light. He had a right facial droop (which is his baseline). COMPLICATIONS/SIGNIFICANT EVENTS: 1. Postoperative atrial fibrillation; being treated with amiodarone and Coumadin; also on Lopressor. 2. Postoperative thrombophlebitis of the right arm; being treated with intravenous Ancef. 3. Postoperative urinary tract infection; has been on a 5-day course of p.o. Levaquin. 4. Hyperglycemia; being treated with sliding-scale as well as his regular insulin regimen of Glargine 52 units subcutaneous q.h.s. and Humalog insulin sliding-scale. MEDICATIONS ON DISCHARGE: (Medications on discharge included) 1. Metoprolol 75 mg p.o. b.i.d. 2. Docusate sodium 100 mg p.o. b.i.d. 3. Enteric-coated aspirin 325 mg p.o. q.d. 4. Isosorbide mononitrate 90 mg p.o. q.d. 5. Amiodarone 400 mg p.o. t.i.d. (through [**4-15**]; then amiodarone 400 mg p.o. q.d.). 6. Ferrous gluconate 324 mg p.o. t.i.d. 7. Glargine insulin 52 units subcutaneous q.h.s. 8. Metformin 100 mg p.o. b.i.d. 9. Humalog insulin sliding-scale. 10. Vitamin C 500 mg p.o. b.i.d. 11. Percocet one to two tablets p.o. q.4h. p.r.n. for pain. 12. Acetaminophen 650 mg p.o. q.4h. p.r.n. for pain. DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Status post coronary artery bypass graft times three. 3. Type 2 diabetes mellitus. 4. Hypertension. 5. Hypercholesterolemia. 6. Erectile dysfunction. CONDITION AT DISCHARGE/DISPOSITION: Condition on discharge was pending; as he will be discharged on [**4-13**] pending blood glucose control and a 24-hour course of intravenous antibiotics for his thrombophlebitis. He will be discharged to home at that time with [**Hospital6 407**] services for INR checks, as he will be on Coumadin. Dose of Coumadin was pending. DISCHARGE FOLLOWUP: The patient was to follow up with Dr. [**Last Name (STitle) 70**] in two weeks. He was to follow up with his primary care physician in two weeks, and he was to follow up with the [**Hospital **] Clinic for insulin adjustments on [**5-1**]. He also had another follow-up appointment at [**Hospital **] Clinic on [**5-16**]. The patient was also to follow up in the [**Hospital 409**] Clinic in two weeks. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Last Name (NamePattern1) 4060**] MEDQUIST36 D: [**2114-4-12**] 12:27 T: [**2114-4-12**] 15:30 JOB#: [**Job Number 4061**]

[ "997.1", "429.71", "V45.82", "250.00", "599.0", "411.1", "996.72", "414.01", "427.31" ]

icd9cm

[ [ [] ] ]

[ "39.61", "36.12", "88.56", "39.64", "37.22", "36.15" ]

icd9pcs

[ [ [] ] ]

13192, 13320

20653, 21210

20029, 20632

12614, 13065

15303, 18639

18654, 20002

13340, 15285

11133, 11151

21232, 21943

11180, 11940

11963, 12587

13082, 13175

27,890

165,787

31254

Discharge summary

report

Admission Date: [**2137-6-4**] Discharge Date: [**2137-6-12**] Date of Birth: [**2066-8-10**] Sex: F Service: MEDICINE Allergies: Lipitor Attending:[**First Name3 (LF) 783**] Chief Complaint: s/p fall, MS changes Major Surgical or Invasive Procedure: 1) L video-assisted thoracic surgery (VATS) ([**2137-6-6**]) 2) Pericardial window ([**2137-6-6**]) 3) IVC filter ([**2137-6-6**]) History of Present Illness: 70 y/o F with a PMHx of pancreatic CA s/p Whipple [**2133**] with recent metastatic recurrence to liver, lungs, bone presented to [**Hospital1 2436**] today with progressive SOB. Two weeks she developed the acute onset of right shoulder pain and was found on CXR to have diffuse pulmonary mets thought to be due to a recurrence of her pancreatic CA. She was to follow up with her oncologist when she noticed the progressive onset of SOB and fatigue. She went into [**Hospital1 2436**] today and had a CTA which showed a PE in her RUL PA as well as her L pulmonary vein. She was transferred to [**Hospital1 18**] for further management. In the ED, her VS were: temp 98.1, HR 72, BP 145/65, RR 18 97%2L. Past Medical History: 1) Pancreatic CA s/p Whipple [**2133**] at [**Hospital1 336**]; recently found to recur with mets to bone, spine, lungs, liver 2) NIDDM 3) GERD 4) HTN 5) Diet controlled hypercholesterolemia Social History: Lives with daughter in [**Name (NI) 4444**]. Family History: non-contributory Physical Exam: VS: Temp:100.2 BP:167/79 HR:93 RR:24 O2sat: 99% 2L NC GEN: Cachetic, ill appearing. Slightly uncomfortable at rest, dyspneic with sentences HEENT: PERRL, EOMI, anicteric, MM dry. No scleral icterus. No significant JVD RESP: Crackles present at mid left lung field. Moving air throughout. Using accessory muscles but no abd breathing noted. CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly. Scar noted at epigastrium. EXT: no edema, erythema SKIN: No jaundice. NEURO: AAOx3. Moves all ext throughout Pertinent Results: LENIs [**6-4**]: No evidence of DVT CXR [**6-4**]: Limited examination demonstrating left pleural effusion with atelectasis, as well as possible right lung "pseudotumor" versus true parenchymal mass and possible lymphangitic carcinomatosis. TTE [**6-5**]: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is a moderate sized pericardial effusion, with the greatest amount of fluid apically. There is brief right atrial diastolic collapse and early (brief) RV diastolic invagination. There is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, consistent with impaired ventricular filling. Brief Hospital Course: 70 y/o F with a PMHx of pancreatic CA s/p Whipple [**2133**] with recent metastatic recurrence to liver, lungs, bone found to bilateral PEs and pericardial effusion. After a week long hospital course, the patient was eventually discharged home with hospice. 1. PE: Pt with a recent diagnosis of metastatic recurrence of pancreatic CA to bone, liver, lungs, pleura. Has developed progressive DOE; found to have bilateral PEs as well as pericardial effusion. Given the concern for a likely hemorrhagic pericardial effusion in the setting of her pancreatic CA, was not anticoagulated. Had negative LENIs which did not show any evidence of large clot burden in LEs. Given inability to anticoagulate, was taken for IVC filter placement on [**6-6**]. Further decision to anticoagulate was deferred to heme/onc. 2. Pericardial Effusion: Likely malignant effusion from pancreatic CA. Had TTE on [**6-5**] which showed early tamponade physiology, but patient was HD stable during her ICU stay. Was evaluated by CT surgery and cardiology and given concern for recurrent pericardial effusion from likely malignant effusion, was taken for a pericardial window on [**6-6**]. Chest tube was placed to water seal on and eventually removed. Pericardial fluid cytology was negative for malignant cells. 3. DM: Held metformin while inpt and covered with RISS. She was restarted on metformin upon discharge. 4. HTN: The patient antihypertensives were held on admission given concern for pericardial effusion. Her blood pressure remained stable and he prior medications were never restarted. 5. PNA: The patient developed a RML PNA and was treated with a 14 day course of levofloxacin/flagyl. 6. Pancreatic CA s/p Whipple now recurred: Metastatic pancreatic CA to bone, liver, lungs. Was not a candidate for palliative chemo given diffuse metastatic disease. Was seen by oncology who agreed with holding off on anticoagulation and treating with IVC filter placement. The patient and her family met with the palliative care team and they decided that discharging to home with hospice care would be the best for the patient. She was discharged with to home on [**2137-6-12**] with hospice care. Medications on Admission: Metformin 500 [**Hospital1 **] Oxycodone prn Norvasc (dose?) Atenolol 50 qD Pancrease TID c meals Discharge Medications: 1. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 2. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule, Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*300 capsules* Refills:*2* 3. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 4. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 5. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Disp:*30 Tablet(s)* Refills:*0* 6. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for Anxiety. Disp:*30 Tablet(s)* Refills:*0* 7. Morphine 30 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). Disp:*30 Tablet Sustained Release(s)* Refills:*2* 8. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 6 days. Disp:*6 Tablet(s)* Refills:*0* 9. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 9 days. Disp:*27 Tablet(s)* Refills:*0* 10. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. Disp:*1 bottle* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 269**] Hospice [**Location (un) 270**] East Discharge Diagnosis: 1) Metastatic pancreatic cancer 2) Bilateral pleural effusion 3) Pericardial effusion 4) Bilateral pulmonary embolisms 5) NIDDM 6) GERD 7) HTN 8) Hypercholesterolemia Discharge Condition: Stable. Stable. Discharge Instructions: You were admitted to the hospital with bilateral pulmonary embolisms, otherwise described as blood clots in the vessels of both your lungs. This was making it very difficult for you to breathe. You had a filter placed in your IVC to prevent further clots from getting into your lung. In addition, you were found to have bilateral pleural effusion (which is fluid between the two linings of your lungs), as well as a pericardial effusion (which is fluid between the two linings of your heart). To drain the fluid around your heart, the thoracic surgeons inserted a chest tube into the space between the linings of your heart. This tube was taken out prior to your leaving the hospital. Later, you developed a fever, which was likely due to an infection in your lungs, which we treated with antibiotics. We are giving you antibiotics to finish at home. You need to LEVOFLOXACIN 500mg once a day for another 6 days. You need to take FLAGYL/METRONIDAZOLE 500mg three times a day for another 9 days. We are also giving you a oral mouth wash called nystatin to keep fungus from building up in your mouth. You can resume taking your pancreatic enzymes and metformin at home, but please STOP your norvasc and atenolol. There is no need to take those medications anymore. We are giving you a medication called oxycodone and hydromorphone that you can take as instucted on the bottle for pain control. We also are prescribing you ambien which can be taken at night to help you sleep. You can also take lorazepam 0.5mg as needed for anxiety. Please go to the Emergency Department of the hospital and call your doctor's office if you experience any of the following: * Fever (>101 F) or chills * New and continuing nausea or vomiting * Abdominal or chest pain * Shortness of breath * Redness or drainage, swelling, warmth, or pus around your chest tube site * Any other concerns If you experience clear drainage from your wounds, cover them with a clean dressing and stop showering until the drainage stops for at least two days. Narcotics can cause constipation. Please take an over-the-counter stool softener such as Colace or a gentle laxative such as Milk of Magnesia if you experience constipation. You may resume your regular diet as tolerated. Followup Instructions: Please follow up with your primary care doctor as needed. You can call the hospice people 24 hours a day if needed. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

[ "197.0", "420.90", "415.19", "250.00", "V10.09", "530.81", "401.9", "486", "198.5", "272.0", "197.7", "197.2" ]

icd9cm

[ [ [] ] ]

[ "38.7", "37.12", "88.51", "34.21", "34.24" ]

icd9pcs

[ [ [] ] ]

6881, 6967

3273, 5468

288, 421

7178, 7197

2042, 3250

9506, 9756

1448, 1466

5616, 6858

6988, 7157

5494, 5593

7221, 9483

1481, 2023

227, 250

449, 1154

1176, 1369

1385, 1432

12,855

147,828

30538

Discharge summary

report

Admission Date: [**2126-3-18**] Discharge Date: [**2126-3-24**] Date of Birth: [**2060-3-5**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: asymptomatic with positive stress test Major Surgical or Invasive Procedure: Coronary Artery Bypass Graft x3 [**2126-3-18**] (LIMA to LAD, SVG to OM, SVG to RCA) History of Present Illness: 65 yo female with multiple cardiac risk factors. ETT was positive and she went for cath. This revealed LAD 100%, OM 1 90%, RCA 80%. Referred for CABG. Past Medical History: IDDM peripheral neuropathy HTN elev. chol. CRI ( baseline 1.5) diverticular disease varicosities C-sections x3 Social History: retired 15 pack/year history, quit > 30 years ago denies ETOH lives with husband Family History: father with MI in early 50's Physical Exam: 64 " 86.8 kg NAD no obvious skin lesions EOMI , PERRL, NC/AT neck supple with full ROM, no JVD or carotid bruits CTAB RRR no m/r/g soft, obese,NT, ND, + BS warm, well-perfused, no edema bilat. large varicose veins in calves lateral to posterior fems/DP/PT/radials 2+ bil. Pertinent Results: [**2126-3-24**] 09:30AM BLOOD WBC-13.8* RBC-3.60* Hgb-10.9* Hct-33.1* MCV-92 MCH-30.3 MCHC-33.0 RDW-14.4 Plt Ct-437 [**2126-3-20**] 07:05AM BLOOD WBC-16.4* RBC-3.08* Hgb-9.5* Hct-28.4* MCV-92 MCH-30.9 MCHC-33.5 RDW-14.2 Plt Ct-178 [**2126-3-18**] 11:31AM BLOOD WBC-13.7* RBC-2.65*# Hgb-8.4*# Hct-24.2*# MCV-91 MCH-31.5 MCHC-34.6 RDW-14.5 Plt Ct-197 [**2126-3-24**] 09:30AM BLOOD PT-12.4 PTT-25.7 INR(PT)-1.1 [**2126-3-18**] 11:31AM BLOOD Plt Ct-197 [**2126-3-18**] 11:31AM BLOOD PT-13.3* PTT-31.1 INR(PT)-1.2* [**2126-3-24**] 09:30AM BLOOD Glucose-262* UreaN-34* Creat-1.6* Na-138 K-4.7 Cl-97 HCO3-30 AnGap-16 [**2126-3-18**] 12:25PM BLOOD UreaN-31* Creat-1.3* Cl-109* HCO3-22 CHEST (PA & LAT) [**2126-3-22**] 9:03 AM CHEST (PA & LAT) Reason: eval pleural effusions [**Hospital 93**] MEDICAL CONDITION: 66 year old woman s/p CABGx3 REASON FOR THIS EXAMINATION: eval pleural effusions HISTORY: 66-year-old female status post CABG x3. Evaluate effusions. Comparison is made to prior radiographs dating back to [**2126-3-12**]. PA AND LATERAL CHEST RADIOGRAPH FINDINGS: Since most recent film, there is probably slight increase in size to right- sided small effusion with stable appearance to left-sided small effusion. Left lower lobe/retrocardiac atelectasis persists. There is no evidence of pulmonary edema or pneumothorax. Enlarged cardiac silhouette is unchanged and the hilar contours are unremarkable. IMPRESSION: Slight increase in size to small bilateral pleural effusions (right greater than left). Persistent left lower lobe atelectasis. The study and the report were reviewed by the staff radiologist. DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] DR. [**First Name8 (NamePattern2) **] [**First Name4 (NamePattern1) 1508**]Approved: FRI [**2126-3-22**] 1:25 PM Cardiology Report ECG Study Date of [**2126-3-20**] 10:10:20 PM Atrial fibrillation with a rapid ventricular response. Low precordial lead voltage. Right bundle-branch block. Compared to the previous tracing of [**2126-3-18**] atrial fibrillation with a rapid ventricular response has appeared. Read by: [**Last Name (LF) 578**],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 579**] Intervals Axes Rate PR QRS QT/QTc P QRS T 135 0 108 286/365.42 0 -32 174 PATIENT/TEST INFORMATION: Indication: Coronary artery disease. Hypertension. Intraoperative TEE for CABG procedure Height: (in) 64 Weight (lb): 191 BSA (m2): 1.92 m2 BP (mm Hg): 145/78 HR (bpm): 56 Status: Inpatient Date/Time: [**2126-3-18**] at 09:05 Test: TEE (Complete) Doppler: Limited Doppler and color Doppler Contrast: None Tape Number: 2007AW1-: Test Location: Anesthesia West OR cardiac Technical Quality: Suboptimal REFERRING DOCTOR: DR. [**First Name (STitle) 412**] [**Last Name (Prefixes) 413**] MEASUREMENTS: Left Ventricle - Ejection Fraction: 55% (nl >=55%) Aorta - Ascending: 3.1 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.0 m/sec (nl <= 2.0 m/sec) Aortic Valve - Peak Gradient: 4 mm Hg Mitral Valve - E Wave: 0.6 m/sec Mitral Valve - A Wave: 0.4 m/sec Mitral Valve - E/A Ratio: 1.50 Mitral Valve - E Wave Deceleration Time: 200 msec INTERPRETATION: 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: Normal regional LV systolic function. Overall normal LVEF (>55%). No resting LVOT gradient. LV WALL MOTION: basal anterior - normal; mid anterior - normal; basal anteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal; mid inferoseptal - normal; basal inferior - normal; mid inferior - normal; basal inferolateral - normal; mid inferolateral - normal; basal anterolateral - normal; mid anterolateral - normal; anterior apex - normal; septal apex - normal; inferior apex - normal; lateral apex - normal; apex - normal; RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. No atheroma in ascending aorta. Normal aortic arch diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. No MS. Trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient was under general anesthesia throughout the procedure. The patient appears to be in sinus rhythm. Results were personally Conclusions: Prebypass 1.No atrial septal defect is seen by 2D or color Doppler. 2.Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. 3.There are simple atheroma in the descending thoracic aorta. 4.The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. 5.The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 6. There is no pericardial effusion. Post bypass 1. Patient is being AV paced and receiving an infusion of phenylpehrine. 2. Biventricular systolic function is unchanged. 3. Aorta intact post decannulation. Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD on [**2126-3-18**] 12:33. [**Location (un) **] PHYSICIAN: Brief Hospital Course: Admitted [**3-18**] and underwent cabg x3 with LIMA-LAD,SVG-OM,SVG-dRCA. Tolerated the operation well, bypass time was 63 min and crossclamp was 54 min. Transferred to the CSRU in stable condition on propofol and insulin drips. Did well in the immediate post-op period and extubated that evening. On POD1 the patient continued to do well and transferred to the stepdown floor. Over the next several days the patients activity level was advanced and on POD3 her epicardial wires were removed. That evening she had atrial flutter treated with Amiodarone and beta blockers which she converted to sinus rhythm. On POD 6 it was decided she was stable and ready for discharge to home with visiting nurses. Medications on Admission: metformin 850 mg TID glyburide 10 mg [**Hospital1 **] simvastatin 40 mg daily lisinopril 40 mg daily atenolol 25 mg daily ASA 81 mg daily caltrate 600 + D Lantus 50 units q 8PM Discharge Medications: Colace 100mg twice a day Amiodarone 400mg twice a day until [**3-28**] then decrease to 400mg once a day until [**4-4**] then decrease to 200mg daily Hydromorphone 2mg tablets q3-4h prn pain Furosemide 40mg once a day for 7 days KCL 20 meq once a day for 7 days Lopressor 25mg three times a day Simvastatin 40 mg once a day Metformin 850mg three times a day Glyburide 10 mg twice a day Caltrate 600 + D once a day ASA 81 mg once a day Lantus 50 units once a day (hold lisinopril d/t b/p) Discharge Disposition: Home With Service Facility: [**Hospital **] Hospice and VNA Discharge Diagnosis: s/p cabg x3 IDDM peripheral neuropathy HTN elev. chol. CRI ( baseline 1.5) diverticular disease varicose veins Discharge Condition: good Discharge Instructions: Keep wounds clean and dry. OK to shower, no bathing or swimming. Take all medications as prescribed no lotions, creams, or powders on any incision no driving for one month no lifting greater than 10 pounds for 10 weeks call for fever greater than 100.5, redness or drainage Followup Instructions: see Dr. [**Last Name (STitle) 8049**] in [**12-22**] weeks see Dr. [**Last Name (STitle) 5874**] in [**12-22**] weeks see Dr. [**Last Name (STitle) 1290**] in 4 weeks [**Telephone/Fax (1) 8652**] patient to call for all appointments Completed by:[**2126-3-25**]

[ "401.9", "997.1", "593.9", "356.9", "V15.82", "V17.3", "414.01", "250.00", "V12.79", "427.32", "427.31" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

8310, 8372

6868, 7571

359, 450

8527, 8533

1218, 1989

8855, 9120

878, 908

7798, 8287

2026, 2055

8393, 8506

7597, 7775

8557, 8832

3531, 6806

923, 1199

281, 321

2084, 3505

478, 630

6845, 6845

652, 764

780, 862

17,976

137,738

15163

Discharge summary

report

Admission Date: [**2178-10-30**] Discharge Date:[**2178-11-24**] Date of Birth: [**2122-2-3**] Sex: M Service: HISTORY OF PRESENT ILLNESS: Mr. [**Name14 (STitle) 44169**] is a 56-year-old male with past medical history significant for hypertension who originally presented to outside hospital the day prior to admission with complaint of substernal chest pain. He was treated with Nitroglycerin and continued to drop his blood pressure. He also complained of lower extremity tingling and had decreased femoral pulses bilaterally. A chest x-ray at the time showed widened mediastinum. The patient was intubated and transferred to [**Hospital1 188**] for further management. Emergent transesophageal echocardiogram was performed which demonstrated Type A aortic dissection with a pleural/pericardial effusion and low normal left ventricular function. Cardiothoracic surgery was consulted. The patient was consequently taken to the operating room for an emergent ascending aortic dissection repair. PAST MEDICAL HISTORY: 1. Hypertension. 2. Elbow fracture. 3. Lower gastrointestinal bleed in [**2175**]. 4. History of back spasm. ALLERGIES: Penicillin. MEDICATIONS: 1. Anti-hypertensive medication (Name unknown). SOCIAL HISTORY: Works as manager. Has no history of tobacco use. PHYSICAL EXAMINATION: Temperature is afebrile, heart rate 72, blood pressure 107/palpable. Intubated at 100% oxygen saturation. General: Intubated in no apparent distress, opens his eyes spontaneously. Head, eyes, ears, nose and throat: No jugular venous distention, atraumatic. No bruits. Chest exam: Clear to auscultation bilaterally. Cardiac Regular rate and rhythm. Abdomen is soft, nontender, nondistended. Extremities: Warm, well perfused, bilateral pulses present. LABORATORY: Hematocrit 32.1, white blood count 11.1, platelets 157, INR 1.4. Glucose 194. BUN 21, creatinine 1.1. Sodium 141. Potassium 4.1. Chest x-ray obtained on [**2178-10-30**] showed widened mediastinum. SUMMARY OF HOSPITAL COURSE: The emergent echocardiogram showed definite extensive Type A aortic dissection originating just distal to the aortic valve and extending into the ascending aorta to at least the level of the stomach and mild aortic regurgitation. No definite pericardial effusion was seen. Low normal left ventricular systolic function without focal wall motion abnormality was also noted. The patient was taken to the operating room on [**2178-10-30**] and underwent repair with resection and grafting of the ascending hemi-arch of the aorta valve resuspension using 26 mm Gelweave-Dacron graft and bioglue. The patient received multiple blood products in the operating room. Chest tubes were placed. Cardiopulmonary bypass time was 171 minutes, aortic cross clamp time was 91 minutes. The patient was transferred to the Intensive Care Unit, intubated in fair condition. The patient originally was in sinus rhythm with occasional paroxysmal atrial contractions. He was making good urine. He was placed on insulin drip. He was maintained on Dopamine. The bronchoscopy done on [**11-2**] revealed mild amount of mucous secretions in the left lower lobe region. He was started on Vancomycin and Levofloxacin. The patient experienced a brief episode of hypoxia and intravenous Heparin was started for presumptive pulmonary embolism. CT angiogram was negative for a pulmonary embolism performed on [**2178-11-4**]. At the same time, the patient underwent cardiac catheterization which showed no significant obstructive coronary artery disease, anomalous origin of the left anterior descending, biventricular diastolic dysfunction and no evidence of pulmonary embolism. On postop day four the patient experienced atrial fibrillation and atrial flutter. Cardiology service was consulted. At the time he was being maintained on the Amiodarone, Dopamine, insulin drips. His Amiodarone was increased. The patient was also started on tube feeds do no oral food intake. The patient received additional transfusion postop day five for a hematocrit of 26.9. Anti-coagulation was continued and he was started on Esmolol for rate control. Repeat bronchoscopy was performed given partial pulmonary collapse on the imaging and mucous plugging bronchoscopy. The chest tubes were removed on postop day 7. The patient was maintained on a Lasix drip and also Labetalol. He was noted to be hypertensive at times and was treated appropriately. The patient was transfused again on postop day nine. The patient proved to difficult to wean off the ventilator. Also, Dermatology was consulted regarding a rash in multiple areas of the body. Drug reaction was thought to be the primary suspect. He also developed a fever. The Infectious Disease consult recommended the continue Vancomycin to pan culture the patient and to start Fluconazole. His blood cultures revealed coagulase negative staff on [**2178-11-11**] and [**2178-11-13**]. The patient remained on CPAP/PS by postop day 15. No clear source of fever was identified. The patient went into atrial flutter/atrial fibrillation again on postop day 15. He was extubated on postop day 16. The tube feedings were stopped. He appeared alert and oriented. He did experience some short of breath post extubation. His atrial fibrillation was difficult to control. Cardiology was re-consulted. On [**2178-11-18**] he underwent an ablation procedure for his atrial flutter by the Electrophysiology service. The procedure was without complications and the patient converted to sinus rhythm. The plan was to anti-coagulate the patient for the next six weeks. The sensitivity of the two positive blood cultures were different which was suggestive of a possible contaminant. The patient was stable. He was transferred to the regular floor in stable condition. He remained afebrile. He was making good urine. He was ambulating with assistance. He remained in sinus rhythm with occasional premature ventricular contractions. He was maintained on oral Labetalol, Coumadin, Amiodarone and Lopressor. Physical therapy was consulted which recommended rehabilitation facility post discharge. The patient was consequently discharged to the rehabilitation facility in good condition. PLAN: Anti-coagulation for a total of six weeks. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Rehabilitation facility. DISCHARGE DIAGNOSIS: 1. Type A ascending aortic dissection status post repair. 2. Skin rash, possibly drug related, status post skin biopsy. 3. Fever of unknown origin. 4. Hypertension. DISCHARGE MEDICATIONS: 1. Coumadin times six weeks (dose to be adjusted for INR goal of 2 to 2.5). 2. Tylenol 650 mg p.o. p.r.n. 3. Vancomycin 1 gram intravenous q 18 hours until [**2178-11-27**]. 4. Pantoprazole 40 mg p.o. q day. 5. Amiodarone 400 mg q day times six weeks. 6. Labetalol 200 mg p.o. three times a day. 7. Metoprolol 100 mg p.o. three times a day. 8. Milk of Magnesia p.r.n. 9. Percocet one to two tabs p.o. q 4 to 6 hours p.r.n pain. 10. Ibuprofen 400 mg p.o. q 6 hours p.r.n. 11. Lasix 40 mg p.o. b.i.d. times 10 days. 12. Potassium chloride 20 mEq p.o. b.i.d. times 10 days. 13. Colace 100 mg p.o. b.i.d. p.r.n. constipation. 14. Aspirin 81 mg p.o. q day. DISCHARGE INSTRUCTIONS: 1. The patient is to see Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1290**] in approximately four weeks. 2. The patient is to see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 44170**] (PCP) in one to two weeks, [**Telephone/Fax (1) 44171**]. The patient is to see Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**] (Cardiology) in two to three weeks. 3. Coumadin dose is to be adjusted to the INR level of 2 to 2.5. Coumadin is to be continued for six weeks from time of discharge. 4. Vancomycin intravenous is to be continued until [**2178-11-27**] with the dose as above. [**Last Name (STitle) **] DR.[**Last Name (Prefixes) 413**],[**First Name3 (LF) 412**] 02-351 Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2178-11-23**] 20:21 T: [**2178-11-23**] 20:32 JOB#: [**Job Number 18930**]

[ "441.01", "423.0", "428.30", "693.0", "518.81", "427.32", "427.31", "998.11", "518.0" ]

icd9cm

[ [ [] ] ]

[ "37.12", "89.64", "38.45", "96.72", "88.56", "37.23", "33.23", "39.31", "42.23", "88.72", "88.43", "39.61", "37.34" ]

icd9pcs

[ [ [] ] ]

6378, 6404

6622, 7292

6425, 6599

7316, 8216

2046, 6322

1339, 2017

159, 1024

1046, 1248

1265, 1316

6347, 6354

55,049

158,978

30642

Discharge summary

report

Admission Date: [**2142-3-29**] Discharge Date: [**2142-4-3**] Date of Birth: [**2084-9-17**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 4765**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: Mr. [**Known lastname 72655**] is a 57 yo M with PMH of mild hyperlipidemia, who presented to [**Hospital1 **] with chest pain. Pt states that his chest pain began around 2:30pm in the afternoon when he was sitting down talking on the phone. He describes the pain as a chest pressure across his chest, that was worse with leaning back or any upper body movement, and with deep inspiration. The pain was improved with leaning forward. He also had associated SOB, but denied associated nausea, vomiting, or diaphoresis. He states that the pain became worse over the next couple of hours. He spoke with his wife, and they talked with their PCP. [**Name10 (NameIs) 3754**] was initial concern for musculoskeletal pain given playing badminton the day before; however, his pain continued and his wife call 911. At his worst, the pain was [**9-12**]. He was taken to the [**Hospital1 **] ED. . At [**Hospital1 **] ED, his initial VS were 127/47, 59, 34 Temp 98.1, 95% on RA. He was placed on NRB 20mins later for unclear reasons, with O2 sats 98%. ECG with STE in I, aVL, V3-V6. He received 325mg en route, Plavix 600mg, integrillin, heparin, nitro gtt, and morphine. Labs there were notable for WBC 14.3, Trop <0.01. He was transferred to [**Hospital1 18**] for cath. . Cardiac cath demonstrated thrombus in prox left circ that probably lysed; without intervention. Plan to stay on integrilin x 36 hours, heparin, prasugrel to be started in a.m. (already loaded with plavix at OSH). . On presentation to the CCU, VS were Temp 99, HR 74, BP 126/71, RR 19, 93% on 4LNC. He continued to have mild [**2-4**] chest pain, again continued to be positional, pleuritic in nature, much improved from prior. He also had some mild abdominal discomfort with palpation, but otherwise denied pain, nausea. He says his SOB had greatly improved. . Prior to today, he has not experienced any chest pain, SOB, or DOE. He is an active gentleman, exercising for 3 days per week, 1.5hrs at a time, and he denies any recent decreased exercise tolerance. . On review of systems, he endorses right knee pain with exercise. He also has snoring at night, and wakes up because his wife nudges him. Otherwise, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors, runny nose, cough, sore throat. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: - Diabetes + Dyslipidemia + Hypertension (previously on Diovan, off for past year after BP improved after weight loss) 2. CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: none -PACING/ICD: none 3. OTHER PAST MEDICAL HISTORY: Duodenal ulcer, H. pylori, treated 14yrs ago ?OSA - pt with snoring, had sleep study, not formally diagnosed, not on CPAP Social History: Pt with lives his wife. [**Name (NI) **] has two grown children 30 and 35yo, and 4 grandchildren. He works full-time as a software engineer for [**Company 378**]. His wife states that he tries to adhere to a South Beach diet and to eat healthy. -Tobacco history: denies -ETOH: once per week, 2 shots of whiskey or glass of wine -Illicit drugs: denies Family History: His grandmother had an MI at 64yo. Great-aunt with CVA. Otherwise no early MI, DVT's, or PE's. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: T=99 BP=126/71 HR=74 RR=19 O2 sat=93% on 4L NC GENERAL: pleasant male in NAD, laying flat in bed. 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 difficult to appreciate given pt's body habitus CARDIAC: PMI located in 5th intercostal space, midclavicular line. RRR, normal S1, S2. No murmurs or rubs appreciated. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Mildly decreased BS at bases, otherwise clear without wheezes or crackles though only fair respiratory effort ABDOMEN: +BS, Obese, Soft, non-distended, mild tenderness to deep palpation of epigastrium, though no rebound or guarding. No HSM appreciated. No abdominal bruits. EXTREMITIES: Warm dry, gauze intact in R groin with red blood on gauze, not spread beyond drawn lines, no femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ Pertinent Results: ADMISSION LABS: [**2142-3-30**] 08:54AM BLOOD WBC-14.3* RBC-4.31* Hgb-13.1* Hct-37.0* MCV-86 MCH-30.4 MCHC-35.3* RDW-13.5 Plt Ct-267 [**2142-3-29**] 11:50PM BLOOD WBC-14.7*# RBC-4.85 Hgb-14.4 Hct-42.0 MCV-87 MCH-29.7 MCHC-34.3 RDW-13.4 Plt Ct-239 [**2142-3-29**] 11:50PM BLOOD Neuts-92.1* Lymphs-3.8* Monos-3.8 Eos-0.1 Baso-0.2 [**2142-3-29**] 11:50PM BLOOD PT-13.9* PTT-24.1 INR(PT)-1.2* [**2142-3-29**] 11:50PM BLOOD Glucose-149* UreaN-19 Creat-1.0 Na-138 K-3.7 Cl-104 HCO3-25 AnGap-13 [**2142-3-29**] 11:50PM BLOOD CK(CPK)-75 [**2142-3-29**] 11:50PM BLOOD Calcium-9.0 Phos-2.3* Mg-1.8 Cholest-133 [**2142-3-29**] 11:50PM BLOOD Triglyc-110 HDL-47 CHOL/HD-2.8 LDLcalc-64 [**2142-3-29**] 11:50PM BLOOD %HbA1c-6.0* eAG-126*. DISCHARGE LABS: [**2142-4-3**] 07:40AM BLOOD WBC-7.0 RBC-3.52* Hgb-10.6* Hct-31.0* MCV-88 MCH-30.2 MCHC-34.3 RDW-14.3 Plt Ct-338 [**2142-4-3**] 07:40AM BLOOD Glucose-105* UreaN-14 Creat-1.0 Na-139 K-3.9 Cl-105 HCO3-27 AnGap-11 [**2142-4-3**] 07:40AM BLOOD Mg-2.1 STUDIES: CXR [**2142-3-30**]: IMPRESSION: Bibasilar atelectasis and cardiomegaly, better evaluated on concomitantly performed chest CT. . CATH [**2142-3-29**]: READ PENDING . CTA [**2142-3-30**]: IMPRESSION: 1. No pulmonary embolism. 2. Bibasilar consolidations which may be due to atelectasis from splinting although a small superimposed pneumonia is not excluded. 3. Small to moderate pericardial effusion; however, no etiology for the pericardial effusion is identified on this study. 4. Stomach distended with fluid. . TTE [**2142-3-30**]: Conclusions The left atrium is elongated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. There is a mild resting left ventricular outflow tract obstruction. There is inferolateral, basal inferior/inferoseptal hypokinesis but overall left ventricular function is hyperdynamic with an estimated ejection fraction >70 percent. Right ventricular chamber size is normal. with focal basal free wall hypokinesis. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is systolic anterior motion of the mitral valve leaflets. An eccentric, laterally directed jet of mild to moderate ([**2-4**]+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The pulmonary artery systolic pressure could not be determined. There is a small pericardial effusion. There is mild right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology. Clinical correlation recommended. TTE [**2142-4-2**]: The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with focal hypokinesis of the basal half of the inferolateral wall. The remaining segments contract normally (LVEF = 55 %). Right ventricular cavity size and free wall motion are normal. There is a small to moderate sized circumferential pericardial effusion (1.6cm anterior to the right ventricle and 0.7-1.0cm elsewhere) with evidence of mild right atrial and right ventricular diastolic collapse suggesive of increased pericardial pressure/early tamponade physiology. Compared with the prior study (images reviewed) of [**2142-3-30**], the pericardial effuion is larger and early tamponade physiology is suggested. TTE [**2142-4-3**]: 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. There is mild posterior leaflet mitral valve prolapse. There is a moderate sized pericardial effusion. The effusion appears circumferential. No right ventricular diastolic collapse is seen. There is brief right atrial diastolic collapse. Compared with the findings of the prior study (images reviewed) of [**2142-4-2**], the pericardial effusion is larger, although the degree of hemodynamic impairment appears similar. . MICRO: BCX [**2142-4-1**]: NGTD UCX [**2142-4-1**]: NGTD Brief Hospital Course: HOSPITAL COURSE: Mr. [**Known lastname 72655**] is a 57 yo M with PMH of mild hyperlipidemia, who presented to [**Hospital1 **] with chest pain with STE in lateral leads and negative CE's x1, transferred to [**Hospital1 18**] for cath. Cath demonstrated thrombus in proximal LCx, though lysed, without intervention. Pt transferred to CCU post-cath given hypoxia, with continued high oxygen requirement for close monitoring. Post operative course complicated by active extravasation from iliac/commonfemoral artery that required placement of DES to CFA. Most likely etiology to chest pain is viral pericarditis. . ACTIVE ISSUES: # COMMON FEMORAL ARTERY INJURY: Post-operative course complicated by active extravasation from CFA. The patient became acutely hypotensive on the floor. He revieved atropine x 2, protamine and 4 total units of pRBC and 1 unit of platelets yesterday with significant volume rescussitation. CT abd and pelvis were consistent w/ RP bleed from femoral site prompting referral to cath lab and placement of DES. Post cath double groin check unremarkable and stable hct. Heparin gtt, integrilin and prasugrel discontinued in setting of acute bleed. The patient was re-started on aspirin and plavix after HCt stable. Per interventional cardiology, he should continue ASA and Plavix. . # CHEST PAIN: Initial differential diagnosis included ACS, vs. pericarditis, vs. non-cardiac etiologies such as PE vs. musculoskeletal vs. gastric ulcer. Pt presented with crescendo sounding chest pain with concern for ACS. ECG??????s concerning at OSH with STE in lateral leads. Catheterizaiton demonstrated thrombus in proximal left circ, without intervention. Patient continued on integrellin, prasugrel and heparin gtt post cath (events outlined above). Cardiac enzymes cycled and negative. Etiology of chest pain ultimately most likely pericarditis given pleuritic, positional nature and diffuse STE. PE not seen on CTA. Lipid panel checked for risk stratification LDL 64, A1c 6.0. His chest pain improved, and remained only mild with position. The patient was not treated for ACS with ace-inhibitor, betablocker and full dose statin as etiology of chest pain less likely consistent with CAD and more likely pericarditis. . # PERICARDITIS: Pericardial effusion noted on echo and CTA post cath of unclear etiology. Pericarditis likely given history of positional chest pain on admission, recent symptoms of CP. Dresslers considered however troponins flat on admission making recent coronary event unlikely. Viral etiology most probable. Pulsus normal, blood pressures stable. Echo consistent with impaired filling concerning for tamponade physiology. Repeat TTE showed larger pericardial effusion , although the degree of hemodynamic impairment appeared similar. He is to have a repead echocardiogram in two day to monitor pericardial effusion. . # PUMP: Patient with no previous history of heart failure, and denies symptoms of heart failure given no recent DOE, leg edema, PND, or orthopnea. No evidence of HF on exam. Echo demonstrated basal inferior/inferoseptal hypokinesis but overall left ventricular function is hyperdynamic with an estimated ejection fraction >70 percent. Pt continued to appear euvolemic. . # RHYTHM: Sinus rhythm. Monitored on telemetry without events. . # LEUKOCTYOSIS, low grade fevers: WBC 14.3 at OSH, 14.7 here on admission, and trended down during admission. No localizing s/s infection. However, pt developed low-grade fevers on HD2. Possibly related to stress response in setting of above. Fevers possibly related to blood in abdomen. Fever curve was trended and patient was no longer febrile on the day of discharge . INACTIVE ISSUES: . # HLD: Pt on Lipitor 10mg daily at home. Increased to Atorvastatin 80mg daily as above. Lipid panel showed LDL 64, and he was placed back on Lipitor 10mg daily. . # Snoring: Pt has symptoms concerning for OSA, though he says he has never used a mask and does not recall being diagnosed with OSA. Pt may need add'l workup as outpatient. . TRANSITIONAL CARE: 1. CODE: FULL 2. MEDICAL MANAGEMENT: Start ASA 325mg daily, Plavix 75mg daily 3. FOLLOW-UP: Medications on Admission: MEDICATIONS: Lipitor 10mg daily Aleve prn Omega FA's Vitamin D 1000 IU daily Discharge Medications: 1. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a day. 4. atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Discharge Disposition: Home Discharge Diagnosis: Pericarditis Pericardial effusion Retroperitoneal Bleed Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You had trouble breathing and chest pain and a echocardiogram showed that you have fluid around the lining of your heart. The chest pain is likely because of an inflammation that is leading to the fluid accumulating. You did not seem to have a heart attack and no interventions were performed on your coronary arteries. You had severe bleeding from the groin area after the catheterization and needed a stent to repair the artery. Please keep watch over the right groin area and call Dr. [**Last Name (STitle) **] if you have any increase in pain, swelling or redness. You will need to take an aspirin every day to keep the stent patent, no plavix is needed per Dr. [**Last Name (STitle) **]. You will need to return on Thursday [**4-5**] for another achocardiogram Dr. [**Last Name (STitle) 72656**] and [**First Name4 (NamePattern1) 1258**] [**Last Name (NamePattern1) 69336**] will be in contact with you about the results of this echocardiogram. Dr. [**Last Name (STitle) **] does not see outpatients so you were scheduled in the Russian [**Hospital 43084**] clinic with Dr. [**Last Name (STitle) 171**] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP. . We made the following changes to your medicines: 1. Start taking a full dose aspirin to keep the stent open, you will need to take this every day for one month 2. You can take Aleve again as needed for chest pressure but please let Dr. [**Last Name (STitle) **] know if this gets worse or you become short of breath. Followup Instructions: . Please make an appt to be seen by your primary care doctor in about 3 weeks. Department: CARDIAC SERVICES When: WEDNESDAY [**2142-4-11**] at 1 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2003**], 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: ECHO LAB When: THURSDAY [**2142-4-5**] at 10:00 AM With: ECHOCARDIOGRAM [**Telephone/Fax (1) 62**] Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage

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icd9cm

[ [ [] ] ]

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icd9pcs

[ [ [] ] ]

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3873, 4083

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3502, 3857

47,272

125,948

13611+56471+56472

Discharge summary

report+addendum+addendum

Admission Date: [**2114-2-16**] Discharge Date: [**2114-2-23**] Date of Birth: [**2041-3-21**] Sex: M Service: CARDIOTHORACIC Allergies: Shellfish Attending:[**First Name3 (LF) 165**] Chief Complaint: Exertional chest pain Major Surgical or Invasive Procedure: [**2114-2-16**] Three Vessel Coronary Artery Bypass Grafting utilizing left internal mammary artery to left anterior descending with saphenous vein grafts to obtuse marginal and PDA. History of Present Illness: This is a 72 year old male who developed exertional chest discomfort, throat fullness, and dyspnea this [**2113-10-21**]. His symptoms occur only with exertion and never at rest. He had significantly decreased his walking pace as to not provoke the symptoms. He was referred for a cardiac catheterization which revealed severe three vessel coronary artery disease. He underwent routine preoperative evaluation, and is now cleared to proceed with surgical revascularization. Past Medical History: - Type 1 Diabetes Mellitus - Peripheral neuropathy - Hyperlipidemia - History of Spontaneous pneumothorax at age 19 - ? Pulmonary fibrosis - [**2111**] CAT scan suggesting some pulmonary fibrosis. Patient had been reluctant to workup in the past - Allergic rhinitis - Constipation - Cervical Spinal with left hand tingling - s/p Laminectomy - s/p Tonsillectomy Social History: Race:Caucasian Last Dental Exam:> 1 year Lives with: Wife Contact: [**Name (NI) 402**] [**Name (NI) **] (daughter) cell# [**Telephone/Fax (1) 41078**] Occupation: Works at the airport teaching aircraft maintenance Cigarettes: Smoked no [x] yes [] ETOH: < 1 drink/week [x] [**2-27**] drinks/week [x] >8 drinks/week [] Illicit drug use: denies Family History: Mother died of MI at age 75 with enlarged heart at autopsy. Older brother had CABG at age 71. Physical Exam: PREOP EXAM BP: 114/78 Pulse:84 Resp:18 O2 sat:97/RA Height:6' Weight:153 lbs General: WDWN male in no acute distress Skin: Dry [x] intact [x] HEENT: PERRLA [] EOMI []Ptosis of left eyelid Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds+ [x] Extremities: Warm [x], well-perfused [x] Edema [] _____ Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: - Left:- Pertinent Results: [**2114-2-16**] Intraop TEE: PRE BYPASS No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. There is mild to 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%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is mild [**Hospital1 **]-leaflet mitral valve prolapse. Mild to moderate ([**1-22**]+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results in the operating room at the time of the study. POST BYPASS The patient is atrially paced. There is normal biventricular systolic function. The mitral regurgitation is improved and is now trace to mild. The thoracic aorta is intact after decannulation. No other significant changes from the pre-bypass exam. . [**2114-2-21**] 04:40AM BLOOD WBC-14.4* RBC-3.06* Hgb-10.0* Hct-28.5* MCV-93 MCH-32.7* MCHC-35.0 RDW-12.2 Plt Ct-263 [**2114-2-16**] 11:39AM BLOOD WBC-3.1* RBC-2.51*# Hgb-7.8*# Hct-22.9*# MCV-92 MCH-31.1 MCHC-34.0 RDW-11.9 Plt Ct-138*# [**2114-2-21**] 04:40AM BLOOD UreaN-28* Creat-1.0 Na-140 K-4.2 Cl-97 [**2114-2-16**] 12:36PM BLOOD UreaN-30* Creat-0.8 Na-142 K-3.9 Cl-112* HCO3-27 AnGap-7* Brief Hospital Course: Mr. [**Known lastname **] was admitted and underwent Coronary artery bypass graft x3,(left internal mammary artery to left anterior descending artery and saphenous vein grafts to the obtuse marginal artery and posterior descending artery)with Dr. [**First Name (STitle) **]. For surgical details, please see operative note. He tolerated the procedure well and was transferred to the CVICU intubated and sedated for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. He weaned off pressor support and beta-blocker/statin/aspirin and diuresis was initiated. All lines and drains were discontinued per proptocol. He maintained stable hemodynamics and transferred to the Step down unit on postoperative day one. Physical Therapy was consulted for evaluation of strength and mobility. His postoperative course was essentially uncomplicated. He complained of dysphagia and a speech and swallow eval was done. His diet advanced to regular. Nystatin mouth wash was initiated for oral thrush. 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 to Newbridge on the [**Doctor Last Name **] in good condition with appropriate follow up instructions. Medications on Admission: -ATORVASTATIN 40 mg daily -FEXOFENADINE 60 mg [**Hospital1 **] prn -LANTUS 100 unit/mL Solution- 11 units daily at dinner time -HUMALOG 100 unit/mL Cartridge- SS before meals -LISINOPRIL 5 mg daily -METOPROLOL SUCCINATE 50 mg daily -NITROGLYCERIN 0.4 mg Tablet PRN -MIRALAX 17 gram/dose Powder- 1 packet by mouth at bedtime -ASPIRIN 81 mg daily -VITAMIN D3 1,000 unit daily Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. 5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 6. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. lisinopril 5 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 8. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**1-22**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 10. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen (17) grams PO DAILY (Daily) as needed for constipation. 11. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day): for thrush. 12. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 1 weeks: 400 mg [**Hospital1 **] through [**2-25**]. 13. amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks: 400 mg daily [**2-26**] through [**3-4**]. 14. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day: 200 mg daily starting [**3-5**] ongoing. 15. insulin glargine 100 unit/mL Solution Sig: Fifteen (15) units Subcutaneous at dinner. 16. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. 17. potassium chloride 10 mEq Capsule, Extended Release Sig: One (1) Tablet Extended Release PO once a day for 5 days: hold for K+ > 4.5. 18. insulin sliding scale and fixed dose ( attached) Discharge Disposition: Extended Care Facility: Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**] Discharge Diagnosis: Coronary Artery Disease, s/p CABG Diabetes Mellitus Dyslipidemia Possible Pulmonary Fibrosis Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**First Name (STitle) **] [**2114-3-27**] at 1:15p, [**Hospital Ward Name **] 2A Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4135**] [**2114-3-20**] at 8:30am Please call to schedule appointments with your Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3649**] in [**4-26**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2114-2-21**] Name: [**Known lastname **],[**Known firstname 133**] Unit No: [**Numeric Identifier 7408**] Admission Date: [**2114-2-16**] Discharge Date: [**2114-2-23**] Date of Birth: [**2041-3-21**] Sex: M Service: CARDIOTHORACIC Allergies: Shellfish Attending:[**First Name3 (LF) 265**] Addendum: Discharge to rehab cancelled for elevated BS. Insulin adjusted and cleared for discharge to rehab the next morning on POD #6. Sliding scale and fixed dose insulin chart included in discharge papers. Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. 5. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO three times a day: hold for SBP <90 and HR <55. 7. polyvinyl alcohol-povidone 1.4-0.6 % Dropperette Sig: [**1-22**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 8. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen (17) grams PO DAILY (Daily) as needed for constipation. 9. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day): for thrush. 10. amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks: 400 mg daily [**2-22**] through [**2-28**]. 11. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day: 200 mg daily starting [**3-1**] ongoing. 12. insulin glargine 100 unit/mL Solution Sig: Fifteen (15) units Subcutaneous at dinner. 13. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. 14. potassium chloride 10 mEq Capsule, Extended Release Sig: One (1) Tablet Extended Release PO once a day for 5 days: hold for K+ > 4.5. 15. insulin sliding scale and fixed dose ( attached) 16. lisinopril 10 mg Tablet Sig: 1.5 Tablets PO once a day. 17. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Discharge Disposition: Extended Care Facility: Newbridge on the [**Doctor Last Name **] - [**Location (un) 1502**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**] Completed by:[**2114-2-22**] Name: [**Known lastname **],[**Known firstname 133**] Unit No: [**Numeric Identifier 7408**] Admission Date: [**2114-2-16**] Discharge Date: [**2114-2-23**] Date of Birth: [**2041-3-21**] Sex: M Service: CARDIOTHORACIC Allergies: Shellfish Attending:[**First Name3 (LF) 265**] Addendum: Mr. [**Known lastname 7409**] stay was extended while awaiting final approval from his insurance. On post-operative day seven his insurance approved his transfer to rehab at Newbridge on the [**Doctor Last Name **]. All folow-up appointments were advised. Discharge Disposition: Extended Care Facility: Newbridge on the [**Doctor Last Name **] - [**Location (un) 1502**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**] Completed by:[**2114-2-23**]

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icd9cm

[ [ [] ] ]

[ "36.12", "36.15", "39.61", "99.62" ]

icd9pcs

[ [ [] ] ]

12824, 13038

4345, 5653

297, 482

8082, 8293

2567, 4322

9063, 10306

1749, 1844

10329, 11961

7966, 8061

5679, 6055

8317, 9040

1859, 2548

236, 259

510, 986

1008, 1371

1387, 1733

27,027

102,889

47594

Discharge summary

report

Admission Date: [**2128-12-6**] Discharge Date: [**2128-12-9**] Date of Birth: [**2060-5-28**] Sex: M Service: SURGERY Allergies: Ivp Dye, Iodine Containing Attending:[**First Name3 (LF) 1234**] Chief Complaint: AAA Major Surgical or Invasive Procedure: PROCEDURE: 1. Endovascular repair of aorta iliac aneurysms. 2. Zenith modular bifurcated stent graft. 3. Embolization of right hypogastric artery with a 16 mm Amplatzer. 4. Extension of stent graft into right external iliac artery. 5. Left iliac extender. 6. Bilateral catheter in aorta. 7. Complicated repair of right common femoral artery. History of Present Illness: [**Known firstname **] [**Known lastname **] presents for followup of his aortic/iliac aneurysm. I saw him extensively in the hospital. He has a very recent and extensive cardiac history and has aneurysms of the aortoiliac artery and both popliteal arteries Past Medical History: Relevant PAST MEDICAL HISTORY: -COPD uses 2L 0xygen @ night -Prostate cancer with radiation and hormone treatment 3 yrs ago, -Obstructive sleep apnea wih occasional CPAP; however does not use CPAP -Cor pulmonale -Obesity -? elevated cholesterol (never checked) Social History: Social history is significant for the tobacco use: quit [**3-14**] weeks ago, but had previously smoked 2 PPD for >30 years. There is no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death. His father died of CHF at age 85 (also had prostate cancer). No other members had heart disease of any kind. Physical Exam: a/o x 3 nad grossly intact supple farom neg lymphandopathy cta rr abd benign groin inc / surgical / C/D/I Pulses: Fem [**Doctor Last Name **] DP PT Rt 2+ 2+ 2+ 2+ Lt 2+ 2+ 2+ mono Pertinent Results: [**2128-12-8**] 06:15AM BLOOD WBC-10.2# RBC-3.11* Hgb-9.4* Hct-28.8* MCV-93 MCH-30.2 MCHC-32.6 RDW-14.6 Plt Ct-173 [**2128-12-8**] 06:15AM BLOOD Plt Ct-173 [**2128-12-8**] 06:15AM BLOOD Glucose-116* UreaN-15 Creat-1.0 Na-139 K-4.3 Cl-103 HCO3-32 AnGap-8 [**2128-12-8**] 06:15AM BLOOD Calcium-9.0 Phos-2.9 Mg-2.1 [**2128-12-7**] 8:07 AM CHEST (PORTABLE AP) Reason: r/o inf, eff Comparison is made with prior study performed 12 hours earlier. Cardiac size is top normal. The lungs are clear aside from left basilar atelectasis. There is no pneumothorax or pleural effusion. [**2128-12-6**] 8:03:00 PM EKG Sinus rhythm. Baseline artifact makes interpretation difficult. Non-specific T wave changes in leads I and aVL. Low QRS voltage in the limb leads. Compared to tracing of [**2128-12-1**] bradycardia is absent. Rate PR QRS QT/QTc P QRS T 67 144 92 420/432 75 33 85 Brief Hospital Course: Mr. [**Known lastname **],[**Known firstname **] W [**Numeric Identifier 100576**] was admitted on [**2128-12-6**] with iliac Anuerysm. He agreed to have an elective surgery. Pre-operatively, he was consented. A CXR, EKG, UA, CBC, Electrolytes, T/S - were obtained, all other preperations were made. PROCEDURE: 1. Endovascular repair of aorta iliac aneurysms. 2. Zenith modular bifurcated stent graft. 3. Embolization of right hypogastric artery with a 16 mm Amplatzer. 4. Extension of stent graft into right external iliac artery. 5. Left iliac extender. 6. Bilateral catheter in aorta. 7. Complicated repair of right common femoral artery. . 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. Because of the complication of the case. Pt was transfered to the [**Date Range 42137**] for further care. In the [**Date Range 42137**] opt extubated. Pt also r/o for MI. Upon being stabalized from the [**Name (NI) 42137**], pt transferd to the VICU for further care. While in the VICU he recieved monitered care. When stable he was delined. His diet was advanced. A PT consult was obtained. When he was stabalized from the acute setting of post operative care, he was transfered 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 pt die recieve 1 unit of PRBC for post operative anemia secondary to acute blood loss during the OR procedure. Medications on Admission: [**Last Name (un) 1724**]: ASA 325', Colchicine 0.6', Flovent MDI, Lisinopril 2.5', Metformin 500'', Neurontin 100 prn, Spiriva inhaler, Plavix 75', Simvastatin 80', Toprol XL 25' Discharge Medications: 1. Other ASA 325', Colchicine 0.6', Flovent MDI, Lisinopril 2.5', Metformin 500'', Neurontin 100 prn, Spiriva inhaler, Plavix 75', Simvastatin 80', Toprol XL 25' 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 6. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 7. Neurontin 100 mg Capsule Sig: One (1) Capsule PO once a day. 8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 10. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 12. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: Aortoiliac aneurysms Anemia secondary to blood loss / requiring blood transfusion DM, HTN, CAD, Chol, CHF (EF 45%), COPD (home O2 2L)obesity Discharge Condition: Good Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Division of Vascular and Endovascular Surgery Endovascular Abdominal Aortic Aneurysm (AAA) Discharge Instructions Medications: ?????? Take Aspirin 325mg (enteric coated) once daily ?????? Do not stop Aspirin unless your Vascular Surgeon instructs you to do so. ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What to expect when you go home: It is normal to have slight swelling of the legs: ?????? Elevate your leg above the level of your heart (use [**2-14**] 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 It is normal to feel tired and have a decreased appetite, your appetite will return with time ?????? Drink plenty of fluids and 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: ?????? When you go home, you may walk and go up and down stairs ?????? You may shower (let the soapy water run over groin 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 or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? After 1 week, you may resume sexual activity ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate ?????? No driving until you are no longer taking pain medications ?????? Call and schedule an appointment to be seen in [**4-16**] weeks for post procedure check and CTA What to report to office: ??????1 Numbness, coldness or pain in lower extremities ??????2 Temperature greater than 101.5F for 24 hours ??????3 New or increased drainage from incision or white, yellow or green drainage from incisions ??????4 Bleeding from groin puncture site SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site or incision) ??????1 Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call vascular office. If bleeding does not stop, call 911 for transfer to closest Emergency Room. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2128-12-28**] 10:30 Completed by:[**2128-12-9**]

[ "V45.82", "493.20", "327.23", "412", "441.4", "428.0", "285.1", "V10.46", "250.60", "357.2", "428.22", "401.9", "272.0", "414.01" ]

icd9cm

[ [ [] ] ]

[ "39.57", "99.04", "39.79", "39.71" ]

icd9pcs

[ [ [] ] ]

5844, 5850

2758, 4491

290, 642

6036, 6043

1847, 2735

8756, 8941

1413, 1605

4721, 5821

5871, 6015

4517, 4698

6067, 8171

8197, 8733

1620, 1828

247, 252

670, 930

983, 1216

1232, 1397

1,269

172,465

7107

Discharge summary

report

Admission Date: [**2176-10-25**] Discharge Date: [**2176-11-8**] Date of Birth: [**2100-3-31**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 13386**] Chief Complaint: s/p fall, subarachnoid hemorrhage, subdural hemorrhage, delirium, dementia Major Surgical or Invasive Procedure: PEG tube placement. History of Present Illness: HPI: 76 yo F h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 309**] Body dementia now s/p fall with reported head trauma. Pt fell down 10 stairs on [**2176-10-25**]. History of falls, last fall ~3 mo ago. Pt does not remember event, believes she was unconscious for ~2 min. Patient was immediately ambulating immediately after event, and per son was mentally at baseline. Denies hx of seziures. No F/C, N/V, CP, SOB. Past Medical History: PMH: 1. [**Last Name (un) 309**] Body Dementia - most recent evaluation by behavioral neurology [**8-11**]. Noted to have parkinsonian signs, cognitive decline, and visual hallucinations. 2. HTN 3. CAD 4. ?CVA 5. Glaucoma Social History: Lives with son, denies EtOH, smoking. [**Name (NI) 26487**], husband died ~10 [**Name2 (NI) 1686**] ago from prostate cancer. Family History: No history of LBD per son. Physical Exam: Current Exam: Tm 100.7 Tc: 99.4 HR 64 BP 113/56 RR 11 O2 100% 2L NC. Gen: Sleeping in bed, comfortable. Easily arousable to voice, inattentive. HEENT: OP clear, MMM Neck: No LAD, ?left sided thyroid nodule, no JVD Chest: Clear anteriorly Cor: RRR, s1 s2, no m/r/g Abd: +BS, obese, soft, NT, ND Ext: no c/c/e, WWP Neuro: AOx2 (unable to provide date). Responds to questions appropriately, but inattentive to commands. CN II-XII grossly intact other than ?R facial droop. Motor - unable to assess fully given patient cooperation, moving all extremities, increased tone in upper and lower extremities. Reflexes: 2+ throughout, symmetric. Toes downgoing bilaterally. Sensation - unable to assess given patient cooperation. Pertinent Results: [**2176-10-31**] 02:21PM URINE RBC-21-50* WBC-[**6-15**]* Bacteri-MANY Yeast-NONE Epi-0-2 [**2176-10-30**] 03:02AM BLOOD calTIBC-181* VitB12-251 Folate-15.3 Ferritn-466* TRF-139* [**2176-10-30**] 03:02AM BLOOD TSH-1.5 [**2176-10-31**] 05:25AM BLOOD T4-6.0 Free T4-1.1 [**2176-10-30**] 03:02AM BLOOD Phenyto-11.3 [**2176-10-29**] 03:26AM BLOOD Phenyto-13.5 [**2176-10-27**] 03:26AM BLOOD Phenyto-12.6 [**2176-10-26**] 03:32AM BLOOD Phenyto-12.0 [**2176-10-25**] 08:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-6.3 Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . [**2176-11-2**] 9:59 am URINE **FINAL REPORT [**2176-11-3**]** URINE CULTURE (Final [**2176-11-3**]): NO GROWTH. . [**2176-11-2**] 8:05 pm BLOOD CULTURE **FINAL REPORT [**2176-11-8**]** AEROBIC BOTTLE (Final [**2176-11-8**]): NO GROWTH. ANAEROBIC BOTTLE (Final [**2176-11-8**]): NO GROWTH. Brief Hospital Course: Brief Hosp Course: On arrival to [**Name (NI) **] pt stable with T 95.9, HR 78, BP 133/60, RR 16, O2sat: 100% RA. Lacerations to scalp and left elbow. Neuro exam intact w/o focal signs. CT head showed left parietal subdural hemorrhage and subarachnoid hemorrhage. Otherwise imaging negative for fractures or other trauma. . Pt. became aggitated/delta MS [**First Name (Titles) **] [**Last Name (Titles) **]. Was intubated and had repeat head CT which showed no change. Pt. loaded with dilantin, followed by neurosurg. CT Head ([**10-26**]) repeated, showed new region R frontal hypodensity v. motion artifact with ?developing infarct. Pt. extubated [**10-26**]. Spine MRI with old T12 compression fracture and spinal stenosis. C-collar cleared by ortho spine. . Further hospital course by problem: #. Delirium/Dementia: She continued to have delerium/dementia which we believed was likely due to her known history of [**Last Name (un) **] body dementia with worsening cognitive decline chronically. Other contributing factors were the subarachnoid and subdural hemorrhages seen on CT scan as well as pain from injuries sustained during fall. We also believed that the dilantin which was used for seizure prophylaxis in the setting of SDH was a contributing factor. Finally, infection was another likely source for her continued delirium. We treated her pain with acetominophen, and the patient appeared pain free throughout her course on the medical floor. We also stopped her dilantin after 10 days per neurosurgery recommendations, however even off of the dilantin, her mental status did not improve. We examined for sources of infection and found a UTI which we treated as well as treating for likely aspiration pneumonia with ceftriaxone. Labs were sent for TSH, Folate, B12, RPR which all returned within normal limits. . #. SAH/SDH s/p fall: CT on arrival to the ED revealed SAH/SDH and repeat showed no progression of these hemorrhages. SHe was cleared by neurosurgery. Her neuro exam remained non-focal with baseline dementia and superimposed delirium throughout her stay. Given her exam it was felt by both the primary team and by neurosurgery that further imaging would not provide any further clinical information. . #. Fever/UTI/?PNA: Throughout her course, she continued to have low grade temperatures with a max of 101.2. U/A revealed a UTI which was treated. CXR was unrevealing, but in the setting of increased sputum production and fevers, we treated for presumed aspiration pneumonia. In spite of treatment for both of these infectious sources with ceftriaxone for 7 days, here mental status failed to improve and she continued with low grade temperatures. Given very low grade temperatures, it was felt that the patient was not infected and that the most likely source was fevers from her SDH/SAH. If patient has increased fevers in the future, we would recommend testing stool for c. diff given antibiotic regimen while in hospital. . #. GIB: On [**2176-11-4**] her stools were found to be guiac positive. Her hematocrit was low on arrival (30) and trended slightly down throughout her hospitalization. She was hemodynamically stable and her hematocrit was stable on discharge. She was given a PPI and sulcrafate and will continue on these medications. Further investigation was deferred given goals of care and desire not to proceed to further invasive testing. . #. Hypertension: She had a known history of HTN. Given her history of a head injury, we maintained her SBP between 130-160 throughout her hospitalization with her home dose of univasc and IV metoprolol with IV hydralazine prn elevated blood pressures. . #. FEN: Given her inability to eat and her depressed mental status, an NG tube was placed for feeding. As she continued to have delerium and dementia, she was evaluated by speech and swallow and was unable to take POs. Because of this finding and desire by family to continue feeding, PEG tube was placed successfully by IR without complications on [**2176-11-7**]. Pt should have the 3 T fastners removed on [**2176-11-15**]. . #. SOCIAL/GOALS OF CARE: In the setting of her chronic and progressive dementia and recent increases in number of falls, along with her current presentation of continued delirium, the primary team along with her PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 141**], and the family met to discuss goals of care. Both of her sons were present, and [**Name (NI) **] (her health care proxy/son) helped in making decisions. It was felt that given her current condition, the patient would have wanted to be DNR/DNI. It was also felt that given the potential nature of her waxing and [**Doctor Last Name 688**] mental status that the family would like to proceed to PEG for further management in an acute care facility. Medications on Admission: -MVT -Citracal -Nifedipine ER 90 qd -Univasc 15 [**Hospital1 **] -Pravachol 20 qd -Naproxen 220 [**Hospital1 **] -Wellbutrin 225 qd -Perphenazine 2 mg [**Hospital1 **] -Benadryl 25 mg qhs -Xalatan eye drops -Trusopt eye drops Discharge Medications: 1. Latanoprost 0.005 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic HS (at bedtime). 2. Dorzolamide 2 % Drops [**Hospital1 **]: One (1) Drop Ophthalmic TID (3 times a day). 3. Moexipril 7.5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2 times a day). 4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 5. Sucralfate 1 g Tablet [**Last Name (STitle) **]: One (1) Tablet PO QID (4 times a day). 6. Nifedipine 90 mg Tablet Sustained Release [**Last Name (STitle) **]: One (1) Tablet Sustained Release PO once a day. 7. Pravachol 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. 8. Citracal 500 mg Tablet, Effervescent [**Last Name (STitle) **]: One (1) Tablet, Effervescent PO once a day. Tablet, Effervescent(s) Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary 1. Subarachnoid Hemorrhage 2. Subdural hemorrhage 3. Delerium Secondary 1. [**Last Name (un) 309**] Body Dementia Discharge Condition: Stable Discharge Instructions: You were seen in the hospital after a fall. We found that you had bleeds in your brain. These were thought to be stable and no intervention was made. These bleeds will likely resolve over time. You were also found to be delirious. You were treated for possible infections in the lungs and the urine as well as taken off any medications that might affect your mental state. . Please return to the hospital if you have any continued fevers, chills, nausea, vomiting, difficulty breathing, chest pain, abdominal pain, problems with bowel movements or urination, or any other worrisome symptoms. . Please take all medication as prescribed and attend all recommended follow up visits. Followup Instructions: Please follow up with your Primary care physician [**Last Name (NamePattern4) **] [**1-8**] days after leaving the hospital. . Also attend your appointment with Dr. [**Last Name (STitle) **]. . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11771**], M.D. Phone:[**Telephone/Fax (1) 26488**] Date/Time:[**2176-12-26**] 12:00

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

8987, 9053

3016, 3794

392, 414

9220, 9229

2076, 2993

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1287, 1315

8121, 8964

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9253, 9939

1330, 2057

278, 354

3822, 7844

442, 880

902, 1127

1143, 1271

24,489

123,456

13795

Discharge summary

report

Admission Date: [**2174-1-19**] Discharge Date: [**2174-2-3**] Date of Birth: [**2108-5-5**] Sex: F Service: C-MED HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old woman originally admitted to the Medical Intensive Care Unit on [**2174-1-19**] for a decreased blood pressure and confusion. She was at the [**Hospital 38**] Rehabilitation after a recent femoral artery to popliteal artery bypass surgery as well as left transmetatarsal amputation in [**2173-12-12**]. The patient was reportedly doing well postoperatively. She went to the [**Hospital **] Clinic for routine followup on [**1-19**] and was found to be hypotensive with a blood pressure of 60/palpation. She was transferred to the [**Hospital1 1444**]. She denied any prior fevers, chills, wound drainage, nausea, vomiting, or abdominal pain. She did have three days of watery diarrhea prior to presentation. She was admitted to the Medical Intensive Care Unit for hydration and intravenous pressors. PAST MEDICAL HISTORY: 1. Diabetes; complicated by peripheral vascular disease (vascular surgeries as stated above), end-stage renal disease (on peritoneal dialysis), and retinopathy. 2. Hypertension. 3. Coronary artery disease; status post 4-vessel coronary artery bypass grafting in [**2168**]. 4. Asthma. 5. Status post MDP with right arm vein in [**2169**]. 6. Status post left graft stenosis with angioplasty in [**2171-11-13**]. 7. Status post total abdominal hysterectomy. 8. Status post appendectomy. 9. Status post cholecystectomy. 10. Status post right first toe amputation in [**2173-11-12**]. 11. Bilateral cataracts. 12. Status post femoral artery to popliteal artery bypass grafting as summarized above. 13. Status post left transmetatarsal amputation. MEDICATIONS ON TRANSFER: (Medications on transfer to C-MED Service at [**Hospital1 69**] included) 1. Protonix 40 mg p.o. q.d. 2. Aspirin 81 mg p.o. q.d. 3. Nephrocaps one capsule p.o. q.d. 4. Erythropoietin 10,000 units on Monday, Wednesday, and Friday. 5. Heparin subcutaneously. 6. Regular insulin sliding-scale. 7. Metoprolol 25 mg p.o. q.d. ALLERGIES: The patient is allergic to BACTRIM (this causes nausea). The patient reports confusion and disorientation after taking CODEINE previously. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination revealed temperature was 99.2, blood pressure was 108/44, respiratory rate was 14, oxygen saturation was 96% on room air. Generally, she was a pleasant, comfortable, elderly woman lying in bed. Head, eyes, ears, nose, and throat examination revealed the patient had arcus senilis. The pupils were equal, round, and reactive to light and accommodation. Extraocular movements were intact. The throat was clear. The neck was supple. Full range of motion. Jugular veins were flat. No thyromegaly. No carotid bruits. Lungs were clear to auscultation bilaterally. Heart examination revealed the point of maximal impulse was not displaced. There was a regular rate and rhythm. There was normal first heart sound and second heart sound. There were no extra sounds. The abdomen was slightly distended. The abdomen was soft. There were normal active bowel sounds. The abdomen was not tender. Extremity examination revealed the patient had no edema in her lower extremities. There was a well-healed right lower extremity bypass scar as well as a healing left lower extremity bypass graft scar, as well as a bandage over the left transmetatarsal amputation stump. The patient had left-sided sacral (stage I) decubitus ulcers; being treated with dressings daily. PERTINENT LABORATORY VALUES ON PRESENTATION: Laboratory evaluation was significant for occasional hypokalemia (down to approximately 2.9) and hypomagnesemia (down to approximately 1.5). The white blood cell count ranged from 10 to approximately 16; however, the patient remained afebrile. Serial troponins were negative for a myocardial infarction. RADIOLOGY/IMAGING: She had an echocardiogram at the bedside which revealed an ejection fraction of 45%, and no evidence of pericardial effusion. HOSPITAL COURSE: Originally, the patient's hypotension was attributed to hypovolemia secondary to diarrhea. There was no evidence of a cardiac origin for her hypotension. Initially, the patient was placed on broad spectrum antibiotics included levofloxacin, ceftazidime, and vancomycin. Blood cultures were negative, and all three medications were discontinued by [**2174-1-22**]. The patient required pressors over the first night including dopamine/neostigmine but was weaned off successfully after rehydration. Following restoration of her normal blood pressure, the patient developed an episode of atrioventricular node reentrant tachycardia; presumably due to administration of dopamine. The patient was given an amiodarone drip for three days, and then that was terminated on [**2174-1-21**]. She was placed on metoprolol thereafter with intermittent bursts of supraventricular tachycardia and borderline blood pressures. The patient was transferred to the C-MED Service on [**2174-1-24**]. She had one further episode of atrioventricular node reentrant tachycardia controlled with low-dose metoprolol; however, she did not have further episodes of this during the remainder of her hospital stay. 1. CARDIOVASCULAR SYSTEM: As stated above, the patient had some episodes of atrioventricular node reentrant tachycardia. She was placed on metoprolol. The dose was ultimately decreased to 12.5 mg p.o. daily because of hypotension. In consultation with Renal Service, the patient was started on midodrine 5 mg three times per day with improvement in her blood pressure to approximately 100 systolic for the remainder of her hospital course. 2. RENAL SYSTEM: The patient was continued on peritoneal dialysis with five exchanges of 1.5% dextrose daily. The patient required regular repletion of potassium chloride ranging from 40 mEq to approximately 80 mEq per day as well as occasional magnesium supplementation. 3. VASCULAR ISSUES: The patient was evaluated by the Vascular Surgery Service. Her surgical wounds appeared to be healing well; however, she had persistent sacral pain from the decubitus ulcer described above. In consultation with the Palliation Service, she was initially given a trial of OxyContin 20 mg twice daily; however, this medication caused marked somnolence and confusion requiring reversal with naloxone. The patient was also given gabapentin at initially 100 mg twice daily. That dose was increased to 200 mg twice daily after several days. The patient reported some improvement in her pain and was reluctant to continue taking opiates. MEDICATIONS ON DISCHARGE: 1. Gabapentin 200 mg p.o. twice per day. 2. Senna one tablet p.o. twice per day as needed (for constipation). 3. Midodrine 5 mg p.o. three times per day. 4. Erythropoietin (Epoetin Alfa) 20,000 units subcutaneously on Monday, Wednesday, and Friday. 5. Metoprolol 12.5 mg p.o. q.a.m. (hold for a systolic blood pressure under 100 and/or a heart rate below 55). 6. Erythromycin ointment 0.5% in both eyes q.i.d. (until [**2174-2-3**]). 7. Pantoprazole 40 mg p.o. every 24 hours. 8. Heparin flush (100 units per mL) 1 mL intravenously every day in the lumen of her Port-A-Cath. 9. Miconazole powder 0.2% applied under the right breast and the right arm twice per day. 10. Acetaminophen 325 mg to 650 mg p.o. every 6 hours as needed (for pain). 11. Insulin sliding-scale (see attached flow sheet). 12. Heparin 5000 units subcutaneously every 12 hours (until the patient achieves adequate ambulation). 13. Nephrocaps one capsule p.o. once daily. 14. Aspirin 81 mg p.o. once daily. DISCHARGE DIAGNOSES: 1. Hypotension due to dehydration. 2. Atrioventricular node reentrant tachycardia. 3. Diabetes; complicated by peripheral vascular disease (vascular surgeries as stated above), end-stage renal disease (on peritoneal dialysis), and retinopathy. 4. Hypertension. 5. Coronary artery disease; status post 4-vessel coronary artery bypass grafting in [**2168**]. 6. Asthma. 7. Status post MDP with right arm vein in [**2169**]. 8. Status post left graft stenosis with angioplasty in [**2171-11-13**]. 9. Status post total abdominal hysterectomy. 10. Status post appendectomy. 11. Status post cholecystectomy. 12. Status post right first toe amputation in [**2173-11-12**]. 13. Bilateral cataracts. 14. Status post femoral artery to popliteal artery bypass grafting as summarized above. 15. Status post left transmetatarsal amputation. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 4786**] Dictated By:[**Name8 (MD) 7102**] MEDQUIST36 D: [**2174-2-1**] 17:21 T: [**2174-2-1**] 17:36 JOB#: [**Job Number 41472**]

[ "276.8", "427.89", "250.40", "707.0", "250.70", "276.5", "426.89", "585", "458.9" ]

icd9cm

[ [ [] ] ]

[ "54.98", "38.93" ]

icd9pcs

[ [ [] ] ]

7775, 8919

6754, 7753

4151, 6727

165, 1002

1817, 4132

1025, 1791

43,320

110,344

1744

Discharge summary

report

Admission Date: [**2127-9-13**] Discharge Date: [**2127-9-15**] Date of Birth: [**2054-11-9**] Sex: M Service: UROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1232**] Chief Complaint: Hematuria Major Surgical or Invasive Procedure: Clot evacuation, bladder fulgeration History of Present Illness: 72yM with h/o mech aortic valve and atrial fibrillation on coumadin as well as history of recurrent bladder cancer (Transitional Ceel), status post TURBT on [**2127-8-15**]. His post op course was complicated by urinary retention requiring Foley replacement [**Date range (1) 9910**] with intermittent hematuria and passage of small clots since. Was admitted to urology service on [**9-2**] for this and underwent cystoscopy, fulguration, clot evacuation, and catheter exchange. Underwent two days of CBI with weaning and then had successful trial of foley removal. He came to the ED today with 3-4h h/o urinary retention, bladder spasms, and gross hematuria/clots. Patient denies other symptoms including fever, chills, nausea, vomiting, SOB, CP. Reports persisent dysuria since proceedure with one episode of urinary incontinence. . Urology saw pt in ED and 20French 3-way foley was placed and hand irrigated x2. CBI initiated but persistent light pink to fruit punch output. Noted to have 6pt Hct drop and ED reporting EKG changes with V3-V6 ST depressions in setting of elevated rates from RVR. Other vitals okay. Pt given benzos, morphine, oxybutin as well as 18L of CBI. Was continuing to have issues with clots and requiring high levels of nursing care so this, combined with Hct drop (although stable on recheck), and EKG changes prompted [**Hospital Unit Name 153**] admission after urology had previously accepted pt to the floor. . On ICU arrival pt in sporadic pain, but excruciating when present. CBI running with bloody fluid in bag. Urology manually irrigated when pt arrived to ICU. Urology potentially planning for OR in AM. Pt feeling okay inbetween pain spasms except for feeling tired. Past Medical History: Recurrent Bladder ca s/p multiple resections, BCG, mitomycin x8, docetaxel and Adriamycin AVR in [**2100**] with a mechanical valve . Carbomedics Bileaflet (INR Goal = 2.5-3.5) HTN Atrial fibrillation HLD Erectile dysfunction OSA -> CPAP h/o diverticulitis Surgical Hx: Surgical History significant for AVR, hernia repair, tonsils, hydrocelectomy [**2120**], TURBT [**12/2123**], Bladder biopsy [**2123**] and 7/[**2124**]. Social History: Married. Retired barber. Denies tobacco, recreational drugs, or alcohol excess although has alcohol hx Family History: Father with [**Name2 (NI) 499**] cancer in his 70s Physical Exam: Admission: Vitals: 98.0 / 149 (Afib) / 124/83 / 20 and 99% on RA General: Alert, oriented x 3, in distress when spasms present HEENT: Sclera anicteric, MMM Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: IRIR, elevated rate in 120s, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, BS+ GU: foley in place with CBI running, Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Discharge: HR: 80s-90s GU: No FOley, voiding spontaneously Pertinent Results: [**2127-9-13**] 07:25AM BLOOD WBC-5.1 RBC-3.75* Hgb-12.9* Hct-37.0* MCV-99* MCH-34.4* MCHC-34.9 RDW-14.6 Plt Ct-184 [**2127-9-13**] 07:25AM BLOOD Neuts-52.4 Lymphs-37.8 Monos-7.2 Eos-1.9 Baso-0.7 [**2127-9-13**] 07:25AM BLOOD PT-21.0* PTT-34.7 INR(PT)-1.9* [**2127-9-13**] 07:25AM BLOOD Glucose-110* UreaN-11 Creat-1.0 Na-144 K-4.6 Cl-106 HCO3-25 AnGap-18 [**2127-9-13**] 11:30AM BLOOD CK(CPK)-54 [**2127-9-13**] 11:30AM BLOOD CK-MB-3 cTropnT-<0.01 [**2127-9-14**] 06:05AM BLOOD CK-MB-2 cTropnT-<0.01 [**2127-9-14**] 06:05AM BLOOD Calcium-7.9* Phos-3.6 Mg-1.8 [**2127-9-15**] 04:09AM BLOOD WBC-3.4* RBC-2.90* Hgb-10.0* Hct-27.8* MCV-96 MCH-34.5* MCHC-36.0* RDW-14.6 Plt Ct-139* [**2127-9-15**] 04:09AM BLOOD PT-29.6* PTT-37.7* INR(PT)-2.9* [**2127-9-15**] 04:09AM BLOOD Glucose-103* UreaN-11 Creat-0.9 Na-143 K-4.0 Cl-111* HCO3-26 AnGap-10 [**2127-9-15**] 04:09AM BLOOD Calcium-8.1* Phos-4.0 Mg-2.0 [**2127-9-13**] 07:25AM URINE Color-Red Appear-Cloudy Sp [**Last Name (un) **]->1.035 [**2127-9-13**] 07:25AM URINE Blood-LG Nitrite-NEG Protein-500 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-SM [**2127-9-13**] 07:25AM URINE RBC->50 WBC-0-2 Bacteri-NONE Yeast-NONE Epi-0 Brief Hospital Course: 72yM with h/o mech aortic valve and atrial fibrillation on coumadin as well as history of recurrent bladder cancer (Transitional Ceel), status post TURBT on [**2127-8-15**] presenting with recurrent hematuria and passage of clots since proceedure, now improved s/p CBI. . # Hematuria with clots and urinary obstruction: Intermittent since TURBT on [**8-15**]. Had been home for 10 days but had sudden urinary retention likely due to clot obstructing bladder outlet. Urology saw in ED and aggressively irrigated, started oxybutin, and CBI. He underwent cystoscopy which showed a large clot with bleeding. A vessel was cauterized. He was transfused 1 unit PRBC. He was given oxybutynin for spasm. His hematuria resolved. FOley was removed and he voided spontaneously prior to discharge. He was given Cephalexin while inpatient. He will follow up with urology. . # Afib with RVR: RVR in ED resolved with diltiazem administration. Rates actually down into 60s with one dose of 120mg (was on home dose equivalent to 120mg QID). Diltiazem was decreased to 360mg daily at discharge. Warfarin was stopped and he will have INR check on [**9-18**] and will call PCP with result to restart warfarin [**9-18**]. INR therapeutic at time of discharge. . # Mechanical Aortic Valve: See above for anticoagulation management. . # HTN: Well controlled on only diltiazem. Diltiazem dose decreased as above. Medications on Admission: Coumadin 2.5mg every day except 5mg on Friday Diltiazem 360mg q.a.m. and 120 q.p.m. Simvastatin 5mg Qd Percocet PRN Amoxicillin PRN ppx Docusate Ascorbic Acid Co-Enzyme Q MTV Niacin Vitamin E Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 2. oxybutynin chloride 5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day as needed for bladder spasms. Disp:*20 Tablet Extended Rel 24 hr(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. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for headache, pain. 5. Macrobid 100 mg Capsule Sig: One (1) Capsule PO twice a day for 3 days. Disp:*6 Capsule(s)* Refills:*0* 6. diltiazem HCl 180 mg Capsule, Extended Release Sig: Two (2) Capsule, Extended Release PO DAILY (Daily). Disp:*60 Capsule, Extended Release(s)* Refills:*1* 7. Outpatient Lab Work INR and hematocrit check [**2127-9-17**], results to be faxed to [**Telephone/Fax (1) 164**], warfarin dosing to be decided by PCP based on INR goal 2.5-3.5. 8. niacin Oral 9. coenzyme Q10 Oral 10. vitamin E Oral 11. ascorbic acid Oral 12. Zocor 5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Bladder cancer, gross hematuria Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: -Do not lift anything heavier than a phone book (10 pounds) or drive until you are seen by your Urologist in follow-up -You may continue to periodically see small amounts of blood in your urine--this is normal and will gradually improve -Resume all of your pre-admission medications except as noted. You have indicated that you NO longer take Iron tablets and that you do NOT take zocor as prescribed (40mg/day) but take 5-10mg day. Please review this with your PCP. Your diltiazem has been decreased: Prescribing: diltiazem HCl (Oral) 180 mg Capsule, Extended Release Sig: Two (2) Capsule, Extended Release PO DAILY (Daily). Do NOT take a dose at night unless your PCP tells you to at follow up. Please do not take warfarin (coumadin) until you have your INR checked on [**9-18**]. You will have your INR checked in the [**Hospital Ward Name 23**] center and you should call your PCP with the result that day so he may advise you what dose of warfarin to start taking the evening of [**9-18**]. -Always call to inform, review and discuss any medication changes and your post-operative course with your primary care doctor -Colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication. Discontinue if loose stool or diarrhea develops. Colace is a stool softener, NOT a laxative -Do not eat constipating foods for 2-4 weeks, drink plenty of fluids to keep hydrated -No vigorous physical activity or sports for 4 weeks or until otherwise advised -Tylenol should be your first line pain medication, a narcotic pain medication has been prescribed for breakthrough pain >4. Replace Tylenol with narcotic pain medication. -Max daily Tylenol (acetaminophen) dose is 4 grams from ALL sources, note that narcotic pain medication also contains Tylenol -Do not drive or drink alcohol while taking narcotics and do not operate dangerous machinery. -If you have fevers > 101.5 F, vomiting, severe abdominal pain, or inability to urinate, call your doctor or go to the nearest emergency room. Followup Instructions: Call Dr[**Doctor Last Name **] office tomorrow to schedule/confirm your follow-up appointment AND if you have any questions. Provider: [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 276**], M.D. Phone:[**Telephone/Fax (1) 164**] Please follow up with your PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 133**] regarding your medications and post operative course and INR monitoring/coumadin dosing. You should call and schedule an appointment to be seen in the next 1-2 weeks. UPCOMING APPOINTMENTS: Labwork in [**Hospital Ward Name 23**] center on [**2127-9-18**]-hematocrit and INR check. Call Dr.[**Name (NI) 5049**] office with INR result on [**9-18**] to decide on warfarin dosing which should begin [**9-18**]. Provider: [**Name10 (NameIs) 9909**] FLOOR UNIT Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2127-9-18**] 11:30 Provider: [**Name10 (NameIs) 9909**] FLOOR UNIT Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2127-9-25**] 12:30 Provider: [**Name10 (NameIs) 9909**] FLOOR UNIT Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2127-10-2**] 11:30

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icd9cm

[ [ [] ] ]

[ "57.93" ]

icd9pcs

[ [ [] ] ]

7244, 7250

4504, 5893

313, 352

7326, 7326

3293, 4481

9552, 10694

2673, 2726

6136, 7221

7271, 7305

5919, 6113

7477, 9529

2741, 3274

264, 275

380, 2088

7341, 7453

2110, 2536

2552, 2657

26,419

167,630

14675

Discharge summary

report

Admission Date: [**2175-5-30**] Discharge Date: [**2175-6-7**] Service: Trauma Service HISTORY OF PRESENT ILLNESS: This is an 84-year-old man status post Motor vehicle accident who was noted to be swerving while driving with a questionable loss of consciousness while driving and struck another vehicle. The patient was taken to an outside hospital where he began to complain of chest pain. He became agitated and was subsequently intubated. The patient remained hemodynamically stable. The patient was transferred to [**Hospital1 190**] for further medical care. PAST MEDICAL HISTORY: Significant for hypertension, pacer and questionable coronary artery disease. MEDICATIONS: Adalat, Lipitor and Isosorbide. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION: Upon presentation the patient presented with a temperature of 97.6, pulse 86, blood pressure 160/90, he was satting 100% and was intubated. The patient's pupils were equal, round and reactive to light and accommodation, 3 mm. Tympanic membranes were intact. The chest was clear to auscultation, without crepitations. The heart was regular. Bowel sounds were present. Abdomen was soft, non distended. Rectal was of normal tone without gross blood. He was moving all four extremities. LABORATORY DATA: Initial labs, Chem 7, 144 sodium, 3.8 potassium, 104 chloride, 27 bicarb, 25 BUN, .9 creatinine. He had a white count of 14.9 with hematocrit of 41 and platelet count of 212,000. Initial ABG was PH 7.41, PCO2 43, PO2 452, CO2 29, base excess 2. Patient underwent a head CT which was found to be negative for bleed. Patient also underwent chest CT which was negative as well as an abdominal CT which was negative. C spine film was negative. The chest x-ray showed a questionable mediastinum widening which was ruled out with a chest CT and no pneumothorax. The C spine was negative. HOSPITAL COURSE: Initially the patient was admitted to the surgical Intensive Care Unit secondary to the hypertension and agitation along with the patient's status of being intubated. While in the unit the patient's C collar remained in place secondary to the inability to clinically clear the neck due to the patient's state of mind at the time. The patient was unable to follow commands at that time. The patient was extubated on day #3 and was transferred to the floor. The patient had remained stable throughout his admission to the surgical Intensive Care Unit, was considered stable for transfer to the floor on [**6-1**]. Neurology was consulted for a questionable possible TIA vs seizures for this patient. An EEG was done which revealed to be normal. Upon the [**Hospital 228**] transfer to the floor he initially failed a swallow evaluation and had a [**Hospital 43199**] tube placed and was started on tube feeds on [**6-2**]. Subsequently on [**6-5**] the patient passed his swallow evaluation and was started on a full liquid diet which was rapidly advanced. The patient had no problems tolerating the diet, his [**Name (NI) 43199**] tube was pulled. The patient has been seeing physical therapy regarding outpatient rehab. His C collar was cleared and removed. The patient is stable, alert and awake, having no trauma issues at this time. The patient will be transferred to a rehab facility from [**Hospital1 188**]. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: To rehab. DISCHARGE MEDICATIONS: The patient will be discharged home on Metoprolol 25 mg po bid, Ramipril 2.5 mg po q d, Isosorbide Dinitrate 10 mg po bid, Atorvastatin 20 mg po q d. FOLLOW-UP: With the trauma surgery clinic within two weeks. The patient is also to go to rehab. The patient is also advised to follow-up with neurology for outpatient work-up of question of seizure. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**] Dictated By:[**Last Name (STitle) 43200**] MEDQUIST36 D: [**2175-6-6**] 06:03 T: [**2175-6-6**] 07:16 JOB#: [**Job Number 43201**]

[ "332.0", "V45.01", "780.2", "412", "427.89", "401.9", "272.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

3421, 4043

1909, 3335

792, 1891

128, 582

605, 769

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61,748

166,725

41706

Discharge summary

report

Admission Date: [**2181-10-6**] Discharge Date: [**2181-10-19**] Date of Birth: [**2097-12-13**] Sex: M Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 783**] Chief Complaint: s/p fall down 8 steps Major Surgical or Invasive Procedure: PICC line placement History of Present Illness: 83M with CAD (MI [**09**] years ago, CABG #1 30 years ago at [**Last Name (un) 1724**], CABG #2 20 years ago at [**Last Name (un) 1724**]), ICD/PCM who was in his usual state of health until [**10-6**] when he fell while carrying a door up some stairs. He was taken to an OSH where he was awake but perseverating. He then started vomiting. He was paralyzed and intubated to protect his airway. He wastransferred to [**Hospital1 18**] where a Head CT showed SAH (massive SAH, bilat SDH. Downward transtentorial herniation. Effacement of the midbrain bilaterally, uncal herniation cannot be excluded. Occ fracture extending to the foramen magnum). . His course is complex and is summarized in the following follows. He was intubated in SICU on admission. On admission, he got 1 unit of platelets given. On [**10-7**], he was febrile with worsening head CT, however, he improved in respiratory status, was able to wean down from vent. Due to fever and concern for aspiration PNA, sputum cultures were sent, blood culture negative thus far. He was extubated on [**10-8**]. On [**10-9**], vanc/cefepime was started. He had a fall from bed. Subsequent CT head showed no significant change. He passed Speech and Swallow. The following day on [**10-10**], he was cleared from c-collar. Echo showed EF of 20-25% with LV thrombus calcified. He was restarted on home lasix. Renal function improving. ABX was dc'd as sputum showed 2+GPCpc/2+GPR/sparse yeast and no fever. He was cleared collar and tolerated POs. . Of note, CT Torso showed left upper lobe lung mass and subcarinal enlarged node is seen. Just below this there is a 3.8 cm mass, difficult to be certain whether this is in the left atrium or just extrinsic to it. There is also a calcified left ventricle aneurysm with thrombus. Multiple hypodensities in Splenic, left renal and left upper quadrant concerning for metastases. The is a left thyroid nodule, incompletely evaluated. . On transfer: VS at transfer: afebrile, 125/70, HR 90-100, RR 20-30, 90-100% on NC. Past Medical History: CAD, V-paced, s/p CABG based on the scar Gout CAD CHF CRF Social History: Social Hx: Quit smoking 30 years ago. Travels to [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **] (PCP in [**Name9 (PRE) 108**]). Travelled to [**Country 14635**] with the military. . Family History: Family Hx: Unknown Physical Exam: PHYSICAL EXAM: Gen: Intubated, sedated. Ext: cold to touch . Neuro: Off propofol: Pupils 3-2 mm, no corneals, no cough, no gag, not over breathing the vent. No movement to BUE except for some hand twitching to noxious. No movement with the BLE except for some twitching of his toes to noxious. . At the time of discharge the patient's neurologic exam was substantially improved. He was intermittently oriented x1-2 and responsive to basic commands. He was moving all extremities. Pertinent Results: Laboratories at admission: [**2181-10-6**] 10:18AM BLOOD WBC-8.7 RBC-4.20* Hgb-12.1* Hct-35.0* MCV-83 MCH-28.8 MCHC-34.5 RDW-13.5 Plt Ct-170 [**2181-10-6**] 10:18AM BLOOD PT-12.8 PTT-26.3 INR(PT)-1.1 [**2181-10-7**] 02:06AM BLOOD Glucose-115* UreaN-29* Creat-1.2 Na-138 K-4.1 Cl-104 HCO3-22 AnGap-16 [**2181-10-7**] 02:06AM BLOOD Albumin-3.7 Calcium-8.2* Phos-3.8 Mg-2.1 [**2181-10-7**] 02:06AM BLOOD Albumin-3.7 Calcium-8.2* Phos-3.8 Mg-2.1 [**2181-10-7**] 02:06AM BLOOD Phenyto-10.0 [**2181-10-6**] 10:42AM BLOOD Type-ART Rates-/14 Tidal V-550 pO2-378* pCO2-33* pH-7.46* calTCO2-24 Base XS-1 -ASSIST/CON Intubat-INTUBATED CT Head: Extensive SAH, R frontal ICH, bilateral SDH that appear chronic with some acute component. Occipital nondisplaced fracture. There could be some blood at the midbrain with effacement. No hydrocephalus noted. CTA Head: Pre-lim read prior to recons: negative for aneurysm. This was discussed with the neuro-radiology attending. [**10-6**] CT head - 1. Massive subarachnoid hemorrhage. 2. Bilateral subdural hemorrhages. 3. Occipital fracture extending to the foramen magnum. Ct C-spine - No CT evidence for acute fracture or malalignment. However, severe degenerative changes puts the patient at risk for cord contusion even with minor trauma [**10-6**] CT C/A/P - 1. Left upper lobe lung mass and subcarinal enlarged node is seen. Just below this there is a 3.8 cm mass, difficult to be certain whether this is in the left atrium or just extrinsic to it. There ias also a calcified left ventricle aneurysm with thrombus. Cardiac echo suggeted. 2. Splenic, left renal and left upper quadrant complex hypodensities, concerning for metastases. This finding was discussed with 3. Right mainstem intubation. 4. Left thyroid nodule, incompletely evaluated. Ultrasound could be performed non-urgently for further evaluation [**10-6**] CT-Angiogram - 1. Head CT has shown diffuse subarachnoid hemorrhage with small bilateral subdural hematomas. The subarachnoid hemorrhage is predominantly seen at the convexity but also seen in the right sylvian fissure greater than left side. No occipital fracture is seen. 2. CT angiography of the head demonstrates no definite aneurysm, vascular occlusion, or high-grade stenosis. 3. CT angiography of the neck demonstrates vascular calcifications, but no evidence of high-grade stenosis or occlusion in the carotid or vertebral arteries. 4. Left upper lung mass, left mediastinal lymphadenopathy, and upper lung scarring are noted and correlation with the torso CT is recommended. [**2181-10-8**] CT BRAIN FINDINGS: In comparison to [**2181-10-7**] examination, there has been no substantial change in the extent of the widespread multicompartmental hemorrhages. Bilateral subdural collections are again evident. Subarachnoid blood, distributed throughout the bilateral frontoparietal and temporal regions, with clot forming in the right sylvian fissure, does not appear substantially increased from the prior examination. There is no shift of normally midline structures. A small amount of layering intraventricular blood is evident, with no significant change in ventricular size or shape to suggest developing hydrocephalus. The imaged osseous structures and soft tissues are unremarkable. The sphenoid sinuses are partially opacified in this intubated patient. IMPRESSION: Extensive multicompartmental, including subarachnoid and subdural hemorrhage, as well as small amount of intraventricular blood, stable when compared to the study from [**2181-10-7**]. [**2181-10-9**] CXR Heterogeneous opacification in the right lung is probably largely pulmonary edema, since perihilar edema was already present in the left lung yesterday and has worsened. Moderate cardiomegaly is stable and there has been a slight increase in mediastinal vascular caliber, which could be a reflection of supine positioning rather than an indication of elevated central venous pressure or volume. Left lower lobe consolidation has worsened in the interim. Whether this is pneumonia or active aspiration, or atelectasis or even asymmetric pulmonary edema is radiographically indeterminate. Left upper lobe mass is a known feature. Transvenous right atrial and left ventricular pacer leads and right ventricular pacer defibrillator lead are in standard placements. Calcified apical ventricular aneurysm is also longstanding. Brief Hospital Course: Mr. [**Known lastname 37564**] was transferred to [**Hospital1 18**] intubated after OSH imaging revealed SAH after fall down 8 stairs. He was admitted to NICU for further management. A cervical collar was maintained. But cleared on [**10-10**] after no reports of neck pain and no fracture. The patient was admitted initially by neurosurgery and subsequently transfered to medicine for further evaluation of multiple medical conditions. . Neuro: CTA of the brain was obtained but did not demonstrate evidence of aneurym. He thrombocytopenic on arrival and was given platelet transfusion. Repeat CT imaging of his brain demonstrated persistent b/l sub dural hematoma's and worsening diffuse SAH. His exam improved and he was able to be extubated without incident. Per neurosurgery there was no indication for surgical intervention. His mental status continued to worsen over the course of next several days. It was noted he was also having fevers and elevated white count. He was treated for presumed VAP. Per laboratory evaluation, it was noted that he had pancreatitis and developed ilieus with colonic distension. He was treated symptomatically and continued on antibiotics. He continued to deteriorate. He was made CMO toward the end of his hospitalization and was discharged on home hospice. . Pulmonary: Plain CXR imaging was suspicous for aspiration, thus sputum was sent which showed GP rods and cocci. He was on Vancomycine and cefipime for this. Final culture showed yeast and normal respiratory flora and the anitbiotics were discontinued. He required IV Lasix on [**10-10**]. He underwent CT toros to rule out additional injury. This was significant for LUL lung mass concerning for malignancy. Per IP, further workup would have required CT guided biopsy. At the time of discharge the wife and HCP as well as the patient's daughter were not inclined towards invasive diagnostic procedures and the mass was not further evaluated. PET CT or further imaging may be indicated pending family wishes. He was treated with Vanc/cefepime for presumed VAP due to his MS decline. . Cardiac: CT torso showed a also a calcified left ventricle with aneurysm and thrombus. ECHO was done for further work up and EF was noted to be 20-25 % (baseline from OSH records). Further evaluation of left ventricular thrombus would require TEE and based on families desires to avoid invasive procedures was not indicated at this time. Anticoagulation was similarly not indicated due to the patient's SAH. . Left thyroid nodule: incompletely evaluated on CT torso. Outpatient work up needed but deferred at this time due to multiple other conditions and family's reluctance to pursue invasive procedures. . CT Torso: Splenic, left renal and left upper quadrant complex hypodensities, concerning for metastases. The underlying pathology of these hypodensities remains unclear though may be due to abdominal visceral or lung metasteses. At the time of discharge, the wife [**Name (NI) 382**] and daughter were not interested in invasive diagnostic procedures and this was not further evaluated. . Hematology: Plavix and Aspirin was stopped due to head injury. INR was elevated to 1.5 and Vitamin K was started on [**10-10**]. The elevated INR was thought to be due to poor nutrition; DIC was unlikely given the stability of the patient and the normal platelet count. Nutrition services were consulted to assist with management of the patient's diet. Vitamin K was given again on [**10-12**]. . Renal: He had acute renal insufficanty and developed hypernatremia over the course of his hospital stay. His renal failure resolved and his creatinine returned to his baseline of 1.3. The etiology of his hypernatremia was initially unclear. [**Name2 (NI) 227**] the patient's decreased PO intake during his admission, it was thought that this was a contributing factor. However, partial diabetes could not be excluded based on his urine osms in the mid400s. He was treated with gentle hydration with D5W with care not to overload his heart given EF of 20-25%. Electrolytes were monitored twice daily while the patient was hypernatremic. He was given multiple boluses and free water intravenously. Transitional: He was discharged to hospice. Medications on Admission: Allopurinol 100 mg daily Alprazolam 0.5mg TID ASA 81 mg daily Plavix 75 mg daily Digoxin 0.125 mg daily Lasix 40 mg [**Hospital1 **] Indomethacin 75 mg daily Imdur 60 mg daily Nazonex spray daily Potassium Chloride 20meq daily Ramipril 2.5mg Daily Ranitidine 150 mg daily Simvastatin 40mg qhs Sprionolactone 25mg daily Vitamine B daily Carvedilol 6.25mg [**Hospital1 **] Discharge Medications: 1. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig: 5-10 mg PO Q2H (every 2 hours) as needed for pain or respiratory distress. 2. Ativan 1 mg Tablet Sig: 1-2 Tablets PO four times a day as needed for sizeure. 3. haloperidol 1 mg Tablet Sig: 1-2 Tablets PO q4h:prn as needed for agitation. Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 25997**] House Discharge Diagnosis: subdural hemaoma's bilaterally subarachnoid hemorrhage left upper lobe lung mass Pulmonary edema aspiration pneumonia Pancreatitis Ilieus fever occipital skull fracture non displaced Renal insufficiency cardiac aneurysm with thrombus Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: You were admitted to the hospital after you fell down some stairs. You sustained injury to your brain including subdural hematoma, hemorrhage into the brain and subarachnoid hemorrhage. You also sustained a skull fracture. None of these injuries required srgical intervention. You also had a cat scan of your body to assess for other injury. Incedentally found was a lung mass in the left upper lobe with masses in spleen and thyroid. You were also noted to have pancreatitis, Ilieus, fever from aspiration pneumonia. Unfortunately, these combination of events have lead you to a state where your goals of care was targetted towards your comfort in accordance to your living will. You were discharged to hospice near your home where you can spend more time with your family in the last days of your life. Discharged home on home hospice. Followup Instructions: None [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

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icd9cm

[ [ [] ] ]

[ "38.93", "96.71" ]

icd9pcs

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Discharge summary

report+addendum

Admission Date: [**2182-11-12**] Discharge Date: [**2182-11-16**] Date of Birth: [**2124-6-22**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2182-11-12**] Mitral Valve Repair (30mm ring with P2 resection and A2 oversewing) History of Present Illness: 58 y/o male with h/o mitral regurgitation for past 8-10 years and has been followed by serial echocardiograms. Most recent echo showed 3+ mitral regurgitation with partial posterior mitral leaflet flail. He has been c/p dyspnea with very heavy exertion. Past Medical History: Mitral Regurgitation, Asthma, Migraine headaches, h/o funal ear infections, s/p Polypectomy, s/p Tonsillectomy, s/p Dental Implant Social History: Denies tobacco use. Admits to drinking wine and hard liquor on weekends. Family History: non-contributory Physical Exam: At discharge: VS: 98.3 113/71 68SR 20 94%RA Gen: NAD, WG, WN [**Male First Name (un) 4746**] Chest: LCTAB Heart: RRR, no murmur or rub Abd: NABS, soft, non-tender, non-distended Ext: trace edema Neuro: grossly intact Incision: sternotomy c/d/i without erythema or drainage Pertinent Results: [**11-12**] Echo: PRE-BYPASS: 1. The left atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the descending thoracic aorta. 5. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. No aortic regurgitation is seen. 6. The mitral valve leaflets are myxomatous. There is a flail of the P2 segment. The mitral valve leaflets do not fully coapt. An eccentric, anteriorly directed jet of severe (4+) mitral regurgitation is seen. 7. There is no pericardial effusion. POST-BYPASS: Pt is in sinus rhythm and is on an infusion of phenylephrine 1. Left and right ventricular function is preserved. 2. The aorta is intact post decannulation. 3. The patient is status post mitral valve repair, with P2 resection, band annuloplasty, and [**First Name8 (NamePattern2) **] [**Last Name (un) 84256**] stitch. There is now trivial mitral regurgiation. The peak gradient of 2mmHg at cardiac output of 5 L/min. 4. The remainder of the exam is unchanged. Radiology Report CHEST (PORTABLE AP) Study Date of [**2182-11-13**] 12:05 PM [**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG CSRU [**2182-11-13**] SCHED CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 107530**] Reason: CT removal- r/o ptx [**Hospital 93**] MEDICAL CONDITION: 58 year old man with REASON FOR THIS EXAMINATION: CT removal- r/o ptx Wet Read: JWK WED [**2182-11-13**] 3:01 PM PFI: Tiny right apical pneumothorax. Final Report INDICATION: 58-year-old man status post chest tube removal. COMPARISON: [**2182-11-12**] FRONTAL CHEST RADIOGRAPH: There has been removal of a Swan-Ganz catheter, endotracheal tube, nasogastric tube, mediastinal drain, and right-sided chest tube. There is a residual tiny right apical pneumothorax. The patient has had mitral valve replacement and median sternotomy wires are intact. There are expected post-operative changes including linear atelectasis at both lung bases. Findings paged to [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4020**] on [**2182-11-13**] at 3 p.m. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) **] [**Doctor Last Name **] DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**] Approved: WED [**2182-11-13**] 4:24 PM Imaging Lab [**2182-11-16**] 07:20AM BLOOD WBC-6.5 RBC-2.69* Hgb-8.7* Hct-24.0* MCV-89 MCH-32.3* MCHC-36.1* RDW-13.5 Plt Ct-202 [**2182-11-16**] 07:20AM BLOOD Glucose-94 UreaN-23* Creat-0.9 Na-138 K-3.7 Cl-99 HCO3-33* AnGap-10 [**2182-11-16**] 07:20AM BLOOD Mg-2.2 Brief Hospital Course: Mr. [**Known lastname 107531**] was a same day admit after undergoing all pre-operative work-up as an outpatient. On [**11-12**] he was brought directly to the operating room where he underwent a mitral valve repair. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in stable condition. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. Diuretics and beta blockers were initiated and he was gently diuresed towards his pre-op weight. On post-op day one he was transferred to the telemetry floor for further care. Chest tubes and epicardial pacing wires were removed per protocol. Beta-blocker was optimized. He continued to progress and was discharged to home on POD # 4 All follow up apppointments were advised. Medications on Admission: Lisinopril 40mg qd, Aspirin 81mg qd, Advair, Flonase, Imitrex prn, Tylenol #3 prn Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. 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. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). Disp:*qs * Refills:*0* 6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400mg 2x/day x 1 week, then 200mg 2x/day x 1 week, then 200mg daily. Disp:*120 Tablet(s)* Refills:*0* 9. Imitrex 50 mg Tablet Sig: One (1) Tablet PO once a day as needed for headache: may repeat x1 if symptoms not resolved after 2 hours. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 932**] VNA Discharge Diagnosis: Mitral Regurgitation s/p Mitral Valve Repair PMH: Asthma, Migraine headaches, h/o funal ear infections, s/p Polypectomy, s/p Tonsillectomy, s/p Dental Implant 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. [**Last Name (STitle) **] in 4 weeks Dr. [**Last Name (STitle) 120**] in [**1-13**] weeks Dr. [**Last Name (STitle) 2903**] in [**12-12**] weeks Completed by:[**2182-11-16**] Name: [**Known lastname 17562**],[**Known firstname **] Unit No: [**Numeric Identifier 17563**] Admission Date: [**2182-11-12**] Discharge Date: [**2182-11-16**] Date of Birth: [**2124-6-22**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 741**] Addendum: Medications adjusted. Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. 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. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). Disp:*qs * Refills:*0* 6. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400mg 2x/day x 1 week, then 200mg 2x/day x 1 week, then 200mg daily. Disp:*120 Tablet(s)* Refills:*0* 9. Imitrex 50 mg Tablet Sig: One (1) Tablet PO once a day as needed for headache: may repeat x1 if symptoms not resolved after 2 hours. Disp:*20 Tablet(s)* Refills:*0* 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks. Disp:*7 Tablet(s)* Refills:*0* 11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 1 weeks. Disp:*7 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 2333**] VNA [**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**] Completed by:[**2182-11-16**]

[ "V70.7", "346.90", "V45.89", "493.90", "424.0" ]

icd9cm

[ [ [] ] ]

[ "39.64", "35.12", "39.61", "88.72" ]

icd9pcs

[ [ [] ] ]

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343, 430

6600, 6606

1304, 2793

7117, 7715

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883, 957