ChanBeDu/relevant_section_length · Datasets at Hugging Face

3,482

156,471

50034

Discharge summary

report

Admission Date: [**2153-5-7**] Discharge Date: [**2153-5-19**] Date of Birth: [**2097-4-20**] Sex: M Service: MEDICINE Allergies: Penicillins / Codeine / Pork Derived (Porcine) Attending:[**First Name3 (LF) 2279**] Chief Complaint: Shortness of breath. Major Surgical or Invasive Procedure: 1.) Placement of left internal jugular central venous line [**2153-5-9**] 2.) Placement of arterial line [**2153-5-9**] 3.) Endotracheal Intubation [**2153-5-9**] History of Present Illness: Mr. [**Known lastname 17204**] is a 56 year-old man with end-stage COPD on 2L home O2 (FEV1 19% predicted, baseline pCO2 50s), CAD s/p CABG and bare metal stent, with recent hospitalizations (>10 in the past year) presenting with shortness of breath, dyspnea on exertion, increased oxygen requirement to 3.5L, and worsened cough productive of green sputum x 4 days. His symptoms have been gradually worsening so that he feels short of breath even at rest, whereas at baseline he can walk one block without rest. He is a current smoker (a few cigarettes per day) but has recently decreased his tobacco use. He also endorses a chronic history of intermittent left-sided chest pain that lasts for seconds to minutes while at rest, occurs once each day, and last occurred in the emergency department. The pain radiates to his left ribs and shoulder blade; he does not take nitroglycerin for it. He denies any current chest pain. He denies any symptoms of fevers/chills, night sweats, no abdominal pain or diarrhea, no urinary symptoms, no difficulties swallowing. He denies seasonal allergies, sick contacts, symptoms of edema or increased dietary sodium intake. Compliance with medications is difficult to assess, as patient is unable to identify medications and states he is taking those listed per [**Hospital1 18**] computer system. Of note, the patient was recently seen [**2153-4-27**] in COPD [**Hospital 702**] clinic with Dr. [**Last Name (STitle) **], who reduced his prednisone dose from 60 to 40 mg qday and prescribed doxycycline to be used PRN for COPD exacerbation symptoms as a preventative measure to hospitalization. It is unclear if the patient has taken the doxycycline at home. He was also seen in the [**Hospital1 18**] ED [**2153-5-3**] for cellulitis of his left elbow, for which he was treated with a planned 7-day Bactrim and Clindamycin course and subsequent course of Bactrim prophylaxis, the Clindamycin was discontinued a day later at Urgent Care due to minimization of risk of C. diff. His most recent dose of Bactrim was a prophylactic dose, although the 7-day period for treatment is not completed. Mr. [**Known lastname 17204**] states that his left elbow is infected as a result of chronically leaning on it in bed. In the [**Hospital1 18**] emergency department, initial vital signs were: 96.5 103 162/74 24 94%. His serum laboratory values were significant for a WBC of 13 with 85% neutrophils, no bands. EKG demonstrated prominent, peaked P waves with poor R wave progression (also present on [**2153-4-23**] EKG). Troponin was negative x1. Blood cultures were taken and CXR demonstrated no pneumonia by preliminary read. He received Duonebs x3, IV methylprednisolone, and a dose of IV Azithromycin. He also received 4 mg IV Morphine for chronic low back pain, s/p orthopedic surgery for spinal stenosis. Past Medical History: 1.) COPD on 2L home O2 overnight 2.) CAD s/p MI and CABG; PCI [**5-/2150**]: patent LIMA to the LAD, RIMA to the RCA, BMS placed in the RCA distal to RIMA; Cath [**12/2150**]: widely patent LIMA and RIMA grafts; patent distal RCA stent and known occluded native LAD and RCA. Nuclear Stress [**1-/2151**] Nuclear Perfusion Stress: no anginal symptoms or ischemic ST segment changes. 4.) Thoracic aortic anuerysm s/p repair [**2148**] 5.) Tobacco abuse; 1ppd since age 21 6.) Hypercholesterolemia 7.) Hypertension 8.) History of head trauma in [**2118**] from MVA with post-traumatic grand mal seizure, now off anti-epileptics 9.) Neurogenic claudication 10.) S/p spinal stenosis surgery [**1-/2152**], previously on 10 mg oxycodone qday for pain, recently violated narcotics contract Social History: Patient lives with his sister-in-law and her young children. Endorses 30 pack-year tobacco history, now smokes 1 pack q2weeks. Has previous history of 16-30 beers/day, states he has not had alcohol in 2 years. Denies history of IVDU. Family History: Family history of CAD, with death of mother at age 59 of MI, father at age 61 of MI, cousin at age 41 of MI, uncle at age 41 of MI. Has sister with severe COPD; brother died of throat cancer. Physical Exam: ADMISSION PHYSICAL EXAM VS: 97.0 107/61 72 16 98% on 2L; Pain: [**2-8**] in low back. GENERAL: Man appearing older than stated age with Cushingoid habitus, lying in bed without tripode position, breathing with pursed lips. HEENT: Cushingoid facies. Oropharynx clear. NECK: No JVD appreciated. Shotty anterior cervical lymphadenopathy. CHEST: Limited air movement with inspiratory: expiratory ratio of 1:4. Diffuse inspiratory and expiratory rhonchi. No fremitus, egophony, or dullness to percussion appreciated. No pain to palpation over anterior chest. HEART: Regular rate and rhythm without murmurs, gallops, or rubs. No accentuated second heart sound. ABDOMEN: Abdomen is soft, non-tender, and non-distended. +BS. MSK: No spinal point tenderness. SKIN: Multiple ecchymoses on his skin and arms. No pitting edema in lower extremities. 2 mm wound ulceration through sub-cutaneous tissue with no surrounding erythema or fluctuance. ACCESS: 20G IV in R wrist DISCHARGE PHYSICAL EXAM VS: 98.1 100/52 57 20 92-98% on 2L GENERAL: Man appearing older than stated age with Cushingoid habitus, lying back in bed without tripoding, breathing with pursed lips with increased work of breathing. HEENT: Cushingoid facies. Oropharynx clear. NECK: No JVD appreciated. Shotty anterior cervical lymphadenopathy. CHEST: Limited air movement with inspiratory: expiratory ratio of 1:4. Diffuse inspiratory and expiratory rhonchi. No fremitus, egophony, or dullness to percussion appreciated. No pain to palpation over anterior chest. HEART: Regular rate and rhythm without murmurs, gallops, or rubs. No accentuated P2. ABDOMEN: Abdomen is soft, non-tender, and non-distended. +BS. MSK: No spinal point tenderness. SKIN: Multiple ecchymoses on his skin and arms. No pitting edema in lower extremities. Left elbow Stage 3 pressure ulcer; right elbow Stage 1 pressure ulcer. ACCESS: None. Pertinent Results: ADMISSION LABS: [**2153-5-7**] 11:45AM BLOOD Glucose-101* UreaN-9 Creat-0.6 Na-134 K-6.5* Cl-95* HCO3-26 AnGap-20 [**2153-5-7**] 11:45AM BLOOD Calcium-8.8 Phos-4.0 Mg-1.9 [**2153-5-7**] 11:45AM BLOOD WBC-13.0* RBC-5.28 Hgb-13.8* Hct-44.0 MCV-83 MCH-26.1* MCHC-31.3 RDW-16.4* Plt Ct-203 [**2153-5-8**] 01:27PM BLOOD CK(CPK)-22* [**2153-5-7**] 11:45AM BLOOD cTropnT-<0.01 [**2153-5-7**] 09:35PM BLOOD cTropnT-<0.01 DISCHARGE LABS: [**2153-5-19**] 06:30AM BLOOD Glucose-93 UreaN-17 Creat-0.7 Na-141 K-4.0 Cl-91* HCO3-44* AnGap-10 [**2153-5-19**] 06:30AM BLOOD Calcium-9.6 Phos-3.6 Mg-1.9 [**2153-5-19**] 06:30AM BLOOD WBC-9.0 RBC-4.13* Hgb-10.6* Hct-34.0* MCV-83 MCH-25.6* MCHC-31.0 RDW-15.6* Plt Ct-209 IMAGING: [**2153-5-7**] Admission CXR: 1. No acute cardiopulmonary process. 2. Hyperinflated lungs, compatible with the patient's history of COPD. MICROBIOLOGY: [**2153-5-10**] 3:57 pm SPUTUM Source: Endotracheal. GRAM STAIN (Final [**2153-5-10**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2153-5-13**]): Commensal Respiratory Flora Absent. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. Piperacillin/Tazobactam sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 16 I CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- 1 S GENTAMICIN------------ 8 I MEROPENEM------------- =>16 R PIPERACILLIN/TAZO----- 32 S TOBRAMYCIN------------ <=1 S ACID FAST SMEAR (Final [**2153-5-11**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. Brief Hospital Course: This patient is a 56 year-old man with history of severe COPD (FEV1 19%) on home oxygen, with history of CAD s/p MI with CABG and BMS, admitted for COPD exacerbation, intubated and transferred to MICU for hypercarbic respiratory failure, readmitted to floor with trigger [**2153-5-15**] for hypoxemia/hypercarbia/respiratory distress. After family discussion [**2153-5-17**], patient decided to go home [**2153-5-19**] on hospice and was medically stablized for discharge home to [**Hospital 67382**]. #) COPD exacerbation: The patient presented with increased sputum production and dyspnea with poor air movement and signs of expiratory limitation on exam. He had no infiltrate and pneumonia was not thought to be a primary process. He has a history of multiple previous admissions for COPD exacerbations and his symptoms were consistent with previous episodes. On presentation he received 125 mg IV methylprednisolone x1 followed by 60 mg of prednisone PO daily as well as azithromycin and increased frequency of inhalers. He failed to improve significantly and on hospital day two was intubated for hypoxic and hypercarbic respiratory failure and unresponsiveness (just prior to this episode he received one additional dose of methylprednisolone 125 mg IV*1). After his intubation he was transferred to the MICU where he received standing ipratroprium and albuterol MDIs, had his antibiotics switched to levofloxacin and continued on prednisone 60 mg PO daily. He was extubated after four days and after his extubation was switched from Levofloxacin to Ciprofloxacin [**2153-5-12**] given his sputum culture grew only Pseudomonas and no gram positive organisms (CXR never showed a clear infiltrate); and 7-day course completed during hospitalization. Prednisone taper initiated on day 8 from 60 mg to 40 mg per the patient's pulmonologist, Dr. [**Last Name (STitle) **]. Patient was discharged on standing Prednisone (40 mg qday), standing Albuterol/Ipratropium MDIs (2 puffs 4hr); he could not tolerate nebulizers. He was continued on prophylactic TMP/Sulfa for PCP prophylaxis given his degree of immunosuppression. He required 2L NC at rest with increased O2 requirement of 4L NC with exertion; this should be titrated prn for goal O2sat 89-94%. #) Hypoxic and hypercarbic respiratory failure: The patient failed to improve after his first two days of standard COPD therapy and continued to be wheezy with limited air movement. On the morning of his third hospital day he received two mg of IV morphine for his chronic back pain. Of note, this was significantly less than he had previously received for pain. Shortly after receiving this he was noted to be slumped over and minimally responsive. He received naloxone 2g with minimal improvement. A code blue was called [**2153-5-9**] AM for respiratory distress and need for intubation but the patient never stopped breathing or became pulseless. He was successfully ventilated with bag mask and no significant period of hypoxia was noted. He was intubated secondary to work of breathing and altered mental status. Arterial blood gas could not be successfully obtained until after the code though a VBG afterwards demonstrated PCO2 of 162. He was intubated with significant issues with autopeep and refractory hypoxemia though eventually improved with bronchodilator therapy and considerable steroids. Acidemia in the 7.3 range was tolerated given the patient's chronic hypercarbic respiratory failure. Eventually, the patient was extubated successfully on [**2153-5-12**], with respiratory distress later in the day attributed to flash pulmonary edema. He received NIPPV with considerable improvement and remained off NIPPV after the evening of [**5-12**]. Afterwards his oxygen requirement remained at 2 L to saturate around 93-98% at rest. Of note, when not compliant with nasal cannula or with exertion, patient has desaturations as low as 64%, which responded to non-rebreather and shovel mask with humidified oxygen. Throughout his admission he remained hypercarbic, with baseline pCO2 in 80s and serum bicarbonate in mid-40s. #) Shock: The patient developed hypotension after his intubation and required phenylephrine for refractory hypotension after fluids and despite an adequate CVP. This was thought to be a combination of cardiogenic shock, due to his high amounts of autopeep increasing intrathoracic pressure and diminishing venous return, as well as a component of distributive shock due to the Propofol he initially received for sedation after intubation. He remained normotensive to hypertensive from [**2153-5-11**] forward. #) Hypertension: The patient was hypertensive after his extubation, which was thought to be part of the cause of his acute hypoxia and flash pulmonary edema. He was treated transiently with labetalol 10 mg IV *1 then restarted on his home Metoprolol and Lisinopril with controlled blood pressures. #) Pain Control: The patient has chronic low back pain and a history of a narcotics contract through [**Company 191**] though he violated his contract [**4-11**]. At admission he was treated with standing Tramadol, Acetaminophen, and Lidocaine patch. After complaining of chest pain (with no EKG changes and negative troponins x2), he received 2x 4 mg IV Morphine [**2153-5-11**] as well as 1x 2 mg IV Morphine [**2153-5-12**]. Shortly after receiving this last dose of IV Morphine he experienced hypercarbic respiratory arrest, not responsive to 2 g Narcan and thought to be unrelated to the event. After his extubation he complained of back pain and was treated with morphine IR with reasonable pain control. When he returned to the floor, he initially received continued standing Tramadol, Acetaminophen, and Lidocaine patch. As this was inefficacious and decision was made for patient to enter hospice care at home, he was transitioned to MS Contin [**Hospital1 **] with PO Morphine elixir 10-20 mg q4hr PRN pain and dyspnea and standing Acetaminophen. #) Elbow Wound: The patient has an elbow wound that is s/p a 7-day course of DS TMP/Sulfa for presumed cellulitis of left elbow wound shortly prior to hospital admission. No signs of active skin infection were noted during this hospitalization, but patient has a left elbow Stage 3 decubitus ulcer and right elbow Stage 1 decubitus ulcer secondary to leaning on the elbow in bed. He received a wound care consult, and wound was kept sterile and dry. Plan for wound care in hospice on discharge. #) CAD: In discussion with patient, decision made to continue all of his previous outpatient cardiac medications. This can be readdressed as his condition evolves. #) End of life discussions: A care connection meeting was held with Mr. [**Known lastname 17204**] and his sister-in-law/HCP [**Name (NI) **] [**Name (NI) 17204**] (present via conference call) to discuss goals of care and a safe plan for discharge. Mr. [**Known lastname 104472**] ultimate goal is to return home (with [**Doctor First Name **] and her children) and to be comfortable. We discussed that going home with hospice would best help him and his family achieve his goals of care, and that he would be able to receive morphine for both management of his chronic pain and dyspnea. Hospice has arranged supplies such as a hospital bed and wheelchair at home. He would not be required to be home bound. He does understand that he needs to wear his oxygen at all times and increase the amount with exertion. Both Mr. [**Known lastname 17204**] and [**Doctor First Name **] were in agreement with this plan. [**Doctor First Name **] was especially supportive and cited her willingness to do whatever she could to keep him comfortable and take care of him at home. Based on this discussion, he was full code in the hospital (if respiratory failure not reversible, would only want to be intubated long enough for family to say goodbye) but expresses preferences consistent with being made DNR/DNI upon discharge home with hospice. DNR/DNI form was reviewed and signed with the patient in agreement. If he develops respiratory distress, the plan would be to call hospice first. Mr. [**Known lastname 17204**] and [**Doctor First Name **] understand that this is a continual conversation and can be readdressed with his hospice team and providers as his condition evolves. Medications on Admission: ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) Steroids: PREDNISONE - 10 mg Tablet - 4 Tablet(s) by mouth daily continue until instructed to taper FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - (Prescribed by Other Provider; not taking per patient) (Not Taking as Prescribed) - 500 mcg-50 mcg/Dose Disk with Device - 1 Disk(s) inhaled twice a day Antibiotics: SULFAMETHOXAZOLE-TRIMETHOPRIM - (Prescribed by Other Provider) - 800 mg-160 mg Tablet - 1 Tablet(s) by mouth QMOWEFR ([**Doctor First Name 766**] -Wednesday-Friday) ALBUTEROL SULFATE - 0.63 mg/3 mL Solution for Nebulization - 1 neb INH q6 hours as needed for shortness of breath FUROSEMIDE - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) IPRATROPIUM BROMIDE - (Prescribed by Other Provider) - 0.2 mg/mL (0.02 %) Solution - 1 Solution(s) inhaled every six (6) hours IPRATROPIUM-ALBUTEROL [COMBIVENT] - 18 mcg-103 mcg (90 mcg)/Actuation Aerosol - 2 puffs po every four hours as needed as needed for shortness of breath use when not able to use nebulizer LISINOPRIL - 20 mg Tablet - 1 Tablet(s) by mouth once a day METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 100 mg Tablet Extended Release 24 hr - 1 Tablet(s) by mouth daily O2 AT 2L/MIN CONTINUOUS, FOR PORTABILITY PULSE DOSE SYSTEM - - qd with any activity once a day OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth once a day SIMVASTATIN - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth once daily at bedtime TRAMADOL - 50 mg Tablet - 0.5 - 1 Tablet(s) by mouth [**Hospital1 **]- TID as needed for severe pain TRAZODONE - 50 mg Tablet - 1 Tablet(s) by mouth at bedtime as needed for insomnia CALCIUM CARBONATE - (OTC) - 200 mg (500 mg) Tablet, Chewable - 1 Tablet(s) by mouth three times a day CHOLECALCIFEROL (VITAMIN D3) - (Prescribed by Other Provider) - 400 unit Tablet, Chewable - 2 Tablet(s) by mouth once a day FERROUS SULFATE - (Prescribed by Other Provider) - 325 mg (65 mg iron) Tablet - 1 Tablet(s) by mouth once a day for iron Discharge Medications: 1. [**Hospital **] Please evaluate and admit to [**Hospital 2188**]. 2. prednisone 20 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*0* 3. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. Disp:*15 Tablet(s)* Refills:*0* 4. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO MWF ([**Hospital 766**]-Wednesday-Friday). Disp:*12 Tablet(s)* Refills:*0* 5. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). Disp:*180 Tablet(s)* Refills:*0* 6. furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours). Disp:*5 inhaler* Refills:*2* 8. MS Contin 15 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO twice a day as needed for Pain, discomfort, shortness of breath. Disp:*60 Tablet Extended Release(s)* Refills:*1* 9. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig: 0.5-1 mL PO Q4H:PRN as needed for Pain, discomfort, shortness of breath. Disp:*60 mL* Refills:*1* 10. nicotine 22 mg/24 hr Patch 24 hr Sig: One (1) patch Transdermal once a day. Disp:*30 patches* Refills:*0* 11. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*0* 12. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID:PRN as needed for constipation. Disp:*60 Tablet(s)* Refills:*0* 13. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 14. simvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime. 15. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One (1) Tablet PO three times a day. 16. ergocalciferol (vitamin D2) 400 unit Tablet Sig: Two (2) Tablet PO once a day. 17. ferrous sulfate 325 mg (65 mg iron) Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO once a day. 18. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 19. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 20. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 21. Home O2 2L NC at rest at all times, increase to 4L NC with exertion. Titrate to goal O2sat 89-94%. Discharge Disposition: Home With Service Facility: [**Location (un) **] Discharge Diagnosis: Primary diagnosis: Chronic obstructive pulmonary disease exacerbation Secondary diagnoses: - Very severe COPD (FEV1 19%) on home O2 - CAD s/p MI and CABG Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. O2 saturation at rest with 5L: 92-93%; O2 saturation on RA: 75-88%; O2 saturation with exertion: 64-85% Discharge Instructions: You were admitted to the medicine service of [**Hospital1 18**] because of worsening breathing symptoms, increased need for supplemental oxygen at home, and cough with green sputum. In the hospital your breathing symptoms became much worse and you required a breathing tube and were managed in a specialized unit of the hospital, the medical intensive care unit. You received steroid medications, antibiotics, and nebulized medications to improve your breathing. We also gave you IV and oral pain medications to help you manage your pain. During your hospitalization, we had a discussion with you and your health care proxy, in which you decided that the best option for future care would be to go home with a hospice service (Beacon), which would best support you and provide for your comfort at the end of your life. We made the following changes to your medications: 1.) We added oral Morphine elixir, 10-20 mg every 4 hours as needed for pain. 2.) We added MS Contin, a long-acting type of oral Morphine, 15 mg twice a day. 3.) We stopped your Ultram. It is important that you review these medication changes with your primary care physician. Followup Instructions: Please follow up with your primary care physician after discharge to review the medication changes that were made in the hospital. You can call [**Telephone/Fax (1) 250**] to schedule a visit. The following appointments have been previously scheduled: Department: SPINE CENTER When: [**Telephone/Fax (1) **] [**2153-6-18**] at 12:20 PM With: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 3736**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: PULMONARY FUNCTION LAB When: THURSDAY [**2153-7-12**] at 8:40 AM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES When: THURSDAY [**2153-7-12**] at 9:00 AM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**Telephone/Fax (1) 612**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]

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41349

Discharge summary

report

Admission Date: [**2196-4-29**] Discharge Date: [**2196-5-7**] Date of Birth: [**2144-1-11**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1115**] Chief Complaint: Acute pancreatitis Major Surgical or Invasive Procedure: none History of Present Illness: Mr [**Known lastname **] is a 52M with h/o ETOH abuse, alcoholic pancreatitis, CAD who presented to [**Hospital3 417**] hospital with on day of n/v/abd pain and found to have acute pancreatitis and ETOH withdrawal on [**4-21**]. At the time of presentation his Lipase was 984 and CT abd/pelvis showed mild peripancreatic edema and fluid infiltration in retroperitoneum. The patient was intially treated on the medicine service with IVF, analgesia and kept NPO. However, his course was complicated by Delirium tremens for which he was transferred to the critical care unit on [**4-23**]. He was treated with dexmedetomide and IV lorazepam with improvement. At this time the patient is 7 days out from his last drink and maintained on IV lorazepam. The patient began to complain of increasing abdominal pain with note of increased abdominal girth and tenderness on exam. Repeat CT showed enlargement of the pancreas with circumferential peripancreatic fluid collection and enlarging collection in lesser sac and splenic hilium, as well as retroperitoneal fluid, and findings suggestive of pancreatic necrosis. In addition, the patient has been persistently febrile over the past few days with maximum temp of 102 with persistant leukocytosis (wbc 15K with 30% bands). His cultures prior to transfer were negative to date other than CDIFF. He was found to have postive CDIFF PCR and was started on IV flagyl. Planned to start PO vancomycin but not administered prior to transfer. He has remained HD stable throughout his course with BP 110s, HR in 90-100s, O2 stas 96% on 2L NC (dropping to 88% on RA), foley in place draining 100-1500cc/hr on D51/2NS 20KCL at 75cc/hr. He has been kept NPO and was on PPN prior to transfer. (He apparently failed speech and swallow evaluation on the day of discharge). He was transferred to [**Hospital1 18**] for further management of his pancreatitis with consideration of needle aspiration of pancreatic bed to exclude superinfection. On the day of discharge, labs were significant for lipase 38, albumin 1.8. normal LFTs, glucose 197, prealb 4.8, WBC 15, HCT 30. Past Medical History: - ETOH abuse - Alcoholic Pancreatitis - Previous sepsis - PE, IVC filter? - Cardiomyopathy w/ VFib arrest s/p Placement of cardioverter defibrillator [**11/2194**] - Hypertension - Hyperlipidemia - Coronary artery disease - GERD - splenic infarct Social History: Per records: Ambulates with cane at baseline. Employed as a sheet metal worker. He has never smoked tobacco. Occasional marijuana and cocaine use. Drinks 3-4 beers approximately 5 days per week. He is married with 3 children. Family History: Per records: no significant cardiac history Physical Exam: Vitals: T 100.2 151/78 108 91-84 on 2L NC General: Alert, oriented to self, intermittently to place and date HEENT: Sclera anicteric, dry MMM, white plaque on tongue, PERRL Neck: supple, JVP not elevated CV: Regular, tachycardic, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear anteriorly but difficult to assess due to poor patient cooperation. Abdomen: distended, bowel sounds present, soft, tender to palpation largely in epigastrium GU: foley with clear yellow urine Skin: erythematous rash in groin Ext: warm, well perfused, 2+ pulses, no edema Neuro: Altered, intermittently able to respond to questions appropriately, moves all exremities DISCHARGE LABS VS: 98.2 105-123/60-75, 67-74, 20, 96% RA BG 133-140 I/O [**Telephone/Fax (1) 90021**]/[**2183**] + BM GEN: generally well appearing, but does appear uncomfortable. HEENT: EOMI, sclera anicteric, OP clear NECK: No LAD CV: RRR, No m/r/g, nl S1, S2 LUNGS: CTAB, no wheezing, no crackles ABD: No epigastric tenderness, normal bowel sounds, non-distended EXT: No edema, 2+ radial, DP, PT pulses bilaterally. Erythematous and slightly tender R great toe, no abnormalities appreciated on left foot. NEURO: CN II-XII intact Moving all four extremities spontaneously, gait normal. Appropriate, alert. Pertinent Results: OSH: CT abd/pelvis [**4-27**] Small right mod left pleural effusion. heart enlarged. no pericardial effusion. no biliary dilation but high density material in gallbladder. Progressive severe pancreatitis wit pancreatic enlargement and new findings of pancreatic necrosis. peri pancreatic, lesser sac, retroperitoneal, mesenteric fluid collections. new thickened transverse colon. Pancreatic severity index [**5-8**]. . ADMISSION [**2196-4-29**] 01:41AM BLOOD WBC-19.5*# RBC-3.25* Hgb-10.4*# Hct-30.9* MCV-95 MCH-32.1* MCHC-33.7 RDW-13.8 Plt Ct-369 [**2196-4-29**] 01:41AM BLOOD Neuts-88.1* Lymphs-7.0* Monos-3.7 Eos-1.0 Baso-0.2 [**2196-4-29**] 01:41AM BLOOD Glucose-144* UreaN-11 Creat-0.7 Na-136 K-4.7 Cl-101 HCO3-23 AnGap-17 [**2196-4-29**] 01:41AM BLOOD Albumin-3.1* Calcium-9.2 Phos-3.2 Mg-2.1 . PERTINENT [**2196-4-29**] 01:41AM BLOOD PT-15.4* PTT-24.6* INR(PT)-1.4* [**2196-4-29**] 01:41AM BLOOD ALT-22 AST-41* LD(LDH)-457* AlkPhos-87 TotBili-0.3 [**2196-4-29**] 09:34AM BLOOD Lipase-57 [**2196-4-29**] 01:41AM BLOOD Triglyc-133 [**2196-4-29**] 02:08AM BLOOD Lactate-2.1* [**2196-4-29**] 02:08AM BLOOD freeCa-1.20 [**2196-4-29**] 02:02AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.009 [**2196-4-29**] 02:02AM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-NEG [**2196-4-29**] 02:02AM URINE RBC-38* WBC-1 Bacteri-FEW Yeast-NONE Epi-0 __________________________________________________________ [**2196-5-1**] 10:53 pm URINE Source: CVS. **FINAL REPORT [**2196-5-3**]** URINE CULTURE (Final [**2196-5-3**]): NO GROWTH. __________________________________________________________ [**2196-5-1**] 1:57 pm BLOOD CULTURE Source: Venipuncture #2. **FINAL REPORT [**2196-5-7**]** Blood Culture, Routine (Final [**2196-5-7**]): NO GROWTH. __________________________________________________________ [**2196-5-1**] 1:57 pm BLOOD CULTURE Source: Venipuncture. **FINAL REPORT [**2196-5-7**]** Blood Culture, Routine (Final [**2196-5-7**]): NO GROWTH. __________________________________________________________ [**2196-5-1**] 1:52 pm URINE Source: Catheter. **FINAL REPORT [**2196-5-2**]** URINE CULTURE (Final [**2196-5-2**]): NO GROWTH. __________________________________________________________ [**2196-4-30**] 8:22 am BLOOD CULTURE Source: Venipuncture. **FINAL REPORT [**2196-5-6**]** Blood Culture, Routine (Final [**2196-5-6**]): NO GROWTH. __________________________________________________________ [**2196-4-30**] 4:07 am BLOOD CULTURE Source: Venipuncture. **FINAL REPORT [**2196-5-6**]** Blood Culture, Routine (Final [**2196-5-6**]): NO GROWTH. __________________________________________________________ [**2196-4-29**] 9:46 pm URINE Source: Catheter. **FINAL REPORT [**2196-5-1**]** URINE CULTURE (Final [**2196-5-1**]): NO GROWTH. __________________________________________________________ [**2196-4-29**] 9:50 pm BLOOD CULTURE Source: Venipuncture. **FINAL REPORT [**2196-5-5**]** Blood Culture, Routine (Final [**2196-5-5**]): NO GROWTH. __________________________________________________________ [**2196-4-29**] 9:34 am BLOOD CULTURE Source: Venipuncture. **FINAL REPORT [**2196-5-5**]** Blood Culture, Routine (Final [**2196-5-5**]): NO GROWTH. __________________________________________________________ [**2196-4-29**] 1:41 am BLOOD CULTURE Source: Venipuncture. **FINAL REPORT [**2196-5-5**]** Blood Culture, Routine (Final [**2196-5-5**]): NO GROWTH. __________________________________________________________ [**2196-4-29**] 1:41 am MRSA SCREEN Source: Nasal swab. **FINAL REPORT [**2196-5-1**]** MRSA SCREEN (Final [**2196-5-1**]): No MRSA isolated. STUDIES: [**2196-5-1**] CXR Feeding tube tip is in the distal stomach. There is obscuration of the left hemidiaphragm in the retrocardiac region consistent with volume loss/infiltrate. The remainder of the lungs are clear. Single dual-lead cardiac pacemaker is again visualized. DISCHARGE LABS [**2196-5-7**] 06:50AM BLOOD WBC-6.0 RBC-2.69* Hgb-8.5* Hct-26.0* MCV-97 MCH-31.8 MCHC-32.8 RDW-13.7 Plt Ct-587* [**2196-5-7**] 06:50AM BLOOD Glucose-120* UreaN-5* Creat-0.7 Na-142 K-4.7 Cl-108 HCO3-27 AnGap-12 [**2196-5-7**] 06:50AM BLOOD Calcium-9.2 Phos-5.1* Mg-1.8 Brief Hospital Course: Mr [**Known lastname **] is a 52M with h/o ETOH abuse, pancreatitis, CAD who presented to [**Hospital3 417**] hospital with acute pancreatitis on [**4-21**] c/b ETOH withdrawal with [**Hospital 90022**] transferred to the [**Hospital1 18**] MICU for further management of pancreatitis and delirium who has been managed conservatively. ACUTE CARE # Acute Pancreatitis Patient with h/o pancreatitis likely secondary to ETOH abuse (TG 133). There was concern for pancreatic necrosis at OSH, however review of imaging here showed acute pancreatitis but no etiology of necrosis. Upon transfer from OSH, he was initially febrile with a mild leukocytosis, and this was attributed to possible cytokine release from pancreatitis. He was managed at OSH and at [**Hospital1 18**] with IVF, NPO and pain control, received tube feeds, this was subsequently stopped and Dobhoff was discontinued. He was then trialed on clear diet but had recurrence of pain, he was again NPO with IV dilaudid pain medications, and then diet was advanced and he was transitioned to PO dilaudid without any worsening of pain. He was discharged on BRAT diet with very cautious advancement. # CDIFF colitis - tested positive at OSH and given IV flagyl, but was started on PO vanc on [**5-1**] for 14 day course. At time of discharge, he was having formed stools. # ETOH abuse/delirium tremens: Last drink over 2 weeks ago. Patient's course complicated by delirium tremens, he was started on Precedex and Lorazepam gtt at the OSH, this was tapered off and discontinued with radical improvement in mental status, which could indicated that benzo intoxication was a large contributor to his delirium. No signs of alcohol withdrawal. He was started on thiamine, MVI, folic acid. Social work was consulted and he was felt to be pre-contemplative regarding cessation of alcohol. # Gout: R podogra, possibly some left foot metatarsal pain. Improved with treatment with Indomethacin 50mg TID for now and also Omeprazole to decrease risk of GIB (not preventative). At time of discharge, he had mild pain at R podogra but no pain on left foot. # Anemia: Likely secondary to ETOH abuse. Mildly elevated LDH but haptoglobin is elevated, making hemolysis unlikely. OSH labs showed low iron, high ferritin (consistent with anemia of chronic disease). No evidence of bleeding. # Transaminitis-resolved, but initially was mild and consistent with alcohol-related liver disease. # fungal infections: The patient endorsed crural candial infection and was treated with miconazole powder; he also had oral candidiasis and was treated with nystatin s/s TRANSITIONS OF CARE # Communication: wife, HCP [**Name (NI) **] (cell) [**Telephone/Fax (1) 90023**]; (home) [**Telephone/Fax (1) 90024**] # Code: Full (confirmed with wife in MICU) # ISSUES TO DISCUSS AT FOLLOW UP: - Consider ASA - Outpatient EGD recommended # PENDING STUDIES AT TIME OF DISCHARGE: - none Medications on Admission: Home Medications: - Omeprazole 20 dialy - Percocet 5/325 1-2 tabs Q six hours prn - flexeril 15mg po dilay - tramadol 50mg po q six hours prn - citalopram 20mg po daily -indomethacin 25mg po q8hrs prn -tricor 145mg po daily Medications on Transfer - Acetaminophen - Heparin 5000U Sq q8hours - Hydromorphone 1mg IV Q 2hours prn - Ativan 1mg IV q 2hours prn - Lorazepam 1mg IV q 8hrs - Metoprolol 2.5mg IV Q6hrs - ondansetron 4mg iv 8 Discharge Medications: 1. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*30 Tablet(s)* Refills:*0* 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Tricor 145 mg Tablet Sig: One (1) Tablet PO once a day. 5. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 6 days. Disp:*24 Capsule(s)* Refills:*0* 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO once a day as needed for constipation. Disp:*30 Capsule(s)* Refills:*0* 7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. quetiapine 25 mg Tablet Sig: 1-2 Tablets PO twice a day: One pill in the morning and 2 pills in the evening. Disp:*90 Tablet(s)* Refills:*0* 11. indomethacin 25 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day) as needed for gout. Disp:*30 Capsule(s)* Refills:*0* 12. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed for itch in groin. Disp:*1 container* Refills:*0* 13. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every [**3-4**] hours as needed for pain: Do not drive or drink alcohol while taking this medication. Do not exceed the recommended dose. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Alcoholic Pancreatitis Alcohol withdrawal Gout clostridium difficile colitis Secondary Diagnosis: hypertension hyperlipidemia coronary artery disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr [**Known lastname **], You were admitted for pancreatitis, which was likely due to alcohol. Your hospital course was complicated by withdrawal from alcohol and gout, both of which have improved. You should eat a very conservative diet, and avoid alcohol above all else. We recommend for you to eat a BRAT diet, which stands for banana, rice, applesauce and toast. You must quit drinking alcohol. You have expressed your desire to engage with AA, and we highly recommend that you follow through with your intention to do this. Please note the following changes to your medications: - STOP percocet - STOP Flexeril - STOP tramadol - START dilaudid for pain, discuss decreasing the dose with your PCP. [**Name Initial (NameIs) **] START senna and colace as a bowel regimen while you are taking dilaudid - START folic acid - START thiamine - START multivitamin - START vancomycin for 6 more days - START miconazole powder for the itch in your groin as needed - START indomethacin for gout, stop when no longer needed. Do not exceed 50mg three times per day. - START seroquel one dose in the am and two doses in the pm. Please be sure to follow up with your primary care physician. [**Name10 (NameIs) **] recommend that you get an outpatient EGD. Please discuss this recommendation with your PCP. Followup Instructions: Name:[**Doctor Last Name **] [**Location (un) 90025**],MD Specialty: Primary Care Address: 1350 [**Location (un) **] STEET, [**Apartment Address(1) **], [**Hospital1 **],[**Numeric Identifier 13435**] Phone: [**Telephone/Fax (1) 27360**] When: [**Last Name (LF) 2974**], [**5-13**] at 2:30pm Department: CARDIAC SERVICES When: WEDNESDAY [**2196-5-18**] at 1 PM With: DEVICE CLINIC [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: WEDNESDAY [**2196-5-18**] at 1:40 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "96.6" ]

icd9pcs

[ [ [] ] ]

13972, 13978

9008, 11821

323, 330

14192, 14192

4333, 8985

15670, 16549

2989, 3034

12409, 13949

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264, 285

358, 2459

14117, 14171

14018, 14096

14207, 14319

2481, 2730

2746, 2973

52,001

189,007

26203

Discharge summary

report

Admission Date: [**2182-8-20**] Discharge Date: [**2182-8-31**] Date of Birth: [**2134-1-6**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 20224**] Chief Complaint: intubated post-op Major Surgical or Invasive Procedure: Right hip total replacement revision [**8-23**] History of Present Illness: Mr. [**Known lastname **] is a 48 year-old man who is being transferred to the [**Hospital Unit Name 153**] for monitoring after hip replacement surgery and hardware removal complicated by significant blood loss. The patient initially injured his hip after falling from a roof in [**2178**]. He suffered a right hip fracture at the time that was repaired with an IM nail. Recently, he developed R groin and hip pain, found to be due to AVN of the femoral head. Today he underwent a prolonged procedure involving removal of the IM nail and associated hardware followed by bipolar hip replacement. The procedure took over four hours. Pt had approximately 3L of blood loss. He received 1750cc of cell [**Doctor Last Name 10105**] blood in the OR, 2 units of pRBC, and 6L of colloid. He did require some neosynephrine during the procedure which was weaned prior to transfer. Past Medical History: s/p R femur fracture with IM nailing in '[**78**] Hypertension (not on medication) Social History: Smokes 2 packs per day. Drinks 6 beers per day. Family History: Denies. Physical Exam: General: arousable, in no acute distress, AOx2 HEENT: Sclera anicteric, MMM Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi. Exam limited patient sedated and restrained. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel present, no rebound tenderness or guarding, no organomegaly Ext: R hip with dressing in place, bilateral 1+ pedal pulses, bilateral LE TEDS stockings, abductor pillow in place Neurologic: not assessed Pertinent Results: [**2182-8-29**] 04:24AM BLOOD WBC-6.5 RBC-2.85* Hgb-9.2* Hct-28.1* MCV-99* MCH-32.2* MCHC-32.7 RDW-16.5* Plt Ct-96* [**2182-8-28**] 03:41PM BLOOD WBC-6.9 RBC-2.81* Hgb-9.1* Hct-27.9* MCV-99* MCH-32.4* MCHC-32.6 RDW-15.9* Plt Ct-99*# [**2182-8-27**] 04:09AM BLOOD PT-13.9* PTT-26.6 INR(PT)-1.2* [**2182-8-29**] 04:24AM BLOOD Glucose-143* UreaN-21* Creat-0.8 Na-142 K-3.5 Cl-109* HCO3-28 AnGap-9 [**2182-8-28**] 03:41PM BLOOD Glucose-115* UreaN-21* Creat-0.9 Na-143 K-4.0 Cl-110* HCO3-27 AnGap-10 [**2182-8-29**] 04:24AM BLOOD Calcium-8.1* Phos-3.4 Mg-2.0 [**2182-8-28**] 03:41PM BLOOD Calcium-8.0* Phos-2.7 Mg-2.2 [**2182-8-26**] 11:46AM URINE Color-Yellow Appear-SlHazy Sp [**Last Name (un) **]-1.010 [**2182-8-26**] 11:46AM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-5.0 Leuks-NEG [**2182-8-26**] 11:46AM URINE RBC-254* WBC-0 Bacteri-MOD Yeast-NONE Epi-0 [**2182-8-26**] 11:46AM URINE CastHy-4* [**2182-8-26**] 08:43PM URINE Osmolal-678 [**2182-8-21**] 2:32 am SPUTUM Source: Endotracheal. **FINAL REPORT [**2182-8-25**]** GRAM STAIN (Final [**2182-8-21**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). RESPIRATORY CULTURE (Final [**2182-8-25**]): SPARSE GROWTH OROPHARYNGEAL FLORA. HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE POSITIVE. HEAVY GROWTH BETA-LACTAMASE POSITIVE: RESISTANT TO AMPICILLIN. STREPTOCOCCUS PNEUMONIAE. MODERATE GROWTH. Note: For treatment of meningitis, penicillin G MIC breakpoints are <=0.06 ug/ml (S) and >=0.12 ug/ml (R) Note: For treatment of meningitis, ceftriaxone MIC breakpoints are <=0.5 ug/ml (S), 1.0 ug/ml (I), and >=2.0 ug/ml (R) For treatment with oral penicillin, the MIC break points are <=0.06 ug/ml (S), 0.12-1.0 (I) and >=2 ug/ml (R). SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STREPTOCOCCUS PNEUMONIAE | CEFTRIAXONE----------- 0.12 S ERYTHROMYCIN---------- =>1 R LEVOFLOXACIN---------- 1 S PENICILLIN G---------- 0.25 S TETRACYCLINE---------- =>16 R TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S CXR [**2182-8-30**]: Increased airspace opacification in the left lower lobe suggests early pneumonia. Bilateral lower lobe atelectasis and cardiomegaly is unchanged. CT C spine [**2182-8-30**]: No fracture or malalignment. Mild diffuse degenerative changes. Right femur/pelvis film [**2182-8-30**]: FINDINGS: There is a right revision hip prosthesis. No periprosthetic fractures are seen. There is again seen a prominent butterfly fragment within the superomedial soft tissues. There are several broken screw fragments in the right distal femoral diametaphysis. Joint space narrowing at the medial compartment of the knee is seen. There is a knee joint effusion. CT Head [**2182-8-30**]: No acute intracranial process. Partial opacification in mastoid air cells, which is present on the prior CT of [**2179-1-28**]. Brief Hospital Course: This is a 48 yo man with alcohol dependance who was presented for elective right total hip replacement revision. His surgery was long and he was not able to be immediately exubated due to left lower lobe collapse. He also developed left lower lobe pneumonia (H.flu) treated with 8 days of iv unasyn. He was able to be extubated [**8-22**] but then developed acute alcholol withdrawl, requiring valium and haldol. He then became delerious, likely due to hypernatremia, icu delerium, pain, infection, and difficulty clearing sedating medications with some component of alcoholic hepatitis. This delayed his ability to participate with PT. He required seroquel to help his delerium clear. He was lucid on [**2182-8-31**], and insisted on discharge. He was evaluated by PT and OT and felt unsafe to go home. Despite this he was able to clearly state understanding of risks and benefits of going home and signed out against medical advice. His hospital course was complicated by hypertension, which was not known prior to admission. He was started on metoprolol and clonidine for this and discharged on metoprolol. He was noted to have atrial fibrillation with RVR while acutely ill with pneumonia and intubated, this converted and he remained in sinus. Given CHADS score he was not recommended to be on anticoagulation given acute surgery but should discuss this as an outpatient with his pcp. [**Name10 (NameIs) **] was treated with thiamine, folate, multivitamin given his alcohol dependance. He was arranged to have home lovenox for DVT prophylaxis, and VNA with PT. He was noted to have anemia and thrombocytopmenia, likely due to acute blood loss perioperatively with poor marrow response due to alcoholic suppression and consumption of platelets perioperatively that was improving on discharge. He should have repeat CXR with his PCP [**Name Initial (PRE) 176**] 1 month to ensure resolution of his pneumonia. Medications on Admission: Percocet 5-325mg 1-2 tabs q6 prn Discharge Medications: 1. Enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg Subcutaneous Q12H (every 12 hours) for 14 days. Disp:*28 mg* Refills:*0* 2. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Therapeutic Multivitamin Liquid Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital6 486**] Discharge Diagnosis: Right hip replacement revision Hypertension Alcohol withdrawl Alcoholic hepatits Delerium Pneumonia Discharge Condition: Unsteady with ambulation independently, but able to state clearly risk and benefits of further treatment, unwilling to accept further inpatient care. Discharge Instructions: You were admitted for right hip hardware revision. Your hospitalization was complicated by left lower lobe collapse, pneumonia, delerium, alcohol withdrawl and hypertension. You have decided to leave the hopsital against medical advice. You should follow up with Dr. [**Last Name (STitle) 64940**] [**Name (STitle) 5322**] by [**2182-9-6**], please call [**Telephone/Fax (1) 1228**]. At this appointment you will have your sutures removed. You should keep your wound covered with dry guaze, changed daily and keep this dry with showering. Once the dressing is without discharge for 2 days you may get the wound wet. No soaking in tubs or hot tubs or pools for 3 weeks. It is vitally important that you continue with lovenox twice daily to prevent blood clots. You were started on a medication, metoprolol, to help with high blood pressure. It is recommended you follow up with Dr. [**Last Name (STitle) 2450**] for this. You are strongly encouraged to abstain from alcohol and attend alcoholics anonymous. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 64940**] [**Name (STitle) 5322**] on Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2450**], within [**2-8**] weeks: [**Telephone/Fax (1) 250**]. Provider: [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 1652**] Date/Time:[**2182-9-9**] 4:30

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icd9cm

[ [ [] ] ]

[ "96.05", "33.24", "96.6", "78.65", "81.52", "96.71" ]

icd9pcs

[ [ [] ] ]

8123, 8173

5445, 7361

333, 383

8317, 8469

2082, 5422

9526, 9916

1480, 1489

7444, 8100

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7387, 7421

8493, 9503

1504, 2063

276, 295

411, 1292

1314, 1398

1414, 1464

1,351

152,398

21575

Discharge summary

report

Admission Date: [**2188-5-3**] Discharge Date: [**2188-5-9**] Date of Birth: [**2113-2-18**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 348**] Chief Complaint: Fevers, hypotension at HD Major Surgical or Invasive Procedure: Placement of a tunnelled dialysis catheter. History of Present Illness: The pt. is a 75 year-old male with ESRD on HD, CAD s/p MI and vfib arrest [**2183**] s/p AICD, CHF (EF 20%), atrial fibrillation, HTN who presented from HD in [**Location (un) 2498**] with a fever to 101.6F and hypotension. Mr. [**Known lastname 18575**] reports feeling in his usual state of health until the evening PTA, when he [**Last Name (un) 4996**] to have a headache and difficulty sleeping, though denies any fevers, chills, night sweats, or dyspnea. Shortly after arrival to his HD session on the day of admission, he began to have rigors, chills, and was noted to be diaphoretic and cyanotic. He was given vancomycin 1g and 100mg gentamicin, and referred to the [**Hospital1 18**] ED. Of note, Mr. [**Known lastname 18575**] also had a much abbreviated HD session, reportedly secondary to difficulty with his L tunneled HD line. He denies noticing any recent discharge from his line, or any tenderness around the line. On ED arrival, T=100.5, P96, BP 73/36, RR 20 sat 96%. BP increased with a saline bolus (unclear from [**Name (NI) **] records how much fluid he received, though appears to be 250cc fluid) as well as empiric levofloxacin 500mg. BP increased to 90-100's, and lactate declined from 2.5 -> 1.6. However, he then became more hypotensive to sbp 70's, looked more lethargic, ICU evaluation called. He denied any recent sick contacts, cough, sore throat, abdominal pain, diarrhea, dysuria, or new rashes. Just feels generalized fatigue. He spent one evening in the MICU where his blood pressure was stabilized with NS boluses. He defervesced. He received one dose of vancomycin when he was discovered to have 4/4 bottles with GPC. His tunnelled catheter was removed by IR today. At the time of transfer, the pt. stated that he felt "great." He offered no complaints. He specifically denied fever, chills, rigors, chest pain, SOB, N/V/D. Denied pain. Past Medical History: 1.HTN 2. Atrial fibrillation- coumadin was recently discontinued secondary to hemoptysis 3. Coronary Artery Disease - cardiac cath [**2187-9-24**] after MI and v.fib arrest: Total occlusion of non-dominant RCA. Severe systolic ventricular dysfunction with reduced cardiac output (has occluded RCA that fills via LCX, but multiple inf wall, inf septal, post HK/AK, ef 20-30%). 4. s/p AICD placement secondary to recent V.Fib arrest 5. Congestive Heart Failure (Ischemic Cardiomyopathy)- EF 20-30%. Echo [**8-26**] akinesis of the inferior septum, inferior free wall, and posterior wall, and moderate-to-severe hypokinesis of the rest of the left ventricle. 6. ESRD-post-obstructive renal failure from his enlarged prostate and likely hypotensive episode during V. fib arrest. 7. Obstructive uropathy, 8. [**Name (NI) 48445**] Pt admitted end of [**9-26**] with hemoptysis. R/o TB, s/p bronchoscopy x 2, s/p negative tap of pleural effusion for w/u of malignancy, s/p normal EGD. Pt was recently taken off of coumadin and now no hemotysis. 9. gastritis with gastric antrum ulcer on EGD [**8-26**] 10. sigmoid diverticulosis 11. Left [**Month/Year (2) 56832**] embolus s/p embolectomy 12. Enlarged prostate (obstructive uropathy) and increased PSA (60) Social History: Pt used to work in the factory of [**State 20475**]. His wife died 3 years ago. He had four children, two whom died in their early adulthood. Quit tobacco few years ago. 120-180 pack year history. EtOH: quit a few years ago. Drinks ~ 1 per week but not in rehab. Drank heavily but could not quantify for me. No IVDU. Family History: No CV, DM, HTN, or cancer in the family. Physical [**State **]: PE T 100 101/58 ---> 70's/60 75 99% 2L Gen: patient appears stated age, found lying flat in bed, appears fatigued, at times taking deep breaths and breathing through pursed lips HEENT: Sclera anicteric, conjunctiva uninjected, PERL, EOMI, MMM, no sores in OP Neck: JVP 7, no LAD, nl ROM , supple Cor: RRR nl S1 S2 II/VI HSM at apex R axilla Chest: bilateral crackles [**11-26**] of the way up. Tunneled HD site with small amt of drainage ([**Doctor Last Name 352**] colored), with erythema surrounding the line exit site for 1-2cm, though no tenderness or induration. Abd: soft, NT/ND, +BS. No HSM appreciated. EXT: no calf tenderness. trace edema. Multiple ecchymoses on his arms. Neuro: MS [**First Name (Titles) **] [**Last Name (Titles) **] other than mild somnelence, CN II-XII in tact with the exception of bilateral hearing loss, UE/LE strength 5+ bilaterally. Pertinent Results: [**2188-5-3**]: CHEST AP: There is stable cardiomegaly. The aorta is unfolded. Mediastinal and hilar contours are stable. Single lead ICD and left IJ Hickman catheters are in unchanged position. There is pulmonary vascular congestion. Diffusely increased interstitial markings are noted. There are no definite pleural effusions. Osseous and soft tissue structures are stable. IMPRESSION: Pulmonary edema. No evidence of pneumonia. [**2188-5-2**] 07:10PM BLOOD WBC-10.2 RBC-4.97# Hgb-15.6# Hct-47.7# MCV-96 MCH-31.5# MCHC-32.7 RDW-17.3* Plt Ct-165 [**2188-5-2**] 07:10PM BLOOD Neuts-90.1* Bands-0 Lymphs-6.4* Monos-3.2 Eos-0.1 Baso-0.2 [**2188-5-2**] 09:05PM BLOOD PT-15.4* PTT-36.6* INR(PT)-1.6 [**2188-5-2**] 07:10PM BLOOD Glucose-144* UreaN-45* Creat-5.2* Na-138 K-3.9 Cl-101 HCO3-19* AnGap-22* [**2188-5-3**] 11:00AM BLOOD ALT-22 AST-22 CK(CPK)-39 AlkPhos-79 Amylase-32 TotBili-0.8 [**2188-5-3**] 11:00AM BLOOD cTropnT-0.16* [**2188-5-2**] 09:18PM BLOOD Calcium-9.0 Phos-4.8* Mg-1.7 ABG: [**2188-5-5**] 01:15PM BLOOD Type-ART pO2-76* pCO2-30* pH-7.42 calHCO3-20* Base XS--3 TTE ([**2188-5-5**]) 1. The left atrium is mildly dilated. The left atrium is elongated. The right atrium is moderately dilated. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis. Overall left ventricular systolic function is severely depressed. [Intrinsic left ventricular systolic function may be more depressed given the severity of valvular regurgitation.] Resting regional wall motion abnormalities include inferior, inferolateral and septal akinesis. The remaining left ventricular segments are hypokinetic. 3.Right ventricular chamber size is normal. There is mild global right ventricular free wall hypokinesis. 4.The ascending aorta is mildly dilated. The aortic arch is mildly dilated. 5.The aortic valve leaflets (3) are mildly thickened. No AI seen. No mass seen on aortic valve [**Last Name (un) **]. 6. The mitral valve leaflets are normal. Moderate to severe (3+) mitral regurgitation is seen. No mass seen on the mitral valve. 7.There is mild pulmonary artery systolic hypertension. 7.There is no pericardial effusion. 8. There ia an echogenic density in the right ventricle consistent with a wire (AICD). Impression: No echocardiographic evidence of endocarditis. No change from the previous study of [**2187-12-5**]. Brief Hospital Course: 1. MRSA bacteremia: The source was felt to be due to a tunnelled line infection given the temporal relation of the symptoms to use of the dialysis line. Cultures from hemodialysis center and the first set of cultures at the [**Hospital1 18**] grew out MRSA. The dialysis line was removed by the IR service on hospital day 2. He was given vancomycin, dosed by level. He defervesced over the course of the first hospital day. A TTE was performed on hospital day three and was not suggestive of endocarditis. There was no murmur on [**Hospital1 **]. Surveillance cultures remained negative. He was discharged with the plan that he was to receive an additional 2 week course of vancomycin to be dosed by level at hemodialysis (to complete a three week course). 2. ESRD: The hemodialysis catheter was removed on hospital day 2. He was followed by the renal service who felt that the pt. did not require dialysis on an urgent basis and that it would be acceptable to wait until which time a new permanent dialysis line could be placed. His creatinine remained stable. He was started on sevelamer for hyperphosphatemia. A new tunnelled line was placed by the IR service on hospital day six, after which he underwent hemodialysis. 3. CHF: The pt's ACE inhibitor was held on admission due to hypotension. On further questioning, it was discovered that the pt. had not been taking this medication "for some time" because his understanding was that this medication was only for high blood pressure which he does not have. The use of ACE inhibitors in CHF was discussed with the pt. Lisinopril was restarted on hospital day four. 4. PAF: The pt. was maintained on his usual dose of digoxin. Metoprolol was originally held in the context of hypotension. As above, the pt. had not been taking the metoprolol "for some time" as he believed that this was for hypertension and he felt his blood pressure was too low (usually 100-110 systolic). After discussion with the pt, he was restarted on metoprolol for combination of atrial fibrillation, CAD and CHF. 5. BPH: The pt was maintained on tamsulosin. Medications on Admission: Digoxin 125mcg po qSu, Tu, TH Calcium Carbonate 500 mg TID W/MEALS Atorvastatin 40 mg po daily Protonix 40mg po daily lisinopril 5mg po BID, pt had not been taking metoprolol 12.5mg po bid, pt. had not been taking senna 1 tab [**Hospital1 **] Tamsulosin 0.4mg po daily colace 100mg po bid nephrocaps 1cap QDay Discharge Medications: 1. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*90 Tablet, Chewable(s)* Refills:*2* 2. Atorvastatin Calcium 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 6. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 7. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). 8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO qTues, Thurs, Sat, Sun: To be taken on non-dialysis days. Disp:*30 Tablet(s)* Refills:*2* 9. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 10. Vancomycin 1,000 mg Recon Soln Sig: One (1) Intravenous to be dosed by level at hemodialysis for 2 weeks. Discharge Disposition: Home Discharge Diagnosis: -MRSA bacteremia from tunnelled dialysis catheter infection -end-stage renal disease on hemodialysis -paroxysmal atrial fibrillation -congestive heart failure with an EF of 20% -benign prostatic hyperplasia Discharge Condition: Afebrile, stable. Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Please continue to take all medications as prescribed. Please attend all follow-up appointments, including hemodialysis appointments. If you experience recurrent fever, chills or other concerning symptoms, please call your primary care doctor or come to the emergency department for evaluation. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Where: LM [**Hospital Unit Name 3126**] CENTER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2188-6-5**] 10:40 Please follow-up with your primary care doctor within the next 7-10 days.

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26172

Discharge summary

report

Admission Date: [**2150-2-7**] Discharge Date: [**2150-3-18**] Date of Birth: [**2108-5-26**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1055**] Chief Complaint: variceal bleed Major Surgical or Invasive Procedure: [**Last Name (un) **] probe insertion, twice TIPS placement, with revision Intubation History of Present Illness: HPI: 41 yo with etoh cirrhosis here after 3 days of progressive nausea and womiting bright red blood. In total about 500cc and finally presented to [**Hospital3 3583**] with the bleeding, reportedly found to have a Hct of 19 and hypotensive, was given 7 units of PRBC, FFP and Vitamin K. There he had an EGD which showed large esophageal varices with recent signs of bleeding and gastric varices of which the esophageal verix was sclerosed. Started on octreotide and prononix drip and Hct prior to transfer was 29. . On arrival here feels better, no longer with nausea, no recent vomiting, or any pain. Feels better after transfusion. Last vomitied 3 am this am. Last BM an hour ago still dark, marroon colored stool. He denies any hx of GI bleed in past, last drink [**2150-1-23**] when detoxed from etoh, had previously drank 2pints of Vodka and none currently. . ROS: very hungry and thirsty, over last yr has had about 40lb unintentional weight loss, noted scleral icterus over last 1.5 yrs, and SOB prior to ED visit otherwise no other complaints. Past Medical History: etoh cirrhosis, per pt hepatitis w/u as outpt was negative etoh abuse-- recent detox [**2150-1-23**] DM-- on metformin/glucotrol HTN-- on lisinopril depression-- on GERD Social History: married, works as a car salesman, no hx of drug/IV drug abuse, secually active only with wife, previous 2pints/vodka/day, 1ppd x12yrs Family History: +hx of DM and heart disease, no liver disease Physical Exam: PE: VS: 139/69 P 79 Rr24 Sat 97%RA GEN aao, nad HEENt +Scleral icterus, dry MM CHEST CTAB no wheezes, rales CV RRR no murmurs ABD soft NT/ND, +BS, no ascites, +guiaic positive maroon colored stool EXT no edema or asterixis Pertinent Results: [**2150-2-7**] 09:30PM URINE MUCOUS-RARE [**2150-2-7**] 09:30PM URINE RBC-2 WBC-0 BACTERIA-FEW YEAST-NONE EPI-<1 [**2150-2-7**] 09:30PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2150-2-7**] 09:30PM URINE COLOR-LtAmb APPEAR-Clear SP [**Last Name (un) 155**]-1.015 [**2150-2-7**] 09:30PM PLT COUNT-110* [**2150-2-7**] 09:30PM PT-15.0* PTT-28.4 INR(PT)-1.5 [**2150-2-7**] 09:30PM WBC-10.4 RBC-2.95* HGB-9.8* HCT-27.4* MCV-93 MCH-33.2* MCHC-35.7* RDW-18.6* [**2150-2-7**] 09:30PM HCV Ab-NEGATIVE [**2150-2-7**] 09:30PM IgG-799 [**2150-2-7**] 09:30PM AFP-3.4 [**2150-2-7**] 09:30PM HBsAg-NEGATIVE HBs Ab-POSITIVE HBc Ab-NEGATIVE HAV Ab-NEGATIVE [**2150-2-7**] 09:30PM ALBUMIN-2.6* CALCIUM-7.2* PHOSPHATE-2.9 MAGNESIUM-1.2* [**2150-2-7**] 09:30PM LIPASE-27 [**2150-2-7**] 09:30PM ALT(SGPT)-41* AST(SGOT)-80* LD(LDH)-198 ALK PHOS-77 AMYLASE-30 TOT BILI-3.2* [**2150-2-7**] 09:30PM GLUCOSE-166* UREA N-21* CREAT-0.7 SODIUM-145 POTASSIUM-3.8 CHLORIDE-114* TOTAL CO2-22 ANION GAP-13 . Abdominal US [**2150-2-9**] 1. Reversal of normal portal flow. No evidence of portal thrombus. 2. Echogenic, small shrunken liver, with ascites. Focal liver lesions in this echogenic liver cannot be excluded on the basis of this study. . TIPS placement [**2150-2-9**] 1. Transjugular intrahepatic portal systemic shunt placement. However,little flow through the TIPS after the procedure. Most flow still through the significantly dilated varices and spontaneous splenorenal renal shunt. The sheath was left in situ for further evaluation at the next day. 2. Unsuccessful attempt to sclerose varices arising from the portal and splenic veins with absolute alcohol. 3. Successful ultrasonographic guidance paracentesis with withdrawal of 3000cc of ascites. . TIPS revision [**2150-2-10**] 1. Successful reversion of transjugular intrahepatic portal systemic shunt with reduction of a pressure gradient between the portal vein and the right atrium. 2. Successful embolization of coronary vein varix. . Abd US [**2150-2-11**] Patent TIP shunt with velocities ranging from 30-130 cm/sec. There is a focal area with lack of wall-to-wall flow in the mid TIPS, which should be reevaluated by repeat study tomorrow. If this is persistent, possibility of a clot within the TIP shunt must be considered and hence short- term reevaluation is necessary. A large coarse echogenic liver without focal lesions. Ascites. Gallbladder sludge. . Liver US [**2150-2-13**] 1. Trace amount of perihepatic ascites, insufficient in size to safely mark a spot for paracentesis. 2. Large coarse echogenic liver, without focal lesions . Chest XR [**2150-2-16**]: There is an endotracheal tube, whose distal tip is at the level of the clavicles. There is a right-sided central venous catheter with the distal tip in the SVC. There has been interval placement of [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] tube with the distal tip projecting over the pylorus. The inflated balloon of the tube is in the fundus of the stomach. There is a stent seen within the right upper quadrant consistent with the TIPS. There is complete opacification of the left lung with volume loss in this region. This may be secondary to large pleural effusion versus consolidation. The lateral half of the right chest has been excluded from the study. There is vascular congestion in the visualized portions of the right lung.TIPS revision [**2150-2-16**] Embolization of varices arising from the splenic vein using a total of 38 coils (the varices rise from the coronary vein and two branches of the splenic vein). Balloon dilation of the TIPS with a 10-mm angioplasty balloon. Significantly increased flow through the TIPS and decreased variceal flow. . Abd US [**2150-2-18**] Patent TIPS with velocities ranging from 52-206 cm per second. Note is made of interval increase in velocity within the distal aspect of the TIPS. Continued short term surveillance may be appropriate. . Chest XR [**2-19**]/-6 1. Interval development of right upper lobe collapse. 2. Stable-appearing left lower lobe atelectasis and collapse. 3. [**Last Name (un) **] tube seen within the stomach. The balloon is not identified. . CT abdomen: [**2149-2-26**] 1. No evidence of intra-abdominal bowel pathology. 2. Decompensated liver failure with portal hypertension and ascites. Patient is status post TIPS placement and variceal coiling. 3. Splenorenal shunt. 4. Air in bladder reflects an indwelling catheter. . ECHO [**2150-3-3**] Trace aortic regurgitation with normal valve morphology. Preserved global and regional biventricular systolic function. . Chest XR [**2150-3-7**] There is a left-sided central venous catheter with distal tip in the proximal SVC. This is unchanged in position. There is a feeding tube identified with its tip below the gastroesophageal junction. The cardiac silhouette is enlarged but unchanged. There are low lung volumes secondary to poor inspiratory effort. There is again seen bilateral pleural effusions and a left retrocardiac opacity unchanged. Pulmonary vascular markings are prominent consistent with mild-to-moderate edema which is also unchanged. . Left upper extermity US [**2150-3-12**] There is no evidence of DVT. . Chest XR [**2150-3-12**] Improvement in appearance of the right lung likely related to partial resolution of pulmonary edema. Cardiomegaly is still present and there is still evidence of CHF. Unchanged retrocardiac opacity consistent with atelectasis. Brief Hospital Course: 41 yo man with DM, HTN, Alcoholic cirrhosis with new variceal bleed admitted on [**2-7**]. . #. GI bleed: In the MICU the pt continued to have hematemesis despite octreotide and protonix iv but an initial EGD did not show any active bleed therefore further sclerosing was deferred. Due to extend of the both esophageal and gastric varices an urgent transjugular intrahepatic portal systemic shunt was placed on the [**2150-2-9**]. Which intially did not show sufficient flow but was then successfully revised on the [**2150-3-13**] with reduction of a pressure gradient between the portal vein and the right atrium. Also, successful embolization of coronary vein varix. Then reocclussion and revision on the [**2150-2-16**]. The pt continued to have hematemesis and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 10045**] tube was inserted on the [**2-12**] and subsequently removed on the [**2-13**] b/o stabilization. Octreotide was discontinued. A repeat EGD on the [**2-16**] showed varices at the middle third of the esophagus and lower third of the esophagus as well as varices at the fundus. Otherwise normal egd to stomach antrum. It was determined that there was still high risk for rebleeding. Because of rebleeding that day another EGD was done and 2 bands were placed without cessation of bleeding. Octreotide was restarted. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 10045**] probe was reinserted and a revision of the TIPS was performed on the same day. A coiling procedure to embolize bleeding vessels was performed. THe pt stabilized and the [**Last Name (un) 10045**] was removed on the [**2150-2-20**]. Octreotide was continued. The pt had a mild oozing of blood on the [**2150-2-21**] but was stable since then. Octerotide was discontinued on the [**2150-2-25**]. The pt did not have any evidence of bleeding since the [**2150-2-22**]. The pt received a total of 40 U of Fresh frozen plasma, 24 U of PRBC in addition to the 7U received at the OSH and 9U of platelets throughout his stay in the ICU. Nadolol was started on the [**2150-3-7**]. The pt continued to be trace guaiac positive, but did not have any more signs of gross bleeding. The hematocrit continued to trend down slowly, which was attributed rather to hemolysis in the context of liver disease than to low grade GI bleed. The pt has a very high risk of rebleeding given the extend of his disease. The pt??????s family was made aware of severity of pt's condition. The pt has not required any blood transfusions since [**2150-3-8**] and has maintained a stable hematocrit since then. . # BP/Hypotension: The patient is hypertensive at baseline. He was found to have episodes of hypotension requiring Levophed in the context of severe blood loss and later sepsis. Adrenal insufficiency along with hepatic failure/anasarca/ hypoalbuminism were thought to be contributing in the etiology. There was no evidence of a cardiac event. Patient cortisol level on [**2-28**] am was only 13.7 and patient underwent high dose steroid course for 5 days (hydrocortisone/ fludrocortisone) that allowed his BP to return to normal and he was weaned off levophed. GIB and sepsis was treated as above and the pt??????s BP stabilized. Patient while in ICU was maintained at a goal CVP of 9, with a BP goal 90-130. With resolution of his GIB and sepsis, patient became more hypertensive despite diuresis. His hypertension was managed with captopril and amlodipine. Nadolol was added also for prevention of variceal bleed. Hypertensive medications were titrated up for further for optimal control. . # ID ?????? While in the MICU the pt also suffered from a ventilator associated MRSA pneumonia which was treated with Vancomycin for two weeks. Subsequently he developed a central line related VRE infection resulting into sepsis, successfully treated with a course of Linezolid of seven days after removal of the line. During the sepsis pt intermittently required Levophed for hypotension as above. Pt was also treated with Piperacillin and Tazobactam for suspected SBP although a paracentesis was never performed due to the persistently small amount of ascites after the initial drainage during the TIPS procedure. As the pt became afebrile and no evidence of SBP was found he was continued on prophylactic Ciprofloxacin which was later stopped. Echocardiogram performed on [**3-3**] did not show any evidence of endocarditis. . #. Alcoholic cirrhosis: Patient with significant disease and varices, and very poor prognosis. Hepatitis serologies were negative. Not a transplant candidate per Hepatology service, but needs to be reevaluated. SW consult was obtained for family coping with poor prognosis. Patient with uptrending bilirubin and INR throughout the inital MICU course most likely in the context of GIB and sepsis. As the overwhole status improved and the GIB and sepsis resolved the total bilirubin stabilized and then slowly trended down. The pt was severly encephalopathic in the context of the liver failure especially after the placement of the TIPS. He was started on Lactulose to achieve [**5-20**] BM a day and subsequently was also started in Rifaximin. Vit K was given without substantial effect on the pt??????s coagulation factors. A total of 40 U of Fresh frozen plasma and 9U of platelets were given throughout the active episodes of GIB. The pt was initially given TPN and was subsequently switched to tube feedings through Doboff. With improving mental status the pt was switched to oral intake and the Doboff was removed. . # Hypoxia/Respirator Dependance ?????? Prolonged intubation period even after resolution of GIB and line-related sepsis was attributed to pneumonia, atelectasis and fluid overload. Patient was gradually diuresed with lasix prn and lasix gtt. He was treated with Vanco/Linezolid as above. Due to long intubation period (>2 weeks) and his persistent requirement for PEEP, patient underwent evaluation for Tracheostomy placement by IP. However he was able to tolerate a trial of CPAP well and subsequently was successfully extubated on [**3-6**] only requiring intermittent CPAP aferwards. Patient continued to require oxygen support that was gradually weaned off along with further diuresis and improvement in his pneumonia and atelectasis. . #. DM: Patient was on insulin drip while intubated. He was converted to a sliding scale on [**3-9**] with NPH 30 units in the morning and 10 units at night and was then further adjusted for tight glucose control. Given his stable finger sticks, oral agents can be restarted soon after discharge. . # ARF: Patient had intermittent elevated Cr during hospitalization. DDx included hepatorenal vs prerenal. FeNa<1%, with UNa low of 14. Patient was started on octreotide and midodrine with mild improvement of renal function. Patient tolerated diuresis well with good UO, his max Cr was 1.4. Midodrine was d/c along with levophed as patient renal function improved. ARF subsequently resolved. . # # L arm inabilitiy to elevate: most likely axillar neuropathy from fall prior to presentation. No further diagnostic tests necessary at this point. Will need aggressive PT. The pt will follow up with neurology clinic as an outpatient. Medications on Admission: pervacid metoformin glucotrol lisinopril lactulose lexapro Discharge Medications: 1. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed. 2. Zinc Oxide-Cod Liver Oil 40 % Ointment Sig: One (1) Appl Topical PRN (as needed). 3. Artificial Tear Ointment 0.1-0.1 % Ointment Sig: One (1) appl Ophthalmic once a day as needed. 4. Nicotine 14 mg/24 hr Patch 24HR Sig: One (1) patch Transdermal once a day. 5. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Rifaximin 200 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO 2X (TIMES 2). 11. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Nadolol 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 15. Lactulose 10 g/15 mL Solution Sig: Thirty (30) ML PO QID (4 times a day) as needed for titrate to [**4-18**] bowel movements per day. 16. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Thirty (30) Units Subcutaneous qam. 17. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Fifteen (15) Units Subcutaneous qpm. 18. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: One (1) sliding scale Subcutaneous qachs. Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital of [**Location (un) **] & Islands - [**Location (un) 6251**] Discharge Diagnosis: Variceal bleed Respiratory failure Ventilator associated pneumonia Line related sepsis Alcoholic cirrhosis Hypertension Esophageal and gastric varices Diabetes Mellitus Acute renal failure Discharge Condition: Stable, AAOx3, breathing at baseline Discharge Instructions: Please let the nurses or doctors at the [**Name5 (PTitle) **] center know if you experience any lightheadedness, dizziness, nausea, vomiting, blood in your stool or dark stools or any other concerns. . Please take all medications as instructed Followup Instructions: Please follow up with the liver clinic; you have an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2150-4-1**] 1:30pm. Call them at [**Telephone/Fax (1) 56990**] to register. Please follow up with neurology clinic for your left shoulder pain. You have an appointment with Dr. [**Last Name (STitle) 575**] [**Name (STitle) **] on [**2150-4-1**] at 4pm, on the [**Location (un) **] of the [**Hospital Ward Name 23**] Building. Please call them at [**Telephone/Fax (1) 44**] to register. Please follow up with your PCP [**Name Initial (PRE) 176**] 1-2 weeks after you are discharged from rehab.

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icd9cm

[ [ [] ] ]

[ "96.72", "99.15", "54.91", "38.91", "38.93", "00.14", "45.13", "39.79", "42.33", "39.1", "39.49", "96.04", "96.6" ]

icd9pcs

[ [ [] ] ]

16650, 16762

7757, 14985

329, 417

16995, 17034

2167, 7734

17326, 17969

1861, 1908

15095, 16627

16783, 16974

15011, 15072

17058, 17303

1923, 2148

275, 291

445, 1499

1521, 1693

1709, 1845

41,035

102,460

37356

Discharge summary

report

Admission Date: [**2135-2-1**] Discharge Date: [**2135-2-4**] Date of Birth: [**2048-10-7**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1185**] Chief Complaint: hemoptysis Major Surgical or Invasive Procedure: Rigid bronchoscopy. History of Present Illness: Mr. [**Known lastname 1968**] is an 86yo M with PMH of metastatic renal cell carcinoma with metastasis to the right lung, with endobronchial disease, s/p broncheal stenting in [**2133**], with multiple episodes of non-massive hemoptysis, and recent rigid bronchoscopy with balloon dilatation of Bronchus intermedius, who is admitted to the MICU with hemoptysis. . . Two days prior to admission he had worsening of his chronic cough with associated retching and nausea. He felt feverish and noted maximum temperature 98.2 at home. He was seen in [**Location (un) **] [**Last Name (un) 19700**] treated with nebulizer treatments and discharged home. Around midnight following day, he began coughing up blood in teaspoon quantities which he estimates adds up to approximately 3/4-1 cup. He developed dyspnea and returned presented to [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 19700**] hospital. Where vitals were 148/80 79 18 97% RA. HGB/HCT was 13.6/41, INR 1.1. He was given 500cc IVNS and albuterol/atrovent nebs. Non-Con CT chest showed known pulmonary mets apparently unchanged from [**2135-1-4**] thought the final read was not available. He was transferred to [**Hospital1 18**] ED for further management. . In the ED inital vitals were, 97.8 62 138/72 20 97% 2L NC. Labs were notable for Na 130, WBC 3.3, Hgb/Hct 12.5/37, Plts 129, normal coags. CXR showed elevated right hemidiaphragm with minimal mediastinal shift to the right. He was not given any blood transfusions or intervenous fluids. He was seen by IP who recommended bronch with rigid scope and admission to the ICU for close monitoring. Vitals on transfer were P:71 BP:151/65 20 100% 3LNC. . Of note, patient underwent bronchoscopy [**2135-1-17**] with where stenosis of the bronchus intermedius stent was noted and treted with balloon dilation of the right middle segment/bronchus intermedius and tumor ablation with electrocautery of granulation tissue within the stent and in the distal end of the stent. Past Medical History: Oncologic History: - in [**4-/2122**] Mr. [**Known lastname 1968**] had a right-sided kidney lesion found incidentally. He underwent a right nephrectomy at [**Hospital1 84018**]. Pathology noted a 3-cm clear cell lesion, grade I - II, confined to the cortex. Ureteral & vascular margins were free of tumor, no vascular invasion was seen. Right adrenal gland was (-). He was followed serially with CT scans. - in late [**2132**], developed recurrent hemoptysis which prompted ENT evaluation & chest imaging, which showed a compressive mass in the right bronchus. He had a flexible bronchoscopy at [**Hospital1 1562**] complicated by significant bleeding & was transferred to [**Hospital1 18**] [**2133-1-14**]. Chest CT showed a mass encasing the right pulmonary artery & invading the bronchus intermedius. He underwent a rigid bronchoscopy w/ tumor biopsy, debridement, & stent placement [**2133-1-15**]. underwent argon plasma coagulation. - He had brachytherapy at [**Hospital3 2358**]. - on [**2133-5-27**] he had a metal stent placed by IP. - on [**2133-6-8**] started on sunitinib. - on [**2133-6-18**] developed hemoptysis requiring Sutent hold through [**2133-6-23**] & again [**Date range (1) 36573**]. - [**Date range (1) 14706**] Sutent was restarted, completed 1 cycle; but [**2133-7-21**] bloodwork showed low WBC/Plts, drug was again held through [**2133-8-8**]. He returned [**2133-8-25**] & reported scant hemoptysis x 2 days & his Sutent was stopped. He was then on 25mg x14 days of 28 day cycle. - on [**2133-11-25**], saw Dr. [**Last Name (STitle) **] for bronchoscopy which showed stent in good position, no endobronchial lesions were seen. - [**2133-12-29**] with ongoing cough, sputum production. trial of albuterol INH & Pulmonology recommended use of PPI/fluticasone. He was seen again 2 weeks later, w/o improvement in his symptoms. - [**1-9**] Platelets>150 and CT chest showed interval growth of right hilar mass, w/ worse occlusion of the R mainstem bronchus. We then increased Sutent dosing to 37.5mg/day on 2 week on, 2 week off basis. - in follow-up [**2134-2-2**], his cough had improved but plts were low, necessitating hold - on [**2134-2-17**], restarted once plts 98 - follow-up [**2134-3-2**], He was doing well apart from ongoing respiratory symptoms of cough, sputum production & scant hemoptysis/mild epistaxis. His platelets were 109. At that time we discussed possibly resuming Sutent earlier than 2 weeks off therapy if respiratory symptoms persisted. He resumed drug 1 week later & returned [**2134-3-30**]. He did well w/ only scant hemoptysis. He had stopped Flonase due to epistaxis. - on [**2134-4-1**] bronchoscopy w/ Dr. [**Last Name (STitle) **] which showed a large endobronchial lesion in the [**Hospital1 **], friable w/ stent [**03**]% occluded. - on [**2134-5-18**] was doing well apart from scant hemoptysis. platelets were stable at 95. - on [**2134-6-8**], for follow up, doing well apart from 2-3 days of pruritic rash on left sided torso consistent with herpes zoster. We initiated valacyclovir TID for 14 days. He developed pain at the site which continued despite use of Tylenol and was prescribed a lidocaine patch. - On [**2134-7-13**] CT appeared to show overall minimal decrease to affected area and decreased compression of the right main stem bronchus. Stable appearance of the stent within the bronchus intermedius. Notable is interval development of a left adrenal nodule with rim of enhancement given characteristics and rapid growth concerning for metastasis. Interval resolution of the right pleural effusion. - On [**2134-9-30**] pulm rigid bronch revealed his metal stent well-covered with granulation tissue was visualized in the bronchus intermedius. An 80% stenosis to the right lower lobe was seen distal to the stent, and the bronchoscope could not pass. Electrocautery was used in strips along the [**Hospital1 **], then forceps were used to gently open the RLL to 60-70% remaining stenosis. PMH/PSH: Renal cell Carcinoma Hypothyroidism, Lyperlipidemia, Hypertension. Status post partial right adrenalectomy, and right nephrectomy Social History: He is married and he and his wife live on [**Hospital3 4298**]. His wife was recently diagnosed with early stage breast cancer and is being seen by Dr. [**First Name (STitle) **] here at [**Hospital1 18**] from Breast Oncology. Pt worked for an investment firm in [**Location 8398**]and retired 20 years ago. He smoked a pipe one to two times a day for >20 years and smoked cigars for two years. He drinks one scotch every three weeks Family History: Father mastoid infection and died in his 50s. Mother CHF died in her 70s. Older sister alive and well. Three adult children alive and well. Physical Exam: Admission exam Vitals: T:97.2 BP:143/72 P:67 R:20 O2:93% 2LNC General: Elderly male wearing glasses appearing comfortable, occasionally coughing, alert, oriented, no acute distress HEENT: Pink conjunctiva, no crusted blood in nasopharynx or oral pharynx Neck: supple, JVP not elevated, no LAD Lungs: Broncheal breath sounds on the rigt, left CTA. No wheezes 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, trace ankle edema. Labs: see below Discharge exam: Vitals: T:97.0 128/75 p65 r20 98% General: Elderly male wearing glasses appearing comfortable, occasionally coughing, alert, oriented, no acute distress HEENT: Pink conjunctiva, no crusted blood in nasopharynx or oral pharynx Neck: supple, JVP not elevated, no LAD Lungs: Broncheal breath sounds on the right, left CTA. Faint expiratory wheezes and rhonchi, R>L. 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, trace ankle edema. Labs: see below Pertinent Results: Admission labs [**2135-2-1**] 03:23PM BLOOD WBC-3.5* RBC-3.81* Hgb-12.4* Hct-35.9* MCV-94 MCH-32.7* MCHC-34.7 RDW-14.2 Plt Ct-118* [**2135-2-1**] 09:50AM BLOOD Neuts-75.9* Lymphs-15.4* Monos-5.9 Eos-2.4 Baso-0.3 [**2135-2-1**] 09:50AM BLOOD PT-12.2 PTT-32.3 INR(PT)-1.1 [**2135-2-1**] 09:50AM BLOOD Glucose-112* UreaN-14 Creat-1.1 Na-130* K-7.2* Cl-97 HCO3-27 AnGap-13 [**2135-2-1**] 09:50AM BLOOD Phos-3.5 Mg-1.6 Discharge labs Studies [**2134-2-1**] CXR: The cardiac and mediastinal contours appear unchanged including moderate tortuosity of the aorta. The heart is probably normal in size. Elevation of the right hemidiaphragm with substantial opacity involving the right hilum and nearby cardiophrenic sulcus appear similar compared to the recent prior examination. Regarding the lung parenchyma, no definite nodules are demonstrated radiographically. IMPRESSION: Similar medial right basilar opacity which is nonspecific but shows air bronchograms, perhaps associated with radiation fibrosis in the appropriate setting, although coinciding malignant mass in the area is not excluded. . [**2135-2-2**] Bronchoscopy in brief: The procedure, indications, preparation and potential complications were explained to the patient, who indicated his understanding and signed the corresponding consent forms. A standard time out was performed as per protocol. The procedure was performed for diagnostic and therapeutic purposes at the operating room. A physical exam was performed. The bronchoscope was introduced orally and advanced under direct visualization until the tracheobronchial tree was reached.The procedure was not difficult. The quality of the preparation was good. The patient tolerated the procedure well. There were no complications. . Other findings: Intubated with 11-12 Dumon-[**Doctor Last Name 25373**] bronchoscope. The main trachea was normal in appearance. Clear oozing blood was noted in the RMSB. The flexible bronchoscope was used to clean the airways. There were no abnormalities of the left sided airways. The RBI stent was noted to be fractured at multiple areas. There was a stent post jutting into the RMSB but was not damaging airway. The stent was clearly fractured at the distal end. There was a mild increase in bleeding from the proximal aspect upon entering the stent. The RMSB was intubated with the rigid scope. Tissue ablation with electrocautery was used to achieve hemostasis with good effect. Upon further inspection the RML bronchus was jailed. The RUL was extrisically compressed. There were no complications. [**2135-2-3**] Bilateral U/s Lower Extremities: IMPRESSION: No evidence of DVT within right or left lower extremities. [**2135-2-3**] CXR: IMPRESSION: No new areas of consolidation to suggest an acute pneumonia. Similar post treatment appearance of right lung as described. Dishcarge Labs: [**2135-2-4**] 06:45AM BLOOD WBC-3.3* RBC-3.76* Hgb-12.4* Hct-36.2* MCV-96 MCH-33.1* MCHC-34.4 RDW-13.9 Plt Ct-110* [**2135-2-1**] 09:50AM BLOOD Neuts-75.9* Lymphs-15.4* Monos-5.9 Eos-2.4 Baso-0.3 [**2135-2-4**] 06:45AM BLOOD Glucose-122* UreaN-21* Creat-1.1 Na-131* K-4.1 Cl-94* HCO3-32 AnGap-9 [**2135-2-3**] 09:30PM BLOOD CK(CPK)-147 [**2135-2-3**] 09:30PM BLOOD CK-MB-4 cTropnT-<0.01 [**2135-2-3**] 03:00PM BLOOD CK-MB-5 cTropnT-<0.01 [**2135-2-4**] 06:45AM BLOOD Calcium-8.4 Phos-3.1 Mg-1.6 Brief Hospital Course: Mr. [**Known lastname 1968**] is an 86yo M with PMH of metastatic renal cell carcinoma to the lungs, who presents with hemoptysis. . # Hemoptysis: While we initially entertained other reasons for the hemoptysis, the obvious source seemed to be his lung metasteses. On the night of his admission he underwent rigid broncoscopy by IP who saw that he had a fractured bronchus intermedius stent with friable tissue around it, causing right main stem bleeding. The tissue was cauterized, otherwise without incident, and then the patient was taken back to the MICU. He had an uneventful night, and the was transferred to the floor for additional monitoring. In the MICU that morning he had a fever to 100.4, which was believed to be from the procedure, and no cultures were taken, no antibiotics were given. His O2 saturation and Hct remained stable on the floor during his stay. Subjectively his cough decreased to him, and reports that the productive of his cough decreased, was less bloody. He was initially mainatined on 2L NC O2 coming out of the MICU, but was weaned do room air. At discharge, he was walking around the floor relatively quickly, without shortness of breath or coughing. . # Chest Pain: The patient had an episode of chest pain on the night of his floor stay, and then again during the day on [**2-3**]. The pain he said was typical of a chronic CP that he has intermittently. They seemed to be related to excercise, after his finishes walking, non-descript per him, but [**7-10**], right anterior chest wall, worse with breathing, and lasting for hours, then spontaneosly resolving. Because of this we cycled two troponins, which were negative, got a CXR which didn't show new focal consolidation, and got lower extremity U/S, which was also negative for DVT. We were initially concerned about PE, but the history of it wasn't great, was not tachycardic (although beta blocked), maintaining his O2 saturation on his own. On the other hand, he has little pulmonary reserve, and PE could be devastating. Ultimately the CP didn't recur, and no further work up was done. . # Renal Cell Carcinoma: The patient is currently off the Sutent per his oncologist, who agreed that it was good to stop it for now. We emailed his oncology team to inform them of everything that was happening, and they were happy to hear from us. Otherwise, the decision to resume his Sutent will be made at a later date by his oncologist. . # HTN: Pt is currently currently normotensive, given hemoptysis will hold antihypertensives until hemostasis has been achieved. . # Hypothyroidism: Wasn't an active issue. Continued Levothyroxine 100mg Daily. . # Post herpatic neuralgia: affecting left abdomen. Unchanged from past, not active during this hospitalization, using lidocaine patch. . . . . Transition Issues: 1) He will require additional instrumentation by IP. The IP office is going to call him, but the patient was instructed to call them if he hadn't heard from them in 1 to 2 days. 2) At some time the question of whether to restart his Sutent will have to be made. that will be decided upon by his oncology team in conjunction with the interventional pulmonologists. 3) His amlodopine and atenolol were stopped during this admission due to concern of hypotension and blood loss. He was normotensive here the entire time, and was discharged without him starting them again. His blood pressure will need to be re-checked to resume his medication. . . . . . Medications on Admission: ALBUTEROL SULFATE - 90 mcg HFA 2 puffs INH q4 AMLODIPINE - 5 mg Daily ATENOLOL - 50 mg Daily BENZONATATE - 200 mg TID PRN CODEINE-GUAIFENESIN - 100 mg-10 mg/5 mL Liquid - 5 ml QHS PRN LEVOTHYROXINE - 100 mcg Daily LIDOCAINE - 5 % (700 mg/patch) Adhesive Patch, OMEPRAZOLE - 20 mg Daily SIMVASTATIN - 20 mg Daily SUNITINIB [SUTENT] - 37.5 mg daily two weeks on, one weeks off. GUAIFENESIN [MUCINEX] - 1,200 mg [**Hospital1 **] Discharge Medications: 1. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day. 2. atenolol 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. benzonatate 100 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day) as needed for Cough. 4. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Topical once a day as needed for pain. 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 8. sunitinib 12.5 mg Capsule Sig: Three (3) Capsule PO once a day: Daily, two weeks on, one weeks off. 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*50 Capsule(s)* Refills:*1* 10. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:*50 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 11. codeine sulfate 15 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for cough. Disp:*50 Tablet(s)* Refills:*1* 12. guaifenesin 1,200 mg Tablet, ER Multiphase 12 hr Sig: One (1) Tablet, ER Multiphase 12 hr PO twice a day. Disp:*60 Tablet, ER Multiphase 12 hr(s)* Refills:*2* 13. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Inhalation five times a day as needed for shortness of breath or wheezing. Disp:*2 * Refills:*1* 14. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing/dyspnea. Disp:*20 mL* Refills:*3* Discharge Disposition: Home Discharge Diagnosis: 1) Sub-massive hemoptysis. 2) Fractured endobronchial stent with friable tissue. 3) Shortness of breath. 4) Intermittent chest pain. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname 1968**], It was a pleasure to meet you during your stay here. To summarize, you came to the hosptial because you were becoming increasingly short of breath and you were coughing up more blood than usual. The interventional pulmonologists performed a bronchoscopy which showed that one of the your stents was broken, and that you had some bleeding tissue around the stent. They cleaned the tissue up with cautery, dilated the stent with a balloon, and this seemed to resolve your symptoms. On the day after your procedure you had a slight temperature, but that quickly went down and nothing came of it. You were monitored in the hospital first in the ICU, and then on the general medical floor, and then later we determined it was safe for you to go home. You have a follow up appointment already scheduled with the pulmonologists for next week. It was a pleasure to see you, thank you for coming to [**Hospital1 18**]. Followup Instructions: The Interventional Pulmonologists will call you to schedule an appointment to be seen in a week or two. If you do not hear from them in a day, call them at [**Telephone/Fax (1) 7769**]. Their address is : [**Last Name (LF) **],[**First Name3 (LF) **] MULTI-SPECIALTY SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] MULTI-SPECIALTY THORACIC UNIT-CC9 These are other appointments that you currently have scheduled. Keep these appointments. Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2135-2-22**] at 1 PM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**0-0-**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2135-2-22**] at 2:00 PM With: DRS. [**Name5 (PTitle) **]/[**Doctor Last Name **] [**Telephone/Fax (1) 13016**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2135-2-22**] at 2:00 PM With: DR. [**First Name8 (NamePattern2) 2801**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Name6 (MD) **] [**Name8 (MD) **] MD [**Doctor Last Name 1189**] Completed by:[**2135-2-4**]

[ "197.0", "786.50", "272.4", "799.02", "401.9", "996.59", "E878.1", "V45.73", "053.19", "786.30", "V10.52", "198.7", "287.5", "V15.82", "244.9" ]

icd9cm

[ [ [] ] ]

[ "32.01", "32.28" ]

icd9pcs

[ [ [] ] ]

17390, 17396

11799, 15276

313, 334

17573, 17573

8432, 11776

18696, 20194

6974, 7116

15753, 17367

17417, 17552

15302, 15730

17724, 18673

7131, 7761

7777, 8413

263, 275

362, 2358

17588, 17700

2380, 6505

6521, 6958

31,038

174,978

50

Discharge summary

report

Admission Date: [**2102-6-12**] Discharge Date: [**2102-6-16**] Date of Birth: [**2044-7-15**] Sex: M Service: MEDICINE Allergies: Bactrim / Hismanal / Iodine; Iodine Containing / Neurontin Attending:[**First Name3 (LF) 562**] Chief Complaint: Hematemesis and hypotension Major Surgical or Invasive Procedure: EGD x 2 History of Present Illness: 57M PMH HIV, lymphoma in remission, GERD BIBA with hematemesis and hypotension. He reports fatigue and burning epigastric pain over the past two days. His partner found him the morning of admission having vomited coffee ground emesis and called EMS. Denies melena, BRBPR. No history of GI bleeding in the past. He did undergo EGD and colonoscopy in [**2100**] revealing esophagitis and a colonic adenoma. No other lesions found at that time. . In the ED, VS: T 98.3 BP: 64/42 HR: 119 RR: 18 SaO2: 95%RA. - Cordis placed. - Given 4L NS. - Hematocrit 20.8 from baseline 37.7 [**2102-5-15**]. - Given 2 units uncrossmatched blood. - FAST exam: question free fluid in the abdomen. - Given protonix 40 mg IV, levofloxacin 750 mg IV, flagyl 500 mg IV. . No further episodes of hematemesis since presentation to the ED. He currently denies chest pain, shortness of breath, lightheadedness, abdominal pain, nausea, vomiting. Denies fevers, chills. Past Medical History: 1. HIV, diagnosed in [**2074**] - CD4 288, VL < 50 [**2102-5-15**]. 2. Stage III non-Hodgkin's lymphoma [**2089**], status post m-BACOD. 3. Stage III Hodgkin's disease [**8-/2092**], status post ABVD, had recurrence stage IA Hodgkin's disease right neck. He was treated with 1 [**2-8**] cycles of British MOPP, discontinued due to systemic side effects and which was followed by a course of XRT. 4. Anal biopsies demonstrating low grade squamous intraepithelial lesion as well as high grade squamous intraepithelial lesion. 5. Grade III esophagitis due to reflux. 6. Iron deficiency anemia. 7. Status post lumbar laminectomy. 8. Status post appendectomy. 9. Hypothyroidism. 10. Hyperlipidemia. 11. History of herpes zoster. 12. Chronic pain status post MVA/zoster. Social History: Lives with partner who is HCP. [**Name (NI) **] alcohol, smoking, or drug use. Family History: Non-contributory. Physical Exam: VS: T: 98.9 BP: 110/70 HR: 98 RR: 18 SaO2: 98% 2L NC GEN: NAD HEENT: AT, NC, PERRLA, EOMI, anicteric, OP with dried blood, MM dry Neck: Supple CV: RRR, nl s1, s2, no m/r/g PULM: CTAB, no w/r/r with good air movement throughout ABD: Soft, NT, ND, + BS, no HSM EXT: Warm, dry, +2 distal pulses BL NEURO: Sleepy, oriented x 2, confused at times, CN II-XII grossly intact, MAEW . EKG: ST 115, PAC. NA/NI. No ST-T changes. Pertinent Results: [**2102-6-12**] WBC-20.3*# Hgb-7.3*# Hct-20.8*# MCV-89 RDW-14.3 Plt Ct-284 Neuts-83.3* Bands-0 Lymphs-14.7* Monos-1.7* Eos-0.1 Baso-0.1 PT-14.5* PTT-30.9 INR(PT)-1.3* Glucose-155* UreaN-132* Creat-2.0* Na-133 K-4.8 Cl-99 HCO3-16* AnGap-23* ALT-19 AST-38 CK(CPK)-238* AlkPhos-49 TotBili-0.1 Lipase-45 Calcium-9.1 Phos-5.0*# Mg-1.7 Lactate-4.0* . Blood cultures [**6-12**]: [**4-11**] coag negative staph; [**2-10**] yeast -> candidia [**Month/Day (4) 563**] Followup cultures (8 bottles) final negative. . EGD ([**6-12**]): Esophagus: Granular, sclerosed appearing mucosa was noted in the distal esophgaus with scant red blood. No bleeding lesion was seen. Stomach: Clotted blood was seen in the stomach the full stomach body could not be assessed due to resdual material. The visualized fundus, body and antrum were normal. Duodenum: Clotted blood was seen in the duodenum. Normal mucosa was noted. . CXR ([**6-12**]): No evidence of pneumonia, mild bibasilar atelectasis. . ECG ([**6-12**]): ST 115, PAC. NA/NI. No ST-T changes Brief Hospital Course: A/P: 57M PMH HIV, h/o lymphoma in remission, GERD with grade III esophagitis p/w acute UGIB and hypotension, admitted to the MICU. . # UGIB: Initially hypotensive with SBP 60's as per HPI. Received blood and fluid resuscitation (7 units PRBCs total this admission; 2 were emergency crossmatch). Admitted to MICU. EGD [**6-12**] with the above results. On [**6-13**] patient had reported hematocrit drop from 27 to 18; received 2 units and subsequent hematocrits >30 and stable (?erroneous value). EGD was done again in light of hematocrit drop, again showing esophagitis but no other lesions. Last transfusion on [**2102-6-13**]. GI and surgery followed patient during admission. Source of bleed appeared to be esophagitis, as no other upper lesions noted. PPI was continued with [**Hospital1 **] dosing and sucralfate started. Patient was also asked to avoid chloral hydrate (had been taking at home for sleep), which can cause gastritis. . # Coag negative staph bacteremia. [**4-11**] cultures were positive from [**6-12**], initially thought to perhaps be a contaminant but further bottles then became positive. Started vanco on [**6-13**]. Patient with recent root canal and given amox; ?source. TTE was done without evidence of vegetation. Given low suspicion of endocarditis, TEE was not done. Surveillance cultures were all negative. Planned to treat patient with a 14 day course of IV vancomycin; midline placed. However, prior to arrangements being made for home IV antibiotics, then patient insisted on leaving AMA. Midline pulled and patient placed on suboptimal regimen of levofloxacin PO x 14 days. He was informed that his treatment regimen was not ideal and could lead to persistent bacteremia and associated poor outcomes, but refused to stay until arrangements could be made (if they could be at all given his insurance). . # Fungemia. On [**2102-6-15**] PM, [**2-10**] blood cultures from [**2102-6-12**] turned positive for budding yeast. He was given a dose of caspofungin. Possible portal of entry from subclinical esophagitis and entry to bloodstream during GI bleed. The seriousness of fungemia was discussed with him, as well as needs to continue IV antifungal treatments. As above, he insisted on leaving on [**2102-6-16**], against medical advice. He appeared to have good understanding of his disease and its risks (patient also a former nurse) but felt that further workup was unnecessary and he had had his mind set on leaving that day. Efforts to look for source sites were attempted; he had CT torso (no evidence of source for his fungemia). Ophthalmology was also consulted for dilated eye exam, to which he initially agreed but then refused once they arrived. He also refused to stay in house for ID consult. As above, with him leaving AMA and no home IV treatment possible, he was discharged home on a planned 2 week course of fluconazole. Following discharge, blood cultures were followed and the yeast was determined to be [**First Name5 (NamePattern1) 564**] [**Last Name (NamePattern1) 563**] (high resistance rates to fluconazole). Both patient and PCP made aware of this on [**2102-6-19**]. Per PCP and patient, planning for very close followup over the next several weeks to include blood cultures, daily temperature checks, etc. Patient refused return to the hospital for IV treatment and further workup. Of note, 8 further bottles of blood cultures were negative (now final). . # Hypotension: SBP 60s on arrival; primarily hypovolemic with ?septic component as above. Followup callout to the floor, his SBP was in the low 90s but he was asymptomatic, not tachycardic. SBPs recorded from outpatient notes generally ~110, but patient reports BPs in 90's usually. Random cortisol in unit was 28.4. . # Leukocytosis: initially thought to be a stress response. Then with 3/4 cultures positive for staph as above, also yeast as above. CXR without infiltrate and UA negative. . # Delirium: Noted in the MICU in the setting of massive GIB and bacteremia. The patient's baseline mental status per partner is oriented x 3 but occasionally confused. Nonfocal neurologic examination and once on medical floor he was back to baseline per partner. [**Name (NI) **] last onc outpatient notes - increasing fatigue and slurred speech. Valium was held. . # Acute renal failure: Likely prerenal. Baseline creatinine 1.0-1.1. Resolved. . # HIV: CD4 288, VL < 50 [**2102-5-15**]. Continued Atripla. . # Thrombocytopenia. Likely consumptive/dilutional given bleed and resuscitation. Improved. . # Chronic pain: Chronic BLE pain thought due to zoster/MVA. Continued lidocaine patch and amitriptyline. . # Depression: No active issues. Continued effexor. . # Hypothyroidism: No active issues. Continued levothyroxine. . # Hyperlipidemia: No active issues. Continued lipitor. . # CODE: DNR/DNI, confirmed with patient and HCP . # COMMUNICATION: Patient, partner [**Name (NI) 565**] [**Name (NI) 566**] (HCP) . Medications on Admission: Omeprazole 40 mg [**Hospital1 **] Topamax 200 mg QHS Lipitor 80 mg DAILY Amphetamine Salt Combo 5 mg (sig unavailable) Atripla 600 mg-200 mg-300 mg one tablet QHS Valium 10 mg DAILY PRN Amitriptyline 150 mg QHS Levoxyl 175 mcg DAILY Lidoderm 5 % Patch one patch to each foot bilaterally Discharge Medications: 1. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): to each foot. 2. Topiramate 200 mg Tablet Sig: One (1) Tablet PO once a day. 3. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 4. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Amitriptyline 150 mg Tablet Sig: One (1) Tablet PO at bedtime. 6. Venlafaxine 150 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 7. Dextroamphetamine 5 mg Tablet Sig: Three (3) Tablet PO QAM (once a day (in the morning)). 8. Dextroamphetamine 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for insomnia. 10. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 11. ATRIPLA [**Telephone/Fax (3) 567**] mg Tablet Sig: One (1) Tablet PO once a day. 12. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day): avoid taking with levothyroxine (stagger medications by at least 2 hours). Disp:*120 Tablet(s)* Refills:*0* 13. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 14 days. Disp:*14 Tablet(s)* Refills:*0* 14. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO once a day for 14 days. Disp:*28 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Upper GI bleed Esophagitis, grade III Bacteremia, coag negative staph Fungemia . HIV/AIDS Hypovolemic shock Delerium Hyperlipidemia Discharge Condition: Stable Discharge Instructions: You were admitted after vomiting blood. You were given blood products and fluids and improved. Your endoscopy showed evidence of significant irritation of the esophagus. You were also found to have a bacterial infection in your blood, which was treated for several days with IV antibiotics. On the day before discharge, you were noted to have yeast in the blood. We recommended that you stay in the hospital for IV antibiotics and to get you set up for home antibiotics; however, you chose to do oral therapy at home. . Return to the hospital or call your doctor if you note blood in your stools or vomit, abdominal pain, lightheadedness, shortness of breath or chest pain, fever > 101, or any new symptoms that you are concerned about. . Since you were admitted, we have made the following changes to your medications: - please do not take CHLORAL HYDRATE. You can take CLONAZEPAM or other sleeping medications if you are having insomnia. - you will receive 2 oral medications for infection: levofloxacin and fluconazole. It is possible that these medications will not be sufficient to treat your bloodstream infection. - we have also started SUCRALFATE for the stomach. Followup Instructions: You have the following upcoming appointments at [**Hospital1 18**]: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) 568**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2102-7-21**] 3:15 [**First Name11 (Name Pattern1) 569**] [**Last Name (NamePattern4) 570**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2102-8-7**] 11:30 . PCP appt with Dr. [**Last Name (STitle) 571**]: Monday [**6-19**] at 2:40pm

[ "202.80", "530.82", "790.7", "117.9", "293.0", "785.59", "272.4", "530.12", "041.19", "042" ]

icd9cm

[ [ [] ] ]

[ "99.04", "45.13" ]

icd9pcs

[ [ [] ] ]

10478, 10484

3775, 8740

346, 355

10660, 10669

2699, 3752

11894, 12355

2227, 2246

9078, 10455

10505, 10639

8766, 9055

10693, 11871

2261, 2680

279, 308

383, 1325

1347, 2114

2130, 2211

15,651

115,590

23913

Discharge summary

report

Admission Date: [**2185-4-25**] Discharge Date: [**2185-4-28**] Date of Birth: [**2130-1-25**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: known murmur with mitral valve prolapse and dyspnea on exertion Major Surgical or Invasive Procedure: Minimally invasive MVR(27mm partial annuloplasty band) [**2185-4-25**] History of Present Illness: Mr. [**Known lastname 60969**] has had known mitral valve prolapse with mild dyspnea on exertion and was referred to Dr. [**Last Name (STitle) **] for surgical repair. Past Medical History: mitral valve prolapse sleep apnea s/p herniorrhaphy s/p back surgery s/p L eye surgery Social History: he loves with his wife, has a remote tobacco history, [**12-26**] glasses of wine/day. Family History: non contributory Pertinent Results: [**2185-4-28**] 05:40AM BLOOD WBC-8.5 RBC-3.52* Hgb-11.2* Hct-31.4* MCV-89 MCH-31.8 MCHC-35.7* RDW-13.1 Plt Ct-135* [**2185-4-28**] 05:40AM BLOOD Plt Ct-135* [**2185-4-27**] 05:55AM BLOOD Glucose-109* UreaN-13 Creat-0.9 Na-135 K-4.1 Cl-99 HCO3-31* AnGap-9 Brief Hospital Course: Mr. [**Name13 (STitle) **] was admitted on [**4-25**] and taken to the operating room with Dr. [**Last Name (STitle) **] for a minimally invasive mitral valve repair with quadrangular resection of the posterior leaflet and a 27mm annuloplasty band. He was transferred to the intensive care unit in stable condition. He was weaned and extubated from mechanical ventilation on his first postoperative evening without difficulty. He was transferred to the regular floor on POD#1, began working with physical therapy and was cleared by POD#2. He developed muscle spasm in his back which was successfully treated with Valium and NSAIDS, and was cleared for discharge and discharged to home on POD#3. Medications on Admission: aspirin 81mg qd MVI Discharge Medications: 1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 2. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO twice a day for 7 days. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Dilaudid 4 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 6. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:*120 Tablet(s)* Refills:*2* 7. Diazepam 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:*20 Tablet(s)* Refills:*0* 8. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Mitral regurgitation Discharge Condition: Good. Discharge Instructions: Follow medications on discharge instructions. You may not drive for 4 weeks. You may not lift more than 10 lbs. for 6 weeks. You should shower, let water flow over wounds, pat dry with a towel. Followup Instructions: Make an appointment with Dr. [**Last Name (STitle) 60965**] for 1-2 weeks. Make an appointment with Dr. [**Last Name (STitle) 1290**] for 4 weeks. Completed by:[**2185-4-28**]

[ "429.5", "424.0", "V15.82", "780.57" ]

icd9cm

[ [ [] ] ]

[ "35.33", "39.61" ]

icd9pcs

[ [ [] ] ]

2997, 3046

1202, 1902

385, 458

3111, 3118

922, 1179

3360, 3538

885, 903

1973, 2974

3067, 3090

1928, 1950

3142, 3337

282, 347

486, 655

677, 765

781, 869

23,014

100,120

43569

Discharge summary

report

Admission Date: [**2165-8-2**] Discharge Date: [**2165-8-5**] Date of Birth: [**2098-2-18**] Sex: M Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Dark blood from G-tube Major Surgical or Invasive Procedure: EGD-ulcer in the distal esophagus with active bleeding. s/p clipping of the vessel with good homostasis. History of Present Illness: 67 yo M with h/o CAD, recently admitted from [**6-21**] to [**7-25**] where he presented with severe headache, CT notable for large intracranial bleed. Found to have vertebrobasilar aneurysm, s/p coiling and stenting, ventriculostomy. Course complicated by L sided PE and was treated with heparin. Hospital course also complicated by CHF, failure to wean from vent, s/p trach, PEG placment. Patient was eventually weaned from vent at end of hospitalization. On discharge, patient was able to open eyes to stimulation, and had spontaneous movment of the R side. Patient was discharged on [**Month/Day (4) **], plavix, heparin gtt. Pt. sent to [**Hospital3 **]. Came to ED on [**7-26**] with hypotension , sbp in 80s, responded to IV boluses, cleared by N-[**Doctor First Name **] (no change). On [**8-1**], patient noted to have 50 cc dark blood in G-tube at rehab. In ED, patient was afebrile, hr-82, bp-121/64. Dark blood failed to clear with lavage. GI was subsequently consulted. In ED, hct-30, INR-2.9. Got vit K 5mg sq, IV protonix, 4 units FFP, 2 large [**Last Name (un) **] IVs placed. CXR showing CHF opacities or effusions. EKG showing NSR at 90 bpm, nl axis, IVCD in L bundle pattern, 1-[**Street Address(2) 1766**] depr in V3-6 (old) and TWI in V3-6, I L (old). Past Medical History: -CAD, s/p MI, CABG x 2 in '[**50**] and '[**62**], multiple stents -htn -s/p MV annuloplasty in '[**62**] -s/p AICD -s/p intracranial bleed [**5-28**], per HPI -mult L sided PEs ([**6-28**]) -h/o hyponatremia -VRE pos -CHF - [**6-28**] echo with EF 30%, moderate regional LV systolic dysfunction with near AK of inferior and inferolateral walls, sever HK of anterolat. wall. Physical Exam: T 97.6 BP 121/64 P82 RR30 100% 4LNC Gen: Minimally resonsive, unable to follow commands HEENT: NC/AT, PERRL 2mm bilaterally Lungs: +upper airway sounds, no crackles, no wheezing, good air movement CV: RRR, nl S1, S2, no murmurs Abd: Soft, NTND, no withdraw with deep palpation. +G-tube Ext: no edema, clubbing, cyanosis Neuro: responds minimally to verbal stimuli, withdraws to pain. Pertinent Results: [**2165-8-5**] 04:49AM BLOOD WBC-9.2 RBC-3.52* Hgb-10.6* Hct-32.2* MCV-92 MCH-30.1 MCHC-32.9 RDW-15.6* Plt Ct-400 [**2165-8-4**] 04:34PM BLOOD Hct-34.2* [**2165-8-3**] 11:41PM BLOOD Hct-32.5* [**2165-8-3**] 04:00AM BLOOD WBC-10.0 RBC-3.51* Hgb-10.6* Hct-31.5* MCV-90 MCH-30.4 MCHC-33.8 RDW-15.6* Plt Ct-379 [**2165-8-2**] 10:42PM BLOOD Hct-28.3* [**2165-8-2**] 08:13PM BLOOD Hct-29.2* [**2165-8-2**] 10:03AM BLOOD Hct-23.7*# [**2165-8-5**] 04:49AM BLOOD PT-14.7* PTT-56.5* INR(PT)-1.4 [**2165-8-4**] 08:16PM BLOOD PTT-39.1* [**2165-8-4**] 04:32AM BLOOD PT-14.7* PTT-24.2 INR(PT)-1.4 [**2165-8-3**] 04:00AM BLOOD PT-15.2* PTT-26.1 INR(PT)-1.5 [**2165-8-2**] 10:40AM BLOOD PT-16.7* PTT-30.1 INR(PT)-1.8 [**2165-8-2**] 04:15AM BLOOD PT-20.8* PTT-37.0* INR(PT)-2.9 [**2165-8-5**] 04:49AM BLOOD Glucose-117* UreaN-22* Creat-0.4* Na-143 K-3.9 Cl-108 HCO3-27 AnGap-12 [**2165-8-2**] 04:15AM BLOOD Glucose-113* UreaN-26* Creat-0.6 Na-133 K-5.3* Cl-96 HCO3-29 AnGap-13 [**2165-8-4**] 04:32AM BLOOD ALT-28 AST-30 AlkPhos-124* [**2165-8-3**] 06:45PM BLOOD CK-MB-3 cTropnT-0.07* [**2165-8-2**] 10:43PM BLOOD CK-MB-4 cTropnT-0.05* [**2165-8-2**] 04:00PM BLOOD CK-MB-3 cTropnT-<0.01 Brief Hospital Course: 1)Upper GI bleed: Patient was on coumadin for recent hx of PE and received 4 units of FFP and vit K in the EW to correct his INR. Coumadin was held intinitally for possible active bleed. GI was consulted and EGD was done on [**2165-8-2**] which showed an ulcer in the distal esophagus with active bleeding from that site. Successful clipping of the vessel was achieved using a Resolution Endoclip device and then injected with epinephrine for hemostasis. Patient received total of 3 units of PRBC. Patient was continued on PPI for prophylaxis and serial hematocrit was done which remained stable (Hct>30). 2)Neuro: Patient has a hx of intracranial bleed s/p basilar stent. Patient on Plavix and [**Date Range **] for post-stent prophylaxis. Patient remained lethargic which is his baseline. He was able to follow simple commands at times, moving his hands and feet and occasionally giving verbal response. Per family member, patient appears to be more alert than before. Neurosurgery following this patient and strongly urged to hold Coumadin for the risk of re-bleeding intracranially. After discussion with Dr. [**Last Name (STitle) 1132**] from neurosurgery, it was decided to discharge patient with Lovenox. 3)A-fib: During EGD proceduse, clipping of the bleeding vessel was done and epinephrine was injected to that site. Right after the epinephrine was injected, he went into rapid afib to 150's with ST depressions. He was given a total of 10 mg of lopressor with some decrease in his HR to the 120's-130's. After 10 mg of IV diltiazem, his HR came down to the 90's-100's and his BP dropped to the 80's briefly. MI was ruled out with serial cardiac enzymes and he was given 25 mg of lopressor. Patient remained on sinus tachycardia, and lopressor was titrated up to 50 mg tid. Patient did show good response to IV diltiazem 10 mg. 4)PE prophylaxis: Patient initially on Coumadin 12.5 mg qd and Dalteparin 7500 units [**Hospital1 **], but were held due to GI bleed with INR 2.9 and PTT 37. Neurosurgery seen the patient and strongly discouraged discontinuing Coumadin due to recent history of intracranial bleed. However, patient just had PE and is at risk for another thrombotic event. After discussion with the neurosrugery attending Dr. [**Last Name (STitle) 1132**], it was decided to discharge the patient with Lovenox. 5)ID: On [**8-4**] sputum gram stain showed gram positive cooci and rhonchi on exam. CXR intially appeared as LLL opacity so Vancomycin 1 g q12 was started. However after reviewing the film with the team on [**2165-8-5**], CXR was more consistent with fluid overload with effusion than consolidation. Since patient is afebrile with normal WBC and not showing symptom of pneumonia, Vancomycin was discontinued. Medications on Admission: protonix 40 qd, senna 2 [**Hospital1 **], epo [**2161**] units q Tu/Sat, amantidine 100 [**Hospital1 **], coumadin 12.5 [**Last Name (LF) **], [**First Name3 (LF) **] 325 qd, lopresor 25 [**Hospital1 **], dalteparin 7500 units [**Hospital1 **] Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO QD (once a day). 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO QD (once a day). 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 4. Enoxaparin Sodium 80 mg/0.8 mL Syringe Sig: Eighty (80) mg Subcutaneous Q12H (every 12 hours). 5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Esophageal bleed Atrial fib Intracranial bleed s/p stent at vertebrobasilar aneurysm Hx of pulmonary embolism CAD CHF Discharge Condition: Hemodynamically stable, no active bleeding. Discharge Instructions: Patient needs to seek medical attention (ED, PCP), if he has bloody vomit, bloody stool, blood from G-tube, dyspnea, chest pain, new neurological deficit, fever/chills. Followup Instructions: Patient needs to be seen by his PCP as soon as possible and he has an appointment with neurosurgery on following date. Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) **], MD Where: LM [**Hospital Unit Name 12006**] Phone:[**Telephone/Fax (1) 3666**] Date/Time:[**2165-8-9**] 2:30 [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2165-8-5**]

[ "V44.1", "285.1", "V44.0", "V45.81", "428.0", "412", "427.31", "530.21", "401.9" ]

icd9cm

[ [ [] ] ]

[ "45.13", "99.04", "99.07", "96.6", "42.33" ]

icd9pcs

[ [ [] ] ]

7286, 7356

3770, 6536

338, 445

7518, 7563

2576, 3747

7780, 8241

6830, 7263

7377, 7497

6562, 6807

7587, 7757

2171, 2557

276, 300

473, 1758

1780, 2156

68,006

165,933

34836

Discharge summary

report

Admission Date: [**2116-10-21**] Discharge Date: [**2116-11-1**] Date of Birth: [**2038-6-21**] Sex: F Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamide Antibiotics) / Penicillins / Methyldopa Attending:[**First Name3 (LF) 1505**] Chief Complaint: aortic stenosis/coronary artery disease Major Surgical or Invasive Procedure: [**2116-10-23**] - Aortic Valve replacement (21mm [**Company 1543**] Mosaic Ultra porcine), corornary artery bypass grafts x 1 (LIMA-LAD) History of Present Illness: This 78 year old white female presented elsewhere with chest pain awakening her. She had associated diaphoresis and after receiving nitoglycerine she was hypotensive, requiring fluids. Her pain resolved, she was stable and ruled in for an a non ST infarction. Catheterization revealed single vessel disease and critical aortic stenosis ([**Location (un) 109**] 0.8). She was transferred for cardiac surgery. Past Medical History: hypertension hypothyroidism degenerative joint disease asthma hypercholesterolemia depression Social History: heavy smoker in past, d/c 20 years denies ETOH Lives with her hushand Family History: 2 brother had premature coronary disease Physical Exam: 59 SB 18 135/63 96% RA GEN: Elderly female in NAD SKIN: Unremarkable NECK: Supple, FROM, No JVD LUNGS: diminished at bases, o/w clear HEART: RRR, no murmur or rub ABD: S/NT/ND/NABS EXT: Warm, well perfused. No varicosities, Pulses 2+, trace edema NEURO: Nonfocal Pertinent Results: [**2116-10-23**] ECHO PRE-BYPASS: The left atrium is moderately 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. 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 simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (area <0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is moderate valvular mitral stenosis (area 1.0-1.5cm2). Moderate ([**12-25**]+) mitral regurgitation is seen. There is no pericardial effusion. POST-BYPASS: Left and right ventricular function is preserved. The aorta is intact. An aortic bioprosthesis is well seated with good leaflet excursion. There is no AI. The aortic valve gradients are appropriate. Mitral regurgitation is mild to moderate. The remainder of the examination is unchanged. [**2116-10-22**] Carotid Ultrasound Minimal plaque with bilateral less than 40% carotid stenosis. [**2116-10-31**] 08:30AM BLOOD WBC-9.8 RBC-3.43* Hgb-10.8* Hct-31.8* MCV-93 MCH-31.4 MCHC-34.0 RDW-14.3 Plt Ct-386 [**2116-11-1**] 07:10AM BLOOD PT-23.7* INR(PT)-2.3* [**2116-10-31**] 08:30AM BLOOD Glucose-101 UreaN-11 Creat-0.8 Na-138 K-4.1 Cl-100 HCO3-30 AnGap-12 Brief Hospital Course: Following admission she received dental clearance and carotid ultrasonography. There was no contraindication for surgery. On [**10-23**] she went to the operating room where aortic valve replacement and a single graft were done. See operative note for details. She weaned from bypass on Neosynephrine and propofol and was sent to the CVICU in stable condition. She weaned from pressors, awoke intact and was extubated. She developed rapid atrial fibrillation, requiring amiodarone and beta blockers to control ventricular response and convert to sinus. Coumadin was started, as the patient would vascillate between SR and Afib. She made excellent progress with physical therapy, showing good strength and balance before discharge. The patient was diuresed toward her preoperative weight. She was discharged in good condition to home on POD9. Medications on Admission: Avapro 75mg/D Lasix 20,g/D Prilosec 20mg/D Lipitor 40mg/D Synthroid 88mcg/D Fluoxetine20mg/D KCL 20mEq/D Flovent 44 [**Hospital1 **] ASA 81mg/D Toprol XL 12.5mg/D Discharge Medications: 1. Outpatient Lab Work INR drawn on Monday [**2116-11-2**] with results to Dr. [**Last Name (STitle) 3497**] ([**Telephone/Fax (1) 79768**]. 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for temperature >38.0. Disp:*60 Tablet(s)* Refills:*0* 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 5. 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:*0* 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*0* 8. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*qs * Refills:*0* 9. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 10. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400mg/day for 3 days, then 200mg 2x/day for 1 week, then 200mg/day. Disp:*120 Tablet(s)* Refills:*0* 11. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). Disp:*qs * Refills:*0* 12. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed. Disp:*qs * Refills:*0* 13. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*0* 14. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 15. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO DAILY (Daily) for 2 weeks. Disp:*14 Packet(s)* Refills:*0* 16. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: .5 Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*0* 17. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: MD to adjust dose daily with goal INR [**1-26**] for A-fib. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: VNA of Southeastern Mass. Discharge Diagnosis: coronary artery disease aortic stenosis hypothyroidism asthma hypertension depression hypercholesterolemia degenerative joint disease postop A Fib Discharge Condition: good Discharge Instructions: no driving for 4 weeks and off all narcotics no lifting more than 10 pounds for 10 weeks report any fever greater than 100.5 report any redness of, or drianage from incisions report any weight gain greater than 2 pounds a day or 5 pounds a week shower daily, no baths or swimming no lotions, creams or powders to incisions take all medications as directed Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) Dr. [**Last Name (STitle) 8579**] in [**1-26**] weeks Dr. [**Last Name (STitle) 40075**] in [**12-25**] WEEKS ([**Telephone/Fax (1) 40076**]) Please call for appointments Completed by:[**2116-11-1**]

[ "272.0", "244.9", "V15.82", "E878.2", "401.9", "458.29", "997.1", "424.1", "427.31", "V17.3", "493.20", "414.01", "311", "715.90", "410.71" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.21", "36.15" ]

icd9pcs

[ [ [] ] ]

6489, 6545

3112, 3961

366, 506

6736, 6743

1513, 3089

7147, 7421

1166, 1208

4175, 6466

6566, 6715

3987, 4152

6767, 7124

1223, 1494

287, 328

534, 946

968, 1063

1079, 1150

53,947

157,921

41442

Discharge summary

report

Admission Date: [**2170-7-26**] Discharge Date: [**2170-8-2**] Date of Birth: [**2119-2-24**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1406**] Chief Complaint: Exertional chest pain Major Surgical or Invasive Procedure: [**2170-7-27**] Cardiac catheterization [**2170-7-30**] Coronary artery bypass grafting x5 with the left internal mammary artery to left anterior descending artery and sequential reverse saphenous vein graft to the posterior left ventricular branch artery and the posterior descending artery and reverse saphenous vein graft to the obtuse marginal artery and the ramus intermedius artery History of Present Illness: Mr [**Known lastname **] is a 51 year old man with HTN, HL, CAD, S/P des to RCA in [**1-/2170**] now presents with exertional CP and a positive stress test here for cath. Mr [**Known lastname **] began having chest pain about 6 weeks ago. Comes with exertion to [**12-31**] mile walking. He says that it may be slowly increasing in frequency. He does not have SOB or NV with CP. He has not had CP at rest. He saw his cardiologist abut 1 week ago who scheduled a stress test. During the stress test today he was noted to have 3mm depressions in II,III,and AVF after 4 mins on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] protocol and stopped for CP. He was given SL NTG and was started on a heparin GTT and was transferred to [**Hospital1 18**] for cath. On arrival to the floor his vitals were T 98 HR 74 124/73 98% RA. He reports being CP free since the stress test. He aslo denies SOB NV. Past Medical History: Coronary artery disease s/p Des to RCA in [**1-/2170**] Hypertension Hypercholesterolemia GERD Social History: -Tobacco history: 10 pack years, quit 1.5 years ago -ETOH: social -Illicit drugs: none Lives in [**Hospital1 **] with his wife and 2 daughters Family History: Father MI [**09**], Brother MI [**08**] otherwise non-contributory Physical Exam: ADMISSION EXAM: VS: T=97.9 BP= 125/82 HR= 65 RR= 18 O2 sat= 98% GENERAL: WDWN Man in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple with JVP of 8 cm. CARDIAC: Distant heart sounds. RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ Pertinent Results: [**2170-8-2**] 04:22AM BLOOD WBC-9.5 RBC-3.67* Hgb-11.0* Hct-31.4* MCV-86 MCH-29.9 MCHC-34.9 RDW-13.6 Plt Ct-174 [**2170-8-2**] 04:22AM BLOOD Glucose-103* UreaN-13 Creat-1.0 Na-139 K-4.9 Cl-99 HCO3-31 AnGap-14 [**2170-7-30**] Intra-op TEE: Conclusions 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. 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 simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). Dr. [**Last Name (STitle) **] was notified in person of the results in the operating room at the time of the procedure. POST BYPASS Normal biventricular systolic function. The thoracic aorta is intact after decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4901**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2170-7-30**] 15:33 ?????? [**2161**] CareGroup IS. All rights reserved Brief Hospital Course: The patient was brought to the Operating Room on [**2170-7-30**] where the patient underwent CABG x 5 with Dr. [**Last 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. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 3 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: Albuterol 2puffs [**Hospital1 **] Clopidogrel 75 mg daily Advair 1 puff [**Hospital1 **] Lisinopril 5mg daily lorazepam 1mg [**Hospital1 **] metoprolol SA 50 mg daily NTG SL PRN Ranitidine 150 mg [**Hospital1 **] Aspirin 325 mg MVI Discharge Medications: 1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for SOB. 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. fluticasone-salmeterol 100-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 4. lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety/sleep. 5. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for CP. 6. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 12. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 13. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 14. furosemide 20 mg Tablet Sig: Two (2) Tablet PO once a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* 15. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day for 7 days. Disp:*14 Tablet Extended Release(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Coronary artery disease s/p Coronary artery bypass graft x 5 Past medical history: Hypertension Hypercholesterolemia GERD 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- 1+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) **] on [**Telephone/Fax (1) 170**] Date/Time:[**2170-9-6**] 1:00 WOUND CARE NURSE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2170-8-9**] 10:00, at Dr.[**Name (NI) 10342**] office [**Hospital Unit Name **] Cardiologist/PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] (for Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] W.) [**Telephone/Fax (1) 4475**], [**8-27**], 3:30pm **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2170-8-2**]

[ "411.1", "530.81", "401.9", "272.4", "V15.82", "V17.3", "V45.82", "V58.63", "414.01", "300.00", "493.90" ]

icd9cm

[ [ [] ] ]

[ "88.56", "36.14", "37.22", "36.15", "39.61" ]

icd9pcs

[ [ [] ] ]

7132, 7181

4215, 5287

331, 720

7346, 7561

2653, 4191

8484, 9159

1953, 2021

5569, 7109

7202, 7263

5313, 5546

7585, 8461

2036, 2634

270, 293

748, 1658

7285, 7325

1792, 1937

3,388

198,808

6015+6016

Discharge summary

report+report

Admission Date: [**2108-1-5**] Discharge Date: [**2108-1-13**] Date of Birth: [**2060-3-25**] Sex: F Service: [**Last Name (un) **] REASON FOR ADMISSION: Pancreas transplant secondary to pancreatic failure. HISTORY OF PRESENT ILLNESS: The patient is a 47 year old female, status post cadaveric renal transplant [**2106-11-2**] for renal failure secondary to insulin dependent diabetes mellitus who presents for pancreas after kidney transplant. On admission patient reports feeling generally well. She denies fever, chills, nausea, vomiting, recent weight loss, chest pain, shortness of breath or dizziness. PAST MEDICAL HISTORY: Significant for CMV virus recently treated in [**2107-10-12**]. Insulin dependent diabetes mellitus times 25 years. Diabetic retinopathy, renal failure, status post cadaveric renal transplant [**2106-11-2**], gastropathy, hypertension, hypercholesterolemia, chronic constipation and a right cataract. PAST SURGICAL HISTORY: Includes cadaveric renal transplant [**10-14**], appendectomy 30 plus years ago, tubal ligation 20 plus years ago, cesarean section 25 plus years ago, uterine ablation [**13**] plus years ago and breast biopsy in [**2102**]. MEDICATIONS ON ADMISSION: Include Prograf 3 mg B.I.D, CellCept [**Pager number **] mg B.I.D, prednisone 5 mg q daily, Bactrim 1 tablet Monday, Wednesday and Friday, Protonix 40 mg q daily, Lipitor 20 mg q daily, Lopressor 50 mg B.I.D, Colace 100 mg B.I.D, Os-Cal-D 500 mg B.I.D and aspirin 81 mg q daily, Humalog sliding scale insulin 12 units q h s. ALLERGIES: To penicillin. FAMILY HISTORY: Positive history of breast cancer and lung cancer on the maternal side. PHYSICAL EXAMINATION: Vital signs: 98.3, 72, 170/90, 18, 97 percent on room air. General: Patient is alert and oriented. She appears comfortable. Head, eyes, ears, nose and throat: Pupils equal, round and reactive to light. Head normocephalic. No jugular venous distension or lymphadenopathy noted. Chest clear to auscultation bilaterally. Heart regular rate and rhythm. Abdomen nondistended, soft, nontender. Extremities: Decreased sensation in the toes bilaterally. 2 plus dorsalis pedis pulses bilaterally. BRIEF HOSPITAL COURSE: The patient was admitted on [**2108-1-5**] for pancreas transplant secondary to pancreatic failure. After complete preop patient underwent transplant after kidney transplant. Post surgery patient was transferred to the post anesthesia care unit in stable condition on PCA for pain control and insulin drip to control blood sugar levels. DICTATION ENDS [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 4841**] Dictated By:[**Last Name (NamePattern1) 16264**] MEDQUIST36 D: [**2108-1-15**] 20:46:37 T: [**2108-1-15**] 22:03:12 Job#: [**Job Number 23669**] Admission Date: [**2108-1-5**] Discharge Date: [**2108-1-13**] Date of Birth: [**2060-3-25**] Sex: F Service: [**Last Name (un) **] REASON FOR ADMISSION: Pancreas transplant secondary to pancreatic failure. HISTORY OF PRESENT ILLNESS: This is a 47-year-old female, status post cadaveric renal transplant on [**2106-11-2**] for insulin-dependent diabetes mellitus, presents for pancreas- kidney transplant on [**2108-1-5**]. On admission the patient reports feeling generally well. She denies fever or chills. No history of vomiting, recent weight loss, bowel changes, dysuria, nausea, vomiting or episodes of dizziness. PAST MEDICAL HISTORY: Significant for recent CMV virus treated in [**10/2107**], insulin-dependent diabetes mellitus times 25 years, renal failure, status post cadaveric renal transplant, diabetic retinopathy, gastropathy, hypertension, hypercholesterolemia, neuropathy, chronic constipation and right cataract. PAST SURGICAL HISTORY: Cadaveric renal transplant [**10/2106**], status post appendectomy 30 plus years ago, status post tubal ligation status post 20 years ago, status post cesarean section 25 plus years ago, status post uterine ablation [**13**] plus years ago, left breast biopsy in [**2102**]. MEDICATIONS: Medications on admission included aspirin 81 mg p.o. once a day, Bactrim one tablet Monday, Wednesday and Friday, CellCept [**Pager number **] mg p.o. twice a day, Prograf 3 mg p.o. twice a day, prednisone 5 mg p.o. twice a day, Protonix 40 mg p.o. twice a day, Lipitor 20 mg p.o. twice a day, Lopressor 50 mg p.o. twice a day, Os-Cal D 500 mg p.o. twice a day, Colace 100 mg p.o. once daily, Humalog sliding scale, Lantus 12 units at bedtime. The history is significant on the maternal side for breast cancer and lung cancer. ALLERGIES: Penicillin. SOCIAL HISTORY: The patient denies tobacco, alcohol or illicit drug use. PHYSICAL EXAMINATION: Vital signs: 98.2 degrees, 72, 170/90, 18, 96 percent on room air. General: The patient is alert and oriented times three. She appears comfortable. HEENT: Normocephalic. No scleral icterus. Pupils are equal, round and reactive to light. No lymphadenopathy or jugular venous distention noted. Chest clear to auscultation bilaterally. Heart regular rate and rhythm without murmur, click or rub rule out gallop. Abdomen nondistended. Bowel sounds normal active, soft, nontender to palpation. Extremities: Decreased sensation in the toes. Dorsalis pedis 2 plus pulses bilaterally. BRIEF HOSPITAL COURSE: The patient presented to [**Hospital1 346**] on [**2108-1-5**] for pancreas-kidney transplant secondary to pancreatic failure. After complete preop, the patient was taken to the Operating Room. The patient underwent pancreas-kidney transplant. The operation was notable for moderate blood loss, required the transfusion of 2 units of blood. Postoperatively, the patient remained stable and after recovering the Post Anesthesia Care Unit, was transferred to the floor in stable condition. On the morning of postoperative day number one, the patient was transferred to a monitored bed because of hypotension with systolic pressures in the 80's. Hematocrit as well was low, down to 27 from 32. The patient was transfused with 2 units packed red cells. On postoperative day two, although clinically appearing stable and with vital signs within normal limits, the patient's hematocrit was again low at 26. Her [**Location (un) 1661**]-[**Location (un) 1662**] again as well was increased up to 695 for 24 hours. She was taken to the Operating Room for wash out and evacuation of one liter hematoma. She required the transfusion of one unit of blood and three packs of platelets for a platelet count of 65. Post-transfusion her creatinine rose to 28.4 and she remained clinically stable. Postoperative day three, again the patient was clinically stable. She was kept n.p.o. and continued to make good urine output. Her blood sugars remained stable. Amylase and lipase were 38 and 19 respectively. Postoperative day number 4 the patient was transferred to the floor in stable condition. Her blood sugars continued to be well controlled and monitored closely. She did have a mild fever up to 101.3 degrees. Blood culture, urine culture and chest x-ray were obtained. The urinalysis and urine culture as well as chest x-ray were unremarkable. However, the blood cultures eventually grew out Staphylococcus coag negative bacteria. She was maintained on vancomycin and Zosyn until the time that the final cultures came back, at which time she was placed on Linezolid therapy. The patient continued to progress well and the graft continued to show good function throughout her hospital course. On postoperative day six, she did require platelet transfusion for platelet count of 87. She continued to remain clinically stable. Her abdominal wound continued to appear well healing. She began ambulating which she did easily and often. She began taking p.o. intake which she tolerated well. Postoperative day no. 7 a pancreatic ultrasound was obtained which showed good vascular flow throughout the pancreas. Postoperative day eight, now with the patient in very stable condition, with blood sugars well controlled without the aid of insulin, and with her amylase and lipase stable, the patient was transferred home in good condition. Throughout her hospital course, she was maintained on immunosuppressive therapy including FK, prednisone, MMF, and ATG. Her levels were checked consistently and her doses were maintained accordingly. DISCHARGE MEDICATIONS: 1. Acyclovir 50 mg p.o. once a day. 2. Metoprolol 50 mg p.o. twice a day. 3. Bactrim single strength 1 tablet p.o. once a day. 4. Prednisone 5 mg p.o. once a day. 5. Propoxyphene 650 mg p.o. q.6h. as needed. 6. Protonix 40 mg p.o. once a day. 7. MF 250 mg p.o. twice a day. 8. Metoclopramide 10 mg p.o. once a day. 9. Linezolid 600 mg p.o. twice a day. 10. Nystatin 100,000 unit per ml suspension, 5 ml p.o. four times a day. 11. Tacrolimus 1 mg p.o. twice a day. 12. Prochlorperazine 10 mg p.o. q.6h. The patient is to have a CBC, chemistry-7, calcium, phosphate, AST, total bilirubin, amylase and lipase with urinalysis every Monday and Thursday. She is to have Tacrolimus level every Monday and Thursday as well obtained with the results called to the Transplant Center. She is to follow-up within one week with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] and Dr. [**First Name (STitle) **] [**Name (STitle) **], MD. Of note, there was a previous dictation that had been started and was cut off in the middle. That dictation can be discarded. [**Name6 (MD) **] [**Name8 (MD) **], [**MD Number(1) 4841**] Dictated By:[**Last Name (NamePattern1) 16264**] MEDQUIST36 D: [**2108-1-15**] 21:11:27 T: [**2108-1-15**] 22:19:01 Job#: [**Job Number 23670**]

[ "357.2", "362.01", "458.29", "250.61", "790.7", "401.9", "250.51", "041.10", "998.12", "V42.0", "250.41", "285.1", "996.62" ]

icd9cm

[ [ [] ] ]

[ "52.82", "99.04", "99.05", "00.93", "54.12" ]

icd9pcs

[ [ [] ] ]

5374, 8427

1609, 1682

8450, 9790

1238, 1592

3809, 4660

4758, 5350

3083, 3471

3494, 3785

4677, 4735

7,546

158,207

5006

Discharge summary

report

Admission Date: [**2188-4-1**] Discharge Date: [**2188-4-23**] Date of Birth: [**2112-8-21**] Sex: F Service: SICU HISTORY AND CLINICAL COURSE: The patient was admitted status post coronary artery bypass grafting times three on [**2188-3-18**] with postoperative fevers and treated for pneumonia and a urinary tract infection with ciprofloxacin and transferred to rehabilitation on [**2188-3-29**]. She was subcutaneously seen at an outside hospital for dyspnea, decreased oxygen saturation and question of left lower lobe pneumonia with a white blood cell count of 19. She was also noted to have a sternal wound drainage, culture positive for Staphylococcus and Enterococcus. The patient was treated with vancomycin and levofloxacin and transferred to the Surgical Intensive Care Unit on [**2188-4-1**]. She was continued on vancomycin and ciprofloxacin here. She was found to have a left pleural effusion and a chest tube was placed on [**2188-4-3**]. She was also consulted from thoracic surgery to plastic surgery for sternal debridement. On [**2188-4-3**], the patient was taken for operative debridement of her sternal wound infection and dehiscence. The chest wall was left open and, on [**2188-4-5**], she had further debridement and flap closure using the right rectus abdominal flap to the chest wall and a left pectoralis advancement flap to the chest wall. The skin was able to be closed with staples in the midline and [**Location (un) 1661**]-[**Location (un) 1662**] drains were left in place Postoperatively, the patient required inotropic support with Dopamine. She also had oxygen requirements. In addition, she had postoperative fevers with a normal white blood cell count most of the time and persistent metabolic alkalosis, which was treated at times with Diamox and subsequently treated with a hydrochloric acid drip. The patient also had persistent respiratory failure issues. Ventilator wean was unsuccessful and, on [**2188-4-18**], the patient had a percutaneous tracheostomy placed. During the hospitalization, with this respiratory failure, the patient underwent several bronchoscopies which were consistent with chronic inflammatory changes. The patient also was seen by neurology for left upper extremity weakness. At the time of this dictation, this weakness is still being worked up by neurology. Unfortunately, the patient is not able to be 100% cooperative with the physical examination and the exact nature of this injury is difficult to discern at this time. However, the patient is scheduled for an EMG study and will be seen by outpatient neurology. A brachial plexopathy is highly differential for this left arm weakness secondary to intraoperative trauma. At the same time, a posterior cord injury is also being entertained as well as a right middle cerebral artery infarction. The patient had a PICC line placed by interventional radiology on [**2188-4-17**]. Despite this patient's chronic hospital course, the flaps and chest wall actually are intact and doing well. The patient is planned for six weeks of vancomycin and, when going to rehabilitation, she should continue this. On [**2188-4-23**], the day of discharge, this patient is on day 24 of vancomycin, so she needs to continue a six week course, for approximately 18 more days. The patient's latest complete blood count shows a white blood cell count of 7.5, hematocrit 28.5 and platelet count 175,000. Chemistries show a sodium of 147, potassium 3.9, chloride 103, bicarbonate 32, BUN 35, creatinine 0.7 and glucose 151. DISCHARGE MEDICATIONS: Lasix p.r.n. to make negative one to two liters daily. Levothyroxine 0.175 mg p.o./ngt q.d. Vancomycin 1 gm i.v.q.24h. Heparin 5,000 units s.c.t.i.d. Lopressor 25 mg p.o.b.i.d. Epogen 3,000 units s.c.q. Monday, Wednesday and Friday. Albuterol and Atrovent nebulizers q.4h. and p.r.n. NPH insulin 80 units s.c.b.i.d. Zoloft 25 mg p.o./ngt q.d. Vitamin C 500 p.o./ngt q.d. Sliding scale regular insulin 151 to 200 fingerstick two units, 201 to 250 four units, 251 to 300 six units, 301 to 350 eight units, 351 to 400 ten units and [**Name8 (MD) 138**] M.D. Zinc sulfate 220 mg p.o./ngt q.d. Potassium chloride 40 mEq p.o.b.i.d. while taking Lasix. Magnesium sulfate p.r.n. magnesium less than 2. Mycostatin powder p.r.n. to skin folds. Calcium gluconate p.r.n. Morphine sulfate 1 to 2 mg i.v.q.4h.p.r.n. Ativan 0.5 mg i.v.q.12h.p.r.n. CONDITION ON DISCHARGE: Stable. DISCHARGE DIAGNOSES: Status post mediastinitis. Coronary artery bypass grafting sternal wound dehiscence with flap reconstruction. Tracheostomy placement. Respiratory failure. Metabolic alkalosis. Left arm weakness. Postoperative fevers. Staphylococcus and Enterococcus wound infection. FO[**Last Name (STitle) **]P: The patient is to follow up with neurology, [**Telephone/Fax (1) **], with Dr. [**Last Name (STitle) **], [**First Name3 (LF) **] call to schedule an appointment in one to two weeks. She is to follow up with plastic surgery in one week, Dr. [**Last Name (STitle) 13797**], for drain management and future plans for flap care. She is to follow up with Dr. [**Last Name (Prefixes) 2545**] from cardiothoracic surgery as needed. She is to follow up with her primary care physician in one to two weeks for management of any further pulmonary issues. DISPOSITION: To rehabilitation. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**] M.D.02-351 Dictated By:[**Last Name (NamePattern1) 8344**] MEDQUIST36 D: [**2188-4-23**] 08:25 T: [**2188-4-23**] 09:34 JOB#: [**Job Number 20725**]

[ "998.59", "511.9", "250.01", "518.81", "244.9", "366.9", "V45.81", "427.31" ]

icd9cm

[ [ [] ] ]

[ "86.22", "86.69", "34.04", "77.61", "83.82", "31.29", "38.93" ]

icd9pcs

[ [ [] ] ]

4484, 5610

3595, 4429

4454, 4463

26,377

133,552

43328

Discharge summary

report

Admission Date: [**2111-4-14**] Discharge Date: [**2111-4-18**] Date of Birth: [**2026-10-28**] Sex: F Service: MEDICINE Allergies: Keflex / Latex Attending:[**First Name3 (LF) 1257**] Chief Complaint: Sympomatic GIB. Major Surgical or Invasive Procedure: None. History of Present Illness: Mrs. [**Known lastname **] is an 84-year-old female with a PMH significant for chronic atrial fibrillation, chronic anemia, and CAD s/p CABG sent to the ED for symptomatic anemia now admitted tot he MICU for GIB. The patient initially presented to her PCP yesterday after feeling orthostatic, dizzy, and increasing short of breath with climbing the 12 steps in her house over the past 3 days. In addition, she states that she has had a dull chest pain going across her chest and radiating for the past 1-2 months, which has been worse in the past 3 days. She denies any change to her bowel movements, including melena or hematochezia. At that time, a hct was checked which today returned as 17 from a baseline of 25-30. She was then referred to the ED for further evaluation. . Of note, the patient has a long history of anemia requiring transfusions with multiple GI evaluations including upper and lower endoscopy, and capsule study without a clear localizing GI source. Since [**2107**], she has received a total of 7 units PRBCs at [**Hospital1 18**]. She is followed by Dr. [**Last Name (STitle) 349**] of Gastroenterology, and Dr. [**Last Name (STitle) 2539**] of Hematology has also evaluated the patient for non-GI sources of anemia, with an unremarkable bone marrow biospy in [**2101**] and SPEP in [**2109**]. . In the [**Hospital1 18**] ED, initial VS afebrile 62 198/61 20 98%RA. The patient was noted to have a hct of 17.6. She has black tarry guaiac positive stools, had a negative NGL, with an ECG that demonstrated lateral STD. She was started on a ppi gtt, transfused 2 units PRBC, and was admitted to the MICU for further management. . Currently, the patient is resting comortably without complaints. Denies any CP/SOB, f/c/s, n/v/d, abd pain, palpitations, orthopnea, PND Past Medical History: 1. Atrial fibrillation - coumadin discontinued in the setting of GI bleed 2. CAD s/p CABG, has stable angina 3. Peripheral vascular disease 4. Hypertension 5. Anemia of chronic disease 6. Obesity 7. Arthritis 8. Irritable bowel syndrome 9. Bilateral renal artery stenosis status post right stent [**8-/2103**] 10. s/p left hip replacement 11. s/p appendectomy 12. s/p tonsillectomy 13. s/p cataract surgery [**14**]. Hypothyroidism 15. Chronic Diastolic Heart Failure Social History: Home: Lives alone. widowed. 5 grown children in the [**Location (un) 86**] area Occupation: previously employed as a substitute teacher part-time; EtOH: Denies Drugs: Denies Tobacco: 1 1/2-2ppd x15 years, quit in the [**2070**] Family History: Mother deceased 94 DM/CAD/MI Father deceased 81 DM/CAD Sister deceased Breast CA/DM Sister deceased [**Name2 (NI) 93302**] child birth/bleed Physical Exam: VS: 97.6 62 200/65 16 98%RA Gen: NAD HEENT: MMM, OP clear. CV: Irregular S1+S2, S4 Pulm: CTAB Abd: S/ND, non-specific TTP +bs Ext: Trace pitting edema bilaterally. Neuro: AOx3, CN II-XII intact aside from difficulty hearing. Pertinent Results: [**2111-4-14**] 09:57PM CK(CPK)-86 [**2111-4-14**] 09:57PM CK-MB-4 cTropnT-0.03* [**2111-4-14**] 09:57PM HCT-25.3*# [**2111-4-14**] 02:19PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.009 [**2111-4-14**] 02:19PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [**2111-4-14**] 02:19PM URINE RBC-1 WBC-2 BACTERIA-FEW YEAST-NONE EPI-4 TRANS EPI-<1 [**2111-4-14**] 01:05PM K+-4.8 [**2111-4-14**] 01:05PM HGB-5.7* calcHCT-17 [**2111-4-14**] 12:35PM GLUCOSE-104* UREA N-60* CREAT-2.1* SODIUM-139 POTASSIUM-5.6* CHLORIDE-105 TOTAL CO2-23 ANION GAP-17 [**2111-4-14**] 12:35PM estGFR-Using this [**2111-4-14**] 12:35PM CK(CPK)-79 [**2111-4-14**] 12:35PM cTropnT-0.04* [**2111-4-14**] 12:35PM CK-MB-4 [**2111-4-14**] 12:35PM DIGOXIN-1.7 [**2111-4-14**] 12:35PM WBC-11.5* RBC-1.97*# HGB-5.5*# HCT-17.6*# MCV-90 MCH-27.7 MCHC-31.0 RDW-18.0* [**2111-4-14**] 12:35PM NEUTS-85.0* LYMPHS-10.3* MONOS-3.8 EOS-0.5 BASOS-0.5 [**2111-4-14**] 12:35PM PLT COUNT-475* [**2111-4-14**] 12:35PM PT-12.9 PTT-22.9 INR(PT)-1.1 . CXR [**2111-4-14**]: Single AP view of the chest demonstrates stable moderate cardiomegaly. The thoracic aorta is tortuous, with mural calcifications. Post-CABG changes and sternotomy wires are redemonstrated. The lungs are low in volume, with bibasilar atelectasis, particularly on the left. There are mild central vascular congestion and a suggestion of Kerley B lines in the left base, raising question of evolving early edema. There is no pneumothorax or pleural effusion. The left costophrenic angle is partially excluded. Multilevel lumbar spondylosis is present. IMPRESSION: Stable cardiomegaly, mild central vascular congestion, and possible evolving early edema. Bibasilar dependent atelectasis more pronounced on the left. No definite consolidation to suggest pneumonia. Brief Hospital Course: Mrs. [**Known lastname **] is an 84-year-old woman with chronic atrial fibrillation (off Coumadin), chronic anemia followed by Dr. [**Last Name (STitle) 2539**] (history of bone marrow biopsy), renovascular resistant hypertension with renal artery stent (complicated with occlusion), and coronary and peripheral artery disease who presented to [**Hospital1 18**] MICU on [**2111-4-14**] with symptomatic anemia related to her third episode of major gastrointestinal bleeding. Her previous extensive GI work up was nondiagnostic (EGD, colonoscopy and incomplete capsule endoscopy). She was taken off Coumadin after her second major bleeding and now she has a recurrent significant anemia while taking aspirin only. On MICU presentation, she had mild elevation of troponin (0.04) with mild nonspecific lateral ECG changes. The MICU team was concerned about demand ischemia but she had no evidence of acute myocardial infarction. In the MICU, 2 PI Vs were placed and her hemodynamics were carefully monitored. Patient was seen by GI, who recommended endoscopy. She was severely hypertensive without evidence of hypertensive emergency. She received 5 units of RBC transfusion for an initial Hgb of 5.5 and hematocrit of 17.6. Her Endoscopy EGD) showed no source of bleeding despite guaiac positive stools. The GI service recommended capsule endoscopy if she develops recurrent bleeding. During her hospitalization, she was noted to have worsening kidney function along with Labetalol and Digoxin chronic toxicity with classic saggy ST depression, atrial fibrillation with very slow ventricular response rate as low as 30 (range 30-40), and mildly elevated digoxin level of 2.3 (does not correlate with toxicity). Her Labetalol and Digoxin were discontinued and her severe hypertension was treated with Imdur (new medication), Hydralazine, and Norvasc. After her heart rate recovered, we restarted the Labetalol because of CAD and uncontrolled hypertension. We did NOT restart Digoxin because of risk of toxicity in elderly with CKD. Her heart rate recovered to 50-70 even after restarting the Labetalol. We also added Minoxidil (new medication) for better control as her SBP was 170-200. She was not candidate for ACE/[**Last Name (un) **] because of risk of hyperkalemia and worsening CKD because of RAS and treatment with Aldactone. She was also noted to be on 3 different diuretics (Aldosterone, HCTZ, and Torsemide). These diuretics were held in the setting of acute worsening of her kidney function. We restarted Aldactone and Torsemide but not the HCTZ because of decreased GFR (decreased efficacy) and risk of electrolyte abnormalities. Several medication changes were made to address her uncontrolled hypertension, worsening kidney function and bradycardia (see below). We communicated the above with her Cardiologist, PCP, [**Name10 (NameIs) **], and her hematologist. We also discussed findings with her daughter who is her HCP and explained all her medications in details. We asked her to follow up with her PCP for frequent [**Name Initial (PRE) **]/H monitoring. Medications on Admission: Atorvastatin 10 mg daily Digoxin 125 mcg daily Amlodipine 10 mg daily Hydralazine 50 mg po tid Labetalol 100 mg po bid Aldactone-HCTZ 25-25 daily Torsemide 10 mg daily Levothyroxine 88 mcg daily NTG SL prn ASA 81 mg daily Omeprazole 20 mg daily Triamcinolone crm Flucinolone crm for scalp Hydrocortisone-pramoxine crm prn Folate Discharge Disposition: Home Discharge Diagnosis: Blood loss anemia Third major GI bleeding Atrial fibrillation with severe bradycardia. Betablocker and Digoxin Toxicity. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted because of blood loss anemia. You were treated with blood transfusions. An upper endoscopy did not show the source of bleeding. We noted that you had worsening of your kidney function along with severe slowing of your heart rate. We communicated with your primary care physician and Cardiologist regarding several changes to your medications to address your very low heart rate. Please call your PCP and hematologist for follow up appointment and check your blood level next week. We have made several changes to your medications. Please take the new ones only and do not mix with old medications. Followup Instructions: Department: VASCULAR SURGERY When: THURSDAY [**2111-8-13**] at 10:15 AM With: VASCULAR LAB [**Telephone/Fax (1) 1237**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: VASCULAR SURGERY When: THURSDAY [**2111-8-13**] at 11:15 AM [**Telephone/Fax (1) 1237**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: VASCULAR SURGERY When: THURSDAY [**2111-8-13**] at 11:15 AM With: VASCULAR LAB [**Telephone/Fax (1) 1237**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

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icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

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292, 299

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3,392

136,949

16773+56803

Discharge summary

report+addendum

Admission Date: [**2171-12-26**] Discharge Date: [**2172-1-21**] Date of Birth: [**2134-12-19**] Sex: F Service: Transplant Surgery HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 47382**] is a 37-year-old female with a past medical history significant for hepatitis C cirrhosis (Child class B) with end-stage liver disease who is listed for transplant. The patient presented to the Emergency Department with the acute onset of abdominal pain. This was associated with nausea and vomiting, but no fevers or chills. She states that she has had a bowel movement and has passed flatus in the recently. A workup done in the Emergency Department demonstrated a small-bowel obstruction with a focal transition point as seen on computed tomography scan. She was aggressively resuscitated in the Emergency Department and was taken to the operating room for an exploratory laparotomy. PAST MEDICAL HISTORY: 1. Hepatitis C. 2. Child class B/C cirrhosis. 3. Non-Hodgkin lymphoma. 4. History of Clostridium difficile colitis. 5. History of esophageal varices. 6. Status post multiple episodes of lower extremity cellulitis. 7. Status post splenectomy. 8. Status post multiple skin grafts. MEDICATIONS ON ADMISSION: 1. Lasix 20 mg by mouth twice per day. 2. Aldactone 50 mg by mouth once per day. 3. Ursodiol 300 mg by mouth three times per day. 4. Nadolol 20 mg by mouth once per day. 5. Protonix 40 mg by mouth once per day. 6. Doxepin 10 mg by mouth once per day. 7. Keflex 250 mg. ALLERGIES: The patient denies any known drug allergies. FAMILY HISTORY: The patient has a family history of congestive heart failure and hypercholesterolemia. SOCIAL HISTORY: The patient does computer work for the [**Company 26765**]. She denies tobacco and alcohol use. She lives with her mother and brother. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed her temperature was 98 degrees Fahrenheit, her heart rate was 105, and her blood pressure was 126/60. In general, the patient was awake but not responsive. Her heart was tachycardic without murmurs. The lungs were clear to auscultation. The abdomen was obese, soft, tender to palpation in the left lower quadrant but not firm or distended. The skin was pale but warm. PERTINENT LABORATORY VALUES ON PRESENTATION: Pertinent laboratory studies revealed her white blood cell count was 17. Her hematocrit was 26. Prothrombin time was 16, partial thromboplastin time was 36, and her INR was 1.7. Her creatinine was 1.1. Her aspartate aminotransferase was 86, alanine-aminotransferase was 44, total bilirubin was 4.7, and her amylase was 30. BRIEF SUMMARY OF HOSPITAL COURSE: On the day of admission, the patient was taken to the operating room where an exploratory laparotomy was performed along with lysis of adhesions for a small-bowel obstruction. She tolerated the procedure well and was discharged to the Surgical Intensive Care Unit for postoperative monitoring. The patient's postoperative course was complicated by hepatic encephalopathy and coagulopathy with resulting prolonged extubation. Due to her decompensated liver disease, she had persistently elevated creatinine levels and INR. The encephalopathy resolved slowly with the use of lactulose. She also received multiple blood products throughout her hospital stay. She was initially treated with total parenteral nutrition for nutritional support; however, this was transitioned to tube feeds during her hospital stay. On postoperative day 19, the patient was successfully extubated. Throughout her stay, she was treated with vancomycin, Zosyn, and fluconazole for positive sputum and urine cultures. The patient was transferred to the floor on postoperative day 20 with improvement in her encephalopathy. By this time, her creatinine had returned to a stable level at 0.5. Her aspartate aminotransferase, alanine-aminotransferase, and total bilirubin levels remained elevated but stable throughout her hospitalization. During her hospitalization, she was evaluated for transplantation and was seen by the Dental Service and the Ophthalmology Service. After a video swallow study was done on [**2172-1-16**], the patient was started on an oral diet. On postoperative day 24, the patient's staples were removed and Steri-Strips were applied. There was an area approximately 5 mm X 5 mm that remained open and packed with wet-to-dry gauze dressing changes. On postoperative day 26, after completing a 14-day course of vancomycin, she was discharged to rehabilitation in stable condition. She was to remain on lactulose as treatment for her encephalopathy. At the time of discharge, her INR remained stable in the 2.5 range to 2.7 range. The remainder of her liver enzymes remained elevated but stable. CONDITION AT DISCHARGE: Condition on discharge was good. DISCHARGE STATUS: The patient was discharged to a rehabilitation facility for physical therapy and wound care. DISCHARGE DIAGNOSES: 1. Hepatitis C. 2. Child class B/C cirrhosis. 3. Non-Hodgkin lymphoma. 4. History of Clostridium difficile colitis. 5. History of esophageal varices. 6. Status post splenectomy. 7. Status post multiple skin grafts. 8. Status post exploratory laparotomy with lysis of adhesions for a small-bowel obstruction. 9. Hepatic encephalopathy. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was instructed to follow up with the [**Hospital 9786**] Clinic for further evaluation. 2. The patient was instructed to use her eyedrops as needed with Ophthalmology followup per her discretion. 3. The patient was instructed to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in approximately two weeks for assessment. MEDICATIONS ON DISCHARGE: 1. Albuterol inhaler as needed. 2. Artificial Tears 1 to 2 drops to both eyes as needed. 3. Lactulose 30 mg by mouth three times per day. 4. Insulin sliding-scale (as written). 5. Prevacid 30 mg by mouth once per day. 6. Spironolactone 25 mg by mouth once per day. 7. Ursodiol 300 mg by mouth three times per day. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 1331**] Dictated By:[**Last Name (NamePattern1) 26023**] MEDQUIST36 D: [**2172-1-21**] 10:22 T: [**2172-1-21**] 10:30 JOB#: [**Job Number 47383**] Name: [**Known lastname 8766**], [**Known firstname 3410**] Unit No: [**Numeric Identifier 8767**] Admission Date: [**2171-12-26**] Discharge Date: [**2172-1-23**] Date of Birth: [**2134-12-19**] Sex: F Service: Transplant Surgery ADDENDUM: Mrs. [**Known lastname **] was discharged to rehabilitation on [**2172-1-23**]. She stayed longer than the anticipated discharge date of [**2172-1-21**], in order to receive physical therapy and occupational therapy as needed. Prior to discharge, her midline wound was opened with a sterile hemostat clamp and patched with 1/4 inch Nu-Gauze. She will continue to have this wound packed twice daily with wet to dry dressing changes until it granulates in. She was again instructed to follow up if she had any questions or concerns. [**First Name11 (Name Pattern1) 399**] [**Last Name (NamePattern4) 2801**], M.D. [**MD Number(1) 401**] Dictated By:[**Last Name (NamePattern1) 7438**] MEDQUIST36 D: [**2172-1-22**] 15:41 T: [**2172-1-22**] 17:50 JOB#: [**Job Number 8768**]

[ "482.41", "790.7", "518.5", "286.7", "571.5", "452", "070.44", "560.81", "276.5" ]

icd9cm

[ [ [] ] ]

[ "54.59", "50.12", "96.72", "38.93", "38.91", "99.04", "99.15", "33.22", "99.07" ]

icd9pcs

[ [ [] ] ]

1595, 1683

4985, 5330

5765, 7456

1242, 1577

5363, 5739

2681, 4802

4817, 4964

182, 906

928, 1216

1700, 2652

13,992

111,514

18926

Discharge summary

report

Admission Date: [**2180-2-4**] Discharge Date: [**2180-3-9**] Date of Birth: [**2104-1-23**] Sex: M Service: SURGERY Allergies: Amiloride / Atenolol / Cardura / Amoxicillin Attending:[**First Name3 (LF) 2597**] Chief Complaint: AAA Major Surgical or Invasive Procedure: 1. Resection and repair of abdominal aortic aneurysm with 18 mm Dacron tube graft. 2. Flexible sigmoidoscopy [**2180-2-7**] 3. Flexible sigmoidoscopy [**2180-2-15**] History of Present Illness: This 76-year-old gentleman has a 5.5 cm aneurysm of the infrarenal aorta. The anatomy was unsuitable for endovascular repair. Past Medical History: COPD, asthma, CAD recent angio for unstable angina, Chronic afib, HTN, OSA, GERD, freq nose bleeds, s/p pilonidal cyst Social History: pos smoker pos alcohol Family History: non contributary Physical Exam: PE: AFVSS NEURO: PERRL / EOMI MAE Neg pronator drift Sensation intact to ST Neg Babinski HEENT: NCAT Neg lesions nares, oral pharnyx, auditory Supple / FAROM / Trach placed without signs of infection neg lyphandopathy, supra clavicular nodes LUNGS: CTA b/l CARDIAC: RRR without murmers ABDOMEN: Soft, NTTP, ND, pos BS, neg CVA tenderness, PEG tube placed EXT: rle - palp fem, [**Doctor Last Name **], pt, dp lle - palp fem, [**Doctor Last Name **], pt, dp Pertinent Results: INDICATION: 76-year-old man status post abdominal aortic aneurysm repair. Please place PICC line. TECHNIQUE/FINDINGS: The patient was placed supine on the angiography table. Ultrasound demonstrated patent left brachial and basilic veins. The left arm was prepped and draped in the usual sterile fashion. 1% lidocaine was administered subcutaneously for local anesthesia. Under ultrasound guidance, at 21-gauge introducer needle was inserted into the left basilic vein. A 0.018-inch guide wire was advanced through the needle into the superior vena cava using fluoroscopic guidance. The needle was exchanged for an introducer sheath and then a 4-French single lumen PICC was cut to a length of 48 cm based on the markings on the wire. The PICC was placed over the wire through the sheath and the wire and sheath were removed. The catheter was flushed and aspirated, capped and heplocked. The catheter was fixed in place using a statlock device, and sterile transparent dressing was applied. A final limited chest radiograph confirmed catheter tip position in the superior vena cava/right atrial junction. There were no procedural, or immediate post- procedural complications. The catheter is ready for use. IMPRESSION: Successful placement of a 48-cm 4-French single lumen PICC by way of the left basilic vein, with the tip in the superior vena cava. The catheter is ready for use. [**2180-3-7**] 4:57 AM CHEST (PORTABLE AP) FINDINGS: The left lung base and extreme right lung base are excluded from the radiograph. Allowing for this factor, the cardiomediastinal silhouette appears stable. A tracheostomy tube and right subclavian venous catheter remain unchanged in standard positions. No pneumothorax or mediastinal widening is present. A small to moderate right and smaller left pleural effusion are unchanged. The pulmonary vasculature is normal. There is continued right infrahilar opacity, which could represent a small pneumonia. IMPRESSION: Limited study secondary to exclusion of the lung bases from the radiograph. Persistent small to moderate bilateral pleural effusions with right perihilar opacity, which could represent focal pneumonia. If clinically indicated, the chest radiograph can be repeated with no additional cost to the patient. [**2180-2-25**] 11:11 AM MR HEAD W/O CONTRAST; MRA BRAIN W/O CONTRAST No prior studies are available for comparison. TECHNIQUE: Multiplanar T1- and T2-weighted images of the brain were obtained, with diffusion-weighted images. MRI OF THE BRAIN: The study is somewhat limited by motion artifact. The ventricles and sulci are prominent, consistent with involutional change. There is no shift of normally midline structures. There are no foci of restricted diffusion within the brain to suggest acute infarction. There are small foci of T2-hyperintensity within the cerebral periventricular white matter, nonspecific, likely representing chronic micro-ischemic change, and small chronic lacunes are noted within the right basal ganglia and periventricular white matter. There are no abnormal foci of susceptibility within the brain to indicate either acute or chronic hemorrhage. Fluid is noted within both mastoid air cells, perhaps related to prolonged supine position and/or intubation. MRA OF THE BRAIN: The intracranial vertebral and internal carotid arteries are patent with normal signal. Minimally attenuated middle cerebral arteries with mural irregularity, bilaterally, consistent with mild atherosclerotic change. The major vessels of the circle of [**Location (un) 431**] are patent, without aneurysmal dilation or flow-limiting stenosis. The left vertebral artery terminates in the left PICA, a common anatomic variant. IMPRESSION: 1. No evidence of hemorrhage, acute infarct or cerebral edema. 2. Foci of T2 hyperintensity within the cerebral periventricular white matter, likely representing chronic microvascular ischemic change. Small lacunar infarctions are noted particularly within the right periventricular cerebral white matter. 3. Unremarkable cranial MRA with no flow-limiting stenosis. EEG Study Date of [**2180-2-21**] OBJECT: EVALUATE FOR SEIZURES. FINDINGS: ABNORMALITY #1: Throughout this recording, a generally slowed background rhythm was seen. It was predominantly in the mixed theta frequency range. No sharp or epileptiform features were observed. At times, normal waking background rhythms were seen. SLEEP: No stage II sleep was observed. CARDIAC MONITOR: Showed an irregularly irregular rate and rhythm. IMPRESSION: This is a mildly abnormal EEG due to the presence of theta frequency background slowing seen predominantly throughout this recording. No focal or epileptiform features were observed. Common causes of encephalopathies include medications, metabolic processes, infectious processes, and anoxic events. Note is made of an irregular cardiac rhythm [**2180-2-14**] 11:32 AM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST INDICATION: Recent abdominal aortic aneurysm repair, now with leukocytosis. COMPARISON: CT of the abdomen and pelvis from [**2180-2-6**]. TECHNIQUE: Multidetector CT scanning was performed from the level of the thoracic inlet to the level of the pubic symphysis after the administration of oral and intravenous contrast (150 cc of Optiray). CT OF THE CHEST: An endotracheal tube tip terminates 7.2 cm above the carina on the scout image. Nasogastric tube tip is seen within the fundus of the stomach. A right-sided Swan-Ganz catheter tip is in the right main pulmonary artery. A left central venous line tip is in the superior vena cava. Borderline lymphadenopathy is seen in the paratracheal, precarinal, subcarinal, and prevascular regions, the largest node measures 12 mm in short axis and is best seen on series 2, image 28. There is a small pericardial effusion. The heart and great vessels appear unremarkable. Again seen are extensive emphysematous changes in the lungs bilaterally. Small bilateral pleural effusions are seen with associated adjacent compressive atelectasis. In the left lower lobe, fluid-filled bronchi are seen within areas of atelectasis. CT OF THE ABDOMEN: The liver, gallbladder, adrenal glands, spleen, and pancreas appear unremarkable. There is a small amount of fluid in the perihepatic region, as well as the right and left paracolic gutters and anterior to Gerota's fascia on the left. The loops of small and large bowel appear normal in caliber and contour. The kidneys enhance and excrete contrast symmetrically. Again seen is a right parapelvic cyst, which is unchanged since the prior study. The previously seen retroperitoneal stranding in the perirenal and pararenal spaces is improved since the prior study. Again seen is thickening of Gerota fascia, left greater than right. The patient is status post open abdominal aortic aneurysm repair, with skin staples seen along the lateral left abdominal wall. There is shotty retroperitoneal and mesenteric lymphadenopathy, without pathologically enlarged lymph nodes by CT criteria. No free air is identified within the abdomen or within the subcutaneous soft tissues. CT OF THE PELVIS: There is a Foley catheter within the urinary bladder, with an air- fluid level in the bladder lumen. The prostate, seminal vesicles, and rectum appear unremarkable. Some free fluid is seen within the pelvis as well as few scattered borderline pelvic lymph nodes, which do not meet criteria for pathologic enlargement. There is pronounced subcutaneous fat stranding in the anterior soft tissues. No concerning lytic or sclerotic lesions are identified within the osseous structures. IMPRESSION: 1. Improved retroperitoneal fat stranding with persistent free fluid seen within the abdomen and the pelvis. Subcutaneous fat stranding is seen in the distal anterior abdominal wall, which may be related to subcutaneous edema although cellulitis in this area cannot be excluded. Clinical correlation is recommended. 2. Small bilateral pleural effusions with associated compressive atelectasis. In the left base, there are fluid-filled bronchi within atelectatic lung; infected fluid within bronchi cannot be excluded. 3. Extensive emphysematous changes in the lungs bilaterally. 4. Lines and tubes in appropriate positions. [**2180-2-7**] Left Ventricle - Ejection Fraction: 50% to 55% (nl >=55%) INTERPRETATION: Findings: Study done in the ICU secondary to hemodynamioc instability and hypoxia LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast or thrombus in the LA/LAA or the RA/RAA. All four pulmonary veins identified and enterthe left atrium. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. A catheter or pacing wire is seen in the RA and extending into the RV. Secundum ASD. The IVC is normal in diameter with appropriate phasic respirator variation. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Low normal LVEF. No resting LVOT gradient. No LV mass/thrombus. 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 ascending aorta diameter. Simple atheroma in ascending aorta. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Mild thickening of mitral valve chordae. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. Normal main PA. PERICARDIUM: No pericardial effusion. Conclusions: The left atrium is mildly dilated. No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. A secundum type atrial septal defect is present. Overall left ventricular systolic function is low normal (LVEF 50-55%). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the ascending aorta. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no pericardial effusion. [**2180-2-7**] 8:51 AM UNILAT UP EXT VEINS US RIGHT P TECHNIQUE: Right upper extremity venous ultrasound and Doppler examination. FINDINGS: The right internal jugular vein shows normal color and spectral Doppler flow. The right subclavian vein also shows normal flow characteristics. The right axillary, brachial and basilic veins show normal compressibility, augmentation, and Doppler flow and waveforms. There is no intraluminal thrombus identified. IMPRESSION: No evidence of deep vein thrombosis. [**2180-3-9**] 03:36AM COMPLETE BLOOD COUNT White Blood Cells 11.0 Hemoglobin 9.2 Hematocrit 28. MCV 92 MCH 29.9 MCHC 32.7 RDW 15.1 Platelet Count 531* [**2180-3-9**] 03:36AM RENAL & GLUCOSE Glucose 100 Urea Nitrogen 19 Creatinine 0.5 Sodium 142 Potassium 3.7 Chloride 107 Bicarbonate 26 Anion Gap 13 CHEMISTRY Calcium, Total 8.1 Phosphate 2.7 Magnesium 1.9 HEMATOLOGIC Vitamin B12 790 PITUITARY Thyroid Stimulating Hormone 4.0 OTHER ENDOCRINE Cortisol 14.7 [**2180-2-19**] 3:51:30 PM Atrial fibrillation Anterior T wave changes are nonspecific Repolarization changes may be partly due to rhythm No change from previous Intervals Axes Rate PR QRS QT/QTc P QRS T 80 0 82 398/433.71 0 72 89 [**2180-2-18**] 08:51PM GENERAL URINE INFORMATION Urine Color Yellow Urine Appearance Clear Specific Gravity 1.009 DIPSTICK URINALYSIS Blood NEG Nitrite NEG Protein NEG Glucose NEG Ketone NEG Bilirubin NEG Urobilinogen NEG pH 8.0 Leukocytes NEG [**2180-3-5**] 3:03 pm Source: Left Subclavian CVL. WOUND CULTURE (Final [**2180-3-7**]): No significant growth. [**2180-2-28**] MRSA SCREEN Source: Nasal swab. STAPH AUREUS COAG +. MODERATE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML STAPH AUREUS COAG + | OXACILLIN------------- R [**2180-3-5**] 12:41 am URINE URINE CULTURE (Final [**2180-3-6**]): NO GROWTH. [**2180-2-21**] 4:06 pm BRONCHOALVEOLAR LAVAGE GRAM STAIN (Final [**2180-2-21**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2180-2-27**]): OROPHARYNGEAL FLORA ABSENT. PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. KLEBSIELLA PNEUMONIAE. RARE GROWTH. ENTEROBACTER CLOACAE. RARE GROWTH. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. KLEBSIELLA PNEUMONIAE | ENTEROBACTER CLOACAE | | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN--------- <=0.25 S GENTAMICIN------------ <=1 S <=1 S IMIPENEM-------------- <=1 S <=1 S LEVOFLOXACIN----------<=0.25 S <=0.25 S MEROPENEM-------------<=0.25 S <=0.25 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=20 S <=1 S [**2180-3-6**] ALT: 87 AP: 268 Tbili: 0.3 AST: 149 [**2180-3-6**] URINE UreaN: 1189 Creat: 111 Na: 23 Osmolal:675 [**2180-2-20**] 10:13 pm BLOOD CULTURE AEROBIC BOTTLE (Final [**2180-2-26**]): NO GROWTH. ANAEROBIC BOTTLE (Final [**2180-2-26**]): NO GROWTH. Brief Hospital Course: Pt had a difficult hospital course Pt admitted on [**2180-2-4**] [**2180-2-4**] - [**2180-2-5**] Underwent a Resection and repair of abdominal aortic aneurysm with 18 mm Dacron tube graft. The procedure went well. There were no complications. Pt transfered to the PACU instable condition / intubted, with epidural. Pt recieved 6 ltrs fluid intra-op. [**2180-2-6**] Pt intubated / difficult wean transfer to the SICU for cont care. Pt drops O2 sats / with fevers to 104 / pan cx'd with cxr and CTA Requires increase in vent support. Pt found to have pnuemonia / broad spectrum antibioticcs started. diuresed / serial ABG's followed [**2180-2-7**] - [**2180-2-10**] Swan placed Flexible sigmoidoscopy to r/o bowel ischemia / neg for colitis epidural stopped / requires pressors / vent support Nutrition consult / TPN started / cw fevers and increase wbc [**2180-2-11**] Bronchoscopy performed (pos for exudate) TPN s / cw fevers and increase wbc pressors / vent support Aggressive pulm toilet [**2180-2-12**] Bronchoscopy performed (pos for exudate) TPN s / cw fevers and increase wbc pressors / vent support Aggressive pulm toilet General surgery consulted / fevers and increase wbc [**2180-2-14**] Flexible sigmoidoscopy ( neg for colitis ) Bronchoscopy pos mucos plug RLL TPN / cw fevers and increase wbc pressors / vent support Aggressive pulm toilet [**2180-2-15**] TPN / cw fevers and increase wbc pressors / vent support Aggressive pulm toilet ID consult / Pulmonary consulted Lines swithed / pan cx [**2180-2-16**] TPN / cw fevers and increase wbc pressors / vent support Aggressive pulm toilet [**2180-2-17**] - [**2180-2-19**] TPN off / Tube feeds started / insulin drip for increase BS cw fevers and slight decrease in wbc pressors / vent support Aggressive pulm toilet NGT DC'D - OGT placed [**2180-2-20**] Nuero consult / MRI / EEG pressors / vent support Aggressive pulm toilet [**2180-2-21**] Bronchcoscopy performed ( pos for exudate ) [**2180-2-22**] - [**2180-2-27**] cw fevers and slight decrease in wbc pressors / vent support Aggressive pulm toilet pt found to have increase in sodium / free water given / mental status improves Peep is decreased / lasix is DC'd / pt is even on pre-op weight AB tailored to sesitivities / Vancomycin DC's / Cefipime continued [**2180-2-28**] - [**2180-2-29**] cw fevers and slight decrease in wbc pressors / vent support Aggressive pulm toilet pt found to have increase in sodium / free water given / mental status improves [**2180-3-1**] - PEG / Trachea placement cw fevers and slight decrease in wbc pressors / vent support Aggressive pulm toilet increase in sodium / free water given / [**2180-3-2**] TF started Pt mental / resp staus improves / teperature improves pressors are weaned off / vent support Aggressive pulm toilet C-Diff neg x two Pt allowed OOB to chair OT / PT consult [**2180-3-3**] OOB vent support Aggressive pulm toilet / TF [**2180-3-4**] - [**2180-3-5**] vent support Aggressive pulm toilet / TF Decrease FiO2 / peep OT / PT [**2180-3-6**] Cefipime DC'd / Zosyn started pt kept negative with gentle diuresis OOB vent support Aggressive pulm toilet / TF [**2180-3-7**] - [**2180-3-10**] TF at goal Heparin DC'd / cw coumadin WBC stable / Afebrile Pt stable for DC to [**Hospital 5442**] rehab Taking TF / OOB to chair / pos BM / foley to gravity Medications on Admission: Albuterol, ASA, Digoxin, Diltiazem, Diovan, Lasix, Protonix, Simvastatin, plavix Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed. 4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 5. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime) for 1 doses: moniter INR goal is [**1-7**]. 6. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous after meds / qid / as needed as needed. 7. Potassium Chloride 20 mEq Packet Sig: Two (2) Packet PO PRN (as needed) as needed for K<4.0. 8. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 10. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 12. Lansoprazole Oral 13. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO QID (4 times a day) as needed for Ca<1.12. 14. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 15. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed. 16. Morphine Sulfate 2 mg IV Q4H:PRN 17. Hydralazine 20 mg/mL Solution Sig: One (1) Injection Q4H (every 4 hours) as needed for SBP>150. 18. Piperacillin-Tazobactam 4.5 g Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours). 19. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 20. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 21. Metoclopramide 5 mg/mL Solution Sig: One (1) Injection Q6H (every 6 hours). 22. Magnesium Sulfate 50 % Solution Sig: One (1) Injection PRN (as needed) as needed for Mg<2.0. 23. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**12-6**] Puffs Inhalation Q4H (every 4 hours) as needed. 24. Insulin Sliding Scale & Fixed Dose Fingerstick Q1H Insulin SC Fixed Dose Orders Breakfast Bedtime NPH 30 Units NPH 20 Units Insulin SC Sliding Scale Regular Glucose Insulin Dose 0-59 mg/dL [**12-6**] amp D50 60-120 mg/dL 0 Units 121-160 mg/dL 3 Units 161-200 mg/dL 6 Units 201-240 mg/dL 9 Units 241-280 mg/dL 12 Units 281-320 mg/dL 15 Units 321-360 mg/dL 18 Units > 360 mg/dL Notify M.D. Adjust sliding scale as needed / wean off of q 1 hr / to qid Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast [**Location (un) 38**] Discharge Diagnosis: AAA SIRS / septic shock likely pulm etiology. Difficulty weaning from ventalator bilateral lower lobe pneumonia. unresponsiveness likely [**1-6**] encephalopathy (from PNA) Stupor ARF ICU sinusitis Discharge Condition: Stable / vented / g-tube Discharge Instructions: Log term care: G - tube care Trach care Vent support Wound care watch for: respiratory problems signs of infection bowel problems Followup Instructions: When Stable Follow-up with Dr [**Last Name (STitle) **] office at [**Telephone/Fax (1) 51748**] Completed by:[**2180-3-9**]

[ "486", "493.20", "441.4", "584.9", "995.94", "785.52", "427.31", "276.2", "997.3", "401.9", "473.9", "518.5" ]

icd9cm

[ [ [] ] ]

[ "96.6", "99.15", "43.11", "38.44", "38.93", "45.24", "31.1", "96.72", "33.23" ]

icd9pcs

[ [ [] ] ]

21983, 22062

15786, 19219

306, 477

22304, 22331

1359, 15763

22512, 22639

831, 849

19350, 21960

22083, 22283

19245, 19327

22355, 22489

864, 1340

263, 268

505, 633

655, 775

791, 815

11,067

151,910

14822

Discharge summary

report

Admission Date: [**2155-10-4**] Discharge Date: [**2155-10-8**] Date of Birth: Sex: M Service: GEN [**Doctor First Name 147**] HISTORY OF PRESENT ILLNESS: This is the dictation of Discharge Summary which had been left neglected by the resident staff. This was a 79 year old man who was transferred to my care from the [**Hospital 16843**] Hospital with purported mesenteric ischemia. In [**2131**], he apparently had undergone a Whipple procedure for an apparent benign neuro-endocrine tumor. Several years later and approximately three years prior to the present admission, he had been admitted to the [**Hospital 43537**] Medical Center for what appeared consistent with obstructive cholangitis. From what I could determine, the patient had had intrahepatic biliary duct stones which were successfully treated by lithotripsy and percutaneous drainage. He then did well until the present admission. Three weeks prior to presentation to [**Hospital 16843**] Hospital, the patient had developed progressive shortness of breath and crampy abdominal pain with nausea; 48 hours prior to transfer here he was admitted to the outlying hospital where he was septic and completely anuric. I was told that a colonoscopy on [**9-9**] had been unremarkable and had been performed for anemia. The patient also was found to be in new onset atrial fibrillation at the time of his transfer to us. PAST MEDICAL HISTORY: 1. Insulin dependent diabetes mellitus. 2. History of deep venous thrombosis. 3. Hypertension. 4. History of upper gastrointestinal bleed. 5. History of prior tracheotomy and Whipple procedure. MEDICATIONS: 1. Paxil. 2. Lisinopril. 3. Insulin. 4. Ranitidine. LABORATORY: On admission, the white blood cell count was 67,000 with a hematocrit of 35. The platelets were 25,000 with laboratories consistent with disseminated intervascular coagulation. The creatinine was 3.7. His liver function tests were diffusely elevated with a total bilirubin of 9.7. He was acidotic with a pH of 7.21. His lactate was 6. HOSPITAL COURSE: The patient was transferred by [**Location (un) 7622**] Helicopter and was intubated en route. After presentation here, he was immediately transferred to the Intensive Care Unit. I performed a bedside rigid sigmoidoscopy which showed normal mucosa to 20 cm. His stool was heme negative. Reviewing the CT scan from the outside lying hospital, he clearly had intrahepatic ductal dilatation. He was profoundly septic requiring intravenous Levophed. He was taken to the Interventional Radiology Suite where a successful transhepatic cholangiogram was performed showing complete obstruction, presumably at the level of a previous hepaticojejunostomy. A catheter was left to external drainage. Over the next two days, he remained profoundly hypotensive requiring multiple pressors. He was maintained on broad spectrum antibiotics. His urine output was restored to a very low level of oliguria. He developed progressive dry gangrene of the fingers and toes. Despite his very very modest improvement, after consultation with the family, in view of his grim prognosis, he was made comfort measures only and expired on [**2155-10-8**]. CONDITION AT DISCHARGE: Expired. DISCHARGE STATUS: Expired. DISCHARGE DIAGNOSES: Ascending cholangitis with biliary tract obstruction. SURGICAL PROCEDURES AND DATE: None. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**], M.D. [**MD Number(1) 521**] Dictated By:[**Last Name (NamePattern4) 1779**] MEDQUIST36 D: [**2155-12-9**] 13:39 T: [**2155-12-9**] 15:52 JOB#: [**Job Number 43538**]

[ "584.5", "038.3", "276.2", "518.81", "785.59", "286.6", "576.1", "V10.09", "576.2" ]

icd9cm

[ [ [] ] ]

[ "51.98", "99.15", "48.23", "38.91", "89.64", "38.93", "87.51", "96.72" ]

icd9pcs

[ [ [] ] ]

3304, 3672

2078, 3227

3243, 3282

180, 1415

1437, 2060

19,275

153,723

26442

Discharge summary

report

Admission Date: [**2117-3-25**] Discharge Date: [**2117-5-6**] Date of Birth: [**2051-3-2**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 148**] Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: [**2117-3-25**] ERCP with stent placement [**2117-4-3**] 1. Exploratory laparotomy. 2. Washout and drainage of peritoneal cavity. 3. External drainage of the pseudocyst. 4. Debridement of pancreatic necrosis. 5. Open cholecystectomy. 6. Omentectomy. [**2117-4-9**] 1. Re-exploration of a recent laparotomy with planned return to OR. 2. Gastrojejunostomy tube placement (MIC tube). 3. Ventral hernia repair. [**2117-4-26**] CT-GUIDED DRAINAGE FOR ABDOMINAL PUS COLLECTION. [**2117-5-3**] ERCP BILIARY ONLY WITH STENT REMOVAL History of Present Illness: 66 y.o. male who presents to the ER from the [**Hospital1 18**]-[**Location (un) 620**] after being transferred from rehab. There, he was found to have temperature of 103F gram neg rods on blood gram stain. He has recent histroy of pancreatitis and c.diff, for which he has a PICC line, to recieve Vancomycin and Flagyl. His complaints consist of nausea, vomiting and epigastric abdominal pain. Past Medical History: MRSA on screen [**3-22**] EtOH pancreatitis--on pancrease Hypertension recent C. diff colitis Social History: ? ETOH abuse Admitted from [**Hospital1 18**]-[**Location (un) 620**] from rehab Physical Exam: On presentation to [**Hospital1 18**]: 97.2 121 110/58 31 97%RA Tachypnea, ill appearing HEENT: nl CV: tachycardic no M/R/G lungs: cta-b Abd: soft, distended, tender in epigastrium, + rebound, no guarding, no BS Ext: warm well perfused Pertinent Results: ANAEROBIC BOTTLE (Final [**2117-4-1**]): REPORTED BY PHONE TO DR [**Last Name (STitle) 65355**] [**2117-3-29**] AT 2:38PM. KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES. KLEBSIELLA PNEUMONIAE. FINAL SENSITIVITIES. SECOND STRAIN. FLUID CULTURE (Final [**2117-4-7**]): LACTOBACILLUS SPECIES. SPARSE GROWTH. KLEBSIELLA PNEUMONIAE. RARE GROWTH. FLUID CULTURE (Final [**2117-4-28**]): KLEBSIELLA PNEUMONIAE. HEAVY GROWTH. STENOTROPHOMONAS (XANTHOMONAS) MALTOPHILIA. SPARSE GROWTH. WOUND CULTURE (Final [**2117-5-2**]): KLEBSIELLA PNEUMONIAE. RARE GROWTH. [**2117-3-25**] 06:23PM BLOOD WBC-23.8* RBC-3.00* Hgb-10.1* Hct-29.4* MCV-98 MCH-33.6* MCHC-34.4 RDW-15.0 Plt Ct-320 [**2117-3-25**] 06:23PM BLOOD ALT-51* AST-56* AlkPhos-341* Amylase-230* TotBili-4.1* SPECIMEN SUBMITTED: GALLBLADDER, NECROTIC PANCREAS AND OMENTUM (3). Procedure date Tissue received Report Date Diagnosed by [**2117-4-3**] [**2117-4-5**] [**2117-4-7**] DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/stu DIAGNOSIS: I. Gallbladder (A): Chronic active cholecystitis. No calculi. II. Pancreas, partial pancreatectomy (B - D): Necrotic tissue. III. Omentum (E - G): Surface fibrosis and acute inflammatory exudate. CT ABDOMEN W/CONTRAST [**2117-4-2**] 1:04 PM CT CHEST W/CONTRAST; CT ABDOMEN W/CONTRAST CONCLUSION: 1. Almost complete necrosis of the pancreas. Small residual areas of enhancing pancreatic parenchyma in the proximal tail to distal body and in the posterior pancreatic head. 2. Large amount of intra-abdominal ascites, no localized collection. Moderate left basal pleural effusion and left basal atelectasis. 3. The CBD stent appears in good position, no intrahepatic biliary dilatation. 4. No abnormal large or small bowel loop dilatation, orally administered contrast medium has passed into the ascending colon. Mild circumferential thickening along some undistended mid ileum and part of the ascending colon. Differential possibilities include thickening due to low-protein state, third space loss. Vascular compromise is also a consideration depending on current clinical correlation. Brief Hospital Course: The patient was started on broad spectrum antibiotics (vanco, levo, flagyl, and fluc) and was brought emergently to the ERCP suite. A plastic stent was placed at this time and pus was returned. He had been intubated and was trasferred to the unit. Stress dose steroids were started emperically. He initially required support with levophed and large amounts of fluid. The levophed was weaned off off over the next 2-3 days, there was still a large fluid requirement however. His WBC count improved over the next few days as well. On PPD 5 a post pyloric feeding tube was placed and tube feeds were started. Diuresis was begun on PPD 6, and he started to have a good responce from this. As his diuresis continued, his vent requirements improved, but he did continue to require the vent. The paitent was extubated on HD 9, however, he requried reintubated the same day due to respiratory distress. At this point he requrired more levophed and volume. At this point he was doing very poorly, and GI was reconsulted for flex sig, which was normal. At this point a CT showed necrotic pancreas and ruputed pseudocysts. He was brought for laparotomy, and extensive pancreatic debridement was undertaken. The abdomen was left open and drains were placed. In the initial post op period he did well, but his abdomen was still open and he was brought back to the operating room on POD 11 for closure and feeding tube placement, which was uneventful. Vent weaning was begun post op, and he was slowly taken off the vent support and was extubated on POD 6. He required a great deal of O2 support but as more fluid came off, his respiratory status improved. He was txf'ed to the floor on POD 12 from his abdominal closure. Speech and swallow saw the paitient and found that he was safe to take po's and his diet was started to be advanced. On POD 16 he spiked a fever. CT was obtained that showed fluid collection. CT-guided drainage was done, and antibiotics were started. He responded well to the CT-guided drainage as his temp fell to normal and WBC count began to normalize. His PO intake increased, supplemented by tubefeed. On day of discharge, he had been out of bed when working with a physical therapist, taking good PO's, as well as producing good urine output and adequate stool. He will be discharged to a rehability center in stable condition. Medications on Admission: Pancrease atenolol lovenox nexium folic acid vancomycin Flagyl Discharge Medications: 1. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 2. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q4-6H (every 4 to 6 hours) as needed for temp >101. 3. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane [**Hospital1 **] (2 times a day) as needed. 4. Albuterol 90 mcg/Actuation Aerosol Sig: 4-6 Puffs Inhalation Q4H (every 4 hours) as needed. 5. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 7. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. Psyllium Packet Sig: One (1) Packet PO TID (3 times a day). 9. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed. 10. Ipratropium Bromide 0.02 % Solution Sig: Two (2) Inhalation 4HRS (). 11. Albuterol Sulfate 0.083 % Solution Sig: Two (2) Inhalation Q3-4H (Every 3 to 4 Hours) as needed. 12. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 9 days. 13. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 14. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. 15. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 2 days. 16. Furosemide 10 mg/mL Solution Sig: Two (2) Injection [**Hospital1 **] (2 times a day). 17. Insulin Sliding Scale Insulin SC (per Insulin Flowsheet) Sliding Scale & Fixed Dose 18. If blood glucose below 60 give apple/[**Location (un) 2452**] juice or 1 Amp Dextrose Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: 1. Acute alcohol-related pancreatitis. 2. Perforated pseudocyst. Discharge Condition: Stable Discharge Instructions: [**Month (only) 116**] return to taking outpatient medications. Please follow directions as discussed previously with Dr. [**Last Name (STitle) **]. Please take medications as prescribed and read warning labels carefully. If signs of infections such as purulent discharge from wound/drains, increased pain and redness at wound/drains, please call or go to the emergency room. Remember to call for a follow up appointment (bellow). [**Month (only) 116**] take quick showers but no baths. Absolutely no smoking. For wound care, please refer to page 1. Followup Instructions: Please Arrive at the [**Hospital Ward Name 23**] Blg ([**Hospital Ward Name 516**]) Radiology at 7:15 AM to get a CT scan of the Abdomen an then see [**First Name8 (NamePattern2) **] [**Doctor Last Name **] the same day at 10 AM (see below). No eating or drinking 3 hours before scan. Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2832**], MD Phone:([**Telephone/Fax (1) 2363**] Date/Time:[**2117-5-28**] 10:00 Completed by:[**2117-5-6**]

[ "303.90", "553.21", "995.92", "576.2", "518.81", "576.1", "577.1", "577.2", "577.0", "567.21", "250.00", "401.9", "575.12", "568.89", "593.9", "535.60", "038.9" ]

icd9cm

[ [ [] ] ]

[ "51.22", "51.85", "97.55", "45.24", "53.51", "96.6", "99.07", "96.04", "44.39", "54.91", "99.15", "00.17", "51.87", "96.72", "54.4", "52.22", "99.04" ]

icd9pcs

[ [ [] ] ]

8204, 8274

3975, 6343

326, 869

8385, 8394

1786, 3952

8995, 9466

6456, 8181

8295, 8364

6369, 6433

8418, 8972

1526, 1767

272, 288

897, 1296

1318, 1413

1429, 1511

25,203

184,154

15585+15586

Discharge summary

report+report

Admission Date: [**2140-9-22**] Discharge Date: [**2140-9-28**] Date of Birth: [**2068-8-17**] Sex: M Service: HISTORY OF PRESENT ILLNESS: This is a 77-year-old male with a history of diabetes, hypertension, hypercholesterolemia, pacer for sinus node dysfunction, who was pre-op for hip surgery, undergoing a pharmacologic stress test when he complained of [**9-22**] chest pain. The nuclear test showed (by report from his cardiologist, Dr. [**First Name4 (NamePattern1) 45070**] [**Last Name (NamePattern1) **]), a large reversible anterior lateral wall defect. Echocardiogram was obtained concurrently that showed no wall motion abnormalities. The patient continued to report 10/10 chest pain and was given an aspirin, Diltiazem 120 mg, Lopressor 50 mg po, Nitroglycerin drip was started, Heparin drip was started, and given 80 mg of IV Lasix, and was transferred to [**Hospital1 69**] for a cardiac catheterization. The patient initially presented to the CCU as the cath was deferred with an INR of 2.7 at the time, status post 5 mg of subcutaneous Vitamin K at [**Hospital3 28116**]. In the CCU he reported pain all over for months (including his chest, knees, fingers, nails). However, objectively appeared comfortable, falling asleep easily during conversation. The patient has a history of mental retardation and is notable to be a poor historian. PAST MEDICAL HISTORY: Diabetes type 2, peripheral vascular disease, status post right CVA, GERD, hypertension, dysphagia, esophageal motility disorder, bilateral hip replacement, gout, hypothyroid, pacer dependent, SA node dysfunction, cervical stenosis status post decompressive laminectomy, benign prostatic hypertrophy, osteopenia, paroxysmal atrial fibrillation on Coumadin, question of a history of CHF, question of a history of myocardial infarction in the past, mental retardation, nursing home resident. ALLERGIES: Patient has questionable allergies to NSAIDs. MEDICATIONS: Prior to admission, Coumadin 2.5 mg q h.s., Zinc, Vitamin C, Vitamin D, Lipitor 10 mg po q d, Diltiazem 120 mg po q d, Maalox 30 cc po q a.m., Terazosin 1 mg po q h.s., Spironolactone 25 mg po q h.s., Levothyroxine 0.15 mg po q d, Metoprolol 50 mg po tid, KCL 10 mEq po bid, Ranitidine 150 mg po q h.s., Lasix 80 mg po bid, Glyburide 5 mg po q d, Insulin sliding scale, prn Vicodin, Tylenol. PHYSICAL EXAMINATION: On admission temperature was 96, blood pressure 120/66, heart rate 60, respiratory rate 14, 100% O2 saturation on two liters. In general the patient was a somnolent male, poor historian, in no apparent distress, appearing comfortable. His oropharynx was clear, his pupils were equal and reactive to light, his sclera were anicteric, his neck was without carotid bruits, his JVP was approximately 8 cm. His heart was regular rate and rhythm, with distant heart sounds, and no murmurs. His lungs were clear to auscultation bilaterally, abdomen was soft, nontender, nondistended with normoactive bowel sounds. His extremities were without cyanosis or edema, and his neurologic exam was non focal. A rectal examination was guaiac negative. LABORATORY DATA: On admission his sodium was 139, potassium 4.3, BUN 44, creatinine 1.9, glucose 237, white blood cell count 11.6, hematocrit 42.5, platelet count 417,000. His PT was 22.6, PTT 150, INR 3.5, CK on admission 547, CK MB 7, troponin 0.6. His EKG was V paced at 60 beats per minute. He had left axis deviation with QRS of 136. There were ST elevations in leads V1 through V4 with V2 lead approximately 3 mm and elevation. There were no T wave inversions or reciprocal changes. HOSPITAL COURSE: 1. Cardiac: Ischemia - The patient was initially transferred for catheterization that was deferred in the setting of elevated INR at 3.5 on admission to [**Hospital1 188**]. The Heparin and Nitroglycerin drips he presented with were discontinued following negative cardiac enzymes times three. His peak CK was 1,020, peak troponin was 1.1, his EKG following that initial EKG showed no ST changes and was V paced. He had several episodes of burning chest pain during his stay, all relieved with Maalox and without hemodynamic or EKG changes. He was maintained on aspirin, Lipitor, beta blocker and ACE inhibitor throughout his stay. He was taken electively to the cardiac catheterization laboratory on [**9-26**] where a left heart catheterization was performed. There were normal filling pressures. A left ventriculogram was not obtained in view of his renal insufficiency. His coronaries were right dominant system. His RCA; had mid 40% and 50% stenoses at hinge points with mild diffuse luminal irregularities; large distal bed, supplying collaterals to LAD. His left main coronary artery; had 95% ostial LMCA with hint of LAD disease. The LAD; had 90% mid LAD at D1; 70% D1. The left circumflex; had modest to small OM's without much of an AV groove system. His catheterization was complicated by some "burning" chest pain where Heparin was given. He had no chest pain at the end of the case. Regarding interventional details, given the patient's poor functional status with developmental delay, he was likely a suboptimal candidate for CABG. The decision was made for Intracath to treat the left main coronary artery and a stent was subsequently placed in the left main coronary artery. A mid LAD stent was also placed and an extra supportive stent in the diagonal of the LAD was also placed. Following the case, the patient remained chest pain free throughout the remainder of his hospitalization. The patient was started on 75 mg of Plavix for a 45 day course. Under no circumstance shall Plavix be discontinued. The patient shall receive aspirin indefinitely and elective repeat angiography in two months to screen for left main coronary artery restenosis is mandatory and the patient will be scheduled for an appointment. Pump - The patient has a dry weight of 116 kg. There was no clinical evidence of heart failure nor radiographic evidence by chest x-ray during this admission. The patient's Spironolactone and Lasix were held for this reason. His follow-up echocardiogram was obtained on [**9-23**]. It showed ejection fraction of greater than 55%, preserved biventricular systolic function with an E to A ratio of 0.7, mild symmetric left ventricular hypertrophy, mild mitral regurgitation and mild dilatation of the aortic root. The patient will be discharged without diuretics. Rhythm - Patient has a history of paroxysmal atrial fibrillation. His Coumadin was held initially in the setting of supratherapeutic INR. The patient will be restarted on a lower dose of Coumadin as an outpatient. The patient was noted to be on Diltiazem prior to admission. This medication was not continued during hospitalization nor will be continued following discharge. The patient was maintained on telemetry throughout his course. It appeared that the AV delay was relatively short with multiple fusion beats noted on his EKG in telemetry. Electrophysiology was consulted. He has a [**Company 1543**] [**Last Name (un) **] SDR 303 dual chamber pacer which senses at a P greater than 2.9 millivolts, R greater than 11.2 millivolts and paces at less than 0.5 millivolts at 0.4 milliseconds. The pacer was reprogrammed with an AV delay that allowed his native conduction. He was paced AV; 280 milliseconds and sensed AV; at 240 milliseconds. Cardiac Valves - The patient has mild MR. 2. Renal: The patient has chronic renal insufficiency with baseline creatinine of approximately 1.8. He presented with a creatinine of 2.0 and was discharged with creatinine of 1.2. He did receive a dye load Intracath for which he was prehydrated and treated with Mucomyst. The patient maintained good urine output throughout his hospitalization. 3. Genitourinary: The patient had hematuria on admission in the setting of a traumatic Foley insertion and a supratherapeutic INR. This issue resolved by discharge as his INR trended down. The patient has a history of benign prostatic hypertrophy and should continue his Terazosin. 4. Endocrine: The patient has insulin dependent diabetes mellitus. This admission he was maintained on regular insulin sliding scale. He can return to his nursing home with a sliding scale and ultimately can transition back to his NPH doses. 5. Orthopedic: The patient has bilateral hip replacements with apparently loosening hardware in the left hip. The patient should follow-up with his orthopedic surgeons. It is important for them to note that surgery should not be undertaken for at least two weeks following stenting. They should note also that the patient is on dual antiplatelet therapy with Plavix and aspirin. Under no circumstance can the Plavix be discontinued. If they are willing to operate on him with dual antiplatelet therapy, then they may do so, otherwise surgery should be held for the six week course of antiplatelet therapy to be completed. 6. Code Status: The patient is full code, confirmed with the nursing home. His proxy is [**Name (NI) 14880**] [**Name (NI) 4135**] (his sister). DISCHARGE DIAGNOSIS: 1. Coronary artery disease, status post percutaneous intervention. DISCHARGE CONDITION: Stable. DISCHARGE MEDICATIONS: Zestril 2.5 mg po q d, hold for systolic blood pressure less than 95, Isordil 10 mg po tid, hold for systolic blood pressure less than 95, Metoprolol 25 mg po bid, hold for systolic blood pressure less than 95, heart rate less than 55, Plavix 75 mg po q d times 44 days (under no circumstances should Plavix be stopped in the next 44 days as this includes it should not be stopped for potential surgery nor for any bleeding if it were to occur), Aspirin 325 mg po q d, Lipitor 10 mg po q d, Coumadin 2 mg po q h.s., Nitroglycerin 0.4 mg sublingual prn chest pain, may repeat every 5 minutes prn chest pain up to three doses in 15 minutes, Levothyroxine 150 mcg po q d, Terazosin 1 mg po q h.s., Protonix 40 mg po q d, Zinc 220 mg po q d, Vitamin D 400 units po q d, Vitamin C 500 mg po bid, Regular insulin sliding scale, Glyburide 5 mg po q d, Artificial Tears, 1-2 drops OU qid. Medications on a prn basis: Tylenol and Vicodin as the patient had been taking prior at his nursing home facility. FOLLOW-UP: 1. Plavix must be given for 44 days, do not discontinue under any circumstances (for example, do not discontinue for surgery, do not discontinue if GI bleed). 2. Aspirin shall continue indefinitely (may discontinue in the perioperative period). 3. Patient must return for cardiac catheterization in 8 weeks (the nursing home facility will be called with follow-up date and time). 4. Daily weights should be checked 2-3 times per week. The patient's dry weight is 116 kg. If she exceeds said weight, consider Lasix. 5. Check INR two times per week, adjust Coumadin for a goal INR of 2.0 to 3.0. 6. Check creatinine two times per week (baseline creatinine approximately 1.8). If creatinine is greater than 2.2, [**Name8 (MD) 138**] M.D. 7. If patient has chest pain, treat with sublingual Nitroglycerin. If persists, take immediately to the Emergency Room (consider possible stent occlusion). 8. If patient is lightheaded or dizzy, check heart rate and blood pressure (consider hold parameters on Isordil, Zestril and Metoprolol). 9. Fingersticks and regular insulin sliding scale to be continued. Once insulin requirements can be trended, consider placing patient back on an NPH regimen. 10. Patient has a stage I sacral decubitus ulcer, please provide wound care with A&D lotion and dressing. PHYSICIANS: The patient's primary cardiologist is Dr. [**First Name4 (NamePattern1) 45070**] [**Last Name (NamePattern1) **]. The patient's primary care physician is [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Known firstname **]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**] Dictated By:[**Name (STitle) 45071**] MEDQUIST36 D: [**2140-9-27**] 17:27 T: [**2140-9-27**] 17:42 JOB#: [**Job Number 45072**] Admission Date: [**2140-9-22**] Discharge Date: [**2140-10-2**] Date of Birth: [**2068-8-17**] Sex: M Service: ADDENDUM: The [**Hospital 228**] hospital course was further complicated by: Genitourinary - Gross hematuria - Upon removal of the Foley catheter, the patient was noted to have gross hematuria, passed multiple clots. The urology service was consulted. Upon flexible cystoscopy, a false urethral passage was appreciated. The presenting hematuria was likely secondary to traumatic Foley insertion in the setting of anticoagulation. The source was likely urethral as the bladder was without abnormalities. A Foley catheter was inserted by the urology service to tamponade the bleeding passage. He had no urinary retention subsequently. His hematocrit was stable following the episode. His urine was initially dark, however, resolved to clear by the day of discharge. The patient will follow-up with [**Hospital 159**] Clinic, telephone [**Telephone/Fax (1) 45073**]. The patient will be scheduled for an appointment and this appointment will be telephoned to his nursing home. He will be discharged with a Foley catheter in place. The Foley will be removed upon returning for this urology appointment. The [**Hospital 228**] hospital course was also complicated by acute on chronic renal failure. The patient's creatinine increased to 2.8. This was likely prerenal azotemia in the setting of volume depletion. A fractional excretion of sodium confirmed this as it was 0.2. The patient's Lisinopril was held, and he was gently resuscitated with intravenous fluids to a creatinine level of 1.9 on the day prior to discharge. Also a renal ultrasound was obtained during this admission which demonstrated no hydronephrosis, no structural kidney abnormalities. The [**Hospital 228**] hospital course was also complicated by a sacral decubitus ulcer which was graded Stage II by the day of discharge. The patient should continue to have wound care at the site. One other follow-up issue of note, the patient's Plavix on the day of discharge [**2140-10-2**], is now to be resumed for forty (40) more days. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**] Dictated By:[**Name8 (MD) 22959**] MEDQUIST36 D: [**2140-10-2**] 04:36 T: [**2140-10-2**] 07:53 JOB#: [**Job Number **]

[ "707.0", "414.01", "599.4", "584.9", "593.9", "V53.31", "317", "996.4", "250.00" ]

icd9cm

[ [ [] ] ]

[ "88.56", "57.32", "36.05", "37.22", "36.06" ]

icd9pcs

[ [ [] ] ]

9235, 9244

9268, 14527

9144, 9213

3643, 9123

2388, 3626

160, 1385

1408, 2365

21,319

159,100

18561

Discharge summary

report

Admission Date: [**2117-1-29**] Discharge Date: [**2117-2-11**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 898**] Chief Complaint: s/p fall with altered mental status Major Surgical or Invasive Procedure: Tunneled Catheter placement Central line placement History of Present Illness: Ms. [**Known lastname 50992**] is a [**Age over 90 **] yo female with a h/o atrial fibrillation, CHF, hypertension, diastolic dysfunction, DM2, stage V chronic kidney disease and hypothyroidism who is transferred to [**Hospital1 18**] following two falls on [**11-28**]. Daughter states that she sat down earlier in the day on the staircase landing complaining of knee pain. At that time, she hit her head against the wall but was subsequently alert and oriented. Later in the day, around 4 p.m. she fell from the top of the staircase backwards down approximately 10 stairs. She was initially responsive and not complaining of any pain, but was unable to move. Her daughter called EMS. When EMS arrived, she was sitting on a bottom step, conversational. Her head subsequently dropped back and her mouth opened and she became unresponsive. . On initial exam at [**Hospital1 **] [**Location (un) 620**], patient was not responding to questions but opened her eyes to verbal stimuli. A CT of her c-spine was significant for C4/C5 space widening with ? anterior ligamentous sprain due to trauma. CT of her head was reported as negative. She was treated with a dose of ceftriaxone for reported UTI. . She was admitted to the ICU at [**Hospital1 **] [**Location (un) 620**] where she was reported to be fidgeting and moaning in bed, but otherwise nonverbal. BP was elevated to 228/122 and she was given 10 mg of IV labetalol without result. She was started on a nitroglycerin gtt at 0100 for BP control. She was noted to have a surgical right pupil. She was subsequently transferred to the MICU at [**Hospital1 18**] for MRI/MRA of her posterior circulation. Past Medical History: 1) Atrial fibrillation 2) Diastolic CHF, EF 60% 3) Hypertension 4) Diabetes mellitus, Type II x 20 years 5) Stage V chronic kidney disease (Cr 4.1 in [**10-9**]), followed by Dr. [**Last Name (STitle) 4090**], were planning for tunneled catheter when the patient becomes sicker and requires dialysis 6) Hypothyroidism 7) Secondary hyperparathyroidism Social History: Resides with daughter at home. Independent and performs all ADL's at baseline, except requires assistance with bathing. Ambulates with a cane. Family History: non-contributory . Physical Exam: VS: T 97.7, 176/79, HR 79, RR 15, SpO2 95% Gen: elderly WF, in c-collar, lying on right side in fetal position HEENT: normocephalic, atraumatic CV: regular rate, sinus rhythm on telemetry, nl S1 S2 Resp: CTA, normal respiratory effort Abdomen: soft, +BS, no grimace to deep palpation Extrem: no edema, 2+ pulses Skin: superficial abrasions on upper portion of posterior torso Neuro: unable to perform complete neuro exam due to lack of patient cooperation, eyes squeezed shut bilaterally, unable to assess pupil reactivity; cogwheeling of upper right extremity, hypertonic in upper extremities bilaterally; upgoing toes on right, downgoing on left; does not follow commands; some spontaneous movements in all extremities Pertinent Results: [**2117-1-29**] 04:20AM URINE BLOOD-MOD NITRITE-NEG PROTEIN-500 GLUCOSE-250 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2117-1-29**] 04:20AM NEUTS-95.9* BANDS-0 LYMPHS-2.4* MONOS-1.1* EOS-0.2 BASOS-0.2 [**2117-1-29**] 04:20AM WBC-18.0*# RBC-4.11* HGB-12.7 HCT-36.7 MCV-89 MCH-30.8 MCHC-34.5 RDW-14.1 [**2117-1-29**] 04:20AM ASA-NEG tricyclic-NEG [**2117-1-29**] 04:20AM TSH-10* [**2117-1-29**] 04:20AM cTropnT-0.04* [**2117-1-29**] 12:00PM CK-MB-7 cTropnT-0.06* [**2117-1-29**] 12:00PM GLUCOSE-198* UREA N-69* CREAT-6.0* SODIUM-132* POTASSIUM-4.8 CHLORIDE-98 TOTAL CO2-21* ANION GAP-18 MR of head [**1-29**]: No evidence of an acute infarct. Possible tiny subacute infarct in the white matter of the left frontal lobe. . MRA of head and neck [**1-29**]: Nonvisualization of the right vertebral artery could be due to thrombosis. . EEG [**1-30**]: This is an abnormal EEG due to the presence of bursts of generalized slowing superimposed upon a slow background. This is most consistent with a moderate encephalopathy of toxic, metabolic, or anoxic etiology. No evidence of ongoing seizure activity was seen, and no focal abnormalities were noted. . CT T spine [**1-29**]:Multilevel degenerative changes w/o evidence of acute fracture or dislocation in the T-spine. . CT L spine [**1-29**]: Compression deformity of L1 with approx. 50% loss of height centrally. Most likely this represents a chronic degenerative process, although acute component difficult to exclude. Brief Hospital Course: 1) Altered mental status: difficult to determine whether pre or post fall. CT head reported as negative at the outside hospital; however, official report not available. She was transferred here for the explicit purpose of MRI/MRA to assess posterior circulation, given widened disk space at C4/C5 and question of cervical sprain. . At [**Hospital1 18**], patient's MS changes were initially thought to be post-concussive vs. secondary to uremia as mental status seemed to improve with hemodyalisis. However, after multiple dialysis sessions and correlated improving creatinine, patient's mental status remained stable. An MRI on [**2-2**] showed multiple new small emolizations and again a poorly visualized vertebral artery. Neurology continued to follow throughout hospitalization. - TEE [**2-4**] showed signs of hypertrophic cardiomyopathy with mod MR [**First Name (Titles) **] [**Last Name (Titles) **]. - TEE was performed to eval for atrial thrombus as possible source of emboli. - Carotid U/S showed < 40% stenosis of both carotids. - EEG showed diffuse slowing consistent with encephalopathy. - Serial cardiac enzymes to r/o MI as precipitant for fall were negative. . Neurology continued to follow the patient and believes her mental status changes are likely due to bihemispheric infarcts. Neurology will follow up with the patient in one month. . 2) S/P fall with widened disk space w/ cervical strain: Orthospine consult recommended keeping patient in a soft collar until seen in clinic as patient unable to tolerate MR of spine. . 3) Stage V CKD: Cr of 5.6, stable from end of [**Month (only) 1096**] BUN/Cr of 69/5.4. Patient was previously planning to undergo hemodialysis. - Nephrology service followed throughout hospitatization and recommended dialysis. The family consented and HD was started. A Right subclavian tunnelled catheter was placed by IR for HD use. A RUE vein mapping for possible AVM in the future was obtained. The patient was given multiple transfussions of FFP for HD. The patient is on a Monday, Wednesday, Friday schedule for dialysis. . 4) Hypertension: initially managed with nitroglycerin gtt while in the MICU but titrated off with stable blood pressure's after. Patient maintained on a regimen recommended by Nephrology of metoprolol which was titrated to effect as norvasc and hydralzine (initiated in the MICU) were discontinued. Patient's blood pressure continued to be stable. . 4) Atrial fibrillation: Remained rate controlled with beta-blocker, and intially anticoagulated with coumadin. Coumadin was discontinued secondary to supratherapeutic INR prior to HD line insertion. 3 bags of FFP given to reverse INR prior to temporary catheter placement. Heparin drip started [**2-2**] once new embolizations identified on MRA. Coumadin was restarted. Heparin was continued as the patient is not therapeutic on coumadin. The patient had a decrease in her platelets while on heparin to a nadir of 94 however her plat . 5) DM2: Pt was treated with sliding scale of insulin for hyperglycemia. . 6) FEN: Pt tolerating po. Nutrition was consulted as patient was not taking in enough calories. Her diet was adjusted and was given supplements with all her meals and snacks. Pt was encouraged to eat. Discussed with family the possibility of placing a PEG. Family felt patient's diet was sufficient at this time. . 7) Yeast infection: Pt thought to have yeast infection. Treated with one dose of diflucan. . 8) Code status: DNR/DNI, readdressed with daughter today. Medications on Admission: 1. Norvasc 2.5 mg qday 2. Diovan 40 mg daily 3. HCTZ 12.5 mg QOD 4. Lanoxin 6.25 mg daily 5. Lipitor 20 mg daily 6. Lasix 40 mg daily 7. Levoxyl 100 mcg daily 8. Warfarin 2 mg 5day/week, 1 mg Monday & Thursday 9. Toprol XL 125 mg daily 10. Detrol LA 2 mg daily 11. Betamol 0.5% - 1 drop [**Hospital1 **] OU 12. NPH insulin 10 units [**Hospital1 **] 13. Reglan 10 mg PRN nausea 14. Vitamin D 50,000 units per week 14. Phoslo 1334 mg TID 15. Slo-Mag 64 mg daily 16. MVI 17. Tylenol PRN knee/back pain Discharge Medications: 1. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: 1000 (1000) units Intravenous Continuous infusion: Please titrate per attached sliding scale. Can discontinue heparin once INR is [**2-6**] for 48 hours. 2. Detrol LA 2 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO at bedtime. 3. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a week. 4. Insulin NPH-Regular Human Rec Subcutaneous 5. Insulin Regular Human Subcutaneous 6. Slow-Mag 64 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. 7. Multi-Vitamin Tablet Sig: One (1) Tablet PO once a day. 8. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every six (6) hours as needed for pain. 9. Reglan 10 mg Tablet Sig: One (1) Tablet PO three times a day as needed for nausea. 10. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. 11. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 12. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO once a day. 13. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO once a day: Please titrate to achieve INR of [**2-6**]. 14. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at [**Hospital6 1109**] - [**Location (un) 1110**] Discharge Diagnosis: s/p Fall Dementia [**2-5**] cerebral infarctions C4-C6 ligamentous injury Altered Mental Status Stage V Kidney Disease Atrial Fibrillation Yeast Infection Discharge Condition: Afebrile, Vital Signs Stable Discharge Instructions: Dialysis You were started on dialysis while in the hospital. Your last day of dialysis was [**2117-2-10**]. You should continue receiving dialysis on a Monday, Wednesday, Friday schedule. Atrial Fibrillation You coumadin was stopped and then restarted. You are being treated with heparin while the coumadin levels become therapeutic. Neck strain Please follow these instructions carefully: * Rest as much as possible. Increase your activity slowly when you start to feel better. * Apply cold packs or heat, whichever you find more comfortable, off and on through the day. * Be careful not to freeze or burn your skin. Do not put ice directly on your skin (place it in a plastic bag and wrap it in a towel). If you use a heating pad, keep it on low. * Take any prescribed medicines as directed. Do not drive, operate machinery or drink alcohol while taking pain medicines or muscle relaxants. Return to the Emergency Department or see your own doctor right away if any problems develop, including the following: * Your pain gets worse. * You develop pain, numbness, tingling or weakness in your arms or legs. * You lose control of your bowels or urine ("passing water"). * Trouble walking. * Your pain is not getting better after 2 days. * Anything else that worries you. Shortness of breath * Rest: You should restrict your activities until you are completely better. * Drink plenty of liquids (unless your doctor has told you not to.) Do not consume alcohol until you are completely better. * Many lung conditions are related to smoking. If you smoke, quitting now can help some problems, and prevent others from getting worse. * Be sure to take any prescribed medications as you were instructed. Continue your previously prescribed medications unless you were instructed to do otherwise. Yeast Infection. You were treated for a yeast infection. If you have worsening vaginal discharge, please notify your primary care provider for further treatment Followup Instructions: While on heparin, she will need platelets checked daily. Should platelet levels drop below 100, the heparin should be stopped and other medications may need to be started - please consult with [**Name8 (MD) **] MD [**First Name (Titles) 4120**] [**Last Name (Titles) 50993**]. Please check her INR every other day and adjust coumadin accordingly for a goal of [**2-6**]. Once INR is [**2-6**] for 48 hours, can discontinue heparin drip. Please check finger stick before meals and at bedtime, and use attached sliding scale for adjustments. She will need to keep the soft neck collar on until seen by orthopedics in clinic (see appointments below). Follow up with neurology on [**2117-3-9**] at 3:30pm with Dr [**Last Name (STitle) **]. Call [**Telephone/Fax (1) **]/8913 for more information and location of the appointment Follow up with orthopedics on [**2117-2-19**] at 1:30pm with Dr [**Last Name (STitle) 50994**] Please call [**Telephone/Fax (1) **] for more information. The appointment will be at the [**Location (un) 551**] of [**Hospital Ward Name 23**] Clinical Center

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icd9cm

[ [ [] ] ]

[ "99.04", "39.95", "99.07", "38.95" ]

icd9pcs

[ [ [] ] ]

10210, 10355

4897, 4908

297, 350

10554, 10585

3374, 4874

12687, 13777

2597, 2618

8962, 10187

10376, 10533

8438, 8939

10609, 12664

2633, 3355

222, 259

378, 2046

4924, 8412

2068, 2420

2436, 2581

28,915

117,945

48820

Discharge summary

report

Admission Date: [**2175-1-20**] Discharge Date: [**2175-1-27**] Date of Birth: [**2122-7-22**] Sex: F Service: CARDIOTHORACIC Allergies: Amoxicillin Attending:[**First Name3 (LF) 5790**] Chief Complaint: Tracheobronchomalacia. Major Surgical or Invasive Procedure: [**2175-1-20**] Flexible bronchoscopy with bronchoalveolar lavage, right thoracotomy and tracheoplasty with mesh, left main stem bronchoplasty with mesh, right main stem bronchus/bronchus intermedius bronchoplasty with mesh. History of Present Illness: Ms. [**Known lastname **] is a 52-year-old woman who was found to have severe, diffuse tracheobronchomalacia. Her main symptom was dyspnea; but she also had a chronic productive cough. She has also had orthopnea and recurrent respiratory infections. She responded well in terms of her dyspnea to the stent placement therefore is admitted for right thoracotomy, trachaelplasty with mesh placement. Past Medical History: COPD (on 2L home O2) Asthma Allergic rhinitis Atopic dermatitis HTN AoRegurgitation Major Depressive Disorder with Psychotic Features History of Polysubstance Abuse, primarily Cocaine Anxiety Disorder NOS with Situationally Bound Panic Attacks with Agoraphobia Polysubstance abuse hx Ulcerative colitis menorrhagia GERD OSA Narcolepsy Right humerus fx Social History: Pt lives with family. No alcohol or IVDU. Patient has hx of cocaine abuse. On disability. Previous smoker but quit in [**2154**], smoked [**12-24**] PPD from 15 to 25 yo (5pk-yr) and 2 PPD from 25 to 32 yo (14 pk-yr) for total of 19 pk-yr. Family History: No family hx of cancer or CAD or DVT/PE. Physical Exam: VS: T 98.1 HR: 87 SR BP: 138/80 96% 2L General: no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple Card: RRR Resp: faint bibasilar crackles otherwise clear GI: obese, abdomen soft non-tender/non-distended Extr: warm no edema Incision: R thoracotomy site clean dry intact, no erythema. CT site clean intact Skin: Right lower extremity with scattered psorasis areas with some skin breakdown Neuro: non-focal Pertinent Results: [**2175-1-24**] WBC-10.7 RBC-3.57* Hgb-9.0* Hct-28.9 Plt Ct-302 [**2175-1-23**] WBC-14.0* RBC-3.62* Hgb-9.4* Hct-29.0 Plt Ct-309 [**2175-1-20**] WBC-20.2*# RBC-4.67 Hgb-11.7* Hct-38.5 Plt Ct-357 [**2175-1-26**] UreaN-12 Creat-0.6 Na-144 K-3.8 Cl-105 HCO3-30 [**2175-1-25**] Glucose-120* UreaN-14 Creat-0.5 Na-142 K-3.8 Cl-103 HCO3-30 [**2175-1-20**] Glucose-160* UreaN-13 Creat-0.8 Na-137 K-4.9 Cl-101 HCO3-24 [**2175-1-26**] Mg-1.9 [**2175-1-23**] 12:11 pm SPUTUM GRAM STAIN (Final [**2175-1-23**]): 3+ (5-10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Final [**2175-1-25**]): MODERATE GROWTH Commensal Respiratory Flora. Chest X-Ray: [**2175-1-25**] The right internal jugular line has been removed. The right upper lobe opacity has improved in the interim and might be consistent with resolution of post-surgical hematoma. [**2175-1-22**] Chest tube remains and there is no evidence of pneumothorax or substantial effusion, though pleural thickening persists on the right. Mild vascular congestion is again seen and there are some streaks of atelectasis at the left base. [**2175-1-21**] Atelectasis has cleared from the right middle lobe, but consolidation persists in the upper lobe could be asymmetric re-expansion edema, contusion or less likely this early in the postoperative period, aspiration pneumonia. Borderline cardiomegaly and mild pulmonary vascular congestion persists and there is subsegmental atelectasis in the left lung, unchanged. Right pneumothorax is minimal, at the apex, if any, and right pleural collection is also very small, if any, one basal and one apical pleural tube is still in place. With the chin down, the tip of the endotracheal tube 2.45 cm above the carina is acceptable. Right jugular line ends at the junction of brachiocephalic veins. Mediastinal drains noted. Brief Hospital Course: Mrs. [**Known lastname **] was admtitted on [**2175-1-20**] for Flexible bronchoscopy with bronchoalveolar lavage, right thoracotomy and tracheoplasty with mesh, left main stem bronchoplasty with mesh, right main stem bronchus/bronchus intermedius bronchoplasty with mesh. She was extubated in the operating room transferred to the SICU for airway monitoring and management. Respiratory: aggressive pulmonary toilet with mucolytic nebs and chest PT were administered. She titrated to her home O2 of 2L with oxygen saturations in the high 96%. Chest-tube: Posterior chest tube was removed on POD2. She was followed by serial chest films which showed atelectasis and stable tiny right apical pneumothorax. Cardiac: She remained hemodynamically stable. Her afterload medications were restarted. GI: Her colitis medications were restarted. Her bowel function returned to [**Location 213**]. Nutrition: She tolerated a diabetic diet. Renal: On POD 1 she went into acute renal failure with a peak CRE 1.8. With hydration her renal function returned to her baseline of 0.8 on POD 2. Her diuretics were restarted and she was gentley diuresed. Maintained good urine output. Endocrine: her Blood sugars were 130-150's and covered by insulin sliding scale. Her home diabetic medications were restarted once she started a regular/diabetic diet. Pain: Epidural in place was managed by the acute pain service. It came out on POD4 and she was converted to PO pain medications. Neuro: history of bipolar, depression for which her home medications were restarted on POD1. Disposition: She was seen by physical therapy who deemed her safe for home. She continued to make steady progress and was discharged to home on POD7 Medications on Admission: Mucomyst nebs tid Aripiprazole 10 mg PO Daily Benzonatate 200 mg PO TID prn couch Clobetasol 0.05% ointment [**Hospital1 **] 2 weeks per month Fluoxetine 60mg PO Daily Fluticasone 50 mcg spray INH [**Hospital1 **] Fluticasone 220 mcg Aerosol - 2 puffs INH [**Hospital1 **] Advair diskus 500 mcg-50 mcg 1 puff INH [**Hospital1 **] Lasix 20 mg Q8AM & 2PM Xopenex 0.63 mg/3 mL nebs TID prn SOB Xopenef HFA 45 mcg INH Q4hrs prn SOB Lisinopril 20 mg PO Daily Mesalamine delayed release 400 - 4 tablets PO TID Metformin 850 mg PO BID Montelukast 10 mg PO Daily Omeprazole delayed release 20 mg PO Daily Tiotropium Brominde 18 mcg, 1 cap INH QAM (10minutes after Advair) Guaifenisen - 1,200 mg Tab, 1 PO BID Loratidine - 10 mg Tablet - 1 PO QAM Discharge Medications: 1. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Aripiprazole 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 5. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: Four (4) Tablet, Delayed Release (E.C.) PO TID (3 times a day). 6. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: [**12-24**] Tab Sust.Rel. Particle/Crystals PO DAILY (Daily). 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 12. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 13. Metformin 850 mg Tablet Sig: One (1) Tablet PO twice a day. 14. Xopenex HFA 45 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Inhalation every four (4) hours as needed for shortness of breath or wheezing. 15. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. Disp:*70 Tablet(s)* Refills:*0* 16. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain/headache. 17. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: Three (3) mL Inhalation every 4-6 hours as needed for wheezing. 18. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO twice a day. 19. Calcium Carbonate-Vitamin D3 500 mg(1,250mg) -400 unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Tracheobronchomalacia. Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Discharge Instructions: Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if experience: -Fevers > 101 or chills -Increased cough, shortness of breath or sputum production -Incision develops drainage -Daily weights: keep a log -Continue inhalers and nebulizers -Continue incentive spirometer 10x every hour while awake -You may shower. No tub bathing or swimming for 6 weeks -Take narcotics with stool softners. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] Date/Time:[**2175-2-7**] 11:00 in the [**Hospital Ward Name 121**] Building Chest Disease Center [**Hospital1 **] I Chest X-Ray 10:30 in the [**Hospital Ward Name 517**] Clinical Center [**Location (un) **] Radiology Department Follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 13959**] [**Telephone/Fax (1) 250**] Completed by:[**2175-1-27**]

[ "327.23", "347.00", "692.9", "278.01", "998.2", "300.21", "V46.2", "626.2", "584.9", "401.9", "304.23", "296.24", "V45.89", "530.81", "493.20", "472.0", "250.00", "556.9", "424.1", "E870.0" ]

icd9cm

[ [ [] ] ]

[ "03.90", "33.24", "33.48", "33.43", "96.56", "31.79" ]

icd9pcs

[ [ [] ] ]

8488, 8545

4057, 5779

302, 530

8612, 8612

2119, 4034

9184, 9605

1606, 1648

6568, 8465

8566, 8591

5805, 6545

8757, 9161

1663, 2100

239, 264

558, 957

8626, 8733

979, 1332

1348, 1590

10,498

128,056

30835

Discharge summary

report

Admission Date: [**2179-4-9**] Discharge Date: [**2179-4-23**] Service: MEDICINE Allergies: Morphine Attending:[**First Name3 (LF) 134**] Chief Complaint: Chest pain. Major Surgical or Invasive Procedure: None. History of Present Illness: Mr. [**Known lastname 72974**] is an 86 year-old male with a history of CAD (s/p CABG in [**2164**]) who presents with chest pain. Awoke at nursing home at 3am with chest pressure ([**4-22**] and left sided). No associated nausea, dizziness, SOB. Pain resolved with nitro and tylenol. Later in the morning, was found to be hypotensive at 80/40 so he was sent to NWH. Cardiac enzymes showed CK 339, MB 12.2, MBI 3.5, Trop I 30 and EKG revealed STE V2-5 with Q waves. Given lovenox, lopressor and aspirin, transferred here for ICU bed availability. No lytics were given as the patient has a history of a SDH in [**11-17**]. In the ED, vitals showed T 97.7, BP 80/61, HR 75, RR 21, 91% on six liters NC. Pressures remained stable in the 80-90s systolic as previous fluids were finished. Past Medical History: 1. Coronary artery disease: a. CABG ([**2164**]) 2. Mitral valve replacement with severe MR 3. Atrial fibrillation s/p pacemaker ([**2176**]) OTHER PAST HISTORY: 1. Lung cancer: recently diagnosed - c/b post-obstructive pneumonia (on moxiflox) 2. Chronic obstructive pulmonary disease 3. Chronic kidney disease (SCr at baseline 1.2 on [**4-8**]) 4. h/o GIB with PUD s/p gastrectomy 4. Hypothyroidism 5. Prostate cancer 6. h/o Subdural hematoma ([**11-17**]) while on coumadin 7. h/o Pelvic fracture in MVA ([**2133**]) Social History: Social history is significant for the absence of current tobacco use (quit in [**2164**]). There is no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: vitals - T 96.6, BP 88/62, HR 67, 02 sat 92% on 6 liters. gen - cachectic male, in no distress and in good spirits heent - no conjunctival palor or scleral icterus; pupils equal and reactive; no elevated JVP with dry MM cv - irregular irregular with a III/VI systolic murmur heard best at the apex with radiation to the axilla pulm - decreased breath sounds >1/2 up on right with dullness to percusion; left side with crackles at the base abd - soft, thin, non-tender ext - warm, prominant varicose veins; no edema; pulses showed 2+ DP/PT/carotid/femeral neuro - alert, oriented to person, "[**Hospital3 **]" and "[**Month (only) 547**] [**2178**]"; did not know exact date Pertinent Results: [**2179-4-9**] 08:10PM BLOOD WBC-15.1* RBC-4.55 Hgb-14.5 Hct-42.4 MCV-93 MCH-32.0 MCHC-34.3 RDW-16.0* Plt Ct-303 [**2179-4-9**] 08:10PM BLOOD Neuts-78.4* Lymphs-8.9* Monos-6.8 Eos-5.6* Baso-0.4 [**2179-4-9**] 08:10PM BLOOD PT-15.0* PTT-45.5* INR(PT)-1.3* [**2179-4-9**] 08:10PM BLOOD Glucose-98 UreaN-24* Creat-1.4* Na-134 K-4.2 Cl-98 HCO3-26 AnGap-14 [**2179-4-9**] 08:10PM BLOOD CK(CPK)-299* [**2179-4-10**] 06:55AM BLOOD CK(CPK)-193* [**2179-4-9**] 08:10PM BLOOD CK-MB-14* MB Indx-4.7 [**2179-4-9**] 08:10PM BLOOD cTropnT-3.43* [**2179-4-10**] 06:55AM BLOOD CK-MB-9 cTropnT-3.30* [**2179-4-10**] 06:55AM BLOOD Calcium-8.1* Phos-3.2 Mg-2.9* [**2179-4-11**] 06:02AM BLOOD Triglyc-79 HDL-42 CHOL/HD-2.7 LDLcalc-54 . EKG #1 ([**2179-4-9**] at 20:50) showed afib with rate of 70; left axis; biphasic TW in V2-V4; ST-elevations in V2-V5 with Q-waves in V2-V4. . 2D-ECHOCARDIOGRAM ([**2179-4-10**]): The left atrium is markedly dilated. The right atrium is markedly dilated. There is moderate regional left ventricular systolic dysfunction with anteroseptal akinesis and apical akinesis/dyskinesis. EF 35-40% No definite apical thrombus seen. Mild to moderate ([**12-15**]+) mitral regurgitation. [3+] tricuspid regurgitation. . Chest CT [**2179-4-14**]: 1. Secretions within the bronchus intermedius with post- obstructive right middle and lower lobe collapse. Associated endobronchial tumor cannot be excluded. Bronchoscopy would be helpful for both therapeutic and diagnostic purposes. 2. Narrowing right upper lobe bronchus by right hilar adenopathy. Bulky mediastinal adenopathy is consistent with patient's history of malignancy. Comparison to outside studies would be helpful as well as dedicated contrast- enhanced study if the patient's renal function permits. 3. Bilateral pleural effusions, right greater than left with adjacent dependent atelectasis. 4. Mild interstitial edema and multichamber cardiomegaly. 5. Emphysema. . Pelvis xray: Cortical irregularity of the right greater trochanter. CT is recommended for further characterization of this finding. . [**2179-4-16**] pleural fluid cytology: Pleural fluid: POSITIVE FOR MALIGNANT CELLS. Consistent with metastatic adenocarcinoma. [**2179-4-20**] pleural fluid: Pleural fluid: NEGATIVE FOR MALIGNANT CELLS. Mesothelial cells, some with reactive changes. Macrophages, lymphocytes, and blood. Brief Hospital Course: 1. STEMI/Coronary artery disease: Presented with chest pain, elevated cardiac enzymes and EKG changes which were consistent with an ST-elevation MI. Q-waves were present in V2-V4 (and a new finding). Given the patient's co-morbid conditions (including CKD), held off on catheterization and decision was made to pursue medical management only. A head CT was obtained to evaluate for brain mets and after this returned negative, a heparin gtt was started. Aspirin and statin were continued. An echo was obtained on HD2 which showed an EF of 35-40% and regional LV wall motion abnormalities which included: mid anteroseptal - akinetic; anterior apex - akinetic; septal apex- akinetic; inferior apex - akinetic; lateral apex - akinetic; apex - dyskinetic. Given these finding, plan for 1 month of anticoagulation with coumadin was planned (no longer given the patient's history of a SDH and a GI bleed). Beta-blocker was also started. Atorvastatin was increased from 10mg daily to 40mg daily. On discharge the patient was bridged to coumadin with lovenox. 2. Acute renal failure: Baseline SCr of ~1.2 and a presenting Scr of 1.4. This may have represented decreased perfusion in the setting of his STEMI. The plan was for optimization of forward flow. His Cr trended back to baseline and remained stable. He had a small bump in his Cr to 1.6 in the setting of diuresis which then trended down and remained stable. 3. Lung cancer: Recently diagnosed at OSH. Records were obtained and confirmed diagnosis of adenocarcinoma from bronhial washings. He was evaluated by Heme/Onc staff and felt to be at least T3 although no formal staging was performed. Oncology felt that the patient was too frail and deconditioned to undergo chemo/xrt and the plan was to follow up with Dr. [**First Name8 (NamePattern2) 3551**] [**Last Name (NamePattern1) 8631**] at [**Hospital1 **] as outpatient to discuss possible palliative chemo vs. hospice. No further management was done while an inpatient. While at [**Hospital1 18**] a repeat non-contrast chest CT was performed that showed b/l pleural effusions and a likely R endobronchial tumor with post- obstructive collapse of the right middle and lower lobes in addition to hilar and mediastinal LAD. IP was consulted for possible bronch +/- stenting vs thoracentesis. It was felt that the patient would not tolerate a significant procedure including general anesthesia and therefore a rigid bronch and stent was not pursued. Heme/Onc was consulted and agreed that the patient would not tolerate chemo at the moment given his frailty and recent significant MI. Palliative care became involved to fascilitate discussion about palliative options and possible hospice. Records from OSH remarked that the patient had uptake in his pelvis so a pelvic xray was obtained to look for possible mets. The xray showed a cortical irregularity in the greater trochanter on the right which was concerning for metastatic disease. During his hospital stay the patient had a significant oxygen requirement with O2 sats 88-96% on 6L NC and 15L high flow oxygen. Chest xrays and CT demonstrated a large R pleural effusion with RML and RLL collapse. A large volume thoracentesis was performed on [**4-16**] by IP and 2.5L of fluid were removed. He was able to be weaned off of the high flow oxygen and maintained on 6L NC. His effusion quickly reaccumulated and the patient was taken for pleurex catheter placement on [**4-20**] for further drainage. Following drainage he was maintained comfortably on 4L of 02 by nasal canula. 4. Post-obstructive pneumomia: The presenting symptom for the patient's new malignancy. Presented on moxiflox, which was changed to levofloxacin during the hospitalization. Treatment was through [**2179-4-14**] (14 days total). The patient required 6 liters of oxygen to keep sats above 90 (which was stable from pre-admission). He remained afebrile. 5. Hypothyroidism: Continued outpatient synthroid. 6. Mitral valve replacement with severe MR: Audible murmur on exam. IVF were given with care while the patient initially presented dry. 7. Chronic obstructive pulmonary disease: Flovent and atrovent nebs were used, along with oxygen to keep sats in the 91-93 range. Medications on Admission: 1. Aspirin 81mg daily 2. Lasix 40mg daily 3. Potassium 20mEq daily 4. Lipitor 10mg daily 5. Synthroid 125mcg daily 6. Omeprazole 20mg daily 7. Flovent 2 puffs daily 8. Folate 0.4mg daily 9. Calcium/Vitamin D 500mg QID 10. Fosamax plus D [**Telephone/Fax (1) 72975**] 1 tab weekly 11. Quinine 250mg QHS PRN leg cramps 12. Moxifloxacin 400mg daily ([**Date range (1) 13342**]) Discharge Medications: 1. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain: 1 tab every 5 min. up to 3 tabs. for relief of chest pain. If chest pain continues contact 911. 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 9. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 11. Trazodone 50 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. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO QHS (once a day (at bedtime)) as needed for sleep. 14. Docusate Sodium 100 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 15. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) injection Subcutaneous Q12H (every 12 hours) for 5 days. 16. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) for 1 months. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 1110**] Discharge Diagnosis: Primary: ST elevation myocardial infarction adenocarcinoma of the lung hypertension atrial fibrillation chronic obstructive pulmonary disease hyperlipidemia hypothyroidism chronic renal insufficiency secondary: history of gastrointestinal bleeding history of subdural hemmorhage history of mitral valve replacement Discharge Condition: fair, shortness of breath improved. Discharge Instructions: You were admitted to the hospital for a myocardial infarction you are being treated medically for this, it is important for you to continue to take your medications as prescribed. . You were also evaluated by oncology for your lung cancer. . A pleurex catheter was placed because of your re-occuring right pleural effusion. This will need to be drained intermittently - the stitches at the location of the tunnel will need to be removed in 10 days after placement of the pleurex catheter, The stitches around the catheter should stay in. . You were started on anticoagulation with coumadin which you should continue to take for a period of 1 month. Followup Instructions: please follow up with your primary care physician [**Last Name (NamePattern4) **] [**12-15**] weeks. PCP: [**Name10 (NameIs) 72976**],[**Name11 (NameIs) 72977**] [**Telephone/Fax (1) 72978**] Completed by:[**2179-4-22**]

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icd9cm

[ [ [] ] ]

[ "34.04", "34.91" ]

icd9pcs

[ [ [] ] ]

11128, 11211

4933, 9175

226, 233

11570, 11608

2552, 4910

12305, 12528

1761, 1843

9600, 11105

11232, 11549

9201, 9577

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1858, 2533

175, 188

261, 1048

1070, 1599

1615, 1745

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194,366

4273+55562+55563+55564

Discharge summary

report+addendum+addendum+addendum

Admission Date: [**2100-9-5**] Discharge Date: [**2100-9-24**] Date of Birth: [**2045-5-5**] Sex: M Service: MEDICINE HISTORY OF PRESENT ILLNESS: This is a 55 year-old male with a past medical history significant for rheumatoid disorder characterized as rheumatoid arthritis diagnosed in [**2100-7-12**] and hypercholesterolemia who presented with a nine month history of polyarthritis with a positive [**Doctor First Name **], history of muscle weakness, weight loss, three days of diarrhea, headache and four days of progressive dyspnea on exertion and orthopnea as well as a rash that started four days prior to admission. When the patient presented to the Emergency Department he was found to be hypertensive with blood pressures of 220s/150s. He was also found to be in congestive heart failure thought to be secondary to volume overload and acute renal failure. The patient was given Labetalol intravenous and sublingual nitroglycerin in order to stabilize his blood pressure. He was also diuresed with intravenous Lasix. After this regimen the patient appears to be more comfortable, however, was then found to have chain soaks respirations, however, continued to be arousable. At this point he was intubated for respiratory distress likely secondary to volume overload from his congestive heart failure and acute renal failure. PAST MEDICAL HISTORY: 1. Hypercholesterolemia, not on any medications. 2. Hernia. 3. Benign prostatic hypertrophy. 4. Rheumatologic syndrome initially presumed to be lupus associated polyarthritis with [**First Name8 (NamePattern2) **] [**Doctor First Name **] of 1 to 1280 with multiple negative antibodies for double stranded DNA, SCL 70 treated with Prednisone, Methotrexate from [**Month (only) 956**] to [**2100-6-12**] and treated with _________ from [**Month (only) **] to [**2100-6-12**], which was discontinued three weeks prior to admission. ALLERGIES: No known drug allergies at the time of admission. Current drug allergies include Bactrim, which causes a rash. Captopril, which causes a rash and heparin with positive hit antibodies. MEDICATIONS ON ADMISSION: Vitamin E, multivitamin, Synalar .025 t.i.d., Prednisone 10 q day, and 20 herbal supplements with multiple ingredients that the patient had been taking for the three weeks prior to admission. These include co-enzyme Q, loda seed, __________, xanthium, _______, milk thistle, intestinal food and build, _____ enzyme, vitamin B complex, and viro detox blend. SOCIAL HISTORY: The patient is married and lives with his wife. [**Name (NI) **] has both a son and a daughter. [**Name (NI) **] socially drinks alcohol and is a nonsmoker. FAMILY HISTORY: No history of coronary artery disease. Uncle with systemic lupus erythematosus. REVIEW OF SYSTEMS: Muscle weakness for nine months prior to admission, diarrhea for three days prior to admission. Headache for two days prior to admission. Raynaud's symptoms for several months prior to admission. Weight loss approximately 30 pounds. Rash four days prior to admission. Questionable dysphagia for months prior to admission. Short term memory loss in the months prior to admission. Urinary symptoms including incomplete bladder emptying, inability to initiate stream, occasional "bladder pain" for six months prior to admission. PHYSICAL EXAMINATION: Vital signs pulse 72. Blood pressure 113/77. Map of 92. Pulse ox 100% on assist control ventilation with an FIO2 of 60%. Respiratory rate 18. In general, the patient is well developed, well nourished, white male sedated and intubated. HEENT examination reveals normocephalic, atraumatic. Head symmetric, minimally reactive, pupils 3 mm. Neck JVP increased to the angle of the mandible. No lymphadenopathy. Cardiovascular examination normal, point of maximal impulse, normal S1 and S2. Regular rate and rhythm. No murmurs, rubs or gallops. Pulmonary examination coarse breath sounds with crackles, but one half to three quarters of the way up right greater then left. Abdomen soft, nontender, nondistended, positive bowel sounds. Extremities 2+ dorsalis pedis pulses bilaterally. No clubbing, cyanosis or edema. Skin faint [**Doctor Last Name **] salmon colored macular rash over lower extremities. LABORATORY DATA ON ADMISSION: White blood cell count 11.8, hematocrit 34.6, platelets 150. Sodium 135, potassium 4.5, chloride 99, bicarb 22, BUN 45, creatinine 2.7 with a normal baseline of 1.1, glucose 119, ALT 17, AST 30, alkaline phosphatase 97. T bili .9, albumin 3.7. Urinalysis 100 protein, 10 red blood cells, 3 white blood cells. Differential on the white blood cell count showed neutrophils 79%, lymphocytes 8.5%, monocytes 5.3%, eosinophils 6.6%, basophils .7%. [**Last Name (un) **] revealed 1+ aniso, 1+ _______, occasional ovalocytes and occasional _______ cells. Urinalysis also showed a small amount of blood, negative nitrite, negative leukocyte esterase. Analysis of urine sediment revealed dysmorphic white blood cells, granula casts, fatty casts. Urine was negative for eosinophils. CPK 119, CKMB 8, troponin 8.7 this is decreased from an initial troponin of 15.9 with a CPK of 144 and MB index of 7.6. Albumin 3.7, calcium 9.5, phos 4.7, magnesium 2.1. C3 C4 levels are within normal limits. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) 736**] Dictated By:[**Name2 (NI) 7315**] MEDQUIST36 D: [**2100-9-23**] 14:19 T: [**2100-9-23**] 14:36 JOB#: [**Job Number 18527**] Name: [**Known lastname 3009**], [**Known firstname **]/JR. Unit [**Name2 (NI) **]: [**Numeric Identifier 3010**] Admission Date: [**2100-9-5**] Discharge Date: [**2100-9-23**] Date of Birth: [**2045-5-5**] Sex: M Service: HOSPITAL COURSE: 1. Renal: Renal biopsy showed thrombotic microangiopathy. The patient was placed on hemodialysis with no improvement in BUN or creatinine. Patient's elevated phosphorus did decrease with treatment with Amphojel and the patient was switched to calcium carbonate. The patient had a MRA of the kidneys which showed no evidence of renal artery stenosis. Patient had Perm-A-Cath placement on [**9-21**]. Patient was treated with ACE inhibitor for scleroderma renal crisis. 2. Pulmonary: Patient initially intubated for respiratory distress secondary to volume overload. Patient was extubated and then reintubated for congestive heart failure secondary to diastolic dysfunction from elevated blood pressures. The patient had a bronchoscopy with sanguinous return on BAL with a question of diffuse alveolar hemorrhage and a chest CT scan that showed bibasilar consolidation. The patient was treated for a 10 day course of Levaquin for pneumonia in addition to the three day course of Cefepime with dramatic improvement in his chest x-ray and no further pulmonary issues. The patient was extubated on [**9-18**] and remained off oxygen. 3. Anemia: The patient had iron studies consistent with anemia of chronic disease, question of gastrointestinal bleed with two episodes of melena and bright red blood per rectum. Nasogastric tube lavage is negative and patient continued to have a stable hematocrit post-transfusion. 4. Rheumatology: The patient was diagnosed with scleroderma with a skin biopsy of the hands revealing changes consistent with scleroderma. He had dermal and subcutaneous dense sclerosis with thickened hyalinized small vessels. The patient had a negative ANCA, negative double stranded DNA, negative anticentromere antibody, negative rheumatoid factor, negative centromere, negative SCL-70, negative GBN antibodies. Patient was also worked up for antiphospholipid syndrome, and was negative for lupus anticoagulant and anticardiolipin antibodies. He was initially treated with high dosed steroids which were then tapered. Diagnosis was scleroderma. 5. Cardiac: The patient initially had a troponin leak thought to be secondary to demand subendocardial ischemia from volume overload. He had an echocardiogram that showed an ejection fraction greater than 55%, no valvular disease and mild symmetric left ventricular hypertrophy. The patient was initially placed on Lopressor for blood pressure control. However, this was discontinued secondary to concerns for exacerbation of Raynaud's. 6. Hypertension: Patient had extremely labile hypertension throughout his hospital course with systolic blood pressures in the 200s and diastolics in the 100s. Patient was finally stabilized on a regimen of enalapril 10 mg [**Hospital1 **] with good blood pressure control with a goal blood pressures 120s-140s systolic. Patient was found to have an allergy to Captopril manifested as a diffuse maculopapular rash and this was discontinued. 7. Muscle weakness: Patient with a nine month history of diffuse muscle weakness prior to presentation. This was found to be worse with muscle strength 3-4/5 in both bilateral upper and lower extremities which was worse since being in the hospital. Patient is currently being worked up by Neurology for question of steroid myopathy versus other etiologies of this muscle weakness. The patient is to have a head MRI to rule out any evidence of microangiopathy and possibly EMG to further evaluate his muscle weakness. The patient will be going to rehabilitation for aggressive physical therapy. 8. Thrombocytopenia: The patient had an acute drop in his platelet count from 143-78 during a one day period after being on empiric Heparin drip for a question of antiphospholipid syndrome during his hospital course. Heparin was discontinued and patient was found to have a positive HIT antibody. 9. Rash: Patient initially presented with a diffuse reticular rash. Left thigh biopsy revealed a hypersensitivity reaction most likely secondary to ingested antigens from the multiple herbal supplements the patient had been on prior to admission. This rash resolved and there were no further complications. The patient also had a diffuse maculopapular rash during his hospital course thought to be secondary to captopril which improved after discontinuation of the captopril. 10. Followup: The patient is to have an echocardiogram to evaluate for pulmonary artery hypertension. The patient is to have a video swallow study to further evaluate esophageal dysmotility with possible sclerodermal involvement, and patient will have followup with outpatient Rheumatology for his scleroderma. At this point treatment will include aggressive blood pressure control with ACE inhibitor and rehabilitation for his muscle weakness. Medications on discharge will be dictated in a followup discharge summary addendum. [**Name6 (MD) 3011**] [**Last Name (NamePattern4) 3012**], M.D. [**MD Number(1) 3013**] Dictated By:[**Last Name (NamePattern4) 3014**] MEDQUIST36 D: [**2100-9-23**] 15:10 T: [**2100-9-23**] 15:06 JOB#: [**Job Number 3015**] Name: [**Known lastname 3009**], [**Known firstname **]/JR. Unit [**Name2 (NI) **]: [**Numeric Identifier 3010**] Admission Date: [**2100-9-5**] Discharge Date: Date of Birth: [**2045-5-5**] Sex: M Service: [**Hospital1 248**] The date of discharge is still pending. The reason for admission was as above. HOSPITAL COURSE BY PROBLEM: 1. Renal: The patient transferred from the MICU to the Medicine Floor for management of his renal failure after he was extubated. He continued to get hemodialysis 3x a week on Monday, Wednesday, and Friday. He was continued on enalapril 10 mg [**Hospital1 **]. His blood pressures were initially well controlled, but then began to increase the systolics in the 150s and diastolics in the 80-90s. He was additionally treated with amlodipine 5 mg po q day. At the time of this dictation, his blood pressure is still slightly elevated and he may require additional enalapril and amlodipine doses. The patient's hemodialysis is uneventful and he is tolerating the procedure reasonably well. 2. Pulmonary: The patient was transferred to the floor after extubation and his O2 saturations remained adequate. The patient did not complain of any shortness of breath or cough. He had a transthoracic echocardiogram to evaluate for pulmonary artery systolic hypertension. This echocardiogram was done on [**2100-9-30**], and was remarkable just for borderline pulmonary artery systolic hypertension. There were some concern of crackles throughout his hospital course here heard on examination. However, these crackles were inconsistent and would usually decrease after hemodialysis and thus were attributed to fluid overload. 3. Anemia: The patient had iron studies in the MICU consistent with anemia of chronic disease. However, here he has a low iron indicating that he might have iron deficiency anemia in addition. He at this time that his iron studies are pending. 4. Rheumatology: The patient's followup was still continued by Rheumatology. They advised continuation of the ACE inhibitor with the hope for resolution of renal failure and possible discontinuation of dialysis at some point in the future. For now, the sclerodermal renal crisis seemed to be the most possible diagnosis given the renal biopsy and the skin biopsy confirming scleroderma. His prednisone was eventually tapered off and discontinued on [**9-26**]. He was also thought to have polyneuropathy secondary to a vasculopathy related to his scleroderma. Rheumatology recommended that this patient avoid steroids given that the Nephrology team felt that perhaps in the future he could come off dialysis. The data and the literature indicates that steroids could trigger renal crisis and potentially worsen this patient's renal failure. 5. Cardiac: The patient initially had a troponin leak. He had no further episodes of flash pulmonary edema secondary to hypertension while on the floor. The repeat echocardiogram showed a normal ejection fraction and only mild pulmonary artery systolic hypertension. 6. Hypertension: As mentioned above, the patient has some effect on enalapril and amlodipine, and the doses may be increased by the time the patient is discharged to a rehabilitation facility. 7. Muscle weakness: A Neurology consult was called and an EMG was done. The EMG was not consistent with a myopathy, but rather consistent with a sensory-motor polyneuropathy especially in the right lower extremity. This was thought to be due or related to his vasculopathy. Polyneuropathy and scleroderma is somewhat rare, but is thought to be the most plausible explanation for his neuropathy. He was treated with Neurontin 300 mg po q4-8 and Capsaicin for the hyperesthesia that he feels on his right foot. He also is treated with oxycodone 10 mg q4-6 hours for pain relief. There was some suggestion that a nerve biopsy may be helpful in demonstrating whether this patient has vasculopathy, related neuropathy, and whether steroids would be indicated. At this time the team has decided to avoid the steroids if at all possible and continue treatment with the Neurontin, Capsaicin, and oxycodone. 8. Thrombocytopenia: This was due to exposure to Heparin and the patient was found to have positive Heparin platelet Factor IV antibodies. He is no longer receiving any Heparin of any kind either on the floor or in dialysis. 9. Rash: The patient has had multiple recurrences of a rash. He initially presented with a rash that was felt to be due to a hypersensitivity reaction secondary to his herbal supplements he would be taking prior to admission. A second rash was noted after taking captopril in the MICU and now a third rash has been noted after transfer to the floor. Another skin biopsy has been done to evaluate whether this represents hypersensitivity reaction either to Neurontin which is the only new medication after changing from the Intensive Care Unit to the floor or enalapril via cross allergy reaction with the Captopril. It is thought that potentially the prednisone was initially masking hypersensitivity reaction. However, this preliminary diagnosis is only hypothesis and final results of a biopsy and determination of the offending [**Doctor Last Name 932**] will be determined and added on to this discharge summary. 10. Infectious Disease: This is a [**Last Name **] problem. The patient over the last three days prior to this dictation has had temperatures up to 101.8 without subjective cough or shortness of breath. His urine culture grew out Enterococcus sensitive to ampicillin. He was placed on ampicillin for this treatment. However, he continues to have temperatures and has multiple sets of blood cultures pending at the time of this dictation. In addition, a chest x-ray has been negative for a pneumonia, however, a repeat chest x-ray is pending. The possibilities include hemodialysis line infection versus other systemic infection versus fever attributable to collagen vascular disease. The patient's white blood cell count has not been elevated and at the time of this dictation, his white blood cell count is 7.1 with a differential of 44 neutrophils, 14 lymphocytes, 7 basos, and 36% eosinophils. 11. Eosinophilia: The patient had only a slight eosinophilia in the Intensive Care Unit the highest number being 10%. Upon transfer to the floor a few days prior to this dictation, he was noted to have an eosinophilia of 20% rising to 40%. Workup was underway. Various possibilities were put forth such as adrenal insufficiency, collagen vascular disease, hypersensitivity to medication and finally, but least likely a helminthic infection. Stool, ova, and parasites are pending at this time. This infectious cause is considered less likely because the patient has no travel history. 12. Endocrine: The patient was discontinued off his prednisone on [**9-26**] and has been doing well. He believes that his motor weakness, neuropathy, and neuropathic pain is better off the prednisone. He continues to make progress in rehabilitation, however, a low sodium and eosinophilia would point towards the possibility of an adrenal insufficiency. An am cortisol was checked and was found to be 13. An ACTH stim test make the diagnosis of adrenal insufficiency has not been done yet at the time of this dictation. In addition, as TSH is high at 8.2 and T4 thyroxine level is being checked to rule out hypothyroidism. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 166**] Dictated By:[**Name8 (MD) 74**] MEDQUIST36 D: [**2100-10-1**] 15:13 T: [**2100-10-7**] 09:36 JOB#: [**Job Number 3016**] Name: [**Known lastname 3009**], [**Known firstname **]/JR. Unit [**Name2 (NI) **]: [**Numeric Identifier 3010**] Admission Date: [**2100-9-5**] Discharge Date: [**2100-10-8**] Date of Birth: [**2045-5-5**] Sex: M Service: ADDENDUM: This is an addendum to the discharge summary from [**2100-10-1**]. Therefore, this discharge summary covers from [**2100-10-1**] to [**2100-10-8**]. Of note, a typed copy of this addendum was provided to the patient on his discharge to the rehabilitation facility. ADMISSION DIAGNOSIS: Hypertensive emergency. DISCHARGE DIAGNOSIS: Scleroderma. 1. INFECTIOUS DISEASE: In the hospital, the patient became intermittently febrile. Several sets of blood cultures were negative. Several chest x-rays were negative. The last one reported a left pleural effusion, small, that was improving. The patient was initiated empirically on antibiotics including amoxicillin and ceftriaxone because one set of urine cultures showed Enterococcus sensitive to ampicillin. At this point, ID was consulted. It was concluded that the temperatures were more likely due to remnants of the drug reaction given the lack of source of infection. By the date of discharge, the patient remained afebrile for 48 hours and his eosinophilia history had decreased. 2. ENDOCRINOLOGY: Cortisol stimulated test was performed to assess for possible adrenal insufficiency. The results showed stimulation at one hour to 22. The patient was not felt to have adrenal insufficiency. The patient's thyroid tests revealed possible mild hypothyroidism. It was recommended that the patient be reassessed after his acute hospitalization. 3. RENAL: The patient received hemodialysis on [**2100-10-8**] in the a.m. DISCHARGE CONDITION: Fair. Discharged to a rehabilitation facility. DISCHARGE DIAGNOSIS: 1. Scleroderma. 2. Renal failure. 3. Hypertension. DISCHARGE MEDICATIONS: 1. Docusate sodium 100 mg p.o. b.i.d. 2. Pantoprazole 40 mg p.o. q.d. 3. Calcium carbonate 500 mg p.o. t.i.d. 4. Nephrocaps one capsule p.o. q.d. on hemodialysis treatment days. 5. Gabapentin 300 mg p.o. q. 48 hours. 6. Capsaicin one application topical t.i.d. 7. Hydroxyzine HCL 25 mg p.o. q.i.d. 8. Hydrocortisone cream 2.5% one application topical b.i.d. 9. Fluconazole cream topical b.i.d. 10. Enalapril maleate 10 mg p.o. b.i.d. 11. Amlodipine besylate 5 mg p.o. q.d. p.r.n. 12. Senna. 13. Bisacodyl. 14. Nystatin. 15. Lorazepam. 16. Acetominophen 17. Oxycodone. DISCHARGE FOLLOW-UP PLANNING: 1. The patient was set up with Neurology following with Dr. [**Last Name (STitle) 3017**], given number, [**Telephone/Fax (1) 3018**]. 2. The patient was set up for Rheumatology appointment on [**2100-10-22**]. 3. The patient was set up with a Medicine follow-up appointment with Dr. [**Last Name (STitle) 3019**] at [**Telephone/Fax (1) 3020**] on [**2100-10-8**]. DISCHARGE RECOMMENDATIONS: The patient was discharged with recommendations for hemodialysis, physical therapy, and occupational therapy. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 224**], M.D. [**MD Number(1) 225**] Dictated By:[**Last Name (NamePattern1) 3021**] MEDQUIST36 D: [**2101-3-11**] 10:40 T: [**2101-3-11**] 21:08 JOB#: [**Job Number 3022**]

[ "428.0", "518.81", "714.0", "410.71", "272.0", "584.9", "486", "287.5", "710.1" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.72", "39.95", "86.11", "38.95", "33.24", "55.23" ]

icd9pcs

[ [ [] ] ]

20507, 20556

2703, 2784

20655, 22047

20577, 20632

2150, 2509

5840, 11330

3359, 4289

19284, 19309

2804, 3336

11358, 19262

168, 1365

4304, 5823

1388, 2123

2526, 2686

67,384

185,723

39415

Discharge summary

report

Admission Date: [**2138-5-13**] Discharge Date: [**2138-5-17**] Date of Birth: [**2103-12-8**] Sex: M Service: CARDIOTHORACIC Allergies: Amoxicillin Attending:[**First Name3 (LF) 1505**] Chief Complaint: Palpitations Major Surgical or Invasive Procedure: [**2138-5-13**]: Sternotomy/ Cryoablation/ Radiofrequency ablation of right ventricular scar/ endocardial mapping History of Present Illness: 33 yo male with history of splenic laceration after traumatic skiing accident, who presented to OSH with 2 week history of palpitations.He presented to his PCP The patient was transferred from OSH on [**8-23**] for evaluation of polymorphic VT. He has responded to amiodarone therapy without further recurrence of V-tac. He would like to come off of amiodarone due to side effects and he would like to return to work as a fire-fighter. He presents for PAT today prior to his sternotomy for RV aneurysm resection vs. cryoablation. Past Medical History: Skiing accident [**12/2136**] resulting in splenic laceration that was treated conservatively, no surgery. Social History: Works as a firefighter. Married with a son. Social EtOH use. Recently quit smoking. No drug use. Family History: Mom - "arrhythmia" GM - CABGx3 Father - HTN Uncle - diabetes ?type1? Physical Exam: Pulse:53 Resp:16 O2 sat: 100% B/P Right: 135/80 Left: Height:5'[**37**]" Weight:238 LBS General: NAD, WGWN, appears stated age Skin: Dry [x] intact [x] no rash HEENT: PERRLA [x] EOMI [x] OP benign Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: +2 Left: +2 DP Right: +2 Left: +2 PT [**Name (NI) 167**]: +2 Left: +2 Radial Right: +2 Left: +2 Carotid Bruit Right: 0 Left: 0 Discharge VS: T: 98.9 HR: 73 SR BP: 137/83 Sats: 98% RA WT 110 kg General: 34 year-old male in no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple no lymphadenopathy Card: RRR Resp: decreased breath sounds otherwise clear GI: benign Extr: warm no edema Incision: sternal clean dry intact margins well approximated no erythema Neuro: AA&O Pertinent Results: [**2138-5-17**] WBC-6.6 RBC-4.09* Hgb-12.4* Hct-35.3* MCV-86 MCH-30.2 MCHC-35.1* RDW-13.8 Plt Ct-226 [**2138-5-15**] WBC-7.5 RBC-3.66* Hgb-11.5* Hct-31.1* MCV-85 MCH-31.5 MCHC-37.0* RDW-13.3 Plt Ct-152 [**2138-5-17**] Glucose-104* UreaN-15 Creat-1.1 Na-136 K-4.7 Cl-97 HCO3-31 [**2138-5-17**] Calcium-9.5 Phos-4.1 Mg-2.0 [**2138-5-15**] Na-135 K-4.3 Cl-99 [**2138-5-15**] Glucose-127* UreaN-16 Creat-1.0 Na-132* K-4.0 Cl-97 HCO3-28 [**2138-5-13**]: TTE: Prebypass No spontaneous echo contrast is seen in the body of the left atrium or left atrial appendage. No spontaneous echo contrast is seen in the body of the right atrium. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated with normal free wall contractility. There is an echodense area of the free wall consistent with myocardial scarring; however, no evidence of an aneurysm is seen. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. Postbypass The patient is in sinus rhythm and on no inotropes or pressors. Left ventricular systolic function continues to be normal. Right ventricular function is now mildly depressed globally. The previous area of echodensity is now seen as an area of echolucency and is not well visualized. Trace mitral regurgitation and tricuspid regurgitation are unchanged. The visible portion of the thoracic aorta is intact post decannulation. CXR: [**2138-5-15**]: IMPRESSION: AP chest compared to moderate postoperative widening of the cardiomediastinal silhouette relative to the preoperative appearance is stable. There has been no progressive widening, or is there are any pneumothorax after removal of midline and right pleural drains. A moderate degree of bibasilar atelectasis is stable on the left and on the right has migrated from the mid to the lower lungs, but overall not worsened. No pneumothorax. No pulmonary edema. Small left pleural effusion has not necessarily changed. Brief Hospital Course: The patient was admitted to the hospital and brought to the operating room on [**2138-5-13**] where the patient [**Date Range 1834**] sternotomy/cryoablation/radiofrequency ablation of right ventricular scar/ endocardial mapping. See operative note for full details. 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 on no inotropic or vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. EP was following and recommended changing Lopressor to Torpol XL at discharge. 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 [**Doctor Last Name **] services in good condition with appropriate follow up instructions. Medications on Admission: Lopressor 75mg [**Hospital1 **] Amiodarone- discontinued [**2138-4-23**] Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* 3. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*4 Tablet(s)* Refills:*0* 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): take with narcotics. 6. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*70 Tablet(s)* Refills:*0* 7. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for pain: take with food and water. 8. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Right ventricular aneurysm/ polymorphic ventricular tachycardia Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Dilaudid Incisions: Sternal - healing well, no erythema or drainage 1+ Edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] ***Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [**Last Name (STitle) **] on [**Telephone/Fax (1) 170**] Date/Time:[**2138-6-12**] 1:00 [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **] [**Location (un) 551**] [**Hospital Unit Name **] Cardiologist: Dr [**Last Name (STitle) **] [**Telephone/Fax (1) 62**] Date/Time:[**2138-6-18**] 2:40 [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) **] Cardiology Wound follow-up in [**Hospital Unit Name **] [**Last Name (NamePattern1) **] [**Hospital Unit Name **] on [**Telephone/Fax (1) 170**] Date/Time:[**2138-5-27**] 10:30 Please call to schedule appointments with your Primary Care Dr. [**First Name (STitle) 17385**] in [**4-1**] weeks [**Telephone/Fax (1) 25734**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2138-5-17**]

[ "414.10", "458.29", "427.1" ]

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Discharge summary

report+report+report+addendum+addendum

Admission Date: [**2117-1-7**] Discharge Date: [**2117-1-11**] Date of Birth: [**2055-3-17**] Sex: F Service: MEDICINE HISTORY OF PRESENT ILLNESS: This is a 61-year-old female with severe chronic obstructive pulmonary disease, who was recently admitted to [**Hospital1 69**] from [**11-25**] to [**2116-12-4**]. During this admission, she (for the first time) required intubation. The patient was not able to be weaned off the ventilator, and a tracheostomy was placed. The patient was discharged to [**Hospital3 **] Center. She was eventually weaned off the ventilator on [**12-20**]. The tracheostomy was discontinued on [**12-28**]. The patient was undergoing a prednisone taper and was down to 10 mg by mouth once daily when she developed a worsening in her symptoms. Therefore, the prednisone was increased to 30 mg by mouth once daily and levofloxacin (which had recently been discontinued) was empirically restarted. The patient initially responded to these interventions, but developed more respiratory distress on the evening of [**1-7**]. The patient was started on BiPAP. An arterial blood gas was done, which showed a pH of 7.14, a PCO2 of 94, and a PO2 of 89. The patient was transferred to [**Hospital1 69**]. By the time she arrived here, on BiPAP, she seemed to have improved, with an arterial blood gas of pH 7.37, PCO2 of 48, PO2 of 57. PAST MEDICAL HISTORY: 1. Chronic obstructive pulmonary disease, on 3 liters of oxygen at home, with history of frequent hospitalization and frequent rapid steroid tapers 2. Hypertension 3. Anxiety 4. Tracheobronchitis with sputum positive for stenotrofamonas and methicillin resistant staphylococcus aureus 5. Depression 6. Hypercholesterolemia ALLERGIES: Sulfa, shellfish and penicillin cause difficulty with breathing. Codeine causes mental status changes. HOME MEDICATIONS: Heparin 5000 units subcutaneously twice a day, Reglan 10 mg by mouth three times a day, Singulair 10 mg by mouth once daily, potassium chloride 30 mEq by mouth once daily, Zantac 150 mg by mouth twice a day, Diltiazem 60 mg by mouth four times a day, Nystatin swish and swallow four times a day, Zoloft 50 mg by mouth daily at bedtime, Beconase AQ two sprays twice a day, Atrovent metered dose inhaler two puffs four times a day, Flovent 220 two puffs twice a day, prednisone 20 mg by mouth once daily, Serevent two puffs twice a day, levofloxacin 500 mg by mouth once daily, vancomycin 1 gram intravenously every 12 hours, albuterol two to four puffs every two hours as needed. SOCIAL HISTORY: Retired secretary, lives alone. No alcohol use. The patient has an 80 pack year smoking history, and had cut down, but continued to smoke up to the prior admission. FAMILY HISTORY: Father died at age 47 of suicide and alcohol use. Mother died at age 51 of coronary artery disease. PHYSICAL EXAMINATION: On admission, temperature 99.1, blood pressure 189/85, heart rate 130, respiratory rate 20, oxygen saturation 92% on 3 liters. In general, very thin, tremulous, in no acute distress. Head, eyes, ears, nose and throat: Pupils equal, round and reactive to light, extraocular movements intact, sclerae anicteric. Neck supple, with no lymphadenopathy. Cardiovascular: Tachycardic, no murmurs, gallops or rubs. Chest was clear to auscultation bilaterally, with no wheezes, but decreased breath sounds throughout. Abdomen was soft, nontender, nondistended, with positive bowel sounds, no hepatosplenomegaly. Extremities were warm, with no edema. LABORATORY DATA: White count 12, hematocrit 41.9, platelets 421. Chem 7 was 136/4.4/94/27/14/0.5/149. Electrocardiogram showed sinus tachycardia at a rate of 112, normal axis, left ventricular hypertrophy, old Q waves in Leads V1 through V3, with no significant changes when compared to study from [**2116-11-26**]. Chest x-ray showed no infiltrate, flattened diaphragms, consistent with emphysema. HOSPITAL COURSE: The patient was transitioned to oxygen by nasal cannula and was admitted to the Medical Intensive Care Unit for observation. The patient did well in the Medical Intensive Care Unit, without further need for BiPAP. Antibiotics were continued, and the patient was placed back on high dose steroids. During the first night in the Medical Intensive Care Unit, the patient reports some vague "chest heaviness" and jaw tingling. Electrocardiogram done at this time showed new T wave inversions with subsequent normalization. Cardiac enzymes were cycled, and showed a troponin elevated at 2.4, with a normal CK. The patient was called out to the medical floor on the following day, [**1-8**]. On the floor, the patient continued to do well, with oxygen by nasal cannula. She was continued on her prednisone taper and antibiotics, and was transitioned from nebulizer treatments to metered dose inhaler therapy. The patient was evaluated by Physical Therapy, and she will benefit from continued pulmonary rehabilitation. The patient's troponins quickly fell towards normal. The patient had no further episodes of chest pain or jaw discomfort. It is thought likely that this non-Q wave myocardial infarction occurred in the setting of high demand from tachycardia (due to frequent albuterol treatments), and hypoxia from her chronic obstructive pulmonary disease flare. The patient may require further cardiac workup when the current medical issues are improved. DISCHARGE CONDITION: Medically stable for discharge to rehabilitation. DISCHARGE STATUS: To pulmonary rehabilitation. DISCHARGE DIAGNOSIS: 1. Chronic obstructive pulmonary disease flare DISCHARGE MEDICATIONS: Atrovent two to four puffs every four to six hours as needed, albuterol two puffs every four to six hours as needed, prednisone 60 mg by mouth once daily (taper by 10 mg weekly as tolerated), Captopril 6.25 mg by mouth three times a day, levofloxacin 500 mg by mouth once daily for an expected two week course, Ativan .25 mg by mouth every six hours as needed, Diltiazem 90 mg by mouth four times a day, Flonase two sprays per nostril once daily, Nystatin swish and swallow four times a day, Flovent four puffs twice a day, Serevent two puffs twice a day, Zoloft 50 mg by mouth daily at bedtime, Zantac 150 mg by mouth twice a day, Reglan 10 mg by mouth three times a day, Singulair 10 mg by mouth once daily, aspirin 325 mg by mouth once daily, heparin 5000 units subcutaneously twice a day, Boost Plus one can three times a day. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**], M.D. [**MD Number(1) **] Dictated By:[**Last Name (NamePattern1) 15468**] MEDQUIST36 D: [**2117-1-10**] 23:09 T: [**2117-1-11**] 00:00 JOB#: [**Job Number 36265**] Admission Date: [**2117-1-7**] Discharge Date: [**2117-1-20**] Date of Birth: [**2055-3-17**] Sex: F Service: MEDICAL ICU CHIEF COMPLAINT: Shortness of [**Year (4 digits) 1440**]. PRIMARY CARE DOCTOR: Dr. [**First Name (STitle) **]. HISTORY OF PRESENT ILLNESS: This is a 61-year-old female with a history of severe chronic obstructive pulmonary disease on three liters of 02 at home for the last two or three years, who was admitted to the [**Hospital6 649**] from [**11-25**] to [**12-4**] for severe chronic obstructive pulmonary disease exacerbation, who was intubated on [**2116-11-25**] for hypoxic and hypercarbic failure. She was extubated and then that night on [**2116-11-26**] was reintubated and sedated, hypotensive, had to have some dopamine and got a little bit tachycardic. Levophed was placed on. It was difficult to wean from the ventilator secondary to anxiety. The patient was trached on the [**12-1**] and then discharged to [**Hospital3 **] on the 11th. Patient was off the ventilator at [**Hospital3 **] on [**2116-12-20**] and then decannulated off the trach on [**2116-12-28**] and antibiotics were stopped on the 9th, as well as her prednisone was also stopped on the 8th. It was down to 10 from her previous 60 in hospital. Patient had an episode of shortness of [**Year (4 digits) 1440**] on the day of admission at the rehabilitation center. Prednisone was increased to 30 and they restarted levofloxacin. Patient continued to have shortness of [**Year (4 digits) 1440**]. They tried putting her on BiPAP of 14 and 5 with two liters and failed the trial of BiPAP at the rehabilitation center as the patient had worsening shortness of [**Last Name (LF) 1440**], [**First Name3 (LF) **] it was decided to admit her to the [**Hospital6 1760**]. In the Emergency [**Hospital1 **], patient was given 60 IV of Solu-Medrol and one gram of vancomycin as well. PAST MEDICAL HISTORY: Chronic obstructive pulmonary disease on three liters 02 at home, frequent hospitalizations, frequent steroid tapers, hypertension on diltiazem 60 q.i.d., anxiety disorder. Tracheobronchitis, repeatedly positive for Stenotrophomonas as well as Methicillin resistant Staphylococcus aureus, depression and was started on Zoloft, and increased cholesterol on Lipitor prior to her [**Month (only) 404**] admission. ALLERGIES: Sulfa, codeine, shellfish and questionable Augmentin. MEDICATIONS ON ADMISSION: Heparin 5000 subcutaneous b.i.d., Reglan 10 t.i.d., Singulair, KCL, Zantac 150 b.i.d., diltiazem 60 q.i.d., nystatin swish and swallow, Zoloft 50 q.h.s., Beconase, Atrovent, Flovent, prednisone 20, Serevent, levofloxacin 500 b.i.d., as well as albuterol q. 2 prn. SOCIAL HISTORY: The patient was born in [**Location (un) 86**], no alcohol use. Has an 80 pack year history of smoking. Two pack per day for about the last 40 years. FAMILY HISTORY: Father died at 47 from alcohol and suicide. Mother died at 61 from coronary artery disease. PHYSICAL EXAM ON ADMISSION: Temperature of 99.1. Blood pressure 184/85. Heart rate in the 130s. Respiratory rate 78. 02 saturation of 92% on three liters. Generally, thin 61-year-old female on a nonrebreather mask in no acute distress. Head, eyes, ears, nose and throat: Normocephalic, atraumatic. Pupils equal, round and reactive to light. Extraocular muscles were intact. Sclerae are anicteric with a BiPAP mask on. Neck was supple with no lymphadenopathy. Cardiovascular was tachycardic with no murmurs, rubs or gallops. Chest was clear to auscultation bilaterally with no wheezing. Abdomen was soft, nontender, nondistended, positive bowel sounds. Extremities were warm with no cyanosis, no clubbing or edema. Neurological was alert and oriented times three. Cranial nerves II through XII are intact. Nonfocal exam. LABS ON ADMISSION: White blood cell count of 12.0, hematocrit of 41.9, platelets of 421,000. Chem-7: Sodium 136, potassium 4.4, chloride 94, bicarbonate 27, BUN 14, creatinine 0.5, glucose of 147. Patient had a last echocardiogram on [**2116-11-27**] with an ejection fraction of around 60% with moderate pulmonary hypertension. In the Emergency Department, on four liters nasal cannula her arterial blood gases was 7.14, 94, 89. Once placed on the BiPAP of 14 and 5, arterial blood gases was 7.37, 48 and 50. Electrocardiogram on admission was sinus tachycardia with a rate of 112, normal axis, left ventricular hypertrophy, old Qs in V1 through V3. no significant T wave changes. Chest x-ray showed no infiltrates but flattened diaphragm compatible with emphysema, small bilateral pleural effusions. Patient was admitted to the Medical Intensive Care Unit overnight and was placed on her BiPAP as well as a steroid taper was started at 60 mg po q.d. Patient remained pretty comfortable and that night was also given albuterol and Atrovent nebulizers prn. Flovent, Serevent, MDIs and Singulair were obtained. Patient was also started on levofloxacin as well as a dose of vancomycin in the Emergency Room which was thought to be may worsening of a pneumonia. Patient was admitted to the Medical Intensive Care Unit overnight and remained on BiPAP. She did well on BiPAP and was able to be transferred over to a nasal cannula in the morning. Patient was then called out to the floor and was transferred to the floor. Of note, the night that patient was in the Medical Intensive Care Unit, patient had an episode of chest tightness, heaviness, as well as some jaw tightness, at which time an electrocardiogram was done which showed some T wave inversions and subsequent normalization with a troponin that was slightly elevated. Patient had troponin peak of 2.4. CKs remained flat. Patient was started on aspirin and ACE inhibitor as the beta-blocker was felt to be contraindicated given the patient's severe chronic obstructive pulmonary disease. [**Hospital **] medical course continued to be on the floor in terms of monitoring her respiratory status in which she required BiPAP in the evening time, as well as continued nebulizer q. 2-3 hours on the floor. Patient's cardiovascular status, patient had a Cardiology Consult who thought that a catheterization would not be warranted at this time and basically was told to use aspirin as well as ACE inhibitor for some after load reduction and to continue the diltiazem. Infectious Disease wise, the patient was continued on her levofloxacin throughout her course and for her depression, patient was continued on Zoloft. On [**2117-1-15**], it was warranted that the patient wasn't getting any better on the floor with on and off use of the BiPAP but no improvement in her overall state as patient continued to need the BiPAP on and off, as well as desaturating and having episodes in which she became more tachycardic, as well as hypertensive with desaturations down into the low 80s. Patient was transferred to the Medical Intensive Care Unit for further pulmonary management as well as for questionable tracheostomy if patient failed to do well on the BiPAP machine. On day of admission to the Medical Intensive Care Unit, patient's white count increased to 23.4 and hematocrit of 31.2. With the elevated white count a new chest x-ray that showed a right lower lobe consolidation with some small pleural effusions. It was decided that we would change the antibiotics to broaden the coverage, so we began vancomycin as well as ceftazidime to cover the patient's Methicillin resistant Staphylococcus aureus, as well as the Stenotrophomonas that she has had in the past. Patient was continued on her diltiazem, aspirin, as well as captopril for her non Q wave myocardial infarction and patient was monitored on the BiPAP as well as nasal cannula throughout the day. At different times of the day, the patient required her BiPAP and at different times of the day, the patient was on nasal cannula. Mostly using the BiPAP in the evening times and at night time. Patient had her pulmonary function tests faxed over to us from her outside hospital which showed severely decreased lung fields and increased TLC and FRC and RV diffusion. DLCO was mildly to moderately severely decreased. Patient's FEV1 was .82. Patient continued on the BiPAP as needed and will follow-up this dictation with an addendum for further events that happen in the Medical Intensive Care Unit. [**Name6 (MD) 2467**] [**Last Name (NamePattern4) 10404**], M.D. [**MD Number(1) 10405**] Dictated By:[**Last Name (NamePattern1) 6234**] MEDQUIST36 D: [**2117-1-20**] 12:13 T: [**2117-1-20**] 12:13 JOB#: [**Job Number 36787**] Admission Date: [**2117-1-7**] Discharge Date: [**2117-2-2**] Date of Birth: [**2055-3-17**] Sex: F Service: MEDICAL INTENSIVE CARE UNIT ADDENDUM Note: This brief summary is an addendum to multiple previous discharge summaries from other services. HISTORY OF PRESENT ILLNESS: The patient is a 61-year-old female with severe chronic obstructive pulmonary disease. The patient has been admitted to [**Hospital3 **] several times since the beginning of the year for exacerbations of her chronic obstructive pulmonary disease. During her first admission in [**Month (only) 404**], the patient had elective tracheostomy placed and had been discharged to pulmonary rehabilitation. Her tracheostomy was discontinued at rehabilitation, and several days later, the patient developed worsening respiratory distress. The patient was readmitted on this visit on [**2117-1-7**]. The patient's previous time in the MICU and on the floor has been outline in previous discharge summaries. The patient was readmitted to the Medical Intensive Care Unit on [**2117-1-29**], for elective tracheostomy placement which was originally scheduled to be done on [**3-31**]; however as a result of logistical problems, the patient was held in the MICU for several days before the tracheostomy was placed. The indication for elective tracheostomy was an increasing need for mechanical assist ventilation. The patient, prior to tracheostomy, had been spending in the area of 20-24 hours out of the day on BIPAP by facial mask, which the patient was having some discomfort with. The patient's respiratory status was largely unchanged from the 8th through the 11th in the MICU. The patient was using her BIPAP machine with inspiratory pressure of 12 and expiratory pressure of 5, FI02 of 50%, and rate of 12 to 14. Elective tracheostomy placement was done on the afternoon of [**2117-2-1**]. Attending physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Name (STitle) **] assisted by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 36857**]. The procedure was done under general endotracheal anesthesia after rapid sequence intubation. The tracheostomy was placed without complications, and placement was confirmed by bronchoscopy. The patient was extubated immediately after the procedure and recovered without event. The patient on [**2117-1-31**], was transfused 1 U of packed red blood cells for a hematocrit of 26.9. The patient's posttransfusion hematocrit was 30.8 and remained stable. The patient was continued on Vancomycin and Ceftazidime for days 14 through 17 for a total course of 28 days. The patient is ready for discharge on [**2117-2-2**], to pulmonary rehabilitation. Screening has been arranged through the care manager. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], M.D. [**MD Number(1) 36858**] Dictated By:[**Name8 (MD) 24599**] MEDQUIST36 D: [**2117-2-1**] 20:37 T: [**2117-2-1**] 20:35 JOB#: [**Job Number 36859**] Name: [**Known lastname 1810**], [**Known firstname 1647**] Unit No: [**Numeric Identifier 6569**] Admission Date: [**2117-1-7**] Discharge Date: [**2117-1-26**] Date of Birth: [**2055-3-17**] Sex: F Service: MEDICAL ADDENDUM: The patient was transferred from the Medical Intensive Care Unit to [**Location (un) 6572**] Service on [**2117-1-22**], for placement. HOSPITAL COURSE: Mrs. [**Known lastname **] was moved from the Medical Intensive Care Unit to CC7 on [**2117-1-22**], at approximately 9 p.m. Respiratory-wise, the patient was continued on Albuterol and Atrovent nebulizers as well as Prednisone taper. She was maintaining saturations between 89 to 90% on six liters nasal cannula and doing well on Bi-PAP overnight. However, on the morning of [**2117-1-24**], she had an episode of tachypnea and tachycardia with the following arterial blood gas: pH 7.48, pCO2 40, and pO2 of 60. She was kept on nasal cannula oxygen. Chest x-ray showed no change in prior right lower lobe infiltrate. She had been well covered with Ceftazidine and Vancomycin which was at that time day seven of a three week course. No further antibiotics were indicated. Her white count was followed carefully over the next few days and showed increase from a low of 14 to a maximum of 18. She was afebrile during that time and on day of discharge, [**2117-1-26**], white count had returned to 14. Pulmonary consult was re-consulted on [**2117-1-26**], to effectively rule out possibility of lung resection and transplant. The patient is a poor candidate at this time secondary to poor nutrition and concomitant medical problems. The idea of tracheostomy was reintroduced at this time but the patient is reluctant to undergo procedure. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg p.o. q. day. 2. Protonix 40 mg p.o. q. day. 3. Heparin 5000 units subcutaneously twice a day. 4. Trental 400 mg p.o. three times a day. 5. Flovent four puffs inhaled twice a day. 6. Ceftazidine two grams intravenous q. eight hours to end [**2117-2-8**]. 7. Vancomycin one gram intravenous twice a day to end [**2-8**]. 8. Tums, one tablet p.o. three times a day. 9. Fosamax 10 mg p.o. q. day. 10. Albuterol two puffs q. two to six hours p.r.n. 11. Tylenol 325 to 650 mg p.o. q. four to six hours p.r.n. 12. Ativan 0.25 mg to 0.5 mg p.o. intravenously q. six hours p.r.n. 13. Reglan 10 mg p.o. three times a day. 14. Zoloft 50 mg p.o. q. h.s. 15. Captopril 37.5 mg p.o. three times a day. 16. Diltiazem 60 mg p.o. four times a day. 17. Prednisone 20 mg p.o. q. day times two days, then 10 mg p.o. q. day times three days, then end. 18. Dulcolax 10 mg p.o., p.r. q. day p.r.n. 19. Colace 100 mg p.o. twice a day p.r.n. 20. Atrovent two puffs q. four hours. DISCHARGE INSTRUCTIONS: 1. The patient is to use Bi-PAP at night and as needed. Please use Quantam or Quantam-like Bi-PAP. 2. She may require a tracheostomy at a later time. DISCHARGE DIAGNOSES: 1. Severe end-stage chronic obstructive pulmonary disease. 2. Hypertension. 3. Tracheobronchitis. 4. Depression. 5. Hypercholesterolemia. 6. Anxiety. 7. Coronary artery disease status post non-Q wave myocardial infarction. 8. Methicillin resistant Staphylococcus aureus. 9. Allergy to sulfa, codeine, Augmentin and shellfish. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 166**] Dictated By:[**Name8 (MD) 1037**] MEDQUIST36 D: [**2117-1-26**] 14:04 T: [**2117-1-26**] 14:17 JOB#: [**Job Number 6573**] Name: [**Known lastname 1810**], [**Known firstname 1647**] Unit No: [**Numeric Identifier 6569**] Admission Date: [**2117-1-7**] Discharge Date: [**2117-2-8**] Date of Birth: [**2055-3-17**] Sex: F Service: MICU ADDENDUM: This brief summary is an addendum to a previous summary dictated by the undersigned on [**2117-2-1**]. On the evening of hospital day 26, the day of the patient's percutaneous tracheostomy, the patient began experiencing difficulty with respiration overnight. The patient was noted to be hypotensive and tachycardic and was difficult to ventilate by bagging. The patient's tracheostomy was found to be very positional and on [**2117-2-2**], the patient underwent bronchoscopy to evaluate the position of the tracheostomy tube. Bronchoscopy revealed that the beveled edge of the tracheostomy tube was in contact with the left lateral wall of the tracheostomy. The tracheostomy was changed from a 7 to a French tube. The procedure was done by attending physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], assisted by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 6574**]. The procedure was done under general endotracheal anesthesia without complications. The patient continued to be intermittently hypertensive throughout the remainder of her hospital stay. The patient's tracheostomy was felt to be in good position as her oxygenation and ventilation were appropriate. However, multiple attempts to wean the patient off of ventilator support on to a trial of tracheostomy mask were unsuccessful. The patient would become agitated and hypertensive and be required to go back to pressure support ventilation. It was felt that the etiology of the patient's hypertension and apparent respiratory distress were likely anxiety related as the patient's arterial blood gases and oxygen saturations all appeared to be within good limits. Multiple regimens of angiolytics were attempted including Ativan, Haldol, Klonopin, Remeron and Xanax. The patient's hypertension continued to be difficult to control and on [**2117-2-7**], the patient was placed on Hydralazine 10 mg p.o., four times a day with p.r.n. intravenous dosing to control her systolic blood pressure. Throughout her post-tracheostomy course, the patient's systolic blood pressures reached as high as 270 systolic. In order to further work-up the patient's hypertension, urinary catecholamines were sent on [**2117-2-7**] and results of that collection are pending. On [**2117-2-6**], the patient was noted to have a small amount of bright red blood suctioned from her tracheostomy site of approximately 30 cc. Again, on [**2117-2-7**], the patient was suctioned with a small amount, approximately 10 cc., of bright red blood per tracheostomy. The patient is expected to undergo bronchoscopy on [**2117-2-8**]. It is felt that the bleeding is likely related to the tracheostomy site and not bleeding from any more distal site within her bronchial tree. From a Nutrition standpoint, the patient was noted to have continued poor p.o. intake, both preceding and after her tracheostomy. The patient, therefore, had a PEG tube placed by Interventional Radiology on [**2117-2-4**], without complications. At the time of this discharge, the patient is tolerating her tube feeds well at a goal of 50 cc. per hour of ProMod with fiber. Hematologically, the patient was transfused one unit of packed red blood cells on [**2117-2-3**] for a hematocrit of 24.8. The patient was transfused again on [**2117-2-7**], two units of packed red blood cells for a hematocrit of 22.8. Labs to evaluate the patient's anemia revealed a normal iron, TIBC, and ferritin. The patient is ready for discharge to Pulmonary Rehabilitation on [**2117-2-8**], in fair condition. DISCHARGE DIAGNOSES: 1. Severe chronic obstructive pulmonary disease. 2. Status post percutaneous tracheostomy. 3. Anxiety disorder. 4. Status post PEG tube placement. 5. Severe systolic hypertension. An updated list of the patient's current medications will be available via patient referral page one. [**Name6 (MD) 73**] [**Name8 (MD) 72**], M.D. [**MD Number(1) 352**] Dictated By:[**Name8 (MD) 6575**] MEDQUIST36 D: [**2117-2-7**] 21:15 T: [**2117-2-7**] 21:31 JOB#: [**Job Number 6576**]

[ "410.71", "272.0", "518.81", "300.00", "V09.0", "427.89", "486", "491.21", "401.9" ]

icd9cm

[ [ [] ] ]

[ "31.1", "33.21", "97.23", "43.19" ]

icd9pcs

[ [ [] ] ]

5449, 5549

9650, 9757

25961, 26476

20264, 21247

5570, 5619

9198, 9463

18891, 20241

21271, 21424

1880, 2560

2890, 3944

6910, 7007

15712, 18873

10601, 15683

8691, 9171

9480, 9633

27,160

162,256

27961

Discharge summary

report

Admission Date: [**2111-9-7**] Discharge Date: [**2111-9-10**] Date of Birth: [**2053-12-3**] Sex: M Service: MEDICINE Allergies: Nitroglycerin Transdermal Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 68083**] is a 57 yoM w/ metastatic renal cell cancer with mets to his brain and lungs currently most recently being treated with gemcitabine and sutent with known UE / IJ thrombosis on lovenox presents with shortness of breath x 3 days with an acute worsening the a.m. of admission. He states he has initially had DOE but has progressed to shortness of breath at rest. He complains of PND and orthopnea, his orthopnea is stable and he has been sleeping in a recliner since his last discharge over a month ago. He Has had a cough for 1-2 weeks, it is improving, occ productive of clear white sputum without any change in sputum, no hemoptysis. He also complains of dysphagia of solids, not liquid, no odynophagia. No regurgitation. . He denies any abd pain, recent constipation- last BM 48hrs ago, no diarrhea, no nausea / vomiting. No dysuria. Chronic BRBPR but none lately, attributed to hemorrhoids in past as evaluated by GI. He has pain related to a sacral decub which he developed on his last admission, this has been healing well, not open, no discharge or foul odor. No fevers or chills. No increase in throat / face swelling but a ?of slightly increased "tightness." He had not noticed any change in upper ext swelling except after BP cuff applied in ED increase in LUE swelling which reduced with elevation of arm. . Given decadron 10mg IV x 1, vanc / cefepime / levaquin, given percocet 5/325 x 1 and combivent nebs x 3 for shortness of breath. CT chest w/ concern of lymphangitic spread of tumor, large lymphadenopathy and known venous occlusion. T 95.8 HR 96 BP 141/94 RR 24 O2 100% on 2L. . Past Medical History: # metastatic renal cell cancer to lung and brain - diagnosed [**5-/2109**] - s/p uncomplicated laparoscopic L radical nephrectomy [**2109-5-27**] - s/p bevacizumab treatment [**8-/2109**] and high-dose IL-2 [**9-/2109**] - s/p Sutent treatment [**1-/2110**] - [**8-/2110**] - s/p microsurgical stereotactic volumetric resection of L parietal lobe lesion [**2111-1-21**] - s/p CyberKnife therapy on [**2111-2-6**] - started clinical trial ABT-869 on [**2111-3-24**] # R venous sinus thrombosis on lovenox x 2 months # h/o C diff colitis # hypertension # hyperlipidemia # hypothyroidism # GERD Social History: The patient was born in [**State 9512**]. He is a graduate of [**Location (un) 68081**]. He has worked for the Caterpillar Tractor Company for the last 22 years. He lives in [**Location 1294**] with his wife. [**Name (NI) **] enjoys golf. He has a daughter of 30 and another child as well. Family History: Father w/ CVA at 80 No h/o of coagulopathies Physical Exam: T: 97.1 BP: 125 HR: 74 RR: 24 O2 91% RA, 99% on 3L Gen: appears in mild resp distress, tachypneic, speaking in [**3-14**] word sentances. HEENT: No conjunctival pallor. No icterus. MMM. OP clear. Neck: Fullness B/L. bulky lymphadenopathy. TTP R supraclavicular region. no stridor CV: RRR. nl S1, S2. No murmurs, rubs or [**Last Name (un) 549**] LUNGS: L lung field lower [**12-10**] bronchial breath sounds ABD: + BS. Soft, NT, ND. No HSM. EXT: LUE edema esp in dorsal aspect of hand. no lower ext edema, clubbing or cyanosis. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Moving all extremities. Pertinent Results: [**2111-9-7**] 06:43AM GLUCOSE-136* UREA N-23* CREAT-1.1 SODIUM-131* POTASSIUM-4.5 CHLORIDE-93* TOTAL CO2-25 ANION GAP-18 [**2111-9-7**] 06:43AM ALT(SGPT)-11 AST(SGOT)-11 LD(LDH)-309* ALK PHOS-86 TOT BILI-0.3 [**2111-9-7**] 06:43AM CALCIUM-8.4 PHOSPHATE-4.4 MAGNESIUM-1.9 [**2111-9-7**] 06:43AM WBC-3.9* RBC-3.66* HGB-9.6* HCT-29.7* MCV-81* MCH-26.3* MCHC-32.4 RDW-24.9* [**2111-9-7**] 06:43AM PLT COUNT-426 [**2111-9-7**] 06:43AM PT-15.8* PTT-39.6* INR(PT)-1.4* [**2111-9-6**] 11:08PM PO2-95 PCO2-39 PH-7.47* TOTAL CO2-29 BASE XS-4 [**2111-9-6**] 09:50PM COMMENTS-GREEN TOP [**2111-9-6**] 09:50PM LACTATE-2.3* [**2111-9-6**] 09:30PM GLUCOSE-117* UREA N-24* CREAT-1.1 SODIUM-131* POTASSIUM-4.2 CHLORIDE-93* TOTAL CO2-29 ANION GAP-13 [**2111-9-6**] 09:30PM WBC-5.9 RBC-3.94* HGB-10.3* HCT-32.3* MCV-82 MCH-26.1* MCHC-31.9 RDW-24.1* [**2111-9-6**] 09:30PM NEUTS-66.6 LYMPHS-21.9 MONOS-9.5 EOS-1.5 BASOS-0.4 [**2111-9-6**] 09:30PM HYPOCHROM-2+ ANISOCYT-3+ POIKILOCY-1+ MACROCYT-1+ MICROCYT-3+ POLYCHROM-NORMAL OVALOCYT-1+ TEARDROP-OCCASIONAL [**2111-9-6**] 09:30PM PLT COUNT-482* [**2111-9-6**] 09:30PM PT-14.5* PTT-35.4* INR(PT)-1.3* CTA No central PE. Massive mediastinal, hilar and neck adenopathy. Increased left pleural effusion with near collapse of the left lower lobe. Small pericardial effusion. Interstitial thickening in the left upper lobe, concerning for lymphangitic tumor spread. The airway remains narrowed at the level of the true vocal cords. Thrombosis of the left brachiocephalic and proximal IJ, with IJ reconstitution distally. Total occlusion of the right internal jugular vein. CXR: 1. Moderate left basal effusion along with atelectasis and possibly consolidation in the left lower lobe. 2. Mediastinal lymphadenopathy as documented on CT of [**2111-7-7**]. Brief Hospital Course: A/P: 57yoM metastatic RCC to lungs/brain, recently admitted for increased neck swelling with worsened neck LAD and neck mass, p/w shortnes of breath and dyspnea on exertion. 1. Shortness of breath: patient has multiple reasons for shortness of breath including L pleural effusion (new when compared to [**6-16**], on [**7-27**] had a CT neck which included much of lung and there was a small pleural effusion at that time however the L lung parenchyma and effusion have worsened), ?lymphangitic spread of tumor given the interstitial thickening of the LUL of the lung, mets to lung and mediastinal / hilar lymphadenopathy on CT scan of chest. Given lack of leukocytosis, cough, fevers would or clear infiltrate (although area of L lung w/ pleural effusion and lobar collapse makes it difficult to rule out radiographically) will hold antibiotics for now and monitor for leukocytosis (although just given steroids) and fever curve. Patient progressed to respiratory distress and was intubated. Following family discussion, patient was made [**Month/Year (2) **] measures only. He self extubated and died shortly thereafter. 2. Code status: Following discussion with patient's wife, he was made [**Name (NI) 9036**] Measures Only. He self-extubated and died shortly thereafter. Medications on Admission: Amlodipine 10 mg daily Atenolol 50 mg daily Lovenox 100 mg [**Hospital1 **] Nexium 40 mg [**Hospital1 **] HCTZ 25 mg daily Synthroid 88 mcg daily Prochlorperazine 10 mg Q6H prn nausea ativan 0.5mg po prn nausea trazodone 100mg po qhs prn tessalon perrls oxycodone 5-10mg po prn senna prn gemcitabine / sutent Discharge Medications: Patient died Discharge Disposition: Expired Discharge Diagnosis: Patient died Discharge Condition: Patient died Discharge Instructions: Patient died Followup Instructions: Patient died [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2111-9-15**]

[ "197.0", "244.9", "272.4", "530.81", "707.03", "V12.51", "V10.85", "455.6", "707.20", "787.20", "511.9", "401.9", "785.6", "276.1", "V10.52" ]

icd9cm

[ [ [] ] ]

[ "87.41", "96.04", "87.03" ]

icd9pcs

[ [ [] ] ]

7135, 7144

5457, 6738

300, 306

7200, 7214

3620, 5434

7275, 7454

2926, 2973

7098, 7112

7165, 7179

6764, 7075

7238, 7252

2989, 3601

253, 262

334, 1980

2002, 2595

2613, 2910

17,696

125,266

20017

Discharge summary

report

Admission Date: [**2152-11-19**] Discharge Date: [**2152-11-24**] Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 348**] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: colonscopy EGD sigmoidoscopy History of Present Illness: 80 M with hx of R hemicolectomy due to ischemic colitis from artery embolization for GIB who developed melena colored stool with some mixed with blood approximately 2d PTA. His stools are frequently black because of iron supplimentation. Amount of blood is minimal. He had two bloody BMs this am, last one at 10 am on DOA. One episode of bilious vomiting yesterday. Seen at [**Hospital 45887**] Hospital and Hct= 35.4. NGL negative. Received one unit PRBC and 2 L enroute. Some subjective abd pain wit palpation per pt. No SOB/CP. Overall feels well. Admitted to the [**Hospital Unit Name 153**] for observation. [**Hospital Unit Name 153**] course significant for episode of large BM with hypotension with MAPs in the 40s. Repeat NGL negative, HCT drop from 32-> 23 and received 2u PRBCs. GI consult was obtained and EGD unremarkable, colonscopy revealed extensive diverticular disease throughout the colon, with no active site of bleeding. However, most of the blood was located in the sigmoid colon. Tagged RBC scan performed on [**2152-11-20**] which was unremarkable. Surgical consult suggested that subtotal colectomy would be an option but last resort. GI suggested to pursue repeat look at sigmoid colon to discern possible bleeding source. Currently, pt feels well. His last BM was this afternoon in the ICU after having clear liquids. He states he had 2 BM that were BRBPR with black stool. He denies any fevers, chills, abdominal/chest pain, SOB, n/v. Past Medical History: 1. CAD with CABG in [**2141**], no MI since 2. HTN 3. OA 4. Gastrectomy and Billroth II. Revised to a Roux-en-Y in [**2151**]. 5. GIB [**2151**] intitally embolized by IR. Developed right ischmeic colitis requiring right hemicolectomy. Social History: Lives with wife in [**Name (NI) **]. Former smoker, quit in [**2108**]. No etoh [**2141**]. Family History: Non-contributory. Physical Exam: Physical on admission to [**Hospital Unit Name 153**]: Temp 97 9 BP 132/65 Pulse 59 Resp O2 sat 98% RA Gen - Alert, no acute distress HEENT - PERRL, extraocular motions intact, anicteric, mucous membranes moist Neck - no JVD, no cervical lymphadenopathy Chest - Clear to auscultation bilaterally CV - Normal S1/S2, RRR, no murmurs, rubs, or gallops Abd - Soft, nontender, nondistended, with normoactive bowel sounds Back - No costovertebral angle tendernes Extr - No clubbing, cyanosis, or edema. 2+ DP pulses bilaterally Neuro - Alert and oriented x 3, cranial nerves [**3-30**] intact, upper and lower extremity strength 5/5 bilaterally, sensation grossly intact Skin - No rash Rectal: blood tinged on glove, external non-tender hemmorhoids, guiac +, good tone Physical on admission to floor: T 98.4 BP 130/80 HR 58 RR 18 95%@RA Unchanged physical exam from [**Hospital Unit Name 153**] admission. Pertinent Results: [**2152-11-19**] 02:09PM BLOOD WBC-7.8 RBC-3.70* Hgb-10.6* Hct-31.5* MCV-85 MCH-28.7 MCHC-33.7 RDW-14.5 Plt Ct-252 [**2152-11-22**] 04:25AM BLOOD WBC-7.5 RBC-3.60* Hgb-10.6* Hct-31.6* MCV-88 MCH-29.3 MCHC-33.4 RDW-14.2 Plt Ct-202 [**2152-11-19**] 02:09PM BLOOD Glucose-88 UreaN-20 Creat-1.1 Na-140 K-4.1 Cl-107 HCO3-27 AnGap-10 [**2152-11-22**] 04:25AM BLOOD Glucose-115* UreaN-9 Creat-1.0 Na-140 K-4.1 Cl-107 HCO3-28 AnGap-9 [**2152-11-19**] 02:09PM BLOOD Calcium-8.5 Phos-3.4 Mg-1.8 GI BLEEDING STUDY Reason: 80 Y/O MAN WITH GI BLEED IN PAST WITH BRBPR AND HEMATOCRIT DROP. INTERPRETATION: Following intravenous injection of autologous red blood cells labeled with Tc-[**Age over 90 **]m, blood flow and delayed images of the abdomen for 90 minutes were obtained. Blood flow and delayed blood pool images show no focus of abnormal uptake to suggest GI bleed. There is possible aneurysmal dilatation of the distal aorta and ectasia of the right iliac artery. IMPRESSION: No evidence of active GI bleeding on this study. Possible aneurysmal dilatation of the distal aorta and ectasia of the right iliac artery. EGD Findings: Esophagus: Normal esophagus Stomach: Normal stomach Duodenum: Normal duodenum Impressions: Normal EGD to mid-jejunum Colonoscopy Findings: Excavated Lesions Extensive diverticular disease was seen throughout the entire colon. No active site of bleeding was visualized. However, most of the blood appears to be located in the sigmoid colon. The color of stool in the transverse colon appeared brown in color. Impressions: Diverticulum in the entire colon Blood in the sigmoid colon The source of bleeding is likely due to diverticular disease in the sigmoid colon Recommendations: Repeat flexible sigmoidoscopy once bleeding has stopped to reassess for lumenal pathologies. Serial Hct Maintain 2 peripheral IV's at all times. Repeat tagged RBC scan if pt rebleeds acutely. Sigmoidoscopy Findings: Excavated Lesions Multiple non-bleeding diverticula were seen in the sigmoid colon, descending colon and splenic flexure. Impression: Extensive diverticulosis of the sigmoid colon, descending colon and splenic flexure Brief Hospital Course: 1. GI Bleeding: Pt was emergently admitted to the ICU for monitoring and observation and the GI service was consulted. Emergent colonoscopy was performed revealing extensive diverticuli but no source of bleeding. An EGD was performed which was unremarkable. Surgery was consulted in regrads to possible surgical colectomy but he was deemed too high a risk for surgical removal and felt that if possible this should be medically managed. He was transfused 2 units of RBCs. A repeat sigmoidoscopy was performed to better visualize his sigmoid colon, since the majority of bleeding was seen in this area. Sigmoidoscopy revealed extensive diverticuli without source of bleed. His diet was advanced to a low-residue diet and tolerated without complications. ***If he has further episodes of hematochezia, he is instructed to proceed to the nearest ED for stability and then needs immediate angiography to investigate bleeding source. *** 2. HTN: Continues on his outpatient medications. His ASA will be held in the light of rebleeding. He needs to follow up with his cardiologist in regards to restarting his ASA. Medications on Admission: toprol xl 100 mg qd ASA 81 mg qd acupril 20 mg qd pravachol 10 mg qd vioxx in past but bextra last 3 days FeSO4 started recently Discharge Medications: 1. Toprol XL 100 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. 2. Accupril 20 mg Tablet Sig: One (1) Tablet PO once a day. 3. Pravachol 10 mg Tablet Sig: One (1) Tablet PO once a day. 4. Protonix 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* Discharge Disposition: Home Discharge Diagnosis: Lower gastrointestinal bleed, likely diverticular bleed of unknown source. Coronary Artery disease s/p R hemicolectomy secondary to artery embolization for GIB Hypertension Osteoarthritis s/p Billroth II for GERD Discharge Condition: stable Discharge Instructions: follow up with your PCP in the next 1-2 weeks. Please proceed to the CLOSEST emergency room if you are experiencing further bleeding. Please make sure you bring a copy of your discharge summary when you go. Followup Instructions: follow up with your PCP in the next 1-2 weeks.

[ "562.12", "414.00", "V45.81", "280.0", "401.9" ]

icd9cm

[ [ [] ] ]

[ "48.23", "99.04", "45.13", "45.23" ]

icd9pcs

[ [ [] ] ]

7038, 7044

5321, 6441

264, 295

7301, 7309

3141, 5298

7566, 7616

2185, 2204

6620, 7015

7065, 7280

6467, 6597

7333, 7543

2219, 3122

219, 226

323, 1801

1823, 2060

2076, 2169

27,532

129,997

27170

Discharge summary

report

Admission Date: [**2149-8-24**] Discharge Date: [**2149-8-28**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7455**] Chief Complaint: Fever and hypoxemia Major Surgical or Invasive Procedure: None History of Present Illness: 86 year old male resident of [**Hospital 599**] Nursing home sent to [**Hospital1 **] for w/up of fever w/ tachycardia, tachypnea and hypoxemia. . Pt reportedly transferred from dementia unit of nursing home to sub-acute unit on [**2149-8-23**] for IVF for 'dehydration' due to decreased PO intake. In sub acute unit pt noted to be SOB w/ T=102.2, R=36, BP 130/70, P132, O2 sat 71% on 3L NC. At that time pt was noted to be alert and verbally responsive but confused. Pt was transferred to [**Hospital1 **] on [**8-24**] for further eval. Per daughter, pts mental status has deteriorated over the past two weeks. Pt previously spoke in understandable sentances whereas now he mumbles largely incoherently. . In ED VS 102.4 HR 129 BP 112/88 RR 30 sat 71% on 2L. pt was placed on BiPap. CXR w/ finding of RLL pneumonia - pt given vanco/ceftriaxone. Past Medical History: PMHx: dementia hx TIA depression psychosis GERD htn Lumbosacral surgery Urological disorder, details unknown Chronic Diarrhea Social History: Lives in nursing home ([**Hospital1 599**] of [**Last Name (un) **] [**Doctor Last Name **]), daughter, [**Name (NI) **] [**Name (NI) 66676**], is HCP ([**Telephone/Fax (1) 66677**], C [**Telephone/Fax (1) 66678**]), no tobacco, no EtOH Family History: Father with [**Name (NI) 2481**], Brother had a stroke Physical Exam: PE: (Upon MICU arrival) T:99.9 BP:103/82 P:104 RR:22 O2 sat:99% on BiPAP gen: pt mumbling incoherently, awake HEENT: NC/AT Chest: Basilar crackles Heart: tachycardic, regular rhythm, no M/R/G Abd: soft, NT/ND Ext: moves all 4 extremities Skin: warm, well perfused, decreased turgor neuro: pt follows occasional commands, mumbles incoherently Pertinent Results: ED labs/imaging: ABG on cpap 7.35/36/259/21 lactate 1.9 trop T .08 Na 146/ K 4.8/Cl 112/HCO3 22/BUN 77/Cr 2.0/glucose 122 wbc 3.3/ hgb 11.8/ hct 36.7/ plt 281, diff N 86/0 bands/L 10/M 4 . UA: mod blood, tr protein, occ bact, <1 epi, otherwise nl . EKG: sinus tachycardia . CXR: [**2149-8-24**]: FINDINGS: The heart is normal in size. The aorta is mildly ectatic. Large infiltrate can be seen within the right lower lobe. Aside from the left basilar atelectasis, the remaining lungs appear clear. There is a probable small right pleural effusion. There is no left pleural effusion. There is no pneumothorax. There is evidence of spinal fusion of the lower lumbar vertebral bodies. Multiple tiny clips project along the lateral aspects of the lower thoracic spine. IMPRESSION: Right lower lobe pneumonia and small right pleural effusion . Brief Hospital Course: 86 yo male w/ fever, tachycardia, tachypnea and hypoxia presents from nursing home w/ RLL pneumonia. . # RLL pneumonia: In ED patient hypoxic to 70s, put on bipap. He was able to transition to facemask upon MICU arrival. His respiratory distress was likely secondary to pneumonia given clinical picture of fever, tachypnea and hypoxemia in light of CXR finding of RLL infiltrate. Given that he lives in nursing home and was hospitalized recently ([**7-28**] - [**7-29**]), and may also be at risk for aspiration pneumonia, he was covered for broad spectrum pathogens w/ vanco and unasyn. Sputum cultures were taken but contaminated. Blood cultures showed no growth to date. He was transitioned to oxygen by nasal cannula. He was able to go to the medical floor on [**8-27**] and is currently on oxygen at 2L/min. His antibiotics were changed to oral levofloxacin and metronidazole, to complete a 10 day course. Possible aspiration worked up as below. . # Comfort care measures: per family, care directed towards comfort is most appropriate at this time. They have seen progressive decline over the last few weeks and patient has not been taking in good PO. He is DNR/DNI/no procedures/no lines. He will likely become do not hospitalize following his discharge with involvement of hospice. We stopped restraints, IV fluids, lab draws, and some medications. He can resume PO intake for comfort. . # Dehydration: His family reported very poor PO intake during the last few weeks. He was given IV fluid boluses and maintenance fluids. Due to concern of aspiration, he was kept NPO; bedside swallow studies were performed but were inadequate. He was going to have a video swallow study; however he was too lethargic at the time and, after discussion with the family regarding goals of care, this was not reattempted. He was allowed to eat pureed diet and thickened liquids as tolerated as part of his comfort care measures. . # Renal Insufficiency: His Cr 2.0 at admission, up from 1.3 at d/c on [**7-29**]. This was likely prerenal given recent decreased PO intake, tachycardia, clinical exam and chronic diarrhea. He was given IV fluids as above. This improved to his most recent value of 1.3. . # HTN - He was hypertensive to SBP 180s beginning on [**8-25**] w/ moderate tachycardia to 120. He was restarted on home altace at 5 and also started on metoprolol 50 TID as well due to inadequate control on altace only. His blood pressures have improved with this regimen. . # Chronic Diarrhea: Has had diarrhea for months to years and takes loperamide chronically. No abd pain. Culture and C.diff were negative. Loperamide was restarted for comfort. . # Hypernatermia: pt w/ hypernatremia on admission. This resolved with IV fluids. . # Code status: DNR/DNI/no central access or procedures. Likely will become hospice and do not hospitalize. Medications on Admission: MEDS on admission: Namenda 5mg po BID zyprexa 2.5mg po BID prn agitation acetominophen 1000 po tid altace 5mg po daily lasix 20 mg po MWF loperamide 2mg po BID plavix 75 mg po daily tramadol hcl 25 mg po tid ALL: NKDA Discharge Medications: 1. Ramipril 5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily): hold for SBP<100. 2. Tramadol 50 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 3. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for agitation: may substitute Zydis dissolvable tablet . 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): hold for SBP<100 and HR<60 . 5. Loperamide 2 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. 7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 7 days. 8. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain or fever. 9. Morphine Concentrate 20 mg/mL Solution Sig: 2-4 mg PO Q2H (every 2 hours) as needed for pain, dyspnea, or anxiety. 10. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) inhalation Inhalation every four (4) hours as needed for shortness of breath or wheezing. 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) inhalation Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. Discharge Disposition: Extended Care Facility: [**Hospital1 599**] of [**Location (un) 55**] Discharge Diagnosis: Pneumonia Hypoxemia Poor PO intake Dementia Discharge Condition: Stable, comfortable, on oxygen by nasal cannula Discharge Instructions: You were admitted with low oxygen levels and found to have a pneumonia. You needed to stay in the intensive care unit for a few days to support your oxygen levels. You are still getting oxygen for comfort. . We discussed the goals of your care with your family. We are in agreement that the focus should be on making you comfortable. If these goals change, please discuss this with your primary care doctor, Dr. [**Last Name (STitle) **]. . We have made the following medication changes: We have stopped some of your medications, including Plavix, Namenda, and Lasix. We have added sublingual morphine for pain control and comfort. We added metoprolol for your blood pressure. We have also added 2 antibiotics, Levofloxacin and Metronidazole, for the treatment of your pneumonia. You can also use nebulizer treatments for trouble breathing or wheezing if needed. Followup Instructions: Please followup with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], if you have any questions about your health or your care. Your care providers will also be giving your family more information and involvement with Hospice services.

[ "787.91", "507.0", "294.8", "530.81", "584.9", "276.51", "276.0", "799.02", "311", "403.90", "585.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7195, 7267

2889, 5744

282, 289

7355, 7405

2027, 2866

8321, 8601

1592, 1648

6014, 7172

7288, 7334

5771, 5776

7429, 7900

1663, 2008

7920, 8298

223, 244

317, 1172

5790, 5991

1194, 1321

1337, 1576

26,248

174,716

4227

Discharge summary

report

Admission Date: [**2158-11-15**] Discharge Date: [**2159-1-2**] Date of Birth: [**2113-9-2**] Sex: M Service: MEDICINE Allergies: Morphine / Amoxicillin / Darvocet-N 100 / Sulfonamides / Demerol / Dilaudid Attending:[**First Name3 (LF) 2186**] Chief Complaint: Abnormal labs Major Surgical or Invasive Procedure: L [**First Name3 (LF) 18371**] HD catheter placement PICC placement Temporary HD catheter placement History of Present Illness: Patient is a 45 yo male with type 1 diabetes c/b esrd since [**2152**] on tiw dialysis, multiple amputations who was sent to the ED for abnormal potassium and glucose. The labs were originally done b/c patient was to get thrombectomy today for his av fistula. Dialysis was able to access the fistula, however, surgery requested a venogram before the holiday weekend. In addition patient's blood sugar is elevated to 485. He is admitted for aggressive electrolyte managment and venogram to r/o clot in av fistula. . Patient has no complaints, no cough/sob/f/c/n/v/cp/urinary/bowel sx Past Medical History: HTN Hyperchole Hx of CHF but last TTE [**11-23**] lvh and ef 50-55%, mild mr [**First Name (Titles) **] [**Last Name (Titles) 18372**]l enlargement gastroparesis s/p b/l bka's and mult finger amputations hx of neuropathy R AV fistula Depression Gerd s/p right hip arthroplasty hx of mssa bacteremia from graft infection [**11-23**] Cath [**2152**] no flow limiting disease Social History: Patient used to work as carpenter, plumber, and dishwasher but has not worked for years. He continues to smoke 1 pack every three days. He has a 30-pack-year history of tobacco. He denies the use of alcohol or any recreational drugs. Family History: The patient reports one brother with hypertension but could not elaborate further regarding family history. Physical Exam: T 96 HR 73 RR 16 O2 98% Gen: awake, chronically ill appearing, NAD HEENT: neck supple, eomi, anicteric, jvp flat Lungs: CTA ant Heart: s1 s2 2/6 sem abd: soft nt/nd +bs Ext: sym bka, R graft undergoing dialysis Neuro: aox3 Pertinent Results: [**2158-11-15**] 09:21PM GLUCOSE-135* UREA N-65* CREAT-7.5*# SODIUM-134 POTASSIUM-6.3* CHLORIDE-103 TOTAL CO2-22 ANION GAP-15 [**2158-11-15**] 09:21PM CALCIUM-9.6 PHOSPHATE-2.4* MAGNESIUM-2.3 [**2158-11-15**] 09:21PM FDP-0-10 [**2158-11-15**] 09:21PM FIBRINOGE-165 [**2158-11-15**] 05:00PM UREA N-31* [**2158-11-15**] 02:55PM UREA N-70* [**2158-11-15**] 01:43PM TYPE-[**Last Name (un) **] PH-7.21* [**2158-11-15**] 01:43PM GLUCOSE-471* LACTATE-0.9 NA+-128* K+-7.6* CL--92* TCO2-27 [**2158-11-15**] 01:43PM freeCa-1.26 [**2158-11-15**] 01:30PM UREA N-88* CREAT-8.8* [**2158-11-15**] 01:30PM CK(CPK)-48 [**2158-11-15**] 01:30PM cTropnT-0.21* [**2158-11-15**] 01:30PM CK-MB-NotDone [**2158-11-15**] 01:30PM CALCIUM-9.6 PHOSPHATE-2.6* MAGNESIUM-2.6 [**2158-11-15**] 01:30PM WBC-3.3* RBC-5.53 HGB-13.6* HCT-43.9 MCV-79* MCH-24.5* MCHC-30.9* RDW-18.5* [**2158-11-15**] 01:30PM NEUTS-50 BANDS-0 LYMPHS-35 MONOS-6 EOS-9* BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2158-11-15**] 01:30PM PLT COUNT-71* [**2158-11-15**] 09:00AM GLUCOSE-485* UREA N-87* CREAT-8.6*# SODIUM-126* POTASSIUM-7.7* CHLORIDE-89* TOTAL CO2-27 ANION GAP-18 [**2158-11-15**] 09:00AM WBC-3.4* RBC-5.22# HGB-12.7* HCT-41.0 MCV-79*# MCH-24.3*# MCHC-30.8* RDW-18.5* [**2158-11-15**] 09:00AM PLT SMR-VERY LOW PLT COUNT-75*# [**2158-11-15**] 09:00AM PT-15.6* PTT-30.0 INR(PT)-1.7 . MR Venogram: 1. Initial venogram demonstrated stenoses of the left brachiocephalic vein. Based on the diagnostic findings, it was decided that the patient would benefit from and was a good candidate for angioplasty. The left brachiocephalic vein was angioplastied to 10mm with acceptable angiographic result. 2. A 14.5-French 20-cm long cuff-to-tip tunneled dual-lumen hemodialysis catheter was placed via the left subclavian vein with tip in the right atrium. The catheter can be used immediately. 3. Successful placement of a 8.5-French x 16 cm quadruple-lumen central venous catheter with by way of the right common femoral vein with tip in the right common iliac vein. The catheter can be used immediately. . MR [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 18371**]: IMPRESSION: Large amount of subcutaneous and intramuscular edema within the left [**Last Name (NamePattern4) 18371**] as described, without drainable fluid collection. Findings are nonspecific yet could be related to postsurgical change, however superimposed infection cannot be excluded. . 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 (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. There is no aortic valve stenosis or regurgitation present. 5.The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. 6.There is no pericardial effusion. . Bone marrow biopsy: Non-specific lymphoid profile; no phenotypic evidence of increased myeloblasts or of lymphoma is seen in this limited panel. correlation with clinical findings and morphology (see separate report) is recommended. Flow cytometry immunophenotyping may not detect [**Doctor Last Name **] lymphomas due to topography, sampling or artifacts of sample preparation. Please refer to S06-571. . MR Chest: CONCLUSION: 1. Normal flow demonstrated in the right or left internal jugular veins, moderate narrowing of the stented left brachiocephalic vein, but the SVC and left subclavian veins remain patent. 2. Thin linear potential filling defect within the left subclavian vein could represent partially duplicated venous system or non occlusive thrombus. Direct correlation with ultrasound is advised. . CXR: 1. Clear lungs. 2. Mild cardiomegaly. 3. Emphysema. Brief Hospital Course: A/P: Patient is a 45 yo m with type 1 DM c/b esrd on dialysis, and mult other medical problems who presents with hyperglycemia, and hyperkalemia. . # ESRD on HD: ESRD with HD Tu, Th, Sat. The patient was originally admitted because of access issues w/ his AV fistula. Venogram of the fistula revealed significant stenosis of the fistula and renal/transplant/IR have all been coordinating care to arrange alternative access. A MR venogram was obtained to better evaluate the central venous structures prior to planning his access. In the meantime, the patient had a tunnelled groin HD catheter that was used. However, on [**2158-11-24**] the patient became acutely febrile to 104. At this time, renal and IR were consulted and the decision was made to remove his groin HD catheter and to obtain only a temporary PICC w/out further HD access. Renal was comfortable with the patient missing his scheduled Saturday HD session and planned to readdress his access issue on [**11-27**]. Because of access issues, a L femoral HD graft was placed. This procedure was, unfortunately, complicated by persistent fevers. His blood cultures grew MDR klebsiella only sensitive to meropenem from the 15-17th. Despite abx he continued to be febrile for the next week. An MRI of the L [**Month/Day (4) 18371**] showed no abscess but a WBC scan showed increased uptake at the site of the graft. Because of this, transplant removed the L [**Month/Day (4) 18371**] graft on [**12-15**]. He went w/out HD for the week and then access was established with a new temp cath triple lumen VIP line in the R groin on [**12-18**], and a triple lumen catheter in the R groin on [**12-26**]. Patient has been receiving meropenem through the triple lumen post-HD. HD is currently being done using the L subclavian HD tunneled catheter. . # Klebsiella cellulitis: Transplant surgery and wound care were following and caring for L groin wounds inhouse. The cellulitis over L groin has greatly improved in erythema, edema, warmth, and patient's pain was well controlled without pain meds. Klebsiella that was swabbed from the wound (does not necessarily correlate with infectious organism causing cellulitis) was resistant to all but zosyn, meropenem, imipenem. Blood cultures were negative since [**2158-12-6**]. The patient has been on Meropenem since [**2158-12-17**], and will be continued until [**2159-1-5**], which is 3 weeks after the L groin graft had been removed on [**2158-12-15**]. Pt had been spiking fevers to 101 until L groin graft was removed and meropenem was started. Vanco was given [**Date range (1) 18373**]. MRI L [**Date range (1) 18371**] showed no fluid collections/abscess. . # IV access: Patient has a HD cath in L subclavian vein placed by IR, who had to do angioplasty and stent to open L subclavian vein. The patient has no venous access in the R subclavian vein according to MR venogram which was repeated. . # Fever: As above, the patient became acutely febrile to 104 on [**2158-11-24**]. His blood cultures grew only strep viridans and he was treated at HD w/ vancomycin. He remained afebrile w/ negative cultures for several days before his graft was placed but developed MDR klebsiella bacteremia in the immediate aftermath of graft placement. B/c of his amoxicillin allergy, he was desensitized to meropenem in the MICU and was continued on this [**Doctor Last Name 360**]. Despite this therapy, he continued to spike fevers and his graft was eventually removed following a WBC showing uptake at the graft site. After removal of the L groin graft, fever disappeared within 24-48 hrs, and did not return. . # Hyperglycemia: The patient has a hx of brittle diabetes type 1, with an initial BG of 485 on presentation. He was seen by [**Last Name (un) **] in the past but has not f/u with them since [**2156**]. He states that he likes to keep his glu>200 at home b/c he develops severe hypoglycemic episodes if he is more closely controlled. He was placed back on his last known insulin dose (10u AM NPH), continued to demonstrate hyperglycemia, and his NPH was eventually titrated up to 12u qAM and 4u qPM. Around this time, he became acutely febrile to 103 and, since this time, he has had several hypoglycemic episodes, most often in the early AM. He was followed by [**Last Name (un) **] throughout his stay, and his eventual insulin dose was 8 NPH at breakfast and 8 NPH at dinner, with iss. . # Elevated Troponin: patient is not having chest pain currently. He has had elevated troponins in past, cardiology had seen him in [**11-23**] and recommended an outpatient stress. Several EKGs did not show significant change. . # Hyponatremia: The patient was originally hyponatremic and this was attributed to his severe hyperglycemia. It corrected with better blood glucose control. . # Decreased platelets: The patient has a baseline of 150-200k that was noted to be 71 during his admission. He also had an elevated PT/INR. Hematology evaluated the paitent and eventually did a bone-marrow bx that showed only a hypocellular marrow that was not c/w MDS. It was thought that his new thrombocytopenia might be [**12-21**] drug reaction but he reported no new medications in the past year. His levels were closely followed an self-resolved through his admission. . # Hypertension: He was treated with Coreg and was discharged on 18.5 [**Hospital1 **]. He had intermittent problems w/ hypotension in the setting of his infectious episodes and his antihypertensives were held during this time. . # Depression: He was continued on his outpt sertraline although heme-onc said that this medication would be the first to stop if his plts remain low in the future. . # Hypothyroidism: We continued his outpatient synthroid throughout his admission. Medications on Admission: Levothyroxine Sodium 175 mcg PO Q SAT, SUN Acetaminophen 325-650 mg PO Q4-6H:PRN Loperamide HCl 2 mg PO QID:PRN Aluminum-Magnesium Hydrox.-Simethicone 15-30 ml PO QID:PRN Metoclopramide 5 mg PO TID Artificial Tears 1-2 DROP OU QID:PRN Minoxidil 2.5 mg PO BID Atorvastatin 40 mg PO DAILY NIFEdipine CR 60 mg PO BID Bisacodyl 10 mg PO DAILY:PRN Nephrocaps 1 CAP PO DAILY Brimonidine Tartrate 0.15% Ophth. 2 DROP OU QHS Nitroglycerin Ointment 2% 0.5 in TP Q6H:PRN SBP > 160 Carvedilol 12.5 mg PO BID Oxazepam 10 mg PO HS Calcium Carbonate 1000 mg PO TID W/MEALS Oxycodone-Acetaminophen [**11-20**] TAB PO Q4-6H:PRN Clonazepam 0.5 mg PO BID Pantoprazole 40 mg PO Q12H Doxercalciferol 1 mcg PO QHD Paroxetine HCl 20 mg PO QHS Dorzolamide 2%/Timolol 0.5% Ophth. 1 DROP OU [**Hospital1 **] Prochlorperazine 10 mg PO/IV Q6H:PRN Docusate Sodium 100 mg PO DAILY Sarna Lotion 1 Appl TP [**Hospital1 **]:PRN Epoetin Alfa 15,000u QHD NPH 10 units SC QAM RISS Sevelamer 1600 mg PO TID Lactulose 30 ml PO BID Sucralfate 1 gm PO TID Lactic Acid 12% Lotion 1 Appl TP ASDIR Timolol Maleate 0.5% 1 DROP OU [**Hospital1 **] Levothyroxine Sodium 150 mcg PO Q MON, TUES, WED, [**Last Name (un) **], FRI Topiramate 25 mg PO BID Discharge Medications: 1. Epoetin Alfa 10,000 unit/mL Solution Sig: Per guidelines Injection ASDIR (AS DIRECTED). 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 4. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**11-20**] Drops Ophthalmic QID (4 times a day) as needed. 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Levothyroxine 150 mcg Tablet Sig: One (1) Tablet PO Q MON, TUES, WED, [**Last Name (un) **], FRI (). 8. Levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO Q SAT, SUN (). 9. Brimonidine 0.15 % Drops Sig: Two (2) Drop Ophthalmic QHS (once a day (at bedtime)). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 11. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 13. Sucralfate 1 g Tablet Sig: One (1) Tablet PO TID (3 times a day). 14. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 15. Ammonium Lactate 12 % Lotion Sig: One (1) Appl Topical ASDIR (AS DIRECTED). 16. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 17. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 18. Ipratropium Bromide 0.02 % Solution Sig: One (1) nebulizer Inhalation Q6H (every 6 hours) as needed. 19. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 20. Doxercalciferol 0.5 mcg Capsule Sig: Two (2) Capsule PO QHD (each hemodialysis). 21. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 22. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours as needed for 10 days. 23. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 24. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Eight (8) units Subcutaneous Qbreakfast. 25. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Eight (8) units Subcutaneous Qdinner. 26. Carvedilol 6.25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 27. Meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg Intravenous DAILY (Daily) for 3 days. Discharge Disposition: Extended Care Facility: Emerald Court Health & Rehabilitation Center - [**Location (un) **] Discharge Diagnosis: Primary diagnosis: Klebsiella cellulitis Secondary diagnosis: DM1, ESRD on HD Discharge Condition: Fair, VSS stable, Klebsiella cellulitis much improved in erythema, edema, warmth. Patient is comfortable and moving around halls in the wheelchair. Discharge Instructions: Please return to the emergency room if you experience increasing leg pain, fever, chills, chest pain, shortness of breath, or other concerning symptoms. Followup Instructions: 1. [**Last Name (un) **] Diabetes and Primary Care: Dr. [**First Name (STitle) **] [**Name (STitle) **], [**Telephone/Fax (1) 9979**] 2. Transplant Surgery: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2159-1-4**] 11:00 AM 3. Infectious Disease: [**Telephone/Fax (1) 457**], [**2159-1-16**], 2:00 PM, Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 18374**] 4. Primary Care: [**Telephone/Fax (1) 250**], if you would like further [**Hospital1 18**] primary care followup Completed by:[**2159-1-2**]

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icd9cm

[ [ [] ] ]

[ "41.31", "88.49", "39.56", "39.50", "39.27", "39.49", "39.95", "00.40", "38.95", "38.93", "99.04", "88.67" ]

icd9pcs

[ [ [] ] ]

15736, 15830

6189, 11970

349, 450

15952, 16103

2101, 6166

16304, 16896

1733, 1842

13226, 15713

15851, 15851

11996, 13203

16127, 16281

1857, 2082

296, 311

478, 1066

15913, 15931

15870, 15892

1088, 1463

1479, 1717

4,735

199,213

49444

Discharge summary

report

Admission Date: [**2133-5-15**] Discharge Date: [**2133-5-23**] Date of Birth: [**2067-7-27**] Sex: F Service: CARDIOTHOR REASON FOR ADMISSION: The patient is a 65 year old woman who is a postoperative admission; she is admitted directly to the Operating Room for a mitral valve replacement and is seen in preadmission testing. The patient's chief complaint was a decreased exercise tolerance and an increase in fatigue since [**Month (only) 359**] of last year. HISTORY OF PRESENT ILLNESS: The patient is a 65 year old woman who was in her usual state of health until [**2132-1-23**] when she began to experience decreased exercise tolerance. She also developed substernal chest pain in [**2132-11-22**] for which she was brought to the Emergency Room of [**Hospital1 69**]. She ruled in for a myocardial infarction and was found to be in mild congestive heart failure at that time. She was also found to have mitral regurgitation and atrial fibrillation. She has continued to have decreased exercise tolerance since her myocardial infarction and was referred to Dr. [**Last Name (STitle) **] for evaluation of mitral valve repair. A cardiac echocardiogram done in [**2133-2-22**], showed a left atrial enlargement, right atrial enlargement and ejection fraction of 55%, focal root and ascending aortic calcifications, three plus mitral regurgitation and mild tricuspid regurgitation. Mild pulmonary hypertension. Cardiac catheterization done in [**2132-11-22**], showed a right dominant system with occlusion of the distal left anterior descending status post thrombectomy and percutaneous transluminal coronary angioplasty of the distal left anterior descending at that time. PAST MEDICAL HISTORY: 1. Mitral regurgitation. 2. Atrial fibrillation. 3. Congestive heart failure. 4. Hypothyroidism. 5. Status post myocardial infarction. 6. Asthma. 7. Chronic bronchitis. 8. Mild cataracts. 9. Borderline hypertension. 10. Diverticulosis. 11. Osteoarthritis. 12. Gallstone pancreatitis. 13. Incision of pilonidal cyst. 14. Carpal tunnel release. 15. Cholecystectomy. MEDICATIONS: 1. Amiodarone 200 mg q. day. 2. Diovan 80 mg q. day. 3. Coumadin 5 mg q. day. 4. Aspirin 325 q. day. 5. Folate 1 q. day. 6. Levoxyl 100 micrograms q. day. 7. Multivitamin one tablet q. day. 8. Vitamin E, no dose specified. 9. Vitamin C, no dose specified. 10. Calcium, no dose specified. 11. Azatadine 10 mg q. day. 12. Glucosamine no dose specified. 13. Detrol with also no dose specified. ALLERGIES: No known drug allergies, although demerol does cause nausea and vomiting. FAMILY HISTORY: Mother died at 88 of congestive heart failure. Father died at 83 of congestive heart failure. Four sisters, all with hypertension and hypercholesterolemia. Occupation is a nurse, formerly at [**Hospital1 190**]. She lives alone here in [**Location 1268**], [**State 350**]. Denies tobacco use, rare alcohol use. No other recreational drug use. PHYSICAL EXAMINATION: Height 5'1", weight 164 pounds, heart rate 80 and sinus rhythm; blood pressure 120/80; respiratory rate 16. In general, in no acute distress. Appears stated age. Skin is well hydrated, no rashes or lesions. HEENT: pupils equally round and reactive to light. Extraocular movements are intact. Normal buccal mucosa. Neck is supple; no jugular venous distention or thyromegaly with a left cervical lymph node. Chest with bibasilar crackles; no wheezes or rhonchi. Heart is regular rate and rhythm with S1 and S2, with a II/VI ejection murmur heard best at the apex, radiating to the left axilla. Abdomen is soft, mildly obese, nontender, nondistended. Mid-abdominal scar which is well healed. Extremities are warm with no edema or cyanosis. Mild varicosities of bilateral lower extremities. Neurologic is cranial nerves II through XII grossly intact. No motor or sensory deficits. Pulses: Femoral two plus bilaterally, dorsalis pedis one plus bilaterally; posterior tibial one plus bilaterally. Radial two plus bilaterally. Carotids are two plus with no bruits. LABORATORY: White blood cell count 4.7, hematocrit 37.5, platelets 291. Sodium 138, potassium 4.4, chloride 101, CO2 29, BUN 20, creatinine 0.8, INR 3.0. Chest x-ray with no pleural effusions, resolution of congestive heart failure pattern. Degenerative changes of skeletal structures, left atrial enlargement consistent with history of mitral valve disease. No active pulmonary process. Electrocardiogram is sinus rhythm, rate of 66, PR is 180; QRS 100, QT 464. T waves in III and F with non-specific ST changes. HOSPITAL COURSE: As stated previously, the patient was a direct admission to the Operating Room where she underwent a mitral valve replacement with a #31 [**First Name8 (NamePattern2) 1495**] [**Male First Name (un) 923**] Mechanical Valve and a Mays. Her bypass times was 140 minutes with a cross clamp time of 103 minutes. Please see the Operating Report for full details and summary. She had an mitral valve replacement and Mays. She tolerated the procedure well and was transferred from the Operating Room to the Cardiothoracic Intensive Care Unit. At the time of transfer, the patient was in a sinus rhythm at 74 beats per minute with a mean arterial pressure of 64. She had Neo-Synephrine at one point at 5 mics per kg per minute and propofol at 20 mics per kg per minute. The patient did well in the immediate postoperative period, however, within an hour of arrival in the Intensive Care Unit, she did start to have a problem with excessive chest tube bleeding. Her ACT was mildly elevated for which she was treated with Protamine. Her INR was mildly elevated for which she was treated with fresh frozen plasma. In addition, the patient received two units of packed red blood cells and a bag of platelets, following which the patient's chest tube drainage dissipated. The patient remained hemodynamically stable throughout that period. On postoperative day one, the patient continued to be hemodynamically stable. Her sedation was discontinued at that time. She was weaned from the ventilator and successfully extubated. Her chest tubes and Swan-Ganz catheter however were left in place at that time for further monitoring. On postoperative day two, the patient remained on a low dose Neo-Synephrine infusion to maintain an adequate blood pressure. She remained hemodynamically stable. Her beta blockade was begun in the late afternoon of postoperative day two following a weaning of her Neo-Synephrine as was her diuretic therapy. Additionally, the patient was begun on Coumadin on postoperative day two. On postoperative day three, the patient remained hemodynamically stable off of all vasoactive intravenous infusions. Her chest tubes were removed as was her temporary pacing wires and she was transferred to the floor for continuing postoperative care and cardiac rehabilitation. Over the next several days, the patient had an uneventful postoperative course. She received Coumadin daily with an attempt to increase her INR to the therapeutic range of 3.0 to 3.5. Additionally she was on a heparin infusion during that period of time. With the assistance of the nursing staff and the Physical Therapy staff, the patient's activity level was increased. On postoperative day seven, the patient's INR had increased to 1.9. Up to that point, she had received Coumadin 5 mg times three consecutive days, followed by Coumadin 7.5 mg on [**5-21**] and 30th. At this point, we anticipate that the patient's INR will be in the mid 2.0 range on Saturday, [**5-23**], and at that point she will be considered for discharge to home with daily INR checks until she reaches her goal INR of 3.0 to 3.5. At the time of this dictation, the patient's physical examination is as follows: Vital signs with temperature of 99.0 F., heart rate 70 in sinus rhythm; blood pressure 95/45; respiratory rate 20; O2 saturation of 96% on room air. Weight preoperatively was 73 kilograms. At discharge her weight is 75.8 kilograms. Laboratory data was white blood cell count of 8.7, hematocrit 29, sodium 142, potassium 4.5, chloride 106, CO2 31, BUN 12, creatinine 0.7, glucose 89. INR on [**Last Name (LF) 2974**], [**5-22**] is 1.9. On physical she is alert and oriented times three, moves all extremities and follows commands. Respiratory is clear to auscultation bilaterally. Cardiac is regular rate and rhythm with S1, S2 with mechanical click. Sternum is stable. Incision with Steri-Strips, open to air, clean and dry. Abdomen is soft, nontender, nondistended with normoactive bowel sounds. Extremities are warm and well perfused with less than one plus edema bilaterally. DISCHARGE MEDICATIONS: 1. Metoprolol 12.5 mg twice a day. 2. Furosemide 20 mg q. day times two weeks. 3. Potassium chloride 20 mEq q. day times two weeks. 4. Enteric coated aspirin 81 mg q. day. 5. Amiodarone 400 mg q. day. 6. Levoxyl 100 micrograms q. day. 7. Warfarin as directed with goal INR of 3.0 to 3.5; warfarin doses 04/26 was 5 mg, [**5-19**] was 5 mg, [**5-20**] 5 mg, [**5-21**] 7.5 mg; on [**5-22**] 7.5 mg. 8. Acetaminophen 650 mg q. six p.r.n. 9. Percocet 5/325 one to two q. four to six hours also p.r.n. CONDITION AT DISCHARGE: The patient's condition on discharge is good. DISCHARGE DIAGNOSES: 1. Mitral regurgitation status post mitral valve replacement with a #31 [**First Name8 (NamePattern2) 1495**] [**Male First Name (un) 923**] mechanical valve. 2. Atrial fibrillation status post Mays procedure. 3. History of congestive heart failure. 4. Hypothyroidism. 5. Asthma. 6. Chronic bronchitis. 7. Cataracts. 8. Borderline hypertension. 9. Diverticulosis. 10. Osteoarthritis. 11. Gallstone pancreatitis. 12. Status post cholecystectomy. 13. Status post excision of pilonidal cyst. 14. Status post carpal tunnel release. 15. Coronary artery disease status post percutaneous transluminal coronary angioplasty of the left anterior descending. DISCHARGE STATUS: The patient is to be discharged to home with visiting nurses. DISCHARGE INSTRUCTIONS: 1. Follow-up in the wound clinic in two weeks. 2. To follow-up with Dr. [**Last Name (STitle) 284**] in three weeks. 3. Follow-up with Dr. [**Last Name (STitle) **] in four weeks. 4. Additionally, the patient's INR is to be followed by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 103494**], telephone number [**Telephone/Fax (1) 2936**]. Her first INR check is to be done by the visiting nurses the day following discharge. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Name8 (MD) 415**] MEDQUIST36 D: [**2133-5-22**] 16:56 T: [**2133-5-22**] 18:42 JOB#: [**Job Number 103495**]

[ "427.31", "412", "414.01", "428.0", "998.11", "394.0", "E878.8", "491.9", "416.8" ]

icd9cm

[ [ [] ] ]

[ "96.71", "35.24", "89.64", "96.04", "99.07", "37.78", "99.05", "38.91", "39.61", "38.93", "37.33", "99.04" ]

icd9pcs

[ [ [] ] ]

2627, 2976

9326, 10066

8724, 9242

4617, 8701

10090, 10791

2999, 4599

9258, 9305

516, 1712

1734, 2610

29,358

195,405

48848

Discharge summary

report

Admission Date: [**2144-6-1**] Discharge Date: [**2144-6-14**] Date of Birth: [**2073-11-20**] Sex: M Service: SURGERY Allergies: Lipitor Attending:[**First Name3 (LF) 1234**] Chief Complaint: Popliteal aneurysm s/p embolization Major Surgical or Invasive Procedure: PROCEDURE: Ligation of left popliteal artery aneurysm and proximal superficial femoral artery to distal-above-knee bypass graft using 6-mm ringed PTFE. Procedure: Flexible bronchoscopy. History of Present Illness: This 70 year old man has a history of CAD, s/p CABG and ischemic cardiomyopathy. He also has a significant history of aortic, iliac and popliteal aneurysms, s/p treatment as noted below. He has significant bilateral popliteal artery aneurysms that have increased in size with identifiable thrombus in both. Past Medical History: -CAD s/p CABG -abdominal aortic aneurysm -iliac artery aneurysm -ischemic cardiomyopathy -restrictive lung disease, no evidence of obstruction, present for quite some time and likely due to his elevated hemidiaphragm from his initial cardiac surgery -TTE: LVEF 35-40%, inferolateral LV HK with moderate AR -hyperlipidemia -peptic ulcer disease Social History: Social history is significant for the absence of current tobacco use, but prior significant use. Widower. There is no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: PE: AFVSS a/o x 3 nad grossly intact supple no carotid bruits cta rrr obese R - palp fem. palp [**Doctor Last Name **]. palp dp. dop pt L - palp fem. palp [**Doctor Last Name **]. palp dp. dop pt [**Name (NI) **] skin lesions Pertinent Results: Initial labs: [**2144-6-1**] 07:49PM GLUCOSE-159* UREA N-20 CREAT-1.2 SODIUM-140 POTASSIUM-5.4* CHLORIDE-101 TOTAL CO2-35* ANION GAP-9 [**2144-6-1**] 12:35PM BLOOD WBC-5.0 RBC-4.06* Hgb-13.5* Hct-40.4 MCV-100* MCH-33.2* MCHC-33.3 RDW-13.8 Plt Ct-148* Abg requiring re-intubation: [**2144-6-3**] 01:08AM BLOOD Type-ART Temp-38.4 FiO2-95 O2 Flow-4 pO2-233* pCO2-96* pH-7.21* calTCO2-41* Base XS-6 AADO2-366 REQ O2-64 Intubat-NOT INTUBA Most recent labs: [**2144-6-11**] 02:00AM BLOOD WBC-5.9 RBC-3.14* Hgb-10.1* Hct-31.1* MCV-99* MCH-32.1* MCHC-32.4 RDW-13.3 Plt Ct-267 [**2144-6-12**] 05:48AM BLOOD Glucose-111* UreaN-41* Creat-1.2 Na-138 K-5.1 Cl-98 HCO3-34* AnGap-11 [**2144-6-9**] 03:07PM BLOOD Type-ART O2 Flow-5 pO2-61* pCO2-58* pH-7.37 calTCO2-35* Base XS-5 Intubat-NOT INTUBA Comment-NASAL [**Last Name (un) 154**] Brief Hospital Course: Mr. [**Known lastname **] [**Last Name (Titles) 1834**] ligation of left popliteal artery aneurysm and proximal superficial femoral artery to distal-above-knee bypass graft using 6-mm ringed PTFE on [**2144-6-1**]. He was transferred to VICU post-operatively. He triggered that night secondary to increased O2 requirements. Resolved with diuresis. Troponins were cycled and were mildly elevated. POD #1 his Swann was taken out and he was started on plavix. He was given light diuresis for his CHF. Cardiology saw him for brief run of SVT and mild troponin elevation. They suggested light diuresis, metoprolol [**Hospital1 **] and O2 sats of 90-92%. On POD 2 pt became agitated. After more agitation with ativan an abg was checked to reveal a CO2 of 96. Pt was emergently intubated and transferred to the icu. There he became hypotensive and required neo. This was weaned off by morning. He received a bronchoscopy on POD 3 whcih revealed copious thick green secretions in the ETT but the lower airways were relatively clear. Pulmonology rec levaquin and light diuresis. On POD #4 he was extubated, promptly failed and had to be re-intubated. Following this, he was weaned slowly. He remained intubated for the next two days again with gentle diuresis and continued levaquin. Citrobacter grew from the sputum cxs which was sensitive to the levaquin. TFs were initiated at this time. His sedation was changed from versed fentanyl to precedex. He was treated with agressive chest physical therapy. He was extubated on POD #6 with transition to Bipap for support which he tolerated well. POD #7 his cordis was changed to a triple lumen. He was tolerating 30% O2 face tent with only mild sputum production. He was oob to a chair. He was advanced to clears then a regular diet. POD # 9 he needed more fluid and was given a few boluses of 25% albumin. His CXR showed an effusion on the left, hemi-diaphragm elevation which was chronic, and question of a new infiltrate. He was re-bronched and tracheobronchomalacia was found particularly in the left mainstem. By POD # 10 he had completed his course of antibiotics. His respiratory status was still marginal so he was kept in the icu another day. On pod # 11 he was febrile, cultured and restarted on levaquin. Beta-blockers were increased for heart rates around 100. He was transferred to the floor. He had multiple PVCs which was treated with electrolyte repletement. POD 12 his central line was taken out. Today he was cleared for home by PT. Medications on Admission: Atenolol 50mg, Furosemide 20mg , Lisinopril 5mg, Simvastatin 10mg, Aspirin 325mg, Nitroglycerin SL prn Discharge Medications: Levofloxacin 750 mg PO DAILY to be completed on [**6-18**] Albuterol [**12-4**] PUFF IH Q4H Aspirin 325 mg PO DAILY Simvastatin 10 mg PO DAILY Clopidogrel 75 mg PO DAILY Docusate Sodium 100 mg PO BID Atenolol 50mg Furosemide 20mg Lisinopril 5mg Nitroglycerin SL prn Discharge Disposition: Home With Service Facility: care group home care Discharge Diagnosis: Left leg popliteal artery aneurysm with distal embolization. Discharge Condition: Good Discharge Instructions: Continue to take your medications as prescribed. Ambulate daily Take levaquin until [**6-18**]. Return to Emergency Room if you develop and significant increase in coughing or shortness of breath. Return if you develop a fever > 101 or your wound becomes red or has drainage. Return if you develop sudden pain or coolness to your foot. Use your home O2 as needed. Your goal saturation should only be 90%. Followup Instructions: Call Dr.[**Name (NI) 1720**] Office [**Telephone/Fax (1) 1241**] to schedule a follow up visit in [**1-5**] weeks. You will have visiting nurses and physical therapy. Also please follow up with your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 1144**] and your cardiologist [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Completed by:[**2144-6-14**]

[ "584.9", "414.00", "518.5", "519.19", "428.0", "428.22", "414.8", "V45.81", "442.3" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.71", "39.52", "39.29", "33.23", "96.04", "96.6" ]

icd9pcs

[ [ [] ] ]

5535, 5586

2567, 5090

303, 492

5691, 5697

1718, 2544

6153, 6603

1373, 1456

5244, 5512

5607, 5670

5116, 5221

5721, 6130

1471, 1699

228, 265

520, 828

850, 1195

1211, 1357

64,160

185,586

47146

Discharge summary

report

Admission Date: [**2171-5-12**] Discharge Date: [**2171-5-16**] Date of Birth: [**2096-3-12**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2901**] Chief Complaint: SOB, chest burning Major Surgical or Invasive Procedure: None History of Present Illness: 75 yo F with PMH of DM2, HTN, distant CVA now presenting with SOB and chest burning x 1 day. She presented to [**Hospital **] hospital today after waking up with SOB and some chest burning primarily across the anterior left part of her chest. Rated sensation as [**5-29**]. Per pt she has never had this before. . She states she's noticed increased lower extremity swelling over the last week. Additionally, her daughters note that she has been occasionally disoriented over the last several weeks which is not her baseline. Patient states that she felt like her thinking has been 'fuzzy' over the last 2 days. . After experiencing the chest burning, her daughter noticed that she was gurgling as she talked and EMS was called. They noted on arrival that her sats were mid- 70s. She was placed on NRB, and improved to the mid-90s. Burning was releived with SL nitro in the field, down to 0/10. At OSH ED, she received a 600cc fluid bolus, but then received ? 40 + 20 mg of IV lasix after deciding she was in CHF. Also recieved 162mg ASA, sL nitro and 0.5" inch of nitropaste. Noted to be in ARF with K of 6.1, for which she received kayexylate. Foley was placed and put out 300cc. ABG was 7.37/32/90/18 on 100% FiO2. Patient placed on CPAP with good effect. The BiPAP was titrated off at 1:30PM but sats dropped to 92% so re-started. Transferred to [**Hospital1 18**] for further care. . In the ED, initial vitals were 99.5 91 143/78 18 94-95% on. She was noted to have rales but trace peripheral edema on exam. Labs revealed elevated WBC ct to 12.4 but no bandemia. Was noted to have ARF to 3.4 and pro BNP elevated to 10,238. A CXR was performed which was revealing for interval development of bilateral pleural effusions, also new hilar prom c/w CHF, possible retrocardiac density seen. EKG showed NSR, no peaked T waves, but ? <1mm in V3-V5, I, II. First set of CE's revealed flat CKs with elevated trop to 0.05 in the setting of ARF. Lactate and U/A were normal. Spiked a temp of 100.8 in ED. Blood and urine cultures were sent, she received vanc 1g, CTX 1g, levoquin 750mg, tylenol, and morphine. She was placed on BiPAP and a nitro gtt and was admitted to the CCU for presumed CHF exacerbation +/- PNA. Foley had put out an additional 700cc prior to transfer, when most recent VS were temp 100.8 (not rechecked since tmax) HR 99 BP 150/49 22 99% on CPAP. . On review of systems, she reports a prior history of stroke over 10 years ago, denies deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She does report recent chills though she states she is ofte cold. Denies recent fevers, or rigors. She endorses exertional buttock or calf pain and reports a prior hx of PVD. Additionally, she reports intermittent diarrhea which has been life long. Finally, she reports pain in her lower back ad thing where she fell 2 days ago. 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. . She does endorse a fall yesterday for which she had a head laceration sutured (2 stitches). A CT head at that time was negative per family report. Past Medical History: 1. CARDIAC RISK FACTORS: Diabetes, Hyperlipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: None -PERCUTANEOUS CORONARY INTERVENTIONS: None -PACING/ICD: None 3. OTHER PAST MEDICAL HISTORY: # H/o CVA [**2157**] # Visceral stenosis (70% stenosis of the celiac, SMA, and [**Female First Name (un) 899**] followed by [**Doctor Last Name **]) # PVD # DM II - not on insulin, most recent A1c 7.1 in [**6-26**] # Hypertension # Migraine headaches # Gastritis - no peptic ulcer disease history. # Depression x30 years, initially reactive. Social History: Widowed and lives alone. No tobacco, ETOH, or Illicit drugs: Family History: Mother had CAD and MI. Father died at a young age of MI. Physical Exam: VS: T= 100.1 BP= 146/61 HR= 100 RR= 23 O2 sat= 99% on [**7-24**] CPAP GENERAL: Elerly female wearing bipap, breathing comfortably. NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Dry MMM. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple, JVP difficult to assess give mask ventilation, but does not appear grossly elevated. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. S2/6 SEM thoughout precordium. No S3 or S4 appreciated. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Crackles to mid lung fields bilaterally. No rhonchi or wheeze. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Typanitic to percussion, no fluid wave or dullness at flanks. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ Radial 2+ Left: Carotid 2+ DP 2+ Radial 2+ NEURO: A/o to person, place, time and purpose, strength 5/5 UE and LE, sensation intact throughout Pertinent Results: EKG ([**2171-5-12**]): Sinus rhythm. Consider left atrial abnormality although is nondiagnostic. Nonspecific ST-T wave changes. Since previous tracing of [**2162-3-1**], sinus tachycardia rate slower. CXR 1V ([**2171-5-12**]): Findings compatible with congestive heart failure. Left retrocardiac density also noted and pneumonia is therefore considered. Recommend correlation with lateral view to further assess. CXR 2V ([**2171-5-13**]): Small right and moderate left pleural effusion are unchanged allowing the differences in positioning of the patient. Increased retrocardiac opacities likely atelectasis. No other interval change. TTE ([**2171-5-14**]): The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. There is mild symmetric left ventricular hypertrophy with normal cavity size. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. There is borderline pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Impaired left ventricular relaxation. Mild aortic regurgitation. Minimal aortic stenosis. Compared with the report of the prior study (images unavailable for review) of [**2166-7-16**], there is minimal aortic stenosis. Borderline elevated pulmonary artery pressures are slightly higher. On admission ([**2171-5-12**]): WBC-12.4* Hgb-9.6* Hct-28.2* MCV-86 Plt Ct-372 Neuts-84.4* Lymphs-10.3* Monos-4.6 Eos-0.4 Baso-0.2 PT-12.5 PTT-27.0 INR(PT)-1.1 Glucose-183* UreaN-59* Creat-3.4*# Na-135 K-5.3* Cl-103 HCO3-18* Calcium-8.7 Phos-6.1*# Mg-2.0 Iron-14* calTIBC-247* Ferritn-120 TRF-190* CK(CPK)-179* > 151* CK-MB-4 > 4 proBNP-[**Numeric Identifier **]* cTropnT-0.05* > 0.15* On discharge ([**2171-5-16**]): WBC-8.0 Hgb-8.5* Hct-25.6* MCV-86 Plt Ct-399 Glucose-59* UreaN-44* Creat-1.6* Na-140 K-3.7 Cl-102 HCO3-23 Mg-2.0 Blood cultures: No growth, final Urine culture: No growth, final Urine legionella: Negative MRSA screen: Negative Brief Hospital Course: 75 year-old female with diabetes mellitus type II, hypertension, CVA admitted [**2171-5-12**] with dyspnea and fever. Hospital course was as follows. 1. Acute on chronic diastolic heart failure: On admission, clinically volume overloaded with bibasilar crackles and pulmonary edema on chest radiograph. In [**2165**], TTE showed EF65-70% with likely impaired LV relaxation suggesting diastolic dysfunction at that time. Repeat TTE during this hospitalization again revealed impaired LV relaxation with LVH and preserved systolic function. Precipitant was not clear; no indication of cardiac ischemia. Differential included dietary indiscretion and possible infectious etiology, as discussed below. In the emergency department, patient was placed on BiPAP and a nitro gtt given hypertension and respiratory distress. She was effectively diuresed with Lasix 80-100mg IV doses, and on discharge was transitioned to Lasix 40mg PO. On discharge, her medication regimen includes [**First Name8 (NamePattern2) **] [**Last Name (un) **], Lasix, and a beta-blocker. She was instructed on taking her medications and following a low-salt diet. She was asked to weigh herself on a daily basis. 2. Acute on chronic renal failure: Creatinine 3.4 on admission, last in our system was 1.5 in 7/[**2169**]. Fe(UN) 58% indicated likely not prerenal. Other likely cause was ATN from hypoperfusion in setting of acute heart failure. GFR improved by greater than 50% during hospital course with heart failure management, as above. 3. Pneumonia: T100.8 on admission. Noted to have leukocytosis and left shift. Retrocardiac density was seen on chest radiograph. Patient was treated with vancomycin, ceftriaxone, and levofloxacin in the emergency department, and narrowed to levofloxacin in the CCU. 4. Diabetes mellitus: Metformin and glipizide were held in house and blood glucose management with Humalog sliding scale insulin. On discharge, patient was restarted on glipizide. Given low blood glucose at times, metformin was help and patient was requested to follow-up with her PCP regarding when/if to restart this medication. Patient was continued on aspirin. 5. s/p Fall: Patient fell 2 days prior to admission. Mechanical fall. Had small head laceration. CT head negative per family report. Patient a/o x3, neuro exam non-focal. Pain controlled with acetaminophen and morphine, as needed. Patient was evaluated by physical therapy; recommendation was home with cane and home PT. 6. Iron-deficiency anemia: Hct 28 on admission, per old records, here has been normal (35-40) in [**2162**], though suspect may be anemia of chronic disease with some element of effect from chronic renal failure. Started on iron supplementation. Stool guaiac negative x1. Had colonoscopy ([**2171-5-7**], [**Location (un) 620**]): Diverticulosis; small colon polyp; history of multiple polyps; rule out microscopic colitis; hemorrhoids. 7. Hypertension: As above, initially required nitro gtt. On discharge, was restarted on [**Last Name (un) **], beta-blocker. 8. Dyslipidemia: Continued on statin per home regimen. 9. Peripheral [**Last Name (un) 1106**] disease: Continued Plavix, aspirin per home regimen. Initially held gapapentin given renal failure; restarted on discharge. **COMMUNICATION: Daughter [**Name (NI) **] [**Name (NI) 34407**] (HCP) [**Telephone/Fax (1) 99912**]. Other daughter [**Name (NI) **] [**Name (NI) 1968**] [**Telephone/Fax (1) 99913**], son [**Name (NI) **] [**Name (NI) 34407**], brother-in-law [**Name (NI) **] [**Name (NI) 37307**]. Medications on Admission: aspirin 81 mg daily clopidogrel 95 daily atenolol 100mg daily atorvastatin unknown dose benicar 40mg daily gabapentin 600mg tid glipizide 5mg daily HCTZ 25mg daily metformin 500mg daily nifedipine 90mg daily trazodone 150mg daily Discharge Medications: 1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Trazodone 150 mg Tablet Sig: One (1) Tablet PO once a day as needed for Insomnia. 5. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 6. Glipizide 5 mg Tablet Extended Rel 24 hr (2) Sig: One (1) Tablet Extended Rel 24 hr (2) PO once a day. 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Benicar 40 mg Tablet Sig: One (1) Tablet PO once a day. 9. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 1 days. Disp:*1 Tablet(s)* Refills:*0* 11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Acute on Chronic Diastolic Congestive Heart Failure Hypertension Left Lower Lobe Pneumonia Acute on Chronic Kidney Disease Iron Deficiency Anemia Diabetes Mellitus Discharge Condition: stable. Dry weight 124 pounds Discharge Instructions: You were admitted with congestive heart failure which caused fluid overload and trouble breathing. Additionally, you may have a pneumonia and you had antibiotics to treat this. You have been started on lasix daily to keep the fluid from reaccumulating. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs in 1 day or 6 pounds in three days. Adhere to 2 gm sodium diet. Please call Dr. [**Last Name (STitle) 2903**] if you have any further trouble breathing, fluid in the legs, chest pains, nausea, light headedness or any other concerning symptoms. Please get a blood pressure cuff and check your blood pressure at home, keep a log and bring to your doctor's appts. Medication changes: 1. Your atenolol was changed to Metoprolol which is better for heart failure. STOP taking Atenolol 2. Furosemide (Lasix): to prevent fluid from accumulating 3. Ferrous Sulfate: to treat your anemia 4. Levofloxacin: 1 dose at home to finish a 7 day course to treat your pneumonia 5. DISCONTINUE your hydrochlorothiazide 6. DISCONTINUE your metformin as your blood sugars have been low in the hospital. Please check your blood sugars immediately after waking in the morning and restart metformin on Monday [**5-20**]. Followup Instructions: [**Month (only) **]: Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB) Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2171-7-3**] 10:30 Provider: [**Name10 (NameIs) 14633**],EQUIPMENT Date/Time:[**2171-7-3**] 10:30 Provider: [**Name10 (NameIs) **] [**Apartment Address(1) 871**] ([**Doctor First Name **]) [**Doctor First Name **] LMOB (NHB) Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2171-7-3**] 11:30 Primary Care: [**Last Name (LF) **],[**First Name3 (LF) **] K. Phone: [**Telephone/Fax (1) 2205**] Date/time: [**5-23**] at 10:15am. Cardiology: [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 911**], MD Phone: [**Telephone/Fax (1) 62**] Date/time: [**6-20**] at 2:00pm. [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 436**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**] Completed by:[**2171-5-22**]

[ "428.33", "403.90", "276.7", "V12.54", "250.00", "585.9", "280.9", "584.5", "486", "443.9", "428.0" ]

icd9cm

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icd9pcs

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11818, 12804

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66,807

166,588

1484

Discharge summary

report

Admission Date: [**2199-5-5**] Discharge Date: [**2199-5-23**] Date of Birth: [**2120-1-12**] Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern1) 1838**] Chief Complaint: Unresponsiveness and left-sided weakness Major Surgical or Invasive Procedure: PEG tube insertion [**2199-5-17**] History of Present Illness: 79RHF with paroxysmal atrial flutter/AF previously well controlled on sotalol and on dabigatran for anticoagulation, CAD, mild to moderate mitral regurgitation, diastolic CHF, HTN, HLD, CKD presents with unresponsiveness and left-sided weakness. Patient was apparently at her usual state of health other than feeling tired when her son spoke to her on the phone at 8pm on [**5-3**]. No-one sw her in the interim on [**5-4**] and on [**5-5**] a son saw her in bed at 10am, asked if she was ok and she did not respond but he did not think much of it and attributed this to her being tired. However, when her other son came to check on her at 19:00 today ([**5-5**]), he found her to be unresponsive, had been incontinent of urine and had her right leg hanging onto the floor and the other leg in bed. Son gave her a small amount of water and apparently managed this as she was motioning that she wanted water and appeared dry. She was not moving her left side and was very drowsy and not talking. EMS were called and she was noted to be in fast Aflutter in 150s and in the ambulance they administered IV diltiazem which brought her HR to the low 100s. BP was stable throughout and on arrival at the [**Hospital1 18**] ED BP was 120s-130s/70s and she had been incontinent of stool. There was initial concern regarding whether she would need to be intubated as she was obtunded and not opening her eyes. Her respiratory status remained stable save requirement for suctioning and sats maintained at 100s and RR ranged from 20s when unstimulated to 30s when stimulated. She had clear left hemiparesis and right gaze deviation. Patient does not feel in pain or shortness of breath but more expanded ROS not possible due to difficulties communicating and conscious level. Patient is oriented partially and does not appear to be aphasic but is very dysarthric. Patient had persistent tachycardia and had a further 10mg IV diltiazem prior to transfer to the ICU. Patient thirsty and saying she wants water. Past Medical History: PMH: - Paroxysmal atrial flutter/atrial fibrillation previously well controlled on sotalol and on dabigatran for anticoagulation s/p failed TEE cardioversion [**3-/2198**] - CAD-single vessel (80% AVG) per cath [**12-14**] - Mild to moderate Mitral regurgitation - Diastolic CHF - HTN - HLD - Asthma - CKD - anemia attributed to a combination of chronic kidney disease and myelodysplasia. Bone marrow biopsy performed [**2198-8-18**] showed erythroid-dominant marrow with megaloblastic maturation and dyserythropoiesis consistent with evolving myelodysplastic syndrome. No cytogenetic abnormalities were identified. She has been maintained on Aranesp injections with a goal hemoglobin 11.0 g/dL. - Osteoarthritis of knees, shoulders, gets frequent injections . PSurgHx: s/p total abdominal hysterectomy. s/p bilateral hip replacements Social History: Mrs [**Known lastname 8768**] lives alone but sons visit and a neighbour checks on her. She is a widow. She has four children. There is a restraining order against her eldest son. [**Name (NI) **] services where someone comes in to help with bathing and cooking. Otherwise she is able to do her ADLs - can dress, eat and toilet herself. Occupation: She is retired but previously worked as an American Airlines interpreter. She speaks five languages. Mobility: Unaided per family. Smoking: Never Alcohol: Never Illicits: Denies Family History: Mother - died of bone cancer Father - MI died lung ca Sibs - brother had a stroke in early 70s. Others apparently well. Children - 3 sons 1 daughter all well. Physical Exam: At admission: Vitals: T:Afebrile P:105 R:32 BP:126/83 SaO2:100% on 100% O2 General: Drowsy, very dysarthric, retaining secretions but allowing suctioning. Able to communicate. HEENT: NC/AT, no scleral icterus noted, dry MM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity. Pulmonary: Lungs decreased BS right > left base Cardiac: RRR (in flutter on monitor), nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds. Extremities: 2+ radial, weak DP pulses bilaterally and cold peripheries. Pitting edema to knees bilaterally. Skin: no rashes or lesions noted. Neurological examination: NIH Stroke Scale score was 15-16 1a. Level of Consciousness: 1 latterly 2 but can awake with eyes open with this 1b. LOC Question: 1 1c. LOC Commands: 0 2. Best gaze: 2 3. Visual fields: 2 4. Facial palsy: 2 5a. Motor arm, left: 3 5b. Motor arm, right: 0 6a. Motor leg, left: 3 6b. Motor leg, right: 0 7. Limb Ataxia: 0 8. Sensory: 0 9. Language: 0 10. Dysarthria: [**1-7**] 11. Extinction and Neglect: 0 - Mental Status: Best GCS E4 V4-5 M6 (on right) but very drowsy and takes some effort to arouse ORIENTATION - Alert, oriented to self and to [**Hospital1 18**], [**Hospital 86**] hospital not date SPEECH Unable to relate history. Language is sparse but does not seem to be aphasic although is complicated by severe dysarthria. NAMING Pt. was able to name several low frequency objects - did not use stroke card due to vision problems. [**Location (un) **] - Unable to due to vision problems (homonymous hemianopia) ATTENTION - Unable to assess but very drowsy but will generally obey commands COMPREHENSION Able to follow both midline and appendicular commands There was no evidence of clear neglect but difficult to assess given homonymous hemianopia although did not feeling me touching her on the left - Cranial Nerves: I: Olfaction not tested. II: PERRL 2 to 1.5mm sluggish bilaterally. Likely left homonymous hemianopia as doe snot blink to threat on left. Funduscopic exam not possible due to poor cooperation with likely cataracts bilaterally with present red reflexes. III, IV, VI: Right gaze deviation and can look at best only just past midline but not fully to the left V: Facial sensation intact to light touch. Good power in muscles of mastication. VII: Left facial droop VIII: Hearing intact to voice bilaterally. IX, X: Palate elevates pretty symmetrically. [**Doctor First Name 81**]: Weak on left trapezius. XII: Tongue protrudes in midline with reasonably normal velocity movements. - Motor: Normal bulk, tone throughout on right. Flaccid on left. Dense hemiparesis on left. No adventitious movements, such as tremor, noted. No asterixis noted. Dense hemiparesis left arm weaker than leg - On right UE weakness proximally [**3-10**]-/5 and otherwise strong in RUE. Best in left UE is finger flexion against gravity ([**3-11**]) and slight elbow flexion ([**2-10**]) to noxious. In RLE hip flexion 4-/5 at best and good power distally likely 4+/5. To noxious, on left can dorsiflex ankle [**3-10**]-/5 and plantar flex [**3-11**] with contraction of IP ([**1-10**]) and knee extension ([**1-10**]) and otherwise no apparent power. - Sensory: Can feel light touch all 4 limbs and grimaces to noxious all 4 limbs. - DTRs: BJ SJ TJ KJ AJ L 2 2 2 0 0 R 2 2 2 0 0 There was no evidence of clonus. [**Last Name (un) 1842**] negative. Plantar response was flexor on right, extensor on left. - Coordination: No evidence of ataxia on right and left hemiparesis so unable to assess. - Gait: Unable to assess. Exam at time of transfer out of NeuroICU: Patient has eyes closed spontaneously, responds to voices/commands while eyes closed. Opens eyes when asked. Speaks in at least 4 word phrases (Per son, speaks limited English), follows all commands and answers most questions appropriately. Speech is dysarthric but improving. At time patient seems to perseverate on ideas. R gaze preference, can cross midline to left. Left neglect is improving and responds to stimuli on left/identifies L hand as her own. PERRL. Inconsistent blink to threat on left. EOMI. Left facial droop. Moves right side spontaneously and at least 3-4/5. Flaccid LUE that extensor postures to noxious. LLE triple flexes to noxious. Grimaces to noxious throughout. Extinction on left to DSS. . . Discharge examination: Patient has eyes closed spontaneously often with evident eye opening apraxia although can open her eyes spontaneously at times. She has had a fluctuating examination and has been more or less responsive at times but better currently. Verbalising well without suggestion of significant aphasia and talking in short sentences. She follows commands and can answer questions appropriately. Speech is dysarthric but improving. Right gaze deviation, unable to cross the midline to left. Left homonymous hemianopia. Left facial droop. Moves right side spontaneously and at least 3-4/5. Flaccid LUE with minimal flexion in UE to noxious, likely slight left [**Last Name (un) 5355**] dorsiflexion is a spinal reflex. Grimaces to noxious throughout. Left neglect and cannot identify left hand as her own consistently. Pertinent Results: Laboratory investigations: Admission labs: [**2199-5-5**] 08:50PM BLOOD WBC-16.2* RBC-3.43* Hgb-11.6* Hct-35.3* MCV-103* MCH-33.8* MCHC-32.9 RDW-16.2* Plt Ct-501* [**2199-5-5**] 08:50PM BLOOD PT-13.5* PTT-24.8* INR(PT)-1.3* [**2199-5-5**] 08:50PM BLOOD Glucose-166* UreaN-15 Creat-0.8 Na-140 K-4.0 Cl-102 HCO3-23 AnGap-19 [**2199-5-5**] 08:50PM BLOOD ALT-12 AST-28 AlkPhos-68 TotBili-1.6* [**2199-5-5**] 08:50PM BLOOD Albumin-4.3 Calcium-10.1 Phos-3.2 Mg-1.8 . Other pertinent labs: [**2199-5-6**] 03:00AM BLOOD Albumin-4.0 Calcium-9.6 Phos-3.4 Mg-1.9 Cholest-141 [**2199-5-6**] 03:00AM BLOOD Triglyc-180* HDL-26 CHOL/HD-5.4 LDLcalc-79 [**2199-5-6**] 03:00AM BLOOD %HbA1c-6.0* eAG-126* [**2199-5-6**] 03:00AM BLOOD TSH-0.91 [**2199-5-12**] 06:20AM BLOOD Vanco-18.1 [**2199-5-5**] 08:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2199-5-5**] 08:57PM BLOOD Glucose-163* Lactate-2.5* Na-140 K-4.6 Cl-103 calHCO3-26 [**2199-5-6**] 01:14PM BLOOD Lactate-0.9 [**2199-5-6**] 01:14PM BLOOD freeCa-1.22 [**2199-5-6**] 03:00AM BLOOD CK-MB-6 cTropnT-0.05* [**2199-5-6**] 02:45PM BLOOD CK-MB-4 cTropnT-0.03* [**2199-5-11**] 01:15PM BLOOD CK-MB-2 [**2199-5-11**] 09:10PM BLOOD CK-MB-2 [**2199-5-5**] 08:50PM BLOOD Lipase-35 [**2199-5-6**] 03:00AM BLOOD ALT-14 AST-35 CK(CPK)-431* AlkPhos-61 TotBili-1.6* [**2199-5-6**] 02:45PM BLOOD CK(CPK)-484* [**2199-5-10**] 12:55AM BLOOD ALT-19 AST-33 AlkPhos-48 TotBili-0.8 [**2199-5-11**] 01:15PM BLOOD CK(CPK)-121 [**2199-5-11**] 09:10PM BLOOD CK(CPK)-71 [**2199-5-12**] 06:20AM BLOOD CK(CPK)-214* [**2199-5-5**] 08:50PM BLOOD Fibrino-462* . Discharge labs: [**2199-5-23**] 05:40AM BLOOD WBC-8.8 RBC-3.09* Hgb-9.8* Hct-29.6* MCV-96 MCH-31.7 MCHC-33.0 RDW-17.4* Plt Ct-573* [**2199-5-23**] 05:40AM BLOOD PT-16.2* PTT-32.1 INR(PT)-1.5* [**2199-5-23**] 05:40AM BLOOD Glucose-141* UreaN-23* Creat-0.7 Na-137 K-4.0 Cl-104 HCO3-26 AnGap-11 [**2199-5-23**] 05:40AM BLOOD ALT-12 AST-21 AlkPhos-72 TotBili-0.6 [**2199-5-23**] 05:40AM BLOOD Albumin-3.5 Calcium-9.9 Phos-3.2 Mg-2.1. . Urine: [**2199-5-6**] 02:05AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]->1.050* [**2199-5-6**] 02:05AM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [**2199-5-6**] 02:05AM URINE RBC-3* WBC-1 Bacteri-NONE Yeast-NONE Epi-1 [**2199-5-10**] 09:23PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010 [**2199-5-10**] 09:23PM URINE Blood-NEG Nitrite-POS Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM [**2199-5-10**] 09:23PM URINE RBC-2 WBC-13* Bacteri-FEW Yeast-NONE Epi-1 TransE-<1 [**2199-5-10**] 09:23PM URINE CastHy-2* [**2199-5-10**] 09:23PM URINE Mucous-MOD [**2199-5-13**] 05:53PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.003 [**2199-5-13**] 05:53PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [**2199-5-6**] 02:05AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG amphetm-NEG mthdone-NEG . . Microbiology: [**2199-5-16**] BLOOD CULTURE Blood Culture, Routine-NO GROWTH [**2199-5-16**] BLOOD CULTURE Blood Culture, Routine-NO GROWTH . [**2199-5-15**] CATHETER TIP-IV WOUND CULTURE-NEGATIVE [**2199-5-14**] BLOOD CULTURE Blood Culture, Routine-NO GROWTH [**2199-5-14**] BLOOD CULTURE Blood Culture, Routine-NO GROWTH . [**2199-5-11**] 10:51 am SPUTUM Source: Expectorated. **FINAL REPORT [**2199-5-11**]** GRAM STAIN (Final [**2199-5-11**]): <10 PMNs and >10 epithelial cells/100X field. Gram stain indicates extensive contamination with upper respiratory secretions. Bacterial culture results are invalid. PLEASE SUBMIT ANOTHER SPECIMEN. RESPIRATORY CULTURE (Final [**2199-5-11**]): TEST CANCELLED, PATIENT CREDITED. . [**2199-5-11**] BLOOD CULTURE Blood Culture, Routine-NO GROWTH [**2199-5-10**] BLOOD CULTURE Blood Culture, Routine-NO GROWTH . [**2199-5-6**] 2:05 am URINE Source: Catheter. **FINAL REPORT [**2199-5-8**]** URINE CULTURE (Final [**2199-5-8**]): ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S . [**2199-5-10**] 9:23 pm URINE Source: Catheter. **FINAL REPORT [**2199-5-12**]** URINE CULTURE (Final [**2199-5-12**]): <10,000 organisms/ml. MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. . . Cardiology: ECG Study Date of [**2199-5-5**] 8:35:34 PM Atrial flutter with rapid ventricular response. Diffuse ST-T wave abnormalities. Compared to the previous tracing of [**2198-8-22**] ventricular rate is more rapid. ST-T wave abnormalities are more pronounced. Ventricular ectopy is no longer seen. Read by: [**Last Name (LF) **],[**First Name3 (LF) **] E. Intervals Axes Rate PR QRS QT/QTc P QRS T 110 0 68 348/435 0 12 72 . Portable TTE (Complete) Done [**2199-5-6**] at 11:33:01 AM Conclusions The left atrium is elongated. A possible left atrial appendage thrombus is suggeseted in some views (clip [**Clip Number (Radiology) **]), but could not be confirmed. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. There is moderate pulmonary artery systolic hypertension. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Possible left atrial appendage thrombus. Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild aortic regurgitation. Dilated ascending aorta. If clinically indicated, a TEE would be better able to identify a possible left atrial appendage thrombus. Compared with the prior study (images reviewed) of [**2195-12-11**], the rhythm is now atrial fibrillation with a rapid ventricular response and a left atrial appendage thrombus is suggested. . Portable TEE (Complete) Done [**2199-5-6**] at 3:34:43 PM Conclusions No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. Right and left atrial appendage ejection velocity is good (>20 cm/s). No atrial septal defect is seen by 2D or color Doppler. Left ventricular systolic function is grossly normal (EF>55%). Right ventricular chamber size and free wall motion are normal. There complex (>4mm, non-mobile) atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. IMPRESSION: No left atrial appendage thrombus. Complex, non-mobile atheroma in the descending thoracic aorta. Mild mitral regurgitation. Mild aortic regurgitation. . ECG Study Date of [**2199-5-16**] 10:00:04 AM Atrial flutter. Borderline low voltage. Compared to the previous tracing of [**2199-5-5**] no change. Read by: [**Last Name (LF) **],[**First Name3 (LF) **] Intervals Axes Rate PR QRS QT/QTc P QRS T 96 0 94 370/433 0 14 13 . . Radiology: [**2199-5-5**] CTA head and neck: FINDINGS: New hypodensity in the right parietotemporal and occiptal lobes, extending into the right basal ganglia and internal capsule, is consistent with an acute right MCA and PCA territory infarct. Hyperdense appearance of the right MCA, is most suggestive of a thrombus. There is mass effect on the body of the right lateral ventricle. Small hyperdense area within the right globus pallidus (2:18), may represent small hemorrhage within the infarct. The basal cisterns are normal. There is complete opacification of bilateral maxillary sinuses and partial opacification of bilateral anterior ethmoid/frontal sinuses. The hypoplastic mastoid air cells are clear. CT ANGIOGRAM: NECK: Minimal atherosclerotic calcification is seen at the aortic arch. The origins of both carotid and vertebral arteries are normal. Mild atherosclerotic calcification is seen in both carotid bifurcations, without evidence of hemodynamically significant cervical stenosis. The cervical portions of the vertebral arteries are normal. HEAD: There is complete occlusion of the supraclinoid right internal carotid artery (just distal to a patent right ophthalmic artery) with thrombus extending into the M1 segment of the right middle cerebral artery. There is minimal filling of the right M2 branches. There is occlusion of the distal basilar artery with the tip patent. Moderate atherosclerotic calcification is seen in the cavernous portion of both internal carotid arteries. The intracranial portion of the vertebral arteries, basilar artery and their major branches are patent. The imaged lung apices are clear. A small amount of secretions are seen within the trachea. The pharyngeal mucosal spaces are normal. Minimal anterolisthesis of C7 on T1, is likely degenerative in etiology. IMPRESSION: 1. CT HEAD: Acute right MCA and PCA territory infarcts. Dense right MCA consistent with thrombus. Possible small focus of hemorrhage within the right basal ganglia region. 2. CT OF THE HEAD AND NECK: Occlusion of the supraclinoid right internal carotid artery and M1 branch of the right MCA. Flow is seen within the right MCA M2 branches distally. Occlusion of the distal basilar artery with the tip patent and non visualization of the right posterior communicating artery. . [**2199-5-6**] NCHCT: IMPRESSION: Large right middle cerebral and posterior cerebral artery territory infarct, similar in appearance compared to prior. Stable mass effect on the right lateral ventricle without evidence for herniation. . [**2199-5-6**] Portable NCHCT: IMPRESSION: Large right middle cerebral and posterior cerebral arterial territory infarction overall unchanged in appearance compared to the most recent prior study performed five hours earlier with mass effect on the right lateral ventricle but no evidence of midline shift, hemorrhagic transformation, or herniation at this time. . [**2199-5-7**] NCHCT: IMPRESSION: 1. Focal hyperdensity in the right basal ganglia is concerning for early petechial or hemorrhagic changes with increased mass effect on the right lateral ventricle and 2 mm leftward shift of normally midline structures from [**2199-5-6**]. 2. Narrowing of the right suprasellar cistern with effacement of the right cerebral peduncle but no frank uncal herniation. 3. Unchanged extent of large right middle cerebral and posterior cerebral territorial infarction. . CT HEAD W/O CONTRAST Study Date of [**2199-5-9**] 6:09 PM IMPRESSION: Evolving right MCA/PCA territorial infarct with central hyperdensities compatible with hemorrhagic conversion, with slightly increased leftward parafalcine herniation and minimally increased right vertex sulcal effacement. No evidence for transtentorial or uncal herniation. ATTENDING NOTE: Subtle hyperdensities within infarct can be due to petechial hemorrhage or uninvolved brain paranchyma. . CHEST (PORTABLE AP) Study Date of [**2199-5-10**] 4:28 AM IMPRESSION: 1. Small right pleural effusion and bibasilar atelectasis. 2. Possible early CHF. . CHEST (PORTABLE AP) Study Date of [**2199-5-10**] 9:57 PM FINDINGS: Compared to the film from earlier the same day, lung volumes are lower. It is difficult to assess for a lower lobe infiltrate given volume loss in both lower lungs and probable effusions. . CHEST (PA & LAT) Study Date of [**2199-5-12**] 9:18 AM FINDINGS: Feeding tube tip is in the proximal stomach. There is blunting of the CP angles, but no definite infiltrate. Heart size is mildly enlarged. Upper lungs are clear. . CT HEAD W/O CONTRAST Study Date of [**2199-5-12**] 9:32 AM IMPRESSION: Evolving right MCA/PCA territorial infarct with slight improvement of edema. There are no new areas of hemorrhage or infarction; however, MR is more sensitive if not CI . . BILAT LOWER EXT VEINS Study Date of [**2199-5-13**] 1:33 PM IMPRESSION: No DVT in the right or left lower extremity. . ABDOMEN U.S. (COMPLETE STUDY) Study Date of [**2199-5-15**] 8:20 AM IMPRESSION: 1. Splenic infarct involving one-third of the splenic volume with an area of liquefaction. 2. Splenomegaly, measuring 14 cm. 3. Cholelithiasis without ultrasound evidence of cholecystitis. 4. Simple cyst within the upper pole of the right kidney. The remainder of the study is normal. . CT ABD & PELVIS WITH CONTRAST Study Date of [**2199-5-15**] 6:05 PM FINDINGS: The left atrium is mildly enlarged. The left auricle is partially visualized (2, 1) with no apparent filling defect within it. Calcifications are seen in the aortic valve and in the course of the RCA. No pericardial effusion is identified. Subcentimeter pulmonary nodule is seen in the right middle lobe (2, 5), unchanged from prior examination. Inferior to the prior nodule another subcentimeter nodule is seen in the right middle lobe (2, 7) unchanged from prior examination. A tiny pulmonary nodule is seen in the lingula (2, 7), unchanged from prior examination. No pleural effusion is identified. The liver is within normal limits. No focal lesions are identified. A hyperdense material is seen in the gallbladder consistent with sludge. No signs of cholecystitis are seen. A hypoattenuating region is seen in the upper pole of the spleen measuring 38 x 75 x 89 mm consistent with the patient's known splenic infarct. The pancreas is within normal limits. Both adrenals are unremarkable. Several hypoattenuating lesions are seen within both kidneys, too small to characterize. The largest lesion is seen in the lower pole of the right kidney measuring 14 x 15 mm (2, 38) with a density of 30 Hounsfield units. Large amount of stool is seen in the large bowel. Small bowel is within normal limits. A nasogastric tube is seen with its tip in the stomach. No peritoneal or retroperitoneal lymphadenopathy is identified. PELVIS: Streak artifact due to bilateral hip replacement. Tiny gas bubble is seen within the urinary bladder, might be secondary to catheterization of the bladder. Atherosclerotic changes are seen along the course of the aorta. Atherosclerotic plaque is seen at the level of the SMA (2, 29). At the level of the origin of the celiac axis there is a round filling defect (2, 24). No other filling defects are identified. The portal vein and its branches, the splenic vein and the SMV are patent. The vena cava and its branches are within normal limits. OSSEOUS STRUCTURES: Degenerative changes are seen along the course of the spine. Compressed fracture of L2 vertebra. Bilateral hip replacement. No concerning lytic or osteoblastic lesions are seen. IMPRESSION: 1. Splenic infarct, as described. 2. Atherosclerotic plaque at the level of the SMA. 3. Rounded peripheral filling defect is seen in just above the origin of the celiac axis. The appearance of the filling defect is most consistent with emboli. 4. Gallbladder sludge without signs of cholecystitis . CHEST (PRE-OP PA & LAT) Study Date of [**2199-5-16**] 2:56 PM Comparison is made with prior study [**5-12**]. There are persistent low lung volumes. Left lower lobe opacities have almost resolved. There are no new lung abnormalities, pneumothorax or large pleural effusions. Cardiomegaly is accentuated by the low lung volumes. NG tube tip is in the stomach. Brief Hospital Course: 79RHF with paroxysmal atrial flutter/AF previously well controlled on sotalol and on dabigatran for anticoagulation, CAD, mild to moderate mitral regurgitation, diastolic CHF, HTN, HLD, CKD presented on [**2199-5-5**] with unresponsiveness and left-sided weakness and found to have a severe right MCA/PCA syndrome on examination. CT showed extensive right MCA and PCA infarcts (PCA infarct was felt likely embolic from fetal PCA) which were felt to be embolic from her Aflutter. On further questioning, the patient had been mistakenly taking once daily dabigatran which is a considerable underdosing and inadequate anticoagulation. She was admitted to the ICU and dabigatran and other anticoagulation was held due to concern for hemorrhagic conversion and she was treated with aspirin alone initially. TTE showed a possible left atrial appendage thrombus and she therefore proceeded to a TEE which showed no evidence of thrombus but complex, non-mobile atheroma in the descending thoracic aorta. She had persistently poor swallow assessments and aspirated on all consistencies and a Dobbhoff tube was placed. She had significant issues regarding AF with RVR although she was in general not hemodynamically compromised and her rate control regimen was extensively changed and cardiology were involved. Eventually hr heart rate was controlled on a combination of diltiazem and metoprolol. She was transferred to the floor and there, she was also noted to have intermittent prolonged apneic spells which were felt to likely represent OSA and given her NG tube she could not have CPAP. This should be assessed in the community for possible OSA. She did not desaturate with these episodes. She was treated for a UTI and then started spiking fevers which were attributed to likely aspiration pneumonia/HCAP although little to find on CXR or other infectious workup, ID were [**Year (4 digits) 4221**] and eventually signed off and she completed an 8 day course of IV vancomycin and piperacillin/tazobactam and fevers settled. Due to fluctuating conscious level, she had an EEG which showed no evidence of epileptiform discharges. In the process of working up her fevers she had an U/S abdomen which showed a splenic infarct and CT abdomen/pelvis suggested a likely embolic source with evidence of a likely embolus above the origin of the celiac axis and an atherosclerotic plaque at the level of the SMA. Due to her continued poor swallow, she proceeded to a PEG on [**2199-5-17**] without complication. Following her PEG insertion, she was restarted on anticoagulation with warfarin with an overlap of aspirin until therapeutic INR. She had brief episodes of RVR and this eventually settled and rate was eventually well controlled. She was noted to have a Hb drop from 9 to 6.8 in the setting of an inadequate reticulocyte count and although stool was minimally guaiac positive, this was not enough to explain this loss and after hematology, GI and general surgery consults, this was felt to represent her MDS and required 2 units of RBCs. Post-transfusion, her Hb remained stable and she had no episodes of hemodynamic compromise with this Hb drop. She was transferred to rehab on [**2199-5-23**]. She has neurology, hematology and cardiology follow-up. . . # Neurology: Patient has had no prior stroke but has considerable stroke risk factors of paroxysmal atrial flutter/AF previously well controlled on sotalol but taking an inadequate dose of dabigatran, CAD, mild to moderate mitral regurgitation, diastolic CHF, HTN, HLD. Initial neurological exam revealed patient to be drowsy but arousable, oriented x2 (to self and place) with no apparent aphasia (names reasonably/follows commands) but significant dysarthria. CN examination reveals PERRL, EOMI, a left facial droop, right gaze deviation but cannot cross midline with left homonymous hemianopia. Limb exam revealed a dense left hemiparesis with slight withdrawal in LUE and toe extension and knee flexion on LE and good spontaneous movement on right, grimaces to noxious throughout, brisker reflexes on right and right extensor plantar. CTA head and neck showed a hyperdense right MCA sign, acute right MCA and PCA territory infarcts, a dense right MCA consistent with thrombus and a possible small focus of hemorrhage within the right basal ganglia region with mass effect on right lateral ventricle but no MLS. CTA showed occlusion of the supraclinoid right ICA and M1 cutoff reconstituting distally. There was also thought to be occlusion of the distal basilar artery with the tip patent with no right PCA seen although her PCA embolism was felt to be secondary to a fetal PCA. CT on [**5-6**] was stable. Stroke risk factors were assessed and patient was monitored on telemetry. This revealed multiple episodes of RVR requiring PRN diltiazem, metoprolol and at times requiring IV medications. Patient was treated with a HISS with a goal for normoglycemia. Stroke risk factors were assessed with HbA1c 6.0% and FLP revealed Chol 141 TGCs 180 HDL 26 LDL 79. TSH was 0.91. UA was positive and UCx revealed pan sensitive E coli. Simvastatin was changed to atorvastatin 20mg qd. The likely cause of her extensive infarcts was felt to be embolic from her AF/Aflutter in the setting of the patient mistakenly underdosing dabigatran resulting in inadequate anticoagulation. She was admitted to the ICU and dabigatran and other anticoagulation was held due to concern for hemorrhagic conversion and she was treated with aspirin alone initially. TTE on [**5-6**] showed possible left atrial appendage thrombus with mild symmetric LVH with preserved global and regional biventricular systolic function, mild AR and a dilated ascending aorta. She therefore proceeded to a TEE the same day which showed no left atrial appendage thrombus and complex, non-mobile atheroma in the descending thoracic aorta. Ideally, she required anticoagulation but due to the large infarct, this was felt to be too great a risk for considerable hemorrhagic conversion and was deferred until after PEG placement. She was seen by S&S and found to have significant dysphagia, she was therefore made NPO and a Dobbhoff tube was inserted. In the ICU she had episodes of RVR and she was initially treated with IV diltiazem. CT head remained stable and patient clinically improved such that she was transferred out of the ICU to Neuro step-down on [**5-9**] but returned a few hours later after SBP decreased to 80s and she was having 20s apneic episodes. Repeat CT scan showed central hyperdensities compatible with hemorrhagic conversion, with slightly increased leftward parafalcine herniation and minimally increased right vertex sulcal effacement and patient clinically improved. The apnea was felt to be due to OSA with superimposed stroke. Patient again remained stable and patient was transferred back to the floor on [**2199-5-10**]. There, she was noted to be more lethargic with fluctuating conscious level and an EEG was requested which showed slowing but no epileptiform activity. She had continued RVR and diltiazem much improved HR but BP was borderline hypotensive and metoprolol was tapered and uptitrated diltiazem and eventually BP improved and rate was well controlled on the last 3 days of her hospitalisation. General surgery were [**Year (4 digits) 4221**] regarding possible PEG placement given continued severe dysphagia but wanted to defer surgery until fevers settled. General surgery were re-contact[**Name (NI) **] after she had no further fevers and patient proceeded to PEG insertion on [**2199-5-17**] without complication. Following her PEG insertion, she was restarted on anticoagulation with warfarin (dabigatran cannot be crushed) on [**2199-5-19**] with an overlap of aspirin until INR is therapeutic. She remained stable (see Hb drop and rationale in hematology section) and was transferred to rehab on [**2199-5-23**]. We held darbepoetin due to possible increased stroke risk and this should be re-addressed by hematology at her soon o/p appointment. . # CVS: Patient has a history of AF/AFlutter diagnosed in [**2194**] s/p a failed cardioversion in [**2195**], HTN, HLD and single vessel CAD who presented with embolic right MCA/PCA stroke as above likely due to cardioembolism from her AF in the setting of inadequate anticoagulation as the patient has been taking her dabigatran only once daily. Dabigatran and other anticoagulation was held due to concern for hemorrhagic conversion and she was treated with aspirin alone initially. Patient had been well controlled rate-wise in the community on sotalol and diltiazem XR 240mg qd. Her rate control and anti-hypertensive agents were initially held and during her hospitalisation, she had several episodes of RVR requiring IV rate control agents (diltiazem and metoprolol) and her diltiazem was uptitrated. Whilst in the ICU, the patient had [**1-7**] second pauses on telemetry for which she was asymptomatic and this was felt likely related to medications given patient had been started on both metoprolol, diltiazem, in addition to her sotalol. Patient was initially transferred out of ICU on [**5-9**] but due to a drop in BP to SBP 80s and 20 sec apneic episodes, was transferred back to ICU for overnight monitoring. She received IVF 250ml boluses x2 and her BP improved although in general her SBO was mainly in 90s and 100s. The patient was initially continued on only sotalol 80mg po bid but due to persistent pauses and further AF with RVR, cardiology were [**Month/Day (4) 4221**], sotalol was stopped and she was continued on diltiazem and metoprolol. She had continued episodes of RVR and diltiazem was uptitrated. Other than very occasional tachycardic episodes, she achieved good rate control with diltiazem 75mg Q4H and metoprolol 25mg tid. Following her PEG insertion, she was restarted on anticoagulation with warfarin (dabigatran cannot be crushed) with an overlap of aspirin until INR is therapeutic. . # ID: Patient had an initial leucocytosis with WBCs up to 17.6 and this resolved. UA was positive and she was started on Ciprofloxacin on [**5-7**] for UTI (10,000 -100,000 Ecoli in urine) and was treated with a 3 day course. She however started to spike fevers to 102.5F on [**5-10**] and she was started empirically on Vancomycin and Piperacillin/Tazobactam on [**5-11**] for possible HAP but no good evidence of infection on CXRs. She was pancultured and these revealed no growth to date. To further investigate fevers, Doppler U/S of the legs revealed no evidence of DVT and ID were [**Month/Day (1) 4221**] when she again spiked a fever to 101.5F on [**5-14**] who recommended awaiting cultures and completing antibiotic course with further investigations if further fevers. Abdominal U/S showed a large splenic infarct and to better characterise this, the patient was evaluated with CT abdomen/pelvis which showed her splenic infarct but no evidence of metastatic infection or occult infection. Her fevers settled and were felt likely secondary to HAP/aspiration pneumonia and she completed an 8 day course of Vancomycin and Piperacillin/Tazobactam stopped on [**2199-5-17**]. She remained stable after this and had no further fevers. . # GIS: In the process of her infectious workup, she was found to have a splenic infarct on her abdominal ultrasound. She had some mild generalised abdominal pain and CT abdomen/pelvis showed her previously documented 38 x 75 x 89 mm splenic infarct, in addition to an atherosclerotic plaque at the level of the SMA and a rounded peripheral filling defect just above the origin of the celiac axis likely representing emboli and the likely cause of her splenic infarct was therefore felt to be embolic. There was no evidence of metastatic infection in addition to unchanged pulmonary nodules (stable from prior study) and gallbladder sludge without cholecystitis. She had significant fecal loading and she was treated with laxatives. She had guaiac positive stool as below but did not represent melaena and did not require endoscopy after GI consultation. Her Hb drop was felt to represent her MDS given grossly inadequate reticulocyte count 0.1. . # Hematology: Patient has a history of MDS on darbepoetin. Given her stroke and risks associated with increasing blood viscosity, darbepoetin was held while in hospital. She had a chronic anemia with HCt 27-30. She developed what we feel to be a reactive thrombocythemia and from [**Date range (1) 8769**] he was noted to have a Hb drop from 8.5 to 6.8 in the setting of an inadequate reticulocyte count (0.1) and although stool was minimally guaiac positive, this was not enough to explain this loss. After hematology, GI and general surgery consults, this was felt to represent her MDS and required 2 units of RBCs and she had been usually requiring 2 units per month in the community prior to starting darbepoetin. Post-transfusion, her HB remained stable at 9.8 and she had no episodes of hemodynamic compromise with this Hb drop. She has hematology follow-up. Her CBC will need to be trended at rehab and there they should consider restarting darbepoetin as per hematology. . # RS: Patient was persistently tachypneic during her hospitalisation and this improved. Her O2 stats were stable throughout. CXRs showed atelectasis and effusions which improved after her home furosemide was restarted and she was treated with an 8 day course of IV piperacillin /tazobactam for presumed HCAP/aspiration pneumonia although there was no clear evidence of pneumonia on CXR. She remained stable from a pulmonary perspective. She had episodes of sleep apnea up to 20s during her hospitalisation and this improved as her mental status improved. PCP should consider [**Name Initial (PRE) **]/p sleep study evaluation for this. . # FEN: Patient was too lethargic during the first few days of her stay to participate in official swallow evaluation. A Dobbhoff was placed and she was started on low dose TFs that were then titrated up to a nutritional level. Speech re-evaluated patient and found persistent poor swallow aspirating on all consistencies and she proceeded to a PEG tube insertion on [**2199-5-17**]. . # ENDO: HbA1c was 6%. Patient was placed on a HISS with a goal of normoglycemia. . # [**Male First Name (un) **]: She had urinary retention following catheter removal and straight cathed 700ml. A urinary catheter was placed on the day of transfer due to continued retention. Further voiding trial to be performed at rehab. . . Transitional issues: - Hb trended down from 9 to 6.8 and was seen by GI, gen surgery and hematology and felt due to her MDS. Will need regular CBC checks at rehab and may require transfusion as required. Was not hemodynamically unstable as a result of her Hb drop. - Darbepoetin has been held and should be restarted as deemed appropriate by hematology - she has hematology follow-up - She has had episodes of AF with RVR and she may require further uptitration of her diltiazem or metoprolol although has been well controlled over the past 3 days. - Following PEG, patient was started on warfarin with goal INR [**2-8**]. She will be overlapped with aspirin 81mg and s/c heparin until INR is therapeutic. - Next INR to be drawn on [**2199-5-24**]. - Patient had PEG tube on [**2199-5-17**] and has been discharged on tube feeds. - Patient had urinary retention following removal of catheter. Further voiding trial to be performed at rehab. - PCP should consider evaluation for OSA in the community. Medications on Admission: ALENDRONATE - (Prescribed by Other Provider) - 35 mg Tablet - 1 Tablet(s) by mouth weekly DABIGATRAN ETEXILATE [PRADAXA] - 150 mg Capsule - 1 Capsule(s) by mouth twice a day - per report patient had only been taking this once daily prior to admission DARBEPOETIN ALFA IN POLYSORBAT [ARANESP (POLYSORBATE)] - (Prescribed by Other Provider) - 300 mcg/mL Solution - weekly DILTIAZEM HCL - (Prescribed by Other Provider) - 240 mg Capsule, Ext Release 24 hr - 1 Capsule(s) by mouth once a day FOLIC ACID - (Dose adjustment - no new Rx) - 1 mg Tablet - 1 Tablet(s) by mouth daily FUROSEMIDE - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth once a day LIDOCAINE - 5 % (700 mg/patch) Adhesive Patch, Medicated - apply one patch to painful area once a day for 12 hours, then off for 12 hours OMEPRAZOLE - (Prescribed by Other Provider) - 20 mg Capsule, Delayed Release(E.C.) - 1 Capsule(s) by mouth once a day SIMVASTATIN - (Prescribed by Other Provider) - 10 mg Tablet - 1 Tablet(s) by mouth daily SOTALOL - (Prescribed by Other Provider) - 80 mg Tablet - 1 Tablet(s) by mouth twice a day TRAMADOL - (Prescribed by Other Provider) - 50 mg Tablet - 1 Tablet(s) by mouth three times a day as needed for pain Medications - OTC ACETAMINOPHEN - (Prescribed by Other Provider) - 500 mg Tablet - 1 Tablet(s) by mouth twice a day CALCIUM CARBONATE-VITAMIN D3 - (Prescribed by Other Provider) - 600 mg-400 unit Tablet - 1 Tablet(s) by mouth twice a day DOCUSATE SODIUM - (Prescribed by Other Provider) - 100 mg Capsule - 1 Capsule(s) by mouth twice a day MULTIVITAMIN - Tablet - 1 Tablet(s) by mouth once a day. Please do NOT dispense an iron-containing multivitamin. SENNOSIDES [SENNA] - (Prescribed by Other Provider) - 8.6 mg Tablet - 1 Tablet(s) by mouth twice a day Discharge Medications: 1. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily). 2. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 3. senna 8.8 mg/5 mL Syrup Sig: One (1) PO BID (2 times a day). 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 5. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. polyvinyl alcohol-povidon(PF) 1.4-0.6 % Dropperette Sig: [**1-7**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 8. insulin regular human 100 unit/mL Solution Sig: per sliding scale Injection ASDIR (AS DIRECTED). 9. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for Fungal rash. 10. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. 11. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. alendronate 35 mg Tablet Sig: One (1) Tablet PO once a week. 13. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 14. calcium carbonate-vitamin D3 600 mg(1,500mg) -400 unit Capsule Sig: One (1) Capsule PO twice a day. 15. multivitamin Tablet Sig: One (1) Tablet PO once a day. 16. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day: Continue until INR therapeutic. 17. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 18. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO three times a day. 19. diltiazem HCl 30 mg Tablet Sig: 2.5 Tablets PO Q4H (every 4 hours). 20. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day): Continue s/c heparin until INR theraputic. Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital for Continuing Medical Care - [**Location (un) 1121**] ([**Hospital3 1122**] Center) Discharge Diagnosis: Primary diagnoses: 1. Embolic large right middle cerebral artery and posterior cerebral artery infarcts likely secondary to AF/AFlutter and inadequate anticoagulation (taking half dose dabigatran) 2. Dysphagia secondary to above requiring PEG tube insertion 3. Splenic infarct likely embolic 4. Myelodysplastic syndrome requiring transfusion as an inpatient . Secondary diagnoses: 1. Atrial Fibrillation/Atrial flutter with episodes of rapid ventricular rate 2. Hospital acquired pneumonia 3. Likely obstructive sleep apnea 4. Urinary tract infection Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. Neurologic: Patient has eyes closed spontaneously often with evident eye opening apraxia although can open her eyes spontaneously at times. She has had a fluctuating examination and has been more or less responsive at times but better currently. Verbalising well without suggestion of significant aphasia and talking in short sentences. She follows commands and can answer questions appropriately. Speech is dysarthric but improving. Right gaze deviation, unable to cross the midline to left. Left homonymous hemianopia. Left facial droop. Moves right side spontaneously and at least 3-4/5. Flaccid LUE with minimal flexion in UE to noxious, likely slight left [**Last Name (un) 5355**] dorsiflexion is a spinal reflex. Grimaces to noxious throughout. Left neglect and cannot identify left hand as her own consistently. Discharge Instructions: It was a plesuare taking care of you during your stay at the [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **]. You presented with unresponsiveness and left sided weakness. CT showed a very large stroke affecting the right side of your brain. This was felt to be a result of a combination of your irregular heartbeat and that you were mistakenly only taking your Pradaxa once as opposed to twice per day. You were initially admitted to the ICU and you had high heart rates which required medications to treat this. You had a heart ultrasond (echocardiogram) including a repeat tran-esophageal echocardiogram which showed no clear evidence of clot in your heart. CT scans of the head remeined stable and you were initially transferred back to the floor but due to bloodpressure issues you were transferred back. You were eventually able to be transferred out of the ICU. You were treated for a urinary tract infection and then you began spiking fevers and the infectious diseases doctors [**First Name (Titles) **] [**Last Name (Titles) 4221**]. You were treated with broad spectrum antibiotics for a likely pneumonia and the fevers settled. In tthe process of your work-up, we found a stroke to your spleen which is also likely because of a blood clot. For this reason and to reduce your risk of strokes we started you on warfarin which is another blood thinner. Risks of this are as before namely increasd bleeding risk for instance if you cut yourself it will be more difficult to stop bleeding and if you hit your head you need to seek urgent medical attention as there is a risk of bleeding in the brain. You had significant swallowing problems and you were initially fed with an NG tube but given continued poor swallowing on repeated assessments, you had a feeding tube called a PEG tube inserted into your stomach on [**2199-5-17**]. There were no complications from your surgery and you were transferred to rehab on [**2199-5-23**]. We thought you likely have sleep apnea given pauses in respirations observed on the floor. Assessment with a sleep study can be organised by your PCP. Your blood cpount dropped an this was felt likely due to your myelodysplastic syndrome and you required a blood transfusion for this. We have arranged hematology follow-up as below. Medication changes: We STARTED aspirin to overlap with warfarin until INR is therapeutic We STARTED warfarin 5mg daily We STOPPED dabigatran We HELD darbepotin and this can be restarted on the advice of hematology who you will see in clinic We CHANGED diltiazem extended release to diltiazem 75mg every 4 hours We STOPPED sotalol We CHANGED omeprazole to famotidine We CHANGED simvastatin to atorvastatin 20mg daily We STOPPED tramadol We STARTED metoprolol 25mg three times daily Please continue your other medications as prescribed Followup Instructions: Please see your PCP on discharge from rehab. We have arranged the following stroke neurology follow-up: Department: NEUROLOGY When: FRIDAY [**2199-7-5**] at 1:30 PM With: [**First Name8 (NamePattern2) **] [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 3445**], MD [**Telephone/Fax (1) 2574**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage We have arranged the following hematology follow-up: Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [**2199-6-5**] at 1:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 6050**], MD [**Telephone/Fax (1) 8770**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage You have the existing cardiology follow-up: Department: CARDIAC SERVICES When: THURSDAY [**2199-7-11**] at 2:40 PM With: [**Name6 (MD) 1918**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[ "96.6", "88.72", "43.11" ]

icd9pcs

[ [ [] ] ]

44840, 44976

25759, 40226

354, 391

45572, 45572

9236, 9263

49484, 50663

3842, 4003

43069, 44817

44997, 45358

41253, 43046

46573, 48925

10858, 19385

4018, 5082

45379, 45551

40247, 41227

48945, 49461

273, 316

419, 2419

5905, 9217

19394, 25736

9279, 9697

9719, 10842

45587, 46549

2441, 3280

3296, 3826

13,009

172,611

46905

Discharge summary

report

Admission Date: [**2171-4-24**] Discharge Date: [**2171-4-26**] Date of Birth: [**2091-2-11**] Sex: M Service: NSU HISTORY OF PRESENT ILLNESS: The patient is an 80-year-old gentleman with a history of cerebral left ICA stenosis. The patient had a left MCA stroke in [**2170-9-26**], and has a history of coronary artery disease with a CABG in [**2165**], hypertension, GERD, with an EF greater than 55% on echo. PHYSICAL EXAMINATION ON ADMISSION: The patient is in no acute distress. Awake, alert, and oriented with expressive speech aphasia. Cardiovascular with a regular rate and rhythm. A 1/6 systolic murmur. The lungs are clear. Extremities with trace ankle edema on the right side only. Gait is slightly unsteady. Carotids are 2+ bilaterally. A bruit on the left. Upper extremity strength 5-/5 on the right upper and lower extremities with mild spastic right hand movements. The reflexes are 2+ at the knees. HOSPITAL COURSE: The patient is admitted status post a left internal carotid artery stent placement without intraprocedure complication. Postoperatively, the patient was monitored in the ICU where he remained. His carotid ultrasound before the procedure showed right ICA stenosis of 60% and a left of 80% to 99%. The patient tolerated the procedure well and was monitored in the ICU post procedure. He was awake, alert, and oriented x 3. He continued to have expressive aphasia, following commands, visual fields full. Pupils equal, round and reactive to light. EOMs full. Face symmetric. Full strength in all extremities with no drift. Sensation intact to light touch. Reflexes 2+ throughout. The patient was transferred to the regular floor. On postprocedure day 1, he was out of bed ambulating and tolerating a regular diet. Assessed by physical therapy and occupational therapy and found to be safe for discharge to home without services. DISCHARGE FOLLOWUP: He will follow up with Dr. [**Last Name (STitle) 1132**] in 2 weeks. MEDICATIONS ON DISCHARGE: 1. Plavix 75 mg p.o. daily 2. Aspirin 325 mg p.o. daily 3. Colace 100 mg p.o. b.i.d. 4. Atenolol 25 mg p.o. daily 5. Amaryl 5 mg p.o. daily 6. Atorvastatin 20 mg p.o. daily 7. Zantac 150 mg p.o. b.i.d. CONDITION ON DISCHARGE: The patient's condition was stable at the time of discharge. [**Name6 (MD) **] [**Last Name (NamePattern4) 1359**], [**MD Number(1) 1360**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2171-4-26**] 15:46:58 T: [**2171-4-26**] 16:55:35 Job#: [**Job Number 99503**]

[ "433.10", "E934.2", "530.81", "599.7", "401.9", "V45.81" ]

icd9cm

[ [ [] ] ]

[ "00.64", "00.61" ]

icd9pcs

[ [ [] ] ]

2003, 2207

958, 1886

1907, 1977

165, 456

471, 940

2232, 2543

82,466

142,707

42477

Discharge summary

report

Admission Date: [**2142-3-17**] Discharge Date: [**2142-3-22**] Date of Birth: [**2076-8-30**] Sex: F Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2836**] Chief Complaint: Trauma: pedestrian struck: L1 burst fracture, unstable Left femur fracture L sup/inf pelvic ramus fracture occipital scalp laceration Major Surgical or Invasive Procedure: [**2142-3-21**] IVC filter [**2142-3-17**] Left femur - retrograge nail [**2142-3-17**] post [**Last Name (un) **] lami fusion T11-L3 History of Present Illness: [**Known firstname 553**] [**Known lastname 91944**] is a 65 year old woman who presents S/P low-speed (<15mph) ped strike by an SUV at crosswalk. EMS reports light blood loss on scene, A&Ox3 with full memory of the accident, no damage to the car, and patient rolled up onto the [**Doctor Last Name **]. BP 124/palp, GCS 15. She is complaining of left leg pain. Timing: Constant Quality: Sharp Severity: Severe Duration: Minutes Location: Leg Context/Circumstances: Status post pedestrian struck by car Mod.Factors: Worse with Movement Past Medical History: Possible incomplete heart valve Social History: Denies Alcohol, Drugs and Smoking Family History: NC Physical Exam: PHYSICAL EXAMINATION: upon admission: [**2143-1-15**] HR: 88 BP: 135/87 Resp: 20 O(2)Sat: 100 Normal Constitutional: Awake and responding to questions HEENT: Two 3cm lacerations (V-shaped) on right occipital. 3:2 bilateral pupils equal, round and reactive to light. Cervical collar in place Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm Abdominal: Mid-abdominal tenderness. Soft, Nondistended. Pelvic: Pain with palpation of pelvis, but stable Extr/Back: Left femur deformity. Left thigh ecchymosis. Right knee abrasion. Good palpable pulses distally. Skin: Warm and dry Neuro: Speech fluent Psych: Normal mood, Normal mentation Physical examination upon discharge: [**2142-3-22**] vital signs: t=989, hr=88, bp=128/76, rr 18, oxygen sat 94% room air General: sitting comfortaly in chair with TLSO brace CV: Ns1, s2, -s3,-s4 LUNGS: Clear upper, unable to fully assess bases related to TLSO brace on ABDOMEN: soft EXT: feet warm, + dp bil. lower ext. +3/+5, steri-strips to stab wound left upper thigh, ecchymosis to left leg, right knee abrasion, ecchymosis to post. aspect of left arm., full elbow ROM, full wrist ROM, + radial bil. Neuro: Alert and oriented x3, conversant Pertinent Results: [**2142-3-22**] 05:05AM BLOOD WBC-5.6 RBC-2.64* Hgb-8.0* Hct-22.7* MCV-86 MCH-30.3 MCHC-35.2* RDW-14.8 Plt Ct-266 [**2142-3-21**] 05:02AM BLOOD WBC-6.8 RBC-2.67* Hgb-8.1* Hct-22.3* MCV-84 MCH-30.3 MCHC-36.3* RDW-15.2 Plt Ct-188 [**2142-3-20**] 12:37AM BLOOD WBC-8.2 RBC-2.70* Hgb-8.1* Hct-22.8* MCV-85 MCH-30.1 MCHC-35.6* RDW-14.9 Plt Ct-144* [**2142-3-17**] 08:15PM BLOOD WBC-4.2# RBC-2.73*# Hgb-8.3*# Hct-23.4*# MCV-86 MCH-30.5 MCHC-35.5* RDW-14.8 Plt Ct-200# [**2142-3-17**] 09:15AM BLOOD WBC-13.9* RBC-4.18* Hgb-12.9 Hct-36.0 MCV-86 MCH-30.9 MCHC-35.9* RDW-13.2 Plt Ct-493* [**2142-3-22**] 05:05AM BLOOD Plt Ct-266 [**2142-3-21**] 05:02AM BLOOD Plt Ct-188 [**2142-3-18**] 01:59AM BLOOD PT-13.3* PTT-26.8 INR(PT)-1.2* [**2142-3-17**] 03:24PM BLOOD Fibrino-104*# [**2142-3-17**] 09:15AM BLOOD Fibrino-250 [**2142-3-22**] 05:05AM BLOOD Glucose-114* UreaN-10 Creat-0.3* Na-138 K-3.6 Cl-102 HCO3-30 AnGap-10 [**2142-3-21**] 05:02AM BLOOD Glucose-108* UreaN-10 Creat-0.3* Na-138 K-4.0 Cl-102 HCO3-31 AnGap-9 [**2142-3-18**] 03:33PM BLOOD CK(CPK)-1423* [**2142-3-17**] 08:15PM BLOOD ALT-23 AST-43* AlkPhos-23* TotBili-1.0 [**2142-3-18**] 03:33PM BLOOD CK-MB-12* MB Indx-0.8 cTropnT-<0.01 [**2142-3-22**] 05:05AM BLOOD Calcium-7.8* Phos-2.3* Mg-1.6 [**2142-3-17**] 07:13PM BLOOD freeCa-1.07* [**2142-3-17**]: chest x-ray: IMPRESSION: No acute cardiac or pulmonary process. L1 burst fracture better appreciated/evaluated on CT. [**2142-3-17**]: cat scan of the head: IMPRESSION: Scalp laceration, but no evidence of intracranial hemorrhage or obvious fracture. [**2142-3-17**]: cat scan of the c-spine: IMPRESSION: No fracture or malalignment with normal prevertebral soft tissues [**2142-3-17**]: cat scan of the abdomen: No acute intra-abdominal or intrathoracic injury. 2. L1 burst fracture with retropulsed fragments and minimally displaced fracture of the right L1 lamina; these findings suggest an unstable fracture and if clinical concern for cord injury exists, MR would be recommended. 3. Fracture of the left pelvis as described above\ [**2142-3-17**]: x-ray of the right ankle: IMPRESSION: No acute fracture or dislocation [**2142-3-17**]: bilateral knee x-ray: . Extensively comminuted left femoral supracondylar fracture, without definite intra-articular extension. No dislocation. 2. Probable left suprapatellar joint effusion. 3. Extensive soft tissue densities along the medial aspect of the right knee, concerning for a hematoma. No acute fracture of the right knee seen. [**2142-3-17**]: x-ray of left femur: . Extensively comminuted left distla femoral fracture, without definite intra-articular extension. 2. Displaced transverse mid diaphyseal left femoral fracture with bony overriding. 3. Non-displaced left superior and inferior pubic rami fractures. [**2142-3-17**]: left knee x-ray: FINDINGS: In comparison with earlier studies of this date, a pin is seen transfixing the proximal tibia. Comminuted and displaced fracture of the distal femur is again seen. [**2142-3-17**]: MR of lumbar spine: . Based on the numbering used shown on se 2, im 10, burst fractureinvolving the L1 vertebral body, with areas of discontinuity in the outline of the anterior longitudinal and posterior longitudinal ligament at a few levels and the possibility of injury/focal disruption. Retropulsion of the posterior aspect of L1 body, with moderate canal stenosis and minimal deformity on the cord. Pre- and paravertebral soft tissue swelling/hematoma. Osseous details are better assessed on the prior CT torso. Ligamentous changes are better seen on the STIR sequence. 2. Multilevel multifactorial degenerative changes in the lumbar spine from L2-S1 levels with areas of marrow edema at L5 and S1 levels and in the anterior disc which may relate to degenerative changes. Correlate clinically for injury-related changes. No significant canal or foraminal stenosis from L2-S1. Mild foraminal narrowing noted at L5-S1 levels. Other details as above. [**2142-3-17**]: x-ray of the lumbar spine: FINDINGS: Images from the operating suite show placement of a posterior fusion device extending from T11 through L3. Further information can be gathered from the operative report. [**2142-3-17**]: lower extremity fluro: FINDINGS: Multiple images from the operating suite show placement of an intramedullary rod about fracture of the distal femur. Further information can be gathered from the operative report. [**2142-3-17**]: lower extremity fluro: FINDINGS: Multiple images from the operating suite show placement of an intramedullary rod about fracture of the distal femur. Further information can be gathered from the operative report. [**2142-3-18**]: EKG: Atrial fibrillation with rapid ventricular response. Low limb lead voltage. ST segment depression and T wave inversion in leads II, III and aVF. Delayed precordial R wave transition and right ventricular conduction delay. No previous tracing available for comparison. Clinical correlation is suggested. [**2142-3-18**]: bil. foot x-ray: FINDINGS: Portable images show a prominent hallux valgus on the right with degenerative changes involving the first MTP joint. No definite fracture is appreciated. On the left, there may be a sequela of previous osteotomy involving the first metatarsal. No definite fracture is seen on this limited study. [**2142-3-19**]: ECHO: Conclusions The left atrium is elongated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 65%). 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 leaflets are mildly thickened. There is mild bileaflet mitral valve prolapse. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Tricuspid valve prolapse is present. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. [**2142-3-19**]: chest x-ray: Linear opacity at the left base likely reflects scar near subsegmental atelectasis. Lungs otherwise are well inflated and remain without evidence of focal airspace consolidation, pleural effusions or pneumothorax. Overall, cardiac and mediastinal contours are stable. Calcification in aorta consistent with atherosclerosis. Persistent thoracolumbar curvature. A hardware overlying the lower thoracic and upper lumbar spine. No pulmonary edema [**2142-3-21**]: Abdominal fluro: Single spot fluoroscopic image from the operating room is provided. The image demonstrates an inferior vena cava filter which is placed just above the lowermost level of the lumbar spine transpedicle fixation. For further details, please consult the operative report in the online medical record dated [**2142-3-21**]. Brief Hospital Course: 65 year old female admitted to the acute care service after being struck by a vehicle. Upon admission, she was made NPO, given intraveous fluids, and underwent radiographic imaging. She was found to have an unstable L1 burst fracture, left femur fracture, left sup/inf pelvic ramus fracture, and a occipital scalp laceration. Because of the extent of her injuries, she was evaluated by Orthopedics and Neurosurgery. She was intubated in the emergency room and taken to the operating room where she underwent a T11-L3 laminectomy fusion and a left femoral IM nailing. She had 800cc blood loss during the procedure and required 1000cc blood. Intra-op her blood pressure was supported with neosynephrine. She was monitored in the intensive care unit after the procedure. On POD #1, she was extubated without incident. She did require additional blood for a hematocrit of 25. During this time, she also had a short run of atrial fibrillation treated with IV lopressor and amiodarone. Neosynephrine was resumed for hypotension. An echocardiogram was done which was normal. After receiving blood, the neosynephrine was weaned off. Her heart rate was controlled with oral amiodarone. On POD # 2 she was fitted for the TLSO brace and had a physical therapy evaluation. Her vital signs remained normal and she was transferred to the surgical floor. Her diet was advanced to a regular diet. Because of her decreased mobility, she was taken to the operating room on POD #4 where she underwent placment of an IVC filter without incident. Her vital signs are stable with a hematocrit of 23.0 and a white blood cell count of 5.6. She is tolerating a regular diet. She has been encouraged to use the incentive spirometer and has maintained on oxygen saturation of 96% on 3 liters. She has been assessed by physical therapy and recommendations made for discharge to an extended care facility where she can further regain her strength and mobility. Of Note: her foley catheter was d/c today [**2142-3-22**], she is due to void at 6:30 pm Of note: she will need x-ray of spine with brace on when she returns for follow-up Medications on Admission: [**Last Name (un) 1724**]: flonase 50", MVI, VitC, VitE Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) cc Injection TID (3 times a day). 2. sodium chloride 0.65 % Aerosol, Spray Sig: [**1-29**] Sprays Nasal TID (3 times a day) as needed for stuffiness. 3. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2) Spray Nasal [**Hospital1 **] (2 times a day). 4. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 5. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 6. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: hold for increased sedation, resp. rate <10. 10. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 11. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 12. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 13. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 14. calcium carbonate 500 mg calcium (1,250 mg) Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. furosemide 20 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): reassess after 48 hours to determine need. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Trauma: pedestrian struck: L1 burst fracture, unstable Left femur fracture L sup/inf pelvic ramus fracture occipital scalp laceration Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair LLE TDWB RLE WBAT in hinged [**Doctor Last Name 6587**] unlocked TLSO brace when OOB HOB < 30, bedrest until TLSO in place Discharge Instructions: You were admitted to the hospital after you were hit by a vehicle. You sustained injuries to back, pelvis, and leg. You were taken to the operating room where you had a repair of your left femur and a stablization of your back. You were monitored in the intensive care unit after the surgery. You have been seen by physical therapy and you are now preparing for discharge to a rehabiltation facility where you can further regain your strength and mobility. Followup Instructions: Department: ORTHOPEDICS When: FRIDAY [**2142-3-30**] at 10:15 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**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: FRIDAY [**2142-4-20**] at 10:40 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: SPINE CENTER When: FRIDAY [**2142-4-20**] at 11:00 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3736**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2142-3-23**]

[ "808.2", "806.4", "821.23", "873.0", "427.31", "285.1", "808.41", "E878.1", "E814.5", "805.4" ]

icd9cm

[ [ [] ] ]

[ "81.05", "86.59", "96.04", "81.62", "38.7", "79.15", "96.71", "03.53" ]

icd9pcs

[ [ [] ] ]

13404, 13474

9704, 11826

440, 576

13654, 13654

2710, 9681

14440, 15335

1462, 1466

11932, 13381

13495, 13633

11852, 11909

13955, 14417

1481, 1481

1503, 1505

264, 402

2175, 2691

604, 1307

1520, 2158

13669, 13931

1329, 1363

1379, 1446

5,679

124,525

42961

Discharge summary

report

Admission Date: [**2143-4-8**] [**Year/Month/Day **] Date: [**2143-4-16**] Date of Birth: [**2065-7-10**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2145**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: 77 yo male with CAD s/p CABG and stents, pacemaker (with recent revision in [**State 108**] [**2143-3-22**]), chronic hypoxia on home 6L 02 [**1-2**] obesity and low DLCO as well as COPD, DM2, PVD who presented with several days of worsening dyspnea. He also notes increased bilateral leg swelling and abdominal swelling over this same timecourse. Denies recent fever, rhinorrhea, cough, sick contact, chest pain, nausea, headache, confusion. However, he does notes that from the time he got on the airplane on Thursday through Saturday he did not have any oxygen at all. He reports that his insurance company denied compressed portable 02 for him despite his pulmonologist in FLA writing them a letter. His wife noted that the whole weekend the patient appeared short of breath and slightly blue around the lips but that he refused to come into the hospital until this morning. . In the ED initial vital signs were initally notable for 02 in the 70s on 6L. Patient appeared cyanotic and tachypneic and lungs diffusely wheezy with some crackles. Labs notable for a normal CBC and electrolytes except creatinine of 1.3 (1.2 in [**Month (only) 404**]). Troponin - x1. U/A negative. BNP 1312. Patient had LENIs which were negative. CXR showed pacer leads intact, mild/mod pulm edema, LLL consolidation likely atelectasis, cannot rule out pneumonia. Patient was given IV methylpred, Levofloxacin and 40 IV lasix and diuresed about 1.5L.EKG showed pacing spike. VS on transfer: 97 70 131/59 20 on NRB 95% RA. Past Medical History: #. Coronary artery disease with bypass surgery in [**2126**], circumflex stenting in [**2133**] and rotational atherectomy in [**2136**] with inability to deliver a stent. His most recent coronary angiogram in [**2138**] showed diffuse moderate disease, not suitable for further intervention. Left ventricular end-diastolic pressure was elevated to 24 mm. #. Exertional dyspnea, which was felt to be multifactorial with a role of left ventricular diastolic dysfunction along with known restrictive pulmonary disease and obesity. #. Placement of a permanent pacemaker in [**State 108**] in [**2140-10-1**] for high-grade AV block and revision [**3-/2143**] to 3 lead pacer #. Hypertension. #. Hyperlipidemia with most recent lab studies at [**Last Name (un) **] in [**2142-3-31**] showing total cholesterol 132, LDL 71, HDL 49 and triglycerides 151. #. Difficult to control diabetes. #. Obesity. #8. Vascular disease being followed by Dr. [**Last Name (STitle) **] with no further interventions felt appropriate at the time of his last visit. # spinal stenosis, # colon polyps, # Chronic renal insufficiency s/p renal stent in [**2131**] # obstructive sleep apnea, # diabetic retinopathy, # cataracts Social History: Patient is married. retired plumber. Patient smoked 2 packs/day for 35 years, quit in [**2126**]. Occasional Alcohol. Lives in [**State 108**] part of the year. History of asbestos exposure, but without CT evidence of asbestos-related lung or pleural disease. Family History: Non-contributory Physical Exam: EXAM ON ADMISSION VS: afebrile HR 72 BP: 124/51 02: 90% on NRB GEN: AOx3, has some difficulty completing sentences but NAD HEENT: MMM, JVP difficult to assess but appears to be at the angle of the jaw, Cards: distant HS, but RRR no audible murmur. Pacer site with healing scar, no [**State **] Pulm: Crackles at the bases, no wheezing, Abd: Obese, BS+, soft, NT, no rebound/guarding, no HSM Limbs: 2+ edema to the knees, venous stasis changes. Skin: No rashes or bruising Neuro: CNs II-XII intact. 5/5 strength in U/L extremities. DTRs 2+ BL. sensation intact to LT. EXAM ON [**State 894**] VS: T 97.7 HR 72 BP 126/66 RR 20 O2 sat: 93-98% 6L NC GEN: Alert oriented, ambulating, NAD HEENT: MMM, JVP difficult to assess but decreased since admission Cards: RRR, no m/g/r, pacer site with healing scar Pulm: CTAB, no wheezes Abd: obese, +bs, soft, NT Limbs: 1+ edema to knees, venous stasis changes Neuro: CNs II-XII intact. 5/5 strength in U/L extremities. DTRs 2+ BL. sensation intact to LT. Pertinent Results: Labs on admission: [**2143-4-8**] 10:10AM BLOOD WBC-10.2 RBC-5.22 Hgb-15.9 Hct-47.7 MCV-91 MCH-30.5 MCHC-33.4 RDW-14.5 Plt Ct-187 [**2143-4-8**] 12:35PM BLOOD Glucose-103* UreaN-34* Creat-1.3* Na-143 K-4.6 Cl-105 HCO3-29 AnGap-14 [**2143-4-8**] 07:50PM BLOOD PT-15.6* PTT-25.8 INR(PT)-1.4* [**2143-4-8**] 10:10AM BLOOD cTropnT-<0.01 [**2143-4-8**] 07:50PM BLOOD CK-MB-4 cTropnT-<0.01 [**2143-4-8**] 07:50PM BLOOD CK(CPK)-36* [**2143-4-8**] 07:50PM BLOOD Calcium-9.5 Phos-3.9 Mg-2.1 [**2143-4-8**] 10:21AM BLOOD Lactate-2.0 [**2143-4-8**] 11:00AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG Labs on [**Year/Month/Day **]: [**2143-4-16**] 06:25AM BLOOD WBC-9.0 RBC-5.03 Hgb-15.5 Hct-45.8 MCV-91 MCH-30.9 MCHC-33.9 RDW-14.0 Plt Ct-156 [**2143-4-16**] 06:25AM BLOOD Glucose-116* UreaN-24* Creat-1.2 Na-137 K-4.1 Cl-97 HCO3-32 AnGap-12 [**2143-4-16**] 06:25AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.3 PORTABLE AP CHEST RADIOGRAPH: A biventricular pacemaker device is new compared to prior examination. The triple leads are intact and project over the expected location of the right atrium, right ventricle, and coronary sinus. Median sternotomy wires appear grossly intact on this frontal projection. Bilateral interstitial opacities, septal thickening, and perihilar haziness are findings consistent with new mild-to-moderate pulmonary edema. Blunting of the bilateral costophrenic angles, left greater than right, is likely secondary to pleural effusions. There is no definite focal consolidation or pneumothorax. Increased density at the lung bases may be secondary to pleural fluid or partial atelectasis. The cardiac silhouette is mildly enlarged. IMPRESSION: 1. New mild-to-moderate pulmonary edema, likely cardiogenic etiology. 2. New bilateral effusions, moderate on the left and small on the right. 3. Possible partial bibasilar atelectasis 4. Intact pacemaker leads with standard position. Bilateral LENI: IMPRESSION: No evidence of DVT in the examined veins. Evaluation of the peroneal veins could not be completed. CHEST (PA & LAT): In comparison with the study of [**4-12**], there is continued enlargement of the cardiac silhouette with evidence of elevated pulmonary venous pressure in this patient with pacemaker device in place. The opacification at the left base has somewhat decreased, consistent with re-aeration of much of the left lower lobe and decreased effusion. ECHOCARDIOGRAM WITH BUBBLE STUDY: Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF 70%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The right ventricular cavity is dilated with depressed free wall contractility. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. 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. At least moderate [2+] tricuspid regurgitation is seen. Due to the technically suboptimal nature of this study, the severity of tricuspid regurgitation and severity of pulmonary hypertension may be grossly underestimated. There is (at least) moderate pulmonary artery systolic hypertension. There is no pericardial effusion. No obvious intracardiac shunt detected by agitated saline contrast imaging (on very suboptimal views) . If clinically indicated, a transesophageal echocardiographic study with agitated saline contrast is recommended. . IMPRESSION: Suboptimal image quality. This study is inadequate to exclude the presence of an intracardiac shunt Brief Hospital Course: 77 year old male with significant cardiac disease s/p CABG, stents and pacemaker, also with chronic hypoxia on 6L02 at home who presents with acute hypoxia. . # Hypoxic Respiratory Distress: Etiology is a combination of pulmonary disease (restrictive pulmonary physiology and decreased DLCO of unknown etiology with obesity and OSA) plus exacerbation of congestive heart failure. The immediate trigger of the acute hypoxia was due to the patient not having oxygen for 2 day while traveling. . In the MICU, LENIs were negative and there was low pretest probability for PE. His hospital day 2 CXR was notable for fluid overload, and he was diuresed 3L. He subsequently reported dietary indiscretion at [**State 108**], and this may be the primary contributor of his elevated O2 requirement. He was continued on Standing Albuterol and Ipratropium nebs. He was not given ABX or steroids. Cardiac enzymes and EKG were wnl. Per discussion with his [**State 108**] cardiologist and pulmonologist, it appears that his baseline 6L O2 requirement is multifactorial from obesity hypoventilation, COPD, decreased DLCO, and pulmonary hypertension. His transient elevated O2 requirement to face tent improved to his baseline 6L NC (90% saturation) with diuresis. . After transfer to the floor, he continued to be diuresed. Respiratory status improved to O2 sat 93 - 95% on 6L NC. TTE with bubble study was performed which was of poor quality and could not definitively rule out intracardiac shunt. We discussed with his pulmonologist here the concern that there still remains a question of whether he has an intracardiac shunt, and whether he may need future evaluation for this given he has significant chronic hypoxemia. (?further evaluation with TEE, cath, or cardiac MRI? ) He will follow-up with outpatient pulmonologist and cardiologist after [**State **]. He was discharged on 6L oxygen. . # Hematuria: felt to be from traumatic foley placement in ED. Today, urology placed 20 french foley, no cystoscopy performed, manually irrigated, 900 cc came out (no prior GU history). . # History of CAD/Hypertention: Patient was asymptomatic throughout and was ruled out with two sets of cardiac enzyme. He was continued on aspirin, simvastatin, and plavix. Patient was started on Lisinopril 10 mg po qd. His atenolol was stopped and transitioned to carvedilol. Primary doctor was notified and will uptitrate beta-blocker as appropriate. Patient has close follow-up with primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **]. . # Chronic diastolic CHF: Echocardiogram with bubble study was performed. LVEF was >70%, but with left ventricular inflow pattern suggests impaired relaxation. Patient was overloaded on admission and was diuresed with 40 to 80 mg furosemide with good output. His furosemide dose was increased to 60 mg po per day prior to [**Last Name (Titles) **]. Patient educated about heart-failure appropriate diet. Nutrition consult provided education regarding heart failure, diabetic diet. . # COPD: PFT from [**3-/2142**] obtained from [**State 108**] showed restrictive disease with decreased DLCo. Etiology most likely from obesity/OSA, but definitely cause is still unclear. [**Name2 (NI) **] was kept on albuterol and ipratropium nebs while inpatient. He will follow-up with outpatient pulmonologist (Dr. [**Last Name (STitle) 575**] after [**Last Name (STitle) **] who was involved in his care here throughout. . # Type 2 DM: Patient is noncompliant with his diet at baseline and was on very significant regimen of U500, symilin, and insulin. Insulin requirements were dramatically decreased while on diabetic diet as inpatient. [**Last Name (un) **] consult was involved throughout the hospital course. Patient will follow-up with outpatient endocrinologist. . # OSA: Patient was kept on CPAP while inpatient and encouraged to use it consistently at home. . -likely [**1-2**] chronic hypoxia Medications on Admission: Before Breakfast: U500 14 mg/dl =70 regular insulin Before Lunch: U500 6 mg/dl = 30 regular insulin Before Dinner: U500 10 mg/dl = 50 regular insulin At Bedtime: Symlin 120 mcg. **PAtient reports taking with each meal Vitamin D [**Numeric Identifier 1871**] Unit take 1 by Oral route every month Glyburide 5 Mg 2 twice a day Atenolol 25 Mg take 1 tablet (25MG) by ORAL route every day Norvasc 10 Mg take 1 tablet (10MG) by ORAL route every day Diphenhist 25 Mg qhs, for sleep Plavix 75 Mg 1 time per day Zocor 20mg once a day Lasix 40mg 1 per day Aspirin 325mg 1 time per day Betamethasone Dipropionate 0.05% as directed Lamisil 1 % as directed Albuterol 90mcg as directed Advair 250/50 inh [**Hospital1 **] [**Hospital1 **] Medications: 1. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 2. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO once a month. 6. glyburide 5 mg Tablet Sig: Two (2) Tablet PO twice a day. 7. Diphenhist 25 mg Capsule Sig: One (1) Capsule PO at bedtime. 8. betamethasone dipropionate 0.05 % Ointment Sig: One (1) application Topical once a day: As directed. 9. Lamisil 1 % Cream Sig: One (1) application Topical once a day: as directed. 10. ranolazine 500 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO twice a day. 11. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day: 90-day supply. Disp:*90 Tablet(s)* Refills:*0* 12. furosemide 40 mg Tablet Sig: 1.5 Tablets PO once a day. Disp:*135 Tablet(s)* Refills:*0* 13. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*180 Tablet(s)* Refills:*0* 14. Advair Diskus 250-50 mcg/dose Disk with Device Sig: One (1) Inhalation twice a day: Rinse after use. 15. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation once a day. 16. insulin glargine 100 unit/mL Solution Sig: Twenty (20) units Subcutaneous once a day: Before breakfast. Disp:*1 bottle* Refills:*2* 17. insulin glargine 100 unit/mL Solution Sig: Forty (40) units Subcutaneous once a day: At bedtime. Disp:*1 bottle* Refills:*2* 18. Humalog 100 unit/mL Solution Sig: See below Subcutaneous Before each meal and at bedtime: Please see sliding scale attached. . Disp:*1 bottle* Refills:*2* 19. lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 20. furosemide 40 mg Tablet Sig: 1.5 Tablets PO once a day. Disp:*45 Tablet(s)* Refills:*0* 21. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*0* 22. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation every six (6) hours. 23. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation every six (6) hours. [**Hospital1 **] Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] [**Name (NI) **] Diagnosis: PRIMARY DIAGNOSIS: Coronary artery disease Chronic diastolic congestive heart failure Diabetes mellitus Hypertension Hyperlipidemia Obstructive sleep apnea Restrictive lung disease . SECONDARY DAIGNOSES: Peripheral vascular disease Cataracts [**Name (NI) **] Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. [**Name (NI) **] Instructions: Mr. [**Known lastname 92736**], you were admitted to the [**Hospital1 827**] because you had difficulty breathing. You were initially admitted to the ICU where you got breathing treatments and received medications to help remove fluid from your lungs. You got better and were transferred to the regular medicine floor. There, we asked your primary pulmonologist to come see you. We did an ultrasound of your heart which was reassuring. We asked the nutritionist to see you to educate you about diabetic, low sodium diet that you should be on. . You will follow-up with yout primary care doctor, cardiologist, pulmonologist, and endocrinologist after [**Hospital1 **]. . Please monitor your weight daily and if you observe a greater than 3 lb gain, please let your primary care doctor know. . Please use your CPAP machine and oxygen consistently. If you were to travel, you must have oxygen with you at all times as well. . Medications: ADDED: - Lisinopril 10 mg by mouth daily - Carvedilol 6.25 mg by mouth twice a day CHANGED: - Furosemide INCREASED to 60 mg by mouth daily - Insulin regimen (please see print out of your new regimen) REMOVED: - Atenolol 25 mg by mouth daily Followup Instructions: Department: [**Hospital1 18**] [**Location (un) 2352**] - ADULT MED When: MONDAY [**2143-4-22**] at 11:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD [**Telephone/Fax (1) 1144**] Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: [**Hospital1 18**] [**Location (un) 2352**] - ADULT MED When: WEDNESDAY [**2143-4-24**] at 12:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD [**Telephone/Fax (1) 1144**] Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: ADULT SPECIALTIES When: TUESDAY [**2143-4-30**] at 9:30 AM With: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD [**Telephone/Fax (1) 8645**] Specialty: Cardiology Building: [**Location (un) 2790**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site Endocrinology ([**Last Name (un) **]) Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 14116**] [**2142-5-9**] @ 10 AM [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**] Completed by:[**2143-4-16**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8301, 12226

323, 329

4447, 4452

16920, 18265

3399, 3418

12252, 12962

3433, 4428

276, 285

15190, 15289

12992, 15160

357, 1870

15308, 15561

4466, 8278

15576, 16897

1892, 3104

3120, 3383

50,772

192,389

35222

Discharge summary

report

Admission Date: [**2111-2-4**] Discharge Date: [**2111-2-5**] Date of Birth: [**2036-1-15**] Sex: F Service: MEDICINE Allergies: Penicillins / Morphine Attending:[**First Name3 (LF) 2485**] Chief Complaint: Hypoxia Major Surgical or Invasive Procedure: None History of Present Illness: 75F [**Name (NI) **] pt with a hx of COPD ([**1-14**] spirometry with (FVC 0.96, FEV1 0.47, ratio of 49, 71% predicted), on 3L 02, hx bilateral PE's ([**3-17**]), AF (currently anticoagulated), non-obstructive CAD, EF 75% to 80% ([**3-17**]), pacemaker and dementia (baseline AO [**2-7**]), presented today from [**Month/Day (2) **] with hypoxia. . Per [**Month/Day (2) **] records the pt was noted at 10:45pm to have the following vitalsL: 97.5 125/78, 89 RR24 and 83% on 3L (baseline 3L, usually in 90s). The pt received Albuterol Nebs x2 (10:55pm and 11:15pm) and was subsequently sent to the ED. . Upon arrival to the ED 96.2 94 139/90 20 94. Pt reported to have Crackles L>R. Denied SOB. ABG 7.42/64/62. The pt was given neb, Solumedrol 125mg IVx1. ED was concerned for LUL infiltrate and thus drew BCx and treated pt with Vancomycin 1gm IV, Levofloxacin 750mg IVx1. Vitals prior to transfer to the floor 92 150/90 22 94% on 4L. . The patient unable to adeuately answer the following review of symptoms: fever, chills, night sweats, loss of appetite, fatigue, chest pain, palpitations, rhinorrhea, nasal congestion, hemoptysis, dyspnea, orthopnea, paroxysmal nocturnal dyspnea, nausea, vomiting, diarrhea, constipation, hematochezia, melena, dysuria, urinary frequency, urinary urgency, focal numbness, focal weakness, myalgias, arthralgias Past Medical History: PER OMR - AF on coumadin - CAD (per chart; however had non-obstructive CAD on previous cath) - Multiple bilateral PE's ([**3-17**]) - DMII - Dyslipidemia - COPD - Anemia with basline HCT 31-33 - Osteoporosis - Chronic joint pain - GERD - Dementia - anxiety / depression - Dysphagia per records though not noted to be on special diet - Dementia - MRSA PNA req. ICU admission with ETT - Acute Cholangitis ([**2110-3-12**] with acute cholangitis due to choledocolithiasis underwent urgent ERCP with stenting) - Pulmonary Nodule Noted on CT [**3-17**]: 6-mm left lower lobe nodule Social History: reports h/o smoking, no ETOH, no drugs, resides at [**Location (un) 745**] HCC Family History: NC Physical Exam: T= 98 BP=158/87 HR=102 RR=16 O2=95%RA PHYSICAL EXAM GENERAL: Pleasant, chronically ill appearing appearing in NAD. Oriented to self, not location or date. HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: Irregularly irregular, S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. [**Last Name (un) 22116**]= flat LUNGS: Dimished BS at right base, left sided crackles. Poor airmovement. No appreciable wheezes anteriorly or posteriorly. ABDOMEN: NABS. Soft, obese, NT, ND. No HSM EXTREMITIES: Trace bilateral pedal edema, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox1. Appropriate. CN 2-12 grossly intact. 5/5 strength in UEs. [**2-7**]+ reflexes, equal BL. Normal coordination. Gait assessment deferred PSYCH: Calm, pleasant Pertinent Results: ADMISSION LABORATORY STUDIES: 11.9 10.4 >---< 284 38.4 MCV-98# NEUTS-75.9* LYMPHS-16.9* MONOS-6.2 EOS-0.8 BASOS-0.2 . GLUCOSE-202* UREA N-39* CREAT-0.8 SODIUM-145 POTASSIUM-4.5 CHLORIDE-99 TOTAL CO2-39* LACTATE-1.8 . PT-39.6* PTT-36.9* INR(PT)-4.1* . ABG: O2-89 O2 FLOW-4 PO2-62* PCO2-64* PH-7.42 TOTAL CO2-43* BASE XS-13 AADO2-505 REQ O2-85 COMMENTS-NASAL [**Last Name (un) 154**] . UA BLOOD-NEG NITRITE-POS PROTEIN-25 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG RBC-0 WBC-0-2 BACTERIA-MANY YEAST-NONE EPI-0 . MICRO: Sputum gram stain: 4+ GPC cx pending urine cx pending . CXR [**2111-2-4**]: Evaluation is limited by the position of the head over the upper chest and low lung volumes. Again noted is increased opacification at the left lung base, most likely atelectasis and increased pleural effusion, although underlying infection is not excluded. There is slight upper lobe redistribution, particularly on the left, with hilar fullness, but there is no overt pulmonary edema. The heart size is not significantly changed allowing for differences in technique. Two pacer leads follow a normal course from the right-sided battery pack terminating in the expected position of the right atrium and ventricle. Degenerative change of the bilateral glenohumeral joints is noted with unchanged inferior displacement of the right shoulder. IMPRESSION: Slight interval increase in left pleural effusion and basilar atelectasis. Cardiomegaly and probable mild failure, but no overt pulmonary edema. . MICRO: urine cx: >100,000 GNR, speciation pending . SPUTM GRAM STAIN (Final [**2111-2-4**]): <10 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS, CHAINS, AND CLUSTERS. Discharge Labs: [**2111-2-5**] 05:36AM BLOOD WBC-10.5 RBC-3.94* Hgb-11.8* Hct-37.3 MCV-95 MCH-30.0 MCHC-31.7 RDW-15.9* Plt Ct-315 [**2111-2-5**] 05:36AM BLOOD Glucose-178* UreaN-27* Creat-0.5 Na-144 K-3.5 Cl-101 HCO3-36* AnGap-11 [**2111-2-5**] 05:36AM BLOOD Calcium-9.0 Phos-2.9 Mg-1.8 Brief Hospital Course: A/P: 75F [**Name (NI) **] pt with hx of bilateral PE's, AF, COPD, Non-Obstructive CAD and Dementia, presenting with hypoxemia. . # Hypoxemia: Pt on baseline 3L at [**Name (NI) **], presented to the MICU on 3L. ED ABG with p02 of 62, pCO2 of 64 indicative of A-a gradient. No clear evidence of infiltrate on CXR, although could not exclude retrocardiac opacity as source of infection. Pt now at baseline 02 requirement. Unclear precipitating events for transient hypoxia (COPD excerbation resolving with steroids, atelectasis, fluid overload, PE). Pt now at baseline without appreciable wheezes on exam. No increase in sputum production from baseline. No reported fevers of chills. The patient was continued on 3L 02. The pt was discharged with 4 additional days of PO cefpodoxime to treat presumed bronchitis. . # Hypercarbia: Pt with PFTs suggestive of COPD (FVC 0.96, FEV1 0.47, ratio of 49, 71% predicted), however pt with tachypnea, wheezing. ?increase in productive cough. Pt with hx of pCO2 50-70s. Currently breathing comfortably and mentating likely close to baseline. HCo3 of 39 is at patients approximate baseline. . # Fluid Status: Pt with initial Hct of 38 (baseline approx 30), in setting of increase BUN and slightly increased [**Name (NI) **] pt that was suggestive of intravascularly depletion, however her fluid status is difficult to assess given crackles on physical exam and suggestion of mild fluid overload on CXR. The patient was felt to be close to euvolemia and thus was not diuresed during her hospital course. . # UTI: Pt positive urine cx >100K GNR. Per [**Name (NI) **] records the pt was part way through a course of PO macrobid, given the patients pulmonary symptoms, the patient was started on PO Cefpodoxime to cover both urinary and pulmonary potential organisms. . #. Mental Status: Non-focal neuro exam. Baseline reported to be AOx1-2. Patient currently calm. Unclear if patient altered from baseline. The patients daughter was [**Name (NI) 653**] and per report her mental status exam was at baseline at the time of discharge. . # DM II:ISS while in house . # Atrial Fibrillation: Currently rate controlled on Metoprolol and Diltiazem. INR was supratherapeutic without signs of bleeding. The ICU team anticipate jump in INR given pt received Levaquin, and thus the patients Coumadin was held. The patient was discharged on her home dosing of Metoprolol and Diltiazem. . The patients INR was 2.7 on discharge. Given that she will remain on cefpodoxime for 4 additional days the plan will be as following: Fri [**2-6**]: Cefpodoxime , No Coumadin Sat [**2-7**]: Cefpodoxime , No Coumadin Sun [**2-8**]: Cefpodoxime , 0.5mg Coumadin Mon [**2-9**]: Cefpodoxime , 0.5mg Coumadin, INR Check Tue [**2-10**]: Cefpodoxime , Coumadin per INR Medications on Admission: Coumadin 1mg Daily Zocor 40mg PO Daily Metoprolol 50mg PO TID Diltiazem 60mg PO Four Times Daily Albuterol 2.5mg/3ml (0.083% Neb) Ipratroium 0.02% Advair 100mcg/50mcg Humalog SQ Novolin 70/30 Clonazepam 0.5mg PO BID Paroxetine 10mg PO Daily Zolpidem 5mg TAB Colace 100mg Senna 8.6mg 2 tabs PO [**Name (NI) **] MOM Ferrous Gluconate 324mg PO Daily Pantoprazole 40mg Daily Vicodin 5/500mg Guaifenesin 100mg/5ml Lidocaine 5% Saline Nasal Spray Discharge Medications: 1. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation every four (4) hours as needed for Wheeze. 3. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 4. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 7. Vicodin 5-500 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Cefpodoxime 100 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. 10. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Ferrous Gluconate 325 mg (37.5 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Paroxetine HCl 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 17. Phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 3 days. 18. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 19. Insulin NPH & Regular Human 100 unit/mL (70-30) Suspension Sig: 26 units qAM, 22 units qPM Subcutaneous twice a day. 20. Insulin Lispro 100 unit/mL Solution Sig: per sliding scale Subcutaneous QACHS. 21. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 22. Prednisone 5 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital **] HEALTH CARE CENTER Discharge Diagnosis: Primary Diagnosis- Bronchitis Secondary Diagnosis- COPD 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: You were admited to the hospital with low oxygen levels which were not much diferent from your usual oxygen levels. You had a chest X ray which did not show any pneumonia. We think your symptoms may be from bronchitis. You also had a urinary tract infection. You were treated with 5 days of cefpodoxime, an antibiotic, for both of these infections. We made the following changes to your medications. 1. We added Cefpodoxime for a urinary tract infection and bronchitis 2. We added Pyridium for urinary burning Please keep all of your follow-up apointments and take all of your medications as prescribed. Followup Instructions: Please make an appointment to see your primary care doctor in the next 2-3 weeks. You should also follow up with your pulmonary doctor, Dr. [**Last Name (STitle) 58318**].

[ "491.22", "V58.61", "427.31", "V12.51", "294.8", "530.81", "599.0", "V45.82", "790.92", "300.4", "276.2", "518.84", "250.00", "272.4", "414.01", "E934.2" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10659, 10720

5414, 7217

289, 295

10820, 10820

3302, 5103

11622, 11797

2385, 2389

8676, 10636

10741, 10799

8211, 8653

10992, 11599

5119, 5391

2404, 3283

242, 251

323, 1671

10834, 10968

1693, 2273

2289, 2369

47,226

199,627

17272+56839

Discharge summary

report+addendum

Admission Date: [**2122-1-20**] Discharge Date: [**2122-2-6**] Date of Birth: [**2068-7-22**] Sex: M Service: CARDIOTHORACIC Allergies: Fentanyl Attending:[**First Name3 (LF) 5790**] Chief Complaint: Tracheobronchomalacia and tracheomegaly. Major Surgical or Invasive Procedure: [**2122-1-23**] Flexible bronchoscopy with bronchoalveolar lavage and right thoracotomy with thoracic tracheoplasty with mesh, right main stem bronchus and bronchus intermedius bronchoplasty with mesh, and left main stem bronchoplasty with mesh. [**2122-1-24**] Flexible bronchoscopy with therapeutic aspiration of secretions. [**2122-1-28**] Flexible bronchoscopy through the tracheostomy tube. [**2122-1-20**]: Flexible bronchoscopy. History of Present Illness: Mr. [**Known lastname **] is a 53-year-old gentleman who has tracheomegaly and tracheobronchomalacia. He has severe dyspnea as well as recurrent infections. He is maintained with a tracheostomy with home O2. Because of the severity of his dyspnea and inability to have very much functionality for his activities of minimal daily living, he wished to undergo repair. He had previously had metal stents in place which were painstakingly removed at the last stay here in [**Location (un) 86**]. We wanted to wait several weeks for the mucosa to heal. The recent bronchoscopy two days back revealed that the mucosa was much more normal in appearance so it still looked somewhat edematous and slightly inflamed. Past Medical History: DM II, CAD, L CVA 8 years ago, asthma, OSA, emphysema, tracheobroncheomalacia c/b multiple pneumonias and s/p stents both metal and plastic, ? Mounre-Kuhu syndrome (tracheomegaly), spinal fusion L3-4 w/ chronic lower back pain SURGICAL Hx: multiple pulm stents, s/p tracheostomy in setting of stroke 8 yrs prio, cholecystectomy/appy, hernia repair, TENS L side abd, lumbar fusion Social History: lives in [**Country **], (past pulm procedures in SD), married lives w/ family, past underground miner, +EtOH, past smoker quite 10 years ago Family History: Non-contributory Physical Exam: On discharge: Gen: NAD, A+OX3, tracheostomy in place CV: RRR Resp: Rhonchi bilaterally worse with expiration (significantly decreased from early post-op exam), however good breath sounds bilaterally, good inspiratory effort, incision is c/d/i Abd: Soft, NT/ND Ext: 1+ edema bilaterally Pertinent Results: [**2122-2-4**] WBC-11.8* RBC-2.97* Hgb-8.6* Hct-25.4* Plt Ct-411 [**2122-2-3**] WBC-11.5* RBC-2.82* Hgb-7.9* Hct-24.7* Plt Ct-354 [**2122-2-1**] WBC-13.7* RBC-2.68* Hgb-7.6* Hct-23.8* Plt Ct-289 [**2122-1-31**] WBC-16.4*# RBC-2.79* Hgb-8.0* Hct-24.0* Plt Ct-286 [**2122-1-30**] WBC-10.2 RBC-2.87* Hgb-8.2* Hct-25.0* Plt Ct-292 [**2122-1-26**] WBC-15.0* RBC-3.18* Hgb-9.3* Hct-27.5* Plt Ct-228 [**2122-1-25**] WBC-22.1*# RBC-3.48* Hgb-10.4* Hct-29.6* Plt Ct-257 [**2122-1-23**] WBC-20.2*# RBC-3.94* Hgb-11.3* Hct-34.1* Plt Ct-351 [**2122-1-20**] WBC-10.1 RBC-4.05* Hgb-11.6* Hct-34.6* Plt Ct-344 [**2122-1-20**] Neuts-60.9 Lymphs-29.3 Monos-5.9 Eos-3.3 Baso-0.6 [**2122-2-4**] Glucose-88 UreaN-14 Creat-0.6 Na-141 K-3.5 Cl-108 HCO3-28 [**2122-2-3**] Glucose-170* UreaN-17 Creat-0.7 Na-145 K-4.1 Cl-113* HCO3-23 [**2122-2-2**] Glucose-100 UreaN-17 Creat-0.7 Na-146* K-3.8 Cl-113* HCO3-23 [**2122-2-2**] Glucose-165* UreaN-17 Creat-0.8 Na-144 K-4.0 Cl-114* HCO3-21 [**2122-1-24**] Glucose-180* UreaN-6 Creat-0.7 Na-138 K-4.4 Cl-104 HCO3-26 [**2122-1-23**] Glucose-171* UreaN-6 Creat-0.8 Na-137 K-5.4* Cl-104 HCO3-24 [**2122-1-20**] Glucose-182* UreaN-11 Creat-0.8 Na-141 K-4.1 Cl-104 HCO3-30 [**2122-2-4**] Calcium-8.4 Phos-4.0 Mg-2.0 [**2122-1-22**] Source: Endotracheal. GRAM STAIN (Final [**2122-1-23**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2122-1-26**]): MODERATE GROWTH OROPHARYNGEAL FLORA. STAPH AUREUS COAG +. MODERATE GROWTH. GRAM NEGATIVE ROD(S). SPARSE GROWTH. OF TWO COLONIAL MORPHOLOGIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S TRIMETHOPRIM/SULFA---- <=0.5 S [**2122-1-23**] 8:40 am BRONCHOALVEOLAR LAVAGE **FINAL REPORT [**2122-2-3**]** GRAM STAIN (Final [**2122-1-23**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2122-2-3**]): OROPHARYNGEAL FLORA ABSENT. Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. STAPH AUREUS COAG +. >100,000 ORGANISMS/ML.. MEROPENEM Susceptibility testing requested by DR.[**Last Name (STitle) 48381**],[**First Name3 (LF) 48382**] [**2122-1-30**]. MEROPENEM SENSITIVIT sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. BETA STREPTOCOCCI, NOT GROUP A. 10,000-100,000 ORGANISMS/ML.. NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML.. sensitivity testing performed by Microscan. NON-FERMENTER, NOT PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML.. 2ND TYPE. sensitivity testing performed by Microscan. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | NON-FERMENTER, NOT PSEUDOMONAS AERUGIN | | NON-FERMENTER, NOT PSEUDOMO | | | AMIKACIN-------------- 32 I 16 S CEFEPIME-------------- 16 I <=1 S CEFTAZIDIME----------- =>16 R <=2 S CEFTRIAXONE----------- =>32 R 16 I CIPROFLOXACIN--------- =>2 R 2 I CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S =>8 R 4 S IMIPENEM-------------- 8 I 4 S LEVOFLOXACIN----------<=0.12 S 4 I 2 S MEROPENEM------------- S 4 S 1 S OXACILLIN------------- 1 S PIPERACILLIN---------- =>64 R 32 I PIPERACILLIN/TAZO----- =>64 R <=8 S TOBRAMYCIN------------ 8 I 2 S TRIMETHOPRIM/SULFA---- <=0.5 S =>2 R =>2 R [**2122-1-28**] BRONCHOALVEOLAR LAVAGE GRAM STAIN (Final [**2122-1-28**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2122-1-31**]): OROPHARYNGEAL FLORA ABSENT. PSEUDOMONAS AERUGINOSA. ~[**2112**]/ML. PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 8 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- 2 I GENTAMICIN------------ 8 I MEROPENEM------------- 2 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 2 S [**2122-1-31**] 7:52 pm SPUTUM Source: Endotracheal. GRAM STAIN (Final [**2122-1-31**]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Preliminary): OROPHARYNGEAL FLORA ABSENT. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. GRAM NEGATIVE ROD #2. MODERATE GROWTH. PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 8 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN--------- 2 I GENTAMICIN------------ =>16 R MEROPENEM------------- 2 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 4 S [**2122-1-24**] MRSA SCREEN MRSA SCREEN (Final [**2122-1-26**]): No MRSA isolated. Brief Hospital Course: Post-operatively, the patient was admitted to the ICU for further monitoring ([**1-23**]). Neuro: The patient's pain was intially managed by pain service as he had an epidural in place. Originally a combination of bupivacaine and dilaudid, his epidural was split and remained just bupivacaine with a dilaudid PCA. In addition he was given his Methodone (home dose) IV. His pain was not controlled well. APS added dexmedetomidine drip which the patient seemed to respond to well. Over the course of his recovery, his epidural was discontinued, the drip was weaned and stopped and IV dilaudid PRN was ordered. As soon as he was able to tolerate PO, all IV pain medications were discontinued and he was started on PO methadone, percocet and gabapentin. Near the end of his ICU course, the patient became delirious and pulled out his dobloff. Zyprexa and haldol PRN were started. He responded well. Once on the floor, the patient did not require further anti-psychotic medications. Resp: The patient was placed on the ventilator post-operatively. His settings were weaned down appropriately. For most of his hospital course, he was placed on a rate. On [**1-24**] he acutely desaturated to the 70%. An emergent bronchoscopy was performed. As predicted his airways semi-collapse during expiration secondary to his tracheomalacia. In addition his bovina tracheostomy appeared to have traveled proximally away from the carina and was above his site of dynamic collapse. Under bronchscopic guidance, the tracheostomy was advanced 2-3 cm distally past his site of collapse. From then on, the patient did not have any other episodes of desaturations/hypoxia. Routine ABG and CXR showed progression. His ventilator settings were weaned as tolerated. The patient required multiple bronchscopies for mucous plugging and frequent washings for what appeared to be tracheobronchitis. He was placed on a 2 week course of antibiotics for this. Eventually he was placed on tracheostomy collar trials which he tolerated well. On the floor the patient ambulated with a trach mask/supplemental O2. His tracheostomy sutures were taken out on the day of discharge. CV: The patient's hemodynamics were stable during his hospital course. He became intermittently hypertensive in the ICU and required Lopressor and Clonidine. GI: A dobloff was placed on [**1-26**] and tube feeds were started. The feeds were advanced to goal to 50 cc/hr. Nutren Pulmonary was used to lower the incidence of hypercapnia. Speech and swallow was consulted and evaluated the patient on [**2-3**]. The patient was able to tolerate PO feeds without any evidence of aspiration. However he was noted to fail PMV trials due to breath stacking. His TF were D/Ced and he was started on soft feeds. He did not report any N/V. Renal: The patient was slowly diuresed to his admit weight. Labs were checked daily and replacement lytes were given as needed. The patient responded well to the Lasix diuresis and eventually mobilized his fluids and began to auto-diuresis. His foley was discontinued near the end of his ICU stay and the patient voided without any difficulties. ID: Multiple BAL and sputum samples grew out Pseudomonas sensitive to both Meropenem and Ceftaz. In addition a early BAL culture grew out Staph Auerus Coag positive (pan sensitive). The patient was put on a 2 week course of [**Last Name (un) **] and Ceftaz to cover both organisms. Prophylaxis: The patient was ordered for sequential compression devices and subcutaneous heparin for DVT prophylaxis. He was given PPI therapy for gastric ulcer prophylaxis. The patient was also encouraged to get up and ambulate as early as possible. Medications on Admission: ASA 81mg daily, Baclofen 10mg daily, escitalopram 20mg daily. furosemide 20mg daily, methadone 30mg qhs, omeprazole 20mg daily, prednisone 5mg daily, simvastatin 40mg daily Discharge Medications: 1. Furosemide 20 mg Tablet [**Last Name (un) **]: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet [**Last Name (un) **]: One (1) Tablet PO DAILY (Daily). 3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2* 4. Methadone 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a day). 5. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One (1) PO BID (2 times a day). Disp:*300 ml* Refills:*2* 6. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 8. Gabapentin 400 mg Capsule [**Last Name (STitle) **]: Two (2) Capsule PO BID (2 times a day). Disp:*120 Capsule(s)* Refills:*2* 9. Simvastatin 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Metoclopramide 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Disp:*120 Tablet(s)* Refills:*1* 11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Last Name (STitle) **]: Six (6) Puff Inhalation Q4H (every 4 hours) as needed. Disp:*2 inhalers* Refills:*2* 12. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: Six (6) Puff Inhalation Q4H (every 4 hours) as needed. Disp:*2 inhalers* Refills:*2* 13. Oxycodone-Acetaminophen 5-325 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*80 Tablet(s)* Refills:*1* 14. Insulin NPH Human Recomb 100 unit/mL Cartridge [**Last Name (STitle) **]: One (1) 18 Subcutaneous twice a day. Discharge Disposition: Home Discharge Diagnosis: Tracheobroncheomalacia c/b multiple pneumonias and s/p stents both metal and plastic; Mounier-[**Doctor Last Name 6530**] syndrome (tracheomegaly) COPD Diabetes Mellitus type II Coronary artery disease L CVA 8 years ago Discharge Condition: stable Discharge Instructions: Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if experience: -Fever > 101 or chills -Increased shortness of breath, cough or sputum production -Chest pain -Trach care as previous. Supplement oxygen Trach collar -Incision develops drainage. -You may shower no tub bathing or swimmming -No driving while taking narcotics Followup Instructions: Provider: [**Name10 (NameIs) 1532**] [**Last Name (NamePattern4) 8786**], MD Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2122-2-17**] 11:00 Provider: [**Name10 (NameIs) 12554**] CLINIC INTERVENTIONAL PULMONARY (SB) Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2122-2-17**] 11:30 Provider: [**Name10 (NameIs) **] INTAKE,ONE [**Name10 (NameIs) **] ROOMS/BAYS Date/Time:[**2122-2-17**] 12:30 Completed by:[**2122-2-6**] Name: [**Known lastname 8941**],[**Known firstname 8942**] Unit No: [**Numeric Identifier 8943**] Admission Date: [**2122-1-20**] Discharge Date: [**2122-2-6**] Date of Birth: [**2068-7-22**] Sex: M Service: CARDIOTHORACIC Allergies: Fentanyl Attending:[**First Name3 (LF) 3454**] Addendum: Patient given script for methadone 10 mg PO TID (home dose). Patient's methadone usage monitored by PCP in [**Country 8944**]. He usually gets his scripts every month for a one month supply. Because the patient was in the hospital, he did not obtain a script and will need a month's supply to hold him over until he sees his PCP. Discharge Disposition: Home [**Name6 (MD) **] [**Last Name (NamePattern4) 3455**] MD [**MD Number(2) 3456**] Completed by:[**2122-2-6**]

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icd9cm

[ [ [] ] ]

[ "96.72", "33.24", "96.6", "33.21", "33.48", "33.22", "96.05", "31.79" ]

icd9pcs

[ [ [] ] ]

16149, 16293

8571, 12252

316, 756

14626, 14635

2414, 7953

15021, 16126

2074, 2092

12475, 14333

14383, 14605

12278, 12452

14659, 14998

2107, 2107

7994, 8548

2122, 2395

235, 278

784, 1494

1516, 1898

1914, 2058

19,493

109,275

12938

Discharge summary

report

Admission Date: [**2140-11-14**] Discharge Date: [**2140-11-17**] Date of Birth: [**2098-9-9**] Sex: F Service: MEDICINE Allergies: Ciprofloxacin Hcl / Epinephrine / Pentothal / Flagyl Attending:[**First Name3 (LF) 1674**] Chief Complaint: Progressive dyspnea Major Surgical or Invasive Procedure: EGD History of Present Illness: Ms. [**Known lastname 39729**] is a 42-year-old woman with history of chronic mesenteric ischemia s/p R hemicolectomy/[**Female First Name (un) 899**] reimplantation in [**6-9**], HTN, hypercholesterolemia who presented to the ED with intermittent, exertional SOB. Patient reports further worsening in breathing status over past several days, with milder exertion required to elicit shortness of breath; associated with non-productive cough, generalized weakness, and dizziness. No chest pain, fevers, chills, vomiting, black stool. She does intermittently pass blood clots in her stool which was thought to be due to internal hemorrhoids. No syncopal episodes. LMP earlier this month, no heavy or unusual bleeding. Given persistence of symptoms, she sought evaluation in the ED. . In the Emergency Department, initial VS were T 98.3; BP 120/52; HR 93; RR 15; O2 98%RA. She received a CTA to rule out PE given elevated d-dimer, which was negative. Hct results then returned at 19.0, and she received 2 units PRBCs. She also received 40mEq potassium and 1L NS IV bolus given low BP in 90s. . On arrival to the [**Hospital Unit Name 153**], patient reported that she was feeling much better. Denied chest pain or shortness of breath. Pan-review of systems negative including cardiac, GI and GU. Past Medical History: -HTN -Hyperlipidemia -Chronic fatigue -Chronic headaches -Fibromyalgia -Depression/Anxiety -Talus fracture -Cervical cancer -GERD -Hydronephrosis -Mild COPD -Chronic mesenteric ischemia - known occlusion of SMA and celiac, [**Female First Name (un) 899**] was re-implanted in [**2140-6-3**] by vascular surgery -Recent admission [**7-9**] for ? TIA - foudn to have microvascular infarcts on MRI and HTN. PAST SURGICAL HISTORY - Appendectomy [**2131**] - [**6-3**]: ileocecectomy without re-[**Last Name (LF) 39727**], [**First Name3 (LF) 899**] re-implantation - [**6-5**]: SBR, R colectomy, ileocolic reanastamosis - [**6-28**]: ERCP-choledochal-duodenal fistula proximal to major papillary opening Social History: Smoking history, no current alcohol use, but did use alcohol in past Family History: Mother and aunt with coronary artery disease and carotid disease. Both parents died of lung cancer, mother at age 73, father at age 68. Physical Exam: VS: T 98.6; BP 111/52; HR 72; RR 12; O2 100% RA GEN: Pleasant middle aged woman in NAD, comfortable HEENT: anicteric sclerae. MMM. OP clear. NECK: No JVD. Supple, FROM HEART: S1S2 RRR. Mid-peaking systolic murmur LUNGS: CTA B/L ABD: well-healed midline surgical scar. soft, NT/ND. + BS. No HSM EXT: No C/C/E. 2+ DP and PT bilaterally NEURO: AO x 3. No focal exam deficits. CN II-XII intact grossly. Pertinent Results: EGD with small bowel enteroscopy on [**2140-11-16**]: Ulcers in the antrum (biopsy) Normal mucosa in the duodenum Normal mucosa in the jejunum Brief Hospital Course: #Anemia/Dyspnea/Lightheadedness - Symptoms attributed to anemia from GI bleed given guiac positive stools. Pt's crit bumped appropriately to 3U PRBC, and was kept above 28 given her history of vascular disease. Pt was on Plavix because of her [**Female First Name (un) 899**] stent, which was initially held in the context of GI bleeding, but restarted on HD2. GI was consulted who proceeded to perform a small bowel enteroscopy on [**11-16**] which revealed oozing ulcers in the antrum of the stomach. Punch biopsies were taken at that time to assess for H. Pylori which on discharge are pending. Their recomendations were to start Prilosec 40 mf po BID. #Peptic Ulcer Disease: Hematocrit stabilized, ulcers found in antrum of stomache with signs of recent bleeding. GI suggests [**Hospital1 **] Prilosec. Dr. [**Name (NI) 3407**], pts vascular surgeon was contact[**Name (NI) **] re: anti-platelet therapy. He emailed that he only would ask for aspirin daily as tolerated, and does not feel Plavix is necessary from his standpoint. In the past, the neurology team had started pt on Plavix and in their notes had referred to it's benefits in setting of pt's PVD. Pt discharged and told to continue full dose aspirin and to discontinue plavix. Please have hct rechecked on [**2140-11-22**] when pt visits PCP [**Name Initial (PRE) 3726**]. #EKG Changes - Patient with inferolateral downsloping ST changes in setting of Hct 19.0, that were new compared to [**2140-7-3**] study. Pt was started on ASA 325. Pt denied chest pain and ruled out for MI by enzymes x3. Cardiology was consulted who felt that these changes were likely demand ischemia in the setting of anemia, and their interpretation of the ECGs indicated that they felt that the new ST changes were resolving with transfusion. TTE showed no wall motion abnormalities. Cardiology's recomendation was to follow up in clinic for assessment and workup of likely CAD given her extensive history of vascular disease. Follow up [**Year (4 digits) 1988**] with Dr. [**Last Name (STitle) 73**] in 12/[**2140**]. #Hypotension - Pt was transiently hypotensive to the 90's in the ED for which she was fluid resucitated with 1L of NS. Her anti-hypertension medications were held in this setting. She remained stable through remainder of hospital course with SBP in the 90s. She was told to continue beta blocker (given concern for cardiac ischemia) but to discontinue HCTZ and verapamil until re-assessed by PCP. #Sore Throat - Pt reported having had a sore throat for several months at this admission, which was exacerbated by swallowing and occassionally impaired her breathing. ENT was consulted who gave the diagnosis of laryngopharyngeal reflux disease, and recomended high dose PPI and follow up in [**Hospital **] clinic in [**4-8**] weeks. #Chronic Mesenteric Ischemia - Pt reported having no acute abdominal pain since her surgery in [**Month (only) **]. She was on plavix due to the [**Female First Name (un) 899**] stent which was placed. The plavix was initially held while an acute GI bleed was ruled out, but then restarted when the problem appeared to be more chronic. Vascular was consulted, and they had no new recomendations at this time. Dr. [**Last Name (STitle) 3407**] emailed that pt does not need Plavix at this time. #Irritable Bowel Syndrome - Continued dicyclomine, no changes made. #Hyperlipidemia - Continued Zocor, pt had good lipid levels in [**Month (only) 205**]. #Depression and Anxiety - Continued fluoxitine but held nortriptyline based on cardiology recomendation that nortriptyline can increase orthostatic hypotension. Pt will follow up with her PCP in one week to determine whether she needs to restart nortriptyline. Medications on Admission: dicyclomine 2 caps TID fluoxetine 10mg qd nortriptyline 10mg qd PLAVIX 75mg qd ranitidine 150mg [**Hospital1 **] Colace [**Hospital1 **] HCTZ 25mg qd metoprolol 25mg [**Hospital1 **] verapamil 80mg tid simvastatin 20mg qd Discharge Medications: 1. Dicyclomine 10 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). Disp:*180 Capsule(s)* Refills:*0* 2. Fluoxetine 10 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*0* 3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for headaches. Disp:*50 Tablet(s)* Refills:*0* 5. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*15 Tablet(s)* Refills:*0* 9. Prilosec 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* 10. Outpatient Lab Work Hct checked on [**2140-11-22**] at Dr.[**Name (NI) 12522**] office Discharge Disposition: Home Discharge Diagnosis: peptic ulcer disease Discharge Condition: Good po intake, hct stable for 3 days. Discharge Instructions: Please follow up with your uncoming appointments with Dr. [**Last Name (STitle) 3407**] and Dr. [**Last Name (STitle) 2161**]. Call your primary care doctor, Dr. [**Last Name (STitle) 2161**], or return to ER with increased blood in bowel movements, abdominal pain, chest pain, shortness of breath, or other concerning symptoms. Your medication list has been rechecked and is correct. Please be sure to ask Dr. [**Last Name (STitle) 7790**] about whether or not to continue Nortryptiline. Followup Instructions: 1)Dr. [**Last Name (STitle) 3407**]: VASCULAR LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2140-11-22**] 8:00 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2140-11-22**] 9:00 2)Provider: [**Name10 (NameIs) 1576**],[**First Name8 (NamePattern2) 2352**] [**Doctor Last Name 4694**] APG (SB) Phone:[**Telephone/Fax (1) 1579**] Date/Time:[**2140-11-22**] 3:30 3) Dr. [**Last Name (STitle) 2161**] [**2140-12-5**] at 11:00am at the [**Hospital3 **] [**Location (un) 86**] site [**Hospital Unit Name 1825**] [**Hospital Ward Name **]. Also follow up with cardiology and ENT Dr. [**Last Name (STitle) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**] Completed by:[**2140-11-17**]

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icd9cm

[ [ [] ] ]

[ "45.13", "99.04" ]

icd9pcs

[ [ [] ] ]

8369, 8375

3231, 6964

334, 340

8440, 8481

3064, 3208

9021, 9861

2491, 2630

7236, 8346

8396, 8419

6990, 7213

8505, 8998

2645, 3045

275, 296

368, 1663

1685, 2388

2404, 2475

63,769

174,570

47960+47961+47962

Discharge summary

report+report+report

Admission Date: [**2131-12-28**] Discharge Date: [**2132-1-3**] Date of Birth: [**2065-12-21**] Sex: F Service: CARDIOTHORACIC Allergies: Latex / Pollen Extracts / Adhesive Bandages Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: s/p MVR (mechanical) History of Present Illness: 66 year old woman with a history of hypertrophic cardiomyopathy and dyspnea on exertion who was first seen by our service in [**2131-3-24**]. She wanted to evaluate her options and in the mean time her medications were advanced. She continued to have dyspnea on exertion despite maximal medical therapy. Past Medical History: IHSS/HOCM Hypertension Dyslipidemia Colonic polyps History of scarlet fever Ventral hernia s/p Tonsillectomy Social History: Works as a director of housing. Lives with her husband. Denies smoking and drinks rare alcohol. Family History: Father died at 61 from "severe" CAD Physical Exam: Discharge: Vitals: 98.2 132/68 86 20 98% RA General: pleasant, answers questions appropriately Lungs: clear to auscultation bilaterally Sternum: stable. Incision clean and dry COR: RRR Abdomen: normoactive bowel sounds. Soft and nontender without rebound and guarding Extremities: warm Pertinent Results: [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 101201**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 101202**] (Complete) Done [**2131-12-28**] at 11:16:38 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. [**Hospital1 18**], Division of Cardiothorac [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] [**Last Name (LF) **], [**First Name3 (LF) **] Division of Cardiothoracic [**Doctor First Name **] [**First Name (Titles) **] [**Last Name (Titles) **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2065-12-21**] Age (years): 66 F Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Abnormal ECG. Aortic valve disease. Hypertension. Hypertrophic cardiomyopathy. Mitral valve disease. Shortness of breath. ICD-9 Codes: 402.90, 786.05, 440.0, 424.0 Test Information Date/Time: [**2131-12-28**] at 11:16 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6507**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2008AW1-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Four Chamber Length: 5.0 cm <= 5.2 cm Left Ventricle - Septal Wall Thickness: *1.6 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.5 cm 0.6 - 1.1 cm Left Ventricle - Ejection Fraction: 55% to 65% >= 55% Aortic Valve - Peak Gradient: *140 mm Hg < 20 mm Hg Findings LEFT ATRIUM: Mild LA enlargement. No spontaneous echo contrast is seen in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. No spontaneous echo contrast in the body of the RA. A catheter or pacing wire is seen in the RA and extending into the RV. No spontaneous echo contrast in the RAA. No ASD by 2D or color Doppler. LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size. RIGHT VENTRICLE: Normal RV wall thickness. Normal RV chamber size. Normal RV systolic function. AORTA: Normal aortic diameter at the sinus level. Simple atheroma in aortic root. Normal ascending aorta diameter. Simple atheroma in ascending aorta. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve leaflets. Mild (1+) AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. Severe mitral annular calcification. [**Male First Name (un) **] of mitral valve leaflets. No MS. Mild to moderate ([**1-24**]+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The patient received antibiotic prophylaxis. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. patient. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-CPB:1. The left atrium is mildly dilated. No spontaneous echo contrast is seen in the left atrial appendage. 2. No spontaneous echo contrast is seen in the body of the right atrium. 3. No atrial septal defect is seen by 2D or color Doppler. 4. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. 5. Right ventricular chamber size is normal. with normal free wall contractility. 6. There are simple atheroma in the aortic root. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 7. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. Mild (1+) aortic regurgitation is seen. Severe LVOT gradient is seen with dagger like velocity profile of outflow tract obstruction. 8. The mitral valve leaflets are moderately thickened. There is severe mitral annular calcification. There is systolic anterior motion of the mitral valve leaflets. Mild to moderate ([**1-24**]+) mitral regurgitation is seen and is exaggerated by provocative maneuvers. Dr. [**Last Name (STitle) **] and [**Doctor Last Name **] were notified in person of the results POST-CPB: On infusion of phenylephrine. AV pacing. Well-seated mechanical valve in the mitral position with 5 mmHg mean gradient and trivial washing jets seen. LVOT gradient is now mild with a peak of 14-16 mmHg. LVEF is preserved at 60 %. Aortic contour is normal post decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2131-12-28**] 13:27 Pathology Examination Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 101203**],[**Known firstname **] S [**2065-12-21**] 66 Female [**-8/4756**] [**Numeric Identifier **] Report to: DR. [**Last Name (STitle) **]. [**Doctor Last Name **] Gross Description by: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) 80901**]/dif SPECIMEN SUBMITTED: mitral valve leaflets. Procedure date Tissue received Report Date Diagnosed by [**2131-12-28**] [**2131-12-28**] [**2132-1-1**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/ttl Previous biopsies: [**-7/3434**] COLON BIOPSIES 2. DIAGNOSIS: Mitral valve leaflets: Valvular tissue with myxomatous change. Clinical: Mitral insufficiency, septal myoma. Gross: The specimen is received fresh labeled with the patient's name, "[**Known firstname 2048**] [**Known lastname **]," the medical record number, and "mitral valve leaflets." It consists of multiple fragments of tan white valvular tissue measuring in aggregate 4.5 x 3.5 x 0.9 cm. Attached to the valve is a piece of tan brown spongy tissue measuring 1.1 x 0.9 x 0.4 cm. The specimen is represented as follows: A = valve with attached mass, B = additional representative sections of mitral valve. Brief Hospital Course: The patient was admitted as a same day and was brought to the operating room following standard protocol. She received IV cefazolin for peri-operative antibiotics as she was not in the hospital for more than 24 hours. She underwent a mitral valve replacement with a mechanical valve. Please see operative note for full details. Post-operatively she was admitted to the CVICU for invasive hemodynamic monitoring. She was weaned from her drips and extubated on POD 1. She was transferred to the step down floor on POD 1. She was started on coumadin on POD 1 for a mechanical mitral valve. Her coumadin was titrated and she was started on IV heparin on POD 4 for a subtherapeutic INR. On POD 6 her INR was therapeutic at 2.9. Physical therpay was consulted and to work on strength and balance. She was gently diuresed towards her pre-operative weight. On POD 6 she was stable for discharge to home. Medications on Admission: Toprol XL 150 mg po BID MVI Colace 100 mg po bid Omega 3 fatty acids Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 30 days. Disp:*60 Capsule(s)* Refills:*0* 3. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 4. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 5. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 5 days. Disp:*5 Tablet(s)* Refills:*0* 6. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 5 days. Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 7. Warfarin 5 mg Tablet Sig: 1.5 Tablets PO once a day: Please take 1.5 pills daily until Dr [**Last Name (STitle) 2912**] instructs you to take a different dose. Disp:*50 Tablet(s)* Refills:*0* 8. Warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day: Please take daily dose as prescribed by Dr [**Last Name (STitle) 2912**]. Take 7.5 mg (using the 5 mg pills) until he instructs otherwise. Disp:*50 Tablet(s)* Refills:*0* 9. Toprol XL 100 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day. Disp:*45 Tablet Sustained Release 24 hr(s)* Refills:*0* Discharge Disposition: Home With Service Facility: tba Discharge Diagnosis: s/p MVR HOCM hypertension dyslipidemia s/p scarlet fever 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 ([**Telephone/Fax (1) 170**]) please call for appointment Dr. [**First Name (STitle) 807**] in 1 week ([**Telephone/Fax (1) 823**]) please call for appointment Dr. [**Last Name (STitle) 2912**] in [**2-25**] weeks please call for appointment Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse ([**Telephone/Fax (1) 3071**]) Need INR checks monday/wednesday/friday for mechanical mitral valve, goal INR 3-3.5. Level checked friday [**2132-1-4**] with results to Dr[**Name (NI) 43030**] office (fax - [**Telephone/Fax (1) 13359**]) Completed by:[**2132-1-3**] Admission Date: [**2132-1-9**] Discharge Date: [**2132-1-15**] Date of Birth: [**2065-12-21**] Sex: F Service: CARDIOTHORACIC Allergies: Latex / Pollen Extracts / Adhesive Bandages Attending:[**First Name3 (LF) 1505**] Chief Complaint: Redness and drainage at base of sternal wound Major Surgical or Invasive Procedure: sharp debridement lower pole sternal wound [**1-10**]. History of Present Illness: 66 year old woman s/p mechanical MVR [**12-28**]. Uneventful post-operative course, discharged to home on POD6. After discharge patient states she started having fever and chills and returned for evaluation. Past Medical History: IHSS/HOCM Hypertension Dyslipidemia Colonic polyps History of scarlet fever Ventral hernia s/p Tonsillectomy Social History: Works as a director of housing. Lives with her husband. Denies smoking and drinks rare alcohol. Family History: Father died at 61 from "severe" CAD Physical Exam: Admission T 102.2 Hr 88 Bp 101/66 RR 18 O2sat Gen Pasty appearance Neuro A&Ox3. nonfocal exam Pulm CTA-bilat CV RRR Abdm soft, NT/+BS Ext warm, well perfused, no edema Sternal wound + erythema of lower [**1-25**] wound bed. Small amount drainage on dressing but unable to express any drainage. No fluctuance. Discharge VS 97.9 110/80 91 20 Gen: pleasant, no acute distress Neuro: alert and oriented x 3 Chest: lungs clear bilaterally COR: regular rate and rhythm Sternum: wound vac in place Abdomen: soft and nontender Extremities: warm with trace edema Pertinent Results: [**2132-1-9**] 09:43PM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-SM [**2132-1-9**] 09:43PM URINE RBC-2 WBC-18* BACTERIA-FEW YEAST-NONE EPI-7 [**2132-1-9**] 05:20PM GLUCOSE-115* UREA N-16 CREAT-0.9 SODIUM-138 POTASSIUM-4.3 CHLORIDE-102 TOTAL CO2-27 ANION GAP-13 [**2132-1-9**] 05:20PM WBC-14.4*# RBC-3.18* HGB-9.9* HCT-28.1* MCV-88 MCH-31.1 MCHC-35.2* RDW-14.5 [**2132-1-9**] 05:20PM NEUTS-88.7* LYMPHS-7.6* MONOS-3.4 EOS-0.1 BASOS-0.1 [**2132-1-9**] 05:20PM PLT COUNT-376 [**2132-1-9**] 05:20PM PT-30.9* INR(PT)-3.2* [**2132-1-14**] 06:05AM BLOOD WBC-7.4 RBC-3.00* Hgb-9.4* Hct-27.1* MCV-90 MCH-31.4 MCHC-34.8 RDW-15.2 Plt Ct-481*# [**2132-1-14**] 06:05AM BLOOD Plt Ct-481*# [**2132-1-14**] 06:05AM BLOOD PT-22.5* INR(PT)-2.2* [**2132-1-13**] 05:43AM BLOOD UreaN-11 Creat-0.8 Na-142 K-3.8 [**2132-1-13**] 05:43AM BLOOD Vanco-16.8 [**Known lastname 101201**],[**Known firstname **] S [**Age over 90 101204**] F 66 [**2065-12-21**] CT CHEST W/CONTRAST Clip # [**Clip Number (Radiology) 101205**] Reason: evaluate for abscess in patient who may go to OR today [**1-11**] Contrast: [**Hospital 13288**] [**Hospital 93**] MEDICAL CONDITION: 66 year old woman with s/p MVR [**12-28**], now with erythema and drainage Final Report INDICATION: 66-year-old female with recent mitral valve replacement and now with erythema and drainage. COMPARISON: CT colonography, [**2130-11-22**]. TECHNIQUE: MDCT axial images through the chest were obtained following the administration of intravenous contrast and displayed at 5- and 1.25-mm collimation. A series of sagittal and coronal images were reformatted for review. FINDINGS: Expected postoperative findings following mitral valve replacement include mild mediastinal and presternal soft tissue swelling. A small post- operative periaortic fluid collection measures 30 Hounsfield units and likely represents fluid in a pericardial recess. At the soft tissue defect in the subxiphoid region, there is mild soft tissue swelling and edema but no discrete abscess. Sternal wires are intact and osseous structures do not demonstrate lucency or destruction to suggest osteomyelitis. Scattered mediastinal nodes are not enlarged. Small bilateral pleural effusions are expected, as is linear scarring/atelectasis at the bases. There is a discrete 10 mm right thyroid nodule. While the study is not designed for subdiaphragmatic evaluation, there are two simple-appearing hepatic cysts and a large ventral abdominal wall hernia with a 4.4-cm neck containing an unremarkable-appearing loop of large bowel. A 13 mm left adrenal lesion measured 8 [**Doctor Last Name **] on a previous non- contrast CT scan and was diagnosed as an adenoma. IMPRESSION: 1. Postoperative stranding and edema but no discrete abscess. 2. Small postoperative periaortic fluid collection, the significance of which is indeterminant. 3. Large ventral abdominal hernia containing a loop of large bowel. 4. Right thyroid nodule which warrants additional followup with ultrasound. 5. Left adrenal adenoma. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) **] [**Doctor Last Name **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3891**] Approved: FRI [**2132-1-11**] 6:03 PM [**Known lastname 101201**],[**Known firstname **] S [**Age over 90 101204**] F 66 [**2065-12-21**] Radiology Report CHEST PORT. LINE PLACEMENT Study Date of [**2132-1-11**] 11:38 AM [**Hospital 93**] MEDICAL CONDITION: 66 year old woman with new Picc REASON FOR THIS EXAMINATION: 48 cm long SL Picc in left basilic vein, need Picc tip placement Final Report HISTORY: 66-year-old female with new PICC line placement. COMPARISON: Chest radiograph [**2132-1-2**]. AP CHEST RADIOGRAPH: Left PICC line with tip terminating in the mid SVC. There are improvement of the left lower lobe atelectasis, minimal bilateral pleural effusion, as well as vascular congestion. Cardiomediastinal silhouette is unremarkable. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) 75229**] [**Name (STitle) **] DR. [**First Name8 (NamePattern2) 1569**] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 11006**] Approved: FRI [**2132-1-11**] 3:42 PM Brief Hospital Course: Patient admitted to cardiac surgery service and she was started on IV antibiotics. Plastic surgery and infectious disease services were consulted. On hospital day 2 the wound was debrided at the bedside. The wound bed has no necrotic tissue and good blood supply. Wet to dry packings were initiated. On hospital day 3 a PICC was placed. On hospital day 5 a VAC dressing was placed. On hospital day 7 she was discharged home with IV antibiotics and wound vac. Medications on Admission: ASA 81' Colace 100" Dilaudid [**2-26**] Q4/prn Zantac 150" Warfarin 7.5' Toprol XL 150' Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 5. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). Disp:*90 Tablet Sustained Release 24 hr(s)* Refills:*2* 6. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) gm Intravenous Q 12H (Every 12 Hours) as needed for sternal wound infection for 2 weeks. Disp:*qs gm* Refills:*0* 7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). Disp:*qs qs* Refills:*2* 8. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO once a day: Dr [**Name (NI) 39759**] office to adjust dose. Disp:*30 Tablet(s)* Refills:*0* 9. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:*14 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: KCI Discharge Diagnosis: Superficial wound infection. S/P mechanical MVR PMH: HTN, ^chol, colonic polyps, [**Last Name (un) **] fever, ventral hernia, s/p tonsillectomy Discharge Condition: stable Discharge Instructions: Keep wound clean and dry. OK to shower, no bathing or swimming. No powder cream or lotion to wounds. Take all medications as prescribed. Call for any fevers or change in wound appearance. Followup Instructions: 1) Dr [**Last Name (STitle) **] in 2 weeks. Patient to call for appt([**Telephone/Fax (1) 1504**]) 2) Dr [**First Name (STitle) **] ([**Telephone/Fax (1) 1429**]) on [**1-30**] @10:15Wound clinic 3) Wound check on monday [**2132-1-21**] on [**Hospital Ward Name 121**] 6 at 11:30 am 4) Need INR checks monday/wednesday/friday for mechanical mitral valve, goal INR 3-3.5. Level checked wednesday [**2132-1-16**] with results to Dr[**Name (NI) 43030**] office (fax - [**Telephone/Fax (1) 13359**]) 5) Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 74432**] in the [**Hospital **] clinic in 2 weeks ([**Telephone/Fax (1) 4170**] 6) Need weekly labs: BUN/CR, ESR, CRP, CBC w/Diff, Vanco level (goal 15-20) Results to Dr [**Last Name (STitle) 74432**] fax: ([**Telephone/Fax (1) 6313**] Completed by:[**2132-1-15**] Admission Date: [**2132-1-15**] Discharge Date: [**2132-1-16**] Date of Birth: [**2065-12-21**] Sex: F Service: CARDIOTHORACIC Allergies: Latex / Pollen Extracts / Adhesive Bandages Attending:[**First Name3 (LF) 922**] Chief Complaint: superficial sternal wound- wound vac malfunction Major Surgical or Invasive Procedure: none History of Present Illness: The patient is a 66 year old female who underwent mitral valve replacement on [**2131-12-28**]. Postoperative course was uneventful. The patient returned [**1-9**] with a superficial sternal wound infection. She was discharged with IV antibiotics and a wound vac yesterday ([**1-15**]). She returned last evening with a reported wound vac malfunction. She was due for her antibiotic dose and by returning to the hospital, had missed the visiting nurse- therefore, she was admitted overnight for IV antibiotics. Past Medical History: IHSS/HOCM Hypertension Dyslipidemia Colonic polyps History of scarlet fever Ventral hernia s/p Tonsillectomy Social History: Works as a director of housing. Lives with her husband. Denies smoking and drinks rare alcohol. Family History: Father died at 61 from "severe" CAD Physical Exam: VS: 98.3, 115/67, 88SR, 18, 95%RA Gen: NAD, WG, overweight WF HEENT: unremarkable Chest: lungs CTAB CV: RRR no murmur (audible click of mechanical valve) Abd: NABS, soft, non-tender, non-distended,large ventral hernia Ext: trace edema sternal wound: with vac, no cellulitis about edges, drainage is serosanguinous without any pus Pertinent Results: [**2132-1-16**] 05:09AM BLOOD UreaN-11 Creat-0.7 K-3.6 [**2132-1-16**] 05:09AM BLOOD Mg-2.2 [**2132-1-16**] 05:09AM BLOOD PT-25.8* INR(PT)-2.5* Brief Hospital Course: The wound vac was inspected and found to be working appropriately. IV antibiotics were administered as scheduled. The patient was discharged home again with VNA services and appropriate follow up instructions. Medications on Admission: Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 5. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). 6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 9. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses: dose to change daily by Dr. [**Last Name (STitle) 2912**] for goal INR 2.5-3.5. 10. 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. 11. Vancomycin 1000 mg IV Q 12H Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 5. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). 6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 7. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 9. Warfarin 7.5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses: dose to change daily by Dr. [**Last Name (STitle) 2912**] for goal INR 2.5-3.5. 10. 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. 11. Vancomycin 1000 mg IV Q 12H Discharge Disposition: Home With Service Facility: KCI Discharge Diagnosis: Superficial wound infection. S/P mechanical MVR Discharge Condition: good Discharge Instructions: Keep wound clean and dry. No bathing or swimming. No powder cream or lotion to wounds. Take all medications as prescribed. Call for any fevers or change in wound appearance. Followup Instructions: 1) Dr [**Last Name (STitle) **] in 2 weeks. Patient to call for appt([**Telephone/Fax (1) 1504**]) 2) Dr [**First Name (STitle) **] ([**Telephone/Fax (1) 1429**]) on [**1-30**] @10:15Wound clinic 3) Wound check on monday [**2132-1-21**] on [**Hospital Ward Name 121**] 6 at 11:30 am 4) Need INR checks monday/wednesday/friday for mechanical mitral valve, goal INR 3-3.5. Level checked wednesday [**2132-1-16**] with results to Dr[**Name (NI) 43030**] office (fax - [**Telephone/Fax (1) 13359**]) 5) Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 74432**] in the [**Hospital **] clinic in 2 weeks ([**Telephone/Fax (1) 4170**] 6) Need weekly labs: BUN/CR, ESR, CRP, CBC w/Diff, Vanco level (goal 15-20) Results to Dr [**Last Name (STitle) 74432**] fax: ([**Telephone/Fax (1) 6313**] Completed by:[**2132-1-16**]

[ "272.4", "611.1", "041.12", "682.2", "398.99", "425.1", "394.1", "E878.1", "V12.72", "401.9", "998.59" ]

icd9cm

[ [ [] ] ]

[ "86.28", "35.24", "38.93", "39.61", "93.57" ]

icd9pcs

[ [ [] ] ]

24921, 24955

22490, 22702

21107, 21114

25047, 25054

22322, 22467

25277, 26111

21920, 21957

23823, 24898

16708, 16740

24976, 25026

22728, 23800

25078, 25254

4707, 7850

21972, 22303

21019, 21069

16772, 17486

21142, 21658

21680, 21790

21806, 21904

44,793

174,421

53872

Discharge summary

report

Admission Date: [**2105-5-2**] Discharge Date: [**2105-5-31**] Date of Birth: [**2048-2-11**] Sex: F Service: MEDICINE Allergies: Sulfa(Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 1185**] Chief Complaint: fever, back pain Major Surgical or Invasive Procedure: 1. L2 bilateral hemilaminotomy. 2. L3 laminectomy without facetectomy. 3. L4 laminectomy with far lateral decompression, psoas debridement. 4. L5 laminectomy. 5. S1 laminectomy. 6. Removal of intraspinal abscess. 7. Deep biopsy, bone. 8. Fluoroscopic-guided abscess drainage x2 History of Present Illness: Pt is a 57Y F with Hx of SLE on Prednisone 10mg daily at baseline who is transferred from [**First Name4 (NamePattern1) 11560**] [**Last Name (NamePattern1) **] with low back pain and bilateral LE weakness. History is obtained from pt and what is available from outside records. She states that for the past 3 months, she has experienced increased fatigue, anorexia, malaise, and an approximate 20lb unintentional weight loss. She also notes that she has increased back pain. On [**2105-3-10**], she received an epidural injection for back pain and, per report, received an additional 2 injections the week before [**4-14**]. Since [**Month (only) 958**], she has been having weakness of her bilateral LE and dull (not burning) pain in her thighs that has been getting progressively worse. The pain is now [**8-18**] in intensity with movement; she denies any bowel or bladder incontenance or anesthesia. . She went to [**Last Name (un) 11560**] on [**4-14**] where an MRI showed a fluid epidural collection L5-S1 causing lateral recess stenosis at S1; DDx included hematoma vs. abscess. She was admitted to [**Last Name (un) 11560**] on [**4-14**] where Neurosurgery, IR, and ID all felt that the risks of draining the collection outweighed the benefits; Neurosurgery thought that the collections were a result of the injections themselves and not abscesses. After receiving IV ABX(per her report), she was discharged on the 10th. The patient was, by her report, admitted again from [**4-22**] - [**4-24**] and had a repeat MRI which showed "Interval significant decreasein the size of bilateral epidural fluid collections at the S1 level. The degree of stenosis is markedly reduced. However, there is slight residual encroachment on the S1 nerve root. Clinical correlation is suggested." She was given pain control and again discharged without any other interventions. She saw her Rheumatologist as an outpatient who both said her pain and fluid collection was not the result of SLE and did not change any medications. She represented to LGH on [**4-30**] for pain control and weakness. Her prednisone was increased from 20 to 40mg daily. EMG confirmed an extensive sensorimotor neuropathy. She received blood cultures and an echo out of concern for occult infection and was transferred to [**Hospital1 18**] for rheum consult and a second opinion. Of note, she states that she had a temp of 102 at the beginning of [**Month (only) 958**], Temps 99-100 throughout the month, and was noted to have a T of 101.3 at the time of transfer. She also notes "fogginess" in her thinking and times where her "mind goes blank" which has been going on through the past 3 months and she thinks is caused by her increased stress. She has no auditory or visual hallucinations and only minor tension headaches for the past 3-4 months. Her thinking has not improved on prednisone. On arrival to [**Hospital1 18**], she is requesting to take a shower and has [**8-18**] pain. She states that her pain was initially well-controlled with MSIR 15mg PO before transfer. Review of Systems: (+) Per HPI, chronic, mild, diffuse, abdominal pain and diarrhea after ABX which has now stopped (-) Denies chills, night sweats, recent weight gain. Denies blurry vision, diplopia, loss of vision, photophobia. Denies sinus tenderness, rhinorrhea or congestion. Denies chest pain or tightness, palpitations, lower extremity edema, PND. Denies cough, shortness of breath, or wheezes. Denies nausea, vomiting, constipation, melena, hematemesis, hematochezia. Denies dysuria, stool or urine incontinence. Denies arthralgias or myalgias. Denies rashes or skin breakdown. No numbness/tingling in extremities. No SI, overwhelming anxiety, or anhedonia. All other systems negative. Past Medical History: SLE diagnosed in [**2078**] Ex-Lap in [**2091**] for menorrhagia Skin grafts to LE in [**2098**] secondary to medication reaction Total teeth extraction Social History: Lives with her husband in [**Name (NI) **], [**2-9**] EtOH/day, smokes 1 pack per day x 10 years, no illegal drugs. Family History: No connective tissue diseases known; sister had Leukemia, father had Lymphoma Physical Exam: Admission Exam: VS: 97.4 bp 120/65 HR 51 RR 17 SaO2 100RA GEN: frail, cachectic, slightly fatigued, awake, alert, head bobbing while talking which she states has been going on for [**4-12**] years for unknown reasons HEENT: EOMI, sclera anicteric, conjunctivae clear, OP moist and without lesion; bruise on bridge of nose NECK: Supple, no JVD CV: Reg rate and rhythm, normal S1, S2. No m/r/g. CHEST: Resp unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABD: Soft, NT, ND, no HSM, bowel sounds present MSK: normal muscle tone and bulk SPINE: point tenderness near L5 EXT: No c/c/e, 2+ DP/PT bilaterally SKIN: No rash, warm skin NEURO: oriented x 3, CN II-XII intact, 5/5 strength throughout, intact sensation to light touch PSYCH: tangential thought process at times, normal thought content, appropriate, slightly flat affect On discharge she was afebrile, blood pressure stable at 90s-100s/40s-50s. No neurologic deficits. Pertinent Results: Admission Labs: [**2105-5-2**] 10:45PM GLUCOSE-105* UREA N-19 CREAT-0.6 SODIUM-133 POTASSIUM-4.5 CHLORIDE-92* TOTAL CO2-29 ANION GAP-17 [**2105-5-2**] 10:45PM ALT(SGPT)-18 AST(SGOT)-24 LD(LDH)-152 ALK PHOS-64 TOT BILI-0.3 [**2105-5-2**] 10:45PM ALBUMIN-3.6 CALCIUM-9.5 PHOSPHATE-3.9 MAGNESIUM-1.6 [**2105-5-2**] 10:45PM CRP-195.2* [**2105-5-2**] 10:45PM WBC-11.8* RBC-3.79* HGB-11.8* HCT-34.6* MCV-91 MCH-31.2 MCHC-34.2 RDW-12.3 [**2105-5-2**] 10:45PM NEUTS-89.9* LYMPHS-6.1* MONOS-3.1 EOS-0.8 BASOS-0.1 [**2105-5-2**] 10:45PM PLT COUNT-403 [**2105-5-2**] 10:45PM PT-11.1 PTT-29.9 INR(PT)-1.0 [**2105-5-2**] 10:45PM SED RATE-105* [**2105-5-2**] 10:45PM BLOOD CRP-195.2* [**2105-5-3**] 04:03AM BLOOD [**Doctor First Name **]-POSITIVE * Titer-1:80 [**2105-5-3**] 02:05PM BLOOD dsDNA-POSITIVE * Cardiac Enzymes [**2105-5-11**] 08:32PM BLOOD CK-MB-10 MB Indx-13.2* cTropnT-0.25* [**2105-5-12**] 02:14AM BLOOD CK-MB-14* MB Indx-8.0* cTropnT-0.41* [**2105-5-12**] 12:02PM BLOOD CK-MB-12* MB Indx-7.4* cTropnT-0.20* [**2105-5-12**] 07:28PM BLOOD CK-MB-7 cTropnT-0.14* [**2105-5-13**] 03:34AM BLOOD CK-MB-5 cTropnT-0.09* CSF [**2105-5-13**] 08:14AM CEREBROSPINAL FLUID (CSF) WBC-110 RBC-20* Polys-74 Lymphs-15 Monos-11 [**2105-5-13**] 08:14AM CEREBROSPINAL FLUID (CSF) WBC-105 RBC-35* Polys-84 Lymphs-13 Monos-3 [**2105-5-13**] 08:14AM CEREBROSPINAL FLUID (CSF) TotProt-252* Glucose-71 LD(LDH)-91 Anemia Studies: [**2105-5-26**] 05:57AM BLOOD calTIBC-222* VitB12-288 Folate-6.7 Hapto-173 Ferritn-373* TRF-171* Hypercoagulability Studies: [**2105-5-13**] 10:00PM BLOOD Thrombn-43.8* [**2105-5-10**] 05:25AM BLOOD QG6PD-9.6 [**2105-5-15**] 05:12AM BLOOD b2micro-1.5 [**2105-5-15**] 05:12AM BLOOD ACA IgG-1.6 ACA IgM-4.8 Rheum Studies: [**2105-5-2**] 10:45PM BLOOD ESR-105* [**2105-5-3**] 02:05PM BLOOD dsDNA-POSITIVE * [**2105-5-3**] 04:03AM BLOOD [**Doctor First Name **]-POSITIVE * Titer-1:80 [**2105-5-2**] 10:45PM BLOOD CRP-195.2* [**2105-5-3**] 05:30AM BLOOD C3-123 C4-20 [**Last Name (un) **] Stim Testing: [**2105-5-28**] 06:20AM BLOOD Cortsol-7.9 [**2105-5-28**] 06:36AM BLOOD Cortsol-15.0 [**2105-5-28**] 08:39AM BLOOD Cortsol-18.2 MICROBIOLOGY: **LUMBAR EPIDURAL ABSCESS SWAB FINAL REPORT [**2105-5-27**]** GRAM STAIN (Final [**2105-5-4**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2105-5-11**]): NOCARDIA FARCINICA. SPARSE GROWTH. IDENTIFIED BY [**Hospital1 4534**] LABORATORIES [**2105-5-19**]. ACID FAST SMEAR (Final [**2105-5-5**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. FUNGAL CULTURE (Final [**2105-5-21**]): A swab is not the optimal specimen for recovery of mycobacteria or filamentous fungi. A negative result should be interpreted with caution. Whenever possible tissue biopsy or aspirated fluid should be submitted. NOCARDIA FARCINICA. IDENTIFIED IN ACID FAST CULTURE. POTASSIUM HYDROXIDE PREPARATION (Final [**2105-5-4**]): Test cancelled by laboratory. PATIENT CREDITED. Inappropriate specimen collection (swab) for Fungal Smear (KOH). ACID FAST CULTURE (Final [**2105-5-27**]): A swab is not the optimal specimen for recovery of mycobacteria or filamentous fungi. A negative result should be interpreted with caution. Whenever possible tissue biopsy or aspirated fluid should be submitted. . NO MYCOBACTERIA ISOLATED. DUE TO OVERGROWTH OF NOCARDIA FARCINICA UNABLE TO CONTINUE MONITORING FOR AFB FOR 8 WEEKS. NOCARDIA FARCINICA. IDENTIFIED BY [**Hospital1 4534**] LABORATORIES [**2105-5-19**]. Sensitivities performed by [**Hospital1 **] laboratories ([**2105-5-25**]). FINAL SENSITIVITIES. SENSITIVE TO AMOX/CLAV (MIC: [**9-12**] MCG/ML). RESISTANT TO CEFEPIME (MIC: >32 MCG/ML). RESISTANT TO CEFTRIAXONE (MIC: >64 MCG/ML). SENSITIVE TO IMIPENEM (MIC: 4 MCG/ML). SENSITIVE TO CIPROFLOXACIN (MIC: 1 MCG/ML). [**Month/Day (4) 110509**] MIC: <= 0.25 MCG/ML: NO INTERPRETATION AVAILABLE. RESISTANT TO CLARITHROMYCIN (MIC: > 16 MCG/ML). SENSITIVE TO AMIKACIN (MIC: <= 1 MCG/ML). RESISTANT TO TOBRAMYCIN (MIC: > 16 MCG/ML). Intermediate TO: DOXYCYCLINE (MIC: 4 MCG/ML). Intermediate TO: MINOCYCLINE (MIC: 4 MCG/ML). SENSITIVE TO TMP/SMX (MIC: <= 0.25/4.75 MCG/ML). SENSITIVE TO LINEZOLID (MIC: 2 MCG/ML). ANAEROBIC CULTURE (Final [**2105-5-11**]): NO ANAEROBES ISOLATED. [**2105-5-13**] 8:14 am CSF;SPINAL FLUID SOURCE: LP,TUBE#3. **FINAL REPORT [**2105-5-13**]** CRYPTOCOCCAL ANTIGEN (Final [**2105-5-13**]): CRYPTOCOCCAL ANTIGEN NOT DETECTED. (Reference Range-Negative). Performed by latex agglutination. Results should be evaluated in light of culture results and clinical presentation. [**2105-5-13**] 8:14 am CSF;SPINAL FLUID SOURCE: LP,TUBE#3. GRAM STAIN (Final [**2105-5-13**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [**2105-5-16**]): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST CULTURE (Preliminary): The sensitivity of an AFB smear on CSF is very low.. If present, AFB may take 3-8 weeks to grow.. NO MYCOBACTERIA ISOLATED. GRAM POSITIVE RODS. BRANCHING RODS. VIRAL CULTURE (Preliminary): NO VIRUS ISOLATED. [**2105-5-13**] 9:00 am ABSCESS Source: epidural. GRAM STAIN (Final [**2105-5-13**]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). SMEAR REVIEWED; RESULTS CONFIRMED. FLUID CULTURE (Final [**2105-5-16**]): NOCARDIA SPECIES. SPARSE GROWTH. NOCARDIA FARCINICA. IDENTIFICATION PERFORMED ON CULTURE # 343-5173G ([**2105-5-4**]). ANAEROBIC CULTURE (Final [**2105-5-17**]): NO ANAEROBES ISOLATED. FUNGAL CULTURE (Final [**2105-5-29**]): NOCARDIA FARCINICA. IDENTIFICATION PERFORMED ON CULTURE # [**Numeric Identifier 110510**] [**2105-5-4**]. ACID FAST SMEAR (Final [**2105-5-14**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. NOCARDIA FARCINICA. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 343-5173G, [**2105-5-4**]. [**2105-5-21**] 3:45 pm ABSCESS Source: Epidural abscess. **FINAL REPORT [**2105-5-27**]** GRAM STAIN (Final [**2105-5-21**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [**2105-5-24**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2105-5-27**]): NO GROWTH. MRI L SPINE [**5-3**] IMPRESSION: 1. Large extensive spinal abscess involving the inferior aspect to the thoracic spine and lumbar spine ,involving the epidural and intradural spaces with anterior displacement of the terminal spinal cord and nerve roots.The findings in the intradural space may represent arachnoiditis with loculated collections. There is associated arachnoiditis and extension of the abscess into the right psoas muscle. Findings are significantly worse since the prior exam. 2. Complex fluid collection with rim enhancement involving the left posterior paraspinal soft tissues, suspicious for an abscess. There is extensive edema and soft tissue inflammation in the posterior paraspinal soft tissues, worse on the left. MRI SPINE [**5-8**] IMPRESSION: 1. There is no evidence of focal or diffuse lesions throughout the cervical or thoracic spinal cord to indicate a spinal cord edema or cord expansion, there is no evidence of spinal cord compression. 2. Minimal degenerative changes identified at C7/T1, consistent with posterior disc bulge, causing mild right side neural foraminal narrowing. Apparently, there is no evidence of abnormal enhancement throughout the cervical and thoracic spine, however, the examination is limited due to patient motion. 3. The patient is status post abscess removal and drainage in the lumbar region with laminectomies from L2 through L5/S1 levels as described above, fluid collection is noted posteriorly in the surgical bed, possibly consistent with a post-surgical fluid/phlegmon, formally a CSF leak cannot be completely excluded, persistent focus with fluid and air noted in the right psoas, with a far lateral surgical change and pattern of enhancement surrounding the thecal sac, possibly consistent with residual abscess formation, close followup is advised, the previously noted abscess in the left paraspinal musculature has been reduced in size. HEAD CT [**2105-5-12**] IMPRESSION: Large bilateral thalamic hypodensities, bilateral occipital pole hypodensities, and possible left frontal hypodensity. The differential diagnosis includes venous ischemia, perhaps due to deep cerebral vein or dural sinus thrombosis; vasculitis caused by meningitis; basilar tip thrombosis, or PRES. MRI may help clarify the nature of the abnormalities and determine patency of the veins and sinuses. . Brain MRI/MRA/MRV [**2105-5-12**] IMPRESSION: 1. Extensive increased T2 FLAIR signal involving bilateral thalami as well as the parieto-occipital white matter with areas of slow diffusion in the bilateral thalami and just posterior to the left occipital [**Doctor Last Name 534**] representing ischemia/infarct. Differential diagnosis includes PRESS versus less likely venous ischemia. MRV sequences demonstrate a questionable filling defect in the posterior aspect of the superior sagittal sinus, but with likely artifact since the post-contrast MPRAGE demonstrates normal venous enhancement in this region. 2. Global dural enhancement also present in the prior exam, which may be related to recent lumbar puncture versus inflammatory/infectious meningitis. BRAIN MRI [**2105-5-21**]: 1. Decrease in the previously noted FLAIR hyperintense areas in the periventricular white matter, with near-complete resolution of the FLAIR hyperintense areas involving the thalami and adjacent parenchyma. Correlate clinically and f/u as clinically indicated- etiology uncertain and includes PRES/Seizure related changes/ other etiology. 2. Interval development of increased signal in the transverse and sigmoid sinuses on some of the sequences, question slow flow/artifact/related to venous sinus thrombosis. Consider MR venogram for better assessment, as the present study is limited due to motion artifacts. 3. Interval development of small bilateral subdural fluid collections, ? related to intracranial hypotension given the h/o recent cisternal puncture. Correlate clinically and consider followup. BRAIN MRV [**2105-5-21**]: No evidence of dural venous sinus thrombosis. MR [**Name13 (STitle) 6452**] [**2105-5-19**]: 1. Redemonstration of a large fluid collection in the posterior spinous soft tissues, which is irregular in shape, in close proximity to the thecal sac margins at some levels. This is mildly decreased in some areas; however, no significant change is noted. Assessment is somewhat limited due to motion-related artifacts. The possibilities include simple fluid collection/abscess/pseudomeningocele. Correlate clinically to decide on the need for further workup. There is also reactive edema to changes noted in the posterior spinous soft tissues in the lower thoracic and in the lumbar and in the sacral regions. 2. Decrease in the areas of fluid collection/abscess in the right psoas muscle. 3. Unchanged appearance of the thickened cauda equina nerves related to arachnoiditis. 4. Renal lesions- likely cysts- correlate with prior studies/US TTE [**2105-5-29**]: The left atrium and right atrium are normal in cavity size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The estimated cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (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. IMPRESSION: Normal biventricular cavity sizes with preserved global and regional biventricular systolic function. Increased PCPW. Compared with the prior study (images reviewed) of [**2105-5-11**], the findings are similar. CLINICAL IMPLICATIONS: Based on [**2100**] AHA endocarditis prophylaxis recommendations, the echo findings indicate prophylaxis is NOT recommended. Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. Brief Hospital Course: Primary Reason for Hospitalization: 57yoF with a h/o SLE on prednisone transferred from OSH with fever and lumbar epidural abscess Active Issues: # Lumbar epidural abcess: Pt was transferred from OSH due to concern for lumbar epidural abscess given her fevers and worsening epidural fluid collection on MRI with extension to the psoas and paraspinal soft tissue. On [**5-4**] she underwent L3-S1 laminectomy, incision and drainage and was transferred to the ortho spine service. The infectious disease service was consulted and she was initially treated with IV vancomycin and cefepime. Intraoperative cultures subsequently grew beaded gram positive rods and partial acid-fast bacilli concerning for either non-tuberculin mycobacteria vs nocardia, and her antibiotics were changed to imipinem, linezolid, and amikacin. On [**5-11**] her course was complicated by intractable nausea/vomiting and mental status changed, then had 3 generalized tonic-clonic seizures. She was given IV ativan and keppra load and was transferred to the medical ICU. Her seizures were felt most likely [**3-12**] imipinem but also raised concern for possible CNS involvement of her infection. Imipenem was discontinued and her seizures resolved, however she continued to have altered mental status. She was electively intubated to obtain an MRI/MRA/MRV which showed thalamic and white matter changes of unclear etiology as well as dural enhancement, felt most c/w PRESS. CSF sample was obtained from a sub-cisternal puncture and initially showed no organisms, WBC 110, Prot 252, Gluc 71. She was empirically started on IV acyclovir, which was then discontinued once CSF HSV PCR returned negative. Repeat cultures of the epidural abscess were obtained by fluoroscopic drainage on [**5-13**], gram stain showed gram positive rods. Cultures were sent to [**Hospital1 **] for speciation and ultimately the organism was identified as Nocardia farcinica. Sensitivity data showed susceptibility to Bactrim and fluoroquinolones. Given her sulfa allergy, she required monitored Bactrim desensitization in the ICU, which she tolerated well. She was transitioned to IV Bactrim and PO [**Hospital1 **], and will likely require several months of antibiotic therapy. There was discussion of repeating surgical washout of the abscess, however given her clinical improvement the risk of the surgery was felt to outweigh the benefit. She is scheduled to follow up in the infectious disease [**Hospital 4898**] clinic and orthopedic clinic. She should have labs monitored closely while on antibiotics, including CBC, electrolytes, and LFTs with results faxed to the Infectious Disease RNs. MRI prior to d/c showed a worsening psoas abscess. After discussion with ortho spine and Infectious disease, it was felt surgery would not be an effective treatment for this patient and may make the infection worse. She will be treated with IV antibiotics for now with close ortho-spine and ID follow up. # Seizures: As noted above, [**Hospital **] hospital course was complicated by seizure activity requiring ICU transfer. This was felt most likely [**3-12**] imipenem. Her seizure activity resolved after starting Keppra and stopping imipenem. Per [**State 350**] state law, she is prohibited from driving for the next 6 months. She is scheduled to follow up in neurology clinic. # EKG changes with elevated troponin: In the context of the patient's seizures, she had elevated cardiac enzymes with Troponin-T peaking at 0.41. She was also noted to have EKG changes with depressions in the lateral and inferior leads and a <1mm elevation in V3-V4. These findings were felt most likely [**3-12**] seizure activity. Her cardiac enzymes were trended and returned to [**Location 213**]. Later in her hospital course she had an episode of orthostatic hypotension, complained of "indigestion" (had just eaten) and was noted to have ST elevations (appearing like Jpoint elevations) on telemetry and on V3-V5 on 12 lead EKG. She was otherwise hemodynamically stable. Her symptoms improved with Maalox and the ST changes resolved. Repeat EKG later in her hospitalization showed Q waves in lead II, which were not seen previously. Cardiac enzymes were again cycled and were normal. She had a TTE which showed preserved systolic function and no focal wall motion abnormality. She never endorsed chest pain or pressure during her hospitalization, although at times c/o "indigestion" associated with meals. On discharge, she was started on ASA 81mg daily. She was not started on a statin given her expected long course of antibiotic therapy. Would recommend further cardiac evaluation within the next month as an outpatient with a stress echo once her functional status improves. #HA: Pt c/o frequent headache which is worse with standing after her subcisternal puncture, felt c/w post-LP headache. Blood patch was considered but given infectious risk this was deferred. She was treated with fioricet as needed. #SLE on chronic steroids: Pt has taken prednisone 10mg daily for SLE for many years. She received stress dose hydrocortisone peri-operatively and then was rapidly tapered. She later received additional stress dose steroids in MICU due to her seizure activity and acute deterioration, and was again tapered to prednisone 10mg daily after she clinically improved. She developed orthostatic hypotension which raised concern for possible adrenal insufficiency, however [**Last Name (un) 104**] stim test was reassuring. The endocrinology service was consulted and did not feel there was indication to increase her steroid regimen. She was continued on her home prednisone 10mg daily at discharge. # Pleural effusion: Pt had small left sided pleural effusion incidentally noted on chest X-ray on [**2105-5-10**]. She denied dyspnea, hypoxia, or chest pain. Repeat CXR on [**2105-5-20**] showed stability of the effusion. Given that she was asymptomatic, thoracentesis was deferred. Would recommend repeat CXR in [**5-15**] weeks to monitor for change. Transitional issues: - She was discharged on IV Bactrim and PO [**Last Name (LF) **], [**First Name3 (LF) **] likely require several months of antibiotics. She is scheduled to f/u in [**Hospital **] clinic and ortho clinic. - She was discharged on PO Keppra for seizure activity during her hospitalization. Per MA state law she cannot drive for 6 months. She is sched to f/u in neurology clinic. - Given EKG changes during hospitalization, she was started on ASA 81mg daily. Statin was deferred due her expected prolonged course of antibiotics. Would recommend further cardiac eval with exercise stress testing in the outpatient setting once her functional status improves. - She should have repeat CXR to monitor small left pleural effusion - F/u R femur sclerotic lesion seen on Xray [**2105-5-3**] - Full code Medications on Admission: Prednisone 10mg PO daily Naprosen PRN pain Percocet 1 tab q4 PRN pain Discharge Medications: 1. levetiracetam 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 2. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain: Max dose 3g daily. 3. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for headache: max acetaminophen 3 gm day . 4. prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. [**Month/Day/Year **] 400 mg Tablet Sig: One (1) Tablet PO daily (). 6. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 8. sulfamethoxazole-trimethoprim 400-80 mg/5 mL Solution Sig: Two Hundred (200) mg Intravenous Q8H (every 8 hours). Discharge Disposition: Extended Care Facility: [**Location (un) **] Nursing & Rehabilitation Center - [**Location (un) **] Discharge Diagnosis: Lumbar epidural abscess Seizure Orthostatic hypotension 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: Dear Ms. [**Known lastname **], You were admitted to [**Hospital1 18**] because of an infection in your spine. You had surgery to wash out the infection and were started on antibiotics. You will need to continue the antibiotics for several weeks after leaving the hospital. You should follow up with the infectious disease service and the orthopedic surgery service for continued monitoring and treatment of your infection. While you were here, you had a seizure requiring monitoring in the intensive care unit. This likely happened because of antibiotic you were taking for your infection. You are no longer taking that antibiotic, and you were started on medication to prevent further seizures. According to [**State 350**] state law, you cannot drive for 6 months after your seizure. We have scheduled an appointment for you to follow up in the neurology clinic. Please note the following changes to your medications: -START Bactrim 200mg by IV every 8 hours -START [**State **] 400mg by mouth daily -START Fioricet 1 tab every 6 hours as needed for headache -START aspirin 81mg daily -START Levetiracetam (Keppra) 1000mg twice daily -START omeprazole 20mg once daily You should also continue your prednisone 10mg daily. Please see below for your currently scheduled follow up appointments. It has been a pleasure taking care of you at [**Hospital1 18**] and we wish you a speedy recovery. Followup Instructions: Department: Orthopedics (Spine Center) Name: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] When: Dr. [**Last Name (STitle) 25817**] office is working on a follow up appointment for 9-15 days after your hospital discharge. If you have not heard from Dr. [**Last Name (STitle) 25817**] office in 2 business days please call the office number listed below. Location: [**Hospital1 18**] ORTHOPEDICS Address: [**Location (un) **], [**Hospital Ward Name **] 2, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 8603**] Department: INFECTIOUS DISEASE When: THURSDAY [**2105-6-11**] at 11:30 AM With: [**Name6 (MD) **] [**Name8 (MD) 32437**], 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: NEUROLOGY When: FRIDAY [**2105-6-12**] at 1 PM With: DRS. [**Name5 (PTitle) **]/[**Doctor Last Name **] HAERENTS [**Telephone/Fax (1) 44**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Name6 (MD) **] [**Name8 (MD) **] MD [**Doctor Last Name 1189**]

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15741

Discharge summary

report

Admission Date: [**2164-3-12**] Discharge Date: [**2164-3-21**] Date of Birth: [**2120-8-12**] Sex: F Service: MEDICINE Allergies: Topiramate / Aripiprazole / Shellfish / Bee Pollen Attending:[**First Name3 (LF) 943**] Chief Complaint: AMS Major Surgical or Invasive Procedure: Paracentesis [**2164-3-12**], [**2164-3-19**] Thoracentesis [**2164-3-13**] History of Present Illness: 43F with history of alcoholic hepatitis recent admission [**Date range (1) 45338**] for GI bleed without clear source, subsequently developing c. diff (treated with IV flagyl and PO vanc taper), SBP, and HCAP (treated with vanc/cefepime). She was discharged to nursing home yesterday, and now is transferred back to [**Hospital1 18**] for AMS . By reports of EMS at [**Hospital 38**] Rehab, was febrile to 101.7 today, had a pCXR which was c/w PNA, went into SVT with rate 220's, transferred to [**Hospital1 **], given adenosine and verapamil and a total of 3L NS, given APAP and Vanc and Zosyn and was transferred here. Here in the ED she is afebrile and altered, unable to answer questions. Labs showed WBC of 12.5, with stable Hct and Plt. Electrolytes wnl, with exception of low Mg at 1.5 and low Ca at 7.4. Trop was 0.02, INR 3.0. CT a/p obtained to look for toxic megacolon which was negative for this. However it did show large new right pleural effusion leading to atelectasis/near collapse of right lower lobe. Also with Multifocal ill defined opacities in the LUL may reflect infectious process. Also with splenomegaly and varices signialying portal hypertension. Diagnositc paraentesis deferred due to elevated INR and low Plt and past IR requirement. She was given IV flagyl for possibility of toxic megacolon. She also received another 1L NS in the ED. SBPs remained stable in the 110s-120s and HRs in the 100s . On arrival to the MICU, VS are 98.5 120 126/68 99% 2L. She reports that she feels like a truck has hit her, but not elaborating much further . Review of systems: Difficult to obtain. She feels like a "truck hit her" with some SOB, abd pain/distension Past Medical History: - Alcoholic cirrhosis s/p TIPS - s/p cholecystectomy [**2153**] - Gastroesophageal reflux disease - Bipolar disorder - HTN - Depression/anxiety - Recent burns to both hands [**11/2163**] (housefire) s/p skin grafting from R thigh Social History: She lives with her husband and 2 children, ages 16 and 17. Smokes 1 pack every few weeks. Used to be an accountant. Describes a few beers daily. Denies other drug use. Family History: NC Physical Exam: ADMISSION EXAM: T98.5 HR 120 BP 126/68 99% 2L General: encephalopathic, mumbling, but a/ox3. HEENT: Sclera icteric, dry MM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Tachy, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally anteriorly Abdomen: Distended, ascites present with fluid wave, diffusely tender. GU: no foley Ext: warm, well perfused, 2+ pulses, 1+ peripheral edema Neuro: CNII-XII intact, moving all extremities . DISCHARGE EXAM: VS: 99.8 @ [**2081**] 99.1 114/79 98 19 98/RA I/o: NR/350 BMx1 (ON) 1500/1125 x5 (24) GENERAL: Chronically ill appearing female in NAD. Jaundiced. HEENT: Sclera icteric. MMM. CARDIAC: tachycardic but regular, 2/6 systolic murmur along left sternal border, hyperdynamic precordium LUNGS: clear anteriorly, pt would not cooperate with posterior exam ABDOMEN: Distended and tympanic w shifting dullness, tender to palpation over right upper quadrant. +BS EXTREMITIES: 1+ edema b/l to the thigh. Warm and well perfused, no clubbing or cyanosis. no asterixis, still with mild tremor Pertinent Results: ADMISSION LABORATORY DATA [**2164-3-12**] 01:10AM BLOOD WBC-12.5* RBC-2.62* Hgb-7.8* Hct-25.8* MCV-98 MCH-29.9 MCHC-30.4* RDW-21.9* Plt Ct-107* [**2164-3-12**] 01:10AM BLOOD Neuts-82.9* Lymphs-9.6* Monos-5.5 Eos-1.4 Baso-0.6 [**2164-3-12**] 01:10AM BLOOD PT-31.2* PTT-43.1* INR(PT)-3.0* [**2164-3-12**] 01:10AM BLOOD Glucose-97 UreaN-16 Creat-0.6 Na-137 K-4.1 Cl-106 HCO3-23 AnGap-12 [**2164-3-12**] 10:09AM BLOOD ALT-12 AST-41* LD(LDH)-233 CK(CPK)-20* AlkPhos-64 TotBili-4.1* [**2164-3-12**] 01:10AM BLOOD Calcium-7.4* Phos-3.1 Mg-1.5* [**2164-3-12**] 01:28AM BLOOD Lactate-1.2 . URINALYSIS: [**2164-3-12**] 01:10AM URINE Color-DKAMB Appear-Cloudy Sp [**Last Name (un) **]-1.019 [**2164-3-12**] 01:10AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-SM [**2164-3-12**] 01:10AM URINE RBC-1 WBC-15* Bacteri-FEW Yeast-NONE Epi-<1 TransE-<1 . PLEURAL FLUID ANALYSIS: [**2164-3-12**] 01:49PM ASCITES WBC-4175* RBC-3425* Polys-94* Lymphs-0 Monos-6* [**2164-3-12**] 01:49PM ASCITES TotPro-3.7 Glucose-26 Creat-0.6 LD(LDH)-586 TotBili-3.1 Albumin-2.1 [**2164-3-13**] 07:04AM PLEURAL WBC-298* RBC-[**Numeric Identifier 22432**]* Polys-11* Lymphs-18* Monos-0 Eos-1* Meso-66* Macro-4* [**2164-3-13**] 07:04AM PLEURAL TotProt-2.7 LD(LDH)-117 Amylase-15 Albumin-1.6 [**2164-3-19**] 10:18AM ASCITES WBC-60* RBC-3770* Polys-16* Lymphs-16* Monos-0 Macroph-68* [**2164-3-19**] 10:18AM ASCITES TotPro-3.3 Glucose-59 Creat-0.4 LD(LDH)-298 TotBili-3.1 Albumin-1.9 . DISCHARGE LABORATORY DATA [**2164-3-21**] 06:00AM BLOOD WBC-7.4 RBC-3.29* Hgb-10.0* Hct-32.3* MCV-98 MCH-30.4 MCHC-30.9* RDW-22.1* Plt Ct-126* [**2164-3-21**] 06:00AM BLOOD PT-27.8* PTT-38.5* INR(PT)-2.7* [**2164-3-21**] 06:00AM BLOOD Glucose-92 UreaN-11 Creat-0.3* Na-130* K-3.8 Cl-102 HCO3-25 AnGap-7* [**2164-3-21**] 06:00AM BLOOD ALT-13 AST-29 AlkPhos-101 TotBili-3.2* [**2164-3-21**] 06:00AM BLOOD Calcium-8.5 Phos-3.7 Mg-1.5* . MICROBIOLOGY: [**2164-3-12**] 1:10 am BLOOD CULTURE **FINAL REPORT [**2164-3-18**]** Blood Culture, Routine (Final [**2164-3-18**]): NO GROWTH. . [**2164-3-12**] 1:49 pm PERITONEAL FLUID PERITONEAL FLUID. **FINAL REPORT [**2164-3-18**]** GRAM STAIN (Final [**2164-3-12**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2164-3-15**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2164-3-18**]): NO GROWTH. . [**2164-3-12**] 7:00 pm BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. . [**2164-3-13**] 7:04 am PLEURAL FLUID PLEURAL FLUID. **FINAL REPORT [**2164-3-19**]** GRAM STAIN (Final [**2164-3-13**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [**2164-3-16**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2164-3-19**]): NO GROWTH. . [**2164-3-19**] 10:18 am PERITONEAL FLUID PERITONEAL. GRAM STAIN (Final [**2164-3-19**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Preliminary): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. . IMAGING: # CT OF THE CHEST [**2164-3-12**]: The aorta is normal in caliber without evidence of dissection. The pulmonary artery appears well opacified without evidence of perfusion defects to suggest acute pulmonary embolus. Great vessels are unremarkable. The heart is mildly enlarged without pericardial effusion. There is a large right pleural effusion of intermediate density measuring up to 30 Hounsfield units in attenuation, new since [**2164-3-4**] exam. The right lower lobe is largely collapsed with surrounding pleural effusion. Segmental branches of the right lower lobe bronchus appear narrowed. Patchy opacity in the left lung base likely represents atelectasis. Multiple ill-defined opacities in the left upper lobe are also noted. There are scattered mediastinal lymph nodes, which do not meet CT criteria for pathologic enlargement. There is no hilar lymphadenopathy. No pathologically enlarged axillary lymph nodes are seen. CT OF THE ABDOMEN: The liver demonstrates a lobular contour compatible with patient's history of underlying cirrhosis. There is 1.7 x 1.7 cm hypodense lesion centered in segment II (4B:94) measuring 20 Hounsfield units in attenuation, presumably a cyst which appears longstanding. No new hepatic lesion is identified. TIPS shunt is in place. The spleen is enlarged measuring 14 cm in craniocaudal direction. Nasoenteric tube is post-pyloric in position. Large gastric diverticulum is again noted (4B:96). Pancreas enhances homogeneously. Adrenal glands are normal. Kidneys enhance and excrete contrast symmetrically without evidence of hydronephrosis or renal masses. Large amount of ascites present. There is no evidence of small bowel obstruction. There is extensive mesenteric stranding. Perigastric and perisplenic varices are again noted. Intra-abdominal aorta and its branches appear patent and are normal in caliber. There are multiple retroperitoneal lymph nodes, which appear pathologically enlarged. For example, a right paraaortic lymph node measures 2.3 x 1.4 cm in aggregate (4B:115). There is no free air in the abdomen. CT OF THE PELVIS: Large amount of free fluid is present. Bladder is largely decompressed around the Foley catheter. The uterus appears unremarkable. The rectum, sigmoid colon appear normal. Linear areas of calcifications in the cul-de-sac are again noted, unchanged since [**2164-3-4**], which maybe related prior embolization material. OSSEOUS STRUCTURES: No suspicious lytic or sclerotic lesions are seen. IMPRESSION: 1. Large right pleural effusion of intermediate density is new since [**2164-3-4**] exam, leading to atelectasis/near collapse of the right lower lobe. 2. Multifocal ill-defined opacities in the left upper lobe may reflect infectious or hemorrhage. 3. No evidence of acute aortic injury or pulmonary embolus. 4. Cirrhotic liver. TIPS shunt in place. Splenomegaly and extensive varices signify portal hypertension. 5. Hypodense lesion in segment II of the liver is longstanding and presumably represents a cyst. 6. Large gastric diverticulum. 7. Large amount of ascites. 8. Retroperitoneal lymphadenopathy, as described above. . # CT ABD & PELVIS W/O CONTRAST Study Date of [**2164-3-14**] CT OF THE CHEST WITHOUT IV CONTRAST: Evaluation of the thoracic structure is limited due to lack of intravenous contrast. Bilateral ground-glass opacities, most confluent at the left apex and lingula (2:22), have increased and are suggestive of a worsening infectious process. There is a moderate right pleural effusion; decreased in size in comparison to prior study from [**2164-3-12**] status post therapy thoracocentesis. Mild atelectatic changes are noted at the left base and appear slightly increased in comparison to prior study. The heart is moderately enlarged but without pericardial effusion. A left subclavian central venous catheter is visualized with the tip at the distal SVC. CT OF THE ABDOMEN WITHOUT IV OR ORAL CONTRAST: Again noted is large non-hemorrhagic ascites, similar in comparison to prior study from [**2164-3-12**]. Evaluation of the abdominal structures is limited due to lack of intravenous contrast. The colon appears diffusely dilated and suggestive of ileus. There is no evidence of free air. An enteric tube is visualized with the tip in the jejunum. No hemorrhage is noted in the abdomen. The liver demonstrates a nodular contour, consistent with patient's known cirrhosis. Again noted is a hypodense lesion in the left lobe of the liver in segment II (3:47), which appears stable in comparison to prior study and better delineated on that study. No new hepatic lesions are identified. The TIPS shunt appears in place. A large gastric diverticulum is again noted (3:53). The spleen remains enlarged at 14 cm. Otherwise, unopacified stomach, bilateral adrenal glands and bilateral kidneys appear unremarkable. Perigastric and perisplenic varices are again noted. There are multiple retroperitoneal lymph nodes and lymph node conglomerates which appear pathologically enlarged and stable compared to prior study from two days ago (3:74). Emblization coils are again noted. CT OF THE PELVIS WITHOUT IV OR ORAL CONTRAST: Evaluation of the pelvic structures is limited due to lack of intravenous contrast. Large amount of ascites noted. The rectum, sigmoid colon appears somewhat dilated and consistent with likely ileus. A Foley catheter is noted in the bladder. Linear calcifications are again noted in the cul-de-sac and unchanged dating back to [**2164-3-4**] and may be related to prior embolization material. OSSEOUS STRUCTURES: There are no lytic or sclerotic osseous lesions suspicious for malignancy. IMPRESSION: 1. No evidence of a retroperitoneal hematoma. 2. Ground-glass opacities in bilateral upper lobes with more confluent opacities in the left upper lobe and lingula have increased and are concerning for worsening infection. 3. Moderate right pleural effusion smaller than prior study from [**2164-3-12**] after thoracocentesis. 4. Large nonhemorrhagic ascites. 5. Fluid-filled distended large bowel loops, likely representative of ileus. 6. Sequela of cirrhosis with a nodular liver, splenomegaly, TIPS shunt, varices. 7. Diffuse body anasarca. 8. Gastric diverticulum, stable. . # DUPLEX DOPP ABD/PEL Study Date of [**2164-3-16**] The liver is normal to slightly large in size and homogeneous in echotexture with some mild overall increase in echogenicity. A 2.8 cm septated cyst is seen in segment III, but there are no other focal liver lesions seen. There is a moderate amount of ascites in the perihepatic region as well as in the lower quadrants bilaterally. There is also a moderate right pleural effusion. The spleen is massively enlarged at 17.6 cm length. Color-flow and pulse Doppler waveform analysis was performed. The main portal vein velocity is 29 cm/sec and velocities within the TIPS shunt range from 31-187 cm/sec. This range of velocities is similar to the prior scan and respiratory variability is seen within the TIPS shunt as well as wall-to-wall flow on color-flow imaging. The anterior right and left portal vein show reverse flow towards the TIPS shunt. CONCLUSION: Patent TIPS shunt with stable velocities compared to the prior scan of [**2164-2-20**]. Ascites and right pleural effusion are noted. . # PARACENTESIS DIAG/THERAP W IMAGING GUID Study Date of [**2164-3-19**] PROCEDURE: Written informed consent was obtained from the patient after explaining the indications, risks, and benefits of the procedure. A preliminary four-quadrant ultrasound identified extensively loculated ascites in the abdomen. The largest area of ascites was identified in the mid central lower abdomen. A timeout was performed per [**Hospital1 18**] protocol during which the patient, the procedure, and site were confirmed. The lower midline abdomen was prepped and draped in standard sterile fashion. Skin and subcutaneous tissues were anesthetized with 1% buffered lidocaine. The peritoneal cavity was entered with a 7 cm 5 French [**Last Name (un) 11097**] catheter. Serosanguineous ascites was aspirated. Samples were sent to the lab. After applying the tube to suction, flow was very limited. After attempts to manipulate the catheter, a second 15 cm 5 French [**Last Name (un) 11097**] catheter was then inserted into the peritoneal cavity under direct ultrasound guidance. The catheter crossed several septations in the fluid and aspiration was performed while pulling back the catheter as each ascitic pocket was evacuated. Despite this second attempt, only 300 cc of serosanguineous ascites was ultimately drained. The septations were visualized to be collapsing under realtime visualization. The patient tolerated the procedure well. There were no immediate post-procedural complications. The attending physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], was present and supervising throughout the entire procedure. IMPRESSION: Limited paracentesis due to extensively loculated ascites. Only 300 cc of serosanguineous ascites could be aspirated. Samples were sent for the requested laboratory studies. Brief Hospital Course: Ms [**Known lastname 45209**] is a 43 year old female with a history of alcoholic cirrhosis, recent admission for GI bleed in the setting of clostridial colitis and spontaneous bacterial peritonitis, and pneumonia, who was admitted initially to the MICU for fevers and altered mental status, treated for HCAP, SBP, and C. diff colitis. . ACTIVE ISSUES: # Multifocal PNA: Pt was noted to have multifocal opacities on chest CT scan on admission. She was started on broad spectrum antibiotics for HCAP coverage, as well as possible aspiration with vancomycin, Zosyn, and Flagyl. She had a right sided thoracentesis for drainage of a large pleural effusion. Her pleural fluid culture did not speciate any bacteria. She completed an 8 day antibiotic course and was successfully weaned off oxygen and maintained her oxygen saturation > 95% on room air. . # Bacterial Peritonitis: Pt had a diagnostic paracentesis on admission which revealed a WBC of 4175 with 94% PMN. Her ascitic fluid cultures had no growth, but she was covered for bacterial peritonitis with vanc, Zosyn and Flagyl as above. She also received IV albumin on day 1 and day 3. Her infection was thought to be secondary to c. diff colitis, and therefore was not considered spontaneous. She had a repeat paracentesis during her hospitalization, which showed a WBC 60 with 16% PMN. Following completion of her IV antibiotics, she was transitioned to ciprofloxacin prophylaxis with 500 mg daily. . # Recent C. diff: Pt was at the beginning of a vancomycin taper at time of admission for c. diff colitis which was diagnosed at her previous admission. She was treated with PO vancomycin and IV Flagyl during this admission. After completion of her IV antibiotics for peritonitis and pneumonia, she was restarted on her PO vancomycin taper, to complete a 6 week course. . # Anemia: Pt had a history of hematochezia on a recent admission. Her hematocrit was low at 21 on admission, and she received a total of 4 units PRBC. Her hematocrit then stabilized around 30 and remained there for the rest of her hospitalization. We suspect that the etiology of her slow blood loss is portal gastropathy. . # Tachycardia: Pt was tachycardic on presentation to the OSH, and required adenosine for SVT with rates to 220. She received IV fluids on admission here, with resolution of her tachycardia. . CHRONIC ISSUES: # [**Known lastname **] cirrhosis: Pt had a prior history significant for gastrointestinal bleeding from varices s/p IR-guided embolization ([**1-15**]) and EGD with injection of glue to duodenal varix in third part of duodenum ([**1-24**]), s/p recent TIPS. Her MELD score on admission was 24. She was encephalopathic on admission, which resolved with lactulose and rifaximin. Her total bilirubin and INR remained elevated, but consistent with her recent baseline. There was a question as to when her last drink was, as pt reported had an elevated [**Month/Day (4) **] level at OSH. Pt met with social work during this admission, and she was advised to enter relapse prevention counseling once out of rehab. She was restarted on Cipro prophylaxis after her IV antibiotics were completed. A therapeutic ultrasound guided paracentesis was attempted during this admission, however only 300 cc was removed due to extensive loculations. Pt was continued on tube feeds via Dobbhoff. Her diuretic regimen was also increased while in house due to peripheral volume overload. Pt took all medications by mouth. . # Bipolar disorder: Pt has a diagnosis of bipolar disorder that appeared untreated during this admission. We attempted to get psychiatry involved because of concern that her psychiatric issues may impair her ability to continue treatment for her alcohol abuse and continued transplant evaluation. The patient, however, refused to meet with psychiatry. They recommended Haldol as needed for agitation, which the patient did not require. This should be followed closely as an outpatient. . = = = = = = = = = = = = = = = = = = = = ================================================================ Transitional issues - Pt is to be continued on a long term PO vancomycin taper: 1 tab QID for 7 days ([**Date range (1) 45339**]) -1 tab [**Hospital1 **] for 7 days ([**Date range (1) 45340**]) -1 tab daily for 7 days ([**Date range (1) 45341**]) -1 tab every other day for 7 days ([**Date range (1) **]) -1 tab every 3 days for 14 days ([**Date range (1) 45342**]). - Enteral feedings: continue current tube feedings indefinitely. To be followed by liver center nutrition. - Encephalopathy: Currently oriented and at MS baseline. Continue lactulose and rifaximin. Goal [**1-22**] bowel movements daily. - She expressed desire to receive medications via Dobbhoff however she was strongly encouraged to take them orally given no contraindication to po medications. No medications are to be administered via Dobbhoff if possible to avoid occlusion of tube lumen. - Pt should be enrolled in relapse prevention therapy as an outpatient. - She should continue to follow up with psychiatry for ongoing treatment of her bipolar disorder and alcohol abuse. - Pt should have blood work checked 3 times a week, including : CBC, chemistry 10, AST, alt, alk Phos, bilirubin, INR/PT, PTT. Fax results to liver center # [**Telephone/Fax (1) 4400**] attn: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**]. ICD-9: 571.2. Medications on Admission: furosemide 20 mg Tablet Sig: Three (3) Tablet PO once a day. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO three times a day: titrate to [**2-23**] BMs per day. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). multivitamin Tablet Sig: One (1) Tablet PO once a day. spironolactone 50 mg Tablet Sig: Three (3) Tablet PO once a day. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for Severe Anxiety. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). vancomycin 125 mg Capsule Sig: One (1) Capsule PO see taper: -1 tab QID for 7 days ([**Date range (1) 30341**]) -1 tab [**Hospital1 **] for 7 days ([**Date range (1) 35542**]) -1 tab daily for 7 days ([**Date range (1) 45335**]) -1 tab every other day for 7 days ([**Date range (1) 45336**]) -1 tab every 3 days for 14 days ([**Date range (1) 45337**]). Disp:*62 Capsule(s)* Refills:*0* 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. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Discharge Medications: 1. lactulose 10 gram/15 mL (15 mL) Solution Sig: Thirty (30) ml PO three times a day: titrate to [**2-23**] bowel movements daily. 2. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 8. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 9. vancomycin 125 mg Capsule Sig: One (1) Capsule PO per taper: 1 tab QID for 7 days ([**Date range (1) 45339**]) -1 tab [**Hospital1 **] for 7 days ([**Date range (1) 45340**]) -1 tab daily for 7 days ([**Date range (1) 45341**]) -1 tab every other day for 7 days ([**Date range (1) **]) -1 tab every 3 days for 14 days ([**Date range (1) 45342**]). . 10. white petrolatum-mineral oil Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 11. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 12. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: Do not exceed 2grams tylenol daily. . 13. furosemide 40 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 14. furosemide 80 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 15. spironolactone 100 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 16. spironolactone 100 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 17. Outpatient Lab Work Please check labs, three times weekly: CBC, chemistry 10, ast, alt, alk phos, bilirubin, INR/PT, PTT. Fax results to liver center # [**Telephone/Fax (1) 4400**] attn: Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**]. ICD-9: 571.2. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 1110**] Discharge Diagnosis: PRIMARY: SBP Pneumonia C. Diff colitis . SECONDARY Pulmonary effusion [**Location (un) **] cirrhosis Ascites Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Ms. [**Known lastname 45209**], You were admitted to the [**Hospital1 18**] with fever and altered mental status. You were found to have an accumulation of fluid in your right lung, which was subsequently drained and your breathing improved. We treated you for a pneumonia, as well as an infection in your abdominal fluid. You were continued on your previous antibiotic regimen for your diarrhea. Please make the following changes to your medications: # INCREASE lasix to 80 mg in the morning, 40mg in the evening # INCREASE spironolactone 200 mg in the morning, 100mg in the evening # RESTART your vancomycin 125 mg taper as follows: 1 tab QID for 7 days ([**Date range (1) 45339**]) -1 tab [**Hospital1 **] for 7 days ([**Date range (1) 45340**]) -1 tab daily for 7 days ([**Date range (1) 45341**]) -1 tab every other day for 7 days ([**Date range (1) **]) -1 tab every 3 days for 14 days ([**Date range (1) 45342**]). Continue all other medications as prescribed Followup Instructions: Department: LIVER CENTER When: FRIDAY [**2164-3-30**] at 10:00 AM With: [**First Name11 (Name Pattern1) 674**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 13146**] [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Unit Name **] [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: LIVER CENTER When: FRIDAY [**2164-5-4**] at 3:20 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], MD [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Unit Name **] [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Completed by:[**2164-3-24**]

[ "303.90", "785.0", "511.9", "995.91", "518.0", "571.2", "486", "578.9", "456.21", "038.9", "280.0", "567.23", "789.59", "296.80", "276.3", "008.45", "572.2", "572.3" ]

icd9cm

[ [ [] ] ]

[ "34.91", "96.6", "54.91" ]

icd9pcs

[ [ [] ] ]

25383, 25466

16445, 16783

314, 392

25619, 25619

3700, 6261

26803, 27471

2570, 2574

23352, 25360

25487, 25598

21859, 23329

25802, 26234

2589, 3077

3093, 3681

6294, 7191

26263, 26780

2022, 2114

271, 276

16798, 18789

420, 2002

7273, 16422

25634, 25778

18805, 21833

2136, 2368

2384, 2554

7223, 7237

21,969

128,556

17079

Discharge summary

report

Admission Date: [**2141-12-18**] Discharge Date: [**2141-12-22**] Date of Birth: [**2067-12-19**] Sex: M Service: MEDICINE Allergies: Aldactazide Attending:[**First Name3 (LF) 106**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: s/p cardiac catheterization on [**2141-12-18**] with stent History of Present Illness: 74 year old man with HTN, prior treatment at an assortment of hospitals, patient denies history of MI, (+) 3 prior cardiac arrests per patient report from VTach/VFib, apparently had an ICD x 2 ([**2127**], [**2133**]) but it was removed when leads were not working and patient did not want another one. Patient also states he has had a cardiac catheterization in the recent past which looked okay and no interventions were done at that time. On day of admission, patient went to the gym. After working out had [**3-19**] chest pressure radiating to Jaw, nausea, shortness of breath and diaphoresis. EKG with 3-4mm ST elevation V1-V3, ST depression inferiorly. Patient states he has known A.Fib and there was supposed to be a decision this week whether to start Coumadin. He is DNR/DNI but willing to have cath/PCI. He was transferred from [**Hospital3 628**] to [**Hospital1 18**] for catheterization. . ED: 2mg morphine, IV nitro 20mcg/min, heparin 5000 unit bolus, no drip, integrelin bolus 7.3 cc, integrelin gtt 13cc/hour, Plavix 300, asa 325, Lopressor 5mg IV x2. Past Medical History: Ventricular tachycardia Atrial Fibrillation CAD prior ICD x 2 (not currently working) lumbar radiculopathy osteoarthritis BPH. Social History: He lives in [**Location 620**]. He volunteers at the [**Hospital1 **] in [**Location (un) 620**]. Former electrical engineer. Family History: Significant for coronary artery disease, he is an occasional alcohol user, he quit tobacco 20 years ago. Physical Exam: T 97.6 HR 78 BP 104/64 RR 17 99%/2L n.c. Gen: AOx3, NAD HEENT: anicteric sclera, MMM CV: irregularly irregular Pulm: CTA-Ant Abd: (+) BS, soft, ND/NT groin: small groin ooze, no hematoma Ext: WWP, no edema, 1+ DP b/l . EKG on admission: irregularly irregular, HR 84, Nl axis, ST elevation V1-V4, I. ST depressions II, III, aVF (reciprocal changes). . post-cath EKG: irregularly irregular, HR 74, Nl axis, 1-[**Street Address(2) 1766**] elevations V2. T wave inversions V3-6. Pertinent Results: [**2141-12-18**] 02:00PM BLOOD WBC-9.5 RBC-4.09* Hgb-13.7* Hct-37.1* MCV-91 MCH-33.6* MCHC-37.1* RDW-12.5 Plt Ct-111* [**2141-12-18**] 02:00PM BLOOD PT-15.9* PTT->150* INR(PT)-1.7 [**2141-12-18**] 02:00PM BLOOD Glucose-133* UreaN-20 Creat-1.5* Na-135 K-5.0 Cl-108 HCO3-17* AnGap-15 . [**2141-12-18**] 02:00PM BLOOD ALT-14 AST-37 . [**2141-12-18**] 02:00PM BLOOD CK(CPK)-392* CK-MB-60* MB Indx-15.3* [**2141-12-18**] 11:56PM BLOOD CK(CPK)-1322* CK-MB-259* MB Indx-19.6* [**2141-12-19**] 04:07AM BLOOD CK(CPK)-1193* CK-MB-220* MB Indx-18.4* cTropnT-5.78* [**2141-12-20**] 07:25AM BLOOD CK(CPK)-348* CK-MB-40* MB Indx-11.5* . [**2141-12-18**] 02:00PM BLOOD Mg-2.0 Cholest-154 [**2141-12-18**] 02:00PM BLOOD HDL-34 CHOL/HD-4.5 LDLmeas-116 . [**2141-12-18**] Cardiac Catheterization FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Likely severe left ventricular diastolic heart failure 3. Acute anterior myocardial infarction, managed by acute primary PCI of the proximal LAD with thrombectomy and deployment of a drug-eluting stent. 4. Mild pulmonary arterial hypertension. 5. Perclose suture deployment at the right femoral arteriotomy site. COMMENTS: 1. Selective coronary angiography demonstrated single vessel coronary artery disease in this right dominant circulation. The LMCA had a mild distal tapering of 30%. The LAD had a 95% proximal thrombotic stenosis beginning at a very small D1 and spanning a small D2 with TIMI 2 flow distally. The LCX had diffuse non-obstructive plaquing to 30% ostially, and 30% in the mid vessel. There was a large OM branch without flow limiting disease. The RCA was a dominant vessel with diffuse non-obstructive plaquing to 40% with TIMI 2 flow. 2. Post-intervention hemodynamics from right heart catheterization demonstrated severely elevated right sided filling pressures (RVEDP 17 mmHg). The PWP catheter was unable to be fully lodged in the wedge position; the mean PCWP was estimated at ~25mmHg with large V-waves seen superimposed on the PA tracing. Cardiac index and output were severely depressed at 3.6 L/min and 1.7 L/min/m2 respectively (using an assumed oxygen consumption). 3. Left ventriculogram was not performed to reduce contrast load. 4. Successful thrombectomy and stenting of the thrombotic LAD lesion were performed with a 3.5 mm Cypher drug-eluting stent, which was post-dilated using a 3.75 mm NC balloon, with a 5% residual stenosis, loss of a small 2nd diagonal branch, no apparent dissection, and TIMI 2 flow (see PTCA Comments). 5. The right femoral arteriotomy site was closed with a Perclose Proglide device with good hemostasis after limited angiography showed no significant arterial pathology. . [**2141-12-19**] Echocardiogram: The left atrium is elongated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly-to-moderately depressed (ejection fraction 40 percent) secondary to akinesis of the apex, severe hypokinesis of the interventricular septum, and moderate hypokinesis of the anterior free wall; the other walls are hyperdynamic. No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. . [**2141-12-22**] Discharge INR 1.2 Brief Hospital Course: 73 yo M with HTN, AFib, h/o cardiac arrest presents after acute Anterior ST elevation myocardial infarction. Patient was transferred from outside hospital for cardiac catheterization and is s/p thrombectomy and [**Month/Day/Year **] to proximal-LAD. He tolerated the procedure well and was monitored in the Coronary Intensive Care unit for 24 hours before being transferred to Cardiology [**Hospital1 **]. . 1. CV: Ischemia: s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **] to proximal LAD. Continue ASA, started Plavix, atorvastatin and Beta-blocker. Cycled cardiac enzymes until trended down (peak CK 1322). Integrelin was given at 1/2 dose as patient has renal insufficiency (Cr 1.5-1.8 during admission). Integrelin was continued 18 hours post-catheterization and then stopped. Continued Heparin post-cath given patient's history of AFib as well as the risk of forming thrombus if Apex is now akinetic. Echo done on [**12-19**] showed akinesis of apex without thrombus. He was started on Coumadin after the benefits/risks were discussed with him and bridged with Lovenox. He received Lovenox teaching and is to continue this until his INR is 2.0 or greater. Pump: Checked Echo on [**12-19**], EF 40%. Started ACEI for afterload reduction, and titrated up as blood pressure tolerated. Digoxin (home medication) was stopped during hospitalization as it was felt it may not be beneficial for this patient. Rhythm: known AFib, rate-controlled. Started on Coumadin on [**12-20**]. . 2. CRI: Monitored Creatinine, unsure of baseline, 1.5-1.8 during hospitalization. Patient should have BUN/Creatinine monitored as outpatient while on ACE Inhibitor. . 3. FEN: Cardiac/Heart Healthy diet. Low sodium diet. Monitored electrolytes and repleted to keep Potassium > 4.0 and Magnesium > 2.0. . 4. Dispo: Patient to be discharged to home. Patient was cleared by Physical therapy to be safe for home discharge. As he was started on Coumadin for akinetic apex and Atrial Fibrillation, he is to have his blood drawn at [**Hospital 4068**] Hospital on [**12-25**] and these results to be sent to the physician covering for his primary care doctor (Dr. [**Last Name (STitle) 11302**]. Patient should continue Lovenox until INR therapeutic (2.0 or greater). He will need long-term cardiology follow-up, and will likely need a repeat Echocardiogram in [**2-10**] months to evaluate heart function and to see if patient is a candidate for ICD placement in the future. Patient was instructed by nutrition on the importance of low-sodium diet and to weigh himself daily and call his physician for possible need for diuretics if weight gain > 2 lbs or leg swelling develops. Patient should have BUN/Creatinine follow-up as outpatient as he was started on ACE Inhibitor. He was also given instructions to set up cardiac rehab as an outpatient. . DNR/DNI Medications on Admission: digoxin 0.25 terazosin 2 alprazolam 0.5 qhs Darvocet q4 spironolactone 25 mg po qday Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 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. Alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for insomnia. 5. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 7. Terazosin 2 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 8. Coumadin 2.5 mg Tablet Sig: Two (2) Tablet PO at bedtime. Disp:*60 Tablet(s)* Refills:*1* 9. Lovenox 60 mg/0.6mL Syringe Sig: One (1) Subcutaneous twice a day for 3 days. Disp:*6 * Refills:*0* Discharge Disposition: Home Discharge Diagnosis: ST elevation Myocardial infarction Atrial fibrillation Discharge Condition: stable Discharge Instructions: Please call your physician or return to the hospital if you experience chest pain, shortness of breath, increased leg swelling, palpitations, weight gain of > 2 lbs or other concerning symptoms. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 29111**] [**Name (STitle) 11302**] (Internal Medicine and Cardiology), [**Street Address(2) 48020**], [**Location (un) 620**], MA ([**Telephone/Fax (1) 29110**]) on Wednesday, [**2141-12-27**] at 12:00 p.m. Dr. [**Last Name (STitle) 11302**] will be covering for Dr. [**Last Name (STitle) 3060**]. . Please have your blood drawn to check Hematocrit, PT and INR while on Coumadin at [**Hospital 4068**] Hospital Lab on Friday [**2141-12-22**] and have these results sent to Dr. [**Last Name (STitle) 29111**] [**Name (STitle) 11302**] (fax # [**Telephone/Fax (1) 48021**]). . Please continue Lovenox injections until your INR blood level on Coumadin is 2.0 or greater (results should be faxed to Dr. [**Name (NI) 48022**] office). Completed by:[**2141-12-22**]

[ "414.01", "428.0", "428.30", "427.31", "724.2", "715.90", "403.91", "410.11", "427.89" ]

icd9cm

[ [ [] ] ]

[ "36.07", "00.45", "88.56", "00.40", "99.20", "00.66", "37.23" ]

icd9pcs

[ [ [] ] ]

10131, 10137

6087, 9020

285, 346

10236, 10245

2381, 3161

10488, 11299

1758, 1865

9155, 10108

10158, 10215

9046, 9132

3178, 6064

10269, 10465

1880, 2107

235, 247

374, 1448

2121, 2362

1470, 1598

1614, 1742

8,658

112,026

20128

Discharge summary

report

Admission Date: [**2138-11-3**] Discharge Date: [**2138-11-17**] Service: ADMISSION DIAGNOSIS: 1. Status post fall with epidural hematoma and C6 fracture. DISCHARGE DIAGNOSIS: 1. C6 burst fracture with epidural hematoma. 2. Paroxysmal atrial fibrillation requiring Amiodarone. 3. Cardiac pacer requiring interrogation. 4. Left lower lobe pneumonia. 5. Chronic ventilatory dependence with inability to wean. 6. Left upper extremity deep vein thrombosis. 7. Ability to anti-coagulate requiring IVC filter placement for pulmonary embolism prophylaxis. 8. Malnutrition requiring tube feeds. 9. Fever of unclear origin. PROCEDURES: 1. Evacuation of epidural hematoma C6 corpectomy and fusion with cage on [**2138-11-4**]. 2. Spinal fusion [**2138-11-7**]. HISTORY OF PRESENT ILLNESS: The patient is an 83-year-old man with a past medical history significant for hypertension, paroxysmal atrial fibrillation, sick sinus syndrome, status post pacer in [**2134**], left lower lobe pneumonia and polypectomy. He also has a past medical history significant for hernia repair times three, transurethral resection of prostate, left total knee replacement and lumbosacral decompression for spinal stenosis in [**2130**]. The patient fell approximately a week prior to admission and had upper back and neck pain. A CT at that time was negative. He was diagnosed with a left lower lobe pneumonia and treated with Levaquin. The patient continued with syncopal episodes and fell on the night prior to admission. On the day of admission, in the PCP's office the patient had a syncopal episode with a blood pressure in the 50's. He was unresponsive for several minutes but had a carotid pulse. He was transferred to [**Hospital3 3834**] which CT of the C-spine revealed a C6 fracture. Solu Medrol was bolused and started as a drip. The patient was unable to move his lower extremities, was insensitive from above the nipple to his toes. He had minimal motor function in his bilateral upper extremities and complained of C-spine pain. PAST MEDICAL HISTORY: 1. Hypertension. 2. Paroxysmal atrial fibrillation. 3. Sick sinus syndrome. 4. Pacer [**2134**]. 5. Left lower lobe pneumonia. 6. Tachybrady syndrome. 7. Syncope. 8. Hearing loss. PAST SURGICAL HISTORY: 1. Sigmoid polypectomy. 2. Hernia repair times three. 3. Transurethral resection of prostate. 4. Left total knee replacement. 5. Benign skin cancer removal on his forehead. 6. Lumbosacral decompression for spinal stenosis. ALLERGIES: Sulfa. MEDICATIONS ON ADMISSION: 1. Norvasc 5 mg once a day. 2. Amiodarone 200 mg once a day. 3. Coumadin three times a week. 4. Klonopin. SOCIAL HISTORY: Noncontributory. PHYSICAL EXAMINATION: On admission the patient was afebrile with normal vital signs. His GCS was 15, his pupils are equal, round, and reactive to light and accommodation. His heart was irregular. Lungs clear. Abdomen was soft, nontender, nondistended. He had decreased rectal tone and he was heme positive. He had no sensation from just above the nipple line to his feet. He was unable to move his trunk or lower extremities. He had bilateral upper extremity weakness with 3/5 wrist extension and [**11-24**] grip. His dorsalis pedis pulses were palpable bilaterally. He had no gross deformities of his thoracic lumbar spine but was tender over his cervical spine. Of significance the patient's INR on admission was 5.1. His electrocardiogram was V-paced with no acute ischemia. IMAGING: CT of the spine showed a C6 burst fracture. Chest x-ray with a question of a right seventh rib fracture. Pelvis x-ray: No fracture. TLS: No fracture. CT of abdomen and pelvis was no free fluid negative. HOSPITAL COURSE: The patient was seen and evaluated by Neurosurgery service in the Emergency Room. He was felt to have a C6 burst fracture and there was concern of an epidural hematoma given the fact that the patient had a pacemaker he was unable to undergo an magnetic resonance scan and was therefore scheduled for a CT myelogram. The patient was given Factor VII emergently to reverse his anti-coagulation as well as FFP. He was resuscitated, access was obtained and he was transferred to the Intensive Care Unit. The rest of his hospital course will be done by systems. 1. Neurologic. The patient was seen and evaluated by Neurosurgery. He was taken to the operating room in the early morning of [**2138-11-4**] for an evacuation of an epidural hematoma and C6 corpectomy and cage placement. Postoperatively the patient had little return of neurologic function with minimum movement of his toes bilaterally and triple flexion. On [**2138-11-7**] the patient returned to the O.R. for a posterior fusion. Again, his neurologic postoperative course showed minimal neurologic improvement. The patient was awake, alert and following commands and was transferred out of bed to the chair throughout his postoperative course when it was felt to be safe by Neurosurgery. 2. Cardiovascular. Given the fact that the patient had several bouts of syncope prior to admission and had a history of tachybrady syndrome, paroxysmal atrial fibrillation as well as sick sinus syndrome he was seen and evaluated by the Cardiology service. His pacemaker was interrogated and felt to be functioning fine. He was kept on his home dose of Amiodarone. His cardiac enzymes were cycled and were found to be negative. Cardiology felt that no further intervention was needed during his hospital course. 3. Respiratory. The patient was intubated in the operating room for his first surgery and was extubated postop. He had an episode where he desated however and was felt to be unable to maintain his respiratory drive. He was therefore, semi-electively reintubated on postop day zero. The patient had a prolonged ventilatory course and was unable to be weaned off the ventilator despite diuresis, aggressive pulmonary toilet and multiple bronchoscopies. He was admitted with a left lower lobe infiltrate and did spike fevers throughout his hospital course that were felt to be secondary to this infiltrate. 4. Gastrointestinal: The patient had no issue from the gastrointestinal standpoint. He was started on tube feeds and advanced to goal uneventfully. 5. Genitourinary. The patient had Foley throughout his hospital course. His urine output was adequate and he was diuresed with Lasix with a good response. He did have an episode of hypernatremia and hyperkalemia and thus free water was given to the patient with resolution of this problem. [**Name (NI) 227**] his fever spikes his urine was cultured throughout his hospital stay. 6. Heme/Vascular. Given the fact that the patient was unable to be anti-coagulated and was felt to be high risk for pulmonary embolism, an IVC filter was placed in the patient, was done on [**2138-11-4**] without problem. The patient's coagulopathy was reversed with FFP. Given the fact that the patient continued to have recurrent fevers he underwent bilateral lower extremity ultrasounds to rule out deep vein thrombosis as well as upper extremity ultrasound at the site of PICC line given his left upper extremity swelling. His lower extremity ultrasounds were negative but he did have a left upper extremity deep vein thrombosis. Vascular surgery was consulted and given the fact that this was asymptomatic I felt this could be treated conservatively. 7. ID. The patient was placed on Levofloxacin for left lower lobe pneumonia when he was admitted. Ancef was then added for periop coverage given his prosthetic material in his spine. He continued to spike fevers throughout his hospital course and on [**2138-11-13**] did grow out gram positive rods in his sputum. Otherwise, no clear source was found for his fever. 8. FEN. As mentioned in gastrointestinal section the patient was maintained on tube feeds. He did have an episode of hypernatremia and hyperkalemia which was treated with free water. His electrolytes were repleted as needed, otherwise he had no issues. 9. General Disposition: Given the patient's inability to wean off the vent and his family wishes on [**2138-11-17**] it was decided that the patient would be removed from ventilatory support. His daughter understood that the patient would not survive this but she felt it was his wish to not live in his current status therefore on [**2138-11-17**] he was extubated and expired. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 11889**] Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2139-1-5**] 15:13 T: [**2139-1-5**] 15:17 JOB#: [**Job Number 54139**]

[ "453.8", "427.31", "518.5", "344.00", "428.0", "707.0", "805.06", "E888.9", "997.1" ]

icd9cm

[ [ [] ] ]

[ "84.51", "96.04", "03.09", "81.62", "77.89", "38.91", "96.72", "96.6", "38.7", "81.02", "33.24", "38.93" ]

icd9pcs

[ [ [] ] ]

189, 781

2567, 2678

3742, 8705

2291, 2541

2735, 3724

106, 168

810, 2057

2079, 2268

2694, 2712

49,615

160,270

33364

Discharge summary

report

Admission Date: [**2165-11-21**] Discharge Date: [**2165-12-1**] Date of Birth: [**2082-9-24**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 922**] Chief Complaint: Ankle Swelling Major Surgical or Invasive Procedure: Coronary Artery Bypass Grafting x 3 (Left internal Mammary Artery grafted to Left anterior descending artery/Saphenous vein grated to Obtuse Marginal/Posterior left ventricular artery)-[**2165-11-21**] History of Present Illness: This is an 83 year old male admitted to [**Location (un) **] with congestive heart failure (acute systolic HF) and NSTEMI. New echocardiogram showed LVEF of 43% with mild MR [**First Name (Titles) **] [**Last Name (Titles) **]. He was stabilized on medical therapy and transferred to the [**Hospital1 18**] for further evaluation and treatment. Cardiac catheterization here revealed severe three vessel disease. Given the severity of his disease, he has been referred for surgical revascularization. Past Medical History: Past Medical History - CAD, Ischemic Cardiomyopathy - Hypertension - Dyslipidemia - History of Complete Heart Block - Chronic Renal Insufficiency - Anemia - Spinal Stenosis - Lumbar scoliosis - Varicose veins Past Surgical History - Biventricular Pacemaker - Hand SurgeryCARDIAC: Social History: quit smoking at age 21, does not currently use alcohol or illicit drugs Family History: No history of early cardiac death. Otherwise non-contributory. Physical Exam: Physical Exam Pulse: 70 SR Resp: 20 O2 sat: 98% RA Temp: 98.7 B/P Right: 123/63 Left: 118/66 Height: 68" Weight: 155lbs General: WDWN elderly male in NAD Skin: Dry, warm, intact, No JVD. Multiple nevi/keratosis noted, particularly along sternal tract. HEENT: NCAT, PERRLA, EOMI, Sclera anicteric, OP Benign Neck: Supple [x] Full ROM [x], nO jvd Chest: Mildly diminished at basis R>L Heart: RRR, NlS1-S2, No M/R/G Abdomen: Soft [X] non-distended [X] non-tender [X] bowel sounds + [X] Extremities: Warm [X], well-perfused [X] Trace Edema Varicosities: Right GSV with gross varicosities likley branches from mainGSV. Left appears suitable on standing. Neuro: Grossly intact, No focal deficits, MAE, Gait steady. 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: Faint bruit Left: None Pertinent Results: [**2165-11-25**] 05:07AM BLOOD WBC-16.3* RBC-3.87* Hgb-11.8* Hct-35.8* MCV-93 MCH-30.4 MCHC-32.9 RDW-16.3* Plt Ct-414 [**2165-11-21**] 11:28AM BLOOD WBC-32.9*# RBC-2.41*# Hgb-7.4*# Hct-22.6*# MCV-94 MCH-30.6 MCHC-32.7 RDW-13.0 Plt Ct-445* [**2165-11-22**] 08:10AM BLOOD PT-17.5* PTT-32.8 INR(PT)-1.6* [**2165-11-21**] 11:28AM BLOOD PT-21.1* PTT-37.4* INR(PT)-2.0* [**2165-11-25**] 05:07AM BLOOD Glucose-114* UreaN-46* Creat-1.1 Na-136 K-4.2 Cl-101 HCO3-26 AnGap-13 [**2165-11-21**] 12:32PM BLOOD UreaN-51* Creat-1.3* Cl-107 HCO3-23 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], J [**Hospital1 18**] [**Numeric Identifier 77443**] (Complete) Done [**2165-11-21**] at 9:09:32 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) 177**] C. [**Hospital Unit Name 927**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2082-9-24**] Age (years): 83 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Abnormal ECG. Aortic valve disease. Congestive heart failure. Coronary artery disease. Left ventricular function. Mitral valve disease. Right ventricular function. ICD-9 Codes: 427.60, 424.1, 424.0 Test Information Date/Time: [**2165-11-21**] at 09:09 Interpret MD: [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD Test Type: TEE (Complete) 3D imaging. Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 6507**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2009AW05-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *5.7 cm <= 4.0 cm Left Atrium - Four Chamber Length: *5.7 cm <= 5.2 cm Left Ventricle - Septal Wall Thickness: 0.7 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 0.7 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: *7.0 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 6.2 cm Left Ventricle - Fractional Shortening: *0.11 >= 0.29 Left Ventricle - Ejection Fraction: 20% to 25% >= 55% Aorta - Annulus: 2.0 cm <= 3.0 cm Aorta - Sinus Level: 3.2 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.7 cm <= 3.0 cm Aorta - Ascending: 2.7 cm <= 3.4 cm Aorta - Descending Thoracic: 2.5 cm <= 2.5 cm Aortic Valve - Valve Area: *1.5 cm2 >= 3.0 cm2 Findings Due to severe global LV dysfunction and poor SvO2 (50%), epinephrine infusion was started immediatey after inductioon with significant improvement inLV function. The reoprted WMA's are being reported with the epinephrine infusion Multiplanar reconstructions were generated and confirmed on an independent workstation. LEFT ATRIUM: Moderate LA enlargement. Moderate to severe spontaneous echo contrast in the body of the LA. Depressed LAA emptying velocity (<0.2m/s) No thrombus in the LAA. All four pulmonary veins identified and enter the left atrium. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is seen in the RA. No ASD by 2D or color Doppler. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal LV wall thickness. Severely dilated LV cavity. Severe regional LV systolic dysfunction. Severe global LV hypokinesis. Severely depressed LVEF. RIGHT VENTRICLE: Mildly dilated RV cavity. Mild global RV free wall hypokinesis. AORTA: Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Moderately thickened aortic valve leaflets. Mild AS (area 1.2-1.9cm2). No AR. MITRAL VALVE: Moderately thickened mitral valve leaflets. Mild mitral annular calcification. Moderate thickening of mitral valve chordae. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. Suboptimal image quality - poor echo windows. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-BYPASS: The left atrium is moderately dilated. Moderate to severe spontaneous echo contrast is seen in the body of the left atrium. The left atrial appendage emptying velocity is depressed (<0.2m/s). No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is severely dilated. There is severe regional left ventricular systolic dysfunction with akinetic apex, iferior wall and lateral wall. There is moderate hypokinesis of the remaining segments (LVEF =20-25 %). . The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. There is moderate thickening of the mitral valve chordae. POST CPB: 1. Marginally improved LV global and focal systolic function with backgeound inotropic support. EF= 30%. 2. Mildly improved RV globa;l RV systolci function. 3. Intact aorta and unchanges valvular structure and function Electronically signed by [**First Name8 (NamePattern2) 6506**] [**Name8 (MD) 6507**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2165-11-21**] 12:15 ?????? [**2158**] CareGroup IS. All rights reserved. Brief Hospital Course: [**11-21**] Mr.[**Known lastname 77440**] was taken to the operating room and underwent Coronary Artery Bypass Grafting x 3 (Left internal Mammary Artery grafted to Left anterior descending artery/Saphenous vein grated to Obtuse Marginal/Posterior left ventricular artery). Cross Clamp time=63 minutes. Cardiopulmonary Bypass Time=85 minutes. Please refer to DR[**Last Name (STitle) 5305**] operative report for further details. He tolerated the procedure well and was transferred to the CVICU in critical but stable condition intubated, sedated, and on pressors and inotropes to optimize cardiac hemodynamics. Postoperatively, EP interrogated his dual chamber [**Company 1543**] PPM. Mr.[**Known lastname 77440**] [**Last Name (Titles) 5058**] neurologically intact and was extubated without difficulty. All lines and drains were discontinued in a timely fashion. Aspiirin, Beta-blocker, statin and diuresis was initiated. POD#3 he was transferred to the step down unit for further monitoring. Physical Therapy was consulted for evaluation of strength and mobility. He continued to progress and on POD#10 he was cleared by Dr.[**Last Name (STitle) 914**] for discharge to rehab. All follow up appointments were advised. Medications on Admission: Medications(transfer): Metoprolol 25 [**Hospital1 **], lasix 20 qd, Lisinopril 20 qd, Aspirin 325 qd, SQ Heparin, Lipitor 10 qd Active Meds: 1. 2. Acetaminophen 3. Aspirin EC 4. Atropine Sulfate 5. Azithromycin 6. Furosemide 7. Heparin 8. Lisinopril 9. Metoprolol Tartrate 10. Pneumococcal Vac Polyvalent 11. Potassium Chloride 12. Simvastatin 13. Sodium Chloride 0.9% Flush Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever/pain. 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metolazone 2.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 2 weeks. 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day for 2 weeks. 10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO BID (2 times a day) for 2 weeks: hold for K>4.5. Tab Sust.Rel. Particle/Crystal(s) Discharge Disposition: Extended Care Facility: [**Hospital6 25759**] & Rehab Center - [**Location (un) **] Discharge Diagnosis: 1. Severe 3-vessel coronary artery disease. 2. Ischemic cardiomyopathy. 3. Complete heart block status post pacemaker/defibrillator. 4. Poor left ventricular function with an ejection fraction of 30%. 5. Previous inferior wall myocardial infarction. Discharge Condition: Alert and oriented x3 nonfocal Ambulating with assistance Sternal pain managed with percocet prn Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: Please call to schedule appointments Surgeon Dr.[**Last Name (STitle) 914**] in 4 weeks [**Telephone/Fax (1) 170**] Primary Care Dr.[**Last Name (STitle) 11375**],[**First Name3 (LF) **] R. [**Telephone/Fax (1) 11376**] in [**11-23**] weeks Cardiologist Dr [**Last Name (STitle) 11493**], [**First Name3 (LF) **] in [**11-23**] weeks Wound check appointment - [**Hospital Ward Name 121**] 6 ([**Telephone/Fax (1) 3071**]) - your nurse will schedule Completed by:[**2165-12-1**]

[ "414.8", "V53.31", "410.22", "724.02", "403.90", "428.0", "511.9", "585.9", "041.7", "428.22", "414.01" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

11062, 11148

8430, 9654

337, 541

11450, 11549

2505, 6793

12174, 12654

1481, 1545

10081, 11039

11169, 11429

9680, 10058

11573, 12151

6842, 7949

1560, 2486

282, 299

569, 1071

1093, 1375

1391, 1465

7959, 8407

32,743

133,436

10062

Discharge summary

report

Admission Date: [**2198-9-5**] Discharge Date: [**2198-9-11**] Date of Birth: [**2124-1-13**] Sex: M Service: CARDIOTHORACIC Allergies: Hydrochlorothiazide Attending:[**First Name3 (LF) 922**] Chief Complaint: left arm pain Major Surgical or Invasive Procedure: [**2198-9-5**] CABG x4/ left CEA (LIMA to LAD, SVG to DIAG, SVG to OM, SVG to PDA) History of Present Illness: 74 yo male originally seen in [**3-10**] after diagnosis of CAD. Workup revealed bilat. carotid disease. Referred for CABG/ left CEA with Drs. [**Last Name (STitle) 914**] and [**Name5 (PTitle) **]. Past Medical History: HTN DM CRI MI CAD although the MI appears silent gout elevated cholesterol osteoarthritis cataracts Social History: Alcohol, two glasses a week. Tobacco, stopped in [**2182**]. He smoked one to two packs a day for 20 years. He is a salesman, retired. Family History: Father died of stroke, mother broke hip - died of blood clot, brother with unknown resp problems Physical Exam: Admission: 70" 83.9 kg NAD skin unremarkable EOMI/PERRL neck supple, full ROM, no JVD, ? bil. carotid bruits CTAB RRR , no murmur present soft, NT, ND, + BS warm, well-perfused, no edema superficial varicosities noted left foot healing neuro grossly intact, alert and oreinted x3, MAE, nonfocal exam 1+ bil. fems, 0-1+ bil DP/PTs 2+ bil. radials Discharge: VS T 98.6 BP 143/78 HR 69SR RR 18 O2sat 96% RA Gen NAD Neuro A&Ox3, nonfocal exam CV RRR, sternum stable- incision CDI Pulm CTA bilat Abdm Soft, NT/+BS Ext warm, trace pedal edema Pertinent Results: Conclusions Pre-Bypass: 1. The left atrium is mildly dilated. 2. Overall left ventricular systolic function is mildly depressed (LVEF= 45 %). There is anterior and apical wall hypokinesis. The remaining left ventricular segments contract normally. Right ventricular chamber size and free wall motion are normal. 3.The descending thoracic aorta is mildly dilated. There are complex (>4mm), mobile atheromas, and ulcerated plaques in the descending thoracic aorta. 4.The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. The aortic valve leaflets are mildly thickened. Aortic sclerosis is noted, [**Location (un) 109**] is between 2.2-2.4 cm2. No aortic regurgitation is seen. 5. The mitral valve appears structurally normal with trivial mitral regurgitation. 6. There is no pericardial effusion. 7. There is lipomatous hypertrophy of the interatrial septum. No ASD by 2D or color doppler. Post-Bypass 1. LV function is preserved. 2. Aortic contours appear intact after decannulation. Mobile atheromas appear essentially unchanged.. 3. All other findings unchanged. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**Name6 (MD) 928**] [**Name8 (MD) 929**], MD, MD, Interpreting physician [**Last Name (NamePattern4) **] [**2198-9-5**] 17:21 [**2198-9-5**] 06:29PM GLUCOSE-79 NA+-138 K+-5.0 [**2198-9-5**] 06:16PM UREA N-44* CREAT-3.0* CHLORIDE-113* TOTAL CO2-22 [**2198-9-5**] 06:16PM WBC-13.7* RBC-2.95* HGB-9.0* HCT-26.4* MCV-90 MCH-30.4 MCHC-33.9 RDW-14.0 [**2198-9-5**] 06:16PM PLT COUNT-149* [**2198-9-5**] 06:16PM PT-15.6* PTT-45.1* INR(PT)-1.4* [**2198-9-11**] 05:50AM BLOOD WBC-10.7 RBC-2.55* Hgb-7.8* Hct-23.4* MCV-92 MCH-30.7 MCHC-33.5 RDW-15.6* Plt Ct-239 [**2198-9-11**] 05:50AM BLOOD Plt Ct-239 [**2198-9-11**] 05:50AM BLOOD UreaN-73* Creat-3.3* [**2198-9-10**] 06:10AM BLOOD Glucose-98 UreaN-80* Creat-3.7* Na-143 K-3.9 Cl-108 HCO3-24 AnGap-15 [**Known lastname **],[**Known firstname **] [**Medical Record Number 33623**] M 74 [**2124-1-13**] Radiology Report CHEST (PORTABLE AP) Study Date of [**2198-9-7**] 10:39 AM [**Last Name (LF) **],[**First Name7 (NamePattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5204**] CSRU [**2198-9-7**] SCHED CHEST (PORTABLE AP) Clip # [**Clip Number (Radiology) 33624**] Reason: s/p ct d/c [**Hospital 93**] MEDICAL CONDITION: 74 year old man with REASON FOR THIS EXAMINATION: s/p ct d/c Provisional Findings Impression: LCpc FRI [**2198-9-7**] 3:50 PM Since yesterday, the patient was extubated, the nasogastric tube, the Swan-Ganz and the left chest tube were removed. She remained in right internal jugular vein. Retrocardiac atelectasis decreased. Bilateral small pleural effusions decreased. Interstitial abnormality has improved. There is no overload. There is no pneumothorax. Final Report CHEST PORTABLE AP REASON FOR EXAM: 74-year-old man with chest tube removal. Since yesterday, the patient was extubated, the nasogastric tube, the Swan- Ganz catheter and the left chest tube were removed. The sheath of the Swan- Ganz is still in place in right internal jugular. Interstitial abnormality improved. Retrocardiac atelectasis decreased. Bilateral small pleural effusions also decreased. There is no overload and no pneumothorax. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) 4078**] [**Name (STitle) 4079**] DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**] DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**] Brief Hospital Course: Admitted [**9-5**] and underwent CEA/CABG surgery with Drs. [**Last Name (STitle) **] and [**Name5 (PTitle) 914**]. Transferred to the CVICU in stable condition on insulin, phenylephrine and propofol drips. Did well in the immediate postoperative period. Was weaned from ventilator and extubated on day of surgery. Remained hemodynamically stable on POD1 but remained in ICU for neurologic monitoring. On POD2 was transferred from ICU to stepdown floor. Once on the floor had an uneventful post-op course and was discharged home with visiting nurses on POD6. Medications on Admission: allopurinol 100 mg daily felodipine 10 mg daily glipizide 5 mg daily imdur 30 mg daily lopressor 50 mg [**Hospital1 **] nitro SL prn percocet prn simvastatin 80 mg daily ASA 325 mg daily Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 4. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 5. Glipizide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: s/p CABGx4/left CEA(LIMA to LAD, SVG to DIAG, SVG to OM, SVG to PDA) PMH:CAD bil. carotid disease PVD with prior left foot gangrene hypertension hypercholesterolemia osteoarthritis NIDDM cataracts CRI gout Discharge Condition: good Discharge Instructions: no lifting greater than 10 pounds for 10 weeks no driving for one month and until off all narcotics no lotions, creams or powders on any incision shower daily, and pat incisions dry call for fever greater than 100.5, redness, or drainage Weigh daily and report any weight gain greater than 3 pounds Followup Instructions: see Dr. [**Last Name (STitle) **] in [**1-3**] weeks see Dr. [**Last Name (STitle) **] in 2 weeks [**Telephone/Fax (1) 1241**] see Dr. [**Last Name (STitle) **] in [**2-4**] weeks see Dr. [**Last Name (STitle) 914**] in 4 weeks [**Telephone/Fax (1) 170**] SMA7 to be drawn by VNA on [**9-18**] with results called to Dr [**Last Name (STitle) 914**] @[**Telephone/Fax (1) 1504**] Completed by:[**2198-9-11**]

[ "276.2", "433.10", "411.1", "585.4", "433.30", "414.01", "250.00", "403.90", "272.0", "584.9", "276.7" ]

icd9cm

[ [ [] ] ]

[ "36.15", "00.40", "39.61", "88.72", "36.13", "38.12" ]

icd9pcs

[ [ [] ] ]

6869, 6927

5270, 5830

298, 386

7177, 7184

1586, 3971

7531, 7941

910, 1009

6067, 6846

4011, 4032

6948, 7156

5856, 6044

7208, 7508

1024, 1567

245, 260

4064, 5247

414, 614

636, 738

754, 894

77,643

138,158

38413

Discharge summary

report

Admission Date: [**2196-12-13**] Discharge Date: [**2196-12-15**] Date of Birth: [**2161-1-22**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1257**] Chief Complaint: Metformin Overdose Major Surgical or Invasive Procedure: None. History of Present Illness: The patient was not cooperative with the interview and refused to participate in the full history and physical. . HPI: This is a 35 year-old female with a history of Hepatitis C who presents following an overdose. The patient reports that she was in her usual state of health. At 3am on [**2196-12-13**] she states she accidently took 10 pills of metformin thinking that it was neurontin. She also reports recent relapse of crack cocaine and heroin. The patient reports that she developed abdominal pain, nausea, vomiting, and diarrhea. Per Tox report she had 5 episodes of emesis. The patient also reports lower back pain that began this morning as well. She denied any numbness/weakness, incontinence, or fevers, but did report slight chills. . In the ED, 98.3 78 97/58 20 100% RA. The patient's labs were significant for a WBC 37.6 with 83% neutrophils without bands. She was empirically covered with Flagyl and CTX. He denied any prior antibiotics use. Her lactate was noted to be 4.0 and anion gap of 17. Her Bicarb was 19 and Cr. 1.4. Her Tox screen was positive for BZD, opiates and cocaine. Her glucose remained at 43 despite amps of D50 (total 3 given) and started on a D10 gtt. She was seen by tox who recommended q4 lactate and q1 FS. Upon searching her belongings she was found to have a crack pipe, knife and insulin syringe. . On arrival the patient was not cooperative and stated "I've already told the other doctors [**Name5 (PTitle) 85546**]" and "leave me alone." She complainted of feeling "uncomfortable" and stated she had some lower back pain. . ROS: The patient denies any fevers, constipation, melena, hematochezia, chest pain, shortness of breath, cough, urinary frequency, urgency, dysuria, focal weakness, vision changes, headache, rash or skin changes. Past Medical History: Hepatitis C "Mood" Issues (per patient) Social History: Pt lives in [**Location 86**]. Smokes 1/2ppd x 15years denied EtOH Reports relapse with heroin and cocaine use Family History: Unable to obtain Physical Exam: On admission: GEN: not cooperative with the exam, sleeping, but easily arousble, beligerent, no acute distress HEENT: AT/NC, MMM, COR: RRR, no M/G/R, normal S1 S2 PULM: Lungs CTAB, no W/R/R ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, no palpable cords NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. On discharge: T:98.3 BP 106/65 HR 64 RR 18 O2 sat 100% on RA GEN: alert, interactive, in no acute distress HEENT: AT/NC, MMM, clear oropharynx COR: RRR, no M/G/R, normal S1 S2 PULM: Lungs CTAB, no W/R/R ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Motor and sensation grossly intact. Pertinent Results: Admission labs: [**2196-12-13**] 01:15PM BLOOD WBC-37.6*# RBC-4.57 Hgb-13.0 Hct-39.0 MCV-85 MCH-28.5 MCHC-33.5 RDW-16.4* Plt Ct-411 [**2196-12-13**] 01:15PM BLOOD Neuts-83.3* Lymphs-10.7* Monos-4.0 Eos-1.0 Baso-1.0 [**2196-12-13**] 02:25PM BLOOD PT-14.4* PTT-25.6 INR(PT)-1.2* [**2196-12-13**] 01:15PM BLOOD Glucose-46* UreaN-14 Creat-1.4* Na-140 K-4.5 Cl-104 HCO3-19* AnGap-22* [**2196-12-13**] 01:15PM BLOOD ALT-34 AST-37 CK(CPK)-318* AlkPhos-90 TotBili-0.5 [**2196-12-13**] 01:15PM BLOOD Albumin-4.5 Calcium-9.6 Phos-6.2* Mg-1.9 . Other labs: [**2196-12-13**] 01:15PM BLOOD HCG-<5 [**2196-12-13**] 01:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2196-12-13**] 08:24PM BLOOD Type-ART pO2-95 pCO2-33* pH-7.38 calTCO2-20* Base XS--4 [**2196-12-13**] 08:24PM BLOOD Lactate-1.2 [**2196-12-13**] 02:37PM BLOOD Lactate-4.0* . . Urine: [**2196-12-13**] 03:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.018 [**2196-12-13**] 03:00PM URINE Blood-NEG Nitrite-NEG Protein-75 Glucose-NEG Ketone-TR Bilirub-SM Urobiln-NEG pH-5.0 Leuks-NEG [**2196-12-13**] 03:00PM URINE RBC-0-2 WBC-0-2 Bacteri-NONE Yeast-NONE Epi-0-2 [**2196-12-13**] 03:00PM URINE CastHy-21-50* CastWBC-[**2-4**]* [**2196-12-13**] 03:00PM URINE Eos-NEGATIVE [**2196-12-13**] 03:00PM URINE Hours-RANDOM UreaN-162 Creat-188 Na-44 K-45 Cl-77 [**2196-12-13**] 03:00PM URINE UCG-NEGATIVE [**2196-12-13**] 03:00PM URINE bnzodzp-POS barbitr-NEG opiates-POS cocaine-POS amphetm-NEG mthdone-NEG . . Microbiology: [**2196-12-13**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2196-12-13**] BLOOD CULTURE Blood Culture, Routine-PENDING . . Radiology: XR CHEST (PORTABLE AP) Study Date of [**2196-12-13**] 2:36 PM FINDINGS: The cardiomediastinal and hilar contours are normal. The lungs are clear. Subtle bibasilar lung opacities likely reflect breast shadowing. The left costophrenic angle has been excluded from this study. There is no large pleural effusion or pneumothorax. The osseous structures appear intact. IMPRESSION: No acute cardiopulmonary process. . TTE: The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 65%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The aortic valve is not well seen. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. The mitral valve leaflets are mildly thickened. The mitral valve leaflets are myxomatous. There is no mitral valve prolapse. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. No masses or vegetations are seen on the tricuspid valve, but cannot be fully excluded due to suboptimal image quality. No masses or vegetations are seen on the pulmonic valve, but cannot be fully excluded due to suboptimal image quality. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. No obvious vegetations seen. If clinically indicated, a transesophageal echocardiographic examination is recommended. Brief Hospital Course: 35 year-old female with a history of Hepatitis C who presents with N/V/D and lower back pain following accidental metformin overdose. . Plan: #. Overdose: The patient reports accidently taking 10 pills of metformin. Denies suicidal ideation preceding ingestion. Labs notable for anion gap acidosis and an elevated lactate of 4.0 on admission. Toxicology consulted. Lactate trended Q4hr. Downtrending at time of discharge with gap closing. Labs also notable for hypoglycemia to 46 on admission. Patient required 3 amps of d50, d10 gtt, IV D5W for 1L. Sugars stabilized prior to transfer. Interesting, hypoglycemia is not an expected complication of metformin overdose. Patient was found to have insulin syringes, but denied insulin injection. C-peptide sent to evaluate for insulin usuage. Patient placed on CIWA protocol q3 with po valium 5-10mg CIWA > 10. Ordered oxycodone prn to help with withdrawal sx and pain. Social work and psych consulted prior to transfer to floor- felt safe for discharge to her sister in law's home in [**Location (un) 32944**]. Patient asymptomatic on floor [**Doctor Last Name **] below 5 on CIWA throughout. Was discharged with a few doses of neurontin to last her until follow up with her PCP and psychiatrist. . #. Leukocytosis: Pt on admission with leukocytosis of 37.6 with normal differential and no bands without any localizing symptoms of infection. Patient initially covered with ceftriaxone and metronidazole due to question C. difficile. On the floor patient transitioned to IV vancomycin. Due to history of IVDU MRI ordered to assess for epidural abscess. Patient refused MRI. TTE ordered to assess for valvular vegetations. TTE without vegetations. Patient afebrile throughout hospitalization. Follow-up WBC downtrended to 11 with nl differential. . #. Hypoglycemia: Pt with continued hypoglycemia as low as 46 on arrival. Pt reported taking metformin, but this is not a known complication. Concern for possible accidental/intentional insulin injection vs infection. Insulin level and c-peptide ordered; pending at time of discharge. Finger sticks stabilized prior to discharge- 105 the morning of discharge. . # Substance Abuse. Patient with long history of drug and alcohol abuse. Tox screen + opiates, cocaine, benzos on admission. Placed on CIWA scale. Social work and psych consulted. Patient without SI/HI in ICU or on the floor. . #. [**Last Name (un) **]: Pt with Cr 1.4 on admission. Previously with Cr of 0.7. Likely represents pre-renal etiology from dehydration and poor po intake. Creatinine improved to 0.9 on hospital 2 after IV hydration. . # Disposition- Patient reported a history of dometic violence, so she was seen by social work and a representative from the Center for Violence Prevention and Recovery. She was given resources about violence prevention and a safe home was identified for her at her sister-in-law's place in [**Location (un) 32944**]. She was discharged with a T pass and cab vouchers to this location. . Pending on discharge: [**2196-12-13**] C peptide level, insulin level, blood cultures x2 Medications on Admission: Neurontin 800mg QID Klonopin 1mg QID Discharge Medications: 1. gabapentin 400 mg Capsule Sig: One (1) Capsule PO QID (4 times a day). Disp:*8 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: Drug overdose Acute kidney injury Hypoglycemia Secondary: Substance abuse Hepatitis C Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 13959**], You were admitted to the hospital because of a drug overdose. Your blood sugar was very low and you suffered acute kidney injury. You were monitored in the intensive care unit and treated with intravenous fluids and your condition gradually improved. You were evaluated by toxicology specialists and psychiatrists who felt it was safe to discharge you. You were also seen by a social worker who helped provide resources to help with your living situation. We recommend that you follow up with your primary care doctor and/or psychiatrist within the next week. It was a pleasure taking care of you at the [**Hospital1 18**]. We wish you a speedy recovery. Followup Instructions: Please follow up with your primary care doctor, Dr. [**Last Name (STitle) **]. Call [**Telephone/Fax (1) 85547**] to schedule the appointment. Please also follow up with your psychiatrist Dr. [**Last Name (STitle) 85548**]. Completed by:[**2196-12-15**]

[ "724.2", "305.50", "251.2", "E858.0", "787.01", "962.3", "584.9", "070.70", "276.2", "276.51", "305.60" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9758, 9764

6461, 9458

325, 333

9914, 9914

3157, 3157

10784, 11040

2350, 2368

9627, 9735

9785, 9785

9566, 9604

10065, 10761

2383, 2383

9472, 9540

267, 287

361, 2143

3174, 3692

9804, 9893

2397, 2758

9929, 10041

2165, 2206

2222, 2334

3704, 6438

68,507

101,555

39869

Discharge summary

report

Admission Date: [**2174-11-3**] Discharge Date: [**2174-11-8**] Date of Birth: [**2109-3-19**] Sex: M Service: CARDIOTHORACIC Allergies: bee stings Attending:[**First Name3 (LF) 922**] Chief Complaint: Chest pain, shortness of breath Major Surgical or Invasive Procedure: [**2174-11-4**] 1. Coronary artery bypass grafting x2 with left internal mammary artery to left anterior descending coronary artery; reverse saphenous vein single graft from the aorta to the ramus intermedius coronary artery. 2. Endoscopic left greater saphenous vein harvesting. History of Present Illness: Mr. [**Known lastname 61502**] is a 65 year old man who complains of increasing chest pain and dyspnea on exertion over the past 10-14 days. Cardiac Catheterization: Date: [**2174-11-3**] Place: [**Hospital 5279**] Hospital Severe LM ramus and PDA lesions. Normal EF Past Medical History: Diabetes with polyneuropathy Hypertension Hyperlipidemia Obesity Diverticulitis of the large intestine Chronic renal insufficiency Sleep apnea, CPAP of 10 Hyperthyroidism GERD Tubular edenoma w polypectomy, conoloscopy due [**2176**] HOH Social History: Race:Caucasian Last Dental Exam: 6 weeks ago, no infections at that time Lives with:girlfriend (pt is divorced) Occupation:barber Tobacco:20 pack year history, quit 1 wk ago ETOH:[**12-22**] drinks per week Family History: brother w CAD s/p stenting in 40s, died of bladder CA in 60s Physical Exam: On Admission Pulse: 56 Resp:23 O2 sat: 93 B/P 133/81 Height: 5'8" Weight:220 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact [x] Pulses: Femoral Right: 2+ Left: 2+ DP Right: 1+ Left: 1+ PT [**Name (NI) 167**]: 1+ Left: 1+ Radial Right: 2+ Left: 2+ Carotid Bruit Right: - Left: - Pertinent Results: Admission Labs: [**2174-11-3**] 11:51PM GLUCOSE-134* UREA N-23* CREAT-1.0 SODIUM-133 POTASSIUM-8.6* CHLORIDE-100 TOTAL CO2-25 ANION GAP-17 [**2174-11-3**] 11:51PM CK-MB-2 cTropnT-<0.01 [**2174-11-3**] 11:51PM WBC-7.8 RBC-5.28 HGB-15.0 HCT-43.2 MCV-82 MCH-28.4 MCHC-34.7 RDW-14.3 [**2174-11-3**] 11:51PM PLT COUNT-177 [**2174-11-3**] 11:51PM PT-12.8 PTT-25.3 INR(PT)-1.1 [**2174-11-3**] 04:19PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.018 [**2174-11-3**] 04:19PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2174-11-3**] 04:05PM GLUCOSE-112* UREA N-22* CREAT-0.8 SODIUM-138 POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-26 ANION GAP-13 [**2174-11-3**] 04:05PM ALT(SGPT)-47* AST(SGOT)-32 LD(LDH)-132 CK(CPK)-57 ALK PHOS-55 AMYLASE-54 TOT BILI-0.8 [**2174-11-3**] 04:05PM LIPASE-26 [**2174-11-3**] 04:05PM CK-MB-3 cTropnT-<0.01 [**2174-11-3**] 04:05PM TSH-3.4 [**2174-11-3**] 04:05PM T4-7.5 T3-117 [**2174-11-3**] 04:05PM BLOOD %HbA1c-7.4* eAG-166* Discharge LAbs: [**2174-11-8**] 04:45AM BLOOD WBC-7.6 RBC-2.93* Hgb-8.4* Hct-24.4* MCV-83 MCH-28.7 MCHC-34.4 RDW-14.7 Plt Ct-229# [**2174-11-8**] 04:45AM BLOOD Plt Ct-229# [**2174-11-4**] 07:50PM BLOOD PT-13.1 PTT-26.0 INR(PT)-1.1 [**2174-11-8**] 04:45AM BLOOD Glucose-134* UreaN-24* Creat-0.9 Na-135 K-4.3 Cl-99 HCO3-30 AnGap-10 Radiology Report CHEST (PA & LAT) Study Date of [**2174-11-6**] 1:46 PM [**Hospital 93**] MEDICAL CONDITION: 65 year old man with s/p POD 2 CABG CT removal Final Report Two views. Comparison with [**2174-11-4**]. The patient is status post CABG as before. An endotracheal tube, nasogastric tube, chest tube, mediastinal drain, and Swan-Ganz catheter have been withdrawn. Lung volumes are low. There is bibasilar streaky density consistent with subsegmental atelectasis or consolidation in the retrocardiac area as before. There is interval blunting of the left costophrenic sulcus. Mediastinal structures are unchanged. IMPRESSION: Interval increase in left pleural fluid. There is no other significant change since removal of line and tubes. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 40% >= 55% Aorta - Ascending: *3.8 cm <= 3.4 cm Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Mild regional LV systolic dysfunction. Mildly depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Mildly dilated ascending aorta. Simple atheroma in descending aorta. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Mild [1+] TR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions Prebypass No atrial septal defect is seen by 2D or color Doppler. There is mild regional left ventricular systolic dysfunction with hypokinesia of the apex, apical and mid portions of the anteroseptal walls. Overall left ventricular systolic function is mildly depressed (LVEF= 40%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Dr. [**Last Name (STitle) 914**] was notified in person of the results on [**2174-11-4**] at 1530 Post bypass Patient is in sinus rhythm. Biventricular systolic function is unchanged. Mild mitral regurgitation persists. Aorta is intact post decannulation. Brief Hospital Course: Mr. [**Known lastname 61502**] was transferred on [**2174-11-3**] from [**Hospital 9464**] Hospital for management of his coronary artery disease. He was continued on IV heparin. Preoperative work-up was completed. He was brought to the operating room on [**2174-11-4**] for coronary artery bypass graft surgery. See operative report for further details. He received cefazolin for perioperative antibiotics and was transferred to the intensive care unit for postoperative management. In the first twenty four hours he was weaned from sedation, awoke neurologically intact and was extubated without complications. On post operative day one he was started on beta blockers and diuretics. He continued to do well and was transferred to the floor hemodynamically stable. The remainder of his hospital coursewas uneventful. Exam below summaries hospital events: Respiratory: aggressive pulmonary toilet, nebs, incentive spirometer he titrated off oxygen with saturations of XXXX on room air. Chest-tubes: Mediastinal and left pleural chest tubes were removed on POD2. Cardiac: beta-blockers were titrated as tolerated hemodynamically. He remained hemodynamically stable in sinus rhythm. ASA and statin were continued. GI: H2 Blocker and bowel regime throughout hospital stay. Nutrition: cardiac healthy, diabetic diet was tolerated Renal: renal function within normal limits with good urine output. His electrolytes were replete as needed. He was diuresed to pre operative weight Endocrine: maintained on insulin drip in CVICU and transition to insulin sliding scale with blood sugars < 150. He was started on his home dose Metformin. Gabapentin was restarted on postoperative day 1 Neuro/Pain: No neurological events. Antidepressant was restarted. Well controlled with percocet. Disposition: He was seen by physical therapy and deemed safe for home. He was discharged home with visiting nurses on [**2174-11-8**]. Medications on Admission: Lopressor 25mg [**Hospital1 **] Nitrostat 0.4 SL PRN ASA 81mg daily Norvasc 2.5mg daily Vitamin C 500mg daily Lisinopril 10mg daily Pravachol 40mg HS Gabapentin 600mg [**Hospital1 **] Cymbalta 60mg QAM Fish Oil 1200mg [**Hospital1 **] Glucosamine Chondroitin 500mg [**Hospital1 **] Omeprazole 20mg daily Metformin 500mg daily Cialia 20mg PRN Discharge Medications: 1. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO QAM (once a day (in the morning)). 2. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 3. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) 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. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. 7. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*65 Tablet(s)* Refills:*0* 8. metformin 500 mg Tablet Sig: One (1) Tablet PO once a day. 9. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 10. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 11. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 7 days. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Home Health & Hospice Care Discharge Diagnosis: Coronary Artery Disease s/p cabg Diabetes with polyneuropathy Hypertension Hyperlipidemia Obesity Diverticulitis of the large intestine Chronic renal insufficiency Sleep apnea, CPAP of 10 Hyperthyroidism GERD Tubular edenoma w polypectomy, conoloscopy due [**2176**] HOH Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Right leg - healing well, no erythema or drainage. Trace Edema Discharge Instructions: -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 -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. [**Last Name (STitle) 914**], Tuesday, [**2174-11-22**], 2pm Cardiologist: none Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) 76709**] [**Telephone/Fax (1) 76133**] in [**1-20**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2174-12-1**]

[ "272.4", "327.23", "250.60", "403.90", "357.2", "414.01", "585.9", "530.81", "278.00", "413.9" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

9945, 10002

6416, 8347

308, 602

10317, 10529

2120, 2120

11290, 11772

1407, 1470

8740, 9922

3609, 5344

10023, 10296

8373, 8717

10553, 11267

3184, 3572

5388, 6393

1485, 2101

237, 270

630, 904

2136, 3168

926, 1166

1182, 1391

8,205

121,116

11347

Discharge summary

report

Admission Date: [**2114-2-3**] Discharge Date: [**2114-2-10**] Date of Birth: [**2059-9-16**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 898**] Chief Complaint: Admitted to MICU for GIB, originally c/o dizziness and dark stool Major Surgical or Invasive Procedure: EGD with epinephrine injection and BICAP cautery History of Present Illness: 54 y/o F with h/o OCD and anemia p/w progressive dizziness, dark stool over past week. She reported having falls at home, no LOC but fell and hit head with head laceration 4 days prior to admission. She also had been vomiting coffee grounds last 2 days prior to admission. She reports taking "a lot" of Excedrin over past week for LBP. She reported no h/o GI bleed. In ED, her initial BP 80/50s and the pt was A&O X3 able to give hx but sleepy. After 20 min pt. became unresponsive and brady'd down to 30-40s. The patient was then intubated, given epinephrine and atropine, with IV access difficult to obtain with bilateral unsuccessful groin sticks (possibly a sticks)placed 2 PIVs and 14G R EJ. Hct returned at 14%, K was 6.7, ABG 7.09/34/326 on 100% intubated. Given Ca, bicarb, 5 U PRBCs and 2L IVF with improved BP 120/70s and HR 70s. GI came to do emergent EGD and found gastric ulcer and duodenal bulb ulcers c/w NSAID toxicity, thought to be source. CT head negative. Abd CT showed ? gall bladder sludge with edema otherwise negative. She was admitted then to the MICU for further monitoring and management. Past Medical History: Anemia OCD Depression GERD (but thought Actonel was for GERD) history of "high white blood cell count" Social History: Lives alone in [**Location (un) **], moved from [**Location (un) 7349**] in [**2110**] and feels that she left "her city." Works as administrative assistant at temp firm. SIster lives in [**Location 701**], no children, single. Denies EtOH and IVDA. Family History: Father died at 75 of MI Mother died at 74 of colon cancer Sister had ulcers, otherwise healthy Physical Exam: On admission: T 98.2/ 74// 120/80// 19// 100% on NRB Gen: sedated and intubated HEENT: MMM, no JVD Neck: Suple, JVP 4 cm Heart : RRR, no m/g/r Lungs: B/l exp wheezes Abs: s/nt, slight distension, +BS Ext: no edema, 2+ pulses On transfer from MICU to floor [**2114-2-5**]: AF/96// 168/88/ rr22-29// spo2 100% on 4L NC Gen: pleasant, a7ox3, NAD, somewhat disheveled middle-aged female sitting in chair, conversant HEENT: MMM, anicteric sclerae, right eyelid erythematous and slightly swollen Neck: Suple, r EJ in place, no jvd Heart : RRR, no m/g/r Lungs: CTAB Abs: s/nt, slight distension, no HSM, negative [**Doctor Last Name 515**] sign, +BS Ext: 1+ b/l LE edema, 2+ DPs b/l Pertinent Results: CBC: [**2114-2-3**] 02:00PM BLOOD WBC-27.4*# RBC-1.55*# Hgb-4.6*# Hct-14.6*# MCV-94 MCH-30.0 MCHC-31.9 RDW-18.1* Plt Ct-367 [**2114-2-5**] 04:32AM BLOOD WBC-18.3* RBC-3.51* Hgb-10.6* Hct-30.1* MCV-86 MCH-30.2 MCHC-35.3* RDW-16.7* Plt Ct-167 [**2114-2-3**] 02:00PM BLOOD Neuts-86* Bands-4 Lymphs-9* Monos-1* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2114-2-4**] 04:00AM BLOOD Neuts-85.2* Bands-0 Lymphs-11.1* Monos-3.3 Eos-0.2 Baso-0.1 Chemistries: [**2114-2-3**] 02:00PM BLOOD Glucose-86 UreaN-67* Creat-1.6* Na-134 K-6.7* Cl-95* HCO3-14* AnGap-32* [**2114-2-5**] 04:32AM BLOOD Glucose-85 UreaN-14 Creat-0.4 Na-142 K-4.0 Cl-114* HCO3-22 AnGap-10 LFTs: [**2114-2-3**] 05:33PM BLOOD ALT-399* AST-647* LD(LDH)-1358* AlkPhos-77 Amylase-37 TotBili-0.9 [**2114-2-4**] 04:00AM BLOOD ALT-454* AST-966* LD(LDH)-968* CK(CPK)-1050* AlkPhos-78 Amylase-37 TotBili-0.8 Cardiac enzymes: [**2114-2-4**] 04:00AM BLOOD cTropnT-<0.01 [**2114-2-3**] 05:33PM BLOOD cTropnT-<0.01 [**2114-2-3**] 02:00PM BLOOD CK-MB-33* MB Indx-1.9 cTropnT-<0.01 Initial Toxin Screen: [**2114-2-4**] 04:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-POS Brief Hospital Course: 54 y/o f with massive GI Blead and bradycardic arrest in ED, with evidence of active bleeding at gastric and duodenal ulcers. Patient's admission comprised of 2 day MICU stay with continued hemodynamic stability, followed by several days on the medicine [**Hospital1 **] for monitoring, physical therapy, treatment for hypoxia and neurologic evaluation. 1. Upper GI Bleed: PUD likely [**3-7**] NSAIDs. Pt was continued on PPI, initially IV and transitioned to oral. Her hematocrit was monitored twice daily initially, and then daily. All NSAIDS and Actonel were held, with a recommendation to continue to avoid these medications after discharge. Gastrin level was elevated, but believed secondary to PPI therapy. Pt will require outpatient GI follow-up. Finally, concern regarding the level of insight underlying the patient's large doses of NSAIDs, coupled with her family's concerns about her psychiatric history, prompted psychiatric and neurologic evaluations. Both of these services followed the patient through her admission. 2) Question of cholescystitis: RUQ U/S for ? sludge and GB wall thickening on CT. U/S equivocal. HIDA scan negative. [**Doctor First Name **] consulted but ascertained that there were no further surgical needs. Cultures and hepatitis serologies were unrevealing, and exam and LFTs normalized. Increased LFTs were likely [**3-7**] hypotension on presentation. 3) Elevated LFTS: DDx includes cholecytitis, effect of hypotension, muscle damage. Likely dignosis was hypotension on presentation given negative work-up delineated above. Held Lipitor given transaminitis for outpatient review. 4) Bradycardia: possibly due to massive GI Bleed, or elev K and acidosis, resolved in ICU 5) Metabolic acidosis: -likely lactic acidosis from hypotention and hypovolemic shock, although lactate mildly elevated (but checked after resucitation), aspirin negative, resolved in ICU. 6) Leukocytosis: some evidence of PNA on CT with 4+ GPCs on GS, also ? gallbladder wall edema on CT. Evidence lacking for cholecytitis, MICU team hypothesis was that elevation [**3-7**] demargination under stress. Continue to monitor, f/u cultures, d/w PCP. [**Name10 (NameIs) **] was on vanco/unasyn in the ICU, narrowed to levofloxacin as she had suggestion of pneumonia but no other infection. 7) Wheezing/SOB: Patient with likely COPD as she has smoked [**3-8**] PPD x over 30 years. The patient improved with nebulizer treatments, and will be discharged on bronchodilators with outpatient follow-up. 8) Neuro/Pyschiatric: Patient on Fluoxetine, clonazepam and Anafranil at home, which were originally held in the ICU. Psychiatry consult was called after discussion with the patient's sister, who was concerned about her inability to work and general lack of ability to care for herself, most clearly manifested financially. The psychiartry consult had no medication recommendations, and her TSH/B12/Folate/RPR were all negative or within normal limits as appropriate. They suspected a cognitive problem and were concerned by her lack of judgement however, and also recommended an MRI. The read of this MRI was notable for multiple T2 high-signal-intensity abnormalities in the periventricular white matter and centrum semiovale. The findings suggested a demyelinating disorder, or potentially a microvascular angiopathy. There was also an area of abnormality in the left periatrial white matter, which could represent one of these demyelinating areas or could represent a small subacute infarct. The neurology team recommended an LP for routine analysis, oligoclonal bands, and ACE level to evaluate for multiple sclerosis and sarcoidosis; [**Doctor First Name **], ANCA, CRP, and ESR levels to evaluate for vasculitis; formal neuropsych evaluation as an outpatient and follow-up in behavioral neurology clinic. The LP was performed prior to discharge, and the bulk of the serologic testing was performed. The patient's PCP will [**Name9 (PRE) 702**] these studies as an outpatient. In addition, the psychiatry team tried to get in touch with her PCP and psychiatrist as an outpatient, but had been thusfar unsucessful at the time of discharge. 9) FEN: Patient was tolerating a normal house diet at the time of discharge. 10) follow-up: A follow-up appointment was arranged for the patient with her PCP before discharge. She was also given instructions for neurology, behavioral neurology, psychiatry and neuropsychiatric testing follow-up. Finally, she was recommended to have her hematocrit checked the week following discahrge to ensure continued stability. Medications on Admission: Fluoxetine 20 mg po QD Lipitor 20 mg po QD Klonipin 1 mg up to tid prn Anafranil 250 mg po QD Actonel 5 mg po QD Discharge Medications: 1. Fluoxetine HCl 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*2* 3. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for anxiety. 4. Clomipramine HCl 50 mg Capsule Sig: Five (5) Capsule PO DAILY (Daily). 5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Salmeterol Xinafoate 50 mcg/Dose Disk with Device Sig: One (1) inhalation Inhalation Q12H (every 12 hours). Disp:*60 inhalation* Refills:*2* 7. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**2-4**] puffs Inhalation four times a day. Disp:*1 MDI* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Gastric and duodenal ulcers Blood loss anemia Depression Reactive Airway Disease Obsessive-Compulsive Disorder Discharge Condition: Stable Discharge Instructions: * Return to ER or call Dr. [**Last Name (STitle) **] for any stomach pain, coffee-ground vomit, bloody or black stools, lightheadedness or any other concerning symptoms. * Avoid all NSAIDs, aspirin, Excedrin or any related symptoms. * Try to avoid smoking as this slows the healing of ulcers. * Take all medications as prescribed. * Follow-up with your doctors as recommended. Followup Instructions: 1) Follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] within 1 week for a blood test. You also have an appointment with her Wednesday [**2-14**] at 1:15; the results of your lumbar puncture may be available at that time as well. Her office is at One [**Location (un) **] Place, and can be reached at ([**Telephone/Fax (1) 6712**]. 2) Follow-up with your psychiatrist Dr. [**First Name (STitle) **] as soon as possible after discharge, within 1-2 weeks. 3) Follow-up with behavioral neurology in [**2-4**] weeks: ([**Telephone/Fax (1) 17518**] 4) Neurology: Follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1274**] in [**2-4**] weeks([**Telephone/Fax (1) 19252**]. 5) Neuropsychiatric testing: ([**Telephone/Fax (1) 36355**]. Dr. [**Last Name (STitle) **] can help you arrange this as well. Completed by:[**2114-4-1**]

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Discharge summary

report

Admission Date: [**2161-10-12**] Discharge Date: [**2161-10-15**] Date of Birth: [**2077-8-10**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1436**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 33681**] is a 84 year old male with severe aortic stenosis (valve area of 0.9 cm2; LVEF of 50-55%; peak velocity of 2.0 m/s based on TTE on [**2160-6-9**]) and [**Year (4 digits) **] III/IV COPD (FEV1 46% of predicted on [**4-/2160**] PFTs), Coronary artery disease s/p NSTEMI with peaked troponin of 0.23 in [**7-/2159**] and inferior wall motion abnormality in TTE (08/[**2158**]). . He presents to the ED with two day history of shortness of breath. He reports having increased lower extremity swelling, paroxysmal noctural dyspnea, two pillow orthopnea, whitish productive sputum and abdominal distention over past two days. He does not report fever, chills, pleuritic chest pain, palpatations, dizziness, syncope or sick contacts. [**Name (NI) **] reports he has been using his inhaler more frequently yesterday without any help. Of note they were at his son's house for [**Holiday **] dinner. Patient and family do not report any sick contacts or high salt intake. No history of eating outside. . In the ED, initial VS were: 98.2 97 131/61 30 96%. EKG showed sinus rhythm at rate of 90 with prolong AV delay and LBBB which is similar to his previous EKG (01/[**2159**]). No ST-T changes compared to prior. CXR showed pulmonary vascular congestion with cephalization of vessels. Labs significant for normal WBC, creatinine at baseline of 2.3, troponin of 0.07, BNP of 2776, Mg of 1.4 and lactate of 4.0 . He was treated for COPD exacerbation with IV methylprednisolone 125 mg x 1; azithromycin 500 mg IV x 1; albuterol/ipratropium q1 nebs. He also received IV lasix 20 mg x 1 for acute on chronic systolic heart failure though no urine output was noted. CPAP with 4LNC was started to help with respiratory distress from acute on chronic systolic heart failure and COPD exacerbation. He was transferred for further evaluation and management of hypoxemic respiratory distress. His vitals prior to transfer were afebrile 87 127/72 24 99-100% CPAP 4LNC. . On arrival to the MICU, he reports feeling better after CPAP and therapeutic regimen in the ED. Extensive discussion revealed he would not like to be intubated or have cardiac resuscitation which was confirmed with wife and HCP [**Doctor First Name 12239**] at bedside. He is ok with noninvasive positive pressure ventilation mask like CPAP and BPAP. He reports having daily bowel movement. His baseline shortness of breath is with walking to the bathroom which has worsened to any activity over past two days. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: 1. COPD Stage III (FEV1 46% expected [**4-/2160**]) 2. Severe aortic stenosis with valve area of 0.9 cm2 and mitral reguritation (moderate) 3. coronary artery disease: Regional WMA on TTE 4. hypertension 5. hypercholesterolemia 6. chronic kidney disease with h/o uretral stones 7. benign prostatic hyperplasia 8. colonic adenomas ([**2158**]) Social History: - Tobacco: > 60 pack year history of smoking. Quit in [**2152**]. - Alcohol: Significant alcohol use in the past. Rare intake over past several years. Had a glass of wine over [**Holiday **] - Illicits: None Lives with his wife in [**Name (NI) 3494**]. Has 2 kids and 6 grandkids. Originally from [**Country 6257**]. Emigrated in [**2103**]. Used to work in the foundry. He is able to do his of ADLS. His wife does most of his [**Name (NI) 4461**] including bills, shopping, laundry and houswork. Family History: Not relevant at this age. Physical Exam: Admission Physical Exam: Vitals: T:97.9 BP:137-67 P:99 R:26 O2:96%6LNC GENERAL: Elderly gentleman in moderate respiratory distress whose speech is punctuated by brief, forceful inspirations. NECK: No jugular venous distention appreciated though difficult to ascertain with thick neck, CARDIAC: Difficult to hear over audible wheezing but late peaking systolic murmur with absent S2 noted over subxiphoid process. LUNGS: Using accessory muscles. Inspiratory and expiratory wheezes with minimal air movement. Prolonged expiratory phase. ABDOMEN: Soft and nontender. Distended. No hepatosplenomegaly appreciated. No shifting dullness noted. BACK: No concerning lesions, no CVA tenderness. EXTREMITIES: 2+ pedal edema bilaterally. 1+ edema to knee bilaterally. Appropriate temperature to touch at distal extremities. PULSES: 1+ femoral and PD pulses. Regular radial pulse NEURO: Alert and oriented x 3. Did not ascertain muscle strength due to shortness of breath. 98.6 129/77 (119-139) 92% 1L 189.6 --> 189 --> 186lbs I/O: [**Telephone/Fax (1) 106145**] GENERAL: Patient comfortable NECK: No JVP appreciated [**12-17**] neck habitus. CARDIAC: Distant heart sounds. II/VI systolic, late peaking crescendo/decrescendo murmur heard best in L sternal and RUS border. No appreciable radiation. Carotid pulse unremarkable. LUNGS: Inspiratory and expiratory wheezes and rhonchi. Moderate air movement. ABDOMEN: Soft and nontender. Distended. No hepatosplenomegaly appreciated. No shifting dullness noted. EXTREMITIES: 1+ LE edema bilaterally to ankle. Warm lower extremities. PULSES: Regular radial pulses. Distal pedal pulses present to palpation. NEURO: Alert and oriented x 3. Pertinent Results: ADMISSION LABS: [**2161-10-12**] 07:40AM BLOOD WBC-7.7 RBC-3.31* Hgb-8.6* Hct-27.1* MCV-82 MCH-26.0* MCHC-31.7 RDW-14.7 Plt Ct-160 [**2161-10-12**] 07:40AM BLOOD Neuts-77.0* Lymphs-14.4* Monos-5.6 Eos-2.6 Baso-0.4 [**2161-10-12**] 07:40AM BLOOD Glucose-126* UreaN-43* Creat-2.3* Na-134 K-4.2 Cl-95* HCO3-27 AnGap-16 [**2161-10-12**] 07:40AM BLOOD ALT-27 AST-27 LD(LDH)-288* CK(CPK)-772* AlkPhos-89 TotBili-0.2 [**2161-10-12**] 07:40AM BLOOD CK-MB-19* MB Indx-2.5 proBNP-2776* [**2161-10-12**] 07:40AM BLOOD cTropnT-0.07* [**2161-10-12**] 07:40AM BLOOD Albumin-4.2 Calcium-8.7 Phos-4.1 Mg-1.4* [**2161-10-13**] 04:17AM BLOOD Type-[**Last Name (un) **] Temp-36.7 pO2-62* pCO2-50* pH-7.39 calTCO2-31* Base XS-3 [**2161-10-12**] 07:48AM BLOOD Lactate-4.0* PERTINENT INTERVAL LABS: [**2161-10-14**] 07:30AM BLOOD Glucose-88 UreaN-76* Creat-3.0* Na-138 K-3.7 Cl-93* HCO3-36* AnGap-13 [**2161-10-14**] 07:30AM BLOOD LD(LDH)-238 CK(CPK)-511* [**2161-10-12**] 07:40AM BLOOD cTropnT-0.07* [**2161-10-12**] 08:04PM BLOOD CK-MB-14* MB Indx-1.9 cTropnT-0.05* [**2161-10-13**] 02:59PM BLOOD CK-MB-9 cTropnT-0.08* [**2161-10-14**] 07:30AM BLOOD CK-MB-7 cTropnT-0.11* [**2161-10-13**] 04:17AM BLOOD Lactate-1.0 [**2161-10-14**] 07:30AM BLOOD Ret Aut-1.9 [**2161-10-14**] 07:30AM BLOOD LD(LDH)-238 CK(CPK)-511* [**2161-10-14**] 07:30AM BLOOD calTIBC-371 Hapto-292* Ferritn-14* TRF-285 [**2161-10-14**] 07:30AM BLOOD Calcium-8.8 Phos-4.2 Mg-2.2 Iron-23* DISCHARGE LABS: [**2161-10-15**] 07:35AM BLOOD WBC-7.7 RBC-3.27* Hgb-8.5* Hct-27.1* MCV-83 MCH-26.0* MCHC-31.4 RDW-15.2 Plt Ct-182 [**2161-10-15**] 07:35AM BLOOD Glucose-86 UreaN-85* Creat-3.0* Na-141 K-4.1 Cl-98 HCO3-34* AnGap-13 [**2161-10-15**] 07:35AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.1 URINE [**2161-10-12**] 02:22PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008 [**2161-10-12**] 02:22PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG MICRO: Blood Cultures ([**2161-10-12**]) x2: NGTD Urine Culture ([**10-12**]): No growth MRSA screen: negative STUDIES: ECG ([**10-12**]): Moderate baseline artifact. Because of the baseline artifact, it is difficult to identify atrial activity. The rhythm is regular at a rate of 98 beats per minute. Probably normal sinus rhythm. Complete left bundle-branch block. Possible prolonged A-V conduction. Compared to the previous tracing of [**2159-8-8**] no diagnostic interval change. CXR Portable ([**10-12**]): FINDINGS: There is a focal area of hazy opacity in the left lower lobe with loss of the left cardiac margin. This finding appears unchanged when compared to prior radiographs on NCT. There is prominent bronchopulmonary vascular markings with possible interstitial edema in the peripheral interlobular septa. There is no pleural effusion or pneumothorax. The imaged osseous structures are intact. There is no free air below the right hemidiaphragm. IMPRESSION: Mild pulmonary vascular congestion and interstitial edema compatible with CHF. ECHO ([**10-13**]): The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with basal to mid inferolateral hypokinesis. [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] The right ventricular cavity is dilated with normal free wall contractility. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets are moderately thickened with mild to moderate aortic stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate to severe (3+) mitral regurgitation is seen. Severe [4+] tricuspid regurgitation is seen. The pulmonary artery systolic pressure could not be determined. Significant pulmonic regurgitation is seen. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2160-6-9**], the left ventricular wall motion abnormality is new and there is now associated prominent mitral regurgitation that is likely ischemic (post-infarction). CXR ([**10-14**]): FINDINGS: PA and lateral views of the chest. Mild cardiomegaly, compared with [**2157**], the heart size has increased and the left atrium and left ventricle are more prominent. Previously seen mild interstitial pulmonary edema has decreased compared with [**2161-10-12**]. Aortic valve calcifications. No pleural effusion. No pneumothorax. No infiltration. The mediastinal and hilar contours are normal. IMPRESSION: 1. Decrease in pulmonary edema compared with [**2161-10-12**]. No infiltrate. 2. Mild cardiomegaly, compared with [**2157**], the heart size has increased and the left atrium and left ventricle are more prominent. Brief Hospital Course: ======================= BRIEF HOSPITAL SUMMARY ======================= Mr. [**Known lastname 33681**] is a 84 year old male with severe aortic stenosis, COPD, CAD s/p NSTEMI in [**2158**] p/w shortness of breath, most likely from COPD exacerbation. ======================= ACTIVE ISSUES ======================= # COPD excacerbation: Pt was treated with levalbuterol and ipratropium nebs, azithromycin x 5 days and prednisone 40mg daily x 5 days. He has 2 days remaining at time of discharge. Lung symptoms improved. He was still wheezing at discharge, but per patient and family, he was improved compared to his baseline. Pt was sent home on ambulatory O2 of 1L when ambulating. # Shortness of breath/acute on chronic systolic CHF: The patient's shortness of breath most likely due to COPD exacerbation. He also had a smaller component of pulmonary edema from acute on chronic systolic heart failure. He was initialy admitted to the MICU where the patient was intially started on diueresis with Lasix bolus of 40 mg IV, but was soon started on a Lasix drip with goal net negative output of 2 liter. He was also given prednisone 40mg daily and azithromycin along with levalbuterol and ipratropium nebs for COPD. The patient's O2 requirement improved with his diueresis and upon transfer to the floor, he was breathing comfortably on nasal cannula. While being diuresed, [**Hospital1 **] lytes were checked and repleted. His rate control was also increased, as metoprolol was started at 25 mg q8, with target heart rate in the 80s to ensure adequate time for diastolic filling. This was then stopped as it seemed to exacerbate his underlying lung disease. # Severe aortic stenosis and diastolic dysfunction/CAD: Pt declines any invasive procedures or surgical interventions. Troponin were elevated, appropriate for his renal failure. MB was flat. His echo showed some inferolateral hypokinesis which likely reflects a prior MI within the last year ([**2159**] echo negative). Pt does not want any cardiac catheterization procedures. Continued on ASA 81. Pt declines to take his statin. Stopped his metoprolol on this admission since it seemed to exacerbate his COPD symptoms. # Lactic acidosis: Lactate initialy 4.0, improved to 1.0. Likely due to acute low perfusion state from acute on chronic systolic heart failure and severe aortic stenosis. Acute Renal Failure/ CKD: Baseline Cr 2.2-2.5. While in MICu, he was started n lasix drip for pulmonary congestion. His symptoms improved and lasix drip was stopped. While on drip, Cr increased, bicarb increased, K decreased, suggesting over-diuresis. Lasix was stoped and Cr stabalized at 3.0. He has renal follow up. # HTN: Stopped his home HCTZ on this admission since BP stable on current medications. Also stopped his metoprolol since seemed to exacerbate his COPD. Continued his amlodipine 10mg daily. Lasix was held and may be resumed when Cr improves to baseline. #Anemia: Pt found to have anemia that is likely combination of Fe def anemia and from CKD. [**Name (NI) **] pt start ferrous sulfate [**Hospital1 **] and will fu with nephrologist to discuss if he would benefit from Epo supplementation. Workup for iron deficiency can be considered outpatient, although pt and family do not want any invasive procedures. ========================== INACTIVE ISSUES ========================== 7. HLD: Atoravastatin discontinued during last admission. Appropriate considering age and comorbidity with risk/benefit. Pt does not wish take his statin. 8. BPH: Continued tamsulosin 0.4 mg po qhs ============================= TRANSITIONAL ISSUES ============================= 1. Fe Deficiency anemia: can discuss with pt whether or not to work this up. Started Ferrous Sulfate 2. Acute Renal Failure: [**Hospital1 **] checking Cr on post-discharge visit to see if it trends down. Pt's ARF likely from over-diuresis. 3. MEDICATION CHANGES: STOP: Metoprolol, this is likely making your wheezing and lung COPD worse. STOP: Hydrochlorothiazide, your blood pressures do well without this medication. Your primary care doctor can consider restarting this medication outpatient. STOP: stop Lasix for now. You have no fluid in your lungs and you do not need this at this time. However, your primary care doctor may wish to resume this medication when your kidney function returns to normal. START: Iron supplentation: you have anemia from low iron and we recommend you take iron supplements START: Azithromycin- this is an antibiotic for your reason lung infection. You will take this for 2 more days. START: Prednisone 40mg daily. This is for your emphysema flair. You will take this for 2 more days. START: LevAbluterol nebulizer. You can take this instead of your albuterol inhaler since it is easier to take and allows more of the medicine to go to your lungs. You can take the ipratropium nebulizer instead of your atrovent inhaler and instead of the combivent inhaler. Medications on Admission: Albuterol sulfate 90 mcg HFA Aerosol inhaler [**11-16**] puff q4-6 Amlodipine 10 mg po qdaily Lasix 20 mg po prn edema (patient reports not taking any) HCTZ 25 mg po qdaily Atrovent HFA 17 mcg/actuation HFA Aersol 2 puffs q6 Combivent 18 mcg-103 mcg (90 mcg) 2pff QID Latanoprost 0.005% drops 1 drop both eyes at bedtime Metoprolol 50 mg ER po qdaily Omeprazole 40 mg po qdaily Tamsulosin 0.4 mg ER po qhs Aspirin 81 mg po qdaily Fish oil-DHA-EPA 1,200 mg-144 mg-216 mg Capsule po BID Discharge Medications: 1. Home oxygen Sig: One (1) When Ambulating only: 1-2 L when ambulating only. Ambulatory O2 RA=85%. Ambulatory O2 with 1L NC: 89%. Dx: COPD. Disp:*1 1* Refills:*0* 2. levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation Q2H (every 2 hours) as needed for wheezing. Disp:*300 ml* Refills:*3* 3. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. nebulizer & compressor Device Sig: One (1) Miscellaneous every four (4) hours as needed for shortness of breath or wheezing. Disp:*1 u* Refills:*0* 5. nebulizer accessories Kit Sig: One (1) Miscellaneous every four (4) hours as needed for nausea. Disp:*1 unit* Refills:*0* 6. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. Disp:*300 ml* Refills:*2* 7. Atrovent HFA 17 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puff Inhalation every six (6) hours as needed for shortness of breath or wheezing. 8. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puff Inhalation four times a day. 9. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 10. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 11. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 14. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 15. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 2 days. Disp:*2 Tablet(s)* Refills:*0* 16. azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. Disp:*2 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: primary diagnoses: COPD exacerbation Acute on chronic heart diastolic failure secondary to aortic stenosis Acute Kidney Injury Iron Deficiency Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [**Known lastname 33681**], It was a pleasure taking care of you. You were admitted to the hospital for shortness of breath. We treated you for both an exacerbation of COPD and also for an acute on chronic episode of heart failure. While in the hospital, you had an echocardiogram. We diuresed you (removed fluid) and gave you nebulized breathing treatments and azithromycin; and your breathing improved significantly. You should weigh yourself every day, and call your doctor if you gain more than 2 pounds in one day. Your kidney function is a little worse then usual but is stable these last 2 days of your hospitalization. We anticipate that it will improve over the next few days now that you are no longer on the lasix medication. Please make sure to follow with your primary care doctor who will check your kidney function. We scheduled an appointment for you to see a kidney doctor in the next 2 weeks. You should continue taking all of your medications as you had prior to your hospitalization, except: STOP: Metoprolol, this is likely making your wheezing and lung COPD worse. STOP: Hydrochlorothiazide, your blood pressures do well without this medication. Your primary care doctor can consider restarting this medication outpatient. STOP: Lasix for now. You have no fluid in your lungs and you do not need this at this time. However, your primary care doctor may wish to resume this medication when your kidney function returns to normal. START: Iron supplentation: you have anemia from low iron and we recommend you take iron supplements START: Azithromycin- this is an antibiotic for your reason lung infection. You will take this for 2 more days. START: Prednisone 40mg daily. This is for your emphysema flair. You will take this for 2 more days. START: LevAbluterol nebulizer. You can take this instead of your albuterol inhaler since it is easier to take and allows more of the medicine to go to your lungs. You can take the ipratropium nebulizer instead of your atrovent inhaler and instead of the combivent inhaler. Followup Instructions: Department: [**Hospital3 249**] When: TUESDAY [**2161-10-20**] at 8:40 AM With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 3990**], [**First Name3 (LF) **] [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: WEST [**Hospital 2002**] CLINIC/NEPRHOLOGY When: TUESDAY [**2161-10-27**] at 1 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**], MD [**Telephone/Fax (1) 721**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: PULMONARY FUNCTION LAB When: THURSDAY [**2161-10-29**] at 1:40 PM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: MEDICAL SPECIALTIES When: THURSDAY [**2161-10-29**] at 2:00 PM With: [**Name6 (MD) 610**] [**Name8 (MD) **] RN/DR. [**Last Name (STitle) 611**] [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage *This appointment is with a specialist who will focus directly on COPD management as you transition from the hospital to home. After this visit, you will be scheduled with Dr. [**Last Name (STitle) **] or with a new pulmonologist who will follow you. Department: CARDIAC SERVICES When: MONDAY [**2161-11-23**] at 9:20 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2385**], MD [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

18169, 18227

10771, 14648

326, 333

18421, 18421

5909, 5909

20682, 22536

4168, 4195

16232, 18146

18248, 18400

15723, 16209

18604, 20659

7363, 10748

4235, 5890

2872, 3272

14668, 15697

267, 288

361, 2853

5925, 7347

18436, 18580

3294, 3638

3654, 4152

10,168

199,365

11661+11664

Discharge summary

report+report

Admission Date: [**2111-1-8**] Discharge Date: Date of Birth: [**2036-4-3**] Sex: M Service: Medicine Intensive Care Unit-Green Team HISTORY OF PRESENT ILLNESS: The patient is a 74 year old male with a history of coronary artery disease, status post coronary artery bypass graft times three vessel on [**2110-12-4**] and hypertension, atrial fibrillation, chronic obstructive pulmonary disease, hypothyroidism and congestive heart failure who was transferred from an outside hospital to [**Hospital6 256**] for management of congestive heart failure. Following the patient's coronary artery bypass graft in [**Month (only) **], he spent two weeks at [**Hospital6 1760**] with a course prolonged by a prolonged intubation, Clostridium difficile, lower gastrointestinal bleed, ischemic colitis, congestive heart failure and atrial fibrillation. He was transiently discharged to rehabilitation and then discharged to home but was readmitted to [**State 20192**] Center after one day of being at home in which he complained of shortness of breath. At that time he had a negative lower extremity ultrasound and intermediate probability V/Q scan. He was started on Coumadin, they also considered aspiration. The patient had a swallow evaluation which showed difficulty swallowing and he was started on a diet of pureed solid and liquids. The patient had an echocardiogram which showed ejection fraction of 35 to 45% and he remained in atrial fibrillation. They tried to diurese him, however, his BUN and creatinine were elevated. Of note, he also had a fall out of bed on [**2111-1-6**] but had a negative head computerized tomography scan. He was transferred to [**Hospital6 1760**] on [**1-8**] for further evaluation and workup. PAST MEDICAL HISTORY: 1. Coronary artery bypass graft times three vessel on [**2110-12-4**] with hospital course prolonged due to prolonged intubation, Clostridium difficile, ischemic colitis, lower gastrointestinal bleed, pneumonia, atrial fibrillation and congestive heart failure. 2. Paroxysmal atrial fibrillation times three years. 3. Congestive heart failure. 4. Hypothyroid. 5. Coronary artery disease. 6. Increased lipids. 7. Left inguinal hernia. 8. Hypertension. 9. Depression. 10. Chronic renal insufficiency. 11. Abdominal aortic aneurysm measuring 4.7 cm. 12. Bilateral vein ligation. 13. Status post hemorrhoid operation. SOCIAL HISTORY: The patient has a 65 to 70 pack/year tobacco smoking history. He is also recently widowed in [**Month (only) **] of last year. ALLERGIES: Dramamine. MEDICATIONS ON ADMISSION: 1. Combivent metered dose inhaler 2. Aspirin 81 mg per day 3. Prilosec 20 mg per day 4. Flomax .4 per day 5. Prozac 10 mg per day 6. Lopressor 25 mg per day PHYSICAL EXAMINATION: Physical examination on admission revealed vital signs with temperature 96.3, blood pressure 82/49, respiratory rate 26, heartrate in 110s. Oxygen saturation is 91% on 3 liters. In general, the patient is a fairly ill-appearing male in no acute distress. His extraocular movements are intact. His pupils are equal, round, and reactive to light. His oropharynx is without erythema or exudate. He does not have any lymphadenopathy in his neck. There is no jugulovenous distension. His heart appears irregular and tachycardiac with normal S1 and S2. There is a systolic murmur. Lungs, he has bibasilar rales. Abdomen, there are normal bowel sounds, soft, nontender, nondistended. Extremities are without edema and his vasculature has good capillary refill. LABORATORY DATA: On admission he has a white count of 8.8, hemoglobin 10.8, hematocrit 31.9, platelets 221. PT is 23.9, PTT 44.3 and INR of 4.0. Chemistry reveals sodium 143, potassium 4.5, chloride 111, bicarbonate 20, BUN 37 and creatinine 1.5. Glucose 107. Calcium is 7.8, magnesium 2.2, phosphorus 2.6, and albumin 2.7. IMPRESSION: The patient is a 74 year old male, status post coronary artery bypass graft in [**Month (only) 1096**] who has essentially had difficulty returning to his baseline presurgery, most notable for difficulties with his breathing. So, he is being admitted for further workup of respiratory compromise and at this time the leading diagnosis is congestive heart failure. HOSPITAL COURSE: Pulmonary - On [**1-10**], the patient was noted to be with shortness of breath and low oxygen saturations. He has 7.47 PH, PCO2 24, and PO2 of 51. The Intensive Care Unit Team was called to the floor and the patient was brought to the Intensive Care Unit, intubated and started on pressor support ventilation 5 and 5 and started on Dopamine drip. Chest x-ray showed emphysema with a worse diffuse interstitial process. A right internal jugular line was placed as well as a right A line placed. A Swan-Ganz catheter was placed. A computerized axial tomography scan demonstrated diffuse groundglass and reticular opacities, left greater than right, extensive emphysema with left pleural effusion and also a left adrenal adenoma and a small retrosternal fluid collection. On [**1-14**], the patient eventually went into adult respiratory distress syndrome due to bilateral infiltrates, a pulmonary capillary wedge pressure was 18 and pAO2/FIO2 ratio of less than 150. His adult respiratory distress syndrome was thought to be secondary to the following: First the Amiodarone-toxicity. The patient was on Amiodarone prior to his heart surgery in [**Month (only) **], however, on postoperative day #2 he developed atrial fibrillation. Following the surgery he was transferred to the [**State 20192**] Center on Amiodarone and Coumadin. Due to the hypothesis that his respiratory compromise could be secondary to Amiodarone toxicity, his Amiodarone was discontinued on [**1-12**] and the patient was started on Prednisone 60 mg per day. The patient did have a right open lung biopsy on [**1-17**] which showed foamy macrophases suggesting Amiodarone toxicity as well as bacterial pneumonia (see below). His Prednisone has since been tapered such that he is now taking 15 mg of Prednisone per day. The next likely hypothesis for his adult respiratory distress syndrome was an infectious pneumonia. On [**1-12**], he was started on Levaquin and Flagyl to cover for an aspiration pneumonia. On [**1-13**] the patient was started on Vancomycin for a sputum culture showing Gram positive cocci in pairs and clusters. On [**1-13**], thoracentesis was done and 550 cc of bloody pleural fluid was removed. This was deemed a hemorrhagic exudate. On [**1-16**] the patient was started on Ceftazidime to cover from gram negative rods. This was later confirmed to be a pseudomonal pneumonia as well as Pseudomonas in his urinary tract infection. The patient had Pseudomonas growing out of a bronchioalveolar lavage as well as from a urine culture. The patient was then double covered for Pseudomonas pneumonia on [**1-19**] when we started Tobramycin. The patient was also noted to have cryptococcus neoformans growing from a pleural fluid sample from [**1-13**] and a pleural fluid from [**1-17**] and also from the tissue biopsy on [**1-19**]. He was started on Fluconazole. Subsequently his blood was positive for cryptococcal antigens. We discontinued his Fluconazole and on [**1-21**] started Ambazone. In summary of his pulmonary issues the patient developed adult respiratory distress syndrome most likely secondary to Amiodarone toxicity, Pseudomonas pneumonia and cryptococcus involving the pulmonary system as well. On [**1-23**], a tracheostomy was performed. On [**1-28**], the patient spent two hours off the ventilator and then on [**1-29**] the patient spent several hours off of the ventilator with a tracheostomy mask. Cardiovascular - Initially the patient was found to be hypertensive and tachycardiac and started on intravenous fluids, Digoxin and Lopressor. He was also in atrial fibrillation and on Amiodarone. On [**1-9**], echocardiogram demonstrated an ejection fraction of 60-65% with normal right ventricular and left ventricular function with moderate tricuspid regurgitation. On [**1-12**], his Amiodarone was discontinued and on [**1-13**], the patient converted to normal sinus rhythm. On [**1-17**], he went back to atrial fibrillation and a heparin drip was started on the following day. On [**1-27**], the patient was becoming hypertensive and at that time was started on Lopressor and his dose was increased to 25 mg b.i.d. On [**1-28**], the patient experienced chest pain, however, ruled out for myocardial infarction based on his cardiac enzymes. Gastrointestinal - On [**1-19**], the patient had a post pyloric tube placed. He received total parenteral nutrition and tube feeds for several days. On [**1-22**], he had a percutaneous endoscopic gastrostomy tube placed. On [**1-25**], the patient was noted to be hypotensive and his hematocrit fell to 23. He was guaiac positive and on lavage had bright red blood coming from the lavage. Over the next 24 hours he received 6 units of packed red blood cells, 3 units of FFP, his heparin and Coumadin was discontinued and he was also given two bags of platelets. To further rule out the gastrointestinal bleed source, the patient on [**1-26**] went for endoscopic gastroduodenoscopy (EGD). The findings of that were blood in the gastroesophageal junction, submucosal tear and blood in the percutaneous endoscopic gastrostomy and jejunostomy site but no active bleeding was seen. Heme - The patient prior to developing the gastrointestinal bleed had received 2 units of blood on [**1-12**] and 1 unit of blood on [**1-14**], and another unit of blood on [**1-19**]. He was started on a heparin drip for anticoagulation on [**1-8**], however, this was discontinued on [**1-25**]. Also of note the patient has remained somewhat thrombocytopenic throughout his stay with platelets averaging between 87 and 110. Renal - The patient came in with chronic renal insufficiency and came with a creatinine of 1.5. His creatinine did improve with fluids and around the time of discharge his creatinine is .8. His antibiotics have been renally dosed. Also of note, on [**1-14**], his urine chemistry demonstrated a positive urine anion gap of 26. This was determined to be a non-anion gap metabolic acidosis with a positive urine anion gap which was deemed a compensatory mechanism for his respiratory alkalosis. Endocrinology - The patient was noted to have a TSH of 62. He was initially started on Synthroid 50 mcg and was increased to his current dose of 125 mcg/day. Also of note, due to hyperglycemia the patient was started on insulin drip for tighter glucose control on [**1-17**]. He is now off of the drip and on a sliding scale insulin. Infectious disease - 1. Pseudomonas pneumonia, treated with Ceftazidime 2 gm intravenously q. 12 hours, this was started on [**1-16**] and should continue for a total of 21 days, as well as Tobramycin 110 mg intravenously q. 12 hours, this was started on [**1-19**] and should continue for a total of 14 days. 2. Cryptococcus neoformans in the pulmonary system, treated with Ambazone 250 mg intravenously per day, started on [**1-21**] and this should continue for a total of two weeks, followed by Fluconazole 400 mg intravenously for another 8 to 10 weeks. Neurological - The patient had a computerized tomography scan of his head on [**1-22**] for evaluation of altered mental status. This showed no hemorrhage, positive atrophy and positive ventriculomegaly with a question of normal pressure hydrocephalus. CONDITION ON DISCHARGE: Good. DISCHARGE STATUS: The patient will be discharged to a rehabilitation facility in the next few days. DISCHARGE INSTRUCTIONS: 1. The patient should follow up with his primary care physician as well as Dr. [**Last Name (STitle) 36953**] his pulmonologist. 2. Discharge medications - Please see addendum to follow shortly. DISCHARGE DIAGNOSIS: 1. Amiodarone toxicity 2. Pseudomonas pneumonia 3. Pulmonary cryptococcosis secondary cryptococcus neoformans 4. Gastrointestinal bleed 5. Atrial fibrillation 6. Hypertension 7. Hypothyroidism 8. Coronary artery disease 9. Anemia 10. Chronic renal insufficiency 11. Depression DR.[**First Name (STitle) **],[**First Name3 (LF) **] 11-575 Dictated By:[**Name8 (MD) 36954**] MEDQUIST36 D: [**2111-1-29**] 18:18 T: [**2111-1-29**] 19:05 JOB#: [**Job Number 36955**] Admission Date: [**2111-1-8**] Discharge Date: [**2111-2-3**] Date of Birth: [**2036-4-3**] Sex: M Service: MEDICAL INTENSIVE CARE UNIT, GREEN TEAM ADDENDUM DISCHARGE MEDICATIONS: Ceftazidime 2 g IV q.12 hours, day 18 of 21, Ambazone 250 mg IV q.d. to be infused over 2 hours, day 13 of 14, the Ambazone course will be completed on [**2111-2-4**], at which time he should start taking Fluconazole 400 mg p.o. or IV q.d. x 8-10 weeks, regular Insulin sliding scale, Colace 100 mg p.o. b.i.d., Synthroid 125 mcg p.o. q.d., Prevacid elixir 30 mg p.o. q.d., tube feeds with Peptamen 75 cc/hr, Aspirin 81 mg p.o. q.d., Prednisone 10 mg p.o. q.d., this is day 2 at 10 mg, he should continue this for a total of 5 days, and then switch to 5 mg p.o. q.d. x 7 days, Neutra-Phos 1 packet per G-tube t.i.d., Lopressor 75 mg b.i.d., Lasix 20 mg p.o. q.d., Calcium Gluconate p.r.n., Magnesium Sulfate p.r.n., Ativan 0.5-1.0 mg p.r.n., Haldol 0.5-1.5 mg p.r.n., DISPOSITION: The patient is discharged to a rehabilitation facility in stable condition. [**Doctor Last Name **] Dictated By:[**Last Name (NamePattern1) 29450**] MEDQUIST36 D: [**2111-2-3**] 13:06 T: [**2111-2-3**] 13:59 JOB#: [**Job Number 36960**]

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icd9cm

[ [ [] ] ]

[ "99.15", "45.13", "33.28", "96.04", "38.93", "96.6", "34.91", "31.1", "96.72" ]

icd9pcs

[ [ [] ] ]

12661, 13722

11928, 12637

2599, 2763

4277, 11551

11709, 11907

2786, 4260

182, 1757

1779, 2403

2420, 2573

11576, 11685

3,026

189,501

3930

Discharge summary

report

Admission Date: [**2196-11-10**] Discharge Date: [**2196-11-29**] Date of Birth: [**2153-9-21**] Sex: M Service: LIVER TRANSPLANT SURGERY REASON FOR ADMISSION: Orthotopic liver transplantation to treat end-stage liver disease. HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is a 43-year-old male with a history of worsening liver failure due to alcohol abuse. This has been complicated with the development of massive ascites, anasarca, worsening renal function, portal hypertension, and encephalopathy. The patient was called into the hospital after an offer for a cadaveric liver for transplantation was accepted by the transplant team. A recent admission from [**2196-10-17**] to [**2196-11-6**] occurred for a left lower extremity leg abscess which was incised and drained and treated with antibiotics. This had prevented him from receiving a liver transplant earlier. At this point, he has fully recovered from his leg abscess. He denies any fevers, chills, nausea, or vomiting. He says he has been quite well since he was discharged. PAST MEDICAL HISTORY: 1. End-stage liver disease due to alcohol use. 2. Left lower extremity abscess. 3. Massive ascites. 4. Portal hypertension. 5. Anasarca. 6. History of encephalopathy. PAST SURGICAL HISTORY: 1. Status post right inguinal hernia repair in [**2163**]. 2. Status post tonsillectomy. 3. Status post left lower extremity incision and drainage of an abscess on [**2196-10-31**]. MEDICATIONS ON ADMISSION: Include Aldactone 300 mg p.o. once daily, Lasix 80 mg p.o. in the morning and 40 mg p.o. in the evening, Protonix 40 mg p.o. once daily, clotrimazole 10 mg p.o. four times daily, Benadryl 25 mg p.o. once daily, lactulose 30 mg p.o. three times daily, Ativan as needed, and Levaquin 500 mg p.o. once daily. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient smoked half a pack a day times 24 years. He said he had two drinks a day for 20 years but has stopped drinking at this point. He did have cocaine use in the [**2171**] but denies any current use. FAMILY HISTORY: The patient's father had coronary artery disease diagnosed at the age of 55. His mother had a history of breast cancer. PHYSICAL EXAMINATION ON PRESENTATION: The patient's temperature was 99.5, the heart rate was 60, the blood pressure was 148/86, and oxygen saturation was 96 percent on room air. He is [**Age over 90 **] kilogram. On admission, he awake, alert, and oriented times three. In no acute distress. He was jaundiced. Examination was significant for a soft, distended, nontender abdomen; consistent with ascites. He had trace lower extremity edema bilaterally; otherwise unremarkable. PERTINENT LABORATORY DATA ON PRESENTATION: His white count was 5, his hematocrit was 31, and his platelets were 74. INR was 2.5. Fibrinogen was 114. BUN and creatinine were 16 and 0.9. The sodium was 139, the potassium was 3.5, the chloride was 104, and the bicarbonate was 27. His AST was 53, ALT was 20, alkaline phosphatase was 102, and bilirubin was 11.1. His antibody titers were significant for [**Doctor Last Name 3271**]-[**Doctor Last Name **] virus IgG positive and a varicella IgG positive. His CMV and hepatitis panels were all negative. The patient is O Rh negative blood type. RADIOLOGIC STUDIES: A chest x-ray which demonstrated a left pleural effusion with some left basilar atelectasis. Electrocardiogram showed a normal sinus rhythm with nonspecific ST-T wave findings. His echocardiogram from [**2196-10-18**] had an ejection fraction of 55 percent with trivial mitral regurgitation. SUMMARY OF HOSPITAL COURSE: The patient was admitted to the Transplant Surgery floor where he was seen and evaluated by the transplant team prior to the Operating Room. He was given 1 gram of Solu-Medrol, 1 gram of CellCept, 20 mg of Simulect, fluconazole, Valcyte, and a dose of antibiotics; per the preoperative protocol. On the day of admission, he was taken to the Operating Room where he underwent a orthotopic cadaveric liver transplant with a portal vein to portal vein anastomosis. A celiac access tube branch patch anastomosis and a common bile duct to common bile duct anastomosis with internal stent. The details of the Operative Report are found in his medical record. Postoperatively, the patient was transferred to the Surgical Intensive Care Unit - intubated but in stable condition. In the immediate postoperative course, in the Surgical Intensive Care Unit, he was treated for postoperative thrombocytopenia with a platelet transfusion and postoperative anemia with blood transfusions and demonstrated a rise in his creatinine but never demonstrated any oliguria or anuria. Over the next several days, he was weaned off his ventilator support and extubated by postoperative day four. His hemodynamics initially were hyperdynamic, and with resuscitation and support he became normal dynamic and the PA catheter was removed, and he was diuresed with loop diuretics in order to help with his fluid status and respiratory status. Concurrently, his nutritional status was maintained with parenteral nutrition. On postoperative day five, the patient was transferred to the Transplant floor. Around this time he also developed paranoia, confusion, and began to refuse medical treatment. Psychiatry was involved and deemed him to have a delirium likely secondary to the steroid regimen for immunosuppression. He was monitored closely, and he subsequently improved in terms of his mental status and did pose a danger to himself. On the floor, though he continued to improve and progress, this was somewhat slow. His nutritional status required optimization which was facilitated with the Nutritional team. His blood glucose levels began to rise, and the [**Hospital **] Clinic staff assisted in adjusting an insulin regimen to maintain normal glycemia. He worked extensively with Physical Therapy in gaining his mobility and strength following his significant surgery. Immunosuppression was cyclosporin, CellCept, and a steroid taper. On postoperative day 14, the patient had a witnessed seizure on [**2196-11-26**]. By description, he was shaking his arms and legs. The episode lasted about one minute. The patient's eyes were open, but they were rolled to the back of his head and there was "foaming at the mouth." He had a postictal episode and did remember any of the events prior, during, or immediately after the event. His hemodynamics remained stable. His cyclosporin level that day was found to be 1400. A CT scan of the head demonstrated a question of a low attenuation in the right parietal lobe, but there was no mass effect, midline shift, or any bleeds. The primary cause of this seizure was thought to be cyclosporin toxicity. There was no anti-seizure medication started, and Neurology followed and agreed with the current management. Other significant events revealed the patient did have hypertension during his admission which was treated with oral beta blockades. He also underwent a liver biopsy for rising liver function tests on [**2196-11-21**] which was diagnosed with moderate acute cellular rejection. He was treated with a pulse steroid of Solu-Medrol. Following these events, the remaining hospitalization was uneventful. The patient was tolerating a diet. He was ambulating with Physical Therapy and was able to perform his daily activities. All drains and lines had been removed by the time of his discharge date. His discharge AST was 22, ALT was 33, alkaline phosphatase was 131, and total bilirubin was 3.4. The patient was discharged home on [**2196-11-29**] and will be closely followed by the Transplant office. DISCHARGE DIAGNOSES: 1. End-stage liver disease. 2. Massive ascites. 3. Portal hypertension. 4. Encephalopathy. 5. Hypertension. 6. Diabetes. 7. New onset seizure. 8. Postoperative anemia. 9. Postoperative thrombocytopenia. 10. Acute cellular rejection of a liver transplant. SURGICAL PROCEDURES PERFORMED: 1. Orthotopic cadaveric liver transplant on [**2195-12-11**]. 2. Ultrasound-guided liver biopsy on [**2196-11-21**]. MEDICATIONS ON DISCHARGE: 1. Fluconazole 400 mg p.o. once daily. 2. Bactrim single strength one tablet p.o. once per day. 3. Protonix 40 mg p.o. once daily. 4. CellCept 1 gram p.o. twice daily. 5. Oxycodone 5 mg p.o. q.8h. as needed. 6. Valganciclovir 450 mg p.o. once daily. 7. Lasix 20 mg p.o. once daily. 8. Diltiazem sustained release 180 mg p.o. once daily. 9. Prednisone 20 mg p.o. once daily. 10. Neoral 200 mg p.o. twice daily. 11. Lantus subcutaneously as directed by [**Last Name (un) **]. CONDITION ON DISCHARGE: The patient is stable, tolerating a diet, and ambulating. DISCHARGE DISPOSITION: Will be discharged home. DISCHARGE FOLLOWUP: The patient was to follow up with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] in the [**Hospital 1326**] Clinic within one week. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD,PHD[**Numeric Identifier **] Dictated By:[**Last Name (NamePattern1) 8958**] MEDQUIST36 D: [**2196-12-21**] 12:42:45 T: [**2196-12-21**] 13:49:22 Job#: [**Job Number 17496**]

[ "251.8", "E932.0", "572.2", "403.90", "287.5", "293.0", "285.9", "996.82", "572.3", "572.4", "780.39", "571.2", "570" ]

icd9cm

[ [ [] ] ]

[ "00.93", "99.15", "50.59", "99.00", "38.93", "50.11", "89.68", "99.04", "99.05" ]

icd9pcs

[ [ [] ] ]

8764, 8790

2095, 3618

7732, 8144

8170, 8656

1505, 1850

1291, 1478

3647, 7711

8811, 9276

279, 1077

1099, 1268

1867, 2078

8681, 8740

15,693

119,249

14041

Discharge summary

report

Admission Date: [**2149-2-7**] Discharge Date: [**2149-2-24**] Date of Birth: [**2073-7-9**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: Chest pain with exertion and after eating. Major Surgical or Invasive Procedure: Cardiac Catheterization [**2149-2-7**] History of Present Illness: The patient is a 75 year-old man with a history of mild coronary artery disease, aortic stenosis and peripheral vascular disease who presented to [**Hospital1 **] [**Location (un) 620**] on [**2-5**] with acute onset of right sided shoulder pain after eating dinner. He was at rest at onset. The pain was dull, [**4-2**] pain and did not radiate. He had no accompanying shortness of breath, nausea, vomiting, or diaphoresis. The patient has had similar pain in the past that was associated with exertion and after eating a heavy meal. Pain did not resolve on its own but was relieved in the emergency room after 3 sublingual nitroglycerin. EKG was done and showed sinus tachycardia at 108, left axis, and [**Street Address(2) 4793**] depressions V4, V5. Enzymes were cycled and the second set of enzymes was positive with a troponin of .066. A heparin drip was started. Enzymes trended up to peak TnT of 0.135. An echocardiogram showed an ejection fraction of 15 to 20% which was markedly depressed from his previous echocardiogram in [**2146**] which showed an ejection fraction of approximately 50%. There was global left ventricular hypokinesis and mild symmetric left ventricular hypertrophy. The right ventricular function was normal. He was transferred to the [**Hospital1 **] for cardiac catheterization. He also notes a recent cough productive of clear sputum and wheezing but has no shortness. On [**2-4**] he was started on a prednisone taper and Azithromycin and he was continued on this at the outside hospital. He has a history of smoke inhalation injury and has "bronchitis" with reactive airways, especially in cold weather. He has not had pulmonary function tests. He denies being on prednisone before but states when his wheezing flares, his primary care physician gives him [**Name Initial (PRE) **] Z-pak which helps. Currently he denies CP, SOB, N/V, abdominal pain, dizziness. Denies groin pain/leg pain. ... ... ROS: Denies N/V/abdpain. Denies HA, visual changes, neuro deficits. Past Medical History: coronary artery disease myocardial infarction peripheral vascular disease aortic stenosis spinal stenosis benign prostat hypertrophy hypertension hyperlipidemia chronic renal insufficiency chronic obstructive pulmonary disease complete occlusion of the left carotid artery status post right carotid endarterectomy left femoral artery stent right superficial femoral artery percutaneous transluminal coronary angioplasty status post appendectomy Social History: Retired firefighter, married. Quit smoking 25 years ago. Family History: Non-contributory Physical Exam: General: no acute distress, mildly obese Neck: supple, full range of motion Chest: clear to auscultation anteriorly, decreased breath sounds right lower lobe Heart: regular rate and rhythm, III/VI holosystolic murmur Abdomen: positive bowel sounds Extremities: cool, no edema, no varicosities Neuro: grossly intact Pulses: Femoral: 2+ bilaterally DP: 1+ right, 0 left PT 1+ right, 0 left Radial; 2+ bilaterally Bruits: present bilaterally Pertinent Results: [**2149-2-7**] 04:15PM BLOOD WBC-7.6 RBC-3.86* Hgb-11.6* Hct-34.9* MCV-90 MCH-30.0 MCHC-33.2 RDW-14.4 Plt Ct-183 [**2149-2-20**] 06:30AM BLOOD WBC-8.9 RBC-3.54* Hgb-10.5* Hct-31.5* MCV-89 MCH-29.6 MCHC-33.3 RDW-14.9 Plt Ct-227 [**2149-2-7**] 04:15PM BLOOD PT-13.3* PTT-25.9 INR(PT)-1.2* [**2149-2-21**] 06:05AM BLOOD PT-21.1* INR(PT)-2.0* [**2149-2-7**] 04:15PM BLOOD ALT-19 AST-15 Amylase-37 TotBili-0.3 [**2149-2-8**] 12:10PM BLOOD CK-MB-NotDone cTropnT-0.12* [**2149-2-8**] 08:50PM BLOOD CK-MB-NotDone cTropnT-0.10* [**2149-2-7**] RIGHT GROIN ULTRASOUND: Artery and vein are well visualized, and there is no evidence of pseudoaneurysm or AV fistula. Normal waveforms are elicited in both vein and artery. [**2149-2-7**] CARDIAC CATHETERIZATION: Coronary arteries are normal. Severe aortic stenosis. Moderate systolic and diastolic ventricular dysfunction. [**2149-2-11**] ECHOCARDIOGRAM Prebypass: There is severe aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The aortic regurgitation jet is eccentric, directed toward the anterior mitral leaflet. The mitral valve leaflets are moderately thickened. Mild (1+) mitral regurgitation is seen. There is a small pericardial effusion. Postbypass: Normal RV systolic function. Overall LVEF 30-40% (on epinephrine) with no focalities. A bioprosthetic valve is seen in the native aortic position, functioning well and stable in position with a peak residual gradient of 12mm of hg. Ascending aorta looks normal with no evidence of dissection. [**2149-2-15**] ECHOCARDIOGRAM: Overall left ventricular systolic function is severely depressed wityh global hypokinesis (most prominent in basal to mid septum). No masses or thrombi are seen in the left ventricle. There is severe global right ventricular free wall hypokinesis. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. [**2149-2-15**] ECHOCARDIOGRAM: The left atrium is moderately dilated. Overall left ventricular systolic function is severely depressed with global hypokinesis and akinesis of the inferior wall. Tissue velocity imaging E/e' is elevated (>15) suggesting increased left ventricular filling pressure (PCWP>18mmHg). A bioprosthetic aortic valve prosthesis is present. The aortic prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. The left ventricular inflow pattern suggests a restrictive filling abnormality, with elevated left atrial pressure. There is moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Brief Hospital Course: Mr. [**Known lastname 6692**] was evaluated by the cardiac surgical service and underwent preoperative testing in preparation for aortic valve repair. Courses of steroids and Azithromycin were completed pre-operatively for presumed bronchitis. A right groin ultrasound s/p catheterization was negative for pseudoaneurysm or arteriovenous fistula. On [**2149-2-11**] he underwent aortic valve replacement with [**Last Name (un) **] [**Doctor Last Name **] pericardial valve. Postoperatively, he was taken to the cardiac surgical intensive care unit. There sedation was weaned, and he was extubated. His ICU course was uncomplicated, and he was transferred to the cardiac surgical step down unit on postoperative day 1. Physical therapy was consulted for assistance with strength and mobility. On post-operative day 2 he developed atrial fibrillation with a rapid ventricular rate. He was treated with intravenous beta blockade and intravenous amiodarone. He converted to sinus rhythm, but again developed atrial fibrillation/atrial flutter. Intravenous heparin was started. He was transferred to the cardiac surgical intensive care unit for reintubation and cardioversion. He was cardioverted to sinus bradycardia with 100 Joules and was extubated the next day. Intravenous amiodarone was transitioned to oral amiodarone and follow-up echocardiogram showed no evidence of tamponade. He was gently diuresed toward his preoperative weight and Beta blockade was advanced as tolerated. ACE inhibitor was started for optimum blood pressure control and low ejection fraction. He was transferred to the cardiac surgical step down unit in stable condition after a few days. He developed a mild left forearm cellulitic phlebitis which was treated with Levofloxacin . He worked with physical therapy and was found safe for home discharge. He was discharged to home on [**2149-2-24**] with planned follow-up with cardiac surgery. All questions were answered to his satisfaction upon discharge. Medications on Admission: Terazosin 5 mg qd ASA 325 mg qd Plavix 75 mg qd Lisinopril 40 mg qd Lipitor 80 mg qd Zetia 10 mg qd Verapamil 240 mg qd Folate 400 mg qd Vitamin B Vitamin C Vitamin B12 Flovent 2 puffs qid Albuterol prn Prednisone 40 mg taper Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours). Disp:*qs qs* Refills:*2* 6. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*qs qs* Refills:*2* 7. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO once a day: take two tablets daily for one week then one tablet daily thereafter. Disp:*60 Tablet(s)* Refills:*2* 8. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Disp:*30 Capsule(s)* Refills:*2* 10. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. Warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Dosage will vary according to INR. Disp:*90 Tablet(s)* Refills:*2* 12. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 13. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. Disp:*120 ML(s)* Refills:*2* 14. Carvedilol 3.125 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 15. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:*120 Tablet(s)* Refills:*2* 16. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day for 14 days. Disp:*28 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: AS CAD HTN MI hyperlipidemia PVD CRI COPD TO L carotid spinal stenosis BPH Discharge Condition: good Discharge Instructions: Shower, wash incisions with mild soap and water and pat dry. No lotions, creams or powders to incisions. Call with fever >101, redness or drainage from incision, or weight gain more than 2 pounds in one day or five pounds in one week. No lifting more than 10 pounds for 10 weeks. No driving until follow up with surgeon. Followup Instructions: Dr. [**Last Name (STitle) 1290**] in two weeks Dr. [**Last Name (STitle) **] in one week Dr. [**Last Name (STitle) **] in one week Completed by:[**2149-2-25**]

[ "412", "427.31", "V12.51", "401.9", "428.31", "451.82", "491.22", "600.00", "424.1", "443.9", "585.3", "790.92", "411.1", "V45.82", "425.4" ]

icd9cm

[ [ [] ] ]

[ "35.21", "88.56", "37.23", "99.62", "99.04", "88.72", "89.64", "39.61" ]

icd9pcs

[ [ [] ] ]

10316, 10365

6132, 8126

362, 402

10484, 10491

3498, 6109

10861, 11023

3006, 3024

8403, 10293

10386, 10463

8152, 8380

10515, 10838

3039, 3479

280, 324

430, 2447

2469, 2915

2931, 2990

5,727

145,607

51924

Discharge summary

report

Admission Date: [**2155-8-4**] Discharge Date: [**2155-8-10**] Date of Birth: [**2096-11-3**] Sex: M Service: MEDICINE Allergies: Morphine Attending:[**First Name3 (LF) 678**] Chief Complaint: chest pain, shortness of breath Major Surgical or Invasive Procedure: theraputic thoracentesis History of Present Illness: HPI: 58 M with ESRD on HD, CAD, CHF, DM. Chest pain since 2pm today. He was lifting something earlier in the day, then took a shower and had onset at this time. Used cocaine yesterday, but this "has nothing to do with it" per patient report. Pain worse with coughing. + dyspnea earlier today, though denies currently. + nonproductive cough x "a couple days", + palpitations, denies N/V, fever, edema. Also reporting back pain with ?radiation to chest. Has had multiple admissions in past for CP especially in setting of cocaine use, enzymes flat. Reports not taking many of his meds lately, but has been going to all HD sessions. Endorses depression. In the ED, VS: 97.3, HR 145, BP 153/107, R 37, 100% 4L NC. Given ASA, lorazepam, diltiazem (total 30 IV and 60 PO). No nitro. Also concern that tachycardia related to low volume status, given 750 cc fluid with significant worsening of CXR. Benadryl for itching. Levaquin and Ceftriaxone as ED concerned that with CXR could not r/o infiltrate and concern for infection causing tachycardia. 10 units regular insulin for hyperglycemia. FAST done and reportedly negative, no pericardial effusions. Past Medical History: ESRD on hemodialysis (Tues/Thurs/Sat, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9449**] Dialysis, [**Location 1268**], [**Telephone/Fax (1) 69669**]) Type II diabetes mellitus CAD s/p MI (pt does not recall), MIBI in [**11-19**] showed reversible defects inferior/lateral CHF with EF 20-25% (from echo in [**6-/2155**]) and severe global hypokinesis Hypertension Dyslipidemia Atrial fibrillation History of gastrointestinal bleed: Duodenal, jejunal, and gastric AVMs, s/p thermal therapy; sigmoid diverticuli. Chronic pancreatitis Hepatitis C GERD Gout s/p arthroscopy with medial meniscectomy [**5-/2149**] Depression s/p multiple hospitalizations due to SI Polysubstance abuse: crack cocaine, EtOH, tobacco Erectile dysfunction s/p inflatable penile prosthesis [**5-/2148**] Social History: Smokes 3 cigarettes/day. 42 pack year history. Hx of alcohol abuse, with DTs and detoxification. Last crack cocaine use was day prior to admission. Lives with a female partner. Family History: Father with alcoholism. Cousin with [**Name2 (NI) 14165**] cell. Mother with renal failure, d. 58. Son with diabetes. Physical Exam: PHYSICAL EXAM: Vitals: T97.7, 146/99, P 107, R27, 99% on 4L General: chronically ill appearing, appears uncomfortable in bed but no resp distress. on later exam tachypneic with rest/sleep, and restless when woken. HEENT: NC/AT, PERRL (4->3mm), MMM Neck: JVD appears to ear at 45 degrees. No LAD Lungs: decreased at bases R>L, few R basilar crackles, few anterior wheezes. Heart: Regular, slightly tachy, soft SM at LLSB Abdomen: +BS, protuberant, nontender. Extrem: warm, 2+ pulses, trace bilat edema. LUE fistula, +bruit/hum Neuro: alert, oriented to [**8-5**], [**Hospital3 **]. Pertinent Results: [**2155-8-5**] 10:14AM BLOOD WBC-5.6 RBC-4.42* Hgb-13.2* Hct-40.5 MCV-92 MCH-30.0 MCHC-32.7 RDW-16.8* Plt Ct-118* [**2155-8-4**] 06:20PM BLOOD Neuts-73.7* Lymphs-17.8* Monos-5.1 Eos-2.1 Baso-1.4 [**2155-8-5**] 02:20AM BLOOD ALT-21 AST-17 LD(LDH)-191 CK(CPK)-106 AlkPhos-144* TotBili-1.6* [**2155-8-5**] 10:14AM BLOOD CK-MB-7 cTropnT-0.22* [**2155-8-4**] 06:20PM BLOOD cTropnT-0.21* [**2155-8-5**] 04:08PM BLOOD pH-7.93* Comment-PLEURAL FL [**2155-8-5**] 02:30AM BLOOD Lactate-1.7 [**2155-8-4**] 09:06PM BLOOD Lactate-2.9* CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2155-8-5**] 4:08 AM No Pulmonary embolism or acute aortic syndromes. Large right and small left pleural effusions with bilateral patchy ground glass opacities and small amount of right fissural fluid, suggesting pulmonary edema. Moderate cardiomegaly. ([**First Name8 (NamePattern2) 30217**] [**Doctor Last Name **], [**Numeric Identifier 83113**]) [**2155-8-9**] 6:02 pm STOOL CONSISTENCY: WATERY Source: Stool. **FINAL REPORT [**2155-8-10**]** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2155-8-10**]): REPORTED BY PHONE TO [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 106841**] ON [**2155-8-10**] AT NOON. CLOSTRIDIUM DIFFICILE. FECES POSITIVE FOR C. DIFFICILE TOXIN BY EIA. (Reference Range-Negative). A positive result in a recently treated patient is of uncertain significance unless the patient is currently symptomatic (relapse). Brief Hospital Course: A/P: 58 M with CAD, CHF, DM, ESRD on HD, cocaine abuse p/w chest pain and shortness of breath 1 day following cocaine abuse. ##. Chest pain. Pt was originally admitted to the ICU for hypervolemia and chest pain with a recent history of cocaine use. Work up of the chest pain showed negative troponins, unremarkable EKG. CTA Chest also showed negative for PE and aortic dissection. Chest pain thought to be musculoskeletal as pain was reproducible and relieved by Tylenol. ##. Shortness of breath. During admission pt was noted be hypervolemic, he has a history of non-adherence to dialysis regimen. A Chest xray in the ICU showed bilateral pleural effusions that were subsequently tapped and shown to be transudative. Pt's shortness of breath appeared to improved following thoracentesis, pt was discharged home with complaints of shortness of breath. ##. C-Diff colitis: After transfer to the wards from the ICU pt was noted to have some right upper quadrant pain with diarrhea. An abdominal U/S was performed and showed no evidence of biliary disease. C. Diff assay was shown to be positive on the day of discharge. Pt was given a prescription of Flagyl and a follow up appointment was made for [**2155-8-18**]. ##. ESRD on HD: Pt received hemodialysis whilst in house on his schedule Tuesday, Thursday, Saturday. Pt was also given a prescription for Cinacalcet 30mg. ##. A-fib with RVR: Pt was rate controlled on PO Metoprolol for his A-fib whilst in house. On a review of his outpatient notes it appears as if a discussion was initiated regarding starting Warfarin on Mr. [**Known lastname 107485**]. It appears that at that time Mr. [**Known lastname 107494**] history of non-adherence would leave him to a higher risk:benefit ratio if he were started on Warfarin. ##. systolic/diastolic CHF (EF 20-25%). Upon admission to the ICU pt was noted to be hypervolemic. Pt was continued on Lisinopril and monitored for fluid balance. He was able to return to euvolemic status following repeated hemodialysis. From his clinincal status it is likely that his fluid status is due to his adherence to dialysis versus a primary cardiac issue. ##. DM type II: Mr. [**Known lastname 107485**] was continued on his home insulin (NPH 20 [**Hospital1 **]) with sliding scale. Medications on Admission: MEDICATIONS AT HOME: (per d/c summary [**2155-7-16**]) 1. Sevelamer HCl 800 mg TID W/MEALS 2. Labetalol 400 mg [**Hospital1 **] 3. Sertraline 50 mg DAILY 4. Thiamine HCl 100 mg DAILY 5. Pantoprazole 40 mg Q24H ( 6. Atorvastatin 20 mg DAILY 7. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: [**1-15**] Tablet, Sublinguals Sublingual PRN (as needed). 8. Senna 8.6 mg [**Hospital1 **] as needed. 9. Aspirin 81 mg DAILY 10. B Complex-Vitamin C-Folic Acid 1 mg DAILY 11. Diphenhydramine HCl 25 mg Q6H as needed for pruritis. 12. Insulin NPH Twenty units Subcutaneous twice a day. 13. Camphor-Menthol 0.5-0.5 % Lotion QID (4 times a day) as needed for itching. 14. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H as needed for pain. 15. Lisinopril 10 mg Tablet once a day. 16. Mupirocin 2 % Ointment Sig: One (1) application Topical once a day for 7 days. * Reports not taking most meds, says he is taking lisinopril, labetalol, insulin. Not taking aspirin ("[**2-15**] bleeding"). No nitro. Discharge Medications: 1. Sevelamer HCl 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2. Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. Diphenhydramine HCl 25 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for pruritis. 10. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. 11. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Capsule PO once a day. 12. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: [**1-15**] Sublingual PRN as needed for chest pain. 13. Acetaminophen 500 mg Capsule Sig: Two (2) Capsule PO every six (6) hours as needed for pain. 14. Cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Month/Day (2) **]:*30 Tablet(s)* Refills:*2* 15. Labetalol 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 16. Insulin Lispro 100 unit/mL Solution Sig: One (1) unit Subcutaneous qAC + qHS: Per your insulin sliding scale. 17. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO three times a day for 14 days. [**Month/Day (2) **]:*42 Tablet(s)* Refills:*0* 18. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Fifteen (15) units Subcutaneous qAM: Please check your sugars before you eat and before bedtime. If your sugars continue to be above 150 please start this medication. 19. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Ten (10) Subcutaneous qPM: Please check your sugars before you eat and before bedtime. If your sugars continue to be above 150 please start this medication. Discharge Disposition: Home Discharge Diagnosis: Hypervolemia Discharge Condition: Stable, Afebrile Discharge Instructions: You were admitted to the ICU as you were having chest pain and difficulty breathing. Whilst in the hospital a complete work up of your heart and your lungs showed that your shortness of breath was due to you have too much fluid in your body. Before being discharged you were able to walk around without needing oxygen. In the hospital you had some diarrhea that tested positive for C. Difficile, please ensure you drink fluids and take your antibiotic Flagyl three times a day for the next 14 days. We started you on a new medication, please take Cinacalcet 30mg a day. we also started you on an antibiotic Metronidazole, please take it 3 times a day for the next 14 days. Your sugars have been well controlled without your NPH medication. Please check your sugars before you eat and at night. If your sugars continue to be >150 restart your NPH medication 15units in the morning and 10 units at night. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Please continue to go to your dialysis. Followup Instructions: Provider: [**First Name8 (NamePattern2) 5478**] [**Name11 (NameIs) 5479**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2155-8-18**] 1:30 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RN, CS Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2155-8-20**] 10:00 [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(1) 684**]

[ "E854.3", "311", "287.5", "428.0", "414.01", "008.45", "530.81", "786.50", "585.6", "274.9", "250.00", "403.91", "305.00", "305.60", "511.9", "970.8", "428.43" ]

icd9cm

[ [ [] ] ]

[ "39.95", "34.91" ]

icd9pcs

[ [ [] ] ]

10191, 10197

4836, 7115

299, 325

10254, 10273

3270, 4813

11368, 11757

2533, 2653

8158, 10168

10218, 10233

7141, 7141

10297, 11345

7162, 8135

2683, 3251

228, 261

353, 1501

1523, 2322

2338, 2517

27,615

151,228

1475

Discharge summary

report

Admission Date: [**2151-9-24**] Discharge Date: [**2151-9-25**] Date of Birth: [**2095-2-4**] Sex: M Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 2817**] Chief Complaint: syncope Major Surgical or Invasive Procedure: none History of Present Illness: 56M with several year history of DMII for which he has only recently started undergoing treatment (HgA1c 9.6 on [**2151-8-13**]) who presents with two episodes of syncope in the day PTA. The pt reports that yesterday he apparently had an episode of questionable syncope, the exact details of which he cannot recall but per his wife he appeared very "wobbly" on his legs and then lost consciouness briefly. On the night PTA the pt's wife also noted that he was confused and not making sense when speaking. On the morning of admission the pt was feeling better, however while walking down a flight of stairs he again lost consciouness. He denies experiencing any prodrome and when he awakened very quickly felt back to his baseline, althoug he endorses feeling poorly for the last several weeks. After this episode, the pt presented to the ED for evaluation. Of note, he reports he has been compliant with his insulin regimen. . In the ED, initial vitals were 98.6, 104, 20, 85/49 and 96% RA. Routine chemistries revealed a elevated Glu of 775; K 4.8, and a Cr 2.8 (prior Cr ~ 1 in [**2145**]). The pt was felt to be in DKA and was given IVF and started on an insulin gtt. The pt was also given a dose of Ancef for a concern of a left inguinal cellulitis; he had reported this complaint to his PCP several days PTA and, though not evaluated in person, was being treated with PO bactrim. He mentions that his wife performed an I&D to the area on the day PTA. . On ROS, the pt endorses progressive blurring of his vision over the last several weeks, as well as feeling generally poorly and noting that he is unsteady on his feet. He has also experienced a 30 lb weight loss over the last three months and endorses frequent urination. Otherwise he denies any fevers, chills, nausea, vomiting, abdominal pain, diarrhea, constipation (though he has been stooling slightly less frequently lately), melena, hematochezia, chest pain, shortness of breath, orthopnea, PND, lower extremity oedema, cough, urinary urgency, dysuria, lightheadedness, gait unsteadiness, focal weakness, headache, rash or skin changes. Past Medical History: HTN hypercholesterolemia gout OSA back pain depression CKD, recent baseline Cr around 1.5 with one recent measurement at 3.6 Social History: Regular MJ use. Never tobacco. No EtOH. [**Hospital 8735**] healthcare administrator. Family History: The pt's father is 78 and currently dying from esophageal CA. Mother is 77 and in good health. The pt has two brothers in good health. No FH of DM or early CAD. Physical Exam: GEN: Well-appearing, well-nourished, no acute distress HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, no W/R/R ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E, warm, 2+ DP pulses GROINS: Left groin with 1cm x 1.5cm warm, slightly fluctuant area of erythema; no appreciable fluid collection. Non-tender. NEURO: Alert, oriented to person, place, and time. CN II ?????? XII intact. Moves all 4 extremities. Strength 5/5 in upper and lower extremities. Patellar DTR +2. Plantar reflex downgoing. No cerebellar dysfunction. SKIN: No jaundice, cyanosis, or gross dermatitis. No ecchymoses. Pertinent Results: [**2151-9-24**] 02:35PM WBC-11.4* RBC-4.67 HGB-13.4* HCT-40.3 MCV-86 MCH-28.7 MCHC-33.3 RDW-13.4 [**2151-9-24**] 02:35PM NEUTS-82* BANDS-0 LYMPHS-10* MONOS-8 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2151-9-24**] 02:35PM GLUCOSE-775* UREA N-27* CREAT-2.8*# SODIUM-122* POTASSIUM-4.6 CHLORIDE-88* TOTAL CO2-18* ANION GAP-21* . ECG: Sinus rhythm at 94 bpm, normal axis and intervals. TWIs noted in III. No prior for comparison. . CXR: The cardiomediastinal silhouette is unremarkable. The lungs are clear. Brief Hospital Course: 56 yo male admitted with DKA occuring in the setting of question left groin cellulitis. . # DKA: The pt was admitted to the MICU and continued on an insulin gtt. Plasma volume and potassium were repleted. His syncopal episodes were thought likely the result of dehydration, although other causes could not be fully excluded. After several hours of care, the pt stated he was unhappy being in the hospital and wanted to leave. He was informed of the risks of doing this, including permanent disability and death, but nevertheless requested discharge. The pt signed the AMA form and was advised to contact his PCPs office in the morning for follow-up. MICU attending was able to make contact with PCP in the AM who is aware of the situation and will follow up with the patient Medications on Admission: Bactrim DS 1 tab [**Hospital1 **] for leg cellulitis (day of admission = day 3) Januvia 50 mg daily Tricor 145 mg daily Reglan 10 mg [**Hospital1 **] Flomax 0.4 mg qHS Nexium 40 mg [**Hospital1 **] ASA 81 mg daily Cymbalta 60 mg daily atorvastatin 20 mg daily Provigil 200 mg daily Lantus, ~85 units qPM, 35 units qAM Humalog sliding scale Discharge Medications: Bactrim DS 1 tab [**Hospital1 **] for leg cellulitis (day of admission = day 3) Januvia 50 mg daily Tricor 145 mg daily Reglan 10 mg [**Hospital1 **] Flomax 0.4 mg qHS Nexium 40 mg [**Hospital1 **] ASA 81 mg daily Cymbalta 60 mg daily atorvastatin 20 mg daily Provigil 200 mg daily Discharge Disposition: Home Discharge Diagnosis: DKA syncope hyponatremia acute renal failure cellulitis Discharge Condition: Unstable. Discharge Instructions: You were admitted with diabetic ketoacidosis. This is a life-threatening condition. You are elecating to leave the hospital against medical advice. You are advised to contact your primary care physician first thing in the morning to seek further care. Followup Instructions: Please contact your [**Name (NI) 6435**] office in the morning for further care.

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167,618

6358

Discharge summary

report

Admission Date: [**2143-11-8**] Discharge Date: [**2143-11-20**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2745**] Chief Complaint: right lower extremity edema, hand tremor, lethargy and fevers Major Surgical or Invasive Procedure: Right Internal Jugular Venous Catheter Left percutaneous nephrostomy [**2143-11-12**] History of Present Illness: 88yo woman with hx of recent right hip fracture ([**Month (only) **]), breast ca s/p resection, hyperchol, renal stones, dementia who presents from [**Hospital6 24605**] with increased right lower extremity edema, hand tremor, lethargy and fevers from rehab. Per records, had fevers to 100.7 in rehab yesterday and received tylenol. Unable to obtain u/a. She had been lethargic and refusing to eat x24h. She was much less responsive and interactice than her baseline. . In the ED: VS: 101.9, HR 147, BP 145/108 RR 19 O2 94% RA. Abdomen noted to be firm but not tender. U/A positive for leuks, blood, many bacteria, >50 WBC, 0-2 EPIs. Lactate 5.8 initially. CVL placed in right IJ. Sepsis protocol started. Received ceftaz 1g, vanco 1g, tylenol, and ativan for agitation. Total of 5L IVF. Required levophed to maintain MAP>65. HR improved to 100, BP down to SBP 83 at one point but stabilized at 100/40s. Repeat lactate 1.3. Past Medical History: Recurrent Right Breast Cancer stage IIB (T3NxMx) 1.8 cm grade II infiltrating ductal carcinoma, s/p right radical mastectomy in '[**99**] and right re-excision partial mastectomy in '[**35**] Hypertension Hypercholesterolemia Renal stones Benign positional vertigo TAH-BSO at age 45 s/p tonsillectomy Osteopenia of the Hip Hearing Loss Nondisplaced right greater trochanter fracture in [**Month (only) **]. Social History: No tobacco or alcohol. Lives in rehab. Daughter, son and daughter-in-law very involved in her care. Family History: HTN, no clotting disorders Physical Exam: Physical Exam on Admission: VS: 100.2 101/56 HR 92 SpO2 100% 3L, on levophed 0.03 Gen: sedate, responds to shouting or sternal rub. tries to bite or move out of restraints HEENT: MM Dry, JVP flat, right IJ line Cards: RRR, no murmurs, rubs Lungs: crackles left sided, no wheeze Abd: BS diminished. abd protuberant, mildly tender throughout, no rebound. no HSM Legs: Right calf > Left calf. no palp cord. pulses palpable. no edema. Neuro: minimally interactive. responds to loud stimuli or sternal rub. toes equiv bilat. PERRLA, tongue midline, face symmetric. Rectal: OB neg Pertinent Results: LABS ON ADMISSION: =================== Trop-T: 0.01 CK: 43 . 143 105 27 --------------< 99 4.6 19 1.9 Ca: 8.5 Mg: 2.3 P: 3.9 ALT: 9 AST: 14 Cortsol: 46.6 . WBC: 9.2 HCT 33.6 Plt 413 . N:61 Band:20 L:8 M:3 E:0 Bas:0 Atyps: 7 Metas: 1 . PT: 17.0 PTT: 30.8 INR: 1.5 (no known baseline) . U/A: mod leuks, large blood, >50 WBC, many bacteria . VBG: 7.37/32/58 Lactate 5.8 -> 1.3 Hct: 33 -> 26 SvO2 - 88 . STUDIES: ========= RENAL U.S. [**2143-11-8**] IMPRESSION: 1. Hyperechoic focus without shadowing in the left renal pelvis may represent sloughed papilla in the collecting system (renal papillary necrosis). Similarly, the hyperechoic focus at the right mid collecting system may represent papillary necrosis, although review of static images make it difficult to distinguish from hilar fat. 2. Bilateral renal cysts. No evidence of hydronephrosis/obstruction. . BILAT LOWER EXT VEINS PORT [**2143-11-8**] IMPRESSION: 1. Occlusive thrombosis involving the right popliteal vein, superficial femoral vein, and common femoral vein. 2. No DVT involving the left lower extremity. . PORTABLE ABDOMEN [**2143-11-8**] IMPRESSION: Nonspecific nonobstructive bowel gas pattern. Limited evaluation for the presence of free air. Follow up upright or left side down decubitus radiographs are recommended if clinical suspicion exists for free air. . CHEST (PORTABLE AP) [**2143-11-8**] IMPRESSION: 1 Right IJ central line with its tip in the right atrium. Retraction by approximately 5 cm is advised. 2. Left basilar airspace opacity, possibly representing atelectasis and/or pneumonia. . CHEST (PORTABLE AP) [**2143-11-8**] IMPRESSION: Process involving the left CP angle, not present on the remote study, which may represent early pneumonic infiltrate. . EKG [**2143-11-8**] Sinus tachycardia with delayed R wave transition. Low limb lead voltage. Non-specific ST-T wave abnormalities. No previous tracing available for comparison. TRACING #1 . EKG [**2143-11-8**] Normal sinus rhythm with diffuse low voltage. Left atrial abnormality. Diffuse ST-T wave flattening. Compared to tracing #1 there has been no diagnostic interval change. TRACING #2 . CT ABDOMEN AND PELVIS W/O CONTRAST [**2143-11-11**] IMPRESSION: 1. Moderate left hydronephrosis and hydroureter extending to the left ureteropelvic junction, at which point an intraluminal filling defect is suggested. Direct visualization may be considered to exclude a mass given the elevated creatinine. 2. Additional 2-mm distal left ureteral calculus is non-obstructing. 3. Sigmoid diverticulosis, without evidence of diverticulitis. 4. Cholelithiasis. 5. New 13-mm hepatic hypoattenuating lesion is incompletely evaluated. While this may represent focal fatty infiltration, given the patient's history of breast cancer, further evaluation with ultrasound is recommended. Alternatively, if the patient's creatinine normalizes, an MRI may be considered. 6. A 4- mm non- calcified pulmonary nodule. A followup chest CT is recommended in 12 months. At this time, asymmetric right upper lobe pleural thickening can also be reevaluated. 7. Presumed pancreatic tail cystic lesion is likely benign given equivocal growth over several years. 8. Moderate bilateral pleural effusions with adjacent atelectasis. . PORTABLE ABDOMEN [**2143-11-11**] IMPRESSION: 1. Appropriately positioned nasogastric tube with tip not visualized on current film but likely within the second and third portion of the duodenum. 2. Bibasilar pulmonary opacity which may represent atelectasis and/or pneumonia. Please refer to dedicated chest radiograph for further details. . Portable TTE (Complete) Done [**2143-11-11**] The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. Right ventricular systolic function is 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. Physiologic mitral regurgitation is seen (within normal limits). There is borderline pulmonary artery systolic hypertension. There is an anterior space which most likely represents a fat pad. IMPRESSION: Mild tricuspid regurgitation. Aortic valve sclerosis. Mild mitral leaflet thickening. No focal vegetation seen. . ANTEGRADE UROGRAPHY [**2143-11-12**] IMPRESSION: 1. Mildly dilated left renal pelvis and left ureter. 2. Successful placement of an 8 French APD percutaneous nephrostomy tube under ultrassonographic and fluoroscopic guidance, with pigtail coiled in the left renal pelvis. Tube is connected to an external bag. . CHEST (PORTABLE AP) [**2143-11-12**] FINDINGS: In comparison with the study of [**11-9**], relatively low lung volumes persist. Streaky atelectatic opacifications are again noted, especially at the right base. Of course, it is difficult to unequivocally exclude pneumonia. The right IJ catheter has been removed. . CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST [**2143-11-14**] IMPRESSION: 1. Normal orbits and no abnormalities of the orbital apices. However, MRI would provide better evaluation of this region. 2. Paranasal sinus changes as described above. . LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2143-11-15**] IMPRESSION: 1. Liver normal; lesions described on prior CT not visualized. 2. Cholelithiasis, without evidence for acute cholecystitis. . RENAL U.S. [**2143-11-18**] IMPRESSION: No hydronephrosis. Unchanged bilateral renal cysts. Right pleural effusion. . D/C LABS: [**2143-11-19**] CBC: WBC-10.7 RBC-3.56* Hgb-10.3* Hct-32.6* MCV-92 MCH-29.1 MCHC-31.7 RDW-16.3* Plt Ct-858* . CHEMISTRY: Glucose-77 UreaN-6 Creat-0.8 Na-139 K-3.8 Cl-102 HCO3-21* AnGap-20 Brief Hospital Course: Ms. [**Known lastname 19916**] is an 88 y.o. F with history of severe dementia, right hip fracture who presented from rehab with 1-2 days of increased lethargy and right lower extremity swelling. She was admitted to MICU for urosepsis requiring pressors, found to have RLE DVT and bacteremia, and called out of the MICU for further medical management. # Hypotension [**1-25**] urosepsis: The etiology of hypotension was thought to be likely urosepsis given her grossly positive U/A . Her HR improved with IVF. She was quickly weaned off Levophed. Initially treated with Vancomycin and Zosyn for possible PNA and then switched to Ciprofloxacin for more likely UTI. Pt continued to spike through on this regimen, and then was switched to ceftriaxone, vancomycin for GPR bacteremia and gram positive bacteriuria. Blood culture from [**11-8**] grew lactobacillus. Blood culture from [**11-9**] grew out [**Female First Name (un) **]. ID was consulted, and ampicillin and caspofungin were added. Vancomycin and ceftriaxone were stopped. A TTE was also obtained that showed no vegetations. TEE was recommended originally in the MICU, but the pt's family declined. CT abdomen and pelvis showed left hydroureter and hydronephrosis with an opacity thought possibly due to a stone. Study was limited by lack of IV contrast secondary to impaired renal function. Urology was consulted and recommended percutaneous nephrostomy which was performed on [**2143-11-12**]. Urine cultures and cytology were that were positive for [**Female First Name (un) **]. On the floor, she has remained afebrile with her current course of antibiotics. Ophthalmology was consulted to assess for [**Female First Name (un) **] endopththalmitis, which was not seen; however, a CT was done to assess any compression of optic nerve, which was negative. TEE was not performed given that the risks outweighed the benefits of the study, especially given the negative TTE. [**Female First Name (un) 564**] susceptibilities are pending and will not return until [**11-21**]. At that point [**Hospital1 18**] will contact rehabilitation facility with sensitivities and appropriate antifungal (caspo vs. fluc) will be selected. In either case (caspo vs. fluc), antifungal therapy will be continued until [**12-5**], and antibiotic therapy (ampicillin) will be continued until [**11-22**]. . # RLE edema: B/L LENIs showed extensive occlusive thrombosis involving the right popliteal vein, superficial vein, and common femoral vein. No DVT involving the left lower extremity. Started on heparin drip and later Coumadin 5 daily. It was decided in a discussion with her family on long-term anticoagulation as patient essentially immobile s/p hip fx and therefore low risk of fall. On transfer to the floor, the patient's INR was supratherapeutic, and her coumadin was held. Her goal INR is [**1-26**], and it will need to be checked daily in rehab and coumadin restarted when therapeutic. . # Nephrolithiasis and Hydroureter: CT abd/pelvis showed L hydroureter and mixed attenuation at UV junction possibly c/w stone. Could be the source of the patient's sepsis. She was s/p left percutaneous nephrostomy [**2143-11-12**] for hydronephrosis. UA from both nephrostomy and catheter showed moderate leukocytes and bloody urine with [**Female First Name (un) **] from urine cultures. Repeat U/S on [**11-15**] and [**11-18**] showed no hydronephrosis. Per urology, will need f/u to diagnose ureteral abnormality by cystoscopy as an outpatient. Has outpatient urology appointment scheduled. . # CV: No hx of ischemia. Unlikely ischemia now given fever, u/a. Continued ASA. Enzymes cycled on admission(trop; 0.01, 0.04, 0.04 CK (43, 181,181) with negative MB fraction. No ischemic changes on ECG. [**11-9**] Tachycardia (AFib w/ RVR vs. MAT) into HR 200 with adequate bp, good response to IV lopressor 5mg. Thought fever and sepsis were precipitants. Was on heparin IV for DVT. . # Delirium/baseline dementia: Patient had required ativan in the ED. She was switched to zyprexa and 2 point restraints prn. Per family, pt still not at baseline functioning. Prior to admission, she was able to walk and hold conversations with family members. Minimized sleep/wake disturbances. Temporarily required 1:1 sitter during hospitalization but by discharge was pleasant but still A+O x [**12-25**] . # Anemia: Iron studies consistent with anemia of chronic disease. Active type and screen maintained. Trended Hct and was given one unit of pRBC with appropriate rise. . # ARF: Baseline Cr 0.9-1 in [**2141**]. Was likely due to ATN and nephrolithiasis. Resolved with gentle IVFs, by DC was down to 0.7. . # Hepatic mass: A new 13-mm hepatic hypoattenuating lesion is incompletely evaluated on CT scang that may represent focal fatty infiltration. Given the patient's history of breast cancer, further evaluation with ultrasound was recommended. Liver U/S on [**11-15**] did not see this new lesion. Will defer management of this questionable mass as outpatient. . # Pulmonary nodule: A 4-mm non-calcified pulmonary nodule was found on CT scan. A f/u chest CT is recommended in 12 months as outpatient; at the same time, the asymmetric right upper lobe pleural thickening can also be reevaluated . # s/p fracture: Nonoperable. PT and OT consulted. . # Poor po intake: Nutrition consulted, diet changed accordingly. Ensure TID added. Megace added to medication regimen. Per my patient with her. PEG was discussed with family and decision was made to not place a feeding tube. . # PPX: coumadin, H2 blocker, bowel regimen. . # FEN: [**Month (only) 116**] have ground solid diet with thin liquids, if tolerates, may advance- advance as tolerated with the following caveat: single sips of thin liquid, pills crushed in ice cream. . # Code: DNR/DNI: would be ok with 1 shock only, no chest compressions, no intubation. Pressors ok. Discussed with HCP . # Access: PIV x 2, Right PICC . # Contact: son and daughter-in-law: [**Name (NI) 24606**] and [**Name (NI) **]: [**Telephone/Fax (1) 24607**] (c) and [**Telephone/Fax (1) 24608**] (h) . Medications on Admission: Medications per records from rehab: mirtazapine 15mg qhs colace [**Hospital1 **] trazodone 25mg TID tylenol prn vitamin C zinc 220 daily MVI ASA 243 daily SQ Hep TID (stopped [**10-29**]) bisacodly prn MOM prn Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day). 2. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO BID (2 times a day) as needed for agitation. 3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 6. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 11. Megestrol 20 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). 12. Fluconazole 200 mg Tablet Sig: Three (3) Tablet PO Q24H (every 24 hours): if selected as antifungal of choice (TBD [**11-21**]), then last dose will be [**12-5**]. 13. Ampicillin Sodium 2 gram Recon Soln Sig: Two (2) grams Recon Soln Injection Q6H (every 6 hours) for 2 days: last dose 11/30. 14. Haloperidol Lactate 5 mg/mL Solution Sig: 2.5 mg Injection [**Hospital1 **] (2 times a day) as needed for agitation. 15. Caspofungin 70 mg Recon Soln Sig: Fifty (50) mg Recon Soln Intravenous Q24H (every 24 hours): if selected as antifungal of choice (TBD [**11-21**]), last dose 12/13. 16. Acetaminophen 650 mg Suppository Sig: One (1) Suppository Rectal Q6H (every 6 hours) as needed. 17. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed. 18. Outpatient Lab Work please draw LFTS (ALT, AST, and total bilirubin) on [**11-25**] and [**12-2**] and fax results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7443**] at [**Telephone/Fax (1) 24609**] Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: PRIMARY: 1. Urosepsis 2. Right lower extremity DVT 3. Lactobacillis bacteremia 4. Candidal fungemia . SECONDARY: 1. Nephrolithiasis 2. Hydroureter 3. Dementia 4. Anemia 5. Acute renal failure 6. Pulmonary nodule 7. Hepatic mass 8. s/p hip fracture Discharge Condition: Stable Discharge Instructions: You were admitted for increased lethargy and right lower extremity swelling. You were found to have urosepsis, and while in the ICU, you needed medicines to keep your blood pressure within normal limits. You were also started on antibiotics and antifungals to combat this infection. You were also found to have a clot in your right lower extremity. You were given medications for anticoagulation. . Please keep all your medical appointments. Please take all your medications as prescribed. You will need to take an antibiotic until [**11-22**] and an antifungal medicine until [**12-5**]. You will also need to take coumadin, a blood thinner, and the level of this medicine in your blood will will often be checked at your rehab center. . If you have any of the following symptoms, please call your doctor or go to the nearest ER: fever>101, chest pain, shortness of breath, abdominal pain, burning with urination, black stools, or any other concerning symptoms. Followup Instructions: UROLOGY: will need f/u to diagnose ureteral abnormality by cystoscopy Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Doctor Last Name **] Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2143-12-5**] 11:00 . RADIOLOGY: CT showed 4- mm non- calcified pulmonary nodule. A followup chest CT is recommended in 12 months. Your PCP can [**Name9 (PRE) 24610**] this. Please also make an appointment to follow up with your PCP.

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35961

Discharge summary

report

Admission Date: [**2136-11-13**] Discharge Date: [**2136-11-19**] Date of Birth: [**2079-5-19**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4760**] Chief Complaint: Transfer from OSH with DVT and PE Major Surgical or Invasive Procedure: thrombolysis for significant clot burden and visible clot in R atria History of Present Illness: This is a 57 year old gentleman with a history of ulcerative colitis who is transferred from [**Hospital3 1443**] Hospital ED at the patient's request with a diagnoiss of DVT and PE. He had been in his usual state of health until a few weeks ago, he noted left sided calf pains. He did not think much of this as he had a friend who had an achilles injury that was similar. However, 3 days ago, he came home early from work feeling tired and with generalized weakness. He then noticed that he was feeling increasingly short of breath. His shortness of breath persisted and he began to have dyspnea even with minimal exertion such as walking to the bathroom. He notes that 2 days prior, he was in the bathroom when he felt severely dyspneic and lightheaded. The next thing he remembers is waking up with his head leaning on the toilet seat. He believes that he lost consciousness for a few seconds. His breathing stabilized over the next day, but he began to have much more severe left sided leg pain, radiating to his thigh. This resulted in him seeing his PCP urgently today. Following his PCP visit, he had an outpt US done which revealed a left sided distal femoral vein DVT and he was asked to go to the ED for a CTA. He was seen at [**Hospital1 3793**] ED where he had a CTA that revealed extensive acute pulmonary emboli. He was started on coumadin 10 mg PO and heparin bolus of 5000 units. He was then transferred to the [**Hospital1 18**] ED at the patient's request. Of note, he did travel to [**Location (un) 73711**] by plane on [**11-6**] to visit his son, prior to the onset of the above symptoms. Otherwise denies personal or family history of thrombotic events. No recent hospitalizations or surgeries. EDVS: 98.6 HR 99 BP 136/70 RR 14 97% 2L. He was given lovenox 80 mg SQ x 1 and admitted to the medicine service. . On the floor, he feels that his breathing is improved. He currently does not have LLE pain. His pain is reproducible with exertion. . ROS: Positive for chills several days ago. Also with fleeting palpitations about 3 days ago. Denies chest pain. Also denies fever, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: Ulcerative colitis: has been inactive. He is supposed to take "3 brown tablets" for maintenance, but does not recall the name as he has not taken them for the last few weeks. Social History: Married with 2 children. Works as a police officer. Drinks a few beers every other day. Smokes a cigar almost weekly. Denies illicit drug use. He is otherwise healthy, exercises almost daily, walking around a track and does push ups and sprints. Family History: Mother: Healthy Father: Stroke in his 70s 2 Brothers: Hypertension 1 Brother: Type I DM 2 Children: Healthy Physical Exam: VS: T 99.8 140/78 HR 84 RR 18 97% 2L GEN: Middle-aged man in NAD, speaking in full sentences, awake, alert HEENT: EOMI, PERRL, sclera anicteric, conjunctivae clear, OP moist and without lesion NECK: Supple, no JVD CV: Reg rate, normal S1, S2. No m/r/g. CHEST: Resp were unlabored, no accessory muscle use. +Faint expiratory wheezing LL base, otherwise scattered rhonchi ABD: Soft, NT, ND, no HSM (guaiac neg in ED) EXT: +Warmth, trace edema of LLE, 2+ DP/PT pulses SKIN: No rash Pertinent Results: [**2136-11-13**] 07:15AM GLUCOSE-119* UREA N-21* CREAT-1.1 SODIUM-140 POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-26 ANION GAP-13 [**2136-11-13**] 07:15AM ALT(SGPT)-19 AST(SGOT)-30 ALK PHOS-81 TOT BILI-1.3 [**2136-11-13**] 07:15AM ALBUMIN-3.7 [**2136-11-13**] 07:15AM WBC-10.0 RBC-3.97* HGB-12.8* HCT-36.6* MCV-92 MCH-32.2* MCHC-35.0 RDW-13.4 [**2136-11-13**] 07:15AM PLT COUNT-168 [**2136-11-13**] 07:15AM PT-15.5* PTT-31.0 INR(PT)-1.4* [**2136-11-12**] 11:50PM GLUCOSE-107* UREA N-21* CREAT-1.0 SODIUM-141 POTASSIUM-3.5 CHLORIDE-105 TOTAL CO2-24 ANION GAP-16 [**2136-11-12**] 11:50PM estGFR-Using this [**2136-11-12**] 11:50PM WBC-10.6 RBC-4.11* HGB-13.0* HCT-36.6* MCV-89 MCH-31.7 MCHC-35.6* RDW-13.3 [**2136-11-12**] 11:50PM NEUTS-81.5* LYMPHS-12.1* MONOS-5.5 EOS-0.4 BASOS-0.5 [**2136-11-12**] 11:50PM PLT COUNT-164 [**2136-11-12**] 11:50PM PT-15.3* PTT-61.9* INR(PT)-1.3* . [**11-14**] ECHO: The left atrium is normal in size. A mobile 2 x 1.4cm mass is seen in the right atrium. It appears to be attached to the Eustachian valve. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Transmitral Doppler and tissue velocity imaging are consistent with normal LV diastolic function. There is no left ventricular outflow obstruction at rest or with Valsalva. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mobile mass in the right atrium measuring 2 x 1.4cm. It is associated with the Eustachian valve and has the appearance of a thrombus. It prolapses back and forth into the inferior vena cava. Spontaneous echo contrast is seen in the IVC, consistent with slow flow. The right ventricle has normal size and function. Normal regional and global left ventricular systolic function without significant valvular abnormality. . [**11-15**] ECHO: Focused Study: No mass or thrombus is seen in the right atrium or right atrial appendage. There is a prominent Chiari network versus Eustachian valve seen in the right atrium. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size is normal. with normal free wall contractility. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2136-11-14**], the right atrial mass/thrombus is no longer present. . CT venogram [**11-19**]: prelim read: No evidence of new venous thrombosis. Interval resolution of IVC thrombus. 3 low attenuation liver lesions, likely benign. Brief Hospital Course: This is a 57 year old with a history of ulcerative colitis admitted with left lower extremity DVT and extensive bilateral PE. . # DVT/PE: Extensive emboli involving all pulmonary lobes and DVT in LLE found on LENI and CTA chest at outside hospital. Possibly provoked by immobility with travel although could also be considered unprovoked. Patient was intially managed with lovenox and coumadin. However, ECHO performed upon transfer showed mobile clot in IVC and RA. Lovenox and coumadin were held and patient was transferred to the CCU where he received tPA infusion 100 mg over 2 hours on [**11-14**]. Heparin gtt was restarted once his PTT was < 60 and he received coumadin the day after his tPA infusion after having no evidence of bleeding complications. Repeat ECHO showed resolution of prior visualized clot suggesting successful thrombolysis. He remained hemodynamically stable throughout admission. He had no O2 requirement and no subjective SOB. He was transitioned to subQ lovenox at 1 mg/kg dosing [**Hospital1 **] 2 days after his tPA. He remained in house for close monitoring given significant clot burden and persistent discomfort in L calf from DVT. Vascular surgery was consulted who recommended CT venogram to evaluate for anatomic cause of current clot. Venogram showed no thrombus in IVC, iliacs, or proximal femoral veins or anatomic abnormality to explain his significant clots. While in house his LLE was wrapped sequentially with ace bandages and he was given a prescription for graded compression stockings. . Given that patient's clots seem to be unprovoked and given the severity of his clots including clot in transit, he may require lifelong anticoagulation. As an outpatient he will need follow up of the labs sent from his first hospital as a hypercoaguable work up. He is scheduled to follow up with vascular and pulmonary as an outaptient. He reports being up to date on age appropriate cancer screening but this should be readdressed with his PCP. . # Ulcerative colitis: Currently inactive. Patient had been off his maintainence medication mesalamine as he felt it made no difference in his course. It was offered to restart this during his hospitalization but he decided not to restart. He can discuss this further with his primary caregivers as an outpatient. . # Low attention liver lesions: Noted incidentally on CT venogram. Benign in appearance according to initial read from radiology. Could consider follow up imaging as an outpatient with a triphasic CT scan or MRI of liver per PCP. Medications on Admission: Medications for UC, cannot recall name Discharge Medications: 1. Lovenox 80 mg/0.8 mL Syringe Sig: Eighty (80) mg Subcutaneous twice a day. Disp:*14 syringes* Refills:*0* 2. Outpatient [**Name (NI) **] Work PT/PTT/INR check three times a week (Monday, Wednesday, Friday) until INR [**12-18**] and instructed to change by your PCP. [**Name10 (NameIs) **] check as outpatient [**2135-11-21**] at PCP office visit. Please have results faxed to Dr. [**Last Name (STitle) 74756**] at [**Telephone/Fax (1) 77934**], attention: [**Doctor First Name **] if not done at his office. 3. Warfarin 6 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 4. thigh high graded compression stockings 40 mmHg at ankles, graded down to 20 mmHg Discharge Disposition: Home Discharge Diagnosis: Primary: 1. pulmonary emboli 2. deep vein thrombosis 3. low attenuation liver lesions Secondary: 1. ulcerative colitis Discharge Condition: Stable. Good O2 sats on RA. Ambulating independently. Hemodynamically stable. Discharge Instructions: You were admitted to the hospital for shortness of breath and episodes of loss of consciousness. You were found to have a blood clot in your leg as well as in your heart and lungs. Due to the blood clot that was seen in your heart, you received tPA to break up the blood clots and you had no evidence of bleeding. You were started on coumadin to thin your blood and you were treated with heparin and then lovenox to help thin your blood until your coumadin levels were therapeutic. . Please continue to use your compression stockings as prescribed. . Please continue all medications as prescribed. Continue lovenox and coumadin as prescribed. You will need to have blood work drawn 2-3 times/week until your coumadin levels are at your goal (INR [**12-18**]). These levels should be followed by your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 74756**]. Once your INR is between [**12-18**], you should continue the lovenox for 3 more days. . Please follow up as listed below. Please discuss seeing a Hematologist with your PCP regarding work up of a possible underlying hypercoagulable state. . Please call your doctor or return to the hospital if you experience recurrent loss of consciousness, chest pain, shortness of breath, palpitations, nausea, vomiting, abdominal pain, or any other concerns. It is very important that you follow up with your appointments and take all of your medications as directed. Followup Instructions: Please follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 74756**] on [**2135-11-21**] at 10:30 am. Phone [**Telephone/Fax (1) 81655**]. . Please have your blood work checked as ordered and have the results faxed to Dr.[**Name (NI) 81656**] office at fax: [**Telephone/Fax (1) 77934**] or have the blood work drawn at your visit. He will help you titrate your coumadin and lovenox depending on your results. You should have 3-5 days of lovenox after your INR is at goal. . Please follow up with Pulmonologist [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**2136-12-24**] at 1:30 pm. Phone: ([**Telephone/Fax (1) 513**]. . Please follow up with vascular surgeon Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**2136-12-25**] at 9:30 am. Phone: ([**Telephone/Fax (1) 2867**]

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icd9cm

[ [ [] ] ]

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icd9pcs

[ [ [] ] ]

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52373

Discharge summary

report

Admission Date: [**2143-1-31**] Discharge Date: [**2143-2-3**] Date of Birth: [**2061-9-12**] Sex: M Service: MEDICINE Allergies: Indocin / Ace Inhibitors Attending:[**First Name3 (LF) 9002**] Chief Complaint: Upper GI bleed Major Surgical or Invasive Procedure: EGD [**1-31**] History of Present Illness: Mr. [**Known lastname 108240**] is an 81-year-old male with a history of prostate cancer, status post radical prostatectomy, osteoarthritis, status post bilateral TKR, hypercholesterolemia, and hypertension, who presents with N/V/D for a few days. . Per report, he had had N/V/D which has been nonblood for several days. Today, he got up to go the bathroom, and had a syncopal event, in which he lost conciousness for several seconds, but did not strike his head. His wife called EMS, who upon arrival appreciated a pulse of 80/palp; at this time, the patient also vomited bright red blood, estimated to be 100-200 cc. Baseline BP per clinic notes is 130/60. In the ED, initial VS were 80 86/41 16 100%. He underwent NGL, in which 500 cc of fluid was placed, without clearance of fluid upon suction; approximately 700 cc of fluid was suctioned back. He was guiaic negative from below. In the ED he was started on protonix push, with a gtt, as well as 250 mg IV Erythromycin. He received 3 L NS as well as 1 U pRBC which was uncrossed secondary to time concerns. An 18 and a 16 G were placed for access. Upon transfer his vitals were 116/50 68 17 100% RA. . His labs in the ED were notable for lactate 5.1, Cr 1.7 (baseline 1.6?), HCT 28.8 (baseline 35.7). . His labs were notable for lactate of 5.1, HCT 28.8. He was started on a pantoprazole gtt. . He was seen in the ED in the last week of [**Month (only) 956**] for constipation, and was treated with a bowel regimen at that time. . On arrival to the MICU, he is AAOx3; repeat HCT was lower to 24, with lactate trending down. . On repeat questioning, he endorses stomach pains for the past 3 weeks, which he has been itnermittently treating with Aleve; he says that they are not made better or worse with food ingestion. This morning, his wife indicated he was watching Tv when he got up to use the bathroom; she heard a thump, and whens he came to see him, he was not responsive, and had his eyes rolled to the back of his head. There was no bowel or bladder incontence. She went ot see him because she had heard a small cry for help. Upon seeing him, he was not responsive to questions; the wife says he was this way for about 3 minutes. He endorses having taken Aleve for the past 2 weeks about 6 pills. He endorsed dry heaving last night, and first time vomiting this AM. Apparently his colchine dose was also increaed about a week ago. Past Medical History: BELL'S PALSY GOUT HYPERCHOLESTEROLEMIA HYPERTENSION OBESITY OSTEOARTHRITIS PROSTATE CANCER SEBORRHEIC DERMATITIS SYNCOPE TINNITUS URINARY RETENTION Social History: He is getting out of the house more often with his knee fixed. Sometimes daily. Usually he goes to church, shopping. He does not drink alcohol or smoke cigarettes. He is not sexually active currently, trying to follow a low-fat and low-salt diet but unclear how successful he is doing that. They eat a lot of chicken and fish. He does not like vegetables as much. Family History: Noncontributory. His sons are both doing well as well as his grandchildren. One of their sons, however, has a congential heart defect with only three [**Doctor Last Name 1754**] to his heart. Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly 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, finger-to-nose intact Pertinent Results: [**1-31**] CXR: FINDINGS: AP single view of the chest has been obtained with patient in supine position. NG tube has been placed. Under penetration makes it difficult to identify the tube with certainty, but a special contrast copy identifies the NG tube to reach below the diaphragm including the side port. No new pulmonary abnormalities are seen. Multiple external cables are overlying the chest. . [**1-31**] EGD: Impression: A single cratered 3 cm ulcer was found at the pylorus with a large overlying clot. Because of the risk of recurrent bleeding in this setting, endoscopic intervention was undertaken. First, 8-10 cc of epinephrine 1/[**Numeric Identifier 961**] hemostasis was injected at the perimeter of the ulcer. A 7 Fr. gold probe was then applied for hemostasis. After cautery, brisk bleeding was noted from the ulcer. Additional epinephrine injection was applied and two endoclips were successfully applied to the ulcer with excellent hemostasis. Recommendations: NPO, serial HCT, continue PPI drip. H.pylori serology and treat if positive NSAID avoidance Repeat EGD in 8 weeks for re-evaluation. If there is rebleeding, repeat endoscopy can be considered, however IR team should be alerted as well, as likelihood of success with repeat endoscopic intervention is relatively low . . Micro: [**2143-1-31**] 9:12 pm SEROLOGY/BLOOD **FINAL REPORT [**2143-2-1**]** HELICOBACTER PYLORI ANTIBODY TEST (Final [**2143-2-1**]): POSITIVE BY EIA. . discharge labs: [**2143-2-3**] 06:20AM BLOOD WBC-9.1 RBC-3.73* Hgb-11.2* Hct-31.0* MCV-83 MCH-30.0 MCHC-36.2* RDW-13.0 Plt Ct-182 [**2143-2-3**] 06:20AM BLOOD Plt Ct-182 [**2143-2-3**] 06:20AM BLOOD Glucose-100 UreaN-17 Creat-1.2 Na-140 K-3.5 Cl-103 HCO3-31 AnGap-10 [**2143-2-3**] 06:20AM BLOOD Calcium-8.9 Phos-2.7 Mg-1.6 Brief Hospital Course: Mr. [**Known lastname 108240**] is an 81-year-old male with a history of prostate cancer, status post radical prostatectomy, osteoarthritis, status post bilateral TKR, hypercholesterolemia, and hypertension, who presetns with GI bleed. . # Upper GI Bleed: H. pylori EIA came back positive. On EGD visualized ulcer with scarring, responding to clips and epinephrine injection. He received a total of 3 units of blood and 1 bag of platelets. Subsequent Hct checks remained stable at 30 after hemostasis was achieved. He was continued on a pantoprazole drip for a total of 72 hrs and then transitioned to pantoprazole 40mg PO BID. on [**2143-2-1**], H. pylori ab came back +, although not the most sensitive or specific test, his pretest probability is quite high, given that his NSAID exposure was rather minimal. LR of + h.pylor is 4, if assume 75% pretest prob, then would have >90% post test prob with + testhe was initiated on amoxocillin and clarithromycin in addition to ppi. No bx were taken during EGD b/c pt was actively bleeding, but will need to re-scope in 6-8wks to make sure resolution of ulcer has occured. There is some risk that ulcer could be from malignant process (unlikely), so GI will bx when re-scope in in [**5-3**] weeks. . # N/V/diarrhea: Unclear if related to his ulcer and resultant bleed. During hospitalization he had several episodes of melena after scope. This resolved by the time he was discharged. . # Hypertension: Remained normotensive until he was transferred to the floor. His chlorthalidone was restarted first, followed by losartan. He remained normotensive on these medications, so atenolol was not restarted at discharge. . # AoCKD: Cr a year ago was 1.2, and on labs has increased to 1.6 in [**Month (only) 956**]. Worsening renal fxn had not been worked up at that point, but could be related to progression of hypertensive nephropathy. Pts Cr was 1.8 on admission, and after fluid resuscitation and blood products it returned to baseline of 1.6. FeUrea and FeNa were high, consistent with post-renal or intrinsic process. When pt was transferred to floor, we started him on IVF, because was -3L over past day. The following day, his cr was 1.2 and on discharge cr remained at 1.2. . # HLD: Initially held home simvastatin, aspirin. On discharge, pt was started on rosuvastatin 10mg qday while on clarithromycin due to documented risk of rhabdo with combo of simvastatin and clarithromycin. . # Gout: Initially held colchicine in the setting of fluctuations in renal injury. Pt reports that he has been only taking colchicine apprx 2-3x/wk because of the price of the medication. On discharge, this medication was held, due to possible interaction with clarithromycin. . Transitional: 1. Pt should continue pantoprazole 40mg PO BID. If he has trouble affording this medication, he can substitute omeprazole equivalent [**Hospital1 **]. 2. When stops clarithromycin can restart colchicine and simvastatin. Gave pt 14day prescription for rosuvastatin while on clarithromycin 3. Held ASA at time of discharge 4. If pt needs MRI within 4 weeks of discharge, he should have a KUB first to make sure clips are not still present in stomach. After four weeks he will have passed the clips and will be ok for MRI 5. Will need follow endoscopy in [**5-3**] wks after discharge. Bx will be taken to rule out malignancy at this time. If ulcer still present, will need an additional endoscopy q6-8wks until ulcer resolves. 6. At time of discharge, only BP med that was restarted was chlorthalidone, holding atenolol and losartan. Medications on Admission: atenolol 50 mg Daily chlorthalidone 25 mg Daily colchicine 0.3 to 0.6 mg Daily losartan 100 mg Daily simvastatin 40 mg Daily acetaminophen 1000 mg PRN aspirin 325 mg Daily Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 2. clarithromycin 250 mg Tablet Sig: Two (2) Tablet PO Q12H (every 12 hours) for 25 doses. Disp:*50 Tablet(s)* Refills:*0* 3. amoxicillin 500 mg Capsule Sig: Two (2) Capsule PO every twelve (12) hours for 25 doses. Disp:*50 Capsule(s)* Refills:*0* 4. chlorthalidone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day for 14 days. Disp:*14 Tablet(s)* Refills:*0* 7. losartan 100 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Upper GI bleed (pyloric ulcer) hypovolemic shock h. pylori infection Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dr. [**Last Name (STitle) **]. [**Known lastname 108240**], It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted for a gastrointestinal bleed. In the ICU, an endoscopy was performed and it showed an ulcer in your stomach. The gastroenterologist was able to stop the bleeding during this procedure. The cause of your ulcer is most likely an infection called H. Pylori. We are treating this infection with two antibiotics (clarithromycin and amoxacillin) and an acid reducing medication (pantoprazole). You will need to take the antibiotics for 2 weeks and stay on the acid reducing medication indefinitely. If you have trouble affording this medication, you can request a prescription for twice daily omeprazole (a substitution med) from your PCP. [**Name10 (NameIs) **] is very important, however, that you take this acid suppressing medication, as not taking it puts you at much higher risk for rebleeding. You will also need a follow-up endoscopy, to make sure that your ulcer has healed. This procedure has been scheduled in [**Month (only) 547**], the appointment info is below. . It is also important to stop taking your aspirin medication indefinitely. Aspirin can increase your chances of bleeding again. You can bring this issue up with your primary care physician the next time that you see him/her. . If, for any reason, you need an MRI within the next 4 weeks, please inform the ordering doctor that you have non-MRI compatible clips in your stomach. These clips will ultimately pass in your stool, and after 4 weeks it will be safe to get an MRI if needed. . If you should have black, tarry stools, or red, bloody stools, or if you feel lightheaded, you should call your PCP or report to the emergency department as soon as possible. . We have made the following changes to your home medication regimen START: Pantoprazole 40 mg by mouth every 12hrs START: Clarithromycin 500 mg by mouth every 12hrs until [**2143-2-16**] START: Amoxicillin 1000 mg by mouth every 12hrs until [**2143-2-16**] STOP: Aspirin STOP: colchicine until you have finished your course of antibiotics STOP: atenolol, your PCP may decide to restart this after you seen him/her STOP: any over the counter NSAID medication (ibuprofen, naproxen/aleve). Tylenol is not an NSAID and ok to take for pain STOP simvastatin while you are taking clarithromycin, there is a potentially dangerous interaction between these two medications. You can restart simvastatin after you stop taking clarithromycin. While you are on clarithromycin, you can take a substitute medication called rosuvastatin. We have provided a prescription for rosuvastatin. CONTINUE the rest of your home medication regimen Followup Instructions: Department: WEST PROCEDURAL CENTER When: THURSDAY [**2143-3-14**] at 9:00 AM With: WPC ROOM THREE [**Telephone/Fax (1) 5072**] Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: GI-WEST PROCEDURAL CENTER When: THURSDAY [**2143-3-14**] at 9:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6953**], MD [**Telephone/Fax (1) 463**] Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: [**Hospital3 249**] When: WEDNESDAY [**2143-2-6**] at 10:30 AM With: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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icd9cm

[ [ [] ] ]

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icd9pcs

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51661

Discharge summary

report

Admission Date: [**2184-1-6**] Discharge Date: [**2184-1-14**] Date of Birth: [**2130-1-14**] Sex: M Service: MEDICINE Allergies: Wellbutrin / Aspirin Attending:[**Doctor First Name 3290**] Chief Complaint: Hypothermia, frostbite Major Surgical or Invasive Procedure: Central line placement History of Present Illness: This is a 54-year-old gentleman with a history of mantle cell lymphoma s/p R-CHOP and allo SCT with recent relapse, h/o bipolar disorder, and history of alcohol abuse transferred from OSH with severe hypothermia following suicide attempt. Patient reports taking at least 20 pills last night, combination of Valium, Zyprexa, and Ambien, and walked outside near his home in [**Location 9583**]. He then rested on the snow and fell asleep, with intent not to wake up. Per his family, patient's girlfriend left for work around 5 p.m., at which time patient was still in home. When girlfriend returned after 11, patient had left lights on in house and had left. Girlfriend and friends/family searched for patient, could not find patient, and called police the next morning. Police then found the patient shortly after noon in the snow, and immediately called EMS. In the field, patient had a temp of 26 C. He was intubated in the field. Warming blankets were placed on patient, and transported to OSH. First responders were unable to obtain IV access en route, IO placed in left tibia. Given vecoronium, etomidate, fentanyl, and versed en route to OSH. . At OSH, patient received NG lavage, warm IVF, and warm bladder irrigation. Had 500 cc pre-hospital, 3000 cc IVF, 600 cc NG, 1500 cc bladder irrigation. UOP of 1800 cc. Ended up (+) 3 liters at OSH. Initial ABG 7.23, 47, 249, 19. Hct 47.4. platelets 101. acetaminophen < 10. alcohol < 5. INR 1.1. AST 54. lipase 22. CK 3702. glucose 85. Patient then transferred to [**Hospital1 18**] ED for further management. . In ED, vital signs 28 C, HR 60, sinus, 136/99 RR 16 100% on AC FiO2 100%, PEEP 5, RR 14, Vt 500. Received warmed IVF one liter NS, placed on Arctic Sun, with temp trend of 28.8 -> 29.2 -> 29.9 -> 34.3 -> 34.5 -> 36.6 over four hours. Started on propofol, received fentanyl 50 mcg x 1. 1000 cc in, 4000 cc UOP. Transferred to ICU. . Upon arrival to the floor, patient was transitioned from AC to PS, was alert and following commands, had normal O2 sat on minimal settings, and was extubated without incident. . Patient stated he has been severly depressed over the past month, under a lot of pressure, particularly financial. Relapse of mantle cell lymphoma has also just been diagnosed. He did express suicidal ideation and intent with plan when taking medications and falling asleep in the snow. . Following extubation, the patient was complaining of mild left leg discomfort. He could not feel his hands. Remainder of ROS unremarkable. Patient has not been ill recently. Past Medical History: Past oncologic history: Mantle Cell NHL --Presentation ([**1-16**]): Axillary, inguinal swellings which disappeared spontaneously, then recurred 1-2 weeks later ----R inguinal lymph node biopsy ([**2180-2-18**]): Non-Hodgkin's lymphoma, B-cell, mantle cell type ----PET: Stage III disease --Treatment: Completed 6 cyles R-CHOP on [**2180-6-7**] --Received cyclophosphamide for stem cell mobilization on [**2180-7-14**] --Received Neupogen for stem cell collection . Past medical history: 1. Allergic Rhinitis . Past surgical history: 1. R inguinal lymph node biopsy on [**2180-2-18**] 2. Appendectomy ([**11-13**]) Social History: Patient lives alone and is a real estate manager as well as co-ownder of [**Last Name (un) 107040**] [**Hospital1 778**] Grill. He has never been married but has 3 children. Tobacco: [**1-11**] PPD x 30 years, last use 1 month ago ETOH: heavy use (12 beers + [**1-12**] shots of hard liquor), last drink 6 weeks ago Illicit drugs: cocaine on weekends, last use in [**2-16**]. . Emergency contact: [**Name (NI) 14492**] (Brother) [**Telephone/Fax (3) 107041**]. Family History: His father died of cancer, possibly liver, with mets to bone. His mother is alive at age 80 with no known illness. He has eight siblings who are currently well. His youngest sister had [**Name (NI) 4278**] disease as a child, cured with chemotherapy and radiation, and now with breast CA, s/p mastectomy. Physical Exam: VS: 97.9 HR 129 BP 121/70 RR 20 94% tent mask GEN: mildly uncomfortable, alert, oriented x 3 HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: coarse upper airway breath sounds transmitted to lungs, good airmovement CV: RR, tachycardic, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: both hands with extensive erythema/violaceous color with bullae; both hands splinted SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated in lower extremities. 2+DTR's-patellar and biceps Pertinent Results: CXR [**2184-1-6**] 1. Nasogastric tube with distal tip projecting over the gastric fundus, although with distal side port at the level of the GE junction/very distal esophagus. Recommend advancement so that it is well within the stomach. 2. Appropriate position of the endotracheal tube, approximately 4.9 cm above the carina. 3. Clear lungs. . CXR [**2184-1-7**] Recently described bilateral perihilar opacities have rapidly resolved and were likely due to pulmonary edema. Lungs are currently clear. Cardiomediastinal contours are within normal limits for portable technique. Brief Hospital Course: This is a 53-year-old gentleman with recurrent mantle cell lymphoma on chemotherapy admitted with hypothermia after suicide attempt. . # FROSTBITE: Hand/plastic surgery followed patient throughout admission. They saw no evidence of compartment syndrome or infection. Hand surgery team recommended daily dressing changes and elevation whenever possible. Patient's need for surgical debridement or amputation will be determined at a future date by the Hand surgery team. Patient's pain was initially managed with low doses of IV dilaudid prn and standing acetaminophen. Pain was easily controlled and patient was switched to oxycodone 5 mg po prn pain. He averaged 1 to 2 pills per day. Would recommend continuing acetaminophen scheduled and using oxycodone prn for pain control. Patient should be evaluated by Hand/Plastic Surgery team within one week of discharge. The following wound instructions may be modified after he has been reassessed by a hand/plastic surgeon. . WOUND CARE INSTRUCTIONS PER [**Hospital1 18**] HAND SURGERY TEAM: Bilaterally - Please dress the fingers (circumferentially), palm / dorsum of hand,and any area that is blistered with Xeroform gauze. Place opened / loose 4x4s between each digit loosely. DO NOT DEBRIDE BLISTERS THAT ARE INTACT OR RUPTURED. Cover with dry 4x4's. Wrap with dry kerlix. Replace / secure splints. Hang the Left upper extremity to IV pole for 24 hours ([**Date range (1) 107042**]). Then keep bilateral hands elevated on two pillows above the level of his heart. Please expect tissues to become very dark and or black as the injury demarcates. If evidence of infection arises please contact [**Hospital1 18**] hand surgery [**Name (NI) 2678**]. Should he not be able to be evaluated by a Hand/Plastic surgeon while inpatient at [**Hospital3 **] psychiatric facility, a follow-up appointment in the hand surgery clinic at [**Hospital1 18**] has been scheduled for 8am on [**2184-1-20**]. Call [**Telephone/Fax (1) 3009**] if appointment can be cancelled. Remove dressings as needed for OT evaluation / treatment. . # RECURRENT MANTLE CELL LYMPHOMA: Receiving chemotherapy as an outpatient prior to admission. He was scheduled to receive his next cycle of chemotherapy on [**2184-1-19**]. However, due to his psychiatric condition, the decision has been made to postpone his chemotherapy until his depression is being appropriately managed. Because significant delays in his chemotherapy may effect his prognosis, we strongly recommend evaluation by an Oncology team to confirm patient's willingness to pursue chemotherapy once his depression is being managed, and to provide necessary chemotherapy in a timely manor. Patient's most recent oncology notes is attached to his discharge paperwork. For all additional questions regarding his oncology care please contact his primary oncologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 18**]. She is reachable by page at [**Telephone/Fax (1) 2756**] or by phone at [**Telephone/Fax (1) 3237**]. . # HYPOTHERMIA: Resolved with rewarming in the ICU, now normothermic, with improvement in EKG and platelets. Patient likely has significant cold induced diuresis given significant urine output. He will likely require increased oral fluid intake while kidneys regain ability to concentrate urine. Frostbite injuries as below. . # ACUTE RESPIRATORY FAILURE: In setting of hypothermia and altered mental status. Patient was easily extubated upon transfer to MICU. His hypoxia resolved with autodiuresis and improved respiratory drive. . # SUICIDE ATTEMPT: Patient has a history of depression and bipolar disorder. Mr. [**Known lastname **] admits that recent event was a suicide attempt. He had a 1:1 sitter during admission and a section 12. He was seen by psychiatry who recommended inpatient psychiatric hospitalization. He was treated with zyprexa 5 mg po qhs during his hospitalization. . # HISTORY OF ALCOHOL AND POLYSUBSTANCE ABUSE: ETOH and acetaminophen negative both here at at outside hospital. Patient was given a banana bag and initially monitored on a CIWA scale for withdrawal. His CIWA scale was discontinued when he had several consecutive days without requiring benzodiazapines. He was continued on daily thiamine, folic acid, and multivitamin supplement during his admission. Would recommend continuing his folate and multivitamin after discharge. . # RHABDOMYOLYSIS: Likely from hypothermia and immobility as he was "found down" on ground. CKs peaked at >9000. Mr. [**Known lastname **] was treated with IV fluids and bicarbonate. There was never any evidence of renal failure. . # SINUS TACHYCARDIA: Unclear etiology however, as per previous clinic notes, patient has been persistently tachycardic in the past. Etiologies include: dehydration, chemo-induced cardiomyopathy, pain, or PE. His tachycardia persisted once out of the ICU and ECG showed sinus tachycardia. He had no other concerning sypmtoms for PE, specifically persistent hypoxia or chest pain. Heart rate ranged from 100 to 130 and responded minimally to pain medications. Heart rate also responded to increased fluid intake. Patient's inabilty to use his hands to drink decreased his ability to keep up with water losses. Patient was strongly encouraged to drink more fluids. . # Anemia and thrombocytopenia: Patient's initial lab abnormalities may be attributed to his lymphoma and recent chemotherapy as well as his response to hypothermia. His hematocrit and platelet count were stable on day of discharge. # Constipation: Patient's sedentary behavior and inability to help himself use the bathroom has likely contributed to his constipation. Patient was started on senna, docusate, and miralax and started having daily bowel movements. Encourage increased water, fiber, activity, and continuation of current bowel regimen. Medications on Admission: Acyclovir 400 mg TID Emend 1 capsule daily for two days following chemotherapy Dexamethasone 4 mg daily for two days following chemotherapy Lamotrigene 25-50-100 rapid dissolve tablet daily Olanzapine 5 mg QHS Omeprazole 20 mg daily PRN Ondansetron 8 mg daily for two days following chemotherapy Penciclovir 1% cream apply to affected area as needed Sildenafil 100 mg [**1-11**] tab daily PRN Discharge Medications: 1. Wound Care Bilaterally - Please dress the fingers (circumferentially), palm / dorsum of hand,and any area that is blistered with Xeroform gauze. Place opened / loose 4x4s between each digit loosely. DO NOT DEBRIDE BLISTERS THAT ARE INTACT OR RUPTURED. Cover with dry 4x4's. Wrap with dry kerlix. Replace / secure splints. Hang the Left upper extremity to IV pole for 24 hours ([**Date range (1) 107042**]). Then keep bilateral hands elevated on two pillows above the level of his heart. Please expect tissues to become very dark and or black as the injury demarcates. If evidence of infection arises please contact [**Hospital1 18**] hand surgery [**Name (NI) 2678**]. Follow-up in the hand surgery clinic [**2184-1-20**]. Call [**Telephone/Fax (1) 3009**] for appt. Remove dressings as needed for OT evaluation / treatment. 2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 5. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen (17) grams PO DAILY (Daily) as needed for constipation. Disp:*1 bottle* Refills:*3* 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*2* 7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 9. olanzapine 2.5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*0* 10. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every 6-8 hours as needed for pain for 2 weeks: Hold for sedation or RR < 12. 11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day as needed for heartburn. Discharge Disposition: Extended Care Discharge Diagnosis: Hypothermia Rhabdomyolysis Acute respiratory railure Frostbite Acute renal failure Depression Suicide attempt Discharge Condition: Patient is unable to use hands and therefore is dependent for most eating, drinking, bathing and changing clothes. He is alert and oriented. Discharge Instructions: You were brought to the hospital after being found down in the snow. He were believed to have taken an overdose in medications and lost consciousness in the snow. You suffered serious injuries due to the cold temperatures including hypothermia, respiratory failure, and frostbite. You were managed in the ICU and your lungs improved. You were transferred to the medical floor where you were monitored closely. Your hands suffered significant injuries from the cold and required daily wound care and dressing changes. You were followed closely by the hand/plastic surgery team and you will continue to require daily wound care and close follow up after discharge. Followup Instructions: You will REQUIRE follow up with the Hand/[**Hospital 3595**] clinic as well as Oncology service. These services will be provided by the [**Hospital 2586**] medical center while you are admitted to their psychiatric facility. Please schedule follow up with your psychiatrist, primary care provider, [**Name10 (NameIs) **] oncologist within one week of discharge from the [**Hospital3 **] psychiatric facility.

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icd9cm

[ [ [] ] ]

[ "96.71", "38.93" ]

icd9pcs

[ [ [] ] ]

14200, 14215

5740, 11635

304, 328

14369, 14513

5136, 5717

15231, 15645

4065, 4372

12078, 14177

14236, 14348

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14537, 15208

3486, 3570

4387, 5117

242, 266

356, 2928

3439, 3463

3586, 4049

192

194,518

12840

Discharge summary

report

Admission Date: [**2131-1-3**] Discharge Date: [**2131-1-7**] Date of Birth: [**2066-7-27**] Sex: M Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: This is a 64-year-old gentleman who began having episodes of dizziness starting four years ago. These symptoms led to a stress test and a cardiac catheterization four years ago. Over the past year he has had increased fatigue and a positive stress test in [**9-13**]. Ejection fraction was measured to be 36% at this time. He was found to have an ischemic cardiomyopathy. The results of this work-up led to a cardiac catheterization on [**2130-11-3**]. The following occlusions were found: LAD 100%, circumflex 90%, left posterior descending artery 80%, right coronary artery 90%, ejection fraction 35%. The patient is referred to Dr. [**Last Name (STitle) **] for coronary artery bypass graft surgery. PAST MEDICAL HISTORY: Question of MI. The patient denies any nausea, myocardial infarction, coronary artery disease as described above. Insulin dependent diabetes mellitus, hypercholesterolemia, rheumatoid arthritis, left carotid disease status post stenting, peripheral vascular disease. PAST SURGICAL HISTORY: Left carotid stent placed in [**2130-11-13**]. MEDICATIONS: On admission, Humalog 8 units q a.m., Humulin N 88 units q a.m., Humalog 4 units, Humulin N 16 units q p.m. IC-Klor-Con 10 mEq [**Hospital1 **], Lipitor 40 mg po bid, Digoxin 0.25 mg po q day, Zestril 20 mg po q day, enteric coated Aspirin 81 mg po q day, Azulfidine 500 mg po q day, Coreg 12.5 mg po bid, Plavix 75 mg po q day (stopped [**2130-12-27**]). ALLERGIES: No known drug allergies. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Tobacco abuse, quit 10 years ago, denies use or abuse of alcohol, denies any recreational drugs. PHYSICAL EXAMINATION: On admission, vital signs, pulse 67, blood pressure 182/85, height 5 feet, 10 inches, weight 186 lbs. General impression, well nourished, in no apparent distress. Skin, good skin tone, dry patches on elbows and calves bilaterally, multiple skin tags. HEENT: Darkened teeth, several missing, no lymphadenopathy. Pupils equal, round and reactive to light. Neck, no jugulovenous distension, no palpable lymph nodes, no thyromegaly. Chest, decreased breath sounds at the right base, left is clear to auscultation. Cardiac, regular rate and rhythm, S1 and S2, there is a 2/6 systolic murmur radiating to the left clavicular area. Abdomen soft, nontender, non distended, positive bowel sounds, no hepatosplenomegaly. Extremities, multiple scratch abrasions on both calves. No clubbing, cyanosis or edema is appreciated. Legs are warm, well perfused, no ulcers or venous stasis disease. There are no varicosities. Neuro, cranial nerves III through XII grossly intact, non focal. Motor strength 4/5 in the upper extremities and [**6-17**] in the lower extremities. Femoral pulse 2+ bilaterally, DP 2+ bilaterally, PT 1+ bilaterally, radial 2+ bilaterally. HOSPITAL COURSE: The patient was admitted to [**Hospital1 346**] on [**2131-1-3**]. On day of admission he had a coronary artery bypass graft of three vessels performed by Dr. [**Last Name (STitle) **]. He had left internal mammary artery anastomosis to the LAD, saphenous vein graft to OM and saphenous vein graft to PDA. Please see previously dictated operative note for more details. The patient tolerated the procedure well without problems and was discharged from the operating room to the cardiac surgery recovery unit. On leaving the operating room the patient was intubated and was on a Neo-Synephrine and Propofol drip. The patient's postoperative course was uncomplicated and on the first postoperative day he was weaned off all vasoactive drips, was extubated and transferred to the patient care floor. On the floor the patient ambulated well and continued to make good progress. The only minor complication was a fever spike on the evening of postoperative day #1. For this, chest x-ray was obtained, urinalysis was obtained, cultures were sent of blood, sputum and urine and white count was checked. The white count was not elevated and all other investigations did not yield the source of the fever. The patient was afebrile for the duration of his hospital course. The patient's chest tubes were removed on postoperative day #2 as were his pacing wires. By postoperative day #4 the patient was ambulating level 5, all wires and tubes were removed and was ready to go home. On this day there was minimal erythema noted around the sternum for which he was started on a 10 day course of Keflex. Examination on discharge, temperature 99.3, pulse 86, blood pressure 138/64, respiratory rate 18, 94% on room air. The patient was comfortable. Lungs were clear to auscultation bilaterally. Heart regular. Sternum stable. There was no drainage, minimal erythema around the staple line. His abdomen is soft, nontender, non distended with bowel sounds. His extremities have no edema. His saphenectomy wounds were well healed with no evidence of erythema or exudate. DISCHARGE DISPOSITION: To home. CONDITION ON DISCHARGE: Stable. DISCHARGE MEDICATIONS: Lasix 20 mg po bid times one week, potassium chloride 20 mEq po bid while on Lasix, Percocet 1-2 tablets po q 4-6 hours prn, Colace 100 mg po bid while taking Percocet, Aspirin 325 mg po q day, Plavix 75 mg po q day, NPH insulin 20 units subcu q a.m., Lopressor 75 mg po bid, Iron Sulfate 325 mg po tid, Keflex 500 mg qid times 10 days. FO[**Last Name (STitle) **]P: The patient will see his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 39507**] in three weeks. The patient will see Dr. [**Last Name (Prefixes) 411**] in [**4-16**] weeks. DISCHARGE DIAGNOSIS: 1. Status post coronary artery bypass graft times three. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Last Name (NamePattern1) 6355**] MEDQUIST36 D: [**2131-1-8**] 10:37 T: [**2131-1-10**] 13:06 JOB#: [**Job Number 39508**]

[ "714.0", "443.9", "414.8", "250.01", "414.01", "272.0" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

5118, 5128

1679, 1697

5186, 5763

5784, 6120

3018, 5094

1205, 1662

1835, 3000

178, 888

911, 1181

1714, 1812

5153, 5162

40,080

162,107

38256

Discharge summary

report

Admission Date: [**2106-5-31**] Discharge Date: [**2106-6-5**] Date of Birth: [**2027-8-4**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: dyspnea, weight gain, hypotension Major Surgical or Invasive Procedure: none History of Present Illness: 78 y/o F with hx of CHF, likely secondary to ischemic cardiomyopathy, hx of CVA who is now hemiplegic and nonverbal, who presents from [**Hospital 100**] Rehab with increased dyspnea, weight gain and inability to diurese. She recently has been changed from lasix 80 mg PO BID to 40 mg IV BID. Her SBPs had decreased slightly to the 90s. Per the rehab report, her last weight in [**Month (only) 547**] (presumed dry weight) was 128 lbs. Now she is 165 lbs. Over the last three days; when the IV lasix started, her weight has fluctuated up and down by one pound each day and she clinically has not improved. . In the ED, initial vitals were T 98.3, P 84, BP 90/52, R 20, and 93% on 2L. She received no medications in the ED. She did transiently drop her SBPs to the 60s, she was still apparently arousable and mentating. She was given 250 cc IVF bolus in the ED and her SBPs returned to the 90s. She had recently been treated for c.diff and the worry for sepsis prompted the MICU admission. She received no abx or blood cultures. . On arrival to the floor, the patient is alert and nods head sometimes to questions. Unclear if she understands english, but nodded "yes" to difficulty breathing and "no" to pain. She moans intermittently. Past Medical History: Systolic CHF, EF 25% Ischemic Caridiomyopathy STEMI [**2103**] s/p PCI BiV PPM with ICD Moderate MR/TR Afib on coumadin HTN Hyperlipidemia Pulmonary HTN Hypoalbuminemia CVA with residual R hemiplegia and aphasia in [**2103**] Social History: Patient initially from [**Country 2045**] and moved to the US in [**2077**]; was well until [**2105-10-27**] when she had a secondy stroke and she has since been in a long-term care facility. She has 2 daughters and 1 son (the son still lives in [**Country 2045**]). Her HCP is her daughter who is a nurse [**First Name (Titles) **] [**Name (NI) 100**] Rehab. Unclear hx of smoking, tobacco or etoh. Family History: non-contributory Physical Exam: General Appearance: No acute distress Eyes / Conjunctiva: PERRL, Pupils dilated Head, Ears, Nose, Throat: Normocephalic, Poor dentition Cardiovascular: (S1: Normal), (S2: Normal), (Murmur: Systolic) Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Present), (Left DP pulse: Present) Respiratory / Chest: (Breath Sounds: Clear : , Crackles : at bilateral bases) Abdominal: Soft, Non-tender, Bowel sounds present Extremities: Right lower extremity edema: 3+, Left lower extremity edema: 3+ Musculoskeletal: Unable to stand Skin: Not assessed Neurologic: Attentive, Responds to: Not assessed, Movement: Not assessed, Tone: Not assessed, hemiplegia and aphasia Pertinent Results: [**2106-5-31**] 09:21PM SODIUM-156* POTASSIUM-3.5 CHLORIDE-116* [**2106-5-31**] 04:30PM URINE HOURS-RANDOM SODIUM-23 POTASSIUM-62 CHLORIDE-LESS THAN TOTAL CO2-<5 [**2106-5-31**] 04:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-25 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-6.5 LEUK-TR [**2106-5-31**] 04:30PM URINE RBC-[**1-29**]* WBC-[**1-29**] BACTERIA-OCC YEAST-NONE EPI-0-2 TRANS EPI-0-2 [**2106-5-31**] 04:30PM URINE HYALINE-21-50* . Echo [**2106-6-1**] TTE: The left atrium is mildly dilated. The estimated right atrial pressure is 10-20mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity size is top normal/borderline dilated. Overall left ventricular systolic function is severely depressed with (LVEF= 20 %). The right ventricular cavity is dilated with moderately to severely depressed free wall contractility. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**11-28**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Severe [4+] tricuspid regurgitation is seen. There is at least moderate pulmonary artery systolic hypertension. There is a very small pericardial effusion. . CXR [**2106-6-1**] PA&L IMPRESSION: 1. Moderate right pleural effusion and associated right basilar opacity, likely representing atelectasis. Superimposed pneumonia cannot be excluded. 2. Cardiomegaly and central venous congestion without frank pulmonary edema. 3. Left PICC extends to the mid superior vena cava. Brief Hospital Course: 78 year old lady with history of congestive heart failure, likely secondary to ischemic cardiomyopathy, history of cerebral vascular event who is now hemiplegic, who presents from [**Hospital 100**] Rehab with increased dyspnea, weight gain and inability to diurese. . # Heart Failure (CHF) : The presention of weight gain, dyspnea and pleural effusion on CXR likely secondary to acute on chronic CHF. The patient was volume overloaded, with bilateral lower extremity edema and evidence of pulmonary edema and has mild dyspnea. CXR unremarkable for florid CHF, except large effusion. TSH normal. The patient has known EF of 20-25% from recent echo. Repeat echo on [**6-1**] revealed LVEF of 20%, RV dysfunction, severe TR and mild/moderate MR. Trigger for heart failure likely related to new cardiac event, but unclear. The patient was diuresed with a lasix drip with initially good urine output, however diuresis was limited by hypotension (as described below). The patient's urine output persistently decreased despite up-titration of the lasix drip. Metalazone was added to assist with diuresis. A dopamine drip was considered to improve diuresis with positive ionotropic support, however the patient's persitant tachycardia limited its use. The patient's breathing became more labored and tachypnic. On HD 4, the patient's family decided to make her comfort care only, rather than pursue more invasive measures. The lasix drip and metalazone were continued, tube feeds were terminated, and morphine was administered in 1 mg boluses as needed for patient comfort. On HD 5 the patient was transferred back to [**Hospital 100**] rehab. The medication protocol for [**Hospital1 100**] will be left to the discretion of the palliative care team there and their discussions with the family. . # Hypotension: Etiology cardiac shock versus over-diuresis at prior rehab versus infection. The etiology likely heart failure in the setting of underlying CHF, elevated BNP, normal renal function and electrolytes not indicative of overdiuresis and positive fluid balance. The patient required a levophed support on the morning of admission [**6-1**]. With diuresis necessary for heart failure (see above), pt continued to be in hypotensive state. She required addition of Levophed pressor on HD2, which was again weaned. Systolic BPs were maintained >80 as long as patient urinating and mentating. Of note, cx were all negative. Carvedilol and Lisinopril were held while hypotensive. . # Hypernatremia: The patient??????s hypernatremia was likely secondary to severe free water deficit of 3.8L. The patient had been getting 125 cc free water flushes every 6 hours at [**Hospital 100**] Rehab which was likely not enough. The patient was given 3 L of D5W with free water flushes with correction of serum sodium. Free water flushes were increased to 300 ml every 6 hours. Hypernatremia resolved on HD2, and electrolytes were monitored throughout her stay. . # Atrial fibrillation / Tachycardia : The patient is rate controlled with heart rates in the 90s as an outpatient, but was persistently sinus tachycardia in ICU. Would ideally like a HR in the 70s if possible to optimize filling time. However, the patient was hypotensive which made diuresis and rate control difficult. On hospital day 3, the patient's rate was controlled with Metoprolol 5mg IV at times when BP was MAP>60. The patient was started on 50mg three times a day to provide better basal rate control. Heart rates improved marginally to <120. The patient was not therapeutic on coumadin on HD 3. Her coumadin was increased marginally to 1.5mg daily on HD 4, with consideration of it's interaction with metronidazole and the patient's stroke risk. . # Diarrhea / C. Diff: The patient developed C. diff diarrhea confirmed by stool antigen testing. She was initiated on metronidazole on HD 3. The patient finished a course of metronidazole at [**Hospital1 100**] on [**5-29**] for C diff. . # CAD: The patient has unknown anatomy, although echo suggests old inferior MIs; EKG does not suggest new or ongoing ischemia. Carvedilol and lisinopril were held for hypotension and her ASA 162 mg was continued. . # Hypoalbuminemia / poor nutrition: Has low albumin and is likely anasarcic in addition to the fluid overload from heart failure. Nutrition consult suggested tube feeds in addition to diet, and pt was started on low sodium/cardiac healthy diet. Tube feeds were discontinued when the patient was . # Hx of CVA: The patient has hemiplegia. Stable, unclear if she is at her baseline mental status, but is alert and interactive. . # Code: Pt was DNR/DNI during ICU stay, confirmed with patient using interpretor Medications on Admission: Lasix 60 mg PO BID --> 40 mg IV BID Metoprolol 50 mg TID --> carvedilol 3.125 mg [**Hospital1 **] ASA 162 mg daily Lisinopril 10 mg daily Nitro patch 0.2 mg/hr Spironolactone 37.5 mg [**Hospital1 **] Coumadin 1 mg daily Omeprazole 40 mg daily Albuterol nebs q6hrs Ipratropium nebs q6hrs Flagyl course from [**Date range (1) 85263**] Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain/fever. 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours). 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for tachycardia. Disp:*90 Tablet(s)* Refills:*0* 4. 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. 5. Metolazone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Morphine Concentrate 20 mg/mL Solution Sig: 1-2 mg PO Q 1 hr as needed for pain. 7. Flagyl 500 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 14 days. 8. Lasix 40 mg Tablet Sig: One (1) Tablet PO every six (6) hours. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: End- stage Congestive Heart Failure Atrial Fibrillation C difficile Discharge Condition: Mental Status: Minimally clear and coherent. Level of Consciousness: Minimally Alert and somewhat interactive. Activity Status: Bed bound - dependent hemiplegia. Discharge Instructions: You were admitted with worstening fluid overload due to your chronic CHF. While you were here, we were unable to take this fluid off of you. You and your family have decided to send you back to [**Hospital 100**] Rehab with hospice care. You also got C difficile infection while you were here and were started on flagyl for treatment of this on [**6-3**]. We are sending you out with comfort- oriented meds to be changed as needed by the palliative care team at [**Hospital 100**] Rehab. Followup Instructions: Please follow up with Physicians at [**Hospital 100**] Rehab for further diuresis and comfort measures. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "424.0", "438.11", "428.0", "276.0", "V58.61", "V45.02", "008.45", "272.4", "285.9", "414.01", "397.0", "412", "401.9", "416.0", "427.31", "438.20", "428.43", "458.9", "V45.82" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10848, 10914

4891, 9589

354, 360

11026, 11026

3093, 4868

11728, 11971

2321, 2339

9972, 10825

10935, 11005

9615, 9949

11214, 11705

2354, 3074

281, 316

388, 1635

11041, 11190

1657, 1884

1900, 2305

16,564

142,725

10830

Discharge summary

report

Admission Date: [**2189-11-11**] Discharge Date: [**2189-11-22**] Date of Birth: [**2130-2-11**] Sex: F Service: ORTHOPEDIC HISTORY OF THE PRESENT ILLNESS: Cervical spondylotic myelopathy. HOSPITAL COURSE: This is a very pleasant 59-year-old female with cervical spondylotic myelopathy, who underwent C4 to C7, who underwent C4, C5 and C6 corpectomy and C3 to C7 fusion using a fibular allograft. Postoperatively, the patient was admitted to the Intensive Care Unit for overnight observation. On postoperative day #1, [**2189-11-12**], the patient was extubated and had [**Last Name **] problem or difficulty. However, he had a sore throat and he was able to tolerate a clear liquid diet. On postoperative day #1, [**2189-11-12**] the patient was noticed to have a weakness of her left deltoid. The patient received physical therapy throughout the hospital stay for left arm weakness, which gradually improved throughout this hospital stay. On postoperative day #1, which was on [**2189-11-12**], the CT scan of the cervical spine was obtained, which showed the hardware to be malpositioned. On hospital day #2 the hematocrit went down to 26.9, for which she received two units of packed red blood cells. On postoperative day #3, which was [**2189-11-14**], the hematocrit was 34. Due to the fact that the cervical spinal plate was malpositioned, the patient was taken back to the operating room on [**2189-11-6**] for removal of the screw and the adjustment of the anterior cervical plate. Postoperatively, from this operation, the patient had gradual improvement of the left arm strength. On hospital day #5, the patient was tolerating a clear liquid diet, however, he had difficulty tolerating solid food. On hospital day #5, the patient had decreased saturation on room air to about 88 and 89 and the patient was placed on face mask. At this time x-ray showed elevated hemidiaphragm on the left side. The patient had fluoroscopic examination on hospital day #8, which showed normal movement of the diaphragm. Upon request of the Medicine consultation, x-ray taken on [**2189-11-17**] showed question consolidation of the left lower lobe. The patient was placed on Levaquin for the diagnosis of pneumonia. The patient continued the antibiotics throughout the hospital course. On postoperative day #8, the patient was advancing to a regular diet with slight nausea, which improved, after discontinuation of the narcotic pain medications. The patient was tolerating the pain with a combination of Tylenol and Ultram. The patient continued physical therapy. The patient was able to walk independently on [**2189-11-20**]. CT scan with sagittal reconstruction was taken on [**2189-11-16**] showing hardware to be in correct position and fibular graft, even though not optimal, in acceptable position. Throughout this hospital stay, the patient was in a cervical collar and instructed to continue wearing the cervical collar for the next three months. Throughout this hospital stay, the patient gradually improved his oxygen supplementation and on [**2189-11-20**] the oxygen supplementation in the form of face mask was discontinued. At that time, the room saturation was at 96 to 97. The patient was able to tolerate solid food on [**2189-11-19**]. The patient was ambulating well, tolerating solid food, good pain control. The patient was not nauseated on [**2189-11-21**]. The patient was discharged home on [**2189-11-23**] in good condition. X-ray studies, taken throughout this hospital course showed fullness on the right hilum of the right lung. It was discussed with the patient to followup with the primary care physician to rule out any pathology of the right lung. The patient understood and the primary care physician was [**Name (NI) 653**]. CONDITION ON DISCHARGE: Good. The patient was tolerating solid food and had good pain control on [**2189-11-22**]. Upon discharge, the left arm weakness was improving slowly. FINAL DIAGNOSIS: Cervical spondylotic myelopathy status post fusion from C3 to C7 and C4, C5, and C6 corpectomy. DISCHARGE MEDICATIONS: Levaquin for antibiotics. The patient was instructed to take this ten days after discharge. Upon discharge, the patient had no neck pain. The patient was feeling comfortable. We will see this patient back in the Orthopedic Surgery Clinic within three weeks. We will obtained EMGs of the left arm, prior to this visit. [**First Name11 (Name Pattern1) 32782**] [**Last Name (NamePattern1) 32783**], M.D. [**MD Number(1) 32784**] Dictated By:[**Last Name (NamePattern1) 35330**] MEDQUIST36 D: [**2190-1-7**] 12:23 T: [**2190-1-12**] 11:52 JOB#: [**Job Number **]

[ "E878.1", "V15.08", "723.0", "723.4", "486", "721.1", "276.6", "447.1", "996.4" ]

icd9cm

[ [ [] ] ]

[ "77.77", "78.59", "81.02", "99.04" ]

icd9pcs

[ [ [] ] ]

4130, 4732

230, 3812

4009, 4106

3837, 3991

8,018

103,794

54447

Discharge summary

report

Admission Date: [**2128-12-29**] Discharge Date: [**2129-1-3**] Service: MEDICINE Allergies: Feldene / Ceftriaxone / Augmentin Attending:[**First Name3 (LF) 2297**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **] yo [**Age over 90 **] speaking female with severe Parkinson's, CRI, recurrent UTI's, diastolic CHF, afib, dementia, ppm for bradycardia who presented from NH for ? PNA and dehydration, found to be persistently hypotensive in ED and transferred to MICU for possible sepsis. History is obtained from daughter, as patient is noncommuncative currently. Per daughter, patient was in USOH (baseline includes some eating, drinking, wathcing tv, looking at pictures, and somewhat verbal to daughter) until [**Name (NI) 2974**] when appetite declined. Labs sent with nothing revealing. On Sunday patient stopped eating and began sleeping all of the time. Tues CXR done which demonstrated possible PNA vs CHF. No cough, fever. Levofloxacin x 1 given. Sent to ED for possible PNA and dehydration. . Vitals were initially stable in ED until pt became hypotensive to systolic of 70's. Pancultured and given ceftriaxone (has true allergy to this), vancomycin 1000mg x 1, flagyl 500 mg x 1, and dexamethasone 10 mg IV x 1. Central line placed (unable to get in touch with daughter to get permission for this) and started on levophed. Also guaic positive in ED. . Of note the patient has been admitted in the past ([**2128-7-10**]) for urosepsis treated with Augmentin after patient got AIN s/p Ceftriaxone, then again in [**2128-8-10**] with change in mental status & possible urosepsis but cultures negative. Most recent admission in [**Month (only) 359**] for UTI with possible urosepsis (E. coli in urine, MSSA in blood, treated with meropenem), PNA, hypernatremia. . ROS: Unable to obtain from patient. Per daughter, afebrile, more sleepy, no SOB, cough, URI sxs, CP, abd pain, diarrhea, constipation. Lives in [**Location **] so +sick contacts. Past Medical History: #Recurrent urinary tract infections #Congestive heart failure with a normal EF, 4+ MR. [**First Name (Titles) **] [**Last Name (Titles) 113**] [**2121**] #Bipolar disorder #Parkinson's disease #Asthma #OA #s/p DDD pacer in [**2121**] for bradycardia. Social History: Lives [**Hospital3 **]. Daughter is [**First Name5 (NamePattern1) 335**] [**Last Name (NamePattern1) 111445**] who is on staff at [**Hospital1 18**] as [**Hospital1 595**] interpreter (beeper [**Numeric Identifier 111446**]) Family History: Non contributory Physical Exam: per admitting resident: Vitals: 97.1, 91, 84/58 (MAP 62), 22, 100% on 2L HEENT: PERRL, left eye closed, unable to assess EOM, anicteric sclera, MMM, OP clear Neck: supple, no LAD, no thyromegaly Cardiac: RRR, NL S1 and S2, no MRGs Lungs: crackle at right base, o/w CTAB Abd: soft, NTND, NABS, no HSM, no rebound or guarding Ext: contracted, warm, 2+DP Neuro: unable to fully assess d/t patient noncompliance/unresponsiveness. CN III intact, will not squeeze hands or follow commands Pertinent Results: Labs: [**12-29**] INR 7.5 (NH) Na 158(from 157 day prior) , K 5.7, Cl 121, HCO317, BUN 77, Cr 6.7 (from 6.9 day prior) . Studies: UA: tr leuks, neg nit, [**3-14**] WBC, few bact, tr ket, sm bili . CXR: Dual chamber pacer in place. Left lower lobe with consolidation and possibly a left pleural effusion. . EKG: NSR, LAD, poor R wave progression, Q wave in III and V1, 0.[**Street Address(2) 1755**] depressions in V4-V6. . CT Head: Moderate size bilateral occipital lobe low density zones- consider vertebrobasilar infarction. Involvement of cortex argues against infection. Hypertensive encephalopathy is possible, but requires clinical correlation. . [**Street Address(2) **] [**2128-11-9**]: Mild LVF. EF nml (>55%). RV nml. Mild AR. Trivial MR. . Brief Hospital Course: [**Age over 90 **] yo [**Age over 90 **] speaking female with severe Parkinson's, CRI, recurrent UTI's, diastolic CHF, afib, dementia, ppm for bradycardia who presented with a possible PNA and dehydration, found to be persistently hypotensive in emergency department and transferred to MICU for possible sepsis. Patient had a history of multiple recent previous admissions. The patient presented hypotensive and somnolent. She was given IV fluid resuscitation and broad antbiotic coverage, she also was started on pressors. Her head CT showed changes consistent with vertebrobasilar infarction rather than infection. The patient's condition did not improve with maximal care, and given her poor prognosis, the family decided to pursue comfort measures only. The patient passed away in presence of her family on [**2129-1-3**] Medications on Admission: D5 1/2 NS at 80cc/hr Roxanol 2.5 mg SL Q4H prn Procrit 2,000 SQ MWF MVI Seroquel 25 mg PO BID Seroquel 12.5 mg PO Q4H prn Metoprolol 50 mg PO TID Hydralazine 10 mg PO Q6H Sinemet 25/100 TID Oxycodone 2.5 mg PO Q 8H prn Acet prn Warfarin 5 mg PO QD Discharge Medications: NA Discharge Disposition: Expired Discharge Diagnosis: expired Discharge Condition: expired Discharge Instructions: NA Followup Instructions: NA

[ "276.51", "286.9", "332.0", "585.9", "486", "428.0", "250.00", "584.9", "038.9", "995.92" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

5044, 5053

3891, 4718

253, 259

5104, 5113

3115, 3539

5164, 5169

2577, 2596

5017, 5021

5074, 5083

4744, 4994

5137, 5141

2611, 3096

202, 215

287, 2043

3548, 3868

2065, 2318

2334, 2561

5,225

182,314

13222+56435

Discharge summary

report+addendum

Admission Date: [**2181-2-20**] Discharge Date: [**2181-3-7**] Service: HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 40306**] is an 88-year-old gentleman with a history of hypertension, aortic stenosis and chronic atrial fibrillation who had occasional episodes of mild chest discomfort that were unrelated to activity. The pain resolved with sublingual nitroglycerin. In [**2180-3-21**] he had an echocardiogram which showed moderate MR [**First Name (Titles) **] [**Last Name (Titles) **] and mild to moderate AS. In [**2180-10-21**], he had a stress echocardiogram which showed a small distal anterior reversible defect with an ejection fraction of 59% and no wall motion abnormalities. His electrocardiogram had 2 to [**Street Address(2) 8206**] depressions in 2, 3, AVF and V4 through V6. He underwent cardiac catheterization on [**2181-2-20**] which showed severe three vessel coronary artery disease. There was 40% tapering of the proximal left main. The proximal LAD had moderate diffuse disease and the mid LAD was 90% stenosed. There was tandem 70% mid distal lesion. Two diagonal branches had severe proximal stenosis. A codominant left circumflex had 70% stenosis proximal to the OM1. The large branch OM was 70% stenosed prior to the bifurcation. There were collaterals to the distal RCA and the BLTDA was normal. The mid RCA was totally occluded. There was an ejection fraction of 61% and significant right iliac and femoral peripheral vascular disease was demonstrated as well. There was moderate aortic stenosis and mitral regurgitation and elevated biventricular filling pressures. PAST MEDICAL HISTORY: 1. Hypertension 2. Chronic atrial fibrillation 3. Aortic stenosis 4. Gastroesophageal reflux disease 5. Seizure disorder, status post hydrocephalus with shunt placement in [**2173**]. MEDICATIONS PRIOR TO SURGERY: 1. Imdur 30 mg po qd 2. Dilantin 200 mg po q a.m. and 100 mg po q p.m. 3. Tagamet 300 mg po qd 4. Adalat 60 mg po qd 5. Digoxin 0.125 mg po qd 6. Imipramine 10 mg po tid 7. Coumadin 8 mg 3x a week and 7 mg 4x a week ALLERGIES: The patient has no known drug allergies. HOSPITAL COURSE: The patient was taken to the Operating Room on [**2181-2-21**] at which time he underwent coronary artery bypass graft x3 with saphenous vein graft to the OM and then to the diagonal sequentially, saphenous vein graft to the RPDA. Intraoperatively, the patient began having severe hemoptysis and became unstable. At that point, it was decided to abort the procedure and thus the patient was incompletely revascularized with the LAD lesion not being bypassed. The patient was brought to the cardiothoracic surgery recovery unit on an epinephrine drip and propofol. His hemoptysis resolved, however intraoperatively he did receive 6 units of packed red blood cells, 2 units of platelets, as well as 8 units of fresh frozen plasma. The patient did not have any further active hemoptysis during his hospital course. His postoperative course was complicated by a prolonged vent wean. The epinephrine was quickly weaned off of on postoperative day #1. He underwent a bronchoscopy on postoperative day #2 which showed only friable mucosa in the left main stem and left lower lobe bronchus. There was a clot filling the left main stem bronchus which was evacuated. The patient was very slow to awaken from sedation, but on postoperative day #4 he was moving all extremities and following commands. On postoperative day #3, his platelets were noted to be low on 68. At this point, his Zantac was discontinued as well as all heparin from his lines was discontinued. The patient was extubated on postoperative day #4. At this point, the patient failed a swallow study and a feeding tube was placed and tube feeds were started. A second swallow study was attempted on postoperative day #8 which he again failed. At this point, a PEG was placed. The patient's white blood cell count was noted to have increased on postoperative day #9 to 15,000 and then continued to increase to 24,000. At this point, cultures were sent and the patient was started on broad spectrum antibiotics. Of note, he was afebrile throughout this course. The patient was started on vancomycin and ceftazidime. The vancomycin was discontinued when the cultures returned with only H. flu from the sputum. His urine cultures were positive for Escherichia coli that was sensitive to ceftazidime as well and ............... A repeat urine culture is pending at this time. The patient's Foley catheter has been discontinued and a [**State 2690**] catheter has been placed. On discharge, the patient's white blood cell count is improving and is down to 14,000 on [**3-6**]. His BUN and creatinine are 33 and 0.7. On exam, he is awake and alert. His speech is slightly garbled but easily intelligible. He has no focal neurological weakness on peripheral motor exam. His heart is irregular but rate controlled in the 80s. His lungs are clear to auscultation bilaterally with diminished breath sounds at the bases. His abdomen is soft, nontender, nondistended. His extremities are warm and he has +[**3-25**] motor strength in bilateral upper and lower extremities. His wounds are healing well and are clean, dry and intact with no signs of infection, cellulitis or erythema. The patient is being discharged to rehabilitation. DISCHARGE MEDICATIONS: 1. Captopril 25 mg per feeding tube tid 2. Lopressor 100 mg per feeding tube qd 3. Plavix 75 mg per feeding tube qd 4. Tylenol 650 mg per feeding tube q 4 to 6 hours prn for pain 5. Enteric coated aspirin elixir 325 mg per feeding tube qd 6. Ceftazidime 2 gm intravenous q 12 hours x10 days to be discontinued on [**3-17**] 7. Prevacid 30 mg per feeding tube qd 8. Dilantin 200 mg per feeding tube q a.m. and Dilantin 100 mg per feeding tube q p.m. [**Known firstname 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Last Name (NamePattern1) 25727**] MEDQUIST36 D: [**2181-3-6**] 15:05 T: [**2181-3-6**] 15:27 JOB#: [**Job Number 40307**] Name: [**Known lastname 7236**], [**Known firstname 63**] Unit No: [**Numeric Identifier 7237**] Admission Date: [**2181-2-20**] Discharge Date: [**2181-3-7**] Date of Birth: [**2092-8-10**] Sex: M Service: OMITTED FROM THE LIST OF MEDICATIONS: Coumadim. He is being on 5 mg per feeding tube q.d. Goal INR is 1.5 to 2. He is being anticoagulated for chronic atrial fibrillation. He will need his PT and INR checked and the dose adjusted at rehabilitation. [**Known firstname 63**] [**Last Name (NamePattern4) 7238**],M.D [**MD Number(1) 1509**] Dictated By:[**Last Name (NamePattern1) 7239**] MEDQUIST36 D: [**2181-3-6**] 15:52 T: [**2181-3-6**] 15:36 JOB#: [**Job Number 7240**]

[ "997.3", "411.1", "786.3", "518.0", "397.0", "396.2", "427.31", "780.39", "414.01" ]

icd9cm

[ [ [] ] ]

[ "88.53", "33.23", "36.15", "36.13", "43.11", "88.56", "37.22" ]

icd9pcs

[ [ [] ] ]

5403, 6889

2168, 5380

112, 1630

1652, 2150

20,116

162,637

5880

Discharge summary

report

Admission Date: [**2127-8-1**] Discharge Date: [**2127-8-5**] Date of Birth: [**2053-3-5**] Sex: F Service: MEDICINE Allergies: Amiodarone Attending:[**First Name3 (LF) 2704**] Chief Complaint: PEA arrest in the ED Major Surgical or Invasive Procedure: Temporary pace wiring placed on [**2127-7-31**] and removed on [**2127-8-3**] History of Present Illness: Prior Hospitalizations 74F with a hx of HTN, hyperlipidemia, diabetes who has recent complicated medical admissions. In [**2127-2-25**], she had an intracatheterization MI (clotted off LAD, LCX on [**2127-3-24**]) with cardiac arrest and subsequent resuscitaiton requiring ECMO. Kissing stents of the LMCA into the LAD and Lcx were deployed. The patient course was complicated by RP bleed. Her last echo ([**2127-3-28**]) shows LVEF 30% with LV basal and mid inferior hypokinesis with basal and mid inferolateral and lateral akinesis. . The patient most recent hospitalization was [**7-17**] -[**7-24**]. During which time she had CHF symptoms and found to have an increase PA pressure. The patient was started on Amiodarone and instructed to restart Toprol. . Current hospitalization Pt was in usual state of health until day of admission when she took first doses of Toprol XL (25mg) (~2PM). She began to complain of DOE and headache and presented to the ED ~11PM on day of admission. . EMS found HR to be in 50s, BP 70s/palp. In ED was given fluids, and began to feel slightly better. Admitted to OBS. Patient then began to brady down to 40s in junctional rhythm ultimately requiring Atropine, then Epinephrine and transcutaneous pacing as well as a second liter of fluid. Cardiology consult was called and at the time of arrival, patient had been intubated for airway protection given continued bradycardia and hypotension. Dopamine was started with minimal effect. During evaluation, patient went into PEA and was given epinephrine 1mg with good effect, and pulse was reestablished. Dopamine was run wide-open. Following initial stabilization, patient returned to PEA, and ACLS/CPR was initiated. Patient continued to receive epinephrine up to a total dose of 5mg as well as glucagon, at which point she was again stabilized on dopamine drip 20mcg. STAT Echocardiogram following stabilization revealed: No effusion, mild RV hypokinesis, good LV function, 2+MR. Once the patient stabilized she was tx to the CCU. Past Medical History: Diabetes mellitus Hypertension C section hysterectomy mild LV systolic dysfunction at baseline Social History: Married, lives with her husband in [**Location (un) 686**]. No stairs. Daughter lives on the [**Location (un) **] of her house. Family History: noncontributory Physical Exam: T 99.8 BP 97/53 P 91 RR 9 O2 sat 100% Vent settings: AC 500 X 14 PEEP % Gen: Opens eyes to voice, responds to commands HEENT: IJ in place on R side of neck, Pulm: coarse, rhonchorous bs bilaterally Heart: reg rate, S1S2q, [**3-30**] blowing systolic murmur loudest at apex Abd: soft, ND, +BS Ext: no edema, warm extremities with good pulses Neuro: responds to commands, PERRL, downgoing toes for Babinski Pertinent Results: Labs on Admission [**2127-7-31**] 11:55PM BLOOD WBC-6.2 RBC-4.18* Hgb-12.6 Hct-39.5 MCV-95 MCH-30.1 MCHC-31.8 RDW-14.0 Plt Ct-185 [**2127-7-31**] 11:55PM BLOOD PT-13.0 PTT-25.8 INR(PT)-1.1 [**2127-7-31**] 11:55PM BLOOD Glucose-236* UreaN-25* Creat-1.9* Na-139 K-4.4 Cl-104 HCO3-20* AnGap-19 [**2127-7-31**] 11:55PM BLOOD Calcium-9.4 Phos-4.2 Mg-1.9 . Cardiac Enzymes [**2127-8-1**] 06:45AM BLOOD CK(CPK)-72 [**2127-8-1**] 09:30PM BLOOD CK(CPK)-48 [**2127-8-1**] 06:45AM BLOOD CK-MB-NotDone cTropnT-0.09* . ECHO [**2127-8-1**] The left atrium is moderately dilated. Overall left ventricular systolic function is moderately depressed with focal akinesis/thinning of the basal 2/3rds of the inferolateral and inferior walls. The remaining segments contract well. The right ventricular cavity is mildly dilated with severe hypokinesis of the apical 2/3rds of the free wall. The aortic valve leaflets (3) are mildly thickened but with good leaflet excursion. The mitral valve leaflets are structurally normal. ?Moderate (2+) mitral regurgitation is seen (focused views). There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . ECG [**2127-7-31**] Junctional mechanism at rate 52 with marked Q-T interval prolongation and anterolateral T wave inversion. Consider drug effect, primary CNS pathology and/or myocardial ischemia. Also noted is right axis deviation. Compared to the previous tracing of [**2127-4-15**] the mechanism is junctional rather than sinus, the rate is slower, Q-T interval prolongation (borderline on the prior tracing) is now marked, and there is new T wave inversion in leads V2-V5. T waves are inverted in leads I, aVL and V6 on both tracings. . ECG [**2127-8-1**] Compared to the previous tracing the rhythm is now sinus bradycardia at rate 51 rather than junctional at rate 52. Q-T interval prolongation and precordial and lateral T wave inversions persist. The differential is as before. . ECG [**2127-8-4**] Sinus rhythm Consider left atrial abnormality Q-Tc interval appears prolonged but is difficult to measure Consider right ventricular overload Nonspecific T wave abnormalities Clinical correlation is suggested Since previous tracing of [**2127-8-3**], no significant change Brief Hospital Course: Course in the ED EMS found HR to be in 50s, BP 70s/palp. In ED was given fluids, and began to feel slightly better. Admitted to OBS. Patient then began to brady down to 40s in junctional rhythm ultimately requiring Atropine, then Epinephrine and transcutaneous pacing as well as a second liter of fluid. Cardiology consult was called and at the time of arrival, patient had been intubated for airway protection given continued bradycardia and hypotension. Dopamine was started with minimal effect. During evaluation, patient went into PEA and was given epinephrine 1mg with good effect, and pulse was reestablished. Dopamine was run wide-open. Following initial stabilization, patient returned to PEA, and ACLS/CPR was initiated. Patient continued to receive epinephrine up to a total dose of 5mg as well as glucagon, at which point she was again stabilized on dopamine drip 20mcg. STAT Echocardiogram following stabilization revealed: No effusion, mild RV hypokinesis, good LV function, 2+MR. The patient was transferred to the CCU and her course was as follows: 1. Cor: The patient has a hx of CAD s/p kissing stents of LAD/LCX. The patient was maintained on aspirin and plavix. The BB and amiiodarone were initially held. The BB was later restarted. 2. Rhythm: The etiology of the patient's PEA was unknown. During the initial part of her course she was in a junctional rhythm and hypotensive. An atrial pacer was placed and the patient remained in NSR and her BP improved. The patient was later weaned off of the dopa gtt and the pacer was removed. Her BB and Amiodarone were held as this may have contributed to her PEA. It was later felt that the patient's presentation was secondary to the amiodarone. The patient was restarted on lopressor 25 [**Hospital1 **]. Amiodarone has since been listed as one of her allergies. 3. Pump: During the code, an emergency ECHO was performed. No pericardial effusion was noted. The patient's EF was 35-40%. The final report was significant for the following: The left atrium is moderately dilated. Overall left ventricular systolic function is moderately depressed with focal akinesis/thinning of the basal 2/3rds of the inferolateral and inferior walls. The remaining segments contract well. The right ventricular cavity is mildly dilated with severe hypokinesis of the apical 2/3rds of the free wall. The aortic valve leaflets (3) are mildly thickened but with good leaflet excursion. The mitral valve leaflets are structurally normal. ?Moderate (2+) mitral regurgitation is seen (focused views). There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. After reviewing the ECHO , the patient's cardiologist recommended MV repair. However the patient refused. 4. Airway protection: The patient was intubated strictly for airway protection. She was later extubated once deemed medically stable. Her O2 sats were stable on room air. 5. ARF: Creatinine increased from 1.2 to 1.4 within 48 hours. This was attributed to ATN (ischemic assault). Her creatinine was monitored. Her FeNa was 0.6, suggestive of a prerenal azotemia. PO fluids were encouraged. 6. Dispo: The patient was discharged home with services and scheduled to followup with her cadiologist, Dr. [**Last Name (STitle) 1911**], and her PCP, [**Last Name (NamePattern4) **]. [**First Name (STitle) 1395**]. Medications on Admission: Per prior discharge summary 1. Amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day for 7 days: Take from [**7-25**]. Disp:*7 Tablet(s)* Refills:*0* 2. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day: Take from [**Month (only) 205**] onwards. Disp:*30 Tablet(s)* Refills:*2* 3. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 9. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 11. Spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* Discharge Medications: 1. Atorvastatin Calcium 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. 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* 4. Lisinopril 5 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day: To be taken with dinner. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Bradycardia secondary to amiodarone sensitivity Discharge Condition: Good Discharge Instructions: You must call 911 immediately if you feel short of breath, have chest pain or pressure, palpitations, pain radiating to your jaw or numbness or tingling in your arms. Followup Instructions: You should follow-up with you PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) 1395**] in one week. An appt has been made for you to see Dr. [**First Name (STitle) 1395**] on [**2127-8-12**] at 10:30am, location: [**Apartment Address(1) 2942**], [**Location (un) **]. You should follow-up with your cardiologist, Dr. [**Last Name (STitle) 1911**]. You have an appt with him on [**8-14**] at 1:00pm on the [**Location (un) **] of the Clinical Center on the [**Hospital Ward Name 516**]. Completed by:[**2128-8-22**]

[ "584.5", "250.00", "427.5", "414.01", "401.9", "427.89", "276.2", "424.0", "V45.82", "428.0", "780.6", "427.31", "458.29", "E942.0", "412" ]

icd9cm

[ [ [] ] ]

[ "96.04", "89.64", "37.78", "99.60", "38.91", "96.72" ]

icd9pcs

[ [ [] ] ]

11210, 11268

5435, 8843

289, 369

11360, 11367

3165, 5412

11582, 12111

2707, 2724

10324, 11187

11289, 11339

8869, 10301

11391, 11559

2739, 3146

229, 251

397, 2426

2448, 2545

2561, 2691

3,123

143,779

43184

Discharge summary

report

Admission Date: [**2198-4-20**] Discharge Date: [**2198-4-24**] Date of Birth: [**2124-1-3**] Sex: M Service: SURGERY Allergies: Diltiazem Attending:[**First Name3 (LF) 3223**] Chief Complaint: MVC Major Surgical or Invasive Procedure: none History of Present Illness: 74 y/o male brought to [**Hospital1 18**] via EMS after MVC. Patient was restrained driver. Per report patient ran into the back of an [**Company 2318**] bus and continued on through an intersection with a red light and then struck a parked car. The patient had no obvious signs of head trauma, no LOC. He had no complaints of pain in the trauma bay. Per report he was confused at the scene. He had no recollection of the events. Past Medical History: 1.cad s/p cabg 2.CHF 3.hyperlipidemia 4.htn 5.gout 6.polymyalgia rheumatica 7. diabetes Social History: Drinks 1-3 beers/night, smokes 1ppd for "[**Age over 90 **] years... all my life." no illicit drug use. Lives alone, no children, has siblings in the area Family History: Mother with CAD and stroke. Physical Exam: in the trauma bay: Vitals: Temp 100 rectal BP 158/70 HR 90 RR 16 sats 100% on NRB GCS 14 FS 206 GEN: elderly male, NAD, lying supine on hard board, alert and oriented x 4, slowed speech, does not appear to understand some questions, unable to provide medical history HEENT: NCAT, PERRL, EOMI, TM clear bilaterally, midface stable, OP clear NECK: in c-collar, NTTP PULM: CTA bilaterally CHEST: no crepitus or pain CV: regular, ECG NSR ABD: SNTND, FAST neg RECTAL: normal tone, guiac negative PELVIS: stable to AP/Lateral compression EXT: atraumatic, WWP, no edema BACK: NTTP, no step-off or deformity NEURO: CN II-XII intact, no focal motor or sensory deficits. Pertinent Results: [**2198-4-20**] 01:00PM BLOOD WBC-7.6 RBC-3.67* Hgb-10.6* Hct-31.3* MCV-86 MCH-29.0 MCHC-34.0 RDW-15.1 Plt Ct-350 [**2198-4-22**] 05:35AM BLOOD WBC-8.5 RBC-3.42* Hgb-9.8* Hct-29.3* MCV-86 MCH-28.7 MCHC-33.4 RDW-15.1 Plt Ct-300 [**2198-4-20**] 01:00PM BLOOD Glucose-213* UreaN-33* Creat-2.2* Na-143 K-4.3 Cl-105 HCO3-24 AnGap-18 [**2198-4-22**] 05:35AM BLOOD Glucose-115* UreaN-31* Creat-1.9* Na-142 K-4.3 Cl-105 HCO3-24 AnGap-17 [**2198-4-20**] 01:00PM BLOOD CK(CPK)-36* Amylase-119* [**2198-4-20**] 01:00PM BLOOD CK-MB-NotDone cTropnT-0.04* [**2198-4-21**] 11:15AM BLOOD CK(CPK)-28* [**2198-4-20**] 01:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2198-4-22**] 12:33PM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.015 [**2198-4-22**] 12:33PM URINE Blood-LG Nitrite-POS Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD URINE CULTURE (Final [**2198-4-24**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Trimethoprim/sulfa sensitivity confirmed by [**Doctor Last Name 3077**]-[**Doctor Last Name 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S LEVOFLOXACIN----------<=0.25 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Imaging [**2198-4-20**] Head CT: IMPRESSION: No intracranial hemorrhage is identified. [**2198-4-20**] CT C-spine IMPRESSION: No fracture or dislocation is identified within the cervical vertebrae. Degenerative changes are seen at multiple levels, most pronounced at the C5-C6 level, with moderate to severe spinal canal stenosis CT of Abd/Pelvis IMPRESSION: 1. Small extracapsular hematoma adjacent to the right posterior liver. 2. Small low attenuation left hepatic focus, which is too small to be characterized. If the patient sustained trauma to this area, this could represent a small contusion. 3. Small right pleural effusion. 4. Defect of right L3 lamina, which does not appear to be an acute finding. 5. Extensive atherosclerotic disease involving the aorta, mesenteric and renal vessels EEG [**2198-4-23**] IMPRESSION: This is an abnormal routine EEG due to a slowed background rhythm with intermittent generalized delta frequency slowing. These findings suggest deep, midline subcortical dysfunction and are consistent with an encephalopathy. Common causes include infection, metabolic abnormalities, and medication affects. No lateralizing or epileptiform abnormalities were seen. Brief Hospital Course: TSICU [**Date range (3) 93066**] After initial stabilization in the trauma bay, the patient was taken to the CT scanner for imaging studies. His only significant injury related to the trauma of the MVC was a small subcapsular hematoma of his liver. However, the patient began to develop shortness of breath in the trauma bay after obtaining his CT scans. He had been supine for a considerable length of time and was also under a significant stress [**1-3**] the MVC. At no time did he complain of chest pain. A chest x-ray was obtained showing possible CHF. An ECG did not show any ischemic changes. The patient has severe underlying cardiac disease with a depressed ejection fraction predisposing him to pulmonary edema. The patients blood pressure climbed to 200/100 and he was tachypneic and tachycardic. He was treated with IV lasix, oxygen and started on a nitro drip. Cardiology was called and the CHF team was consulted for optimal management. The patient quickly improved, but was monitored overnight in the ICU. [**Date range (3) 93067**]: The following day the patient was transferred to the hospital floor and cardiology was consulted regarding his outpatient heart failure/CV medications. He was continued on his beta-blocker, ace, and statin, but his asa and plavix were held [**1-3**] his hematoma. Throughout the [**Hospital 228**] hospital course, serial HCTs were done and they remained stable indicating no significant bleeding from the hematoma. The patient was restarted on his asa and plavix on [**4-22**]. The patient has an underlying severely compromised cerebral blood as evidenced by prior MRI/MRA. He had no memory of the accident and neurology was consulted at the request of cardiology to help optimize his blood pressure to ensure adequate cerebral perfusion while not putting extra stress on his heart. Neuro recommended a goal SBP of >120. The patient also has a L subclavian stent that requires coumadin dosing. The patient should not be restarted on his coumadin until 1 week post injury which is Friday [**4-27**]. Once the patient has a theraputic INR his plavix may be discontinued. The patient had a urine sample checked and was discovered to have a UTI. The culture is susceptible to E Coli and bactrim was prescribed and should be taken for 5 days after discharge. The patient was evaluated by Physical and Occupational therapy who found him to have good strength and mobility but to be of considerable safety risk to himself in that he was unable to answer appropriately when asked the names/doses of his medications, what he would do in an emergency and also was noted to have difficulty in tasks with concentration and memory. Therefore placement was arranged in a SNIF. On the day of discharge the patient was tolerating PO, was afebrile, voiding well, and was agreeable to placement. Cardiology and neurology were both aware of the patient's discharge planning. Medications on Admission: asa, plavix, lisinopril, lasix, lipitor, atenolol, prevacid Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): this should be continued until patient has an INR of 2.0-3.0 range. Once INR is >2.0 please discontinue plavix. 3. Lisinopril 10 mg Tablet Sig: 1.5 Tablets PO once a day. Tablet(s) 4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lansoprazole 15 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for UTI for 5 days. 8. Donepezil Hydrochloride 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. Tamsulosin HCl 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO DAILY (Daily). 10. Toprol XL 50 mg Tablet Sustained Release 24HR Sig: 1.5 Tablet Sustained Release 24HRs PO once a day: hold if HR<60 or SBP<100. 11. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 12. Coumadin 2 mg Tablet Sig: Two (2) Tablet PO at bedtime: please start on Friday [**4-27**]. Check INR on daily for 1 week until theraputic at INR [**1-4**]. Adjust dose as appropriate. 13. Glucophage 500 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) Discharge Disposition: Extended Care Facility: [**Hospital3 537**]- [**Location (un) 538**] Discharge Diagnosis: Subcapsular hematoma of the liver Secondary diagnoses: 1.cad s/p cabg 2.CHF 3.hyperlipidemia 4.htn 5.gout 6.polymyalgia rheumatica 7. diabetes Discharge Condition: good Discharge Instructions: You should take all of your medication as prescribed during this admission. You will begin taking Coumadin on Friday of this week. After your INR becomes theraputic you will stop taking plavix. You may continue regular activity as tolerated. Avoid heavy lifting or straining. You should eat a cardiac low sodium diet. Return to the emergency room if you develop fevers, chills, chest pain or shortness of breath, nausea, vomiting, abdominal pain, lightheadedness, black or bloody stools, weakness in your arms or legs, changes in speech, inability to urinate or any other concerning symptoms. Followup Instructions: Follow up with Behavioral Neurology with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Telephone/Fax (1) 1690**] in [**12-3**] weeks after your discharge. Follow up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in the stroke clinic in 1 month after discharge. Call [**Telephone/Fax (1) 93068**] for an appointment. Follow up with Cardiology, Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **], on [**5-29**] at 2:30PM. You may call [**Telephone/Fax (1) 4022**] if you need to change your appointment. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**]

[ "725", "428.0", "427.32", "864.01", "E812.0", "294.8", "599.0", "V45.81", "272.4", "274.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9255, 9326

4815, 7725

272, 278

9514, 9520

1762, 3620

10163, 10876

1036, 1065

7835, 9232

9347, 9382

7751, 7812

9544, 10140

1080, 1743

9403, 9493

229, 234

306, 737

3629, 4792

759, 848

864, 1020

64,796

170,765

31703

Discharge summary

report

Admission Date: [**2109-11-13**] Discharge Date: [**2109-11-21**] Date of Birth: [**2047-1-19**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5790**] Chief Complaint: Left upper lobe lung cancer. Major Surgical or Invasive Procedure: [**2109-11-13**] Left intrapericardial pneumonectomy and intercostal muscle flap buttress to the pneumonectomy [**Last Name (LF) **], [**First Name3 (LF) **] lymphadenectomy, bronchoscopy with aspiration. History of Present Illness: Mr. [**Known lastname **] is a 62-year-old gentleman with a biopsy-proven left upper lobe lung cancer. His mediastinoscopy and mediastinal lymph node staging by VATS AP window dissection was negative for nodal spread. The patient had marginal pulmonary function tests and we did try to clarify this further with both VQ testing which revealed passable reserves following a left upper lobectomy with an expected predicted postoperative FEV1 of 48% and DLCO of 41%. He had a predicted postoperative FEV1 of closer to 39% and 34% following pneumonectomy. He was admitted for resection with possible pneumonectomy. Past Medical History: Prostate cancer, status post radical prostatectomy and XRT Status post appendectomy Status post cholecystectomy Skin cancer Social History: Married. Works as a swimming pool service contractor. Drinks 10 drinks/week. Quit smoking 20 years ago and had been a 60ppy smoker. No smokes cigars. Family History: Father deceased MI. Mother deceased emphysema. Sister and brother had AAA repairs. Physical Exam: VS: General: no apparent distress HEENT: normocephalic, mucus membranes moist Neck: supple Resp: clear breath sounds right, left absent Card: RRR GI: benign Extr: warm no edema Incision: Left thoracotomy site clean dry intact Neuro: non-focal Pertinent Results: [**2109-11-20**] WBC-11.0 RBC-3.25* Hgb-10.6* Hct-30.9* Plt Ct-268 [**2109-11-19**] WBC-10.6 RBC-3.25* Hgb-10.7* Hct-30.8* Plt Ct-258 [**2109-11-14**] WBC-20.1*# RBC-4.03* Hgb-12.7* Hct-37.5 Plt Ct-274 [**2109-11-20**] Glucose-91 UreaN-16 Creat-1.0 Na-139 K-3.5 Cl-100 HCO3-31 [**2109-11-19**] Glucose-95 UreaN-23* Creat-1.0 Na-139 K-4.2 Cl-102 HCO3-31 [**2109-11-14**] Glucose-112* UreaN-19 Creat-2.1*# Na-139 K-6.6* Cl-105 HCO3-27 [**2109-11-14**] Glucose-110* UreaN-21* Creat-2.0* Na-141 K-6.0* Cl-106 HCO3-24 [**2109-11-16**] CK-MB-4 cTropnT-0.04* [**2109-11-18**] CK-MB-3 cTropnT-0.01 [**2109-11-19**] CK-MB-3 cTropnT-<0.01 CXR: [**2109-11-19**]: There is no change in the appearance of the chest, compared to the prior study, including status post left pneumonectomy with surgical clips at the left hilus, near opacification of the left hemithorax, with small amount of air remaining in the pneumonectomy cavity and elevation of the left hemidiaphragm. Mild rightward mediastinal shift has stabilized. The right lung remains relatively clear. Thoracotomy changes are seen on the left. Left chest wall emphysema has decreased. [**2109-11-18**]: A small amount of air is still present in the left hemithorax. The left post- pneumonectomy cavity is mainly occupied by fluid. There is stable shifting of the cardiomediastinal silhouette towards the right. The right lung is grossly clear. Left subcutaneous emphysema has minimally decreased. [**2109-11-17**]: interval increased opacification of the left hemithorax. Right lung is relatively clear. There is subcutaneous emphysema in the left chest wall extending into the neck. Small foci of air remain in the left upper thorax. Surgical clips are present at the left hilum. [**2109-11-15**]: Post-surgical changes including resolution of the left pleural air cavity and increasing fluid. Persistent subcutaneous air as described. [**2109-11-13**]: Status post pneumonectomy with two round areas of opacity in the left hemithorax, which may represent loculated fluid collections and/or postoperative hematoma. PICC: [**2109-11-18**] Right PICC tip is in the lower SVC. Brief Hospital Course: Mr. [**Known lastname **] was admitted on [**2109-11-13**] and had successful left pneumonectomy. He was extubated in the operating room, transferred to the TSICU for further management. Respiratory: He required aggressive pulmonary toilet, nebs and chest PT to Right lung to maintain oxygen saturations in the high 90's. He eventually weaned off oxygen with saturations 97% on Room air. Chest-tube was removed on POD 1. Serial chest films showed opacification of the left hemithorax, right clear lung. Cardiac: He required a small amount of pressures for hypotension. On POD4 he had an episode or rapid afibrillation and hypotension after lopressor & diltiazem IV. He was transferred back to the TSICU converted to sinus rhythm with amiodarone and beta-blocker. Electrolytes were repleted as needed. Cardiac enzymes were negative x 3. He remained in sinus rhythm with heart rate in the 50-60's. His amiodarone was titrated to maintance dose and beta-blocker changed to toprol daily. GI: PPI's were given for prophylaxis. Normal bowel funtion returned. Renal: Immediately postoperative the Creatinine level peaked to 2.2 with low urine output. His potassium level was also elevated to 6.6 and was normalized with insulin, and Kayexalate. With gental hydration his creatinine level improved to his base of 1.0 and good urine output. The foley was removed Incision: Left thoracotomy site clean Pain: Epidural managed by the acute pain service. On POD1 the epidural was replaced. The epidural was removed on POD5. He converted to PO Dilaudid and tylenol with good pain control. IV access: [**2109-11-18**] A right PICC line was placed in the Right Basilic vein and terminated in the distal SVC. Neuro: non-focal Medications on Admission: Randitine Discharge Disposition: Home With Service Facility: [**Hospital **] Home Health Care Discharge Diagnosis: Left upper lobe mass Prostate cancer, status post radical prostatectomy and XRT Status post appendectomy Status post cholecystectomy Skin cancer Discharge Condition: stable Discharge Instructions: Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if experience: -Fever > 101 or chills -Increased shortness of breath, cough or sputum production -Chest pain -Incision develops drainage -You may shower. No tub bathing or swimming for 4 weeks -No driving while taking narcotics. Completed by:[**2109-11-26**]

[ "E878.8", "305.1", "V10.46", "458.29", "799.02", "E849.7", "564.00", "998.81", "427.31", "162.3", "196.1", "486" ]

icd9cm

[ [ [] ] ]

[ "33.24", "83.82", "32.49", "03.90", "38.93", "40.3" ]

icd9pcs

[ [ [] ] ]

5845, 5908

4053, 5785

353, 560

6097, 6106

1900, 4030

1537, 1622

5929, 6076

5811, 5822

6130, 6455

1637, 1881

284, 315

588, 1201

1223, 1349

1365, 1521

52,657

116,379

37415

Discharge summary

report

Admission Date: [**2120-10-30**] Discharge Date: [**2120-11-12**] Date of Birth: [**2043-11-15**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1406**] Chief Complaint: recurring dyspnea following community aquired pneumonia Major Surgical or Invasive Procedure: [**2120-11-1**] Coronary artery bypass grafting x2: Left internal mammary artery to the left anterior descending artery, and reverse saphenous vein graft to the first diagonal artery. History of Present Illness: Mr. [**Known lastname **] is a 76 yo male with chronic renal failure who presented to MWMC with recurrent dyspnea following treatment for community acquired pneumonia. On admission, he ruled in for NSTEMI and chest x-ray revealed pulmonary edema. He was also started on hemodialysis for volume control. Since initiation of dialysis and completion of antibiotic therapy, his dyspnea has significantly improved. Recent cardiac catheterization revealed severe single vessel coronary artery disease with depressed LV function. He was therefore transferred to the [**Hospital1 18**] for surgical revascularization. Past Medical History: Past Medical History: Coronary Artery Disease, recent NSTEMI Acute on Chronic Diastolic CHF End Stage Renal Failure, on hemodialysis Hypertension Dyslipidemia Type II Diabetes History of DVT - right leg Recent Pneumonia- no culture data available, patient states everything was negative Anemia of Chronic Disease, on Epogen every 2 weeks,Constipation History of Shingles - 5 years ago Past Surgical History s/p Placement of Double Lumen Dialysis Catheter [**2120-9-29**] s/p Left Arm AV Fistula [**2120-9-29**] s/p Bowel Obstruction Repair/LOA [**2112**]- no resection required s/p Abd Aortic Aneurysm Repair [**2110**] s/p Hemorrhoidectomy s/p Right Rotator Cuff Repair Social History: Race: caucasian Last Dental Exam: edentulous Lives with: Wife Occupation: retired computer repairman Tobacco: 15 PYH, quit 40 years ago ETOH: rare, no history of abuse Family History: non contributory Physical Exam: Review of Systems General: 30 pound weight loss over last month which he attributes to poor appetite. Appetite currently improving. No recent fevers. Patient states he and his family has the "swine flu" back in early [**Month (only) **] - diagnosis not confirmed. Skin: Eczema [] Psoriasis [] Skin Cancer [] +facial port wine stain HEENT: Hearing aide(s) [] Glasses [x] Other: Denies[] Respiratory: Asthma [] COPD [] Pneumonia [x] Cough [] Sputum [x] Other- Cough/Hemoptysis has resolved Cardiac: Chest pain [] SOB [x] DOE [x] Orthopnea [x] PND [x] GI: Nausea [] Vomiting [] Diarrhea [x] Constipation [x] Heartburn/GERD [] Other: Diarrhea resolved after ABX GU: Dysuria [] Frequency [] Prostate [] GYN [] other: Denies[x] Musculoskeletal: Arthritis [x] - left knee pain Peripheral Vascular: Claudication [] Other: Denies [x] Psych anxiety [] depression [] Other: Denies [x] Endoicrine Diabetes [x] thyroid [] Other: denies [] Heme/ID: + History of DVT, no history of PE Neuro: TIA [] CVA [] Neuropathy [] Seizures (x) Denies Physical Exam T: 98.2 Pulse: 84 B/P: 157/76 Resp: 18 O2 sat: 95% 2L Height: 73 inches Weight: 89.8 kg General: Elderly male in no acute distress, non-toxic appearance Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Bibasilar rales Heart: RRR [x] normal s1s2, no murmur or rub Abdomen: Soft[x] non-distended[x] non-tender[x] bowel sounds+ [x] - well healed midline and LLQ incisions Extremities: Warm [x], well-perfused [x] Edema - none Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: 1 Left: 1 DP Right: 1 Left: 1 PT [**Name (NI) 167**]: 1 Left: 1 Radial Right: 2 Left: 1 Carotid Bruit Right: none Left: none Pertinent Results: Preop [**2120-10-30**] 01:10PM PT-14.8* PTT-150* INR(PT)-1.3* [**2120-10-30**] 01:10PM PLT COUNT-231 [**2120-10-30**] 01:10PM WBC-9.2 RBC-3.70* HGB-10.2* HCT-32.0* MCV-86 MCH-27.5 MCHC-31.9 RDW-17.1* [**2120-10-30**] 01:10PM %HbA1c-6.1* [**2120-10-30**] 01:10PM ALBUMIN-3.2* MAGNESIUM-2.7* [**2120-10-30**] 01:10PM LIPASE-192* [**2120-10-30**] 01:10PM ALT(SGPT)-16 AST(SGOT)-27 LD(LDH)-260* ALK PHOS-61 AMYLASE-148* TOT BILI-0.2 [**2120-10-30**] 01:10PM GLUCOSE-113* UREA N-46* CREAT-6.4* SODIUM-144 POTASSIUM-4.5 CHLORIDE-106 TOTAL CO2-24 ANION GAP-19 [**2120-10-30**] 06:13PM URINE RBC-0-2 WBC-[**5-8**]* BACTERIA-FEW YEAST-NONE EPI-0-2 TRANS EPI-0-2 RENAL EPI-0-2 [**2120-10-30**] 06:13PM URINE BLOOD-TR NITRITE-NEG PROTEIN-500 GLUCOSE-100 KETONE-TR BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG post op [**2120-11-6**] 04:45AM BLOOD calTIBC-139* Ferritn-396 TRF-107* [**2120-11-6**] 08:50AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE IgM HBc-NEGATIVE [**2120-11-10**] 06:15AM BLOOD WBC-7.5 RBC-3.11* Hgb-8.5* Hct-26.6* MCV-85 MCH-27.2 MCHC-31.9 RDW-18.0* Plt Ct-298 [**2120-11-10**] 06:15AM BLOOD Plt Ct-298 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT: [**Known lastname **], [**Known firstname 275**] Indication: Intraoperative TEE for CABG procedure. Aortic valve disease. Congestive heart failure. Coronary artery disease. Left ventricular function. Preoperative assessment. Right ventricular function. Shortness of breath. Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 45% >= 55% Aorta - Annulus: 2.2 cm <= 3.0 cm Aorta - Ascending: *3.5 cm <= 3.4 cm Aortic Valve - Peak Velocity: 1.6 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: 10 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 6 mm Hg Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. Bidirectional shunt across the interatrial septum at rest. Small secundum ASD. LEFT VENTRICLE: Mild regional LV systolic dysfunction. Mildly depressed LVEF. [Intrinsic LV systolic function likely depressed given the severity of valvular regurgitation.] RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Mild AS (area 1.2-1.9cm2). No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Mild (1+) 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. The patient was under general anesthesia throughout the procedure. No TEE related complications. The patient appears to be in sinus rhythm. Results were personally reviewed with the MD caring for the patient. Left pleural effusion. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions Prebypass There is a bidirectional shunt across the interatrial septum at rest. A small secundum atrial septal defect is present. There is mild regional left ventricular systolic dysfunction with hypokinesia of the apex, apical and mid portions of the anterior septum. Overall left ventricular systolic function is mildly depressed (LVEF= 45 %). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). The [**Location (un) 109**] by planimetry is 2.2 cm2and by continuity equation it is 1.2 cm2. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified in person of the results on [**2120-11-1**] at 0915am. Very poor transgastric views Post bypass Patient is AV paced and receiving an infusion of phenylephrine and epinephrine. Biventricular systolic function is unchanged. There is trivial mitral regurgitation. Aorta is intact post decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2120-11-1**] 13:12 Radiology Report CHEST (PORTABLE AP) Study Date of [**2120-11-4**] 7:28 AM [**Hospital 93**] MEDICAL CONDITION: 76 year old man with CABG/ESRD Final Report CHEST RADIOGRAPH FINDINGS: As compared to the previous radiograph, the left-sided pleural effusion and subsequent retrocardiac atelectasis are unchanged. The pre-existing right pleural effusion and subsequent atelectasis are minimally increased. No newly occurred focal parenchymal opacities, no other changes. Unchanged right-sided double-lumen catheter. DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4130**] Approved: MON [**2120-11-4**] 2:46 PM [**2120-11-7**] 04:50AM BLOOD PT-13.6* PTT-31.4 INR(PT)-1.2* [**2120-11-12**] 05:15AM BLOOD Glucose-78 UreaN-47* Creat-5.9* Na-140 K-4.3 Cl-103 HCO3-27 AnGap-14 Brief Hospital Course: Mr [**Known lastname **] was transferred from MWMC on [**2120-10-30**] for coronary revascularization. He was dialysed prior to surgery. He was taken to the Operating Room on [**2120-11-1**] for coronary artery bypass grafting. Please see opertive note for details., in summary he had coronary artery bypass grafting x2 with left internal mammary artery to the left anterior descending artery, and reverse saphenous vein graft to the first diagonal artery. His bypass time was 70 minutes with a crossclamp of 58 minutes. He tolerated the operation well and was transferred to the cardiac ICU intubated and sedated on neosynepherine infusion. He remained hemodynamically stable in the immediate post-op period was weaned from pressors, the ventilator and extubated in stable condition. He had dialysis on POD1 and was transferred from the ICU to the step down unit on POD #3. He was started on betablockers and had several sinus pauses, the Bblockers were stopped and electrophysiology was consulted. Per Dr [**Last Name (STitle) 2357**] he was cleared for discharge with telemetry monitoring at rehab. He will require follow up with Dr [**First Name (STitle) **] at [**Hospital3 **]. Once his fistula has matured and he is able to have his temporary dialysis catheter removed, he is to be evaluated for a permanent pacemaker. He is not to start on beta blockers until that time. Additional he had several episodes of nonsustained ventricular tachycardia which were evaluated by the electrophysiology service and given EF 40% not treated at this time. He was maintained on a Tuesday-Thursday-Saturday dialysis schedule. He was evaluated and treated by physical therapy and rehab was recommended. The remainder of his hospital stay was uneventful. He was transfered to telemetry rehababilitation at [**Hospital **] Rehabilitation at [**Last Name (un) 59835**] [**Doctor Last Name 3549**] in [**Location (un) 1110**] on POD#11. He requires continued hemodialysis, his last episode of HD was on [**2120-11-12**]. stopped [**11-11**] Medications on Admission: Coreg 3.25", ASA 325', Doxazosin 4', Lotrel 10/40"', Lipitor 20', Protonix 40', Hydralazine 20"', Renvela 800 with meals, Nephrocaps 1', Glipizide 2.5', Florastor 250" Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 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). 6. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 7. Sevelamer Carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*90 Tablet(s)* Refills:*2* 8. Benazepril 20 mg Tablet Sig: Two (2) Tablet PO once a day. 9. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 10. Saccharomyces boulardii 250 mg Capsule Sig: One (1) Capsule PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital1 **]-Northeast-[**Location (un) 1110**] Discharge Diagnosis: CAD (s/p NSTEMI) s/p CABGx2 Acute on Chronic Diastolic Heart Failure, ESRD, HTN, Dyslipidemia, DM2, DVT, CAP, Recent GI Bleed with tx PRBC, Anemia of Chronic Disease on Epogen, Constipation, s/p Left Arm AV Fistula [**2120-9-29**], s/p AAA Repair [**2110**], s/p Hemorrhoidectomy Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - Independent Wound: healing well, no drainage or erythema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on Mon [**2120-12-11**] @ 1PM ([**Telephone/Fax (1) 170**]) Dr [**Last Name (STitle) 84103**] [**Name (STitle) 67625**](Vascular surgeon)[**Telephone/Fax (1) 84104**] in 1 week. Dr [**Last Name (STitle) 67625**] will come to [**Hospital1 **] to see patient if you call his office to let him know patient has arrived. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 68568**] 2 weeks([**Telephone/Fax (1) 5835**]) call for appointment Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] 2 weeks-please call for appointment Completed by:[**2120-11-12**]

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icd9cm

[ [ [] ] ]

[ "39.95", "36.11", "36.15", "88.72" ]

icd9pcs

[ [ [] ] ]

12580, 12658

9381, 11414

380, 566

12982, 12982

3927, 6926

13695, 14355

2103, 2121

11632, 12557

8683, 9358

12679, 12961

11440, 11609

13172, 13672

6970, 8643

2136, 3908

285, 342

594, 1206

12996, 13148

1250, 1901

1917, 2087

82,023

181,150

38374

Discharge summary

report

Admission Date: [**2107-5-6**] Discharge Date: [**2107-6-10**] Date of Birth: [**2058-8-10**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 668**] Chief Complaint: Decompensated liver failure Major Surgical or Invasive Procedure: liver transplantation [**2107-5-22**] Upper endoscopy IR guided dobhoff placed and self dc'd on [**2107-5-13**] History of Present Illness: History obtained from hospital notes and sister [**Name (NI) **]. 48 [**Name2 (NI) **] F with chronic hepatitis C(genotype 1a, biopsy grade [**2-17**], stage 3/4) started on ribavirin/PEG-interferon [**12-26**], initially presented to [**Hospital1 1562**] on [**4-28**] with increasing fatigue, nausea, myalgias, and anorexia x 1 month with abdominal distention, scleral icterus/jaundac x1 week where a RUQ US showed portal vein thrombosis. She was transferred to [**Hospital1 112**] on [**2107-4-29**] for further care of her decompenstate liver failure. There her course has been complicated by HRS and fulminant hepatic failure. Para [**4-28**] with 550cc removed, gram stain negative, blood and urine cx negative to date. At the time of transfer, INR 4.3 up from 3.6, T. bili 23 from 22.7, and Creatinine 1.7. T: 97.9 78 94/50 18 93% on RA wt 150.9 lbs. Getting IV vitamin K [**5-6**], albumin Q6H. AAOx3 but slow to respond. Poor nutritional status. PPD negative. . Patient transferred to [**Hospital1 18**] for transplant evaluation. . On arrival to the floor, patient had low grade temp to 99.2 and was hemodynamically stable Past Medical History: Hepatitis C genotype 1a, dx [**2076**], on ribavirin/PEG-interferon since [**12-26**], VL IVDU heroine, in remission since [**2094**] Depression Social History: Lives alone on [**Hospital3 **]. Works as a waitress in a sports bar. Denies tobacco, occasional marijuana but no other illicit. Prior h/o IV heroine abuse [**2066**]-[**2094**]. Occasional ETOH but none since [**3-/2107**] (wine [**Last Name (un) 55084**]) Family History: Father with hemachromatosis, per sister, pt tested negative for gene. Mother/Father with HTN, Paternal GM with pancreatitis, liver cancer, paternal GM with stroke, maternal GM with heart disease. Physical Exam: VS - Temp: 99.2 HR: 73 BP: 117/65 RR:20 02: 94% RA . GENERAL - thin, comfortable HEENT - slceral icterus, neck veins non engorged, mucous membranes moist, no thyromegaly, no carotid bruits LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/ mildy distended, tender to palpation in RUQ, liver enlarged, ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs) SKIN - jaundiced, facial telangiactasias LYMPH - no cervical, axillary, or inguinal LAD NEURO - alert, inattentive with delayed responses, flat affect. oriented to person, " [**2098-5-3**]", "[**Last Name (un) 2753**]", unable to comply fully with exam. +Asterixis CNs II-XII grossly intact, normal muscle bulk and tone, patient unable to comply with muscle strength testing, sensation, cerebellar exam and gait exam deferred. reflexes mute bilaterally, babinski negative Pertinent Results: . Echo showed Hyperdynamic left ventricular function (EF 75%). Mild mitral regurgitation. Very small pericardial effusion. US showed Prominent extrahepatic and central intrahepatic bile ducts of uncertain significance, biliary sludge CXR no acute pulmonary process Endoscopy showed possible cord Grade I varices, portal hypertensive gastropathy, small Hiatal hernia, CEA 6.3 CA-19-9 59. Ig A 254 EBV negative RPR negative VZV negative rubella negative HIV negative CMV VL negative AMA/[**Doctor First Name **] negative. HAV Ab positive, HAV IgM negative ceruloplasmin 12 CMV negative Brief Hospital Course: 48 year old woman with hx of HCV cirrhosis on peg-interferon/ribavirn for genotype 1a since [**12-26**] presented with decomensated cirrhosis. Pt was jaundiced, with ascites and portal vein thrombosis. Viral load undetectable. Given her acute decompensation, ribaviron/interferon was held. She initially presented to [**Hospital 1562**] Hospital on [**4-28**] with increasing fatigue, nausea, myalgias, and anorexia x 1 month with abdominal distention, scleral icterus/jaundice x1 week where a RUQ US showed portal vein thrombosis. She was transferred to [**Hospital1 112**] on [**2107-4-29**] for further care of her decompenstate liver failure. There her course had been complicated by HRS and fulminant hepatic failure. PPD was negative. Patient was subsequently transferred to [**Hospital1 18**] for transplant evaluation. Given h/o depression, social work evaluated and followed. She did not have suicidal/homicidal ideation. She presented as inattentive with flat affect likely from hepatic encephalopathy. Celexa continued, social work support inhouse with plan for outpatient. Throughout her time at [**Hospital1 18**], liver failure worsened, characterized by rising PT/PTT, INR, and bilirubin. Creatinine increased to 3.0 with evolving hepato-renal syndrome. Course was complicated by hemorrhoidal bleeding and a bleeding abrasion on left upper extremity. Hct dropped to 20 requiring PRBC, FFP and po vitamin K. She was transferred to the MICU for arm and rectal bleeding. She had poor access due to her peripheral edema. In the MICU, CVL placement occurred with elevated INR (5.9 prior to administration of 2 [**Location 16678**]->3.5). She remained in the ICU due to continued bleeding from her central line site. Pressure was held over the site of the catheter, platelets and FFP was transfused, but bleeding continued, requiring multiple PRBC transfusions. Her transfusions were limited by worsening hepato-renal syndrome and generalized volume overload, which caused transient episodes of hypoxia. The patient also demonstrated increasing somlenence and severe asterixis consistent with hepatic encephalopathy. Liver transplant workup was completed. On [**2107-5-22**], a liver donor was available and the patient proceeded to undergo orthotopic liver transplant. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please refer to operative notes for details. Intraop, 2 drains were placed. Postop, she went directly to the SICU for care. She required transfusion with blood products the first day or so to maintain hemostasis parameters. On [**2107-5-23**], liver duplex demonstrated patent hepatic and portal vessels with appropriate direction of flow. Diminished diastolic flow was seen in the right hepatic artery. LFTs continued to decrease with decreased jaundice. CVVHD was required for the first several days for resolving HRS. Hemodialysis was performed on [**5-26**] with removal of 4 liters. Dialysis was then stopped and not resumed. Nephrology followed her. Renal function improved over the remainder of the hospital stay. Liver function steadily improved. She was extubated after a couple days and transferred out of the SICU after 7 days. She was found to have a VRE UTI that was not treated. Repeat urine culture was negative. The lateral JP was removed on [**6-8**]. Medial JP was pulled out by the patient. Immediately postop, cognitive function was slow to improve. She appeared to have a flat affect and was confused. This improved. Mood also improved. Diet was progressed and tolerated, but appetite was poor with insufficient Kcals. A post pyloric tube was placed and tube feeds were started, but feeding tube was removed during an EGD performed on [**6-2**] for bloody stools. Stool was negative for C.diff. EGD revealed portal gastropathy without bleeding source. Hct dropped to 22 requiring transfusion. Hematocrit stabilized. At this point, famotidine was switched to protonix [**Hospital1 **]. A feeding tube was replaced, but pulled out by the patient on the following day. Feeding tube was left out. Kcal counts averaged 1600 to 715 kcals. Nutritional supplements were provided. Of note, insulin was required for hyperglycemia from steroids. [**Last Name (un) **] was consulted and recommended Glipizide 2.5mg qam. She was taught how to check her glucoses. She experienced hyperkalemia likely from RI and prograf effect. IV meds (insulin, dextrose, calcium, bicarb, IV saline and lasix) were given to decrease potassium with only temporary fix of hyperkalemia. A standing dose of lasix (20mg qd )was prescribed. Kayexalate was also given with serum potassium decrease. Immunosuppression and meds teaching was given. She did fairly well with teaching. Cellcept was fairly well tolerated. Steroids were tapered per protocol. Prograf was adjusted per trough levels. PT worked with her and initially recommended rehab, but functional level and safety improved. She was cleared for home safety. She was discharged to her sister's home in [**Hospital1 2436**] with VNA services arranged. Medications on Admission: At home: Celexa 40mg daily Ribavirin 600mg QAM, 400mg QPM PEG-Intron 120mcg SC qweek Ambien 5-10mg po QHS Advil prn . On transfer from [**Hospital1 112**]: Vitamin K 10mg IV x1 on [**5-6**] Rifaximin 400mg po TID Midodrine 12.5mg TID Octreotide 200mcg SC TID Ciprofloxacin 750mh po Qweek Albumin 25gm IV Q6H Zofran prn Ambien 2.5mg po HS prn Discharge Medications: 1. Prednisone 5 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily): starting [**6-11**] thru [**6-21**] then decrease to 15mg..then follow taper schedule. 2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 4. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Sulfamethoxazole-Trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 7. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO 1X/WEEK (FR). 8. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. Tacrolimus 1 mg Capsule Sig: Two (2) Capsule PO Q12H (every 12 hours). 10. Glipizide 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 12. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 13. Kayexalate Powder Sig: Four (4) teaspoons PO once for high potassium: you will be called if you need to take this medication based on your labs. 14. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO twice a day. 15. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Primary Decompensated Cirrhosis now S/P Liver transplant. Hepatorenal syndrome . Hep C infection s/p 4 months ribaviron/interferon Depression Malnutrition GI bleeding Anemia Hyperglycemia Depression Malnutrition Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call the Transplant office [**Telephone/Fax (1) 673**] if you have any of the warning signs listed below Labs to be drawn Saturday [**6-11**] at the [**Hospital Ward Name 1826**] Building Lab at 9:30 AM, Feldburg Lab, [**Location (un) **], [**Hospital Ward Name 516**] Thereafter You will need to have labs every Monday and Thursday at [**Last Name (NamePattern1) 439**] ([**Location (un) 453**] Transplant Office) Check your blood sugar prior to meals and bed time or if you feel shaky/nervous/sweaty/irritable or very hungry No driving, heavy lifting/straining, drinking alcohol You may shower Follow medication list in your notebook Followup Instructions: [**Last Name (LF) **],[**First Name3 (LF) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2107-6-17**] 1:30 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2107-6-17**] 2:40 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2107-6-24**] 2:40 Completed by:[**2107-6-14**]

[ "287.9", "790.01", "799.02", "452", "571.5", "784.7", "305.53", "041.04", "263.9", "537.89", "599.0", "572.4", "070.44", "286.9", "782.3", "572.8", "584.9", "789.59", "276.7", "455.8", "276.1", "427.31", "311" ]

icd9cm

[ [ [] ] ]

[ "99.04", "99.07", "99.05", "38.93", "38.95", "33.24", "00.93", "39.95", "96.6", "50.59", "45.13" ]

icd9pcs

[ [ [] ] ]

10911, 10986

3925, 9005

340, 453

11242, 11242

3303, 3902

12061, 12477

2076, 2275

9398, 10888

11007, 11221

9031, 9375

11393, 12038

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1801, 2060

10,038

111,115

1164

Discharge summary

report

Admission Date: [**2144-2-9**] Discharge Date: [**2144-2-21**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7455**] Chief Complaint: hypotension with positive blood cultures Major Surgical or Invasive Procedure: Ultrasound guided left hip fluid drainage left PICC placement History of Present Illness: 88 yo f with PMH of atrial fibrillation and HTN presented to the ED on [**2144-2-9**] with failure to thrive. According to patient's daughter, patient with increased fatigue and sleepiness x 2 days with associated worsening mobility x 1 day. Patient's daughter then called the geriatrics on-call attending (Dr. [**Last Name (STitle) 1603**] who recommended that she come into the ED. Upon admission to the ED, patient had a fever to 100.1 and was given tylenol. She was given 1L NS as patient looked very dry. She was admitted to the medicine service. . Initially, she was noted to have low grade temps, left hip pain and leukocytosis. Given previous hip replacements, ortho was consulted. Initial XR showed no fracture. Ortho recommended ultrasound of hip and US guided arthrocentesis. LENIs showed no DVT but flattening of the waveform suggsting more proximal obstruction. US hip showed mostly solid 4 cm hematoma extending anteriorly from the femoral prosthesis to the proximal femoral diaphysis with no definite signs of abscess. . Over the next two days, she triggered on [**2-10**] for rigoring, temp to 102, and hypertension. Her abx were broadened to include vancomycin and zosyn. She triggered again on [**2-11**] for BP 79/48 and HR 120, and was bolused with fluids with improved BP to 90's. Initial blood cultures were negative, but repeat cultures on [**2-10**] were noted to be growing 4/4 bottles with GPC's in pairs and chains. She received a total of about 1.5 liters of fluid on the floor. Given possibility of sepsis, she was transferred to the ICU for closer monitoring and treatment despite DNR/DNI. . Initial BP in the MICU was 101/57and HR 100's. She has mild left hip pain, denies chest pain, shortness of breath, other pain. She feels generally "unwell" but is mildly disoriented as is ber baseline by report. She is unwilling to provide further ROS. Past Medical History: PMH: 1. Dementia with memory loss over 20 years 2. Congestive heart failure. Last ejection fraction greater than 55% on last echocardiogram in [**2139**] 3. Atrial fibrillation on coumadin 4. Hypertension 5. History of transient ischemic attacks 6. History of PEs and DVTs 30 years ago 7. Venous stasis changes in bilateral lower extremities 8. Degenerative joint disease with bilateral total hip replacements. Social History: Social Hx: Patient lives with daughters and depends upon them for all ADLs. Patient requires transfer assistance and attends daycare MWF. No Etoh, Tob, Drug use hx. Wears depends as chronically incontinent of urine and uses walker at daycare but not at home. Memory is very poor at b/l. Family History: NC Physical Exam: HOME MEDS: Aricept 5mg PO daily Celebrex 100mg PO bid Colace 100mg PO daily MVI 1 tab PO daily Calcium 600Vit D 125 PO bid Coumadin 2mg PO daily Diltiazem HCl 240mg PO daily Lasix 80mg PO daily Lidoderm patch [**Hospital1 **] prn pain Lisinopril 5mg PO daily KCl 20 PO daily Senna 2 tab PO qhs T3 q4h prn pain . MEDS ON TRANSFER: Lidocaine 5% Patch 1 PTCH TD Q12H Lorazepam 0.5 mg IV ONCE MR1 for MRI Miconazole Powder 2% 1 Appl TP QID:PRN Multivitamins 1 CAP PO DAILY Acetaminophen 325-650 mg PO Q6H:PRN Pantoprazole 40 mg PO Q24H Acetaminophen w/Codeine [**12-3**] TAB PO Q6H:PRN Phytonadione 5 mg PO ONCE Calcium Carbonate 500 mg PO TID Piperacillin-Tazobactam Na 2.25 gm IV Q6H Diltiazem Extended-Release 240 mg PO DAILY Senna 1 TAB PO BID Docusate Sodium 100 mg PO BID Donepezil 5 mg PO HS Vancomycin HCl 1000 mg IV Q48H Erythromycin 0.5% Ophth Oint 0.5 in OU QID Vitamin D 800 UNIT PO DAILY Pertinent Results: [**2144-2-14**] 02:30AM BLOOD WBC-6.8 RBC-3.20* Hgb-9.2* Hct-28.0* MCV-88 MCH-28.9 MCHC-33.0 RDW-15.8* Plt Ct-140* [**2144-2-14**] 02:30AM BLOOD Plt Ct-140* [**2144-2-14**] 02:30AM BLOOD PT-23.4* PTT-33.3 INR(PT)-2.3* [**2144-2-10**] 05:45AM BLOOD Fibrino-668* [**2144-2-10**] 05:45AM BLOOD ESR-74* [**2144-2-14**] 02:30AM BLOOD Glucose-161* UreaN-34* Creat-1.2* Na-143 K-3.8 Cl-113* HCO3-22 AnGap-12 [**2144-2-11**] 05:45AM BLOOD ALT-19 AST-24 LD(LDH)-217 AlkPhos-57 TotBili-1.2 [**2144-2-9**] 01:50PM BLOOD CK-MB-NotDone cTropnT-0.04* proBNP-[**Numeric Identifier 7456**]* [**2144-2-9**] 02:01PM BLOOD Lactate-2.4* K-4.2 [**2144-2-11**] 11:26AM BLOOD Lactate-2.5* . EKG:A fib with left anterior fasicular block but narrow QRS. No ST elevations. . IMAGING: - Hip Unilateral XR - [**2144-2-9**] - Bilateral hip prostheses with multiple chronic abnormalities as described above. No acute fracture or change in alignment. - Left unilateral US - [**2144-2-9**] - No DVT in the imaged veins. However, flattening of the left venous waveforms suggests a more proximal obstruction and further evaluation of the proximal vessels with CT or MR is recommended. - [**2144-2-9**] - Portable CXR - IMPRESSION: Decrease in the size of the chronic right-sided pleural effusion since the prior study of [**Month (only) 547**] - MRI read pending - Hip ultrasound: mostly solid 4 cm hematoma extending anteriorly from the femoral prosthesis to the proximal femoral diaphysis with no definite signs of abscess . [**2-10**] MRI Pelvis: Bilateral masses with a large intrapelvic component, larger on the right, which appear related to the joints. Evaluation is suboptimal. These masses were present on the prior CT examination, but appear somewhat smaller in size. Hematoma is not considered likely due to the chronicity. However, given the history of multiple hip replacements, the bilaterallity, and the unusual appearance of these lesions, foremost consideration is given to a foreign-body reaction. Less likely would be a proliferative synovial condition such as PVNS, or synovial chondromatosis. . [**2-11**] US EXTREMITY NONVASCULAR LEFT LE: Findings most consistent with a hematoma extending anteriorly from the femoral prosthesis to the proximal femoral diaphysis. There are no son[**Name (NI) 493**] findings of an abscess, however, an element of superimposed infection cannot be excluded. . [**2-12**]: US MULT/COMP ABSC/CYST DRAIN/I; GUIDANCE FOR ABSCESS: Successful ultrasound-guided aspiration of left thigh hematoma. 5-6 cc of dark red fluid was sent for Gram stain and culture. Brief Hospital Course: 88 yo f with past medical history significant for atrial fibrillation on coumadin, hypertension, and s/p bilateral hip replacements who presented with lethargy and found to have left hip hematoma now transfered to the MICU for possible sepsis from GPCs. . #) Sepsis: She presented with hypotension in the setting of fevers and elevated WBC count and Group-B streptococcal bacteremia c/w septic physiology. She was admitted to the MICU and was originally started on Vancomycin/Pip-Tazo on [**2-11**] however antibiotics were changed to Penicillin G when hip fluid and blood cultures grew out Group B strep sensitive to penicillin. She defervesced and BPs stabilized and she was transferred out of the unit to the general medicine service. TTE was negative for vegetations. Orthopedics was consulted who offered possible surgical intervention for removal of her hardware from previous total hip replacement, however patient and her family and HCP opted against surgical intervention. Thus, she will need continued IV antibiotics (3 million units IV Pen G q6h) for 6-8 weeks and then will likely need oral antibiotics following IV course. She is scheduled for follow in the infectious disease clinic. . #) Left hip hematoma with secondary infection with Group B strep and source of GBS bacteremia. Her pain was managed with lidoderm patch, standing tylenol and prn morphine IV. She was noted to have had on admission a significant hematocrit drop from her baseline, but her hct remained stable not requiring prbc transfusion. She did, however, receive 3U FFP on admission to the ICU as her INR was supratherapeutic at that time. Her coumadin was held, but her INR did not adequately come down so she required PO vitamin K in order to decrease her INR. As her hct remained stable without any signs of expanding hemotoma, orthopedics was okay with the reinitiation of coumadin for her a. fib, so it was restarted at her home dose. . #) Congestive heart failure: On admission, she had elevated BNP and right-sided pleural effusion. However, she appeared intravascularly dry by labs and initial exam. She was found to be in acute renal failure on presentation thought [**1-3**] to prerenal etiology so her diuretics were held. Echocardiogram revealed moderate LVH with preserved LV systolic function, mild aortic regurgitation, moderate tricuspid regurgitation, and moderate pulmonary hypertension. Upon transfer to the floor, however, she had persistent supplemental oxygen requirement and crackles on pulmonary exam. As her renal function had improved, diuresis was reinitiated and at time of discharge, she was maintaining O2 saturation on room air. She will be discharged on home dose lasix and lisinopril. . #) Acute Renal Failure: Creatinine was elevated to 1.9 intitially, with baseline 0.9-1.1. This was thought most likely secondary to pre-renal etiology possibly secondary to septic physiology and ATN in the setting of hypotension on presentation. Her ACEI and lasix were held and her renal function normalized. Her lasix was restarted and her renal function remained stable. Her ACEI was then restarted with renal function remaining stable at her baseline. . #) Atrial Fibrillation: On chronic anticoagulation as an outpatient, however INR was 4 upon admission. Her coumadin was held, but her INR did not adequately come down likely secondary to dietary vitamin K deficiency so she received additional PO vitamin K with good response of her INR. She does have significant risk of thromboembolic event based on her CHADS score, so hct remained stable without evidence of expanding hematoma when cleared by orthopedics for reinitiation, she was restarted on her home dose of coumadin. INR at time of discharge was 1.9. Additionally, she was continued on diltiazem for rate control. . #) Elevated blood sugar: Although she has no clear documented history of diabetes mellitus and was not on any oral medications upon admission, her blood sugar remained elevated during her entire stay. She was placed on insulin sliding scale while inpatient with goal for tight control in the setting of her infection. This will need to be continued upon discharge and further management evaluated by her primary care physician upon follow up. . #) Hypertension: Although she orinally presented hypotensive, treatment of her infection improved her blood pressure. Her lasix and ACEI were originally held, but were restarted with improvement in her renal function and increase in her blood pressure. . #) Dementia: She was continued on Aricept 5mg PO daily. . #) Osteoporosis: She was continued on calcium and Vitamin D per home regimen 600/125 PO bid. Medications on Admission: HOME MEDS: Aricept 5mg PO daily Celebrex 100mg PO bid Colace 100mg PO daily MVI 1 tab PO daily Calcium 600Vit D 125 PO bid Coumadin 2mg PO daily Diltiazem HCl 240mg PO daily Lasix 80mg PO daily Lidoderm patch [**Hospital1 **] prn pain Lisinopril 5mg PO daily KCl 20 PO daily Senna 2 tab PO qhs T3 q4h prn pain . MEDS ON TRANSFER: Lidocaine 5% Patch 1 PTCH TD Q12H Lorazepam 0.5 mg IV ONCE MR1 for MRI Miconazole Powder 2% 1 Appl TP QID:PRN Multivitamins 1 CAP PO DAILY Acetaminophen 325-650 mg PO Q6H:PRN Pantoprazole 40 mg PO Q24H Acetaminophen w/Codeine [**12-3**] TAB PO Q6H:PRN Phytonadione 5 mg PO ONCE Calcium Carbonate 500 mg PO TID Piperacillin-Tazobactam Na 2.25 gm IV Q6H Diltiazem Extended-Release 240 mg PO DAILY Senna 1 TAB PO BID Docusate Sodium 100 mg PO BID Donepezil 5 mg PO HS Vancomycin HCl 1000 mg IV Q48H Erythromycin 0.5% Ophth Oint 0.5 in OU QID Vitamin D 800 UNIT PO DAILY Discharge Medications: 1. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q12H (every 12 hours). 10. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours): Not to exceed 4g daily. 11. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 12. Oxycodone 5 mg Capsule Sig: [**12-3**] Capsules PO every 4-6 hours as needed for pain. 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 15. Insulin Regular Human 100 unit/mL Solution Sig: as directed Injection ASDIR (AS DIRECTED). 16. Celebrex 100 mg Capsule Sig: One (1) Capsule PO twice a day. 17. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 18. Penicillin G Pot in Dextrose 3,000,000 unit/50 mL Piggyback Sig: 3,000,000 Units Intravenous Q6H (every 6 hours). Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 533**] [**Last Name (NamePattern1) **] for Extended Care - [**Location 1268**] Discharge Diagnosis: Primary: Left hip hematoma with secondary Group B strep infection Group B strep sepsis Congestive heart failure Acute renal failure Elevated blood sugar Hypertension Dementia Atrial fibrillation on chronic anticoagulation Supratherapeutic INR Discharge Condition: Stable, afebrile and without elevated white blood cell count, hemodynamically stable. Discharge Instructions: Please call your doctor or return to the emergency room if you develop fevers, chills, lightheadedness, dizziness, incresed swelling, redness, warmth of your left hip, inability to tolerate food and fluids, worsening shortness of breath or any other symptoms that concern you. . Please follow up with your appointments as below. . Please ensure that you continue to take your antibiotics. Followup Instructions: Please follow up with Dr. [**First Name (STitle) **] [**Telephone/Fax (1) 719**] on Thursday, [**2-27**] at 11:00am. . Please follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in the Infectious Disease clinic on [**3-23**] at 9:30am. . As you have opted against surgical intervention at this time, you can follow up with orthopedics as needed. Dr. [**Last Name (STitle) 1005**] saw you in the hospital and his office phone is ([**Telephone/Fax (1) 2007**]. . Appointment scheduled prior to this admission: Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 252**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2144-4-8**] 10:00

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icd9cm

[ [ [] ] ]

[ "81.91", "38.93", "88.72" ]

icd9pcs

[ [ [] ] ]

13796, 13931

6561, 11233

302, 365

14218, 14306

3963, 6538

14743, 15430

3026, 3030

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13952, 14197

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14330, 14720

3045, 3357

222, 264

393, 2270

2292, 2705

2721, 3010

11589, 12158

18,113

192,642

49453

Discharge summary

report

Admission Date: [**2173-3-27**] Discharge Date: [**2173-3-27**] Date of Birth: [**2117-1-13**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 949**] Chief Complaint: hypothermia Major Surgical or Invasive Procedure: none History of Present Illness: This is a 56 yoM with hepatitis C cirrhosis and hepatocellular carcinoma with a recent admission for hypotension in the setting of polymicrobial SBP discharged home with bridge to hospice returns 3 days following discharge with worsening abdominal distention. . He underwent multiple therapeutic paracenteses during his last hospitalization and his ascites began progressively worsening since discharge. There was plan for therapeutic paracentesis as an outpatient on Monday, but he wife became increasingly concerned and brought him to the ED. . During his last hospitalization, he was found to have polymicrobial SBP with heavy growth of enterococcus, coag negative staph and sparse candidal growth. He completed a course of vancomycin and was discharged home on caspofungin to be continued indefinitely. His creatinine also rose to a max of 3.9 and was attributed to hepatorenal syndrome. He was placed on midodrine and octreotide without improvement in his renal function. Thus, it was decided to discontinue these medications prior to discharge. In discussion with family, it was decided to send the patient home with bridge to hospice. He was discharged off diuretics on medications to control his pruritis, caspofungin, and morphine and ativan for comfort. . In the ED, the pts vitals were: T 34.6 C, P 70-76, BP 94-131/40s-50s, R 18-20, Sat 97-98% RA. He was found to be hypothermic to 93 F with SBP of 95. He was given Vanc/CTX and transferred to the MICU. Past Medical History: 1) Hepatocellular Carcinoma - diagnosed in [**9-25**] after f/u labs for cirrhosis revealed an elevated AFP and imaging studies revealed infiltrative HCC with portal vein thrombosis. Not amenable to transplant given size of lesion. Not a candidate for chemoembolization given portal vein thrombus. Not a candidate for systemic chemotherapy given hepatic decompensation and refractory ascites. Followed by Dr. [**First Name (STitle) 1058**] in oncology who has had multiple discussions with patient regarding his limited treatment options. Has met with [**First Name8 (NamePattern2) 2270**] [**Last Name (NamePattern1) 1764**] from palliative care. 2) Hepatitis C - Per pt. hepC from experimentation with IVDU X 1 as a teen 3) Cirrhosis - approximatly 5 years. s/p palliative pleurex catheter drain, drains 1-1.5L ascitic fluid q72h 4) S/P Cholecystectomy Social History: Lives in [**Hospital1 1474**] with wife. [**Name (NI) **] 3 children and 4 grandchildren. Works as ortho tech @ [**Hospital3 **]. Prior heavy etoh use (4 nips and 2 beers/day), last drink 6 years ago. 1 cigarette/day. Family History: Significant for maternal uncle who died of an unknown cancer, his mother and father are both alive and well. His mother does have asthma and CAD. She is status post a four vessel CABG. His father's medical history is unknown. He has a brother with heart disease and another brother who died of cirrhosis. There is no other liver cancer that he knows of in the family. Physical Exam: Vitals: T 94 BP 100/51 P 75 R 16 Sat 98%RA Gen: Chronically ill-appearing AAM, lying in bed with bear-hugger, somnolent, opens eyes to loud voice, slurred speech HEENT: conjunctivae jaundiced Neck: supple, no LAD, no thyromegaly Chest: CTAB, no wheezes or rhonchi CV: RRR, normal s1 s2, no m/g/r Abd: distended, soft, +fluid wave, mild ttp diffusely Ext: 1+ pitting edema BL LE Skin: Diffuse maculopapular rash over legs and abdomen Neuro: somnolent Pertinent Results: [**2173-3-27**] 06:06PM K+-6.8* [**2173-3-27**] 05:50PM PT-150* PTT-150* INR(PT)-17.5* [**2173-3-27**] 04:09PM LACTATE-2.7* [**2173-3-27**] 04:00PM GLUCOSE-109* UREA N-66* CREAT-4.0* SODIUM-134 POTASSIUM-5.2* CHLORIDE-107 TOTAL CO2-10* ANION GAP-22* [**2173-3-27**] 04:00PM ALT(SGPT)-58* AST(SGOT)-195* ALK PHOS-144* AMYLASE-235* TOT BILI-34.1* [**2173-3-27**] 04:00PM LIPASE-160* [**2173-3-27**] 04:00PM NEUTS-75.5* LYMPHS-16.7* MONOS-6.1 EOS-1.6 BASOS-0.1 [**2173-3-27**] 04:00PM PLT COUNT-59*# Brief Hospital Course: The pt was admitted to the ICU with hypothermia to [**Age over 90 **] F and hypotension with SBP in the 70s. Upon further discussion with the family, the pt was made CMO and decision for comfort measures was made. It was discussed that further aggressive measures, such as dialysis, central line placement, and central line placement would not result in any benefit to his care. It was agreed that he should be made comfortable, as had already been discussed with the palliative care team following his last admission. He was given IV morphine boluses prn (received 6 mg total) for comfort in the setting of abdominal pain/pressure. His O2 sats dropped to the 70s and respirations ceased. He passed within 6 hrs of admission into the ICU likely due to sepsis. Pts wife and family were at the bedside at the time of death. Medications on Admission: 1. Rifaximin 200 mg TID 2. Lactulose 45mL TID 3. Cholestyramine-Sucrose 4 g [**Hospital1 **] 4. Ursodiol 600mg [**Hospital1 **] 5. Pantoprazole 40 mg [**Hospital1 **] 6. Camphor-Menthol 0.5-0.5 % Lotion prn 7. Hydroxyzine HCl 25 mg PO Q6H prn 8. Simethicone 80 mg TID prn 9. Caspofungin 35mg IV qdaily 10. Morphine Concentrate 5 mg/0.25 mL Solution 5-20 mg PO q15min:prn as needed for shortness of breath or wheezing. 11. Ativan 1-2 mg PO q2h as needed for agitation. Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Death Discharge Condition: Expired Discharge Instructions: none Followup Instructions: none

[ "285.9", "155.0", "584.9", "070.70", "572.2", "452" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5692, 5701

4317, 5144

283, 289

5750, 5759

3780, 4294

5812, 5819

2920, 3291

5663, 5669

5722, 5729

5170, 5640

5783, 5789

3306, 3761

232, 245

317, 1788

1810, 2668

2684, 2904

31,260

114,524

2717

Discharge summary

report

Admission Date: [**2108-2-21**] Discharge Date: [**2108-4-14**] Date of Birth: [**2045-4-2**] Sex: F Service: MEDICINE Allergies: Lisinopril / Kefzol / Sulfa (Sulfonamide Antibiotics) / Shellfish Derived Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: Weakness and Shortness of breath Major Surgical or Invasive Procedure: [**2108-2-27**] Right sided cardiac catheterization History of Present Illness: 62 year old woman with pmh significant for dilated right sided systolic heart failure and diastolic left sided heart failure, presenting with hypoxia and hypotension in the setting of diarrhea. The patient states for 3 days prior to her ICU admission she had diarrhea and extreme fatigue and DOE. She was only able to walk a few steps prior to stopping. Normally she can walk a [**12-23**] flight of stairs prior to stopping due to fatigue and DOE but in total able to walk up 2 flights of stairs. She was admitted to the [**Hospital Unit Name 153**] and rehydrated, it was thought that her cardiac index was low due to her dehydration and than she now had a significant shunt through a large PFO (based on + bubble then TEE) which was worsening her oxygenation. Her blood pressure was improved with IVF and dopamine and renal was consulted for her renal failure who thought it was secondary to her low cardiac output state. She has been feeling slightly better over the past few days however still very fatigued and has not walked so is unable to give a history in regards to DOE. She has stable [**1-24**] pillow orthopnea now and prior to admission, no PND. She has noticed an increase in her lower extremity edema since admission. Her diarrhea has stopped. No chest pain. No LH or syncope, no F/C/NS or any other complaints. . She was transferred from the [**Hospital Unit Name 153**] to the [**Hospital1 1516**] service for a R heart cath to [**Hospital1 4656**] the effect of NO on reducing PVR to see if PFO closure would be helpful. Past Medical History: - Diastolic LV failure, pulmonary hypertension, RV systolic dysfunction - Tricuspid regurgitation, evaluated by cardiac [**Doctor First Name **]. not operative candidate at this time. - Atrial fibrillation on aspirin. Decision not to persue anticoagulation - Ulcerative Colitis - Liver disease, (congestion vs. EtOH vs. primary biliary pathophys.) - Alcohol abuse, remote - Ventral hernia repair - Back surgery - History of GI bleed, [**10-28**] with 5cm duodenal ulcer - Hypokalemia - Hyponatremia - hypertension - hypercholesterolemia (TG 53, Chol 145 HDL 71 LDL 63 on [**10/2107**]) Social History: The patient is married. She does have an abusive partner but states that she feels safe at home. She has very supportive children and 17 grandchildren. She drinks ETOH socially and denies smoking Family History: Father with MI at age 68. Mother with breast cancer at 52 Physical Exam: VS: afebrile. HR 100 BP 123/56 96% on 2L GEN: NAD, AOX3 HEENT: JVP 14cm, MM slightly dry, OP clear CARD: [**1-27**] HSM at LLSB, RRR, normal S1, S2 PULM: CTAB ABD: obese, soft, NT, ND, no masses, BS+ EXT: 3+ edema bilaterally, L > R. Midcalf measurements circumference: L 56cm, R 49cm. unilateral LUE swelling NEURO: CN2-12, AOx3, 5/5 strength in all 4 extremities Pertinent Results: [**2108-2-21**] CXR: Since [**2108-1-13**], right pleural effusion decreased, now small with improved adjacent atelectasis. Left pleural effusion also decreased, now tiny. Left-sided central venous line was removed. There is no interstitial edema and no focal area of consolidation. Cardiomegaly persists. . [**2108-2-22**] ECHO: The left atrium is moderately dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). A right-to-left shunt across the interatrial septum is seen at rest. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. [Intrinsic right ventricular systolic function is likely more depressed given the severity of tricuspid regurgitation.] The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The tricuspid valve leaflets fail to fully coapt. Moderate to severe [3+] tricuspid regurgitation is seen. The estimated pulmonary artery systolic pressure is high normal. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2108-1-23**], a right-to-left shung is now identified (no saline used on the prior study). Right ventricular free wall motion is minimally more depressed. The severity of mitral regurgitation is reduced (may be related to lower systemic blood pressure). This constellation of findings is suggestive of primary RV cardiomyopathy (ARVC, myocarditis, ischemia) or prior large intracardiac shunt/ASD and LESS suggestive of a primary pulmonary process (e.g., pulmonary embolism, COPD, PPH, etc.). . [**2108-2-22**] Renal ultrasound: Unremarkable examination without evidence of hydronephrosis. . [**2108-2-23**] RUQ US: No biliary ductal dilation. Probable gallbladder sludge. Right pleural effusion. . [**2108-2-27**] Cardiac Cath: 1. Resting hemodynamics demonstrated marked elevation in biventricular filling pressures, with a baseline RVEDP of 33 mmHg and a mean PCWP of 37 mmHg; moderate pulmonary hypertension with a mean PA pressure of 48 mmHg; and preserved cardiac output. There was no evidence of right-to-left shunting at the current loading conditions. 2. Treatment with 100% FiO2 demonstrated mild improvedment in pulmonary vascular resistance with slight worsening of the PCWP. 3. Treatment with inhaled NO at 40ppm did not change the pulmonary pressures significantly. . [**2108-3-1**] Cardiac MR: 1. Limited and incomplete study secondary to early termination of protocol due to MR system failure. Recommend repeat study at later stage. 2. The left upper, left lower, right upper, and right lower pulmonary veins were visualized in their correct anatomical positions and entered the left atrium. Other anomalous pulmonary venous drainage or ASD cannot be definitively excluded. 3. Normal left ventricular cavity size with normal global systolic function. 4. Moderate right ventricular enlargement with mild systolic dysfunction. No CMR evidence of right ventricular fatty infiltration/dysplasia. 5. The indexed diameters of the ascending and descending thoracic aorta were normal. The main pulmonary artery diameter index was mildly increased. 6. Moderate [**Hospital1 **]-atrial enlargement. 7. A note is made of moderate right pleural effusion and right lower lobe basal atelectasis. . [**2108-3-2**] Cardiac CT: 1. No evidence of anomalous pulmonary vein return. There are two right and two left pulmonary veins draining into the left atrium. 2. Interval decrease in moderate amount of right pleural effusion associated with compressive right lower lobe atelectasis. 3. Unchanged mild cardiomegaly. 4. 3.6-mm lung nodule. If patient has history of smoking or other known risk factors, a followup in one year is recommended. 5. Asymmetric breast parenchyma (left > right). Please correlate with physical examination. Brief Hospital Course: 62 yo female with history of A-fib, CHF, PUD, and Ulcerative Colitis, presented with hypoxia and hypotension. Both hypoxia (secondary to shunting) and hypotension resolved with fluid resucitation in the ICU. She was transferred to the cardiology floor where she has been closely monitored and her heart failure treated with aggressive diuresis. She began having rectal bleeding and was transferred to the [**Hospital Ward Name **] for endoscopy w/ general anesthesia. Cscope report read: 2 small superficial ulcerated areas with very active oozing and adherent clot were noted in the sigmoid and distal transverse colon. The rest of the colonic mucosa looked normal - no evidence of active ulcerative colitis. A single clip was successfully applied to the transverse lesion and 2 clips were successfully applied to the sigmoid lesion. Otherwise normal colonoscopy to cecum. Her bleeding continued slowly but her Hct remained stable and after a short stay in the ICU she was transferred back to the cardiology service for diuresis. ON the cardiology floor she had very poor urine output with lasix gtt so was transferred to the CCU for ultrafiltration. The following is a problem based brief hospital course after her transfer to the CCU. # CHF: Patient has a known complicated CHF history requiring multiple hospitalizations. Patient's right sided heart failure was presumed to be secondary to left diastolic heart failure (EF 55%). During this admission she was found to have a PFO which demonstrated R to L flow and caused her hypoxia. Increasing left sided pressures with IV hydration in the ICU resolved the shunt and hypoxia. Patient was then transferred to the floor. Right heart cath was performed. Pulmonary hypertension did not respond to nitric oxide. Decision was made to treat CHF with aggressive diuresis. Diuresis was titrated up to lasix gtt at 30 cc/hr and metalozone 5 mg po bid with minimal output. At this point patient became hypoxic and hypotensive with acute renal failure again and diuresis was discontinued. Her hypoxia/hypotension improved and her UOP continued to be poor so she was restarted on lasix drip with metolazone and transferred back to cardiology. The patient continued to have poor uop despite lasix gtt at 30. She was transferred to the CCU for UF to remove the excess fluid. Over the next few days she was net negative > 20L. A repeat RH cath showed minimal elevation of PA pressures and PVR. After UF patient had TTE that showed improvement in pressures and UF was discontinued. Her CVP was less than 10, compared to 35+ initially. Subsequetly she was able to maintain a urine output of 30-60 ml/hr without lasix drip. Eventually her vasopressin and phenylephrine were discontinued. She was transitioned to oral midodrine. She occasionally required neosynephrine to keep her MAPs >50 however she continued to have good uop regardless of her pressor requirement. On her repeat TTE, there was evidence of persistent tricuspid regurgitation despite improvement in her volume status. The idea of performing a tricuspid valve repair/replacement was discussed with CT surgery and she had a cardiac MR [**First Name (Titles) **] [**Last Name (Titles) 4656**] her right heart function. As she improved significantly and she was able to maintain her blood pressures and UOP on midodrine alone for many days, the decision was made to postpone discussion of TVR until a later date. She was able to be started on low dose metoprolol 12.5mg [**Hospital1 **] without a significant drop in her blood pressure. She was also restarted on a lower dose of spironolactone 25mg. She was discharged with this medication regimen and strict instructions to monitor her weights daily, and restrict her sodium intake to 2gm per day. The patient will follow up with Dr. [**First Name (STitle) 437**] in 2 weeks. VNA will be provided to ensure medication and nutrition compliance and daily weights are documented. # ARF: Baseline Cr 1.2. Creatinine peaked during this admission at 3.4 shortly after presentation likely secondary to ATN from hypotensive insult. Renal was consulted and patient's mesalamine was held, and discontinued. Diuresis was held initially and her creatinine returned to baseline. With reinitiation of diuresis patient's creatinine again started to rise up to 3.6. She was transferred to the CCU and started on UF as above. After aggressive diuresis, her creatinine continued to trend down suggesting poor forward flow from poor CO from RHF as the cause for her ARF. Her renal function was at her baseline on discharge. # Bacteremia: Patient had hypotension and peripheral vasodilation with elevated WBC about 1 month into her hospitalization. Cultures were drawn and she was found to have serratia from the PA catheter line and coagulase negative staph from the A-line. She was started on Vanc, aztreonam (allergy to cefalosporins and ARF so gentamicin contraindicated), and cipro. The lines were discontinued. Sensitivities of GNRs showed Serratia sensitive to Cipro. She was continued on cipro and aztreonam was discontinued. GPCs were coag negative staph. Repeat TTE showed no vegetations. Follow up blood cultures remained negative. The patient was afebrile many days after discontinuing antibiotic therapy. # UTI: Patient had positive UA with GNRs (>100,000) on her urine culture. She was started on Cipro as above. Sensitivities showed seratia and enterobacter both sensitive to cipro. The patient completed a course of cipro prior to discharge and did not require additional antibiotics. # Atrial fibrillation: Patient has history of chronic atrial fibrillation. She was remained rate controlled thoughout admission. She was not on anticoagulation at presentation. She was treated with daily aspirin and metoprolol until the onset of significant GI bleed. At this time both were held. She underwent PFO closure on [**2108-3-14**] and was not restarted on anticoagulation because of her GIB. She was able to be restarted on metoprolol 12.5mg [**Hospital1 **] for rate control. No other anticoagulation other than aspirin was initiated prior to discharge given her GI bleed. # Hyponatremia: Na 131 on presentation. Patient was clearly hypervolemic. Hypervolemic hyponatremia was related to heart failure and volume overload. The sodium continued to slowly decrease without neurologic compromise. In part this was attribute to vasopressin use in addition to CHF. On discharge her sodium had returned to 130. # LFT abnormalities: Elevated AST and Alk phos with normal ALT on presentation. Liver US showed no pathology. Per outpatient GI workup LFT abnormalities are likely attributed to congestive hepatopathy. Will have the patient follow up with Dr. [**Last Name (STitle) 497**] as an outpatient. # CODE: FULL CODE . # CONTACT: [**Name (NI) **] (son and HCP) [**0-0-**] Medications on Admission: Insulin SC sliding scale MetronidAZOLE Topical 1 % Gel Miconazole 2% Cream Acetaminophen [**Telephone/Fax (1) 1999**] mg PO Q6H:PRN Oxycodone-Acetaminophen 1 TAB PO Q6H:PRN pain Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN sob Pantoprazole 40 mg IV Q12H Artificial Tears 1-2 DROP BOTH EYES PRN Ferrous Sulfate 325 mg PO DAILY FoLIC Acid 1 mg PO DAILY Gabapentin 100 mg PO HS Discharge Medications: 1. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Metronidazole 1 % Gel Sig: One (1) Appl Topical DAILY (Daily) as needed for acne. Disp:*1 tube* Refills:*0* 5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. Disp:*30 Tablet(s)* Refills:*2* 11. Midodrine 10 mg Tablet Sig: Two (2) Tablet PO three times a day. Disp:*180 Tablet(s)* Refills:*2* 12. Gabapentin 100 mg Tablet Sig: Two (2) Capsule PO HS (at bedtime). Disp:*60 Capsule(s)* Refills:*2* 13. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 14. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. Disp:*1 inhaler* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary Diagnoses: Patent Foramen Ovale with shunting Right sided Congestive Heart Failure Atrial fibrillation Acute renal failure Discharge Condition: The patient was hemodynamically stable prior to discharge. Discharge Instructions: You were admitted to the hospital for weakness and shortness of breath. You were found to have low blood pressure and low oxygen levels. You were admitted to the ICU. After you were stablized you were transferred to the floor. There you underwent cardiac catheterization and a series of imaging to [**Hospital 4656**] causes of your heart failure. You were treated with medications to reduce the pressure in your heart and to help your breathing. . Please weigh yourself daily and report weight gain of more than 3 pounds per day or more than 6 pounds per 3 days to Dr. [**First Name (STitle) 437**]. . Please restrict your sodium intake to 2gm per day. . The following changes were made to you home medications: . 1) STOP Toprol 125mg 2) STOP Mesalamine (Asacol) 3) STOP Torsemide 4) Decrease Spironolactone to 25mg daily 5) STOP Colchicine and Codeine 6) START Aspirin 325 mg by mouth daily 7) START Midodrine 20mg three times a day for your blood pressure 8) START Metoprolol 12.5mg twice a day 9) START Metronidazole 1 % Gel Appl Topical DAILY as needed for acne 10) START Trazodone 25 mg at bedtime as needed 11) START Gabapentin 200 mg at bedtime 12) START Albuterol 90 mcg/Actuation Aerosol Two puffs Inhalation every four hours as needed for shortness of breath or wheezing. . Please notify your physician or return to the hospital if you experience if you experience increased shortness of breath, chest pain, loss of consciousness, fever, chills, or any other symptom that is concerning to you. Followup Instructions: Please keep all of your previously scheduled appointments as listed below: 1)Provider [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2108-3-26**] 1:30pm 2)Provider [**First Name11 (Name Pattern1) 3688**] [**Last Name (NamePattern4) 10476**], MD Phone:[**Telephone/Fax (1) 8645**] Date/Time:[**2108-3-15**] 11:00 3)Provider [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13472**], MD Phone:[**Telephone/Fax (1) 13473**] Date/Time:[**2108-3-16**] 10:30 Completed by:[**2108-4-14**]

[ "785.59", "785.51", "276.2", "584.5", "794.8", "428.43", "410.71", "745.5", "038.19", "995.92", "397.0", "532.40", "530.19", "428.0", "535.40", "416.8", "285.1", "996.62", "427.31", "041.85", "276.1", "556.9", "585.3", "599.0" ]

icd9cm

[ [ [] ] ]

[ "37.21", "88.56", "38.95", "88.52", "45.13", "89.64", "37.23", "45.43", "00.12", "44.43", "39.95", "35.52", "38.91", "37.28", "88.55", "38.93", "88.72" ]

icd9pcs

[ [ [] ] ]

16159, 16217

7420, 14280

374, 428

16392, 16453

3297, 7397

18014, 18568

2838, 2897

14704, 16136

16238, 16371

14306, 14681

16477, 17177

2912, 3278

17195, 17991

302, 336

456, 1999

2021, 2608

2624, 2822

81,058

139,569

21406

Discharge summary

report

Admission Date: [**2115-4-16**] Discharge Date: [**2115-4-18**] Date of Birth: [**2030-9-27**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**Doctor First Name 3290**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: Colonoscopy History of Present Illness: 84M history of CAD s/p coronary stenting x 3 with the latest placed 4 weeks ago on Plavix, CHF, superficial bladder cancer s/p resection in [**2113-10-20**] and completed mitomycin chemo in [**Month (only) **], and diverticular disease 50 years ago with partial colectomy who presented to his outpatient gastroenterologist with 2 days of painless bright red blood per rectum. Of note the patient is on aspirin and plavix for his CAD as well as aleve and ibuprofen for back pain. He denies abdominal pain or rectal pain, denies prior history of radiation to his pelvic area and describes mostly brown stool with some red blood in the bowl. He states the bleeding has been off and on for the past 2 days but apparently when in his gastroenterologists office he had a bowel movement that was frank blood. He denies any black, tarry, or sticky stools. Also denies fevers, chills, chest pain, has had shortness of breath recently but none now, N/V/D, weakness, numbness, or tingling. . In the ED, initial VS were: 97.4 70 84/52 99%RA Triggered for hypotension. Given 1.5L and BP 100s. Not tachycardic. Guiac positive. Access: two 18g. Type and cross 2 Units but not transfused. Labs: HCT 33 (Baseline 44 but has been 29-35 in the past), Hb 11, WBC 7, PLT 230. INR 1.1, PTT 26. Na 132, K 3.8, Cl 88, HCO3 34, BUN 86, Cr 2.1 (up from baseline of 0.8-1.0), Mg 3, Ca 9.5, P 4.5. Trop 0.08. UA neg. GI consulted: recc prep and colonoscopy in the AM. Vitals on transfer: 97.4, 67, 107/59, 20, 100%on RA . On arrival to the MICU, patient is calm, comfortable, and asymptomatic. He confirms the above history and states that 50-60 years ago he had a colectomy due to diverticulitis and had a colostomy bag and ultimately re-anastamosis. He states that 8 years ago he had [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2 placed at Ft [**Hospital **] Hospital in [**State 108**] for an MI (primary symptom chest pain) and had no issues since then until 5 months ago when he started developing shortness of breath. He was diagnosed by his cardiologist at [**Hospital1 3278**] with CHF and underwent c. cath 1 month ago for what sounds like optimization with another stent placed (unclear type, he believes it was a [**Hospital1 **]) and has been on plavix. He has had persistent issues with shortness of breath, especially with exertion which his cardiologist has been treating with escalating doses of lasix from 20mg PO BID up to 100mg PO BID. He states that despite this he hasn't been urinating as much as he ought to be. . Review of systems: (+) Per HPI, otherwise negative. Past Medical History: -CAD s/p MI 8 years ago with [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 2 (Ft [**Hospital **] Hospital) and C. cath with stent x [**2115-2-20**] -CHF (unclear subtype, no echo's in our system) -Bladder cancer s/p resection in [**2113**], s/p mitomycin chemo which ended [**2114-11-20**] -Diverticulitis 50 years ago with emergent partial colectomy and later re-anastomosis -GERD -HTN -HLD Social History: Lives with his wife. Used to own an oriental rug business. - Tobacco: 25 pack-year smoking history, quit 15 years ago - Alcohol: Occasionally - Illicits: None Family History: Prostate Ca, otherwise NC Physical Exam: ADMISSION PHYSICAL EXAM: Vitals: T: 97.0 BP: 106/58 P: 71 R: 14 18 O2: 95% RA General: Alert, oriented, no acute distress, somewhat slow and tangential but not abnormally so HEENT: Sclera anicteric, dryish MM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, soft systolic murmur loudest base right, no rubs, no gallops Lungs: Clear to auscultation bilaterally, course crackles about [**1-23**] way up lung fields bilaterally Abdomen: soft, non-tender, non-distended, hyperactive bowel sounds, no organomegaly, well healed chronic scars GU: no foley Ext: warm, well perfused, dopplerable pulses bilaterally, no clubbing, cyanosis or edema, chronic scarring to R hand from reconstructive surgeries Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, slow arthritic gait. . DISCHARGE PHYSICAL EXAM: Pertinent Results: ADMISSION LABS: . [**2115-4-16**] 04:00PM BLOOD WBC-7.1 RBC-3.52*# Hgb-11.0*# Hct-33.2*# MCV-94 MCH-31.3 MCHC-33.1 RDW-13.0 Plt Ct-237 [**2115-4-16**] 04:00PM BLOOD Neuts-76.2* Lymphs-19.2 Monos-4.2 Eos-0.2 Baso-0.1 [**2115-4-16**] 04:00PM BLOOD PT-11.7 PTT-26.5 INR(PT)-1.1 [**2115-4-16**] 04:00PM BLOOD Glucose-134* UreaN-86* Creat-2.1*# Na-132* K-3.8 Cl-88* HCO3-34* AnGap-14 [**2115-4-16**] 09:42PM BLOOD CK(CPK)-95 [**2115-4-16**] 04:00PM BLOOD cTropnT-0.08* [**2115-4-16**] 04:00PM BLOOD Calcium-9.5 Phos-4.5 Mg-3.0* [**2115-4-16**] 05:15PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.008 [**2115-4-16**] 05:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [**2115-4-16**] 05:15PM URINE Hours-RANDOM . PERTINENT LABS: [**2115-4-16**] 04:00PM BLOOD WBC-7.1 RBC-3.52*# Hgb-11.0*# Hct-33.2*# MCV-94 MCH-31.3 MCHC-33.1 RDW-13.0 Plt Ct-237 [**2115-4-17**] 12:36AM BLOOD Hct-32.4* [**2115-4-17**] 11:52AM BLOOD Hct-28.7* [**2115-4-17**] 06:10PM BLOOD Hct-31.8* . DISCHARGE LABS: [**2115-4-18**] 05:30AM BLOOD WBC-4.6 RBC-3.03* Hgb-9.4* Hct-29.3* MCV-97 MCH-30.9 MCHC-31.9 RDW-12.7 Plt Ct-204 [**2115-4-18**] 05:30AM BLOOD Glucose-96 UreaN-30* Creat-0.9 Na-145 K-3.0* Cl-106 HCO3-30 AnGap-12 . IMAGING/STUDIES: CXR Portable [**4-16**]: No evidence of acute disease. EKG [**4-16**]: Sinus rhythm. Left axis deviation. Left bundle-branch block. Compared to the previous tracing of the same date there is no significant change. . COLONOSCOPY: IMPRESSION: Diverticulosis of the right and left side of colon. Otherwise normal colonoscopy to cecum. RECOMMENDATIONS: No blood was seen. The likely etiology of this patients bleeding was diverticular There were no polyps seen. F/u with PCP for discussion of further colonoscopy for screening which would be in ten years. Brief Hospital Course: 84M history of CAD s/p coronary stenting x 3, CHF, superficial bladder cancer prior diverticular disease admitted to the MICU for painless BRBPR and hypotension responsive to fluids. . LOWER GI BLEED: Pt admitted to the MICU with 3 total days of what appears to be LGIB with known diverticula and internal hemorrhoids, roughly 10 point crit drop from prior baseline, and transient hypotension to mid-80's systolically in the ED that responded to small volume IVF bolus. He remained HD stable without tachycardia (although he was initially beta blocked) or alteration in mental status. He underwent colonoscopy by GI that showed diverticulosis without any active bleeding. No polyps were seen. Follow up with PCP for discussion of further colonoscopy screening recommended. . CORONARY ARTERY DISEASE/CHRONIC DIASTOLIC CONGESTIVE HEART FAILURE (EF 55%): Patient with significant CAD s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **] 1 on [**2115-2-6**] on 95% ostial lesion in OM-2 (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], [**Hospital1 **]). On aspirin and plavix. No chest pain or current SOB. States when he had his NSTEMI 8 years ago had terrible CP. Clinically is euvolemic or slightly hypovolemic satting well on RA. He had ROMI with 3 sets of enzymes and EKG which is unchanged from baseline (stable LBBB, left axis deviation). He was continued on his home simvastatin, aspirin 81mg and plavix. . ACUTE KIDNEY INJURY: Cr of 2.1 on admission up from baseline of 0.8-1.0 on admission, Cr downtrended to 0.9 on discharge. Etiology was likely prerenal from hemorrhagic volume loss. Patient advised to avoid NSAIDs as may worsen renal function and make recurrent GI bleed likely. Medications on Admission: -Enalapril 10mg PO daily -Tamsulosin 0.4mg PO QHS -Nitropatch 0.4mg daily -Simvastatin 20mg PO daily -Avadart 0.5mg PO Daily -Metoprolol succinate 25mg PO daily -Aspirin 81mg PO daily -Plavix 75mg PO daily -Ginko Biloba 60mg PO BID -Vitamin D 1000units PO daily -Dulcolax 100mg PO BID -Centrum Silver 1 tab PO daily -Ocuvite 1 tab PO BID -Furosemide 100mg PO BID -Tylenol PRN -Advil PRN -Nyquil PRN -Dayquil PRN -Aleve PRN -Fluticasone 2 sprays daily PRN Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO DAILY (Daily). 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO qHS. 5. enalapril maleate 10 mg Tablet Sig: One (1) Tablet PO once a day. 6. nitroglycerin 0.4 mg/hr Patch 24 hr Sig: One (1) patch Transdermal once a day. 7. Avodart 0.5 mg Capsule Sig: One (1) Capsule PO once a day. 8. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 9. ginkgo biloba 60 mg Tablet Sig: One (1) Tablet PO twice a day. 10. Vitamin D3 1,000 unit Capsule Sig: One (1) Capsule PO once a day. 11. multivitamin with iron Tablet Sig: One (1) Tablet PO once a day. 12. Ocuvite 150-30-6-150 mg-unit-mg-mg Capsule Sig: One (1) Capsule PO twice a day. 13. furosemide 20 mg Tablet Sig: Five (5) Tablet PO once a day. 14. fluticasone 50 mcg/actuation Spray, Suspension Sig: Two (2) sprays Nasal once a day as needed for congestion. 15. Iron with Stool Softener 150 (50)-100 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO once a day: take with food. Disp:*30 Tablet Extended Release(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Diverticulosis Lower gastrointestinal bleeding Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 56536**], It was a pleasure taking care of you! You were admitted to [**Hospital1 1535**] for evaluation and treatment of lower gastrointestinal bleeding. You required an overnight stay in the medical ICU for closer monitoring. You were prepped and underwent a colonoscopy which showed diverticulosis in the colon. The gastroenterologists did not see any bleeding when they did the procedure. Your red blood cells were low, so you will need to take iron supplements. Medication changes: start taking iron with stool softener, 1 tab by mouth daily with food Please follow-up with the appointments listed below. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] H. Address: [**Street Address(2) **],STE 4W, [**Location (un) **],[**Numeric Identifier 809**] Phone: [**Telephone/Fax (1) 4615**] Appointment: Thusday [**2115-4-25**] 10:00am Completed by:[**2115-4-18**]

[ "276.1", "272.4", "V45.82", "562.12", "412", "401.9", "V10.51", "414.01", "796.3", "584.9", "272.0", "564.00", "530.81", "278.00", "428.32", "428.0", "455.0", "276.9" ]

icd9cm

[ [ [] ] ]

[ "45.23" ]

icd9pcs

[ [ [] ] ]

9953, 9959

6367, 8124

282, 295

10050, 10050

4505, 4505

10867, 11126

3520, 3547

8629, 9930

9980, 10029

8150, 8606

10201, 10699

5558, 6344

3587, 4460

2866, 2900

10719, 10844

234, 244

323, 2847

4521, 5287

10065, 10177

5303, 5542

2922, 3328

3344, 3504

4486, 4486

51,724

127,904

53340

Discharge summary

report

Admission Date: [**2144-3-8**] Discharge Date: [**2144-3-18**] Date of Birth: [**2087-12-10**] Sex: M Service: MEDICINE Allergies: Tramadol / Hydrocodone Bitartrate/Apap Attending:[**First Name3 (LF) 800**] Chief Complaint: Nausea and coffee ground PEG tube output Major Surgical or Invasive Procedure: Upper endoscopy History of Present Illness: 56 y/o M with PMHx of NSCL Ca s/p XRT/chemo, R lung lobectomy, DM, dementia, brain injury s/p drug OD [**2118**], normal pressure hydrocephalus on MRI [**2133**], RUE DVT [**4-/2143**], and NEW brain mass s/p frontal cranial resection [**2-29**] admitted [**3-8**] for GI bleed s/p PEG placement [**3-4**] and found to have gastritis and [**Doctor First Name 329**] [**Doctor Last Name **] tear by GI consult team. Since admission patient received 1 unit pRBCs, coumadin was held, and has had a stable/rising HCT since. He was placed on high dose protonix. Noted to be orthostatic [**3-10**] and on lopressor for supine hypertension. Patient admitted with WBC 20K, no abx given or cx drawn. Improved to 14K. Nursing staff reports waxing/[**Doctor Last Name 688**] attentiveness overnight. This AM patient noted to have WBC to 30K. [**Doctor First Name 147**] consulted medicine for orthostatis of unclear duration. Past Medical History: 1. Non small cell lung CA s/p radiation, 1 week chemo?, right lung lobectomy. Current status unclear. 2. Vocal cord paralysis after post lung surgery 3. DM 4. Dementia for last 2 yrs 5. Residual brain damage from drug overdose [**2118**] 6. Possible NPH seen on MRI [**2133**]? 7. RUE DVT 4/[**2143**]. 8. S/P R sub clavian portcath placement [**2143-7-3**] c/b infection removed 1 week later. Now Arteriovenous fistula between the peripheral R subclavian artery and vein Social History: Lives with his wife, was at [**Name (NI) **] prior to admission after last hospitalization; active smoker trying to quit (was 2 ppd X25 years 10 years ago); no alcohol consumption Family History: DM, Heart Disease Physical Exam: On admission: Temp:97.3 HR:104 BP:118/76 Resp:14 O(2)Sat:98% Constitutional: Comfortable Head / Eyes: Staples intact across scalp ENT / Neck: Mucous membranes moist Chest/Resp: Clear to auscultation Cardiovascular: Regular Rate and Rhythm GI / Abdominal: Soft, Nontender, G-tube in place, draining coffee grounds. Rectal: Heme Negative Musc/Extr/Back: No edema Skin: Warm and dry . On transfer from Surgery to Medicine: VS: T98.9, BP148/84, HR95, RR20, 99% RA BP 152/67 supine, 102/67 sitting, 79/59 standing General: Closing eyes, acknowledging questions with nods but refuses to answer HEENT: NCAT, craniotomy incision c/d/i w/ staples in place, EOMI, moist mucus membranes, clear oropharynx Neck: Soft, supple, no LAD Lungs: Bronchial breath sounds, mild rales, no wheezes/rhonchi CV: Regular rate and rhythm, normal S1 + S2, no rubs/gallops, 3/6 systolic murmur at left sternal border Abdomen: Soft, non-distended, +bowel sounds, tenderness to palpation diffusely, no hepatosplenomegaly Ext: Warm, well perfused, +DP/PT pulses, no clubbing/cyanosis, 2+ RUE, trace peripheral edema, multipodus boot in place on RLE Musculoskeletal: Moving all extremities Pertinent Results: Discharge Labs [**2144-3-14**] 06:45AM BLOOD WBC-16.1* RBC-2.84* Hgb-8.3* Hct-24.6* MCV-87 MCH-29.2 MCHC-33.6 RDW-15.2 Plt Ct-244 [**2144-3-16**] 07:40AM BLOOD WBC-5.8 RBC-3.04* Hgb-9.8* Hct-29.1* MCV-96# MCH-32.2*# MCHC-33.6 RDW-12.5 Plt Ct-289 [**2144-3-18**] 08:00AM BLOOD WBC-6.2 RBC-2.89* Hgb-8.5* Hct-25.8* MCV-89 MCH-29.5 MCHC-33.1 RDW-15.3 Plt Ct-246 [**2144-3-18**] 08:00AM BLOOD Glucose-202* UreaN-15 Creat-0.8 Na-140 K-4.0 Cl-105 HCO3-29 AnGap-10 [**2144-3-15**] 08:05AM BLOOD ALT-270* AST-24 AlkPhos-242* TotBili-0.6 [**2144-3-17**] 07:55AM BLOOD ALT-147* AST-14 AlkPhos-193* TotBili-0.4 [**2144-3-18**] 08:00AM BLOOD ALT-108* AST-17 AlkPhos-156* TotBili-0.3 [**2144-3-8**] 08:43PM HCT-24.1* [**2144-3-8**] 03:26PM HCT-26.3* [**2144-3-8**] 11:31AM HCT-27.3* [**2144-3-8**] 07:45AM HCT-29.0* [**2144-3-8**] 03:00AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.020 [**2144-3-8**] 03:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-2* PH-7.0 LEUK-NEG [**2144-3-8**] 03:00AM URINE RBC-1 WBC-1 BACTERIA-MANY YEAST-NONE EPI-1 [**2144-3-8**] 12:55AM GLUCOSE-200* UREA N-17 CREAT-1.0 SODIUM-141 POTASSIUM-4.2 CHLORIDE-99 TOTAL CO2-32 ANION GAP-14 [**2144-3-8**] 12:55AM estGFR-Using this [**2144-3-8**] 12:55AM CALCIUM-8.8 PHOSPHATE-3.6 MAGNESIUM-1.7 [**2144-3-8**] 12:55AM WBC-21.3*# RBC-4.11* HGB-11.7* HCT-35.3* MCV-86 MCH-28.4 MCHC-33.0 RDW-14.4 [**2144-3-8**] 12:55AM NEUTS-92.4* LYMPHS-3.7* MONOS-3.4 EOS-0.4 BASOS-0.1 [**2144-3-8**] 12:55AM PLT COUNT-329 [**2144-3-8**] 12:55AM PT-11.9 PTT-23.9 INR(PT)-1.0 . CXR [**2144-3-12**]- Persistent pneumoperitoneum. The extent and persistence is unusual 1 week after PEG placement, and the possibility of other etiology should be explored. No new or worsening lung abnormalities to suggest pneumonia. . CT head [**2144-3-12**] - No acute intracranial hemorrhage. Post-surgical changes in the right frontal lobe, with mild leftward shift and moderate vasogenic edema and mass effect on the frontal [**Doctor Last Name 534**] of the right lateral ventricle, with improvement compared to the prior CT study of [**2144-3-1**]. Other details as above. Consider followup as felt necessary, with MR, to assess for post-surgical changes/tumor. . . KUB [**2144-3-12**] - No evidence of small/large bowel obstruction. Multiple air filled levels of non-dilated loops of bowel. A large amount of stool is seen in decubitus views. Pneumoperitoneum seen consistent with prior imaging. Appropriate placed G-tube. . CT torso [**2144-3-10**] - Moderate pneumoperitoneum is unchanged from two hours prior, however extent of portal venous gas is improved. Since no other etiology is identified on CT, pneumoperitoneum is could be related to recently placed (and thus incompletely healed) gastrostomy, however clinical correlation is necessary to exclude bowel ischemia. While no oral contrast was administered to assess for leak, no fluid collection is seen within the abdomen. Percutaneous gastrostomy in appropriate position. 2. Atherosclerotic disease, with normal enhancement of mesenteric vessels. No secondary findings of bowel ischemia as cause for portal venous gas. No cause identified for portal venous gas, which may also be iatrogenic ad has been decribed following NG tube placement 3. Cholelithiasis. 4. Small bubble of gas in the urinary bladder, probably due to recent catheterization; correlation with history of such is recommended. 5. Chest findings are as described on CTA chest report from two hours prior. . EKG [**2144-3-10**] - Sinus rhythm. RSR' pattern in leads V1-V2 may be normal variant. Modest low amplitude T wave changes are non-specific. Since the previous tracing of [**2144-3-1**] sinus tachycardia is absent, delayed R wave progression pattern is less prominent and ST-T wave changes have decreased. . RUQ ultrasound with Doppler: Ultrasound liver demonstrates normal echogenicity and contour. No focal liver lesions are seen. The gallbladder is non-distended with a mixture of stones and sludge in the neck. No biliary dilation is seen. The common bile duct measures 5 mm. The portal vein is patent with hepatopetal flow. Doppler waveforms demonstrate normal velocities and flow curves. A trace amount of ascites is present within [**Location (un) 6813**] pouch. The pancreas is unremarkable. The spleen is not enlarged. No varices are identified. IMPRESSION: 1. Normal liver ultrasound. 2. Cholelithiasis without evidence of cholecystitis. . Bilateral LENIs: negative for DVT Brief Hospital Course: The patient was brought into the Emergency Deptarment after having coffee grounds from his PEG tube on [**2144-3-8**]. The PEG had been placed on [**3-4**] for swallow failure and need for enteral feeding. The patient had been discharged to [**Hospital3 **] on [**3-8**]. On presentation he was admitted to the SICU for monitoring and endoscopy. The upper endoscopy peformed by GI revealed grade 3 esophagitis and [**Doctor First Name 329**]-[**Doctor Last Name **] tear. There did not appear to be any bleeding related to the recent PEG tube placement. The patient was kept NPO and recieved tube feeds which he tolerated. Serial hematocrits were checked and remained stable. He had intermittant chest pain, which his wife described as chronic, although he felt it was different than his typical pain. He had an EKG which was unchanged from prior and he had a CTA Chest which showed no PE, but did reveal moderate pneumoperitoneum and portal venous gas likely related to recent gastric insufflation for PEG placement. He became less tolerant of his tube feeds and had an increasing WBC#, as well as persistent orhtostatic hypotension on hospital day 4. At this point a medicine consult was requested to help address these ongoing medical issues. . # LEUKOCYTOSIS: Concern for infectious etiology in setting of orthostatics and tender abdomen. Had been on Dexamethasone since the frontal cranial resection but leukocytosis was new. No diarrhea but possibility of CDiff given high white count and recent hospitalizations/rehab placement. Aspiration pneumonia and microperforation given persistent pneumoperitoneum also on the differential. Increased lethargy since transfer out of the SICU also concerning for encephalitis/meningitis and abscess in setting of recent instrumentation of the central nervous system. Blood and urine cultures did not grow anything. Serial KUBs showed slow resolving of pneumoperitoneum. Lumbar puncture was not done in setting of improved mental status with intravenous fluid rehydration. Of note, patient's liver function tests were noted to be elevated to the 800s (ALT/AST) and total bilirubin ~2. CTA torso did not show any pathology in the liver parenchymal or biliary tree. RUQ ultrasound with dopplers were also negative for any acute processes. It was felt that the patient likely had transient liver damage in setting of hypotension from hypovolemia. Patient LFTs were trended to normal but started rising again to the 100s by day of discharge. Leukocytosis and general physical status improved with starting Zosyn. Patient was eventually transitioned to Unasyn and then Augmentin. - Continue Augmentin 500mg three times daily X10 more days (last day: Saturday, [**3-28**]) - Redraw patient's blood on Monday, [**3-22**] and fax to patient's primary care doctor (Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 35275**]) . # ORTHOSTATICS: Concerning for sepsis (infectious etiology) vs. hypovolemia. More likely the latter given poor Gtube absorption and response to intravenous fluids. Physical therapy worked closely with patient who was no longer orthostatic by day of discharge. . # ABDOMINAL PAIN: Concerning for infection/abscess vs. microperforation given recent instrumentation. Also had been on narcotics without bowel regimen, however, with possibility of ileus given recent surgery and high-residuals from G-tube. Patient was started on metoclopramide, antibiotics and a bowel regimen with resolution of his symptoms. Serial KUBs showed gradual improvement in his pneumoperitoneum. Patient's G-tube site remained clean, dry and intact. Speech and swallow re-evaluated him during this admission and cleared him for PO diet. - Continue PO diet of soft dyphagia solids, thin liquids and medications whole in applesauce. Supplement with Carnation Instant (sugar free) and maintain aspiration precuations. . # NSCLC with brain metastasis: Radiation oncology (Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13014**]) saw patient in-house and felt he would benefit from some adjuvant radiation therapy to be started early next week. Per patient's wife, they plan to transfer his oncology care to the [**Hospital1 18**]. - Radiation Oncology will coordinate with patient and rehab facility regarding outpatient radiation therapy sessions - Continue Decadron taper. Currently Decadron 2mg daily X13 more days. Taper after 13 days to: 1mg daily X 14 days, 0.5mg daily X 14 days. Then STOP. . # DM: Made NPO due to high residuals from Gtube flushes upon transfer to the Medicine Service. Once cleared by Speech and Swallow, patient was resumed on home insulin regimen - Lantus 30 units before bed - Regular insulin sliding scale qACHS . # Anoxic brain injury/dementia: Mildly confused at times, requiring orientation. Otherwise close to baseline. - Resumed home Clonazepam 1mg three times daily - Resumed home Ambien 10mg before bed as needed for insomnia - Also continued patient on home Oxycodone 5-10mg every 4 hours as needed for chronic back pain . # Elevated LFTs: Patient had elevated ALT. Liver ultrasound and CT A/P without obvious metastatic lesions. He should have further outpatient workup and repeat LFTs in [**2-5**] days to assess trend. . # ? aspiration: Patient ultimately passed speech and swallow testing and was tolerating food. PEG tube left in place per nutrition in case not tolerating enough POs. He should have ongoing nutritional assessment. he should have repeat CXR in [**2-5**] days ([**Date range (1) 88312**]) to assess for any evidence of recurrent aspiration in which case may need to modify diet or make patient NPO with re-initiation of tube feeds. Medications on Admission: . Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. . Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID . Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). . Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID . Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY . Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS .Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. . Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID . Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID . Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain,fever. . Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID as needed for [**Female First Name (un) **]. . Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed for nausea. . Levetiracetam 100 mg/mL Solution Sig: 1000 (1000) mg PO BID . Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID . Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H . Clonazepam 1 mg Tablet Sig: One (1) Tablet PO TID . Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for no bm. . Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. . Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units Subcutaneous at lunchtime. . Medications (upon transfer): * Heparin 5000 UNIT SC TID * 1000 mL LR Continuous at 100 ml/hr * Insulin SC (per Insulin Flowsheet) Sliding Scale * Dexamethasone 2 mg PO/NG Q12H * Pantoprazole 40 mg IV Q12H * Tiotropium Bromide 1 CAP IH DAILY * Ondansetron 4 mg IV Q8H:PRN nausea * HYDROmorphone (Dilaudid) 0.25 mg IV Q4H:PRN pain . Allergies: Tramadol / Hydrocodone Bitartrate/APAP Discharge Medications: 1. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 2. Levetiracetam 100 mg/mL Solution Sig: Ten (10) mL PO BID (2 times a day). 3. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 4. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed for agitation. 5. Senna 8.8 mg/5 mL Syrup Sig: [**10-16**] mL PO BID (2 times a day) as needed for constipation. 6. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day). 7. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: [**1-4**] Tablet, Rapid Dissolves PO every eight (8) hours as needed for nausea. 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 9. Oxycodone 5 mg/5 mL Solution Sig: Five (5) mg PO every four (4) hours as needed for pain. 10. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units Subcutaneous at lunchtime. 11. Clonazepam 1 mg Tablet Sig: One (1) Tablet PO three times a day. 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. 13. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO once a day for 13 days: Taper after 13 days to: 1mg daily X 14 days 0.5mg daily X 14 days Then STOP. 14. Bisacodyl 5 mg Tablet Sig: Two (2) Tablet PO once a day as needed for constipation. 15. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for insomnia. 16. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: Hold for sedation, RR<12, confusion. 17. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 18. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 10 days. 19. Humalog 100 unit/mL Solution Sig: 1-12 units Subcutaneous four times a day. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Primary: Esophagitis and [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear, ?abdominal infection Secondary: Non-small cell lung cancer with brain metastasis recently resected, type 2 diabetes mellitus, dementia/anoxic brain injury, chronic back pain Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - requires assistance or aid (walker or cane) Discharge Instructions: You were admitted to the hospital for evaluation after having nausea and bleeding from your PEG tube. Your blood levels remained stable throughout your stay in the hospital. You had an upper endoscopy which reveal esophagitis and a tear at your esophagus-stomach junction. You then showed signs of possible infection, with a high white blood cell count, lightheadedness when standing and abdominal pain. It was felt that you were also likely constipated and dehydrated. You were treated with antibiotics, bowel rest, stool softeners and intravenous fluids with good effect. We made the following changes to your medications: 1. We added augmentin 2. We added seroquel 3. We added pantoprazole 4. We stopped your lorazepam, metoprolol, and nystatin Followup Instructions: * Please make an appointment with your primary care doctor, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 35275**] within 3-4 weeks. . You are scheduled to start radiation therapy to the brain with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13014**] in Radiation Oncology. His office will coordinate the outpatient sessions for after your discharge to rehab. You can reach his office at: ([**Telephone/Fax (1) 8082**] . Department: NEUROLOGY When: MONDAY [**2144-3-30**] at 2:00 PM With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD [**Telephone/Fax (1) 1844**] Building: [**Hospital6 29**] [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 810**] MD, [**MD Number(3) 811**]

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Discharge summary

report

Admission Date: [**2140-7-10**] Discharge Date: [**2140-7-15**] Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Iodine / B12/E,B6-Fa(<1mg)/Mn/Dietary 1 Attending:[**First Name3 (LF) 11495**] Chief Complaint: acute shortness of breath Major Surgical or Invasive Procedure: cardiac catheterization [**7-10**] with stent and IABP placement, central line placement History of Present Illness: 83 y/o Jehovah's witness with PMH significant for Colon CA, DMII, CAD (MI in past, refused angioplasty), living at Sunrise Senior Living Center, was found to be acutely SOB. EMS found pt in severe respiratory distress. No chest pain. RR 32 BP: 130/palp. Able to answer questions but responded with one word answers b/c so SOB. Put on non-rebreather, sent to [**Hospital3 1280**] Hospital. On arrival, BP 152/92 HR 120-130 Afib-Asystole with agonal respirations. Intubated and responded to atropine, with a HR of 77 with pulse (afib) BP 167/145 then went into SVT to 185. She was given IV lasix, IV nitro gtt, ASA, Lopressor 5mg IV, and a heparin drip. Sent to ICU and found to have ST elevation in aVR with depressions in V2-V4 and II, III, and aVF, concerning for right posterior MI. Initially, the pt was in rate-controlled Atrial fibrillation, but developed CHF-- a dobutamine gtt was started and she was transferred to [**Hospital1 18**] for cardiac catheterization. She was given solumedrol, benadryl, and pepcid for allergy ppx, in cath lab, stented left circumflex artery (occl) with BP drop to 60 systolic upon stenting (good flow)--- changed to dopamine gtt. Stented right coronary artery, and started intra-aortic balloon pump. She was subsequently transferred to the coronary care unit on IV dopamine at 10 mcg/kg/min. No GP IIa/IIIb inhibitors started. Of note, she is a Jehovah's witness (with form for no transfusions to be given in the chart). Her HCP is [**Name (NI) **] [**Name (NI) 10076**] ([**Telephone/Fax (1) 107105**]. Her labs at [**Hospital1 **] were CK 99, Trop I 2.01 (M 0-0.34), BNP 407. Past Medical History: 1. Colon ca- recently had abd surgery, found recurrence, but pt refused additional sx or chemo 2. DM type II 3. CAD (s/p prior MI, with refusal of angioplasty) 4. Brain tumor- s/p resection (distant past) 5. Alzheimer's demetia 6. Anxiety 7. Hypothyroidism 8. Seizure d/o 9. Depression 10. Hypercholesterolemia Social History: Unknown smoking history, alcohol. Jehovah's witness. Lives at [**Hospital3 **]. No known family members. HCP are both members of her [**Name (NI) 16042**] witness community. Family History: Non contributory. Physical Exam: VS: T: 96.5 BP: 105/53 P: 89 RR: 25 on vent Vent: AC TV 500/R 25/FiO2 1.0/PEEP 10 ABG: 7.26/43/70 when she first arrived, most recent this PM ABG: 7.32/39/147 General: Sedated and intubated, elderly female HEENT: PERRL, MMM, with blood in the ET tube Neck: JVD to jawline Lungs: With coarse rhonchi throughout. CV: Difficult to assess with IABP in place. Abd: Large pannus. Ventral hernia. Pos BS, no masses. Peripheral ext: Cool, mottled skin. Poor peripheral pulses bilaterally. No edema peripheral ext. 0 pulses, but dopplerable. Neuro: Moving all 4 extremities. Opened eyes but did not follow commands. Neg [**Doctor Last Name 937**] sign and Babinski's sign. . Pertinent Results: Cardiac Catheterization [**2140-7-10**]: Elevated L and R filling pressures. PCWP 33. Nl LMA. LAD occluded proximally with distal collaterals from RCA (right-dominant). CO: 6.06, CI 3.21 PCW: (M/A/V) 33/36/43 RA: (M/A/V) 19/20/26 AO: (S/D/M) 99/53/61 PA: (S/D/M) 61/33/45 RV: (S/D/E) [**2096-11-4**] LMCA: nl LAD: proximally occluded, filling via left and RCA collaterals showing severe diffuse ds LCX: occluded after OM1 RCA: 80% mid lesion; 50% origin posterolateral branch COMMENTS: 1. Selective coronary angiography showed a right dimonant system with severe three vessel disease. The LMCA was angiographically without significant disease. The LAD was proximally occluded and was filled by left-to-left and right-to-left collaterals. The mid and distal LAD was severely diffusely diseased. The proximal LCX was without flow limiting stenoses and filled a moderate sized OM1. The mid LCX was occluded prior to a large OM2. The RCA was a large dominant vessel with a mid 80% stenosis and a 50% stenosis at the origin of the PL branch. There was a considerable amount of right to left collaterals to the LAD. 2. Limited hemodynamics showed severe pulmonary hypertension (PA mean 47 mmHg). The left and right sided filling presures were severely elevated (RA mean 20 mmhg, RVEDP 19 mmHg, PCW mean 37 mmHg). The cardiac output was normal with low systemic resistance (CO 6.2 l/min, CI 3.3 l/min/m2). 3. Successful PTCA and stenting of the RCA with a 2.5 x 18 mm Cypher DES. Final angiography revealed no residual stenosis, no apparent dissection, and normal epicardial flow (see PTCA comments). 4. Successful PTCA and stenting of the RCA with a 3.0 x 13 mm Cypher DES. FInal angiography revealed no residual stenosis, no apparent dissection, and normal epicardial flow (see PTCA comments). 5. Successful insertion and timing of a 30 cc intraaortic balloon pump. FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Severe elevation of left and right sided pressures 3. Moderately severe pulmonary hypertension. 4. Acute inferolateral myocardial infarction with cardiogenic shock managed by PTCA and placement of drug-eluting stents in the mid LCX and mid RCA. 5. Successful insertion of an intraaortic balloon pump. . Arrived in cath lab with SBP 100 on 15mcg dobutamine. LCX occlusion crossed and dilated and stented Cypher with no residual, nl flow. 60% prox M1 ds with moderate distal LCX ds, after LCX PCI, SBP decr to 60. IABP inserted via LFA and dobutamine changed to dopamine with return of SBP to 100. RCA lesion dilated, Cypher stent with no residual, normal flow. . Echocardiogram [**2140-7-11**] Conclusions: The left atrium is elongated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small with near cavit obliteration during systole. Overall left ventricular ejection fraction is normal to hyperdynamic (EF 65-75%, Inotropes?) with basal to mid infero-lateral wall hypokinesis. No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. . [**7-14**], [**7-15**], and [**2140-7-10**]: All blood cultures were negative. [**7-14**] and [**2140-7-10**]: All urine cultures were negative. [**2140-7-14**] 8:12 pm SPUTUM Site: ENDOTRACHEAL Source: Endotracheal. **FINAL REPORT [**2140-7-18**]** GRAM STAIN (Final [**2140-7-15**]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2140-7-18**]): OROPHARYNGEAL FLORA ABSENT. STAPH AUREUS COAG +. RARE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S PENICILLIN------------ =>0.5 R . CXR [**2140-7-11**] IMPRESSION: AP chest compared to [**7-10**] at 1:03 p.m.: Moderately severe pulmonary edema has improved dramatically. The ascending Swan-Ganz line tip projects over the main pulmonary artery, tip of the intraaortic balloon pump projects over the left main bronchus approximately 7 cm from the apex to the aortic knob. The heart is normal size. Small left pleural effusion persist. No pneumothorax. Nasogastric tube coiled in the stomach. . CXR [**2140-7-13**] IMPRESSION: AP chest compared to 9:09 a.m. on [**7-12**]. Severe pulmonary edema has worsened, accompanied by increasing moderate-sized bilateral pleural effusions. Heart size top normal. ET tube in standard placement. Nasogastric tube looped in the stomach. A Swan-Ganz catheter has been removed. No pneumothorax. . REPEAT CXR [**2140-7-13**] IMPRESSION: AP chest compared to 8:05 a.m. Severe infiltrative pulmonary abnormality, worse in the right lung than the left has improved slightly, perhaps function of increased positive pressure ventilation or interval diuresis. Small-to-moderate bilateral pleural effusions persist. The heart is normal size. There is no pneumothorax. ET tube in standard placement. Nasogastric tube passes below the diaphragm and out of view. . CXR [**2140-7-15**] INDICATION: Right subclavian placement. PORTABLE AP CHEST AT 8:12 A.M: Comparison is made to [**2140-7-13**]. The endotracheal tube is in satisfactory position in the mid trachea, but the cuff is hyperinflated, expanding the trachea. Right subclavian central venous line tip is in the upper SVC. NG tube tip not visualized, off inferior cassette edge. Cardiac size remains stable at the upper limits of normal. There is improvement in multiple bilateral asymmetrical areas of hazy opacity, likely from resolving pulmonary edema. Small bilateral effusions and residual lower lobe atelectasis remain. Endotracheal tube cuff findings were called to Dr. [**Last Name (STitle) 10919**] at 4:25 p.m. on [**2140-7-15**]. . CT ABD/PEL [**2140-7-13**] CT ABDOMEN WITHOUT ORAL, WITHOUT INTRAVENOUS CONTRAST: A nasogastric tube descends below the diaphragm, and is coiled within the stomach. There are mild coronary artery calcifications. Large bilateral pleural effusions are seen, resulting in compressive atelectasis, and there are mild ground glass opacities within the lungs. Imaging of the abdomen is limited by the lack of intravenous contrast. Allowing for this, the liver attenuates normally without focal nodules or masses. A single 3mm calcification seen within the liver dome, consistent with prior granulomatous infection. The patient is status post cholecystectomy and surgical clips are seen within the right upper quadrant. The pancreas, spleen, bilateral adrenal glands, and intra-abdominal loops of large and small bowel are unremarkable. The kidneys appear slightly atrophic, but are symmetric. There are moderate calcifications involving the abdominal aorta without aneurysmal dilatation. There is no free fluid identified within the abdomen to indicate a retroperitoneal hematoma. CT PELVIS WITHOUT ORAL, WITHOUT IV CONTRAST: CT imaging was continued into the mid thigh. The muscles attenuate normally, and fat planes are preserved. There is no evidence of retroperitoneal hematoma or bleeding into the thigh. A right femoral vein catheter extends to the level of the superior ischia. Suture material is seen within the distal sigmoid. A large amount of subcutaneous edema extends along the abdomen and pelvis. Foley catheter is seen within a collapsed bladder. IMPRESSION: No evidence of retroperitoneal hematoma. Findings consistent with fluid overload including bilateral pleural effusions, ground glass opacities within the lungs, and subcutaneous edema. These findings were discussed with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] form the Medicine service at 2pm on [**2140-7-13**]. . CT HEAD [**2140-7-14**] CT OF THE HEAD WITHOUT CONTRAST: There is no intracranial hemorrhage or mass effect. There is no shift of the normally midline structures. The ventricles and sulci are symmetrical and appropriate in size for the patient's age. No major vascular territorial infarction is appreciated on this non-contrast CT exam. Bone windows show evidence of prior craniotomy defect and burr holes seen in the right frontal cortex. Partial opacification of the mastoid air cells is seen bilaterally, which probably relates to intubation. Probable cerumen is seen in the right external auditory canal. IMPRESSION: No intracranial hemorrhage or mass effect. . CARDIAC ENZYMES: [**2140-7-10**] 12pm CK 3680, MB 412, TnT 21.34 (PEAK) [**2140-7-10**] 8pm CK 2545, MB 234, TnT 19.70 TRENDING DOWN [**2140-7-11**] CK 1571, MB 93, Tn not done . LABS: [**2140-7-10**] Na 141, K 4.1, Cl 110, HCO3 20, BUN 22, Cr 1.1, Glucose 239 [**2140-7-15**] Na 136, K 3.7, Cl 110, HCO3 18, BUN 30, Cr 0.9, Glucose 201 [**2140-7-10**] 12:56PM ALT(SGPT)-46* AST(SGOT)-307* CK(CPK)-3680* ALK PHOS-67 TOT BILI-0.3 [**2140-7-10**]: ABG 7.32/40/147 LACTATE-2.1* . [**2140-7-10**] WBC 33.7 HCT 36.3 PLT 306 [**2140-7-11**] WBC 31.1 HCT 32.4 PLT 265 [**2140-7-12**] WBC 22.1 HCT 19.8 PLT 240 [**2140-7-13**] AM WBC 17.8 HCT 14.7 PLT 165 [**2140-7-13**] PM WBC 19.7 HCT 16.0 PLT 209 [**2140-7-14**] WBC 13.4 HCT 14.8 PLT 198 [**2140-7-15**] WBC 11.3 HCT 14.0 PLT 182 . HEMOLYSIS LABS [**2140-7-11**] LDH 785, [**2140-7-13**] LDH 570 [**2140-7-11**] RETIC CT 2% [**2140-7-11**] HAPTOGLOBIN 84, [**2140-7-13**] HAPTOGLOBIN 132 . IRON STUDIES revealed low serum Fe, low TIBC, high ferritin . TSH 1.3 WNL Brief Hospital Course: Impression: 84 y/o Jehovah's witness with h/o colon CA, brain CA, DM II, CAD with MI in past, refused angioplasty, and Alzheimer's ds presents with STEMI s/p cath with Cypher stents to LCX, RCA complicated by cardiogenic shock with IABP placement with hypotension on pressors, worsening pulm status, now intubated. Her hospital course was complicated by profound anemia, septic shock, cardiovascular and respiratory failure. The patient died on [**2140-7-15**]. 1. CARDIAC: The patient underwent catheterization on [**2140-7-10**] showing a right dominant system with severe three vessel disease. The LMCA was angiographically without significant disease. The LAD was proximally occluded and was filled by left-to-left and right-to-left collaterals. The mid and distal LAD was severely diffusely diseased. The proximal LCX was without flow limiting stenoses and filled a moderate sized OM1. The mid LCX was occluded prior to a large OM2. The RCA was a large dominant vessel with a mid 80% stenosis and a 50% stenosis at the origin of the PL branch. There was a considerable amount of right to left collaterals to the LAD. She demonstrated severe pulmonary hypertension (PA mean 47 mmHg). The left and right sided filling presures were severely elevated (RA mean 20 mmhg, RVEDP 19 mmHg, PCW mean 37 mmHg). The cardiac output was normal with low systemic resistance (CO 6.2 l/min, CI 3.3 l/min/m2). Her final cath diagnoses were: 1. Three vessel coronary artery disease. 2. Severe left and right sided diastolic dysfunction 3. Severe pulmonary hypertension. She was placed on IABP post cath, which was weaned 1 day post cath. As she was hypotensive post procedure, she was started on pressors. It was not clear the etiology of her hypotension her first night post cath, as her CI was fine, but she was persistently 70s-90s/50s-60s with cool, clammy extremities and peripheral vasodilation. Cardiogenic shock was considered. She was started on dopamine gtt and maxed out on dosage with persistent MAP in 40s-50s, then given dobutamine, which was weaned. As it was then felt she was not likely in cardiogenic shock, she was begun on levophed with good response in her mean arterial pressure (MAP >60). At this time, however, she spiked a temperature to 102, was pan cultured, and started on empiric broad-spectrum antibiotic therapy. Her shock was most likely secondary to sepsis. A MAP of >60 was kept during her stay in the unit, supported by pressors and fluid boluses. As she is a Jehovah's witness, she would not accept transfusions of pRBCs, so epoetin and ferrous sulfate were begun as adjunctive therapy. She was also started on aspirin, plavix, a statin, and integrillin gtt for her coronary disease. Despite aggressive measures, the patient acutely decompensated on [**2140-7-15**] in the setting of profound anemia, cardiovascular and respiratory failure, and sepsis. . 2. Septic shock: Though the pt had a cardiac index of 3.3 in the cath lab, post-cath the pt seemed peripherally vasodilated. Initially, the pt was afebrile, and it was thought her low systemic vascular resistance was secondary to medications for intubation, however, during the night post-cath, she spiked a temp to 102, and was pan-cultured with blood cx X2 sent, ua and urine cx sent, with endotracheal cx sent. [All blood cultures during her stay ([**7-10**], [**7-14**], and [**7-15**]) were negative. All urine cultures sent during her stay ([**7-10**] and [**7-14**]) were negative. An endotracheal culture from [**7-10**] grew coag positive S. aureus. A sputum cx from [**2140-7-10**] grew sparse oropharyngeal flora.] A CXR during the night of her admission to the CCU demonstrated extensive bilateral perihilar infiltrates involving virtually all segments of the lungs. She was started empirically on IV Vancomycin and IV Zosyn for broad coverage (started [**2140-7-11**]) and these meds were continued throughout her stay. She was begun on pressors to maintain a MAP of >60. Despite aggressive measures with IVF boluses, pressors, and IV antibiotics, the pt expired [**2140-7-15**], as stated above. . 3. Profound anemia secondary to gastrointestinal bleeding with bloody secretions in ET tube after IABP removal. No evidence of retroperitoneal bleed on Abdominal/Pelvic CT scans. It was unclear the precise etiology of the pt's source of bleed. She developed guiaic positive stool during her stay, and heparin gtt was held. Initially, on arrival to CCU, the pt had bloody secretions in the ET tube, which persisted for several days, then resolved. Her health care proxy was notified of her profound anemia, and because she is a Jehovah's witness, no tranfusions were given to the patient to correct her anemia. Instead, fluid boluses with pressors were given to maintain her MAP. IV ferrous sulfate, and epoetin was given to the pt. Blood draws were minimized and only necessary labs were obtained. The pt's Hct dropped from 36 on [**7-10**] to 20.5 on [**7-11**]. A CT scan of abd/pel did not reveal a retroperitoneal bleed post-cath. Her IABP removal was not complicated by bleeding in excess of normal to explain her acute drop in Hct. On [**7-13**] her Hct was 14.7, and had held steady in the 14-16 range for three days. She developed bloody stools four days post-admission, and GI was consulted. A nasogastric lavage was performed and was negative. Her hemolytic workup was negative. Her stool was guiaic positive and maroon in color. It was felt she had a lower GI bleed, however she was not stable enough to undergo colonoscopy. Her heparin gtt was discontinued. Her MAP was supported as stated above. On the day of her death, her Hct was 14.0. Her health care proxy was informed of all events and procedures during her stay, and was given updates as to her Hct and measures being taken to support her MAP. . 4. RESPIRATORY: The pt's CXR was read as "extensive bilateral perihilar infiltrates involving virtually all segments of the lungs." Post-cath, she was intubated and sedated on mechanical ventilation. She was unable to be weaned from the vent secondary to hypoxia. Her CXR improved somewhat during her stay, with [**2140-7-12**] CXR showing mild-to-moderate residual pulmonary edema, largely basal, unchanged since [**7-11**], having improved dramatically since [**7-10**], with leftward mediastinal shift reflecting left lower lobe atelectasis, accompanied by persistent small left pleural effusion. CXR on [**2140-7-15**] demonstrated multiple bilateral asymmetrical areas of hazy opacity, likely from resolving pulmonary edema. Her small bilateral effusions and residual lower lobe atelectasis remained. She remained on broad spectrum IV antibiotics throughout her admission. . 6. DM TYPE II: Her blood sugars were well controlled with sliding scale insulin, and fingersticks were checked qid. . # Decreased mental status: A head CT was performed to rule out intracranial bleed as a cause of her depressed mental status and inability to be weaned from the vent (a central cause for respiratory depression/hypoxia was considered) and in the setting of possible systemic hypoperfusion given her septic picture, and was negative for intracranial bleed or mass effect or any acute abnormality. The pt remained minimally responsive and sedated and intubated throughout her stay. . 7. seizure d/o No seizures occurred during her admission. Her Dilantin level at [**Hospital1 **] was 10.6. We restarted dilantin on admission. . 8. Alzheimer's ds: Her Aricept was held in light of her critical status. . 9. Depression: Her Zoloft was held in light of pt's unstable status. She remained intubated and sedated throughout her stay, only minimally responsive on sedation. . 10. CODE: FULL CODE, although her health care proxy requested at admssion that he wanted to be notified if there was futility/no benefit to further aggressive measures. The health care proxy was communicated with nearly every day by housestaff physicians, RNs in the CCU and the attending physician as to the pt's prognosis, status, and measures being taken in her care. He was involved in all decision making. . Medications on Admission: 1. Lipitor 20mg po qd 2. Zestril 2.5mg po qd 3. Imdur 60mg po qd 4. Dilantin 100mg po tid 5. Zoloft 75mg po qd 6. Risperadol 0.5mg po qd 7. Aricept 10mg po qd 8. Synthroid 0.025mg po qd 9. Lasix 80mg po qd 10. KCl 10-20mg po qd 11. Atenolol 50mg po qd 12. MVI 13. Ca suppl 14. Vit C 15. ASA 81mg po qd 16. Vit E Discharge Disposition: Expired Discharge Diagnosis: 1. Sepsis 2. Profound anemia, with lower gastrointestinal bleed, with inability to give transfusions (patient is a Jehovah's witness) 3. ST-segment elevation myocardial infarction status post stent placement to left circumflex artery and right coronary artery 4. Cardiac catheterization complicated by hypotension treated with pressors and IV fluids, cardiogenic shock status post intra-aortic balloon pump placement 5. pulmonary edema and respiratory failure on mechanical ventilation 6. altered mental status 7. history of colon cancer 8. history of brain cancer 9. Alzheimer's disease 10. Type II Diabetes Mellitus 11. history of depression Discharge Condition: Pt expired on [**2140-7-15**] in setting of sepsis on broad-spectrum IV antibiotics, hypotension on pressors and IV fluids. Pt had profound anemia despite IV ferrous sulfate, fluid boluses, and epoeitin as pt was a Jehovah's witness with lower GI bleeding and without evidence of retroperitoneal bleed after cardiac cath. Hemolysis labs negative. With STEMI s/p cardiac catheterization with stents placed and IABP placement and removal. Completed by:[**2140-8-3**]

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Discharge summary

report

Admission Date: [**2162-5-23**] Discharge Date: [**2162-6-3**] Date of Birth: [**2102-4-19**] Sex: M Service: CARDIOTHORACIC Allergies: Sulfa(Sulfonamide Antibiotics) / Valium Attending:[**First Name3 (LF) 165**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2162-5-23**] - Cardiac catheterization [**2162-5-27**] - Urgent off-pump coronary artery bypass graft x3: Left internal mammary artery to left anterior descending artery and saphenous vein grafts to diagonal and left radial artery graft to the ramus artery. History of Present Illness: 60 yo M with h/o HTN, HLD, and ?ischemic colitis presenting with progressive chest pain. He was found to have an acute myocardial infarction. He was taken to the cath lab where he was found to have multi-vessel Coronary Artery Disease. Cardiac surgery was consulted for surgical revasculariztion. Past Medical History: Coronary Artery Disease -Myocardial infarction -Hypertension -hypercholesterolemia -CRI creat 1.4 on admission -Ischemic colitis -CT scan revealed emphysema Social History: Pt is a former Police officer and paramedic. He lives with his wife [**Name (NI) **] and they have three children. - Tobacco history: Former smoker, quit 2.5 years prior. 40 packyears. - ETOH: Denies - Illicit drugs: Denies Family History: Pt reports his mother died of a heart attack and his twin brother recently require a stent placement. His older son has [**Name (NI) 4522**] disease. Physical Exam: ADMISSION PHYSICAL EXAMINATION: VS: T 98.7 BP 116/67 HR 76 RR 18 O2 sat 97% on 3L GENERAL: NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple, JVP unable to be appreciated given body habitus. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. soft systolic murmur ([**3-8**]). 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. NABS. EXTREMITIES: No clubbing/cyanosis. 1+ b/l pedal edeam. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. NEURO: AAOx3, CNII-XII intact, sensation grossly intact PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ . Transfer to CT surgery exam: GENERAL: Awake, alert and oriented x3. Mood, affect appropriate. Interactive, comfortable and in NAD HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: Supple, JVP low CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, S1, S2 clear and of good quality, HRs in 50s. soft systolic murmur ([**3-8**]). No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use, moving air well and symmetrically. CTAB, no crackles, wheezes or rhonchi. No faint expiratory wheezes on this mornings exam. ABDOMEN: Distended but Soft, NT, voluntary guarding but no rebound. No HSM or tenderness. NABS. EXTREMITIES: No clubbing/cyanosis. trace b/l pedal edema. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. NEURO: AAOx3, CNII-XII intact, sensation grossly intact PULSES: Right: DP 2+ PT 2+ Left: DP 2+ PT 2+ Pertinent Results: DATA: - ECG: NSR at 77, normal axis, normal intervals, no STE/STD. . - ECHO: Prelim - mild RV dilation, no focal wall motion abnormalities . - CARDIAC CATH: Interventional details The LAD-diagonal branches can be approached with a simultaneous V stenting technique in the LAD and diagonal branch. It appears that both stents will be approximately 20 mm in length. In addition, the large ramus branch also has diffuse disease that will require a long stent in the event of residual ischemia. The patient's chest pain was improved - and we have the time to discuss the options of CABG versus multivessel bifurcation stenting with long DES. The risk of stent thrombosis with two long stents in this location is not negligible. We will begin more aggressive beta blockage (his HR is in the 90s), administer IV eptifibatide x 18 hours, and titrate his IV NTG for pain control. We will hold his clopidogrel in the event that surgery is selected. Assessment & Recommendations 1. Two vessel coronary artery disease (LAD, ramus) 2. Consider CABG v. multivessel PCI . - CTA Chest ([**2162-5-23**]) - IMPRESSION: 1. No evidence of acute aortic syndrome or pulmonary embolus. 2. Centrilobular emphysema predominantly in upper lobes. Right middle lobe and lingular atelectasis. 3. Small hiatal hernia. . -ECHO [**5-24**] Conclusions Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with preserved global biventricular systolic function. No pericardial effusion identified. . [**2162-5-27**] ECHO The interatrial septum is [**Month/Day/Year 76472**]. A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. There is mild symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. : Normal overall LV and RV systolic function with no regional wall motion abnormalities. Mild MR. [**First Name (Titles) **] [**Last Name (Titles) **] with PFO and left to right shunt. Post OPCABG Ventricular function is preserved. Valve function similar to Pre CABG. . [**2162-5-27**] Intra-op TEE: Conclusions The interatrial septum is [**Month/Day/Year 76472**]. A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. There is mild symmetric left ventricular hypertrophy. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. : Normal overall LV and RV systolic function with no regional wall motion abnormalities. Mild MR. [**First Name (Titles) **] [**Last Name (Titles) **] with PFO and left to right shunt. Post OPCABG Ventricular function is preserved. Valve function similar to Pre CABG. Brief Hospital Course: Mr. [**Known lastname 76473**] was admitted to the [**Hospital1 18**] on [**2162-5-23**] for further management of his chest pain and myocardial infraction. He was placed on heparin and plavix. Chest xray suggested a widened mediastinum and thus a ct scan was obtained. This showed a small hiatal hernia, emphysema and no aortic dissection or embolism. A cardiac catheterization was performed which revealed severe two vessel disease. Given the severity of his disease, the cardiac surgical service was consulted. Mr. [**Known lastname 76473**] was worked-up in the usual preoperative manner. [**First Name8 (NamePattern2) 6**] [**Doctor Last Name 6237**] test was performed which showed the left radial artery to suitable for use as conduit. Plavix was held. On [**2162-5-27**], Mr. [**Known lastname 76473**] was taken to the operating room where he underwent off pump coronary artery bypass grafting to three vessels. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. He later awoke neurologically intact and was extubated. Plavix and imdur were started for his off pump bypass and his free radial graft respectively. On postoperative day one, he was transferred to the step down unit for further recovery. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. Chest tubes and pacing wires were discontinued without complication. He developed Acute Kidney Injury with rise in creatinine to 2.4. Lisinopril and Lasix were discontinued and creatinine would trend down. Urine output remained stable. Additionally, radial artery harvest site and sternum developed serosanguinous drainage. These sites were painted with chloraprep and dressings were changed TID, drainage diminished. The patient was evaluated by the physical therapy service for assistance with strength and mobility, and it was felt that the patient was safe to be discharged to home with VNA and physical therapy services. It is now felt on [**2162-6-3**] that the patient is safe for discharge on post-operative day #7. [**6-1**] By the time of discharge on POD **** the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged ***** in good condition with appropriate follow up instructions. Medications on Admission: HOME MEDICATIONS: - Nebivolol 20 mg daily - Ramapril 20 mg daily - Simvastatin 10 mg daily - Omeprazole 20 mg daily Discharge Medications: 1. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disp:*60 Disk with Device(s)* Refills:*2* 2. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* 3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*30 Capsule(s)* Refills:*0* 6. 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* 7. mesalamine 250 mg Capsule, Extended Release Sig: Four (4) Capsule, Extended Release PO QID (4 times a day). Disp:*240 Capsule, Extended Release(s)* Refills:*0* 8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 9. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 10. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain mild . Disp:*60 Tablet(s)* Refills:*0* 11. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 7 days. Disp:*7 Tablet(s)* Refills:*0* 12. potassium chloride 10 mEq Tablet Extended Release Sig: One (1) Tablet Extended Release PO once a day for 7 days. Disp:*7 Tablet Extended Release(s)* Refills:*0* 13. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Coronary Artery Disease -Myocardial infarction -Hypertension -hypercholesterolemia -CRI creat 1.4 on admission -Ischemic colitis -CT scan revealed emphysema Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oxycodone and tylenol Incisions: Sternal - healing well, mild erythema at distal pole of sternal incision and along left radial harvest site incision. Leg Right - healing well, no erythema or drainage. Edema: trace 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 provided. 4) No driving for approximately one month and while taking narcotics. Driving will be discussed at follow up appointment with surgeon when you will likely be cleared to drive. 5) No lifting more than 10 pounds for 10 weeks 6) 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 WOUND CARE Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2162-6-8**] 10:00 in the [**Hospital **] Medical office building, [**Doctor First Name **] [**Hospital Unit Name **] Surgeon: Dr. [**First Name (STitle) **] on [**2162-6-29**] 1:30, [**Telephone/Fax (1) 170**] in the [**Hospital **] Medical office building, [**Doctor First Name **] [**Hospital Unit Name **] Cardiologist: Dr. [**Last Name (STitle) 11493**] [**2162-6-14**] 2:15p Please call to schedule appointments with your Primary Care Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 71168**] [**Telephone/Fax (1) 33146**] in [**5-6**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2162-6-3**]

[ "414.01", "V85.41", "272.4", "410.71", "783.1", "492.8", "585.9", "285.9", "729.1", "584.5", "553.3", "557.9", "403.90", "276.1", "493.90", "V15.82" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

11537, 11586

7171, 9516

315, 578

11787, 12092

3391, 7148

12981, 13938

1348, 1500

9682, 11514

11607, 11766

9542, 9542

12116, 12958

1515, 1525

9560, 9659

1547, 3372

265, 277

606, 907

929, 1088

1104, 1332

47,747

133,421

11883+56299

Discharge summary

report+addendum

Admission Date: [**2192-2-3**] Discharge Date: [**2192-2-9**] Date of Birth: [**2128-12-25**] Sex: M Service: MEDICINE Allergies: Primidone Attending:[**First Name3 (LF) 2167**] Chief Complaint: shortness of breath, ICU transfer for unstable respiratory status Major Surgical or Invasive Procedure: none History of Present Illness: 63M with Hx of COPD, recent hospital stay for COPD exacerbation due to Influenza A viral (antigen+) [**Date range (1) **], returns with 2d worsening dyspnea, continued productive cough, and subjective fevers at home. Patient was treated with prednisone 50 mg x 5 days, antibiotics x 5 days, and nebulized albuterol, tiotropium and fluticasone. Patient improved within the first two days, with normal O2 Sats on room air, was discharged with two more days of antibiotics (Azythromycin) and prednisone 50mg. Currently he reports... In the ED: sats initially 80s on RA, up to mid 90s on 3L. CxR showing new lobar PNA ceftriaxone, cefepime, vanco, nebs. Vitals: 102 107/55 93% 4L 20. Has had tenuous sat in ED and 3-4L NC, desatted on nebulizer. ABG okay, but working on NRB . . On the floor, pt feel much better, satting 90% on 60% face mask, changed to NRB. ROS: 2 days of worsening SOB, tightness, and subjective fevers, no CP, no dizziness, no n/v/ but some loose stools atributed to milk and cereal. Past Medical History: - COPD: mild-moderate; FEV1 66% predicted, FEV1/FVC 80% predicted - Cauda equina syndrome: dx [**8-7**], s/p L2-laminectomy in [**11-6**], with baseline BLE paresis, neuropathic pain, and neurogenic bladder/bowel - Abdominal pain / Dyspepsia - H. pylori gastritis, s/p treatment; ?hiatal hernia on CXR today - Hyperthyroidism [**1-9**] [**Doctor Last Name 933**] disease s/p radioi-active iodine ablation [**10/2191**], now on replacement therapy - Erectile dysfunction - h/o Pneumonia, [**2186**] - L hip sebaceous cyst - chronic groin pain, on Ultram Social History: 60 pk-yr smoker, quit 5 yrs ago. Denies EtOH use, no IVDA. He is divorced and lives alone in [**Location 4288**]. He went on disability after the surgery for the cauda equina syndrome. Semi-retired, previously worked in administration for construction company. Family History: Denies any major family illnesses. Father died age [**Age over 90 **], mother died age [**Age over 90 **]. Sister w/breast cancer. No premature heart disease or other cancers. Physical Exam: Vitals: T: BP: 120/73 P: 102 R: 16 18 O2 99% NRB: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: good air movement, minimal posterior wheezes, and left lll crackles, CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops, distant 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: [**2192-2-3**] 06:15AM PLT COUNT-194 [**2192-2-3**] 06:15AM WBC-6.2 RBC-5.53 HGB-14.9 HCT-45.7 MCV-83 MCH-26.9* MCHC-32.6 RDW-15.2 [**2192-2-3**] 06:15AM ALT(SGPT)-49* AST(SGOT)-38 ALK PHOS-71 TOT BILI-0.7 [**2192-2-3**] 06:24AM LACTATE-1.3 [**2192-2-3**] 08:25AM LACTATE-1.0 [**2192-2-3**] 08:25AM TYPE-ART PO2-77* PCO2-33* PH-7.46* TOTAL CO2-24 BASE XS-0 INTUBATED-NOT INTUBA [**2-3**] CXR: FINDINGS: There has been interval development of new patchy opacities projecting over the left mid and lower hemithorax with stable appearance to left basilar atelectasis and elevation of the left hemidiaphragm. Remaining lungs appear clear. No large effusions or pneumothorax, pulmonary edema is identified. IMPRESSION: New left-sided pneumonia. Brief Hospital Course: Assessment and Plan: This is a 63 yo with COPD, recent hospital stay for Influenza A, returning with SOB and CxR showing new left sided PNA. # SOB: combination of COPD exacerbation in the setting of viral and now bacterial superinfection. good air movement, not tachypnic, not retaining Recv'd abx for HAP. Gram positive cocci in pairs, sensitivities pend, MRSA screen + Recv'd Solumedrol 3 doses with quick taper of po prednisone afterwards. Remained influenza positive. Weaned o2 - not on at d/c. Started with standing nebs - transitioned to prn. . #. Hyperthyroidism - The patient had a history of Grave's disease s/p radioactive iodine ablation. Synthroid was continued at home dose. . #. GERD / dyspepsia - The patient had a history of H Pylori gastritis, s/p tx with ongoing symptoms. CXR showed large hiatal hernia. Home regimen of Protonix 20mg daily and Pepcid [**Hospital1 **] was continued. . #. Cauda equina syndrome - Symptoms were at baseline per patient, with right foot drop requiring brace, which he brought with him. Gabapentin was continued at outpatient dose. . #. Chronic pain - Tramadol and ibuprofen PRN. High dose Gabapentin, stabilized at home, but impressive dose. pt insists on continuation of this dose. will cont for now, needs to be readressed on the floor and as outpatient . # FEN: 1L NS IVF, repletee electrolytes prn, regular diet . # Prophylaxis: Subcutaneous heparin Medications on Admission: 1. Albuterol 2. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 3. Fluticasone 110 mcg 4. Gabapentin 800 mg, PO Q4H 5. Omeprazole 20 mg Capsule 6. Levothyroxine 125 mcg 7. Tramadol 50 mg PO DAILY (Daily). 8. Tiotropium Bromide 18 mcg Capsule, w/Inhalation 9. Calcium Carbonate 500 mg 3 times a day 10. Cholecalciferol (Vitamin D3) 400 unit [**Unit Number **] times a day 11. Multivitamin,Tx-Minerals 12. Cyanocobalamin Oral 13. Pepcid Oral 14. Prednisone 50 mg PO DAILY 2 days. 15. Azithromycin 250 mg Tablet PO Q24H for 2 days. 16. Ibuprofen 400 mg PO Q8H as needed. Discharge Medications: 1. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 2. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 3. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 6. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day). 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed. 10. Omeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 11. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed. 12. Prednisone 10 mg Tablet Sig: One (1) dose PO DAILY (Daily) for 6 days: TWO tablets on days 1 and 2, ONE tablet on day 3 and 4, and half a tablet on days 5 and 6. Stop on day 7 . Disp:*7 tablets* Refills:*0* 13. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO 6 TIMES A DAY (). 14. Doxazosin 1 mg Tablet Sig: Two (2) Tablet PO at bedtime as needed for insomnia. 15. Pepcid 40 mg Tablet Sig: One (1) Tablet PO once a day. 16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*0* 17. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*60 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Bacterial pneumonia Influenza COPD Secondary Chronic pain Hypothyroid Discharge Condition: Improved Discharge Instructions: You were admitted with pneumonia after having had influenza. You received antibiotics for seven days and improved during the course of your admission. Please take the medications we have prescribed as directed. Please call your doctor or return to the ER for: * Increased shrortness of breath * Fevers, chills, nausea, vomiting * Worsening symtpoms * With any new or concerning issues Followup Instructions: Please call Dr. [**Last Name (STitle) 13959**] [**Telephone/Fax (1) 250**] and Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**] tomorrow to arrange for follow-up appointments early next week. It is important that you mention that you were recently hospitalized for pneumonia and will need close follow-up. Please keep your other appointments as scheduled below: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2192-2-10**] 10:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5340**], MD Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2192-3-23**] 4:40 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 13960**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2192-4-16**] 8:00 Name: [**Known lastname **],[**Known firstname 63**] Unit No: [**Numeric Identifier 6748**] Admission Date: [**2192-2-3**] Discharge Date: [**2192-2-9**] Date of Birth: [**2128-12-25**] Sex: M Service: MEDICINE Allergies: Primidone Attending:[**First Name3 (LF) 6749**] Addendum: Regarding Mr. [**Known lastname 6750**] shortness of breath - he was influenza positive and was superinfected and being actively treated for HAP which speciated MRSA in his sputum. Discharge Disposition: Home [**First Name11 (Name Pattern1) 1194**] [**Last Name (NamePattern1) 6751**] MD [**MD Number(2) 6752**] Completed by:[**2192-3-5**]

[ "V02.54", "338.29", "244.0", "491.21", "530.81", "344.60", "482.42" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

9437, 9603

3754, 5163

335, 341

7621, 7632

2976, 3731

8067, 9414

2244, 2421

5800, 7469

7519, 7600

5189, 5777

7656, 8044

2436, 2957

230, 297

369, 1372

1394, 1949

1965, 2228

78,007

126,070

35375

Discharge summary

report

Admission Date: [**2117-3-1**] Discharge Date: [**2117-3-3**] Date of Birth: [**2042-1-20**] Sex: F Service: NEUROLOGY Allergies: Macrobid Attending:[**First Name3 (LF) 2569**] Chief Complaint: Hand numbness Major Surgical or Invasive Procedure: MRI/MRA EEG History of Present Illness: Ms. [**Known lastname 45224**] is a 75 year old right handed woman with history of prior left occipital parenchymal hemorrhage now presenting with left arm and face numbness and headache, found to have a new hemorrhage on head CT. This morning she awoke with a mild left sided constant dull headache, which is unusual for her. Then this afternoon around noon, she noted the sudden onset of paresthesias followed by numbness in a glove distribution on her left hand. The sensation traveled up her left arm to her elbow over the course of a few seconds, at which time she also noted the left half of her tongue and left lower [**2-9**]'s of her face also with paresthesias. She waited to see if the symptoms resolved, and then called her PCP who suggested she call EMS. By the time EMS arrived her left arm and face symptoms had resolved completely- total duration ~2 hours. She still had a mild left sided vertex headache. She was taken to [**Hospital3 417**] where head CT revealed a deep left occipital hemorrhage (periventricular) and punctate R frontal hemorrhages in the hand area of the cortex. At present she notes stable R inferior quadrant defect in her visual field. She has persistent mild L vertex headache. She denies blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denied difficulties producing or comprehending speech. Denied focal weakness. No bowel or bladder incontinence or retention. Denied difficulty with gait. On review of systems, the pt denied recent fever or chills. No night sweats. She's gained [**3-10**] pounds over the last few months. No cough or shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Denied rash. Past Medical History: Left occipital hemorrhage- ([**2116-9-7**])- presented with "fireworks" in her visual field, no headache, she was admitted to [**Hospital1 2025**], seen by Dr. [**First Name (STitle) **] there, but no longer follows. She had visual filed testing subsequently and told she had R inferior quadrantanopsia and hence no longer drives. Hypertension Vertigo- takes meclizine PRN Bilateral TKR no history of MI Social History: lives with her husband, she is a retired administrative assistant at the [**Company 3596**], now volunteers, never smoker, drinks "[**Female First Name (un) **] cup" of wine each night at recommendation of her PCP, [**Name10 (NameIs) **] illicit or IV drug use. Family History: Father- colon cancer, d. 85 Mother- Dementia, d. 85 Brother- d. age 40 secondary to ETOH. Physical Exam: Vitals: T 98.1, BP 129/62, HR 88, R 16, Sat 97% 2L General: Awake, cooperative, very pleasant, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no JVD or carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: pbese, soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3. Able to relate history without difficulty. Attentive, able to name [**Doctor Last Name 1841**] backward without difficulty. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Able to read without difficulty. Speech was not dysarthric. Able to follow both midline and appendicular commands. There was no apraxia or neglect. -Cranial Nerves: Olfaction not tested. PERRL 3 to 2mm and brisk. There is a right inferior quadrantanopsia. There is no ptosis bilaterally. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. EOMI without nystagmus. Normal saccades. Facial sensation intact to pinprick. She has slight right facial asymmetry, however upon active use of facial muscles there is no asymmetry or weakness. Hearing intact to finger-rub bilaterally. Palate elevates symmetrically. 5/5 strength in trapezii and SCM bilaterally. Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. No adventitious movements noted. No asterixis noted. VERY slight right upward drift. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB L 5 5 5 5 5 5 5 5 5 5 5 5 5 5 R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 -Sensory: No deficits to light touch, pinprick, cold sensation, vibratory sense, proprioception throughout. No extinction to DSS. Graphestesia intact on L hand. -Coordination: No intention tremor, dysdiadochokinesia noted. No dysmetria on FNF or HKS bilaterally. -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 2 2 2 2 1 R 2 2 2 2 1 Plantar response was flexor on the right, she has a right hammer toe. No tensing of the L tensor fascia [**Last Name (un) 80640**] -Gait: deferred. Pertinent Results: [**2117-3-3**] 05:35AM BLOOD WBC-6.6 RBC-4.33 Hgb-13.5 Hct-38.8 MCV-90 MCH-31.3 MCHC-34.9 RDW-13.8 Plt Ct-197 [**2117-3-2**] 08:57AM BLOOD WBC-6.8 RBC-4.13* Hgb-13.2 Hct-37.6 MCV-91 MCH-32.0 MCHC-35.1* RDW-13.3 Plt Ct-209 [**2117-3-1**] 08:20PM BLOOD WBC-8.7 RBC-4.55 Hgb-14.5 Hct-40.6 MCV-89 MCH-31.9 MCHC-35.7* RDW-13.2 Plt Ct-253 [**2117-3-1**] 08:20PM BLOOD Neuts-68.5 Lymphs-25.1 Monos-4.5 Eos-1.3 Baso-0.5 [**2117-3-3**] 05:35AM BLOOD Plt Ct-197 [**2117-3-2**] 08:57AM BLOOD Plt Ct-209 [**2117-3-1**] 08:20PM BLOOD PT-13.0 PTT-23.7 INR(PT)-1.1 [**2117-3-1**] 08:20PM BLOOD ESR-7 [**2117-3-3**] 05:35AM BLOOD Glucose-96 UreaN-19 Creat-0.7 Na-141 K-3.7 Cl-106 HCO3-28 AnGap-11 [**2117-3-1**] 08:20PM BLOOD Glucose-112* UreaN-20 Creat-0.8 Na-140 K-3.3 Cl-100 HCO3-31 AnGap-12 [**2117-3-2**] 08:57AM BLOOD CK(CPK)-211* [**2117-3-1**] 08:20PM BLOOD ALT-15 AST-24 AlkPhos-69 TotBili-0.6 [**2117-3-3**] 05:35AM BLOOD Calcium-8.8 Phos-2.8 Mg-2.0 [**2117-3-2**] 08:57AM BLOOD Calcium-8.9 Phos-2.6* Mg-1.7 [**2117-3-2**] 08:57AM BLOOD CK-MB-5 cTropnT-<0.01 [**2117-3-1**] 08:20PM BLOOD CRP-1.4 [**2117-3-1**] 08:20PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG MRI Brain: 1. No acute infarction. 2. No significant change in the appearance of the left occipital lobe hemorrhage, with mild surrounding edema. No gross enhancement noted. Evaluation for subtle enhancement is limited due to the pre-contrast T1- weighted appearance. Followup study can be considered AFTER RESOLUTION of the hemorrhage to assess for any underlying vascular or mass lesion. 3. Patent major intracranial arteries and the major dural venous sinuses, as described above, the latter being better evaluated on the MP-RAGE post-contrast sequences performed. 4. Punctate foci of hyperdensity noted in the right frontal vertex appear to be vaguely identifiable on the present study. No abnormal enhancement is noted in this location to suggest a vascular or neoplastic etiology. These may relate to mineralization. 5. Scattered foci of negative susceptibility in the brain can represent microhemorrhages or cavernomas or related to amyloid angiopathy. Brief Hospital Course: Pt was admitted for further evaluation and management of her small paranchymal bleed. She was initially observed overnight in the NICU. She was monitored with frequent neurochecks and cardiac telemetry. She had an MRI which showed stable size and possible underlying amyloid angiopathy. She was transfered to the neurology floor. She did well throughout the admission. She was evaluated by PT and was cleared to go home without any further therapies. She will follow-up with Dr. [**First Name (STitle) **]. Medications on Admission: HCTZ 50mg daily NTGN SL- takes PRN for chest pain, she has had none recently, scheduled for stress test in two weeks. Atenolol 12.5mg daily Klorcon 10meq daily meclizine 25mg daily Loratadine 10mg daily Fluticasone 5mg Calcium Vitamin E Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for headache. 2. Hydrochlorothiazide 12.5 mg Capsule Sig: Four (4) Capsule PO DAILY (Daily). 3. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). Discharge Disposition: Home Discharge Diagnosis: ICH Discharge Condition: Stable Discharge Instructions: You were admitted because of a small bleed. If you have any new weakness, numbness, dizziness or double vision you should return to the ED. Followup Instructions: F/U with Dr. [**First Name (STitle) **] - Please call [**Telephone/Fax (1) 44**] to update your information and get your appointment details Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) 162**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2117-5-3**] 1:30 [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**]

[ "431", "V43.65", "784.0", "277.39", "438.89", "401.9", "780.4", "368.46" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8921, 8927

7689, 8203

282, 295

8975, 8984

5515, 7666

9173, 9565

2930, 3022

8491, 8898

8948, 8954

8229, 8468

9008, 9150

4077, 5496

3037, 3575

229, 244

323, 2206

3590, 4060

2228, 2634

2650, 2914

16,992

107,483

47321

Discharge summary

report

Admission Date: [**2110-2-28**] Discharge Date: [**2110-3-5**] Date of Birth: [**2038-10-25**] Sex: M Service: CCU ADMITTING DIAGNOSIS: Torsades. HISTORY OF THE PRESENT ILLNESS: The patient is a 70-year-old gentleman who presented from rehabilitation after his AICD fired three times. The patient complained of fatigue and buttock pain as well as difficulty sleeping. The patient denied chest pain and shortness of breath. He did have low-grade temperatures in the Emergency Department. The patient had no new paroxysmal nocturnal dyspnea. No orthopnea. He did have a cough productive of sputum. The patient denied abdominal pain, dysuria, hematuria. He stated that his appetite was poor. He denied odynophagia. He reports dysphagia with solids for many years. The patient was recently hospitalized for a presyncopal/syncopal event and shocked. At that time, he had been started on Amiodarone and was inducible for V tach. At that time, he underwent placement of a biventricular [**Last Name (LF) **], [**First Name3 (LF) **] AICD. In the Emergency Department, the patient was noted to be in torsades. He was started on a lidocaine drip. PAST MEDICAL HISTORY: 1. Cardiomyopathy: Nonischemic. His ejection fraction was less than 15% in [**2109-4-8**]. He has 3+ MR, 1+ AR, 2+ TR. He has biventricular failure. 2. Status post dual-chamber biventricular pacemaker/AICD placement one week prior to admission. 3. SVC thrombosis. 4. Hypertension. 5. Hypercholesterolemia. 6. Left eye decreased acuity. MEDICATIONS AT HOME: 1. Coumadin 5 mg p.o. q.d. 2. Lisinopril 5 mg p.o. q.d. 3. Digoxin 0.125 mg p.o. q.o.d. 4. Amiodarone 400 mg p.o. b.i.d. 5. Pravastatin 40 mg p.o. q.d. 6. Aspirin 81 mg p.o. q.d. 7. Prevacid 30 mg p.o. q.d. ALLERGIES: Penicillin causes rash. Aldactone causes acute renal failure. SOCIAL HISTORY: The patient is married. He is retired. He is a nonsmoker, nondrinker. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 100.8, heart rate 90 and paced, blood pressure 102/60, respiratory rate 98% on 2 liters, respiratory rate 20. General: The patient is a chronically ill appearing man. He was in no apparent distress. HEENT: The extraocular eye movements were normal. The pupils were equal and reactive to light bilaterally. There was no scleral icterus. The oropharynx was normal. Neck: JVD is at 10 cm. There were no carotid bruits. Lungs: Crackles at the bases bilaterally. No wheezing. Heart: Regular rate and rhythm with systolic murmur loudest at the left lower sternal border. There was a rub at the apex. There was an S3. There was no S4. Abdomen: There was a negative hepatojugular reflux. The liver was nonpulsatile. The abdomen was nontender, nondistended. Extremities: There was no pedal edema. Peripheral pulses were palpable. There was no clubbing. There was ecchymosis over the right shoulder and arm. There was no edema in the left arm. Neurologic: The patient was alert and oriented times three. There was no facial droop. The tongue was midline. Cranial nerves were normal. Strength was [**5-12**] in the upper extremities bilaterally. Strength in the lower extremities was [**5-12**]. The toes were downgoing. LABORATORY DATA: White count 14.5, hematocrit 37, platelets 357,000. INR 2.0. PTT 33. Sodium 136, potassium 4.8, chloride 99, bicarbonate 26, BUN 20, creatinine 0.8, glucose 88. CK 36. Troponin 0.3. Digoxin 0.6. The chest x-ray showed an increased effusion on the right and left side. There was increased retrocardiac infiltrate and mild diffuse interstitial pattern. The [**Month/Day (1) **] leads were in place. The AICD was in place. EKG: There was increased QT interval initiating V tach. The device was unable to pace at a rhythm. Shock delivered. The corrected QT interval was greater than 600 milliseconds. HOSPITAL COURSE: The patient was admitted to the CCU for V tach/torsades de [**Last Name (un) **]. 1. TORSADES: The patient remained hemodynamically stable. The patient was maintained on his lidocaine drip. His magnesium and potassium were repleted aggressively to a goal of magnesium greater than 2.0 and potassium greater than 5.0. His Amiodarone and digoxin were held. The patient was seen by the EP Service and a [**Company 1543**] dual-chamber biventricular ICD was placed. The patient was maintained on telemetry. The patient was maintained on mexiletine. 2. INFECTIOUS DISEASE: It was felt that the patient likely had a pneumonia. His sputum eventually grew out Staphylococcus. The patient was maintained on levofloxacin and vancomycin for this. A repeat chest x-ray done on [**2110-3-3**] showed improving pneumonia. 3. HYPOTENSION: The patient was noted to be hypotensive to the high 90s during the admission. This was felt to be secondary to his cardiomyopathy. One of his Lasix doses was held. The patient was continued on spironolactone and lisinopril. He was encouraged to take p.o. intake. DISPOSITION: The patient was seen by Physiotherapy and it was felt that the patient would benefit from a [**Hospital 3058**] rehab. DISCHARGE DIAGNOSIS: 1. Cardiomyopathy. 2. Ventricular tachycardia/torsades de [**Last Name (un) **], status post biventricular [**Last Name (un) **] and AICD. 3. Superior vena cava thrombosis. 4. Hypotension. 5. Hypercholesterolemia. 6. Decreased acuity of vision in the left eye. DISCHARGE MEDICATIONS: 1. Magnesium oxide 400 mg p.o. b.i.d. 2. Senna two tablets p.o. b.i.d. p.r.n. 3. Vancomycin 1 gram IV q. 12 h. until [**2110-3-9**]. 4. Dulcolax 10 mg p.o./p.r. q.d. p.r.n. 5. Colace 100 mg p.o. b.i.d. 6. Mexiletine 150 mg p.o. q. 12 hours. 7. Spironolactone 25 mg p.o. q.d. 8. Levofloxacin 250 mg p.o. q. 24 hours until [**2110-3-9**]. 9. Lisinopril 5 mg p.o. q.d. 10. Protonix 40 mg p.o. q.d. 11. Pravastatin 40 mg p.o. q.d. 12. Aspirin 81 mg p.o. q.d. DISCHARGE FOLLOW-UP: The patient is being discharged to a rehabilitation facility. He will continue to be followed by his primary cardiologist, Dr. [**Last Name (STitle) 911**]. He will also follow-up in the Device Clinic. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. [**MD Number(1) 1009**] Dictated By:[**Last Name (NamePattern1) 222**] MEDQUIST36 D: [**2110-3-4**] 03:44 T: [**2110-3-4**] 16:55 JOB#: [**Job Number **]

[ "482.41", "458.9", "427.1", "425.4", "E878.1", "996.04", "428.0" ]

icd9cm

[ [ [] ] ]

[ "37.26" ]

icd9pcs

[ [ [] ] ]

5459, 6422

5168, 5436

3904, 5147

1567, 1858

1984, 3886

158, 1178

1200, 1546

1875, 1969

76,459

182,031

49603

Discharge summary

report

Admission Date: [**2197-4-21**] Discharge Date: [**2197-4-24**] Date of Birth: [**2113-9-12**] Sex: F Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamide Antibiotics) / Hydralazine Attending:[**First Name3 (LF) 165**] Chief Complaint: palpitations Major Surgical or Invasive Procedure: none History of Present Illness: Mrs. [**Known lastname 1826**] is [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 664**] 83 yo s/p AVR w/19mm bioprosthesis on [**4-11**] w/Dr. [**Last Name (STitle) 914**]. Her post op course was notable for prolonged junctional rhythm. Electrophysiology was consulted and it was decided that she did not need a pacemaker at that time and weh was discharged to rehab on no nodal blocking agents on [**4-17**]. She has been doing well at rehab, she underwent dialysis today and tonight when she began experiencing palpitations. Upon arrival to the ED her HR was 130s-160s and SBP 120s to 140s. She received 10mg diltiazem which brought her heart rate down to 120s. EKG shows some lateral ST depression thought to be due to rate related changes. Past Medical History: Aortic Stenosis, s/p AVR [**2197-4-11**] readmitted with rapid atrial fibrillation PMH: ESRD secondary to Pauci-immune Crescentric Glomerulonephritis from hydralazine, on HD since [**Month (only) 205**] (Tu, Th, Sa) Paroxysmal AFib/Aflutter in [**8-6**] during acute renal failure, loculated pericardial effusion Steal Syndrome from AV fistula Hypertension Dyslipidemia GERD Gout Age-related Macula Degeneration Social History: -Lives alone, independent in most ADLs, but daughter assists with shopping and some meals -Tobacco: none -Alcohol: none -Illicits: none Family History: -Father: died at 80 of "[**Last Name **] problem" -Mother: died at 89 of "something with her heart" -No history of rheumatologic illness, prostate, breast, ovarian, or colon cancer. Physical Exam: Pulse:140 AF Resp:22 O2 sat:95% on 2 L NC B/P Right: 116/64 Left: Height: Weight: General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [x] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema none Varicosities: None [x] Neuro: Grossly intact [x] Pulses: DP Right:2+ Left:2+ PT [**Name (NI) 167**]:2+ Left:2+ Radial Right:2+ Left:2+ Sternal incision w/mod ecchymosis on superior portion, no drainage or erythema, sternum stable Pertinent Results: [**2197-4-24**] 06:30AM BLOOD WBC-6.1 RBC-3.52* Hgb-10.7* Hct-32.2* MCV-92 MCH-30.4 MCHC-33.2 RDW-17.5* Plt Ct-226 [**2197-4-24**] 06:30AM BLOOD PT-13.8* INR(PT)-1.2* [**2197-4-23**] 03:22AM BLOOD PT-13.7* PTT-43.7* INR(PT)-1.2* [**2197-4-22**] 02:31AM BLOOD PT-13.7* PTT-43.6* INR(PT)-1.2* [**2197-4-21**] 01:50AM BLOOD PT-13.9* PTT-41.9* INR(PT)-1.2* [**2197-4-24**] 06:30AM BLOOD Glucose-100 UreaN-50* Creat-2.7* Na-133 K-4.2 Cl-96 HCO3-26 AnGap-15 Brief Hospital Course: The patient is s/p AVR [**2197-4-11**] with Dr. [**Last Name (STitle) 914**]. She was discharged to rehab. She returned with palpitations and was found to be in rapid atrial fibrillation. Diltiazem brought the rate down in the ED and she was admitted to CVICU. Dr. [**Last Name (STitle) **] consulted on the patient for EP. She was started on Norpace and did convert to sinus rhythm. Anticoagulation was initated with warfarin. Renal consulted for hemodialysis. She was maintained on her usual Tuesday, Thursday, Saturday schedule. The patient was discharged back to rehab with appropriate follow up instructions on hospital day 4. Medications on Admission: acetaminophen 650mg prn colace 100mg [**Hospital1 **] simvastatin 20mg daily asprin 81mg daily protonix 40mg daily albuterol nebs guaifenesin 600mg twice daily norvasc 5mg daily Discharge Medications: 1. warfarin 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): goal INR [**3-2**] for [**Name8 (MD) **], MD to dose daily. 2. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fevre/pain. 6. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 8. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 9. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): **HOLD MID-DAY DOSE FOR HEMODIALYSIS ON TUES/THURS/SAT.**. 10. disopyramide 150 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at [**Doctor Last Name 5749**] [**Doctor Last Name **] Village - [**Location (un) **] Discharge Diagnosis: Aortic Stenosis, s/p AVR [**2197-4-11**] readmitted with rapid atrial fibrillation PMH: ESRD secondary to Pauci-immune Crescentric Glomerulonephritis from hydralazine, on HD since [**Month (only) 205**] (Tu, Th, Sa) Paroxysmal AFib/Aflutter in [**8-6**] during acute renal failure, loculated pericardial effusion Steal Syndrome from AV fistula Hypertension Dyslipidemia GERD Gout Age-related Macula Degeneration Discharge Condition: Alert and oriented x3 nonfocal Ambulating with assistance Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Edema: trace pedal edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: Cardiac Surgery, Provider: [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2197-5-9**] 1:00 in the [**Last Name (un) 2577**] Building [**Last Name (NamePattern1) **] Cardiology, Provider: [**Name10 (NameIs) **] [**Name8 (MD) 10828**], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2197-5-16**] 2:00 [**Hospital Ward Name 516**] [**Hospital Ward Name 23**] Clinical Center [**Location (un) 3971**] Follow-up with Renal for HD on Tues-[**Last Name (un) **]-Sat. Please call to schedule the following: Electrophysiology, Dr. [**Last Name (STitle) **] in 1 month [**Telephone/Fax (1) 62**] Primary Care Dr. [**Last Name (STitle) 20009**],[**First Name3 (LF) 5557**] D. [**Telephone/Fax (1) 9347**] in [**5-2**] weeks Labs: PT/INR Coumadin for a-fib Goal INR [**3-2**] First draw [**2197-4-25**] Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by MD **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:[**2197-4-24**]

[ "403.91", "996.73", "427.31", "530.81", "362.50", "272.4", "274.9", "E942.6", "V42.2", "285.9", "E879.8", "V45.11", "582.89", "585.6" ]

icd9cm

[ [ [] ] ]

[ "38.95", "39.95" ]

icd9pcs

[ [ [] ] ]

4934, 5112

3068, 3710

324, 331

5569, 5753

2591, 3045

6541, 7795

1730, 1913

3939, 4911

5133, 5548

3736, 3916

5777, 6518

1928, 2572

272, 286

359, 1123

1145, 1560

1576, 1714

29,074

169,482

46791

Discharge summary

report

Admission Date: [**2194-3-12**] Discharge Date: [**2194-3-17**] Date of Birth: [**2129-6-13**] Sex: F Service: MEDICINE Allergies: Verapamil Attending:[**Last Name (NamePattern1) 4377**] Chief Complaint: Nausea and emesis Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname 6164**] is a 64 y.o. F with L ilium plasmacytoma of the bone diagnosied in [**10-11**] and multiple myeloma in [**3-13**] when bone marrow showed 40-50% plasma cells, admitted on [**2194-3-12**] for nausea, vomiting, and abdominal cramping. On the night of admission, she received 0.5 mg IV ativan for nausea, and one hour later, she was noted to be somnolent, reacting to voice and pain. Noted to have new rebound tenderness in RUQ and hypoactive bowel sounds, and she was transferred to the [**Hospital Unit Name 153**] for further evaluation. During her ICU course, surgery was consulted and on examination, she had no acute abdomen and did not need any type of surgical evaluation. Her CT Abd/Pelvis showed no bleed around the liver. Her blood pressures remained elevated during her ICU course in 160-170's systolic, which was treated with IV lopressor. She was felt to be stable for management on the BMT floor. . Currently, she feels nauseous, which occurred since day of admission. She has had emesis x 2, greenish in color and little in volume. Her abdomen is a "little sore" from her emesis. Otherwise, she denies any current pain. . Denies HA, vision changes, cough, congestion, rhinorreha, chest pain, SOB, diarrhea, constipation, BRBPR, hematuria, dysuria. Past Medical History: 1. Multiple myeloma - completed C1D8 of velcade/dex on [**2193-11-25**] - In [**9-10**] she was referred to orthopedics and underwent an MRI which revealed a large mass in the left iliac [**Doctor First Name 362**] that was destroying the cortical bone. A biopsy done in [**10-11**] revealed this to be a large plasmacytoma. CT torso did not reveal any other lesions anywhere else. The pt received radiation to the plasmacytoma in [**11-10**]. More recently she developed a symptomatic lytic lesion on her left fibula and received radiation to that (2/[**Date range (3) 99311**]). Her bone marrow aspirate and biopsy done on [**2193-4-3**] showed extensive involvement with plasma cells. By immunohistochemistry, CD138 positive plasma cells occupied, on average, 40-50% of marrow cellularity. Kappa and lambda staining showed monoclonality for kappa light chain. Cytogenetics revealed 46XX karyotype but FISH showed borderline abnormality for the D13S319 probe (6% monosomy 13). She was enrolled on the dendritic vaccine study (protocol # 04-098) on [**2193-4-26**] and started pulse dose Decadron therapy on [**2193-5-6**] and Thalidomide on [**2193-6-28**]. Her left fibula needed XRT again in late [**8-11**] at a different spot due to a new painful lytic lesion. Also with anterior gum resection of plasmacytoma. 2. left ilium plasmacytoma - tx with XRT [**2192**], XRT to left fibula [**4-/2193**] 3. HTN 4. s/p TAH BSO [**2179**] for leiomyomas, menorrhagia. 5. hepatic hemangiomas first diagnosed in [**2181**]. 6. Migraines 7. Mitral regurgitation 8. Granular cell tumor s/p excision [**2180**]. 9. Hepatic segment V resection, cholecystectomy [**2194-1-10**] . ONCOLOGIC HISTORY: - [**11-10**]: Radiation to left ilium plasmacytoma - 2/[**Date range (3) 99311**]: Radiation to left fibula painful lytic lesion - [**2193-4-30**]: Enrolled on the dendritic vaccine study (protocol # 04-098) - [**2193-5-6**]: started pulse dose Decadron therapy - [**2193-6-28**]: Started Thalidomide + Decadron - [**8-11**]: Radiation to a new painful left fibula lytic lesion - [**11-11**]: Velcade started along with Thal/Dex - [**2193-11-27**]: Thal/Coumadin stopped due to probabe liver hemangioma subcapsular bleed; Vel/Dex continued - [**2194-1-10**]: Resection of liver cavernous hemangioma - [**2194-1-29**]: Left femur gamma nail placement Social History: Patient lives in [**Hospital1 1474**] with youngest daughter and two grandchildren. Patient works as computer instructor at [**Company 3596**] in downtown [**Location (un) 86**]. Patient denies tobacco, EtOH, illicit drug use. Family History: - Prostate cancer in her uncle. - Father passed away from heart disease. Physical Exam: **Exam upon return from [**Hospital Unit Name 153**]** Vitals - T: 100.1 BP: 160/92 HR: 97 RR: 20 02sat: 98% room air GENERAL: pleasant, overweight female sitting in bed, conversant and appropriate SKIN: no rashes HEENT: MMM, OP clear, no erythema or exudate CARDIAC: RRR, nl S1, S2, no r/g, 2/6 sem at LUSB LUNG: CTAB, no w/r/r ABDOMEN: soft, NABS, NDNT, no rebound tenderness, no guarding EXT: no c/c/e Pertinent Results: [**3-13**] CT abdomen/pelvis IMPRESSION: 1. Limited examination secondary to lack of intravenous or oral contrast administration. No large intra-abdominal collections. Possible antral gastric thickening which could be compatible with gastritis. Numerous foci of air present within the bladder are likely related to introduction of Foley balloon. However, cystitis cannot be excluded. 2. Stable appearance of large segment VIII hemangioma. 3. Multiple lytic lesions consistent with patient's history of multiple myeloma, grossly stable in appearance compared to [**2194-1-16**]. New interval left femoral head fixation [**3-13**] CT Head 1. No evidence of intracranial hemorrhage. 2. New extensive innumerable punctate lytic lesions throughout the calvarium and skull base. Findings consistent with progression of multiple myeloma. 3. Expansile soft tissue lesion extending from the sphenoid bone into the sphenoid sinuses. Findings are also consistent with progression of multiple myeloma. For more detailed evaluation of this skull base expansile lesion gadolinium-enhanced MRI could provide better characterization. CXR [**3-14**] IMPRESSION: No pneumonia or acute cardiopulmonary process. Compression wedge deformity with possible lucent lesions in mid thoracic vertebral bodies, consistent with known h/o multiple myeloma, similar to the CT scan from [**2194-2-4**]. CT abdomen/pelvis [**3-15**] WITH ORAL CONTRAST IMPRESSION: 1. Mild nonspecific thickening of the gastric folds and proximal duodenum. This may represent infectious or inflammatory gastroenteritis. No bowel obstruction or appendicitis. 2. Stable large right hepatic lobe lesion most likely representing a hemangioma. 3. Stable right renal angiomyolipoma. 4. Small amount of free fluid in the pelvis. 5. Multiple lytic osseous lesions involving several vertebral bodies and the pelvis. The largest of these occupies a majority of the left iliac bone and appears without change. Findings are in keeping with a history of myeloma. ---------------- MRI HEAD (PRELIM READ) [**3-15**] FINDINGS: As seen on the CT, there is an expansile lesion identified at the skull base involving the basisphenoid extending and protruding into the sphenoid sinus. The mass is hypointense both on T1- and T2-weighted images with minimal marginal enhancement. The findings are consistent with the diagnosis of a focal myeloma deposit. Several foci of signal abnormality with enhancement are seen in the skull consistent with multiple myeloma. Multiple periventricular and subcortical hyperintensities are seen due to small vessel disease. There is no abnormal parenchymal, vascular or meningeal enhancement identified. IMPRESSION: Skull base lesion consistent with myeloma which involves the basisphenoid and protrudes into the sphenoid sinus. Multiple lytic lesions in the skull are suggestive of multiple myeloma. No acute infarct seen. No parenchymal enhancement identified. ------------------ EEG Study Date of [**2194-3-16**] OBJECT: RULE OUT SEIZURES. FINDINGS: ABNORMALITY #1: There were several bursts of focal mixed frequency slowing seen independently in the left and right temporal regions. BACKGROUND: Included a well-formed 10 Hz alpha frequency in posterior areas bilaterally during wakefulness. HYPERVENTILATION: Could not be performed. INTERMITTENT PHOTIC STIMULATION: Could not be performed. SLEEP: The patient appeared to remain awake or minimally drowsy throughout the record. No stage II sleep was obtained. CARDIAC MONITOR: Showed a generally regular rhythm. IMPRESSION: Abnormal EEG in the waking and drowsy states due to the bilateral and independent areas of focal mixed frequency slowing. These suggest bilateral subcortical dysfunction. The tracing cannot specify the etiology, but vascular disease is a relatively common cause of such findings. Nevertheless, there were no areas of fixed or more prominent focal slowing, and there were no epileptiform features. ------------------- LABS COMPLETE BLOOD COUNT WBC Hct MCV Plt Ct [**2194-3-17**] 07:20AM 5.5 * 34.5* 87 265 [**2194-3-16**] 06:15AM 9.4 35.2* 87 220 [**2194-3-15**] 06:00AM 17.9* 35.6* 88 201 [**2194-3-14**] 06:00AM 13.1* 33.0* 86 164 [**2194-3-13**] 03:09PM 32.2* [**2194-3-13**] 04:51AM 12.8*# 34.3* 89 172 [**2194-3-12**] 08:31PM 7.6 3 34.5* 89 176 [**2194-3-12**] 02:20PM 6.9 39.0 92 179 [**2194-3-12**] 08:31PM PLT COUNT-176 RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2194-3-17**] 07:20AM 95 4* 0.5 139 3.4 101 30 11 [**2194-3-16**] 06:15AM 121* 3* 0.6 136 3.71 102 23 15 [**2194-3-15**] 06:00AM 128* 5* 0.5 137 2.9*1 103 25 12 [**2194-3-14**] 06:00AM 95 10 0.4 145 3.3 111* 23 14 [**2194-3-13**] 03:09PM 122* 10 0.5 142 3.2* 110* 21* 14 [**2194-3-13**] 04:51AM 122* 9 0.6 144 2.9*1 109* 25 13 [**2194-3-12**] 08:31PM 125* 9 0.5 143 3.1* 107 28 11 [**2194-3-12**] 02:20PM 112* 11 0.5 146* 3.4 106 30 13 . [**2194-3-12**] 02:20PM ALT(SGPT)-18 AST(SGOT)-24 LD(LDH)-295* ALK PHOS-108 TOT BILI-1.0 [**2194-3-15**] Lipase 20 [**2194-3-17**] 07:20AM ALT 27 AST 15 LDH 218 ALK PHOS 92 TOT BILI 0.9 [**2194-3-12**] 08:31PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2194-3-16**] 06:15AM HEPATITIS HBsAg NEGATIVE HBsAb NEGATIVE HBcAb NEGATIVE HAV Ab NEGATIVE HEPATITIS C Ab NEGATIVE . [**2194-3-15**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL negative [**2194-3-15**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2194-3-15**] URINE URINE CULTURE-FINAL negative [**2194-3-13**] URINE URINE CULTURE-FINAL negative [**2194-3-12**] BLOOD CULTURE Blood Culture, Routine-negative [**2194-3-12**] BLOOD CULTURE Blood Culture, Routine-negative Brief Hospital Course: 64 y.o. F with L ilium plasmacytoma of the bone diagnosed in [**10-11**] and multiple myeloma in [**3-13**] when bone marrow showed 40-50% plasma cells, who was admitted for nausea, vomiting, and abdominal cramping, transferred briefly on night of admission to the MICU for altered mental status. . # Altered mental status On the night of admission the patient received 0.5 mg IV ativan for nausea, and one hour later, she was noted to be somnolent, but reacting to voice and pain. Noted to have new rebound tenderness in RUQ and hypoactive bowel sounds, and she was transferred to the [**Hospital Unit Name 153**] for further evaluation. ABG was within normal limits and mental status returned to baseline shortly thereafter. AMS was thought most likely secondary to medications (compazine and ativan given within close proximity). However, other etiologies such as seizure, infection (given increased WBC and low grade fever) and myeloma (patient underwent MRI Head which showed sphenoid sinus lesion consistent with myeloma) were entertained. Neurology was consulted, and found no focal neurological findings. An EEG performed on [**3-16**] was abnormal but did not show epileptiform activity. Though one blood culture was still pending at the time of this dictation, no cultures were positive and infection was thought a less likely etiology. At time of discharge her neurological and mental status exam were normal, at baseline. She was advised to schedule a follow up appointment with neurology within 2 weeks. . # Abdominal cramping, Nausea, Vomiting The patient developed rebound tenderness in the setting of altered mental status. CT abdomen showed no acute intrabdominal process, surgery evaluated and agreed. Patient had a repeat scan 2 days later in the setting of low grade fever, leukocytosis and mild RLQ tenderness. CT showed likely enteritis involving gastric and duodenal mucosa. She was started on Zosyn empirically with c. diff pending. Patient initially had loose stools at home but has had none since admission. Also considered in the differential was opiate withdrawal since she had been taking oxycodone Q4H for a prolonged period of time. Given that she had only taken 4 oxycodone tablets in the last 6 days PTA this is much less likely, symptoms typically present and peak within 24-48 hours. Most likely this was a viral gastroenteritis. As of [**3-15**] patient's nausea was much improved and she was advanced from clears to full liquids to regular diet at time of discharge. One blood culture was still pending at the time of discharge and this should be followed. . # Hypertension SBPs were elevated to 190s. She required IV hydralazine in the ICU to maintain her BPs less than 170. Patient had not taken her medications on the day of admission. Upon transfer to the floor her oral medications were restarted (lisinopril, amlodipine, HCTZ), she was placed on a low sodium diet, fluids were stopped, and she was weaned off IV hydralazine. Her blood pressure lowered gradually into systolic 150s, and were trending down on discharge. CT and MRI showed no evidence of bleed or acute infarct. . # Multiple Myeloma MRI head with expansile lesion at skull base/sphenoid sinus consistent with myeloma. Her primary oncologists plan to discuss the possibility of radiating the lesion with the radiation oncologists and this will be discussed at her follow up hem/onc appointment on [**2194-3-21**]. Medications on Admission: Amlodipine 10 mg po daily HCTZ 25 mg po daily Lisinopril 40 mg po daily Oxycodone 5-10 mg po q5 hours prn pain Compazine 10 mg po q8 hours prn nausea Ambien 5 mg po qhs prn insomnia Acetaminophen 650 mg po q6 hours prn fever Biotin 1 mg po daily Dulcolax 10 mg po daily prn constipation Vitamin B12 500 mcg po daily Colace 100 mg po BID Hexavitamin 1 tablet po daily Vitamin B6 1 tablet po daily Senna Discharge Medications: 1. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 5. Compazine 10 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. 6. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 7. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for fever or pain. 8. Biotin 1 mg Tablet Sig: One (1) Tablet PO once a day. 9. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: [**2-5**] Tablet, Delayed Release (E.C.)s PO once a day as needed for constipation. 10. Vitamin B-12 500 mcg Tablet Sig: One (1) Tablet PO once a day. 11. Hexavitamin Tablet Sig: One (1) Tablet PO once a day. 12. Vitamin B-6 Oral 13. Outpatient Physical Therapy Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: Gastroenteritis Hypertension Multiple myeloma Discharge Condition: Stable Discharge Instructions: You were admitted with gastroenteritis. Your symptoms eventually resolved. You had a brief decrease in consciousness while you were here which was likely due to some nausea medications you received. You had an MRI of the head which showed a lesion consistent with myeloma, the radiation oncologists will evaluate whether you might benefit from radiating this lesion. Please discuss this further with your oncologist at your follow up appointment. You were also evaluated by neurology who performed an EEG which showed no evidency of seizure activity. However, they did recommend following up with them within 2 weeks. Please call them at ([**Telephone/Fax (1) 5563**] to make an appointment as soon as possible. Please return to the ER if you develop any fever, chills, nausea, vomiting or ANY worrisome symptoms. Please take your medications as prescribed and go to all follow up appointments. Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2194-3-21**] 2:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1984**], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2194-3-20**] 1:00 Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2194-3-20**] 12:40 . Please call Dr. [**Last Name (STitle) 2442**] or Dr. [**Last Name (STitle) 851**] (Neurology) at ([**Telephone/Fax (1) 5563**] to make a follow up appointment within 2 weeks. Completed by:[**2194-3-19**]

[ "276.50", "E939.4", "780.09", "401.9", "E939.1", "008.8", "203.00", "228.04", "203.80", "424.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

15385, 15440

10524, 13951

296, 302

15530, 15539

4772, 10501

16484, 17101

4256, 4330

14404, 15362

15461, 15509

13977, 14381

15563, 16461

4345, 4753

239, 258

330, 1629

1651, 3995

4011, 4240

54,695

113,991

42390

Discharge summary

report

Admission Date: [**2105-1-18**] Discharge Date: [**2105-1-26**] Date of Birth: [**2064-4-15**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 922**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [**2105-1-20**]: 1. Bentall procedure with a 27-mm On-X composite valve graft with coronary button reimplantation. The On-X data is reference #[**Serial Number 91787**], serial number [**Serial Number 91788**]. 2. Pericardial reconstruction using the CorMatrix product. Reference CMCV-0003-402, lot #[**Serial Number 91789**]. History of Present Illness: Six months to one year of increasing SOB and chest pain when lying supine. No PCP. [**Name10 (NameIs) **] to [**Hospital6 **] on [**2105-1-17**] with hemoptysis and hypertension. CT chest and ABD w/ and w/o contrast done revealed a ascending aortic aneurysm measuring 6.6 cm which does not extending beyond the level of the asc aorta. There is a segmental dissection falp in the posterior aorta. A bicuspid valve was also noted. Cardiac surgery was consulted for surgical correction. Past Medical History: Hypertension Anxiety IBS Social History: Lives with:parents who are in their 80's Occupation:owns a recording studio Cigarettes: Smoked no [x] yes [] last cigarette _____ Hx: Other Tobacco use:marijuana [**12-22**] cigarettes/day ETOH: < 1 drink/week [] [**1-27**] drinks/week [x] [**6-2**] pack of beer per day] >8 drinks/week [] Family History: father w/ AAA repair 7 years ago, brother w/bicuspid aortic valve Physical Exam: Pulse:85 Resp: 18 O2 sat:97%RA B/P Right: 128/56 Left: Height: 5' 8" Weight:85.9kg General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur [x] grade V/VI over rigth sternal border Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + x Extremities: Warm [x], well-perfused [x] Edema:none Varicosities: None [x] Neuro: Grossly intact [x] 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: radiating Left:none Pertinent Results: [**2105-1-19**] Cardiac Cath 1. Selective coronary angiography of this right-dominant system demonstrated no angiographically apparent flow-limiting coronary disease. The LMCA, LAD, and LCx had no obstructive disease. The RCA was not selectively engaged, however aortogram demonstrated no angiographically apparent flow-limiting disease. 2. Limited resting hemodynamics revealed a wide pulse pressure with an SBP of 125mmHg and a DBP of 51mmHg. 3. Aortogram demonstrated a dilated aortic root and significant aortic regurgitation. [**2105-1-20**] ECHO Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. A tiny patent foramen ovale is present. Overall left ventricular systolic function is mildly depressed (LVEF= 40 - 45 %). Right ventricular chamber size and free wall motion are normal. The ascending aorta is severely dilated. A mobile density is seen in the ascending aorta consistent with an intimal flap/aortic dissection. Severe (4+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is a small pericardial effusion. Post-CPB: The patient is AV-Paced, on an infusion of epinephrine. There is a prosthetic aortic valve in place with no leak and no AI. Residual mean gradient = 5 mmHg. Trace MR, no TR. RV systolic fxn is preserved. The inferior wall of the LV is akinetic. Overall systolic fxn is reduced mildly further from pre-bypass. There is a tube graft replacing the ascending aorta. The descending aorta is intact. [**2105-1-26**] 05:00AM BLOOD WBC-3.6* RBC-3.05* Hgb-9.6* Hct-29.0* MCV-95 MCH-31.4 MCHC-33.0 RDW-13.4 Plt Ct-301 [**2105-1-18**] 05:17PM BLOOD WBC-5.2 RBC-4.03* Hgb-12.8* Hct-37.1* MCV-92 MCH-31.7 MCHC-34.4 RDW-13.5 Plt Ct-160 [**2105-1-26**] 05:00AM BLOOD PT-28.1* INR(PT)-2.7* [**2105-1-18**] 05:17PM BLOOD PT-14.4* PTT-33.3 INR(PT)-1.3* [**2105-1-26**] 05:00AM BLOOD Glucose-95 UreaN-12 Creat-1.0 Na-139 K-4.3 Cl-101 HCO3-29 AnGap-13 [**2105-1-18**] 05:17PM BLOOD Glucose-134* UreaN-14 Creat-1.1 Na-139 K-3.7 Cl-103 HCO3-28 AnGap-12 Brief Hospital Course: Mr. [**Known lastname 91790**] was admitted to the [**Hospital1 18**] on [**2105-1-18**] for further management of his bicuspid aortic valve insufficiency and aortic aneurysm. He was worked-up in the usual preoperative manner. A cardiac catheterization was performed which revealed no significant coronary artery disease. A dental consult was obtained and he was cleared for surgery after having panorex films of his teeth. On [**2105-1-20**], Mr. [**Known lastname 91790**] was taken to the operating room where he underwent a bentall procedure using a 27mm On-X mechanical valve. CARDIOPULMONARY BYPASS TIME:165 minutes.CROSS-CLAMP TIME: 133 minutes.CIRCULATORY ARREST TIME: 17 minutes. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. Over the next several hours he awoke neurologically intact and was extubated. On postoperative day one, he was transferred to the step down unit for further recovery. Coumadin and heparin were started for anticoagulation for his mechanical on-x valve. He was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. The remainder of his hospital course was essentially uneventful. By post-operative day #6 his INR was therapeutic and he was ready for discharge to home. All follow-up appointments were advised. Medications on Admission: Coreg 12.5mg [**Hospital1 **], lisinopril 5mg daily, ASA 81mg, lasix 40mg daily, protonix 40 daily Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 4. 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 DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 weeks. Disp:*7 Tablet(s)* Refills:*0* 8. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO DAILY (Daily) for 1 weeks. Disp:*14 Tablet Extended Release(s)* Refills:*0* 9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day for 1 months. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 10. Coumadin 2.5 mg Tablet Sig: as directed Tablet PO once a day. Disp:*90 Tablet(s)* Refills:*2* 11. Coreg 3.125 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 12. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses. Disp:*1 Tablet(s)* Refills:*0* Discharge Disposition: Home with Service Discharge Diagnosis: uncontrolled hypertension IBS anxiety Ascending aortic aneurysm with bicuspid aortic valve insufficiency Subacute aortic dissection involving the ascending aorta and aortic root only Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Left Groin - healing well, no erythema or drainage. Edema 1+ 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 provided. 4) No driving for approximately one month and while taking narcotics. Driving will be discussed at follow up appointment with surgeon when you will likely be cleared to drive. 5) No lifting more than 10 pounds for 10 weeks 6) Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) 914**] at [**2105-2-23**] at 1:45pm [**Hospital Ward Name **] [**Location (un) **], [**Hospital Unit Name **] Wound check [**2105-1-29**] at 10:15am [**Hospital Ward Name **] [**Location (un) **], [**Hospital Unit Name **] Cardiologist: Please seek a cardiologist via your primary care physician and make an appointment as soon as possible. Please call to schedule appointments with your Primary Care Dr.[**Last Name (STitle) 50167**] ([**Telephone/Fax (1) 91791**] on [**2105-1-26**] 1:45PM [**Last Name (un) **]. [**Hospital1 487**], [**Numeric Identifier 39146**] **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 valve Goal INR [**1-23**] First draw [**2105-1-26**] Results to phone fax ([**Telephone/Fax (1) 91792**] [**First Name9 (NamePattern2) 5035**] [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] confirmed with [**Doctor First Name **] on [**2105-1-23**] Completed by:[**2105-1-26**]

[ "746.4", "401.9", "285.9", "564.1", "441.01", "V58.61", "V70.7", "300.00", "428.0", "423.0" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.22", "88.56", "88.42", "37.49", "38.45" ]

icd9pcs

[ [ [] ] ]

7424, 7443

4377, 5787

297, 627

7670, 7896

2282, 4354

8785, 9963

1513, 1580

5937, 7401

7464, 7649

5813, 5914

7920, 8762

1595, 2263

238, 259

655, 1140

1162, 1188

1204, 1497

13,437

175,252

42751

Discharge summary

report

Admission Date: [**2175-9-9**] Discharge Date: [**2175-9-13**] Service: ID/CHIEF COMPLAINT: This is a 73 year old female with a history of supraventricular tachycardia and coronary vasal spasm and previous myocardial infarction. PAST MEDICAL HISTORY: 1. Coronary vasospasm - The patient has had a previous admission in [**2166**] and [**2170**] with precipitation by stress. In the past she has had two previous myocardial infarctions and a previous coronary catheterization showing normal coronary arteries without blockages. Echocardiogram in [**2171-8-26**] showing anterior, septal, apical, inferoposterior hypokinesis with normal right ventricular function and an ejection fraction that was moderately depressed. 2. Hypertension 3. Myotonic dystrophy 4. Appendectomy 5. Deep vein thrombosis 6. Bilateral cataract surgery ADMISSION MEDICATIONS: 1. Diltiazem 2. Metoprolol 3. Vasotec 4. Serax ALLERGIES: Ativan causes agitation HISTORY OF PRESENT ILLNESS: The patient presented to [**Location (un) 745**] [**Hospital 18896**] Hospital with shortness of breath with walking. The patient was out walking with her husband and lost site of her husband and became anxious. At presentation at [**First Name5 (NamePattern1) 745**] [**Last Name (NamePattern1) 18896**] the patient's electrocardiogram showed ST elevation and Q waves inferiorly and anteriorly. The patient was lysed with TNK. Subsequently the patient had issues with hypotension and respiratory distress and was intubated. She was started on Dopamine infusion. Cardiac enzymes done at [**First Name5 (NamePattern1) 745**] [**Last Name (NamePattern1) 18896**] showed a CK of 244 and a troponin of 30. The patient continued to have ST elevations anterolaterally and was transferred to [**Hospital6 256**]. The patient was taken to the Cardiac Catheterization Laboratory which demonstrated normal coronary arteries. It was noted that the patient had sluggish flow through her coronary arteries and her TIMI fren count improved with intracoronary Diltiazem infusions. SOCIAL HISTORY: The patient drinks one drink per day and is a nonsmoker. She lives with her husband in an apartment. FAMILY HISTORY: The patient's father died of diabetes in his 70s and her mother died of a pulmonary embolism at the age of 58. Her mother also had a history of myotonic dystrophy. PHYSICAL EXAMINATION: On presentation to the Coronary Care Unit the patient was afebrile and was hemodynamically stable. General examination showed an older white female in no apparent distress. She appeared her stated age. Head and neck examination, the patient was intubated with no lymphadenopathy, tracheal deviation. Her pupils were equal and reactive to light. Neurologically the patient was awake, alert, responding to commands and moving all limbs. Respiratory examination was significant for some bilateral inspiratory crackles diffusely. Cardiovascular examination showed no jugular venous distention. She had normal heartsounds with no extra heartsounds and no murmurs. She did not have any peripheral edema. Abdominal examination was unremarkable. HOSPITAL COURSE: The patient was extubated the day following admission. She had cardiac enzymes done which trended downward during her admission. Her CK and MB trends were 352/23 to 315/16 to 149/6 to 114/7. The patient had another further episode of shortness of breath during her hospital stay which was related to anxiety upon hearing that her temperature was 100.6. She was noted to be in sinus tachycardia at 140 and her shortness of breath subsequently resolved following diltiazem bolus intravenously and p.o. Serax. Psychiatry Service was also consulted to provide input regarding the patient's anxiety management. It was recommended at that time that the patient start Paxil and continue with Klonopin for a week to two weeks post discharge to provide coverage while the Paxil was being loaded. The patient was discharged home on [**2175-9-13**] in stable condition. DISCHARGE MEDICATIONS: 1. Serax 15 mg p.o. q.h.s. 2. Colace 100 mg p.o. b.i.d. 3. Cardizem CD 120 mg p.o. q.d. 4. Amlodipine 5 mg p.o. q.d. 5. Enteric coated aspirin 325 mg p.o. q.d. 6. Paxil 10 mg p.o. q.h.s. 7. Metoprolol 25 mg p.o. b.i.d. 8. Sublingual nitroglycerin prn CONDITION ON DISCHARGE: The patient was discharged home in stable conditions. DISCHARGE INSTRUCTIONS: Follow up with primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] later this week or early next week. [**Name6 (MD) 9272**] [**Name8 (MD) 9273**], M.D. [**MD Number(1) 9274**] Dictated By:[**Name8 (MD) 26201**] MEDQUIST36 D: [**2175-9-14**] 14:26 T: [**2175-9-14**] 15:27 JOB#: [**Job Number 92375**] cc:[**2175**]

[ "300.00", "412", "359.2", "401.9", "V12.51", "V45.61", "410.41", "428.0" ]

icd9cm

[ [ [] ] ]

[ "96.71", "88.56", "37.22" ]

icd9pcs

[ [ [] ] ]

2203, 2369

4047, 4307

3157, 4024

4412, 4839

872, 961

2392, 3139

104, 242

990, 2066

264, 849

2083, 2186

4332, 4387

55,920

133,525

52864+59471

Discharge summary

report+addendum

Admission Date: [**2182-4-23**] Discharge Date: [**2182-5-8**] Date of Birth: [**2121-3-14**] Sex: M Service: MEDICINE Allergies: Vancomycin Analogues / Histamine / Ciprofloxacin / Penicillins / Cephalosporins / Aspirin Attending:[**First Name3 (LF) 2736**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: 61yoM with non-ischemic dilated cardiomyopathy, known CAD involving the LAD, CHF (EF 30-35%), afib on Coumadin presenting for chest pain and dyspnea. Of note, he was recently admitted for Chest Pain and afib with RVR. He reports that the chest pain has been chronic and persistent since his recent discharge. He has noted worsening shortness of breath since discharge, particularily over the past 3 days. He endorses mild leg swelling, DOE, orthopnea and pnd. He denies increased salt intake and notes that he has largely stayed in bed since leaving the hospital. no sick contacts, no recent uri sx, no diarrhea/abd pain. He presented to the ED where he was found to be in Afib with RVR (HR 145). He was treated with IV metoprolol 5 mg x 2, morphine, aspirin, and nitroglycerin. CXR was obtained and was negative. WBC 11.0 and Lactate 2.3. CE's showed Trop 0.13, slightly up from last Trop during prior recent hospital admission. EKG was obtained. He was given nitropaste which decreased his blood pressure preventing further rate control. The patient was admitted to cardiology for rate control. . Currently, he is in NAD but continues to have chest pain and requests pain meds. He would like a solution to prevent repetitive admission.s . On review of systems, + as in HPI. All of the other review of systems were negative. 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: Dilated cardiomyopathy non-ischemic. CHF (EF 30-35%) PFO . CVA in [**2175**]--L sided facial droop Osteoarthritis. Depression. History of Hodgkin's disease s/o surgical removal at age 18 followed by chemotherapy. . PAST SURGICAL HISTORY: 1. Appendectomy. 2. Hernia repair. 3. Back surgery after falling from 36 feet. 4. Multiple operations on his left knee and his right knee. 5. Multiple abdominal surgeries, first to remove small bowel polyps and then followed by surgeries to fix complications of previous surgeries. 6. Lymph node removal from the groin that was infected Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. He lives with his sister and her family that includes a spouse, grown children and grandchildren. States there is always someone home. Sister recently had knee surgery, is now mobile again. Family History: Father had 1st heart attack at 35 then died of MI at 45. Mom with DM2, died of AAA rupture. Physical Exam: Gen: awake, alert, slightly uncomfortable appearing but NAD HEENT: sclera anicteric, MMM, OP clear CV: irregularly irregular, no r/m/g appreciated Lungs: faint bibasilar crackles, no wheezes, crackles, or rhonchi Abd: bowel sounds present, soft, non-tender, non-distended Ext: warm, well-perfused, DPs/PTs palpable, 1+ pedal edema Pertinent Results: On admission: [**2182-4-23**] 08:10PM CK(CPK)-167 [**2182-4-23**] 08:10PM CK-MB-22* MB INDX-13.2* cTropnT-0.15* [**2182-4-23**] 12:02PM LACTATE-2.3* [**2182-4-23**] 11:45AM GLUCOSE-131* UREA N-44* CREAT-1.8* SODIUM-139 POTASSIUM-3.6 CHLORIDE-104 TOTAL CO2-24 ANION GAP-15 [**2182-4-23**] 11:45AM estGFR-Using this [**2182-4-23**] 11:45AM cTropnT-0.13* [**2182-4-23**] 11:45AM proBNP-8480* [**2182-4-23**] 11:45AM D-DIMER-1346* [**2182-4-23**] 11:45AM WBC-11.0 RBC-4.95 HGB-14.4 HCT-43.7 MCV-88 MCH-29.2 MCHC-33.1 RDW-19.1* [**2182-4-23**] 11:45AM NEUTS-71.8* LYMPHS-20.3 MONOS-4.1 EOS-3.1 BASOS-0.6 [**2182-4-23**] 11:45AM PLT COUNT-204# [**2182-4-23**] 11:45AM PT-26.2* PTT-30.0 INR(PT)-2.5* Creatinine [**2182-4-24**] 07:40AM BLOOD Creat-2.5* [**2182-4-25**] 06:30AM BLOOD Creat-3.0* [**2182-4-26**] 04:16AM BLOOD Creat-2.6* [**2182-4-27**] 02:55PM BLOOD Creat-2.8* [**2182-4-28**] 09:51PM BLOOD Creat-2.7* [**2182-4-30**] 03:37AM BLOOD Creat-2.2* [**2182-5-5**] 07:30AM BLOOD Creat-2.3* MICROBIOLOGY: C. diff negative IMAGING: TEE: The left atrium is moderately dilated. Mild spontaneous echo contrast is seen in the body of the left atrium. The left atrial appendage emptying velocity is depressed (<0.2m/s). No thrombus is seen in the left atrial appendage. No spontaneous echo contrast or thrombus is seen in the body of the right atrium or the right atrial appendage. There is a patent foramen ovale with respirophasic flow across the interatrial septum visible at rest on color flow doppler. Overall left ventricular systolic function is moderately depressed. There are simple atheroma in the descending thoracic aorta down to 35cm from incisors. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. Tricuspid valve is normal with mild tricuspid regurgitation. Pulmonic valve is normal. No pulmonic regurgitation. There is no pericardial effusion. IMPRESSION: No LA/LAA/RA/RAA thrombus. Mild spontaneous echo contrast in the LA. Stretched patent foramen ovale visible at rest. Moderately depressed left ventricular systolic function. Moderate mitral regurgitation. Mild tricuspid regurgitation. Compared with the prior transesophageal study (images reviewed) of [**2182-3-29**], there is no LAA thrombus seen on the present study and only mild spontaneous echo contrast in the LA. Right heart catheterization: COMMENTS: 1. Limited resting hemodynamics revealed moderate pulmonary artery hypertension with maximal PASP of 49mmHg when at baseline and PVR of 4.4 [**Doctor Last Name **]. With the addition of 100% FiO2, there was a slight fall in mean PA pressure with a PASP of 51mmHg and PVR of 2.3 [**Doctor Last Name **]. With the addition of inhaled iNO, there was a slight further fall in both PA pressure with a mean PASP of 41mmHg and PVR of 2.1 [**Doctor Last Name **]. There was a modest improvement in CI with the addtion of 100% FiO2 and iNO from baseline; 2.32 L/min/m2 at baseline, 3.03 L/min/m2 with 100% Fi02 and 3.09L/min/m2 with iNO. FINAL DIAGNOSIS: 1. Moderate pulmonary artery hypertension. 2. No non-invasive oxymetric evidence of right-to-left shunting under the current loading conditions (arterial puncture not attempted given INR of 2.8). 3. Mildly elevated PCW consisted with mild LV diastolic heart failure. 4. Slight improvement in PA pressures with 100% O2, with reduction in PVR driven in part by rise in PCW. With the addition of iNO, slight further improvement in PA pressures with slight further reduction in PVR (using assumed unchanged VO2 throughout). Brief Hospital Course: 61 year old male with history of CAD, non-ischemic cardiomyopathy, DM2, hypertension, and AF, presenting initially with CP and SOB, then developed cardiogenic [**Doctor Last Name **], leading to acute kidney injury and progressive volume overload, admitted to the ICU for milrinone and Lasix gtt??????s with improvement. Hospital course significant for failed electrical cardioversion for AF and detection of shunt from PFO and pulmonary hypertension with mild reversibility, started on sildenafil. . #. PUMP / cardiogenic [**Doctor Last Name **] with sCHF and RV dysfunction with pulm HTN: Initial exam on transfer to CCU significant for findings of volume overload (elevated JVD, lower extremity edema) as well as cool extremities. He was admitted to the CCU in cardiogenic [**Doctor Last Name **] and a PA catheter was placed to tailor therapy. His cardiac index was quite low with elevated PA pressures. TEE and TTE showed RV dysfunction as well as severe systolic failure and right-to-left shunting through a PFO. With concern for increased right-sided pressures with a normal PCWP, it was thought that all of this preload was going into his venous capacitance rather than his left atrium/ventricle. Right heart catheterization was done showing minimal R to L shunting (as seen on TEE), but moderate reversibility of pulmonary hypertension with vasodilator therapy. Throughout these studies, he was continued on a milrinone drip, titrated up to 0.66mcg/kg/min, as well as a furosemide gtt, titrated up to 20mg/hr, which helped to unload his left ventricle and provide improved effective circulating volume through diuresis and decreased afterload. He was started on sildenafil for pulmonary hypertension with good effect. His milrinone and furosemide drips were slowly weaned off and he was transferred to the general cardiology floor. He will follow-up with Dr. [**First Name (STitle) 437**] as an outpatient for further management. #. RHYTHM / Atrial fibrillation and atrial flutter: Patient was admitted to the ICU in Afib with RVR. It was felt that this was a major contributor to the development of cardiogenic [**Last Name (LF) **], [**First Name3 (LF) **] a TEE/DCCV was done. He did convert to normal sinus rhythm, but converted back to Afib about 24 hours later. He was never hemodynamically unstable, but was rate controlled briefly with digoxin, then this was discontinued in favor of B-blockade. He was kept on amiodarone gtt for loading and switched over PO dosing (400mg [**Hospital1 **]) for rhythm control. For anticoagulation, his INR was maintained between [**2-7**] on warfarin. However, her INR did drop below 2 and requiring increasing doses of warfarin to bring him back to the therapeutic range. Because of this, he will follow up with Dr. [**Last Name (STitle) 73**] as an outpatient for consideration of repeat electrical cardioversion once his INR is therapeutic for 3-4 weeks. He will continue on amiodarone at maintenance dosing upon discharge. #. Acute kidney injury: Baseline Cr 1.3-1.4. His poor cardiac output, secondary to both a depressed EF and AF with RVR that was difficult to control, was likely contributing to poor renal perfusion and low sensed volume, explaining worsening renal failure and decreased urine output. He responded well to furosemide and metolazone with Cr steadily falling and very effective diuresis. His dry weight, per patient, is about 85-86kg, and his admission weight was 98.4 kg. He was diuresed down to his dry weight prior to downtitrating both the milrinone and furosemide gtt's. He did develop a metabolic alkalosis (likely contraction alkalosis) and was given acetazolamide 125mg [**Hospital1 **]. His furosemide drip was also weaned off and his creatinine began to improve toward baseline. His bicarbonate began to normalize, possibly due to the development of some diarrhea (C. diff negative), and the acetazolamide was discontinued. . # Chronic musculoskeletal chest pain: Chest pain consistent with prior episodes of chest pain and is likely secondary to afib with rvr. EKG changes may be related to demand ischemia and elevation in cardiac enzymes may be secondary to a combination of demand vs chronic kidney disease. Low suspicion for ACS. His home dose of percocet was continued for pain control. He was continued on aspirin, statin, and B-blocker. . # Fungal rash over dorsum of feet: Erythematous with satellite lesions, with pruritus reported by the patient. This improved quite well on ketoconazole topical cream. . # t2DM: He was continued on Lantus and sliding scale insulin. TRANSITIONAL ISSUES # Follow-up: An e-mail was sent to all providers in his outpatient care (Drs. [**First Name (STitle) 437**], [**Name5 (PTitle) 73**], [**Name5 (PTitle) **], [**First Name3 (LF) **], and PCP [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]). His care will be coordinated between all of these physicians. He should be considered for repeat electrical cardioversion (as above) and possible PFO closure in the future if indicated. Medications on Admission: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 2. simvastatin Oral 3. Lantus 100 unit/mL Solution Sig: One (1) 20 units Subcutaneous at bedtime: 20 units at bedtime. 4. Humalog Subcutaneous 5. warfarin 5 mg Tablet Sig: 0.5 Tablet PO Once Daily at 4 PM. 6. metoprolol tartrate 50 mg Tablet Sig: 1.5 Tablet PO BID (2 times a day). 7. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 8. Imdur 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 9. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 10. furosemide 40 [**Hospital1 **] Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 3. Lantus 100 unit/mL Solution Sig: Twenty (20) Subcutaneous at bedtime. 4. Humalog Subcutaneous 5. oxycodone-acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 6. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Inhalation every 4-6 hours. 7. torsemide 20 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). Disp:*120 Tablet(s)* Refills:*2* 8. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) vial Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 9. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day. Disp:*30 Tablet, ER Particles/Crystals(s)* Refills:*2* 10. Outpatient Lab Work please check Chem-7 and INR on Friday [**5-10**] with result to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] at Phone: [**Telephone/Fax (1) 8598**] Fax: [**Telephone/Fax (1) 98321**] 11. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* 12. warfarin 5 mg Tablet Sig: 0.5 Tablet PO once a day. 13. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day: Take 2 tablets twice daily for 2 days only, then decrease to one tablet daily. Disp:*38 Tablet(s)* Refills:*2* 14. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for pruritis. 15. sildenafil 20 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 16. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 5 days. Disp:*10 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Congestive Heart Failure Atrial Fibrillation with RVR Pulmonary hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - uses walker Discharge Instructions: Dear Mr. [**Known lastname 26818**], It was a pleasure taking part in your care at [**Hospital1 18**]. You were admitted for shortness of breath and atrial fibrillation with rapid heart rate. You were treated with intravenous lasix, metoprolol, as well as a medication to make your heart pump more efficiently. You underwent a catheterization which showed high blood pressures in a portion of your heart that was mildly reversible with medication. When we gave you medication to help with this, your symptoms improved. Your discharge weight was 191 pounds. Please weigh yourself every morning before breakfast and call Dr. [**Last Name (STitle) **] if weight increases more than 3 pounds in 1 day or 5 pounds in 3 days. An appt was made with Dr. [**First Name (STitle) 437**] for evaluation of your heart failure, his office will contact you with an earlier appt is possible before then. You will see Dr. [**Last Name (STitle) 73**] for further evaluate your heart rhythm as well. Right now, you are in a normal sinus rhythm. The following changes were made to your medications: 1. Change the Metoprolol to 25 mg daily of a long acting version 2. Decrease the simvastatin to 20 mg daily 3. Take 2.5 mg of warfarin (coumadin) for the next few days. Your coumadin level may be high because of the antibiotic and the amiodarone. You will get your level checked on Friday. 4. Start potassium supplements, one per day, to prevent your potassium from being low on the new diuretic 5. STart Sildenifil to lower the pressures inside your lung vessels. It is very important that you do not take the Imdur anymore or take an nitroglycerin with this new medicine 6. Start taking amiodarone to keep your heart rhythm in a normal sinus rhythm. You will take 2 pills twice daily for 2 days, then take only one pill daily from then on. You will need to have your liver, lung and thyroid tests followed regularly while you are on this medicine 7. STOP Imdur and Lasix 8. Use sarna lotion as necessary for itchy skin. Please continue your other home medications as previously prescribed Followup Instructions: The following appointments have been made for you: . Urology: Department: SURGICAL SPECIALTIES When: MONDAY [**2182-5-13**] at 1 PM With: [**First Name8 (NamePattern2) 161**] [**Name6 (MD) 162**] [**Name8 (MD) 163**], MD [**Telephone/Fax (1) 921**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Name: [**Last Name (LF) **],[**First Name3 (LF) **] C. Location: [**Hospital1 **] HEALTHCARE-[**Location (un) 8596**] Address: [**Location (un) 8597**], [**Location (un) **],[**Numeric Identifier 3862**] Phone: [**Telephone/Fax (1) 8598**] Appointment: Thursday [**2182-5-16**] at 11:45AM Department: CARDIAC SERVICES When: TUESDAY [**2182-6-25**] at 11:00 AM With: [**Doctor First Name 900**] [**Name8 (MD) 901**], M.D. [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: MONDAY [**2182-7-29**] at 3:30 PM With: DR. [**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: Monday [**5-27**] at 11:15am With: DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 4105**] Building: [**Hospital1 **] [**Location (un) 620**] Completed by:[**2182-5-8**] Name: [**Known lastname 5005**],[**Known firstname **] B Unit No: [**Numeric Identifier 17846**] Admission Date: [**2182-4-23**] Discharge Date: [**2182-5-8**] Date of Birth: [**2121-3-14**] Sex: M Service: MEDICINE Allergies: Vancomycin Analogues / Histamine / Ciprofloxacin / Penicillins / Cephalosporins / Aspirin Attending:[**First Name3 (LF) 1266**] Addendum: Pt was discharged home on [**5-8**]. His creatinine was rising at discharge and an ACE inhibitor medicine was not started pending labs on [**5-10**]. This medicine should be considered for the pt in the future for his systolic CHF. Discharge Disposition: Home With Service Facility: [**Company 720**] [**Name6 (MD) **] [**Last Name (NamePattern4) 1268**] MD [**MD Number(2) 1269**] Completed by:[**2182-5-8**]

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icd9cm

[ [ [] ] ]

[ "99.61", "37.21", "88.72", "89.64" ]

icd9pcs

[ [ [] ] ]

19488, 19674

7015, 12077

369, 376

15047, 15047

3337, 3337

17297, 19465

2878, 2971

12915, 14854

14947, 15026

12103, 12892

6470, 6992

15197, 17274

2207, 2546

2986, 3318

1880, 1938

310, 331

404, 1745

3352, 6453

15062, 15173

1969, 2184

1789, 1860

2562, 2862

7,455

188,733

49353

Discharge summary

report

Admission Date: [**2115-11-12**] Discharge Date: [**2115-11-19**] Date of Birth: [**2050-3-7**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1267**] Chief Complaint: Increasing chest pain Major Surgical or Invasive Procedure: [**2115-11-12**] CABG x 2 (LIMA->mid LAD, SVG->distal LAD) History of Present Illness: This is a 65 year old male with known history of CAD. He has undergone several percutaneous interventions/ stent placements including brachytherapy to his LAD over the last several years. Over the past six months the patient has found that he is using SL nitroglycerin more frequently. He states that he goes through about 100 nitroglycerin tablets within a six week period. His predominant symptom includes left upper arm discomfort that typically occurs on a daily basis, at rest or with exertion. This is always responsive to nitroglycerin. He has also noticed some episodes of chest discomfort associated with his arm pain. These episodes have occurred with exertion and feel very similar to what he had with his prior angioplasties. Other complaints include increased dyspnea on exertion and significant fatigue. He has not had any recent stress testing. Cardiac catheterization in [**2115-10-8**] revelaed a left dominant system and two vessel coronary artery disease. The RCA was a small non-dominant vessel with a RI origin lesion of 80%. The LMCA was normal without any flow limiting lesions. The LAD demonstrated several previous stents with a 99% lesion at the origin with distal flow of TIMI III. Based on the above results he was referred for cardiac surgical intervention. Past Medical History: Hypertension DM2 - dx'd in [**2094**] Hyperlipidemia Arthritis of hands Tonsillectomy Radiculopathy History of Kidney stones GERD Social History: Patient is married with one daughter. [**Name (NI) **] previously worked as a soft wear engineer. Quit tobacco over 15 years ago. Denies excessive ETOH. Family History: Father died of a CVA at age 67. Physical Exam: Vitals: BP 140/80, HR 70, RR 14, SAT 96% on room air General: well developed male in no acute distress HEENT: oropharynx benign, Neck: supple, no JVD, Heart: regular rate, normal s1s2, no murmur or rub Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, no edema, no varicosities Pulses: 1+ distally Neuro: nonfocal Pertinent Results: [**2115-11-17**] 05:40AM BLOOD WBC-10.0 RBC-2.89* Hgb-8.6* Hct-24.9* MCV-86 MCH-29.6 MCHC-34.3 RDW-14.2 Plt Ct-252 [**2115-11-17**] 05:40AM BLOOD Glucose-118* UreaN-28* Creat-0.9 Na-137 K-4.0 Cl-97 Brief Hospital Course: Patient was admitted and underwent two vessel coronary artery bypass grafting by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. For surgical details, please see seperate operative note. There were no complications and he was brought to the CSRU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. It took several days for him to wean from inotropic support. He otherwise did well and transferred to the telemetry floor on postoperative day three. Beta blockade was resumed and advanced as tolerated. He remained in a normal sinus rhythm. Due to persistent elevation in blood sugars, the [**Last Name (un) **] service was consulted to assist in the postoperative management of his diabetes mellitus. Over several days, medical therapy was optimized and he continued to make clinical improvements. He was eventually cleared for discharge on postoperative day seven. At time of discharge, his BP was 120/60 with a HR of 86. His room air saturations were 97% and his discharge chest x-ray showed only small pleural effusions with bibasilar atelectasis. All surgical wounds were clean and dry with sternal staples intact. Medications on Admission: Lipitor 10mg daily. Plavix 75mg qPM. Quinipril 10mg daily every morning. Metoprolol 50mg every morning, 100mg every evening. Aspirin 325mg daily every morning. MVI daily. Lantus insulin 40 units qHS. Humulin R 30 units qAM and qPM Humalog p.r.n. Ntg 0.4mg sublingual p.r.n. Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 1 weeks. Disp:*28 Capsule, Sustained Release(s)* Refills:*0* 3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 weeks. Disp:*14 Tablet(s)* Refills:*0* 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*40 Tablet(s)* Refills:*0* 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*0* 8. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 10. Insulin Glargine 100 unit/mL Cartridge Sig: Forty (40) units Subcutaneous once a day: insulin as prior to surgery. 11. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 12. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day for 1 months. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: CAD s/p CABG, prior PCI DM HTN hyperlipidemia arthritis GERD kidney stones Discharge Condition: Good. Discharge Instructions: Shower, wash incision with soap and water, pat dry. No lotions creams or powders to incisions. Calll with fever, redness or drainage from incision, or weight gain more than 2 poundsin one day or five in one week. No lifting more than 10 pounds or driving. Followup Instructions: Dr. [**Last Name (STitle) **] in [**2-8**] weeks Dr. [**Last Name (STitle) 2204**] in 2 weeks Dr. [**Last Name (STitle) **] in 3 weeks Completed by:[**2115-12-18**]

[ "412", "413.9", "401.9", "V45.82", "414.01", "530.81", "272.4", "250.00" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

5781, 5839

2705, 3904

344, 405

5958, 5966

2483, 2682

6270, 6437

2062, 2096

4229, 5758

5860, 5937

3930, 4206

5990, 6247

2111, 2464

283, 306

433, 1721

1743, 1875

1891, 2046

50,140

168,005

42762

Discharge summary

report

Admission Date: [**2188-2-11**] Discharge Date: [**2188-2-22**] Date of Birth: [**2158-8-4**] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 165**] Chief Complaint: Tachycardia and dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname 50463**] is a 29 year old female with history significant for anxiety, asthma and active IV drug abuse who was most recently discharged from [**Hospital1 18**] on [**2188-2-10**] after undergoing a tricuspid valve replacement and mitral valve repair on [**2188-1-25**] for MSSA endocarditis. Her post-operative course was complicated by persistent fevers with tachycardia/tachypnea (HR in 120's and RR in 20's-30's), multiple bilateral septic pulmonary emboli with abscess formation, and significant right pleural effusion which required a chest tube during her hospitalization. The pleural fluid cultures were negative for organisms, the patient had negative PCR for C. diff, and she was discharged to [**Hospital **] rehab on Zosyn. Prior to discharge a CT of the chest was obtained and demonstrated persistence of her bilateral pulmonary abscesses, increased lower lobe consolidation, but no increase in pleural effusion following removal of her chest tube. At the time, a decortication procedure was not determined to be warranted. Not long following discharge the patient began having episodes of tachycardia and tachypnea and a CTA performed demonstrated new pulmonary emboli. She was thus transferred from rehab for further evaluation. Past Medical History: IV drug abuse asthma anxiety Endocarditis s/p MVR/TVR Social History: Patient is actively abusing tobacco, cocaine and heroin. Denies alcohol abuse. She is single. Family History: Unknown Physical Exam: Pulse: Resp:32 O2 sat:99% on 2L B/P Right: 121/74 Left:120/74 General: Skin: Dry [] intact [x]except skin lesions from drug injections HEENT: PERRLA [x] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally []diminished RT?LT bases. Scattered wheeze, loose cough Heart: RRR [x] Irregular [] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [] Extremities: Warm [x], well-perfused [x] Edema [x] [**1-14**]+_____ 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:n Left:n Pertinent Results: [**2188-2-22**] 05:49AM BLOOD WBC-6.5 RBC-2.95* Hgb-8.8* Hct-28.6* MCV-97 MCH-29.8 MCHC-30.7* RDW-16.9* Plt Ct-323 [**2188-2-21**] 05:44AM BLOOD WBC-6.8 RBC-3.01* Hgb-8.9* Hct-28.7* MCV-95 MCH-29.7 MCHC-31.2 RDW-17.5* Plt Ct-304 [**2188-2-20**] 06:23AM BLOOD WBC-6.8 RBC-2.96* Hgb-8.6* Hct-28.5* MCV-96 MCH-29.2 MCHC-30.4* RDW-17.7* Plt Ct-290 [**2188-2-22**] 05:49AM BLOOD PT-14.3* PTT-76.5* INR(PT)-1.3* [**2188-2-21**] 05:44AM BLOOD PT-14.4* INR(PT)-1.3* [**2188-2-20**] 05:00PM BLOOD PT-15.1* INR(PT)-1.4* [**2188-2-19**] 03:33AM BLOOD PT-25.4* INR(PT)-2.4* [**2188-2-18**] 05:11AM BLOOD PT-25.4* INR(PT)-2.4* [**2188-2-17**] 06:20AM BLOOD PT-24.1* PTT-41.9* INR(PT)-2.3* [**2188-2-21**] Chest CT CT CHEST FINDINGS: Left central catheter tip is in the upper SVC. Extensive mediastinal lymphadenopathy has improved. For instance a prevascular lymph node measuring 6 mm was 8 mm. A right lower paratracheal station lymph node measuring 11 mm was 13 mm. The main pulmonary artery is still enlarged measuring 3.3 cm. A small pericardial effusion has decreased. Patient is status post MVR and TVR. Cardiac size is minimally enlarged, unchanged from prior. Layering nonhemorrhagic small bilateral pleural effusions have decreased. Numerous cavitary lesions throughout both lungs have decreased in size. Lower lobe consolidations and right middle lobe consolidations have also markedly improved. Still there is some air in the pleural cavity bilaterally, more so on the left. There are no new lung opacities. This examination is not tailored for subdiaphragmatic evaluation. As before there is fatty infiltration of the liver. There are no bone findings of malignancy. IMPRESSION: 1. Improved multifocal pneumonia and multiple areas of septic emboli. Improved mediastinal lymphadenopathy. 2. Decrease in pericardial effusion. [**2188-2-14**] Echo Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). 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 valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. A mitral valve annuloplasty ring is present. The mitral annular ring appears well seated with normal gradient. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] A bioprosthetic tricuspid valve is present. The prosthetic tricuspid leaflets appear normal. There is a very small pericardial effusion. IMPRESSION: Normal left ventricular cavity size and wall thickness with preserved global and regional biventricular systolic function. Mildly dilated, hypokinetic right ventricle consistent with primary pulmonary process (COPD, pulmonary embolus, etc.), Well-seated, normally functioning mitral valvuloplasty ring. Well-seated normally functioning bioprosthetic tricuspid valve. Very small pericardial effusion. Left pleural effusion. Brief Hospital Course: Ms. [**Known lastname 50463**] was admitted to the [**Hospital1 18**] on [**2188-2-11**] for further management of her pulmonary emboli. The thoracic surgery service was consulted. A CT scan was performed which showed a pulmonary embolism. She completed her course of zosyn for pseudomonas. She continued nafcillin for her MSSA endocarditis, per the recommendation of the infectious disease service. Her stop date is [**2188-2-27**]. Her pain was controlled with dilaudid, oxycodone, and motrin. [**Month/Day/Year 197**] and heparin were started for her pulmonary emboli. Lasix was started for her pleural effusions. She was started on diltiazem for better heart rate control. An echocardiogram revealed decreased right ventricle function consistent with pulmonary embolism. [**2-21**]/ she went for a follow up chest CT scan which per Radiology revealed: Improved multifocal pneumonia and multiple areas of septic emboli,improved mediastinal lymphadenopathy,and a decrease in pericardial effusion. Dr.[**Last Name (STitle) 7343**] from Thoracic reviewed the Ct scan and determined there was no significant change and that she does not need to follow up with him unless there is a new issue. She continued to make slow progress and was discharged to the [**Hospital **] Hospital Rehabilitation Center on [**2188-2-22**]. She will follow-up with Dr. [**First Name (STitle) **], her cardiologist and the infectious disease service as noted in the discharge paperwork. She will call to schedule appointments with her primary care physician. [**Name10 (NameIs) 197**] [**Name11 (NameIs) 702**] should be arranged prior to discharge from [**Hospital **] Rehabilitation. She prefers to be monitored by Dr. [**Last Name (un) 92402**] for [**Last Name (un) **] dosing if possible upon discharge from rehab. Medications on Admission: -Aspirin EC 81 mg PO DAILY -Amitriptyline 50 mg PO/NG HS -Acetaminophen 650 mg PO Q4H:PRN pain/temp -Diltiazem 15 mg PO/NG [**Hospital1 **] -Furosemide 40 mg IV Q12H -Ipratropium Bromide Neb 1 NEB IH Q6H -Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezes -Heparin 5000 UNIT SC TID -HYDROmorphone (Dilaudid) 2-4 mg PO/NG Q4H:PRN pain -Oxycodone SR (OxyconTIN) 10 mg PO Q12H -Insulin SC (per Insulin Flowsheet) Sliding Scale -Pantoprazole 40 mg PO Q24H -Metoprolol Tartrate 100 mg PO TID Hold for HR < 55 or SBP < 90 and call medical provider. [**Name10 (NameIs) 92403**] Powder 2% 1 Appl TP [**Hospital1 **]:PRN affected areas -Sarna Lotion 1 Appl TP TID:PRN itching -Multivitamins 1 TAB PO/NG DAILY -Milk of Magnesia 30 ml PO HS:PRN constipation -Bisacodyl 10 mg PO/PR DAILY:PRN constipation -Docusate Sodium 100 mg PO BID -Cepacol (Menthol) 1 LOZ PO PRN cough -Clonazepam 0.5 mg PO/NG QHS Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 3. ipratropium bromide 0.02 % Solution Sig: One (1) Neb Inhalation Q6H (every 6 hours). 4. guaifenesin 100 mg/5 mL Syrup Sig: Fifteen (15) ML PO Q4H (every 4 hours). 5. oxycodone 10 mg Tablet Extended Release 12 hr Sig: One (1) Tablet Extended Release 12 hr PO Q12H (every 12 hours). 6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 9. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for affected area. 10. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) for 1 weeks. 11. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. nafcillin in D2.4W 2 gram/100 mL Piggyback Sig: Two (2) grams Intravenous Q4H (every 4 hours): Stop date is [**2188-3-5**]. 13. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 14. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 15. diltiazem HCl 60 mg Tablet Sig: 1.5 Tablets PO QID (4 times a day). 16. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 17. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed for anxiety/insomnia. 18. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed for rash. 19. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 5 days: until edema resolves. 21. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day for 5 days. 22. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush: 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. . 23. diphenoxylate-atropine 2.5-0.025 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for diarrhea. 24. heparin (porcine) in D5W 25,000 unit/250 mL Parenteral Solution Sig: 1700 (1700) units/hr Intravenous ASDIR (AS DIRECTED): Infuse at 1700 units/hour for PTT goal 60-80 until INR >2.0. 25. acetazolamide 250 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) for 1 days. 26. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever/pain. 27. warfarin 5 mg Tablet Sig: Two (2) Tablet PO ONCE (Once) for 1 doses: Give 10 mg [**Hospital1 197**] on [**2188-2-22**] and then as directed for INR goal 2.0-3.0 for PE. Discharge Disposition: Extended Care Facility: [**Hospital6 2222**] - [**Location (un) 538**] Discharge Diagnosis: Endocarditis [**2188-1-25**] Tricuspid valve replacement (29mm [**Company 1543**] Mosaic),mitral valve repair(P2 resection,26mm CG Future Ring) Anxiety IVDA Asthma Pulmonary emboli Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage 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 provided. 4) No driving for approximately one month and while taking narcotics. Driving will be discussed at follow up appointment with surgeon when you will likely be cleared to drive. 5) No lifting more than 10 pounds for 10 weeks 6) 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) **] Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2188-2-26**] 1:30 Cardiologist: Dr.[**Name (NI) 3733**] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2188-2-29**] 1:20 Infectious Diseases: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 8021**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2188-3-5**] 10:30 Please call to schedule appointments with your Primary Care Dr. [**Last Name (un) 92402**] [**Telephone/Fax (1) 72236**] 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** [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2188-2-22**]

[ "041.11", "785.6", "V42.2", "305.51", "305.61", "493.90", "415.12", "305.1", "311", "790.92", "300.00", "415.19", "785.0", "511.9", "285.9", "421.0" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

11513, 11586

5774, 7578

332, 339

11811, 11976

2595, 5751

12950, 13785

1841, 1851

8519, 11490

11607, 11790

7604, 8496

12000, 12927

1866, 2576

269, 294

367, 1636

1658, 1713

1729, 1825

9,980

134,216

30330

Discharge summary

report

Admission Date: [**2184-2-19**] Discharge Date: [**2184-2-26**] Date of Birth: [**2141-3-6**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: SOB, malaise Major Surgical or Invasive Procedure: s/p Emergency BIVAD placement [**2184-2-19**] History of Present Illness: This 42 year old white male with no significant PMHx had a 6 day h/o malaise, acute SOB, chest pressure and abdominal cramping. He presented to [**Hospital 5871**] hospital on [**2184-2-19**] and was in Afib in the 190's. He was treated with Lopressor and Dig. without effect and was started on a Dilt. drip. He developed hypotension and respiratory distress and was intubated and fluid resusitated. An echo revealed an EF of 10% with globar hypokinesis and he was transferred to [**Hospital1 18**] for further management. Past Medical History: Asthma Social History: Unmarried, mother and brother live in [**Name (NI) 108**]. Cigs: none ETOH:?? Works at deli Family History: Unremarkable Physical Exam: WDWM intubated, sedated. HEENT: NC/AT, PERLA, EOMI, oropharynx benign. Neck: supple, FROM, no lymphadenopathy, carotids 2+= bilat. without bruits. Lungs: Clear to A+P CV: Irreg, Irreg without R/G/M Abd.: Obese, soft, nontender without masses or hepatosplenomegaly Ext: without clubbing, cyanosis, 2+ bilat. edema, pulses 2+= throughout Neuro: sedated, has woken and moved all extremities to command. Pertinent Results: [**2184-2-26**] 08:27AM BLOOD Hct-29.3* [**2184-2-26**] 03:49AM BLOOD WBC-24.7* RBC-3.57* Hgb-11.0* Hct-30.8* MCV-86 MCH-30.9 MCHC-35.8* RDW-16.8* Plt Ct-110* [**2184-2-26**] 03:49AM BLOOD PT-13.9* PTT-27.1 INR(PT)-1.2* [**2184-2-26**] 03:49AM BLOOD Glucose-143* UreaN-67* Creat-3.8* Na-135 K-5.0 Cl-101 HCO3-19* AnGap-20 [**2184-2-25**] 03:20PM BLOOD ALT-177* AST-156* LD(LDH)-1337* AlkPhos-56 Amylase-100 TotBili-10.2* [**2184-2-26**] 03:49AM BLOOD Calcium-7.6* Phos-5.6* Mg-2.2 [**2184-2-25**] 08:56PM BLOOD Hapto-<20* [**2184-2-21**] 10:05AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE [**2184-2-21**] 10:05AM BLOOD Smooth-NEGATIVE [**2184-2-21**] 10:05AM BLOOD IgG-676* IgM-67 [**2184-2-24**] 03:15AM BLOOD Vanco-7.5* [**2184-2-21**] 10:05AM BLOOD HCV Ab-NEGATIVE [**2184-2-26**] 08:43AM BLOOD Type-ART pO2-89 pCO2-35 pH-7.40 calTCO2-22 Base XS--1 [**2184-2-26**] 08:43AM BLOOD Glucose-144* Lactate-2.4* K-4.7 RADIOLOGY Final Report CHEST (PORTABLE AP) [**2184-2-25**] 1:15 AM CHEST (PORTABLE AP) Reason: s/p biVAD w/worsening flows-r/o efufsion [**Hospital 93**] MEDICAL CONDITION: 42 year old man who is s/p BiVAD REASON FOR THIS EXAMINATION: s/p biVAD w/worsening flows-r/o efufsion SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Worsening flows. Rule out effusion. Patient post BIVAD. Comparison is made with prior study dated [**2184-2-23**]. FINDINGS: Single AP portable view of the chest shows worsening in mild pulmonary edema and increase in moderate enlarged cardiomediastinal silhouette. The right lateral chest was not included on the film. Bilateral pleural effusions, greater on the right side, have increased. ET tube tip is in standard position. Right internal jugular vein catheter is in the right brachiocephalic vein. Right subclavian vein catheter tip is in the SVC. Unchanged position of the BiVAD. NG tube tip is not well visualized and cannot be followed distally to the distal esophagus. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) 3901**] [**Name (STitle) 3902**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Cardiology Report ECHO Study Date of [**2184-2-25**] PATIENT/TEST INFORMATION: Indication: s/p BIVAD, s/p tamponade and evacuation of hematoma. Tamponade. BP (mm Hg): 86/53 HR (bpm): 105 Status: Inpatient Date/Time: [**2184-2-25**] at 16:00 Test: Portable TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007W000-0:00 Test Location: West Other Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name (STitle) **] R. [**Doctor Last Name **] INTERPRETATION: Findings: This study was compared to the prior study of [**2184-2-25**]. RIGHT ATRIUM/INTERATRIAL SEPTUM: No ASD by 2D or color Doppler. LEFT VENTRICLE: Severely depressed LVEF. AORTA: Normal ascending, transverse and descending thoracic aorta with no atherosclerotic plaque. AORTIC VALVE: Trace AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was monitored by a nurse [**First Name (Titles) **] [**Last Name (Titles) 9833**] throughout the procedure. The patient was sedated for the TEE. Medications and dosages are listed above (see Test Information section). No TEE related complications. The rhythm appears to be atrial fibrillation. Conclusions: No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is severely depressed. The left ventricular cannula is well seen and appears to be patent without significant flow turbulance. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. The aortic valve leaflets (3) appear structurally normal. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary vein flow into the left atrium appears turbulant with increased flow velocities (also present in prior study). There is extrinsic compression of the right heart and left atrium with echodense material (likely hematoma). Impression: Probable hematoma compression of the left atrium, right atrium, and right ventricle. Compared to the prior study, (prior to hematoma evacuation) overall compression may be less marked. Electronically signed by [**First Name11 (Name Pattern1) 553**] [**Last Name (NamePattern4) 4133**], MD on [**2184-2-25**] 16:33. [**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. Cardiology Report C.CATH Study Date of [**2184-2-19**] *** Not Signed Out *** BRIEF HISTORY: 42 year old male with no significant medical history who presented to an outside hospital in atrial fibrillation with rapid ventricular response. An echocardiogram revealed an LVEF of 10%. He become hypotensive requiring intubation and vasopressor support and was transferred to [**Hospital1 18**]. He is now referred to the cardiac cath lab for evaluation of his coronary arteries and placement of an intra-aortic balloon pump. INDICATIONS FOR CATHETERIZATION: Coronary artery disease, cardiogenic shock PROCEDURE: Left Heart Catheterization: was performed by percutaneous entry of the right femoral artery, using a 5 French left [**Last Name (un) 2699**] catheter, advanced to the ascending aorta through a 5 French introducing sheath. Coronary Angiography: was performed in multiple projections using a 5 French JL4 and a 5 French JR4 catheter, with manual contrast injections. Intra-aortic balloon counterpulsation: was initiated with an introducer sheath using a Cardiac Assist 9 French 40cc wire guided catheter, inserted via the right femoral artery. Conscious Sedation: was provided with appropriate monitoring performed by a member of the nursing staff. **ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM **RIGHT CORONARY 1) PROXIMAL RCA NORMAL 2) MID RCA NORMAL 2A) ACUTE MARGINAL NORMAL 3) DISTAL RCA NORMAL 4) R-PDA NORMAL 4A) R-POST-LAT NORMAL 4B) R-LV NORMAL **ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM **LEFT CORONARY 5) LEFT MAIN NORMAL 6) PROXIMAL LAD NORMAL 6A) SEPTAL-1 NORMAL 7) MID-LAD NORMAL 8) DISTAL LAD NORMAL 9) DIAGONAL-1 NORMAL 10) DIAGONAL-2 NORMAL 12) PROXIMAL CX NORMAL 13) MID CX NORMAL 13A) DISTAL CX NORMAL 14) OBTUSE MARGINAL-1 NORMAL 15) OBTUSE MARGINAL-2 NORMAL TECHNICAL FACTORS: Total time (Lidocaine to test complete) = 27 minutes. Arterial time = 25 minutes. Fluoro time = 3.4 minutes. Contrast injected: Non-ionic low osmolar (isovue, optiray...), vol 50 ml Anesthesia: 1% Lidocaine subq. Anticoagulation: Other medication: Epinephrine Weight-based infusion Ffp 2 units Levophed .120mcg/min Milrinone 0.75mcg/kg/min Propofol 30mcg/kg/min Midazolam 1mg Cardiac Cath Supplies Used: 40 DATASCOPE, LINEAR IABP CATHERTER 7.5FR COMMENTS: 1. Selective coronary angiography of this right dominant system revealed no evidence of coronary artery disease. The LMCA, LAD, LCx, and RCA were all widely patent. 2. An IABP was successfully inserted via the right femoral artery. 3. Post-IABP, the cardiac index improved at 3.6 l/min/m2 (from 1.8l/min/m2 prior). FINAL DIAGNOSIS: 1. Coronary arteries are angiographically normal. 2. Successful IABP placement. ATTENDING PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. REFERRING PHYSICIAN: [**Last Name (Prefixes) 413**],[**First Name3 (LF) 412**] CARDIOLOGY FELLOW: [**Last Name (LF) **],[**First Name3 (LF) **] M. ATTENDING STAFF: [**Last Name (LF) **],[**First Name3 (LF) **] A. Brief Hospital Course: The patient was admitted to the CSRU and had an echo and cardiac cath. The echo revealed a 10% EF and a [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 2966**], and the cath showed clean coronaries. He had Abiomed BIVAD placed and was transferred to the CSRU. He remained on Dilt, Neo, Vasopressin and Propofol. He had good VAD flows. He was followed by heart failure and renal. POD#2 he had decreased urine output and had a TEE which was unchanged from preop. He also had elevated LFTs and was followed by hepatology. His creatinine continued to climb and he was started on CVVH on POD#4. He became markedly hypotensive on POD#6 and had a TEE which revealed a large, circumfrential pericardial effusion. He was reexplored at the bedside and clot was evacuated. An echo the following day revealed that there is still hematoma around the heart without tamponade physiology. He had bilateral cheat tubes placed on [**2-25**] and initially there was 2 liters of serosanguinous drainage. He was woken several times and followed commands. On POD#7 he was transferred to [**Hospital1 2025**] for transplant evaluation. Medications on Admission: None Discharge Medications: 1. Phenylephrine HCl 10 mg/mL Solution Sig: 1.9 Injection TITRATE TO (titrate to desired clinical effect (please specify)). 2. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for temperature >38.0. 3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Fentanyl Citrate (PF) 0.05 mg/mL Solution Sig: One Hundred (100) Injection INFUSION (continuous infusion). 7. Midazolam 5 mg/mL Solution Sig: Two (2) Injection TITRATE TO (titrate to desired clinical effect (please specify)). 8. Vasopressin 20 unit/mL Solution Sig: 2.4 Injection TITRATE TO (titrate to desired clinical effect (please specify)). 9. Sodium Chloride 0.9 % 0.9 % Syringe Sig: One (1) ML Injection DAILY (Daily) as needed. 10. Pantoprazole 40 mg IV Q24H 11. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN 10ml NS followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen QD and PRN. Inspect site every shift 12. Diltiazem 5-15 mg/hr IV INFUSION Titrate to HR<100 13. Metoclopramide 5 mg IV Q8H nausea/vomiting 14. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: Eight Hundred (800) units Intravenous ASDIR (AS DIRECTED). Discharge Disposition: Extended Care Discharge Diagnosis: Severe cardiomyopathy Asthma Discharge Condition: Critical Discharge Instructions: Tx to [**Hospital1 2025**] for transplant evaluation. Completed by:[**2184-2-26**]

[ "584.5", "785.51", "422.91", "424.90", "511.9", "423.0", "428.0", "493.90", "425.4", "573.3", "427.31" ]

icd9cm

[ [ [] ] ]

[ "96.72", "39.61", "37.66", "34.04", "88.72", "99.04", "34.03", "88.56", "37.22", "39.95", "37.61", "38.95", "96.6", "34.1" ]

icd9pcs

[ [ [] ] ]

12038, 12053

9466, 10598

333, 381

12126, 12137

1542, 2591

1092, 1106

10653, 12015

2628, 2661

12074, 12105

10624, 10630

9037, 9443

12161, 12245

3785, 6160

1121, 1523

8156, 9020

6830, 8137

281, 295

2690, 3759

409, 937

6192, 6797

959, 967

983, 1076

57,330

179,557

42151

Discharge summary

report

Admission Date: [**2132-10-7**] Discharge Date: [**2132-10-14**] Date of Birth: [**2054-12-31**] Sex: M Service: MEDICINE Allergies: Beta-Blockers (Beta-Adrenergic Blocking Agts) Attending:[**First Name3 (LF) 2782**] Chief Complaint: sudden onset dyspnea Major Surgical or Invasive Procedure: Intubation x2 days; History of Present Illness: Mr. [**Known lastname 5057**] is a 77yo M with HTN, HL, COPD, and newly diagnosed NSCLC , now s/p his first round of chemotherapy. He was transferred to the [**Hospital1 18**] ED in the midst of a RBC transfusion when he developed sudden shortness of breath that was interpreted as a possible transfusion reaction. . He appears to have severe COPD caused by an extensive smoking history. He has poor exercise tolerance which has only worsened in the preceding months. Any exertion, including walking down the street, can cause increased RR and profound SOB. Albuterol can help stop these episodes. He has been pursed-lip breathing for years. He recently underwent TTE evaluation of his exercise intolerance, at which point a relatively large pericardial effusion with tamponade physiology was seen. He was admitted to the CCU [**9-2**]- [**9-6**] and underwent pericardiocentesis, which revealed malignant cells. He recently underwent his first chemo session with taxol for NSCLC. His oncologist is Dr. [**Last Name (STitle) 349**] at [**Location (un) 2274**]. . His fatigue and poor exercise tolerance persisted. He was found to be anemic to 25 and subsequently was brought to 7 [**Hospital Ward Name 1826**] for blood transfusion. Midway through the transfusion, he developed worsening SOB and increased RR. He thinks this episode was similar to his usual bouts of breathlessness, and he admittedly was upset with how long the transfusion was taking. Fearing a transfusion reaction, he was brought to the [**Hospital1 18**] ED for further evaluation. . In the ED, he was found to be tachycardic and tachypneic. Received 20mg IV lasix and underwent BiPAP trial, which was poorly tolerated. Of note, he continued to saturate in the upper90s on 3-4LNC, though remained tachypneic. A bedside echo was done which showed no pericardial effusion per the ED read. He was transferred to the MICU for concern of increased WOB. VS prior to transfer were 97.9 108 150/80 36 99/4L. . On arrival to the MICU, his intial VS were 96.5, 107, 153/63, 95 3LNC. He continues to purse-lip breath. He describes frequent episodes similar to his breathlessness on transfusion, which often pass after coughing or spitting. He otherwise feels well aside from fatigue. He notes no recent couging or cold-like smpyotms, no sore throat, fevers, chills, chest pains or pressure. He has lower extremity edema but no PND, orthopnea. No recent F/C. In the midst of our interview, he had the urge to urinate and abruptly stood to use his urinal- he developed respiratory distress with saturations dipping to the 80s and tachypnea to 50. This episode resolved with supplemental 02. He felt it was similar to the events surrounding his infusion. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, diarrhea, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: - Non-small cell lung cancer - squamous cell carcinoma, s/p MOHS - colonic polyps, last colonoscopy 1 year ago - COPD - gastritis - h/o gout - h/o nephrolithiasis - hypertension - Hyperlipidemia Social History: Lives with his wife in [**Location (un) **]. Retired hardware store owner. Has two boys, both live in [**State **], and one grandson. - Tobacco history: 97.5 pack-year history, still smokes 1.5 ppd - ETOH: 1 glass of wine/night - Illicit drugs: denies Family History: - No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death - Mother: chronic leukemia, died at age 89 - Father: h/o MI, pancreatic cancer, died at age 69 Physical Exam: Admission Exam: Vitals: 96.5, 107, 153/63, 95 3LNC General: Alert, oriented, pursed-lip breathing in the 30s HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: diffuse wheezing heard throughout anterior and posterior lung fields. Fair air movement. No crackles or rhonchi. CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. Abdominal musculature used in exhalation. GU: foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema At the time of his discharge, the patient's vital signs were stable and he had O2 sats of 96% on 2L NC. While he continued to have wheezes with fair air movement on lung exam, there were no basilar crackles. THere was no edema or elevation of the JVP. The Foley had been removed. Pertinent Results: Admission Labs: [**2132-10-7**] 08:23PM URINE HOURS-RANDOM UREA N-679 CREAT-97 SODIUM-71 POTASSIUM-81 CHLORIDE-86 [**2132-10-7**] 08:23PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.013 [**2132-10-7**] 08:23PM URINE BLOOD-SM NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG [**2132-10-7**] 08:23PM URINE RBC-2 WBC-1 BACTERIA-NONE YEAST-NONE EPI-<1 [**2132-10-7**] 08:23PM URINE GRANULAR-2* HYALINE-14* [**2132-10-7**] 08:23PM URINE MUCOUS-RARE [**2132-10-7**] 06:36PM LACTATE-1.3 [**2132-10-7**] 06:30PM GLUCOSE-124* UREA N-30* CREAT-1.5* SODIUM-141 POTASSIUM-4.5 CHLORIDE-104 TOTAL CO2-25 ANION GAP-17 [**2132-10-7**] 06:30PM estGFR-Using this [**2132-10-7**] 06:30PM LD(LDH)-395* CK(CPK)-115 TOT BILI-0.8 [**2132-10-7**] 06:30PM cTropnT-1.00* [**2132-10-7**] 06:30PM CK-MB-5 proBNP-[**Numeric Identifier 91421**]* [**2132-10-7**] 06:30PM IRON-83 [**2132-10-7**] 06:30PM WBC-3.2*# RBC-2.79*# HGB-9.1*# HCT-25.2*# MCV-90# MCH-32.7* MCHC-36.2* RDW-20.8* [**2132-10-7**] 06:30PM NEUTS-22* BANDS-2 LYMPHS-47* MONOS-19* EOS-7* BASOS-1 ATYPS-0 METAS-0 MYELOS-2* NUC RBCS-3* [**2132-10-7**] 06:30PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-2+ MACROCYT-1+ MICROCYT-1+ POLYCHROM-1+ SPHEROCYT-1+ SCHISTOCY-2+ BITE-1+ ACANTHOCY-1+ [**2132-10-7**] 06:30PM PLT SMR-LOW PLT COUNT-132* [**2132-10-7**] 06:30PM PT-17.8* PTT-26.5 INR(PT)-1.6* Notable Labs: [**2132-10-9**] 05:15AM BLOOD FDP-40-80* [**2132-10-7**] 06:30PM BLOOD cTropnT-1.00* [**2132-10-8**] 04:41AM BLOOD CK-MB-6 cTropnT-0.99* [**2132-10-8**] 05:24PM BLOOD CK-MB-5 cTropnT-0.65* [**2132-10-7**] 06:30PM BLOOD calTIBC-257* Hapto-<5* Ferritn-590* TRF-198* [**2132-10-7**] 06:36PM BLOOD Lactate-1.3 EKG [**2132-10-7**]: Sinus tachycardia. Left axis deviation. Right bundle-branch block. Probable small R waves in leads II, III and aVF but consider prior inferior myocardial infarction. ST-T wave abnormalities. Low precordial voltage. Compared to the previous tracing of [**2132-9-3**] the rate is faster. ST-T wave abnormalities are more prominent. Precordial voltage is less prominent. Clinical correlation is suggested CXR [**2132-10-7**]: 1. Moderate enlargement of the cardiac silhouette, similar compared to the prior PET-CT. 2. Dilated and tortuous ascending thoracic aorta. 3. Patchy opacities within the lung bases, which could reflect atelectasis, infection, or aspiration. 4. Known spiculated nodule in the right upper lobe is better appreciated on the recent PET CT. TTE [**2132-10-8**]: The left atrium is elongated. The right atrium is markedly dilated. The estimated right atrial pressure is 5-10 mmHg. The estimated right atrial pressure is at least 15 mmHg. Left ventricular wall thicknesses and cavity size are normal. There is mild global left ventricular hypokinesis (LVEF = 40-45 %). Right ventricular chamber size is normal. with borderline normal free wall function. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild to moderate ([**1-13**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([**1-13**]+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a very small pericardial effusion. IMPRESSION: Mild global left and right ventricular hypokinesis. Mild to moderate mitral regurgitation. Mild to moderate aortic regurgitation. Very small pericardial effusion. Moderate pulmonary hypertension. Compared with the prior study (images reviewed) of [**2132-9-6**], biventricular function is now impaired. Valvular regurgitation is now apparent (previous study was focused). Pulmonary hypertension is identified. . Labs on Discharge: [**2132-10-14**] 09:45AM BLOOD WBC-7.0 RBC-3.15* Hgb-9.8* Hct-31.2* MCV-99* MCH-31.2 MCHC-31.6 RDW-20.8* Plt Ct-135* [**2132-10-14**] 09:45AM BLOOD Plt Ct-135* [**2132-10-14**] 09:45AM BLOOD Glucose-131* UreaN-45* Creat-1.3* Na-143 K-3.7 Cl-99 HCO3-34* AnGap-14 [**2132-10-14**] 09:45AM BLOOD Calcium-8.9 Phos-3.2 Mg-1.8 Brief Hospital Course: Mr. [**Known lastname 5057**] is a 77yoM with COPD, HTN, HLD, and a recent hospitalization for cardiac tamponade who presents from [**Hospital Ward Name **] 7 transfusion unit with acute SOB during transfusion. 1. ACUTE HYPOXIC RESPIRATORY FAILURE: --PNEUMONIA and ACUTE SYSTOLIC CHF: He developed acute shortness of breath early into his blood transfusion which he was receiving for anemia. Transfusion reaction/TRALI was initially suspected though he lacked severe pulmonary edema or hypoxia to support this diagnosis. He was admitted to the MICU due to apparent increased WOB, and was briefly tried on BiPAP in the ED despite normal saturations. Tamponade was ruled out with US in ED. He initially was stable on room air with saturations in the 90s upon admission to the ICU. He related numerous similar episodes of shortness of breath at home and related a progressive worsening of his overall respiratory status and exercise stamina over the preceding months. His CXR showed mild edema and RLL haziness. Widespread wheezing prompted treatment for COPD exacerbation. He decompensated quickly in the unit after getting agitated during a foley adjustment. He desaturated to the 70s-80s and had an increased WOB refractory to nebs, lasix, and NRB. He was urgently intubated. The cause of his decompensation was felt to be multifactorial. He had a trop of 1.00 on admission with flat CK/MB, but new LAD-distributed TWI on EKG, and new onset systolic dysfunction with EF to 40-45% on TTE (new since last month). A cardiac event could have potentially caused his deterioration and CHF exacerbation. Pneumonia was possible based on his RLL infiltrate, and he was treated for HCAP with vanco/cefepime/levaquin. Sputum culture revealed commensal resp flora and sparse GNR. He was started on nebs and steroids for possible COPD exacerbation as well,though these were quickly tapered due to suspicion for more of a CHF etiology. He was aggressively diuresed. He was extubated on [**2132-10-9**] and transfered to the floor on [**2132-10-10**]. . On the floor he was initially saturating in the 90's on 4L NC. He continued to be diuresed gently with PO and occasional IV lasix. His oxygen was weaned as tolerated with a goal of 02 sat of 92%. His steroids were discontinued on [**2132-10-13**] as the etiology of his SOB was thought to be related to pulmonary edema and a possible pneumonia rather than a COPD exacerbation. His vancomycin was discontinued based on sputum data and cefepime and levaquin were continued until further speciation was available. His nebulizers were continued throughout his hospital stay. On the day prior to discharge, cefipime was discontinued as the patient had remained afebrile and without leukocytosis; prednisone was also discontinued since COPD flare appears to not have been the primary etiology of SOB and his symptoms were resolving. PT was consulted and worked with the patient on improving functional status. He was discharged home with home PT services, home 02, and cardiac telemonitoring. . 2)NSTEMI: His troponin elevation to 1.00 is without any similar MB or CK elevation. He had some nonspecific lateral T wave changes, but no chst pain or pressure to suggest ACS. TTE revealed new onset systolic dysfunction with EF 45-50%. Cardiology was consulted, who felt that the chemotherapy (taxol/cisplatin) is not likely to blame and that he had a recent MI. Based on EKG and echo data, there was a possible partial occlusion in the LAD and that the patient may benefit from elective cathetrization. However, based on the absence of symptoms and the comorbidities in the patient, oncology, medicine and the patient's family were in agreement with medical management. On [**2132-10-12**] the patient had an 8 beat run of v-tach. An EKG was essentially unchanged and troponins showed a continued downward trend. . 3. ANEMIA: HCT to 25 of unclear source, though inflammatory disease from malignancy or myelosupression from chemo are both possible. Though his hematrocrit trended downwards in the days prior to discharge, a transfusion was not thought to be necessary by cardiology (goal 25). . 4. NON SMALL CELL LUNG CANCER: currently undergoing taxol chemo; will resume as outpatient. Atrius oncology service followed while the patient was in house. 5. HYPERTENSION: The patient had recently been taken off his dose of 20 mg linisnopril QAM due to low blood pressures. Based on his new diagnosis of CHF, lisinopril was restarted at a dose of 10 mg QAM; his blood pressures remained stable with systolics greater than 110 while in house. . 6. GOUT: Allopurinol and colchicine were continued, this was not an active issue on this admission. Medications on Admission: 1. colchicine 0.6 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 BID (2 times a day). 3. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation q4-6 hours as needed for SOB, wheezing. 4. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 5. allopurinol 100 mg Tablet Sig: Two (2) Tablet PO once a day. 6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Discharge Medications: 1. allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. beclomethasone dipropionate 80 mcg/Actuation Aerosol Sig: One (1) Spray Inhalation twice a day. 4. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) Capsule Inhalation once a day. Disp:*30 capsules* Refills:*2* 7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: [**1-13**] puff Inhalation every four (4) hours as needed for shortness of breath or wheezing. 8. lisinopril 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 9. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 10. Home Oxygen 1-4 liters per minute continuous oxygen via nasal cannula [**Male First Name (un) **]: 99 months Diagnosis: COPD 11. Lasix 20 mg Tablet Sig: Two (2) Tablet PO once a day. Disp:*60 Tablet(s)* Refills:*0* 12. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO every other day for 1 doses. Disp:*1 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Congestive Heart Failure, Possible Pneumonia, COPD, Non-Small Cell Lung Cancer, Anemia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker). Discharge Instructions: Dear Mr. [**Known lastname 5057**], It was a pleasure participating in your care at [**Hospital1 18**]. You were admitted to the medical ICU after presenting to the emergency department for acute onset shortness of breath during a blood transfusion. A reaction to the blood transfusion itself was ruled out. A chest xray showed possible signs of a pneumomia and you were started on broad spectrum antibiotics. It is possible that yoru COPD was contributing to your shortness of breath and you were also given a steroid as well as your usual inhalers. In the MICU you had a second acute episode of shortness of breath that was not responsive to oxygen. Because of your worsening respiratory status you were intubated (given a breathing tube). Laboratory results and an EKG suggested that you may have had a heart attack prior to the hospitalization. An echo cardiogram showed that you had a new onset of congestive heart failure (CHF). It is likely that your shortness of breath was due to too much volume backing up in your lungs. You were given lasix to help reduce the volume in your lungs and your respiratory status improved to the point that you were extubated (breathing tube was removed) two days after you were intubated. Cardiology was consulted to help with your care and suggested the possibility of a cardiac cathetrization to look at the vessels of your heart. However, along with your oncolgy team, it was determined to be best to try to manage your heart disease with medical management. Due to your continued improvement you were transferred to the general medical floor where we continued to monitor your respiratory status and give you lasix to manage your fluid balance. Your steroids were stopped on the medical floor and the medicines for your pneumonia were narrowed to treat the most likely organism. Your regular inhalers were continued. We followed your blood counts throughout your stay and it was not deemed necessary to transfuse additional blood at this time. You will return home with home nursing, oxygen, and physical therapy services. You should keep your oxygen saturation bewteen 88-92% and should use 3L of oxygen when active. You will also have cardiac telemonitoring to assist with monitoring your daily weights and blood pressures. The results of this will automitically be sent to Dr.[**Name (NI) 17793**] office. You should resume the medicines you were previously taking at home with the following changes: START: lisinopril 10 mg QD (daily) START: lasix 20 mg PO (by mouth) QD START: atorvastatin 80 PO QD START: Spiriva 1 puff [**Hospital1 **] (twice daily) CONTINUE: Levofloxacin 750 mg x1 dose ([**10-16**]) Followup Instructions: Please follow up with the appointments below after your discharge from the hospital: Name: [**First Name8 (NamePattern2) 16883**] [**Last Name (NamePattern1) **], NP Specialty: Internal Medicine When: Tuesday [**10-21**] at 9:30am Location: [**Location (un) 2274**]-[**University/College **] Address: [**Hospital1 3470**], [**University/College **],[**Numeric Identifier 23943**] Phone: [**Telephone/Fax (1) 17530**] Dr. [**Last Name (STitle) **] is out of the office next week so you will see his nurse [**First Name8 (NamePattern2) 3639**] [**First Name8 (NamePattern2) 16883**] [**Last Name (NamePattern1) **] at this visit. Name: [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 349**], MD Specialty: Hematology/Oncology When: Thursday [**10-23**] at 1:30p Location: [**Hospital1 641**] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 3468**] Name: [**Doctor First Name 30513**] [**Doctor First Name 88276**], PA Specialty: Cardiology When: Wednesday [**10-29**] at 11:30am Location: [**Hospital1 641**] Address: [**Hospital1 **], [**University/College **], [**Numeric Identifier **] Phone: [**Telephone/Fax (1) 72622**] You will see Dr. [**Last Name (STitle) 91422**] physicians assistant [**First Name5 (NamePattern1) 30513**] [**Last Name (NamePattern1) 88276**] at this visit. Completed by:[**2132-10-15**]

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Discharge summary

report

Admission Date: [**2152-2-9**] Discharge Date: [**2152-2-23**] Date of Birth: [**2074-4-3**] Sex: F Service: MEDICINE Allergies: Atorvastatin / Zestril / Cephalosporins / Penicillins Attending:[**First Name3 (LF) 9240**] Chief Complaint: unresponsive, hypoxia Major Surgical or Invasive Procedure: Endotracheal Intubation History of Present Illness: 77 yo female who lives at [**Hospital3 1186**] (baseline, oriented to person and place) had a fall at [**Hospital3 1186**]. 4 hrs later found unresponsive. Intubated at scene. CXR with RLL collapse/infiltrate; bronch/endotracheal specmen grew MSSA. Also with COPD exacerbation, on prednisone and vancomycin (given unknown PCN/ceph allergy). Extubated last week, failed (believed [**1-7**] COPD) and re-intubated. Extubated again on [**2152-2-18**] and now stable on 2L. Post-second extubation, made DNR/DNI. _______________ MICU summary by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]: HPI: 78f, h/o DM, HTN, found unresponsive 4 hrs after she was put into bed after a fall, intubated on scene, now more responsive - intubated/sedated. According to notes, she fell out of bed around 2am (denied trauma to head); assessment revealed normal vitals and patient was apparently mentating appropriately. She was put back in bed. About 3 hours later, she was found by staff to be unresponsive (she had been complaining of SOB--85% RA, improved with O2). VS were otherwise stable, BG was 97. EMS was called, and she was intubated on the seen and brought to the ED. In the ED, she was hypertensive (220/palp), afebrile, was responsive to commands when off sedation. Initial gas showed severe acidosis (7.11/111/141), potassium was increased to 6 with a creatinine of 1.8. One set of CEs that were negative. EKG showed sinus brady with no obvious ST/T changes. She was given 3 L IVF (was transiently hypotensive to 90s while on propofol -- this resolved off propofol and with IVF). She was found to have a positive UA and was given a dose of levofloxacin. She was given kayexalate for hyperkalemia (improvement of K to 5.3). FAST scan was negative, and she had CT neck/head. CT neck was significant for ?right RP soft tissue prominence (no fracture or dislocation), and CT head was negative for acute event. She was transferred to the [**Hospital Unit Name 153**] for further management. __________________________________________ MICU course -- per [**Hospital Unit Name 153**] notes: [**2-10**]: Bronch without mucous plug. BAL with 1+GPC pairs. Vanc and prednisone started. Echo with preserved EF, sm-mod pericard effusion. [**2-11**]: Failed PS trial due to tachypnea/tachycardia. Restarted lasix and increased lopressor. Added back home clonidine. Changed TFs started. Proteus returned [**Last Name (un) 36**] to cephalosporins/zosyn, so switched cipro to ceftriaxone [**2-12**]: Cleared c-spine clinically. On PS for several hours. UOP very low, gave repeated fluid boluses. Lasix d/c'd for rising Creatinine. [**2-13**]: Extubated, but retained C02/somnolent and required re-intubation. Lantus restarted at 1/2 home dose. [**2-14**]: RUE US - for DVT. Spoke with brother RE: trach, he's thinking about it but likely will pursue. Increased BP meds (clonidine). Diuresed with lasix X 2. [**2-15**]: Brother re: trach: no. Prednisone tapered to 40. Lantus increased to 30. [**2-16**]: DNR/DNI per family. Plan thoracentesis tomorrow, extubation Fri. [**2-17**]: Further discussion with family. No plan for trach. [**Female First Name (un) **] planned but not a large enough effusion. D/c'd antibiotics. [**2-18**]: Extubated. Tolerating at time of writing. Officially DNR/DNI: No re-intubation planned if she worsens. Past Medical History: 1. Status post right total knee replacement 2. DM II, c/b neuropathy and nephropathy. 3. Osteoarthritis. 4. Hypertension. 5. Asthma. 6. Hypercholesterolemia. 7. Parkinson's. 8. Obesity. 9. GERD. 10. Bipolar/paranoia. 11. History of falls. Social History: Shx: lives in an [**Hospital3 **] facility. No known h/o tobacco or alcohol use. Family History: NC Physical Exam: temp 96.5 BP 171/74 HR 58 RR 18 sats 99% on 2 liter oxygen nasal canula gen: very awake, very alert, pleasant, no acute distress, cooperative patient examined sitting up in a chair HEENT: anicteric sclera chest: good inspiratory air movement; a bit ronchorous on expiration throughtout heart: RRR; I could not notice a murmur abd: has PEG. very soft. BS+. not tender at all. is mildly distended tympanitic - notably upper [**12-7**] of abdomen (she is sitting in chair) ext: trace pitting edema LE bilaterally pulses: 2+ DP pulse bilaterally neuro: knows her full name. knows president is "[**Doctor Last Name **]." Identifies all 4 family members in the room correctly. eyebrows up symmetrically tongue is midline biceps is 4+/5 bilaterally handgrip is [**3-9**] bilaterally quads is [**4-8**] bilaterally plantarflexion feet is [**4-8**] bilaterally dorsiflexion feet is [**4-8**] bilaterally sensation to light touch is intact on her face/arms/legs (she correctly identifies the body part I touched) Pertinent Results: [**2152-2-9**] 07:29PM TYPE-ART TEMP-38.0 RATES-20/ TIDAL VOL-400 PEEP-10 O2-60 PO2-88 PCO2-51* PH-7.37 TOTAL CO2-31* BASE XS-2 -ASSIST/CON INTUBATED-INTUBATED [**2152-2-9**] 04:53PM TYPE-ART TEMP-36.6 PO2-241* PCO2-48* PH-7.35 TOTAL CO2-28 BASE XS-0 INTUBATED-INTUBATED [**2152-2-9**] 04:53PM LACTATE-0.7 [**2152-2-9**] 02:59PM GLUCOSE-88 UREA N-36* CREAT-1.4* SODIUM-147* POTASSIUM-4.1 CHLORIDE-111* TOTAL CO2-25 ANION GAP-15 [**2152-2-9**] 02:59PM CK(CPK)-44 [**2152-2-9**] 02:59PM CK-MB-4 cTropnT-0.03* [**2152-2-9**] 02:59PM CALCIUM-9.3 PHOSPHATE-3.0# MAGNESIUM-2.6 [**2152-2-9**] 02:59PM TSH-1.2 [**2152-2-9**] 02:59PM WBC-9.4 RBC-3.76* HGB-11.2* HCT-34.4* MCV-92 MCH-29.9 MCHC-32.7 RDW-16.7* [**2152-2-9**] 02:59PM PT-12.6 PTT-20.3* INR(PT)-1.1 [**2152-2-9**] 02:59PM PLT COUNT-305 [**2152-2-9**] 01:00PM PO2-205* PCO2-33* PH-7.46* TOTAL CO2-24 BASE XS-1 COMMENTS-GREEN TOP, [**2152-2-9**] 01:00PM K+-5.3 [**2152-2-9**] 08:15AM URINE COLOR-Yellow APPEAR-SlHazy SP [**Last Name (un) 155**]-1.025 [**2152-2-9**] 08:15AM URINE BLOOD-NEG NITRITE-POS PROTEIN->300 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-8.0 LEUK-MOD [**2152-2-9**] 08:15AM URINE RBC-0-2 WBC->50 BACTERIA-MANY YEAST-NONE EPI-0 [**2152-2-9**] 08:15AM URINE HYALINE-0-2 [**2152-2-9**] 08:15AM URINE 3PHOSPHAT-FEW [**2152-2-9**] 07:56AM TYPE-ART TIDAL VOL-280 PO2-231* PCO2-87* PH-7.16* TOTAL CO2-33* BASE XS-0 INTUBATED-INTUBATED VENT-CONTROLLED [**2152-2-9**] 06:49AM RATES-/16 PEEP-5 PO2-141* PCO2-111* PH-7.10* TOTAL CO2-36* BASE XS-1 INTUBATED-INTUBATED COMMENTS-GREEN TOP [**2152-2-9**] 06:49AM K+-5.8* [**2152-2-9**] 06:45AM GLUCOSE-125* UREA N-42* CREAT-1.8* SODIUM-143 POTASSIUM-6.0* CHLORIDE-107 TOTAL CO2-28 ANION GAP-14 [**2152-2-9**] 06:45AM estGFR-Using this [**2152-2-9**] 06:45AM ALT(SGPT)-15 AST(SGOT)-17 LD(LDH)-251* CK(CPK)-60 ALK PHOS-106 AMYLASE-25 TOT BILI-0.2 [**2152-2-9**] 06:45AM LIPASE-26 [**2152-2-9**] 06:45AM CK-MB-NotDone cTropnT-0.02* [**2152-2-9**] 06:45AM ALBUMIN-4.2 CALCIUM-10.0 PHOSPHATE-5.8* MAGNESIUM-2.9* [**2152-2-9**] 06:45AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2152-2-9**] 06:45AM WBC-9.3 RBC-3.87* HGB-11.8* HCT-37.5 MCV-97 MCH-30.5 MCHC-31.5 RDW-16.6* [**2152-2-9**] 06:45AM PT-12.5 PTT-22.6 INR(PT)-1.1 [**2152-2-9**] 06:45AM PLT COUNT-334 . CTA chest: 1. No pulmonary embolism or acute aortic pathology. 2. Right lower lobe collapse, left lower lobe partial collapse and patchy atelectasis of the aerated portions of lung. 3. Small bilateral pleural effusions. 4. Endotracheal tube terminates in low position 1-2 cm above the carina. 4. Multiple enlarged mediastinal lymph nodes up to 12 mm are nonspecific. 5. Moderate pericardial effusion. 6. Emphysema. 7. 3 cm predominantly low attenuation lesion of the left hepatic lobe is incompletely characterized, but has features suggestive of a hemangioma. This could be confirmed with ultrasound. . CT C spine: 1. No evidence of acute fracture or dislocation. 2. Soft tissue prominence mostly within the right retropharyngeal space and extending anterior and medial to the right carotid space. This likely represents a hematoma, possibly related to patient's traumatic injury or traumatic intubation. 3. Prominent interseptal thickening within the apices, may be related to underlying failure/volume overload as suggested on chest radiograph done on same day. 4. Multilevel spondylytic changes. . head CT: No intracranial hemorrhage or mass identified. . abd U/S: 2.9-cm lesion of the left hepatic lobe could represent an atypical hemangioma but is not definitively characterized by ultrasound. It does not have particularly worrisome features. If clinically indicated, it could be further characterized with MR after the patient's acute medical problems have resolved. . TTE: The left atrium is normal in size. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). Transmitral Doppler and tissue velocity imaging are consistent with Grade I (mild) LV diastolic dysfunction. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). The left ventricular inflow pattern suggests impaired relaxation. There is a small to moderate sized pericardial effusion. There are no echocardiographic signs of tamponade. Brief Hospital Course: ## PULM - Respiratory failure that was thought to be multifactorial (PNA, COPD, RLL collapse, tracheomalacia, diastolic heart failure) has resolved and pt now on 2 Liters of oxygen by nasal canula with sats of 99%. She is completing a 2 weeks course of vancomcycin for MSSA PNA. ## CARDS - hx of HTN and is on MANY medications for control and still has elevated BP. Has diastolic CHF. Initially BP meds held given instability, but then restarted. On [**2-22**] she triggered on the floor for flash pulmonary edema with elevated BP. After giving IV lasix and better BP control her CHF improved. She may need continued diuresis at NH. Will need daily weights, 1500 cc fluid restriction. ## GI - has hx of PEG and I am not sure why. Tolerates po, apparently. Of note, imaging studies found a possible hemangioma on liver. Will need f/u abdominal MRI per PCP as an outpatient. ## GU - Cr back to normal, follow up with PCP after diuresis. ## ID s/p treatment for proteus UTI and also proteus PNA (sputum + currently finishing abx for MSSA PNA. Pt on vanco bc of concerns of allergies to PCN. Last day will be [**2-25**] of vanco. # ENDO. Pt has DM with HgAIC in [**2149**] of 10. Pt with multiple cardiac risk factors so would hope to get better glucose control. Currently on ss insulin. Restarted pt's home lantus dose. code status: DNR/DNI decision maker is her brother [**Name (NI) **] [**Name (NI) 3234**] [**Telephone/Fax (1) 19567**] Medications on Admission: 1. Novolin R sliding scale 2. Toprol XL 100mg po bid 3. Tylenol 500mg, one tab qid po 4. Alprazolam 0.5 mg tablet po qhs 5. Fleets enema 1 rectally daily prn constipation (2 hr after docolax supp if no BM) 6. Bisocodyl 10 mg supp rectally daily prn constipation (give 24 hrs after MOM of no BM) 7. MOM 30 ml via g-tube daily prn constipation (give on 3rd day without BM) 8. Alprazolam 1 mg tablet po bid prn anxiety/agitation 9. Combivent inhaler 2 puffs by mouth qid prn wheezing 10. Tylenol 650 mg via g-tube q 4 hr prn pain/temp >100 11. Duonieb neb 0.02% qid prn congestion/SOB 12. Lantus 35 units sc q evening 13. Neurontin 50 mg po qhs 14. Isosorbide 60 mg po daily 15. Norvasc 10 mg po daily 16. Prilosec 20 mg po daily 17. Seroquel 100 mg po daily at 4pm 18. Quinine sulfate 260 mg po daily at 8pm 19. Clonidine HCl 0.1 mg po q 12 hr 20. Depakote 250 mg po bid 21. Furosemide 40 mg po daily 22. Senna 2 tablets po bid Discharge Medications: 1. Prilosec 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Zinc Sulfate 220 (50) mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 6. Divalproex 125 mg Capsule, Sprinkle Sig: Two (2) Capsule, Sprinkle PO BID (2 times a day). 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 9. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 10. Losartan 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 12. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO BID (2 times a day). 13. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. Insulin Glargine 100 unit/mL Solution Sig: Thirty Five (35) units Subcutaneous at bedtime. 15. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: sliding scale sliding scale Subcutaneous four times a day. 16. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 17. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Prednisone 10 mg Tablet Sig: taper as directed Tablet PO once a day: Take 3 tabs daily for 3 days, then 2 tabs daily for 3 days, then 1 tab daily for 3 days, then stop. Disp:*18 Tablet(s)* Refills:*0* 19. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q4H (every 4 hours). 20. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q2H (every 2 hours) as needed. 21. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 22. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed. 23. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) g Intravenous Q 24H (Every 24 Hours) for 3 days. Disp:*3 g* Refills:*0* 24. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 1186**] - [**Location (un) 538**] Discharge Diagnosis: Diastolic Congestive Heart Failure Staph Pneumonia Respiratory Failure COPD Discharge Condition: stable Discharge Instructions: Continue your medications as listed. Please continue a 1500 cc fluid restiction, and a low salt diet. Please make sure to weigh yourself daily and call your doctor if you gain more than 3lbs. Please make sure you follow up with your PCP [**Last Name (NamePattern4) **] [**12-7**] weeks. Followup Instructions: 1. Please follow up with Dr. [**Last Name (STitle) **] in [**12-7**] weeks. Please discuss having a follow up abdominal MRI with him to evalaute the liver mass seen on ultrasound.

[ "583.81", "428.31", "491.21", "332.0", "518.81", "599.0", "V43.65", "402.91", "V15.88", "519.19", "278.01", "530.81", "296.80", "707.09", "V44.1", "584.9", "250.60", "276.2", "250.40", "V58.67", "276.7", "357.2", "482.41" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

14617, 14690

9811, 11257

334, 360

14810, 14819

5157, 8624

15154, 15337

4106, 4110

12233, 14594

14711, 14789

11283, 12210

14843, 15131

4125, 5138

273, 296

388, 3728

8633, 9788

3750, 3990

4006, 4090

66,604

194,890

37408

Discharge summary

report

Admission Date: [**2126-2-27**] Discharge Date: [**2126-3-4**] Date of Birth: [**2063-10-27**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Known firstname 4748**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: [**2126-2-28**]: Axillobifemoral bypass graft from the left axillary artery [**2126-3-1**]: 1. Debridement of infected aorta, oversewing of aortic stump both proximally and distally, removal of infected aortic graft and thrombectomy of thrombosed axillobifemoral bypass graft 2. Re-exploration of left common femoral artery for thrombosis. Left iliofemoral embolectomy [**2126-3-4**]: Bilateral chest tube placement History of Present Illness: The pt is a 62-yo man w/ COPD and h/o PE transferred from [**Hospital **] hospital H/o EVAR done for a leaking aneurysm in the setting of MRSA Bacteremia ?mycotic aneurysm in [**2125-12-14**]. He complained of right lower back/groin pain for 2 weeks; Last 2 days he has abdominal pain poorly localized radiates to ths back and b/l groin. It was [**7-23**], associated with nausea and vomiting for 1 day. Decreased appetite last few days. Last BM 2 days ago; passing flatus, no fever, No chest pain/SOB Past Medical History: VASCULAR HISTORY: AAA, Endovascular Repair. PAST MEDICAL HISTORY: Past Medical History: - COPD, on 2L home O2 - frequent pneumonia - h/o PE - h/o EtOH dependence - s/p RLL lobectomy [**2122**] for hamartoma PAST SURGICAL HISTORY: endograft repair of a ruptured abdominal aortic aneurysm. Social History: Smokes [**12-15**] cigarettes / day currently, has >30-pack-year hx. Also has remote h/o EtOH abuse, but does not drink currently. Denies illicits Family History: Non-contributory Physical Exam: On admission: Vital Signs: Temp: 98.3 RR: 21 Pulse: 103 BP: 99% Neuro/Psych: Oriented x3, Affect Normal. Neck: No masses, Trachea midline, No right carotid bruit, No left carotid bruit. Skin: No atypical lesions. Heart: Regular rate and rhythm. Lungs: Clear, Normal respiratory effort. Gastrointestinal: Non distended, abnormal: Diffuse tenderness; No guarding or rebound. Rectal; hard stool; no occult or gross blood Extremities: No popiteal aneurysm, No femoral bruit/thrill, No RLE edema, No LLE Edema, No varicosities, No skin changes. Pulse Exam (P=Palpation, D=Dopplerable, N=None) LUE Radial: P. RLE Femoral: D. DP: D. PT: D. LLE Femoral: D. DP: D. PT: D. Pertinent Results: [**2126-2-26**] 09:36PM BLOOD WBC-6.7 RBC-3.33* Hgb-9.2* Hct-27.7* MCV-83# MCH-27.6# MCHC-33.2 RDW-14.9 Plt Ct-263# [**2126-3-3**] 11:51PM BLOOD WBC-17.4* RBC-3.92* Hgb-11.3* Hct-35.1* MCV-89 MCH-28.8 MCHC-32.2 RDW-16.0* Plt Ct-217 [**2126-2-26**] 09:36PM BLOOD Neuts-77.5* Lymphs-15.1* Monos-6.5 Eos-0.7 Baso-0.2 [**2126-2-26**] 09:36PM BLOOD PT-13.2 PTT-32.1 INR(PT)-1.1 [**2126-3-1**] 05:05PM BLOOD PT-18.0* PTT-116.3* INR(PT)-1.6* [**2126-3-2**] 04:04AM BLOOD PT-13.8* PTT-62.8* INR(PT)-1.2* [**2126-3-3**] 11:51PM BLOOD PT-14.0* PTT-150* INR(PT)-1.2* [**2126-3-1**] 05:05PM BLOOD Fibrino-419* [**2126-3-3**] 06:57PM BLOOD Fibrino-530* [**2126-2-27**] 04:35AM BLOOD ESR-125* [**2126-2-26**] 09:36PM BLOOD Glucose-97 UreaN-11 Creat-0.7 Na-139 K-4.1 Cl-101 HCO3-26 AnGap-16 [**2126-3-1**] 11:48PM BLOOD Glucose-171* UreaN-18 Creat-1.2 Na-134 K-4.9 Cl-105 HCO3-22 AnGap-12 [**2126-3-3**] 11:51PM BLOOD Glucose-181* UreaN-47* Creat-3.1* Na-136 K-7.0* Cl-101 HCO3-17* AnGap-25* [**2126-2-28**] 03:21PM BLOOD ALT-6 AST-9 AlkPhos-63 [**2126-3-3**] 10:26PM BLOOD ALT-32 AST-50* LD(LDH)-594* AlkPhos-102 Amylase-10 TotBili-3.7* [**2126-2-28**] 03:21PM BLOOD CK-MB-2 cTropnT-<0.01 [**2126-3-3**] 02:23AM BLOOD CK-MB-4 cTropnT-<0.01 [**2126-2-28**] 03:30PM BLOOD Type-ART Temp-36.6 O2 Flow-10 pO2-99 pCO2-30* pH-7.45 calTCO2-21 Base XS--1 Intubat-NOT INTUBA [**2126-3-2**] 12:20AM BLOOD Type-ART Temp-37.2 Rates-14/0 Tidal V-600 PEEP-5 FiO2-50 pO2-75* pCO2-48* pH-7.25* calTCO2-22 Base XS--6 Intubat-INTUBATED Vent-CONTROLLED [**2126-3-3**] 03:36PM BLOOD Type-ART Temp-38.1 Rates-16/10 Tidal V-400 PEEP-10 FiO2-80 pO2-95 pCO2-51* pH-7.24* calTCO2-23 Base XS--5 AADO2-429 REQ O2-74 Intubat-INTUBATED Vent-CONTROLLED [**2126-3-3**] 11:55PM BLOOD Type-ART pO2-68* pCO2-74* pH-7.00* calTCO2-20* Base XS--14 [**2126-3-4**] 12:39AM BLOOD Type-ART pO2-58* pCO2-65* pH-6.96* calTCO2-16* Base XS--19 Echo [**2126-3-4**]: No spontaneous echo contrast is seen in the left atrial appendage. No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. There is no aortic valve stenosis. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. IMPRESSION: Preserved [**Hospital1 **]-ventricular systolic function. No pericardial effusion. Brief Hospital Course: Mr. [**Known lastname 634**] was admitted to the vascular surgery service on [**2126-2-26**] for treatment of his abdominal pain and infected aortic graft. He was admitted to the CVICU and placed on vancomycin, ciprofloxacin and flagyl after blood cultures were obtained. He had an uneventful night with stable pain and the following day he was transfered to the VICU. Infectious disease was consulted and they recommended his antibiotic regimen be narrowed to vancomycin alone based on previous cultures. The cultures from this admission grew vancomycin resistant staph aureus, and his antibiotic was changed to daptomycin with ID input. The decision was made to proceed with surgical resection of his infected aortic graft. He was preoped and consented for surgery. On [**2126-2-28**], he was taken to the OR for axillo-bifem bypass to provide distal flow prior to aortic resection. He tolerated this procedure without complication and was transfered to the PACU extubated in stable condition. He arrived to the VICU on a heparin drip at 700units/hr, NPO and with IV dilaudid for pain. The following day, he was prepped for the OR and taken back for resection of his infected aortic graft. He tolerated the procedure well and was transfered to the PACU intubated. It was noted in the PACU that his left foot was cold and without pulses. He was taken back to the OR for exploration and embolectomy. He again remained intubated on transfer to the PACU. Doppler signals were present in both feet post-procedure. He remained in the PACU overnight on a heparin drip. He required several IV fluid boluses to help maintain his SBP >100, but he otherwise remained stable overnight. The next day, the patient was transfered to the CVICU. That evening, he became more difficult to ventilate despite paralysis. He acutely dropped his blood pressure and chest x-ray was obtained revealed a left tension pneumothorax. Left chest tube was placed with improvement of his blood pressure. There continued to be difficulty ventilating the patient and again his blood pressure dropped. A right sided chest tube was placed. ACLS was initiated, but the patient was unable to be resuscitated and expired on [**2126-3-4**]. Medications on Admission: 1. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 3. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 4. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* Discharge Medications: N/A Discharge Disposition: Expired Discharge Diagnosis: mycotic aneurysm s/p axillo-bifem bypass graft and removal of infected graft with resection of infected aorta Discharge Condition: Expired Discharge Instructions: N/A Followup Instructions: N/A Completed by:[**2126-3-6**]

[ "276.7", "V10.11", "V45.89", "584.5", "441.3", "285.9", "458.29", "303.90", "996.74", "493.20", "V12.51", "492.8", "518.5", "571.2", "305.1", "512.1", "041.12", "401.9", "E878.2", "996.62", "444.22", "790.7", "276.2", "427.5" ]

icd9cm

[ [ [] ] ]

[ "39.49", "34.04", "88.72", "99.62", "93.90", "99.60", "38.08", "38.93", "38.91", "33.24", "39.29" ]

icd9pcs

[ [ [] ] ]

8227, 8236

5173, 7377

328, 745

8389, 8398

2489, 5150

8450, 8483

1772, 1790

8199, 8204

8257, 8368

7403, 8176

8422, 8427

1531, 1591

1805, 1805

274, 290

773, 1278

1819, 2470

1388, 1508

1607, 1756

25,559

184,681

27299+57543

Discharge summary

report+addendum

Admission Date: [**2199-5-6**] Discharge Date: [**2199-5-10**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2387**] Chief Complaint: NSTEMI s/p PCI w/stent x2 to RCA c/b cardiac arrest, IABP, and intubated Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: 83yo F w/poorly controlled HTN (LVH), longstanding diabetes, dyslipidemia, renal insufficiency, s/p recent laminectomy on [**2199-5-4**]. During pre-op evaluation had an unremarkable Dobutamine ECHO on [**4-27**]. Post operative course c/b ischemic symptoms, CP, ECG changes-acute inferolateral downsloping ST depressions, and +CE. CK 500S, MB +3.8, Tn-T 7.67 then 37. In setting of being 48hours post op from laminectomy, she did not receive heparin. She received ASA, Nitrates, IV lopressor and underwent a diagnostic cath at NEBH. Cath showed R-dominant systed with 3VD. She was transferred to [**Hospital1 18**] for further intervention. She received 3 UPRBC for anemia at NEBH. . On arrival to Cath lab she received Plavix 300mg. During Cath found 99%RCA Mid/moderate proximal with [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] x2 to RCA. During LAD injection with dye pt went into Asystole, CPR was initiated, gave Atropine 1mg x1, Epi 1mgx1 and placed IABP followed by intubation for airway protection. LAD w/acute occlusion possibly due to vasospasm vs. embolic event as LAD was found to be patent without requiring stent placement immediately after this transient event. She then received [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] stent to L-Cx. Pt underwent TTE in holding area w/EF 40-45%, 1+AR, 2+TR, 1+MR, Overall left ventricular systolic function is mildly to moderately depressed with akinesis of the infero-lateral wall and hypokinesis of the inferior wall. She received Lasix 40mg IV x1 and was sent to the CCU for further management. Past Medical History: -OA -Spinal Stenosis s/p Laminectomy [**2199-5-4**] -Hyperlipidemia -GERD -Renal Insufficiency (Cr 2.4 negative renal U/S) -AI -Depression -IDDM Social History: Lives in [**State 108**] year round, visiting kids in the area Family History: N/C Physical Exam: VS: 120/56 71 Intubated AC 500/14/5/100% ABG:7.33/40/90 GEN: Sedated, Intubated HEENT: ETT in place, RESP: Coarse BS throughout, Crackles at bases CV: Reg Nml S1, S2, 2/6HSM, JVP at 10cm ABD: Soft ND/NT +BS EXT: No peripheral edema, 2+DP pulses b/l Pertinent Results: [**2199-5-6**] 11:27PM POTASSIUM-3.8 [**2199-5-6**] 11:27PM CK(CPK)-457* [**2199-5-6**] 11:27PM CK-MB-21* MB INDX-4.6 cTropnT-3.92* [**2199-5-6**] 11:27PM HCT-30.5* [**2199-5-6**] 11:27PM PLT COUNT-125* [**2199-5-6**] 08:40PM TYPE-ART TEMP-37.3 RATES-14/ PEEP-8 PO2-147* PCO2-32* PH-7.39 TOTAL CO2-20* BASE XS--4 INTUBATED-INTUBATED VENT-CONTROLLED [**2199-5-6**] 08:40PM GLUCOSE-93 [**2199-5-6**] 04:32PM TYPE-ART RATES-14/ TIDAL VOL-500 PEEP-5 PO2-89 PCO2-39 PH-7.37 TOTAL CO2-23 BASE XS--2 INTUBATED-INTUBATED [**2199-5-6**] 03:01PM O2 SAT-96 [**2199-5-6**] 03:01PM TYPE-ART PO2-90 PCO2-40 PH-7.33* TOTAL CO2-22 BASE XS--4 INTUBATED-INTUBATED [**2199-5-6**] 02:53PM GLUCOSE-185* UREA N-24* CREAT-1.6* SODIUM-137 POTASSIUM-3.9 CHLORIDE-106 TOTAL CO2-19* ANION GAP-16 [**2199-5-6**] 02:53PM CALCIUM-7.0* PHOSPHATE-4.0 MAGNESIUM-1.7 [**2199-5-6**] 02:53PM CK-MB-20* cTropnT-2.17* [**2199-5-6**] 02:53PM WBC-11.4* RBC-3.92* HGB-12.0 HCT-34.5* MCV-88 MCH-30.7 MCHC-34.9 RDW-14.2 [**2199-5-6**] 02:53PM PLT COUNT-134* [**2199-5-6**] 12:43PM O2 SAT-95 [**2199-5-6**] 12:43PM K+-3.5 [**2199-5-6**] 12:08PM TYPE-ART RATES-/12 TIDAL VOL-500 PEEP-5 O2-100 PO2-106* PCO2-40 PH-7.27* TOTAL CO2-19* BASE XS--7 AADO2-585 REQ O2-94 -ASSIST/CON INTUBATED-INTUBATED [**2199-5-6**] 12:08PM HGB-14.0 calcHCT-42 O2 SAT-97 [**2199-5-6**] 10:45AM GLUCOSE-151* UREA N-24* CREAT-1.5* SODIUM-140 POTASSIUM-4.4 CHLORIDE-106 TOTAL CO2-21* ANION GAP-17 [**2199-5-6**] 10:45AM ALT(SGPT)-20 AST(SGOT)-96* CK(CPK)-689* ALK PHOS-32* AMYLASE-92 TOT BILI-0.6 [**2199-5-6**] 10:45AM CK-MB-22* MB INDX-3.2 cTropnT-1.71* [**2199-5-6**] 10:45AM ALBUMIN-2.9* CHOLEST-93 [**2199-5-6**] 10:45AM TRIGLYCER-134 HDL CHOL-42 CHOL/HDL-2.2 LDL(CALC)-24 [**2199-5-6**] 10:45AM WBC-11.3* RBC-4.20 HGB-13.2 HCT-36.6 MCV-87 MCH-31.6 MCHC-36.2* RDW-14.1 [**2199-5-6**] 10:45AM NEUTS-84.4* BANDS-0 LYMPHS-9.4* MONOS-5.0 EOS-0.8 BASOS-0.5 [**2199-5-6**] 10:45AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2199-5-6**] 10:45AM PT-12.3 PTT-29.8 INR(PT)-1.1 . EKG: -NSR 74 bpm, L axis deviation -ST depressions V3-V5, TWI III, aVF . Cath at NEBH-R Dominant, LAD 70-80%; D2 90% at origin, Mid LAD 70%, LVEF 49%, 3+MR, Inf-post HK, Mild A/L HK, CI 1.7, LVEDP 30 PCWP 19 . [**Hospital1 18**] Cath [**2199-5-6**]: RCA 99% s/p stent x2, CX 90% cypher stent x1; PA 38/23 Mean 30, PCWP 18 CO 4.87 CI 3.15 . ECHO [**5-6**] Conclusions: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size. Overall left ventricular systolic function is mildly to moderately depressed with akinesis of the infero-lateral wall and hypokinesis of the inferior wall. No masses or thrombi are seen in the left ventricle. 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. Moderate (2+) mitral regurgitation is seen. The mitral regurgitation jet is eccentric. The left ventricular inflow pattern suggests impaired relaxation. Moderate [2+] tricuspid regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Regional LV systolic dysfunction c/w CAD. Moderate mitral and tricuspid regurgitation. No pericardial effusion. . [**5-8**] Renal U/S IMPRESSION: No evidence of hydronephrosis. Simple cysts in both kidneys. . Brief Hospital Course: Asessment: 83 yo F s/p NSTEMI w/3VD on cath, s/p PCI to RCA and Cx, c/b transient occlusion of LAD [**1-24**] embolic event, s/p intubation and IABP placement . # CARDIOVASCULAR 1. CAD: s/p revascularization (see HPI). We continued ASA, Plavix, Beta Blocker and started high dose statin. ACE was held n the setting of ARF (see below). We cycled CE until peak Troponin of 4.32 and CK of 689 (index peak was 5.1). Upon arrival in CCU, we discontinued Nitro gtt, norvasc, and witheld hep gtt and integrellin (s/p recent back surgery). Her IABP was discontinued on HD #1. Her BB was temporarily held for low BP (SBP 80s-90s) but this resolved on HD #1. An echocardiogram showed EF 40-45% with 1+ AI and 2+ MR [**First Name (Titles) **] [**Last Name (Titles) **]. There was inferolateral Akinesis and Inferior Hypokinesis. While she experienced some back pain, she denied CP throughout the admission. . 2. PUMP: TTE w/EF 40-45%, hypotension during cath requiring IABP. We weaned IABP to off (d/c'd IABP [**5-6**]). Given 2+MR, we afterload reduced with gentle diuresis and monitored hemodynamics carefully. BPs were transiently low on HD #1 but resolved. . # RESPIRATORY FAILURE: PT arrested during cath (PEA arrest), requiring CPR and intubation for airway protection. Infiltrate on CXR was thought to be possible aspiration PNA, so we started Clinda on [**5-6**] (planned 7 day course). She was gently diuresis with lasix prn. On HD #1, she was extubated without event after a successful ventillator wean. She remained off the ventillator throughout the duration of the admission and required minimal (2L) Nasal Cannula by day of transfer. . #. RENAL: Underlying renal insufficiency possibly from HTN and DM. She subsequently developed ARF thought to be secondary to ATN with low urine output and a bump in her creatinine with a peak of 3.9 2 days prior to transfer and a BUN of 43 at that time. We avoided nephrotoxin meds, renally dosed all meds and stopped her Ace-inhibitor and held diuretics in the setting of ARF. A renal ultrasound was normal (no hydronephrosis). Urine lytes were consistent with a low FENa. Renal consulted and considered her ARF secondary to contrast nephropathy. . #. HEMATURIA: pt received 3UPRBC at OSH for anemia, unclear whether anemia secondary to hematuria. Cytology was sent and is pending at time of transfer. She received 1 unit of PRBCs on [**5-7**] for a HCT of 30 but this has since stabilized in the low 30s. . #. BACK PAIN: She had pain throughout the admission, She is s/p recent laminectomy. Ortho-spine conulted and stated that unless she had increased pain below the knee of headache, MR/Lspine was not necessary. PT followed but she was too deconditioned during this admission to ambulate. . #. RASH: Pt had a rash s/p percocet. This was switched to Dilauded and the rash resolved. . #. DM: Held oral hypoglycemic meds, ISS and FS during this admission. . #. PPX: Hep SC, PPI . #. CODE: FULL . Medications on Admission: MEDS at Home: -Atenolol 50mg daily -Diovan 100mg daily -Folic Acid -MVI -Calcium -Actonel -Zetia 10mg -Caduet 5/40 off -Cymbalta 60mg daily -ASA 81mg daily -Protonix 40mg daily -Glyburide 10mg [**Hospital1 **] -Glucophage 500mg . MEDS at OSH: - Nitro gtt 40mg/min - Hep gtt - Protonix - Diovan - Zetia - Cymbalta - Lipitor - Norvasc - ASA 325 - Lopressor - Glyburide Discharge Disposition: Extended Care Discharge Diagnosis: NSTEMI with Catheterization and Stents Hyperlipidemia ARF DM Discharge Condition: Stable Discharge Instructions: Please take all medications as prescribed Seek medical attention immediately if you experience new chest pain, shortness of breath, fatigue, dizziness, fainting, arm or jaw pain, or any other new concerning symptoms. Followup Instructions: With Dr. [**Last Name (STitle) **] at NEBH (being transferred to his care today) Name: [**Known lastname 11642**],[**Known firstname 471**] Unit No: [**Numeric Identifier 11643**] Admission Date: [**2199-5-6**] Discharge Date: [**2199-5-10**] Date of Birth: [**2116-2-14**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 276**] Addendum: See discharge meds below Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 6. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 7 days. 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 12. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO HS (at bedtime). 13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 284**] MD [**MD Number(1) 285**] Completed by:[**2199-5-10**]

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icd9cm

[ [ [] ] ]

[ "99.60", "36.07", "00.46", "37.23", "00.66", "00.41", "96.04", "37.61", "99.04", "96.71" ]

icd9pcs

[ [ [] ] ]

11600, 11770

6088, 9059

334, 359

9597, 9606

2524, 6065

9872, 10369

2234, 2239

10392, 11577

9513, 9576

9085, 9454

9630, 9849

2254, 2505

222, 296

387, 1969

1991, 2138

2154, 2218

78,005

110,094

40889

Discharge summary

report

Admission Date: [**2195-9-11**] Discharge Date: [**2195-9-21**] Date of Birth: [**2124-1-28**] Sex: F Service: NEUROSURGERY Allergies: morphine / pollen / cats / Oxycodone Attending:[**First Name3 (LF) 1271**] Chief Complaint: Anterior kyphosis due to tumor T7 and T8. Major Surgical or Invasive Procedure: 1. Open reduction of compression fracture T7 and T8. 2. Arthrodesis from T1 to T11segmental. 3. Instrumentation T1 to T11. History of Present Illness: Dr. [**Last Name (STitle) 739**] saw Ms. [**Known lastname 41033**] as a neurosurgical evaluation follow-up after her visit in the hospital and hospitalization. She has a large lytic lesion on the vertebral body of T7 and minimal on T8 on one side. She was placed on TLSO brace while she was getting radiation treatment in hopes of improving her symptoms and not needing surgery. However, she still has significant back pain and point tenderness. Her strength was full in both lower extremities. No hyperreflexia, no myelopathy. CT imaging showed a lytic lesion at T7 seems to have increased in size and also there is anterior wedge collapse of the T7 vertebral body. Relatively stable T8 lesion. Dr. [**Last Name (STitle) 739**] recommended a thoracic fusion and she agreed to proceed. Past Medical History: PMH: -T3 N0 large cell lung carcinoma with neuroendocrine features, s/p lobectomy and chemotherapy -Asthma -GERD -Hypercholesterolemia PSH: -Open appendectomy -B breast lumpectomy -Left meniscus repair -Right cataract -Carpal tunnel Social History: Lives with family. Tobacco 50 pack-year quit [**2163**]. ETOH occasional Family History: non-contributory Physical Exam: Motor exam: full strength in upper and lower extremities bilaterally Sensory: intact to light touch in all groups incision is with slight staple irritation redness along incision extr: no c/c/e Pertinent Results: [**2195-9-10**] MRI T-Spine: Soft tissue mass replacing the majority of the T7 vertebral body with interval pathologic compression fracture of the T7 vertebral body. Soft tissue mass extends into the T6 and T8 vertebral bodies as described above; findings are again compatible with metastatic disease. [**2195-9-12**] T-spine Xray AP and Lateral: T1-11 fusion, adequate hardware placement and [**Last Name (un) 2043**] alignment [**2195-9-14**] KUB:Diffuse mildly dilated loops of small and large bowel are compatible with ileus. [**9-16**] LENIs - No evidence of deep vein thrombosis either right or left lower extremity. Brief Hospital Course: The patient was admitted to the Neurologic Surgery Service for management of a anterior kyphosis due to tumor T7 and T8. The patient was taken to the OR and underwent an uncomplicated T1-11 instrumented fusion. The patient tolerated the procedure without complications and was transferred to the PACU in stable condition. Please see operative report for details. Post operatively pain was controlled with intravenous medication with a transition to PO pain meds once tolerating POs. The patient tolerated diet advancement without difficulty and made steady advancement with diet and ambulation. On the evening of POD 2 she developed worsening back pain and required an increase in IV pain medication for breakthrough pain. In the morning of POD3 however the patient developed an episode of delerium that cleared over 20-30 minutes, likely related to pain medication and muscle relaxants and exhaustion. UA and culture were sent. Geriatrics team was consulted for recommendations on pain medications to limit delerium. She developed abdomninal pain and distension and KUB demonstrated Ileus. Soap [**Last Name (un) **] enema was administered for presence of larege amounts of stool on KUB. She was passing flatus and was somewhat more confortable on [**9-15**]. She was mobilized with PT and OT. Her Foley was discontinued. Per Geriatrics, trazodone replaced benadryl for her sleep aide and tylenol was made ATC. [**9-16**] patient was having some loose stools, but was having difficulty urinating. She was straight cathed several times and eventually the foley catheter was replaced. Lower extremity Dopplers were performed for complaint of calf tenderness and there was o DVT. Follow up KUB showed minimal improvment in ileus and no SBO. She was OOB more on [**9-17**] and continued to have significant flatus. she had less pain. On [**9-18**], patient continued to have mild nausea. As a result, patient was started on reglan to increase gastric motility. In addition, her foley was d/c'd in routine fasion. She continued to improve in terms of her constipation. She continued to pass [**Last Name (un) **]. Belly pain improved. Now DOD, patient is afebrile, VSS, and neurologically stable. Patient's pain is well-controlled and the patient is tolerating a good oral diet. Pt's incision is clean, dry and intact without evidence of infection. Patient is ambulating without issues. Patient's brace was fitted and patient received instructions on care and appropriate use. She is set for discharge home in stable condition and will follow-up accordingly. Medications on Admission: ALBUTEROL SULFATE - (Prescribed by Other Provider) - albuterol sulfate HFA 90 mcg/actuation Aerosol Inhaler 1 to 2 puffs inhaled every 4-6 hours as needed ESTERTEST - (Prescribed by Other Provider) - GABAPENTIN - gabapentin 100 mg capsule 1 capsule(s) by mouth three times a day HYDROMORPHONE - hydromorphone 2 mg tablet [**1-5**] tablet(s) by mouth every 3-4 hours as needed for pain LACTULOSE - (Prescribed by Other Provider) - lactulose 20 gram/30 mL Oral Soln 30 ml by mouth twice a day MEDROXYPROGESTERONE - (Prescribed by Other Provider) - medroxyprogesterone 2.5 mg tablet Tablet(s) by mouth OMEPRAZOLE - (Prescribed by Other Provider) - omeprazole 20 mg capsule,delayed release 2 (Two) capsule(s) by mouth DAILY VALSARTAN [DIOVAN] - (Prescribed by Other Provider) - Diovan 160 mg tablet 1 (One) tablet(s) by mouth once a day Medications - OTC CHOLECALCIFEROL (VITAMIN D3) - (Prescribed by Other Provider) - cholecalciferol (vitamin D3) 1,000 unit capsule 1 Capsule(s) by mouth DAILY DOCUSATE SODIUM [COLACE] - (Prescribed by Other Provider) - Colace 100 mg capsule 1 capsule(s) by mouth twice a day POLYETHYLENE GLYCOL 3350 - (Prescribed by Other Provider; OTC) - polyethylene glycol 3350 17 gram/dose Oral Powder 17 g by mouth twice a day SENNOSIDES [SENNA] - (Prescribed by Other Provider; OTC) - senna 8.6 mg tablet 1 tablet(s) by mouth twice a day Discharge Medications: 1. Acetaminophen 650 mg PO Q6H max 4g/day 2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheezing Administered by Respiratory 3. Bisacodyl 10 mg PO/PR DAILY 4. Docusate Sodium 100 mg PO BID 5. Famotidine 20 mg PO BID 6. Gabapentin 200 mg PO TID 7. Heparin 5000 UNIT SC TID DVT prophylaxisi 8. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain 9. Lactulose 30 mL PO Q 8H 10. Lidocaine 5% Patch 2 PTCH TD DAILY to paraspinal muscles on each side of incision, DO NOT place over incision. 12 hrs on, 12 hours off 11. Metoclopramide 10 mg PO TID 12. Milk of Magnesia 30 mL PO Q6H:PRN constipation 13. Ondansetron 8 mg IV Q6H:PRN N/V 14. Polyethylene Glycol 17 g PO DAILY no BM 15. Senna 2 TAB PO QHS 16. Simethicone 40-80 mg PO QID:PRN GAS 17. Valsartan 80 mg PO DAILY Hold for SBP < 100 18. Vitamin D 1000 UNIT PO DAILY Discharge Disposition: Extended Care Facility: [**Doctor Last Name **] Nursing & Rehabilitation Center - [**Location (un) **] Discharge Diagnosis: Anterior kyphosis due to tumor T7 and T8. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: ?????? You should wear your brace when out of bed or when your head of bed is above 30 degrees. ?????? You may put the brace on at the edge of your bed. ?????? You may use a shower chair to bathe without the brace on. ?????? No tub baths or pool swimming for two weeks from your date of surgery. ?????? Do not smoke. ?????? 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. Pain medication should be used as needed when you have pain. You do not need to take it if you do not have pain. ?????? Do not take any anti-inflammatory medications such as Motrin, Advil, Aspirin, and Ibuprofen etc. for two weeks. ?????? 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. Followup Instructions: ??????Please return to the office in [**7-14**] days (from date of surgery) for removal of your staples. This appointment can be made with the Physician Assistant or [**Name9 (PRE) **] Practitioner. Please make this appointment by calling [**Telephone/Fax (1) 1272**]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????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 AP and Lateral Thoracic Spine X-rays prior to your appointment. [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2195-9-21**]

[ "E878.1", "530.81", "737.19", "560.1", "V10.11", "733.13", "272.4", "E849.7", "493.90", "V15.82", "458.29", "780.09", "997.49", "401.9", "198.5" ]

icd9cm

[ [ [] ] ]

[ "81.05", "81.64", "03.53" ]

icd9pcs

[ [ [] ] ]

7393, 7498

2558, 5134

344, 469

7584, 7584

1906, 2535

9029, 9739

1658, 1676

6556, 7370

7519, 7563

5160, 6533

7735, 9006

1691, 1887

262, 306

497, 1292

7599, 7711

1314, 1549

1565, 1642

13,440

101,433

29932

Discharge summary

report

Admission Date: [**2138-12-19**] Discharge Date: [**2139-1-20**] Service: SURGERY Allergies: Sulfa (Sulfonamides) Attending:[**First Name3 (LF) 1556**] Chief Complaint: Nausea, vomiting, Abdominal pain, distention. Major Surgical or Invasive Procedure: 1. Subtotal colectomy, end ileostomy, Hartmann's pouch, G-tube 2. Completion sigmoid colectomy, repair of colovesicular fistula, small bowel repair History of Present Illness: Ms [**Known lastname 71508**] is an 84 year old female with complaints of abdominal pain, diarrhea, nausea and vomiting x 1 week, who presented to an outside hospital. She was transferred to [**Hospital1 18**] on [**2139-12-19**] for bowel obstruction, ischemia and worsening abdominal distention and pain. Past Medical History: CAD s/p MI, HTN, DMII Social History: Lives independently, but in the same building with daughter. [**Name (NI) **] 3 children, 2 daughters and 1 son. Daughter [**Name2 (NI) **] is Durable Power of Attorney. The other daughter was recently in a car accident and underwent surgery at [**Hospital1 2025**]. Family History: NC Physical Exam: At time of discharge: Afebrile, VSS A&O X 3, NAD RRR CTAB, mildly decreased breath sounds b/l Abd soft, NT/ND, + bs, no masses, ostomy in RLQ pink, with stool G-tube in place LE trace edema Pertinent Results: [**2138-12-19**] 12:20PM BLOOD WBC-10.2 RBC-5.32 Hgb-14.9 Hct-43.4 MCV-82 MCH-28.0 MCHC-34.4 RDW-16.0* Plt Ct-204 [**2138-12-19**] 12:20PM BLOOD PT-12.9 PTT-32.5 INR(PT)-1.1 [**2138-12-19**] 12:20PM BLOOD Glucose-345* UreaN-34* Creat-1.0 Na-137 K-4.3 Cl-99 HCO3-24 AnGap-18 [**2138-12-19**] 12:20PM BLOOD ALT-17 AST-27 AlkPhos-119* Amylase-27 TotBili-0.9 [**2138-12-19**] 12:20PM BLOOD Lipase-11 [**2138-12-19**] 12:20PM BLOOD CK-MB-7 cTropnT-<0.01 [**2139-1-4**] 02:59AM BLOOD cTropnT-0.21* [**2139-1-4**] 11:29AM BLOOD CK-MB-35* MB Indx-25.5* cTropnT-0.45* [**2139-1-4**] 07:52PM BLOOD CK-MB-NotDone cTropnT-0.55* [**2139-1-5**] 05:25PM BLOOD cTropnT-0.42* [**2139-1-6**] 02:00AM BLOOD cTropnT-0.45* [**2139-1-14**] 07:13AM BLOOD CK-MB-3 cTropnT-0.19* [**2139-1-14**] 01:33PM BLOOD CK-MB-NotDone cTropnT-0.17* [**2139-1-16**] 09:58AM BLOOD CK-MB-NotDone cTropnT-0.06* . [**1-2**] wound swab: VRE . CT Abd [**12-19**]: 1. Markedly dilated colon throughout ascending, transverse, and descending colon with air-fluid levels, overall unchanged since prior study performed on the same day with pneumatosis in the ascending colon. Sigmoid diverticulosis with focal narrowing of the sigmoid colon just distal to the dilatation with wall thickening, due to diverticulitis. This area can be a leading point of obstruction. An underlying mass lesion or cancer cannot be excluded in this area, and further clinical investigation is recommended. 2. Limited evaluation for known sigmoid-vesicle fistula. 3. Small amount of ascites, somewhat increased anterior to the liver. 4. Bilateral renal cysts. 5. Heavy calcification of the aorta and SMA and its branches. Due to atherosclerosis, assessment of the intraluminal process of these branches is limited. . CTA/CT abd [**1-2**]: 1. No evidence of pulmonary embolism. Small bilateral pleural effusions with compressive atelectasis. 2. Left lower quadrant thick-walled peripherally enhancing fluid collection, which appears to communicate with the sutured end of the proximal sigmoid colon via a small collection of extraluminal gas. In the correct clincial setting, this could be consistent with an abscess. 3. Moderate intraabdominal ascites. 4. Status post ileostomy without evidence of small-bowel obstruction. 5. Distended gallbladder. 6. Diverticulosis within the right remnant sigmoid colon. . [**1-16**] VCUG - no leak Brief Hospital Course: Ms [**Known lastname 71508**] was admitted on [**2139-12-19**] from an outside hospital to the ICU. Neuro: Developed confusion during her first 5 days in the ICU. Post-operatively mental status improved. Intermitent delirium throughout admission. Required restraints to prevent DC of pertinent therapies while in the ICU. Currently AAOx3. . Cardiovascular: Complained of chest pain during first few days of admission, a cardiology consult was obtained. She recieved serial enzymes and EKGs. Troponins remained mildly elevated as high as 0.6 throughout her admission, and most recent result now 0.1. She was treated in IUC for unstable angina with nitroglycerin. It was recommended to maximize her medical treatment with Beta blockers, aspirin, a statin and an ACE Inhibitor. Required diuresis of >9L while in the ICU, after 2nd surgery. Continues to have trace lower extremity edema, and recieves lasix po. . Respiratory: She was intubated briefly post-op subtotal colectomy and again for several days after second surgery. Recieved nebulizer treatments post-op in the ICU, after successfully extubated. . Gastrointestinal: Her initial CT scan showed dilated [**Last Name (un) 2432**] colon, wall thickening and pneumatosis see pertinent results. She was initially treated nonoperatively with IV fluids, antibiotics, serial exams and NGT decompression. On HD#5 flexible sigmoidoscopy was performed for colonic decompression. On HD#6, colonscopy was performed for decompression, and revealed pseudomembrane and friable colonic tissue. Her abdomen remained tender and distended despite attempted decompression. She was taken to the OR for Subtotal Colectomy, G tube and ileostomy due to unresponsiveness to non-operative treatment. Ileostomy remains pink and intact, draining green-brown soft stool. Her post-operative course continued uneventfully in the ICU, and she was transferred to the floor POD#6. She developed additional abdominal tenderness and distention. Her HCT dropped and she recieved 1 unit PRBCs. Geriatric consult was obtained to assist with management. On POD#8 a CT scan was obtained which revealed an abcess with a colovesicular fistula. She was taken to the OR for exploration and drainage. She recieved further resection of remaining colon, repair of a leak from [**Doctor Last Name 3379**] pouch and repair of colovesicular fistula. After her 2nd surgery she returned to the ICU and improved steadily. Abdomen remained soft and nontender. She remained on IV antibiotics x 14 days and required pressors for the first few days post-op. Her incision has remained clean, dry, intact, with staples removed on POD#27/18. . Genitourinary: She had a foley catheter from the time of admission. POD#23/14 she recieved a cystoscopy which revealed no leak. Her foley was subsequently dc'd. . Musculoskeletal: Has suffered significant deconditioning since admission, but has consisitently recieved PT. See PT note for further assessment and discussion. Nutrition: She was held NPO at admission, and initiated on TPN by HD#3. Post-operatively she began on TFs, and the TPN was weaned down. By POD#[**3-26**] she was having high residuals on TFs, so TPN was reinitiated. Tf's were dc'ed prior to second surgery. POD# 15/6, she resumed TF's and TPN was tapered again. TF goals were achieved and TPN dc'ed. A diet by mouth was initiated. At time of discharge she is tolerating a regular diet with TF's at goal. Patient is an insulin dependent diabetic. She was followed by [**Hospital **] Clinic for treatment of persistent hyperglycemia. . Pain: Her pain was controlled with IV pain medicines while in ICU. She has been adequately controlled with Tylenol, Motrin & Oxycodone by mouth, per recommendations by Geriatrics. . POD#22/15 Ms [**Known lastname 71508**] was transferred to [**Hospital Ward Name 121**] 9 where she continued to progress well with PT, increasing PO intake, tolerating TFs, and weaning from nasal cannula oxygen. She has remained stable with no acute events. She is discharged to rehab on POD# 27/18. Medications on Admission: Norvasc Atenolol Isosorbide Lasix Insulin Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) mL Injection TID (3 times a day). 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 3. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-23**] Drops Ophthalmic PRN (as needed). 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. Furosemide 40 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 9. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4-6H (every 4 to 6 hours) as needed. 10. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 11. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. 14. Glargine Sig: Twenty Two (22) units at bedtime. 15. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 16. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 17. Ibuprofen 100 mg/5 mL Suspension Sig: Twenty (20) mL PO Q8H (every 8 hours) as needed. 18. Debrox 6.5 % Drops Sig: Five (5) Drop Otic [**Hospital1 **] (2 times a day) for 5 days: both ears. 19. Trazodone 50 mg Tablet Sig: 1/2-1 Tablet PO HS (at bedtime). Discharge Disposition: Extended Care Facility: [**Hospital **] hospital Discharge Diagnosis: [**Last Name (un) **] Colon Diverticulitis S/P Subtotal Colectomy, Ileostomy, Gastrostomy tube S/P Exploratory laparotomy, resection of small intestine with primary anastomosis, Sigmoid colectomy, repair of colovesicular fistula Unstable Angina Discharge Condition: stable Discharge Instructions: Please call the surgeon or return to the Emergency Department if you develop chest pain, shortness of breath, fever greater than 101.5, foul smelling or colorful drainage from your incisions, redness or swelling, severe abdominal pain or distention, persistent nausea or vomiting, inability to eat or drink, or any other symptoms which are concerning to you. No tub baths or swimming. You may shower. If there is clear drainage from your incisions, cover with a dry dressing. Leave white strips above your incisions in place, allow them to fall off on their own. Activity: No heavy lifting of items [**10-5**] pounds until the follow up appointment with your doctor. Medications: Resume your home medications. You should take a stool softener, Colace 100 mg twice daily as needed for constipation. You will be given pain medication which may make you drowsy. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 9325**], MD Phone:[**Telephone/Fax (1) 274**] Date/Time:[**2139-2-6**] 1:15 Completed by:[**2139-1-20**]

[ "562.10", "560.81", "567.22", "564.89", "569.83", "998.59", "997.4", "557.0", "401.9", "596.1", "412", "250.00", "411.1", "789.5", "998.2", "008.45", "414.01", "293.0", "787.3" ]

icd9cm

[ [ [] ] ]

[ "96.72", "38.93", "00.14", "45.24", "96.6", "45.23", "43.11", "57.83", "45.91", "54.59", "45.62", "96.07", "99.04", "45.76", "46.21", "38.91", "45.73", "99.15" ]

icd9pcs

[ [ [] ] ]

9535, 9586

3725, 7760

274, 423

9875, 9884

1334, 3702

10794, 10975

1104, 1108

7852, 9512

9607, 9854

7786, 7829

9908, 10771

1123, 1315

189, 236

451, 759

781, 804

820, 1088

65,959

196,834

47733

Discharge summary

report

Admission Date: [**2131-12-29**] Discharge Date: [**2132-1-2**] Date of Birth: [**2055-8-12**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 4765**] Chief Complaint: ? VT arrest Major Surgical or Invasive Procedure: intubation History of Present Illness: Mrs. [**Known firstname 2270**] [**Known lastname 100793**] [**Last Name (un) **] is a very nice 76 year-old woman with history of CAD s/p CABG x 4, recent [**Last Name (un) 7792**] in [**11-4**], sCHF (EF 25-30%), CAFib, and HTN who was found down at Rehab with VT. Per report, she was doing well at [**Hospital 392**] Rehab until yesterday 8:15 PM when she was found minimally responsive in the toilet without signs of trauma. To minutes afterwards became unresponsive, without pulse and without breathing in front of nursing staff. They started CPR immediately and placed AED that shocked her twice (120 J and 150 J respectively). EMS arrived and per their report she was in sinus rhythm with ventricular ectopy. She had a pulse and was breathing. She received 100 mg lidocaine IV bolus. She was transfered to [**Hospital3 5365**]. Her initial BP was ~70/40 mmHg and no neurologic exam or [**Location (un) 2611**] is documented. She was intubated for "airway protection" with Propofol, etomidate and succynilcoline and BP dropped afterwards and dopamine was started. . Initial labs showed: K of 7.5, creatinine of 3.38, Na 132, WBC of 15.9 with left shift, PLT 246, CK 38, MB 2.3, TNT 0.05. Other labs included: PT 14, INR 1.4, BUN 66, Ca 8.3, AST 52, ALT 39, TP 5.3, Albumin 2.9, Globulin 2.4, AP 162. Her ECG showed sinus rhythm with LBBB unchanged from prior here on [**11-14**]. She received kayexalate, insulin, calcium gluconate and was transfered to the [**Hospital1 18**] for further care. . In the BIDMCs ER VS were T 97.7, HR 81, BP 104/46, RR 19, SpO2 100% on AC 450/5/50/RR?. Per report she was moving L . In discussion with RN at rehab, she denies that patient has h/o 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 further denies patient with complaints of recent fevers, chills or rigors, exertional buttock or calf pain. . Cardiac review of systems [**Name8 (MD) **] RN is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: PAST CARDIOVASCULAR HISTORY: 1. CARDIAC RISK FACTORS: - Diabetes, -Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: -CABG: X4 with anatomy: LIMA-D, SVG-LAD, SVG-PDA, SVG-OM -PERCUTANEOUS CORONARY INTERVENTIONS: None -PACING/ICD: [**Company 1543**] PPM 3. OTHER PAST MEDICAL HISTORY: LMCA had a 90% stenosis filling LAD 100% at the origin LCx 100% at the origin RCA 100% at the mid-vessel. SVG-PDA 100% occluded SVG-LAD patent filling anterograde and retrograde Collaterals to PDA and faintly to the OMB LVG-OMB was occluded proximaly LIMA-diagonal patent 60% stenosis of the left subclavian artery with a 10-15 mmHg gradient PAST MEDICAL HISTORY: CAD s/p CABG x 4 in [**2128**]: marekdly positive stress c/w 3VD in [**2128**] and refused cath at that time. EF last year was >40%. Chronic systolic heart failure EF 25-30% ([**11-4**]) [**Month (only) 7792**] [**Month (only) **]/09 PPM: [**Company 1543**] Sensia SEDR01. Tachy-brady/complete heart block likely in the setting of [**Company 7792**]. Lead Information Chamber Date Implanted Manufacturer Model # Fixation Serial # [**2131-11-14**] ([**12-29**]+) mitral regurgitation Pulmonary Hypertension Chronic AFib: Not anticoagulated due to h/o GIB that required multiple transfusions . Chronic kidney disease: Stage III with eGFR of 46 ml/min and baseline creatinine 1.2. PTH target 35/70. HTN Asthma Gout Hypothyroidism Social History: Lives in [**Location (un) 50955**] with husband (step-father to daughters in [**Name (NI) 86**]). No tobacco, EtOH or illicit drug use. Family History: Brother with Stroke, Sister with CAD s/p CABG, Sister with Angina Physical Exam: VITAL SIGNS - Temp 97.8 F, BP 140/90 mmHg, HR 85 BPM, RR 20 X', O2-sat 100% 50% GENERAL - [**Name (NI) **]-appearing woman, responsive to pain stimuli. HEENT - NC/AT, PERRLA, pupils 3 mm, symetric and responsive to light, EOMI, sclerae anicteric, MMM, OP clear, Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK - supple, no thyromegaly, no JVD, no carotid bruits, RIJ in place LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use HEART - PMI located in 5th intercostal space, midclavicular line. RRR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs), No c/c/e. No femoral bruits. SKIN - no rashes or lesions. No stasis dermatitis, ulcers, scars, or xanthomas. LYMPH - no cervical, axillary, or inguinal LAD NEUROLOGIC: Mental status: Awake and alert, cooperative with exam, normal affect. Cranial Nerves: Pupils equally round and reactive to light, 4 to 2 mm bilaterally. Non papilledema on fundoscopic exam. Extraocular movements unable to assess. Tone in muscles of neck normal. . Cerebellum: Unable to assess. . Motor: Normal bulk bilaterally. Tone normal to increased symetric bilateraly. No observed myoclonus or tremor. No pronator drift. . Sensation: Unable to assess . Reflexes: Hyper-reflectic in right leg; otherwise symetric. Toes downgoing bilaterally. . Coordination: Unable to assess. . Gait: Unable to assess.. 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: CXR-AP (portable) [**2131-12-28**]: 1. Mild volume overload without overt pulmonary edema. 2. ET tube positioned 3.6 cm from the carina. . CT Head w/out contrast [**2131-12-28**]: No acute intracranial hemorrhage. Two small regions of hypodensity in the right frontal lobe, age indeterminate w/o prior study for comparison, but likely chronic infarct. . [**2131-12-29**] URINE: Blood-MOD Nitrite-POS Protein-75 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR RBC-[**6-5**]* WBC-[**6-5**]* Bacteri-MANY Yeast-NONE Epi-0-2 Hours-RANDOM UreaN-321 Creat-155 Na-25 Cl-20 Osmolal-334 . BLOOD: WBC-18.0*# RBC-3.27* Hgb-9.8* Hct-31.4* MCV-96 MCH-30.1 MCHC-31.3 RDW-17.3* Plt Ct-289# Neuts-82* Bands-3 Lymphs-3* Monos-7 Eos-2 Baso-1 Atyps-1* Metas-1* Myelos-0 PT-14.8* PTT-82.4* INR(PT)-1.3* Glucose-131* UreaN-66* Creat-3.3*# Na-137 K-6.4* Cl-109* HCO3-18* AnGap-16 Type-ART pO2-306* pCO2-36 pH-7.29* calTCO2-18* Base XS--8 Glucose-121* Lactate-1.5 Na-136 K-6.1* Cl-108 calHCO3-18* . CT HEAD [**1-1**] There is interval development of hypodense appearance of the cerebral parenchyma on the right side diffusely, in the right frontal, parietal and temporal lobes predominantly, with sulcal effacement and loss of [**Doctor Last Name 352**]-white matter differentiation. Findings can relate to acute infarction or hypoxic/anoxic/ischemic injury Evaluation of basal ganglia, brain stem and posterior fossa structures is limited, as also evidence for herniation. No acute gross hemorrhage is noted. Study significantly limited due to artifacts from the electrodes. Consider repeating after removal of electrodes, if appropriate and correlate clinically. Evaluation for associated infection is limited KUB [**12-31**] An NG tube has been advanced, and is likely within distal stomach. There has been a decrease in distension of a loop of bowel within the mid abdomen, now measuring approximately 4.5 cm (previously 5.5 cm). This likely reflects a small bowel loop rather than colon. There is no free air or pneumatosis. IMPRESSION: 1. Interval improvement in a dilated loop of bowel in the mid abdomen, likely reflecting small bowel. 2. NG tube tip in distal stomach. Brief Hospital Course: Mrs. [**Known firstname 2270**] [**Known lastname 100793**] [**Last Name (un) **] is a very nice 76 year-old woman with history of CAD s/p CABG x 4, recent [**Last Name (un) 7792**] in [**11-4**], HTN, sCHF (EF 25-30%) who had VT arrest in rehab. She was transferred to CCU, received Arctic Sun protocol but never regained cortical function. She passed on [**2131-1-2**] . # Anoxic Brain Injury, R MCA CVA - patient never regained cortical function after neurologic insult prior to admission. EEG showed diffuse brain dysfunction. Repeat CTs showed massive CVA. Serial neuro exams were concerning for brain death. Given prognosis, family communicated that patient would rather pass than "live as a vegetable". A decision was made to slowly withdraw care. Roughly 20 family members were at the bedside in her final days. . #. VF/VT Arrest - No strips, but AED fired twice, so most likely VF/VT arrest secondarely to ischemia after his [**Date Range 7792**]. Never clear how long she was pulseless. There was suggestion of focal neurologic deficits in ED, CT negative. Artic sun protocol completed and repeat CT showed R MCA CVA. While her cardiac status was stable in a LBBB pattern, she had permanent and terminal damage . #. Hypotension/Septic Shock - most likely in the setting of starting mechanical ventilation and with sedation. Patient also dehydrated given diarrhea at rehab. Had + U/A on admission. On rewarming, she required more pressors. Ultimately, she had C. Diff colitis complicated by sepsis and renal failure. She was on PO Vanc and IV flagyl until care was withdrawn . #. Acute Renal Failure (ATN) # Acute on Chronic kidney disease - Patient with diarrhea at home, poor PO intake on lisinopril and spironolactone who comes with worsening of the creatinine. She ultimately had anuric renal failure likely [**1-29**] to sepsis and c diff . # Complicated C Diff Colitis, - had diarrhea at rehab and after cooling was stopped, became septic and KUB showed dilated bowel (likely small). Patient was on PO Vanc and IV flagyl until care withdrawn . # Peripheral Vascular Disease: Patient admitted with dopplerable dorsalis pedis pulses. During septic shock, those pulses became undetectable. By the time of death, her feet were cyanotic and black on the toes. . # Tophaceous Gout: Patient had severe, voluminous tophaceous gout on the feet, R > L Medications on Admission: Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Furosemide 40 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Digoxin 125 mcg Tablet Sig: .5 Tablet PO DAILY (Daily). Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Levothyroxine 137 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Allopurinol 300 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). . Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for rash. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. Maalox 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for tongue sores. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Discharge Medications: deceased Discharge Disposition: Expired Discharge Diagnosis: deceased Discharge Condition: deceased Discharge Instructions: deceased Followup Instructions: deceased Completed by:[**2132-1-2**]

[ "584.5", "995.92", "585.3", "443.9", "414.8", "434.91", "348.1", "276.51", "785.52", "414.02", "276.7", "493.90", "V70.7", "276.2", "038.9", "414.01", "428.0", "286.9", "403.90", "V45.01", "410.72", "427.5", "244.9", "427.31", "274.03", "459.2", "426.3", "274.9", "008.45", "599.0", "416.8", "428.22" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

12046, 12055

8118, 10476

327, 340

12107, 12117

5922, 8095

12174, 12212

4096, 4163

12013, 12023

12076, 12086

10502, 11990

12141, 12151

4178, 5173

2666, 2802

276, 289

368, 2529

5259, 5903

5188, 5243

2833, 3176

3198, 3927

3943, 4080

80,174

140,507

33057

Discharge summary

report

Admission Date: [**2188-7-21**] Discharge Date: [**2188-7-25**] Date of Birth: [**2122-11-5**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2817**] Chief Complaint: recurrent bilateral pleural effusion Major Surgical or Invasive Procedure: pleurex catheter placement History of Present Illness: Mr. [**Known lastname 732**] is a 65 year-old male with newly diagnosed metastatic cancer; pancreatic, to liver to possible lung, transferred from [**Hospital6 17032**] for further management of malignant pleural effusion. On [**2188-7-16**] he underwent right thoracentesis for 1.5 Liters hospitalized overnight then discharged. On [**2188-7-19**] presented to the ED with increased SOB, rapid atrial fibrillation, hypotensive and diarrhea. Chest X-Ray showed bilateral pleural effusion right > left. leukocytosis WBC 51, and BUN/Cre 36/1.3, hyperkalemia K 5.4 He was started on Vancomycin/Zosyn for possible pneumonia which has was discontinued per ID. Flagyl for possible C.diff which was also discontinued for negative culture. ID felt the elevated WBC is possibly secondary to his cancer and steroid use. He was seen by Endocrine who recommended low-dose steroids for hypopituitarism for possible pituitary involvement. He underwent Right thoracentesis today drained for 1 Liter of serosanguinous. Past Medical History: Acute Respiratory failure secondary to malignant pleural effusion. Paroxysmal atrial fibrillation on amiodarone started [**2188-7-19**] Elevated Cre Pk 2.2, now 1.3 base 0.8 Thrombocytopenia Hypertension Hyperlipidemia New-Onset Diabetes Mellitus Morbid obesity Social History: etoh [**3-12**] drinks per day cigarettes 30 pack year history, no current smoker Family History: NC Physical Exam: On admission: Vitals: T- 97.1, HR- 74, BP- 117/92, RR- 13, SaO2- 93% on 6L GEN: NAD. Comfortable. AAO x 3. Follows commands HEENT: Dry mucous membranes. NC in place. No LAD CV: Irregularly irregular. No m/r/g PULM: Decreased bs at bases (L > R). No crackles/rhonci/rales ABD: +bs, soft, NT/ND. EXT: No e/c/c NEURO: AAO x 3. On discharge: Expired Pertinent Results: [**2188-7-25**] 02:45PM BLOOD WBC-51.2* RBC-3.99* Hgb-12.0* Hct-37.9* MCV-95 MCH-30.1 MCHC-31.7 RDW-14.4 Plt Ct-198 [**2188-7-25**] 02:45PM BLOOD Neuts-94* Bands-4 Lymphs-1* Monos-0 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 [**2188-7-25**] 02:52AM BLOOD Glucose-131* UreaN-91* Creat-2.5* Na-134 K-5.2* Cl-103 HCO3-16* AnGap-20 [**2188-7-25**] 02:52AM BLOOD ALT-98* AST-93* LD(LDH)-1311* AlkPhos-440* TotBili-1.2 [**2188-7-25**] 02:52AM BLOOD Albumin-2.5* Calcium-7.7* Phos-6.2* Mg-2.6 [**2188-7-25**] 03:14PM BLOOD Type-MIX pO2-55* pCO2-36 pH-7.16* calTCO2-14* Base XS--15 Intubat-INTUBATED SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: Recent intubation. Patient with bilateral pleural effusion, tachycardia and hypoxia. Comparison is made with prior study performed 5 hours earlier. ET tube tip is in the standard position 6.1 cm above the carina. Right PICC is in place. There is no interval change in large bilateral pleural effusions, pulmonary edema and basilar atelectasis. Echo: The left atrium is mildly dilated. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with preserved global biventricular systolic function. No pericardial effusion. Brief Hospital Course: 65M, with recent diagnosis of metastatic pancreatic cancer. The patient underwent 2 recent therapeutic right thoracenteses at [**Hospital3 **]with 1.5 L removed on [**2188-7-16**] and 1 L removed yesterday which both resulted in symptomatic improvement. He was transferred to Dr.[**Name (NI) 5067**] surgical service on [**2188-7-21**]. HD1: Patient was kept NPO. Interventional pulmonary consulted and a thoracentesis performed. Ultrasound guided right pleurx catheter placement was performed for palliation and 1.5L ml of bloody fluid was drained and sent for analysis. A chest ultrasound also revealed left pleural effusion which was planned for another thoracentesis on the next hospital day. HD2: Due to difficulty in obtaining IV access and labs, PICC line placed for access. Patient also developed worsening renal failure - Cr 2.8 likely pre-renal with hyperkalemia. Urinalysis and urine chemistries sent and pending. Patient hydrated and treated with bicarbonate, dextrose, insulin. EKG did not show any changes. Oncology consulted for work up of his cancer. He was transferred from thoracics to medicine on [**7-22**]. Patient developed hypotension this afternoon (down to the 70s systolic). He received multiple IV fluids bolus with slow response of his BP. Mentation was at baseline. There was concern for pericardial effusion so STAT bedside ECHO was performed. Preliminary results demonstrated no effusion, small LV, mildly hypertrophied LV, and pleural effusion. Given hypotension and possible need for pressors, patient was transferred to the MICU for further management. The patient's blood pressure initially improved with IV fluids, however on the evening of [**7-24**] the patient became anxious from a sensation of shortness of breath. An ABG was performed which was re-assuring, showing a chronic respiratory alkalosis. The patient was given ativan and haldol to good effect. On the morning of [**7-25**] however, the patient became acutely short of breath again and was intubated. He became hypotensive requiring administration of multiple pressors. Attempts to get arterial access for blood pressure monitoring was unsuccessful, and the family was contact[**Name (NI) **] and called to the bedside. He was made CMO and pressor support was withdrawn, and he expired shortly thereafter. Medications on Admission: Amiodarone 200 mg [**Hospital1 **] Atenolol 50 mg [**Hospital1 **] Aspirin 81 mg daily Zocor 40 mg QHS Prednisone 10 mg daily Insulin Lantus 10 Units QHS with insulin sliding scale Arixtra 2.5 mg daily Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Completed by:[**2189-3-17**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

6506, 6515

3902, 6221

341, 369

6566, 6575

2196, 3879

1808, 1812

6474, 6483

6536, 6545

6247, 6451

6599, 6637

1827, 1827

2168, 2177

265, 303

397, 1407

1842, 2153

1429, 1693

1709, 1792

1,569

103,678

13461

Discharge summary

report

Admission Date: [**2177-12-16**] Discharge Date: [**2178-1-8**] Date of Birth: [**2106-8-2**] Sex: F Service: MEDICINE Allergies: Aspirin / Heparin Agents / Morphine / Tylenol Attending:[**First Name3 (LF) 30**] Chief Complaint: CC: pain control, [**First Name3 (LF) **] hypotension Major Surgical or Invasive Procedure: right IJ CVL placement PICC placement History of Present Illness: 71 y.o. female with left tib/fib fracture recently admitted to MICU Green for pain control in the setting of hypotension necessitating Dopamine, later found to have an Enterobacter UTI treated with Meropenem and subsequently called out to the floor upon resolution of hypotension who is now being transferred back for an acute change in mental status. . Patient had been doing well after being called out until yesterday when she triggered for being nonresponsive. Of note, she had gotten Dilaudid in the AM for pain control and had undergone regularly scheduled dialysis with no complications. At the time of the acute change in mental status, a head CT was performed which was normal. An ABG was also performed - 7.37/53/71 (previous ABGs dating back as far as [**2176**] have shown normal CO2 values). She became more responsive after the ABG was performed, interacting appropriately and responding to verbal stimuli, however her mental status continued to wax and wane and a MICU evaluation was requested. . In the ED, vitals were notable for a RR of 10 during most of the day, but otherwise vitals were stable. She was awake, alert and oriented to person and place. She correctly identified the month, but not the date or year. She was able to follow simple commands. Asterixis was noted on exam, despite taking Lactulose, recently increased from 30 mL TID to QID and Rifaximin. Given underlying acid-base disturbance in the setting of mental status changes, she was transferred to the ICU for further management. . In the MICU, she continued to be hypotensive, CTA negative for PE, Urine + enterococcus and started on Meropenem. Mental status improved once agreed to take Lactulose. She also failed her [**Last Name (un) 104**] stim so was started on steroids. Her BP stabilized and she was off pressors and back to the floor. BP was stable during second ICU admission. She did have a hct drop (see below) but heme/onc felt this was not hemolysis and there was no active bleeding but hemoccult + stools. . Currently, patient reports some leg pain at fracture site but otherwise feeling well. She denies f/c, no dizzyness, no dysphagia, no chest pain, no SOB, no cough, no [**Last Name (un) 103**] pain, [**Last Name (un) 103**] girth slightly increased, no dysuria, no hematuria. She has loose stool with copper tinge, no melena, no nausea/vomiting. Past Medical History: - VRE UTI (IV Daptomycin) [**2177-12-6**] - admission [**Date range (1) 40794**]/07 for altered ms [**First Name (Titles) **] [**Last Name (Titles) **] hypotension - Hepatic encephalopathy: multiple episodes s/p lactulose non-compliance - Portal vein thrombosis [**5-10**] but not anticoag for h/o GIB - Type 2 diabetes. - End-stage renal disease, on hemodialysis M/W/F - Cirrhosis [**3-7**] NASH and acetaminophen toxicity. - Gastric angioectasia with h/o GI bleeding in 4/[**2177**]. - Diastolic CHF. EF>55% by echocardiogram in 7/[**2176**]. Mod MR and long mitral deceleration time - ?right sided pleural effusion: diagnosed on U/S [**11/2176**], CXR showed a small effusion - stayed stable in subsequent imaging. - Heparin-induced thrombocytopenia, Ab+ in 1/[**2176**]. - History of seizure disorder, on [**Year (4 digits) 13401**]. - History of infection in the left knee. - History of MRSA and Clostridium difficile and VRE. - History of gram-positive rod bacteremia in 4/[**2177**]. - Status post ORIF of the left distal femur fracture in 12/[**2175**]. Social History: She lives at home. Her daughter is involved in her care. The patient currently denies alcohol use, tobacco use, and illicit drugs. Family History: Noncontributory. Physical Exam: PHYSICAL EXAM: VS: 98.3 HR 54 RR 16 90/29 98% RA GEN: comfortable, obese, jaundiced, NAD NEURO: pos asterixis. alert to person, place, month, situation. - CN II-XII intact, pupils are 2mm and minimally reactive. left buccal fold slightly lower than right - Motor: [**6-7**] bilat upper prox/distal. [**6-7**] right lower prox/distal. left lower not assessed - [**Last Name (un) 36**]: intact to light touch throughout - reflexes: 2+ brachiorad bilat, 1+ knee/ankle on right. toes equiv on right. left lower ex not able to examine [**Last Name (un) 4459**]: jaundiced. Subconjunctival hemorrhage on left lateral eye. MM dry. JVP flat CARDS: III/VI systolic M w radiation to axilla. RRR, no heave LUNGS: decreased BS at right base, otherwise clear, no wheeze ABD: obese, no caput, BS+ NT ND soft, no rebound. no obvious fluid wave. no shifting dullness SKIN: erythematous plaques under left breast and panus. ecchymotic lesions on right and left upper ex. left lower ex bandaged. EXTREMITIES: LUE AV fistula w thrill. DP right dopplerable. [**Last Name (un) 36**] intact left toes. GUAIAC: NEG brown stool Pertinent Results: EKG: sinus brady, rate 50, left anterior fasc block, RBBB pattern, QTc 535, TW flattening diffusely, no other ST-T changes. c/w prior. . CXR: Stable right pleural effusion and a lower lobe opacity which may reflect effusion/atelectasis . Pelvis and ankle: no fracture . Left Leg: Acute fracture involving the proximal tibia and fibula metaphysis with approximately 6 mm medial displacement of the distal fracture fragment . RUQ U/S Note is made that this is a difficult study due to the patient's body habitus. The liver has a coarse echotexture appearance, but there are no lesions identified. There is no biliary dilatation and the common duct measures 0.5 cm. There is a partially shadowing echogenic structure within the gallbladder, which appears to be sludge with developing gallstone. There is no ascites identified. The spleen was not identified on this exam. . CXR: There has been removal of right IJ central venous catheter. A right PICC is seen with its tip terminating in the mid subclavian vein. There is interval resolution of pulmonary congestion and improvement in right pleural effusion which is now small-to-moderate. Right lower lung opacities persist likely representing atelectasis. Streaky atelectasis persists in the left mid and lower lung. Otherwise no new pulmonary infiltrates are identified. The heart size remains enlarged. No pneumothorax is identified. . Ammonia: 35 138 101 19 --------------< 137 3.7 25 4.3 Ca: 9.1 Mg: 2.0 P: 3.3 Trop-T: 0.10 CK: 52 MB: Notdone . WBC: 6.3 HCT: 29.9 PLT: 77 N:80.2 L:9.8 M:5.2 E:4.4 Bas:0.3 . PT: 16.7 PTT: 36.1 INR: 1.5 (baseline: 1.5-1.8) . Echo [**8-8**]: mod symmetric LVH, EF 60-70%, [**2-4**]+MR . CBC [**2177-12-16**] 05:00PM BLOOD WBC-6.3# RBC-2.64* Hgb-9.4* Hct-29.9* MCV-113* MCH-35.5* MCHC-31.3 RDW-19.5* Plt Ct-77*# [**2177-12-18**] 03:11AM BLOOD WBC-10.7# RBC-2.52* Hgb-8.8* Hct-26.5* MCV-105*# MCH-34.9* MCHC-33.2 RDW-20.1* Plt Ct-68* [**2177-12-19**] 04:04AM BLOOD WBC-16.7*# RBC-2.40* Hgb-8.7* Hct-25.7* MCV-107* MCH-36.3* MCHC-33.9 RDW-20.2* Plt Ct-62* [**2177-12-20**] 03:40AM BLOOD WBC-7.5# RBC-2.24* Hgb-7.9* Hct-23.4* MCV-105* MCH-35.3* MCHC-33.7 RDW-20.7* Plt Ct-38* [**2177-12-20**] 04:51PM BLOOD WBC-5.3 RBC-2.34* Hgb-7.9* Hct-23.5* MCV-101* MCH-33.7* MCHC-33.5 RDW-21.5* Plt Ct-27* [**2177-12-21**] 05:01PM BLOOD WBC-5.0 RBC-2.52* Hgb-8.7* Hct-25.9* MCV-103* MCH-34.5* MCHC-33.6 RDW-21.5* Plt Ct-30* [**2178-1-5**] 06:02AM BLOOD WBC-5.2 RBC-2.23* Hgb-7.6* Hct-24.2* MCV-108* MCH-34.2* MCHC-31.6 RDW-21.2* Plt Ct-50* [**2178-1-7**] 05:10AM BLOOD WBC-4.4 RBC-2.53* Hgb-8.7* Hct-26.0* MCV-102* MCH-34.2* MCHC-33.4 RDW-20.9* Plt Ct-34* . ABG [**2177-12-24**] 02:31PM BLOOD Type-[**Last Name (un) **] pO2-319* pCO2-53* pH-7.35 calTCO2-30 Base XS-2 [**2177-12-24**] 05:15PM BLOOD Type-ART pO2-71* pCO2-53* pH-7.37 calTCO2-32* Base XS-3 [**2177-12-25**] 07:41AM BLOOD Type-ART pO2-80* pCO2-45 pH-7.44 calTCO2-32* Base XS-5 . Lactate: [**2177-12-18**] 03:57PM BLOOD Lactate-3.1* [**2177-12-24**] 05:15PM BLOOD Lactate-2.3* . Misc [**2177-12-18**] 12:26PM BLOOD Cortsol-43.5* [**2177-12-31**] 03:32PM BLOOD PTH-161* [**2177-12-24**] 02:12PM BLOOD Ammonia-31 [**2177-12-20**] 03:40AM BLOOD VitB12-[**2095**]* Folate-9.0 [**2178-1-7**] 05:10AM BLOOD Calcium-8.6 Phos-3.3 Mg-1.8 [**2177-12-22**] 03:06AM BLOOD ALT-14 AST-21 LD(LDH)-220 AlkPhos-92 TotBili-5.1* [**2177-12-21**] 04:18AM BLOOD ALT-15 AST-20 AlkPhos-92 TotBili-6.5* DirBili-4.1* IndBili-2.4 . Chem 7 [**2177-12-16**] 05:00PM BLOOD Glucose-137* UreaN-19 Creat-4.3* Na-138 K-3.7 Cl-101 HCO3-25 AnGap-16 [**2177-12-19**] 04:04AM BLOOD Glucose-192* UreaN-35* Creat-5.5* Na-136 K-4.4 Cl-105 HCO3-21* AnGap-14 [**2177-12-23**] 11:09AM BLOOD Glucose-233* UreaN-25* Creat-3.8* Na-136 K-3.8 Cl-101 HCO3-26 AnGap-13 [**2177-12-27**] 05:58AM BLOOD Glucose-169* UreaN-24* Creat-3.1* Na-138 K-4.0 Cl-101 HCO3-27 AnGap-14 [**2178-1-4**] 06:08AM BLOOD Glucose-111* UreaN-24* Creat-3.3* Na-139 K-4.4 Cl-104 HCO3-31 AnGap-8 [**2178-1-5**] 06:02AM BLOOD Glucose-118* UreaN-29* Creat-3.8* Na-140 K-4.9 Cl-105 HCO3-30 AnGap-10 [**2178-1-7**] 05:10AM BLOOD Glucose-101 UreaN-24* Creat-3.3* Na-139 K-4.9 Cl-103 HCO3-31 AnGap-10 Brief Hospital Course: 71 y.o. female with multiple medical problems, namely cirrhosis and current ESBL UTI who was transferred to the MICU for change in mental status. . Hosp course by problem: . MS: delirium intermittently thought initially [**3-7**] hepatic encephalopathy vs infection vs medications. In the ICU, she was hypotensive requiring pressors (see below). She also developed a UTI which was treated. She initially refused lactulose but once she took it, started having BMs and improved MS. She was transferred from MICU to the floor and was stable for several days. She then was found to be hypoventilating after having received dilaudid. Trigger called and she was transferred back to the unit. ABG revealed mild hypercapnea but her sx improved rapidly without much intervention. We felt this was [**3-7**] dilaudid in setting of pt with poor baseline ms (hepatic enceph) as well as urosepsis. Her mental status was stable at discharge. . Hypotension: Baseline SBP 90s-100s. Initially in the MICU, she was at baseline but then she trended downward. She required urgent line placement and aggressive IVF repletion. HD was held for several days and she even required pressors and aggressive IV fluids. She had enterobacter UTI and was treated with meropenem for plan for 10-14d of therapy. She also failed her [**Last Name (un) 104**] stim so was started on steroids. Her BP stabilized and she was off pressors and back to the floor. BP was stable during second ICU admission. Incidentally, CTA neg for PE. She did have a hct drop (see below) but heme/onc felt this was not hemolysis and there was no active bleeding. She continued to have BP's in the 80-90's while on the floor, but was asymptomatic with stable HCT's. Her slightly low BP was attributed to diarrhea and the patient responded to gentle IVF boluses. . HEME POSITIVE STOOLS: The patient has history of upper GI bleeds and has known gastric angioectasia and grade I varices of esophagus. She continued to have maroon-colored stools this hospitalization but she remained asymptomatic and her hematocrit was stable. She continued her PPI and was restarted on propranolol once her BP normalized. Her propranolol has been held due to low blood pressures. . Cirrhosis: Patient appeared encephalopathic on presentation but improved throught her stay and was oriented and interactive. She was compliant with Lactulose and Rifaximin but has been known to stop taking her lactulose. Liver service followed patient and will see her in clinic. . UTI: Patient received Meropenem, based on sensitivity profile, started on [**12-21**] with 10-day total course. . ESRD: on HD, seen by renal during her stay. . Tib/Fib Fracture: S/P set in Breslow Brace. Patient will f/u with orthopedics in 4 weeks with Dr. [**Last Name (STitle) **]. Cautious pain control was initiated given h/o AMS. . Adrenal Insufficiency: Patient mildly abnormal stim test while hypotensive and received steroids which were rapidly tapered. . CHF: History of diastolic dysfunction with significant edema on exam after aggressive hydration. She will continue to have fluid removed by HD. . Diarrhea: The patient had multiple episodes of diarrhea with slightly low BP. Her diarrhea was mostly likely secondary to lactulose and her dose was decreased, with decreasing bowel movements. C.diff was sent, neg x1. . DM: she was continued on ISS . PPx - PPI - Lactulose/Rifaximin - Seizure PPx with [**Last Name (STitle) 13401**] given seizure history - No anticoagulation given HIT and previous GIB; Pneumoboots Medications on Admission: MEDICATIONS; confirmed verbally w daughter: Lasix 40mg nondialysis days Lactulose 30ml TID Levetiracetam 500 mg daily Rifaximin 400 mg Tablet PO TID (not taking at home) Pantoprazole 40 mg Tablet daily Ursodiol 300 mg Capsule PO BID Sevelamer 800 mg Tablet TID w meals Glargine 12u qhs Lispro sliding scale Propranolol 10 mg PO BID . ALLERGIES: ASA Heparin (HIT) Morphine Tylenol Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 2. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 3. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 5. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4 times a day). Hold for diarrhea. 7. Propranolol 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Location (un) **] Manor - [**Location (un) **] Discharge Diagnosis: Primary: Enterobacter UTI with sepsis Proximal left tibial fracture Hepatic encephalopathy Secondary: Diastolic Heart Failure. Reversible inferior wall myocardial perfusion defect Seizure Disorder. Cirrhosis secondary to non-alcoholic steatohepatits Hepatic encephalopathy Gastric angioectasia Chronic renal failure Stage V on Hemodialysis. Pancytopenia. Diabetes Mellitus Type II. HIT antibody positive. Portal vein thrombosis Gallstone pancreatitis MRSA/Clostridium difficile. S/P ORIF of the left distal femur fracture c/b septic knee Discharge Condition: stable Discharge Instructions: You were admitted with a leg fracture. You then developed a urinary tract infection with sepsis, which as now resolved. Do not but weight on your left leg or walk on your own. If you have fevers or chills, please return to the emergency room. Followup Instructions: 1. Please make an appointment to see your PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. [**Telephone/Fax (1) 40793**] for follow-up. 2. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1984**], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2178-2-5**] 11:00 3. Please call to make a follow-up appointment with the Liver clinic. The phone number is: [**Telephone/Fax (1) 2422**]

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icd9cm

[ [ [] ] ]

[ "38.93", "39.95", "99.07", "99.04", "99.21", "38.91", "34.91" ]

icd9pcs

[ [ [] ] ]

13959, 14035

9365, 12909

358, 397

14618, 14627

5193, 9342

14918, 15367

4034, 4052

13340, 13936

14056, 14597

12935, 13317

14651, 14895

4082, 5174

264, 320

425, 2784

2806, 3870

3886, 4018

25,141

175,767

20041

Discharge summary

report

Admission Date: [**2183-1-9**] Discharge Date: [**2183-1-16**] Date of Birth: [**2132-5-3**] Sex: F Service: Thoracic Surgery CHIEF COMPLAINT: Stridor. HISTORY OF PRESENT ILLNESS: The patient is a 50-year-old woman with a history of tracheal stenosis who presented with shortness of [**Year (4 digits) 1440**] and stridor. The patient was admitted for treatment of airway edema and monitoring. The patient has a history of subglottic stenosis secondary to intubation in [**2181**] for severe pneumonia. She has had progressive stridor and planned an elective resection of the stenosis next week. She is presenting today with increasing shortness of [**Year (4 digits) 1440**] and stridor. She actually is unable to climb a flight of stairs secondary to her shortness of [**Year (4 digits) 1440**]. In the Emergency Department, the patient was treated with epinephrine twice, 10 mg of intravenous Decadron, and heliox with good affect and maintained saturations of greater than 98%. At the end of these therapies, she was able to speak in complete sentences. The onset of her shortness of [**Year (4 digits) 1440**] was not acute, it just progressed to the point where it was just not bearable any more. She currently feels comfortable. She has a dry baseline cough. No chest pain. She denies any chest pain, palpitations, any abdominal pain, any nausea, vomiting, fevers, chills, or any lower extremity edema. PAST MEDICAL HISTORY: (Her prior medical history includes) 1. Subglottic tracheal stenosis; status post intubation in [**2182**]. 2. She has a history of a staphylococcal pneumonia in [**2182**]. 3. She also has a history of pancreatitis secondary to hypertriglyceridemia with multiple episodes over the last 20 years. 4. Diabetes mellitus with neuropathy. 5. She is status post cholecystectomy. 6. She has had cataract surgery. 7. She has hypertriglyceridemia. 8. Hypercholesterolemia. MEDICATIONS ON ADMISSION: (Her medications at home included) 1. Nexium 20 mg once per day. 2. Actos 30 mg once per day. 3. Neurontin three times per day. 4. Lipitor 80 mg once per day. 5. NPH insulin with a regular insulin sliding-scale. ALLERGIES: She has no known drug allergies. SOCIAL HISTORY: She is a computer programmer. She is married with two children. She does not use ethanol. She does not smoke. PHYSICAL EXAMINATION ON PRESENTATION: On admission, she was afebrile at 98.1, her pulse was 86, her blood pressure was 154/74, her respiratory rate was 24, and her oxygen saturation was 98% on room air. In general, she was sitting comfortably, breathing easily. Head and neck examination revealed her oropharynx was clear. The mucous membranes were moist. She was anicteric. The neck was supple. No lymphadenopathy. No thyromegaly. Her trachea was midline. Cardiovascular examination revealed a regular rate and rhythm. No murmurs, rubs, or gallops. The lungs were clear to auscultation with a distinct inspiratory stridor. The abdomen was soft, nontender, and nondistended. Positive bowel sounds. Extremities were without any clubbing, cyanosis, or edema. Pulses were 2+ and equal in all four extremities. She had no focal neurologic deficits. PERTINENT LABORATORY VALUES ON PRESENTATION: Her admission laboratories were all within normal limits. PERTINENT RADIOLOGY/IMAGING: A chest x-ray showed no foreign bodies and no acute disease. No infiltrates. No edema. A computerized axial tomography from [**2182-12-19**] showed focal tracheal stenosis at the thoracic inlet secondary to wall thickening up to 7 mm. There were no masses identified. BRIEF SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The patient is a woman who was admitted to the Thoracic Surgery Service for treatment of this tracheal stenosis. In terms of her issues: 1. DIABETES MELLITUS ISSUES: She was continued on her home regimen of NPH with a regular insulin sliding-scale and Actos. She was also continued on her home dose of Neurontin for her diabetic neuropathy. 2. GASTROINTESTINAL ISSUES: She was continued on a proton pump inhibitor throughout the course of her admission. Her nutritional status was a diabetic diet as tolerated. 3. TRACHEAL STENOSIS ISSUES: After being admitted to the Medical Intensive Care Unit, the patient went to the operating room for a rigid bronchoscopy on hospital day two; during which Dr. [**Last Name (STitle) **] confirmed the presence of a subglottic stenosis which was subsequently balloon dilated with a 10 French balloon. On hospital day three ([**1-10**]), the patient was taken to the operating room by Dr. [**Last Name (STitle) 952**] for a tracheal reconstruction. Please refer to the previously dictated Operative Note for the specifics of this operation. The patient tolerated the procedure well and was treated to the Trauma Surgical Intensive Care Unit in good condition with her chin immobilized with a suture between her chin, and her chest, and upper sternum. In the Trauma Surgical Intensive Care Unit, the patient was advanced to a regular diabetic diet without complications and was maintained with an immobilized chin. On postoperative day four ([**1-14**]), the patient was finally transferred to the floor in good condition. On [**1-15**], the patient underwent another bronchoscopy to remove the sutures from the tracheal anastomosis on [**1-10**]. She tolerated this well. On [**1-16**], the patient was afebrile with stable vital signs. She was alert and oriented times three. She was in no apparent distress. The lungs were clear to auscultation bilaterally with minimal stridor. Heart was regular in rate and rhythm. The abdomen was soft, nontender, and nondistended. She was tolerating a regular diet and on her home insulin. She was up walking around. The patient's chin immobilizing suture was cut. DISCHARGE STATUS: The patient was discharged home. CONDITION AT DISCHARGE: Condition on discharge was good. DISCHARGE DIAGNOSES: 1. Airway obstruction. 2. Subglottic tracheal stenosis. 3. History of staphylococcal pneumonia. 4. Status post bronchoscopy and tracheal dilatation. 5. Status post tracheal reconstruction. 6. Diabetes mellitus. 7. Nephrolithiasis. 8. Chronic pancreatitis. 9. Hyperlipidemia. MEDICATIONS ON DISCHARGE: She was restarted on all of her home medications and given prescriptions for Percocet as needed for pain. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was recommended to have follow-up appointments with Dr. [**Last Name (STitle) 952**] and Dr. [**Last Name (STitle) **]. 2. She was told to contact the office if she had any increasing shortness of [**Last Name (LF) 1440**], [**First Name3 (LF) 691**] stridor, any fevers, or any other concerns. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**] Dictated By:[**Last Name (NamePattern1) 1179**] MEDQUIST36 D: [**2183-1-27**] 15:05 T: [**2183-1-27**] 15:39 JOB#: [**Job Number 53964**]

[ "E849.7", "998.89", "E878.2", "478.74", "250.00", "519.1" ]

icd9cm

[ [ [] ] ]

[ "96.04", "31.79", "33.22", "31.99", "31.5", "96.71", "32.01" ]

icd9pcs

[ [ [] ] ]

5991, 6276

6303, 6410

1971, 2235

6443, 7037

3688, 5921

5936, 5970

165, 175

204, 1447

1470, 1944

2252, 3653

1,332

184,124

50196

Discharge summary

report

Admission Date: [**2121-5-15**] Discharge Date: [**2121-5-24**] Date of Birth: [**2043-6-24**] Sex: M Service: MEDICINE Allergies: Amiodarone Attending:[**First Name3 (LF) 2234**] Chief Complaint: Secretions, leukocytosis, fever, hypernatremia Major Surgical or Invasive Procedure: None History of Present Illness: 77 yo M with PMH of CAD/CABG, DM, CRI, AAA/TAA repair, multiple CVA, seizure d/o with recent prolonged hospitalization [**Date range (1) 104709**] for aspiration pneumonia and sepsis requiring intubation and trach/PEG sent from [**Last Name (un) 1188**] house with secretions, leukocytosis, fever, hypernatremia. . After his last hospitalization, he was successfully weaned from trach at [**Hospital1 **] and then moved to [**First Name4 (NamePattern1) 1188**] [**Last Name (NamePattern1) **] on [**4-18**]. Noted over the past week worsened respiratory congestion, fatigue, decreased PO and social interaction (baseline poor MS). Reportedly no diarrhea or pain. Labs on [**5-13**] revealed elevated WBC 25 and he was staretd on levofloxacin and flagyl for concern of recurrent aspiration pneumonia with improvement of WBC 13. Also found to be hypernatremic that refractory to 'hydration', increasing from 150->155. Given acute worsening, patient sent to [**Hospital1 18**] ED for evaluation. DNR reversed by family to FULL CODE, and requesting aggressive measures. . In the ED, T 101.8, HR 70s, labile BPs (170-215/90-120), RR 22, 95% RA. Noted to have respiratory congestion with copious secretions, warm/dry skin, A&Ox1, guaiac negative. Na+ 154, WBC 18 with left shift, no bands, lactate 1.9. U/A negative and blood cultures sent. Given vancomycin, cefepime, and levofloxacin for presumed aspiration PNA. Clear CXR. CT head negative. ECG unchanged. Admitted to [**Hospital Unit Name 153**] for aspiration PNA, hypernatremia, needs too much nursing care to go to floor/aspiration risk. Past Medical History: CAD CABG X 3 VD (70% distal LMCA, 100% PDA/PLV) HTN CHF LEVF 50% ([**11-1**]) MR, TR Anemia (baseline 28.2-33.8) AFib s/p pacer, D/C cardioversion, on Warfarin SDH ([**11-1**]): 3 mm L frontoparietal SDH 12 strokes since [**2105**] DM CRI (baseline Cr 1.5-1.7) LLE cellulitis Surgical History: AAA repair '[**08**] w/ redo in '[**09**] TAA repair '95CAD Social History: [**Hospital 104710**] transferred from [**Hospital3 1186**]. Spanish speaking only . He is currently retired, was an independent truck driver. Tobacco remote history, quit over 10 years ago. Alcohol use is rare Family History: Non-contributory Physical Exam: Afebrile, VSS GEN-- elderly, NAD HEENT -- unremarkable except for right facial droop Heart -- regular Lungs -- sparse right sided rales Abd -- soft, nontender, PEG Ext -- noncooperative, hand contractures Pertinent Results: Admission Lab: [**2121-5-15**] 04:55PM BLOOD WBC-18.0*# RBC-4.55* Hgb-12.9* Hct-40.0 MCV-88 MCH-28.3 MCHC-32.2 RDW-14.7 Plt Ct-268 [**2121-5-15**] 04:55PM BLOOD Neuts-87.8* Lymphs-8.0* Monos-3.8 Eos-0.2 Baso-0.2 [**2121-5-15**] 04:55PM BLOOD Plt Ct-268 [**2121-5-16**] 05:00AM BLOOD PT-14.7* PTT-30.1 INR(PT)-1.3* [**2121-5-15**] 04:55PM BLOOD Glucose-218* UreaN-39* Creat-1.1 Na-154* K-3.9 Cl-115* HCO3-27 AnGap-16 [**2121-5-16**] 05:00AM BLOOD Albumin-3.0* Calcium-9.0 Phos-2.6* Mg-2.2 [**2121-5-15**] 05:23PM BLOOD Lactate-1.9 [**2121-5-15**] 04:55PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.019 [**2121-5-15**] 04:55PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-250 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG ========================================= CT HEAD W/O CONTRAST [**2121-5-15**] 5:45 PM FINDINGS: There is no acute intracranial hemorrhage. Again noted are moderately severe periventricular white matter hypodensities, consistent with chronic microvascular ischemia. The extra-axial spaces, sulci and ventricles are prominent, consistent with age-related involutional changes. Again noted are areas of encephalomalacia in the right occipital and left temporoparietal lobe. Lacunar infarcts within the basal ganglia are again noted. There is no shift of normally midline structures or edema. Surrounding soft tissues and osseous structures are unremarkable. There is a mucosal thickening, involving left maxillary sinus, similar in appearance when compared to [**2119-4-29**]. IMPRESSION: No evidence of acute intracranial hemorrhage. No interval change since [**2119-4-29**]. ========================================== CHEST (PORTABLE AP) [**2121-5-15**] 4:10 PM FINDINGS: The lung volumes are low. The previously noted diffuse perihilar opacities have resolved. Currently, the lungs are clear without consolidation or edema. There is a dual-chamber pacemaker, stable in course and position. The tracheostomy has been removed. There is a tortuous atherosclerotic aorta. The cardiac silhouette size is stable and likely accentuated due to low lung volumes. No effusion or pneumothorax is evident. IMPRESSION: Low lung volumes. Otherwise, the lungs are clear with a hypertensive cardiomediastinal configuration. =========================================== UNILAT UP EXT VEINS US RIGHT [**2121-5-16**] 9:35 AM Grayscale, color flow, and Doppler images of the right upper extremity were obtained. The jugular vein, subclavian vein, axillary vein, brachial veins, and the basilic and the cephalic vein demonstrate normal compressibility, respiratory variation in venous flow, and venous augmentation. IMPRESSION: No DVT in the right upper extremity. =========================================== CHEST (PORTABLE AP) [**2121-5-16**] 6:59 AM SINGLE SEMI-UPRIGHT VIEW OF THE CHEST AT APPROXIMATELY 7:00 A.M.: A dual-lead pacemaker overlying the left hemithorax and median sternotomy wires are unchanged and intact. There is a new airspace opacity along the medial aspect of the right lower lobe that could represent aspiration, given the clinical history. Mild cardiomegaly with a tortuous aorta is unchanged. There is no pleural effusion or pneumothorax. IMPRESSION: New opacity in the medial right lower lobe that could represent aspiration, given the clinical history. ========================================== [**2121-5-15**] 11:09 pm SPUTUM Source: Expectorated. **FINAL REPORT [**2121-5-19**]** GRAM STAIN (Final [**2121-5-16**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. SMEAR REVIEWED; RESULTS CONFIRMED. RESPIRATORY CULTURE (Final [**2121-5-19**]): OROPHARYNGEAL FLORA ABSENT. STAPH AUREUS COAG +. MODERATE GROWTH. OF TWO COLONIAL MORPHOLOGIES. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. YEAST. RARE GROWTH. Legionella Ab negative Influenza A/B DFA negative Urine Cx negative ============================================= Discharge Labs: Brief Hospital Course: 77 year old male with PMH of stroke, presenting with increased secretions, altered mental status and hypernatremia. 1. aspiration pneumonia -- He was initially admitted to the [**Hospital Unit Name 153**] for monitoring, and placed on broad spectrum antibiotics for health care associated organisms, given his recent hospitalization. Initial chest xray showed no infiltrate, but aspiration was suspected given his copious purulent secretions. A subsequent xray showed RLL infiltrate. He was continued on vancomycin and cefepime, and transferred to the floor on the hospital medicine service. Received 8 day course of vanc/cefipime. Pulm status returned to baseline, no supplemental oxygen, breathing comfortably by discahrge. 2. hypernatremia -- secondary to volume depletion. Increased free water flushes through PEG tube and supplemented with IV water--slowly improved sodium to normal levels. On discharge, will continue free water flushes at 300q4h--this seems to have stabilized sodium 3. altered mental status/Stroke with late effects/Multi infarct dementia/Seizure history -- difficult to assess because of poor baseline, but at baseline per family on discharge--arousable by voice, opens, eyes, but confused, disoriented. On floor, had episode of increased somnolence. ABG, ECG, head CT, EEG and labs were unremarkable and patient returned to baseline without further intervention. In setting of infection and correction of hypernatremia, baseline dementia. Maintained on asa, statin, keppra. 4. CAD/chronic diastolic heart failure/Atrial fib s/p pacer: continued on asa, statin, beta-blocker, ace. Decision made to pursue hospice care. Patient being discharged home with hospice. Medications on Admission: Lisinopril 5mg daily Metoprolol 100mg TID Diltiazem 90mg QID Lantus 30 units QHS Lispro insulin SS keppra 500mg TID Zyprexa 2.5mg QHS Senna [**Hospital1 **] Colace 100mg [**Hospital1 **] Aspirin 325mg daily celexa 10mg daily Jevity TF Famotidine 20mg daily Albuterol nebs QID Simvastatin 20mg QHS Levaquin ([**5-13**] started) Flagyl ([**5-13**] started) Discharge Medications: 1. Morphine Concentrate 20 mg/mL Solution Sig: 2-20 mg PO qhour as needed for pain. Disp:*30 ml* Refills:*0* 2. oxyfast Sig: 1-20 mg q1hour as needed for fever or pain: (20mg/ml solution). Disp:*30 ml* Refills:*0* 3. Insulin Glargine 100 unit/mL Solution Sig: Thirty (30) units Subcutaneous at bedtime. Disp:*1000 units* Refills:*2* 4. Insulin Regular Human 100 unit/mL Solution Sig: as directed Injection twice a day: see attached sliding scale. Disp:*200 units* Refills:*2* 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*60 Tablet(s)* Refills:*2* 6. Docusate Sodium 50 mg/5 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day) as needed. Disp:*1000 ml* Refills:*2* 7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(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. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:*60 Tablet(s)* Refills:*2* 11. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 12. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*2* 13. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 14. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day) as needed for constipation. Disp:*150 ML(s)* Refills:*2* 15. Citalopram 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 16. tubefeeding Tubefeeding: Start After 12:01AM; Probalance Full strength; Starting rate:10 ml/hr; Advance rate by 10 ml q4h Goal rate:50 ml/hr Residual Check:q4h Hold feeding for residual >= :100 ml Flush w/ 300 water q4h Discharge Disposition: Home With Service Facility: Hospice of the Good [**Doctor Last Name 9995**] Discharge Diagnosis: 1. Aspiration Pneumonia 2. Hypernatremia 3. Altered Mental Status 4. Stoke with late effects 5. Coronary Artery disease 6. Chronic DIastolic heart failure 7. Multi infarct dementia 8. Seizure 9. Atrial fibrillation Discharge Condition: Stable, afebrile, at baseline mental status, resp status. Discharge Instructions: Follow up as below. All medications as prescribed. Patient going home with hospice care. Followup Instructions: Follow up with Dr. [**Last Name (STitle) 6680**]. Call [**Telephone/Fax (1) 10688**] to schedule follow up. You have an appointment for your pacemaker: Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2121-5-30**] 8:30

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icd9cm

[ [ [] ] ]

[ "96.6" ]

icd9pcs

[ [ [] ] ]

11208, 11286

7181, 8889

318, 324

11544, 11603

2824, 7140

11742, 12007

2566, 2584

9295, 11185

11307, 11523

8915, 9272

11627, 11719

7158, 7158

2599, 2805

232, 280

352, 1943

1965, 2321

2337, 2550

28,745

116,504

31601

Discharge summary

report

Admission Date: [**2107-8-16**] Discharge Date: [**2107-8-22**] Date of Birth: [**2055-5-17**] Sex: M Service: CARDIOTHORACIC Allergies: Codeine Attending:[**First Name3 (LF) 1283**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [**2107-8-16**] Aortic Valve Replacement(23mm ON-X mechanical valve), Replacement of Ascending Aorta(26mm Gelweave Graft), and Closure of Atrial Septal Defect. History of Present Illness: Mr. [**Known lastname 9907**] is a 52 year old male with heart murmur since childhood. He has known aortic valve disease and has been followed by serial echocardiograms. His most recent ECHO revealed severe aortic insufficiency, and severe aortic stenosis with a peak gradient of 97mmHg and mean of 62mmHg. The [**Location (un) 109**] was estimated at 0.7cm2. The LVEF was estimated at 60%. Cardiac catheterization confirmed severe aortic insufficiency and aortic stenosis with evidence of moderately dilated ascending aorta. His coronary arteries were angiographically normal. Based upon the above results, he was referred for cardiac surgical intervention. Past Medical History: Mixed Aortic Valve Disease Dilated Ascending Aorta History of ETOH abuse GERD Anxiety Prior Foot Surgery Social History: Denies history of tobacco. Employed as a chef. He is married, and lives in [**Location 701**]. Family History: Denies premature coronary artery disease. Physical Exam: BP 150-160/80-90, HR 84 regualr, RR 12 Well developed, well nourished male in no acute distress Oropharynx benign, full dentures Neck supple, with FROM, no JVD, no carotid bruits Lungs CTA bilaterally Heart regular rate and rhythm, normal s1s2, mixed diastolic and systolic murmurs noted Abdomen benign Extremities warm, well perfused, no edema Distal pulses 2+ bilaterally Alert and oriented, CN 2-12 intact, 5/5 strength, no focal deficits Pertinent Results: [**8-16**] Echo: Prebypass: 1. A left-to-right shunt across the interatrial septum is seen at rest. A small secundum atrial septal defect is present. 2. There is mild symmetric left ventricular hypertrophy. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%). 3.Right ventricular chamber size and free wall motion are normal. 4.The ascending aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve is bicuspid. The aortic valve leaflets are moderately thickened. There is moderate to severe aortic valve stenosis (area 0.8-1.0cm2). Moderate to severe (3+) aortic regurgitation is seen. 5.Trivial mitral regurgitation is seen. Post bypass: 1. Mechanical aortic valve is well seated and the leaflets move well. Trace aortic regurgitation seen. Peak gradient across the valve is 19 mmHg. 2. Ascending aortic graft is noted. 3. No flow detected across the intra-atrial septum. 4. Preserved biventricular function. [**8-21**] CXR: Small to moderate bilateral pleural effusion, left greater than right, has increased since [**8-18**]. Moderate left lower lobe atelectasis is stable. Right lung is clear. Cardiomediastinal silhouette has a normal postoperative appearance, unchanged. No pneumothorax. [**2107-8-16**] 12:00PM BLOOD WBC-15.3*# RBC-2.71*# Hgb-8.1*# Hct-23.9*# MCV-88 MCH-30.1 MCHC-34.1 RDW-13.7 Plt Ct-210 [**2107-8-22**] 07:00AM BLOOD WBC-10.7 RBC-3.62* Hgb-10.7* Hct-30.7* MCV-85 MCH-29.5 MCHC-34.7 RDW-14.5 Plt Ct-292# [**2107-8-16**] 12:00PM BLOOD PT-15.1* PTT-56.4* INR(PT)-1.4* [**2107-8-20**] 05:15AM BLOOD PT-16.0* INR(PT)-1.5* [**2107-8-21**] 01:50AM BLOOD PT-29.8* PTT-38.8* INR(PT)-3.1* [**2107-8-21**] 09:20AM BLOOD PT-32.4* INR(PT)-3.5* [**2107-8-22**] 06:00AM BLOOD PT-26.1* PTT-37.4* INR(PT)-2.7* [**2107-8-16**] 12:53PM BLOOD UreaN-15 Creat-1.0 Cl-109* HCO3-31 [**2107-8-22**] 07:00AM BLOOD Glucose-110* UreaN-17 Creat-0.9 Na-137 K-4.3 Cl-101 HCO3-28 AnGap-12 [**2107-8-19**] 06:35AM BLOOD Calcium-8.4 Phos-3.8 Mg-2.2 Brief Hospital Course: Mr. [**Known lastname 9907**] was a same day admit and was brought directly to the operating room where he underwent a mechanical aortic valve replacement along with replacement of his ascending aorta and closure of an atrial septal defect. For surgical details, please see separate dictated operative note. Following the operation, he was brought to the CSRU for invasive monitoring in stable condition. Initially coagulopathic, he required multiple blood products with much improvement. Within 24 hours, he awoke neurologically intact and was extubated without incident. He transiently required Labetalol drip for hypertension. He otherwise maintained stable hemodynamics and transitioned to PO beta blockade. Given his history of anxiety and ETOH abuse, he was maintained on Ativan. His CSRU course was otherwise uneventful, and he transferred to the SDU on postoperative day two. Chest tubes and epicardial pacing wires were removed per protocol. Coumadin was initiated on post-op day three and Heparin was used as a bridge until INR was therapeutic. He continued to improve well over the next several days while working with physical therapy for strength and mobility. Once his INR was therapeutic he was discharged home with VNA services and the appropriate follow-up appointments. Dr. [**Last Name (STitle) **] (his cardiologist) will manage his Coumadin. *****Of note, Mr. [**Known lastname 9907**] is enrolled in the ON-X trial.***** Medications on Admission: Ativan prn Zoloft 75 qd Zantac 150 [**Hospital1 **] MVI Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*0* 7. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*0* 8. Sertraline 50 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*0* 10. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 11. Warfarin 2 mg Tablet Sig: One (1) Tablet PO once a day: please take 2 mg [**8-22**] and [**8-23**] - lab draw [**8-24**] and further dosing by Dr [**Last Name (STitle) **]. Disp:*60 Tablet(s)* Refills:*0* 12. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 13. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Aortic Valve Disease, Dilated Ascending Aorta, Atrial Septal Defect s/p Aortic Valve Replacement, Asc. Aorta Replacement, ASD Closure PMH: Anxiety, Gastroesophageal Reflux Disease, History of ETOH abuse 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**] Take Warfarin as directed by Dr. [**Last Name (STitle) **] . INR goal is around 2.5-3. INR should be first checked on this Wednesday. Future blood draws on Monday, Wednesday, Friday or per Dr. [**Last Name (STitle) **]. Followup Instructions: Dr. [**Last Name (STitle) 68853**] in [**4-14**] weeks, please call for appt [**Telephone/Fax (1) 170**] Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] [**9-19**] at 4:45pm. Appt. has already been set up for you. Please call if there are scheduling conflicts. Dr. [**Last Name (STitle) 3321**] in [**2-12**] weeks, please call for appt [**Telephone/Fax (1) 3183**] Wound check please schedule with RN [**Telephone/Fax (1) 3633**] Completed by:[**2107-8-22**]

[ "746.4", "286.9", "V11.3", "300.00", "427.31", "530.81", "441.2", "427.41", "285.9", "745.5", "997.1" ]

icd9cm

[ [ [] ] ]

[ "35.22", "99.62", "99.04", "89.60", "99.07", "40.19", "38.45", "99.05", "39.61", "35.71" ]

icd9pcs

[ [ [] ] ]

7079, 7150

3999, 5444

294, 455

7396, 7402

1919, 3976

8133, 8603

1399, 1442

5550, 7056

7171, 7375

5470, 5527

7426, 8110

1457, 1900

235, 256

483, 1143

1165, 1271

1287, 1383

79,823

147,590

13040

Discharge summary

report

Admission Date: [**2121-10-7**] Discharge Date: [**2121-10-11**] Service: MEDICINE Allergies: Phenobarbital Attending:[**First Name3 (LF) 11839**] Chief Complaint: atrial fibrillation with rapid ventricular response Major Surgical or Invasive Procedure: picc line placement [**2121-10-9**] History of Present Illness: [**Age over 90 **] y/o DNR/DNI male, resident of [**Hospital1 599**] of [**Location (un) 55**] since [**2121-4-19**], with history of atrial fibrillation (on coumadin), prostate cancer s/p TURP, myastenia [**Last Name (un) 2902**], CKD (baseline creatinine ~1.8 per NEBH records), history of aspiration pneumonia in [**2121-4-19**], among other medical problems, who on routine vital signs by nursing home RN today was found to have SBP in the 80s and HR in the 120s. [**Name8 (MD) **] RN, lungs with coarse and adventitial breath sounds. She called an ambulance and patient was brought in to ED. . In the ED, VS were 99.2, 83, 73/54, 24, 95% 3L NC. Labs notable for lactate of 1.8 and troponin of 0.08. Patient's HR was as high as 160s-180s with a systolic blood pressure in the 80s. He was given 1.5 L NS with improvement in HR to 130s and BP into 90s-100s. He was given vancomycin and zosyn due to concern for pulmonary infection and desire to cover for pseudomonas; floroquinolone and other antibiotics were not chosen in order to avoid precipitation of myasthenia flare. Blood cultures were sent. Rate control with nodal agents was not attempted. . In the ED, patient reported 2 days of cough. On exam in the ED he was found to have coarse breath sounds with evidence of volume depletion. Rest of exam was non-focal. He had guaiac positive brown stool. He had no complaints and was interactive with staff. CXR notable for retrocardiac opacity, prominent vasculature, kerley B lines. . VS on transfer to the ICU: rectal temp 100.1, 94/65, 124, 24, 97% 4L NC. Access 2 peripheral IV's (18 guage). . ROS positive for productive cough and "chest congestion." He denied CP, abdominal pain, N/V.Pt asking very pleasantlt to be left alone and does not want any intervetions.He explains that he is [**Age over 90 **] years old and would like to join his deceased wife and mother. . Past Medical History: 1. atrial fibrillation, on warfarin 2. history of prostate cancer s/p TURP ('[**15**]) with resultant urinary incontinence 3. myasthenia [**Last Name (un) 2902**] 4. peptic ulcer disease 5. left knee replacement 6. gout 7. osteoarthritis 8. pedal edema, on furosemide 9. chronic kidney disease (baseline creatinine ~1.8 per NEBH records online) 10. anemia (etiology unclear) on iron 11. s/p cholecystectomy Social History: Nursing home resident at [**Hospital1 599**] of [**Location (un) 55**] since [**2121-4-19**]. He has a distant smoking history (>30 yrs ago) and does not drink alcohol. He is widowed. Family History: non-contributory Physical Exam: On admission to medicine floor: General: well-appearing elderly man, sitting comfortably in no distress, able to complete full sentences without difficulty. Vital Signs:T 97 P 73 BP 129/69 RR 22 O2 sat 100% HEENT: no scleral icterus; oropharynx clear Neck: No JVD,no cervical or clavicular lymphadenopathy Chest: decreased breath sounds overall. CV: irregularly irregular, no murmurs, rubs, or gallops Abdomen: soft, non tender, nondistended, normal bowel sounds; no hepatosplenomegaly Extremities: no edema; full range of motion Neuro: alert, oriented x3; CN 2-12 grossly intact, non focal Pertinent Results: [**2121-10-7**] 06:14PM LACTATE-1.2 [**2121-10-7**] 05:43PM CK(CPK)-59 [**2121-10-7**] 05:43PM CK-MB-5 cTropnT-0.10* [**2121-10-7**] 05:43PM ALBUMIN-3.0* [**2121-10-7**] 11:27AM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.014 [**2121-10-7**] 11:27AM URINE BLOOD-NEG NITRITE-POS PROTEIN-30 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-LG [**2121-10-7**] 11:27AM URINE RBC-2 WBC-41* BACTERIA-FEW YEAST-NONE EPI-1 [**2121-10-7**] 11:27AM URINE HYALINE-1* [**2121-10-7**] 11:27AM URINE MUCOUS-RARE [**2121-10-7**] 07:05AM LACTATE-1.8 [**2121-10-7**] 06:53AM GLUCOSE-101* UREA N-44* CREAT-1.5* SODIUM-144 POTASSIUM-3.3 CHLORIDE-108 TOTAL CO2-23 ANION GAP-16 [**2121-10-7**] 06:53AM estGFR-Using this [**2121-10-7**] 06:53AM cTropnT-0.08* [**2121-10-7**] 06:53AM CALCIUM-8.7 PHOSPHATE-3.2 MAGNESIUM-1.8 IRON-15* [**2121-10-7**] 06:53AM calTIBC-241* VIT B12-828 FOLATE-GREATER TH HAPTOGLOB-247* FERRITIN-142 TRF-185* [**2121-10-7**] 06:53AM WBC-14.0*# RBC-3.11* HGB-10.7* HCT-32.0* MCV-103* MCH-34.4* MCHC-33.4 RDW-14.9 [**2121-10-7**] 06:53AM NEUTS-91.2* LYMPHS-4.9* MONOS-3.3 EOS-0.2 BASOS-0.3 [**2121-10-7**] 06:53AM PLT COUNT-264# [**2121-10-7**] 06:53AM PT-29.6* PTT-35.3* INR(PT)-2.9* [**2121-10-7**] 06:53AM RET AUT-1.7 . urine culture:URINE CULTURE (Final [**2121-10-8**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. GRAM STAIN (Final [**2121-10-8**]): <10 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). 2+ (1-5 per 1000X FIELD): BUDDING YEAST. QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Preliminary): SPARSE GROWTH Commensal Respiratory Flora. CXR:AP portable chest radiograph was obtained in the upright position. There is no evidence of pneumonia or CHF. There is some increased subpulmonic density in the left lung with no clear consolidation. There is no pneumothorax or effusion. There is no free abdominal air. There are no fractures. IMPRESSION: No acute intra-thoracic process. Swallow study: FINDINGS: Barium passes readily into the esophagus without obstruction. There was clear evidence of penetration and aspiration with nectar and honey consistencies of barium. No thin consistencies of barium were administered. There was a great amount of residual within the vallecula and piryform sinuses. For further details, please refer to full OMR notes of the speech and swallow division. IMPRESSION: Evidence of aspiration and penetration with thick consistencies of barium. Brief Hospital Course: [**Age over 90 **] y/o DNR/DNI male, resident of nursing home, with history of atrial fibrillation (on coumadin), dementia, prostate cancer s/p TURP, myastenia [**Last Name (un) 2902**], CKD (baseline creatinine ~1.8 per NEBH records) among other medical problems, who presents with atrial fibrillation with rapid venticular reponse and is noted to have fever and cough, . # Pneumonia: Patient with low grade temperature and rectal temperature of 100.1 in ED. Had elevated WBC with left shift on admission.Pt also reported cough x 2 days at nursing home.Although CXR (portable ) did not show evidence of an infiltrate, clinically pneumonia highly suspicious and pt started on empiric antibiotics for health care associated pneumonia/aspiration pneumonia with vancomycin and zosyn.A picc line was placed for outpt antibiotics hoever on the floor pt developed multiple loose stools and given the fact that his goals of care were changes to CMO IV antibiotics were discontinued and picc-line removed. . #UTI: U/A consistent with possible UTI, however culture c/w fecal contamination. Repeat urine culture was negative. . #C diff: Positive c diff test on admission. Stool for C.Dif tested because of fever of unclear source. However, pt with h/o c.dif in the past and on admission not having abdominal pain or diarrhea. Pt did develop loose bowel movements during hospitalization and was started on po flagyl given positive testing for c.diff and now treatment with antibiotics.IV antibiotics were also discontinued. . # Atrial fibrillation with rapid ventricular reponse: Patient with history of atrial fibrillation on metoprolol for rate control and coumadin for anticoagulation per home regimen.Rate was controlled after IV fluids in the ED. Given IV metoptolol in the unit and oral metoprolol restarted on the floor. Throughout hospitalization blood pressure and heart rate reamined controlled. Lasix was held as pt was admitted with volume depletion. Continuation of lasix per the discretion of Dr [**Last Name (STitle) **].Coumadin was also held due to guaiac positive stools and known anemia. . #Nutrition:Failed Speech and Swallow: A Family meeting took place in the [**Hospital Unit Name 153**] and also I had a telephone discussion with son who is the health care proxy. Family clearly does not want a peg tube. Initially family agreed for a temporary NG tube. NG tube placement attempted in the [**Hospital Unit Name 153**] but was unsuccessful. During attempt pt verbalized that he does not want this and family also against any further attempts.Pt was NPO except for meds given with puree and pt reminded to swallow three times with each bite.Decision of diet at nursing home to be made by family together with nursing home physician. . # Elevated troponin:On admission most likely secondary to demand ischemia in setting of atrial fibrillation with RVR. Troponins peaked at 0.10 and have since trended down . # Chronic kidney disease: baseline creatinine ~1.8 per NEBH records). Cr currently at baseline (1.4).Will avoid nephrotoxic medications and renally dose all medications . # Anemia: Pt with chronic anemia and currently at baseline. Pt with guaiac positive stools but on iron supplement at NH.No evidence of acute bleed. . # myasthenia [**Last Name (un) 2902**]: stable.Pyridostigmine per home regimen was continued. . Code status:DNR/CNI, CMO: Pt and family did not want any aggressive interventions and goal of care to keep pt as comfortable as possible. Pt was made CMO. Discussion on not to admit to the hospital was also made and son, Mr [**Name (NI) 449**] [**Name (NI) 39914**], wishes not to have his father admitted to the hospital again. He will discuss this issue with th enursing home as well. Medications on Admission: - tylenol 325 mg tid - allopurinol 100 mg daily - colace 100 mg daily - ferrous sulfate 325 mg [**Hospital1 **] - lasix 20 mg daily - metoprolol tartrate 25 mg [**Hospital1 **] - prilosec 20 mg daily - mestinon 60 mg 4x/day - coumadin 2 mg po daily - senna 8.6 mg daily qhs - bisacodyl prn daily - fleet enema prn - guafenesin 100 mg prn - duonebs prn - milk of magnesia prn - compazine prn - trazodone prn qhs - ground nectar thick liquid diet, bananas ok 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. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 3. pyridostigmine bromide 60 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 5. docusate sodium 50 mg/5 mL Liquid Sig: [**12-21**] PO BID (2 times a day) as needed for constipation. 6. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 12 days. 7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 9. ferrous sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO twice a day. 10. trazodone 50 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 11. allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day. 12. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 13. Florastor Oral 2 caps po bid Discharge Disposition: Extended Care Facility: [**Hospital1 **] chestnuthill Discharge Diagnosis: Pneumonia Hypotension Clostridium difficile colitis 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: Mr [**Name13 (STitle) 39914**] was admitted with hypotension and a rapid ventricular rate . Hypotension resolved with fluid resuscitation. Patient was transfered to the [**Hospital Unit Name 153**] where he was diagnoseed with a pneumonia and started on antibiotics. A picc-line was placed and swallowing study done.Swallowing study showed that he is aspirating. A peg tube was offered but family and health care proxy decided not to pursue with peg-tube placement.Pt was transfered to the medicine floor and was further monitored. Changes in medication; Started on po flagyl Held coumadin Held lasix Followup Instructions: Follow up with Dr [**Last Name (STitle) **] at nursing home. Lasix held on discharge because of low blood pressure on admission. Continuation of lasix at nursing home at the discretion of Dr [**Last Name (STitle) **].

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