ChanBeDu/relevant_section_length · Datasets at Hugging Face

21,514

140,376

2002

Discharge summary

report

Admission Date: [**2108-9-4**] Discharge Date: [**2108-9-26**] Date of Birth: [**2047-9-9**] Sex: M Service: MEDICINE Allergies: Compazine / Codeine / Atenolol Attending:[**First Name3 (LF) 358**] Chief Complaint: overdose (opitates, benzos, methadone) Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 10983**] is a 60 year old male with a PMH significant for malignant HTN, venous thromboembolism and PE s/p IVC filter, history of heroin abuse on methadone maintenance who presented to the ED initially complaining of suicidal ideation and was noted to be somnolent. In review of Nursing record, patient stated "my girlfriend died and I don't want to live anymore". Patient was placed on tele and HR noted to be in 30s, and became increasingly somnolent. Tox screen was done which was positive for Benzos, Opiates and Methadone. Past Medical History: # Malignant Hypertension, likely d/t medication non-compliance especially with clonidine leading to rebound HTN # Pulmonary Embolus: Recurrent [**Known lastname 11011**] s/p IVC filter, recent admit for PE 11/[**2107**]. Not anticoagulated due to poor compliance and followup. # Heroin abuse: methadone maintenance clinic Habit Management; per pt, quit 20 yrs ago #Suicidal Ideation with O/D (has hidden clonazepam and clonidine tablets in his rectum on admission to hospital previously) # Hepatitis B previous infection, now sAg negative # Hepatitis C, undetectable HCV RNA [**3-29**] # Chronic obstructive pulmonary disease # Gastroesophageal reflux disease # PTSD ([**Country 3992**] veteran) # Anxiety / Depression # Antisocial personality disorder # Microcytic anemia # Vitamin B12 deficiency Social History: Past heroin abuse, now on methadone. No recent illicits. Denies current smoking or [**Last Name (un) **], but has h/o tobacco use 10 years ago. On disability. In the past, patient stated to some providers he had a home in [**Location 4288**] and to others that he was homeless. Currently states he is staying with friends in [**Name (NI) 4288**]. Family History: Father died of MI, mother of pancreatic CA. Physical Exam: VITAL SIGNS: T=99.0 BP=182/93 HR= 36 RR= 15 O2= 99% RA PHYSICAL EXAM GENERAL: unpleasant, somnulent arousable to voice HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. Patient closed eyes upon attempting EOM or light. Patient pupils equal. MMM. OP clear. Neck Supple, No LAD. CARDIAC: Regular rhythm, bradycardic rate. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. LUNGS: CTAB, good air movement biaterally. ABDOMEN: NABS. Soft, NT, ND. EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis pulses bilaterally SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox2. Inappropriate, combative. Moving all limbs but refused to cooperate with neurological exam. PSYCH: tangential thought, somnulent. . Pertinent Results: . UTox. [**2108-9-4**]. Positive for benzodiazepines, opioids, methadone. . EKG [**2108-9-4**]. Marked sinus bradycardia. Q-T interval prolongation. RSR' pattern in lead V1. Since the previous tracing the QRS voltage has decreased. The Q-T interval remains prolonged. The RSR' pattern is more apparent. Clinical correlation is suggested. . Echo. [**2108-9-4**]. The left atrium is elongated. The right 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%). There is no ventricular septal defect. Right ventricular chamber size is top normal and free wall motion is normal. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The tricuspid valve leaflets are mildly thickened. There is borderline pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2108-6-19**], no change. . [**2108-9-4**]. LE Doppler. IMPRESSION: No evidence of DVT in bilateral lower extremity. The previously noted left posterior tibial venous thrombus is not visualized in the current study. Brief Hospital Course: In summary, Mr. [**Known lastname 10983**] is a 60 year old male with Hypertension, history of recurrent PE s/p IVC filter not on anticoagulation due to poor medication compliance, history of substance abuse initially admitted to [**Hospital1 18**] on [**9-4**] for drug overdose (suspected seroquel, klonopin, oxycodone, methadone overdose). He was initially monitored in the ICU due to bradycardia with a prolonged QT interval. His QT interval improved off seroquel and he was call out of the MICU. His hospital course was complicated by a left foot cellulitis at site of IV on patient's foot, treated with one week of Vancomycin and Unasyn. He was getting ready for discharge when he was found in his room unresponsive and hypotensive and then sent back to the MICU. Patient's BP and responsiveness improved with monitoring and was suspected to be due to Klonopin/oxycodone/methadone overdose, but he was ruled out for PE with echo and LENIS which were unremarkable. Patient left AMA on [**9-25**] after being called out of MICU. . 1. Drug Overdose. Patient initially admitted to MICU for observation secondary to drug overdose and prolonged QT interval of 0.52. Patient has long history of drug abuse and he was felt to have overdosed on seroquel, klonopin, oxycodone, and methadone. Toxicology was consulted initiall. He was given a dose of narcan and a dose of glucagon for concern of opioid and beta-blocker overdose. When his QT interval improved, he was trasnferred out of the MICU. Psych was consulted and did not feel he had active suicidal ideation at time of transfer out of MICU. . 2. Substance Abuse. Patient has long history of drug abuse. During his stay, he was often noted to be hording pills. He would not swallow the pills that were administered and he would hide pills in his underwear. When he returned to the MICU on [**9-25**], it was suspected that had horded pills and then taken a supply of these medications all at once resulting in minimal responsiveness and hypotension. . 3. Cellulitis. Patient noted to have a left lower extremity cellulitis at the site of an IV. He was treated with one week of vancomycin and unasyn. His antibiotic course was completed while he was inpatient. . 4. Hypertension. Patient reported to have history of hypertension and reports significant concern about his blood pressure being elevated. However, blood pressure fluctuations are likely related to drug abuse and withdrawal in addition to baseline essential hypertension. During hospital stay, his antihypertesnives were uptitrated. On [**9-24**], patient was found to be hypotensive to 70s systolic and unresponsive likely secondary to up-titration of antihypertensives plus suspected hording of oxycodone/klonopin/methadone. The MICU team felt that his hypertension should not be aggressively managed given his history of poor compliance as and outpatient and fluctuations of BP due to drug abuse. Patient seemed to be at greater risk for episodes of hypotension than the consequences of chronic hypertension. . 5. Hypotensive episode/unresponsiveness. Patient transferred to the MICU on [**9-25**] after a code was called. He did not receive CPR because he was found to have a pulse and SBP in 70s. He was suspected to have taken a stash of narcotics and benzos. He became arousable at the mention of narcan. In the MICU, he was evaluated for PE with echo which did not show right heart strain. He cannot get a CTA due to renal failure and V/Q scan is likely to be difficult to interpret in setting of prior multiple PEs. He was started on empiric anticoagulation with lovenox with the knowledge that he would not continue on anticoagulation as an outpatient due to history of poor compliance. BP and mental status improved overnight and he was trasnfered out of the unit on [**9-26**]. . . History of recurrent PE. Patient has had recurrent PEs. He has an IVC filter. He has not been anticoaulated due to poor compliance. There was breif concern for a recurrent PE when patient was transferred back to MICU on [**9-25**] with hypotension and unresponsiveness. He was evaluated for PE with echo which did not show right heart strain. He cannot get a CTA due to renal failure and V/Q scan is likely to be difficult to interpret in setting of prior multiple PEs. He was started on empiric anticoagulation with lovenox with the knowledge that he would not continue on anticoagulation as an outpatient due to history of poor compliance. BP and mental status improved overnight and he was trasnfered out of the unit on [**9-26**]. . COPD. Patient was continued on home atrovent and advair. Medications on Admission: MEDICATIONS (OMR, patient referred to OMR): Duloxetine 60mg daily Fluticasone-Salmeterol 250-50 mcg/Dose [**Hospital1 **] Quetiapine 150qhs Clonazepam 2mg TID Gabapentin 300 mg [**Hospital1 **] Docusate Sodium 100 mg [**Hospital1 **] Methadone 135mg daily Clonidine 0.2 mg/24 hr weekly on thursdays Ipratropium Bromide inhaler QID prn Omeprazole 20 mg daily Aspirin 81 mg daily Ibuprofen prn Discharge Medications: None. Patient left AMA. Discharge Disposition: Home Discharge Diagnosis: overdose (benzodiazepines, opiates, methadone) left foot cellulitis/phlebitis hypertension depression Discharge Condition: stable Against Medical Advice Discharge Instructions: Patient left AMA from Hospital -- this is what was supposed to be given to patient Dear Mr. [**Known lastname 10983**], You were initially admitted to the intensive care unit because you overdosed on several drugs (opiates, benzodiazepines, and methadone). In the ICU, you were somnolent and your heart rate was very slow, but you recovered and were transferred to the medical service. On the medical service, you developed an infection of the skin on your left foot where an IV had been in place previously. This infection was treated first with IV antibiotics and then with oral antibiotics. Your blood pressure was difficult to control during this period. Some changes have been made to your medications. Please note them below. You should return to the hospital if the infection in your left foot returns. You should also return if you begin to have thoughts of hurting yourself again. Also, please return for any other symptoms which seriously concern you. Followup Instructions: Patient left AMA Completed by:[**2108-10-23**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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9673, 9679

4530, 9182

327, 334

9825, 9856

2941, 4507

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156,331

20352

Discharge summary

report

Admission Date: [**2108-6-5**] Discharge Date: [**2108-6-8**] Date of Birth: [**2062-10-28**] Sex: M Service: MEDICINE Allergies: Tuberculin,Purif.Prot.Deriv. Attending:[**First Name3 (LF) 983**] Chief Complaint: ETOH abuse Major Surgical or Invasive Procedure: none History of Present Illness: 45 year old gentleman with history of ETOH abuse and daily ETOH, IDDM, depression presented after roommate called 911 for excessive drinking. Per roomate, patient had been drinking multiple bottles of rum for the past few days. No known trauma. In triage reported increased depression and endorsed SI. . In the ED, initial VS were: T 98.9, HR 130 , BP 154/85, RR 16, O2 95% on RA. Given haldol 5mg and ativan 2mg for agitation during IV placement. Treated with 3L IV NS with resolution of tachycardia. Labs were originally notable for ETOH of 437, anion gap of 37 and osmolar gap of 415. Was started onf D5 with 20meq KCL for concern of AKA. Repeat chemistries showed no gap. Patient endorsed suicidal ideations and psychiatry was consulted in the ED. They found that patient did not meet section 12 criteria, but would likely benefit from treatment for his substance abuse. While waiting for psychiatry evaluation, patient began to experience withdrawal symptoms. Was treated with PO valium 10mg x 2. Became tachycardia, hypertensive and tremulous. Treated with 4mg IV ativan with marked improvement. Lasted approximately 30-45 minutes and required additional 4mg IV ativan. Admitted to MICU for withdrawal symptoms. . On arrival to the MICU, patient's VS: T 98, HR 111, BP 156/89, RR 28, O2sat 99% on RA. Patient was comfortable and reporting feeling much better. Reports drinking 1-1.5L of rum daily, but only drank half the day prior to admission. Denies any CP/SOB. Denies nausea,vomiting,diarrhea. Denies any pain anywhere. Past Medical History: HTN h/o alcholic hepatitis DM GERD +PPD with negative chest x-ray Social History: Patient is immigrant from El Salvidor, moved to US at age 16. ETOH abuse drinks 1-1.5L of rum per day, denies illicit drugs. Poor social support network Family History: Alcoholism on mother's side. Physical Exam: Admission exam Vitals: T 98, HR 111, BP 156/89, RR 28, O2sat 99% on RA. General: Alert, oriented, no acute distress, occasional tremor HEENT: Sclera anicteric, dMMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Tachycardic, normal rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, mildly distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: no foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: alert and oriented x 3, moving all extremities, sensation intact Discharge exam Tmax: 36.7 ??????C (98 ??????F) Tcurrent: 36.6 ??????C (97.8 ??????F) HR: 88 (77 - 118) bpm BP: 146/101(111) {121/74(83) - 156/105(113)} mmHg RR: 27 (22 - 34) insp/min SpO2: 100% General: Alert, oriented, no acute distress, occasional tremor HEENT: Sclera anicteric, dMMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Tachycardic, normal rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, mildly distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: no foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: alert and oriented x 3, moving all extremities, sensation intact Pertinent Results: Admission labs [**2108-6-5**] 02:40PM BLOOD WBC-8.8# RBC-4.38* Hgb-10.9* Hct-35.0* MCV-80*# MCH-25.0*# MCHC-31.2 RDW-19.9* Plt Ct-474*# [**2108-6-5**] 02:40PM BLOOD Glucose-197* UreaN-12 Creat-0.9 Na-141 K-3.9 Cl-97 HCO3-17* AnGap-31* [**2108-6-5**] 02:40PM BLOOD Calcium-9.1 Phos-3.1# Mg-1.8 [**2108-6-5**] 02:40PM BLOOD ASA-NEG Ethanol-437* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Discharge labs [**2108-6-7**] 02:28AM BLOOD WBC-4.1 RBC-3.92* Hgb-9.7* Hct-31.6* MCV-81* MCH-24.6* MCHC-30.5* RDW-19.8* Plt Ct-193 [**2108-6-7**] 07:43AM BLOOD Glucose-248* UreaN-7 Creat-0.7 Na-135 K-3.6 Cl-99 HCO3-26 AnGap-14 [**2108-6-7**] 07:43AM BLOOD Calcium-8.9 Phos-3.0 Mg-2.3 Studies Head CT: Three attempts were made at imaging; however, the study remains limited due to patient motion. There is no evidence of acute intracranial hemorrhage, edema, mass, mass effect, or large vascular territorial infarction. The ventricles and sulci are mildly prominent, unchanged since [**2101**], reflective of mild diffuse cortical atrophy. There is no shift of normally midline structures. No acute fracture is detected. The middle ear cavities, mastoid air cells, and included views of the paranasal sinuses remain clear. IMPRESSION: Study limited by patient motion, but no acute intracranial process detected. CXR: PORTABLE UPRIGHT AP VIEW OF THE CHEST: There are low lung volumes. The cardiac, mediastinal and hilar contours are within normal limits. The pulmonary vascularity is normal. The lungs are clear without pleural effusion, focal consolidation, or pneumothorax. There are no acute osseous abnormalities. IMPRESSION: No acute cardiopulmonary process. EKG: Sinus tachycardia. Compared to the previous tracing of [**2105-8-22**] the inferior T wave changes have improved which may represent pseudonormalization in the context of the increase in rate. No diagnostic interim change. Brief Hospital Course: 45 year old gentleman with history of ETOH abuse, depression and IDDM presented with ETOH abuse and transferred to MICU for ETOH withdrawal. He was treated with diazepam per CIWA scale. Electrolytes were repleted. He is discharged with outpatient psychiatric follow up at [**University/College 23633**] on [**2108-6-11**]. # ETOH withdrawal - Patient is heavy drinker with recent increased use and experiencing withdrawal symptoms in ED. He was treated with diazepam per CIWA scale, and had significant requirements to control his symptoms of anxiety and tremulousness. He did not have a seizure. Thiamine, folate, and multivitamin were given. He had electrolyte abnormalities and these were repleted. Psychiatry assessed him and did not think section 12 was necessary. Social work was consulted and patient was agreeable to detox facility however given insurance issues he will be seen at [**University/College 23633**] on [**6-11**]. He should continue to follow up with his outpatient provider at [**Name9 (PRE) 112**], already has an appointment in few days. # Refeeding syndrome - The patient was noted to have hypokalemia and hypophosphatemia, perhaps due to mild refeeding syndrome. These were repleted and monitored. These were stable prior to discharge. # Depression - patient endorsing increased depression and SI on arrival to ED. Cleared by psychiatry and psychiatry feels there is a component of substance abuse leading to his depression. Does not meet section 12 criteria. He denied SI once sober in the morning. Substance abuse treatment as above. # DM - Patient is on insulin as outpatient. Maintained on insulin sliding scale while in house, and will be sent home on his outpatient regimen. # Code: Full ========================================== TRANSITIONAL ISSUES # further psychiatric care per outpatient provider Medications on Admission: Medications: confirmed from Dr[**Name (NI) 54590**] office his PCP at [**Name9 (PRE) 112**]. cymbalta 30 mg 1 daily iron sulfate 325 mg daily lantus 40 unit sc daily at bed time lisinopril 20 mg daily MVI nadolol 20 mg daily naproxen 500 mg twice daily as needed trazodone 100 mg daily at bed time vitamin D2 [**Numeric Identifier 1871**] unit weekly Discharge Medications: 1. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. Cymbalta 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 6. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day. 7. Lantus 100 unit/mL Solution Sig: Forty (40) unit Subcutaneous at bedtime. 8. nadolol 20 mg Tablet Sig: One (1) Tablet PO once a day. 9. naproxen 500 mg Tablet Sig: One (1) Tablet PO twice a day as needed for pain. 10. trazodone 100 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 11. Vitamin D2 50,000 unit Capsule Sig: One (1) Capsule PO once a week. Discharge Disposition: Home Facility: [**Hospital1 3578**] DETOX Discharge Diagnosis: Alcohol withdrawal Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr [**Known lastname 54591**], It was a great pleasure taking care of you as your doctor. You were admitted for alcohol withdrawal. You were treated with medications to reduce your symptoms. You have been set up with an outpatient detox program to help treat your addiction to alcohol and should keep those appointments. You should not drink when you go home. The following changes have been made to your medications: ** START thiamine [vitamin] 100mg by mouth daily ** START folic acid 1mg by mouth daily Please continue the rest of your home medications the way you were taking them at home prior to admission. Please follow with your appointments as illustrated below. Followup Instructions: Outpatient psychiatric follow up on [**2108-6-11**] at [**University/College 23631**] as instructed to you. . Department: [**Hospital1 7975**] INTERNAL MEDICINE When: MONDAY [**2108-6-18**] at 3:30 PM With: [**First Name11 (Name Pattern1) 2801**] [**Last Name (NamePattern4) 14773**], NP [**Telephone/Fax (1) 7976**] Building: [**Hospital1 7977**] ([**Location (un) 686**], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Free Parking on Site . Location: [**Hospital6 1708**] [**Doctor Last Name **] CENTER Date: [**2108-6-13**] Time: 03:50 pm With: Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Phone: [**Telephone/Fax (1) 54592**]

[ "250.00", "303.01", "530.81", "291.81", "276.2", "V62.84", "296.30", "V58.67", "401.9" ]

icd9cm

[ [ [] ] ]

[ "94.62" ]

icd9pcs

[ [ [] ] ]

8724, 8768

5565, 7410

299, 305

8831, 8831

3655, 4340

9687, 10356

2160, 2190

7811, 8701

8789, 8810

7436, 7788

8982, 9664

2205, 3636

248, 261

333, 1883

4349, 5542

8846, 8958

1905, 1973

1989, 2144

58,242

168,136

473

Discharge summary

report

Admission Date: [**2201-8-28**] Discharge Date: [**2201-9-15**] Date of Birth: [**2143-10-4**] Sex: M Service: MEDICINE Allergies: Codeine / Streptokinase / Iodine / Bee Pollens Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 57M with PMH of atrial fibrillation on coumadin, systolic + diastolic CHF, CAD h/o MI, COPD on 4L home O2, 4 prior intubations for pneumonia, p/w less than 24 hours of shortness of breath. He was recently admitted from 7/21-27/10 for shortness of breath and was treated for a CHF exacerbation. His lasix 160 mg TID was changed to torsemide 100 mg QD and spironolactine 12.5 mg QD, under the direction of his cardiologist Dr. [**First Name8 (NamePattern2) 401**] [**Last Name (NamePattern1) 437**]. Echo was stable (or even improved MR) compared to prior; EF 30%. His captopril was also increased from 12.5 TID to 50 mg TID. He reports that in the past he had taken as much as 100 mg TID. . He reports SOB started yesterday evening after doing well for several days at home after discharge. His symptoms were helped somewhat with use of BIPAP overnight. He says his O2 req now is 6L from 4L. He denies cough, F/C, chets pain, N/V, and change in BMs. He says he has been taking torsemide 100 mg and spironolactone 12.5 mg QD since discharge, and has been strict with his diet. He does report high diastolic BP above 90-110, which is suboptimal. . On initial interview at admission, his cardiac review of symptoms is positive for [**4-2**] pillow orthopnea, SOB, DOE with 30 feet walking and less than 12 stairs, and generalized fatigue. . In the ED, VS were T 98.1, BP 140/71, HR 91, RR 28, 100% on 6L NC. He was given vancomycin 1 g x 1 and levofloxacin 750 mg IV x 1. He did not yet receive lasix in the ED. EKG showed AFib, HR 89, poor R wave progression, no ST changes. Past Medical History: Type II Diabetes on oral agents Systemic Lupus Erythematosus Coronary Artery Disease s/p MI in [**2186**] Hepatitis C COPD with emphysema and asthmatic component (FEV1 60% predicted [**1-6**]) Diastolic Congestive Heart Failure EF 55% in [**3-/2198**] Seizure disorder TIA [**2187**] Colon Cancer s/p resection in [**2194**] without chemotherapy s/p abdominal trauma with subsequent splenectomy and amputation of digits of his left hand Hyperlipidemia Hypertension h/o cocaine abuse Neuropathy and chronic pain on methadone Chronic Atrial Fibrillation on coumadin Obstructive Sleep Apnea on home CPAP Left Total Knee Replacement [**2201**] Social History: Pt lives with his wife, daughter, son and granddaughter. [**Name (NI) **] is on disability. He used to be a diesel mechanic. He served in [**Country 3992**] and was badly injured in an explosion. The patient quit smoking in [**2181**], 4ppd x 20yrs. "Cheats" with cigars on occasion. Last cigar was smoked in [**9-7**]. No alcohol abuse. History of cocaine abuse, but has been clean since [**2181**]. Denies current recreational drug use. Family History: Adopted Physical Exam: VS in the ED: T 98.1, BP 140/71, HR 91, RR 28, 100% on 6L NC VS on the floor: T 96.4, BP 160/90, HR 80, RR 18, 95% on 5L NC 9did not see admission weight documented yet) General: comfortable in bed; conversant, speaking in full sentences HEENT: sclera anicteric, MMM, oropharynx clear Neck: thick, no LAD, no appreciable JVD Lungs: crackles halfway up on right; good air movement; no r/r/w CV: irregularly irregular, no murmurs appreciated Abdomen: obese, soft, NTND, scar, bowel sounds present, no rebound/guarding Ext: WW, 2+ pulses, no clubbing or cyanosis, no lower extremity edema, pneumoboots in place . Discharge PE: VS: AF, P: 80s, BP: 120s-130s/80s, RR: 18, O2 Sat: 98% on 4L Gen: well-appearing, obese, middle aged male in NAD. Oriented x3. Neck: Supple with no elevation JVP. CV: Regular rate, normal S1, S2. No m/r/g. No S3 or S4. Chest: CTAB, no wheezes, rales, crackles Abd: Soft, NTND. No HSM or tenderness. Ext: no edema, 2+ pulses in DP, PT, and radial bilaterally Pertinent Results: ADMISSION LABS: [**2201-8-28**] 11:50AM BLOOD WBC-13.2* RBC-3.33* Hgb-9.3* Hct-29.2* MCV-88 MCH-28.1 MCHC-32.0 RDW-17.1* Plt Ct-444* [**2201-8-28**] 11:50AM BLOOD Neuts-77.1* Lymphs-14.5* Monos-6.3 Eos-1.6 Baso-0.6 [**2201-8-28**] 11:50AM BLOOD PT-34.4* PTT-31.9 INR(PT)-3.5* [**2201-8-28**] 11:50AM BLOOD Glucose-160* UreaN-15 Creat-1.1 Na-140 K-4.2 Cl-98 HCO3-33* AnGap-13 [**2201-9-6**] 07:16PM BLOOD ALT-250* AST-491* LD(LDH)-686* CK(CPK)-42* AlkPhos-107 [**2201-8-28**] 11:50AM BLOOD proBNP-[**Numeric Identifier 4000**]* [**2201-8-29**] 11:05AM BLOOD Calcium-8.7 Phos-3.8 Mg-2.0 OTHER STUDIES: [**2201-8-30**] 07:15AM BLOOD calTIBC-289 Ferritn-92 TRF-222 [**2201-9-6**] 07:16PM BLOOD VitB12-841 [**2201-9-6**] 07:16PM BLOOD TSH-0.46 ADMISISON EKG: AFib, HR 89, poor RWP, no ST changes. Unchanged from prior. [**2201-8-28**] ADMISSION CXR: no read yet. opacity on right; c/w volume overload vs. PNA [**2201-8-24**] TTE: The left atrium is moderately dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). The right atrium is moderately dilated. The estimated right atrial pressure is 10-15mmHg. The left ventricular cavity is moderately dilated. There is moderate global left ventricular hypokinesis with relative preservation of apical setments. (LVEF = 30%). The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([**1-31**]+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2201-8-20**], the severity of mitral regurgitation and the estimated pulmonary artery systolic pressure are slightly reduced. Biventricular cavity sizes and systolic function are similar. CT head: [**2201-9-6**]: FINDINGS: There is no evidence of hemorrhage, infarction, or masses. There is no shift of midline structures. Ventricles and sulci are slightly prominent, could be due to atrophy. Visualized portion of the paranasal sinuses and mastoid air cells are within normal limits. Osseous structures appear normal. IMPRESSION: Normal study. . Abd US: [**2201-9-8**]: IMPRESSION: 1. No gallstones and no biliary dilatation. Mild hepatomegally. 2. Small right pleural effusion. 3. Small simple right renal cyst. . EKG on [**2201-9-6**] demonstrated atrial fibrillation with no significant change compared with prior dated [**2201-8-28**]. . 2D-ECHOCARDIOGRAM [**2201-8-24**]: The left atrium is moderately dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). The right atrium is moderately dilated. The estimated right atrial pressure is 10-15mmHg. The left ventricular cavity is moderately dilated. There is moderate global left ventricular hypokinesis with relative preservation of apical setments. (LVEF = 30%). The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([**1-31**]+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . Compared with the prior study (images reviewed) of [**2201-8-20**], the severity of mitral regurgitation and the estimated pulmonary artery systolic pressure are slightly reduced. Biventricular cavity sizes and systolic function are similar. . CARDIAC CATH [**2201-9-7**]: 1. Selective coronary angiography in this right dominant system demonstrated no flow limiting lesions. The LMCA had no angiographically apparent disease. The LAD had mild plaquing throughout and the distal LAD was noted to be a small vessel. The Cx had mild plaquing throughout. The RCA had mild plaquing throughout. There was a pseudostenosis of the PL branch at an area of hyperacute angulation which made there appear to a 40% stenosis in the R-PL branch. 2. Limited resting hemodynamics revealed elevated left and right sided filling pressures. The RVEDP was 22 mmHg and the PCWP was 24 mmHg. There was moderate pulmonary hypertension with a PASP of 48 mmHg. The central aortic pressure was 102/65 mmHg. The cardiac index was low at 1.6 l/min/m2. FINAL DIAGNOSIS: 1. Coronary arteries have no flow limiting lesions. 2. Moderate diastolic ventricular dysfunction. 3. Moderate pulmonary hypertension. Brief Hospital Course: - previous to tx to MICU: DIASTOLIC and SYSTOLIC CHF: Mr. [**Known lastname 3989**] was admitted with a CHF exacerbation (acute on chronic diastolic and new systolic). He received doses of antibiotics in the ED for question of a pneumonia on admission CXR, though these were not continued on the floor because clinically he did not have a pneumonia (no fever, no cough or sputum). He was treated with doses of lasix 80 mg IV PRN the first several days of admission and continued on his home dose of torsemide 100 mg QD. His spironolactone was increased from 12.5 mg to 25 mg. He was re-admitted three days after his last hospital discharge, at which point he was treated for CHF, COPD and HAP. On that discharge on [**2201-8-25**], his weight was stable on torsemide 100 mg and spironolactone 12.5 mg. His CHF exacerbation was thought to be related to elevated diastolic blood pressure, and his captopril had been titrated from 12.5 mg TID to 50 mg TID with goal DBP < 80. He was at goal by discharge, yet Mr. [**Known lastname 3989**] reported elevations in his DBP from 90-100's at home in the days between admissions. He denied non-compliance with diet and medications, and reports that he often gets acute onset SOB in the evenings "just as I am getting ready for bed." MICU [**Location (un) **] COURSE # AMS: When came to until, thought possible seizure vs. infx, vs. metabolic vs. HTN. A head ct r/o bleed, and a metabolic work up (tsh, b12, rpr) and infx work up (cxs) were negative. EEG was not done. A neuro c/s was called. Ultimately, we feel this was likely [**3-3**] overmedication, and he will need to be followed up in the outpt arena for titration of his sedating medications and a possible wean. A check of his anti-seizure meds was normal (carbamazepine of 14.1). . #. Acute on chronic systolic + diastolic CHF and HTN: While on the MICU service, we had originally stopped all of his home antihypertensives given the hypertensive emergency that he presented with. He was placed on a nitro-drip and required labetalol IV prn. Over time, his blood pressure returned to baseline and his home medications were restarted. However, the pt's home doses had to be held multiple times for hypotension, so we decreased his dose of diltiazem. Given the CHF, we continued the metoprolol, captopril, spironolactone, simvastatin, isosorbide dinitrate, and the dose will likely have to be continually titrated on the floor. Mr. [**Known lastname 3989**] also went for cardiac cath on Monday [**9-7**] due to relatively recently diagnosed systolic component, which showed clean coronaries. We continued for daily weights, 1500 cc fluid restriction. . #. ANEMIA: considered to have ACD per heme in prior notes. Hct stable here. no further episodes of rectal bleeding, continued the pt on stool softeners (as he was as an outpatient), and we were getting [**Hospital1 **] Hcts, and maintained an active T/S. . #. Afib/History of PE & DVT/anticoagulation: Goal INR 2.5 - 3.5 per OMR. - heparin gtt was started after cath--> can bridge to coumadin. . #. COPD: chronic COPD - stable symptoms. Awaiting pulm rehab as an outpatient. #. Diabetes: diet controlled currently #. Obstructive sleep apnea: home Bipap machine hooked up #. Insomnia: continue on home dose of tizanidine and oxazepam. #. SLE: continue on home dose of plaquenil. # Chronic pain: On methadone recently decreased from 20 mg QID to 10 mg QID under direction of Dr. [**Last Name (STitle) **]. Trying to wean medications as above, will have to follow up with Dr. [**Last Name (STitle) **] regarding status of this. . [**Hospital1 **] C (Cardiology Floor) Hospital Course: #. Acute on chronic systolic + diastolic CHF: Patient was agressively diuresed on torsemide 100 mg po BID and lasix iv as needed to acheive negative output of at least 2 liters per day. Prior to discharge, his torsemide was increased to 150 mg po BID and he was no longer requiring iv lasix. He was He was clinically euvolemic with no crackles on lung exam, no JVD. Blood pressure was aggressively managed with several medications and prevented further worsening of his volume status. He lost about 11 kg on the cardiology floor. His discharge weight was 100.7 kg (from 111 kg on transfer to the floor). . # AMS: On transfer to the floor, he was confused and lethargic but AAOx3. His altered mental status was likely secondary to medications. He had no focal neuro deficits and his CT head was negative. His methadone was decreased from 10 mg po q6h to 5 mg po q6h and then to 5 mg po q6h prn. He tolerated this adjustment without compliant. His tizanidine was decreased from 4 mg po qHS to 2 mg po qHS and oxazepam from 30 mg po qHS to 15 mg po qHS and finally to 10 mg po qHS. His pregabalin was decreased from 100 mg po tid to 25 mg po tid. Once he returned to baseline mental status, he was complaining of neuropathic pain and he was restarted on his home dose of 100 mg po tid. He remained clear and coherent. . #. ANEMIA: Work-up has been done as an outpatient and the etiology is likely anemia of chronic disease. His hematocrit remained at baseline throughout his stay. . #. Afib/History of PE & DVT/anticoagulation: He was in rate-controlled atrial fibtillation for most of his stay. He was anti-coagulated on coumadin 17.5 mg po qD. He had an jump in his INR to 7 and his coumadin was held for 2 days until it dropped below 3. He was restarted on coumadin 7.5 mg po qD. He will follow up with the coumadin clinic at [**Hospital3 3583**] where he already has established care. . #. COPD: Remained stable throughout the hospital stay. He uses 4 L NC at home and he did no require extra oxygen while hospitalized. He was given albuterol PRN and ipratropium for wheezing as well as advair diskus. His COPD medications were not altered and he was discharged on his home medications. He will have pulmonary rehabilitation as an outpatient. . #. Diabetes: diet controlled, stable. No interventions this hospitalization. . #. Obstructive sleep apnea: continued to use CPAP at night. . # Chronic pain: was well controlled on methadone 5 mg po q6h prn. His pregabalin was initially decreased to 25 mg po tid and then increased back to 100 mg po tid when he was complaining of neuropathic pain. . # Hx of seizures: His was continued carbamazepine at 400 mg po tid. There was concern that he dose may have been too high given the elevated lab levels. Neuro was actively involved in this case and asked that he be continued on his home dose. Neuro recs Medications on Admission: 1. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): Take a half pill. Take in the morning. Disp:*15 Tablet(s)* Refills:*2* 2. Captopril 50 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 3. Methadone 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:*112 Tablet(s)* Refills:*0* 4. Torsemide 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Carvedilol 25 mg Tablet Sig: Two (2) Tablet PO twice a day. 6. Isosorbide Dinitrate 40 mg Tablet Sig: One (1) Tablet PO three times a day. 7. Warfarin 17.5 mg once a day 8. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: 1-2 puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 10. Ipratropium Bromide 0.02 % Solution Sig: [**1-31**] puff Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 11. Carbamazepine 400 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO three times a day. 12. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 14. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 15. Oxazepam 15 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 16. Pregabalin 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 17. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 18. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for heartburn. 19. Tizanidine 4 mg Capsule Sig: One (1) Capsule PO at bedtime. 20. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 21. Cyanocobalamin 1,000 mcg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. Carbamazepine 400 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO three times a day. 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 5. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. 6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation four times a day as needed for cough/ wheezing. 10. Captopril 25 mg Tablet Sig: Four (4) Tablet PO TID (3 times a day). 11. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Ipratropium-Albuterol 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for Nebulization Sig: One (1) neb Inhalation every 4-6 hours as needed for wheezing. 13. Carbamazepine 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 14. Pregabalin 25 mg Capsule Sig: Four (4) Capsule PO TID (3 times a day). Capsule(s) 15. Oxazepam 10 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Disp:*30 Capsule(s)* Refills:*0* 16. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*1* 17. Torsemide 100 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*1* 18. Tizanidine 2 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). Disp:*30 Tablet(s)* Refills:*0* 19. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO QID (4 times a day). Disp:*360 Tablet(s)* Refills:*1* 20. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM. Disp:*90 Tablet(s)* Refills:*0* 21. Lactulose 10 gram/15 mL Syrup Sig: 30-60 MLs PO TID (3 times a day). Disp:*900 ML(s)* Refills:*1* 22. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 23. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 24. Isosorbide Dinitrate 20 mg Tablet Sig: Three (3) Tablet PO Q8H (every 8 hours). Disp:*4 Tablet(s)* Refills:*1* 25. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*1* 26. Cyanocobalamin (Vitamin B-12) 1,000 mcg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. 27. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO twice a day. 28. Methadone 10 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain. Discharge Disposition: Home With Service Facility: VNA Assoc. of [**Hospital3 **] Discharge Diagnosis: Primary Diagnoses: (1) Acute on chronic systolic + diastolic CHF (2) Acute altered mental status- now resolved. (3) Hypertension Secondary Diagnoses: (1) Anemia of chronic disease (2) Stable COPD Discharge Condition: On 4L NC which is baseline home O2, denies shortness of breath. Blood pressures running ~120/80. Discharge weight is 221.5 lbs (100.7 kg). Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. You were admitted to the hospital with a congestive heart failure flare. We think this happened because your blood pressure was too high. Your blood pressure medications have been changed and it was better controlled in the hospital. Please check your blood pressure regularly and keep a log of your blood pressures. Please bring this log to your appointments with your doctor. You were started on a diuretic called spironolactone that last time you were in the hospital, and the dose of this was increased this admission. This medication increases the potassium in your blood. You do not need to take as much potassium any more. Please only take what is on this new medication list. We started a medication called torsemide and stopped furosemide. Torsemide is a stronger diuretic than furosemide and this is why the dose is lower. While you were in the hospital, you experienced an several days of confusion or a change in your mental status. You had a CT of your head to look for a stroke. This test was negative. You did not have a stroke. We think your change in mental status was due to your medications. Your doses of methadone, oxazepam, and tizanidine were decreased. Your dose of lyrica was decreased for several days but then was increased when your mental status improved. At your last appointment, we discussed you going to pulmonary rehab by [**Hospital3 3583**]. Please speak to your primary doctor, Dr. [**Last Name (STitle) **] about going to pulmonary rehab. Medication Changes: DECREASED Warfarin from 17.5 mg to 7.5 mg by mouth every day DECREASED methadone from 20 mg to 5 mg by mouth every 6 hours DECREASED oxazepam from 30 mg to 10 mg by mouth at night DECREASED tizanidine 2 mg by mouth at night STOPPED Carvedilol 50 mg po twice a day STOPPED Furosemide 160 mg po three times a day STOPPED Potassiun Chloride 20 mg po once a day INCREASED Isosorbide Dinitrate 40 mg po three times a day ADDED Metoprolol tartrate 150 mg twice a day ADDED Torsemide 150 mg twice a day ADDED Spironalactone 25 mg once a day ADDED Hydralazine 75 mg by mouth four times a day ADDED Diltiazem HLC 60 mg four times a day Followup Instructions: You have the following appointments: Department: CARDIAC SERVICES When: TUESDAY [**2201-9-22**] at 3:00 PM With: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], NP [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 249**] When: WEDNESDAY [**2201-9-30**] at 10:00 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: PULMONARY FUNCTION LAB When: WEDNESDAY [**2201-12-2**] at 4:10 PM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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Discharge summary

report

Admission Date: [**2158-6-17**] Discharge Date: [**2158-6-25**] Date of Birth: [**2088-1-21**] Sex: M Service: MEDICINE Allergies: aspirin / Heparin Agents Attending:[**First Name3 (LF) 3256**] Chief Complaint: Urosepsis, aspiration pneumonia Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 18825**] is a 70 year-old male with history of bladder cancer, CKD IV, PVD s/p b/l LE amputations, [**Hospital **] transferred from [**Hospital1 **] at patient's request following admission for fever to 102 and back pain, where patient was found to have pyelonephritis. Yesterday morning patient started having back pain, dysuria and low grade fevers at home. Patient presented to OSH on [**2158-6-16**] with fever, back pain, leukocytosis, and UTI and was initially admitted to medical floor. Patient was started on zosyn and received NS. He had a renal ultrasound showing bilateral hydronephrosis which is to a similar degree as a retrograde pyelogram in [**2156**]. While at OSH on [**2158-6-17**] at 1:00 AM patient became somnolent and hypoxic with O2 sats in 70s on medicine floor. A code blue was called, but patient was not intubated during the event as he is DNI. He had increased work of breathing and O2 sats of 45 - 55% on NRB. His systolic blood pressure remained 130s - 150s during the event. A blood gas during this event was 6.95/66/46. A CXR showed a large right-sided infiltrate consistent with aspiration pneumonia vs. mucus plug. Patient was urgently transferred to ICU and was started on BiPAP. He required frequent suctioning for copious secretions. Added vancomycin to antibiotic regimen. Vitals on transfer from OSH were 113/42, 74, O2 Sat 95% on NRB. . On arrival to the MICU, patient reports he feels better than he did yesterday on admission. His back pain is somewhat better. He complains of some cough and shortness of breath but this is also improved from earlier today. . Review of systems: (+) Per HPI (-) Denies night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies Denies chest pain, chest pressure, palpitations, or weakness. Denies diarrhea, constipation, or changes in bowel habits. Denies rashes or skin changes. Past Medical History: Bladder cancer (high grade TCC) s/p transurethral resection of a bladder tumor and stent placement peripheral vascular disease with history of aortobifemoral bypass graft and now s/p Left BKA, right AKA diabetes coronary artery disease tobacco dependence Crohn's disease hypertension hypercholesteremia stage IV CKD anemia Depression BPH HIT antibody positive recurrent UTIs with MRSA/VRE in urine Social History: retired, previously worked as a postal worker. He smoked cigarettes, actively smoking, and has smoked for least 30-pack years. He does not drink alcohol. Family History: Negative for prostate or breast cancer, or any urinary tract cancers. Physical Exam: Exam upon admission: Vitals: T: 97.8 BP: 114/65 P: 69 R: 15 O2: 99% on NRB General: Alert, oriented, wearing nonrebreather, in no acute distress HEENT: Sclera anicteric, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, distant heart sounds, no murmurs appreciated Lungs: Diffuse rhonchi, bilateral crackles worse on right Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: left BKA, right AKA, stumps well healed, warm and well perfused, no edema Neuro: CNII-XII grossly intact, Alert, oriented, moving all extremities Pertinent Results: Labs upon admission: Serum [**2158-6-17**] 09:50PM BLOOD WBC-23.7*# RBC-2.92* Hgb-7.5* Hct-24.4* MCV-84 MCH-25.7* MCHC-30.8* RDW-17.2* Plt Ct-294 [**2158-6-17**] 09:50PM BLOOD Neuts-93.7* Lymphs-3.5* Monos-2.7 Eos-0.1 Baso-0.1 [**2158-6-17**] 09:50PM BLOOD PT-16.5* PTT-28.1 INR(PT)-1.6* [**2158-6-17**] 09:50PM BLOOD Glucose-159* UreaN-37* Creat-2.1* Na-147* K-3.7 Cl-113* HCO3-20* AnGap-18 [**2158-6-17**] 09:50PM BLOOD ALT-19 AST-31 AlkPhos-47 TotBili-0.3 [**2158-6-18**] 03:00AM BLOOD CK(CPK)-93 [**2158-6-17**] 09:50PM BLOOD cTropnT-0.64* [**2158-6-18**] 03:00AM BLOOD CK-MB-6 cTropnT-0.52* [**2158-6-17**] 09:50PM BLOOD Calcium-8.2* Phos-3.2 Mg-1.9 [**2158-6-19**] 02:19PM BLOOD Vanco-23.5* [**2158-6-17**] 09:53PM BLOOD Type-[**Last Name (un) **] pO2-44* pCO2-44 pH-7.33* calTCO2-24 Base XS--2 [**2158-6-17**] 09:53PM BLOOD Lactate-1.2 [**2158-6-17**] 09:53PM BLOOD O2 Sat-76 . Urine [**2158-6-17**] 09:50PM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.014 [**2158-6-17**] 09:50PM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG [**2158-6-17**] 09:50PM URINE RBC-99* WBC->182* Bacteri-FEW Yeast-NONE Epi-0 [**2158-6-17**] 09:50PM URINE WBC Clm-MANY [**2158-6-19**] 04:20PM URINE Color-YELLOW Appear-Cloudy Sp [**Last Name (un) **]-1.014 [**2158-6-19**] 04:20PM URINE Blood-LG Nitrite-NEG Protein-100 Glucose-TR Ketone-10 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG [**2158-6-19**] 04:20PM URINE RBC->182* WBC->182* Bacteri-FEW Yeast-NONE Epi-0 [**2158-6-19**] 04:20PM URINE WBC Clm-MANY Mucous-OCC . DISCHARGE LABS: [**2158-6-25**] 06:07AM BLOOD WBC-17.3* RBC-3.24* Hgb-8.9* Hct-27.7* MCV-86 MCH-27.4 MCHC-32.0 RDW-18.2* Plt Ct-459* [**2158-6-20**] 03:48AM BLOOD PT-13.3* PTT-27.5 INR(PT)-1.2* [**2158-6-25**] 06:07AM BLOOD Glucose-84 UreaN-27* Creat-1.7* Na-141 K-3.2* Cl-106 HCO3-22 AnGap-16 [**2158-6-25**] 06:07AM BLOOD Calcium-8.6 Phos-3.6 Mg-1.9 . Microbiology: [**2158-6-17**] 9:34 pm URINE Source: Catheter. **FINAL REPORT [**2158-6-21**]** URINE CULTURE (Final [**2158-6-21**]): STAPH AUREUS COAG +. >100,000 ORGANISMS/ML.. ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | ENTEROCOCCUS SP. | | AMPICILLIN------------ <=2 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R LINEZOLID------------- 2 S NITROFURANTOIN-------- <=16 S <=16 S OXACILLIN------------- 0.5 S TETRACYCLINE---------- <=1 S =>16 R TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ =>32 R . [**2158-6-19**] 4:20 pm URINE Site: NOT SPECIFIED **FINAL REPORT [**2158-6-20**]** URINE CULTURE (Final [**2158-6-20**]): <10,000 organisms/ml. . [**2158-6-19**] Legionella Urinary Antigen (Final [**2158-6-20**]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. . Blood cultures 5/28 and [**6-20**]: pending. . C.diff [**2158-6-20**]: negative . IMAGING: -[**2158-6-24**] CXR: FINDINGS: There is a new left-sided PICC line with tip in the low SVC. This finding was discussed with IV nursing at 9:26 a.m. by Dr. [**Last Name (STitle) **]. There is no pneumothorax. Compared to the study from [**2158-6-18**], there has been interval clearing of the right mid lung infiltrate. There is a patchy area of increased opacity in the left lower lung. It is unclear how much of this is due to overlapping rib shadows, but attention should be paid to this region on followup. . -[**2158-6-21**] b/l UE venous mapping: TECHNIQUE AND FINDINGS: The upper extremity venous system was evaluated with B mode, color and spectral Doppler ultrasound. The subclavian veins present with normal phasicity bilaterally. On the right side, the right cephalic vein is patent with diameters ranging between 0.29 and 0.18 cm. The right basilic vein is patent with diameters ranging between 0.12 and 0.22 cm. On the left side, the left cephalic vein is patent with diameters ranging between 0.12 and 0.25 cm. There is an intravenous access in the distal cephalic vein. The left basilic vein is patent with diameters ranging between 0.14 and 0.22 cm. The brachial and radial arteries are patent with normal Doppler waveforms bilaterally. Small calcifications were noted in the brachial and radial arteries bilaterally. IMPRESSION: Patent basilic and cephalic veins bilaterally, with diameters as described above. . [**2158-6-19**] TTE: Conclusions The left atrium is mildly elongated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The 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. Dilated ascending aorta. No valvular pathology or pathologic flow identified . Brief Hospital Course: 70 year-old gentleman with history of bladder cancer with bilateral ureteral stents, CKD Stage IV, PVD s/p b/l LE amputations, CAD who was transferred to [**Hospital1 18**] MICU from [**Hospital1 **] with MRSA pyelonephritis, likely aspiration pneumonia with acidosis and hypoxia, and NSTEMI thought to be due demand ischemia in setting of infection. CXR showed RLL pneumonia (required Bipap at OSH, but discontinued on arrival to [**Hospital1 18**]). In the ICU, he was treated with vancomycin and zosyn (latter changed to cefepime) to cover both urinary and respiratory pathogens. Echocardiogram showed normal LVEF >55% with dilated descending aorta, but no significant valvular disease or hypokinesis. He remained hemodynamically stable throughout his course in the MICU, although required up to 50% oxygen supplementation. He was called out to the floor, where he was progressively weaned to room air. His outpatient urologist Dr. [**Last Name (STitle) 91657**] was contact[**Name (NI) **] who recommended bilateral ureteral stent exchange. This could not be performed due to SBP's over 200 on the day of the scheduled stent exchange, and urology f/u was made due to the non-emergent nature of the procedure. His BP Rx were uptitrated, with improvement in BP's. His condition remained stable and he had PICC line placed for nafcillin treatment (commenced after completion of an 8-day course of linezolid/cefepime for aspiration PNA, per ID recs). . ACTIVE HOSPITAL ISSUES: # UTI/Pyelonephritis: Patient presented to OSH with fever, back pain, and dysuria. UA consistent with UTI. Concern was for complicated cystitis/pyelonephritis as patient has bladder cancer and ureteral stents. Patient was empirically treated with zosyn and vancomycin at OSH. Patient has previous history of VRE UTIs. OSH culture data showed MSSA. Here, UCx also grew out VRE. Per ID, we started nafcillin (d1=[**6-24**]) for 14-day course for ongoing treatment of MSSA UTI. Per ID, if stents are not changed within a reasonable amount of time, pt will likely need to transition to an oral suppressive [**Doctor Last Name 360**] until stents may be changed (eg cephalexin). Plan was for urology to perform ureteral stent exchange on [**6-23**], but procedure held [**2-23**] SBP's in 200s. Pt will need to f/u with Dr. [**Last Name (STitle) 91657**] as outpt. He was d/c'd on a total 14-day course of nafcillin to treat the MSSA. . # aspiration pneumonia or pneumonitis: This was likely the cause of his dyspnea/hypoxia, and R-sided infiltrate was seen on CXR at OSH. Patient initially required non-invasive ventilation for respiratory acidosis and required frequent suctioning for secretions. It is unclear what precipitated the aspiration event; possibilities include narcotics as the patient was receiving IV morphine Q2H. Patient was not intubated as he is DNI. Pt has a significant smoking history which may exacerbate his pulmonary baseline. Pt passed Speech/swallow consult [**6-20**]. He completed a course for HCAP coverage with Cefepime (d1 = [**6-18**], treated for 8 day course), and linezolid (switched from vanc on [**6-22**] per VRE in urine and ID recs). Sputum culture at [**Hospital1 18**] showed oral flora; legionella neg. . RESOLVING OR CHRONIC ISSUES: . # NSTEMI: Had NSTEMI at OSH in setting of hypotension and infections. Patient with h/o CAD s/p MI. Patient does not know if he has had a previous cardiac catheterization/PCI. On metoprolol, lisinopril, simvastatin at home. Following acute decompensation at OSH, patient with elevated troponin at OSH to 6.46. Aspirin allergy not real (upset stomach) so okay to receive. F/u ECHO showed no new wall motion abnormalities. We continued ASA 81mg daily, simvastatin, beta blocker. . # CKD: Patient with CKD [**2-23**] diabetic nephropathy and obstruction (bladder cancer). Creatinine remained stable. PICC line was placed for naficillin treatment (PICC can be d/c'd after final infusion of naficllin). Prior to PICC placement, pt was eval'd by renal eval regarding possible HD access; renal requested b/l UE venous mapping and recommended PICC placement on dominant (pt's LEFT) arm. . # Diarrhea: Improved. Pt had worsening diarrhea since being admitted to [**Hospital1 18**]. Recent exposure to broad spectrum abx, significant WBC elevation not responding to appropriate treatment for pneumonia. Cdiff neg on [**6-20**]. Flexiseal was placed due to high vol stool in non-ambulatory pt; loperamide given negative cdif, and diarrhea improved quickly thereafter. . # Hypertension: Had to increase metoprolol given NSTEMI, as well as Nifedipine and lisinopril 20mg daily. Required a few doses of prn hydral for SBP's >200. Remained asymptomatic throughout even when having elevated BP's. . # Hypokalemia: Improved. In MICU, had hypokalemia, potentially due to sudden increase in liquid stool output. [**Month (only) 116**] be even more total body hypokalemic than think due to acidosis which should be shifting potassium out of cells. K was repleted prn. . # Metabolic acidosis: Improved. In MICU, had hyperchloremic non-anion gap acidosis. Possibly in setting of normal saline administration. No hypercarbia. Lactate normal. [**Month (only) 116**] also have been due to worsening loose stool overnight with subsequent GI bicarb loss. . # Anemia: Patient p/w HCT of 23.9 at OSH, down from recent baseline of 28. Patient was guaiac negative at OSH, no evidence of RP bleed on OSH CT abdomen. Likely anemia of chronic disease vs. iron deficiency anemia (patient with chronic hematuria). Got 1 unit of PRBCs at [**Hospital1 18**] and Hct remained stable. Fe studies showed low serum Fe, low TIBC, high ferritin; c/w anemia of inflammatory block/chronic dz. . # DM: Patient with insulin dependent DM. Restarted home Qhs lantus 18 units with ISS to cover. . # HL: Continued simvastatin 40 mg daily # Depression: Continued Sertraline 125 mg daily . TRANSITIONS OF CARE: . During this admission, patient was DNI, but OKAY TO RESUSCITATE . Patient to receive infusion services, to get Nafcillin 2g IV q6hrs x 13 days for a total 2week course. Patient's PICC line can be d/c'd after final infusion is given. . *Per ID, if ureteral stents are not changed within a reasonable amount of time, pt will likely need to transition to an oral suppressive [**Doctor Last Name 360**] until stents may be changed (eg cephalexin). Medications on Admission: Ferumoxytol 510 mg per 17 mL Vitamin D 50,000 units weekly metoprolol succinate 25 mg daily Oxycodone-Acetaminophen 5-325 mg TID PRN pain Lorazepam 0.5 mg Oral Tablet [**Hospital1 **] PRN anxiety Nifedipine 60 mg Oral Tablet Extended Release daily Ferrous Sulfate 325 mg (65 mg iron), 2 tablets daily Lisinopril 20 mg daily Lantus 18 units qHS Sertraline 125 mg daily Trazodone 50 mg Oral Tablet Simvastatin 40 mg Oral Tablet Discharge Medications: 1. nafcillin 2 gram Recon Soln Sig: Two (2) grams Intravenous every six (6) hours for 13 days. Disp:*104 grams* Refills:*0* 2. ferumoxytol 510 mg/17 mL (30 mg/mL) Solution Sig: One (1) Intravenous as previously prescribed. 3. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a week. 4. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2* 5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours as needed for pain for 10 days. Disp:*30 Tablet(s)* Refills:*0* 6. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety. 7. nifedipine 90 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO DAILY (Daily). Disp:*30 Tablet Extended Release(s)* Refills:*2* 8. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: Two (2) Tablet PO once a day. 9. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. insulin glargine 100 unit/mL (3 mL) Insulin Pen Sig: Eighteen (18) units Subcutaneous at bedtime. 11. sertraline 50 mg Tablet Sig: 2.5 Tablets PO DAILY (Daily). 12. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: [**1-23**] Adhesive Patch, Medicateds Topical DAILY (Daily) as needed for pain. Disp:*30 Adhesive Patch, Medicated(s)* Refills:*1* 14. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:*30 Patch 24 hr(s)* Refills:*2* 15. loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for diarrhea. Disp:*30 Capsule(s)* Refills:*0* 16. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*60 Tablet, Chewable(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Last Name (un) 6438**] Discharge Diagnosis: Primary: Healthcare-associated pneumonia Urinary tract infection/pyelonephritis Secondary: Bladder cancer peripheral vascular disease diabetes coronary artery disease Crohn's disease hypertension hypercholesteremia stage IV Chronic Kidey Disease BPH 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 Mr. [**Known lastname 18825**], It was a privilege to provide care for you here at the [**Hospital1 **] Hospital. You were transferred here from [**Hospital1 **] after you had respiratory distress. You were treated in the intensive care unit for a pneumonia and urinary tract infection. You were transferred to the regular medical floor. Your condition has improved and you can be discharged to your rehab. The following changes were made to your medications: NEW: none CHANGED: -Metoprolol INCREASED to 50mg daily -Nifedipine INCREASED to 90mg daily -Lisinopril INCREASED to 20mg daily STOPPED: none Please keep your follow-up appointments as scheduled below. Followup Instructions: We are working on a follow up appt with Dr. [**Last Name (STitle) 68158**] [**Name (STitle) 27106**] for next week. You will be called at home by Dr. [**Last Name (STitle) 106900**] office with the appointment. If you have not heard or have questions, please call [**Telephone/Fax (1) 34797**]. Name: [**Last Name (LF) 91657**], [**First Name3 (LF) 82704**] N. MD Location: [**Location (un) 2274**] [**Location (un) 2277**]/UROLOGY Address: [**Location (un) **], SURGICAL UROLOGY DEPT, [**Location (un) **],[**Numeric Identifier 16457**] Phone: [**Telephone/Fax (1) 2284**] When: [**Last Name (LF) 2974**], [**2156-7-6**]:20 AM Completed by:[**2158-6-25**]

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icd9cm

[ [ [] ] ]

[ "38.97" ]

icd9pcs

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54298

Discharge summary

report

Admission Date: [**2112-1-9**] Discharge Date: [**2112-1-15**] Date of Birth: [**2064-10-4**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2145**] Chief Complaint: MSSA Bacteremia Major Surgical or Invasive Procedure: L femoral line Tunneled HD line placement TEE History of Present Illness: 47 yo M with DM, ESRD, on HD presents from HD with fever to 103 by report, cough with clear sputum, nausea and vomiting, non-bloody diarrhea. During HD, pt was started on Vancomycin and Gentamicin. Pt unable to keep anything down X 1 day. . In ED, blood cultures drawn, flu antigen sent. VS w/ Tmax 104.6, HR in 80s-100s, low 100's/40's-60's with drop to 84/52 X 1, O2 high 90's on 2L. Blood cx [**12-28**] shows gram + cocci in pairs, clusters, and chains c/w MSSA. L femoral triple lumen placed. CXR and CT Abd/pelvis were negative. Received IV vanco 1gm IV, levaquin 750mg IV, tylenol, zofran, motrin. Erythema at old AV fistula but patient stated this was old. RSC dialysis cath presumed source. Flu swab (niece w/ flu). . Past Medical History: (Per [**Name (NI) **], pt very sleepy and not able to give much history) -DMII: Since age 10. Has been on and off insulin since then depending on his weight. -ESRD: Dr. [**Last Name (STitle) 1366**] is his nephrologist. He had an attempted fistula on the R wrist which did not mature. He then had a graft which lasted for a few years which clotted off. A trial of a repeat graft was unsuccessful. Current cath was placed [**8-29**]. Has h/o line infections, h/o MRSA infections. -Neuropathy: (foot numbness, h/o foot infxns) -Hypertension: (normally 200's/80's), no h/o heart dz -Obstructive Sleep Apnea: On CPAP at home -Obesity -PVD -GERD -Secondary hyperparathyroidism -Cholecystectomy -Partial L foot amptuation Social History: Originally from [**Location (un) 4708**]. Lives alone in [**Location (un) 4398**] but has family (parents, siblings) in area whom he sees often. Father is [**Name (NI) 111236**] [**Name (NI) 100110**], [**Telephone/Fax (1) 111237**]. Ambulatory at home w/o services. Currently unemployed but formerly worked as an electrician. PCP is [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. No tob/ETOH. Family History: DM, hypercholesterolemia Physical Exam: VS: Temp: 99.8 BP: 107/33 HR: 88 RR: 15 O2sat 88-95% on RA GEN: Morbidly obese male, falling asleep continuously during interview, NAD HEENT: PERRL, anicteric, dry MM, op without lesions NECK: JVP difficult to assess [**12-26**] neck size RESP: CTA b/l but distant breath sounds CV: RR, S1 and S2 wnl, no m/r/g but distant heart sounds ABD: obese, nd, +b/s, soft, nt, no masses or hepatosplenomegaly appreciable EXT: xerosis, RUE fistula w/ erythema which pt states is chronic, no LE edema Pertinent Results: [**2112-1-9**] 03:45PM BLOOD WBC-12.0*# RBC-3.87* Hgb-11.7* Hct-34.6* MCV-90# MCH-30.1 MCHC-33.7 RDW-15.9* Plt Ct-177 [**2112-1-9**] 03:45PM BLOOD Neuts-89.8* Lymphs-6.0* Monos-3.7 Eos-0.2 Baso-0.4 [**2112-1-11**] 03:40AM BLOOD PT-13.9* PTT-26.8 INR(PT)-1.2* [**2112-1-9**] 03:45PM BLOOD Glucose-184* UreaN-19 Creat-7.3*# Na-140 K-4.2 Cl-95* HCO3-34* AnGap-15 [**2112-1-9**] 03:45PM BLOOD ALT-35 AST-55* CK(CPK)-1606* AlkPhos-70 TotBili-0.4 [**2112-1-9**] 10:00PM BLOOD CK(CPK)-2752* [**2112-1-10**] 06:25AM BLOOD CK(CPK)-3619* [**2112-1-10**] 03:53PM BLOOD CK(CPK)-4072* [**2112-1-11**] 03:40AM BLOOD CK(CPK)-3302* [**2112-1-9**] 03:45PM BLOOD Lipase-21 [**2112-1-9**] 03:45PM BLOOD cTropnT-0.23* [**2112-1-9**] 10:00PM BLOOD cTropnT-0.21* [**2112-1-10**] 06:25AM BLOOD CK-MB-9 cTropnT-0.24* [**2112-1-9**] 03:45PM BLOOD Albumin-4.3 Calcium-9.5 Phos-1.8*# Mg-1.5* [**2112-1-9**] 03:45PM BLOOD Vanco-12.3 [**2112-1-10**] 06:25AM BLOOD Vanco-21.0* [**2112-1-9**] 05:20PM BLOOD pO2-39* pCO2-43 pH-7.52* calTCO2-36* Base XS-10 [**2112-1-10**] 01:41AM BLOOD Type-ART pO2-45* pCO2-52* pH-7.43 calTCO2-36* Base XS-8 [**2112-1-9**] 03:56PM BLOOD Lactate-1.7 CT Abd/Pelvis: IMPRESSION: 1. No evidence of acute intra-abdominal pathology. 2. Multiple new round low-attenuation lesions seen within the kidneys bilaterally which do not meet CT criteria for simple cysts on this single- phase study. Given patient's history of hemodialysis, and therefore increased risk of renal cell carcinoma, followup imaging is recommended. CXR: Cardiomediastinal silhouette is unchanged. Pulmonary vasculature is normal. Lungs remain clear, without evidence of overt pleural effusion or pneumothorax. Upper extremity US: IMPRESSION: Thrombosed right antecubital graft. No fluid collection. ECHO: Very suboptimal image quality. The left atrium is elongated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. The left ventricle is hyperdynamic. Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The aortic valve is not well seen. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The mitral valve leaflets are not well seen. No mass or vegetation is seen on the mitral valve. The estimated pulmonary artery systolic pressure is normal. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2111-1-5**], no obvious change but both studies suboptimal. If clinically suggested, the absence of a vegetation by 2D echocardiography does not exclude endocarditis. TEE: The left atrium and right atrium are normal in cavity size. No mass/thrombus is seen in the left atrium or left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Right ventricular chamber size and free wall motion are normal. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 44 cm from the incisors. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. 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. Brief Hospital Course: 47 M with PMH of morbid obesity, ESRD on HD, DM2 (insulin-dependent), OSA and HTN who was admitted from dialysis with fevers and decreased PO intake. He was found to have a MSSA bacteremia, diarrhea, nausea and vomiting. # Bacteremia: The patient was originally admitted to the ICU with relative hypotension given his usual [**Name (NI) 5462**] over 200. He was given IVFs and treated with Vanco (dosed by level) and amp/sulbactam dosed after dialysis) for possible Strep/Staph/enterococcus until speciation of blood cx. The blood cultures grew out MSSA. The antibiotics were changed to Cefazolin, which was given during dialysis. The bacteremia was felt to be most likely secondary to a line infection. The line was removed and a temporary line was placed in Interventional Radiology. The patient was dialyzed through his temporary line. After several days without growth in repeat blood cultures, a new dialysis line was tunneled, also in Interventional Radiology. After being called out to the floor the patient remained hemodynamically stable and afebrile. Repeat blood cultures had no growth at the time of discharge. The patient's outpatient Renal doctor will decide on duration of antibiotic treatment, which will be given during dialysis. The patient had a TTE as well as TEE which did not demonstrate any vegetations, which were of concern given Staph bacteremia. # Fever: The patient was admitted with fevers, most likely from bacteremia. The fevers resolved after treatment with antibiotics as above. The patient also had nausea/vomiting and loose stools. He says that his niece has "the flu" so he could also have a GI virus vs cdiff. He states that he has a mild cough but no obvious infiltrates on CXR. Stools were positive for C. Diff and treatment with Flagyl was initiated. The patient will need to continue Flagyl two weeks after finishing Cefazolin. # Elevated CK: On admission, the patient had elevated CK. He apparently runs a high CK at baseline. The MB fraction was not elevated making a cardiac source less likely. The ICU team was suspicious of rhabdo from lying in one position when ill. EKG showed non-specific TW inversion. The patient did not experience chest pain at any point during his hospital course. Troponin elevated but in the context of renal failure making it more difficult to interpret. CK trended down on serial checks. He had no cardiac symptoms. # HTN: The patient was relatively hypotensive on admission when he was bactermic. His BP normalized with treatment, and the patient was restarted on his outpatient regimen of Cartia and lisinopril # DM: The patient was frequently NPO over this course and was treated with both a sliding scale and half his home insulin regimen. He was discharged on his home regimen and states he has an appointment with [**Last Name (un) **] coming up soon. # OSA: The patient used CPAP throughout his stay with help from the respiratory staff. HCP is father [**Name (NI) 111236**] [**Name (NI) 100110**], [**Telephone/Fax (1) 111237**]. Medications on Admission: Renagel 800 mg 3 tabs tid Phoslo 667 1 tab tid ASA 325 Nexium 40 mg daily Renal soft gel capsule Cartia 180 mg [**Hospital1 **] Sensipar 60 mg daily Insulin NPH 32/16; Regular 15/16 Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Cinacalcet 30 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Sevelamer HCl 800 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO twice a day. 9. CefazoLIN 2 g IV QT/TH to be given in diaylsis on Tuesday and Thursday 10. CefazoLIN 3 mg IV QSAT to be given in dialysis on Saturday 11. Insulin We did not change your home insulin regimen. Please take 15 units regular QAM and 16 units regular QPM (at 4 PM). Please continue taking 32 units NPH qAM and 16 units NPH qPM. 12. Line care Per your outpatient dialysis center 13. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 3 weeks: Please take for two weeks after completing your antibiotics in dialysis. Disp:*63 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: #MSSA bacteremia due to prior indwelling HD line #C.diff infection Secondary: #HTN #OSA #ESRD on dialysis Discharge Condition: Stable for discharge home Discharge Instructions: You were admitted to the hospital with an infection in your blood, most likely caused by an infection from your previous hemodialysis line. You are being treated with antibiotics during hemodialysis. Your outpatient dialysis doctor will decide the duration of these antiobiotics. . Please resume taking your outpatient medications as previously prescribed. We did not change any of your medications except for antibiotics, which you will receive during hemodialysis. You will also need to complete a course of antibiotics for C. Difficle diarrhea. Please complete a three week course of Flagyl for this infection. You will need to take Flagyl for two weeks beyond finishing your antibiotics for dialysis. Please call your doctor or return to the ER with any fever greater than 101, inability to take things by mouth, increasing in your diarrhea or any other symptoms you find concerning. Followup Instructions: You have appointments with the following providers: Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], Phone: [**Pager number 111238**], Date/Time: [**2112-2-5**], 10:15am Please continue dialysis on your regularly scheduled days (Tuesday/Thursday/Saturday). Please discuss the duration of antiobiotics with your outpatient dialysis doctor. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]

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icd9cm

[ [ [] ] ]

[ "38.95", "86.07", "39.95" ]

icd9pcs

[ [ [] ] ]

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330, 378

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12441, 12899

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9812, 9995

11522, 12418

2362, 2854

275, 292

406, 1140

1162, 1880

1896, 2305

5,463

195,685

4745

Discharge summary

report

Admission Date: [**2121-3-18**] Discharge Date: [**2121-3-21**] Date of Birth: [**2072-2-2**] Sex: F Service: Neurosurgery HISTORY OF PRESENT ILLNESS: The patient is a 49-year-old woman with a history of a fall down the stairs with chronic back pain. Developed arachnoiditis from myelogram dye. She had an intrathecal drug pump placed four years ago for chronic pain. Patient was given an overdose of baclofen through her intrathecal drug pump on [**2121-3-10**] and on [**2121-3-13**] she became unresponsive and was admitted to the [**Hospital6 3426**]. The intrathecal drug pump was shut off and patient owly woke up.w. he was trdischarged from [**Hospital6 33**] and came Dr. [**Name (NI) 19941**] office on [**2121-3-14**] where he flushed her intrathecal drug pump and administered the correct dose of baclofen. She was discharged to home. Over the weekend she became psychotic, having episodes of hallucinations and bizarre behavior. She was readmitted to [**Hospital6 33**] on [**Last Name (LF) 766**], [**3-17**]. She was awake and alert on [**3-17**]. On [**3-18**], in the morning, she became lethargic. She was transferred to the Intensive Care Unit at [**Hospital6 3426**] and then subsequently transferred to the [**Hospital1 346**] Neurologic Intensive Care Unit. PHYSICAL EXAMINATION ON PRESENTATION: On arrival, she was awake alert and oriented times three. Her pain was [**3-12**]. She was moving all extremities strongly. Her pupils were equal, round, and reactive to light. She had no meningeal signs. Her cardiac status was a regular rate and rhythm. No murmurs, rubs or gallops. Her chest was clear to auscultation. Her abdomen was soft, with implanted device in the right lower quadrant, and a well-healed lumbar scar. She was [**4-6**] in all muscle groups. PERTINENT LABORATORY DATA ON PRESENTATION: Her urine culture had greater than 100,000 white blood cells on [**2121-3-12**] at [**Hospital6 33**], and she was started on ciprofloxacin. Her blood cultures were negative. Her vital signs were stable. Her white blood cell count was 8.5, hematocrit of 46.4. Sodium of 143, potassium of 3.5, chloride of 104, bicarbonate of 26, blood urea nitrogen of 10, creatinine of 0.5, blood sugar of 88. RADIOLOGY/IMAGING: She had a head CT on [**3-16**] which was negative. HOSPITAL COURSE: On [**2121-3-19**], she was awake alert and oriented times three. Moved everything strongly with no complaints of pain. She was feeling well. She was transferred to the regular floor. She was seen by Physical Therapy and Occupational Therapy who found she would be safe for discharge home using a cane. She was seen by the Psychiatry Service for complaints of hallucinations. They recommended starting Risperdal 0.25 mg p.o. b.i.d. DISCHARGE FOLLOWUP: The patient was to be followed as an outpatient with Dr. [**Last Name (STitle) 6910**] in one week's time. Currently, her intrathecal drug pump is running at 50% of its normal rate, and she will see Dr. [**Last Name (STitle) 6910**] in one week for increasing her pump back to the normal rate. MEDICATIONS ON DISCHARGE: (Medications at the time of discharge were). 1. Risperdal 0.25 mg p.o. b.i.d. 2. Cozaar 50 mg p.o. q.d. 3. Protonix 40 mg p.o. q.d. 4. Levoxyl 5 mcg p.o. q.d. 5. Macrodantin 50 mg p.o. q.i.d. 6. Ciprofloxacin 500 mg p.o. q.12h. (started on [**3-12**] and will discontinue on [**3-22**]). CONDITION AT DISCHARGE: Vital signs remained stable. The patient was afebrile at the time of discharge and in stable condition. DISCHARGE INSTRUCTIONS: Was to follow up with Dr. [**Last Name (STitle) 6910**] in one week. [**Name6 (MD) 6911**] [**Name8 (MD) **], MD [**MD Number(1) 6913**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2121-3-21**] 14:38 T: [**2121-3-22**] 10:20 JOB#: [**Job Number 19942**]

[ "599.0", "724.5", "244.9", "304.00", "292.0", "V45.89", "788.20" ]

icd9cm

[ [ [] ] ]

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icd9pcs

[ [ [] ] ]

3137, 3442

2354, 2793

3588, 3901

3457, 3563

2815, 3110

169, 2335

32,619

150,073

49447

Discharge summary

report

Admission Date: [**2143-2-7**] Discharge Date: [**2143-2-10**] Date of Birth: [**2079-11-13**] Sex: F Service: MEDICINE Allergies: Penicillins / Iodine Attending:[**First Name3 (LF) 1162**] Chief Complaint: initiation of non-invasive ventilation Major Surgical or Invasive Procedure: none History of Present Illness: This is a 63 year-old woman with severe COPD on home O2, history of MAC, bronchiectasis, cavitary lesions, thought secondary to pseudomonas started on tobramycin/DNAase two weeks ago who presents with shortness of breath, cough. She had seen her pulmonologist, Dr. [**Last Name (STitle) 2168**] on [**2143-1-22**] with worsening SOB. She was undergoing outpatient pulmonary rehab, though her symptoms of cough and shortness of breath worsened over the past year. She was started on a three-week course of oral ciprofloxacin in mid-[**Month (only) 1096**] which, did not help. Later in the month, her prednisone dose was increased to 30 mg, which she has tapered down to 10 mg. She was recently started on Tobramycin inhalers. She refers that initially she felt better, but last night she had increased SOB and chest pain. . In the ER her vitals: T 97.9, HR 100, BP 112/71, O2 99 % RA. She was given methylprednisolone 100mg, cipro 500 mg [**Last Name (LF) **], [**First Name3 (LF) **] 325 mg, albuterol 0.083% oxycodone po. Currently pt feels better, but cont to complain of mild SOB. Past Medical History: 1.Severe COPD 2.History of MAC 3.Pseudomonal infection 4.Bronchiectasis Family History: non-contrib Physical Exam: VS: Tmax:97.9 BP: 102/60 HR:88 RR:22 O2sat: 97% on 2 L NC . General Appearance: pleasant, comfortable, NAD, non toxic Eyes: : PERLLA, EOMI, no conjuctival injection, anicteric ENT: no sinus tenderness, MMM, op without exudate or lesions, no supraclavicular or cervical lymphadenopathy, JVP to cm, no carotid bruits, no thyromegaly or thyroid nodules Respiratory: Decreased breath sounds throughout with scattered crackles and end- expiratory wheezes. Cardiovascular: RR, S1 and S2 wnl, no murmurs, rubs or gallops appreciated Gastrointestinal: nd, +b/s, soft, nt, no masses or hepatosplenomegaly Musculoskeletal/extremities: no cyanosis, clubbing or edema Skin/nails: warm, no rashes/no jaundice/no splinters Pertinent Results: [**2143-2-7**] 11:45AM PLT COUNT-446* [**2143-2-7**] 11:45AM NEUTS-72.5* LYMPHS-18.1 MONOS-5.6 EOS-3.3 BASOS-0.5 [**2143-2-7**] 11:45AM WBC-15.9* RBC-4.25 HGB-12.6 HCT-36.0 MCV-85 MCH-29.6 MCHC-34.9 RDW-14.3 [**2143-2-7**] 11:45AM GLUCOSE-94 UREA N-17 CREAT-0.8 SODIUM-142 POTASSIUM-4.1 CHLORIDE-99 TOTAL CO2-36* ANION GAP-11 [**2143-2-7**] 12:00PM LACTATE-0.9 [**2143-2-7**] 09:52PM CK-MB-3 [**2143-2-7**] 09:52PM CK(CPK)-28 [**2143-2-10**] 8:16 am SPUTUM Source: Expectorated. GRAM STAIN (Final [**2143-2-10**]): [**11-9**] PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. RESPIRATORY CULTURE (Pending): Brief Hospital Course: Pt is a 63 y/o F w/ h/o severe COPD on home O2, history of MAC, bronchiectasis, cavitary lesions, thought secondary to pseudomonas, on combination of oral antibiotics and prednisone with worsening SOB. It appeared that her symptoms were chronic with an acute exaccerbation. She was continued on supplemental oxygen and her prednisone dose was increased to 60mg po daily. She was continued on her prior regimen including inhaled tobramycin for her bronchiectasis. The patient was on azithromycin po on admission but was switched to Bactrim DS TIW during the admission. She was transferred to the ICU for titration of BIPAP to help with her severe obstruction. The patient tolerated BIPAP well and was transitioned back to the floor. She was subjectively improved and back on her baseline 2L oxygen with no accessory muscle use and good air movement at her bases. She will follow up with Dr.[**Doctor Last Name **] office regarding an outpatient sleep study. She was discharged on a prednisone taper. Medications on Admission: Atrovent HFA 17 mcg/Actuation--2 puffs three times a day CELEBREX 200 mg--1 capsule(s) by mouth every twelve (12) hours as needed for pain CLARITIN 10 mg--1 tablet by mouth daily COLACE 100 mg--once a day Conjugated Estrogens 0.3 mg--1 (one) tablet(s) by mouth once a day GlycoLax 17 gram (100 %)--once a day MUCINEX 600 mg--one tablet(s) by mouth twice a day OXYCONTIN 20 mg--one tablet(s) by mouth twice a day Oxycodone 10 mg--one tablet(s) by mouth twice a day PROTONIX 20 mg--1 tablet(s) by mouth once a day AMITRIPTYLINE 10 mg--2 tablet by mouth daily IPRATROPIUM BROMIDE 0.2 mg/mL (0.02 %)--1 vial nebulized three times daily as needed for shortness of breath IPRATROPIUM BROMIDE 42 mcg--1 puff inhaled each nostril twice daily PREDNISONE 10 mg--1 tablets by mouth daily Tobramycin 300 mg/5 mL Solution for Nebulization Discharge Medications: 1. NASAL CPAP machine to be worn qhs as tolerated. 5cc setting 2. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 3. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) as needed. 4. Tobramycin 300 mg/5 mL Solution for Nebulization Sig: One (1) Inhalation [**Hospital1 **] (2 times a day). 5. Celecoxib 200 mg Capsule Sig: One (1) Capsule PO BID PRN (). 6. Amitriptyline 10 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 7. Guaifenesin 600 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). 8. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization Sig: One (1) ML Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Disp:*1 qs for 1 month supply* Refills:*3* 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q4H (every 4 hours) as needed. 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily) as needed. Disp:*60 Capsule(s)* Refills:*0* 12. Dulcolax 5 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day as needed for constipation. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*3* 13. prednisone taper Please take 60mg by mouth daily for 4 days, then 50 mg po daily for 4 days, then 40mg po daily for 2 days, then 30mg po daily for 2 days, then 20mg po daily for 2 days, then resume your prior 10mg po daily 14. Prednisone 10 mg Tablet Sig: Six (6) Tablet PO once a day: please see attached steroid taper. Disp:*60 Tablet(s)* Refills:*2* 15. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO Monday, Wednesday, Friday. Disp:*30 Tablet(s)* Refills:*2* 16. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: One (1) Inhalation twice a day. 17. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. Discharge Disposition: Home With Service Facility: [**Hospital1 3894**] Health VNA Discharge Diagnosis: COPD brochiectasis OSA Discharge Condition: stable Discharge Instructions: You were admitted with dyspnea and a COPD exaccerbation and started on Bipap with improvement of your breathing. Please return to the ER if you develop worsening shortness of breath, cough or fevers. Followup Instructions: Dr.[**Doctor Last Name **] office will be contacting you this week regarding an outpatient sleep study. Provider: [**Name (NI) 2482**] [**Name (NI) 2483**], PT, CCS Phone:[**Telephone/Fax (1) 2484**] Date/Time:[**2143-2-18**] 1:00 Provider: [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 2226**] Date/Time:[**2143-4-11**] 11:00 Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2143-4-16**] 11:40

[ "780.57", "515", "300.00", "496" ]

icd9cm

[ [ [] ] ]

[ "93.90" ]

icd9pcs

[ [ [] ] ]

7059, 7121

3143, 4150

320, 326

7188, 7197

2311, 3120

7446, 7943

1553, 1566

5027, 7036

7142, 7167

4176, 5004

7221, 7423

1581, 2292

242, 282

354, 1441

1463, 1537

57,972

147,438

54926

Discharge summary

report

Admission Date: [**2137-7-30**] Discharge Date: [**2137-8-8**] Date of Birth: [**2068-1-14**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2291**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: PICC line placement History of Present Illness: History was obtained from ER and son 69F DM, psoriasis, recurrent cellulitis with history of MRSA, morbid obesity, history of PE/DVT on coumadin presenting with altered mental status and lower extremity cellulitis to [**Hospital1 **]. She has a long history of recurrent lower extremity cellulitis. Per her son, she became acutely altered and confused at home today. Per the son (caregiver), the patient has had 2 weeks of increasing lower extremity edema and pain. Today she became acutely confused and febrile to 103F. She denies any shortness of breath cough or chest pain, belly pain, headache, diarrhea or changes in bowel or bladder habits. At [**Location (un) 620**], she was febrile to 103. Her initial VS were BP 140/83 HR 133 pOx 97 % ([**2137-7-29**] at 2310). She had a non-contrast abdominal CT which was unremarkable for any acute process. Patient was noted to have a cellulitis of the bilateral lower extremities up to the groin. Her initial glucose was 500 on arrival with subsequent decrease to 271 as she received insulin regular 5 units IV followed by insulin infusion at 5 units/hr 3 L of normal saline in addition to rocephin 2 gm IV x 1 vancomycin 1 gm IV and clindamycin 600 mg IV. She was noted to be anxious and hyperventilating. She was given morphine IV and ativan 0.5 mg IV. Labs were performed at [**Hospital1 **]: - WBC 13.2 Hgb 15.2 (baseline 13-14) Plt 162 P 88 % B 1.1 - Na 132 K 4 Cl 94 HCO3 23 BUN 13 Cr 0.6 (baseline 0.8-1) Glc 492 - LFTs Tbili 1.4 ALP 285 ALT 35 AST 60 (elevated since [**2133**]) - Lactate 4.7 - INR 2 - VBG 7.46/33.0/25.0/23.5 - blood cultures were obtained - UA WBC [**4-11**] Neg nitrate/LE VS on transfer were BP 111/71 HR 124 RR 21 pOx 95 RA. Urine output was not recorded. In the ED, initial VS were: 02:46 (unable) 98.2 100 28 87% Labs were performed - WBC 16.1 Hgb 13.6 Plt 134 Diff N 91.9 - Na 141 K 3.6 Cl 108 HCO3 19 BUN 14 Cr 0.7 Glc 130 - Trop < 0.01 - VBG pH 7.34 pCO2 41 pO2 51 HCO3 23 - Lactate 4.5 --> 1.8 ScVO2 76 - UA Bland - Blood cultures x 2 Imaging was performed which showed no evidence of necrotizing fascitis. She received 2 L NS in [**Hospital1 18**] ER. In the emergency department the patient's blood pressures were in the systolic of 90s and decreased to systolic of 80s. A right internal jugular central line was placed, and she was started on levophed at 0.06 with MAP ~ 77. She was admitted to the MICU for severe sepsis. Past Medical History: - History of MRSA - DM2 - ? gout - morbid obesity - history of PE/DVT on coumadin - psoriasis - recurrent cellulitis - h/o transaminits Social History: The patient lives at home with her 2 sons and 1 daughter. She has not worked in abut 20 years, but states she has held a variety of part time jobs prior. She denies alcohol, tobacco, and drugs. Family History: Father - skin cancer Mother - [**Name (NI) 112179**] Brother - healthy as far as she knows Physical Exam: Physical Exam on Admission: VS - per metavision General: AAOx1.5 (self, partial date, does not know place) HEENT: Sclera anicteric, MMM, oropharynx with very poor dentition, EOMI, PERRL Neck: supple, JVP not elevated, no LAD, RIJ in place CV: tachycardiac, regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally antero-laterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, obese, bowel sounds present, no organomegaly. Large pannus with intertrigious candidal. No inguinal LAD GU: foley Ext: warm, well perfused, DP/PT by dopplers only, RLE swelling > LLE. Psoriasis lesions noted. Cellulitis noted predominantly on LLE with streaking up to groin and perineum area. There is a unstagable sacral ulcer that does not appear infected. Neuro: CNII-XII intact, motor grossly intact. Physical Exam on Discharge: VS - T 98.3, 128/82, 85, 18, 95% RA GENERAL - well-appearing obese female in NAD, comfortable LUNGS - CTA bilat, no r/rh/wh, resp unlabored, no accessory muscle use, exam limited by body habitus and patient immobility, posterior lung fields deferred HEART - RRR, [**1-7**] murmur heard at Left USB, nl S1-S2 ABDOMEN - NABS, obese soft/NT/ND, no rebound/guarding EXTREMITIES - patient with significant edema of LE bilaterally, erythema greatly improved over legs bilaterally (previous borders marked, now appears to be chronic skin changes - more erythema over left leg, no tenderness, no warmth, no drainage, also with white scaly patches over LLE, unable to palpate distal pulses secondary to edema SKIN - dry skin patches noted on scalp, face, and arms, scattered bruises on UE bilaterally Pertinent Results: Labs on Admission: [**2137-7-30**] 03:47AM BLOOD WBC-16.1* RBC-4.49 Hgb-14.0 Hct-42.5 MCV-95 MCH-31.2 MCHC-33.0 RDW-14.3 Plt Ct-151 [**2137-7-30**] 08:19AM BLOOD Neuts-91.9* Lymphs-5.4* Monos-2.3 Eos-0.2 Baso-0.1 [**2137-7-30**] 03:47AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [**2137-7-30**] 03:47AM BLOOD Plt Ct-151 [**2137-7-30**] 03:47AM BLOOD Glucose-130* UreaN-14 Creat-0.7 Na-141 K-3.6 Cl-108 HCO3-19* AnGap-18 [**2137-7-30**] 03:28PM BLOOD ALT-29 AST-56* AlkPhos-172* TotBili-1.1 [**2137-7-30**] 08:19AM BLOOD CK(CPK)-334* [**2137-7-30**] 03:47AM BLOOD cTropnT-<0.01 [**2137-7-30**] 08:19AM BLOOD CK-MB-9 cTropnT-<0.01 [**2137-7-30**] 08:19AM BLOOD Calcium-7.7* Phos-3.2 Mg-1.4* [**2137-7-30**] 08:19AM BLOOD %HbA1c-12.7* eAG-318* [**2137-7-30**] 08:29AM BLOOD Type-[**Last Name (un) **] Temp-39.1 pO2-50* pCO2-41 pH-7.34* calTCO2-23 Base XS--3 [**2137-7-30**] 04:06AM BLOOD Lactate-4.5* [**2137-7-30**] 08:29AM BLOOD Lactate-1.8 [**2137-7-30**] 03:50PM BLOOD Lactate-2.1* Labs on Discharge: [**2137-8-6**] 07:00AM BLOOD WBC-7.9 RBC-4.60 Hgb-14.5 Hct-43.3 MCV-94 MCH-31.6 MCHC-33.5 RDW-14.0 Plt Ct-155 [**2137-8-8**] 09:10AM BLOOD PT-36.0* INR(PT)-3.5* [**2137-8-8**] 09:10AM BLOOD Glucose-139* UreaN-11 Creat-0.5 Na-140 K-3.9 Cl-103 HCO3-30 AnGap-11 Studies: CXR [**2137-7-30**]: 1. New right jugular line is in adequate position. There is no pneumothorax. 2. New pulmonary edema is mild. CT Abd/Pelvis and LE with contrast [**2137-7-30**]: IMPRESSION: 1. Non-specific stranding and edema involving the posterolateral soft tissues of the proximal thighs, left greater than right. No fascial air to suggest necrotizing fasciitis. No evidence of abscess. 2. Cholelithiasis without CT evidence of acute cholecystitis. 3. Non-obstructing calculi within the lower pole of the right kidney. 4. Severe degenerative changes of the bilateral femoro-acetabular joints. LE US [**2137-7-30**]: IMPRESSION: 1. Technically limited exam with nonvisualization of the bilateral posterior tibial and peroneal veins. However, no evidence of DVT within both lower extremities down to the level of the popliteal veins. 2. Significant diffuse overlying subcutaneous edema within both lower extremities. ECHO [**2137-7-30**]: The estimated right atrial pressure is 5-10 mmHg. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded due to poor acoustic windows. Left ventricular systolic function is probably hyperdynamic (EF>75%). Right ventricular chamber size is probably normal. with probably normal free wall contractility. There is no pericardial effusion. The valves were not well visualized due to suboptimal views. Brief Hospital Course: Ms. [**Known lastname **] is a 69 y/o F with a past medical history of psoriasis, recurrent cellulitis, DM presents with severe sepsis thought to be secondary to skin/soft tissue infection. Acute Issues: # Sepsis from a skin/soft tissue source: Patient presented from [**Hospital3 **] with fever to 103, tachycardia, and leukocytosis meeting SIRRs criteria with rapidly progressive skin/soft tissue source. She has a history of MRSA and recurrent lower extremity cellulitis in setting of ill-defined history of venous stasis. She had no obvious traumatic portal of entry but does have impaired skin integrity from psorasis and secondary infected interiginous candidal infection. She was started on vanc/cefepime/clindamycin intitially for broad spectrum coverage and was admitted to the MICU. She was breifly hypotensive and required pressors for a short time. Ultimately, she got 9 Liters NS and her blood pressure improved. She also was continued on vanc/cefepime/clindamycin until surgery consult and imaging was negative for evidence of necrotizing fascitis. An ECHO was done in the MICU that showed hyperdynamic function, but was a limited study. The patient's clindamycin was discontinued on trasnfer to the floor. LENI was negative for DVT also. OSH cultures returned showing Group B Strep bacteremia and the patient's vancomycin was discontinued. The cultures showed sensitivity to cephalosporins, but given they did not do MIC values she was changed to cephazolin for q 8 hour coverage. The patient's cellulitis improved significantly and she was afebrile for the entire time on the floor. Repeat blood cultures from [**7-30**] were with no growth. She will complete a total course of 14 days following clearance of blood cultures. Despite recommendations to be discharged to rehab the patient and family refused and preferred to take patient home. Many discussions with patient and family were held and the decision remained to take the patient home. On subsequent re-eval by PT, recommendation was made for home PT with 24 hours assist. Family will provide 24 hour assist. # Acute encephalopathy: The patient presented with altered mental status that improved significantly with therapy. She likley had delirium from toxic-metabolic and infectious etiologies. Her baseline mental status is AAOx3 per reports from her children. She had no focal neurological deficits to suggest primary neurogenic process. The patient's mental status continued to improve and she was AAO x 3 and back to baseline for 3 - 4 days prior to discharge. # Pulmonary edema: Patient developed new 3.5 L NC on admission with CXR showing cardiogenic vs. non-cardiogenic pulmonary edema in setting of fluid resuscitation. ECG showed likely prior inferior infarct. She has no known history of heart failure. ECHO showed hyperdynamic function and no evidence of heart failure. When the patient was transferred to the floor she was stable on 2L NC. She was then weaned to RA in 24 hours and remained stable on RA throughout the remainder of hospital course. Pulm edema likely iatrogenic in setting of aggressive fluid resucitation in the ICU for sepsis. # DM2/Hyperglycemia: Patient had underlying diabetes with no recent A1c on admission. She was hyperglycemic to ~ 500 at [**Location (un) 620**] likely from infection. Her glucose normalized to < 500 after temporary insulin infusion. She was put on lantus 8 units at night and humalog sliding scale. She required approx 12 - 20 units of sliding scale per day. A1C in house was 12.7%. Prior to discharge the patient reported that she did not was to use insulin at home despite our recommendation. Therefore the day prior to discharge she was transitioned to her home glipizie ER 30 mg daily and metformin 1000mg [**Hospital1 **]. Her glucose was relatively controlled with these oral medications. She will need to follow up with her PCP regarding diabetes management. The pt is aware that her blood sugars are suboptimally controlled, especially in the long-term, and that she is at risk for major complications, including CAD, CVA, CKD/ESRD, retinopathy, all of which could predispose to fatal complications. She is aware of these risks and accepts these risks. # Impaired sacral decubitus ulcer: She had unstagable sacral decubitus ulcer that was noted on admission. Wound care was consulted and their recommendations were followed. Patients right gluteal was much improved with less dark pigmentation and bogginess has also resolved prior to discharge. # Tinea Curis: The patient was noted to have bilateral groins and pannus with Intertrigo and candidiasis. She was treated with antifungal powder and cream per wound care consult. # Tinea Pedis and onychomycosis: The patient was also noted to have tenia pedis. Terbinafine cream was started to feet bilaterally per derm. An oral medicaiton was not started for the patient's onychomycosis given baseline chronic transaminits. Chronic Issues: # Psorasis The patient has skin findings on exam consistent with psorasis. She is not on biologics or other apparent therapy. Dermatology was consulted and did not recommend treatment at this time. They provided other recommendations re: above. She will follow up in derm clinic as an outpatient. # Elevated LFTs: Since [**2133**] [**First Name8 (NamePattern2) **] [**Location (un) 620**] records, she has had elevated LFTs and currently elevated on admission near baseline. She will need outpatient follow-up. # History of PE/DVT: Patient on therapeutic systemic anticoagulation. INR became supratherapeutic on day before discharge to 3.8. It was 3.5 on day of discharge. Therefore her warfarrin was held on day before and day of discharge. The patient was instructed to hold warfarrin again day after discharge and the VNA will take INR and fax to PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3142**]. He will initiate restarting warfarrin. # Thrombocytopenia: Likely from marrow suppresion in setting of sepsis. No evidence of DIC. Platelets were trended and came up to 155 prior to discharge. # Gout: Patient had a questionable history of gout. Her allopurinol was held in house. Transitional Issues: -Patient to complete antibiotic course with cefazolin on [**8-13**]. -Patient to follow up with PCP [**Last Name (NamePattern4) **]: improvement of cellulitis, diabetes management, and chronic elevated liver enzymes. -Patient will need to be restarted on warrfarin when appropriate, Dr. [**Last Name (STitle) 3142**] will manage this as confirmed with his office.' -f/u with PCP [**Name Initial (PRE) **] DM2 management Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientPharmacy. 1. Allopurinol 300 mg PO DAILY 2. GlipiZIDE XL 30 mg PO DAILY 3. Warfarin 2.5 mg PO DAILY16 4. Potassium Chloride 10 mEq PO DAILY Duration: 24 Hours chlorcon Discharge Medications: 1. CefazoLIN 1 g IV Q8H RX *cefazolin in dextrose (iso-os) 1 gram/50 mL 1 gram IV every 8 hours Disp #*21 Gram Refills:*0 2. Aquaphor Ointment 1 Appl TP TID:PRN cellulitis apply per wound care recs RX *white petrolatum [Aquaphor with Natural Healing] 41 % Apply to both legs twice daily Disp #*1 Bottle Refills:*0 3. Docusate Sodium 100 mg PO BID:PRN constipation RX *docusate sodium 100 mg one tablet(s) by mouth twice daily Disp #*60 Tablet Refills:*0 4. GlipiZIDE XL 30 mg PO DAILY 5. MetFORMIN (Glucophage) 1000 mg PO BID RX *metformin 1,000 mg one tablet(s) by mouth twice daily Disp #*60 Tablet Refills:*0 6. Miconazole Powder 2% 1 Appl TP QID intertriginous [**Female First Name (un) **] RX *miconazole nitrate [Desenex] 2 % Apply to groin and under belly daily Disp #*1 Each Refills:*0 7. Terbinafine 1% Cream 1 Appl TP [**Hospital1 **] tinea pedis Please apply to feet including inbetween toes. RX *terbinafine 1 % Apply to both feet and inbetween toes twice daily Disp #*1 Each Refills:*0 8. Allopurinol 300 mg PO DAILY Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Primary: Cellulitis Group B Streptococcus Bacteremia Tinea Pedis Tinea cruris Secondary: Diabetes Psoriasis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Patient mostly bed bound while in hospital but reports to walk with a walker. Discharge Instructions: Ms. [**Known lastname **], You were admitted to [**Hospital3 **] Hospital for cellulitis (an infection of the skin) of your legs. While you were at the other hospital before coming to [**Hospital3 **] they also found that the bacteria was in your blood. This means that you have to be treated with IV (through your vein) antibiotics for a longer course. You will complete your antibiotics at home. You will continue to take them 3 times a day. While you were here we also worked on controling your sugar level. You did not want to use insulin at home, therefore we put you back on the medication you were taking at home, glipizide. Additionally we started you on metformin which will also help to control your blood sugar. Please follow up with your primary care doctor. Before you left the hospital your coumadin level was too high. Therefore you will not take your coumadin today and maybe not tomorrow. The home nurse will draw your level and fax it to your primary care doctor who will decide when you should start taking it again. It was a pleasure caring for you, Your [**Hospital1 **] doctors Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) 198**] P. Location: [**Location (un) **] FAMILY PRACTICE Address: [**Street Address(2) 19979**], [**Location (un) **],[**Numeric Identifier 3862**] Phone: [**Telephone/Fax (1) 19980**] Appointment: Tuesday [**2137-8-13**] 2:40pm Department: DERMATOLOGY When: FRIDAY [**2137-8-23**] at 11:15 AM With: [**Last Name (LF) **],[**First Name3 (LF) **] [**Telephone/Fax (1) 1971**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2137-8-9**]

[ "110.4", "V12.55", "287.5", "518.4", "995.92", "349.82", "V58.61", "682.6", "274.9", "707.25", "696.1", "278.01", "250.00", "110.3", "V12.51", "038.0", "707.03" ]

icd9cm

[ [ [] ] ]

[ "38.97" ]

icd9pcs

[ [ [] ] ]

15706, 15755

7741, 12671

325, 347

15908, 15908

4954, 4959

17298, 17896

3174, 3266

14651, 15683

15776, 15887

14363, 14628

16169, 17275

3281, 3295

4142, 4935

13916, 14337

264, 287

6010, 7718

375, 2788

4973, 5991

15923, 16145

12687, 13895

2810, 2947

2963, 3158

78,076

135,270

10767

Discharge summary

report

Admission Date: [**2113-10-20**] Discharge Date: [**2113-10-31**] Date of Birth: [**2043-3-24**] Sex: M Service: SURGERY Allergies: Aspirin / Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 2836**] Chief Complaint: Pancreatic fistula - Pancreatic-cutaneous fistula Major Surgical or Invasive Procedure: None History of Present Illness: 70M w/ gallstone pancreatitis s/p failed ERCP and abdominal compartment syndrome([**2113-7-2**]) c/b vasodilatory SIRS shock w/subsequent decompressive exploratory laparotomy ([**2113-7-3**]), ARF, trached ([**2113-7-24**]), partial closure with mesh ([**2113-7-29**]) and wound vac ([**2113-8-1**]). s/p drainage of pancreatic collection by IR ([**2113-8-13**]), lap minimally invasive pancreatic necrosectomy ([**2113-8-22**], [**2113-8-28**], [**2113-9-4**]) for necrotizing pancreatitis. Pt discharged on [**10-11**] to rehab with pancreatic drain (chest tube into pancreatic necrotic bed). However at rehab, his pancreatic drain fell out. Despite this the patient was afebrile and was doing well on his tube feeds (25-30 cc/hr). The team was informed of this on [**10-17**] and we suggested they place an ostomy appliance over it. However healthcare workers noted increasing output from the fistula and elected to replace the tube. On [**10-20**], the patient was transferred from [**Hospital1 **] to [**Hospital1 18**] ED for increasing fistula output as well as hypotension. Past Medical History: PMHx: asthma, HTN, basal cell carcinoma, DM, gallstone pancreatitis c/b respiratory and renal failure, abdominal compartment syndrome, necrotizing pancreatitis PShx: rib frx plating approx 5 years ago. On last admission [**2113-7-13**] closure, GJ tube [**2113-7-8**] partial abd closure, drsg [**Name5 (PTitle) **] [**2113-7-4**] Open abdomen dressing revision [**2113-7-3**] Decompressive laparotomy, open abd [**2113-7-8**] partial closure abdominal wound [**2113-7-13**] formal closure GJ tube [**2113-7-19**] Decompressive laparotomy, open abd [**2113-7-24**] tracheostomy [**2113-7-29**] abdominal closure with mesh [**2113-8-13**] and [**2113-8-18**] -I&D of pancreatic fluid collection and subsequent upsizing of drain by IR [**2113-8-22**], [**2113-8-28**], [**2113-9-4**] -Laparoscopic pancreatic necrosectomy Social History: Married for 45+ years. Three daughters, one son. Retired six years ago, owned upholstery business. Never smoker, one glass of wine per evening with dinner. No illicits. Family History: Sister died from breast cancer, another sister (deceased) with CRF on HD Physical Exam: At time of admission: 99.4 89 79/55 20 100% TC NAD tracheostomy in place, midline, secure RRR CTA B S/NT/protuberant abdomen. Large vac appliance to midline incision. GJtube in place. Open fistula wound in L flank. Mild erythema posterior to wound, likely due to skin irritation from enzymes in output. No induration or fluctuance around wound. TTP at wound site. extremities without edema PICC line in left arm, peripheral IV in R hand At time of discharge: 97.3, 97, 102 (sinus tach), 112/68, 23, 100% TM 50% NAD, A+OX3 Trach in place, c/d/i RRR CTAB Soft, NT, protuberant abd. VAC taken off - excellent granulation tissue over entire abdominal wound measuring approx 9" X 12", wet to dry placed with absorbant pad over wound. GJ tube c/d/i, left pancreas fistula/opening covered with ostomy bag, slight surrounding erythema but no induration or fluctuance felt no c/c/e Right PICC line c/d/i Pertinent Results: Admit WBC: 7.0 (2 bands) Discharge WBC: 7.7 Admit Hct: 30 Discharge Hct: 25 Admit Cr: 2.1 Discharge Cr: 1.3 Cultures: **FINAL REPORT [**2113-10-27**]** Blood Culture, Routine (Final [**2113-10-27**]): ESCHERICHIA COLI. FINAL SENSITIVITIES. ESCHERICHIA COLI. SECOND MORPHOLOGY. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | ESCHERICHIA COLI | | AMPICILLIN------------ <=2 S <=2 S AMPICILLIN/SULBACTAM-- <=2 S <=2 S CEFAZOLIN------------- <=4 S <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CEFUROXIME------------ 4 S 4 S CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S PIPERACILLIN---------- <=4 S <=4 S PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- =>16 R =>16 R **FINAL REPORT [**2113-10-27**]** GRAM STAIN (Final [**2113-10-24**]): >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2113-10-27**]): Commensal Respiratory Flora Absent. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. OF TWO COLONIAL MORPHOLOGIES. ESCHERICHIA COLI. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | ESCHERICHIA COLI | | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- 16 I <=1 S CEFTAZIDIME----------- 8 S <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN--------- =>4 R =>4 R GENTAMICIN------------ 4 S <=1 S MEROPENEM------------- =>16 R <=0.25 S PIPERACILLIN---------- 16 S <=4 S PIPERACILLIN/TAZO----- 32 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- =>16 R [**10-27**] Catheter TIP IV (left PICC): no growth final Imaging: [**2113-10-23**] CT A/P: Final Report INDICATION: Numerous pancreatic debridements with history notable for gallstone pancreatitis, please evaluate for pancreatic fluid collection. TECHNIQUE: Axial CT images were acquired through the abdomen and pelvis in the absence of intravenous contrast. Note that the creatinine at the time of image acquisition was 1.9. Coronal and sagittal reformatted images were also reviewed. COMPARISON: [**2113-9-29**]. CT ABDOMEN WITHOUT CONTRAST: Small right and trace left pleural effusions are redemonstrated, minimally changed. There are associated bibasilar consolidations, including progressed now complete atelectasis of the right lower lobe with aerosolized secretions filling the bronchus. The visualized cardiac apex reveals extensive coronary arterial calcification, as well as likely coronary arterial stents. There is no evidence of pericardial effusion. The stomach contains a percutaneous gastrojejunostomy tube which is in good position. Otherwise, the stomach and duodenum are unremarkable. The adrenal glands are unremarkable. The spleen is 15.6cm in length. The collapsed gallbladder contains a calcified gallstone. The kidneys are nodular in contour, unchanged from the previous studies. Numerous hepatic hypodensities are stable. There is no free gas in the abdomen and the small amount of ascites visualized previously is now largely resolved. A large pancreatic collection containing both fluid and gas is redemonstrated, difficult to precisely marginate given the absence of intravenous contrast. Roughly, the overall size of the cavity appears minimally smaller than the comparison study, now approximately 131 x 32 mm (2:44), previously 147 x 39 mm. Additionally, the internal components of this collection is changed with less internal gas than was previously present. The percutaneous drain in the comparison study is removed and a moderate cutaneous defect persists at the site of tube entry. Peri-pancreatic fat stranding persists. Pancreatic enhancement or necrosis is not assessed absent intravenous contrast. A small amount of hyperdense material is seen adjacent to the splenic flexure (2:47) in the pancreatic gas and fluid collection. This is unchanged and remains concerning for a fistula in that location. A large ventral abdominal wall defect is unchanged. Regional vascular structures are notable for atherosclerotic calcification of the abdominal aorta, in the absence of aneurysmal dilation. CT PELVIS WITHOUT CONTRAST: The urinary bladder contains a Foley catheter. The prostate and seminal vesicles are unremarkable. The rectum contains a large amount of stool as well as oral contrast. Note is made of sigmoid diverticulosis. There is no free gas or fluid in the pelvis and there is no pelvic or inguinal lymphadenopathy. Note is made of bilateral fat-containing inguinal hernias. OSSEOUS FINDINGS: There is no suspicious sclerotic or lytic osseous lesion. Extensive spinal degenerative changes are unchanged. IMPRESSION: 1. Minimal decrease in size of peripancreatic gas and fluid-containing collection with interval removal of drain. Redemonstration of oral contrast within the collection, consistent with fistula from the adjacent colon. 2. Progression of right lower lobe atelectasis with mucus plugging of right lower lobe bronchus. Redemonstration of bilateral pleural effusions with associated atelectasis. 3. Interval resolution of ascites. 4. Cholelithiasis, Diverticulosis, Splenomegaly, unchanged. Brief Hospital Course: After being transferred to the ED, the patient was noted to be hypotensive in the 80's. He was bolused 2 Liters, placed on Levaphed and transferred to the ICU. His ICU care will be dictated in a organ based system below: Neuro: The patient's pain was well controlled. He needed minimal pain meds and only recieved intermitted dilaudid IV, mainly for VAC changes. Endo: Patient was placed on a insulin sliding scale to maintain his blood sugars 100-120. His insulin in his TPN was adjusted accordingly. CV: His hypotension was deemed secondary to early sepsis likely from bacteremia. He was started on broad spectrum antibiotics and tailored accordingly. His hypotension resolved and the SICU team was able to wean him from his pressor requirement. He has been intermittently tachycardic (sinus) which is controlled with Metoprolol IV. Resp: Given his sepsis early on admission, the patient was placed on pressure support early on. However as his sepsis cleared, he was weaned to trach mask which he tolerated. He continues on trach mask throughout the day without any respiratory issues. He still does require frequent trach suctioning. GI: Initially his tube feeds were restarted but given his increase in his pancreas drain as well as abdominal discomfort, his tube feeds were discontinued. He was made NPO in order to slow down his pancreas output and hopefully slow down the leak. In terms of nutrition he is maintained on TPN. His G-tube is to gravity and his J-tube is clamped. Renal: UOP was at least 30 cc/hr during his hospitalization. His UA was positive but final urine cultures did not show any growth. His Cr on admission was elevated at 2.0 and during his hospitalization course trended downward 1.3. ID: Given his septic picture, the patient was pancultured. BCx were positive for E-coli sensitive to meropenem. Sputum cx like last admission showed pseudomonas growth sensitive to meropenem. His broad spectrum antibiotics were tailored down to only Meropenem. His PICC line was also resited and the tip was cultured with no growth. Surveillence blood cultures did not show any growth. He will continue a 14 day course of Meropenem which was started on [**10-23**] (end date [**2113-11-6**]). His VAC was changed multiple times. VAC changes reveal excellent bed of granulation tissue and the wound appears quite shallow. He will likely need a skin graft over his wound later on in the future. He will be transferred to rehab with wet to dry dressings over his abd wound and will need a VAC appliance placed (white and black foam, see discharge instructions). Heme: During his ICU stay, his hct drifted down from 30 to 22. He was transfused 1 unit of blood and [**Last Name (un) 8692**] Hct increased to 25 appropriately. Medications on Admission: chlorhexidine 0.12% mouthwash [**Hospital1 **], acetaminophen 650 pr prn, ipratropium MDI 6 puff q6h prn wheeze, white petrolatum mineral oil one application OU prn dry eyes, olanzapine 5 mg rapid dissolve [**Hospital1 **] prn agitation, ondansetron 4 mg IV q4h prn nausea, hydromorphone 0.4-1.0 mg q4h prn pain, lorazepam 0.5 mg IV q4h prn anxiety, metoprolol 10 mg IV q4h, RISS Discharge Medications: 1. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours). 2. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 3. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q6H (every 6 hours). 4. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, T>100.4. 5. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 6. Pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours). 7. Metoprolol Tartrate 5 mg/5 mL Solution Sig: One (1) Intravenous Q6H (every 6 hours) as needed for HR>110. 8. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed for N/V. 9. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane [**Hospital1 **] (2 times a day). 10. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed for rash. 12. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO BID (2 times a day) as needed for agitation. 13. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). Discharge Disposition: Extended Care Facility: new [**Hospital 35202**] [**Hospital **] hospital Discharge Diagnosis: Acute on chronic renal failure, pancreatic necrosis, pancreatic fistula, bacteremia, sepsis Discharge Condition: Stable, requires vent capable facility Discharge Instructions: 1) Dilaudid IV PRN for VAC changes 2) Continue SSI and adjust insulin in TPN 3) Metoprolol for intermittent sinus tachycardia 4) Trach mask, needs frequent suctioning to clear secretions 5) No tube feeds, continue TPN 6) Continue Meropenem until [**2113-11-6**] 7) Gtube to gravity 8) VAC changes - 9" X 12 " abdominal wound, cover first with White foam then thin black foam then VAC appliance Followup Instructions: Please follow up with Dr. [**First Name (STitle) **] in clinic in two weeks. Please call the office ([**Telephone/Fax (1) 6347**] to make an appointment. Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain is not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Completed by:[**2113-10-31**]

[ "038.42", "585.9", "V44.0", "403.90", "493.90", "577.8", "577.0", "995.91", "584.9" ]

icd9cm

[ [ [] ] ]

[ "38.93", "99.15", "96.72" ]

icd9pcs

[ [ [] ] ]

14183, 14259

9592, 12359

353, 359

14395, 14436

3535, 9569

14878, 16085

2523, 2598

12790, 14160

14280, 14374

12385, 12767

14460, 14855

2613, 3516

264, 315

387, 1475

1497, 2320

2336, 2507

20,895

186,372

26066

Discharge summary

report

Admission Date: [**2158-2-11**] Discharge Date: [**2158-2-12**] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5790**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Esophagogastroduodecoscopy Bronchoscopy Right thoracotomy Drainage of mediastinum Muscle flap to buttress esophageal perforation Repair of tracheal laceration PEG tube placement Left chest tube placement History of Present Illness: This patient is an 83 year old female who was found on [**2158-2-11**] with difficulty breathing at home after dinner. This progressed to respiratory arrest. CPR was initiated until EMS arrived, when she was intubated. Report from the field indicated a difficult intubation with multiple episoded of vomiting and food in the trachea. The patient was brought to the [**Hospital1 18**] Emergency Department for treatment. Past Medical History: Hypertension Hyperlipidemia Physical Exam: T 101.8 HR 103 BP 103/30 RR 20 SpO2 100% Sedated, intubated Crepitus in neck and face RRR Coarse BS b/l Abdomen soft, NT/ND Brief Hospital Course: The patient was evaluated in the Emergency Department by the general surgical and thoracic surgery services. A CT scan was obtained, which showed extensive subcutaneous emphysema within the soft tissues of the neck extinding into the superior mediastinum adjacent to the trachea and great vessels. Concern at this point was high for a tracheal or esophageal injury. Bronchoscopy at the time was unremarkable. In addition, CT scan showed an extensive consolidative opacity within both lungs bilaterally, which was consistent with aspiration. An EGD was performed, which showed an esophageal tear 16-17cm from the incisors. Prior to EGD, it should be noted that the patient had several episodes of transient hypotension and bradycardia. However, given the dire nature of the patient's condition, the procedure was performed. The patient went to the operating room, where she underwent bronchoscopy, right thoracotomy, drainage of mediastinum, muscle flap to buttress esophageal perforation, repair of tracheal laceration, PEG tube placement, and left chest tube placement for tension pneumothorax immediately post-operatively. The patient was brought to the cardiac surgery ICU in critical condition. She was started on neosynepherine for hypotension. Following this, the patient underwent a PEA arrest at 11pm on [**2158-2-11**]. ACLS protocol was initiated with chest compressions given. A sinus rhythm was recovered, levophed and dopamine were started for additional pressor support. A stat cardiology consult was obtained. An echocardiogram was unable to be obtained due to significant subcutaneous emphysema. The patient's pupils were noted to be fixed and dilated. A stat neurology consult was obtained. The patient was noted to be responsive to painful stimuli. No specific recommendations were made at this time. The patient was too unstable to obtain an MRI. At approximately 7:15am on [**2158-2-12**], the patient had another episode of profound hypotension with bradycardia. Vasopressin was given, and the patient's blood pressure responded intermittently to IV epinepherine and Trendelenburg position. Given the patient's grim prognosis, later that morning discussions were initiated with the family about withdrawl of care. The decision was made to continue supportive care but to not recussitate the patient in the event of a code. At 5:34pm, the patient became hypotensive and bradycardic and soon thereafter went into asystole. The patient was pronounced dead. The family was present and declined autopsy upon request. Medications on Admission: Unknown Discharge Disposition: Expired Discharge Diagnosis: Cardiac arrest Esophageal perforation Hypertension Hypercholesterolemia Discharge Condition: Deceased Followup Instructions: Deceased

[ "286.6", "E911", "514", "518.81", "401.9", "998.2", "958.7", "507.0", "512.1", "348.1", "427.5", "862.32" ]

icd9cm

[ [ [] ] ]

[ "34.04", "33.22", "96.07", "43.11", "99.07", "96.71", "31.79", "42.23", "99.04", "45.13", "42.87", "99.60", "34.09" ]

icd9pcs

[ [ [] ] ]

3753, 3762

1161, 3695

288, 494

3878, 3889

3912, 3924

3783, 3857

3721, 3730

1009, 1138

229, 250

522, 943

965, 994

3,847

148,864

26128

Discharge summary

report

Admission Date: [**2169-1-8**] Discharge Date: [**2169-3-1**] Date of Birth: [**2092-5-27**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1055**] Chief Complaint: transferred from rehab for treatment of renal artery stenosis. Major Surgical or Invasive Procedure: thoracentesis. History of Present Illness: 76yoF with Afib, DM, HTN, PVD, CRI, and sacral/LE ulcers, s/p CEA who was recently admitted to OSH for 1) bradycardia while on labetalol and 2) CHF exacerbation s/p pleural paracentesis where she was also found to have a 3) L RAS on MRI. Of note she has had a prior MICU admission for decompensated CHF which required intubation, in addition to treatment of a Klebsiella UTI for which she is on Meropenem, and hypotension, which was likely in the setting of urosepsis. . She was admitted to [**Hospital1 18**] for RAS intervention, but was found to have Cr 2.2, Ca 13.7, low PTH, and the procedure was deferred. Her course was complicated by a 4) [**Hospital1 7792**] (on [**1-19**]) which was treated medically, and 5) pleural effusions that were tapped (on [**1-22**]) and contained high WBC but no organisms. The patient was transferred to the floors where she was diuresed on high doses of IV lasix with moderate response. She was transferred to the ICU due to resp distress, after several episodes of flash pulm edema and incr. O2 requirement (ABG 7.37/51/63/31). She has received maximal doses of IV lasix (480mg QD) with improving UOP. She is currently sat'ing well on 4L O2 NC. There has been concern from family members about possible 6) altered mental status of Pt; they report that she is not at her usual basline. In addition, several "staring spells" have been noted by nursing. The Pt. is undergoing a neurologic workup. Past Medical History: - Diastolic CHF, s/p prolonged intubation/trach in [**2169**] - Recurrent pleural effusions - HTN - left RAS seen on MRI [**2168-12-21**] - CRI with fluctuating baseline - DM2 w/ gastroparesis, s/p G tube - PVD, s/p CEA - OA, s/p b/l hip replacements - depression - left-sided deafness - sacral and L calf ulcers Social History: Separated and now widowed (previously abusive relationship). One son [**Name (NI) 382**] and one sister. Adopted daughter died in [**2166**]. Hx of smoking up to 4ppd from age 18 to age 63. Used etoh in past, now quit. Family History: Non-contributory. Physical Exam: VS: 98.7, 167/66, 84, 26, 94% 5L NC Gen: elderly female lying in bed in mild-mod respiratory distress HEENT: PERRL, EOMI, MM dry, anicteric Neck: supple, no JVD Lungs: poor airway movement, decreased breath sounds on left, mild crackles on right CV: RRR, nl S1S2, II/VI holosystolic murmur best heard RUSB Abd: +BS, soft, nontender, moderately distended, tympanitic Ext: no c/c/e, WWP, DP pulses 1+ b/l Neuro: DTR 3+ throughout . (upon readmission to MICU [**1-26**]) -Vitals: T: 92.8, HR 55-60, BP 160/60 -> 140s; RR 16, O2Sat 100% on vent. Vent: AC 500x16, 5 peep, 50% FiO2 -General: pale elderly F intubated, sedated -Skin: LE ulcers in dressings -HEENT: pupils 3mm->2mm bilat; ETT in place; anicteric sclera -Neck: supple, no JVD appreciated -Heart: S1S2 RRR, distant heart sounds, ?SM @ apex -Lungs: coarse ronchi anteriorly bilaterally; good air movement on vent -Abdomen: soft, obese, NT, ND, NABS -Extrem: 2+ radial pulses, 1+ DP pulses, trace edema LEs, 1+ pitting edema UEs. . (upon transfer to medical floor) VS: 98.1 | 111/30 | 78 | 24 | 96% on 4L O2NC I/O: 1095/1780, foley with clear yellow urine. gen: Sitting up in bed, screaming in full sentences, NAD. HEENT: PERRL, EOMI, dry MM, OP clear neck: no LAD, no masses, no JVD CV: irreg irreg, nl s1s2, i/vi SEM @LLSB. chest: decreased breath sounds b/l, but good air mvmt throughout, no wheezes, rubs, or ronchi. abd: soft, nt/nd, PEG tube c/d/i (on TFs), no organomegaly. extr: no C/C/E, 1+ dp pulses b/l, L shin ulcer. neuro: yelling, uncooperative, but responsive and directable, cn ii-xii intact; motor, sensory, coordination, language grossly nl. Pertinent Results: CXR [**2-27**]: 1. Pulmonary edema and left pleural effusion. 2. Retrocardiac opacity likely from atelectasis, but pneumonia cannot be excluded, unchanged. . CXR [**2-3**]: No significant interval change. Bilateral pleural effusions, bibasilar atelectasis or consolidation, and mild vascular congestion. . CXR [**2-13**]: Heavy skin-folds project over the right lower lung zone. Pulmonary edema has improved since [**2-8**] and small bilateral pleural effusions are smaller. Heart size is normal. Thoracic aorta is markedly tortuous and heavily calcified and probably dilated in the descending portion, but not acutely changed. [**Month (only) 116**] be a mild-to-moderate degree of left lower lobe atelectasis, not a change. No pneumothorax. Heavily calcified right subclavian artery should not be mistaken for a pneumothorax. . AXR [**2-20**]: Multiple air-fluid levels throughout the abdomen with moderate amount distention, predominantly within the right colon suggestive of ileus. Diffuse opacification of the right lung field. . CXR [**2-20**]: 1. CHF and bilateral pleural effusions, left greater than right. 2. Retrocardiac opacity from atelectasis and/or infiltrate. . MR head [**2-14**]: Chronic periventricular microvascular ischemic or gliotic change. No acute territorial infarct seen. T2 hyperintensity within the mastoid sinuses suggestive of possible inflammatory disease or mastoiditis. Chronic inflammatory changes within the paranasal sinuses as noted above. . EEG [**2-16**]: Abnormal EEG due to the slow and disorganized background. This suggests an encephalopathic condition. Medications, metabolic disturbances, and infection are among the most common causes. The later stages of chronic progressive neurologic illnesses can also produce such findings. Nevertheless, there were no areas of prominent focal slowing, and there were no epileptiform features. . Skeletal survey: No definite evidence of lytic lesion, however, evaluation of pelvis and thoracolumbar spine is limited. . TTE [**2-6**]: 1.The left atrium is normal in size. The left atrium is elongated. 2.There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4. The aortic valve leaflets are mildly thickened. No aortic regurgitation is seen. 5. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 6. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2169-1-14**], no change. . [**2169-1-9**] 01:18PM URINE RBC-[**2-12**]* WBC->50 Bacteri-MANY Yeast-MOD Epi-0-2 [**2169-2-15**] 05:13AM URINE RBC-82* WBC-500* Bacteri-MOD Yeast-MOD Epi-<1 [**2169-2-25**] 02:56PM URINE RBC-23* WBC-344* Bacteri-NONE Yeast-MANY Epi-0 . [**2169-1-10**] 05:40AM BLOOD PEP-SLIGHTLY T IgG-885 IgA-474* IgM-104 IFE-MONOCLONAL [**2169-1-18**] 05:32AM BLOOD PEP-THICKENED IgG-657* IgA-372 IgM-84 [**2169-1-18**] 05:32AM BLOOD [**Doctor First Name **]-NEGATIVE [**2169-1-19**] 08:55PM BLOOD Cortsol-29.7* [**2169-1-9**] 09:20AM BLOOD PTH-9* [**2169-1-10**] 05:40AM BLOOD Free T4-1.0 [**2169-1-10**] 05:40AM BLOOD TSH-6.0* [**2169-1-20**] 05:11AM BLOOD TSH-2.6 [**2169-2-12**] 05:00AM BLOOD calTIBC-178* VitB12-482 Folate-17.4 Ferritn-548* TRF-137* Brief Hospital Course: 76yoF with CHF exacerbation, CAD s/p [**Year/Month/Day 7792**], DM, PVD, CRI, and RAS. . # CHF: TTE revealed preserved RV/LV function. Good diuresis initially on 40mg PO BID lasix, and zaroxylyn, hydral, ISDN, ACE-i. CXR showed improved pleural effusions and persisting LLL atalectasis after transfer to medical floor from ICU. Pt. has been followed by cardiology (re: [**Year/Month/Day 7792**]), PCI probably unlikely to improve cardiac function. Goal 0-0.5 L negative per day, Pt. appears to be euvolemic at the time of discharge. Will continue 40mg PO lasix with extra doses for weight gain. . # renal: Cr bump to 1.5, likely prerenal secondary to overdiuresis. currently euvolemic, will d/c on lasix 40mg QD. no plan for renal artery stenting at this point; Pt. has been normotensive on current bp regimen. . # ID: Pt completed 14d course of meropenem (finished [**2-3**]) for UTI. Elevated WBC, and ESR 135, presumed osteomyelitis in wounds on sacrum and L calf. Pt. remained afebrile. U/a on [**2-15**] was positive for UTI (gram neg. rods). Urine cx negative. Now off meropenem. Will complete a 5-day course of fluconazole for funguria (>100K yeast). . # neuro: ?AMS. no focal findings on exam, and no acute changes on head MR. mental status improved during hospitalization; Pt. more interactive and pleasant. . # anemia: normocytic, iron studies c/w anemia of chronic disease. Hct goal should be >28 given [**Name (NI) 7792**], Pt. was given 20mg IV lasix with transfusions, due to CHF. . # pleural effusions: [**1-19**] pleural fluid grew MRSA, 3300 WBC, but no organisms on stain, pH>7.2. [**1-22**] pleural fluid 2175 WBC, no organsims on stain, Cx NGTD. MRSA likely contaminant (would not expect exudate to resolve to transudate in such short time period); most recent CXR shows resolution of effusions. . # CAD s/p [**Month/Year (2) 7792**] (had tropT of 1.32 [**1-19**]): continue medical mgmt. with ASA, statin, BB, ACE-i, ISDN & hydralazine. Pt. evaluated by cardiology and cath unlikely to benefit Pt's cardiac function given preserved EF and other comorbidities. . # HTN: currently normotensive on medical regimen, etiology likely secondary to RAS. Continue medical mgmt. with ACE-i, BB, hydralazine and ISDN. Will not intervene on RAS at this time due to risks of procedure and good control of bp on meds. . # Hypercalcemia: considered malignancy, meds, hyperparathyroidism. hyperparathyroid ruled out by PTH level. Malignancy less likely to cause acute hypercalcemia. No record of high-Ca meds/infusions, TF (Nepro) does not have high calcium levels. Also considered inactivity in a pt w/ ESRD. Concern for IgG myeloma given positive SPEP. 24-hour urine for Bence-[**Doctor Last Name **] protein: 700-900. Heme/onc saw Pt., no plan for bone marrow biopsy for now given clinical picture. Bone scan negative, but poor study. . # DM: diabetic diet and glargine (10 units QHS), plus insulin sliding scale, ISS, and fingerstick monitoring. On statin and ACE-i. . # Sacral & LE ulcers: Fentanyl patch started on [**1-27**] for chronic pain. continue q6h tylenol, q72h fentanyl patch for pain. - sacrum XR: 1. Limited study. There is some soft tissue irregularity just posterior to the coccyx. No gross evidence of osteomyelitis is identified. 2. Extensive osteopenia without signs for gross fractures. 3. Large calcified uterus. - sacral wound (presumed osteomyelitis) will not be expected to heal with or without Abx as unless Pt. is able to spend a considerable amount of time sitting up or in a position where pressure on the sacrum is relieved. continue wound care. - encourage OOB to chair as tolerated, to relieve pressure off sacrum. - continue wound care and dressing changes. - pt. was seen by plastics while in house. . # Afib: rate controlled with BB. coumadin started, goal INR 2.0-2.5. . # FEN: Currently on sips of thickened clears for now with supplemental tube feeds at(45cc/hr) via PEG tube. . # Access: PIV. . # FULL CODE, confirmed with son. On [**2-17**], son addressed goals of care with Pt, and reports that Pt. still wants aggressive measures as is still full code. . # Comm: son [**Name (NI) **] [**Name (NI) **], [**Telephone/Fax (1) 64823**] (lives in [**Location 7168**], MA). Medications on Admission: Lantus 6 hs RISS Acetaminophen PRN Norvasc 10 qd ASA 81 Vit C Erythromycin Base 250 q6h (motility [**Doctor Last Name 360**]) Nexium 40 qd Lasix 40 po qd Hydralazine 25 TID Imdur 90 daily Synthroid 15 mcg daily Reglan 10 q 6h Minoxidil 20 mg [**Hospital1 **] Potassium 20 daily MVI Xanax 0.25mg q12 prn Loperamide 2 q6 prn Compazine 10 q6 prn ultram 100mg po q6 prn Discharge Medications: 1. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 7. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 9. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 11. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a day). 12. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 14. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 15. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 16. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 17. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 18. Fentanyl 25 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 19. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 20. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 21. Hydralazine 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 22. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q6H (every 6 hours) as needed. 23. Isosorbide Dinitrate 20 mg Tablet Sig: Two (2) Tablet PO AT 0800, 1200, AND 1600 (). 24. Acetaminophen 160 mg/5 mL Solution Sig: [**12-12**] PO QID (4 times a day). 25. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 26. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 27. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day: please check pt's weight every day, if increases >3 pounds, please give extra 40mg lasix. 28. insulin glargine 16 units QHS + humalog sliding scale 29. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 30. Metoprolol Tartrate 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): please hold for hr<55. 31. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO once a day for 4 days. 32. Epogen 20,000 unit/mL Solution Sig: One (1) Injection once a week. 33. Renagel 800 mg Tablet Sig: One (1) Tablet PO three times a day for 7 days. Discharge Disposition: Extended Care Facility: Embassy House Discharge Diagnosis: Principal: 1. Diastolic Heart Failure - Bilateral Pleural Effusions. 2. Acute Renal Failure. 3. [**Month/Day (2) 7792**] - Demand Ischemia. 4. ESBL E. Coli and Klebsiella UTI/Septicemia. 5. Stage IV Sacral Decubitus Ulcer. 6. Left Lateral Thight Full Thickness Ulcer. 7. Atrial Fibrillation. 8. Elevated IgA NOS. 9. Hypercalcemia NOS. 10.Delirium. 11.MRSA Colonization. 12.Respiratory Failure. Secondary: 1. Chronic Kidney Disease Stage III. 2. Peripheral Vascular Disease. 3. Hypertension. 4. Hyperlipidemia. 5. Diabetes Mellitus Type II Controlled with Complications. 6. Anemia of Chronic Disease. 7. Tracheomalacia. 8. Vascular Dementia. 9. Hypothyroidism. 10.Carotid Endarterectomy. 12.Gastroparesis. 13.Osteoarthritis s/p Bilateral THR. Discharge Condition: fair, stable. Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet. Followup Instructions: please continue to follow up with your PCP [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 5194**] as you have been doing. . Referring: [**Last Name (LF) **],[**First Name3 (LF) **] D. [**Telephone/Fax (1) 2395**] . If you would like to arrange follow up with plastic surgery for sacral and leg skin ulcers, please call ([**Telephone/Fax (1) 2868**] to make an appointment. Completed by:[**2169-3-1**]

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Discharge summary

report

Admission Date: [**2156-12-27**] Discharge Date: [**2156-12-31**] Date of Birth: [**2082-2-26**] Sex: F Service: MEDICINE Allergies: Penicillins / Aspirin Attending:[**First Name3 (LF) 5827**] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: none History of Present Illness: 74yo F with HTN, DM, CVA, CRI and hx of frequent falls s/p ORIF [**11-30**] who presented from her NH ([**Hospital3 2558**]) because she was noted to be unresponsive with pulse ox of 64%. The pt is a poor historian, therefore the bulk of the note was created by [**Name9 (PRE) 103558**] from the ED as well as information obtained by the primary team. As per report, the pt was responsive and A&O x3 when she was found by EMS. She does note that she started feeling "lousy and dizzy" for several days PTA. She reported feeling short of breath several days prior to admission on the morning of. She does not recall the period of her unresponsiveness. The pt was unable to elaborate further. She denies dysuria, cough, diarrhea, n/v, ab pain, fevers, pain at all, HA, CP. All of the above information was by report. In ED, the pt was found to have a pulse ox of 85%-->95% on 100%NRB-->94% on 4L. The pt was given ASA and BB IV upon arrival in the ED for her sob. The pt was found to have a RUL infiltrate on CXR and was given ceftriaxone 1 gm IV x 1 and azithro 500 mg IV x1. Her UA was dirty with 50 WBC, +nitrate, but large amt of epithelial cells. Her head CT was negative, as were LENIs. Pt noted to be hypertensive with SBP up to 200s and was given metoprolol 5 mg IV x3. The pt was seen in the ED by the medicine team and while awaiting a bed, developed tongue swelling and worsening difficulty breathing. The pt was then given solumedrol and benadryl 25mg once IV in the ED for presumed allergic reaction and transferred to the ICU for further management. In the [**Hospital Unit Name 153**], the pt reports worsening of herbreathing but denied any overt chest pain, palpitations, abdominal pain, n/v/d. Past Medical History: PAST MEDICAL HISTORY: 1. Hypertension. 2. Diabetes mellitus. 3. History of paranoid schizophrenia. 4. History of frequent falls. 5. History of hypercholesterolemia. 6. Iron deficiency anemia. 7. Status post cerebrovascular accident in [**2149**]. 8. History of granulomatous hepatitis in [**2139**]. 9. Chronic renal insufficiency with a baseline creatinine of 3.2 10. OA 11. Recent ORIF Social History: No ETOH or IVDA. No smoking. Family History: NC Physical Exam: VS: Tm 98.2 HR 75-82 BP 176-206/82-92 R 16-18 Sat 85%RA-->94%4L NC GEN: pleasant elderly AA female in NAD, a and ox 2 (unable to give time/date). HEENT: EOMI, anicteric, pupils contricted, muddy sclerae, dry MM, white cereal noted in back of OP Neck: no LAD, no JVD, no bruits CV: rrr, S1, S2, no m/r/g appreciated Chest: bibasilar rales, mild end expiratory diffuse wheezes, decreased BS throughout, no dullness to percussion Abd: obese, soft, NT, ND, BS+ Ext: wwp, 2+pitting in LLE up to knee, staples on L thigh c/d/i, full DP/PT pulses Neuro: CN II-XII grossly intact, grip strength 4-/5 BL, 2+hip extension (unclear if pt was following commands) Pertinent Results: Labs on Admission [**2156-12-27**] 10:00AM URINE COLOR-Straw APPEAR-Hazy SP [**Last Name (un) 155**]-1.009 [**2156-12-27**] 10:00AM URINE BLOOD-SM NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-MOD [**2156-12-27**] 10:00AM URINE RBC-[**2-13**]* WBC->50 BACTERIA-MOD YEAST-NONE EPI-[**5-21**] RENAL EPI-0-2 [**2156-12-27**] 10:00AM URINE 3PHOSPHAT-FEW [**2156-12-27**] 09:55AM GLUCOSE-220* UREA N-57* CREAT-2.8* SODIUM-134 POTASSIUM-5.4* CHLORIDE-100 TOTAL CO2-24 ANION GAP-15 [**2156-12-27**] 09:55AM ALT(SGPT)-26 AST(SGOT)-26 CK(CPK)-34 ALK PHOS-232* AMYLASE-56 TOT BILI-0.3 [**2156-12-27**] 09:55AM LIPASE-67* [**2156-12-27**] 09:55AM cTropnT-0.16* [**2156-12-27**] 09:55AM CK-MB-NotDone [**2156-12-27**] 09:55AM ALBUMIN-3.4 [**2156-12-27**] 09:55AM WBC-11.7* RBC-3.50* HGB-10.0* HCT-31.0* MCV-89 MCH-28.6 MCHC-32.3 RDW-14.5 [**2156-12-27**] 09:55AM NEUTS-89.0* LYMPHS-7.8* MONOS-2.3 EOS-0.7 BASOS-0.1 [**2156-12-27**] 09:55AM PLT COUNT-682*# [**2156-12-27**] 09:55AM PT-13.5* PTT-21.9* INR(PT)-1.2 . Labs on Discharge [**2156-12-30**] 06:10AM BLOOD WBC-12.6* RBC-3.15* Hgb-9.0* Hct-28.5* MCV-90 MCH-28.6 MCHC-31.7 RDW-15.4 Plt Ct-474* [**2156-12-28**] 01:10AM BLOOD Neuts-98.1* Lymphs-1.4* Monos-0.5* Eos-0.1 Baso-0 [**2156-12-30**] 06:10AM BLOOD Plt Ct-474* [**2156-12-28**] 01:10AM BLOOD PT-13.9* PTT-25.4 INR(PT)-1.3 [**2156-12-30**] 06:10AM BLOOD Glucose-151* UreaN-69* Creat-2.8* Na-134 K-5.2* Cl-99 HCO3-28 AnGap-12 [**2156-12-30**] 06:10AM BLOOD Calcium-8.8 Phos-3.8 Mg-3.8* . Cardiac Enzymes [**2156-12-27**] 09:55AM BLOOD cTropnT-0.16* [**2156-12-27**] 09:55AM BLOOD CK(CPK)-34 [**2156-12-27**] 04:29PM BLOOD CK-MB-NotDone cTropnT-0.13* [**2156-12-27**] 04:29PM BLOOD CK(CPK)-41 [**2156-12-28**] 01:10AM BLOOD CK-MB-3 cTropnT-0.11* [**2156-12-28**] 01:10AM BLOOD CK(CPK)-38 . Radiology HIP UNILAT MIN 2 VIEWS LEFT [**2156-12-30**] Mild-to-moderate degenerative change involves the right hip joint. The bilateral sacroiliac joints and the pubic symphysis is unremarkable. Vascular calcifications are noted. IMPRESSION: ORIF left intertrochanteric femur fracture. Brief Hospital Course: A/P: 74yo F with HTN, DM, CVA, recent ORIF of hip fx found unresponsive with desat to 64%, found to have RUL PNA, UTI and ?anaphylactic reaction. . # Anaphylaxis: Given the patient's allergy to penicillin and tongue swelling after the administration of ceftriaxone, there was concern that she was having an anaphylactic reaction. The patient received Solemdrol and benadryl. The patient was observed in the [**Hospital Unit Name 153**]. The patient was then transferred to the medicine service where she was monitored for respiratory compromise. The patient never decompensated. Her O2sats were stable. At the time of discharge she had decreased swelling of her tongue. #PNA: On CXR the patient was found to have a RUL infiltrate. She was initially treated with Azithromycin and ceftriaxone. However given her adverse reaction to the ceftriaxone, this was discontinued and the patient was started on Vancomycin. Given the patient's residence at [**Location (un) **], she was treated as if she had a community acquired pneumonia. The patient also has a h/o pseudomonal UTI. If the she had decompensated, the plan was to start an abx such as meropenem for wider coverage. . Of note the patient Vanc level was low at 10.5 on [**2156-12-29**]. The patient was scheduled for dosing on the [**12-29**]. At the time of discharge our recommendations will be to check another vanc level prior to dosing. #. UTI: Pt seems to have a dirty UA with 50 WBC, +nitrates, mod bacteria. Repeat UA showed greater than 62 WBCs. At the time of discharge the patient was being treated with Levofloxacin. #SOB: The patient was treated for her PNA. If her condition deteriorated we would have considered CHF secondary to a hypertensive heart. The differential would have also included a PE given the patient's recent ORIF. However, the patient had been maintained on Lovenox. As discharge approached the patient was weaned off of oxygen. Her O2sat was 95% RA. . Of note the patient was ruled out for an MI. The patient was monitored on telemetry in the ICU. An ECG was done which was normal. . #HTN: The patient was maintained on Lopressor, Imdur and Hydralazine. Her hydralazine was increased to 50 TID because of elevated pressures. At the time of discharge her blood pressure was stable. . #. CVA prevention: Tight glycemic and BP control was maintained. The patient also received a statin. . #. Acute on CRI: The patient has a history of chronic renal insufficiency. With low urine outputs she received boluses and diuresed appropriately. The patient's creatinine remained at baseline. Following her ORIF her creatinine has ranged from 2.8 to 3.2. #. Diabetes: The patient was maintained on insulin sliding scale. . #. s/p ORIF The patient was seen by Dr. [**Last Name (STitle) 57373**] during her hospitalization. A repeat hip film was done which showed mild to moderate changes involving the R hip joint and ORIF left intertrochanteric femur fracture. Followup with Dr. [**Last Name (STitle) 1005**] was set up prior to discharge. . #Anemia: The pt has a history of iron deficiency anemia, in addition, has CRI. She was maintained on iron supplements, epogen and her stools were guaiac negative. Her Hct was greated than 27 throughout her course. The patient did not require blood transfusions. . #Schizophrenia: The patient's condition remained stable. . #FEN: Due to her tongue swelling the patient was kept NPO. As her swelling went done her renal, diabetic, cardiac diet was resumed. The patient was seen by speech and swallow and they recommended thin liquids and soft foods. The patient will need further evaluation by the speech and swallow specialists at [**Hospital3 2558**]. The patient's lytes were repleted as needed. She also received kayexylate for hyperkalemia. Her K peaked at 5.9 during this admission, at the time of discharge it was 5.2. . #Line: Patient had PICC line placeon [**2156-12-30**] for ABX . #PPX: Protonix, bowel regimen, SQ Lovenox . #Code status: FULL CODE . #Communication: [**Name (NI) 102399**] [**Name (NI) 98752**] (sister) [**Telephone/Fax (3) 103559**] (Neither phone number connected to sister) . #Dispo: [**Hospital3 2558**] Medications on Admission: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 7. Atorvastatin 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 8. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 9. Epoetin Alfa 3,000 unit/mL Solution Sig: 3000 (3000) units Injection QMOWEFR (Monday -Wednesday-Friday). 10. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily). 11. Hydralazine 25 mg Tablet Sig: Three (3) Tablet PO Q6H (every 6 hours). 12. Enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg Subcutaneous Q24H (every 24 hours) for 4 months. mg 13. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 14. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 15. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. SSI Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily). 3. Metoprolol Tartrate 50 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 4. Epoetin Alfa 4,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 5. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO QOD (). 8. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 10. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 11. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous Q24H (every 24 hours). 12. Insulin Lispro (Human) 100 unit/mL Solution Sig: ASDIR Subcutaneous ASDIR (AS DIRECTED). 13. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 14. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 10 days. Disp:*5 Tablet(s)* Refills:*0* 15. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Atorvastatin 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 17. Hydralazine 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 18. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous Q48H (every 48 hours) for 5 days. Disp:*5 units* Refills:*0* 19. Diltiazem HCl 240 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO once a day. Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: -Community Acquired Pneumonia -Urinary Tract Infection -Anaphylaxis Discharge Condition: Good Vitals stable Patient eating Discharge Instructions: Please seek medical services immediately if you should experience and shortness of breath, fevers, chills or any other worrisome symptom. . Please continue taking your medications as prescribed. Followup Instructions: You are to followup with your primary care physician [**Name Initial (PRE) 176**] [**12-13**] week of discharge. . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2157-2-8**] 1:00 Completed by:[**2157-2-14**]

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Discharge summary

report

Admission Date: [**2111-6-19**] Discharge Date: [**2111-7-3**] Date of Birth: [**2051-6-24**] Sex: M Service: MEDICINE Allergies: Ceftriaxone Attending:[**First Name3 (LF) 613**] Chief Complaint: lower back pain Major Surgical or Invasive Procedure: left knee I&D [**2111-6-20**], [**2111-6-28**] PICC line placement teeth extraction History of Present Illness: Mr. [**Known lastname 17931**] is a 59 yo man with DMII and mitral valve prolapse who presents with several days of severe lower back pain and lower extremity weakness in the context of recent fevers, nightsweats, and left knee effusion. He was in his usual state of health until 2 weeks ago, when he began having night sweats, which soaked through his sheets. He developed myalgias and fever to 103 over the weekend prior to admission ([**6-13**]), which resolved by [**6-15**], when he began having left knee pain and swelling; he went to orthopedic clinic [**6-17**] where his left knee was noted to have a large effusion thought to be related to worsening of his chronic knee osteoarthritis. Arthrocentesis was performed, which improved his pain; he also used vicodin and ibuprofen at home. . The lower back pain began on the day of the arthrocentesis ([**6-17**]) and progressively worsened in severity; he describes it as a sharp pain without any radiation and describes "spasms" of increasing pain. He distinguishes this pain from his past pain associated with degenerative lumbar disease/disc herniations, which produced sciatic symptoms. On the day of presentation, he notes severe back pain and bilateral leg weakness that made him unable to step into the shower. He had no fecal or urinary incontinence, no urinary retention symptoms beyond his baseline BPH symptoms, and no sensory loss of his lower extremities. He had no neurologic symptoms such as weakness or numbness of his upper extremities or trunk. . No recent travel, sick contacts, sexual contacts, risk factors for TB, procedures (other than arthrocentesis), no recent dental cleaning (does have chipped tooth, but does not involve gums). He denies any rashes but notes [**5-28**] "growths" on hand, scrotum; he was seen by a dermatologist, who diagnosed them as benign lesions associated with aging, and removed them with liquid nitrogen. No headache, neck stiffness, or visual changes. No cough, mild SOB, no chest pain. He notes mild worsening of his chronic right knee pain, but denies pain in other joints. He denies abdominal pain, nausea, vomiting, or diarrhea and has a good appetite. +constipation, with no BM x1-2 days. . In the ER his initial VS were: T 97.0 HR 110 BP 155/77 RR 20 O2 sat: 100% on RA. His T max in the ER was 101.5. He was given 2mg IV morphine x 2, then 4mg IV x 2 for pain without much effect. 1mg IV dilaudid improved his pain somewhat. He was given 2L IVF. He was also given tylenol 650mg x 1 and vanc/ceftriaxone. In the ER an MRI (non contrast) was performed which revealed L2-L3 disc protrusion that causes severe canal stenosis with effacement of the thecal sac. In addition there was increased signal of L5-S1 suggesting possible early discitis but there was no contrast. There was no paraspinal soft tissue abnormality. Neuro was consulted and thought a repeat scan with IV contrast should be performed and that the patient had a lower extremity exam that was limited by severe pain but may have some objective weakness of his proximal lower extremities L > R. . Past Medical History: DMII (last A1C 7.7, recently started metformin) Mitral valve prolapse Hiatal Hernia Schatzki's ring (EGD [**6-/2110**]) Social History: Retired, used to work at [**University/College **]as archivist. Lives alone in [**Hospital3 **] facility in [**Location (un) **] in preparation for bilateral knee replacements. Occasional ETOH, no tobacco, no drug use now or any IVDU in the past. Not in a relationship, no recent sexual contact. Family History: Father died at 72 with pulmonary fibrosis. Mother with PVD. Sister with fibromyalgia. Physical Exam: Physical Exam (on floor, [**6-19**] 9am): VS: T 98.7 HR 100 BP 164/91 RR 18 O2 98% on 2L GEN: lying supine, minimal movement, mild distress HEENT: pupils 2mm, minimally reactive to light, sclera anicteric, conjunctivae noninjected, MM dry, fissuring of tongue, oropharynx without lesions or tonsillar exudate, JVP to earlobe but patient supine and unable to sit up due to severe back pain CV: RRR, normal S1, S2, +2/6 systolic murmur at apex, no rubs/gallops PULM: CTAB anteriorly ABD: mildly distended and tense, nontender, no masses or organomegaly LIMBS: WWP, large L knee effusion, patient unable to tolerate exam of knee [**2-24**] pain, left LE swelling BACK: unable to examine [**2-24**] pain SKIN: Warm, dry, anicteric, no rashes NEURO: AOx3, CN2-12 intact (mild decreased hearing on left, but noisy room). Strength 5/5 in upper extremity, proximal and distal; [**5-27**] plantar- and dorsi-flexion bilaterally (unable to examine strength at hip or knee). Sensation to light touch intact throughout. Cerebellar function intact on finger-nose testing; unable to perform heel-shin testing. Gait unable to be examined. Pertinent Results: Arthrocentesis ([**6-17**]): [**Numeric Identifier 100009**] WBCs with 86% PMNs, no crystals, fluid culture grew streptococci . Blood cultures ([**6-19**]): 4/4 bottles positive for gram positive cocci in chains, strep viridans . CBC: [**2111-6-18**] 08:50PM BLOOD WBC-10.0 RBC-4.75 Hgb-12.8* Hct-38.3* MCV-81* MCH-27.0 MCHC-33.4 RDW-13.8 Plt Ct-279 Neuts-82.6* Lymphs-12.5* Monos-3.9 Eos-0.8 Baso-0.2 [**2111-6-24**] 05:43AM BLOOD WBC-8.5 RBC-4.43* Hgb-12.0* Hct-35.5* MCV-80* MCH-27.1 MCHC-33.9 RDW-13.9 Plt Ct-330 [**2111-6-27**] 06:20AM BLOOD WBC-12.2* RBC-4.60 Hgb-12.1* Hct-36.1* MCV-79* MCH-26.3* MCHC-33.5 RDW-13.8 Plt Ct-408. . . Urine: [**2111-6-19**] 12:01AM URINE Blood-NEG Nitrite-NEG Protein-25 Glucose-100 Ketone150 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG RBC-0-2 WBC-0-2 Bacteri-NONE Yeast-NONE Epi-<1 [**2111-6-26**] 03:09AM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG . MRI thoracic and lumbar spine ([**2111-6-18**]): Tspine: Small T3-4 right paracentral disc bulge without cord compression. Otherwise unremarkable tspine: no cord compression or epidural abnormality. Lspine: Multilevel degenerative change, progressed compared to [**2106**]. Most severe at L2-3: posterior disc bulge causing severe canal stenosis with complete effacement of the thecal sac at this level. Multilevel neural foraminal narrowing. No epidural or paraspinal abnormality. . MRI with contrast, lumbar spine ([**2111-6-19**]): No evidence of osteomyelitis. . TTE ([**2111-6-19**]): No valvular vegetations of masses. The left atrium is elongated. Left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Trace aortic regurgitation. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation. . TEE ([**2111-6-23**]): Procedure unsuccessful due to known Schatzki's ring. . [**2111-6-19**] 06:00AM BLOOD WBC-9.0 RBC-4.34* Hgb-11.7* Hct-35.2* MCV-81* MCH-27.0 MCHC-33.2 RDW-13.6 Plt Ct-306 [**2111-6-20**] 06:45AM BLOOD WBC-8.9 RBC-4.42* Hgb-12.1* Hct-35.5* MCV-80* MCH-27.3 MCHC-34.1 RDW-13.8 Plt Ct-274 [**2111-6-20**] 01:03PM BLOOD WBC-10.0 RBC-4.89 Hgb-13.1* Hct-39.2* MCV-80* MCH-26.8* MCHC-33.5 RDW-13.5 Plt Ct-324 [**2111-6-21**] 07:00AM BLOOD WBC-8.9 RBC-4.69 Hgb-12.4* Hct-37.2* MCV-79* MCH-26.4* MCHC-33.3 RDW-13.4 Plt Ct-311 [**2111-6-22**] 07:30AM BLOOD WBC-8.6 RBC-4.45* Hgb-12.0* Hct-35.8* MCV-80* MCH-26.9* MCHC-33.5 RDW-13.6 Plt Ct-301 [**2111-6-23**] 05:45AM BLOOD WBC-7.8 RBC-4.64 Hgb-12.4* Hct-36.7* MCV-79* MCH-26.8* MCHC-34.0 RDW-13.6 Plt Ct-366 [**2111-6-24**] 05:43AM BLOOD WBC-8.5 RBC-4.43* Hgb-12.0* Hct-35.5* MCV-80* MCH-27.1 MCHC-33.9 RDW-13.9 Plt Ct-330 [**2111-6-25**] 06:12AM BLOOD WBC-8.1 RBC-4.31* Hgb-11.7* Hct-34.6* MCV-80* MCH-27.0 MCHC-33.7 RDW-13.8 Plt Ct-304 [**2111-6-25**] 03:40PM BLOOD WBC-10.2 RBC-4.43* Hgb-11.9* Hct-34.3* MCV-78* MCH-26.9* MCHC-34.8 RDW-13.6 Plt Ct-366 [**2111-6-26**] 06:22AM BLOOD WBC-10.0 RBC-4.26* Hgb-11.4* Hct-33.5* MCV-79* MCH-26.7* MCHC-33.9 RDW-13.6 Plt Ct-370 [**2111-6-27**] 06:20AM BLOOD WBC-12.2* RBC-4.60 Hgb-12.1* Hct-36.1* MCV-79* MCH-26.3* MCHC-33.5 RDW-13.8 Plt Ct-408 [**2111-6-19**] 06:00AM BLOOD Neuts-84.2* Lymphs-10.5* Monos-4.7 Eos-0.4 Baso-0.2 [**2111-6-18**] 08:50PM BLOOD Neuts-82.6* Lymphs-12.5* Monos-3.9 Eos-0.8 Baso-0.2 [**2111-7-1**] 12:00PM BLOOD Plt Ct-525* [**2111-7-1**] 12:00PM BLOOD PT-14.1* PTT-28.2 INR(PT)-1.2* [**2111-6-30**] 06:10AM BLOOD Plt Ct-462* [**2111-6-30**] 06:10AM BLOOD PT-13.5* PTT-25.5 INR(PT)-1.2* [**2111-6-29**] 06:35AM BLOOD Plt Ct-450* [**2111-6-29**] 06:35AM BLOOD PT-13.2 PTT-26.0 INR(PT)-1.1 [**2111-6-28**] 06:20AM BLOOD Plt Ct-419 [**2111-6-27**] 06:20AM BLOOD Plt Ct-408 [**2111-7-1**] 12:00PM BLOOD Glucose-232* UreaN-16 Creat-0.8 Na-129* K-4.0 Cl-96 HCO3-28 AnGap-9 [**2111-6-30**] 06:10AM BLOOD Glucose-190* UreaN-11 Creat-0.7 Na-132* K-4.3 Cl-97 HCO3-26 AnGap-13 [**2111-6-29**] 06:35AM BLOOD Glucose-185* UreaN-14 Creat-0.7 Na-131* K-4.4 Cl-95* HCO3-26 AnGap-14 [**2111-6-28**] 06:20AM BLOOD Glucose-198* UreaN-16 Creat-0.7 Na-133 K-4.4 Cl-96 HCO3-30 AnGap-11 [**2111-6-27**] 06:20AM BLOOD Glucose-191* UreaN-14 Creat-0.7 Na-133 K-4.0 Cl-97 HCO3-24 AnGap-16 [**2111-6-25**] 03:40PM BLOOD Glucose-173* UreaN-14 Creat-0.7 Na-134 K-4.0 Cl-100 HCO3-24 AnGap-14 [**2111-6-25**] 06:12AM BLOOD Glucose-209* UreaN-12 Creat-0.7 Na-132* K-4.2 Cl-97 HCO3-27 AnGap-12 [**2111-6-24**] 05:43AM BLOOD Glucose-207* UreaN-15 Creat-0.8 Na-135 K-4.1 Cl-99 HCO3-27 AnGap-13 [**2111-6-23**] 05:45AM BLOOD Glucose-229* UreaN-13 Creat-0.6 Na-134 K-4.2 Cl-97 HCO3-28 AnGap-13 [**2111-6-22**] 07:30AM BLOOD Glucose-244* UreaN-12 Creat-0.6 Na-134 K-3.9 Cl-97 HCO3-27 AnGap-14 [**2111-6-21**] 07:00AM BLOOD Glucose-247* UreaN-10 Creat-0.7 Na-134 K-4.1 Cl-98 HCO3-26 AnGap-14 [**2111-6-20**] 01:03PM BLOOD Glucose-164* UreaN-11 Creat-0.7 Na-137 K-4.0 Cl-101 HCO3-22 AnGap-18 [**2111-6-20**] 06:45AM BLOOD Glucose-207* UreaN-10 Creat-0.7 Na-136 K-3.7 Cl-102 HCO3-24 AnGap-14 [**2111-6-19**] 06:00AM BLOOD Glucose-180* UreaN-11 Creat-0.7 Na-139 K-3.7 Cl-104 HCO3-23 AnGap-16 [**2111-6-29**] 06:35AM BLOOD ALT-17 AST-14 TotBili-0.6 [**2111-6-28**] 06:20AM BLOOD ALT-18 AST-11 [**2111-6-27**] 06:20AM BLOOD ALT-21 AST-16 CK(CPK)-16* AlkPhos-85 [**2111-6-25**] 03:40PM BLOOD CK(CPK)-35* [**2111-6-23**] 05:45AM BLOOD ALT-19 AST-15 [**2111-6-19**] 06:00AM BLOOD ALT-13 AST-15 AlkPhos-75 TotBili-0.5 [**2111-7-1**] 12:00PM BLOOD Calcium-9.7 Phos-4.1 Mg-2.2 [**2111-6-30**] 06:10AM BLOOD Calcium-9.4 Phos-4.0 Mg-2.0 [**2111-6-29**] 06:35AM BLOOD Calcium-9.1 Phos-3.6 Mg-2.0 [**2111-6-28**] 06:20AM BLOOD Calcium-9.4 Phos-4.4 Mg-2.1 [**2111-6-27**] 06:20AM BLOOD Calcium-9.0 Phos-4.3 Mg-2.0 [**2111-6-26**] 06:22AM BLOOD Calcium-8.6 Phos-3.8 Mg-2.0 [**2111-6-25**] 03:40PM BLOOD Calcium-8.9 Phos-4.1 Mg-2.0 [**2111-6-25**] 06:12AM BLOOD Calcium-8.7 Phos-3.4 Mg-2.0 [**2111-6-22**] 07:30AM BLOOD calTIBC-164* Ferritn-424* TRF-126* [**2111-6-25**] 06:12AM BLOOD TSH-2.3 [**2111-6-19**] 06:00AM BLOOD CRP-275.8* [**2111-6-26**] 10:10AM BLOOD Vanco-19.2 [**2111-6-25**] 03:40PM BLOOD Vanco-14.3 [**2111-6-25**] 06:12AM BLOOD Vanco-15.8 . CXR [**6-29**] A thick crescentic opacity in the left lower lobe is more likely atelectasis than pneumonia. The peripheral component has improved slightly since [**6-26**], but the central component has not. Lung volumes remain quite low, but there are no findings to suggest pneumonia elsewhere. There is no pleural effusion or evidence of central adenopathy. Heart size is normal. Ascending thoracic aorta is tortuous or mildly dilated. . ECHO [**6-30**] The left atrium is normal in size. Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. No masses or vegetations are seen on the aortic valve, but cannot be fully excluded due to suboptimal image quality. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The mitral valve leaflets are myxomatous. There is mild mitral valve prolapse. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. An eccentric, anteriorly directed jet of mild (1+) mitral regurgitation is seen. No masses or vegetations are seen on the tricuspid valve, but cannot be fully excluded due to suboptimal image quality. The estimated pulmonary artery systolic pressure is normal. Compared with the prior study (images reviewed) of [**2111-6-19**], mild mitral valve prolapse of the posterior leaflet is now visible. The severity of mitral regurgitation is slightly increased (but still mild). The other findings are similar. . LENI [**6-30**] IMPRESSION: 1. Deep vein thrombosis seen in the right leg and the right superficial femoral vein extending to the right popliteal vein where it is nonocclusive. DVT in one of the two right posterior tibial veins. 2. DVT seen in the left calf in the two posterior tibial veins and in one of the two peroneal veins. Brief Hospital Course: 59 yo M with DMII and mitral valve prolapse presenting with back pain, left knee pain and effusion in the setting of recent fevers and nightsweats, found to have strep viridans bacteremia and septic left knee joint. . # Septic arthritis, left knee: Fluid from [**6-17**] revealed [**Numeric Identifier 100009**] WBCs with 86% PMNs and the culture grew GPC. He was treated with IV vancomycin. He was seen by orthopedic surgery and the infectious disease services. Received an I&D in the OR on [**6-20**]. POD [**5-28**], knee felt warm, swollen without erythema. Per ortho, received an arthroscopy and washout on [**6-28**]. Pt has continued to improve since this procedure. -Patient can be somewhat discouraged and resistant to pushing himself through PT, but is very cooperative with some encouragement . # Back pain, lower extremity weakness: The history of fever and nightsweats and possible septic joint was concerning for vertebral osteomyelitis via hematogenous seeding. A noncontrast lumbar CT and MRI (with and without contrast) were negative for osteomyelitis or epidural abscess but revealed progression of degenerative disease with nerve root compression at L2-L3, L5-S1. He was seen by neurology in the ED given lower extremity weakness. Once the patient's pain was better controlled (with muscle relaxants and opioids), there was no evidence of lower extremity weakness on exam, though exam continued to be limited by knee pain. The back pain is most likely due to degenerative disease, which may have been exacerbated by antalgic gait due to left knee pain. He had ongoing PT while inpatient and pain was well-managed. . # Bacteremia, ?endocarditis: [**4-26**] blood cultures drawn [**6-19**] were positive for strep viridans. Given his increased risk of endocarditis due to mitral valve prolapse, TTE was obtained and was negative for endocarditis and, notably, for mitral valve prolapse. We then proceeded with a TEE, but this was unsuccessful due to a known Schatzki's ring (dx by EGD in [**11-28**]) which prevented the probe from passing. Given his continued nighttime fevers, there was still concern for both bacteremia and endocarditis and so IV antibiotics continued. However, recent vancomycin troughs were sub-therapeutic(7.0) even with high dosing. IV ceftriaxone was considered, but patient has a ?history of a allergic rash with CTX over the weekend. By ID's recommendation, patient went to the unit overnight to receive a ceftriaxone desensitization. Ceftriaxone desensitization subsequently failed [**2-24**] development of hives. Patient was transferred back to medicine team and continued with IV vanco, again with subtherapeutic troughs and continued nightly fevers. White count trended slightly upward (from 8 to 10). Lung exam became suspicious for pna, see below. Due to low vanc troughs, patient was switched on [**6-26**] to daptomycin. ID weighed in and considering new HAP and suboptimally treated bacteremia, determined new abx regimen of linezolid, aztreonam, and cipro, which patient began on [**6-27**]. Pt was changed back over to daptomycin on [**6-30**]. It was not thought that pt had a HAP given no fever, WBC count or cough. CXR confirmed that LLL opacity was due to atelectasis. . #hypoxia-? Hospital acquired pneumonia: on [**6-26**] CXR showed LLL consolidation. With clinical picture of nightly fevers and trending WBC, patient began treatment of levofloxacin. Patient temporarily required 2L NC on the night of [**6-26**] but quickly weaned to RA. ID recommended abx regimen to cover bacteremia, endocarditis, and HAP: linezolid, aztreonam, and cipro. Repeat CXR found LLL opacity attributable to atelectasis and pneumonia coverage was discontinued per above. In addition, pt with sats of 94% on RA. The initial hypoxia may have been due to a small PE given the known b/l DVTs. However, pt is currently undergoing treatment with lovenox and coumadin. He sure be sure to have a therapeutic INR before his lovenox is discontinued. . #B/l DVT/LLE swelling: Admitting physician noted lower extremity swelling on exam, most likely associated with the septic joint, but DVT was ruled out with LE ultrasound on [**6-19**]. However, pt returned to have swelling repeat LENI showed b/l DVT and pt was started on lovenox with bridge to coumadin. His lovenox should be continued until INR is therapeutic. # Hypertension: Patient had no known history of HTN, but found hypertensive (140s-160s/80s-90s) inpatient. Started on metoprolol 25mg PO BID and hypertension well-controlled. Continue as an outpatient, please follow-up with PCP for HTN [**Name9 (PRE) 100010**] would be a great candidate for an ACEI given DM2 history. . # Hyperglycemia: Patient's fasting FS were in the 200s. He was placed on 7U NPH [**Hospital1 **] with HISS coverage preprandially. . # Constipation: Patient complained of constipation upon admission (no BM in past 1-2 days). Placed on a bowel regimen and had a large BM on day 3. Held off on bowel regimen but continued to follow constipation. . # Urinary retention: Patient has history of untreated BPH, began tamsulosin while inpatient, continue as outpatient and follow-up with PCP for changes to this regimen. Medications on Admission: Metformin 500mg po daily Omeprazole 20mg po bid Vicodin and ibuprofen for knee pain over past few days Multivitamin daily 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. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day. 3. Acetaminophen 500 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain, fever: max daily dose 4g. 4. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): please use this daily until the pain improves, then you may use it as needed. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Hydromorphone 2 mg Tablet Sig: 1-3tabs Tablets PO Q3H prn as needed for pain: hold for AMS, resp depression. 7. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours): hold for AMS, resp depression. 9. Ibuprofen 400 mg Tablet Sig: 1-2 Tablets PO Q8H (every 8 hours) as needed for pain: take with meals. 10. Enoxaparin 100 mg/mL Syringe Sig: 100mg Subcutaneous Q12H (every 12 hours): until INR therapeutic on coumadin. 11. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed for itching. 12. insulin Home regimen is metformin 500mg [**Hospital1 **], feel free to restart or use Humalog insulin per sliding scale as needed. 13. Warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: adjust as needed for INR goal [**2-25**]. 14. Daptomycin 500 mg Recon Soln Sig: 600mg Intravenous once a day for 4 weeks: four week regimen: day 1 was [**6-27**], continue until [**2111-7-26**] and as per ID follow up. 15. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 16. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): this can likely be stopped or changed to HCTZ 25mg upon discharge. 17. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) Mucous membrane [**Hospital1 **] (2 times a day). 18. Outpatient Lab Work CBC with diff, ESR, CRP and CPK every monday. All laboratory results should be faxed to Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**]. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: Primary: septic arthritis of the left knee strep viridans bacteremia possible SBE endocarditis bilateral lower extemity DVTs . Secondary: diabetes mellitus type 2 Schatzki's ring Discharge Condition: Hemodynamically stable, afebrile, tolerating po meds and diet, pain controlled with dilaudid and MS [**First Name (Titles) **] [**Last Name (Titles) **]: requires assistance Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Discharge Instructions: . You were admitted to [**Hospital1 69**] for lower back pain and leg weakness. MRI showed degenerative disease of your spine, but no evidence of infection. The lower extremity weakness improved with better pain control. Your blood and the fluid from the knee tap on [**6-17**] grew a type of bacteria called streptococcus, which is being treated with antibiotics. You also had a washout of the left knee by the orthopedics service. You had an ultrasound of your heart to see if the bacteria was infecting your heart valves, but you are already on antibiotics anyway. It was thought that the bacteria came from your mouth. Therefore, you were seen by the dental service and had 2 teeth pulled. In addition, you were found to have blood clots in your legs. For this, you were started on a blood thinning medication. . The following changes to your medications were made: 1) You started daptomycin-an antibiotic 2) You started pain control-dilaudid, MS contin, and a lidocaine patch. Please do not drive while taking this medication. 3) You started anticoagulation-lovenox and coumadin. 4) You started stool softner medication-senna and colace 5) You started blood pressure medication-metoprolol. This can likely be stopped or changed to an ACE inhibitor or hydrochlorothiazide in the outpatient setting. 6) You started peridex after the teeth removal-a cleaning mouthwash. 7) You started tamulosin- a medication to ease urinary flow (Flomax). . Followup Instructions: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2111-6-23**] 12:30--> cancelled, need to reschedule . Department: ORTHOPEDICS When: THURSDAY [**2111-7-16**] at 9:00 AM With: ORTHO XRAY (SCC 2) [**Telephone/Fax (1) 1228**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ORTHOPEDICS When: THURSDAY [**2111-7-16**] at 9:20 AM With: [**First Name11 (Name Pattern1) 2191**] [**Last Name (NamePattern4) 2192**], NP [**Telephone/Fax (1) 1228**] Building: [**Hospital6 29**] [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 249**] When: FRIDAY [**2111-7-31**] at 8:40 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3404**], MD [**Telephone/Fax (1) 250**] Building: [**Hospital6 29**] [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . You will need to have blood work performed every monday as per below. . You should follow up with your dentist after your rehab stay. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

[ "453.42", "564.09", "722.52", "521.00", "421.0", "790.7", "600.01", "750.3", "V64.1", "522.5", "711.06", "250.00", "401.9", "041.09", "453.41", "788.20", "518.0", "424.0" ]

icd9cm

[ [ [] ] ]

[ "23.19", "80.16", "80.86", "80.76", "38.93" ]

icd9pcs

[ [ [] ] ]

21158, 21243

13537, 18753

286, 372

21466, 21640

5210, 13514

23222, 24531

3958, 4046

18926, 21135

21264, 21445

18779, 18903

21748, 23199

4061, 5191

231, 248

400, 3482

21655, 21724

3504, 3625

3641, 3942

50,409

116,096

34577

Discharge summary

report

Admission Date: [**2109-2-23**] Discharge Date: [**2109-3-9**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 613**] Chief Complaint: chest/abd pain Major Surgical or Invasive Procedure: [**2109-2-22**]: central venous line, internal jugular [**2109-2-26**]: PICC line, left arm, removed [**2109-3-9**] History of Present Illness: Mr. [**Known lastname 805**] is a [**Age over 90 **]-year-old man with a history of atrial fibrillation not anticoagulated, hypertension, type 2 diabetes, anemia, and history DVT in [**2100**]. History is per patient and OMR. He was in his usual state of health until the morning of admission when he awoke with periumbilical abdominal pain. The pain is constant and non-radiating. It was accompanied by anorexia, no nausea or vomitting. There was no diarrhea or blood in his stools. Patient reports no eating and no gas or bowel movement since yesterday, although by report he was brought to the ED after being found unresponsive after a bowel movement by the Sherrrill House staff. At the time his BP was stable at 119/66 but O2 Sat 84% on RA-->95% on 2L. He was given an extra dose of lasix 40 mg PO and levofloxacin 500 mg PO x 1 as well as nebs. Received 2 units insulin for FS 393. . In the ED, he was hypotensive with initial vitals BP 84/52, HR 85, RR 20, O2 Sat 84% on RA and 95% on 2L. He was responsive, A&O x 1. On ROS he complained of abdominal pain. He underwent CT scan which was negative for intra-abdominal pathology but showed right lung consolidation and effusion. CXR also notable for RLL consolidation. He received levofloxacin 750 mg IV and ceftriaxone 1 gIV as well as 3 L of IV fluid. BP rose to 100/50, HR 87, O2 Sat 98% on 5L NC. A central venous line was placed. . On ROS, he denies any recent cough, shortness of breath, chest pain. He denies fevers, chills, night sweats or weight loss. No change in bowel movements, blood in bowel movements, or abdominal pain prior to today. Past Medical History: Diabetes Type II Hypertension Partial gastric resection with bilroth II anastomosis for bleeding peptic ulcer ([**2056**]) Multiple prior episodes of SBO Atrial tachycardia: recent hypotensive event from atrial tachycardia causing TIA like symptoms, no evidence of CVA on MRI. Peripheral Neuropathy Remote EtOH Circumcision ([**2106**]) L ankle fracture L DVT s/p filter [**2100**], GIB on coumadin Pernicious anemia GERD Osteoarthritis Right leg bakers cyst Social History: Widowed. No children. Active in church, sings in choir. Lives with friend from church [**Name (NI) **] although recently at [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **]. Pt has remote former EtOH and tobacco history, recently discharged to [**First Name4 (NamePattern1) 2299**] [**Last Name (NamePattern1) **] but had been living with adopted son prior to recent admission. *** DNR/DNI per HC [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (h) [**Telephone/Fax (1) 79368**] and (c) [**Telephone/Fax (1) 79369**] Physical function: Independent at baseline with dressing, toileting, and walking wtih rolling walker. [**Doctor Last Name **] assists with meal preparation, housekeeping, laundry, errands. No home services. Family History: Unknown Physical Exam: Vital Signs: BP 104/52, HR 90, T 96.4, RR 16, weight 91.6 kg, CVP 6-8 Gen: elderly man lying in bed with flat affect, no apparent distress HEENT: moist mucous membranes, pupils bilaterally round and reactive, oropharynx clear without erythema or exudates Neck: supple, JVP ~8 cm Heart: RRR, no audible murmur, faint heart sounds Lungs: few crackles at b/l bases, scant wheezes Abdomen: diffusely tender, maximal in epigastrium and right upper quadrant with inconsistent voluntary guarding, no rebound, hypoactive bowel sounds Extremities: 2+ pitting edema bilaterally, L>R, TEDS in place, extremities warm, pulses doppler-able Rectal: good tone, light brown stool in vault, guaiac negative Pertinent Results: LABS ON ADMISSION 1/9/9: . HEMATOLOGY: [**2109-2-22**] 05:10PM BLOOD WBC-7.6# RBC-3.37* Hgb-10.9* Hct-31.9* MCV-95 MCH-32.2* MCHC-34.1 RDW-15.2 Plt Ct-202# [**2109-2-23**] 02:25AM BLOOD Hct-25.7* [**2109-2-23**] 08:43AM BLOOD Hct-25.6* [**2109-2-23**] 02:07PM BLOOD Hct-25.3* [**2109-2-24**] 05:16AM BLOOD Hct-24.3* [**2109-2-22**] 05:10PM BLOOD Neuts-41* Bands-41* Lymphs-2* Monos-3 Eos-0 Baso-1 Atyps-0 Metas-8* Myelos-4* [**2109-2-22**] 05:10PM BLOOD PT-15.3* PTT-33.2 INR(PT)-1.4* . CHEMISTRY: [**2109-2-22**] 05:10PM BLOOD Glucose-277* UreaN-43* Creat-2.2* Na-137 K-4.4 Cl-96 HCO3-26 AnGap-19 [**2109-2-22**] 05:10PM BLOOD ALT-16 AST-12 AlkPhos-78 TotBili-0.8 [**2109-2-22**] 05:10PM BLOOD Albumin-3.6 Calcium-8.5 Phos-4.6* Mg-1.6 . CARDIAC ENZYMES: [**2109-2-22**] 05:10PM BLOOD CK(CPK)-670* cTropnT-0.07* [**2109-2-22**] 11:20PM BLOOD CK(CPK)-532* CK-MB-2 cTropnT-0.05* [**2109-2-23**] 02:25AM BLOOD CK-MB-3 cTropnT-0.06* . OTHER: [**2109-2-22**] 05:10PM BLOOD Cortsol-61.1* [**2109-2-22**] 05:10PM BLOOD CRP-193.2* [**2109-2-22**] 05:47PM BLOOD Lactate-4.9* [**2109-2-23**] 02:43AM BLOOD Lactate-2.1* . c.diff neg x 4 [**3-8**] KUB: Interval improvement with no significant dilatation of the loops of large bowel. [**3-5**] KUB: Remaining colonic distention, likely of the rectosigmoid region, with interval improvement in the degree of colonic distension [**3-4**] KUB: Worsening pseudoobstruction [**2-28**] CT abd: Dilated loops of descending and transverse colon but with no lead point identified. Wall thickening rectosigmoid and lower left colon c/w colitis [**2-26**] U/S: No LE DVT bilat 1/9 CXR: New ill-defined opacity within the right lower lobe concerning for pneumonia. . Labs prior to discharge: [**2109-3-8**] CBC: WBC-3.5* RBC-2.44* Hgb-7.9* Hct-22.7* Plt Ct-372 --> transfused 1un pRBC --> [**2109-3-9**] Hct-24.2* [**2109-3-8**] Lytes: Glucose-124* UreaN-9 Creat-1.0 Na-139 K-4.1 Cl-105 HCO3-31 AnGap-7* Brief Hospital Course: A [**Age over 90 **] year-old man with a history of DM and HTN presented after an episode of syncope. In the ED he was hypotensive and complained of abdominal pain. He underwent an abd CT scan. The CT scan was negative for abd pathology (did mention slight distention of redundant sigmoid colon) but did show RLL and RML and pneumonia. He stayed in CCU for 2 days for concern of sepsis and was transferred to the floor on [**2-24**]. # [**Hospital 7502**] health care associated Upon transfer to the floor, he was treated w/ levoflox [**Date range (1) 79372**]; ceftriaxone on [**11-26**]; vanco on [**11-27**]. A PICC was placed on [**2-26**] for IV abx and it was removed the day of discharge. He remained afebrile and his respiratory status improved clinically. . # Colonic pseudo-obstruction Pt initially presented with abdominal pain. Pt's abdomen was distended and repeat KUBs showed colonic distentions. A CT scan was concerning for colitis but it was not clinically correlated and pt was c. difficile negative x 4. Multiple bowel regimens were tried and bowel movements resulted, however, he continued to have worsening distention. Rectal tubes were attempted x 2 and may have been slightly helpful. On [**3-6**], GI performed a colonic decompression in which they were able to advance scope to beyond splenic flexure, saw large amount of stool. The next day, the pt was given 1L golytely with resulting multiple soft stools. He did not have a BM after the golytely but his stomach remained soft and repeat KUB showed improvement. . # Decreasing WBC Has been worked up for leukopenia and thrombocytopenia in the past ([**11-21**]). No intervention was made at that time and his cell lines increased on their own. [**Month (only) 116**] be [**3-18**] meds but no new meds. [**Month (only) 116**] be a myelodysplastic picture. By discharge, his WBC was increasing again. . # Anemia Progressively decreasing HCT w/ low reticulocyte count. Transfused 1un pRBC with modest increase in HCT. . # Stage II coccyx ulcer Aggressively cared for by nursing. . # Syncope Most likely caused by hypotension secondary to sepsis and increased vagal tone after bowel movement. . # Acute renal failure Admission creatinine was 2.2 (baseline 1.2). Most likely secondary to poor perfusion in the setting of sepsis and hypotension. With fluids, his Cr decreased appropriately. All meds were renally dosed. . # Diabetes Pt had been on metformin at home but given his ARF at admission and his multiple radiology studies, this medicine was discontinued. He was started on insulin sliding scale and his blood glucoses were usually inthe mid 100s. The sliding scale was continued on discharge. Medications on Admission: metformin 500 mg qd trazodone 25 mg qhs docusate 200 mg qhs acetaminopohen 500 mg q6h prn bisacodyl 10 mg suppository qd prn clotrimazole cream 1% [**Hospital1 **] levothyroxine 75 mcg qd simvastatin 20 mg qd furosemide 40 mg qd omeprazole 20 mg qam MVI RISS fleet enema PRN milk of magnesia PRN senna PRN Discharge Medications: 1. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for gas/abd pain. 6. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 9. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for wheezing. 10. Insulin Regular Human 100 unit/mL Solution Sig: sliding scale Injection QACHS: See attached insulin instructions. 11. Golytely 236-22.74-6.74 gram Recon Soln Sig: One (1) L PO No more than 2x weekly as needed for constipation: Please use under the direction of a physician. [**Name10 (NameIs) **] only be used when pt has not had a bowel movement for >4 days (and is eating a regular diet). 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 1186**] - [**Location (un) 538**] Discharge Diagnosis: Primary: health care- associated pneumonia Colonic pseudo-obstruction Syncope Secondary: pernicious anemia, possible myelodysplastic syndrome Stage II coccyx ulcer Diabetes mellitus type II, uncontrolled with complications Discharge Condition: Fair Discharge Instructions: You were admitted after you passed out. You had a chest xray that revealed you had pneumonia. You were treated with antibiotics. You also had abdominal pain. This was most likely related to colonic pseudo-obstruction. This was treated with laxatives and colonoscopy. Attached, is a list of your medications. While in the hospital, your blood pressure medicines were stopped. They were not restarted upon your discharge because your blood pressure was stable. Please follow up with your primary care doctor regarding the need to re-start these medications. Also, you need to make sure that you are on a bowel regimen. It is very important that you have regular bowel movements. If you have not had a bowel movement by [**2109-3-11**], please call your physician. [**Name10 (NameIs) **] may need to take another medicine to help you go or you may need more intensive treatment. Please adhere to your follow-up appointments. They are important for managing your long-term health. Please return to the hospital or call your doctor if you have temperature greater than 101, shortness of breath, worsening difficulty with swallowing, chest pain, abdominal pain, diarrhea, or any other symptoms that you are concerned about. Followup Instructions: You need to follow up with your primary care doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 79370**], at the [**Hospital 86**] [**Hospital6 **]. Please call [**Telephone/Fax (1) 41354**] 5415 to schedule this apointment sometime in the next 1 to 2 weeks. Please call her sooner if you do not have a bowel movement within the next few days. [**Telephone/Fax (1) **] UNIT Phone:[**Telephone/Fax (1) 164**] Date/Time:[**2109-3-20**] 10:00 [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2109-3-11**]

[ "486", "707.09", "564.89", "250.00", "427.89", "401.9", "995.91", "427.31", "584.9", "281.0", "285.29", "038.9", "707.22" ]

icd9cm

[ [ [] ] ]

[ "96.08", "38.93", "45.23" ]

icd9pcs

[ [ [] ] ]

10421, 10494

6008, 8704

275, 393

10762, 10769

4051, 4789

12051, 12668

3317, 3326

9061, 10398

10515, 10741

8730, 9038

10793, 12028

3341, 4032

4806, 5985

221, 237

421, 2029

2051, 2512

2528, 3301

59,507

116,254

48031

Discharge summary

report

Admission Date: [**2125-8-11**] Discharge Date: [**2125-8-20**] Date of Birth: [**2049-1-31**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 898**] Chief Complaint: Word finding difficulties. Confusion. Major Surgical or Invasive Procedure: None History of Present Illness: Mrs [**Known lastname 3175**] was admitted to [**Hospital1 18**] on [**2125-8-11**]. She is a 76 year-old right-handed woman with a past medical history significant for type 2 diabetes mellitus, HTN, hyperlipidemia, obesity, chronic renal insufficiency, anxiety and spinal stensosis who presented with word finding difficulties. She has been struggling over the last several weeks with generalized, weakness, lethargy, and difficulty getting upstairs (with DOE). Her son visits her every saturday. They did some light shopping and she was last seen normal before a nap at 5:20pm. Then at 6:20 he went to see how she was doing and he noticed a clear language deficit. She was producing "nonsensicle" strings of words, including some simple isolated consonants. Her pronounciation was mildly affected, but it seemed that finding the words was the primary difficulty. There was no facial droop and no appendicular weakness or precipitous change in gait. Her son called EMS. They measured a finger stick of 178. Blood pressure in the field was 230/94. Code stroke was called on [**8-11**] at 7:30pm. Regarding the workup for her weakness/DOE she has had a normal CXR, normal EKG, and a stress ECHO in late [**Month (only) 216**] revealed a normal EF, with poor exercise tolerance, but no EKG changes and no focal hypokinesis. . Of note until these recent difficulties with shorness of breath and fatigue arose she was living independently in a [**Location (un) 1773**] appartment. She doesn't use a walker or cane normally. . Past Medical History: HTN Type 2 diabetes mellitus Hyperlipidemia Anxiety/Depression Obesity Spinal Stenosis. Renal insufficiency of uncertain etiology - thought to be due to HTN, DMII, but then there is a note on [**2125-6-21**] that suggests here renal insufficiency was getting worse faster than one would expect with those etiologies. Social History: Lives alone in [**Location (un) **]. Retired Has 3 children. Is divorced. Has a remote smoking history No ETOH or illicits. Family History: Non-contributory Physical Exam: Physical Exam: Vitals: T:96.7 P:79 R:12 BP:220-265/108 SaO2:100% 2L NC. General: Awake, cooperative, NAD. Somewhat slow to respond. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated - can hear heartbeat in the carotids. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: She has pitting edema in the left lower extremity greater than the right lower extremity. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented to person, place, but thought it was [**Month (only) **] - self corrected to [**Month (only) **], but thought it was the 22nd or 23rd. Unable to do MOTY backwards. She said, "[**Month (only) **], [**Month (only) **], [**Month (only) **]". There is a deficit in fluency, in that her production is slow. She does however make more than 7 words in a sentence. She had difficulty with comprehension. She was unable to understand the visual field testing task. She wasn't able to follow command for formal motor testing. She makes paraphasic errors. These are both semantic and phonemic. She called a chair a table. When registering apple, she said appy. When repeating the word Right Thumb, she said "Light Thrumb". She was suggestible. At one point I asked her son if she was left or right handed. She incorporated my question inappropriately in the middle of another sentence. She was perseverative - saying months when I asked her an unrelated question. She read and repeated normally. She touched her right ear rather than the left ear with the right thumb. Naming was intact for stethoscope, fingers, knuckles, name tag, but she was unable to name the watch, rather calling it a clock. She new [**Last Name (un) 2450**] was president, and [**Last Name (un) 2753**] is running, but didn't know [**Last Name (un) 101306**]. Registered normally other than saying Appy rather than Apple. Recalled only 1 item at 30 seconds. None further with clues. There was no evidence of neglect on interpreting the cookie theft picture. She was not dysarthric per her son. -Cranial Nerves: Olfaction not tested. Pupils surgical. Both do react. Unable to see Fundi. There is no ptosis bilaterally. EOMI without nystagmus. Normal saccades. Facial sensation intact to pinprick. No facial droop, facial musculature symmetric. Hearing intact to finger-rub bilaterally. Palate elevates symmetrically. Tongue protrudes in midline. -Motor: Unable to perform formal motor testing, because she couldn't seem to understand the commands to resist. She had symmetric antigravity strenght in all four limbs. -Sensory: No deficits to light touch, pinprick, cold sensation. vibratory sense diminshed in feet. -Coordination: No intention tremor, dysdiadochokinesia noted. No dysmetria on FNF bilaterally. She didn't understand or wouldn't perform the HKS test. - Reflex: No clonus [**Hospital1 **] Tri Bra Pat An Toes C5 C7 C6 L4 S1 CST L1 2 1 3 2 tonic up R1 2 1 3 2 up -Gait: Stood up slowly. Needed some help. Took very small steps. Used sink and wall to support herself at times. She didn't ever seem like she would fall, to me, but she did ask for assistance. Romberg absent. She was unable to tandem. Pertinent Results: [**2125-8-11**] 07:40PM GLUCOSE-143* UREA N-20 CREAT-2.4* SODIUM-135 POTASSIUM-3.6 CHLORIDE-99 TOTAL CO2-25 ANION GAP-15 [**2125-8-11**] 07:40PM estGFR-Using this [**2125-8-11**] 07:40PM CK(CPK)-63 [**2125-8-11**] 07:40PM CK-MB-NotDone cTropnT-0.02* [**2125-8-11**] 07:40PM ASA-NEG ETHANOL-NEG ACETMNPHN-13.1 bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2125-8-11**] 07:40PM WBC-11.7*# RBC-3.46* HGB-10.3* HCT-30.3* MCV-88 MCH-29.8 MCHC-34.0 RDW-14.5 [**2125-8-11**] 07:40PM NEUTS-79.1* LYMPHS-13.8* MONOS-4.7 EOS-2.0 BASOS-0.3 [**2125-8-11**] 07:40PM PLT COUNT-344 [**2125-8-11**] 07:40PM PT-12.1 PTT-29.2 INR(PT)-1.0 [**2125-8-20**] 05:20AM BLOOD WBC-12.7* RBC-2.90* Hgb-8.6* Hct-25.6* MCV-88 MCH-29.7 MCHC-33.6 RDW-14.5 Plt Ct-423 [**2125-8-12**] 08:54AM BLOOD WBC-17.6*# RBC-3.53* Hgb-10.2* Hct-31.1* MCV-88 MCH-28.9 MCHC-32.9 RDW-14.7 Plt Ct-424 [**2125-8-12**] 08:54AM BLOOD Neuts-94.3* Lymphs-3.9* Monos-1.5* Eos-0.2 Baso-0.1 [**2125-8-20**] 05:20AM BLOOD Glucose-120* UreaN-25* Creat-2.5* Na-138 K-3.8 Cl-101 HCO3-29 AnGap-12 [**2125-8-19**] 05:05AM BLOOD Glucose-109* UreaN-28* Creat-2.6* Na-138 K-3.8 Cl-100 HCO3-30 AnGap-12 [**2125-8-17**] 03:28PM BLOOD Glucose-163* UreaN-34* Creat-2.7* Na-136 K-3.5 Cl-97 HCO3-28 AnGap-15 [**2125-8-16**] 05:49AM BLOOD Glucose-167* UreaN-34* Creat-2.3* Na-136 K-3.7 Cl-100 HCO3-26 AnGap-14 [**2125-8-13**] 03:45AM BLOOD Glucose-153* UreaN-27* Creat-2.6* Na-137 K-4.0 Cl-98 HCO3-29 AnGap-14 [**2125-8-12**] 08:54AM BLOOD ALT-26 AST-30 LD(LDH)-542* CK(CPK)-115 AlkPhos-136* TotBili-1.2 [**2125-8-12**] 08:54AM BLOOD CK-MB-4 cTropnT-0.03* [**2125-8-11**] 07:40PM BLOOD CK-MB-NotDone cTropnT-0.02* [**2125-8-19**] 05:05AM BLOOD Calcium-8.7 Phos-3.2 Mg-1.7 [**2125-8-12**] 08:54AM BLOOD Albumin-3.3* Calcium-8.9 Phos-4.7* Mg-1.6 Cholest-198 [**2125-8-17**] 03:28PM BLOOD calTIBC-195* Ferritn-244* TRF-150* [**2125-8-12**] 08:54AM BLOOD VitB12-497 Folate-GREATER TH [**2125-8-12**] 08:54AM BLOOD %HbA1c-5.8 [**2125-8-12**] 08:54AM BLOOD Triglyc-117 HDL-60 CHOL/HD-3.3 LDLcalc-115 [**2125-8-12**] 08:54AM BLOOD TSH-0.14* [**2125-8-17**] 03:28PM BLOOD PTH-119* [**2125-8-15**] 06:10AM BLOOD T4-7.5 T3-99 Free T4-1.4 [**2125-8-11**] 07:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-13.1 Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2125-8-12**] 10:15AM BLOOD Type-ART pO2-86 pCO2-33* pH-7.49* calTCO2-26 Base XS-2 [**2125-8-12**] 10:15AM BLOOD freeCa-1.09* . [**2125-8-16**] 05:49AM Metanephrines (Plasma) TEST RESULT REFERENCE RANGE ---- ------ --------------- Metanephrines, Fract., Free Normetanephrine, Free 1.23 (High) < 0.90 nmol/L Metanephrine, Free <0.20 < 0.50 nmol/L TEST PERFORMED AT: [**Hospital 4534**] MEDICAL LABORATORIES, [**Street Address(2) **] SW, [**Location (un) **], [**Numeric Identifier **] Complete report on file in the laboratory. . CXR [**8-16**]: IMPRESSION: 1. Interval improvement in previously described pulmonary vascular congestion. 2. Slight interval decrease in bibasilar atelectasis and unchanged small bilateral pleural effusions. . [**8-17**] Renal U/S with dopplers: IMPRESSION: 1. Small kidneys. 2. Non-diagnostic Doppler evaluation. 3. Bilateral pleural effusions. . MRI/MRA: is markedly motion degraded. Within limits of this examination, no aneurysm is seen. There is nonvisualization of the left distal vertebral artery and proximal stenosis or possibly hypoplasia cannot be excluded. I would recommend correlation with MRA of the neck for further evaluation. IMPRESSION: 1. Markedly limited study, essentially nondiagnostic for evaluation of the distal vessels in the brain. No proximal high-grade stenosis is seen. The left distal vertebral artery is not visualized, which may be from proximal hypoplasia or stenosis. 2. No evidence for acute ischemia in the brain or PRES. 3. Mild small vessel ischemic sequelae in the subcortical and periventricular white matter. . Brief Hospital Course: 76 year-old woman with DMII, Hyperlipidemia, obesity, chronic renal insufficiency, anxiety, h/o supressed TSH with cold thyroid nodule, benign essential hypertension who presented with word finding difficulties, SBP 230. She was seen by neurology and felt not a TPA candidate because her score was only 1 and she recoved relatively quickly. She was hypertensive in the ED BP was 196-256/71-136, HR 70's-80's sat 100% 3L NC, T 96.7. She was treated with aspirin 325mg daily, labetolol 20mg iv x2. On arrival to the medical floor her initial vital signs at 2230 were 180/88, 82, 20, 97% RA, temp 96.5. She was cooperative, alert and oriented per report by the neurology resident. Through the night however she was noted by the nursing staff to be confused, pulling at her monitor leads, iv's, etc. Repeat VS at 0400 were 170/75, hr 72, rr 20, 96% on RA. At 0800 she was noted to be 240/120, Hr 117, rr 40, 98% via 8L FM. A trigger was called and she was transferred to the micu for respiratory distress and treated for flash pulmonary edema with 40mg iv lasix x1 with good effect, and albuterol neb. She was then stabilized in the MICU and transferred to the neurology service. Stroke workup was negative, but her blood pressure was not controlled by PO medications. She was given 10 IV hydralazine for SBP>200 q4-6prn. She was then transferred to the medicine service and started on a nitroglycerin drip for BP control. After 2 days she was weaned off the nitro gtt, and eventually her SBP was 130-150 on amlodipine 10 po daily, avapro 150 daily, furosemide 40 po daily and isosorbide dinitrate TID. Looking back in her records there was concern that she was becoming more hypertensive after beta blockers so these were D/C'd and plasma metanepherines were sent to eval for pheochromocytoma. She was seen by the nephrologists for her acute renal failure. They suspected this was due to hypoperfusion [**12-23**] poor forward flow, hypertension and volume overload. Her creatinine peaked at 2.7 and drifted down slowly with lasix diuresis. She was also evaluated for renal artery stenosis with a renal doppler flow study. However, she couldn't hold her breath long enough so this was non-diagnostic. We recommended she follow this up as an outpatient given the unclear reason for the acute worsening of her blood pressure and kidney disease this year. Her Actos was discontinued in the face of critical illness and she was well controlled on SSI. She needs f/u as an outpatient for diabetes regimen as we did not restart Actos. Three days prior to discharge, she developed a leukocytosis, and her urine grew E. Coli. We started her on a 5 day course of Cipro for urinary tract infection. Last day will be Wednesday [**8-22**]. We also learned that she had been taking Xanax three times a day prior to admission. She had high anxiety in the hospital and we started ativan PRN, then restarted her sertraline. Given her altered mental status on arrival we did not want to send her out on any benzodiazepines. Medications on Admission: Actos 15mg daily Amlodipine 5mg Daily Valsartan/HCTZ 320/25 ASA 81mg daily Zocor 80mg daily Was previously taking Zoloft (50mg qd)and Xanax, but these are not on her current lists. Her PCP in recent notes seems to want her on the Zoloft. Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*2* 3. Irbesartan 150 mg Tablet Sig: One (1) Tablet PO QDay () as needed for HTN. 4. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 5. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Isosorbide Dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days: Do not take your iron pills while taking this medication. Disp:*2 Tablet(s)* Refills:*0* 10. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q4H (every 4 hours) as needed for wheezing, SOB. 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Primary Diagnosis: Hypertensive Encephalopathy Flash Pulmonary Edema Secondary Diagnosis: Anxiety Chronic kidney disease DM, type II on oral medications Hyperlipidemia surpressed TSH with cold thyroid nodule Discharge Condition: Stable. Discharge Instructions: You came to the hospital with difficulty speaking and confusion. We found that you had very high blood pressure. You were seen by the neurology service who did not find any evidence that you had a stroke. We believe your symptoms were due to high blood pressure. We treated your high blood pressure with antihypertensive medications. We found that your kidney function is worse that your baseline. The nephrologists saw you and believed this was due to poor blood flow to your kidneys. Your kidney function improved with control of your blood pressure. We also found that you had a urinary tract infection and treated you with antibiotics. . We made the following changes to your medications: STOPPED Xanax Stopped Metoprolol Stopped Actos Stopped Lisinopril Changed Amlodipine 10mg daily Changed Furosemide 40mg daily Added Isosorbide Dinitrate Added Ciprofloxacin for total 5 days, until [**8-22**] Added Ferrous Sulfate (iron supplement) but do not take this until you are done with your antibiotic. . If you have any shortness of breath, confusion, difficulty speaking, difficulty walking, chest pain, swelling in your legs, nausea, vomiting, fever, chills, blood in your urine or any other symptoms that are concerning to you, please call your PCP or come to the emergency room. . Please take your medications as prescribed and follow up with your PCP and your nephrologist as below. . Followup Instructions: Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 1125**] Date/Time:[**2125-8-28**] 9:45 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5340**], MD Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2125-9-4**] 10:00 Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 1125**] Date/Time:[**2125-9-18**] 9:30 Completed by:[**2125-8-26**]

[ "403.90", "599.0", "272.4", "250.00", "585.9", "437.2", "584.9" ]

icd9cm

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[]

icd9pcs

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14450, 14520

9879, 12903

309, 315

14773, 14783

5863, 9856

16228, 16615

2377, 2395

13193, 14427

14541, 14541

12929, 13170

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2425, 3038

15505, 16205

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343, 1879

14632, 14752

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16,630

136,282

16697+16698

Discharge summary

report+report

Admission Date: [**2108-1-3**] Discharge Date: [**2108-1-19**] Service: CARDIAC SURGERY HISTORY OF PRESENT ILLNESS: The patient is a 78 year old male with a known history of valvular disease, mitral regurgitation with a recent admission at [**Hospital3 3583**] for chest pain and positive stress test. Catheterization after he was transferred to [**Hospital1 69**] revealed a 50% left main lesion and three vessel coronary artery disease with a normal ejection fraction and 2+ mitral regurgitation. PAST MEDICAL HISTORY: His past medical history was significant for dyspnea on exertion, fatigue times six months, glaucoma, benign prostatic hypertrophy, bladder polyp resection, hernia repair, bilateral carpal tunnel syndrome repair, transurethral resection of prostate and a remote head injury. MEDICATIONS ON ADMISSION: 1. Aspirin one tablet each day. 2. Lisinopril 2.5 mg a day. 3. Nitroglycerin 0.4 mcg once daily. 4. Flomax 0.4 mg q.h.s. 5. Protonix 40 mg p.o. once daily. 6. Zoloft 50 mg p.o. once daily. 7. Eye drops, name unknown. LABORATORY DATA: His laboratories on admission were white blood cell count 7.0, hematocrit 37.0, and platelet count 120,000. Chem7 revealed sodium 139, potassium 4.1, chloride 102, bicarbonate 25, blood urea nitrogen 13 and creatinine 0.9. Normal coagulation studies. HOSPITAL COURSE: The patient was taken to the operating room on [**2108-1-4**], for a coronary artery bypass graft times two, left internal mammary artery to left anterior descending, saphenous vein graft to OM with a mitral valve repair. The patient did well with the procedure and an EVH was performed on the right thigh. Postoperatively, the patient was transferred to the CSRU, weaned off drips and was extubated. On postoperative day number one, he was doing well, requiring only a small amount of tone with Neo-Synephrine and insulin drip. Plan was made to discontinue Swan on day one and discontinue his chest tube. His hematocrit had drifted down to 23.0 on postoperative day one for which he got two units of red blood cells which brought his hematocrit back up to 28.0 appropriately. His blood urea nitrogen and creatinine on postoperative day two were 15 and 0.8 and he was in no distress whatsoever and was doing well. The Foley was discontinued on day two as well as central line and he was transferred to the floor. Cartia Intensive Care Unit. On [**2108-1-7**], it was noted that the patient had thick sputum and vomiting. Heart rate was in the 120s, pale color, blood pressure as high as 200/90. The patient was in respiratory distress and was transferred back to the CSRU. On that night, he was intubated and A line and central line were placed to help monitor him. Chest tube was inserted to help drain an effusion on the left side. He had some atrial fibrillation and an Amiodarone drip was started. Tube feeds were begun. He spiked and cultures were performed which revealed negative growth. On postoperative day number five, at this point we had started the patient on broad spectrum antibiotics, given chest x-ray showing a likely picture of possible aspiration, some Vancomycin, Levofloxacin and Flagyl. He was aggressively cultured. He was back on Neo-Synephrine, Amiodarone and Propofol and was tolerating tube feeds. No major changes were made. The patient remained in CSRU without any acute issues. Postoperative day six, antibiotics were continued. We weaned off the Neo-Synephrine. Cultures were still negative and decision was made to keep him intubated, p.r.n. pain control, stable with Amiodarone and pulmonary we tried to wean him. He was on Aspirin and deep vein thrombosis prophylaxis. Postoperative day Vancomycin, Levofloxacin and Flagyl day six. His atrial fibrillation, the Amiodarone was rebolused. A new central line was placed. Hematocrit was 28.0, blood urea nitrogen and creatinine normal. Cultures from when he was transferred back to the Intensive Care Unit came back negative blood, negative sputum, negative stool. He had Amiodarone continuing and continuous Lopressor p.o. and he was weaned, pressors weaned and tube feeds were a go. On postoperative day ten, the patient remained in a lot of atrial fibrillation and was weaned off Neo-Synephrine and Heparin drip was started. The patient was doing well. Insulin was started for high sugars. On postoperative day eleven, Vancomycin, Levofloxacin and Flagyl day number nine. The Amiodarone was changed back to intravenous from p.o. which had been performed after his atrial fibrillation. He had some abdominal distention, tenderness, and general surgery was consulted and ultrasound revealed no evidence of cholecystitis or gallstone disease. Liver function tests correlated this as well as ultrasound and CAT scan. White blood cell count at this point was 14.7, hematocrit 26.7, platelet count 255,000 and blood urea nitrogen was 33 and creatinine 0.6. The patient was doing well. On postoperative day twelve, the patient continued on Heparin drip. No acute moves were made. Physical therapy was consulted. The patient was doing well. On [**2108-1-17**], the patient was extubated and was doing well. He received aggressive chest physical therapy and tolerated it well. His saturation still remained 70 pO2 and his saturations were 95 to 100%. He showed no evidence of respiratory distress. His arterial blood gases were drawn in follow-up as well as physical therapy being called who agreed with the plan disposition for rehabilitation. On [**2108-1-18**], the patient was doing well and it was noted that he had some left upper extremity swelling. Ultrasound was done to rule out deep vein thrombosis which it did. The patient on [**2108-1-19**], has a bed at rehabilitation and is going to be scheduled to go there. MEDICATIONS ON DISCHARGE: 1. Potassium Chloride 20 meq p.o. twice a day given so long as potassium is greater than 4.5. 2. Colace 100 mg p.o. twice a day. 3. Milk of Magnesia p.r.n. as needed. 4. Bisacodyl 10 mg suppository PR p.r.n. 5. Flomax 0.4 mg q.h.s. 6. Zoloft 50 mg p.o. once daily. 7. Prednisolone Acetate Ophthalmic drops four times a day. 8. Ocular one drop O.S. four times a day. 9. ******* one drop O.D. once daily. 10. Levofloxacin 500 mg p.o. q24hours for a total of fourteen day antibiotic course. 11. Vancomycin one gram q12hours for a total of two week course. 12. Reglan 10 mg intravenous q4hours. 13. Flagyl 500 mg p.o. three times a day for a total fourteen day course. 14. Tylenol 650 mg to 1000 mg q6-8hours p.r.n. 15. ******** 25 mg p.o. once daily. 16. Percocet Elixir 5 to 10 cc q4-6hours p.r.n. 17. Ipratropium Bromide nebulizer one to two nebulizers every four hours around the clock until 14th and then p.r.n. 18. Albuterol nebulizers one to two nebulizers every four hours around the clock until 14th and then p.r.n. 19. Metoprolol 25 mg p.o. twice a day. 20. Furosemide 20 mg intravenously twice a day times seven days and then reevaluate for body fluid status and make decision to continue or not. 21. Amiodarone 400 mg p.o. once daily. 22. Insulin sliding scale starting at 150 to get 2 units, greater than 200 to get 4 units, greater than 250, to get 6 units, greater than 300 to get 8 units and house officer on call should be notified. All these antibiotics should include hospital days when counting the two week course. Neurologically, the patient is intact at this point. He was sedated while he was intubated and postoperatively he was moving all four extremities without evidence of any ischemia in the brain or any neurologic damage. Cardiac - The patient had bouts of atrial fibrillation while in the hospital. He was started on Amiodarone and blockaded with Lopressor which he tolerated well and he was transferred to the floor out of the Intensive Care Unit with that. Respiratory - The patient's chest tubes have been discontinued and the chest tubes were then replaced during the second admission to the Intensive Care Unit. Otherwise, at baseline he does not have a very good respiratory status and around the clock inhalers of both Albuterol and Ipratropium are being used on him in order to maximize his respiratory status as well as aggressive chest physical therapy. Gastrointestinal - The patient is not tolerating diet and requiring tube feeds for the last ten days. Infectious disease - The patient had increased white count during hospital stay as well as fever to 103 on [**2108-1-8**], and pancultures revealed nothing. The patient was started on Vancomycin, Levofloxacin, Flagyl empirically and none of the cultures showed anything after discussion with the cardiac team. The patient is to go on a total of two weeks of antibiotics as noted on page one. Renal - The patient had no renal issues and did well. Hematology - The patient was transfused two units of blood during his hospital stay. Otherwise, he had a stable hematocrit. No evidence of oozing or bleeding. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Name8 (MD) 16758**] MEDQUIST36 D: [**2108-1-18**] 16:51 T: [**2108-1-18**] 18:39 JOB#: [**Job Number 47260**] Admission Date: [**2108-1-2**] Discharge Date: [**2108-2-23**] Service: MICU ADDENDUM: Please see the cardiothoracic discharge summary for initial event. Briefly, the patient was referred to [**Hospital1 18**] for a cardiac catheterization which was then recommended for the patient to undergo CABG. The patient underwent two vessel CABG with MVR and tolerated the surgery well. On postoperative day number one, the patient was extubated and transferred to the floor. On postoperative day number two, the patient went in and out of atrial fibrillation requiring Amiodarone drip. On postoperative day number five, the patient was reintubated for hypoxic failure, developed fevers, and was presumed to be suffering from an aspiration pneumonia. He received vancomycin, levofloxacin, Flagyl, and Imipenem. He received a 14 day course of these antibiotics. On postoperative day number six, the patient was extubated. On postoperative day number 19, the patient had to be reintubated for hypoxia. At this time, the patient was also cardioverted times two for atrial fibrillation. On postoperative day number 20, the patient had increasing temperature, decreasing blood pressure, and increasing white count and had another episode of aspiration pneumonia versus pneumonitis. On postoperative day number 24, the patient was referred for a tracheostomy and PEG tube placement. On postoperative day number 29, the patient was eventually transferred to the MICU for management of presumed ARDS. PAST MEDICAL HISTORY: 1. Valvular heart disease, aortic and mitral valve replacement. 2. BPH. 3. Glaucoma. ADMISSION MEDICATIONS: 1. Aspirin 81 mg p.o. q.d. 2. Lisinopril 2.5 mg p.o. q.d. 3. Flomax 0.4 mg p.o. q.d. 4. Protonix 40 mg p.o. q.d. 5. Zoloft 50 mg p.o. q.d. 6. Ocuflox eyedrops. 7. Pred-Forte eyedrops to the left eye. 8. Acular eyedrops to the left eye. 9. Betimol eyedrops to right eye. MEDICATIONS ON TRANSFER: 1. Captopril 12.5 mg p.o. t.i.d. 2. Lasix drip. 3. Fentanyl drip. 4. Lopressor 25 b.i.d. 5. Versed drip. 6. Insulin drip. 7. Nystatin swish and swallow q.i.d. 8. Sucralfate 1 gram p.o. q.i.d. 9. Albuterol nebulizers q. four. 10. Atrovent nebulizers q. four. 11. Aspirin. 12. Colace. 13. Prednisone eyedrops to the left eye. 14. Cipro eyedrops to the left eye. SOCIAL HISTORY: The patient is married, a retired mechanic. No history of smoking. FAMILY HISTORY: Negative. PHYSICAL EXAMINATION ON TRANSFER: Vital signs: 97.0, 103, 140/70. General: The patient was intubated, sedated, and paralyzed. HEENT: JVP 8 cm. Coronary: Regular rate and rhythm. No murmurs, rubs, or gallops. Lungs: Coarse breath sounds, decreased breath sounds at the bases. Abdomen: Soft, nontender, nondistended, positive bowel sounds. No hepatosplenomegaly. Extremities: 1+ pulses bilaterally. No lower extremity edema, but 2+ upper extremity edema, pitting. Right subclavian line, right A line. LABORATORY DATA: WBC 11.3, hematocrit 28.3, platelets 230,000. ABGs 7.24, 74, 79 on assist control tidal volume 390, respiratory rate 26, PEEP 12.5, FI02 0.5. The patient had sputum on [**2108-1-28**] with 10-25 polys but no organisms. Urine culture with yeast. Chest x-ray with persistent bilateral pulmonary opacities consistent with ARDS. HOSPITAL COURSE: The patient was started on pressure control ventilation to control his ARDS. He was attempted to be weaned off the pressures and suffered an episode of hypercapnia on [**2108-2-1**] likely secondary to a mucus plug in the main stem bronchus. On [**2108-2-2**], the patient was noted to have bleeding from his tracheostomy site, bleeding mucus plugs. He remained tachycardiac. He was able to be weaned of Neo. He also had problems with his residuals and tube feeds. The patient underwent bronchoscopy on [**2108-2-1**] which revealed trauma to the tracheostomy tip, a small amount of clot, and minimal secretions. Prior to this procedure, the patient had to have his heparin discontinued. The patient required blood transfusion for a slowly decreasing hematocrit. The patient's PEEP was also decreased with hopes of weaning the patient off the ventilator. On [**2108-2-3**], the patient underwent repeat bronchoscopy which revealed purulent sputum in the left lower lobe, status post BAL. The Gram's stain revealed gram-positive cocci in pairs and clusters. The patient was started on vancomycin 1 gram b.i.d. for concern over MRSA. The patient remained total volume overloaded and was slowly diuresed with Lasix. On [**2108-2-4**], the patient had an A line placed in the right radial artery as well as underwent another bronchoscopy to remove the thick secretions. The patient was noted to be in atrial fibrillation with rapid ventricular rate starting at a systolic blood pressure of 120s. The patient was started on an Amiodarone drip with no improvement. The patient remained in atrial fibrillation for a couple of days and then converted on the Amiodarone and Lopressor. The patient had also been started on a heparin drip again for his atrial fibrillation. The patient was noted to have increasing residuals on his tube feeds which required them to be held. On [**2108-2-7**], the patient was noted to have a cuff leak that was able to be stopped with a stop cock. The patient also started to experience bloody secretions, likely secondary to his anticoagulation and his heparin drip was again discontinued. The patient remained on a pressure control mode of ventilation. During this period, the patient also remained hypertensive and had his Toprol increased. On [**2108-2-8**], the patient had an episode of hypotension down to the 70s and remained tachycardiac. The patient's cultures also returned to be positive for MRSA. The patient will complete a course of antibiotics with vancomycin. On [**2108-2-9**], the patient underwent central line and Swan insertion to further characterize the patient's volume status. On [**2108-2-10**], the patient again underwent an episode of hypotension and had to be started on phenylephrine drip. This was transient. The patient was able to come off it slowly. A cardiac echocardiogram did not demonstrate any new changes or signs of ischemic changes following the procedure. He was also placed on sucralfate which was changed from Protonix given his risk of recurrent aspiration pneumonia. The patient was also switched over to assist control for improving cardiopulmonary status. The patient had another episode of hypotension. These episodes of hypotension were thought to be due to tenuous cardiac status and hypotension given diuresis from his CHF. On [**2108-2-14**], the patient underwent a head CT for his continued sedation which was negative. Also, his blood cultures growing positive which were likely secondary to an infected line. He again underwent bronchoscopy on [**2108-2-15**] for increased mucus secretions. No new findings were found on bronchoscopy. He remained on assist control secondary to his sedation. He was unable to have his sedation decreased as the patient became very agitated. On [**2108-2-18**], the patient's blood pressure improved and he was able to come off all of his drips. He was changed to pressure support with hopes of weaning. On [**2108-2-19**], the patient's blood pressure continued to be elevated despite a dose of antihypertensives. He was started on beta blockers and had an ACE inhibitor added. He remained on Amiodarone for his atrial fibrillation which had remained in good control and in normal sinus rhythm. The patient remained on vancomycin for his MRSA pneumonia and line sepsis. On [**2108-2-20**], the patient continues to do well and had his pressure support weaned. On [**2108-2-21**], the patient was noted to have increasing swelling of his left upper extremity on the same line as his left IJ. The patient was referred for left upper extremity ultrasound which demonstrated a clot in the brachial vein. The patient was started on IV heparin which was then switched to Lovenox. The patient continued to have his hypertensive medications increased without much effect. He apparently was maxed out on Lopressor, Captopril. Norvasc 5 was started. The patient was also noted to be slightly more tachypneic with more fluid on his lungs. The patient was diuresed with Lasix 40 IV times two and underwent an episode of hypotension with a systolic blood pressure in the 70s which responded well to fluid resuscitation. The patient is very pre-load dependent. On [**2108-2-23**], the patient was noted to have some small ulceration around the PEG site which appears to not be infected. Cultures have been sent and will be evaluated by Surgery. This is pending at the time of this dictation. The patient's symptoms continue to improve and he remained with good blood pressure control also on NPH insulin for the glucose control. The patient's ventilator has improved overall and will continue to need to be adjusted. The patient was last started on a pressure support of 5 and PEEP of zero which he did not tolerate. These had to be increased again to 10 and 5. Mental status at discharge remained somewhat slow but he was able to follow commands. He will remain on antibiotics until [**2108-2-24**]. He will also require a six week course of anticoagulation with Lovenox/Coumadin given his clot on [**2108-2-22**]. He is improving. He was able to tolerate full nutrition. DISCHARGE STATUS: The patient will be discharged to rehabilitation where his ventilator will be able to be weaned. He will continue one day of antibiotics for his MRSA pneumonia. He will continue his anticoagulation for his upper extremity clot. Long-term anticoagulation for his atrial fibrillation will need to be decided with his PCP given his multiple episodes of bleeding on anticoagulation. The patient will require ophthalmology follow-up for his glaucoma. DISCHARGE DIAGNOSIS: 1. Status post cardiac catheterization. 2. Status post coronary artery bypass graft for two vessel disease and mitral valve replacement. 3. Adult Respiratory Distress Syndrome. 4. Methicillin-resistant Staphylococcus aureus pneumonia. 5. Methicillin-resistant Staphylococcus aureus line infection with sepsis requiring pressors. 6. Left upper extremity brachial vein deep venous thrombosis. 7. Status post tracheostomy and G tube placement. 8. Diabetes mellitus. 9. Atrial fibrillation with rapid ventricular response. DISCHARGE MEDICATIONS: 1. Insulin NPH 44 units b.i.d. 2. Regular insulin sliding scale. 3. Metoclopramide 10 mg p.o. q.i.d. 4. Cipro eyedrops one to two drops O.S. q.i.d. 5. Aspirin 325 mg p.o. q.d. 6. Colace 100 mg p.o. b.i.d. 7. Atrovent two puffs inhaler q. four hours. 8. Albuterol two puffs inhaler q. four hours. 9. Senna two tablets p.o. q.h.s. 10. Amiodarone 200 mg p.o. q.d. 11. Sucralfate 1 gram p.o. q.i.d. 12. Vancomycin 1,000 mg IV q. 24 hours to be completed on [**2108-2-24**]. 13. Metoprolol 100 mg p.o. t.i.d. 14. Timolol 0.5% one drop O.D. q.h.s. 15. Captopril 150 mg p.o. t.i.d. 16. Sertraline 25 mg p.o. q.d. 17. Lovenox 70 mg subcutaneously q. 12 hours. 18. Coumadin 5 mg p.o. q.d. to complete six week course of anticoagulation from [**2108-2-22**]. 19. Amlodipine 5 mg p.o. q.d. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-761 Dictated By:[**Name8 (MD) 17420**] MEDQUIST36 D: [**2108-2-23**] 01:51 T: [**2108-2-23**] 14:00 JOB#: [**Job Number 47261**]

[ "414.01", "427.31", "996.62", "518.5", "507.0", "482.41", "511.9", "424.0", "428.0" ]

icd9cm

[ [ [] ] ]

[ "88.56", "43.11", "96.72", "33.24", "37.22", "36.11", "34.04", "38.91", "31.1", "35.12", "88.53", "36.15", "96.04", "96.6" ]

icd9pcs

[ [ [] ] ]

11631, 12505

19710, 20714

19158, 19687

5831, 10720

838, 1335

12523, 19137

10854, 11134

129, 514

11159, 11529

10742, 10831

11546, 11614

6,543

157,266

25842+57468

Discharge summary

report+addendum

Admission Date: [**2171-6-18**] Discharge Date: [**2171-7-11**] Date of Birth: [**2109-12-29**] Sex: M Service: ORTHOPAEDICS Allergies: Beta-Adrenergic Blocking Agents Attending:[**First Name3 (LF) 8587**] Chief Complaint: Left thigh pain Major Surgical or Invasive Procedure: [**2171-6-19**]: Left femur IMN [**2171-6-26**] Trach and PEG History of Present Illness: The patient is a 61 year old male who presented to the orthopedic clinic on [**2171-6-18**] for a second opinion of his left thigh pain. He had fallen 2 weeks prior at his rehab. X-rays were taken and he was found to have a left midshaft femur fracture. He was directly admitted to the orthopedic service. Past Medical History: CAD - severe, inoperable CAD (s/p cath, no stents); ischemic CM EF 28% in [**2167**] Admission [**2169-6-30**] for cardiac Arrest CKD (unknown etiology, ? baseline Cr 2.7) HTN sacral decubitus ulcer h/o UTI [**3-4**] (MDR enterobacter, h/o MRSA in urine) s/p indwelling foley ([**2167**]) [**2-1**] sacral decubitus schizophrenia (not active since in 20s) paraparesis (progressive over many years, unknown etiology) AFib (on outpatient coumadin) Hypercholesterolemia Horseshoe kidney AAA Social History: Patient is currently a resident at [**Location (un) **] [**Hospital **]care Center. He is a former electrial engineer. He denies any EtOH use. Reports 12 pack-year history, he quit 2 years ago. He denies any illicit drug use. Family History: NC Physical Exam: Upon arrival: AVSS NAD A+O CTA b/l RRR ABD: +distention, palpable mass L mid abd, NT LLE: obvious deformity to left thigh 2+ DP Pertinent Results: ANKLE (AP, MORTISE & LAT) RIGHT, KNEE RIGHT [**2171-6-18**] IMPRESSION: 1. Acute displaced and angulated fracture of the distal left femur. 2. Old fracture of the distal tibia and fibula. 3. Diffuse demineralization. ABDOMEN (SUPINE ONLY) [**2171-6-19**] IMPRESSION: 1. Very distended loops of colon and some distended loops of small bowel, secondary to marked fecal impaction. 2. Focal linear lucencies along the distal colon and a small triangular area of gas in the left lower quadrant, not definitely localizable to either small or large bowel. No definite free intraperitoneal air is identified, and the linear lucencies most likely represent air around impacted stool. However, if the patient has any localizable symptoms such as abdominal pain to raise suspicion for bowel pathology or pneumatosis, CT should be performed for further evaluation. FEMUR (AP & LAT) LEFT [**2171-6-19**] HIP UNILAT MIN 2 VIEWS LEFT; FEMUR (AP & LAT) LEFT IMPRESSION: Obliquely oriented and mildly comminuted fracture of the distal left femoral diaphysis with decreased angulation and persistent displacement. BILAT LOWER EXT VEINS [**2171-6-19**] IMPRESSION: No evidence of DVT in either lower extremity. FEMORAL VASCULAR US LEFT PORT [**2171-6-21**] IMPRESSION: Large left groin hematoma without evidence of pseudoaneurysm. CTA PELVIS W&W/O C & RECONS [**2171-6-21**] 1. Left groin hematoma with intraluminal active extravasation from left femoral arterial puncture. 2. Bilateral dependent consolidation in the upper and lower lung fields, concerning for aspiration. 3. Acute rib fractures of the right anterior two through six ribs with a suggestion of minimal underlying contusion. 4. Rectum largely distended with stool, which was also present on study from [**2169-6-30**]. 5. Cholelithiasis without evidence of cholecystitis. 6. Pelvic horseshoe kidney with delayed excretion of contrast, consistent with renal impairment. 7. Mild intra-abdominal ascites. 8. Stage IV ulcer in the left buttock extending to the left ischial tuberosity. Underlying osteomyelitis cannot be excluded. ECHO Study Date of [**2171-6-21**] IMPRESSION: Extensive regional left ventricular systolic dysfunction suggestive of multivessel CAD. Mild-moderate mitral regurgitation. Compared with the prior study (images reviewed) of [**2170-3-7**], left ventricular systolic function now appears more reduced (the quality of the current study is superior and the estimated LVEF was higher than that reported)). CLINICAL IMPLICATIONS: Based on [**2170**] 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. ECG Study Date of [**2171-6-21**] Sinus rhythm, rate 76. Since the previous tracing of [**2171-6-18**] atrial premature beats are present, QRS complexes have narrowed somewhat, the Q-T interval is prolonged and there is a voltage decreased seen throughout the electrocardiogram. No other changes have occurred. MRA BRAIN W/O CONTRAST [**2171-6-26**] IMPRESSION: Overall no significant change since [**2169-7-7**]. Chronic right frontal lobe infarct and moderate brain atrophy identified. Soft tissue changes are seen in both mastoid air cells and in the maxillary sinuses. No acute infarcts are identified. MRA could not be performed as patient was unable to continue. CT PELVIS W/CONTRAST [**2171-7-1**] CT ABD W&W/O C; CT PELVIS W/CONTRAST IMPRESSION: 1. No evidence of pancreatitis. 2. Cholelithiasis. 3. Small bilateral pleural effusions, right greater than left. 4. 3-cm infrarenal abdominal aortic aneurysm. 5. Horseshoe kidney. 6. Severe fecal loading of the sigmoid colon. 7. Decubitus ulcer extending to the left inferior pubic ramus with cortical irregularity and increased sclerosis consistent with osteomyelitis. 8. Region of lenticular soft tissue attenuation insinuating within the fascia of the left medial thigh. This may be secondary to postoperative infectious or inflammatory etiologies. This must be followed to resolution and clinically correlated. US ABD LIMIT, SINGLE ORGAN PORT [**2171-7-1**] 1. Cholelithiasis; no definite evidence of choledocholithiasis or acute cholecystitis. 2. Infrarenal 3.2 cm abdominal aortic aneurysm. [**2171-6-18**] 07:10PM PT-14.2* PTT-25.3 INR(PT)-1.3* [**2171-6-18**] 07:10PM PLT COUNT-537*# [**2171-6-18**] 07:10PM NEUTS-75.4* LYMPHS-16.7* MONOS-4.0 EOS-3.6 BASOS-0.3 [**2171-6-18**] 07:10PM WBC-12.7*# RBC-3.65* HGB-10.9* HCT-31.9* MCV-87 MCH-29.8 MCHC-34.1 RDW-17.8* [**2171-6-18**] 07:10PM CALCIUM-8.4 PHOSPHATE-4.3 MAGNESIUM-2.8* [**2171-6-18**] 07:10PM ALT(SGPT)-144* AST(SGOT)-139* LD(LDH)-232 ALK PHOS-504* TOT BILI-0.3 [**2171-6-18**] 07:10PM estGFR-Using this [**2171-6-18**] 07:10PM GLUCOSE-136* UREA N-46* CREAT-3.0* SODIUM-137 POTASSIUM-4.2 CHLORIDE-108 TOTAL CO2-18* ANION GAP-15 Brief Hospital Course: The patient was admitted to the orthopedic service on [**2171-6-18**]. He was seen by his PCP for operative clearance. A KUB was done to evaluated the mass in his abdomen, which showed large amounts a stool and chronic constipation. His PCP thought that while he was a high risk, he was stable enough for the OR. On [**2171-6-19**] he was brought to the operating room for fixation of his left femur fracture. He tolerated the procedure well. He was extubated and brought to the recovery room in stable condition. From the PACU he was transferred to the floor for further care. Post operatively he was kept NPO and an aggressive bowel regimen was started. He started passing gas and he was advanced to clears. He was also disimpacted. [**Date Range 409**] care was consulted for his long standing sacral decubitus ulcers. Nutrition was consulted as well. He was evaluated by physical therapy. On POD#2 he was found unresponsive at approximately 7 am and a "code blue" was called. He was resuscited by the code team after approximately 15 minutes of asystole and he was transferred to the SICU for definitive care. The SICU team managed his daily care until he was stable enough to be discharged to rehab. Medications on Admission: Aranesp 25 mcg/ml 1ml q wk, iron, digoxin 0.125mg QOD, Plavix 75mg daily, Simvastatin 40mg daily, ASA 81mg daily, Amiodarone 200mg daily, Lopressor 12.5mg TID, Novolin 32units qam 18units qpm, tylenol, folic acid, nasonex, zyprexa 5mg at HS, senna, vitamin C, colace Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 3. Acetylcysteine 10 % (100 mg/mL) Solution Sig: 3-5 MLs Miscellaneous Q6H (every 6 hours) as needed. 4. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily). 5. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): per insulin sliding scale. 6. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Famotidine in Saline (Iso-osm) 20 mg/50 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours). 8. Potassium Chloride 20 mEq/50 mL Piggyback Sig: One (1) Intravenous PRN (as needed): per kcl sliding scale. 9. Magnesium Sulfate 4 % Solution Sig: One (1) Injection PRN (as needed): per magnesium sulfate sliding scale. 10. Metoclopramide 5 mg/mL Solution Sig: One (1) Injection Q6H (every 6 hours). 11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. Calcium Gluconate 100 mg/mL (10%) Solution Sig: One (1) Intravenous PRN (as needed) as needed for Ionized calcium < 1.15. 13. Sodium Chloride 0.9 % 0.9 % Piggyback Sig: One (1) ml Intravenous every four (4) hours as needed for flush. 14. Phenylephrine HCl 10 mg/mL Solution Sig: One (1) Injection TITRATE TO (titrate to desired clinical effect (please specify)): DRIP TITRATE TO SBP > 100. 15. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Hospital1 **] Discharge Diagnosis: Left femur fracture UTI Discharge Condition: stable Discharge Instructions: Bear weight as tolerated on your left leg. Continue your lovenox injections for a total of 4 weeks. Resume your home medications at their normal doses and take your other medications as prescribed. Keep the incision clean and dry. Use dry sterile dressings as necessary to keep the incisions clean and dry. If you notice any increased redness, drainage, or swelling, or if you have a temperature greater than 101.5 please call the office or come to the emergency department. Physical Therapy: WBAT LLE Treatments Frequency: Use dry sterile dressings as needed to keep incisions clean and dry. Followup Instructions: Follow up with Dr. [**Last Name (STitle) **] in 4 weeks. Call [**Telephone/Fax (1) **] to make this appointment. Name: [**Known lastname 11381**],[**Known firstname **] Unit No: [**Numeric Identifier 11382**] Admission Date: [**2171-6-18**] Discharge Date: [**2171-7-11**] Date of Birth: [**2109-12-29**] Sex: M Service: ORTHOPAEDICS Allergies: Beta-Adrenergic Blocking Agents Attending:[**First Name3 (LF) 3564**] Addendum: On [**2171-6-21**] a "code blue" was called. Mr. [**Known lastname **] was found unresponsive and pulseless on the floor. He was also noted to have a hematocrit of 20 at the time of the "code blue". He was resuscitated, intubated, and then transferred to the SICU for further care. He was placed on a heparin drip and was also placed on an epinepherine, insulin, and levophed drips at different courses of his resucitation. He also received atropine, bicarbonate, and calcium during the code. He was also transfused with 4 units of packed red blood cells due to post operative anemia. Renal was consulted for acidemia and an anion gap that was thought to be due to the prolonged hypoperfusion during the resuscitation on top of his chronic renal failure. He was placed on a bicarbonate drip to help with his kidney function. Vascular surgery was also consulted for a left groin hematoma after placement of a femoral line during the "code blue". The hematoma was stabalized and required no surgical intervention. He was also noted to have a diliated colon which was full of stool. He was disimpacted by general surgery. On [**2171-6-22**] his acidemia was improving. On [**2171-6-23**] he was started on tube feedings and his epinephrine and levophed was continued to be weaned to off. On [**2171-6-25**] neurology was consulted due to slow neurological improvement after cardiac arrest. Neurology recommended an MRI which was done on [**2171-6-26**]. The MRI showed an old stroke and no acute changes but an anoxic brain injury could not be ruled out. Neurology recommended no further follow up care was needed and to follow neurological status. The wound care nurse was also consulted for care of his sacral ulcer wound. On [**2171-6-30**] he was noted to have pancreatitis, his tube feedings were held and his LFT's were followed. His elivated LFT's resolved and he was then restarted on his tube feedings. Constipation remained a problem for him and he was maintained on an agressive bowel regime. On [**2171-7-9**] due to his slow wean off the ventaliator and slow neurological recovery he underwent placement of a tracheostomy. On [**2171-7-10**] a PEG tube was placed in interventional radiolody for tube feedings. He was then medically ready and cleared for transfer to a ventalator rehabilation facility. He was then discharged to rehab on [**2171-7-11**]. Discharge Disposition: Extended Care Facility: [**Hospital3 2215**] Northeast - [**Hospital1 1947**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3565**] MD [**MD Number(2) 3566**] Completed by:[**2171-8-16**]

[ "585.9", "998.12", "348.1", "344.9", "276.2", "707.13", "414.01", "599.0", "518.81", "730.25", "357.89", "707.05", "E884.4", "707.03", "V58.61", "427.31", "707.04", "753.3", "250.00", "821.20", "427.5" ]

icd9cm

[ [ [] ] ]

[ "96.6", "31.1", "79.35", "99.07", "43.11", "96.72", "96.04", "38.91", "00.17", "99.60", "38.93", "99.04", "89.64" ]

icd9pcs

[ [ [] ] ]

13408, 13645

6601, 7821

313, 378

9855, 9864

1660, 4146

10510, 13385

1487, 1491

8138, 9689

9808, 9834

7847, 8115

9888, 10368

1506, 1641

10386, 10395

10417, 10487

4169, 6578

258, 275

406, 716

738, 1227

1243, 1471

75,919

112,333

50642+59270

Discharge summary

report+addendum

Admission Date: [**2139-9-23**] Discharge Date: [**2139-9-26**] Date of Birth: [**2087-5-18**] Sex: F Service: NEUROSURGERY Allergies: Sulfa (Sulfonamide Antibiotics) / Erythromycin Base / Furadantin Attending:[**First Name3 (LF) 1835**] Chief Complaint: Headaches Major Surgical or Invasive Procedure: Suboccipital decompression and C1 laminectomy History of Present Illness: This is a 52 year old female with complaints of headaches, dizziness, light headedness, gait distrubance, coordinaton issues, multiple falls, and visual changes. Of note she has a history of left acoustic neuroma s/p gamma knife radiation in [**2137**] in [**State 3908**]. On imaging of her brain, she was noted to have a newly Diagnosed Chiri Type 1 malformation. She opted to proceed for surgery. Past Medical History: carapl tunnel release, cribiform plate repair [**2126**], gastric bypass [**2132**], titanium plate left wrist [**2139**], Left acoustic neuroma s/p gamme knife [**2137**], anxiety, dression, panic attacks. Social History: retired post-office worker, [**2-1**] ppd smoker x 20 years, social ETOH Family History: NC Physical Exam: At discharge: She is pleasant, and cooperative Incision is clean, dry and intact with nylon sutures Paraspinal spasms are noted Strength and sensory intact bilaterally No [**Doctor Last Name **] or clonus Gait stable Pertinent Results: [**2139-9-23**] 02:41PM WBC-9.1# RBC-4.74 HGB-15.0 HCT-43.4 MCV-91 MCH-31.6 MCHC-34.6 RDW-15.1 [**2139-9-23**] 02:41PM PLT COUNT-250 CT head [**2139-9-23**] Postoperative changes with midline posterior fossa craniectomy for Chiari decompression. Expected post-surgical changes are seen. MRI brain [**2139-9-24**]- Post operative changes are noted. Know Left CPA angle lesion is seen, cerebellar tonsils now with less foramen magnum compression. Brief Hospital Course: Ms. [**Known lastname 1169**] was taken to the OR on [**2139-9-23**] with Dr. [**Last Name (STitle) **]. She underwent a suboccipital craniotomy and C1 laminectomy for chiari malformation. She was put in a collar for comfort and extubated. She was transfered to the SICU where she remained stable overnight. She was on cardene for SBP goal <140. She did not requie this on [**9-24**] and she was transfered to the floor. MRI brain was ordered which showed post operative changes without evidence of infarct or hemorrhage. PT evaluated patient and was cleared for discharge. She had transient facial nerve palsy but improved upon discharge. POD 2 the patient was experiencing intermittent nausea and was reluctant to eat. In addition to IV Zofran she was started on oral Zofran and IV compazine was added to her regimen. Slowly she advanced her diet. 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 inctact without evidence of infection. She is set for discharge home in stable condition and will follow-up accordingly. Medications on Admission: iron, cymbalta, abilify,nortryptiline, lorazepam Discharge Medications: 1. tizanidine 2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for prn pain. Disp:*60 Tablet(s)* Refills:*0* 2. aripiprazole 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. nortriptyline 10 mg Capsule Sig: Two (2) Capsule PO HS (at bedtime). 4. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*90 Tablet(s)* Refills:*0* 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Chiari Malformation Transient left Facial nerve palsy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: General Instructions -You have a cervical collar for comfort. You may wear it for 2 weeks. ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in [**8-9**] days(from your date of surgery) for removal of your staples/sutures and/or a wound check. This appointment can be made with the Nurse Practitioner. Please make this appointment by calling [**Telephone/Fax (1) 1669**]. If you live quite a distance from our office, please make arrangements for the same, with your PCP. ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **] to be seen in __6___weeks. Completed by:[**2139-9-26**] Name: [**Known lastname 1937**],[**Known firstname 1365**] Unit No: [**Numeric Identifier 17157**] Admission Date: [**2139-9-23**] Discharge Date: [**2139-9-26**] Date of Birth: [**2087-5-18**] Sex: F Service: NEUROSURGERY Allergies: Sulfa (Sulfonamide Antibiotics) / Erythromycin Base / Furadantin Attending:[**First Name3 (LF) 599**] Addendum: Overnight prior to discharge the patient experienced some chest discomfort. She believes this was due to anxiety and her cough. An EKG was performed and stable. Cardiac enzymes were sent x3. First 2 sets were negative and then patient refused the third set. She denies any further episodes of pain, N/V or diaphoresis. Discharge Disposition: Home [**Name6 (MD) **] [**Last Name (NamePattern4) 603**] MD [**MD Number(2) 604**] Completed by:[**2139-9-26**]

[ "351.0", "786.59", "787.02", "348.4" ]

icd9cm

[ [ [] ] ]

[ "03.09", "02.12" ]

icd9pcs

[ [ [] ] ]

6924, 7067

1887, 3043

339, 386

3830, 3830

1410, 1864

5609, 6901

1153, 1157

3143, 3703

3753, 3809

3069, 3120

3981, 5586

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1186, 1391

290, 301

414, 816

3845, 3957

838, 1046

1062, 1137

14,611

193,708

50155

Discharge summary

report

Admission Date: [**2134-9-29**] Discharge Date: [**2134-10-9**] Date of Birth: [**2085-10-21**] Sex: F Service: SURGERY Allergies: Bactrim Ds Attending:[**First Name3 (LF) 148**] Chief Complaint: Pancreatic Tail Mass Major Surgical or Invasive Procedure: Laparoscopic Distal Pancreatectomy Intraoperative Ultrasound History of Present Illness: This 48-year-old woman has a history of significant diabetes as well as many of comorbid conditions including Raynaud's, irritable bowel syndrome, peripheral [**First Name3 (LF) 1106**] disease and cardiac disease. She was under the care of Dr. [**Last Name (STitle) **] and our [**Last Name (STitle) 1106**] group many months ago when she had a toe amputation. she received a CAT scan of the abdomen for some reason, and this picked up an incidental lesion in the tail of the pancreas that was around a centimeter in size. It was hypervascular and suggestive of a pancreatic neuroendocrine tumor. Furthermore, a liver/spleen scan showed that this was not a splenule. Past Medical History: Raynauds, neuropathy, htn, DMI, CRI, CVA, UC Social History: occasional alcohol former tobacco (15 pack years) Family History: non contributary Physical Exam: VS: HR 92, BP 146/81 Gen: A+O x3, pleasant, Cushings HEENT: WNL, PERRLA CV: RRR, S1, S2, nonmurmurs Pulm: CTA bilat. Abd: Obese soft, nontender, nondistended, eccymosis from insulin injections. Pertinent Results: CHEST (PA & LAT) [**2134-10-6**] 10:49 AM CHEST (PA & LAT) Reason: r/o infiltrate [**Hospital 93**] MEDICAL CONDITION: 48 year old woman with aspiration event 7 days ago, now with fever. REASON FOR THIS EXAMINATION: r/o infiltrate INDICATION: 48-year-old female with aspiration event 7 days ago. Now presenting with fever. COMPARISONS: Comparison is made to [**2134-10-1**]. TECHNIQUE: PA and lateral views of the chest. FINDINGS: Heart size cannot be assessed in this examination due to low lung volumes. The pulmonary vascularity is normal without evidence of CHF. There is interval marked improvement in the right upper lobe and left lower lobe opacities seen in the prior study. IMPRESSION: 1. Interval improvement of right upper lobe and left lower lobe opacities likely due to prior aspirations. 2. Persistent low lung volumes and bibasilar atelectasis. . ART EXT (REST ONLY) [**2134-10-4**] 11:09 AM ART EXT (REST ONLY) Reason: Please perform ABI's/ PVR's/ dopplers and segmental pressure [**Hospital 93**] MEDICAL CONDITION: 48 year old woman s/p lap distal panc with Hx of DM, Raynauds, toe amp - now with pain and ischemic right 2nd toe REASON FOR THIS EXAMINATION: Please perform ABI's/ PVR's/ dopplers and segmental pressures including the mets and toes ARTERIAL DOPPLER LOWER EXTREMITY REASON: Painful toes. FINDINGS: Doppler evaluation was performed of both lower extremity arterial systems at rest. On the right, Doppler tracings are triphasic at the femoral and popliteal levels only. They are monophasic below. The ankle-brachial index is falsely elevated. Pulse volume recordings show drop off at the ankle level and are flat line at the metatarsals. On the left, Doppler tracings are triphasic at the femoral and popliteal levels only. They are monophasic below. Ankle-brachial index is 0.59. Pulse volume recordings show drop off at the ankle level and approximately 6 mm at the metatarsals. IMPRESSION: Significant bilateral tibial artery occlusive disease, right greater than left. CT TRACHEA W/O C W/3D REND [**2134-10-4**] 3:30 PM CT TRACHEA W/O C W/3D REND Reason: dynamic airway CT to eval for malacia [**Hospital 93**] MEDICAL CONDITION: 48F s/p aspiration PNA< with ? tracheomalacia on bronchoscopy REASON FOR THIS EXAMINATION: dynamic airway CT to eval for malacia CONTRAINDICATIONS for IV CONTRAST: None. CT TRACHEA, DATED [**2134-10-4**] INDICATION: Aspiration pneumonia. Possible tracheomalacia. CT of the trachea was performed according to the CT trachea protocol. This included a standard-dose end inspiratory CT scan followed by a low-dose dynamic expiratory CT of the central airways. Additionally, a limited low-dose acquisition was performed during coughing. The patient had difficulty cooperating with the various components of the examination including end inspiration, dynamic expiration and coughing, somewhat limiting the evaluation. Images obtained with instructions for end inspiration demonstrate slight extrinsic compression of the proximal trachea from the right brachiocephalic artery near the thoracic inlet level. The remaining intrathoracic trachea and main bronchi are of normal caliber without intrinsic or extrinsic compression or stenosis. During dynamic expiratory imaging, there is excessive collapsibility of the trachea and main bronchi which meet criteria for tracheomalacia. For example, in the proximal trachea at the level of the compression deformity, the cross-sectional area decreases from 143 mm2 to 72 mm2. At the level of the aortic arch, cross-sectional area decreases from 180 mm2 to approximately 90 mm2. At the proximal right main stem bronchus, cross-sectional area decreases from 121 mm2 to 55 mm2 and at the proximal left main bronchus, the cross-sectional area decreases from 114 mm2 to 42 mm2. Please note that these measurements may underestimate the degree of malacia due to apparent submaximal inspiratory level. Within the lungs, there are multifocal patchy areas of consolidation and ground glass attenuation, which are overall improved compared to the recent chest CTA of [**2134-9-30**]. The entirety of the lung bases was not included on this study which was tailored to the airways, limiting complete assessment of the lung parenchyma. During dynamic expiratory phase of respiration, there is a moderate degree of air trapping with a lobular pattern. Mediastinal widening due to excessive mediastinal fat is incidentally noted. There are multiple small calcified lymph nodes as well as numerous subcentimeter mediastinal nodes. These nodes are prominent in number but without change since the recent chest CTA. They are likely hyperplastic in the setting of diffuse pulmonary abnormalities. Calcified hilar nodes are also present. Small pleural effusions are present in a dependent location. No suspicious lytic or blastic skeletal lesions are identified within the imaged portions of the skeletal structures. IMPRESSION: 1. Tracheobronchomalacia, diffuse in distribution and mild in degree. However, due to submaximal inspiratory level, the severity of tracheobronchomalacia may be underestimated on this study. 2. Improving multifocal consolidation and ground glass opacities, as compared to recent CTA [**2134-9-30**]. Considering rapid development between [**9-29**] and [**9-30**], this may represent a massive aspiration event complicated by aspiration pneumonia. Asymmetrical pulmonary edema is also within the differential diagnosis. Cardiology Report ECHO Study Date of [**2134-10-1**] PATIENT/TEST INFORMATION: Indication: Left ventricular function. Weight (lb): 202 BP (mm Hg): 124/52 HR (bpm): 119 Status: Inpatient Date/Time: [**2134-10-1**] at 09:58 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2006W000-0:00 Test Location: West SICU/CTIC/VICU Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] MEASUREMENTS: Left Ventricle - Ejection Fraction: >= 80% (nl >=55%) Aorta - Valve Level: 3.0 cm (nl <= 3.6 cm) INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Normal LV cavity size. Normal regional LV systolic function. Hyperdynamic LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic root diameter. AORTIC VALVE: Aortic valve not well seen. MITRAL VALVE: Normal mitral valve leaflets. No MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Conclusions: 1. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). CHEST (PORTABLE AP) [**2134-10-1**] 3:18 AM CHEST (PORTABLE AP) Reason: ARDS vs infiltrate [**Hospital 93**] MEDICAL CONDITION: 48 year old woman with desat with ? ARDS REASON FOR THIS EXAMINATION: ARDS vs infiltrate CHEST PORTABLE INDICATION: 48-year-old woman with desaturation, evaluate for RDS versus infiltrate. CHEST PORTABLE: Comparison is made to a prior study of [**2134-9-30**]. The heart size is difficult to evaluate due to consolidation in both lungs. In the right lung, there is increasing consolidation in the middle lobe. The ET tube is in satisfactory position. A central venous line is seen with its tip in the mid SVC. IMPRESSION: Increasing consolidation in the right lung as described above. Differential diagnosis includes aspiration and multifocal pneumonia. Asymmetric pulmonary edema is included in the differential diagnosis. BILAT LOWER EXT VEINS [**2134-9-30**] 1:28 PM BILAT LOWER EXT VEINS Reason: assess venous flow [**Hospital 93**] MEDICAL CONDITION: 48 year old woman s/p lap distal panc with Hx of DM, Raynauds, toe amp - now with pain and ischemic toe REASON FOR THIS EXAMINATION: assess venous flow HISTORY: 48-year-old female with recent surgery and increasing lower extremity pain and ischemic toe. Assess venous flow. No prior comparison exams are available. BILATERAL LOWER EXTREMITY ULTRASOUNDS: Grayscale and Doppler son[**Name (NI) 1417**] of the left and right common femoral, superficial femoral, and popliteal veins were performed. Normal flow, augmentation, compressibility, and waveforms are demonstrated. No intraluminal thrombus is identified. IMPRESSION: No evidence of DVT bilaterally. CTA CHEST W&W/O C &RECONS [**2134-9-30**] 11:56 AM CTA CHEST W&W/O C &RECONS Reason: eval for pe [**Hospital 93**] MEDICAL CONDITION: 48F pod #1, with desats REASON FOR THIS EXAMINATION: eval for pe CONTRAINDICATIONS for IV CONTRAST: None. CTA OF THE CHEST CLINICAL HISTORY: 48-year-old woman postop day #1 post-resection of pancreatic tail lesion, with desaturation. Evaluate for pulmonary embolism. TECHNIQUE: Multiple transaxial images of the chest were obtained after the administration of intravenous contrast, utilizing the pulmonary embolism protocol. Coronally and sagittally reformatted images were also obtained. Comparison made to prior studies, the most recent dated [**2134-3-13**]. FINDINGS: There is an endotracheal tube and nasogastric tube in place. No intraluminal filling defects in the main pulmonary artery or its proximal branches. The heart is normal in size, without pericardial effusions. Several, prominent and enlarged mediastinal and hilar lymph nodes, some of which are partially calcified, measuring up to 10 mm in the short axis diameter (sequence 4, image #30), adjacent to the left pulmonary artery. These findings are stable compared to prior studies and most likely represent the presence of prior granulomatous disease. There is extensive, bilateral, dependent airspace disease involving nearly the entirety of both lower lobes and a portion of the right upper lobe. While this could represent extensive atelectasis, in this patient with recent surgical history, aspiration and associated pneumonia is more likely etiology. No pleural effusions. Multiplanar reformatted images were useful in the delineation of the above findings. Findings were discussed with surgical house officer, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. IMPRESSION: 1. No evidence of pulmonary embolism, as clinically questioned. 2. Severe, bilateral airspace disease for which aspiration and associated pneumonia is likely etiology. 3. Stable mediatsinal and hilar lympadenopathy. US INTR-OP 60 MINS [**2134-9-29**] 7:36 AM US INTR-OP 60 MINS Reason: PANC MASS ,LAPAROSCOPIC DISTAL PANCREATECTOMY [**Hospital 93**] MEDICAL CONDITION: 48 year old woman with pancreatic abnormality REASON FOR THIS EXAMINATION: Laparoscopic distal pancreatectomy [**2134-9-29**] 9:30am CLINICAL INDICATION: A small hypervascular tumor of the distal pancreas seen on CT scan, for localization and laparoscopic distal pancreatectomy. Laparoscopic ultrasound images of the pancreas were performed via a right upper quadrant port, using a curved array transducer at 7.5 MHz frequency. A 7 x 8 mm hypoechoic nodule was seen in the distal body of the pancreas, corresponding to the lesion identified on CT scan. This nodule is hypoechoic, solid and homogeneous with increased internal vascularity, consistent with a small islet cell tumor. The site of the tumor was localized visually and a surgical clip was placed for a reference, during mobilization for distal pancreatectomy. The surrounding vasculature and particularly the relationship of the atrophic pancreatic body to the splenic vein was continually demonstrated during surgical mobilization. After resection across the body of the pancreas by the E/A stapler device, and completion of mobilization and freeing up of the distal pancreas, the specimen was rescanned in [**Last Name (un) 5153**] and the nodule was identified within the surgical specimen with generous pancreatic margins on both sides. CONCLUSION: Eight-mm tumor of the distal body of the pancreas with successful localization and laparoscopic resection by Dr. [**Last Name (STitle) **], as described. [**2134-10-7**] 7:58 am SWAB Source: JP site. **FINAL REPORT [**2134-10-11**]** GRAM STAIN (Final [**2134-10-7**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. WOUND CULTURE (Final [**2134-10-9**]): STAPH AUREUS COAG +. MODERATE GROWTH. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN----------- =>8 R ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ <=1 S [**2134-10-6**] 1:27 am URINE Y. **FINAL REPORT [**2134-10-9**]** URINE CULTURE (Final [**2134-10-9**]): ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. Trimethoprim/Sulfa sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. KLEBSIELLA PNEUMONIAE. 10,000-100,000 ORGANISMS/ML.. Trimethoprim/Sulfa sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | KLEBSIELLA PNEUMONIAE | | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I 4 S CEFAZOLIN------------- <=4 S <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CEFUROXIME------------ 4 S 4 S CIPROFLOXACIN---------<=0.25 S <=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 NITROFURANTOIN-------- <=16 S 32 S PIPERACILLIN---------- 32 I PIPERACILLIN/TAZO----- <=4 S 8 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S Brief Hospital Course: She was admitted to [**Hospital1 18**] on [**2134-9-29**] for a Laparoscopic distal pancreatectomy. She was stable post-operatively, with good urine output. She was NPO with IV fluids. Her pain management was an epidural and PCA and she was comfortable. She was stable on the floor. On POD 1, she had episode of desaturation, was hypoxic and tachycardic on the floor with O2 sats in the 80s. Anesthesia was immediately called and she was intubated and transferred to the SICU. An EKG did not show any changes. A CTA showed no PE, atelectatic collapse of Right lung. A CXR showed large areas of multilobar air space opacity c/w consolidation in RUL, RLL, and LLL as well as discoid atelectasis in the left mid zone (question aspiration). A CXR on [**10-1**] showed increasing R lung consolidation. A bronch on [**9-30**] was unremarkable. It was suspected that she had a silent aspiration event. She was still needing respiratory support as her sats were low and she was needing high O2 requirements. She was extubated on [**2134-10-2**] and was stable. She responded well to Lasix that helped with lung atelectasis. She was transfered back to the floor and progressed well. Her diet was slowly advanced over the next few days. She reported + flatus on POD 6. Her abdomen was soft, nontender and non-distended. Her small lap incision was C,D,I. A urine analysis and culture were done for fever on [**2134-10-6**] and showed UTI. She was started on Cipro. On [**2134-10-7**], cellulitis was noted around [**Doctor Last Name 406**] drain site and the Cipro was stopped and she was started on Vanc/Levo/Flagyl IV. A wound swab from the JP site revealed STAPH AUREUS COAG +. She was discharged home on Linezolid. Echo [**10-1**]: The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). [**Month/Year (2) **]: Patient well know to Dr. [**Last Name (STitle) **] with ischemic right 2nd toe and 1st left toe. Podiatry was also consulted. Studies: Angio([**2134-3-12**]): R.LE patent CFA/PFA/SFA/Popliteal/AT/PT/peroneal. The AT and PT both of mild disease just above the ankle but run in continuity onto the foot and form an attenuated plantar arch. Pulses: B-fem palp; R-PT & L-DP/PT dopp. She will follow-up with Dr [**Last Name (STitle) **] and Interventional Pulmonary as an outpatient. Medications on Admission: pred 10qAM, 2.5qPM, ASA, lipitor 20', humalog SS, lantus 28-32 qhs, HCTZ 25', folate, lisinopril 10', MVI, FeSO4, fosamax Discharge Medications: 1. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. Disp:*20 Tablet(s)* Refills:*0* 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): take while using narcotics. Disp:*60 Capsule(s)* Refills:*2* 4. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 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). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Metoclopramide 10 mg Tablet Sig: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Disp:*120 Tablet(s)* Refills:*2* 7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. Disp:*1 inhaler* Refills:*5* 8. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed for dry cough. Disp:*250 ML(s)* Refills:*2* 9. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*20 Tablet(s)* Refills:*2* 10. Other medications Resume all of your preadmission medications at prior doses: prednisone 10qAM/2.5qPM, aspirin, lipitor, 20qd, lantus 32untis QHS, humalog SS, HCTZ 25', folate, MVI, iron, fosamax 11. Outpatient Lab Work Weekly CBC while on linezolid. Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Pancreatic Tail Mass Aspiration Raynaud with ischemic Right 2nd toe and Left 1st toe Discharge Condition: Good Discharge Instructions: * Increasing pain * Fever (>101.5 F) * Inability to eat or persistent vomiting * Inability to pass gas or stool * Increasing shortness of breath * Chest pain Please resume all of your regular medications and take any new medications as ordered. Continue to walk several times per day. You may wash and shower your incision. Pat dry. Keep clean and dry. Your steri strips will fall off in [**7-12**] days. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] in [**2-5**] weeks. Call ([**Telephone/Fax (1) 15807**] to schedule an appointment. Provider: [**Name10 (NameIs) 395**],[**Name11 (NameIs) 25**] ([**First Name9 (NamePattern2) **] [**Location (un) **]) [**Location (un) **] INTERNAL MEDICINE Date/Time:[**2134-10-19**] 12:00 Provider: [**Name10 (NameIs) 1111**],[**First Name7 (NamePattern1) 1112**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY (NHB) Date/Time:[**2134-11-4**] 2:15 Please follow-up with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] (Interventional Pulmonology) in 4 weeks. Call ([**Telephone/Fax (1) 17398**] to schedule an appointment. Please follow-up with Dr. [**Last Name (STitle) 174**] (Pancreatologist) in [**10-14**] weeks. Call ([**Telephone/Fax (1) 10499**] to schedule an appointment. Completed by:[**2134-10-12**]

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29920

Discharge summary

report

Admission Date: [**2177-3-2**] Discharge Date: [**2177-3-19**] Date of Birth: [**2108-9-30**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 30**] Chief Complaint: s/p unwitnessed fall; transferred from [**Hospital1 1474**] for eval of intracranial hemorrhage and non-ST elevation MI Major Surgical or Invasive Procedure: - placement and removal of right internal jugular central venous catheter - placement and removal of right femoral central venous catheter - placement of left femoral central venous catheter [**2177-3-4**] IVC filter placement [**2177-3-6**] Bronchoscopy, transbronchial biopsy, bronchoalveolar lavage and brushing [**2177-3-13**] Stereotactic CT guided brain biopsy [**2177-3-14**] Ultrasound-guided liver biopsy History of Present Illness: 68F with HTN, COPD, EtOH abuse, and question of lung CA presented to [**Hospital 1474**] Hospital on [**2177-3-1**], one day after having fallen in the setting of EtOH use. . The fall occurred on [**2177-2-28**]. Pt cannot give much history surrounding the fall but mentions that she was walking towards a chair when she fell. Pt denies chest pressure or chest pain, shortness of breath, or palpitations. Denies hitting her head. The morning after the fall ([**2177-3-1**]) pt's daughter called pt, noted that pt seemed confused, with slurred speech, and brought pt to the ED at [**Hospital 1474**] Hospital. In the ED at [**Name (NI) 1474**] Hospital, pt complained of headache, mild right shoulder pain, and blurry vision. Her exam was significant for a left frontal echymosis and some swelling around her left orbit. Pt was alert and oriented x 3, with no focal neurologic deficits. Laboratory studies were notable for WBC 12.3, Plt 644, Na 129, troponin 5.1, CK 3319. A head CT revealed right parietal intraparenchymal hemorrhage. . Pt was transferred to [**Hospital1 18**] for further workup. In the [**Name (NI) **], pt was febrile to 103 with BP 89/57. Pt was noted to be disoriented and inattentive. Finger-to-nose was unstable, L>R. Pt received Tylenol 1300mg, vancomycin 1g IVx1, levofloxacin 500mg IVx1, flagyl 500mg IVx1, norepinephrine, and dexamethasone. Due to hypotension to 79/palp, code sepsis called and pt was started on levophed. A subclavian line was placed but needed to be pulled [**3-14**] location of tip of catheter. A R fem line was placed and subsequently was pulled out by pt; a L fem line was placed for access. . Does not have any pain now, does not feel thirsty. Pt denies recent fevers at home, denies dysuria, cough, abdominal pain, or changes in bowel movements. Past Medical History: ETOH abuse HTN R lung mass, possibly malignant, with "spot" in liver - pt due for Bx and staging COPD anxiety Social History: Lives alone, has someone help with vacuuming and washing the floors. Used to smoke about 1/2ppd x most of her life - > 45 years, quit 3-4 years ago. States that she drinks 3-4 beers/day but family members have suggested more. Pt denies having had shakes [**3-14**] withdrawal or having h/o seizures. Family History: noncontributory Physical Exam: VS: 97.9 101/67 98 21 99% 4L NC Gen: disheveled appearing, slurring speech, NAD; C collar in place HEENT: dentition poor, MM dry Neck: could not assess JVP 2/2 C collar in place CV: mildly tachycardic, regular, nl S1/S2, no m/r/g Pulm: CTAB anteriorly Abd: soft, NT/ND, +BS, no masses Ext: no c/c/e Neuro: CN II-XII intact; strength 4+/5 bilaterally, sensation intact to light touch, hyperreflexic in patellar and biceps reflexes; toes neither up nor downgoing bilaterally; has difficulty following commands; oriented to person, hospital in [**Location (un) 86**], not to year (says [**2077**]) Pertinent Results: CT head: hemorrhagic foci in L cerebellum and R frontal lobes with surrounding vasogenic edema, concerning for metastatic foci . CT C spine: no acute fracture . Micro: BlCx x 2 negative . EKG: 115bpm, NSR, nl axis, no ST/T wave changes . Bronchial Washings, [**2177-3-6**]: NEGATIVE FOR MALIGNANT CELLS. Pulmonary macrophages and rare bronchial cells. . CXR, [**2177-3-6**]: No evidence of pneumothorax status post transbronchial biopsy. 2. Hazy increased opacity throughout the right upper lobe could be suggestive of a postobstructive process, likely secondary to right hilar adenopathy, better appreciated on recent CT. 3. Rounded nodular opacity in the medial right upper lobe correlates with mass seen on recent CT. . Echo [**2177-3-6**]: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50%) secondary to hypokinesis of the basal half of the inferior and posterior (inferolateral) walls. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valveleaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Suboptimal image quality -patient unable to cooperate. Impression: inferior posterior hypokinesis . CT Chest/Abdomen/Pelvis, [**2177-3-7**]: 1. Right upper lung nodule concerning for lung carcinoma until proven otherwise. 2. Partially occlusive intraluminal filling defects inferiorly from the right upper lobe nodule as well as separate left lower lobe fourth order branch filling defect is better visualized on CTA of [**2177-3-3**], but likely still present. 3. 5.4 x 4.0 x 5.0 cm heterogeneously enhancing liver mass as described. The appearance is more suggestive of a metastatic lesion than primary hepatocellular carcinoma or benign lesion. 4. Multiple hypoattenuating lesions in both kidneys too small to characterize. 5. Stable bilateral small pleural effusions with compressive atelectasis. 6. Atrophic spleen with multiple punctate calcifications indicating prior granulomatous disease. 7. Diverticulosis without evidence of diverticulitis. 8. IVC filter. . [**2177-3-12**] Stereotactic brain biopsy, +6 mm (smear #15 only): Reactive brain, numerous cells with small, pyknotic nucleus and red cytoplasm, and single, microscopic, poorly-preserved fragment of atypical cells, suggestive of metastatic carcinoma. NOTE: The only tissue suggestive of metastatic carcinoma is a single tiny cluster of poorly preserved cells in the final smear. That tissue contains nuclei tightly clustered together and partially molded around each other. The remaining tissue is either air dried, necrotic and partially mineralized, or contains blood with frequent nucleated red blood cells. The latter cells are the predominant preserved cell in the deeper biopsies. Nucleated red blood cells are abnormal and make the diagnosis of carcinoma suspect, especially given to poor preservation of the small cluster of suggestive cells. Given that this patient has a small, calcified spleen, other diagnoses aside from carcinoma should be considered (e.g. granulomatous disease, extramedullary hematopoiesis, bone marrow emboli, chronic infections). The current material alone should NOT be the basis of treatment for metastatic carcinoma. Confirmation of carcinoma elsewhere should be sought (e.g. reviewing outside pathology, additional biopsies of suspect sites). A bone marrow biopsy to determine the cause of the nucleated red cells may be warranted. . [**2177-3-13**] Liver biopsy: POSITIVE FOR MALIGNANT CELLS, consistent with metastatic small cell carcinoma. . [**2177-3-1**] 09:25PM WBC-13.2* RBC-4.01* HGB-12.9 HCT-36.6 MCV-91 MCH-32.2* MCHC-35.3* RDW-13.2 [**2177-3-1**] 09:25PM NEUTS-87.5* BANDS-0 LYMPHS-8.3* MONOS-3.5 EOS-0.6 BASOS-0.1 [**2177-3-1**] 09:25PM CK-MB-28* MB INDX-1.1 [**2177-3-1**] 09:25PM cTropnT-0.45* [**2177-3-1**] 09:25PM LIPASE-28 [**2177-3-1**] 09:25PM ALT(SGPT)-43* AST(SGOT)-111* CK(CPK)-2519* ALK PHOS-59 AMYLASE-33 TOT BILI-0.4 [**2177-3-1**] 09:25PM ALT(SGPT)-43* AST(SGOT)-111* CK(CPK)-2519* ALK PHOS-59 AMYLASE-33 TOT BILI-0.4 [**2177-3-1**] 09:25PM GLUCOSE-145* UREA N-16 CREAT-0.6 SODIUM-129* POTASSIUM-4.0 CHLORIDE-93* TOTAL CO2-20* ANION GAP-20 [**2177-3-1**] 09:46PM LACTATE-1.8 [**2177-3-2**] 03:40AM cTropnT-0.24* [**2177-3-2**] 03:40AM CK(CPK)-[**2093**]* [**2177-3-2**] 03:40AM CK-MB-21* MB INDX-1.1 [**2177-3-2**] 07:57AM CK-MB-18* MB INDX-1.2 cTropnT-0.18* [**2177-3-2**] 07:57AM CK(CPK)-1517* Brief Hospital Course: Ms. [**Known lastname 71492**] is a 68 year old female with a history of alcohol dependence who was admitted to an OSH after a fall in the setting of alcohol intoxication. She was found to have an intracranial hemorrhage and was transferred to [**Hospital1 18**] MICU for further management. During this admission, she was found to have a lung nodule, liver nodule and several brain nodules. She was also found to have multiple pulmonary emboli. . # Intracranial hemorrhage/lesions: The patient experienced a fall in the setting of alcohol intoxication. She was found to have an intracranial hemorrhage and multiple lesions on head imaging. Despite also having a non-ST segment elevation MI, aspirin was held to avoid further intracranial hemorrhage. She was started on dilantin for seizure prophylaxis and it was titrated according to serum levels with adjustment for a low albumin. The patient was also started on dexamethasone for reduction of brain edema per Neurology and Neurosurgery recommendations. The patient was also seen by by Neuro-oncology and Radiation Oncology. Sterotactic brain biopsy was performed which demonstrated metastatic poorly differentiated carcinoma, histologically similar to the tumor in the patient's subsequent liver biopsy. The patient's case was discussed at a Tumor Conference and it was agreed that she should receive outpatient whole brain XRT. Radiation oncology follow up is scheduled with Dr. [**Last Name (STitle) 46811**] at [**Hospital 1474**] Hospital ([**Telephone/Fax (1) 60186**]). Oncology follow-up is scheduled with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 71493**] in [**Hospital1 1474**] ([**Telephone/Fax (1) 71494**]). The patient will follow up with Dr. [**Last Name (STitle) 4253**] should follow up with Neuro-Oncology at [**Hospital1 18**] ([**Telephone/Fax (1) 1844**]) one month after completion of whole brain irradiation. Dexamethasone should be tapered by 25% per week after completion of whole brain radiation. . # Metastatic small cell lung cancer: A lung nodule was identified on chest CT. A bronchoscopy was performed by Interventional Pulmonary in an attempt to gain tissue. However, the lesion was not proximal enough for biopsy. Bronchial washings performed were negative for malignant cells. A CT chest/abdomen/pelvis revealed a large superficial lesion in the liver which was amenable to biopsy by ultrasound and demonstrated metastatic small cell carcinoma. . # Pulmonary embolus: The patient was noted to be tachycardic to the 130's on the day after admission. Differential included alcohol withdrawal versus PE. CTA performed showied intraluminal filling defect arising inferiorly from the right upper lobe lung nodule with extension into a second-order right upper lobe pulmonary artery branch. Additionally, fourth-order partially occlusive filling defects in the left lower lobe consistent with PE were found. No anticoagulation was initiated given the patient's ICH. An IVC filter was placed. The patient's HR and O2 saturation were monitored closely during this hospitalization. She was found to be 95% on RA at rest, but did desaturate to 86% while ambulating with physical therapy. . # Elevated troponin: The patient denies any chest pain during this episode or prior to this episode. Her troponins were found to trend downward (0.45 -> 0.24 -> 0.18 in the setting of negative CK-MBs; CK was elevated most likely secondary to patient's fall and being immobilized for a period of time). It was unclear if the troponins were secondary to PE or NSTEMI. Echocardiogram showed evidence of posterior inferior wall motion abnormalities, raising concern for possible NSTEMI. Medical management with a beta-blocker and statin was initiated. Heparin, aspirin and plavix were contraindicated in the setting of the intracranial hemorrhage. . # Possible sepsis: The patient became hypotensive shortly after admission requiring levophed for a brief period. Given fever and elevated WBC, aspiration PNA resulting in possible sepsis was a concern. It was unclear if her oxygen requirement was at baseline given a history of COPD. Levophed was quickly weaned and the patient remained hemodynamically stable for the remainder of her hospitalization. Broad coverage antibiotic therapy for pneumonia/sepsis was initiated and completed during her stay. . # COPD: The patient had good air movement on admission without rales or wheezes. She was continued on Albuterol and Atrovent nebulizers as needed. . # EtOH dependence: The patient was placed on the CIWA scale with ativan as needed upon admission to the MICU. She was given a multivitamin, folate, and thiamine. She was seen by social work and expressed a desire to stop drinking. . # HTN: Metoprolol was briefly held when the patient was hemodynamically unstable. It was restarted and should be continued. Nifedipine and enalapril were also discontinued, but may be restarted as indicated. Medications on Admission: Enalapril Nifedipine Toprol Albuterol [**Name (NI) **] [**Name (NI) **] (pt does not know doses) Discharge Disposition: Extended Care Facility: [**Hospital 2971**] Rehabilitation and Nursing Center - [**Hospital1 1474**] Discharge Diagnosis: Primary: 1. Stage IV Small Cell Lung Cancer - Metastasis to Brain/Liver 2. Traumatic Right Parietal Intraparenchymal Hemmorhage 3. Aspiration Pneumonia - Sepsis 4. Pulmonary Embolism s/p IVC Filter Placement 5. Non-ST Elevation Inferior Myocardial Infarction 6. Steroid Induced Adrenal Suppression 7. Steroid Induced Diabetes Mellitus 8. ETOH Abuse - Withdrawal . Secondary: 1. Chronic Obstructive Pulmonary Disease 2. Hypertension 3. Alcohol dependence Discharge Condition: Stable. Afebrile. Ambulates with assistance. Tolerating PO. Discharge Instructions: You were admitted to the hospital because you experienced a fall. You were found to have small cell lung cancer that has spread to your liver and brain. There is was evidence of bleeding around the masses in your brain. You were also found to have blood clots in your lungs. Please return to the emergency room or call your doctor if you experience any of the following symptoms: fever > 101.5, severe shortness of breath, headache not controlled with medication, intractable nausea or vomiting, severe pain or any other concerning symptoms. . You should not take any medications that contain aspirin or ibuprofen. Please take all medications as prescribed. . Please follow up with all appointments as scheduled. Followup Instructions: 1. Dr. [**Last Name (STitle) 46811**], Radiation Oncology, [**Hospital 1474**] Hospital. Monday, [**2177-3-24**] at 2PM. [**Telephone/Fax (1) 60186**]. . 2. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 21628**], Oncology, [**Hospital1 71495**] in [**Hospital1 1474**]. Friday, [**2177-3-29**] at 2:30PM. [**Telephone/Fax (1) 71494**]. . 3. Dr. [**First Name (STitle) **] [**Name (STitle) 4253**], Neuro-Oncology, [**Hospital 18**] Hospital. [**Telephone/Fax (1) 1844**]. Dr.[**Name (NI) 71496**] office should arrange for this appointment 1 month after you complete whole brain radiation. . 4. MRI with and without contrast prior to your appointment with Dr. [**Last Name (STitle) 48151**]. This study has been ordered at [**Hospital1 18**]. You should call [**Telephone/Fax (1) 327**] to make an appointment for the study to be done. . 5. Please check albumin and dilantin level check every Monday and Thursday. Prescription for labwork is included in paperwork. . 6. Please check fingerstick blood glucose QID while on dexamethasone. [**Month (only) 116**] cover with sliding scale as needed. . 7. Cranial [**Month (only) **] removal on [**2177-3-21**]. This may be done by [**Name8 (MD) **] RN or MD. [**First Name (Titles) **] [**Last Name (Titles) **] removal, keep wound dry. No dressing should be placed. . 8. Please continue dexamethosone as prescribed. It should be decreased by 25% per week AFTER completion of whole brain irradiation therapy. . 9. Please follow up with your PCP within one month after discharge. You can make an appointment by calling [**Telephone/Fax (1) 28811**].

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icd9cm

[ [ [] ] ]

[ "01.13", "38.93", "33.27", "50.11", "38.7", "33.24" ]

icd9pcs

[ [ [] ] ]

13733, 13836

8638, 13586

389, 805

14334, 14396

3762, 3762

15157, 16775

3114, 3131

13857, 14313

13612, 13710

14420, 15134

3146, 3743

230, 351

833, 2647

3771, 8615

2669, 2781

2797, 3098

20,643

177,851

4427

Discharge summary

report

Admission Date: [**2107-4-13**] Discharge Date: [**2107-4-17**] Date of Birth: [**2039-3-10**] Sex: M Service: MEDICINE Allergies: Levofloxacin Attending:[**First Name3 (LF) 2745**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: none History of Present Illness: 68 yo M with severe COPD p/w shortness of breath and subjective fevers and chills for the past five days. He states that he has not felt well and has been taking his inhalers as directed. Patient called EMS and received nebs. Patient denies any chest pain or dizziness associated with his shortness of breath. Patient has had multiple hospitalizations requiring intubation in the past for COPD. . On arrival to the ED, patient appeared better. Patient had an episode where he desaturated to the low 80s and received Mg, solumedrol, nebs. His VS were 119/43 HR 84 93% on NC 5L RR 25. Patient improved with these measures. He also had tranient altered mental status, that resolved while in the ER. Patient's CXR was c/w a RLL infiltrate and received ceftriaxone and azithro. . On arrival to [**Hospital Unit Name 153**], patient denies any nausea, vomiting. Admits to diarrhea over past several days and persistent lumbar pain. All other ROS is otherwise negative. Past Medical History: CAD s/p NSTEMI in [**2101**] - [**4-10**] cath showed 10% LMCA stenosis, TTE [**8-10**] showed mild RV enlargement and preserved BiV function COPD on baseline 4L NC, nightly BiPAP 12/5 Iron-deficiency anemia b/l Hct ~30% GERD Diverticulosis VRE and Pseudomonas UTI HTN Hyperlipidemia Chronic low back pain s/p L1-L2 laminectomy Bilateral cataract surgery BPH s/p TURP Social History: The patient currently lives in [**Location 686**] with his wife. [**Name (NI) **] is initially from [**Country 7936**], now retired but previously employed as a mechanic for [**Company 19015**]. Tobacco: Patient quit 30 years ago, previous 20 pk-year history. ETOH: Rare social use Illicits: + Marijuana use up to 1 to 2 marijuana cigarettes daily, quit Family History: Mother w/ asthma, Alzheimer's disease. Father w/ [**Name2 (NI) 499**] cancer. Physical Exam: PHYSICAL EXAM GENERAL: Pleasant, well appearing male in NAD HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. JVP not appreciated. LUNGS: Mild basilar crackles, poor air movement biaterally. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior tibial pulses. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. [**1-7**]+ reflexes, equal BL. Normal coordination. Gait assessment deferred PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: [**2107-4-13**] 06:29PM WBC-16.5*# RBC-4.12* HGB-11.0* HCT-34.9* MCV-85 MCH-26.6* MCHC-31.4 RDW-15.2 [**2107-4-13**] 06:29PM NEUTS-76.9* LYMPHS-11.5* MONOS-6.9 EOS-4.3* BASOS-0.5 [**2107-4-13**] 06:29PM PLT COUNT-335 [**2107-4-13**] 06:29PM CK-MB-4 [**2107-4-13**] 06:29PM cTropnT-0.02* [**2107-4-13**] 06:29PM GLUCOSE-86 UREA N-14 CREAT-0.6 SODIUM-134 POTASSIUM-4.6 CHLORIDE-89* TOTAL CO2-37* ANION GAP-13 [**2107-4-13**] 06:43PM LACTATE-2.0 [**2107-4-13**] 11:17PM TYPE-ART RATES-/18 O2 FLOW-4 PO2-65* PCO2-77* PH-7.32* TOTAL CO2-42* BASE XS-9 INTUBATED-NOT INTUBA COMMENTS-NASAL [**Last Name (un) 154**] [**2107-4-13**] CXR The focus in the retrocardiac right lower lobe has increased in size. While this may be indicative of either a slowly-developing pneumonia or possibly aspiration, possibility of an underlying bronchoalveolar cell carcinoma cannot be dismissed. It is likely prudent to obtain a followup CT scan to compare with the one obtained on [**2-16**], [**2107**] soon as an outpatient. [**2107-4-14**] pCXR: COMPARISON: [**2107-4-13**]. FRONTAL CHEST RADIOGRAPH: The cardiomediastinal silhouette is within normal limits. The pulmonary vasculature is normal. In the right and left lower lobes there is mild tram tracking and bronchial wall thickening consistent with bronchiectasis. Patchy bibasilar opacities likely representing aspiration. No pleural effusion or pneumothorax. IMPRESSION: 1. Bibasilar bronchiectasis. 2. Patchy bibasilar opacities likely representing aspiration/aspiration pneumonia. Brief Hospital Course: 68 y/o M with a history of COPD who presents with COPD exacerbation and pneumonia. He was initially in the [**Hospital Unit Name 153**] on arrival, transferred to the hospitalist service on HD#2. . #. COPD: Patient is currently at basline, on 4L NC. Patient's last ABG was 7.32/77/65/42 and is consistent with his propensity to be a CO2 retainer. Patient's mental status was altered while he was in the ER, and may be related to either hypercapnea or hypoxia, but was resolved on presentation to the ICU. He is currently on his home oxygen requirement. He continued albuterol and ipratropium nebs, and changed from IV solumedrol to po prednisone on transfer to the floor. Given his frequent steroid requirement, he was continued on PCP prophylaxis with Bactrim DS MWF. On the medicine floor, the patient clinically improved and was discharged on a long steroid taper, completion of his levofloxacin and his home oxygen at 4-6 liters and outpatient pulmonary medication regimen. The patient was observed to be walking comfortably around the floor for 3 days prior to discharge. . #. Hospital Acquired Pneumonia, RLL: Patient had 5 days of subjective fevers and chills, has leukocytosis, and has hospitalization within past three months. Initiated coverage with Vancomycin, Cefepime, Levofloxacin. He was transferred to the floor on just Levaquin, but leukocytosis on HD#3 went from 7K to 26K so cefepime was resumed but subsequently discontinued. The patient was discharged to complete a 7 day course of levofloxacin. . #. CAD: Stable. Continued ASA, Statin, ACE-I . #. Glaucoma: Asymptomatic currently Continued eye drops . #. Hyperphosphatemia: On the day of discharge, the patient's phosphorus returned at 1.3. The patient had already left the hospital. He will need oral repletion with neutra-phos. Medications on Admission: Alendronate 70 mg Tablet qsunday. Calcium Carbonate 500 mg [**Hospital1 **] Cholecalciferol 800 unit qday. Fluticasone-Salmeterol 250-50 mcg/Dose [**Hospital1 **] Lorazepam 0.5 mg qHS prn. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Oxycodone-Acetaminophen 5-325 mg 1-2 Tablets PO Q4H prn Pravastatin 40 mg DAILY Sertraline 50 mg Daily Tiotropium Bromide 18 mcg Capsule Daily Aspirin 81 mg qday. Trimethoprim-Sulfamethoxazole 160-800 mg qMWF Prednisone 30 mg qDaily Prednisolone Acetate 1 % Drops [**Hospital1 **] Lisinopril 5 mg qday. Albuterol Sulfate 2.5 mg /3 mL 2puffs Q4H Finasteride 5 mg qDaily Montelukast 10 mg qdaily Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO every twelve (12) hours. 5. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Prednisolone Acetate 1 % Drops, Suspension Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 9. Erythromycin 5 mg/g Ointment Sig: One (1) Ophthalmic QID (4 times a day). 10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation every four (4) hours as needed for shortness of breath or wheezing: Ideally use no more than 4 times a day, but may increase if having difficulty breathing. 11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation four times a day. 12. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. 13. BIPAP Sig: One (1) administration at bedtime: Use per home settings. 14. Calcium 600 + D(3) 600 mg(1,500mg) -200 unit Tablet Sig: One (1) Tablet PO twice a day. 15. Finasteride 5 mg Tablet Sig: One (1) Tablet PO once a day. 16. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. 17. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation every six (6) hours as needed for shortness of breath or wheezing. 18. Lactulose 10 gram/15 mL Solution Sig: Thirty (30) mL PO once a day. 19. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime. 20. Oxycodone-Acetaminophen 7.5-325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain: This is a dangerous medication. Minimize using. 21. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) tablet Sublingual use as directed. 22. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) dose Inhalation once a day. 23. Sertraline 50 mg Tablet Sig: One (1) Tablet PO once a day. 24. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR). 25. home oxygen Sig: 4-6 Liters continuously: Continuous home oxygen 4-6 liters. 26. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 27. Levofloxacin 750 mg Tablet Sig: One (1) Tablet PO once a day for 2 days. Disp:*2 Tablet(s)* Refills:*0* 28. Prednisone 10 mg Tablet Sig: Four (4) Tablet PO once a day: Steroid Taper to prednisone 20 mg. Take 4 tablets by mouth once a day for 3 days and then decrease to 3 tablets a day for 5 days and then decrease to 2 tablets once a day and stay at 2 tablets a day. Disp:*120 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: 1. pneumonia, hospital associated 2. COPD exacerbation Discharge Condition: stable, on home oxygen 4-5L O2 by nasal canula Discharge Instructions: You were hospitalized with pneumonia and an exacerbation of your COPD. Please take all medications as prescribed. Follow up with your doctors as previously [**Name5 (PTitle) 1988**], and as [**Name5 (PTitle) 1988**] below. If you have increased shortness of breath, fever greater than 101, chest pain, diarrhea or any other alarming symptoms, return to the emergency department. Do not drive if you take percocet. Followup Instructions: Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2107-8-11**] 10:10 Provider: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2107-8-11**] 10:30 Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2107-8-11**] 10:30

[ "272.4", "275.3", "414.01", "562.10", "799.02", "493.22", "401.9", "530.81", "V13.02", "486", "338.29", "365.9", "564.09", "V12.04", "V46.2", "280.9", "412" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9973, 10031

4549, 6363

293, 299

10130, 10178

2985, 4526

10643, 11093

2083, 2162

7104, 9950

10052, 10109

6389, 7081

10202, 10620

2177, 2966

234, 255

327, 1292

1314, 1694

1710, 2067

5,837

158,606

44359

Discharge summary

report

Admission Date: [**2102-9-17**] Discharge Date: [**2102-9-18**] Date of Birth: [**2077-8-31**] Sex: M Service: [**Hospital1 3253**] HISTORY OF PRESENT ILLNESS: The patient is a 25 year old male without significant past medical history who was found unresponsive outside his home on the morning of admission after having taken gamma-hydroxybutyrate in the context of mild alcohol use the night prior to admission while at a club. His friends found him unresponsive. The patient reported drinking a small amount of gamma-hydroxybutyrate, being in a club drinking several alcoholic drinks, left the club feeling tired. Had drank one Red Bolt drink, a nonalcoholic, high caffeine beverage and then left. He was driving home, took another sip of gamma-hydroxybutyrate and immediately felt extremely tired and unable to drive further. He got into the passenger seat of the car and his friend took over driving. The patient has no further recollection after this. His friends dropped him off at the curb outside his house. His wife heard him, called an ambulance and he was brought to Wood [**Hospital 107**] Hospital. Vitals showed heart rate of 89, blood pressure 172/86, O2 sat 77%. He received 2 mg of Versed and 10 mg of Pavulon and was intubated. Tox screen at Wood was negative for alcohol, positive for cocaine. The patient was transferred to [**Hospital1 18**] for further evaluation and management. Of note, the patient admits to trying cocaine on Friday evening, the 25th. He claims this was his first episode of cocaine use ever. At [**Hospital1 190**] the patient was agitated with blood pressure of 170/110. He received Ativan for sedation. He was given nitroglycerin which was eventually weaned off while still in the E.D. In the ICU the patient became gradually more alert without agitation. He was following commands appropriately and demonstrating spontaneous respirations. He was changed to pressor support of [**5-27**] on which he did very well with good tidal volumes of 600 to 700 cc. He was extubated at 11:15 a.m. on the 26th. Denied any chest pain. PAST MEDICAL HISTORY: None. MEDICATIONS: None. In discussion with the family he was using insulin as part of his body building regimen. Has a history of cycling anabolic steroids. He takes creatinolfosfate as well as ibuprofen. ALLERGIES: No known drug allergies. FAMILY HISTORY: Not significant. SOCIAL HISTORY: He is married, has a small child. Wife denies he has any prior history of drug abuse. She reports he does not consume a large amount of alcohol, maybe two to three drinks in a social setting. Anabolic steroids and insulin use as mentioned above. The patient also notes he had used gamma-hydroxybutyrate several times after working out to help him sleep, but he claims this is his first episode using it in a party setting. PHYSICAL EXAMINATION: Vitals were heart rate of 112, blood pressure 124/56, temperature 96.9. In general, he was well developed, following commands, moving all four extremities, breathing easily. Sclerae were anicteric. Pupils were minimally reactive. Moist mucous membranes, no oral lesions. Neck was supple, no lymphadenopathy, no JVD. Heart was tachy, regular S1, S2 with no murmurs, rubs or gallops. Lungs showed coarse breath sounds throughout. Abdomen was soft, nontender, nondistended. Extremities showed no clubbing, cyanosis or edema, 2+ distal pulses. Tattoo over right deltoid and over back. LABORATORY DATA: Labs from [**Last Name (un) **] showed white count of 8.8, hematocrit 45.9. Sodium was 141, potassium 3.7, chloride 100, bicarb 24, BUN 18, creatinine 1.1, glucose 117, calcium 8.8. PT 12.8, INR 1.0, PTT 27.6. CK 599, MB 3.2. Total cholesterol 193. AST 27, ALT 30, LDH 27. Tox screen was positive for cocaine. Negative for alcohol, opiates. UA showed 15 ketones, 3 to 4 red cells, 3 to 4 white cells, 10 to 15 bacteria, 3 to 10 epithelials. Initial labs at [**Hospital1 1444**] showed white count of 16.3, hematocrit 47.6, platelets 307. Differential showed 92% polys, 5.3% lymphs, 1.9% monos. Chem-7 showed sodium of 137, potassium not listed, chloride 95, bicarb 26, BUN 17, creatinine 1.3, glucose 127. Calcium 9.1, phos 4.3, mag 1.9, albumin 4.4. CK was 603 with MB of 3, troponin less than 0.3. Tox screen positive for cocaine and benzos, however, the patient had received Ativan at Wood [**Hospital 107**] Hospital. LFTs and amylase were unremarkable. UA showed 15 ketones, no cells, few bacteria, 3 epithelials. EKG at [**Last Name (un) **] showed normal sinus rhythm at 80, normal intervals, axis 70, T wave inversions in 3 and aVF, T flattening 2. At [**Hospital1 346**] 3 1/2 hours later EKG showed sinus tach at 120, normal intervals, [**Street Address(2) 4793**] depressions in 2, 3 and aVF, T wave inversions in 3 and aVF, no prior study from this hospital available for comparison. Chest x-ray showed no cardiomegaly, no effusion, bilateral perihilar haziness, no fractures. Head CT showed no acute intracranial hemorrhage, no fractures, small air fluid levels in maxillary and sphenoid sinuses, also mucosal thickening of the ethmoids. Echo showed left atrium normal, normal left ventricular wall thickness. Cavity size and systolic function were normal. There was no pericardial effusion. HOSPITAL COURSE: The patient was transferred to the MICU from Wood [**Hospital 107**] Hospital where his respiratory status continued to improve. He was extubated without difficulty on 11:15 a.m. on the 26th and the patient was called out to the floor. Given his elevated CK on arrival, it was followed during this admission. CKMB and troponin on arrival were 603, 3, less than 0.3. CK trended down from 603, 429, 325, 280 at 6:00 a.m. on the 27th. MB fraction remained at 1. Thus the patient ruled out for myocardial infarction. Given this patient's history of anabolic steroid abuse, insulin abuse for weight lifting purposes as well as indiscretion with recreational drugs, several conversations were held with the patient about decision making in terms of use of recreational substances and the potential dangers in the use of cocaine and gamma-hydroxybutyrate as well as an attempt to communicate to the patient that he was lucky to have come out of this incident without further deterioration. He was recommended to follow up with a substance abuse counselor, given two numbers for both Tri-City substance abuse facility in [**Location (un) 2251**] close to his home in [**Location (un) 4628**] as well as given the name of [**Doctor First Name 7346**] [**Doctor First Name 1191**] at [**Hospital 16175**] clinic. The patient continued to do well and on the afternoon of the 27th felt fine. Other than persistent tachycardia felt well and was discharged to home with recommendations that he follow up with his primary care physician as well as seek out counseling for his poor decision making and substance abuse problems. DISCHARGE DIAGNOSIS: Polysubstance overdose. DISCHARGE STATUS: To home. CONDITION ON DISCHARGE: Stable. DISCHARGE INSTRUCTIONS: Follow up with PCP and substance abuse counselor. DISCHARGE MEDICATIONS: Ilotycin eye ointment for itchy eyes. [**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**] Dictated By:[**Last Name (NamePattern1) 2396**] MEDQUIST36 D: [**2102-9-20**] 11:28 T: [**2102-9-24**] 08:38 JOB#: [**Job Number 95114**]

[ "E852.8", "E855.2", "796.2", "427.89", "967.8", "968.5", "980.0", "518.81", "E860.0" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

2398, 2416

7169, 7451

6981, 7035

5338, 6959

7094, 7145

2884, 5320

178, 2108

2131, 2381

2433, 2861

7060, 7069

28,204

131,992

50466

Discharge summary

report

Admission Date: [**2175-7-6**] Discharge Date: [**2175-7-7**] Date of Birth: [**2102-9-15**] Sex: F Service: NEUROSURGERY Allergies: Ciprofloxacin / Levofloxacin / Norvasc Attending:[**First Name3 (LF) 78**] Chief Complaint: 72yo woman with history of vasculopathy who presents to [**Hospital1 18**] ED after having sustained a fall at her nursing home. Major Surgical or Invasive Procedure: None History of Present Illness: 72yo woman with history of vasculopathy who presents to [**Hospital1 18**] ED after having sustained a fall at her nursing home. Due to the fact that she is on coumadin, she was sent here for further evaluation. Head CT demonstrates a right frontal intraparenchymal hemorrhage and a small subarachnoid hemorrhage along the left transverse sinus. Patient states that she fell after getting out of the bathroom using her walker (~6:30AM). The walker got stuck on the door knob, and she sustained trauma to her head. She also sustained trauma to her left leg and calf. She does not recall any period of loss of consciousness. Past Medical History: - Hypertension - Hyperlipidemia - CAD s/p CABG in [**2167**] - PVD s/p aortobifemoral bypass in [**2166**] at [**Hospital1 2025**], L SFA stent in [**2174**] - CKD, baseline Cr 1.6-2.0 - Left renal artery stenosis of 80% on angiography [**12-22**] - Hypothyroidism - Osteopenia - Recurrent UTI's - S/p right hip replacement and left hip fixation - S/p bladder suspension - Bowel obstruction s/p resection in [**2173**] - Vertigo - OSA - Right MCA aneurysm - Recent L Fem-[**Doctor Last Name **] bypass, d/c'd [**6-13**] - CHF, EF 40% Social History: Patient is single lives with her daughter who is very involved in her care and is her Health Care Proxy: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 105138**] [**0-0-**]. No current or former tobacco or alcohol use. Ambulates with walker. Does not have PT or VNA services. Family History: Family history is significant for CAD in father, siblings (brother at 45yo), and son. Physical Exam: O: V/S BP 180/90 HR 83 RR 20 Pox 97%RA Gen: WD/WN, comfortable, NAD. HEENT: NCAT Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Language: Speech fluent with good comprehension. Naming intact. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light (2-->1mm bilaterally) III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**6-19**] throughout (only limited by splinting from pain). No pronator drift Sensation: Intact to light touch Reflexes: B T Br Pa Ac Right 2 2 2 0 0 Left 2 2 2 0 0 Toes upgoing bilaterally Pertinent Results: [**2175-7-6**] 10:25AM PT-30.4* PTT-33.1 INR(PT)-3.1* [**2175-7-6**] 10:25AM PLT COUNT-183 [**2175-7-6**] 10:25AM NEUTS-82.9* LYMPHS-11.0* MONOS-2.9 EOS-3.0 BASOS-0.2 [**2175-7-6**] 10:25AM WBC-11.3* RBC-3.19* HGB-9.7* HCT-30.5* MCV-95 MCH-30.2 MCHC-31.7 RDW-15.4 [**2175-7-6**] 10:25AM estGFR-Using this [**2175-7-6**] 10:25AM estGFR-Using this [**2175-7-6**] 10:25AM GLUCOSE-106* UREA N-24* CREAT-1.6* SODIUM-140 POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-25 ANION GAP-15 [**2175-7-6**] 10:45AM URINE RBC-0 WBC-[**4-19**] BACTERIA-MOD YEAST-FEW EPI-0-2 Brief Hospital Course: The patient was admitted to the ICU for Q1 neurochecks and close observations. Her INR was reversed with FFP after consult with vascular surgery. She complained of left hip pain which her left leg and hip were studied and negative for any fracture. Repeat CT showed resolving blood she remained neurologically intact. She may restart her coumadin in 10 days. She is being treated for a UTI with Ceftaz she should continue on it until [**7-9**]. Medications on Admission: Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 11. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 12. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 13. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 4. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 5. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 10. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 11. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 12. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 13. Gabapentin 400 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 14. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 15. Furosemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 16. Ceftazidime 1 gram Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours) for 2 doses. Discharge Disposition: Extended Care Facility: On [**Location (un) **] - [**Location (un) **] Discharge Diagnosis: Small right IPH and small SAH after fall Discharge Condition: Neurologically stable Discharge Instructions: CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F [**Month (only) 116**] restart coumadin in 10 days Followup Instructions: Follow up in 1 month with Dr [**First Name (STitle) **] call [**Telephone/Fax (1) 1669**] for an appointment Completed by:[**2175-7-7**]

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icd9cm

[ [ [] ] ]

[ "99.07" ]

icd9pcs

[ [ [] ] ]

6400, 6473

3731, 4177

428, 435

6558, 6582

3143, 3708

7130, 7269

1972, 2059

4989, 6377

6494, 6537

4204, 4966

6606, 7107

2074, 2272

260, 390

463, 1089

2423, 3124

2287, 2407

1111, 1647

1663, 1956

13,306

103,154

6829

Discharge summary

report

Admission Date: [**2193-8-14**] Discharge Date: [**2193-8-23**] Date of Birth: [**2143-2-1**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2195**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Intubation/Extubation, Mechanical Ventilation History of Present Illness: 50 yo male with h/o COPD, CAD s/p STEMI, CHF, OSA, DM2 who presented with 2-3 days of increasing dyspnea, wheezing and lower extremity edema; family also reports cough, no fevers. Pt describes LE edema as acute onset on [**2193-8-9**], associated with intense pruritis of the soles/ankles of both feet developing into swelling. After significant encouragement from family/friends, presented to [**Hospital1 18**] ER on [**2193-8-14**] and was found to be hypercarbic and hypoxic. Pt became somnolent and was intubated in the ED for hypercarbic respiratory failure and admitted to the MICU. VS in the ED were 98.8, 136/85, 125, 26, 75% 2L NC, ABG 7.22/96/59 --> 7.11/134/77. Pt was also given solumedrol, nebs, levofloxacin, magnesium in ED for COPD exacerbation/?PNA; heparin gtt and CTA ordered for ?PE. CTA neg for PE, CT head neg for bleed. . ROS was otherwise negative for chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. No syncope, near-syncope. . MICU course: Pt remained on NIPPV [**11-11**] with FiO2 50% and started on Ceftriaxone/Azithromycin for ?PNA, lasix for fluid overload, nebulizers for COPD exacerbation. Solumedrol was changed to prednisone taper on [**2193-8-19**] starting at 30mg/day. Pt also had BAL on [**2193-8-17**] showing tracheobronchomalacea and mucus in LLL, sputum cx NGTD. Pt was extubated w/o issues the morning of [**8-18**] (day 5 of mechanical ventilation) and has remained stable since. Past Medical History: 1. CAD: 2vd s/p inferior STEMI and BMS to LCx ([**2183**]). cath [**5-15**] showed 30% stenosis of prox LAD, 60% stenosis of mid-LCx before patent OM1 stent, 100% RCA occlusion w/ good lt to rt collaterals 2. PVD s/p stenting of rt common iliac ([**2183**]) 3. CHF w/ preserved EF on MIBI ([**4-14**]) and ECHO ([**1-12**]) 4. COPD, FEV1 1.23 ([**4-15**]) 5. OSA on CPAP [**11-16**] 50% 6. DM2, HbA1c 7.0 ([**6-15**]) 7. Hypercholerolemia 8. Hypertension 9. Obesity Social History: Works in shipping/receiving. T - prev 2ppd X many years, now quit A - few beers per month D - h/o marijuana, no IVDU Family History: Father died in sleep at 59yo, h/o COPD. Mom died at 79yo, had breast cancer. Sister w/ CAD and h/o stroke Physical Exam: On admission to MICU from ED: Gen: Obese caucasian male intubated, sedated, moves to voice HEENT: blood noted around bilateral nares and around mouth; not currently oozing. NECK: Supple, No LAD, No JVD CV: RRR. NL S1, S2. No murmurs, rubs or [**Last Name (un) 549**] LUNGS: BS heard throughout lung fields. no wheezes ABD: normo-active BS, soft, NT, ND. EXT: 1+ edema in the feet bilaterally, DP pulses not palpable. NEURO: sedated On transfer to CC7: VITALS: T 97.4, HR 84, BP 100/66, R 20, 97% 3L NC --> 93% 2L GEN: NAD, A&O X3 HEENT: NCAT, EOMI, normal oro/nasopharynx NECK: Soft, supple, no JVD CV: RRR, no m/g/r, nl S1/S2 PULM: CTAB, no w/r/r, ?mild bilateral basilar crackles on exam ABD: soft, nt/nd, +BS (hypoactive), overweight EXT: no c/c/e, palpable 2+ DP/PT pulses bilaterally, no edema bilaterally Pertinent Results: Admit Labs WBC-13.6*# RBC-5.92 Hgb-17.3 Hct-55.7* MCV-94 MCH-29.3 MCHC-31.1 RDW-12.7 Plt Ct-277 Neuts-61 Bands-16* Lymphs-10* Monos-9 Eos-0 Baso-0 Atyps-4* Metas-0 Myelos-0 Hypochr-OCCASIONAL Anisocy-OCCASIONAL Poiklo-NORMAL Macrocy-OCCASIONAL Microcy-NORMAL Polychr-OCCASIONAL Glucose-171* UreaN-16 Creat-0.6 Na-139 K-4.0 Cl-94* HCO3-36* AnGap-13 cTropnT-<0.01 Calcium-9.1 Phos-4.1 Mg-2.2 pO2-69* pCO2-96* pH-7.22* calTCO2-41* Base XS-7 Glucose-168* Lactate-1.4 ERYTHROPOIETIN: 8.7 4.1-19.5 MU/ML JAK2 V617F NEGATIVE (r/o polycythemia [**Doctor First Name **], etc) . CTA CHEST ([**8-14**]) - IMPRESSION: 1. No evidence of large pulmonary embolus. Evaluation of distal branches are limited. 2. Diffuse subcentimeter ground-glass nodules and more solid-appearing 6-mm nodule in the right lower lobe. Followup CT within 6 months is recommended. 3. Diffuse mediastinal and hilar adenopathy as described above. ECHO ([**8-16**]) - IMPRESSION: No large amounts of right-to-left shunting seen, although images are suboptimal. Normal global biventricular function. Compared with the prior study (images reviewed) of [**2193-1-9**], current images are technically suboptimal, so precise comparison is difficult. No ASD/PFO/VSD detected on bubble study. CXR: The ET tube tip is 8 cm above the carina. NG tube tip is in the stomach. There is no change in the left basal opacity that might represent a developing aspiration pneumonia versus infectious process in combination with atelectasis. Upper lungs are clear and there is no appreciable right pleural effusion. Small amount of left pleural fluid cannot be excluded. BAL Cx: NGTD. Neg legionella, PCP, [**Name10 (NameIs) 3019**], CMV Blood Cx: Neg Sputum Cx: Neg Brief Hospital Course: 50 yo male with h/o COPD, CAD s/p STEMI, CHF, OSA, DM2 who presented with 2-3 days of increasing dyspnea and was intubated emergently in ED for hypercarbic respiratory failure. Pt has since been extubated and almost back to baseline pulmonary function. Etiology remains unclear. HOSPITAL COURSE BY PROBLEM: # RESPIRATORY FAILURE. Combined hypercarbic and hypoxic respiratory failure. Etiology unclear. Chronically elevated hematocrit suggestive of some level of chronic hypoxia. Likely a combination of COPD, OSA. No obvious infection on CXR to suggest PNA. Could also have been in setting of volume overload but did not appear wet on physical exam. - Pt was given a seven day course of Ceftriaxone and five day course of Azithromycin which he finished prior to discharge. - Pt was diuresed with Lasix 40mg daily while in MICU and on the Medicine floors. Pt is to resume home dose of Lasix 20mg upon discharge. - Pt started on a Prednisone taper, 30mg X 3days, 20mg X3days, 10mg X3 days then stop - Pt was continued on Albuterol inhaler, Albuterol/Ipratropium nebs PRN. . # HYPERTENSION. Patient was normotensive during hospital stay. He did have 2 episodes of self-limited, mild hypotension with dizziness (SBP 100) with negative orthostatics. Home metoprolol was continued in house. Lisinopril was held in MICU but restarted on discharge. . # CAD. S/p inferior MI w/ BMS placement. - Continued ASA 325mg, plavix 75mg, pravastatin, metoprolol in house. Lisinopril was held in the MICU [**3-11**] CTA contrast dye. Lisinopril was restarted on discharge home. . # DIABETES, Type II. Well controlled during hospital stay on HISS. - Pt on metformin as outpatient and was restarted on discharge. Medications on Admission: ALBUTEROL SULFATE [VENTOLIN HFA] - 90 mcg HFA Aerosol Inhaler - 2 puffs inhaled every 6 hours as needed BENZOYL PEROXIDE - 2.5 % Gel - apply to acne on the back qday CLOPIDOGREL [PLAVIX] - (Prescribed by Other Provider) - 75 mg Tablet - 75 Tablet(s) by mouth once a day FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 250 mcg-50 mcg/Dose Disk with Device - 1 puff inhaled twice daily rinse mouth after use FUROSEMIDE - 20 mg Tablet - 1 Tablet(s) by mouth once a day KETOCONAZOLE - 2 % Shampoo - apply to body and keep for 5 minutes and then wash. use for 7 days. after that can use once a week for prevention qday LISINOPRIL - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth qday METFORMIN - 500 mg Tablet - [**2-8**] Tablet(s) by mouth twice daily take two tabs in the morning and one tab at night METOPROLOL TARTRATE - 50 mg Tablet - 1 Tablet(s) by mouth twice a day NITROGLYCERIN - 0.4 mg Tablet, Sublingual - 1 Tablet(s) sublingually q5min X 3 doses as needed for chest pain call 911 if no relief after 2nd pill; take up to 3 pills PORTABLE OXYGEN SYSTEM - 4L - to keep O2 sat > 87% when walking PRAVASTATIN - 40 mg Tablet - one Tablet by mouth once a day TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - 18 mcg Capsule, w/Inhalation Device - one capsule inhaled daily UREA [CARMOL 40] - 40 % Cream - apply to affected areas daily Medications - OTC ASPIRIN - 325 mg Tablet - one Tablet(s) by mouth daily MELATONIN - (OTC) - 3 mg Tablet - 1 Tablet(s) by mouth taken at 8 pm nightly MULTIVITAMINS-MINERALS-LUTEIN [CENTRUM SILVER] - (OTC) - Tablet - 1 Tablet(s) by mouth Daily Discharge Medications: 1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*2* 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. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Melatonin 3 mg Tablet Sig: One (1) Tablet PO once a day: At 8pm. 7. Centrum Silver Tablet Sig: One (1) Tablet PO once a day. 8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 9. Metformin 500 mg Tablet Sig: 1-2 Tablets PO twice a day: Take 1000mg in the morning, 500mg at night. 10. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual every 5 minutes as needed for chest pain: Do not exceed 3 doses in 15 minutes. Call 911 if chest pain persists after 3 doses. 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. 12. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) capsule Inhalation once a day. 13. Advair Diskus 250-50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation twice a day. 14. Ventolin HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. 15. CARMOL 40 40 % Cream Sig: One (1) application Topical once a day. 16. Benzoyl Peroxide 2.5 % Gel Sig: One (1) application to back Topical once a day. 17. Ketoconazole 2 % Shampoo Sig: One (1) Topical once a week. 18. Prednisone 10 mg Tablet Sig: Starting tomorrow, [**8-24**], take 20mg daily for two days * Starting [**8-26**], take 10mg daily for three days * Starting [**8-29**], do NOT take any more prednisone. Disp:*10 Tablet(s)* Refills:*0* 19. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q8H (every 8 hours) as needed for SOB. 20. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 21. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 22. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for SOB. Discharge Disposition: Home Discharge Diagnosis: Primary: Hypercarbic respiratory failure Secondary: 1. CAD: Two vessel disease s/p inferior STEMI and bare metal stent to LCx ([**2183**], cath [**5-15**]) 2. Peripheral Vascular Disease s/p stenting of right common iliac ([**2183**]) 3. Congestive Heart Failure w/ preserved ejection fraction on MIBI ([**4-14**]) and ECHO ([**1-12**]) 4. COPD, FEV1 1.23 ([**4-15**]) 5. Obstructive Sleep Apnea on CPAP [**11-16**] 50% 6. Type 2 Diabetes Mellitis, HbA1c 7.0 ([**6-15**]) 7. Hypercholerolemia 8. Hypertension 9. Obesity Discharge Condition: Improved. Vital signs are stable, patient ambulating and on 3L supplemental oxygen. Discharge Instructions: -You were admitted in acute respiratory distress which required that you be intubated, to help you breath. Your respiratory problems were likely due to a combination of COPD, usual breathing difficulties and a respiratory infection. . -It is important that you continue to take your medications as directed. We made the following changes to your medications during this admission: --> ADDED Famotidine 20mg twice daily for GERD --> ADDED Prednisone. You are to slowly decrease your daily dose of this medication as follows: * Starting tomorrow, [**8-24**], take 20mg daily for two days * Starting [**8-26**], take 10mg daily for three days * Starting [**8-29**], do NOT take any more prednisone. --> CONTINUE your home medications: Benzoyl peroxide 2.5% (back wash), Plavix 75mg daily, Lasix 20mg daily, Ketoconazole 2% shampoo, Carmol 40% cream daily, Lisinopril 5mg daily, Metformin 1000mg (two tablets) in the morning/500mg at night, Pravastatin 40mg daily, aspirin 325mg daily, Melatonin 3mg at 8pm daily, Centrum Silver 1 tablet daily, Nitroglycerin 0.4mg sublingual tablets as needed. --> RESUME your breathing medications: Advair 250-50mcg 1 puff twice daily, Spiriva 18mcg inhale one capsule daily, Albuterol 2 puffs every 6 hours as needed, supplemental oxygen. . -Contact your doctor or come to the Emergency Room should your symptoms return. Also seek medical attention if you develop any new fever, chills, trouble breathing, chest pain, nausea, vomiting or unusual stools. Followup Instructions: Please follow-up with your PCP, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 6303**] [**Last Name (NamePattern1) **], in [**3-13**] weeks. You can call her office to make an appointment at: [**Telephone/Fax (1) 250**] . Please follow-up with your pulmonary doctor, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in [**2-8**] weeks. You can call his office to make an appointment at: [**Telephone/Fax (1) 612**]

[ "V45.82", "428.0", "278.00", "518.81", "518.89", "250.00", "276.2", "327.23", "401.9", "414.01", "272.0", "491.21", "428.33" ]

icd9cm

[ [ [] ] ]

[ "33.24", "96.71", "96.04", "96.6" ]

icd9pcs

[ [ [] ] ]

10840, 10846

5276, 5556

322, 370

11410, 11496

3536, 5253

13030, 13487

2580, 2688

8617, 10817

10867, 11389

6998, 8594

11520, 12234

2703, 3517

12252, 13007

275, 284

5585, 6972

398, 1939

1961, 2429

2445, 2564

25,131

136,050

47673

Discharge summary

report

Admission Date: [**2204-1-12**] Discharge Date: [**2204-1-18**] Date of Birth: [**2132-3-13**] Sex: F Service: MEDICINE Allergies: Levaquin / Gabapentin Attending:[**First Name3 (LF) 30**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: Cardiac catheterization with placement of a drug eluting stent to the Left Anterior Descending Artery and placement of a drug eluting stent to the Left Circumflex Artery. History of Present Illness: This is a 71 year-old female with a medical history significant for coronary artery disease (catheterization [**2203-10-19**] w/ known occluded RCA, 90% mid LAD intervened on w/ BMS, minimal LCX) s/p anterior MI in [**2198**] (DES to LAD and distal LCX), paroxysmal atrial fibrillation on coumadin, heart failure with a preserved ejection fraction (55% [**2201**]), and end stage renal disease on hemodialysis presents from home with substernal chest pain. Since her recent hospitalization in [**Month (only) **] she has experienced brief non-exertional intermittent (once per week) substernal chest pain. She describes this as sharp, radiates to the back, associatd with nausea and relieved with SLNG. However, for the past week, this has been happening daily. It typically starts at 8PM at night and continues until 6AM the next morning and has been associated with nausea, vomiting, and diaphoresis. She has missed medication, including aspirin and plavix, during this time. This morning her chest discomfort was more severe, prompting her to go to [**Hospital1 18**] [**Location (un) 620**]. . Of note, the patient was admitted to the [**Hospital1 1516**]-Cardiology service at [**Hospital1 18**] in [**2203-10-18**] after presenting with chest pain, with positive nuclear [**Year (4 digits) **] testing showing a defect in the inferolateral wall and ST-depressions in the lateral leads seen on serial EKGs. Cardiac catheterization ([**2203-10-19**]) known occluded RCA, minimal left circumflex disease, and 90% napkin ring stenosis in the mid-LAD just distal to her previous stent and an Integrity BMS was placed. The first diagonal branch had an ostial pinch lesion on the order of 70% after stenting with TIMI-3 flow. She had chest pain following her procedure with some ST-changes that resolved with Nitro gtt. She was discharged home on [**2203-10-20**] on aspirin,plavix, coumadin. . In [**Hospital1 18**] [**Location (un) 620**], initial vitals: 98.2 HR: 80 BP: 99/49 Resp: 24 O(2)Sat: 94, exam unremarkable. EKG reportedly showed V4-5 ST depession and on repeat with worsening pain showed ST depression AVF, I, V4-6. She was given SLNG with improvement in pain. She was started on nitro gtt and transferred to [**Hospital1 18**]. . In the BIMDC ED, initial VS 97.4 114/80 108 20 94% 4L NC. An EKG showed sinus rhythm, rate of 109, normal axis, ST depressions V3-6, I, II, III, AVF with 1.5mm ST elevation in AVR. Initial labs notable for troponin of 0.08, INR of 2.5. She was transported to the cardiac catheterization lab urgently. In the cath lab she was found to have >90% ostial LAD and LCX disease. She got [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 1 to LAD and [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] 1 to LCX with good return of flow after. She got plavix 600mg. She did not get heparin, integrillin. She did not get FFP. She got 250cc IVF and 80cc contrast in cath lab. . On arrival to the CCU, the patient reports some left shoulder pain but denies chest pain, shortness of breath. . Cardiac review of systems is notable for absence of dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or pre-syncope. . ROS: The patient denies a history of prior stroke/TIA, deep venous thrombosis or pulmonary embolus. They deny bleeding at the time of prior procedures or surgeries. Denies headaches or vision changes. No cough or upper respiratory symptoms. Denies chest pain, dizziness or lightheadedness; no palpitations. Denies shortness of breath. No nausea or vomiting, denies abdominal pain. No dysuria or hematuria. No change in bowel movements or bloody stools. Denies muscle weakness, myalgias or neurologic complaints. No exertional buttock or calf pain. Past Medical History: 1. CARDIAC RISK FACTORS: + Diabetes, Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -PCI: -Cypher x 2 to left circumflex in [**2196**] -Cypher to LAD after NSTEMI in [**2198-11-21**] -catheterization [**2203-10-19**] w/ known occluded RCA, 90% mid LAD intervened on w/ BMS, minimal LCX 3. OTHER PAST MEDICAL HISTORY: -Heart failure with preserved ejection fraction ([**2201**] EF >55%) -Paroxysmal atrial fibrillion on coumadin -Mild to moderate mitral regurgitation (TTE [**2201**]) -carotid artery disease (s/p left carotid stenting, [**2202**]; right carotid with 80-99% stenosis) -h/o recurrent pulmonary edema -ESRD on HD TUES THURS SAT at [**Location (un) **] in [**University/College **] -COPD -Lung CA, status post resection [**2182**] -h/o uterine cancer -Neuropathy secondary to DM -Gout -Sleep apnea (not on CPAP) -Obesity -DVT after a fistula was placed on coumadin -GERD: status post endoscopy in [**2198-11-21**] which revealed nonerosive gastritis, reflux disease -Depression -S/p ligation of LUE AV fistula due to steel syndrome, with DVT -legally blind Social History: -Lives at home w/ husband who is main caregiver -3 children, 1 lives w/ her and is learning disabled -Tobacco history: 1 ppd most of her life, continues to smoke -ETOH: None -Illicit drugs: none Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION EXAM VITALS: 98 114/54 HR:100 100%RRB GENERAL: Appears in no acute distress. Alert and interactive. HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear. Mucous membranes moist. No xanthalesma. NECK: JVP difficult to appreciate due to body habitus CVS: PMI located in the 5th intercostal space, mid-clavicular line. S1, S2 regular rhythm, normal rate III/VI systolic murmur apex RESP: Respirations unlabored, no accessory muscle use. Wheezes right. ABD: soft, non-tender, non-distended, with normoactive bowel sounds. No palpable masses or peritoneal signs. Abdominal aorta not enlarged to palpation, no bruit. EXTR: no cyanosis, 1+ edema, 2+ peripheral pulses DERM: No stasis dermatitis, ulcers, scars, or xanthomas. NEURO: CN II-XII intact throughout. Alert and oriented x 3. strength 5/5 bilaterally, sensation grossly intact. Gait deferred. PULSE EXAM: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ DISCHARGE EXAM: Pertinent Results: ADMISSION LABS [**2204-1-12**] 03:35PM BLOOD WBC-8.4 RBC-3.52* Hgb-10.4* Hct-33.2* MCV-94 MCH-29.5 MCHC-31.2 RDW-13.3 Plt Ct-143* [**2204-1-12**] 03:35PM BLOOD Neuts-77.5* Lymphs-14.2* Monos-5.3 Eos-2.3 Baso-0.7 [**2204-1-12**] 03:35PM BLOOD PT-26.4* PTT-45.3* INR(PT)-2.5* [**2204-1-12**] 03:35PM BLOOD Glucose-51* UreaN-21* Creat-5.7* Na-138 K-5.1 Cl-98 HCO3-22 AnGap-23* . Cardiac Catheterization ([**2204-1-12**]): COMMENTS: 1. Selective coronary angiography of this known right dominant system demonstrated severe 2 vessel coronary artery disease. The right coronary artery was not injected but was known to have diffuse sub-total occlusion on prior angiography. The LMCA was a large vessel free of angiographically significant coronary artery disease. The LAD had an 80% ostial lesion, but was otherwise withouht angiographically significant coronary artery disease and with widely patent stents. The LCX had an 80% ostial lesion but was otherwise without angiographically significant coronary artery disease with widely patent stents. 2. Limited resting hemodynamics revealed normal systemic arterial blood pressure with a central aortic blood pressure of 103/52. 3. Successful PCI to 80% ostial stenoses in both LAD and LCX arteries with deployment of a 3.0 x 15 mm Promus DES to LAD, and a 3.0 x 18 mm Promus DES to LCX, by simultaneous kissing stents technique, reducing both ostial lesions to 0% residual stenoses. 4. Successful deployment of 8 Fr Angioseal closure device to right common femoral artery. FINAL DIAGNOSIS: 1. 3 vessel native coronary artery disease (RCA not injected during this angiogram, but known to have a sub-total occlusion) 2. 80% ostial lesions of both the LAD and LCX 3. Normal systemic arterial blood pressure. 4. Simultaneous kissing stents deployed to LAD and LCX 80% ostial lesions (3.0 x 15 mm in LAD, 3.0 x 18 mm in LCX; both Promus drug-eluting stents), reducing both to 0% residual stenosis. 5. Successful deployment of Angioseal 8 Fr closure device to right CFA. . . TTE [**2204-1-13**]: The estimated right atrial pressure is 0-5 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate regional left ventricular systolic dysfunction with severe hypokinesis of the distal half of the anterior septum and apical akinesis. The basal inferolateral wall is hypokinetic. No left ventricular apical aneurysm is seen The remaining segments contract normally (LVEF = 35-40 %). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets are mildly thickened (?#). There is mild aortic valve stenosis (valve area 1.2-1.9cm2). There is no aortic regurgitation. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Mild symmetric left ventricular hypertrophy with extensive regional dysfunction c/w multivessel CAD. Mild aortic valve stenosis. Moderate mitral regurgitation. Pulmonary artery hypertension. Compared with the prior study (images reviewed) of [**2201-12-9**], regional dysfunction is now present c/w interim ischemia/infarction. Mild aortic stenosis is also now pressent. . . EKG [**2204-1-12**]: Sinus rhythm. Compared to tracing #1 diffuse ST segment depressions persist but improved. Rate PR QRS QT/QTc P QRS T 94 106 104 378/437 63 18 58 . . CXR [**2204-1-12**]: FINDINGS: Patient has received a new right dual-lumen dialysis catheter through the right internal jugular approach ending at mid SVC. Bilateral lung demonstrates increased interstitial marking and pulmonary vascular prominence likely from cardiac decompensation. Heart size is mildly enlarged, but unchanged to prior studies. Small pleural effusions seen on previous radiograph dated [**2202-4-22**] have resolved. No pneumothorax. No discrete opacities concerning for pneumonia. Mediastinal silhouette is normal. IMPRESSION: Prominent interstitial marking, mildly enlarged heart size and prominent vascular markings likely from cardiac decompensation. . . EKG [**2204-1-16**]: Sinus rhythm. Compared to tracing #4 ventricular ectopy is absent and ST segment changes have improved. Rate PR QRS QT/QTc P QRS T 68 122 110 412/426 53 13 59 Brief Hospital Course: 71 year-old female CAD s/p BMS to LAD and 100% occluded RCA [**2203-10-19**], DES to LAD and distal LCX [**2198**], paroxysmal atrial fibrillation on coumadin, diastolic heart failure, recurrent PE's, COPD, OSA, and ESRD on hemodialysis who presented with chest pain found to have antero-lateral NSTEMI s/p DES to LCx and DES to LAD. . #. ACUTE CORONARY SYNDROME/UNSTABLE ANGINA: Patient with history of two vessel coronary artery disease (LAD, chronically occluded RCA) presented with symptoms concerning for angina found to have LAD and LCx disease. She had placement of a DES to ostial LCX and DES to LAD with good angiographic result. She has been chest pain free and hemodynanamically stable since intervention, and is stable from a cardiac standpoint. Repeat EKG [**1-17**] showed improvement of prior ST abnormalities without concerning changes following intervention. She was on a regimen of aspirin 325mg daily, clopidogrel 75mg daily, atorvastatin 80 mg daily, lisinopril 5 mg daily, and up-titrated on metoprolol to 50 mg tid. She will follow up with a cardiologist as an outpatient. . #. ACUTE ON CHRONIC SYSTOLIC AND DIASTOLIC HEART FAILURE: The patient has a history of diastolic heart failure but currently has an EF 35-40% following her NSTEMI. There was moderate regional left ventricular systolic dysfunction with severe hypokinesis of the distal half of the anterior septum and apical akinesis. The basal inferolateral wall appeared hypokinetic. She will need a TTE as an outpatient to monitor for improvement of her EF. ACE inhibitor was initiated for remodeling in the setting of LV dysfunction. The patient currently appears euvolemic without evidence of acute heart failure exacerbation. CXR shows mild volume overload, but the patient had her fluid balance adjusted via hemodialysis and lasix was discontinued in-house per Renal recommendations, as she was anuric throughout her hospital stay. She was on a T/Th/Sat schedule which will be changed to a M/W/F schedule on discharge to [**Hospital 100**] Rehab, as approved by the Renal team. She was discharged on Lisinopril 5 mg PO daily, Metoprolol 50 mg po tid, and Eplerenone 25 mg daily as described above, despite blood pressures 90's-100's for cardiac benefit. . # ALTERED MENTAL STATUS: The patient was somnolent initially, difficult to arouse but arousable with verbal and tactile stimulation following her catheterization procedure. The etiology was believed to be include medication induced from poor clearance of sedative agents, especially given her renal failure. There was initially a concern for hypercarbia from carbon dioxide retention as the patient has sleep apnea and COPD (and element of hypercarbia was seen on ABGs), but the patient's mental status did not improve with bipap administration and improvement of her ABG's. The patient likely became agitated and agressive while in the CCU, consistent with ICU delirium - particularly given her stable neuro exam, reassuring labs, and absence of focal signs or symptoms. She was treated with Zyprexa and Haldol initially but switched to Seroquel for lack of response, and was susbsequently over-sedated. Seroquel was discontinued on transfer to the medicine floor and the patient was written for prn Zyprexa. Her delium cleared upon leaving the CCU and the patient was alert, oriented, and appropriate. . # PAROXYSMAL ATRIAL FIBRILLATION: Patient was in sinus rhythm during her hospital stay with an initially therapeutic INR on coumadin. However, she developed a supratherapeutic INR of 13 for unclear while in the CCU, and was reversed with Vitamin K with good response. She was re-started on Coumadin at a lower dose of 4 mg daily and is currently sub-therapeutic with INR 1.8 and is on a Heparin gtt for bridging to a therapeutic INR [**2-24**] given high CHADS2 score of 4. The patient will need PTT and INR drawn at 5:00pm on [**2204-1-18**] for titration of Heparin drip to PTT goal 60-100. She will also need to have her Coumadin titrated to INR goal [**2-24**], with INR's faxed to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3649**] at [**Telephone/Fax (1) 18820**]. INR will need to be checked on [**1-20**] and [**1-23**] and fax to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3649**] at [**Telephone/Fax (1) 18820**]. . # END STAGE RENAL DISEASE: Patient with end-stage renal disease requiring hemodialysis (T/Th/Sat) schedule. The patient will be switched to a M/W/F schedule on dischage to [**Hospital 100**] Rehab, as described above and as approved by the Renal dialysis consult service. She was initiated on nephrocaps in-house per Renal recs and continued on sevelemer and cinacalcet per her outpatient regimen. . #. GUIAC POSITIVE STOOL: The patient was noted to have some guaiac positive stool following NG tube placement while on Coumadin in the CCU, and was started on Protonix 40 mg IV Q12H (pt also has a history of mild gastritis). On transfer to the floor, the patient was converted to po Ranitidine given her hct was stable without further evidence of GI bleed, and also in the setting of high dose Aspirin daily. . # HYPERTENSION: The patient has a history of hypertension, but had lower blood pressures in the setting of new LV dysfunction (as described above). Blood pressures were 90's-100's while awake and 85-90's when asleep. She was continued on Lisinopril, Metoprolol was uptitrated, and Eplerenone was started for her NSTEMI and heart failure despite blood pressures in the 90's-100's. Holding parameters were liberalized as follows: - Ok to give Lisinopril if SBP >/= 90. - Ok to give Metoprolol if SBP >/= 90. - Ok to give Eplerenone if SBP >/= 100. Blood pressure parameters are goal systolic blood pressure greater than or equal to 90 mmHg while awake, greater than 85 mmHG when asleep. Her home lasix was discontinued per Renal's recommendations as the patient was anuric during this hospital stay. . # DIABETES MELLITUS, NON-INSULIN DEPENDENT: The patient has a history of diet controlled diabetes, not on insulin or oral hypoglycemia agents. HgbA1c 4.9% this admission, calling into question her history of diet-controlled diabetes. . # HYPERLIPIDEMIA: The patient was placed on Atorvastatin 80 mg PO daily as above. . # COPD: Continued Montelukast 10 mg daily and nebulizers as needed. . # DEPRESSION: Continued Paroxetine 20 mg PO daily. . # TOBACCO ABUSE: Patient continues to smoke, precontemplative at this time. Smoking cessation was encouraged and she was given a Nicotine patch 14 mg TD daily. . ========================== TRANSITION OF CARE ISSUES: ========================== Please draw PTT and INR at 5:00pm on [**2204-1-18**]. Titrate Heparin drip to PTT goal 60-100. Please titrate Coumadin to INR goal [**2-24**], and fax INR results to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3649**] at [**Telephone/Fax (1) 18820**]. Please check INR on [**1-20**] and [**1-23**] and fax to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3649**] at [**Telephone/Fax (1) 18820**]. Blood pressure parameters are goal systolic blood pressure greater than or equal to 90 mmHg while awake, greater than 85 mmHG when asleep. Ok to give Lisinopril if SBP >/= 90. Ok to give Metoprolol if SBP >/= 90. Ok to give Eplerenone if SBP >/= 100. Medications on Admission: 1. aspirin 325mg daily 2. clopidogrel 75mg daily 3. lisinopril 5mg daily 4. metoprolol tartate 50mg [**Hospital1 **] 5. Warfarin 6mg daily 6. Furosemide 40mg daily 7. Atorvastatin 80mg daily 8. Paroxetine 20mg daily 9. Sevelemer 800mg TID 10. Fluticasone 2 spray daily 11. Cinacalcet 30mg daily 12. Montelukast 10mg daily 13. Pentoxifylline 400mg daily 14. colchicine PRN gout 15. SLNG Discharge Medications: 1. lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 6. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:*30 Patch 24 hr(s)* Refills:*2* 7. pentoxifylline 400 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO DAILY (Daily). 8. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. fluticasone 50 mcg/Actuation Spray, Suspension Sig: [**1-23**] Nasal once a day. 11. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 12. paroxetine HCl 10 mg/5 mL Suspension Sig: Twenty (20) mg PO DAILY (Daily). 13. eplerenone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 14. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 16. heparin (porcine) in D5W 25,000 unit/250 mL Parenteral Solution Sig: 1150 (1150) units per hour Intravenous per weight based Heparin sliding scale for until INR >2 doses. 17. heparin (porcine) 1,000 unit/mL Solution Sig: 4000-[**Numeric Identifier 2249**] UNIT DWELL Injection PRN (as needed) as needed for line flush: Withdraw 4 mL prior to flushing with 10 mL NS followed by Heparin as above according to volume per lumen. 18. colchicine 0.6 mg Tablet Sig: as directed Tablet PO as directed as needed for gout. 19. nitroglycerin Sublingual Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Non-ST Elevation Myocardial Infarction Delirium 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 worsening chest pain and found to have an electrocardiogram and blood tests concerning for a heart attack. A cardiac catheterization was performed, and two stents were placed to open up blockages in your coronary arteries. You were confused following the catheterization, but this improved during your hospital stay. Because you have heart failure, you should weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. The following changes were made to your home medications: - Epleronone was STARTED - Ranitidine was STARTED - Nephrocaps was STARTED - Metoprolol was INCREASED - Warfarin was DECREASED - Furosemide was STOPPED - Take Plavix 75 mg daily and Aspirin 325 mg daily every day. It is extremely improtant to take Plavix and Aspirin every day without missing any doses. Do not stop taking these medications under any circumstance unless instructed by your cardiologist, as this may cause blocking of the stents that were placed in your coronary arteries. Followup Instructions: Department: [**Hospital **] HEALTHCARE OF [**Location (un) **] When: WEDNESDAY [**2204-2-1**] at 3:40 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 6475**], MD, MPH [**Telephone/Fax (1) 3070**] Building: [**Street Address(2) 8172**] ([**Location (un) 620**], MA) Ground Campus: OFF CAMPUS Best Parking: Parking on Site **Dr [**Last Name (STitle) 100708**] office will also call you tomorrow or Thurs to discuss a sooner appt. Department: CARDIAC SERVICES When: MONDAY [**2204-2-13**] at 2:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], 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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32228

Discharge summary

report

Admission Date: [**2105-12-1**] Discharge Date: [**2105-12-11**] Date of Birth: [**2042-7-23**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 30**] Chief Complaint: Fevers Major Surgical or Invasive Procedure: PICC line placed Left subclavian triple lumen catheter and right arterial line On transfer from OSH, patient had right chest tube in place History of Present Illness: 63 yo M with HTN, hyperlipidemia, and newly diagnosed multiple myeloma, presents on transfer from [**Hospital6 **] with persistent fevers. Patient was admitted to OSH on [**2105-11-22**] with chief complaint of SOB and right knee pain. On further evaluation patient was found to have a complicated right empyema and right knee septic arthritis growing a pansensitive strep pneumo. Antibiotic treament was intiated with ceftriaxone and a right chest tube ([**11-23**]) was placed by thoracic surgery and right knee was washed out with polyethylene liner exchange ([**11-24**]). In addition, patient was found to have cecal dilation on [**11-28**] and illeus, NG tube was placed to continuous suction, and the patient was started on erythromycin. The patient was persistently febrile since admission and his central line was exchanged on [**11-30**], sputum recultured with MRSA, and patient started on vancomycin. Patient was transferred to [**Hospital1 18**] on [**12-1**] at the request of his family for further evaluation for his persistent fevers. Past Medical History: HTN Hyperlipidemia Multiple Myeloma right TKR Social History: Divorced, with 2 children. No smoking, occasional alcohol, no drug use. Lives in [**Location 32775**]. Family History: non-contributory Physical Exam: VS: Temp:101.4 BP: 120/67 HR:88 RR:12 O2sat 99% on FiO2 50% Vent: AC 550/12/5/50% GEN: intubated and sedated HEENT: PERRL, pupils pinpoint, anicteric, MMD, op without lesions NECK: supple, no supraclavicular or cervical lymphadenopathy, no carotid bruits, no thyromegaly or thyroid nodules, could not assess JVP 2/2 body habitus RESP: Decreased BS L>R, with scattered inspiratory crackles CV: HS distant, RR, S1 and S2 wnl, no M/R/G appreciated ABD: distended, no BS appreciated, soft, nt, no masses, unable to assess for hepatosplenomegaly EXT: no c/c/e, warm, good pulses, hands b/l with mottled color SKIN: no rashes/no jaundice NEURO: limited [**1-30**] sedation, face symmetrical, no withdrawal to pain MSK: Right knee - incision c/d/i, no joint erythema, swelling or effusions Pertinent Results: [**2105-12-1**] 07:45PM BLOOD WBC-9.9 RBC-2.91* Hgb-9.3* Hct-28.9* MCV-99* MCH-32.1* MCHC-32.4 RDW-14.8 Plt Ct-319 Neuts-84.6* Lymphs-10.9* Monos-2.9 Eos-1.3 Baso-0.2 PT-14.9* PTT-37.2* INR(PT)-1.3* Glucose-127* UreaN-22* Creat-1.0 Na-140 K-4.2 Cl-113* HCO3-23 AnGap-8 ALT-22 AST-38 AlkPhos-59 TotBili-0.5 Lipase-142* Calcium-7.2* Phos-3.5 Mg-2.6 TotProt-9.2* Albumin-1.7* Globuln-7.5* Calcium-7.6* Phos-4.3 Mg-2.6 Iron-14* calTIBC-107* VitB12-1272* Folate-17.3 Ferritn-GREATER TH TRF-82* Triglyc-226* [**2105-12-6**] TSH-2.2 [**2105-12-2**] CRP-GREATER TH [**2105-12-2**] PEP-ABNORMAL B IgG-6435* IgA-92 IgM-25* IFE-MONOCLONAL [**2105-12-4**] Vanco-12.2 [**2105-12-7**] Vanco-24.9* [**2105-12-1**] Lactate-1.1 [**2105-12-1**] Type-ART Temp-37.8 pO2-102 pCO2-34* pH-7.46* calTCO2-25 Base XS-0 Intubat-INTUBATED [**2105-12-2**] ESR-125* KNEE (2 VIEWS) RIGHT PORT [**2105-12-2**] 5:30 PM Frontal and lateral projections of right knee, with no comparison on PACS, show total right knee replacement prosthesis in near anatomic alignment, and no hardware complications. The suprapatellar effusion is moderate. Osteophytes are present in the patella. Calcifications within the distal quadriceps tendon. Multiple surgical clips are present. IMPRESSION: Right total knee replacement with no complications. [**2105-12-2**] CT SINUS FINDINGS: No prior studies of the head are available for comparison. There is an endotracheal tube in place as well as an orogastric tube. There is minimal mucosal thickening of the right frontoethmoidal recess. There is moderate mucosal thickening of the left sphenoid air cell and minimal mucosal thickening of the right sphenoid air cell. Minimal mucosal thickening with small polypoid lesions is seen within the maxillary sinuses bilaterally. The right OMU is widely patent. The left OMU is somewhat narrowed but still patent. There is bilateral [**Doctor Last Name 13856**] bullosa. Nasal septum is deviated to the right with a right-sided nasal septal spur. The cribriform plates are essentially symmetric. There are no areas of bony destruction. The visualized mastoid air cells are clear. No suspicious bony abnormalities are seen. The visualized orbits are normal. The visualized intracranial structures are grossly normal. Fluid is seen within the nasopharynx. IMPRESSION: Mucosal changes of the paranasal sinuses as described above in the setting of orogastric and endotracheal tubes. No areas of bony destruction. [**2105-12-2**] CT CHEST WITH CONTRAST [**2105-12-2**]: IMPRESSION: 1) Circumferential complex right pleural disease likely due to organizing phase of empyema. No large loculated collections. 2) Bibasilar consolidation likely due to provided history of pneumonia. High attenuation focus within left basilar consolidation may be due to aspirated barium if the patient has received oral contrast at the outside hospital. 3) Small left pleural effusion and trace ascites. 4) Slight overdistention of endotracheal tube cuff. 5) Distended loops of bowel within the imaged portion of the upper abdomen on scout image incompletely evaluated. Consider dedicated abdominal radiograph if warranted clinically. 6) Incompletely imaged distended gallbladder. MRI OF THE TOTAL SPINE HISTORY: 63-year-old man with strep pneumonia, septic arthritis, and empyema who is persistently febrile; assess for epidural abscess. MR OF THE CERVICAL SPINE: TECHNIQUE: Sagittal pre-gado T1, post-gado T1 with and without fat sat, T2, STIR; axial T2-weighted images of the cervical spine were obtained as part of the total spine protocol. FINDINGS: No comparisons are available. There is enhancement and T2 hyperintensity of the retropharyngeal/prevertebral soft tissues extending from the skull base to the C3 level which is concerning for cellulitis/phlegmon. No discrete fluid collections are identified concerning for abscesses. There is minimal T2 hyperintensity and enhancement of the right side of the C2 vertebral body but without destructive changes of the adjacent endplates or signal abnormalities of the C2/3 disc. There is possible T1 hyperintensity in this region on the pre-gado images. These findings likely represent a hemangioma. The remainder of the visualized bone marrow signal is normal with no loss of vertebral body heights. At C3/4, there are degenerative changes of the right uncovertebral and facet joints causing mild right foraminal stenosis. At C4/5, there are degenerative changes of the right facet and uncovertebral joints as well as thickening of the ligamentum flavum which is causing moderate right foraminal stenosis. At C5/6, there is a disc osteophyte complex eccentric to the right and thickening of the ligamentum flavum, the combination of which is causing mild canal stenosis but no foraminal stenoses. No paraspinal soft tissue abnormalities are seen. MR OF THE THORACIC SPINE: TECHNIQUE: Sagittal pre-gado T1, post-gado T1 with and without fat sat, T2, STIR; axial T2-weighted images of the thoracic spine were obtained as part of a total spine protocol. FINDINGS: No comparisons are available. The alignment of the thoracic spine is normal. The visualized bone marrow signal is normal with no loss of vertebral body heights or intervertebral disc space heights. Spinal canal is widely patent. At T2/3, T5/6, T6/7, T8/9, and T9/10, there are small disc protrusions which are not contacting the ventral cord. Partially imaged is an azygos lobe of the right lung. There are also loculated fluid collections within the right pleural space and consolidation of the right lower lobe with apparent bronchiectasis. There is a right-sided chest tube in place. [**2105-12-2**] MR OF THE LUMBAR SPINE: IMPRESSION: 1. Edema and enhancement of the retropharyngeal/prevertebral soft tissues extending from the skull base to the C3 level without discrete fluid collections consistent with cellulitis/phlegmon. No abscesses. 2. No evidence of spondylodiscitis or epidural abscesses. 3. Degenerative changes of the cervical spine causing mild canal stenosis at the C5/6 level. 4. Degenerative changes of the lumbar spine causing mild canal stenosis at the L4/5 level. 5. Loculated fluid collections within the right pleural space with a chest tube in place. There is also consolidation in the right lower lobe with apparent bronchiectasis. [**2105-12-2**] LENIs IMPRESSION: No evidence of DVT. [**2105-12-2**] ECHO: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes and global systolic function. [**2105-12-3**] CT HEAD IMPRESSION: No acute intracranial process. Brief Hospital Course: STREPTOCOCCAL EMPYEMA: Patient had chest tube placement and infusion of TPA with successful drainage. SEPTIC PROSTHETIC KNEE: The patient was taken to the OR at [**Hospital1 34**] for washout polyethylene liner exchange. . MRSA VAP: Secondary to endotracheal intubation, successfully treated. . RETROPHARYNGEAL COLLECTION NOS: The initial imaging studies were concerning for a retropharyngeal collection, but after repeat imaging and ENT consultation this was not felt to be present. . DELIRIUM: Multifactorial including infection and hospitalization, slowly improving with suppotive care and minimizing the use of centrally acting medications. . SVT NOS: The patient had several episodes of SVT, but he remained in sinus for the remainder of the hospitalization. This was likely due to BB withdrawal and acute illness . ANEMIA: Secondary to blood loss from surgery and malignancy (Ferritin > 1000) . MULTIPLE MYELOMA: Diagnosed just prior to admission and he has had no treatment to date. He was treated with IVIG on [**12-4**], and will be due for a second in early [**2105-12-29**]. His work-up has been completed at OSH and his treatment will be managed by his primary oncologist: [**First Name8 (NamePattern2) **] [**Name8 (MD) 4223**], MD, [**Location (un) **], [**Hospital1 **],[**Numeric Identifier 10727**] [**Telephone/Fax (1) 10728**]. . ACUTE RENAL FAILURE: Resolved. . DYSPHAGIA: Still on pureed and thin liquids with supervision. This should continue to improve. . HYPERTENSION: Well controlled, HCTZ stopped, Toprol started for SVT and can be titrated up if there is the blood pressure is not well controlled. . HYPERLIPIDEMIA: Stable, continue statin. . DIABETES MELLITUS TYPE II: FSBS well controlled on Lantus and ISS . LINES: Right antecubital PICC line inserted [**2105-12-4**] . DVT PROPHYLAXIS: Lovenox . DISPOSITION: Being screened for rehabilitation, medically stable to go. Medications on Admission: Home: lisinopril 20mg daily lipitor 20mg daily Prilosec 30mg daily ASA 81 mg daily HCTZ 25mg daily . On Transfer: Albuterol neb Q4H prn Ipratropium neb Q4H prn Morphine 4mg Q30min prn pain Lorazepam 2mg Q1H prn pain Acetaminophen 650mg Q4h prn dilaudid 1mg Q20mins prn Atorvastatin 20mg daily ASA 81 mg dialy Heparin SC TID Combivent 10 puffs Q4hours Insulin SS Metoprolol 2.5mg IV Q6 hours Metoprolol 5mg IV Q6 hours erythromycin 250mg Q8 hours pantoprazole 40mg daily Ceftriazone 2gm Q12 hours Vancomycin 1gm Q12 hours Dexmedethomidine 800mcg Fentanyl gtt TPN Albumin 25% TID Discharge Medications: 1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 3. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a day). 4. Enoxaparin 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever. 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 8. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 9. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q12H (every 12 hours). 10. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 11. Vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q 12H (Every 12 Hours): LAST DOSE [**2105-12-22**]. 12. Haloperidol Lactate 5 mg/mL Solution Sig: One (1) Injection [**Month (only) **] GIVE 0.5-1.0 MG IV Q 2 HOURS PRN AGITATION (). 13. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. 14. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed. 15. Insulin Glargine and SS Give Lantus 5 units HS and Humalog per sliding scale 16. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-30**] Sprays Nasal QID (4 times a day) as needed. 17. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 18. Lisinopril WOULD RESTART THIS MEDICATION AT REHABILITATION IF TOLERATED BY BLOOD PRESSURE (was on 20 mg/day Discharge Disposition: Extended Care Facility: [**Location (un) **] center Discharge Diagnosis: RIGHT STREPTOCOCCAL PNEUMONIAE EMPYEMA STREPTOCOCCAL PNEUMONIAE SEPTIC PROSTHETIC KNEE INFECTION MRSA VENTILATOR ASSOCIATED PNEUMONIA DELIRIUM NOS SVT NOS ANEMIA - BLOOD LOSS AND MALIGNANCY MULTIPLE MYELOMA ACUTE RENAL FAILURE DYSPHAGIA HYPERTENSION HYPERLIPIDEMIA DIABETES MELLITUS TYPE II Discharge Condition: Stable Followup Instructions: Call for appointment with orthopedic surgeon: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 548**] [**Last Name (NamePattern1) 439**], [**Location (un) 86**], [**Telephone/Fax (1) 75347**] Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7443**], MD URGENT CARE ID Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2105-12-18**] 1:30 Call Dr. [**Last Name (STitle) 20090**],[**First Name3 (LF) 177**] S [**Telephone/Fax (1) 7164**] for a follow-up appointment

[ "560.1", "787.20", "481", "401.9", "518.5", "510.9", "711.06", "584.9", "272.4", "427.89", "294.8", "203.00", "482.41", "478.29", "280.0", "250.00", "V09.0", "996.66", "285.22", "V43.65" ]

icd9cm

[ [ [] ] ]

[ "96.6", "99.14", "38.93", "96.72", "99.10", "34.04" ]

icd9pcs

[ [ [] ] ]

14080, 14134

9770, 11673

321, 462

14470, 14479

2587, 9747

14502, 15007

1750, 1768

12302, 14057

14156, 14449

11699, 12279

1783, 2568

275, 283

491, 1544

1566, 1614

1630, 1734

13,356

103,812

45456+45457

Discharge summary

report+report

Admission Date: [**2119-1-25**] Discharge Date: [**2119-1-27**] Service: Neurosurgery HISTORY OF PRESENT ILLNESS: This is a [**Age over 90 **]-year-old woman who fell out of bed at rehabilitation and struck the left side of her head. No loss of consciousness. She complains of a left-sided headache with left shoulder pain. PAST MEDICAL HISTORY: 1. Hypertension. 2. Cerebrovascular accident (times three); no residual deficits. 3. Hernia. 4. Hypothyroidism. 5. Depression. 6. Seizure disorder. 7. Hard of hearing. 8. Odontoid fracture in [**2114**]. ALLERGIES: The patient is allergic to AMOXICILLIN. PHYSICAL EXAMINATION ON PRESENTATION: Vital signs revealed a normal sinus rhythm in the 60s, blood pressure was 236/50, respiratory rate was 17. The patient was awake and alert. She appeared in no acute distress. The lungs were clear to auscultation bilaterally. Cardiovascular examination revealed a regular rate and rhythm. The abdomen was soft, nontender, and nondistended. Extremities were warm and dry. Back and neck were nontender. Neurologically, the patient followed commands. Pupils were equal, round, and reactive to light and accommodation. Extraocular movements were intact. Left periorbital ecchymosis and swelling were noted. Strength was full with no deficits. RADIOLOGY/IMAGING: A head computed tomography revealed right temporoparietal subarachnoid hemorrhage with no shift. A computed tomography of the cervical spine revealed odontoid fracture (type 2) with 4-mm to 8-mm displacement; similar to findings reported in [**2114**]. Shoulder films showed no fracture or dislocation. HOSPITAL COURSE: The patient was admitted for blood pressure control with conservative management. The patient was placed in a hard collar. There were no complications throughout her stay. MEDICATIONS ON DISCHARGE: (Medications at the time of discharge included) 1. Docusate 100 mg p.o. b.i.d. 2. Senna one tablet p.o. q.d. 3. Venlafaxine 25 mg p.o. b.i.d. 4. Phenytoin 150 mg p.o. b.i.d. 5. Levothyroxine 100 mcg p.o. q.d. 6. Pantoprazole 40 mg p.o. q.24h. 7. Tylenol 325 mg to 650 mg p.o. q.4-6h. as needed. DISCHARGE DISPOSITION: The patient was discharged back to rehabilitation. DISCHARGE INSTRUCTIONS/FOLLOWUP: 1. The patient was to follow up with Dr. [**Last Name (STitle) 1327**] in two weeks. 2. The patient was to be discharged with an Aspen collar. [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2119-1-27**] 09:03 T: [**2119-1-27**] 09:04 JOB#: [**Job Number 43955**] Admission Date: [**2119-1-25**] Discharge Date: [**2119-2-1**] Service: NEUROLOGY ADDENDUM: The patient's discharge was delayed until [**2119-2-1**] secondary to lack of rehab bed. Patient's condition remained stable. She was neurologically at her baseline at the time of discharge. [**First Name11 (Name Pattern1) 125**] [**Last Name (NamePattern4) 342**], M.D. [**MD Number(1) 343**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2119-3-2**] 12:55 T: [**2119-3-2**] 13:11 JOB#: [**Job Number **]

[ "780.39", "244.9", "401.9", "852.01", "E884.4", "311" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

2189, 2241

1861, 2164

1659, 1834

2274, 3272

127, 340

362, 1641

2,658

126,865

3544

Discharge summary

report

Admission Date: [**2120-6-4**] Discharge Date: [**2120-6-19**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 759**] Chief Complaint: Change in mental status. Major Surgical or Invasive Procedure: Central line [**2120-6-5**]. History of Present Illness: History from son-in-law: - The pt. is an 86 yr old Burmese-speaking male with a past medical history of severe Parkinson's Disease and Type II DM who p/w tachypnea and change in mental status. Per family, over last 2 days pt has had decreased PO intake and yesterday his BG was in the 40's. Pt was given Ensure and then his BG today was in 400-500s. He has also been having increased sputum production and cough over last several days but no tachypnea until today. Denies F/C. He vomitted en route to ED but family denies any N/V/abd pain/diarrhea prior to that. In the ED, the pt was responsive to pain only and he was febrile to 102. He had a CXR showing multifocal pneumonia and he was started on Levaquin/Flagyl. He had an ABG 7.42/30/68 and lactate of 2.1. Other labs were notable for WBC of 6.3 w 70 % PMNs and 22% bands,GLC of 441 -> 10 Units insulin, 1 liter NS and one banana bag, and AG of 15. - On arrival to MICU, pt responds by opening his eyes but does not speak. He is moving all 4 ext. Per family, this MS is improved from this AM, but not completely at baseline. At baseline, he does speak some, but doesn't really walk. His PD has become severe recently. When admitted previously to NEBH for dehydration he has had similar change in MS per son-in-law. Past Medical History: 1) DM2 2) Parkinson's Disease - has baseline increased stiffness per neuro eval note on [**2118-9-5**] at NEBH 3) GI Bleed: EGD has shown peptic ulcers, gastritis, H. pylori pos. 4) Anemia - microcytic 5) Aseptic Meningitis [**2119-11-13**] Social History: Lives with daughter, son, wife. [**Name (NI) **] [**Name2 (NI) 269**]. Denies tobacco, alcohol. From [**Country 16225**]. Family History: No h/o cancer. Physical Exam: T [**Age over 90 **]F HR 90 BP 138/74 RR 20 95% on 3L NC GEN Opens eyes, repsonds to pain, in NAD HEENT surgical pupil OS, OP very dry. No LAD. Atypical moles on face. No JVD. CVE RRR, nml S1S2, -m/r/g CHEST clear to auscultation b/l ant ABD Guaiac +, soft, ? RUQ/epigastric tenderness, ND, NABS EXT 2+ distal pulses. Warm to touch. NEURO: moves all 4 ext. responds to pain. diffuse muscular rigigity UE>LE. Pertinent Results: CHEST (PORTABLE AP) [**2120-6-5**] 8:33 AM IMPRESSION: Worsening of multifocal consolidations, the most prominent one in the right lower lobe, associated with increasing pleural effusion and underlying CHF. These findings are probably representing progressive multifocal pneumonia. ECG Study Date of [**2120-6-4**] 11:47:38 AM Sinus rhythm Inferior T wave changes are nonspecific Since previous tracing of [**2113-9-4**], no significant change CT HEAD W/O CONTRAST [**2120-6-4**] 1:35 PM IMPRESSION: No acute intracranial hemorrhage. Chronic small vessel ischemic disease. Labs on admission: [**2120-6-4**] 08:00PM WBC-7.2 RBC-4.84 HGB-9.9* HCT-29.7* MCV-61* MCH-20.4* MCHC-33.2 RDW-16.2* [**2120-6-4**] 08:00PM PLT COUNT-194 [**2120-6-4**] 08:00PM NEUTS-46* BANDS-39* LYMPHS-7* MONOS-6 EOS-0 BASOS-0 ATYPS-0 METAS-2* MYELOS-0 [**2120-6-4**] 08:00PM GLUCOSE-202* UREA N-33* CREAT-1.5* SODIUM-144 POTASSIUM-4.0 CHLORIDE-112* TOTAL CO2-20* ANION GAP-16 [**2120-6-4**] 08:00PM CALCIUM-7.9* PHOSPHATE-2.5* MAGNESIUM-2.1 Brief Hospital Course: MICU course, by problem: 1. Aspiration Pneumonia: The pt. was found to have a multifocal pneumonia on admission X-ray, worst in the right lower lobe and felt to be consistent with an aspiration pneumonia. He was placed on levofloxacin and metronidazole. Blood cultures were drawn and were negative. Sputum culture was consistent with oropharyngeal flora. He was successfully weaned down in terms of oxygen requirement during his MICU stay. 2. Encephalopathy: CT of head on admission negative for acute bleed; he has evidence of chronic microvascular infarcts which appear to be unchanged from prior study in '[**18**] at NEBH. As per family, this change is similar to what has happened before when admitted for dehydration. The patient improved significantly with intravenous fluid rehydration. In addition, he received antibiotics. Change in mental status most likely secondary to dehydration in addition to underlying pneumonia and dehydration. 3. ARF: Was secondary to prerenal azotemia and improved with intravenous fluid hydration. 4. Parkinson's diease: The pt. was maintained on carbidopa/levodopa and entacapone. 5. [**Name (NI) 3674**] The pt was found to have guaiac positive stool. Iron studies consistent with chronic disease. As the pt. has a history of gastric ulcers, he was maintained on a PPI. He received one unit of PRBCs while in the MICU. His hematocrit subsequently remained stable. 6. DMII: Pt. takes amaryl 2 mg [**Hospital1 **] at home now with poor PO intake. Thus, oral hypoglycemics were held and the pt. was maintained on a SSI. . The patient was transferred to the floor after his oxygen requirement improved. His course on the medical floor was as below, by problem. # Pneumonia - He was continued on levaquin and flagyl x14 days. His sputum cultures were consistent with oral flora. He was on 4L oxygen when transferred and at discharge is saturating 98% on room air. # Encephalopathy - CT of head was negative for acute bleed - he has evidence of chronic microvascular infarcts which appear to be unchanged from prior study in '[**18**] at NEBH. As per family, the change in his mental status is similar to what has happened before when admitted for dehydration. His mental status improved with antibiotics and IVF but the patient continued to wax and wane; of particular note, this was significant for increased A.M. somnolence and rigidity. An EEG was done to rule out status epilepticus. This showed diffuse slowing consistent with encephalopathy but no evidence of seizure. Neurology also recommended an LP and MRI if his mental status was unimproved. Since he was afebrile the LP was deferred as was the MRI as a brainstem lesion was also thought to be low on the differential diagnosis. His was started on an additional small dose of Sinemet in the morning, resulting in significant improvement in his sleep/wake cycle and with mental status improving to baseline. His comtan was continued on a t.i.d. basis. . # ARF- his creatinine remained stable after leaving the ICU. . # Anemia- Guaiac+, microcytic, and has a history of ulcers. He was maintained on a PPI and his Hct remained stable. Iron studies were consistent with chronic disease. He and his family should consider an outpatient colonoscopy. . # DMII-As profound hypoglycemia and then hyperglycemia with inconsistent po intake was part of his initial presentation, his oral hypoglycemics were discontinued and he was maintained on sliding scale regular insulin. His fingersticks were labile and it was difficult to maintain euglycemia. NPH was added to his morning insulin regimen. His po intake is still not consistent so his sliding scale and NPH may regimen may continue to need adjustment. . # F/E/N: An NGT was placed in the [**Hospital Unit Name 153**] and he was maintained on tube feeds. He passed a video swallow, although was still thought to be aspiration during the study. He is now getting honey liquids and ground solids and his tube feeds have been discontinued. He is at significant risk for aspiration and needs to be fed upright and with careful attention to minimize this risk. . # PPx: He was maintained on SC heparin for DVT propylaxis, PPI for GI prophylaxis as well as a bowel regimen for constipation * # Comm: [**Name (NI) **] in law [**Doctor Last Name **]: Family Contact [**Telephone/Fax (1) 16226**] FULL CODE Medications on Admission: 1) Protonix po 40mg daily 2) Sinemet po 25/250 tid 3) Amaryl po 2mg [**Hospital1 **] 4) Comtan 200mg po tid Discharge Disposition: Extended Care Facility: [**Hospital1 2670**] - [**Location (un) **] Discharge Diagnosis: Sepsis, resolved Aspiration pneumonia, resolving Delerium, resolved Discharge Condition: stable and improved, afebrile, at baseline mental status and oxygenating at room air Discharge Instructions: Please seek immediate medical assistance if you experience worsening mental status, fever greater than 101, shaking chills or any other symptoms of concern to you. Please take all your medications as directed Followup Instructions: Please follow up with your PCP as needed. Please follow up with your outpatient neurologist in 2 weeks Please obtain an outpatient colonoscopy.

[ "332.0", "584.9", "293.0", "250.02", "294.10", "276.5", "281.9", "787.2", "507.0" ]

icd9cm

[ [ [] ] ]

[ "96.6" ]

icd9pcs

[ [ [] ] ]

8087, 8157

3555, 7928

285, 315

8269, 8355

2496, 3082

8613, 8760

2035, 2052

8178, 8248

7954, 8064

8379, 8590

2067, 2477

221, 247

343, 1615

3097, 3532

1637, 1880

1896, 2019

30,887

169,610

9619

Discharge summary

report

Admission Date: [**2146-7-11**] Discharge Date: [**2146-7-18**] Date of Birth: [**2091-8-27**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 949**] Chief Complaint: Altered Mental Status and difficult to wake up. Major Surgical or Invasive Procedure: Therapeutic Parasentesis History of Present Illness: Mr. [**Known lastname 32595**] is a 54M with a PMH significant for cirrhosis complicated by portal HTN and frequent admissions for hepatic encephalopathy. Of note the patient required reversal of his TIPS from the severity of this complication. He was in his usual state of health until the morning of [**7-9**] when his wife found him unresponsive in their bed after the patient had gone to bed with no difficulty the morning prior. She noted that he was "gurgling", attempted to suction him, and called EMS. In the ED at [**Hospital3 **] he was intubated for airway protection. In their ICU he was managed with lactulose enemas while intubated, and his ammonia level fell from 168 to 38. As his mental status improved he was extubated. Approximately one day into his hospitalization he spiked a fever. Urine cultures returned growing ESBL E. coli. His abdomen was noted to be more firm than admission, and there was concern for SBP. The patient was started on levaquin and zosyn. The patient then was transfered to the [**Hospital1 18**] ICU for further management. Past Medical History: 1. EtOH induced cirrhosis -Portal HTN -Grade I esophageal varices -Diuretic refractory ascites. -On [**Hospital1 **] list after a recent 40lb weight loss, MELD score 14 -Multiple admissions to [**Hospital3 3583**] and [**Hospital1 18**] for hepatic encephalopathy -s/p TIPS [**2137**] with frequent revisions i012/[**2144**] and then closure in [**4-/2146**] secondary to hepatic encephalopathy 2. CKD with baseline Cr 1.6 3. DM2, insulin dependent 4. s/p ccy for porcelain gallbladder in [**10/2145**] 5. Carcinoid tumor in gastric fundus 6. OSA on BiPAP at home c/b mild pulmonary hypertension 7. Squamous cell skin ca on left shoulder 8. Pancytopenia -Chronic from underlying liver disease -Baseline HCT in mid 20s -Baseline platelets in 20-40 Social History: Married to wife [**Name (NI) **] and living in [**Name (NI) 3320**]. 16 py h/o smoking, quit 27 years ago. H/O alcohol abuse, quit 10 yrs ago. Remote marijuana/cocaine use in the 60s-70s, no IVDU. Umemployed at present. He previously worked as the Director of food & beverage services on a cruisline in the Hawaiian islands. Family History: Mother, d 56: CVA Father, d 84: [**Name (NI) 2481**] Sister: DM2, seizures Brother, older: [**Name2 (NI) 3495**] disease Brother, younger: [**Name2 (NI) **] known disease Physical Exam: Vital Signs: T=96.3 BP=109/72 HR=90 RR=12 O2=99%RA GENERAL: Pleasant, well appearing male in NAD. A&Ox3. HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No thyromegaly. CARDIAC: Regular rhythm, normal rate. Normal S1, S2. SEM on RUSB [**12-19**]. LUNGS: CTAB, good air movement biaterally. ABDOMEN: Distended, firm, but not tense, non-tender to deep palpation, no HSM (difficult to assess due to pannus). EXTREMITIES: Bilateral chronic venous stasis dermatitis, 2+ pulses, no edema. Patient has a blister of 2cm2 in the posterior part of the L ankle. There is no surroundig erythema and it is not tender. NEURO: A&Ox3, poor short term memory. Appropriate. CN 2-12 grossly intact. Preserved sensation throughout. 5/5 strength throughout. Normal gait. PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: Relevant Imaging: Cxray ([**7-12**]): In comparison with the study of [**6-9**], the left hemidiaphragm is sharply seen, though the costophrenic angle has been excluded from the image. here is haziness involving much of the left hemithorax with preservation of pulmonary markings. This may represent a layering pleural effusion. Some indistinctness of pulmonary vessels raises the possibility of some elevated pulmonary venous pressure. No acute focal pneumonia is appreciated. [**2146-7-18**] 05:50AM BLOOD WBC-1.9* RBC-2.43* Hgb-8.1* Hct-23.3* MCV-96 MCH-33.6* MCHC-34.9 RDW-17.6* Plt Ct-23* [**2146-7-12**] 02:46AM BLOOD WBC-2.5* RBC-2.72* Hgb-9.1* Hct-25.9* MCV-95 MCH-33.4* MCHC-35.0 RDW-16.5* Plt Ct-22* [**2146-7-13**] 05:30AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-1+ Ovalocy-1+ [**2146-7-18**] 05:50AM BLOOD PT-17.5* PTT-44.1* INR(PT)-1.6* [**2146-7-12**] 02:46AM BLOOD Plt Ct-22* [**2146-7-12**] 02:46AM BLOOD PT-20.9* PTT-39.2* INR(PT)-2.0* [**2146-7-18**] 05:50AM BLOOD Glucose-221* UreaN-57* Creat-0.9 Na-131* K-4.3 Cl-103 HCO3-18* AnGap-14 [**2146-7-12**] 02:46AM BLOOD Glucose-221* UreaN-46* Creat-1.2 Na-139 K-3.5 Cl-108 HCO3-22 AnGap-13 [**2146-7-18**] 05:50AM BLOOD ALT-23 AST-33 AlkPhos-133* TotBili-2.0* [**2146-7-12**] 02:46AM BLOOD TotBili-3.3* [**2146-7-18**] 05:50AM BLOOD Albumin-3.1* [**2146-7-12**] 02:46AM BLOOD Albumin-2.9* Calcium-8.6 Phos-2.9 Mg-1.4* [**2146-7-13**] 01:59PM URINE Color-Amber Appear-Clear Sp [**Last Name (un) **]-1.014 [**2146-7-13**] 01:59PM URINE Blood-LG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-15 Bilirub-MOD Urobiln-NEG pH-5.0 Leuks-TR [**2146-7-13**] 01:59PM URINE RBC-[**5-24**]* WBC-0-2 Bacteri-MOD Yeast-OCC Epi-[**2-16**] [**2146-7-15**] 07:32PM URINE Eos-NEGATIVE [**2146-7-15**] 07:32PM URINE Hours-RANDOM UreaN-422 Creat-213 Na-LESS THAN [**2146-7-15**] 07:32PM URINE Osmolal-355 URINE CULTURE (Final [**2146-7-15**]): ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ =>32 R LINEZOLID------------- 2 S NITROFURANTOIN-------- 256 R TETRACYCLINE---------- <=1 S VANCOMYCIN------------ =>32 R Brief Hospital Course: Mr. [**Known lastname 32595**] was found non-responsive was found unresponsive on Saturday [**7-9**]. He was unable to be awakened in the morning. Patient was feeling fine prior this episode. His wife called 911 and pt. was transfered to [**Hospital1 32605**] ICU. During his stay in there he was intubated and received treatment with lactulose 120 ml TID and meropenem for UTI on the UA (pt. had h/o ESBL E coli). Patient had massive explosive diarrhea for 1 day and then his symptoms started to improve. Pt. was extubated and with encephalopathy grade III slowly improving. However, on the afternoon of [**7-11**], he started with a harder abdomen of physical exam. There was a concern for SBP, so patient had a urinalysis, was given Vancomycin/ Zosyn and then was transfered to the ICU of the [**Hospital1 18**]. During the first hospital day at [**Hospital1 18**] Mr. [**Known lastname 32595**] had stable vital signs in the ICU; he was afebrile, he was responsive, extubated, A&Ox2 (time). A UA and urine culture were sent, CXR showed atelectases and a small left pleural effusion, not concerning for pneumonia. On [**7-12**] he was transfered to the [**Doctor Last Name 3271**]-[**Doctor Last Name 679**] service. In the floor, high-dose lactulose was continued. The patient had [**6-25**] bowel movements per day; each one >1 L. Pt. encephalopathy progressively got better until pt. reached his baseline. Lactulose was slowly tapered down. On HD3 cultures at OSH were positive for ESBL E coli. However, patient was improving in treatment with meropenem. On HD4 urine cultures at [**Hospital1 18**] were positive for enterococcus. Since patient was improving in meropenem we decided to keep him on it for the enterococcus. However, during this day the patient had an increase in creatinine from 1.3 to 1.7. Patient was given 1.5 L of IV fluids and second creatinine measurement was 1.9. Patient was continued on IV fluids, encouraged PO intake as well. Urine eos were negative, and FeNa was <1%. Patient was diagnosed with acute renal failure due to dehydration secondary to massive diarrhea. During the entire hospital stay patients WBC count were at his baseline of 1.9-2.1 with Hgb ~10 g/dL and ~30,000 plts. On [**7-17**] patient's abdomen became tense due to the fluid accumulation despite diuretic therapy. Due to the patient's low platalet count and morbid obesity, he was scheduled for USG-guided therapeutic parasentesis on [**7-18**], which was done sucessfully and drained 6.5 L of peritoneal fluid. Patient received 1 bag of platelets before the procedure (23,000 before transfusion, INR 1.6) and he received 8 g of albumin per liter retrieved. Patient was monitored after the procedure for orthostasis and was discharged home. Medications on Admission: Medications on transfer: Levofloxacin 500mg daily Zosyn 3.375mg q6H Lasix 160mg daily Nadolol 20mg daily Pantoprazole 40mg daily Spironolactone 100mg [**Hospital1 **] Lactulose 90cc q6H Rifaximin 200mg [**Hospital1 **] Nystatin powder Medications at home: Lasix 80 mg [**Hospital1 **] Spironolactone Lactulose Nadolol Rifaximin Protonix 40mg daily NPH 70 units [**Hospital1 **] ISS Magnesium 400mg daily Glucerna shakes [**Hospital1 **] Nystatin powder Discharge Medications: 1. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN (as needed). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 5. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 6. Insulin Please continue your prior insulin regimen. 7. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO twice a day. 8. Furosemide 80 mg Tablet Sig: One (1) Tablet PO once a day. 9. Magnessium Take as you were taking it before. 10. Ertapenem 1 gram Recon Soln Sig: One (1) Intravenous every twenty-four(24) hours for 7 days. Disp:*7 Recon [**Male First Name (un) **] Bottles* Refills:*0* Discharge Disposition: Home With Service Facility: [**Male First Name (un) 269**] ASSo. of Cape Cold Discharge Diagnosis: Alcoholic cirrhosis with encephalopahty. Urinaty Tract Infection with extended expectrum beta lactamase producing (ESBL) Eschlerichia coli and enterococcus. Improved Acute Renal Failure Discharge Condition: Stable, breathing comfortably on RA, with peripheral line for IV antibiotics. Discharge Instructions: You were seen at the [**Hospital1 18**] for alcoholic cirrhosis with encephalopathy. You were found very somnolent at home, and were taken to [**Hospital1 32605**] ICU, where you were intubated and given lactulose. You improved, but your abdomen got tense and your urine culture was positive for ESBL E. coli. So you were transfered to the [**Hospital1 18**] on [**7-11**] for further management. You were admitted to our ICU. You were stable during that day and later were transfered to the liver-kidney floor. Your chest x-ray showed a small ammount of fluid in your lungs, but this was not of concern. In the floor you were continued on high-dose lactulose. Your had enormous bowel movements and very frequent, so we tapperred down the lactulose. Your encephalopathy progresively got better until you were at your baseline. However, the excesive ammount of fluid you lost in your stool caused you to have acute renal failure. You were given albumin and fluids back, your lactulose was further tappered down and with this management your creatinine improved back to normal (measurement of kidney function). During the entire hospital course your white blood cells and platelets were low, but quite the same level as before. Your abdomen became tenser, so you required a therapeutic parasenteses. You received platelets before the procedure and albumin afterwards. There were no complications. We did a urine culture in this hospital, which grew enterococcus. Since you were already in antibiotics and improving we continued the antibiotics and will keep them at home to complete a full course. We have no data in the sensitivity of this bacteria to the antibiotics you are receiving, but did not want to change them, because the other options may be toxic to your liver or lower your platalets further. You must keep taking fluids to keep your kidneys working. The key is to maintain your genitals absolutely clean after every bowel movement. You may need to wash yourself with water and soap afterwards, including all your skin folds. Then, perfectly dry your skin. Both bacteria can be found in the stool/gut so, that is the most likely source. Also it is important to take your lactulose so you have [**2-17**] bowel movements per day. Take your diuretics as directed in the med sheet to avoid fluid accumulation in your abdomen. If you become febrile, your wife notes that your mind is not at baseline, the redness in your ankle increases, it becomes painful, you start with tremors in your hands, nausea, vomit or any other thing that concerns you please come back to our ER. Followup Instructions: Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2146-7-19**] 11:10 Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2146-7-19**] 11:30 Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2146-7-19**] 11:30 With your primary care as needed.

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Discharge summary

report

Admission Date: [**2138-4-20**] Discharge Date: [**2138-5-16**] Date of Birth: [**2083-12-22**] Sex: M Service: CARDIOTHORACIC Allergies: Keflex Attending:[**First Name3 (LF) 922**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: Emergent coronary artery bypass grafting x3 on an intra-aortic balloon pump with left internal mammary artery to left anterior descending coronary; reverse saphenous vein single graft from aorta to ramus intermedius coronary artery; reverse saphenous vein single graft from aorta to first obtuse marginal coronary artery. History of Present Illness: 54 YO M with DMII, HTN, HLD, PVD s/p fem-[**Doctor Last Name **] bypass on the left and iliac stent on the right, ? h/o MI without intervention, presented to the ED at [**Hospital1 1474**] found to be in DKA with glucose in the 490's. Per report patient with gradual onset weakness, nausea, loose stool, excessive thirst. Due to decreased PO intake patient omitted "several days" of insulin therapy. Progressive symptoms prompted presentation to OSH ED found to have a ph 7.0 and admitted to ICU for treatment of DKA. In the ICU patient placed on an Insulin gtt overnight and covered empirically with broad spectrum antibiotics: vancomycin and flagyl. In the AM, gap had resolved and pH normalized and transitioned to SQ Lantus. Antibiotics were stopped as clinical suspicion for infection low. Later in morning, he was noted to develop increased agitation, EKG showed ST depression V4-V6. Patient started on Arixtra for anticoagulation as unable to start Heparin secondary to allergy (though pt received hep SQ during OSH stay without problem) and patient refused [**Name (NI) **]. CXR obtained which was consistent with volume overload. He was urgently taken to Cath lab. Per report he was intubated for respiratory stabilization pre-procedure but had never been hypoxic. In cath lab, he was noted to have severe distal left main disease with diffused LAD disease, RCA noted to be chronically occluded, there are collateral artery L-R and R-R, PCWP of 35, EF of [**9-27**]%. IABP was placed through right femoral artery and vein. In the cath lab he was given 40mg of IV Lasix, 5 of dobutamine and 20 of levophed and agumented BP to 140s of note his prior unaugmented SBP was 85-90 systolic. Per med flight patient with uneventful transport. He is sedated (versed) and paralyzed (vecuronium). On arrival to the CCU patient SBP is augmented with levophed. Cardiac surgery consulted for coronary revascularization. Past Medical History: Diabetes mellitus Type II Peripheral Vascular Disease Hypertension Hypercholesterolemia ?prior Myocardial infarctions without intervention Prior Transient Ischemic Attacks History of Alcohol abuse s/p Right lower extremity SFA to AT bypass eith saphenous vein [**2132**] Appendectomy Laparoscopic cholecystectomy Social History: Lives with wife, h/o alcohol abuse with withdrawal though reports no alcohol use in 1.5 years, h/o tobacco abuse 3ppd x 35 years though quit 1.5 years ago. denies IVDU Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: On Admission: GENERAL: Intubated, Sedated, Paralyzed NAD. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, OT tube in place with yellow secretions. No xanthalesma. NECK: Supple. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. SEM heard throughout precordium. No thrills, lifts. No S3 or S4, no peripheral edema. LUNGS: No chest wall deformities, scoliosis or kyphosis. Anterior fields with anterior rhonchi. No audible crackles. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: Cool, missing right toes. Right femoral line in place - No groin hematomas SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ DP 0 PT 0 Left: Carotid 2+ Femoral 2+ dopplerable DP dopplerable PT 2+ T/L/D: - ET in place - foley - IABP in right femoral artery and vein - right and left radial artery line . On Discharge: Pertinent Results: [**2138-5-15**] 05:00AM BLOOD WBC-5.1 RBC-3.23* Hgb-10.3* Hct-31.2* MCV-97 MCH-32.0 MCHC-33.1 RDW-18.1* Plt Ct-197 [**2138-5-13**] 03:17AM BLOOD WBC-4.9 RBC-3.30* Hgb-10.6* Hct-31.4* MCV-95 MCH-32.1* MCHC-33.7 RDW-18.1* Plt Ct-161 [**2138-5-11**] 04:38AM BLOOD WBC-5.1 RBC-3.22* Hgb-10.3* Hct-31.1* MCV-97 MCH-32.0 MCHC-33.2 RDW-18.5* Plt Ct-171 [**2138-5-15**] 05:00AM BLOOD Glucose-116* UreaN-33* Creat-1.2 Na-138 K-4.3 Cl-99 HCO3-30 AnGap-13 [**2138-5-14**] 05:59AM BLOOD Glucose-69* UreaN-31* Creat-1.0 Na-138 K-3.5 Cl-96 HCO3-34* AnGap-12 [**2138-5-13**] 03:17AM BLOOD Glucose-243* UreaN-31* Creat-0.9 Na-134 K-4.4 Cl-94* HCO3-34* AnGap-10 [**2138-5-12**] 05:15AM BLOOD UreaN-26* Creat-0.7 Na-137 K-4.3 Cl-96 . Biomarker Trend: [**2138-4-20**] 01:25AM BLOOD CK-MB-215* MB Indx-14.0* cTropnT-2.54* [**2138-4-20**] 06:59AM BLOOD CK-MB-251* MB Indx-12.5* cTropnT-4.64* [**2138-4-20**] 01:28PM BLOOD CK-MB-167* MB Indx-7.9* cTropnT-5.01* [**2138-4-20**] 10:12PM BLOOD CK-MB-63* MB Indx-4.1 cTropnT-3.30* [**2138-4-21**] 05:01AM BLOOD CK-MB-35* MB Indx-2.8 cTropnT-3.12* [**2138-4-21**] 05:25PM BLOOD CK-MB-15* MB Indx-1.4 cTropnT-3.09* [**2138-4-21**] 11:07PM BLOOD CK-MB-11* MB Indx-1.2 cTropnT-2.39* [**2138-4-20**] 06:59AM BLOOD % HbA1c-11.4* eAG-280* Imaging: . OSH CARDIAC CATH: [**2138-4-19**] LM 90% LAD: 90% Lcx: luminal irregularities RCA: 100% Right heart cath: RA: 15 RV: 50/15 PA: 50/35 PCWP: 35 Cardiac Output: 3.8L/min Cardiac Index: 2L/min/m2. EF: 15%, no significant MR . CXR: PORTABLE CHEST, [**2138-4-20**] FINDINGS: Radiodense tip of an intraaortic balloon pump is at the expected junction of the superior aspect of the aortic knob and left subclavian artery, as communicated by telephone to Dr. [**First Name (STitle) 1255**] on [**2138-4-20**] at 8:20 a.m. Endotracheal tube and nasogastric tube are in standard position. Heart size is normal. Bilateral interstitial pulmonary edema is present as well as an asymmetrical left perihilar alveolar process, likely reflecting asymmetrical edema. . TTE: [**4-/2138**] The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is severe global left ventricular hypokinesis (LVEF = 20-25 %). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. There is no aortic valve stenosis. No aortic regurgitation is seen. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname 275**] [**Hospital1 18**] [**Numeric Identifier 67845**] (Complete) Done [**2138-4-22**] at 1:36:29 PM 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: [**2083-12-22**] Age (years): 54 M Hgt (in): 70 BP (mm Hg): 103/67 Wgt (lb): 150 HR (bpm): 78 BSA (m2): 1.85 m2 Indication: Intraoperative TEE for CABG procedure. Chest pain. Coronary artery disease. Left ventricular function. Preoperative assessment. Right ventricular function. ICD-9 Codes: 786.05, 786.51, 424.0, 424.2 Test Information Date/Time: [**2138-4-22**] at 13:36 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1510**], MD Doppler: Limited Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2011AW3-: Machine: u/s 3 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 20% >= 55% Aorta - Ascending: 2.9 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: Severe regional LV systolic dysfunction. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal descending aorta diameter. AORTIC VALVE: Normal aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: 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. Left pleural effusion. 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 severe regional left ventricular systolic dysfunction with akinesia of the apex and apical portion of the inferior wall. There is also hypokinesia of the apical and mid portions of the anterior, anteroseptal and inferospetal walls . Right ventricular chamber size and free wall motion 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. Mild (1+) mitral regurgitation is seen. Tip of IABP in good position. Dr. [**Last Name (STitle) 914**] was notified in person of the results on [**2138-4-22**] at 1230pm. Post bypass Patient is AV paced and receiving an infusion of phenylephrine, milrinone and epinephrine. LVEF= 35%. Aorta is intact post decannulation. Mild mitral regurgitation present. 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) **] [**2138-4-23**] 17:03 ?????? [**2129**] CareGroup IS. All rights reserved. Brief Hospital Course: 54 Year old male with DMII, Hypertension, Hyperlipidemia, Peripheral vascular disease, question history of Myocardial Infarction without intervention, initially treated for Diabetic keto acidosis but found to have worsening signs of Congestive heart failure, EKG changes, + Cardiac enzymes, ejection fraction of 10%, intubated, IABP in place and on pressors for treatment of cardiogenic shock transferred via med flight from outside hospital. His hospital course was complicated by multiple episodes of VF arrest. On [**2138-4-22**] he was taken to the operating room and underwent emergent coronary artery bypass grafting x3 on an intra-aortic balloon pump with left internal mammary artery to left anterior descending coronary; reverse saphenous vein single graft from aorta to ramus intermedius coronary artery; reverse saphenous vein single graft from aorta to first obtuse marginal coronary artery with Dr.[**Last Name (STitle) 914**]. Cardiopulmonary BYPASS TIME: 92 minutes. CROSS-CLAMP TIME: 64 minutes. Please see operative report for further surgical details. He was transferred to the CVICU intubated, sedated on pressors. He remained intubated on pressors until [**2138-4-28**] when he was weaned off and was successfully extubated. Events: [**2138-5-5**] he was hypotensive requiring pressors and decreasing renal function. An echocargiogram was done and revealed a large pericardial effusion with right ventricular diastolic collapse. He was taken to the operating room for Subxiphoid pericardial window. Respiratory: aggressive pulmonary toilet, chest PT, nebs, his oxygen requirement improved to 2-4Lpm via nasal cannula. Chest-tubes: were all removed per protocol Cardiac: Intermittent atrial fibrillation 90-135, amiodarone bolus and drip with low-dose beta-blocker he converted to sinus rhythm. GI: aggressive bowel regimen and PPI were continued Nutrition: he was seen by Speech and Swallow on [**2138-4-29**] who recommended regular diet thin liquid, medications whole with water. His PO intake was poor. On [**2138-5-7**] he was seen again by Speech who recommended a regular diet, thin liquid and medications whole pills. Nutrition recommended Cardiac, Diabetic, Sugar-Free Carnation Instant Breakfast. His PO intake continued to be poor therefore a Doboff feeding tube was placed and tube feeds were started. Nutrition recommended Boost Glucose Control @ 90 mL x 15 hrs to supplement his PO intake. ID: On [**2138-4-29**] he was seen by infectious disease for low-grade fevers, positive BC for strept viridans, catheter tip with [**Female First Name (un) 564**] Albicans. He completed a 2 week course of Vancomycin and fluconazole per ID recommendations. Renal: Renal function baseline Creatnine 0.9 On [**2138-5-5**] his Creatnine increased to 1.3 peak 2.1 secondary to large pericardial effusion which once treated his renal function returned to his baseline. He was gently diuresed. His electrolytes were repleted as needed. Required foley re-insertion for urinary retention. Flomax was started and he was discharged to rehab with his Foley. He will have a void trial on [**5-20**], following a week of Flomax therapy. Endocrine: Insulin drip was titrated to maintain blood sugars < 150 converted to Lantus with sliding scale regular once transfer to floor Neuro: Flat-affect. follows commands. Pain well controlled with PO pain medications. Disposition: He was seen by physical therapy. Requires max assist for ambulation and lift device. On POD 24 he was discharged to [**Hospital 38**] Rehab Hospital in [**Location (un) 38**]. All follow up appointments were advised. Medications on Admission: Aggrenox 1cap [**Hospital1 **], Trazadone 50mg qhs, lorazepam 1mg Q6H, pantoprazole 40 mg Q12H, metoprolol 50 mg [**Hospital1 **], simvastatin 80 mg QD, Lantus 45u-breakfast & bedtime, RISS Discharge Medications: 1. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 2. enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) Subcutaneous Q12H (every 12 hours). 3. quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 5. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): 400mg daily x 1 week, then 200mg daily until further instructed. 6. atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 11. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 12. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 13. nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 14. nystatin 100,000 unit/g Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for groin yeast. 15. indomethacin 25 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 16. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. insulin glargine 100 unit/mL Solution Sig: Twenty (20) Subcutaneous at bedtime: 20 units at bedtime. 19. insulin regular human 100 unit/mL Solution Sig: One (1) Injection four times a day: per attached Regular Insulin Sliding Scale. 20. furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 1 weeks. 21. potassium chloride 10 mEq Tablet Extended Release Sig: Two (2) Tablet Extended Release PO once a day for 1 weeks. 22. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain, fever. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: 1. Severe 3-vessel coronary artery disease. 2. Acute myocardial infarction. 3. Cardiogenic shock. 4. Malignant ventricular arrhythmias. 5. Severe peripheral vascular disease status post bilateral femoral artery to dorsalis pedal bypasses. 6. Acute respiratory failure requiring intubation. 7. History of esophageal varices. 8. Previous alcoholic. 9. Previous tobacco user. Discharge Condition: Alert and oriented x3 nonfocal Deconditioned Incisional pain managed with oral analgesia Sternal - healing well, no erythema or drainage Leg Right/Left - 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**] 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: Provider [**First Name8 (NamePattern2) 177**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2138-5-20**] 1:45 in the [**Hospital Unit Name **] [**Last Name (NamePattern1) **] [**Hospital Unit Name **] Provider VASCULAR LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2138-5-26**] 12:30 Provider [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2604**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2138-5-26**] 1:30 [**Hospital Unit Name **] [**Last Name (NamePattern1) **] Please schedule the following appointments on discharge from rehab: Cardiology, Dr. [**Last Name (STitle) **] PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 6699**] Completed by:[**2138-5-16**]

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icd9cm

[ [ [] ] ]

[ "38.97", "39.61", "37.61", "37.12", "36.12", "96.72", "38.93", "89.64", "99.69", "36.15", "96.04", "96.6" ]

icd9pcs

[ [ [] ] ]

16314, 16411

10284, 13910

284, 608

16831, 17035

4209, 8961

17959, 18762

3095, 3210

14150, 16291

16432, 16810

13936, 14127

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3225, 3225

4190, 4190

234, 246

636, 2556

3239, 4174

2578, 2892

2908, 3078

64,983

101,162

9207

Discharge summary

report

Admission Date: [**2106-10-4**] Discharge Date: [**2106-10-9**] Date of Birth: [**2049-8-24**] Sex: M Service: MEDICINE Allergies: Morphine / Hydromorphone / Nitroglycerin / Reglan Attending:[**First Name3 (LF) 3984**] Chief Complaint: nausea, vomiting and diarrhea - transfer from [**Hospital3 3583**] Major Surgical or Invasive Procedure: Transesophageal echocardiography Electrical cardioversion History of Present Illness: 57 year old male with pmhx significant for CAD s/p CABG and LAD stent, porcine tricuspid valve, complete heart block s/p pacemaker, hypertension, GERD, biliary stricture s/p CCY and MVA [**2071**] s/p multiple abdominal surgeries including partial liver resection who is transferred from [**Hospital3 3583**] with nausea, vomiting and diarrhea for further GI evaluation. . Patient initially presented to [**Hospital3 3583**] on [**2106-10-3**] with right-sided rib pain, nausea, vomiting (x 1 day) and loose stools (4-5 per day x 1 month, non-bloody). He was found to have a total bilirubin of 1.9, ast 71 and alt of 76; also with elevated white blood cell count of 18.6. Patient had an abdominal CT scan on admission which showed fluid in the colon consistent with enteritis vs colitis. He was started on iv ciprofloxacin and metronidazole. Stool was negative for C.difficile. GI (Dr. [**Last Name (STitle) **] was consulted, reviewed the CT scan with radiology - stable dilation of the CBD compared to [**2102**] and [**2101**] with dilation all the way to the ampulla and no intraluminal abnormality/stone seen; also with stable segmental intrahepatic dilation that appears to be related to previous liver surgery. Dr. [**Last Name (STitle) **] was concerned for biliary obstruction however patient unable to have MRCP due to pacemaker. Per patient's request was transferred to [**Hospital1 18**] for further evaluation. Of note total bilirubin decreased to 1.1 but ALT increased from 76 to 102. . Regarding patient's right-sided rib pain - described as constant, starts under right axilla and radiates to right shoulder and right upper quadrant, worse with inspiration. No recent falls. An x-ray was done at [**Hospital3 3583**] which showed healing fractures of the right 8th and 9th ribs (patient had presented to the [**Hospital1 18**] ED on [**2106-7-26**] after falling out of a broken chair and elbow pushing into right chest wall - pa/lat cxr at the time did not reveal any rib fractures; rib pain had resided two weeks ago). Given patient's significant cardiac history he was monitored on telemetry at [**Hospital3 3583**] without any significant events and ruled out for AMI with 4 sets of negative troponins. CTA of chest was done which was negative for pulmonary embolism (had a positive d-dimer). . Currently patient continues to have right-sided rib pain with inspiration that is [**10-4**] at maximum. Denies any chest pain or sob. Endorses several episodes of palpitations over the past week. Currently denies any abdominal pain. Endorses nausea and dry heaves. No po intake since hospitalization and no further bowel movements. . ROS: - Constitutional: No fevers, chills, sweats, + 2 lbs weight loss, decreased appetite with early satiety x 1 month - HEENT: no changes in vision or hearing, no rhinorrhea, nasal congestion, sore throat, + chronic headaches - Respiratory: no cough, shortness of breath, dyspnea on exertion - Cardiac: + palpitations (several episodes in past week), orthopnea, PND - GI: no BRBPR, melena - GU: no dysuria, hematuria, urgency, frequncey - Hematologic/lymphatic: no bleeding, bruising or lymphadenopathy - MSK: no arthralgias or myalgias - Neuro: no weakness, numbness, seizures, difficulty speaking, changes in memory. - Skin: no rash or pruritis - Psychiatry: no depression or suicidal ideation All other systems negative Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: a)CABG: [**7-/2095**] with SVG to PDA b)PERCUTANEOUS CORONARY INTERVENTIONS: - [**2097**]: Cypher placed in the mid LAD - [**2098**]: PTCA with stent to proximal LAD - [**2101**]: angiograph w/o stenting - [**2104-12-14**]: DES to proximal LAD overlapping with prior stent and POBA to D1 c)PACING/ICD: CHB after CABG, s/p dual chamber pacemaker 3. OTHER PAST MEDICAL HISTORY: - tricuspid valve replacement, porcine [**7-/2095**] - s/p pericardial window - Hypertension - Hypercholesterolemia - MVA [**2071**], 3 month ICU stay at [**Hospital1 2025**] with multiple abdominal surgeries including splenectomy, partial liver resection, partial gastrectomy, and left diaphragm rupture and repair. - GERD - Anxiety - History of migraines - BPH Social History: married with three children, independent not currently working, on disability no current tobacco (distant past hx) no alcohol or illicits Family History: Father - AMI age 40 with hx of rheumatic fever Mother - hypertension [**Name2 (NI) **] known fhx of cancer or diabetes Physical Exam: 97 84P 20RR 116/60 98%RA Appearance: alert, pale appearing, dry heaving Eyes: eomi, perrl, anicteric ENT: OP clear s lesions, mm very dry, no JVD, neck supple Cv: +s1, s2 -m/r/g, no peripheral edema, 1+ dp/pt bilaterally Pulm: decreased bs at bases Abd: multiple old surgical scars, soft, nt, nd, +bs Msk: tenderness right side over ribs 8 and 9; 5/5 strength throughout, no joint swelling, no cyanosis or clubbing Neuro: cn 2-12 grossly intact, no focal deficits Skin: no rashes Psych: appropriate, pleasant Heme: no cervical [**Doctor First Name **] Pertinent Results: OSH Labs [**2106-10-3**]: labs from admission note, awaiting labs to be faxed from [**Hospital3 3583**] wbc 18.6 -> 16 hct 44 plts 212 . 135 103 20 ------------< 3.8 25 0.9 . ast/alt 71/76 t bili 1.9 alk phos 57 albumin 4.4 lipase 27 amylase 38 . c.diff toxin/antigen negative [**Hospital1 18**] Labs: Cardiac enzymes: [**2106-10-4**] 09:00PM BLOOD CK-MB-2 cTropnT-<0.01 [**2106-10-6**] 01:35PM BLOOD CK-MB-2 cTropnT-<0.01 [**2106-10-7**] 05:45AM BLOOD CK(CPK)-28* Labs on discharge: [**2106-10-9**] 06:20AM BLOOD WBC-6.0 RBC-4.49* Hgb-14.5 Hct-42.1 MCV-94 MCH-32.3* MCHC-34.4 RDW-13.0 Plt Ct-256 [**2106-10-9**] 06:20AM BLOOD PT-14.1* PTT-26.6 INR(PT)-1.2* [**2106-10-9**] 06:20AM BLOOD Glucose-109* UreaN-19 Creat-0.8 Na-138 K-4.0 Cl-108 HCO3-24 AnGap-10 [**2106-10-5**] 07:10AM BLOOD ALT-102* AST-41* AlkPhos-68 TotBili-0.7 [**2106-10-9**] 06:20AM BLOOD Calcium-8.7 Phos-3.6 Mg-2.1 [**2106-10-6**] 01:35PM BLOOD TSH-1.4 Microbiology: [**2106-10-4**]: urine cx no growth [**2106-10-4**]: blood cx x 2: no growth to date [**2106-10-6**]: stool studies NO ENTERIC GRAM NEGATIVE RODS, SALMONELLA, SHIGELLA, CAMPYLOBACTER FOUND. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2106-10-6**]): negative OSH Images: [**2106-10-3**] CT abdomen with contrast: cbd 12mm, mild intrahepatic ductal dilatation in anterior segment of right lobe unchanged from [**2102**]; fluid throughout the colon consistent with enteritis or colitis [**2106-10-3**] CTA: no evidence of pulmonary emboli; mild cardiomegaly with right atrial enlargement increased compared with [**2103**] [**Hospital1 18**] Images: [**2106-10-4**] EKG: 77 NSR, nl axis, mix of native beats with RBB morphology and ventricular pacing with LBB morphology [**2106-10-6**] EKG: HR 150s SVT vs aflutter with 2:1 block with RBB morphology [**2106-10-6**] EKG: atrial fibrillation with ventricular sensed QRS/ LBBB at 112 Abdominal U/S: 10/11:11 The liver shows no focal or textural abnormalities. The patient is status post cholecystectomy. The common duct is not dilated. There is no intrahepatic ductal dilatation. Both right and left kidneys are normal without hydronephrosis or stones. The pancreas is unremarkable. The patient is status post splenectomy. The aorta is of normal caliber throughout. The visualized portions of the inferior vena cava appear normal. No free fluid. IMPRESSION: Normal abdominal ultrasound. No intra or extrahepatic ductal dilatation. Echo: [**2106-10-8**] Mild spontaneous echo contrast is seen in the body of the left atrium and the descending aorta. No thrombus is seen in the left atrium or left atrial appendage. No spontaneous echo contrast or thrombus is seen in the body of the right atrium or the right atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is low normal (LVEF 50%). There is borderline free wall hypokinesis of the right ventricle. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque to 35 cm from the incisors. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. IMPRESSION: No thrombus identified. Mildly depressed biventricular function. Brief Hospital Course: 57 year old male with pmhx significant for CAD s/p CABG and LAD stent, porcine tricuspid valve, complete heart block s/p pacemaker, hypertension, GERD, biliary stricture s/p CCY and MVA [**2071**] s/p multiple abdominal surgeries including partial liver resection who was transferred from [**Hospital3 3583**] with nausea, vomiting and diarrhea from likely infectious colitis. Hospital course was complicated by the development of symptomatic atrial fibrillation/ atrial flutter requiring TEE cardioversion. 1. presumed colitis: Patient transferred from OSH with nausea/ vomiting/ diarrhea from likely infectious colitis. CT scan at OSH was compatible with diagnosis of acute colitis vs enteritis, although patient's complaint of diarrhea appears to be more chronic and may warrant further outpatient evaluation. Abdominal ultrasound, stool studies were negative including repeat cdiff toxin although cdiff pcr was still pending at the time of discharge. Symptoms improved with conservative management of initial bowel rest followed by BRAT diet, demerol for pain control (given multiple analgesic allergies) and cipro/flagyl. He was discharged to complete an 8 day course of antiobiotics to end on [**2106-10-9**]. Clostridium difficile pcr will need to be followed as an outpatient. 2. atrial fibrillation/ atrial flutter: complained of symptomatic palpitations with dyspnea x 1 month prior to admission. On further investigation, patient was found to have intermittent afib/ flutter with HR up to 160s resulting in dyspnea and anxiety although otherwise hemodynamically stable. He was transferred to the ICU for further evaluation. Etiology of arrhythmia was unclear: CTA negative for PE at OSH, TSH within normal limitis, ruled out for cardiac ischemia although echo showed biventricular dysfunction. Electrophysiology was consulted to interrogate pacemaker and found that mode switch off device was tracking atrial flutter with resultant ventricular rate of 120-130 bpm. Pacer was readjusted with immediate releif of symptoms of palpitations and 'impending sense of doom.' However, remained in a-fib wih occasional bursts of tachycardia, despite increased b-blocker dosing, so Cariology recommended cardioversion. He subsequently had an elective TEE guided cardioversion and was started on dabigatran [**Hospital1 **] for anticoagulation. He was able to ambulate around the ICU with stable heart rate and no significant symptoms. He was discharged home with increased metoprolol dose of 75mg [**Hospital1 **], dabigatran [**Hospital1 **] and was placed on [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of hearts monitor x 2 weeks to assess for significant remaining arrhythmias. He will follow up with Dr. [**Last Name (STitle) **] to discuss further treatment and evaluation. 3. R.sided rib pain: osh film with healing 8th and 9th rib fractures - no new trauma, ? healing from injury in [**2106-7-26**] and if so unclear why pain improved and is now worsening; PE ruled out by negative CTA; no evidence of PNA; ROMI negative at OSH and at [**Hospital1 18**], making ischemia unlikely. Pain was managed conservatively with demerol and lidocaine patch prn with resolution of symptoms through hospital course. 4. Leukocytosis: likely due to infectious colitis as further infectious evaluation negative including blood, urine and stool cultures. Downtrended throughout hospital course and was normal at the time of discharge. 5. CAD/HTN: As above, no signs of active ischemia per EKG and serial cardiac enzymes. Maintained on home plavix and statin with addition of ASA 81mg. Bblocker was uptitrated for AV nodal blockade. 6. Anxiety: patient complained of significant anxiety relating to palpitations through hospital course which was managed by ativan prn. Transitions of care: # afib/ flutter s/p d/c cardioversion: - KOH monitor x 2 weeks - dabigatran [**Hospital1 **] for anticoagulation until cardiology follow up - bblocker uptitration - follow up with Dr. [**Last Name (STitle) **] # colitis: - complete antibiotic course - f/u cdiff pcr Medications on Admission: Outpatient medications (per osh admission h and p): plavix 75mg daily ativan 1mg po prn metoprolol xl 50mg daily zantac 150mg [**Hospital1 **] crestor 40mg daily . Medications on transfer: crestor 40mg qhs florastor 250mg po tid plavix 75mg po qam toprol xl 50mg qam ciprofloxacin 400mg iv q12h (started [**2106-10-3**]) metonidzaole 500mg iv q8h (started [**2106-10-3**]) ativan 1mg po daily prn demerol 50mg iv q6h prn motrin 600mg q6h prn roxicodone 5mg q4h prn tylenol 650mg q6h prn zofran 4mg iv q6h prn d5ns 100cc/hr Discharge Medications: 1. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. lorazepam 1 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety. 3. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO twice a day. Disp:*180 Tablet(s)* Refills:*1* 4. rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO twice a day. 6. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 days. Disp:*4 Tablet(s)* Refills:*0* 8. metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 2 days. Disp:*6 Tablet(s)* Refills:*0* 9. dabigatran etexilate 150 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*1* 10. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every eight (8) hours as needed for pain for 7 days. Discharge Disposition: Home Discharge Diagnosis: Primary: Supraventricular tachycardia Colitis Chest wall pain Secondary: Coronary artery disease Gastroesophageal reflux disease Dyslipidemia Hypertension Pacemaker Porcine tricuspid valve Anxiety Benign prostatic hypertrophy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr [**Known lastname 1352**], You were transferred to the intensive care unit at [**Hospital1 18**] for fast heart rates that required pacemaker adjustments and an electrical cardioversion. Your heart rate was intermittently fast afterwards, and your metoprolol dose was increased. Your abdominal symptoms improved while taking antibiotics for your colitis. . We have made the following adjustments to your medications: -CONTINUE CIPROFLOXACIN 500 mg every 12 hours, through the end of [**10-9**] (tomorrow) -CONTINUE METRONIDAZOLE 500 mg every 8 hours, through end of [**10-9**] (tomorrow) -START DABIGATRAN 150 mg by mouth every morning and evening. This is a new blood thinner that may make you more likely to bleed. Please see below for warning signs of increased bleeding. Please continue taking this through your appointment with Dr. [**Last Name (STitle) **] (see below for information on how to schedule this appointment). -INCREASE METOPROLOL TARTRATE to 75 mg by mouth, every 12 hours. Please continue taking this regimen until your follow up with Dr. [**Last Name (STitle) **]. At that point, you may be able to switch to a once-daily pill. It is important to continue taking this every 12 hours to maintain your heart rate at a good level. -You can continue to take ACETAMINOPHEN AS NEEDED for pain. Please do not exceed the dosage as recommended on your discharge medication list. . It has a pleasure caring for you. Followup Instructions: You should follow up with the electrophysiologist Dr [**Last Name (STitle) **] [**Name (STitle) **] within one month. Please call his office to schedule an appointment. [**Hospital1 18**] Cardiology [**Street Address(2) 31630**], [**Hospital Ward Name 23**] 7 [**Location (un) 86**], [**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 62**] Fax: [**Telephone/Fax (1) 31631**] . Please also call Dr. [**Last Name (STitle) **] if you have any questions or concerns after your discharge. You can call him even on the weekends, when he should have coverage if he is not in the office. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

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icd9cm

[ [ [] ] ]

[ "88.72", "99.62" ]

icd9pcs

[ [ [] ] ]

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377, 437

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12819, 13087

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3878, 3930

4707, 4846

79,808

186,485

41048

Discharge summary

report

Admission Date: [**2196-2-9**] Discharge Date: [**2196-2-14**] Date of Birth: [**2142-8-6**] Sex: F Service: NEUROSURGERY Allergies: Dilaudid Attending:[**First Name3 (LF) 78**] Chief Complaint: s/p witnessed fall Major Surgical or Invasive Procedure: None History of Present Illness: 53 F pleasant endoscopy technician who fell at the T stop after hitting a patch of ice and struck a patch of ice. She denies any headache/dizinnes/or other changes in sensoriom prior to the fall.She does report loss of vision temporarily in her right eye after the fall, however, her vision returned and is now normal. She did not have any loss of consciousness after the fall, and no focal medical deficits after the fall. Past Medical History: Tonsillectomy Social History: Married mother of 4. Non smoker. Social drinking. Family History: Father with aortic aneurysm. No family hx. of brain aneurysms, VHL syndrome. Physical Exam: On admission: PHYSICAL EXAM: GCS E: 4 V:5 Motor 6 T:96.5 BP:159/78 HR:101 R 18 O2 100 RA Gen: WD/WN, comfortable, NAD. HEENT:clear mucosa Pupils: Reactive to light bilaterally EOMs Intact Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. No C/C/E. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [**3-10**] objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to finger rub bilaterally. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**5-12**] throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Br Pa Ac Right 2 2 2 2 2 Left 2 2 2 2 2 Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin On discharge: She is neurologically intact but does have persistent headache and some vertigo. It is anticipated that these will continue for some time. She was not interested in [**Hospital 98**] rehab and her husband felt she would have ample support at home. She was ambulatory and tolerating po intake. She was discharged to home. Pertinent Results: Head CT [**2196-2-9**]: IMPRESSION: 1. Substantial subarachnoid hemorrhage with a central predominance involving the basilar cisterns with extension of hemorrhage into frontal and parietal sulci. A focal area of hyperdensity in the anterior suprasellar cistern near the anterior communicating artery raises the possibility of aneurysm (that ruptured). Recommend further evaluation with CTA. 2. Small quantity of dependent blood in the occipital [**Doctor Last Name 534**] of the left lateral ventricle. Cspine CT [**2196-2-9**]: IMPRESSION: No acute fracture or malalignment. CTA Head [**2196-2-9**]: IMPRESSION: 1. No aneurysm, or vascular malformation seen to explain the patient's subarachnoid hemorrhage. Given the fall from standing, if clinically indicated, this should be further evaluated with catheter angiography to exclude CTA occult source of bleeding. 2. Normal vascular anatomic variants including a fenestrated anterior communicating artery and a predominantly fetal-type right posterior cerebral artery. Head CT [**2196-2-10**]: IMPRESSION: 1. Diffuse subarachnoid hemorrhage, essentially unchanged in distribution from the study obtained the day before, with no new hemorrhage. 2. Persistent blood within the cistern of lamina terminalis [**2196-2-12**] CT FINDINGS: Diffuse subarachnoid hemorrhage within suprasellar cistern with extension into frontal and parietal sulci is again visualized, however, appears markedly improved in comparison to [**2196-2-10**] exam. There is no intraventricular hemorrhage. There is no evidence of shift of normally midline structures or hydrocephalus. The ventricle and sulci appear normal in size and configuration. There is no cerebral edema or loss of white matter junction differentiation to suggest acute ischemia. The paranasal sinuses and mastoid air cells appear well aerated. The soft tissues and osseous structures appear unremarkable. There are no fractures. IMPRESSION: In comparison to [**2196-2-10**] exam, there is significant improvement in degree of subarachnoid hemorrhage, as described above. Brief Hospital Course: 53F admitted after a witnessed fall with a traumatic SAH, CTA head was negative . She was admitted to the SICU under Neurosurgery. Her neurological exam remained intact. Her Cspine was cleared on [**2196-2-10**]. Given the about of subarachnoid blood, the patient was placed on Nimodipine. On [**2196-2-11**] she was transferred from the ICU to the neuro floor. She advanced in her diet and activity - she was seen by PT and cleared for home. She was discharged to home. Medications on Admission: none Discharge Medications: 1. nimodipine 30 mg Capsule Sig: Two (2) Capsule PO Q4H (every 4 hours). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for consti. Disp:*60 Capsule(s)* Refills:*0* 3. butalbital-acetaminophen-caff 50-325-40 mg Tablet Sig: [**1-10**] Tablets PO Q4H (every 4 hours) as needed for headache. Disp:*40 Tablet(s)* Refills:*0* 4. phenytoin sodium extended 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) for 1 days. Disp:*3 Capsule(s)* Refills:*0* 5. meclizine 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for breakthrough pain. Disp:*40 Tablet(s)* Refills:*0* 7. famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. prednisone 10 mg Tablet Sig: Two (2) Tablet PO once a day for 2 days: then 1 tablet po q daily x 2 days then d/c you must take the famotidine while taking this drug. Disp:*6 Tablet(s)* Refills:*0* 9. Dr. [**Last Name (STitle) **] Please note that [**Known firstname **] [**Known lastname 89507**] was a patient at [**Hospital1 18**] It is recommended that she not work for two weeks from her date of discharge [**2196-2-14**] Please call the office of Dr.[**First Name (STitle) **] if any questions [**Telephone/Fax (1) **] Discharge Disposition: Home Discharge Diagnosis: SAH headache vertigo Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: General Instructions ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. ?????? If you were on a medication such as Coumadin (Warfarin), or Plavix (clopidogrel), or Aspirin prior to your injury, you may safely resume taking this once you receive clearance from your Neurosurgeon. ?????? If you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed. ?????? You have been prescribed Nimodipine. You must stay on this for 21 days from initiation on [**2196-2-10**]. The prescription was faxed on [**2196-2-12**] to: [**Location (un) 89508**] #0810 [**Street Address(2) 89509**]. [**Location (un) **] [**Numeric Identifier 89510**] Phone: [**Telephone/Fax (1) 89511**] Fax: [**Telephone/Fax (1) 89512**] Followup Instructions: Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in 4 weeks with a Brain MRI/MRA w/&w/o ([**Doctor Last Name **] protocol). Please call [**Telephone/Fax (1) 4296**] to make this appointment. Completed by:[**2196-2-14**]

[ "852.01", "780.4", "784.0", "E885.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6842, 6848

4929, 5401

288, 295

6913, 6913

2826, 4906

8365, 8619

871, 950

5456, 6819

6869, 6892

5427, 5433

7064, 8342

994, 1299

2480, 2807

230, 250

323, 749

1592, 2466

979, 979

6928, 7040

771, 787

803, 855

12,765

165,123

10394

Discharge summary

report

Admission Date: [**2138-9-12**] Discharge Date: [**2138-9-20**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2880**] Chief Complaint: Here for BiV pacer placement by CT surgery (epicardial placement) Major Surgical or Invasive Procedure: Epicardial pacer placement by CT surgery History of Present Illness: 87 y/o m with h/o cardiomyopathy EF 25-30%, felt not to be ischemic although has declined stress testing or cath in the past, h/o complete heart block with syncope s/p pacer placement '[**27**], h/o prostate ca, htn comes in now as his EF has worsened significantly and he has worsening DOE and felt to benefit from biV pacing, however attempt to place CS lead was unsuccessful, therefore he was admitted for epicardial LV lead placement, which he underwent successfully [**9-12**] without complication. He still has a R chest tube in place and his pacer appears to be functioning appropriately and will be tx to [**Hospital Unit Name 196**] service. Past Medical History: htn CAD CHF EF 25-30%, 2+ AR pacer placed '[**27**] for high grade AV block and syncope, now s/p epicardial LV lead for biV pacing prostate ca s/p prostatectomy knee arthroscopy Physical Exam: T 98.4 HR 72-74 BP 128-156/57-68 R 19 sat 96 %2L I/O 2.0/1.1L pMN 900/750cc CT out pMN 390 cc gen: NAD A+OX3 HEENT: mmm, JVP at 14 cm CV: RRR no m/r/g pulm: slight bibasilar crackles abd: s/nt/nd +BS ext: no edema, no DPs, trace PTs, warm Pertinent Results: [**2138-9-12**] 04:55PM BLOOD WBC-10.3# RBC-4.33* Hgb-12.3* Hct-36.3* MCV-84 MCH-28.4 MCHC-33.9 RDW-13.8 Plt Ct-210 [**2138-9-16**] 07:00AM BLOOD WBC-7.3 RBC-4.24* Hgb-12.3* Hct-35.9* MCV-85 MCH-28.9 MCHC-34.2 RDW-13.5 Plt Ct-235 [**2138-9-12**] 11:00AM BLOOD PT-13.9* PTT-26.9 INR(PT)-1.3 [**2138-9-16**] 07:00AM BLOOD Glucose-95 UreaN-23* Creat-1.2 Na-137 K-4.0 Cl-103 HCO3-23 AnGap-15 [**2138-9-12**] 04:55PM BLOOD Glucose-144* UreaN-14 Creat-1.0 Na-144 K-3.0* Cl-108 HCO3-26 AnGap-13 [**2138-9-16**] 02:37AM BLOOD CK(CPK)-62 [**2138-9-15**] 12:25PM BLOOD CK(CPK)-92 [**2138-9-14**] 03:48PM BLOOD ALT-10 AST-15 CK(CPK)-104 [**2138-9-16**] 02:37AM BLOOD CK-MB-NotDone cTropnT-0.09* [**2138-9-15**] 12:25PM BLOOD CK-MB-NotDone cTropnT-0.09* [**2138-9-14**] 03:48PM BLOOD CK-MB-2 cTropnT-0.07* [**2138-9-16**] 07:00AM BLOOD Calcium-8.1* Mg-2.2 [**2138-9-12**] 04:55PM BLOOD Calcium-8.2* Phos-2.8 Mg-1.6 [**2138-9-14**] 03:48PM BLOOD TSH-1.1 [**2138-9-12**] 02:14PM BLOOD Type-ART pO2-98 pCO2-35 pH-7.49* calHCO3-27 Base XS-3 Intubat-INTUBATED Vent-CONTROLLED [**2138-9-12**] 02:14PM BLOOD Glucose-116* Lactate-1.6 Na-142 K-3.3* Cl-109 [**2138-9-12**] 02:14PM BLOOD Hgb-12.9* calcHCT-39 [**2138-9-12**] 02:14PM BLOOD freeCa-1.14 . EKG: AV paced at 70, biV pattern CXR ([**9-12**]): RA and RV leads, and LV epicardial lead in expected positions, L chest tube, no PTX, slight bibasilar atelectasis . [**9-16**] CXR: A permanent pacemaker remains in place with leads in right atrium and right ventricle as well as additional epicardial leads. There remains evidence of a small left pleural effusion, not significantly changed in the interval. The lung volumes are slightly improved since the recent study, and atelectatic changes in the lower lobes are overall slightly improved as well. Cardiac and mediastinal contours are stable. IMPRESSION: No significant change in small left pleural effusion. Slight improvement in atelectatic changes, which remain more prominent in the left lower lobe than the right. Brief Hospital Course: 87 y/o m with chb chf - post ct [**Doctor First Name **] implanted biv pacer. . 1. rhythym: underlying 3rd degree AV block, with old RV lead, tx to [**Hospital Unit Name 196**] s/p LV epicardial lead, AV paced at 70 but in afib with irregular response by pacer. The patient was in afib underlying his paced rhythm. He was anticoagulated with heparin without bolus and started on coumadin. Amiodarone was started to regulate underlying rhythm given the low EF and known benefit of atrial kick in pts with low EF. The EP service followed the patient and repeatedly interrogated and changed the settings of the pacemaker. Atrial sensing threshold had to be repeatedly decreased to allow for sensing of the atrial fib waves and proper mode switching during fibrillatory states. After this, there was [**Last Name (un) 34425**] functioning of the pacemaker. . 2. pump: EF 25-30%. Until this hospitalization, had refused stress testing or cath to investigate if there is an ischemic component to his CHF. He was managed with close I/Os, daily weights, low salt diet, cont. coreg and accupril. Because he was likely over-diuresed prior to his transfer to [**Hospital Unit Name 196**], causing his increase in creatinine, he received fluids for a few days without any SOB or evidence of fluid overload. Once Creat had decreased, his ACEI was restarted, fluids were stopped, and he was convinced to undergo stress testing to investigate ischemia (see below). pMIBI estimated EF at >40%. . 3. ischemia: Most recent Echo shows EF has decreased from 40 in [**2134**] to 25-30% in [**Month (only) 116**], felt to be most consistent with hypertensive cardiomyopathy. However, because he had continued to decline stress/cath, ischemic component was unknown. Stress at this hospitalization was conducted and showed no reversible defects. Coreg and accupril were continued as an OP and it was suggested that OP physicians consider addition statin if has no h/o intolerance for cardioprotection. Low-dose ASA was started for cardioprotection. . 4. HTN: Coreg was continued for cardioprotection. Due to rising creatinine, d/c'd accupril and started nitrate/hydral. This caused periodic hypotension. Medications were spread out throughout the day and nitrate/hydral doses were decreased. This decreased the hypotension, but did not resolve the issue. When Creat normalized, restarted accupril with normalization of BP and erradication of hypotensive events. . 5. pulm: Pt initially had O2 requirement and CXR with some bilat effusions stable x 3d after being tx to [**Hospital Unit Name 196**] - thought to be post-operative effusions that would resorb over time rather than [**3-5**] fluid overload from CHF. Daily CXR were monitored because the pt was known to have a low EF and we were walking line of fluids - creat had risen, but fluid overload would have been easy to induce. There was never clinical or radiographic evidence of increasing fluid overload. . 6. pain: well controlled by po percocet at decreasing doses throughout the hosp course. . 7. elev WBC: was elevated just after surgery, but normalized and was thought to be a stress rxn. Medications on Admission: coreg 3.125 mg [**Hospital1 **] accupril 40 mg daily Discharge Medications: 1. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed: Take for pain at the surgical site. Disp:*30 Tablet(s)* Refills:*0* 3. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO As Instructed: Take two (2) tablets twice daily for one week, then take one tablet twice daily for one week, then take one tablet daily. Disp:*60 Tablet(s)* Refills:*0* 4. Quinapril 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 5. Warfarin Sodium 1 mg Tablet Sig: 2.5 Tablets PO at bedtime: Dosage to be adjusted as instructed based on INR measurements. Disp:*60 Tablet(s)* Refills:*0* 6. Outpatient Lab Work Basic Chemistry Panel, PTT, PT, INR. Please draw on Monday [**2138-9-22**] Please fax results to Dr.[**Doctor Last Name 34426**] office: ([**Telephone/Fax (1) 34427**]. 7. Outpatient Lab Work Please draw INR, PT, PTT weekly after [**2138-9-22**]. Please fax results to Dr.[**Doctor Last Name 34426**] office: ([**Telephone/Fax (1) 34427**] 8. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. Disp:*20 Tablet(s)* Refills:*0* 9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Epicardial BiV pacemaker lead placement CHF Atrial Fibrillation Hypertension Discharge Condition: Stable. Discharge Instructions: You had a biventricular pacemaker placed at this hospitalization. During the recovery, you had small decrease in kidney function, which soon resolved. Your blood pressure occasionally became low, but this problem has since resolved. You are doing quite well now, given your recent surgery. . Your heart is being paced by a pacemaker, but you have a condition called atrial fibrillation, which can make a stroke more likely. For this reason you are on coumadin, a blood thinner, and will need to have your INR measured weekly (INR is a measure of how thin your blood is - our goal for you is [**3-6**].). You are also on amiodarone, a medication meant to help resolve your atrial fibrillation. . You will have a nurse come to visit you to measure your vital signs and draw blood for your INR. . You will have physical therapists visit your home to work with you on regaining your strength after you return home. . You have the following appointments: Dr. [**Last Name (STitle) **] - call for appointment in [**2-2**] weeks. . Dr. [**Last Name (STitle) 3321**] - call for appointment in [**3-6**] weeks: ([**Telephone/Fax (1) 31834**] . Pulmonary Function Tests - these have been scheduled for [**9-26**]. The lab will call you to schedule a time for the tests (these are routine tests done for anyone starting amiodarone). You can call them at [**Telephone/Fax (1) 609**] if you do not hear from them early next week. . If you develop light-headedness, dizziness, chest pain, fever, chills, infection at your surgical site, shortness of breath, or other worrisome symptoms, please seek immediate medical attention. Followup Instructions: Dr. [**Last Name (STitle) **] - patient to call for follow-up appointment in [**2-2**] weeks. . Dr. [**Last Name (STitle) 3321**] - patient to call for appointment in [**3-6**] weeks. (Dr. [**Last Name (STitle) 3321**] [**Name (NI) 653**] and will contact patient early next week.) . PFT's on [**9-26**] - order in CCC [**First Name11 (Name Pattern1) 900**] [**Last Name (NamePattern1) 2882**] MD, [**MD Number(3) 2883**] Completed by:[**2138-9-28**]

[ "V10.46", "425.4", "997.1", "402.91", "584.9", "426.0", "427.31", "428.0" ]

icd9cm

[ [ [] ] ]

[ "37.83", "37.74" ]

icd9pcs

[ [ [] ] ]

8151, 8200

3558, 6710

328, 370

8321, 8331

1527, 3535

9998, 10484

6814, 8128

8221, 8300

6736, 6791

8355, 9975

1267, 1508

223, 290

398, 1050

1072, 1252

23,424

185,202

30140

Discharge summary

report

Admission Date: [**2142-5-26**] Discharge Date: [**2142-5-29**] Date of Birth: [**2142-5-26**] Sex: M Service: NB HISTORY OF PRESENT ILLNESS: Baby boy [**Known lastname 71825**] is the former 3.395 kg product of a term gestation pregnancy, born to a 33- year-old G1, P0 woman. EDC was [**2142-5-29**]. Prenatal screens: Blood pressure B+, antibody negative, rubella immune, RPR nonreactive, hepatitis B surface antigen negative, group beta Strep positive. There was spontaneous onset of labor. Rupture of membranes occurred 21 hours prior to delivery. The mother received multiple doses of intrapartum antibiotics. She had a fever to 100.7 degrees Fahrenheit in labor. The infant was born by cesarean section for arrest of descent. Apgars were 8 at one minute and 9 at five minutes. He was admitted to the NICU at 2 hours of life for a routine sepsis evaluation. A complete blood count was within normal limits and he was admitted to the newborn nursery for routine observation. On day of life #2 he was noted to have a rectal temperature of 101.6 Fahrenheit. There appeared to be no environmental explanation for the elevated temperature. He was admitted to the neonatal intensive care unit for his 2nd sepsis evaluation. PHYSICAL EXAM ON ADMISSION TO THE NEONATAL INTENSIVE CARE UNIT ON [**2142-5-27**]: Weight 3.395 kg, head circumference 34 cm. General: Alert, active, non distressed male, pink on room air. Head, eyes, ears, nose and throat: Anterior fontanelle open and flat, palate intact. Chest: Clavicles intact, clear breath sounds with good aeration. Cardiovascular: Regular rate and rhythm, no murmur, good femoral pulses. Abdomen soft, nontender, nondistended, good bowel sounds, no hepatosplenomegaly. Moving all extremities. Spine intact. Normal male genitalia, testes descended bilaterally, patent anus. Neurologically intact reflexes and symmetric tone. HOSPITAL COURSE BY SYSTEMS INCLUDING PERTINENT LABORATORY DATA: Respiratory: This infant was admitted on room air and continued on room air without any episodes of oxygen desaturation. Cardiovascular: This baby has maintained normal heart rates and blood pressures. Fluids/electrolytes/nutrition: This baby has ad lib breast fed or taken Similac 20 calorie per ounce formula. Weight on the day of transfer is 3.18 kg. Infectious disease: A complete blood count was repeated showing a red count of 14,100 with 64% polymorphonuclear cells, 0% band neutrophils. Normal hematocrit and platelets. A blood culture and urine culture were obtained. The parents declined a lumbar puncture and treatment with antibiotics. The baby was observed for an additional 48 hours in the newborn intensive care unit without any other episodes of fever spikes. Both blood cultures from [**5-26**] and [**2142-5-27**] remained no growth to date. Urine culture was also no growth to date. Hematology: Hematocrit is 56.6%. Gastrointestinal: Peak serum bilirubin occurred on day of life #[**2052-5-14**], a total 12 mg per dL. Neurology: This baby has maintained a normal neurological exam during admission and there are no neurological concerns at the time of transfer. Sensory: Hearing screening has not yet been performed, but will be done prior to discharge. CONDITION ON DISCHARGE: Good. DISCHARGE DISPOSITION: Transfer to the newborn nursery at [**Hospital1 69**] for continuing care and observation. PRIMARY PEDIATRICIAN: Dr. [**First Name (STitle) **] [**Name (STitle) **], [**Apartment Address(1) 71826**], [**Location (un) **], MA, phone number [**Telephone/Fax (1) 71827**], fax number [**Telephone/Fax (1) 37260**]. CARE AND RECOMMENDATIONS AT THE TIME OF DISCHARGE: 1. Feeding ad lib p.o. 2. No medications. 3. Outstanding urine and blood cultures. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], [**MD Number(1) 55750**] Dictated By:[**Last Name (Titles) **] MEDQUIST36 D: [**2142-5-29**] 16:07:27 T: [**2142-5-29**] 17:05:10 Job#: [**Job Number 71828**]

[ "V29.0", "779.89", "V05.3", "780.6", "V30.01" ]

icd9cm

[ [ [] ] ]

[ "99.55" ]

icd9pcs

[ [ [] ] ]

3299, 4010

164, 3243

3268, 3275

62,945

188,879

38175

Discharge summary

report

Admission Date: [**2118-6-14**] Discharge Date: [**2118-7-17**] Date of Birth: [**2069-1-1**] Sex: M Service: MEDICINE Allergies: Cephalosporins Attending:[**First Name3 (LF) 4393**] Chief Complaint: Hematemesis Major Surgical or Invasive Procedure: Upper Endoscopy Central Line Placement TIPS Paracentesis A-line Placement Angiogram x3 s/p intubation, mechanical ventilation History of Present Illness: 49M homeless with Hep C, EtOH cirrhosis c/b known varicies (banded [**2114**]) and ascites p/w epigastric pain x3d, hematemesis x10 and maroon BM x10 yesterday at which time he presented to [**Hospital 8**] Hospital. HCTs at the time were reportedly 28-30. Pt got 4u PRBCs in the ED and apparently had SBPs to 60s there. Overnight, the pt had an EGD which showed non-bleeding gastric and esophageal varices with 5 bands placed at the GE jxn. Bright red blood was found in the 3rd and 4th portions of the duodenum, lavaged and cleared although the site of bleeding appeared to be distal to the limit of the scope. Overnight, pt had another 2 bloody BMs and then 2 more this am with about 650cc lost. His HCT today was 16.3 (from 28 this am to 16 at 2p), INR 2.5, SBPs 110s. Pt got FFP x2, 4uPRBCS and 10mg IV Vit K. At transfer, pt is on PPI gtt, octreotide gtt. Has 4x large bore PIVs. Is drowsy but reportedly oriented. Being transferred for further GI eval and possible TIPS. Vitals at transfer: T 98.7 (Tmax 99.2 at 7am on day of transfer) HR 116 BP 129/85 100% on 2L NC. On arrival to the ICU, VS HR 140 BP 123/80 Sats 98% on 2L NC. Pt admits to feeling shaky, similar to his usual symptoms of withdrawl. 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: ETOH cirrhosis (no known path, based on US)- eso varices s/p banding [**2114**]. Esophageal and duodenal ulcers seen on EGD in [**2114**]. ETOH abuse, 1 pint liquor and 8 beers daily at present ?Hep C (Ab positive [**7-/2114**]) Social History: - Tobacco: [**2-5**] PPD - Alcohol: See above, 2 yrs sober then relapsed [**1-12**]. - Illicits: MJ, cocaine quaaludes in the past. Denies IVDU past or present Family History: NC Physical Exam: GEN: intubated, sedated, opens eyes and follows some commands HEENT: +scleral icterus, edema, PERRL; OGT in place Lungs: diminished bs b/l bases CV: RRR, S1S2, no m/r/g ABD: distended, hypoactive bowel sounds, moderate amount of ascites; rectal tube draining melena; condom catheter EXT: generalized anasarca [**4-7**]+, UE/LE with multiple areas of serosanguinous discharge at sites of skin breakdown; generalized jaundice Pertinent Results: ADMISSION LABS: [**2118-6-14**] 04:36PM WBC-9.0 RBC-2.61* Hgb-8.1* Hct-23.7* MCV-91 Plt Ct-71* [**2118-6-22**] 11:39AM Neuts-78* Bands-9* Lymphs-5* Monos-7 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2118-6-14**] 04:36PM PT-21.5* PTT-45.9* INR(PT)-2.0* [**2118-6-14**] 04:36PM Fibrino-83* [**2118-6-14**] 04:36PM Gluc-161* UreaN-17 Creat-0.6 Na-140 K-4.9 Cl-108 HCO3-23 [**2118-6-14**] 04:36PM ALT-14 AST-48* LD(LDH)-207 AlkPhos-47 TotBili-4.2* [**2118-6-14**] 04:36PM Albumin-1.6* Calcium-5.1* Phos-3.2 Mg-1.7 [**2118-6-14**] 04:36PM HCV Ab-POSITIVE* URINE: [**2118-6-16**] 05:34PM Color-Amber Appear-Clear Sp [**Last Name (un) **]->1.035 [**2118-6-16**] 05:34PM Blood-TR Nitrite-NEG Protein-25 Glucose-NEG Ketone-NEG Bilirub-LG Urobiln-NEG pH-6.5 Leuks-NEG [**2118-6-16**] 05:34PM RBC-0-2 WBC-0-2 Bacteri-RARE Yeast-NONE Epi-0-2 RenalEp-0-2 [**2118-6-16**] 05:34PM CastGr-[**4-8**]* CastCel-0-2 PERITONEAL FLUID: [**2118-6-15**] 06:55PM WBC-111* RBC-[**Numeric Identifier 85154**]* HCT,fl-2* Polys-65* Lymphs-17* Monos-7* Mesothe-11* [**2118-6-15**] 06:55PM TotPro-0.1 MICRO: [**6-14**] HCV Viral Load: 169,000 IU/mL. [**6-15**] Peritoneal Fluid Cx: Strep Viridans CLINDAMYCIN----------- S ERYTHROMYCIN---------- 2 R PENICILLIN G---------- 0.06 S VANCOMYCIN------------ <=1 S [**6-16**], [**6-20**] UCx: NEGATIVE [**6-16**], [**6-18**], [**6-19**], [**6-20**], [**6-23**], [**6-24**] BCx: NEGATIVE [**6-29**], [**7-2**], [**7-4**] BCx: *** [**6-20**], [**7-2**] Cdiff: NEGATIVE [**7-4**] Sputum Cx: *** [**7-4**] Peritoneal Fluid Cx: *** STUDIES: [**6-14**] Abd U/S: 1. Echogenic liver with nodular contour, compatible with known history of cirrhosis. 2. Slow flow in a patent main portal vein, demonstrating appropriate hepatopetal direction. 3. Mild wall thickening of the gallbladder, most likely secondary to the hypoalbuminea from the patient's cirrhosis, with a small amount of sludge. 4. Moderate amount of ascites. [**6-15**] CTA Abd/pelvis: 1. Arterio-biliary fistula in segment [**Doctor First Name 690**] with active extravasation of iv contrast into the bile ducts and excretion into the duodenum. 2. The stomach and duodenum are filled with blood clots suggesting additional hemorrhage from a more proximal site (esophageal varices) 3. Increased density of perihepatic ascites likely due to contrast from prior TIPS procedure. 4. Nodular liver, ascites and varices consistent with cirrhosis. 5. Cholelithiasis. [**6-15**] EGD: Impression: - Esophageal varices - Grade B esophagitis (injection) - Blood in the stomach - Duodenal ulcer (injection) - Otherwise normal EGD to second part of the duodenum Recommendations: Esophageal varices noted, esophagitis, and duodenal bulb ulcer. Epinephrine injected to esophagitis, duodenal ulcer. Severe fresh bleeding from varices. Procedure terminated. [**Last Name (un) **] tube placed. Contact[**Name (NI) **] surgery, IR for urgent repeat TIPS attempt, and embolization if concern for distal arterial bleed. Continue octreotide gtt, PPI gtt, antibiotics. [**6-18**] TTE: The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Transmitral and tissue Doppler imaging suggests normal diastolic function, and a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Normal biventricular cavity sizes with preserved global biventricular systolic function. No valvular pathology or pathologic flow identified. [**6-22**] ABD U/S with Doppler: 1. Patent TIPS shunt with velocities of 120 to 190 cm/sec. Patent umbilical vein. 2. Small amount of ascites and left pleural effusion. 3. Gallbladder sludge and gallstones. 4. Splenomegaly and heterogeneous liver consistent with patient's known cirrhosis. [**6-22**] EGD: Impression: - Ulcerations noted in the mid and distal esophagus, no active bleeding. in the esophagus - Mosaic appearance in the stomach compatible with portal hypertensive gastropathy - Scope reached proximal jejunum, blood throughout, no active bleeding, suspect bleeding source distal to proximal jejunum. - Gmed/gcare2 was down, no pictures taken. - Otherwise normal EGD to third part of the duodenum Recommendations: - Please avoid NG suction - Please add on Carafate, continue PPI - Please f/u Hct closely and tranfusion as needed - Proceed with Angio to localize the bleeding source. [**6-24**] CTA torso: 1. No contrast in the duodenum excluding arterial biliary fistula. No evidence of GI bleed. If clinical concern persists, consider nuclear tagged RBC scan. 2. Heterogenoous area of hypoattenuation in the right lobe of the liver likely represents resolving infarction; however, an infection cannot be completely excluded. 3. Ascites and multiple varices noted. 4. Bilateral pleural effusions are increased compared to [**2118-6-15**] with adjacent associated compressive atelectasis versus pneumonia in the correct clinical setting. 5. Gallbladder with vicarious excretion of contrast. 6. Air in the bladder likely secondary to instrumentation. [**6-25**] RBC scan: 1. Intermittent, but brisk bleeding occuring in the left upper quadrant, presumably jejunum, beginning at 28 minutes. 2. Visualization of recanalized umbilical vein draining to the left femoral vein. [**6-26**] CTA abd/pelvis: 1. No specific CT evidence to suggest active GI bleeding. The remainder of the examination is essentially unchanged since study of [**2118-6-24**]. [**6-27**] RUQ U/S with Doppler: 1. Patent TIPS with velocities ranging from 146 to 183 cm/sec, not substantially changed from prior study. Large patent recanalized paraumbilical vein is again identified. 2. Small-to-moderate ascites. Right pleural effusion. 3. Redemonstration of nodular, heterogeneous cirrhotic liver. 4. Gallbladder sludge. Gallbladder wall thickening most likely reflect third spacing/chronic hepatic disease. DISCHARGE LABS: *** Brief Hospital Course: Mr. [**Known lastname **] is a 49M EtOH, HCV cirrhosis c/b varices transferred to ICU with massive UGIB from esophageal varices vs duodenal ulcer, stabilized s/p TIPS. Hospital course c/b respiratory failure, peritonitis (rare strep viridans), worsening liver function, and persistent encephalopathy. Persistent GI oozing from unknown source - s/p angiox3, RBC scans, CTAs; ?jejunum. Had traumatic foley placement with GU bleed, now resolved. Extubated [**7-4**]. . # UGIB: Per EGD at [**Hospital1 8**], multiple non-bleeding esophageal and gastric varices. The site of active bleeding appeared to be in the 3rd or 4th portion of the duodenum, beyond the reach of the endoscope, however he did undergo banding of 5 varices at [**Hospital1 8**]. While at [**Hospital1 8**] he was transfused 8 units of PRBC's and then transferred to [**Hospital1 18**] for further management. Upon arrival to [**Hospital1 18**] it was thought that he was likely bleeding from his varices, and initially another endoscopy was deferred given his recent banding. He was then sent for a TIPS procedure that failed, and overnight the first night he required multiple transfusions of packed red cells, platelets and FFP to maintain hemodynamic stability. The morning of hospital day #2 he underwent another EGD which showed bleeding varices and bleeding from a duodenal ulcer. After the procedure [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] was placed, with some slowing of the bleeding. Later that day he went for a second attempt at TIPS which was successful, overnight that night he required more PRBC's and [**Last Name (un) **] manipulation but finally stopped bleeding. Over the next few days the [**Last Name (un) **] balloons were taken down, and he did not have any further bleeding. On [**6-19**] the [**Last Name (un) **] was removed and his HCT remained stable until [**6-23**]. The patient resumed bleeding and had frank blood draining from his rectal tube. He underwent RBC scan, CTA, and angiogram, which did not locate his bleed. His HCT stabilized again on [**7-1**]. The patient also had coagulopathy [**3-8**] to cirrhosis, requiring multiple units of platelets and FFP. Overall he required 62 units of PRBC's at [**Hospital1 18**], with another 8 more given at [**Hospital1 8**] for a total of 70 units, in addition to 58units of FFP and 29units of platelets. Palliative care consult pending. Dr. [**Last Name (STitle) **] spoke to wife over phone, with ongoing discussions regarding goals of care. . # ETOH abuse: Pt endorsing symptoms of withdrawl at the time of admission. Initially received 10mg valium on arrival to unit, but was intubated for airway protection shortly after arrival to the ICU. After intubation he did not receive any further benzo's and his sedation was held after 4 days in hopes that his mental status would improve. # Hypocalcemia: due to multiple blood transfusions, his ionized calcium was checked with every hematocrit check and aggressively repleted. After he no longer required frequent transfusions his calcium remained stable. # Hepatitis C: Reportedly Ab positive in '[**14**] and never treated. Likely contributing to cirrhosis, hepatitis C antibiody was positive, viral load 170K. With his liver disease after his bleeding had stabilized he was restarted on lactulose and rifaximin due to concern that encephalopathy could be contributing to his decreased mental status. #. Respiratory failure: The patient was intubated shortly after admission for airway protection. He then had increased difficulty oxygenating as his volume status worsened (+30L LOS). CTA had e/o bilateral pleural effusions, compression atelectasis vs PNA. The patient was treated with an 8 day course of vanc/zosyn for VAP. Hypotensive [**7-3**] with concern for ongoing VAP ?????? Vanc/Zosyn was restarted. The patient was extubated successfully on [**7-4**]. Through goals of care discussions with the family, the decision was made not to re-intubate the patient if his respiratory status were to worsen. This was discontinued on [**7-6**], however the patient on [**7-9**] pulled out his dobhoff tube and desaturated to 88%, and was re-started on vancomycin/zosyn for possible aspiration pneumonia. #. Hypotension: Pt became hypotensive on [**7-3**] - ?[**3-8**] to overdiuresis vs infection/sepsis ?????? had elevated WBC count with 6 bands, cannot r/o ongoing VAP in CXR. Restarted on Vanc/Zosyn overnight and bolused 750cc. No e/o SBP on diag para. # GUB: The patient had a GU bleed [**3-8**] to traumatic Foley placement, requiring 6units pRBCs. Evaluated by Urology, who replaced the Foley. The bleed resolved the following day, catheter now draining yellow urine. # Leukocytosis: WBC count 10.1 with 6 bands. Question etiology ?????? transfusion reaction vs drug reaction vs infectious. Pancultured multiple times, which remained negative. Pt finished an 8d course of Vanc/Zosyn for VAP; he was restarted on Abx [**7-3**] with concern for hypotension. He was also started on Cipro for SBP PPx. # Cirrhosis: EtOH/HepC cirrhosis. Tbili was markedly elevated, and the pt was jaundiced. Peritoneal fluid Cx with rare Strep viridans. The patient was treated with Vanc/Zosyn for 8d course. Then continued on Cipro for SBP PPx. He was given Rifaximin and Lactulose for hepatic encephalopathy with good effect. # Altered mental status: Likely [**3-8**] to hepatic encephalopathy - without significant improvement with Lactulose and Rifaximin. CT head was negative for intracranial process. # FEN: Free water flushes/ Replete electrolytes prn/ TF (held pending extubation) # Prophylaxis: Pneumoboots # Access: midline, RIJ, arterial line # Communication: Patient. HCP is son [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 85155**], Also communication with common-law wife [**Name (NI) 8369**] [**Name (NI) **] [**Telephone/Fax (1) 85156**]. # Code: DNR/DNI (discussed with patient??????s family, again on [**6-30**], do not re-intubate patient if he fails extubation). Continue other care. # Disposition: ICU MICU Course- [**Date range (1) 85157**] Patient readmitted to MICU after developing another bleed while on the floor. On admission, code status was reversed and patient intubated for EGD/flex sig. EGD showed severe gastritis and gastropathy. He was also found to have colonopathy. Patient was started on PPI IV BID, octreotide as well as antimicrobials (cipro/flagyl/micafungin). He was extubated and did well. Family decided to pursue CMO on [**7-14**]. Patient will no longer receive blood products. . Pt was made CMO on [**2118-7-14**]. He expired on [**2118-7-17**] at approximately 11:15 AM. His family agreed to pursue autopsy and sought to donate his body to medical science. Medications on Admission: Medications on transfer: Octreotide gtt Protonix gtt Thiamine MVI Folate (s/p banana bag) NS at 200cc/hr Discharge Disposition: Expired Discharge Diagnosis: GI bleed, liver failure Discharge Condition: Expired [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]

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icd9cm

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icd9pcs

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3027, 3027

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41,460

110,198

39268

Discharge summary

report

Admission Date: [**2101-3-14**] Discharge Date: [**2101-3-28**] Service: MEDICINE Allergies: Codeine / Statins-Hmg-Coa Reductase Inhibitors / Zetia / Minipress Attending:[**First Name3 (LF) 2195**] Chief Complaint: chest pain, hemoptysis. Major Surgical or Invasive Procedure: s/p IVC filter placement [**2101-3-17**]. s/p bronchoscopy [**2101-3-20**]. History of Present Illness: Mr. [**Name14 (STitle) 20179**] is a 85 yo male with a history of CAD, PVD, cerebral vascular disease, chronic kidney disease (BL Cr 1.8), who was orignally admitted to [**Hospital3 1443**] Hospital on [**2101-2-19**] with right lower extremity infected gouty arthritis and hemoptysis in the setting of an INR of 9. He was also diagnosed with a penicillin senstitive enterococcus UTI. His INR was reversed with vitamin K. The 1st right MP joint was aspirated and a right foot xray and MRI were negative for osteomyelitis. He was started on colchicine which he did not tolerate, so then was switched to a prednisone taper in addition to IV Vancomycin for presumed MRSA infection. He was discharged to rehab on [**2101-3-8**] on a 7 day course of Keflex with diagnoses of UTI and right foot superinfected MSSA gouty arthritis (uric acid level 8.4). On [**3-12**], he was readmitted from rehab with scrotal cellulitis; scrotal U/S at OSH showed normal intrinsic blood flow in both testes. He was started on 3g [**Hospital1 **] Unasyn for this with improvement. . On [**2101-3-13**], he started to experience hemoptysis, SOB, and chest pain. An EKG showed ST depressions in the lateral leads and troponins were trending up: 0.11 --> 0.18. An echo done on [**2101-3-13**] at the OSH showed LVEF 35-40% (BL 55%) and global LV hypokinesis. . Of note, for his hemoptysis, at OSH AFBs were negative during his first admission. On [**3-13**], he was noted to have a low Hgb of 7.8 (BL 10), which was 9 on repeat blood draw. Most recent Hgb/HCT on day of transfer: 9.2/29.1. He received no transfusions at OSH. On [**3-6**], iron studies at OSH revealed: Fe 24, TIBC 146, Ferritin 600, B12 616, and folate 12.1. Pulmonary saw him and felt the hemoptysis was secondary to a pneumonia. Follow-up CXR showed a resolving RLL infiltrate at OSH. Patient denied any BRBPR or black tarry stools but does have history of colon cancer, s/p resection. His stools were guaiac negative x 1 at OSH. . At the time of transfer, vitals were: 97.5, HR 84 sinus, RR 22, BP 152/92, O2 sat 94% 4LNC. CXR at OSH showed right lung pulmonary edema. He was given lasix 60mg IV then another 20mg IV and has had no chest pain or dyspnea on the morning of transfer on SL NG. He received 3 doses of mucomyst, xopenex nebulizers, and 3 grams of ampicillin for his scrotal cellulitis. He was also clopidogrel loaded: received 75mg on AM of transfer and got 300mg x 2 the day prior. He is being transferred to the floor prior to cath for evaluation given his multiple active medical issues. . On evaluation on the floor, Mr. [**Name14 (STitle) 20179**] reports feeling well. He states that he has had no chest pressure since this morning. He states that he continues to have red hemoptysis multiple times per day along with a productive cough which has been new the past week. He denies fevers, chills, nightsweats or weight loss. He reports feeling well up until late last week when he began having SOB and chest pain at rehab after doing PT exercised in bed. Prior to that, he had not had chest pain for many years per his report. He is not aware that he has ever had an MI in the past. He denies palpitations, current chest pain, PND, but does endorse orthopnea and DOE. . REVIEW OF SYSTEMS: He has a history of ischemic stroke >10 years ago and multiple TIAs and is s/p R carotid endarterectomy. He denies history of deep venous thrombosis, pulmonary embolism, myalgias, or joint pains except for his R toe gout. He endorses new cough and hemoptysis, but denies black tarry stools or BRBPR. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: 1. CARDIAC RISK FACTORS: +Dyslipidemia, +Hypertension 2. CARDIAC HISTORY: Paroxysmal atrial fibrillation, diagnosed in [**10-9**], s/p amiodarone tx. Coronary artery disease, s/p 2 caths, but unknown intervention or findings. Congestive heart failure, diagnosed [**10-9**]. . 3. OTHER PAST MEDICAL HISTORY: Abdominal aortic aneurysm, s/p 2 repairs most recently [**3-/2094**] at [**Hospital1 336**]. Carotid stenosis, s/p R endarterectomy. Chronic renal insufficiency (BL Cr 1.8). History of colon cancer, s/p colectomy with reanastamosis in [**2071**]. PPD positive. Gouty arthritis. Chronic obstructive pulmonary disease (restrictive and obstructive, no oxygen requirement at home). Peripheral vascular disease. Cerebral vascular disease, h/o ischemic stroke in [**2080**] at [**Hospital1 2025**]. Status post left arm amputation after WWII combat injury. Social History: Lives with his wife of 63 years in [**Location (un) 1468**]. He is a WWII veteran and retired field [**Doctor Last Name 360**] of the Veterans Association. He has a 10 pack year smoking history but quit in the [**2060**]. He rarely drinks alcohol. He denies current or past drug use. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death. Physical Exam: ON ADMISSION: VS: T= 98.0 BP= 180/57 HR=84 RR=20 O2 sat=94% on 4LNC. GENERAL: [**First Name9 (NamePattern2) 86883**] [**Last Name (un) **] in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 10 cm. CARDIAC: ?Ventricular trigeminy, dropped beat noted after every three beats, otherwise regular rhythm. No m/r/g. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. +Crackles bilaterally up to mid lung fields. No wheezes or rhonchi. Decreased breath sounds RLL. ABDOMEN: Soft, NTND. NABS. EXTREMITIES: WPP bil LEs. Healing gouty wound R first metatarsal without e/o infection. 1+ DP pulses bil LEs. +2 pitting pretibial edema. SKIN: No stasis dermatitis, scars, or xanthomas. Small stage 2 pressure ulcers on sacrum x 2. . Pertinent Results: Admisison labs: [**2101-3-14**] [**2101-3-14**] 04:40PM BLOOD WBC-6.2 RBC-2.91* Hgb-9.0* Hct-26.8* MCV-92 MCH-31.0 MCHC-33.7 RDW-17.0* Plt Ct-118* [**2101-3-14**] 04:40PM BLOOD PT-13.2 PTT-27.2 INR(PT)-1.1 [**2101-3-14**] 04:40PM BLOOD Glucose-109* UreaN-39* Creat-1.7* Na-144 K-4.0 Cl-105 HCO3-27 AnGap-16 [**2101-3-14**] 04:40PM BLOOD ALT-14 AST-17 LD(LDH)-298* AlkPhos-79 TotBili-0.6 [**2101-3-14**] 06:21PM BLOOD CK-MB-NotDone cTropnT-0.10* [**2101-3-14**] 06:21PM BLOOD ALT-13 AST-19 LD(LDH)-284* CK(CPK)-30* AlkPhos-76 TotBili-0.6 [**2101-3-14**] 04:40PM BLOOD Albumin-2.7* Calcium-8.3* Phos-3.6 Mg-2.0 [**2101-3-14**] 06:21PM BLOOD Triglyc-55 HDL-48 CHOL/HD-3.0 LDLcalc-84 . Cardiac Enzymes: [**2101-3-15**] 07:30AM BLOOD CK-MB-NotDone cTropnT-0.10* [**2101-3-15**] 07:30AM BLOOD CK(CPK)-25* [**2101-3-17**] 04:09AM BLOOD CK-MB-NotDone cTropnT-0.10* [**2101-3-17**] 04:09AM BLOOD CK(CPK)-36* [**2101-3-20**] 03:00AM BLOOD CK-MB-NotDone cTropnT-0.12* [**2101-3-20**] 03:00AM BLOOD CK(CPK)-35* . Discharge Labs: [**2101-3-28**] 06:49AM BLOOD WBC-5.1 RBC-2.62* Hgb-8.3* Hct-24.9* MCV-95 MCH-31.8 MCHC-33.5 RDW-17.2* Plt Ct-133* [**2101-3-28**] 06:49AM BLOOD Glucose-90 UreaN-35* Creat-1.9* Na-141 K-4.2 Cl-100 HCO3-34* AnGap-11 [**2101-3-22**] 05:39AM BLOOD ALT-10 AST-19 AlkPhos-64 TotBili-0.5 [**2101-3-28**] 06:49AM BLOOD Calcium-8.1* Phos-3.2 Mg-2.0 . [**1-11**] 2D-ECHOCARDIOGRAM (OSH): Mild inferior wall hypokinesis, mild aortic insufficiency. LVEF 50-55%. . [**2101-3-13**] 2D-ECHOCARDIOGRAM (OSH): Normal RV function, global LV hypokinesis, LVEF 35-40%. . [**8-10**]: Adenosine Myoview (OSH): medium in size, moderate in degree, predominantly reversible inferior wall defect and inferior wall hypokinesis. LVEF 50%. . [**2101-3-19**] CXR: IMPRESSION: Improving multifocal airspace opacities superimposed upon emphysema. This could be due to either multifocal pneumonia or pulmonary hemorrhage. . [**2101-3-27**] CXR: Compared to the previous radiograph, there is marked improvement with regression in extent and severity of the pre-existing predominantly right parenchymal opacities. However, the opacities are still clearly seen. Unchanged moderate cardiomegaly. Unchanged appearance of the left lung, including a small zone of parenchymal opacity projecting over the left costophrenic sinus. . [**2101-3-21**] RUQ Ultrasound: 1. Multiple gallstones. 2. left intrahepatic biliary dilatation. No obvious mass seen. . [**2101-3-15**] ECHO: LVEF: 45% to 50%. The left atrium is moderately dilated. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with inferolateral/inferior hypokinesis. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . [**2101-3-14**] CTA Chest: IMPRESSION: 1. No pulmonary embolism. 2. Extensive pneumonia or pulmonary hemorrhage. No obvious bleeding site with the exception of possible incipient broncholiths in the right hilus. No bronchial obstruction. 3. Pulmonary hypertension, severe emphysema. 4. Severe atherosclerosis including coronary arteries and shallow plaque ulcerations in the left subclavian artery and aorta.Upper abdominal aortic aneurysm, total extent not imaged. 5. Global cardiomegaly and in particular left ventricular enlargement. 6. Possible localized biliary obstruction, recommend biliary ultrasound. 7. Calcific cholelithiasis. No evidence of cholecystitis. . [**2101-3-14**] LENIs: IMPRESSION: Left calf vein DVT in one of two posterior tibial veins. . Brief Hospital Course: Mr. [**Known lastname **] is an 85 yo male with multiple medical problems including COPD, PVD, and PAF, admitted to an OSH in mid-[**Month (only) 958**] for hemoptysis in setting of supratherapeutic INR of 9.0, and readmitted with scrotal cellulitis several days later. He began having chest pain on [**2101-3-13**] and was noted to have an NSTEMI with elevated troponins and ST depressions on EKG. He was transferred to [**Hospital1 18**] for further evaluation and cardiac catheterization. . MICU COURSE [**2101-3-19**] - [**2101-3-20**]: The patient was transferred to the MICU following an episode of non-massive hemoptysis, tachypnea and tachycardia. He was monitored overnight and received humidified oxygen via NRB and then face tent as needed. He was kept NPO overnight in anticipation of bronchoscopy. The hemoptysis subsided, and Hct remained stable at 23-24. The following morning, he underwent bedside bronchoscopy which revealed multiple blood clots in the larger airways (chiefly right-sided) but no evidence of active bleeding. No mass or lesion was noted. The patient tolerated the procedure well. His vital signs remained stable and oxygen requirement returned to recent baseline. He was therefore transferred back to the floor team on the afternoon following admission to the ICU. . His hospital course is outlined by problem below: . # Hemoptysis: Most likely etiology is from supratherapeutic INR and fluid in lungs. Patient's coumadin was temporarily held and patient was diuresed. CTA ruled out PE. Per OSH records, antiGBM was negative, ANCA negative. [**Doctor First Name **] at [**Hospital1 18**] negative. Patient was free of hemoptysis for 5+ days prior to discharge. Pulmonary was consulted during this admission and followed the patient closely. He should follow up with the pulmonologist listed in the discharge paperwork after rehab. . # CORONARIES: Patient had a NSTEMI this admission. Given his risk factors for bleeding, it was decided to treat the patient with medical managment. Cardiology was consulted. His Aspirin was increased to 325mg once a day. Given the risk of bleeding the consulting cardiologist did not feel that the benefits of Plavix outweighed the risks, therefore he was not discharged on Plavix. Continued ASA, metoprolol and nitrate. Increased home statin to rosuvastatin 40 mg daily. Patient was chest pain free at discharge. . # PUMP: The patient was noted to have inferior thallium defect at OSH; also had dyspnea and CXR at OSH c/w pulmonary edema and CHF. Repeat echo [**3-15**] shows mild regional left ventricular systolic dysfunction with inferolateral/inferior hypokinesis (LVEF 45-50%), mild MR, and mild AR. Diuresed with lasix. Cr slighly bumped from 1.6 on [**3-26**] to 1.9 on [**3-27**]. Cr was stable at 1.9 on day of discharge. Patient was euvolemic on day of discharge. He was discharged on his home dose of lasix. Daily labs, including Cr, strict I/Os, and daily weights are needed. Titrate lasix to keep euvolemic while monitoring Cr. . # RHYTHM: Patient has history of PAF. Rate controlled with beta blocker. Once hemoptysis was stable from pulmonary perspective, coumadin 3mg po qday was restarted. . # Scrotal cellulitis: Patient noted to have scrotal cellulitis on [**2101-3-12**]. Treated with IV Unasyn with improvement. . # Deep vein thrombosis: Left posterior tibial vein with thrombus noted on HD#1 ultrasound. Patient started on heparin drip initially, but discontinued given increasing hemoptysis and respiratory instability. Now s/p IVC filter placement on [**2101-3-17**]. Patient should continue on Coumadin 3mg po qday with goal INR between [**1-5**] for DVT treatment. . # Sacral decubitus ulcers: Noted to be stage 2 at OSH, stable. . # Chronic renal insufficiency: Patient has BL creatinine of 1.8. Cr increased to 1.9 as stated above after diuresis. Please monitor Cr with daily labs, especially if titrating lasix dose. . # COPD: Continued home medication regimen of Advair [**Hospital1 **] and added standing xopenex nebulizer treatments while inpatient. Also added ipratropium inhaler PRN for shortness of breath/wheezing. . CODE STATUS: Confirmed as FULL CODE this admission. He will be discharged to a rehab facility and will need close follow-up with his PCP, [**Name10 (NameIs) 2086**], and pulmonary within 2 weeks of discharge. Medications on Admission: Doxazosin 4 mg po BID Cilostazol 100 mg po BID (for PVD) Furosemide 40 mg daily. Metoprolol tartrate 25 mg po BID. Isosorbide mononitrate 60 mg po daily. ASA 81 mg po daily. Coumadin 3 mg po daily. Lorazepam 0.5 mg prn. Ambien 5 mg prn. Rosuvastatin 10 mg po daily. Advair prn. Latanoprost drops both eyes daily. Hydrocodone 1 tab prn pain. Ocuvite 1 tab daily. Allopurinol 100 mg [**Hospital1 **]. Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: 1-2 puffs Inhalation [**Hospital1 **] (2 times a day). 3. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 5. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed for rash. 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 8. Clotrimazole 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) for 7 days. 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Doxazosin 4 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Rosuvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Latanoprost 0.005 % Drops Sig: 1-2 Drops Ophthalmic HS (at bedtime). 13. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation QID (4 times a day) as needed for SOB, wheezing. 14. Ativan 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 15. Cilostazol 100 mg Tablet Sig: One (1) Tablet PO twice a day. 16. Ocuvite Tablet Sig: One (1) Tablet PO once a day. 17. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 18. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 19. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 20. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 21. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 22. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital - [**Hospital1 8**] Discharge Diagnosis: PRIMARY: Non-ST-Elevation myocardial infarction. Hospital acquired pneumonia. Left posterior tibial vein deep vein thrombosis. Infected gouty arthritis of the right hallux. . SECONDARY: Hypertension Hyperlipidemia Coronary artery disease Chronic obstructive pulmonary disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair (pt is independently ambulatory at baseline). Discharge Instructions: Dear Mr. [**Name14 (STitle) 20179**], you were admitted to the hospital with chest pain and blood in your sputum. Your chest pain was due to a small heart attack, called an NSTEMI. You were treated medically for this. The blood in your sputum was most likley due to fluid in your lungs and excessively high INR. It improved with holding your blood thinning medications. An ultrasound of your legs was done and showed a clot in one of the veins in your left leg. You had a filter, called an IVC filter, placed to prevent this clot from traveling to your lung. You are now deemed medically stable and fit for discharge to a rehabilitation facility. . The following changes have been made to your home medications: 1. Continue Coumadin 3mg by mouth every day 2. STOP HYDROCODONE. 3. Aspirin 81 mg by mouth daily CHANGED TO Aspirin 325 mg by mouth daily. 4. Allopurinol 100 mg by mouth twice a day CHANGED TO Allopurinol 100 mg by mouth once a day. 5. Rosuvastatin (Crestor) 10 mg by mouth daily CHANGED TO Rosuvastatin (Crestor) 40 mg by mouth daily. 6. Continue Lasix 40mg by mouth once a day 7. START Ferrous Sulfate 325 mg by mouth twice a day. . It was a pleasure caring for you during this hospital stay. You should be weighed every day and have your urine output measured. If your weight increases by more than 3lbs or you do not urinate enough your lasix dose should be increased. The physicians at your next facility will help you monitor this. Followup Instructions: Please call your primary care doctor, DR. [**Last Name (STitle) **] at [**0-0-**] to schedule an appointment within two weeks of discharge from rehab. . Please also call DR. [**Last Name (STitle) **] at [**Telephone/Fax (1) 11554**] to schedule an appointment within 1-2 weeks of discharge from rehab. . Please follow up with a pulmonologist. You should follow up with Dr. [**Last Name (STitle) 86144**] at [**Hospital1 2025**]. Please call [**0-0-**] and ask for registration. You will need to register with [**Hospital1 2025**] first before making the appointment. Then call the Pulmonolgist's office at [**Telephone/Fax (1) 86145**] to book an appointment. The soonest available appointment is sufficient. Completed by:[**2101-3-28**]

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Discharge summary

report

Admission Date: [**2161-9-1**] Discharge Date: [**2161-9-18**] Date of Birth: [**2131-8-20**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**Doctor First Name 3290**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Endotracheal intubation and mechanical ventilation History of Present Illness: 30 year old female with h/o asthma who presented with respiratory distress. She reported one to two weeks of rhinorrhea and cough productive of clear sputum, as well as increased wheezing. She needed an increase in frequency of nebs at home and was using them every 4 hours. . This morning, she presented to her PCP's office with SOB after waking up feeling acutely worse. She was found to have an O2 sat of 89%RA and tachycardia to 110. She was given a set of nebs and EMS was called. EMS gave her 125mg IV solumedrol and 2 more nebs. . In our ED, initial vitals were HR 104 RR 29 O2 Sat 97%NRB. She was reportedly diaphoretic and tripoding with prolonged I/E ratio with significant wheezing. She was given continuous duonebs, 2g IV mag, and Zofran (for nausea). She was put on BiPap and felt symptomatically improved with FiO2 100% with pressure support of 3. ABG was done while on BiPap which showed 7.15/65/579/24. She was subsequently intubated due to fatigue. Also given epinephrine x 1. Vitals on transfer T 95.0 HR 117 BP 135/84 RR 22 O2 100% on BiPap. She has 2 PIVs for access. . Notably, she had an admission to [**Hospital1 112**] in [**2159**] for similar symptoms. At that time she was intubated and was difficult to ventilate in spite of continuous nebulizers and high-dose steroids. She was paralyzed on Nimbex and started on heliox. She had a bronch that revealed sputum positive for staph and treated with nafcillin. She also developed pneuomediastinum and pneuoperitoneum felt to be [**1-6**] high ventilatory pressures. She had a normal esophagogram and her ABGs improved. She was extubated 8 days after admission. She also had sinus tachycardia with T wave inversions in V5-V6 that were new and EF showed concentric LVH with EF 40-45% felt to be due to her high ventilatory pressures and severe asthma exacerbation. Past Medical History: Severe Asthma s/p recent intubation [**12/2159**] at [**Hospital1 112**] similar to this admission, also with intubation at age 18 Depression Social History: Lives with boyfriend in [**Name (NI) 86**]. Per family, does not smoke or use other drugs. Report of previous marijuana use (unconfirmed with patient). Used EtOH in college. Has cat at home. Family History: Father has asthma Both parents with cerebralpalsy Physical Exam: On admission VS: T 96.4 HR 99 BP 153/90 O2 Sat 98% on AC TV 380 RR 16 PEEP 5 FiO2 100% GEN: Intubated, but agitated at times, gasping breaths of air despite being on ventilator HEENT: Small but equal and reactive pupils, EOMI, anicteric, MMM, op without lesions, significant nasal flaring with respirations RESP: Significant wheezing throughout, bilateral breath sounds with moderate air movement on ventilator CV: Tachycardia with regular rhythm ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e SKIN: no rashes/no jaundice/no splinters . At Discharge PHYSICAL EXAM: Vitals - Tc:97.5 BP:129/82 (129-176/86-104)HR:80(71-90) RR:16 02 sat:99% RA GENERAL: young female appearing alert no acute distress HEENT: Mild pain on active rotation, flexion and extension at neck, no pain on passive movement. Pain improved with palpation. PERRLA, mucous membs moist, no lymphadenopathy CHEST: CTABL, no crackles, no ronchi CV: S1 S2 Normal in quality and intensity RRR no murmurs rubs or gallops ABD: Non-distended, BS normoactive, Soft, non-tender, no organomegaly EXT: warm, well perfused, no edema. Dorsalis pedis pulses 2+ BL. NEURO: Speech regular rate. AOx3 Cranial Nerves: CNII-CNXII intact BL, MOTOR [**3-9**] BL in upper extremities, [**3-9**] BL in quadraceps, 4+/5 BL gastroch, babinski not assessed. Reflexes 2+ BL biceps/brachioradialis. Sensation to fine touch and position intact in lower extremities BL Pertinent Results: [**2161-9-1**] 12:20PM BLOOD WBC-13.5*# RBC-5.10 Hgb-15.7 Hct-47.6# MCV-93 MCH-30.9 MCHC-33.1 RDW-13.3 Plt Ct-389 [**2161-9-2**] 04:06AM BLOOD WBC-13.4* RBC-4.19* Hgb-12.9 Hct-41.4 MCV-99* MCH-30.8 MCHC-31.2 RDW-12.9 Plt Ct-228 [**2161-9-3**] 05:10AM BLOOD WBC-13.0* RBC-3.76* Hgb-11.6* Hct-35.4* MCV-94 MCH-30.9 MCHC-32.8 RDW-13.6 Plt Ct-130* [**2161-9-4**] 04:08AM BLOOD WBC-11.0 RBC-3.55* Hgb-11.2* Hct-34.4* MCV-97 MCH-31.7 MCHC-32.6 RDW-13.5 Plt Ct-142* [**2161-9-9**] 05:42PM BLOOD WBC-13.8* RBC-3.68* Hgb-11.3* Hct-34.1* MCV-93 MCH-30.8 MCHC-33.3 RDW-14.2 Plt Ct-206 [**2161-9-10**] 04:38AM BLOOD WBC-14.5* RBC-3.72* Hgb-11.6* Hct-33.7* MCV-91 MCH-31.2 MCHC-34.5 RDW-14.7 Plt Ct-243 [**2161-9-15**] 05:15AM BLOOD WBC-15.9* RBC-3.59* Hgb-11.2* Hct-32.8* MCV-91 MCH-31.2 MCHC-34.1 RDW-15.4 Plt Ct-265 [**2161-9-16**] 06:48AM BLOOD WBC-11.5* RBC-3.67* Hgb-11.4* Hct-33.6* MCV-92 MCH-31.1 MCHC-34.0 RDW-15.2 Plt Ct-238 [**2161-9-17**] 06:05AM BLOOD WBC-10.6 RBC-3.61* Hgb-11.5* Hct-33.2* MCV-92 MCH-32.0 MCHC-34.8 RDW-15.0 Plt Ct-247 [**2161-9-18**] 07:40AM BLOOD WBC-8.7 RBC-3.65* Hgb-11.5* Hct-33.5* MCV-92 MCH-31.5 MCHC-34.4 RDW-15.3 Plt Ct-239 [**2161-9-15**] 05:15AM BLOOD PT-13.1 PTT-25.3 INR(PT)-1.1 [**2161-9-14**] 04:11AM BLOOD ESR-8 [**2161-9-1**] 12:20PM BLOOD Glucose-181* UreaN-16 Creat-0.8 Na-142 K-4.1 Cl-110* HCO3-19* AnGap-17 [**2161-9-2**] 04:06AM BLOOD Glucose-242* UreaN-17 Creat-1.0 Na-143 K-4.5 Cl-114* HCO3-15* AnGap-19 [**2161-9-10**] 04:38AM BLOOD Glucose-104* UreaN-15 Creat-0.5 Na-147* K-3.1* Cl-108 HCO3-30 AnGap-12 [**2161-9-11**] 03:01AM BLOOD Glucose-97 UreaN-15 Creat-0.6 Na-142 K-3.0* Cl-104 HCO3-28 AnGap-13 [**2161-9-17**] 06:05AM BLOOD Glucose-98 UreaN-13 Creat-0.6 Na-135 K-3.2* Cl-99 HCO3-28 AnGap-11 [**2161-9-18**] 07:40AM BLOOD Glucose-93 UreaN-16 Creat-0.6 Na-138 K-3.8 Cl-105 HCO3-26 AnGap-11 [**2161-9-1**] 12:20PM BLOOD ALT-19 AST-26 AlkPhos-48 TotBili-0.2 [**2161-9-2**] 04:06AM BLOOD ALT-19 AST-23 AlkPhos-39 TotBili-0.2 [**2161-9-3**] 05:10AM BLOOD CK(CPK)-337* [**2161-9-4**] 04:08AM BLOOD CK(CPK)-237* [**2161-9-8**] 05:56AM BLOOD CK(CPK)-86 [**2161-9-10**] 04:38AM BLOOD ALT-66* AST-51* AlkPhos-34* TotBili-0.6 [**2161-9-12**] 04:03AM BLOOD ALT-128* AST-200* LD(LDH)-510* CK(CPK)-[**Numeric Identifier **]* AlkPhos-38 TotBili-0.6 [**2161-9-13**] 04:12AM BLOOD ALT-145* AST-277* LD(LDH)-557* CK(CPK)-[**Numeric Identifier 75927**]* AlkPhos-34* TotBili-0.4 [**2161-9-14**] 04:11AM BLOOD ALT-202* AST-412* LD(LDH)-584* CK(CPK)-[**Numeric Identifier 22526**]* AlkPhos-38 TotBili-0.5 [**2161-9-14**] 05:03PM BLOOD CK(CPK)-[**Numeric Identifier 75928**]* [**2161-9-15**] 05:15AM BLOOD ALT-267* AST-491* CK(CPK)-[**Numeric Identifier 75929**]* AlkPhos-41 TotBili-0.5 [**2161-9-16**] 06:48AM BLOOD ALT-330* AST-500* CK(CPK)-[**Numeric Identifier 7084**]* [**2161-9-17**] 06:05AM BLOOD ALT-391* AST-494* LD(LDH)-489* CK(CPK)-[**Numeric Identifier 75930**]* AlkPhos-51 TotBili-0.6 [**2161-9-18**] 07:40AM BLOOD ALT-398* AST-361* LD(LDH)-303* CK(CPK)-[**Numeric Identifier **]* [**2161-9-12**] 04:03AM BLOOD Albumin-3.6 Calcium-8.5 Phos-3.0 Mg-1.8 [**2161-9-12**] 04:03AM BLOOD Triglyc-95 [**2161-9-17**] 06:05AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [**2161-9-13**] 02:00PM BLOOD [**Doctor First Name **]-NEGATIVE [**2161-9-1**] 01:51PM BLOOD Type-ART pO2-579* pCO2-65* pH-7.15* calTCO2-24 Base XS--7 Intubat-NOT INTUBA [**2161-9-1**] 05:10PM BLOOD Type-ART pO2-177* pCO2-84* pH-7.07* calTCO2-26 Base XS--8 [**2161-9-1**] 06:03PM BLOOD Type-ART pO2-145* pCO2-86* pH-7.06* calTCO2-26 Base XS--8 [**2161-9-1**] 06:59PM BLOOD Type-ART Temp-35.7 Rates-14/ Tidal V-380 PEEP-5 FiO2-50 pO2-161* pCO2-95* pH-7.04* calTCO2-28 Base XS--7 -ASSIST/CON Intubat-INTUBATED [**2161-9-1**] 08:14PM BLOOD Type-ART pO2-196* pCO2-105* pH-6.97* calTCO2-26 Base XS--10 [**2161-9-2**] 04:27AM BLOOD Type-ART pO2-116* pCO2-80* pH-6.96* calTCO2-20* Base XS--16 [**2161-9-2**] 06:12AM BLOOD Type-ART pO2-120* pCO2-75* pH-6.99* calTCO2-19* Base XS--15 [**2161-9-3**] 09:08AM BLOOD Type-ART Temp-37.2 pO2-119* pCO2-69* pH-7.14* calTCO2-25 Base XS--6 [**2161-9-3**] 12:46PM BLOOD Type-ART Temp-37.3 pO2-120* pCO2-76* pH-7.13* calTCO2-27 Base XS--5 [**2161-9-4**] 04:22AM BLOOD Type-ART pO2-119* pCO2-70* pH-7.16* calTCO2-26 Base XS--5 [**2161-9-4**] 11:48AM BLOOD Type-ART Temp-37.5 Rates-14/ Tidal V-370 PEEP-10 FiO2-40 pO2-106* pCO2-89* pH-7.10* calTCO2-30 Base XS--4 [**2161-9-5**] 04:55AM BLOOD Type-ART Temp-37.3 Rates-16/16 Tidal V-370 PEEP-5 FiO2-40 pO2-130* pCO2-65* pH-7.19* calTCO2-26 Base XS--4 Intubat-INTUBATED [**2161-9-5**] 10:51AM BLOOD Type-ART Temp-36.9 Rates-16/ Tidal V-370 PEEP-5 FiO2-42 pO2-120* pCO2-69* pH-7.16* calTCO2-26 Base XS--5 -ASSIST/CON Intubat-INTUBATED [**2161-9-5**] 09:31PM BLOOD Type-ART Temp-37.3 Tidal V-370 PEEP-5 FiO2-40 pO2-129* pCO2-66* pH-7.23* calTCO2-29 Base XS--1 Intubat-INTUBATED Vent-CONTROLLED [**2161-9-6**] 04:22AM BLOOD Type-ART Rates-16/ Tidal V-370 PEEP-5 FiO2-40 pO2-121* pCO2-68* pH-7.24* calTCO2-31* Base XS-0 Intubat-INTUBATED Vent-CONTROLLED [**2161-9-6**] 01:20PM BLOOD Type-ART pO2-76* pCO2-65* pH-7.29* calTCO2-33* Base XS-2 [**2161-9-6**] 01:41PM BLOOD Type-ART Temp-37.8 Tidal V-370 PEEP-12 FiO2-40 pO2-91 pCO2-66* pH-7.28* calTCO2-32* Base XS-1 -ASSIST/CON Intubat-INTUBATED [**2161-9-8**] 03:07PM BLOOD Type-ART pO2-141* pCO2-48* pH-7.46* calTCO2-35* Base XS-9 [**2161-9-9**] 05:02AM BLOOD Type-ART Temp-37.7 PEEP-5 FiO2-40 pO2-135* pCO2-47* pH-7.46* calTCO2-34* Base XS-9 Intubat-INTUBATED [**2161-9-12**] 12:31PM BLOOD Type-ART pO2-110* pCO2-30* pH-7.54* calTCO2-26 Base XS-4 [**2161-9-1**] 12:37PM BLOOD Lactate-1.0 Na-147 K-4.0 Cl-112 calHCO3-21 [**2161-9-1**] 11:05PM BLOOD Lactate-2.8* [**2161-9-2**] 02:25PM BLOOD Lactate-1.4 [**2161-9-4**] 04:22AM BLOOD Lactate-0.5 [**2161-9-2**] 06:23PM BLOOD freeCa-1.11* [**2161-9-9**] 05:02AM BLOOD freeCa-1.15 Admission Labs: [**2161-9-1**] 12:20PM WBC-13.5*# RBC-5.10 HGB-15.7 HCT-47.6# MCV-93 MCH-30.9 MCHC-33.1 RDW-13.3 [**2161-9-1**] 12:20PM NEUTS-57.5 LYMPHS-32.7 MONOS-3.4 EOS-4.8* BASOS-1.7 [**2161-9-1**] 12:20PM PLT COUNT-389 [**2161-9-1**] 12:20PM PT-13.0 PTT-28.1 INR(PT)-1.1 [**2161-9-1**] 12:20PM TRIGLYCER-82 [**2161-9-1**] 12:20PM ALT(SGPT)-19 AST(SGOT)-26 ALK PHOS-48 TOT BILI-0.2 [**2161-9-1**] 12:20PM GLUCOSE-181* UREA N-16 CREAT-0.8 SODIUM-142 POTASSIUM-4.1 CHLORIDE-110* TOTAL CO2-19* ANION GAP-17 [**2161-9-1**] 12:37PM LACTATE-1.0 NA+-147 K+-4.0 CL--112 TCO2-21 [**2161-9-1**] 01:51PM TYPE-ART PO2-579* PCO2-65* PH-7.15* TOTAL CO2-24 BASE XS--7 INTUBATED-NOT INTUBA [**2161-9-1**] 02:55PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-100 KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2161-9-1**] 02:55PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.007 . Other Pertinent Labs: STUDIES: . [**2161-9-1**] CXR: The lungs are well expanded and clear. The mediastinum is unremarkable. The cardiac silhouette is within normal limits for size. No effusion or pneumothorax is noted. The visualized osseous structures reveal mild degenerative changes in the lower thoracic spine. IMPRESSION: No acute pulmonary process. . [**2161-9-2**] CXR: ET tube with tip positioned 3 cm above the carina is abutting left tracheal wall. Nasogastric tube is seen within the stomach and coursing out of view. Stable hyperinflation. Decrease in bronchial cuffing. No focal opacification concerning for pneumonia. No pleural effusions. Mediastinal, hilar and cardiac contours are normal. Mild thoracolumbar scoliosis noted. IMPRESSION: Stable hyperinflation. Decreased bronchial cuffing. No focal opacification concerning for pneumonia. . [**2161-9-6**] CXR: As compared to the previous examination, there is no relevant change. The tip of the endotracheal tube projects 4.5 cm above the carina, the tube could be advanced by 1-2 cm. The course and position of the nasogastric tube is unchanged. No evidence of pneumothorax. No focal parenchymal opacity suggesting pneumonia. Signs of overinflation are not present. No pleural effusions. Normal size of the cardiac silhouette. . MRI Brain: The findings indicate diffuse white matter disease with multiple foci of microhemorrhages including a larger area of hemorrhage in the splenium of corpus callosum and smaller in the genu of corpus callosum. No evidence of acute infarct is seen. The distribution of disease indicates diffuse white matter abnormality with microhemorrhages and the differential diagnosis includes CADASIL, multiple cavernous malformations, or cerebral vasculitis. In absence of enhancing lesions or abnormal vascular structures, underlying neoplasms or arteriovenous malformation appear less likely. . CT Brain [**2161-9-12**] FINDINGS: Large areas of acute hemorrhage are seen centered in the genu and posterior body of the corpus callosum, with additional partial involvement of the rostrum and splenium. These lesions extend across midline, with adjacent parasagittal parenchymal hypodensity, indicative of edema. There is evidence of intraventricular extension, with high-density blood layering in the left occipital [**Doctor Last Name 534**]. Punctate hyperdense foci in the superior parietal lobes are concerning for intraparenchymal hemorrhage. Diffuse blurring of the [**Doctor Last Name 352**]-white matter junction and sulcal effacement are noted, suggesting global cerebral edema. There is mild 3-mm leftward shift of the normally midline structures. The ventricles and basal cisterns are patent, without current evidence of hydrocephalus or herniation. Air-fluid levels and aerosolized secretions are seen in the right maxillary and bilateral sphenoid sinuses. Partial fluid opacification is also seen in a few ethmoid air cells. The mastoid air cells are clear. No fractures are identified, although this eamination is note tailored for fine bony detail. . IMPRESSION: 1. Acute corpus callosal hemorrhage, with ntraparenchymal/intraventricular involvement, diffuse cerebral edema, and 3-mm leftward shift. The differential includes traumatic brain injury, hemorrhagic infarction venous thrombosis), and underlying vascular malformation or mass lesion. MR [**First Name (Titles) **] [**Last Name (Titles) **] may be helpful for further characterization. 2. Paranasal sinus disease. . CT BRAIN [**2161-9-15**] FINDINGS: Diffuse white matter hypodensity is as previously seen. Multiple foci of hemorrhage are as seen on [**2161-9-12**], with large region of hemorrhage in the splenium of the corpus callosum, and smaller focus in the genu of the corpus callosum. Also, there are punctate intraparenchymal hemorrhage in the bilateral posterior parietal lobes at the [**Doctor Last Name 352**]-white matter junction, and intraventricular hemorrhage in the left occipital [**Doctor Last Name 534**]. Extent of hemorrhage is not changed from three days prior, however, the hyperdense foci are becoming slightly less conspicuous, consistent with evolution of blood products. No definite new focus of hemorrhage is seen. Also, there is no evidence for interval development of large vascular territorial infarction, shift of normally midline structures, hydrocephalus, or herniation. Fluid layering in the sphenoid sinuses is slightly increased from three days prior. . IMPRESSION: . 1. Diffuse white matter hypodensity, overall unchanged. . 2. Multiple foci of hemorrhage, including larger focus in the splenium of the corpus callosum and smaller focus in its genu, overall, showing interval evolution of blood products, but no progression of hemorrhage or new hemorrhage. . 3. No increase in mass effect or hydrocephalus, with small left occipital [**Doctor Last Name 534**] intraventricular hemorrhage, unchanged. . 4. Slight increase in layering fluid with inspissated secretions in the sphenoid sinuses. NOTE ADDED IN ATTENDING REVIEW: The striking symmetry of this process, with extensive white matter disease, and prominent (and hemorrhagic) involvement of the corpus callosum is suggestive of either a toxic/metabolic insult, such as may be seen with inhalational use of heroin ("chasing the dragon") or, alternatively, acute hemorrhagic leukoencephalopathy, which may occur with certain viral infections or acute demyelinative syndromes. Close correlation with clinical and laboratory data is imperative. Brief Hospital Course: 30 year old female with asthma admitted with respiratory distress and severe asthma exacerbation. . #. Asthma Exacerbation and Status Asthmaticus: She presented with a severe asthma exacerbation and status asthmaticus requiring intubation in the ED. She had a profound respiratory acidosis and ventilation was difficult. She was given IV steroids, inhaled bronchodilators and was paralyzed after arrival to the MICU with cisatracurium. She was also sedated with propofol, fentanyl and midazolam. She continued to have substantial acidosis and hypercarbia throughout the first [**11-27**] hours. It gradually improved but she remained with significant resistance on the ventilator despite high dose steroids and inhaled bronchodilators. She was eventually given aminophylline and terbutaline and her ABGs improved. Her paralytics were stopped and she was transitioned to just propofol for sedation. She had a difficult time waking up after her sedation was stopped. She was eventually extubated and weaned off oxygen without difficulty. Maintained on high-dose inhaled steroids, nebulizers ATC and albuterol prn. Throughout the remainder of her course, she did not show signs of asthma exacerbation and the frequency of her albuterol treatments was decreased. . # Critical Care Myopathy: Had profound painless weakness. CK significantly elevated to >22,000. Neurology was consulted and agreed with clinical diagnosis. Strength improved with paralytic/ high-dose steriod withdrawal and physical therapy. She was also noted to have AST>ALT transaminitis this is most likely due to muscle derived AST/ALT rather than representing hepatocellular injury. She was treated with aggressive fluid hydration and her CK trended down to [**Numeric Identifier 890**] at the time of transfer to rehabilitation, her creatinine remained within normal limits and there were no signs of renal failure. Her pain from the headache and neck were managed initially with oxycodone and tramadol however these were discontinued due to sedation and altered sensorium. Her pain was treated with two days of toradol, with excellent response. The plan is to continue toradol PRN until [**2161-9-19**] and transition to diclofenac PRN at rehab. While in rehabilitation, she should continue to have daily electrolyte measurements including CK until CK trends down. . # Intracranial Hemorrhage: After extubation, patient complained of significant neck pain and head ache. Neurology consulted as above. CT showed multiple small diffuse hemorrhages. The stroke service was consulted. MRI showed diffuse white matter disease with multiple foci of microhemorrhages including a larger area of hemorrhage in the splenium of corpus callosum and smaller in the genu of corpus callosum. Given concern for emboli, echo with bubble obtained which showed an interatrial shunt consistent with a stretched patent foramen ovale. Repeat CT showed evolution of intracranial bleed but did not show worsening of bleed. Neurology performed serial exams noting improvement in her weakness and at the time of discharge, she was able to transfer from chair to bed on her own. After transfer from the ICU, she was noted to have waxing and waining level of consciousness which is consistent with delirium and believed to be multifactorial, influenced by the intracranial hemorrhage, lengthy hospital stay, high dose steroids and pain medication. At discharge, she continued to be lethargic in the afternoons with increased attention and consciousness in the mornings. . #. Hospital Acquired PNA: She spiked a fever on hospital day 2 and was started on broad spectrum antibiotics for empiric pneumonia coverage (vancomycin, cefepime, levaquin). She completed an 8 day course (cefepime was stopped on day 6 due to fevers and rash). No infection was found and it was felt that her fevers may have been drug fevers. Her cefepime was stopped on day 6 due to this concern and fevers resolved. . #. Rash: She developed a papular rash felt to be a drug rash possible due to aminophylline or cefepime. Both were stopped and her rash improved. . #. Gastritis: She had mildly bloody NG tube output after multiple days of intubation felt to be likely gastritis. She was started on an IV PPI and remained hemodynamically stable and HCT remained stable for the remainder of her hospital stay. . #. Communication: With parents [**Doctor Last Name 8214**] (cell [**Telephone/Fax (1) 75931**]) and [**Doctor Last Name **] ([**Telephone/Fax (1) 75932**]), home # is [**Telephone/Fax (1) 75933**] . #. Code Status: Full code, confirmed on admission . # Recommendations for rehab: continue physical therapy, continue toradol PRN until [**2161-9-19**] and transition to diclofenac PRN. Continue IV fluids and daily electrolyte measurements including CK until CK trends down. Medications on Admission: Singulair 10mg po daily Albuterol 2.5mg/3ml nebs q4-6h prn Sronyx 01.mg-20mcg po daily (OCP) Albuterol 90mcg inh q4-6h prn Citalopram 40mg po daily Advair 500mcg-50mcg [**Hospital1 **] (fluticasone) Discharge Medications: 1. ketorolac 15 mg/mL Solution Sig: 15-30 mg Injection Q6H (every 6 hours) as needed for pain for 2 days: Final day [**2161-9-19**]. 2. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous PRN (as needed) as needed for line flush. 4. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection 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 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day) as needed for constipation. 7. ipratropium bromide 0.02 % Solution Sig: One (1) NEB Inhalation Q6H (every 6 hours). 8. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed) as needed for eye dryness. 9. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 10. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) NEB Inhalation Q6H (every 6 hours) as needed for wheeze. 11. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q8H (every 8 hours). 12. Sodium Chloride 0.9% Flush 3 mL IV Q8H:PRN line flush Peripheral line: Flush with 3 mL Normal Saline every 8 hours and PRN. 13. Outpatient Lab Work Check electrolytes daily including CK, until CK trends down to normal range. Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital - [**Hospital1 8**] Discharge Diagnosis: Primary Diagnosis Status asthmaticus ....... Secondary diagnoses Severe Asthma intubated [**12/2159**] at [**Hospital1 112**], and at age 18 Critical Illness Myopathy Depression Discharge Condition: Mental Status: Worse in the afternoon, lethargic occasionally confused. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair. Discharge Instructions: Ms [**Known lastname 6483**], It was a pleasure caring for you at [**Hospital1 18**] in your hospital stay. As you know, you were admitted to the intensive care unit for an asthma exacerbation. You were intubated to help you breathe and treated with high dose steroids for your asthma. While intubated, it was necessary to give you medication to prevent you from moving. When the tube was removed and we stopped the sedating medications, you had muscle weakness and pain consistent with a disease called Critical Illness Myopathy. We performed a head CT scan which showed a large amount of bleeding in your brain in a part called the corpus callosum. You were seen by neurology who regularly examined you and recommended repeat head CT which did not show worsening of the bleed. . After stabilization you were treansfered to the general medical service. Your weakness improved and your muscle pain was treated with toradol and ultram with good effect. While on the general medical service, we continued your home asthma regimen and your breathing remained comfortable and you did not sho signs of recurrent asthma attack. . After transfer to the general medical floor, your level of attention and consciousness was noted to fluctuate during the day consistent with delirium. We believe that the delirium was caused by bleeding that you had in your brain, your prolonged hospitalization, high dose steroids and pain medication. . You are being discharged to [**Hospital **] rehabilitation where you will continue physcial therapy until you regain your strength. . We recommend that you follow up with pulmonology neurology and have made appointments for you, please call them to reschedule if necessary. . We made the following changes to your medication: STOP Celexa Followup Instructions: Neurology Name: [**Last Name (LF) **],[**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Location (un) 2274**] - [**Hospital1 **] Address: [**Street Address(2) **], [**Location (un) **],[**Numeric Identifier 7023**] ; 4th fl, [**Apartment Address(1) **] Phone: [**Telephone/Fax (1) 65302**] Appt: [**9-24**] at 3pm . Pulmonology: Name: [**Last Name (LF) 2294**],[**Name8 (MD) 2295**] MD Location: [**Hospital1 641**] Address: [**Location (un) **]., [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2296**] Appointment: Thursday [**2161-10-22**] 2:00pm

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icd9cm

[ [ [] ] ]

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icd9pcs

[ [ [] ] ]

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Discharge summary

report

Admission Date: [**2184-3-19**] Discharge Date: [**2184-3-29**] Date of Birth: [**2141-12-4**] Sex: M Service: MEDICINE Allergies: Piperacillin/Tazobactam/Dex-Is Attending:[**First Name3 (LF) 2160**] Chief Complaint: Hemoptysis Major Surgical or Invasive Procedure: None History of Present Illness: This is a 42 year-old male with a complex obstructive lung disease due to a combination of bronchiectasis and tracheal diverticuli, h/o hemoptysis, followed by Dr. [**Last Name (STitle) **], s/p RM lobectomy, who is being transferred from NWH ED for recurrent hemoptysis and fevers. . Of note, pt has a long h/o hemoptysis and recurrent abx for bronchietasis. He has been coughing up brownish colored sputum again since beginning of [**Month (only) 547**]. He c/o worsening DOE over the last few weeks. Also occasional CP with deep inspiration. He noted a fever of 101 on [**3-7**] and intermittently thereafter. No nightsweats or weight loss. No sick contacts but travel to South [**Country 10181**] from [**Month (only) 404**] to [**Month (only) 958**]. He was started on Levaquin on [**2184-3-10**] but continued to have intermittent fevers and still coughing up brownish sputum with occasional clots. Never frank blood. . Pt went to NWH ED on [**3-19**]. He arrived with some respiratory distress and frequent hemoptysis (1 TBSP frank blood q 10 minutes per Dr. [**Last Name (STitle) **] note in OMR, not confirmed by patient). He was satting 97%-100% on 4L NC, RR 28 to 38, HR in 100s, BP 110s/70s. Labs notable for WBC of 19.8 with 94% segs, 7% bands, Hct 36.9, INR 1.2, UA negative. Suspected RLL pneumonia on CXR. He received Vanc and Zosyn empirically and was transferred to [**Hospital1 18**] for further care. . On arrival to the ICU, he spiked to 101.5, used accessory respiratory muscles and was wheezing. . ROS: Notable for nonbloody diarrhea since having been started on levaquin. The patient denies any weight loss, nightsweats, abdominal pain, N/V, melena or dysuria. Past Medical History: - burn to his right torso s/p release procedure at age 16 - complex obstructive lung disease due to a combination of bronchiectasis and tracheal diverticuli, h/o hemoptysis, followed by Dr. [**Last Name (STitle) **] since [**2179**], prior to that extensive workup in [**Doctor First Name 5256**], ruled out for cystic fibrosis and wegener's disease; s/p multiple courses of abx - s/p RM lobectomy [**2163**] Social History: Lifelong non-smoker who is originally from [**Country 10181**]. Currently unemployed. Lives with his wife and two kids in [**Name (NI) 745**]. No EtOH, IVDU or recreational drugs. Family History: five brothers and sisters, none with lung disease. Father had TB and DM. Physical Exam: Vitals: T: 101.5 BP: 118/71 HR: 123 regular RR: 21 O2Sat: 98% on 2L NC GEN: Thin, middle-aged male in mild respiratory distress, sitting up and leaning forward HEENT: EOMI, PERRL, sclera anicteric, MMM, dried blood around mouth NECK: No JVD, supple COR: tachy but regular, no M/G/R, normal S1 S2 PULM: mild crackles at bases, faint wheezes ABD: Soft, NT, ND, sparse BS, no HSM, no masses EXT: No C/C/E, warm, 2+ DP pulses NEURO: alert, oriented. Moves all 4 extremities. SKIN: No rash. Old scars over extremities from childhood burns. Pertinent Results: At NWH ED, notable for WBC of 19.8 with 94% segs, 7% bands, Hct 36.9, INR 1.2, UA negative. See below for rest. . ECG at NWH ED: ST at 107, nl axis, nl intervals, small Qs (<1mm) in I, aVL, nonspecific ST changes . Studies: CXR at NWH ED: Cystic bronchiectasis with patchy parenchymal opacities in RLL . PFTs [**2184-3-10**]: Actual Pred %Pred Actual %Pred %chg FVC 2.34 4.19 56 FEV1 1.19 3.28 36 MMF 0.58 3.63 16 FEV1/FVC 51 78 65 . CT Chest [**2180-12-19**]: 1) Overall unchanged appearance of extensive tracheal diverticulosis, and extensive bronchiectasis in bilateral lower lobes more prominent on the right, associated with patchy parenchymal opacities and consolidations in the surrounding lung parenchyma, and air-fluid levels within the dilated bronchus as described above. 2) Unchanged appearance of soft tissue density in the right lower lobe along the bronchovascular bundle as described above, which is probably inflammatory due to sequela of bronchiectasis. [**2184-3-19**] 01:25PM WBC-21.4*# RBC-4.03* HGB-11.9* HCT-33.9* MCV-84# MCH-29.5 MCHC-35.0 RDW-13.6 [**2184-3-19**] 01:25PM NEUTS-74* BANDS-9* LYMPHS-8* MONOS-8 EOS-0 BASOS-0 ATYPS-1* METAS-0 MYELOS-0 [**2184-3-19**] 01:25PM PLT SMR-NORMAL PLT COUNT-343# [**2184-3-19**] 01:25PM PT-15.4* PTT-38.0* INR(PT)-1.4* [**2184-3-19**] 01:25PM GLUCOSE-106* UREA N-7 CREAT-0.7 SODIUM-135 POTASSIUM-3.5 CHLORIDE-97 TOTAL CO2-28 ANION GAP-14 ============= RADIOLOGY ============= RENAL ULTRASOUND FINDINGS: The right kidney measures 11.9 cm. The left kidney measures 12.4 cm. No masses or hydronephrosis present within the kidneys. A 6-mm non- obstructing renal calculus is present in the interpolar region of the left kidney. The bladder is mildly distended without focal mass lesion identified within. IMPRESSION: 6-mm non-obstructing stone within the interpolar region of the left kidney. No hydronephrosis. ================== DISCHARGE LABS ================== WBC-8.7 RBC-3.20* Hgb-9.1* Hct-27.6* MCV-86 MCH-28.5 MCHC-33.0 RDW-14.5 Plt Ct-458* Glucose-84 UreaN-20 Creat-1.4* Na-139 K-3.8 Cl-103 HCO3-30 AnGap-10 Calcium-8.6 Phos-5.0* Mg-2.1 Iron-45 calTIBC-252* Ferritn-304 TRF-194* Ret Aut-1.6 Hapto-372* ANCA-NEGATIVE [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-NEGATIVE C3-137 C4-23 Brief Hospital Course: 42 year-old male with a complex obstructive lung disease due to a combination of bronchiectasis and tracheal diverticuli, h/o hemoptysis, followed by Dr. [**Last Name (STitle) **], s/p RM lobectomy, who is being transferred from NWH ED for recurrent hemoptysis and fevers. . Summary of MICU Course: On arrival to the MICU the patient was found to have a temperature of 101.5 and to have intermittent bloody sputum (about the size of a quarter) and was hemodynamically stable. He was started on vancomycin/zosyn to cover likely levofloxacin-resistant pneumonia as RLL infiltrate was seen on CXR. Due to his stability and small amount of bleeding, bronchoscopy was not performed. He was treated with guaifenesin/codeine cough suppressant with the thought that when his bleeding further decreases this could be changed to chest PT. He was given IVF for sinus tachycardia. Blood and sputum cultures were pending at the time of his call out to the floor. He became quite dyspneic and tachycardic with any amount of exertion. ================== MEDICAL COURSE ================== #. Hemoptysis: Known recurrent hemoptysis with known long-standing h/o bronchietasis. Patient remained hemodynamically stable and did not require any intervention. Hemoptysis improved with treatment of underlying pneumonia. . #. Pneumonia: Althouth multiple sputum and blood cultures were obtained, only positive culture was group A streptococcus from outside hospital. Patient treated with Vanc/Zosyn empiracally for 7 days of a planned 14 day course due to development of acute renal failure of unknown etiology (for details see below). Patient was kept without antibiotics for 2 days and treatment completed wit 7 days of levaquin. . #. Acute Renal Failure: On day 5 of antibiotics, patient began to exhibit increase in serum creatinine. No causes of pre-renal or post renal azotemia were found. Workup was unrevealing for cause of intrinsic azotemia, including for negative urine eosinophils, negative ANCA/[**Doctor First Name **] and normal complement levels. Antibiotics were stopped for suspected eosinophil negative acute interstitial nephritis, with good improvement of renal failure, with serum creatinine of 1.4 at time of discharge. Suspect Zosyn is likely offending [**Doctor Last Name 360**], although patient has tolerated penicillins in the past. Although we would avoid using Zosyn and Vancomycin as possible, would not exclude using them in the future as patients underlying lung process is likely to cause further infections without a clear pathogen. Patient will have serum electrolytes checked on the week of discharge, with results available for his PCP visit on [**2184-4-1**]. Defer further management to PCP. . #. Bronchiectasis / Tracheal diverticuli: Followed by Dr [**Last Name (STitle) **], evaluated for Wegner's, Cystic fibrosis, and TB in the past. Appears consistent with Mounier-[**Doctor Last Name 6530**] syndrome as mentioned on pulmonary notes. Patient has Follow up with Dr [**Last Name (STitle) **] at pulmonary clinic. . # Diarrhea: Likely secondary to antibiotic use, patient with negative c. diff x 3. Resolved at time of discharge. . # Code: Full code, confirmed with pt . # Comm: Wife [**Telephone/Fax (1) 55442**] ==== pending labs: ASO titre. Medications on Admission: Mucinex Vitamins Tylenol prn Levaquin since [**2184-3-10**] Discharge Medications: 1. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) nebulizer Inhalation Q4H (every 4 hours) as needed. 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) treatment Inhalation Q6H (every 6 hours) as needed. 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours). Disp:*500 ML(s)* Refills:*0* 5. Levaquin 500 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 6. Outpatient Lab Work Please draw basic metabolic panel (including BUN/Creatinine with Calcium, magnesium and phosphorus) and CBC on [**2184-4-1**]. Please have results available for PCP [**Last Name (NamePattern4) **] [**2184-4-2**]. Discharge Disposition: Home Discharge Diagnosis: Bronchiectasis with exacerbation Pneumonia, multilobar Acute renal failure, resolving Discharge Condition: Afebrile, hemodynamically stable. Discharge Instructions: You were admitted to the hospital because you were having fevers and blood tinged sputum. Here we started you on antibiotics and treated you for a pneumonia. You have improved significantly but will require 7 more days of Levaquin. Please take all medications as prescribed and keep all doctors [**Name5 (PTitle) 4314**]. If you experience worsening cough, new fevers, nausea, vomiting, shortness of breath or any other symptom that concerns you, plase seek medical attention. Followup Instructions: Please schedule a follow up appointment with your primary care physician, [**Name10 (NameIs) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 27772**], on [**Last Name (LF) 2974**], [**4-2**] at 11:30 AM ([**Telephone/Fax (1) 55443**] Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2184-5-7**] 11:10

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

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154,012

20995

Discharge summary

report

Admission Date: [**2103-8-29**] Discharge Date: [**2103-9-4**] Date of Birth: [**2029-3-29**] Sex: F Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 398**] Chief Complaint: Respiratory difficulty due to tumor impingment on L main bronchus Major Surgical or Invasive Procedure: Intubation and debridement of tumor impinging on L bronchus. History of Present Illness: 74yo F with non-small cell Lung CA diagnosed in [**2097**] (stage 3b), presented for bronchoscopy, photodynamic therapy, and debridement of L bronchus on [**8-29**] by interventional pulmonary service. The procedure cleared the LLL & LUL but the lingula remained obstructed at the end of the procedure. In the PACU, the pt became tachpneic with decreased breath sounds on left, increased airway pressures, peak=32 with plateau=27. CXR demonstrated complete opacification of the L lung without midline shift. She was subsequently bronched in the PACU with suctioning of a mucous plug from the L bronchus - showed improvement in pt's breath sounds on L, peak pressure now 24, CXR with improved ventilation of L lung. She was then transferred to the MICU for further evaluation and treatment. Past Medical History: 1)Non-small cell lung CA - dx'd [**2097**], h/o stenting/XRT/chemo in past 2)s/p AVR- metal valve 3)A-fib 4)Type II DM 5)COPD 6)s/p appendectomy 7)s/p cholecystectomy Physical Exam: T-99.8 HR-84 BP-98/49 RR-14 100% Vent: A/C .95 550 14 MV-8 PEEP-5 PIP-24 Gen- Thin, elderly female, NAD HEENT - PERRL/EOMI, ETT in place, moist oral mucosa NEck supple, no JVD Chst - coarse BS RUL, crackles RLL, coarse rhonchi LUL/LLL CR - irreg/irreg, rate in 80's, 2/6 SEM Abd - soft, NT/ND, +BS Ext - warm, trace3 bilat pedal edema Neuro - sedated, opening eyes and moving all extremities purposefully Pertinent Results: [**2103-8-29**] 06:25PM WBC-18.3*# RBC-3.85* HGB-10.1* HCT-31.9* MCV-83 MCH-26.3* MCHC-31.7 RDW-14.3 [**2103-8-29**] 06:25PM GLUCOSE-224* UREA N-25* CREAT-1.3* SODIUM-139 POTASSIUM-5.2* CHLORIDE-102 TOTAL CO2-27 ANION GAP-15 [**2103-8-29**] 06:25PM CALCIUM-9.0 PHOSPHATE-7.0* MAGNESIUM-1.9 [**2103-8-29**] 06:25PM PLT COUNT-303 [**2103-8-29**] 06:25PM PT-13.9* PTT-22.5 INR(PT)-1.2 [**2103-8-29**] 09:16PM TYPE-ART RATES-/14 TIDAL VOL-500 O2-95 PO2-209* PCO2-21* PH-7.63* TOTAL CO2-23 BASE XS-3 AADO2-461 REQ O2-77 -ASSIST/CON INTUBATED-INTUBATED COMMENTS-INTERPRET Brief Hospital Course: 1)Pulmonary - Oxygen sat's, respiratory rate, and peak pressures were monitored closely for indication of recurrent obstruction. Repeat bronch by IP [**9-1**] showed edematous airways. It was felt to be difficult to extubate the patient given edematous airways and aggressive diuresis was begun. On [**9-3**] the RISBI was 73 and the patient strongly desired the tube out; the patient was extubated on [**2103-9-3**]. After extubation, she began to experience respiratory difficulty and required support. She was clear in her wishes to not be reintubated, and was begun on bipap and then on cpap overnight. Morphine was administered to ease her breathing. 2)A-fib/AVR - Coumadin was held until after procedures. IV heparin was restarted [**9-1**], and coumadin was restarted [**2103-9-3**]. 3)DM - The patient was covered with sliding scale insulin. The plan was to resume OP meds when extubated & taking PO meals. She did not take PO meals while hospitalized. 4)FEN - The patient was kept NPO. She was offered an NGT to begin tube feeds, but given her daily reevaluation for extubation, she preferred not to begin tube feeds. She received maintainence fluids while not taking PO's. She was noted to have an increasing anion gap acidosis, perhaps due to starvation ketosis. 5)Oliguria after second bronch in PACU. Received fluid boluses but did not respond with increased urine output. On [**9-2**] oliguria improved, questionably due to position of Foley catheter. She put out approximately 500cc with each dose of 20 IV lasix. 6)ID - Low grade temp on [**2103-9-3**]. Urine, blood, sputum cultures still pending but no growth to date at time of discharge. 7)Prophylaxis - Protonix, SQ Heparin, pneumoboots, SS Insulin, Chlorhexidine. 8)Access - 2 peripheral IV's, Foley catheter. 9)Communication - Husband & daughters 10)Status - DNR/DNI. Medications on Admission: Dig .25 qd, glipizide 5mg qam/2.4mg qpm, coumadin 5mg qd, detrol 2mg qd, lasix, albuterol/atrovent, folate, calcium, glucosamine Discharge Medications: 1. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**6-27**] Puffs Inhalation Q6H (every 6 hours) as needed. 2. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO QD (once a day). 3. Pantoprazole Sodium 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q24H (every 24 hours). 4. Morphine Sulfate 20 mg/5 mL Solution Sig: [**1-19**] PO every [**4-24**] hours as needed for pain. 5. Lasix 20 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed for shortness of breath or wheezing: For fluid overload . 6. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for anxiety. Discharge Disposition: Extended Care Discharge Diagnosis: Lung CA Discharge Condition: Fair Discharge Instructions: Keep pt pain free with morphine. Can treat dyspnea with Morphine and Ativan. Followup Instructions: None

[ "427.31", "496", "934.1", "285.9", "162.2", "V43.3", "512.1", "250.00", "E915" ]

icd9cm

[ [ [] ] ]

[ "96.56", "33.22", "38.93", "32.01", "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

5158, 5173

2500, 4352

374, 437

5225, 5231

1898, 2477

5356, 5364

4531, 5135

5194, 5204

4378, 4508

5255, 5333

1463, 1879

269, 336

465, 1258

1280, 1448

11,619

175,618

28749

Discharge summary

report

Admission Date: [**2141-7-15**] Discharge Date: [**2141-7-18**] Date of Birth: [**2068-3-4**] Sex: F Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 2901**] Chief Complaint: Mobitz [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] AV block w/ LBBB Major Surgical or Invasive Procedure: Placment of temporary pacemaker Placement of permanent pacemaker History of Present Illness: 73 yo woman with hx of HTN, ? afib (never on anticoagulation) and ? CVA was transferred from [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] hospital after being found to have Mobitz type II AV block w/ LBBB. She presented to the OSH this am c/o of dizziness since midnight, however says she actually noted feeling "woozy" with standing for about 1 week. She tolerated this until MN last night when she got out of bed to use the bathroom and noted she was very dizzy. Denied any SOB, CP, N/V; She did have some diarrhea yesterday, but denied any fever or chills, and no urinary symptoms. . The pt presented to OSH where she was found to be in 3rd degree AV block on ECG. She had transcut pacer pads placed, received ASA 325mg x 1 and was medflighted to [**Hospital1 18**]. . Here her ECG demonstrated Morbitz type II with LBBB. She had a temporary wire placed at bedside in R IJ position w/o any complications Past Medical History: HTN Social History: Married. 2 sons, 4 [**Name2 (NI) 69484**] a day for 40 years quit. Takes 2 drinks with dinner. No IVDU. Lives in [**Location 69485**]. Family History: no CAD, CVA, DM, or thyroid disease Physical Exam: Admission: VS: 98.6, 80 V paced, 150/50, 100% on 2L Gen: NAD HEENT: no JVD, MMM CVS: ireg HR, nl s1 and s2, no m/g/r lungs: CTABL ABD: soft, NT/ND Ext: no edema, 2+ DP Pertinent Results: Admission Labs: . [**2141-7-16**] 05:56AM BLOOD WBC-14.6* RBC-4.39 Hgb-14.0 Hct-40.5 MCV-92 MCH-31.9 MCHC-34.5 RDW-13.4 Plt Ct-258 [**2141-7-16**] 05:56AM BLOOD Plt Ct-258 [**2141-7-16**] 05:56AM BLOOD Glucose-138* UreaN-12 Creat-0.6 Na-140 K-3.7 Cl-103 HCO3-28 AnGap-13 [**2141-7-16**] 05:56AM BLOOD Calcium-8.9 Phos-3.0 Mg-2.1 . Radiology: CXR ([**2141-7-15**]): There is a right IJ line with tip projecting over the right ventricle. The lungs are clear without infiltrate or effusion. There is no pneumothorax. CXR ([**2141-7-18**]): Standard position of right pacemaker leads with no evidence of discontinuation. No pneumothorax. Left small pleural effusion grossly unchanged. No evidence of congestive heart failure. . Other Labs: [**2141-7-16**] 09:29AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015 [**2141-7-16**] 09:29AM URINE Blood-LGE Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM [**2141-7-16**] 09:29AM URINE Mucous-RARE Urine cx ([**2141-7-16**])- 4000/ml Gram negative rods (discussed with microbiology lab corresponding to 4000 colonies which was insignificant) Lyme serology ([**2141-7-17**]) - pending Discharge Labs: . [**2141-7-18**] 06:20AM BLOOD WBC-11.3* RBC-3.74* Hgb-12.7 Hct-34.6* MCV-93 MCH-34.0* MCHC-36.7* RDW-13.3 Plt Ct-194 [**2141-7-18**] 06:20AM BLOOD Plt Ct-194 Brief Hospital Course: The patient is a 73 yo F w/ ? h/o afib, ? h/o CVA, HTN p/w Mobitz [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] AV block w/ LBBB. Her hospital course for this admission is as follows: . 1. Morbitz type II AV block : temporary pacer placed when patient first presented with Morbitz type II block as bridge to permanent pacemaker. Held BB for pre-permanent pacer placment; permanent pacer placement on [**2141-7-17**]. Metoprol was restarted initially at 25mg PO bid, titrated up to 50mg PO bid (her home dose); Lyme titer was drawn to search for potential causes of her AV block which was still pending at the time of discharge. Will follow up with her Lyme titer after discharge . 2. HTN: Initially, we held BB as we don't want to supress any escape foci shd her temp wire fail prior to her permanent pacemaker placement, but continued outpt amlodipine 10mg PO qday. Once her permanent pacer was placed on [**2141-7-17**], we restarted her metoprolol, and continued her amlodipine. . 3. ? Afib: pt does not have any recollection of this. not on aspirin or coumadin. She was told to follow up with her PCP for follow up. . 4. ? h/o CVA; pt doesn't have any recollection of this. Will follow up with her PCP within [**Name Initial (PRE) **] week for further workup with imaging. patient remained alert and oriented throughout her stay with normal neuro exam. . 5. ? urine cx - her initial UA showed 32 RBC, 0 WBC, occ bacteria from her cath, and subsequent urine cx grew 4000 colonies/ml of gram negative rods. Patient remained afebrile throughout her stay, and had no urinary symptoms. Discussed with the microbiology lab (insignificant growth most likely from contamination of cath) and infectious disease fellow on call ([**First Name8 (NamePattern2) 803**] [**Last Name (NamePattern1) **]). Recommended no treatment if patient have no symptoms and afebrile. . 6. PPX: colace . 7. Code: Full Medications on Admission: Metoprolol 50mg PO bid Amlodipine 10qd Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): hold for SBP<100. 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for SBP<100 and HR<60. 4. Clindamycin HCl 300 mg Capsule Sig: One (1) Capsule PO four times a day for 5 doses: Please take one dose tonight and four doses tomorrow. Disp:*5 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis Morbitz type II AV block Secondary Diagnosis HTN Discharge Condition: stable in good condition, no fever, chest pain, SOB, Nausea or vomiting. Discharge Instructions: If you experience chest pain, shortness of breath or fevers, or any other serious medical conditions, please return to the emergency room immediately . You should follow a cardiac healthy diet. . Please take all your medications as prescribed . Please follow up with your appointments Followup Instructions: Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 24913**] [**Telephone/Fax (1) 32949**] next Monday [**2141-7-24**] 11:30am, in adddition to the following appointments Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2141-7-24**] 3:30 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**] Completed by:[**2141-7-19**]

[ "E944.4", "426.12", "438.9", "427.31", "V15.82", "458.29", "426.3", "401.9" ]

icd9cm

[ [ [] ] ]

[ "37.72", "37.83" ]

icd9pcs

[ [ [] ] ]

5693, 5699

3210, 5136

362, 428

5811, 5886

1830, 1830

6220, 6695

1588, 1625

5225, 5670

5720, 5790

5162, 5202

5910, 6197

3025, 3187

1640, 1811

232, 324

456, 1391

1846, 2555

1413, 1418

1434, 1572

2567, 3009

23,459

158,957

18478

Discharge summary

report

Admission Date: [**2150-11-4**] Discharge Date: [**2150-11-12**] Service: Cardiac Surgery HISTORY OF PRESENT ILLNESS: This is an 80-year-old gentleman with history of chronic atrial fibrillation and previous history of a coronary artery bypass in [**2132**] with known aortic stenosis, who has had worsening shortness of breath over the last several weeks with one episode of syncope. He went to his cardiologist on [**10-16**] and was noted to be bradycardic with heart rate in the 30s. He subsequently underwent a permanent pacemaker insertion with decreasing dyspnea, however, it was felt that replacement of his aortic valve would again improve his symptoms. Patient underwent cardiac catheterization on [**10-20**], which showed an ejection fraction of 45%. No significant left main disease, totally occluded mid LAD, totally occluded mid left circumflex, totally occluded mid RCA. The SVG to PDA is patent, SVG to OM patent, LIMA to LAD patent. The aortic valve area on cardiac catheterization was 0.94 cm squared with a gradient of 39 mm Hg and heavily calcified. Patient was referred to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 70**] for aortic valve replacement. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Status post CABG in [**2132**]. 3. Aortic stenosis. 4. History of CVA in [**2147**] with left sided visual loss. 5. Chronic atrial fibrillation. 6. History of GI bleed in [**2148**]. 7. Status post left rotator cuff surgery. SOCIAL HISTORY: Patient is a retired carpenter, who lives with his wife. [**Name (NI) **] has a very remote history of tobacco use and very remote history of EtOH use. ALLERGIES: No known drug allergies. PREOPERATIVE MEDICATIONS: 1. Lisinopril 2.5 mg p.o. q.d. 2. Protonix 40 mg p.o. q.d. 3. Lipitor 10 mg p.o. q.d. 4. Enteric coated aspirin 325 mg p.o. q.d. 5. Lasix 40 mg p.o. q.d. 6. Cosopt eyedrops one drop O.U. b.i.d. 7. Coumadin 5 mg p.o. q.d. HOSPITAL COURSE: Patient was admitted to [**Hospital1 346**] on [**2150-11-4**] preoperatively for a redo sternotomy and aortic valve replacement. With his preoperative laboratory data, patient was noted to have an elevated INR of 1.4. It was decided by Dr. [**Last Name (STitle) 70**], that the patient should be admitted and receive 2 units of fresh-frozen plasma to correct his INR to normal prior to proceeding with his cardiac surgery. Patient received 2 units of FFP and his INR is corrected to 1.2, and the patient was taken to the operating room on [**11-5**] for a redo sternotomy and aortic valve replacement with a 21 mm pericardial valve. Patient tolerated the procedure well and was transferred to the Intensive Care Unit on low dosed Neo-Synephrine and propofol drip. Patient was weaned and extubated from mechanical ventilation on the first postoperative day. Patient remained hemodynamically stable with a good cardiac index. No significant chest tube drainage. The Electrophysiology service was contact[**Name (NI) **] on postoperative day #1 for interrogation of his permanent pacemaker. The interrogation showed patient was in underlying atrial fibrillation with slow ventricular response and normal pacemaker function. The patient's epicardial wires were removed on postoperative day #1. Patient's ventricular response began increasing and patient was started on low dose beta blocker. Patient was also started on Lasix. On postoperative day #3, patient was started on Coumadin for his chronic atrial fibrillation. Patient was seen by Physical Therapy, and began ambulating with Physical Therapy. On postoperative day #4, the patient was transferred from the Intensive Care Unit to the regular part of the hospital, where he continued to work with Physical Therapy. By postoperative day #6, the patient was able to ambulate 500 feet with Physical Therapy and climb one flight of stairs without requiring oxygen and remaining hemodynamically stable. On postoperative day #7, patient was cleared for discharge to home. CONDITION ON DISCHARGE: T max 98.4, pulse 70 V-paced, blood pressure 108/58, respiratory rate 16, on room air oxygen saturation 98%. Laboratory data: White blood cell count 8.9, hematocrit 31.4, platelet count 240, potassium 4.5, BUN 14, creatinine 1.0, PT 15.8, INR 1.7. Patient's weight today is 80 kg. Preoperatively, patient was 77 kg. Patient is awake, alert, and oriented times three. Heart regular, rate, and rhythm without rub or murmur. Lungs are coarse bilaterally, but without wheezes or rales. Abdomen is soft, positive bowel sounds, nontender, and nondistended. Sternal incision: Steri-Strips are intact. There is no erythema or drainage. The sternum is stable. Patient's left lower extremity has [**2-9**]+ pitting edema. Patient says he always has at least some edema in his left leg. Right leg has [**1-8**]+ pitting edema. DISCHARGE STATUS: Patient is to be discharged to home in stable condition. DISCHARGE MEDICATIONS: 1. Enteric coated aspirin 81 mg p.o. q.d. 2. Colace 100 mg p.o. b.i.d. 3. Percocet 5/325 [**1-8**] p.o. q.6h. prn. 4. Protonix 40 mg p.o. q.d. 5. Cosopt eyedrops one drop O.U. b.i.d. 6. Lopressor 50 mg p.o. b.i.d. 7. Lasix 40 mg p.o. b.i.d. x7 days, then change to 40 mg p.o. q.d. 8. Potassium chloride 40 mEq p.o. b.i.d. x7 days, then decrease to 40 mEq p.o. q.d. 9. Coumadin 5 mg p.o. on [**11-12**], then PT/INR will be drawn by visting nurse, results called to Dr.[**Name (NI) 50816**] office, and further Coumadin dosing to be determined by Dr.[**Name (NI) 50816**] office. Patient probably will require 5 mg p.o. q.d. which is his preoperative dose. 10. Lipitor 10 mg p.o. q.d. FOLLOW-UP INSTRUCTIONS: Patient should follow up with Dr.[**Name (NI) 50817**] office by phone on [**11-13**], and then see Dr. [**Last Name (STitle) 28436**] in the office in [**1-8**] weeks. Patient should see his cardiologist, Dr. [**Last Name (STitle) 10543**] also in [**1-8**] weeks. Patient is to see Dr. [**Last Name (STitle) 70**] in [**5-12**] weeks. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Last Name (NamePattern1) 1541**] MEDQUIST36 D: [**2150-11-12**] 11:02 T: [**2150-11-12**] 11:10 JOB#: [**Job Number 50818**]

[ "427.31", "V45.01", "401.9", "V45.81", "424.1", "414.01" ]

icd9cm

[ [ [] ] ]

[ "35.21", "39.61" ]

icd9pcs

[ [ [] ] ]

4960, 5646

1972, 4008

1732, 1954

131, 1218

5671, 6316

1240, 1497

1514, 1706

4033, 4937

3,829

121,342

25854

Discharge summary

report

Admission Date: [**2139-9-21**] Discharge Date: [**2139-9-30**] Date of Birth: [**2062-12-16**] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: This 76-year-old male was referred to Dr. [**Last Name (STitle) **] for a history of mitral regurgitation. He had dyspnea on exertion for 6 months and exertional chest pain. He had a 10-year history of mitral valve prolapse followed by serial echo's which showed worsening MR in recent months. He admits to progressive DOE and exertional chest pain. Denies any symptoms at rest. No PND or palpitations or orthopnea/[**Known firstname **] syncope. He remains very active and works almost every day. Preop cardiac cath showed a left-dominant system with a patent stent of his mid left circumflex, 3+ MR, ejection fraction of 62% and a cardiac output of 4.18 L/min. Echo done in [**2139-6-10**] showed mild AI, moderate MR, mild TR and an ejection fraction of 70%. PREOPERATIVE LABORATORY DATA: White count of 8.9; hematocrit of 40.2; platelet count of 294,000. PT of 13.2, PTT of 29.0, INR of 1.2. Urinalysis was negative. Sodium of 139, K of 4.8, chloride of 99, bicarbonate of 26, BUN of 19, creatinine of 0.9 with a blood sugar of 80. ALT of 18, AST of 24, alkaline phosphatase of 119, total bilirubin of 0.7, total protein of 7.3, albumin of 4.6, globulin of 2.7, HbA1C of 5.7%. RADIOLOGIC AND OTHER STUDIES: Preop carotid series showed antegrade flow in both vertebral arteries and moderate plaque with bilateral 40% to 60% carotid stenoses. Preop chest x-ray showed multifocal asbestos-related plaque with some calcified plaque in the left hemithorax with a suggestion of left atrial enlargement, but no other cardiopulmonary abnormality. Please refer to the official report dated [**2139-9-2**]. Preop EKG showed sinus rhythm at 62 with atrial premature depolarizations. Preop echo showed an ejection fraction of greater than 60%, normal aortic root and ascending aorta. No AS. Mild AI. Moderate-to-severe mitral valve prolapse with 2+ MR and 2+ TR. Please refer to the official report dated [**2139-9-11**]. PAST MEDICAL HISTORY: 1. Mitral valve prolapse with mitral regurgitation. 2. Coronary artery disease with left circumflex stent in [**2133**]. 3. Elevated cholesterol. 4. Hypothyroidism. 5. Neurofibromatosis. 6. Pulmonary asbestosis. 7. Bilateral carotid artery stenosis with peripheral vascular disease. PAST SURGICAL HISTORY: Status post inguinal hernia repairs, status post multiple nodule removals for neurofibromatosis and status post basal cell carcinoma on his back. PREOPERATIVE MEDICATIONS: Zetia 10 mg p.o. daily, Levoxyl 75 mcg p.o. daily, Lipitor 40 mg p.o. daily, Toprol XL 100 mg p.o. daily, aspirin 81 mg p.o. daily, calcium and multivitamin daily. ALLERGIES: He had no known allergies. FAMILY HISTORY: His father died at 72 of coronary thrombosis. SOCIAL HISTORY: He lives with his wife. [**Name (NI) **] is a retired computer specialist. He denies any alcohol or tobacco use. PHYSICAL EXAMINATION: Heart rate of 70, respiratory rate of 14, blood pressure on the right of 122/50 and on the left of 120/60, weight of 163 pounds, 5 feet and 6 inches tall. He was in no apparent distress. He had multiple subacute nodules. He had a significant left eye droop. His neck was supple. Full range of motion. Lungs were clear bilaterally. Heart was regular in rate and rhythm with a grade 4/6 systolic ejection murmur at the left lower sternal border. His abdomen was soft, nontender and nondistended with positive bowel sounds. His extremities were warm and well perfused with trace edema on the right greater than the left. Had no known varicosities, and his neurologic exam was grossly intact. He had bilateral 1+ femoral, DP and PT pulses; and a soft carotid bruit on the left and 1+ on the right. HOSPITAL COURSE: He was admitted as a same-day admission on [**9-21**] and underwent mitral valve replacement with a 27- mm [**Last Name (un) 3843**]-[**Doctor Last Name **] pericardial valve by Dr. [**Last Name (STitle) **]. He was transferred to the cardiothoracic ICU in stable condition on an epinephrine drip at 0.02 mcg/kg/min, a nitroglycerin drip at 0.5 mcg/kg/min, and a propofol titrated drip. On postoperative day 1, he had been extubated overnight. He had some short bursts of AFib, but was in sinus rhythm in the morning at 73 with a blood pressure of 123/48. Postop labs as follows: K of 6.0, BUN of 16, creatinine of 0.9, white count of 16.7, PT of 14.3, with an INR of 1.4. He began Lopressor beta blockade and Lasix diuresis. He was alert and oriented, and his exam was otherwise unremarkable; and he was transferred out to the floor in stable condition on an insulin drip in the morning of 0.5 units per hour. On postoperative day 2, his chest tubes were discontinued. He had a 10% right apical pneumothorax, from which he was not symptomatic post chest tube pull. He was in first-degree AV block at a heart rate of 65, maintaining good blood pressure. He continued his perioperative antibiotics; was restarted on his Synthroid and other cardiac medicines. His central venous line was removed. Pacing wires remained in place. He was alert and oriented with an unremarkable exam. A cardiology consult was requested for evaluation of his atrial tachycardia and first-degree AV block. Their recommendation was to continue his beta blocker and continue to monitor. He remained alert and oriented in his 2:1 AV block over the course of the first 2 days. He started to work with the nurses and physical therapists on increasing his activity level and endurance. On postoperative day 3, his chest tubes had been removed. He was encouraged to ambulate and to increase his activity level. He was transfused 1 unit of packed red blood cells for a low hematocrit, but remained hemodynamically stable as his heart rate rose to the 70s. On postoperative day 4, he went back and forth between sinus bradycardia and Wenckebach rhythm. At that point EP consult recommended discontinuing his Lopressor. He went into atrial fibrillation that morning with a ventricular response rate of 57 and a systolic blood pressure of 107; was seen by Dr. [**Last Name (STitle) **] of electrophysiology. The patient went back into sinus rhythm overnight on postoperative day 5; and heparin, which had been started, was stopped. On the 17th, the patient was in sinus rhythm in the 80s; and cardiology reevaluated the patient again as he appeared to be somewhat stable, in sinus rhythm at 80s to 90s with occasional first-degree AV block. On postoperative day 6, he was back in atrial fibrillation but maintaining a good blood pressure of 127/58. Heparin was restarted, and first dose of Coumadin was given of 2 mg later that afternoon for coverage of his atrial fibrillation. His lung sounds were slightly coarse. His heart was irregular, but he remained hemodynamically stable. Pacing wires remained in place. On postoperative day 7, he remained in atrial fibrillation. Pacing wires were discontinued. Discharge planning was begun, and he was restarted on Lopressor 12.5 mg p.o. b.i.d. He had some hyperkalemia with a K of 6.0. Kayexalate was given, and KCL was discontinued with his Lasix therapy. On postoperative day 8, he received a second dose of 5 mg of Coumadin with plans that when his INR crossed 1.5 he would be able to discharge home with VNA services. Beta blockade was increased as tolerated. His INR was 1.3 on postoperative day 8. His sternum was stable. He went back into sinus rhythm and then back to atrial fibrillation on the day of discharge - [**9-30**] - with an INR of 1.8 on Coumadin therapy. DISCHARGE STATUS: He was discharged to home in stable condition. His blood pressure was 115/55, respiratory rate of 20, heart rate of 67, ventricular rate response, in atrial fibrillation, weight of 73.2 kilograms, saturating 98% on room air. DISCHARGE DISPOSITION: He was discharged to home with VNA services on [**2139-9-30**]. DISCHARGE DIAGNOSES: 1. Status post mitral valve repair with a 27-mm pericardial valve. 2. Coronary artery disease; status post left circumflex stent in [**2133**]. 3. Hypercholesterolemia. 4. Hypothyroidism. 5. Neurofibromatosis. 6. Pulmonary asbestosis. 7. Peripheral vascular disease with bilateral carotid artery stenoses. DISCHARGE MEDICATIONS: 1. Colace 100 mg p.o. twice a day. 2. Lipitor 40 mg p.o. once a day. 3. Levothyroxine sodium 75 mcg p.o. once a day. 4. Zetia 10 mg p.o. once a day. 5. Tamsulosin 0.4 mg p.o. once a day at bedtime. 6. Lasix 20 mg p.o. once a day for 7 days. 7. Coumadin 3 mg to be dosed of the afternoon of the 21st and Coumadin 3 mg to be dosed on the afternoon of the 22nd with INR to be drawn by the VNA and then called to Dr. [**Last Name (STitle) 5017**] for continued dosing with a target INR of 2.0 to 2.5 for atrial fibrillation. 8. Metoprolol 25 mg p.o. twice a day. 9. Potassium chloride 20 mEq p.o. once a day for 7 days. DISCHARGE INSTRUCTIONS: The patient was instructed to follow up with Dr. [**Last Name (STitle) **] in the office at 4 weeks postop; to see Dr. [**Last Name (STitle) 5017**] in approximately 2 weeks; and to return to our [**Hospital 409**] Clinic at [**Hospital1 18**] in 2 weeks. The patient was again instructed to have INR checked by VNA on [**Last Name (LF) 2974**], [**10-2**], and call results to Dr.[**Name (NI) 44916**] office ([**Telephone/Fax (1) 5424**]) for further Coumadin dosing. CONDITION ON DISCHARGE: He was discharged on [**2139-9-30**] in stable condition. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2139-10-14**] 15:56:15 T: [**2139-10-14**] 16:57:57 Job#: [**Job Number 2417**]

[ "512.1", "276.7", "424.0", "V45.82", "428.0", "237.70", "244.9", "501", "433.10", "427.31", "369.60", "272.0" ]

icd9cm

[ [ [] ] ]

[ "88.72", "39.61", "35.23", "99.04" ]

icd9pcs

[ [ [] ] ]

7910, 7975

2831, 2878

7996, 8322

8345, 8987

3845, 7886

9012, 9484

2435, 2582

2609, 2814

3032, 3827

166, 2090

2112, 2411

2895, 3009

9509, 9805

46,536

197,638

4255

Discharge summary

report

Admission Date: [**2114-12-3**] Discharge Date: [**2114-12-5**] Service: MEDICINE Allergies: Cephalosporins Attending:[**First Name3 (LF) 398**] Chief Complaint: Sepsis Major Surgical or Invasive Procedure: . History of Present Illness: 86 y/o male with a PMH of PD, CHF, and hypothyroidism BIBA from [**Hospital 100**] Rehab nursing home with hypotension and Proteus growing from the blood and the urine. Of note, Foley was placed [**12-1**] on recommendation of wound consult to protect skin at ulcer site, as patient has healing stage 4 decubitus ulcer. Over the weekend, he had fever (100.8) and chills, and given the recent Foley placement, U/A, urine and blood cultures were sent. He was given one dose of ciprofloxacin on Saturday when the U/A returned positive. Today, the urine and blood grew Proteus, sensitive to Augmentin, aztreonam, pip/tazo, amikacin, cephalopsporins (has cephalopsporin allergy). Resistant 99.8, BP 72/40. Foley D/Cd, and passing frank blood clots. BMP this AM remarkable for ARF with BUN:creatinine 73/3.1, from baseline creatinine 0.9 in [**7-30**]. CBC with WBC 38.6, 56% PMNs. Pt also had reported chest congestion and LLQ pain. In the ED, vitals upon presentation were T 98 BP 143/55 HR 88 RR 18 97%2L. He was given a total of 4L NS. He was also given vancomycin 1 gram IV and Zosyn 4.5 grams IV. On evaluation in the unit, patient reports increased sputum production over last several days, fever and chills at nursing home. Also endorses abdominal pain. ROS: As above, otherwise negative Past Medical History: PD, bedbound Stage IV decubitus ulcer dCHF EF 70% Hypothyroidism h/o GIB h/o c.diff Anemia CRI Malnutrition/dysphagia/aspiration, G-tube GERD CAD s/p CABG [**2097**] Gout Hyperlipidemia Chronic osteomyelitis of heels/coccyx ESBL in urine Social History: Lives at [**Hospital 100**] Rehab. Retired auditor. Former smoker 20 year pack history Family History: Non-contributory Physical Exam: On Presentation: Vitals: T:98 BP:101/65 HR:65 RR: 20 O2Sat:97% on RA GEN: Well-appearing, well-nourished, no acute distress HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: rhoncorous throughout, bronchial breath sounds, no wheeze or crackle ABD: + bs, TTP greatest at LLQ, (+) guarding, no rebound EXT: 1+ [**Location (un) **] bilaterally NEURO: alert, oriented to person, place, and time. SKIN: Stage 4 decub ulcer, stage 2 ulcers on heels bilaterally Pertinent Results: [**2114-12-3**] 12:55PM GLUCOSE-113* UREA N-108* CREAT-3.9* SODIUM-139 POTASSIUM-5.0 CHLORIDE-98 TOTAL CO2-23 ANION GAP-23 [**2114-12-3**] 12:55PM WBC-33.2* RBC-3.60* HGB-11.7* HCT-35.1* MCV-98 MCH-32.5* MCHC-33.3 RDW-14.0 [**2114-12-3**] 12:55PM NEUTS-83* BANDS-10* LYMPHS-5* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2114-12-3**] 12:55PM CK-MB-5 [**2114-12-3**] 12:55PM cTropnT-0.05* [**2114-12-3**] 12:55PM CK(CPK)-137 [**2114-12-3**] 01:12PM LACTATE-3.2* [**2114-12-3**] 12:55PM PT-15.3* PTT-35.1* INR(PT)-1.3* [**2114-12-3**] 12:55PM PLT SMR-LOW PLT COUNT-135* IMAGING: CT A/P: 1. Bibasilar lung consolidations (atelectasis versus pneumonia) with small pleural effusions. 2. Mild wall thickening in the rectum and distal sigmoid colon could be compatible with proctocolitis in the appropriate clinical setting. 3. Sacral decubitus ulcer with evidence of periosteal reaction in the underlying sacrum. Clinical inspection recommended to grade and if needed MRI may be performed to further assess. 4. Fatty atrophy of the pancreas, with multiple exophytic cystic lesions. MRCP is recommended to further assess. 5. Atrophic kidneys. 6. Distal fluid containing small bowel with air- fluid levels. Findings may reflect gastroenteritis. 7. Atherosclerotic disease as described. Brief Hospital Course: Mr. [**Known lastname 3075**] was a 86 yo M with PMH of Parkinson's, c. difficile, chronic renal insufficeny, stage 4 decub ulcer who presents from his nursing home with fevers, increased sputum production, and proteus bacteremia and UTI requiring pressor support. The patient was DNR/DNI on admission. On admission he underwent a CT of his abdomen given abdominal pain and leukocytosis which showed proctocolitis and with his history of C.diff he was empirically treated with flagyl for his. For the proteus bacteremia and UTI he was treated with zosyn. His hypotension was treated with dopamine as he did not want a central line placed and could not receive other pressors. The night before death he was desating due to copious secretions and becoming more dependent on pressors. His CXR in the morning showed many new areas of infiltrate likely consistent with multiple aspiration events. A family discussion was held to address goals of care given his worsening clinical status and DNR/DNI wishes. A priest spent time with the family and patient and a family meeting was held and the decision by both the patient and his daughter (his health care proxy) was to make him [**Name (NI) 3225**] so the pressors were weaned and he was treated with morphine prn for comfort. During the evening he developed asytole on the telemetry monitor. On exam he was nonresponsive to voice or touch, his pupils were nonreactive, he had no spontaneous breathing or breath sounds present, and had no heart sounds present. He was pronounced dead at 8:46 pm. His causes of death were listed as cardiac arrest, sepsis, and Parkinson's Disease. His daughters and their husbands were in the room with him when he died and were informed of his death (Daughter [**Name (NI) **] [**Name (NI) 18482**] (HCP) [**Telephone/Fax (1) 18483**]). They declined an autopsy. The attending overnight, Dr. [**Last Name (STitle) 18484**], was notified by phone. Medications on Admission: Calcium Carbonate 1300 mg PO QHS Fiber Con 625 mg PO daily Carbidopa-Levodopa 25/100 one TAB PO QID Vitamin D 1000 units PO daily Colace 240 mg PO daily Levothyroxine 250 mcg PO daily Metoprolol SR 50 mg PO daily Mirtazapine 15 mg PO QHS Oxycodone 5 mg PO BID Pramiprexole 0.125 mg PO TID Senna one capsule PO QHS Ciprofloxacin 500 mg PO BID Tylenol PRN Bisacodyl 10 mg PR daily PRN Magnesium Miralax PRN Discharge Disposition: Expired Discharge Diagnosis: Cardiac arrest Sepsis Aspiration pneumonia Parkinson's disease Discharge Condition: Expired Completed by:[**2114-12-5**]

[ "428.0", "263.9", "428.32", "530.81", "V45.81", "707.24", "414.00", "995.92", "244.9", "038.9", "427.5", "332.0", "707.03", "785.52", "585.9", "584.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6273, 6282

3875, 5817

228, 232

6389, 6428

2547, 3852

1937, 1955

6303, 6368

5843, 6250

1970, 2528

182, 190

260, 1555

1577, 1817

1833, 1921

49,249

168,029

6204

Discharge summary

report

Admission Date: [**2177-1-20**] Discharge Date: [**2177-2-5**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3918**] Chief Complaint: S/p Fall and 13-point HCT drop. Major Surgical or Invasive Procedure: EGD History of Present Illness: Mrs. [**Known firstname 24188**] [**Known lastname 24189**] is a very nice 87 year-old woman with significant past medical history of CAD s/p MI, HTN, HL, stage I breast ca s/p lumpectomy on remision who comes after a fall and is foung to have a 13-point HCT drop. Patient was in her prior state of health until [**2176-9-5**] when his PCP noted [**Name Initial (PRE) **] 15-pound weight loss. TSH, CBC, mammogram and remaining of work up was unreveiling. She had no localizing symptoms. Today she states she was walking in the common room and while she was turning around she tripped and feel to the floor without hitting her head or losing conciousness. She called for help at her [**Hospital 4382**]. When aid arrived she was found down very somnolent, but responsive without any abnormal movement or signs of loss of sphincter control. There was no visible bleeding or signs of trauma. . In the [**Hospital1 1388**] ER her pain [**4-14**], Temp 98.6 F, HR 104 BPM, BP 143/117 mmHg, RR 16 X', 94% on RA, FBS 192 (orthostatics not done). She was very combative and received 2 mg of ativan and haldol. Her ECG showed lateral ST-depressions. She could not undergo CT scan until more sedated with medications described above. Her CT head was negative for acute pathology and her CT neck showed extensive DJD with canal narrowing. Her labs came back and she had a HCT of 23 from baseline of 36 ([**2176-9-5**]) with 14 WBC and 571 PLTs (85% PMNs, L12).Her CK was 500 with MB of 14 and Trop T of 0.19. Her BMP was significant for sodium of 132, gap of 18, CO2 of 23, glucose of 179 with creatinine of 1.0 and BUN of 30. She became transtiently hypotensive with SBP in 80s and received IVF. Her NGT showed bile and was guaiac negative. Her rectal exam was normal and guaiac negative. Her repeat HCT after fluids was 18 from 23. She received 1 RBC unit. She has 2 18G for access. She was seen by trauma surgery who recommended admission to MICU for monitoring given negative RP-bleed, guaiac negative stool and NG-lavage. . In the ER to look for RP bleed she underwent non-con CT, which showed diffuse nodularity of the stomach, concerning for neoplasm, involving the retroperitoneum, eroding L2 and possibly infiltrating the spinal canal. She then underwent a contrast CT, which showed soft tissue mass medial to L kidney, thickened gastric mucosa and lytic lesions in sacrum as well as stable pulmonary nodule. Her VS prior to transfer were: HR 110 [**Doctor First Name **], BP 110/65 mmHg, RR 23 X', SpO2 100% on 3L. . Of note, patient reports 7 pound weight loss, denies any cough, nausea, vomit, diarrhea. Reports occasional black stool, but no bright red blood or other signs of bleeding. She has been feeling fatigued. No dysphagia. Past Medical History: ONCOLOGIC HISTORY: Pt is status post resection of a left-sided stage I breast cancer on [**2171-8-29**]. Then she underwent adjuvant treatment with Arimidex and decided against Tamoxifen given side effects. She continued therapy for 3 years until [**2174-6-2**], when it was stopped secondarely to severe osteoporosis. Since then se has had yearly negative mammograms (last [**2176-5-6**]). Decided against radiation therapy. PAST MEDICAL HISTORY: H/o Breast ca as above CAD s/p NSTEMI in [**2166**] Hypercholesterolemia: Last lipid profile [**9-13**]: cholesterol 134, HDL cholesterol 37, and LDL cholesterol 69 Gastritis Gastroesophageal reflux disease Anxiety Peripheral vascular disease Osteoporosis: BMD test [**11-11**]: t scores -2.4 spine, -3.9 hip; could not tolerate Fosamax given GI issues Irritable bowel syndrome H/o wrist fracture Hearing loss Osteoartritis H/o cholesterol emboli to the eye H/o pancreatitis Trigger finger PAST SURGICAL HISTORY: Laparoscopic cholecystectomy [**2166-5-29**] Wide excision left breast cancer [**2171-10-3**] Operative fixation of right intertrochanteric hip fracture C-section Social History: She is a retired clerk from an insurance company, is widowed, and lives in an [**Hospital3 **]. She does have two sons nearby; one is unfortunately handicapped. She smoked in the past quiting many years ago and has history of more than 70 pack-years. Family History: Non-contributory. Physical Exam: VITAL SIGNS - Temp 97.8 F, BP 148/76 mmHg, HR 99 BPM, RR 14 X', O2-sat 100% 2 L NC GENERAL - well-appearing woman in NAD, comfortable, appropriate, not jaundiced (skin, mouth, conjuntiva), pale mucous membranes, cachectic-appearing HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear, pale mucous membranes NECK - supple, no thyromegaly, JVD 9 cm, no carotid bruits, EJ very prominent LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use, difficult to auscultate HEART - PMI non-displaced, RRR, no MRG, nl S1-S2, no R-V strain, tachycardic ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding, multi-nodular mass in LLQ with very mild pain on deep palpation EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs), 2+ pitting edema bilateraly up to the knees SKIN - no rashes or lesions LYMPH - no cervical, axillary, or inguinal LAD NEUROLOGIC: Mental status: Awake and alert, cooperative with exam, normal affect. Hearing decreased bilaterally Pertinent Results: Admission Labs: [**2177-1-20**] 05:26PM WBC-14.2*# RBC-2.61*# HGB-7.2*# HCT-23.7*# MCV-91 MCH-27.7 MCHC-30.5* RDW-15.3 [**2177-1-20**] 05:26PM NEUTS-84.0* LYMPHS-12.7* MONOS-2.9 EOS-0.1 BASOS-0.3 [**2177-1-20**] 05:26PM PLT COUNT-571*# [**2177-1-20**] 05:26PM GLUCOSE-179* UREA N-30* CREAT-1.0 SODIUM-132* POTASSIUM-4.5 CHLORIDE-91* TOTAL CO2-23 ANION GAP-23* [**2177-1-20**] 05:26PM ALT(SGPT)-24 AST(SGOT)-44* LD(LDH)-466* CK(CPK)-500* ALK PHOS-106* TOT BILI-0.2 [**2177-1-20**] 05:26PM cTropnT-0.19* [**2177-1-20**] 05:26PM CK-MB-14* MB INDX-2.8 [**2177-1-20**] 05:26PM TOT PROT-5.8* ALBUMIN-3.3* GLOBULIN-2.5 IRON-11* [**2177-1-20**] 05:26PM calTIBC-338 HAPTOGLOB-249* FERRITIN-32 TRF-260 [**2177-1-20**] 05:26PM OSMOLAL-282 CPK ISOENZYMES CK-MB MBIndx cTropnT [**2177-1-22**] 03:53AM 12* 7.3* 0.61* [**2177-1-21**] 09:50PM 18* 5.4 0.73* [**2177-1-21**] 04:32PM 23* 4.2 0.76* [**2177-1-21**] 09:46AM 36* 5.2 0.94* [**2177-1-21**] 02:11AM 50* 4.9 1.05* [**2177-1-20**] 05:26PM 14* 2.8 0.19* [**2177-1-20**] 05:26PM WBC-14.2*# RBC-2.61*# HGB-7.2*# HCT-23.7*# MCV-91 MCH-27.7 MCHC-30.5* RDW-15.3 [**2177-1-20**] 05:26PM NEUTS-84.0* LYMPHS-12.7* MONOS-2.9 EOS-0.1 BASOS-0.3 [**2177-1-20**] 05:26PM PLT COUNT-571*# [**2177-1-20**] 10:03AM URINE HOURS-RANDOM TOT PROT-9 [**2177-1-20**] 10:03AM URINE U-PEP-NEGATIVE F [**2177-1-20**] CT Chest/Ab/Pelvis w/out contrast: IMPRESSION: 1. Extensive gastric mucosal thickening, worrisome for malignancy. 2. Soft tissue density mass moderately displacing the left kidney with adjacent osseous destruction, concerning for a metastasis. 3. Soft tissue density masses within the right hemisacrum and left illiac [**Doctor First Name 362**]. These findings are concerning for metastatic disease. 4. Status post cholecystectomy with dilatation of the common bile duct. Periportal edema. 5. Extensive degenerative changes of the thoracolumbar spine with scoliosis. 6. Extensive coronary artery disease and aortic calcifications. 7. Atelectasis in bilateral lung bases, although infection cannot be excluded. There are small bilateral pleural effusions and evidence of mild pulmonary edema. 8. Heterogeneous thyroid. Ultrasound could be performed on a non-emergent basis for better evaluation if indicated. 9. Diverticulosis without diverticulitis. [**2177-1-20**] CT head FINDINGS: There is no hemorrhage, edema, mass effect, or evidence for acute vascular territorial infarction. There is slight prominence of the ventricles and sulci, compatible with parenchymal involution and stable. There is calcification within the bilateral basal ganglia. There is no shift of normally midline structures, and [**Doctor Last Name 352**]-white matter differentiation remains well preserved. There is slight periventricular white matter hypodensities compatible with sequela of chronic small vessel infarction. Left basal ganglia lacune is chronic. The visualized paranasal sinuses are clear. There are stable calcifications in the posterior aspects of bilateral globes. There are carotid siphon calcifications. IMPRESSION: No acute intracranial pathology. Stable atrophy and chronic small vessel ischemic disease. [**2177-1-20**] CT C-spine 1. Extensive degenerative changes throughout the cervical spine, most pronounced at C5/C6 causing indentation of the thecal sac. If there is concern for cord injury, MRI would be more sensitive for this evaluation. 2. No fracture or dislocation. 3. Heterogeneous appearance to both lobes of the thyroid with multiple nodules. Ultrasound could be performed on a non-emergent basis for further evaluation if clinically indicated. 4. Apical septal thickening indicates mild pulmonary edema. [**2177-1-21**] TTE The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Tissue Doppler imaging suggests a normal left ventricular filling pressure (PCWP<12mmHg). Right ventricular chamber size is normal. with borderline normal free wall function. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are moderately thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Normal biventricular cavity sizes with preserved global and regional biventricular systolic function.. Mild pulmonary artery systolic hypertension. Mild mitral regurgitation. Dilated ascending aorta. CXR [**1-21**] Study demonstrates slight progression of the pulmonary edema, currently interstitial, with some degree of alveolar edema towards the lung bases in combination with bilateral pleural effusions and might be consistent with volume overload. There is also distention of the right upper mediastinal veins including the azygos vein. The small focal consolidations seen on the CT abdomen from [**2177-1-20**] are not visible on the current radiograph. Brief Hospital Course: Mrs. [**Known firstname 24188**] [**Known lastname 24189**] is a very nice 87 year-old woman with significant past medical history of CAD s/p MI, HTN, HL, stage I breast ca s/p lumpectomy on remision who comes after a fall and is foung to have a 13-point HCT drop and CT-scan findings concerning for malignancy. # High grade lymphoma: gastric infiltration and retroperitoneal mass were found to be lymphoma. Pathology looked like Burkitt's, after discussion with the pateint and her family, it was decided that she would not undergo chemotherapy. At that point she was made comfort measures only, and was screened for hospice placement. # Anemia: Hematocrit on presentation 23.7 down from 36 in [**2176-9-5**]. Felt to be chronic given patient's relative compensation, and likely secondary to underlying malignancy of GI origin/involvement given CT findings of gastric mucosal thickening/mass. Patient received 3 units PRBCs with appropriate rise in hematocrit. Labs suggestive of underlying iron deficiency and no evidence of hemolysis. GI was consulted for EGD with endoscopy and requested [**Hospital1 **] PPI and cardiology consult prior to proceeding. After EGD, her Hct remained stable. Lab draws were discontinued after change in goals of care with no sign of active bleeding. Aspirin was discontinued at this time, she was continued on [**Hospital1 **] PPI on discharge. # Abdominal Mass: CT abdomen on presentation was significant for nodular thickening of the stomach, a retroperitoneal mass with vertebral involvement, and bony lesions concerning for metastasis. LFTs also notable for mild transaminitis, but no liver lesions seen on CT. These findings were suggestive of malignancy with a broad differential diagnosis. It was felt that EGD with biopsy was the easiest method to obtain tissue for diagnosis so GI was consulted. SPEP and UPEP were sent for possible GI lymphoma and were negative. EGD revealed multiple submucosal masses in the fundus and body of the stomach. There were also multiple small and large ulcerations noted on mucosa of the massess. Biopsies were taken and consistent with High Grade lymphoma. Decision not to pursue further treatement, patient was made DNR/DNI. # Elevated cardiac biomarkers: On presentation the patient was noted to have a troponin T of 0.19 in the setting of hypotension in the ED. Troponin T peaked at 1.05. The patient never had any chest pain. Elevated cardiac biomarkers felt to be secondary to demand ischemia and trended downward. Given her history of coronary artery disease, the patient was put on a high dose statin, continued on a beta-blocker (though dose was decreased initially because of hypotension in the ED), and continued on aspirin. Transthoracic ECHO showed normal wall motion and preserved EF. Cardiology was consulted and agreed with conclusion of demand ischemia and felt it was safe to proceed with EGD. She had no further episodes of BRBPR during her hospitalization. # Hypoxia: Patient had a new O2 requirement on day 2 in the ICU and appeared volume overloaded on exam. Respiratory status improved after lasix 20 mg IV. Serial CXRs revealed small bilateral pleural effusions and pulmonary edema. She was given another dose of lasix 10mg PO with good response. No further diuresis was given aftr change in goals of care. # UTI: On day of transfer pt was noted to have increased urinary frequency. She had no fevers, abdominal pain or dysuria. UA was obtained which revealed postive leuk esterase and nitrite. Had 4 WBC and few bacteria. Likely contaminated from Foley placement in the ICU. She recieved 3 days of cipro. Approximately 2-3 days later, Mrs.[**Known lastname 24190**] mental status declined, with perseveration on certain topics. This was thought likely to be multifactorial, but UA from foley was consistent with possible UTI. She was started on Cipro with improvement in mental status. Foley discontinued; she should complete a 5-day course of Cipro after discharge. # Altered Mental Status - Likely multifactorial given diagnosis of lymphoma with evidence of spread to L2 and spinal canal. Also had evidence of UTI, now on Cipro. Will continue to monitor. # s/p Fall: Patient had no obvious signs of trauma. CT head was negative for intracranial hemorrhage. CT C spine negative for acute fracture. There was no evidence of infection on evaluation, acute MI felt to be unlikely given absence of chest pain and wall motion abnormalities, and no evidence for seizures or focal neurological deficit. Fall ultimately felt to be mechanical and possibly secondary to volume loss and anemia. # Hypercalcemia: Patient noted to be hypercalcemic on presentation with a corrected calcium of 11. This was felt to be secondary to likely malignancy with bony metastases. She was given fluids and lasix. Labs were discontinued when goals of care were changed. # Acute renal failure: Patient's creatinine was elevated to 1.0, up from her prior baseline of 0.6. Her creatinine returned to baseline with hydration and transfusion. # Hyponatremia: Serum sodium 132 on admission. Noted to be similarly low intermittantly in the past. Resolved with IVF and transfusion. # H/o Stage I Breast CA: last mammogram w/o evidence of recurrence. Metastatic breast cancer remains possibility. # Anxiety: Home clonazepam continued # Osteoarthritis: Continue hydrocodone-acetaminophen Medications on Admission: Centrum 3,500 Unit-18mg-0.4 mg Os-Cal 500-200 Hydrocodone-Acetaminophen 5/500 q PO QID PRN Aspirin 325 mg PO Daily Clonazepam 0.5 mg PO TID Simvastatin 20 mg PO Daily Nitroglycerin 0.3 mg SL PRN chest pain Metoprolol 100 mg [**Hospital1 **] Dicyclomine 10 mg PO QID Magnessium 30 mg PO Prevacid 30 mg PO Daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 3. Dicyclomine 10 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for urinary incontinence. 4. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 5. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. 6. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO three times a day. 7. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for gas. 8. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed for Constipation. 9. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital1 599**] of [**Location (un) 55**] Discharge Diagnosis: Lymphoma - High Grade B-Cell Upper GI bleed Urinary incontinence Hypertension Anemia Urinary Tract Infection Discharge Condition: Mental Status: Confused - sometimes Level of Consciousness:Alert and interactive Activity Status:Ambulatory - requires assistance or aid (walker or cane) Discharge Instructions: You were admitted to the hospital after a fall and found to have a low blood count. You were admitted to the ICU and were given red blood cells. You had an endoscopy that showed that you had ulcers that led to your GI bleed. Your endoscopy also showed multiple tumors in your GI tract. An x-ray during the work-up of your bleeding showed a mass in your abdomen, which was determined to be high grade B cell lymphoma. During discussions with the oncology team, you and your family, it was decided to focus on your comfort and not pursue invasive or curative treatment for your lymphoma. You are being transferred to another facility to continue your care. Medication changes: 1. Simvastatin was stopped in line with change of goals of care 2. Calcium/Vitamin D was discontinued 3. Omeprazole was increased to 40mg twice a day 4. Metoprolol was discontinued given change in goals of care Followup Instructions: Previously arranged appointments at [**Hospital1 18**] are listed below: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2177-4-1**] 11:40 Provider: [**First Name11 (Name Pattern1) 278**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 394**], O.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2177-4-16**] 1:00 [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3922**]

[ "790.29", "599.0", "300.00", "285.22", "200.23", "V10.3", "276.2", "721.0", "401.9", "443.9", "428.31", "348.30", "272.4", "389.9", "428.0", "584.9", "412", "200.20", "285.1", "276.1", "535.50", "564.1", "410.71", "727.03", "414.01", "275.42", "530.81", "733.00" ]

icd9cm

[ [ [] ] ]

[ "99.04", "96.34", "45.16" ]

icd9pcs

[ [ [] ] ]

17450, 17522

10770, 16184

293, 299

17675, 17675

5572, 5572

18772, 19300

4501, 4520

16545, 17427

17543, 17654

16210, 16522

17855, 18517

4049, 4214

4535, 5452

18537, 18749

222, 255

327, 3064

5589, 10747

17690, 17831

3535, 4026

4230, 4485

20,130

104,449

10129

Discharge summary

report

Admission Date: [**2117-8-11**] Discharge Date: [**2117-8-21**] Date of Birth: [**2055-10-24**] Sex: M Service: SURGERY Allergies: Heparin Agents Attending:[**First Name3 (LF) 695**] Chief Complaint: 61 yo M w/ h/o ETOH cirrhosis s/p piggyback orthotopic liver transplant [**2117-7-11**] now p/w tachycardia and hypotension. Major Surgical or Invasive Procedure: Cardiac catheterization and ablation of aberrant focus of atrial pacemaker. History of Present Illness: 61 yo M h/o ETHO cirrhosis s/p piggyback orthotopic liver transplantion in [**2117-7-11**]. Discharged in good condition to [**Hospital3 7**] for Rehab. He has done well there, had wound opened on [**8-4**] and vac placed. Seen by Dr. [**Last Name (STitle) 816**] in clinic on Monday prior to hospitalization c/o lower abdominal pain. A CT scan was ordered that showed mild fluid density intra-abdominal ascites and constipation. No intra-abdominal or Sub Q fluid collections were identified. He presented on [**2117-8-11**] to [**Hospital **] hospital after he had an epidsode of tachycardia to 160 at [**Hospital1 **] followed by hypotension after treatment with IV lopressor. He was given a 1 L fluid bolus, to which his pressure responded. Questionable episode of atrial fibrillation. Upon presentation he was in normal sinue rhythym but denies dizziness, SOB, or CP. Currently he is asymptomatic with the exception of lower abdominal discomfort. Past Medical History: -ESLD s/p OLT (piggyback in [**2117-7-11**]) -IDDM since [**2101**] -CAD s/p stenting in [**2115**] -H/o postop acute renal failure -anemia, thrombocytopenia, HIT+ -s/p cholecystectomy -LIH repair spring [**2115**] Social History: Lives in [**Hospital3 **]. Family History: non-contributory Physical Exam: 98.3 87 187/86 20 100 RA A&0 x 3 NAD, comfortable MMM no scleral icterus, PERRLA EOMI Lungs CTA bilaterally RRR no MRG 2+ carotids bilaterally, no bruits Round, tympanic bowel sounds, distanded vac in place. Tenderness to deep palpation throughout. No guarding or rebound. no c/c/e, distal pulses, 1+ Pertinent Results: Coags: [**2117-8-21**] 06:25AM BLOOD Plt Ct-88* [**2117-8-20**] 06:45AM BLOOD Plt Ct-82* [**2117-8-18**] 05:45AM BLOOD Plt Ct-107* [**2117-8-15**] 05:25AM BLOOD PT-18.0* INR(PT)-2.1 [**2117-8-11**] 08:15PM BLOOD PT-13.6* PTT-25.7 INR(PT)-1.2 Tacrolimus: [**2117-8-19**] 06:20AM BLOOD FK506-4.4* [**2117-8-18**] 05:45AM BLOOD FK506-8.5 [**2117-8-15**] 05:26AM BLOOD FK506-13.5 [**2117-8-14**] 02:08PM BLOOD FK506-15.8 [**2117-8-13**] 09:20AM BLOOD FK506-13.4 Chemistry: [**2117-8-21**] 06:25AM BLOOD Glucose-166* UreaN-45* Creat-1.7* Na-135 K-4.9 Cl-106 HCO3-19* AnGap-15 Brief Hospital Course: He presented on [**2117-8-11**] to [**Hospital **] hospital after he had an epidsode of tachycardia to 160 at [**Hospital1 **] followed by hypotension after treatment with IV lopressor. He was given a 1 L fluid bolus, to which his pressure responded. Questionable episode of atrial fibrillation. Upon presentation he was in normal sinue rhythym but denies dizziness, SOB, or CP. Currently he is asymptomatic with the exception of lower abdominal discomfort. Pt admitted to [**Hospital Ward Name 121**] 10 for observation. On hospital day #2 pt was monitored on telemetry. Cardiology was consulted, and pt was started on diltiazem 30mg PO QID and Lopressor 25 PO TID for better rate control. He was transfered to the ICU for monitoring of recurrent Atrial flutter. His Digoxin was discontinued. Pt initially declined to undergo cardiac catheterization procedure to ablate aberrant pacemaker focus and was continually monitored by telemetry. On [**2117-8-16**] pt decided to undergo cardiac catheterization procedure. His amiodarone was discontinued and his coumadin was discontinued to get his INR<2.0 for the ablative procedure by electrophysiology. On [**2117-8-19**], Pt was given 1 unit FFP and taken to electrophysiology labs for ablation of aberrant atrial focus. Pt did well post-procedure and remained in normal sinue rhythym. He was discharged to home w/ VNA services on [**2117-8-21**] on Coumadin 1mg, FK506 1mg PO BID, and rapamycin 4mg qday. Per Cards his INR is to remain [**1-28**] and he is to follow-up in cardiology clinic. Medications on Admission: ASA Plavix Diflucan Lasix Prevacid Metoprolol Colace CEllcept [**Pager number **]'''' Prednisone 20' Bactrim Flomax Valcyte Prograf 4' Insulin Discharge Medications: 1. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal [**Hospital1 **] (2 times a day) as needed. Disp:*60 Suppository(s)* Refills:*3* 2. Warfarin Sodium 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Will need a level drawn on Monday [**8-23**] and adjust dose accordingly to keep INR [**12-27**]. Disp:*30 Tablet(s)* Refills:*3* 3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*3* 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Prednisone 5 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily). Disp:*105 Tablet(s)* Refills:*2* 6. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:*30 Tablet(s)* Refills:*2* 7. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 9. Valganciclovir 450 mg Tablet Sig: One (1) Tablet PO every other day. Disp:*30 Tablet(s)* Refills:*2* 10. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. Sirolimus 4 mg Tablet Sig: Two (2) Tablet PO once a day: Will need a trough level on Monday [**8-23**] and adjust dose accordingly. Disp:*60 Tablet(s)* Refills:*2* 12. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Will need a trough level on Monday [**8-23**] and adjust dose accordingly. Disp:*60 Capsule(s)* Refills:*2* 13. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Disp:*30 Tablet(s)* Refills:*0* 14. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): Please hold for SBP <100 or HR <55. Disp:*90 Tablet(s)* Refills:*2* 15. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 16. Aspirin EC 81 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* 17. Outpatient Lab Work FK level, Rapamycin level, Coumadin level on Monday [**2117-8-23**] 19. Insulin 70/30 70-30 unit/mL Suspension Sig: One (1) Subcutaneous three times a day: 25 Units with breakfast. 22 Units with lunch. 25 units with dinner. Disp:*qs qs* Refills:*2* Discharge Disposition: Home With Service Facility: VNA Assoc. of [**Hospital3 **] Discharge Diagnosis: Atrial flutter Discharge Condition: stable Discharge Instructions: Patient to call transplant surgery immediately at [**Telephone/Fax (1) 673**] if any feves, chills, nausea, vomiting, abdominal pain, decrease energy, change in bowel movements or urine output. Also if there are changes in skin color, or questions about her medications. Patient needs to have labs drawn every Monday and Thursday in which: CBC, CHEM 10,ALT, alk phosp, PO4, albumin, AST, T. bili, U/A and RAPAMUNE LEVEL. PLEASE FAX RESULTS TO [**Telephone/Fax (1) 697**]. Followup Instructions: Patient to follow up with Transplant surgery at [**Telephone/Fax (1) 673**] in [**1-28**] weeks. Call to make an appt. Follow-up with Dr. [**Last Name (STitle) 911**] in Cardiology clinic as outpatient in [**1-28**] weeks. Please call clinic to schedule. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2117-8-21**]

[ "414.01", "V45.82", "250.00", "V42.7", "593.9", "401.9", "427.32" ]

icd9cm

[ [ [] ] ]

[ "99.07", "99.04", "37.26", "37.34" ]

icd9pcs

[ [ [] ] ]

6982, 7043

2708, 4251

399, 476

7101, 7109

2110, 2685

7631, 8045

1755, 1773

4445, 6959

7064, 7080

4277, 4422

7133, 7608

1788, 2091

235, 361

504, 1456

1478, 1695

1711, 1739

43,673

127,008

37826

Discharge summary

report

Admission Date: [**2132-10-13**] Discharge Date: [**2132-11-11**] Date of Birth: [**2052-9-17**] Sex: M Service: SURGERY Allergies: Ambien / Codeine Attending:[**First Name3 (LF) 371**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [**2132-10-13**] Splenectomy and abdominal washout [**2132-10-27**] IR drainage of intra-abdominal abscess [**2132-10-31**] Percutaneous tracheostomy History of Present Illness: 80M admitted to the emergency room some 3 weeks after having a splenic bleed embolization. He developed a splenic abscess and now developed over the previous night worsening abdominal pain. He was found to be quite ill. He was taken to the operating room after CT scan showed free air gas in the abdomen and what appeared to be an abscess that had leaked around the abscess and the patient was diffusely tender. Past Medical History: PMH: COPD, CAD, HTN, hypercholesterolemia . PSH: Coronary stent, embolization of splenic artery branches Social History: He is widowed and lives alone. He denies ETOH and has a remote smoking history. Family History: Noncontributory Physical Exam: On Discharge: 97.3, 59, 119/56, 23, 98% on trach mask 12L Gen: no distress, alert and oriented HEENT: PERLA, EOMI, anicteric, MMM, Dobhoff tube in place Neck: trach site clean Chest: RRR, lungs with rhonchi bilaterally Abdomen: soft, protuberant, healing midline incision with good granulation tissue at the base with a small area of necrosis at the base of the incision, colocutaneous fistual track without discharge and no surrounding erythema, flank edema Ext: 1+ edema Neuro: moves all extremities well, strength and sensation intact Pertinent Results: [**2132-10-13**] 01:36AM BLOOD WBC-6.8# RBC-4.23* Hgb-11.8* Hct-36.9* MCV-87 MCH-27.8 MCHC-31.9 RDW-14.7 Plt Ct-302# [**2132-10-13**] 08:57AM BLOOD WBC-17.6*# RBC-3.94* Hgb-11.3* Hct-34.4* MCV-87 MCH-28.6 MCHC-32.8 RDW-14.8 Plt Ct-255 [**2132-10-13**] 03:55PM BLOOD WBC-23.8* RBC-3.43* Hgb-9.4* Hct-29.4* MCV-86 MCH-27.5 MCHC-32.1 RDW-14.9 Plt Ct-199 [**2132-10-15**] 03:37AM BLOOD WBC-26.3* RBC-2.91* Hgb-8.1* Hct-24.5* MCV-84 MCH-27.7 MCHC-32.9 RDW-15.1 Plt Ct-226 [**2132-10-15**] 04:04PM BLOOD WBC-27.2* RBC-3.22* Hgb-9.2* Hct-27.3* MCV-85 MCH-28.4 MCHC-33.6 RDW-15.2 Plt Ct-187 [**2132-10-20**] 01:39AM BLOOD WBC-21.6* RBC-3.46* Hgb-9.9* Hct-30.0* MCV-87 MCH-28.7 MCHC-33.1 RDW-15.9* Plt Ct-300 [**2132-10-23**] 01:47AM BLOOD WBC-19.6* RBC-3.68* Hgb-9.9* Hct-32.7* MCV-89 MCH-27.0 MCHC-30.4* RDW-15.3 Plt Ct-531* [**2132-10-25**] 06:00AM BLOOD WBC-16.2* RBC-3.55* Hgb-9.8* Hct-31.6* MCV-89 MCH-27.5 MCHC-30.8* RDW-15.4 Plt Ct-687* [**2132-10-25**] 07:50PM BLOOD WBC-22.0* RBC-4.10* Hgb-11.3* Hct-36.3* MCV-89 MCH-27.6 MCHC-31.2 RDW-15.3 Plt Ct-734* [**2132-10-26**] 01:09AM BLOOD WBC-33.6*# RBC-3.67* Hgb-10.0* Hct-32.7* MCV-89 MCH-27.4 MCHC-30.7* RDW-15.4 Plt Ct-661* [**2132-10-27**] 01:50AM BLOOD WBC-29.4* RBC-3.14* Hgb-8.8* Hct-28.2* MCV-90 MCH-27.9 MCHC-31.0 RDW-15.5 Plt Ct-588* [**2132-10-30**] 02:33AM BLOOD WBC-18.4* RBC-3.01* Hgb-8.2* Hct-25.8* MCV-86 MCH-27.4 MCHC-31.9 RDW-15.8* Plt Ct-436 [**2132-11-2**] 03:47AM BLOOD WBC-14.6* RBC-3.27* Hgb-8.9* Hct-28.8* MCV-88 MCH-27.3 MCHC-31.1 RDW-15.6* Plt Ct-603* [**2132-11-4**] 02:37AM BLOOD WBC-15.8* RBC-2.88* Hgb-7.8* Hct-25.5* MCV-89 MCH-27.2 MCHC-30.8* RDW-15.7* Plt Ct-563* [**2132-11-8**] 01:03AM BLOOD WBC-12.5* RBC-3.13* Hgb-8.4* Hct-27.7* MCV-88 MCH-26.8* MCHC-30.4* RDW-15.6* Plt Ct-517* [**2132-11-9**] 01:43AM BLOOD WBC-16.6* RBC-3.15* Hgb-8.5* Hct-26.5* MCV-84 MCH-26.9* MCHC-32.0 RDW-16.6* Plt Ct-524* [**2132-11-10**] 02:29AM BLOOD WBC-16.8* RBC-3.19* Hgb-8.4* Hct-26.5* MCV-83 MCH-26.5* MCHC-31.9 RDW-16.6* Plt Ct-539* [**2132-11-10**] 11:55PM BLOOD WBC-16.9* RBC-3.27* Hgb-8.6* Hct-28.0* MCV-85 MCH-26.2* MCHC-30.7* RDW-16.3* Plt Ct-496* [**2132-11-10**] 11:55PM BLOOD Glucose-123* UreaN-24* Creat-0.4* Na-136 K-4.1 Cl-100 HCO3-32 AnGap-8 [**2132-10-30**] 02:33AM BLOOD ALT-12 AST-15 LD(LDH)-167 AlkPhos-52 TotBili-0.7 [**2132-10-13**] 08:57AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2132-10-13**] 03:55PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2132-10-14**] 02:46AM BLOOD CK-MB-10 MB Indx-7.1* cTropnT-<0.01 [**2132-10-31**] 12:43PM BLOOD Cortsol-19.8 [**2132-10-31**] 01:20PM BLOOD Cortsol-28.8* [**2132-10-31**] 01:51PM BLOOD Cortsol-31.0* Brief Hospital Course: The patient was admitted and went directly to the operating room on [**2132-10-13**] after imaging revealed a ruptured splenic abscess. Briefly he was admitted to the trauma ICU post-operatively in septic shock. Once this resolved he was transferred to the floor. He had to be transferred back to the ICU for respiratory distress. His hospital course will be detailed by body systems. . Neuro: Immediately post-operatively and during his reintubation he was maintained on sedation while intubated. When the sedation was weaned he was following commmands and has an intact neuro exam and was able to be extubated. He currently has good pain control on oxycodone liquid via his dobhoff tube and intravenous dilaudid for breakthrough pain. He was expressing signs of depression. Geriatrics was consulted and they did not want to start an antidepressant during his acute hospitalization. He was nonetheless started on fluoxetine and has since been in better spirits. . Cardiovascular: Post-operatively he was in septic shock and on multiple vasopressors. These were able to be weaned off. He then had persistent tachycardia and this was found to be a-fib with rapid ventricular response. He was started on Lopressor with good rate control. He has since converted to normal sinus rhythm. An Echocardiogram revealed no intracardiac thrombus. He was able to be transferred to the floor with telemetry. On the floor he developed respiratory distress necessitating a transfer back to the ICU. He was ultimately intubated and found to be in shock requiring multiple vasopressors to maintain an adequate BP. This was presumed septic shock. He was stablized and a CT scan showed an intra-abdominal abscess in the splenic bed. This abscess was drained by interventional radiology. This abscess grew out multi-drug resistant Pseudomonas. After source control was obtained his hemodynamics normalized and he was able to be weaned off of pressors. He currently is normotensive with SBP in the 110-120's with a HR in the 60-80s on lopressor. . Pulmonary: As stated earlier he was intubated for a number of days post-operatively and then extubated. He did develop respiratory distress and subsequently had to be reintubated. He was unable to wean from the ventilator during his second intubation. A family meeting was held. All parties involved agreed that a tracheostomy would benefit Mr. [**Known lastname **]. A bedside percutaneous tracheostomy was performed on [**2132-10-31**]. He was then able to be weaned to trach mask. He was evaluated by speech and swallow for a PMV but he was found to have copious secretions so he continues on trach mask. He doe shave a history of COPD so his PCO2 is in the 50s at baseline. This was exacerbated by lasix so his diuresis was changed to diamox and then eventually stopped. He should have a repeat speech and swallow to evaluate for a PMV. . Gastrointestinal: Tube feeds were initially started via an NGT. He was tolerating goal rate tube feeds. A swallow evaluation was performed and it was recommended that he take nectar thickened liquids and soft solids. His NGT was removed and he was transfered to the floor and the above mentioned diet. During his reintubation, he was given a Dobhoff tube for tube feeds. He is tolerating goal rate tube feeds with bowel movements. He will need another swallow evaluation to see if he can take POs. He had two JP drains placed in the splenic bed that were removed on POD13. The character of the output was alwasy serosanguinous and a JP amylase was checked; this was initially 240 and then decreased to 43 prior to removal. The medial drain site then began to have fecculent output. A small drainage catheter was placed into the drain site and then placed to bulb suction. The drainage continued to be fecculent. A CT with PO and rectal contrast failed to characterize this as a colocutaneous fistula. A sinogram was then obtained and this showed that the drainage catheter was in the colon verifying that this was a colocutaneous fistula. The drainage catheter was removed and an ostomy appliance was placed over the fistula. The drainage decreased and the ostomy appliance was removed and a dry dressing placed over the fistula. . FEN: He is currently tolerating replete with fiber at a goal rate of 80cc/hr. . Genitourinary: Mr. [**Known lastname **] was able to maintain an adequate urine output throughout his hospital course, even when on pressors. After he stablized he was 30kg positive over his dry weight. He was diuresed with lasix and diamox. His bicarbonate was stable and then continued to increase so the lasix was stopped. He is now diuresing on his own. . Infectious Disease: He was started on Vanc/Cipro/Flagyl initially for his septic shock. This was then changed to Vanc/Zosyn. His intra-abdominal cultures grew out Corynebacterium. He was maintained on Vanc/Zosyn for 14 days. He did have a persistent leukocytosis around 24. It was unsure about whether this was due to his splenectomy or infection. His cultures were no growth except for the initial intra-abdominal sample and a sputum culture that grew out coag (+) staph. His WBC decreased to a low of 15. While on the floor when he developed respiratory failure, his WBC increased to 30. He developed septic shock a second time. CT scans revealed an abscess in the splenic bed. This was able to be drained by interventional radiology. Cultures from this abscess grew multi-drug resistent Pseudomonas. He was then started on Meropenem. This was continued for 10 days. His WBC has since returned to a level of 16. He has remained afebrile and repeat cultures have again been negative. He is currently afebrile and on no antibiotics. . Hematological: His hematocrit has been relatively stable as of now around 26-28. At two to three times in his post-operative course his hematocrit did drop to a low of 21. He was not actively bleeding. This hematocrit drop was dilutional due to the massive amounts of IVF he received. Due to the fact that he was still requiring vasopressors, he was transfused to a hematocrit of 28. He received a total of 7units of blood, the last one on [**2132-10-29**]. . Endocrine: His blood sugars have been adquate and he is on a sliding scale insulin. Medications on Admission: Tylenol prn, Tiotropium bromide 18mcg qday INH, Simvastatin 10mg daily, Colace 100mg [**Hospital1 **], Propranalol 20mg [**Hospital1 **], Isosorbide dinitrite 10mg daily, Aspirin 81mg daily Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 2. Insulin Regular Human 100 unit/mL Solution Sig: Per sliding scale units Injection ASDIR (AS DIRECTED). 3. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Six (6) Puff Inhalation Q4H (every 4 hours) as needed for wheeze/sob. 4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q4H (every 4 hours) as needed for wheeze/sob. 5. Fluoxetine 10 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 6. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever >101.5. 7. Oxycodone 5 mg/5 mL Solution Sig: One (1) teaspoon PO Q4H (every 4 hours) as needed for pain. 8. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) teaspoons PO BID (2 times a day). 9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: Four (4) mg Injection Q8H (every 8 hours) as needed for nausea. 12. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 **] - [**Hospital1 8**] Discharge Diagnosis: Ruptured splenic abscess Peritonitis Septic Shock Intra-abdominal abscess Colocutaneous fistula Vent dependent respiratory failure Discharge Condition: Good Discharge Instructions: Call your physician if you experience any of the following: - fever > 101, chills - increasing abdominal pain not relieved by medication - persistent nausea/vomiting - increasing redness around your wounds or purulent/fecculent drainage from your wound - any other concerns or questions you may have . Nutrition: - Continue your tube feeds via your dobhoff tube. You will get a speech and swallow evaluation to see if you can eat and drink. . Meds: - Continue your medications intravenously or via your dobhoff tube. Followup Instructions: Follow up with Dr. [**Last Name (STitle) **] in 2 weeks. Call his office at ([**Telephone/Fax (1) 2300**] to schedule your appointment.

[ "567.22", "401.9", "995.92", "482.41", "785.52", "569.81", "041.7", "289.59", "427.31", "038.9", "272.0", "518.81", "311", "496" ]

icd9cm

[ [ [] ] ]

[ "96.04", "54.91", "96.72", "57.32", "31.1", "38.91", "38.93", "41.5", "96.6", "99.62", "88.03" ]

icd9pcs

[ [ [] ] ]

12099, 12162

4361, 10661

292, 444

12337, 12344

1718, 4338

12910, 13050

1127, 1144

10902, 12076

12183, 12316

10687, 10879

12368, 12887

1159, 1159

1173, 1699

238, 254

472, 886

908, 1014

1030, 1111

77,947

157,138

36133

Discharge summary

report

Admission Date: [**2113-1-1**] Discharge Date: [**2113-1-6**] Date of Birth: [**2049-9-11**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 898**] Chief Complaint: somnolence Major Surgical or Invasive Procedure: Bipap History of Present Illness: The patient is a 63 y/o man with a history of diabetes, schizoaffective disorder, chronic renal failure c/b chronic hyperkalemia, chronic obstructive pulmonary disease, peripheral vascular disease, hypertension, and rheumatoid arthritis who was admitted to the medical service after presenting to the emergency department with a mechanical fall in the setting of pre-syncope. . The patinet is a resident at [**Hospital1 **] Assistted Living. Due to a long standing history of RA, he is wheelchair bound at baseline. Per report, it was on the toilet, when . . In the ED, initial VS: 98.1, 124/86, 16, 100% on 4L. The patients EKG was at baseline, and he remained hemodynamically stable. He was admitted to the medicine team for further evaluation. . On arrival to the floor, the patinet was found unresponsive. He was difficult to arouse, and only able to answer questions in sentence fragments. An ABG was checked, showing a pH of 7.19 pCO2 90 pO2 99 HCO3 36. The patient was admitted to the ICU for initation of BiPAP. . ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. Past Medical History: Coronary Artery disease Hypertension Type 2 DM Peripheral vascular disease H/o PE, on coumadin Rheumatoid arthritis COPD Depression Bipolar Disorder Schizophrenia Glaucoma Social History: Lives in [**Hospital3 **] with roommate, smoked 1 PPD for 35 years, still smoking, quit drinking 4-5 years ago, used to drink socially, no IVDU, but has tried cocaine once. Is wheelchair dependent Family History: Father died of heart disease and also had cancer, mother had cancer. Physical Exam: On admission - Vitals - T:97.0 BP:179/94 HR:99 RR:21 02 sat: 93% 1 L GENERAL: Pleasant, well appearing gentleman in NAD HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No thyromegaly. JVP at clavicle. CARDIAC: Regular rhythm, tachycardic. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. LUNGS: Diffuse wheezes throughout. Poor air movement with decreased BS in L base>R. Pursed lip [**Last Name (un) 4605**] however no increased resp effort. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: 1+ edema to the knee, non-painful to palpation. DP/PT pulses not appreciated. Chronic VS changes bilaterally in LEs. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 intact. Preserved sensation throughout. Strength grossly intact with no focal weaknesses. PSYCH: Listens and responds to questions appropriately, pleasant . On discharge: Vitals - T:97.8 BP:142/84 HR82 RR:22 02 sat: 93% 1 L GENERAL: Pleasant, well appearing gentleman in NAD HEENT: Normocephalic, atraumatic. No conjunctival pallor. No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD, No thyromegaly. JVP at clavicle. CARDIAC: Regular rhythm, tachycardic. Normal S1, S2. No murmurs, rubs or [**Last Name (un) 549**]. LUNGS: Improved aeration, diffuse wheezes throughout at expiration. Pursed lip [**Last Name (un) 4605**] however no increased resp effort. ABDOMEN: NABS. Soft, NT, ND. No HSM EXTREMITIES: 1+ edema to the knee, non-painful to palpation. DP/PT pulses not appreciated. Chronic VS changes bilaterally in LEs with weeping wounds. SKIN: No rashes/lesions, ecchymoses. NEURO: A&Ox3. Appropriate. CN 2-12 intact. Preserved sensation throughout. Strength grossly intact with no focal weaknesses. PSYCH: Listens and responds to questions appropriately, pleasant Pertinent Results: ============== Labs ============== Admission labs [**2113-1-1**] 03:40PM BLOOD WBC-5.9 RBC-4.12* Hgb-11.5* Hct-39.1* MCV-95 MCH-27.8 MCHC-29.3* RDW-15.7* Plt Ct-248 [**2113-1-1**] 03:50PM BLOOD PT-40.5* PTT-37.8* INR(PT)-4.3* [**2113-1-1**] 03:50PM BLOOD Glucose-85 UreaN-45* Creat-2.9*# Na-143 K-5.4* Cl-105 HCO3-27 AnGap-16 [**2113-1-1**] 03:50PM BLOOD CK-MB-5 proBNP-4310* [**2113-1-4**] 04:07AM BLOOD Cortsol-21.1* [**2113-1-1**] 07:44PM BLOOD Type-ART pO2-99 pCO2-90* pH-7.19* calTCO2-36* Base XS-3 Intubat-NOT INTUBA [**2113-1-2**] 04:45AM BLOOD freeCa-1.19 . Discharg labs: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW Plt Ct [**2113-1-6**] 06:45AM 5.2 3.70* 10.5* 34.5* 93 28.3 30.4* 15.4 236 DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas Myelos [**2113-1-3**] 04:30AM 65.1 22.0 10.0 2.3 0.7 RED CELL MORPHOLOGY Hypochr Anisocy Poiklo Macrocy Microcy Polychr [**2113-1-1**] 03:40PM 2+ NORMAL NORMAL NORMAL NORMAL NORMAL BASIC COAGULATION (PT, PTT, PLT, INR) PT PTT Plt Smr Plt Ct INR(PT) [**2113-1-6**] 06:45AM 236 [**2113-1-6**] 06:45AM 21.2* 110.8*1 2.0* Chemistry Glu UreaN Creat Na K Cl HCO3 AnGap 93 31* 1.3* 146* 4.6 104 37* 10 ============== Micro ============== **FINAL REPORT [**2113-1-3**]** URINE CULTURE (Final [**2113-1-3**]): NO GROWTH. ============= Radiology ============= CT Head [**1-2**] 1. Mucosal thickening of the left maxillary and ethmoid sinuses with an air-fluid level in the left maxillary sinus. 2. No acute bleed or masses present. ============= Cardiology ============= [**1-5**] Echo Suboptimal image quality. Overall left ventricular systolic function cannot be reliably assessed (it does appear depressed in certain views with possible infero-lateral hypokinesis). There is abnormal septal motion/position. The diameters of aorta at the sinus, ascending and arch levels are normal. Trivial mitral regurgitation is seen. Tricuspid regurgitation is present but cannot be quantified. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2112-1-18**], no definite change. If indicated, a repeat study with echo contrast (Definity) may assist in assessment of LV function. Brief Hospital Course: 63 yo M with bipolar disorder, schizophrenia, rheumatoid arthritis, COPD, CHF, diabetes mellitus, peripheral vascular disease, hypertension, CKD and questionable pulmonary embolism admitted for syncope now s/p MICU for for acute on chronic respiratory acidosis. . # Hypercarbic respiratory failure: Unrespeonsive upon arrival on the floor. Likely related to a h/o sleep apnea and hx of COPD, however no PFTs on record. Minimal emphysema on CT scan, but exam consistent with COPD given wheezing, pursed lip [**Year (4 digits) 4605**], decreased breath sounds. Started treatment for COPD flare. Patient also underwent a sleep study in house which showed Cheynes-[**Doctor Last Name **] [**Doctor Last Name 4605**] pattern, with intermittent desaturation. The recommendation was night time oxygen and slide sleeping. Had an echo that was a poor quality but systolic CHF was not thought to be a significant contributor. Continued albuterol, ipratropium, advair in house but resumed home inhalers prior to discharge. Continuous O2 sats, titrate to O2 sats to range 88-92% given chronic CO2 retention. Encouraged incentive spirometry. Resumed 10mg PO lasix per home regimen. Patient should have outpatient PFTS. . # Somnolence: Most likely due to CO2 retention in the setting of obesity hypoventilation/COPD. Pt showed significant improvement with initiation of BiPAP. Mental status cleared in the morning with Bipap and did not require Respiratory support for the rest of the day. TSH, Utox, LFTs normal. CT head was negative. On HD#2, BiPAP trial while patient somnolent and after BiPAP x 1 hour ABG 7.23 / 89 / 90. Switched to nasal CPAP x 10-15 minutes ABG 7.27 / 78 / 51. Thought to be multifactorial in the setting of renal failure, uremia and hypercarbia. Confirmed with pharmacy that psych meds are hepatically cleared, so unlikely to have worsened mental status in the setting of acute renal failure. Patient was trialed on CPAP at night and tolerated this well in the icu. Somnolence improved throughout hospitalzation. . # HTN: Improved today. Amlodipine was initiated in ICU, also given labetolol prior to transfer. Resumed patient beta blocker prior to discharge. . # Acute on chronic renal failure: Patinet followed by Dr. [**Last Name (STitle) **] here at [**Hospital1 18**] in evaluation of CRI w/ baseline creatinine of 1.5. The etiology of his chronic kidney disease is felt to be multifactorial, including lithium toxicity, renal hypperfusion from CHF, NSAIDs in setting of RA, PVD with RAS, diabetic/ hypertensive nephropathy. Patient now presents with acute on chronic renal failure. Improved with fluids and Feurea consistent with possible pre-renal azotemia. Limited evidence of CHF on CXR. BNP elevated from baseline. No new medications as possible offenders. Lasix were held in the ICU, and UA and lytes were unremarkable. Currently better than baseline. Avoid nephrotoxic meds. Cont home lasix. . # Hyperkalemia: Potassium high throughout admission. Received polysterene x1 in MICU. No adrenal insufficiency by serum cortisol. Has a history of this in the past. Repeated kayexelate on floor which the patient tolerates well. Put on renal diet. Cont 10mg lasix per home regimen. PCP can consider further w/u as out-pt with trans-tubular K gradient, aldosterone, renin. . # Tachycardia: On admission, concerning for volume depletion given pre-renal state and in the setting of recent confusion with likely poor PO intake. No recent ECG. [**1-1**] ECG was NSR, not tachy. Resumed patient home beta blocker at lower dose. . # LE chronic venous stasis changes: Seen by vascular in the past, c/w chronic venous insufficiency. Wound consult saw patient and recommendations included in discharge paperwork. . # RA: Appears from last rheumatology note more consistent with burnt out disease. Cont home Hydroxychloroquine. Disabling, pt wheelchair bound at baseline, cont home Hydroxychloroquine. . # Pre-Syncope and Fall: clarify events in AM regarding events of fall. No focal neurologic deficits on exam. No fractures on pelvic xray. Unclear history however concerning for mechanical etiology vs confusion in the setting of hypercarbia. No fractures on pelvic xray. PT saw and assessed patient. He should be on fall percautions. . # Enlarged Thyroid on Prior CT: TSH normal. Patient should be set up with thyroid imaging as outpatient. TSH WNL. PCP could consider [**Name9 (PRE) 81959**] ultrasound. # Schizophrenia: Continued risperidone, oxcarbamazapine, divalproex . # H/o PE: Remote history. INR supratherapeutic, held coumadin but then became subtherapeutic so needed a heparin bridge. Coumadin continued and therapeutic at discharge. . # DM: No oral hypoglyemics at baseline. Hemoglobin A1c of 6.1 in [**11-14**]. ISS while in house. Cont ASA 81mg daily. . # BPH: cont flomax . # Glaucoma: cont home gtts # General Care: PPX: ranitidine, therapeutic on coumadin, bowel regimen, ACCESS: PIV, CODE: Full Code, CONTACT: [**First Name4 (NamePattern1) **] [**Known lastname 4587**] [**Telephone/Fax (1) 81392**] FEN: replete lytes prn / low K diet. Discharged to rehab. Medications on Admission: Risperidone 3 mg qhs Latanoprost 0.005 % 1 drop HS Oxcarbazepine 300 mg [**Hospital1 **] Aspirin 81 daily Hydroxychloroquine 200 mg [**Hospital1 **] Divalproex 500 mg [**Hospital1 **] Albuterol [**1-7**] puff q 4 hours PRN Fluticasone 110 mcg 2 puffs [**Hospital1 **] Acetaminophen 325 mg 1-2 Tablets PO Q6H prn pain Ranitidine HCl 150 mg daily Furosemide 10 mg daily Warfarin 6 mg daily Aledronate 70 mg q week Calcitriol 0.25 mg daily Flomax 0.4 mg daily Spiriva 1 cap daily Vitamin D daily Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Risperidone 1 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 3. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 4. Oxcarbazepine 150 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Hydroxychloroquine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 7. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day. 10. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 11. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 14. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 15. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 16. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 17. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 18. Alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. 19. Bacitracin 500 unit/g Ointment Sig: One (1) application Topical once a day. 20. Flomax 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. 21. Flovent HFA 110 mcg/Actuation Aerosol Sig: One (1) IH Inhalation twice a day. 22. Hydrocortisone 1 % Cream Sig: One (1) apply to skin Topical twice a day. 23. ProAir HFA 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) puffs Inhalation twice a day. 24. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) cap Inhalation once a day. 25. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days: Start am of [**2112-1-8**]. Disp:*3 Tablet(s)* Refills:*0* 26. Prednisone 20 mg Tablet Sig: as directed Tablet PO once a day: Please take 2 tablets on [**11-19**] and then take 1 tablet on [**11-21**]. 27. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed for itching. Discharge Disposition: Extended Care Facility: [**Hospital6 1643**] Discharge Diagnosis: Primary: Obesity Hypoventilation Syndrome COPD exacerbation Acute Renal Failure Hyperkalemia Hypertension . Secondary: Depression Diabetes Schizoaffective Disorder Rheumatoid Arthritis Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Out of Bed with assistance to chair or wheelchair Discharge Instructions: You were admitted after an episode of lightheadedness resulting in a fall. Once you arrived on the floor you were unresponsive and we believe this was because you were not [**Hospital6 4605**] enough in combination with your COPD. You were also evaluated by the sleep doctors [**First Name (Titles) **] [**Last Name (Titles) 81960**] [**Name5 (PTitle) 4605**]. You were seen by the wound care nurses for your leg wounds. . You are being discharged to rehab which you should be in for less than 30 days. . The following changes have been made to your medication regimen: 1)We started you on prednisone taper for the next 4 days. 2)We started you on azithromycin for the next 3 days. 3)We changed your metoprolol to 25mg by mouth twice a day. 4)We added amlodipine 10mg daily for your blood pressure. . You will need to be seen by your nephrologist, the sleep doctors and your primary care doctor when you leave rehab. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2088**], MD Phone:[**Telephone/Fax (1) 721**] Date/Time:[**2113-7-11**] 2:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7304**], MD Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2113-3-31**] 9:00 . Please call the Dr. [**Last Name (STitle) 4507**], the sleep doctor, for a follow up appointment at([**Telephone/Fax (1) 513**] within the next 2 weeks. Completed by:[**2113-1-6**]

[ "714.0", "278.8", "584.9", "585.9", "295.70", "518.0", "311", "491.21", "V12.51", "276.2", "V58.61", "403.90", "278.00" ]

icd9cm

[ [ [] ] ]

[ "93.90" ]

icd9pcs

[ [ [] ] ]

14362, 14409

6338, 11441

323, 331

14638, 14638

4028, 6315

15752, 16239

2060, 2130

11985, 14339

14430, 14617

11467, 11962

14808, 15729

2145, 3075

3089, 4009

273, 285

359, 1634

14652, 14784

1656, 1830

1846, 2044

82,442

134,835

51659

Discharge summary

report

Admission Date: [**2123-5-13**] Discharge Date: [**2123-6-24**] Date of Birth: [**2048-11-15**] Sex: M Service: SURGERY Allergies: Iodine; Iodine Containing Attending:[**First Name3 (LF) 371**] Chief Complaint: Fevers, s/p multiple abdominal surgeries at OSH Major Surgical or Invasive Procedure: none during his hospitalization at [**Hospital1 18**] History of Present Illness: Mr. [**Known lastname 107034**] is a 74 yo patient with a h/o CAD, Hepatitis C, DJD, testicular cancer who was transferred from the [**Hospital1 107**] Regional ([**Last Name (un) 33963**], FL) ICU after a prolonged hospital course secondary to complications from an ERCP. Initially, the patient presented on [**2123-4-14**] for chest pain, diagnosed with cholelithiasis with dilated CBD. The patient then underwent an ERCP on [**2123-4-15**] which was complicated by pancreaticoduodenal trauma with gastric artery laceration requiring emergency ex-lap, cholecystectomy, common duct exploration, formal sphincteroplasty, tube gastrectomy with Hunt-[**Hospital1 487**] [**Hospital1 42265**], and diverticulization of duodenal closure over a Foley catheter drain with a 4-5 L estimated blood loss. On [**4-16**], he had reexploration of abd for hemorrhage with evacuation of blood from stomach and small bowel, as well as suture ligation of periampullary bleeding, mesenteric defect, and repair of Hunt-[**Hospital1 487**] [**Hospital1 42265**] disruption by retained clot, and placement of vac as unable to do primary abd closure; estimated blood loss 3 L. He underwent complex abdominal wall closure with pigskin and Marlex Mesh on [**4-19**]. On [**4-24**], he was noted to have increased bile dinage around his T-tube but was thought to be functioning and localized per cholangiogram on [**4-29**]. He underwent tracheostomy placement on [**4-29**] for prolonged intubation. On [**5-8**], pt had an intraabdominal abscess drained. In total he received 90+ units of PRBC's. The abdominal wound was eventually closed with mesh. His hospital course was complicated by fevers and jaundice. On transfer he had 3 JP's, a G-tube, and biliary tube in place (with Tbili of 9). He is now growing Klebsiella, Enterococcus from a hematoma at his open surgical wound site with a concern for infected mesh on vanc, zosyn, and antifungal. He was on TPN. He is on Lovenox for ppx. He has a trach collar and is still vented. Lethargic x several days (very sensitive to sedation), opens eyes, responds to pain but nonverbal and not following commands. Info from OSH: Micro: [**2123-5-10**] Sputum Culture --> Klebsiella Unasyn S Aztreonam S Cefazolin S Cefepime S Ceftriaxone S Gent S Meropenem S Zosyn S Tobramycin S Bactrim S [**2123-5-7**] Abdominal Fluid (hematoma, percutaneous aspirate) 1. klebsiella pneumonia (pan sensitive) 2. Escherichia Coli (R=ampicillin/unasyn, ciprofloxacin) 3. Enterococcus faecalis (S=ampicillin, Gent, Vanco) 4. Yeast 5. Lactobacillus [**2123-5-6**] Abdominal Fluid (RUQ, JP#1) 1. Klebsiella pna 2. enterococcus faecalis 3. lactobacillus 4. yeast [**2123-5-6**] Abdominal Fluid (RUQ, JP#2) 1. Klebsiella pneumonia 2. Enterococcus faecalis 3. Coag negative staph aureus (R=cefazolin, erythromycin, oxacillin, PCN, bactrim; S=rifampin, tetracycline, vanco) [**2123-5-6**] Abdominal Fluid (LUQ JP) 1. Klebsiella pneumonia 2. enterococcus faecalis 3. lactobacillus species 4. yeast [**2123-5-1**] Abdominal Fluid (LUQ JP) 1. Staphylococcus specias coagulase negative (S=Rifampin, tetracylcine, vancomycin) [**2123-4-27**] Sputum Cx - respiratory flora only [**2123-4-29**] Cath Tip Culture (a line) - No growth [**2123-4-28**] Blood Culture - coag negative staphylococcus (S=clinda, rifampin, tetracycline, vancomycin) [**2123-4-26**] Abdominal Fluid (LUQ JP) 1. Coag Neg Staph (S=clinda, rifampin, tetracycline, vanco) 2. Coag Neg Staph (S=clinda, tetracycline, vanco) [**2123-4-27**] Deep Wound Culture 1. Coag Neg Staph (S=clinda, rifampin, tetracycline, vanco) 2. Coag Neg Staph (S=clinda, rifampin, tetracycline, vanco) [**2123-4-26**] Urine Culture - No Growth [**2123-4-26**] Bile Fluid Cx 1. Coag Neg Staph (S=clinda, rifampin, tetracycline, vanco) [**2123-4-26**] Blood Cx - No Growth [**2123-4-26**] Abdominal Fluid (RUQ JP) 1. Coag Neg Staph (S=clinda, rifampin, tetracycline, vanco) 2. Coag Neg Staph (S=clinda, rifampin, tetracycline, bactrim, vanco) [**2123-4-26**] Abdominal Fluid (RUQ JP #2) 1. Coag Neg Staph (S=clinda, rifampin, tetracycline, vanco) [**2123-4-26**] Abscess Smear -- No AFB [**2123-4-26**]: JP #3 No growth HCV Undetectable Viral Load (< 43) [**2123-4-19**] Blood Cx -- E. Coli (R=Amp/Unasyn, Ciprofloxacin) . Images: Reports from OSH: . [**5-8**] CXR: Low lung volumes, crowding of lung markings, linear atelectasis in right mid-lung. . [**5-7**] CT guided abdominal wall collection drainage: 300 cc bloody fluid aspirated . [**5-6**] CT ab/pelvis with oral/IV contrast: post-op changes in upper abdomen. Areas of decreased attenuation in L lob of liver (4.2x6.3cm, 3x2.7cm) which are nonspecific but may represent areas of hepatic injury or ischemia have mildly improved from prior study of [**4-24**]. A 22.6X4.1 cm fluid collection which contains a small drain in the subcutaneous tissues of the lower abdomen has moderately increased in size since [**4-24**]. No contrast progressed distally beyond stomach. No dilated loops to suggest obstruction. . [**5-3**] Upper venous doppler, bilateral: Normal study showing no evidence of thrombus involving the major veins of the UEs. . [**4-29**] Cholangiogram (intraop): biliary tree is opacified, some contrast extravasation; see detailed surgical report for evaluation of findings. . [**4-27**] Upper GI series with gastrografin: Some reflux of gastrografin up into the distal esophagus; no significant movement of gastrografin out of the stomach for greater than 15 minutes. Repeat KUB 30 minutes after study showed no contrast passage into small bowel loops and no evidence for contrast leak. Repeat report 2 hours later also shows no progression of contrast into small bowel. . [**4-24**] CT ab/pelvis w/o IV contrast: hypodensity within the liver with adjacent subhepatic fluid, may represent liver laceration or abscess or collection extending from the subhepatic area affecting the liver parenchyma. Hypodense round structure around the third portion of the duodenum measuring 2.9x4 cm for which hematoma or abscess cannot be excluded. Non-inflamm/post-surgical changes in gallbladder fossa with biliary stent. Ascites. Small bilateral effusions. Anterior pelvic subcutaneous fluid collection with drain within it measuring 9x2.8cm. . [**4-19**] Femoral/popliteal dopplers: No DVT. Hypoechoic area within the soft tissues near the L common femoral [**Last Name (LF) 5703**], [**First Name3 (LF) **] represent edema or fluid structure. . [**4-15**] Trans-catheter embolization: Procedure: celiac arteriogram, SMA arteriogram, cannulation of 2 third-order SMA branches with arteriogram of both; cannulation of gastroduodenal artery and arteriogram; successful embolization of the gastroepiploic and portions of the gastroduodenal artery; post-embolization arteriogram. Findings/Impression: Pseudoaneurysm identified region of the base of the gastroduodenal/gastroepiploic artery which flows in the reverse direction. It was difficult to cannulate the abnormality, although this was cannulated and multiple coils placed across the area of abnormality. There are dilated pancreaticoduodenal arcades and reversed flow in the GDA. . [**4-13**] RUQ US: cholelithiasis and gallbladder sludge; no GB wall thickening or pericholecystic fluid. CBD measures 9 mm, mildly dilated. Past Medical History: Recent surgical history from OSH: [**2123-4-15**]: ERCP with sphincterotomy c/b gastric artery laceration celiac arteriogram, SMA arteriogram, cannulation of 2 third order SMA branches, embolization of the gastroepiploic and portions of gastroduodenal artery [**2123-4-15**]: Emergenct Ex-lap with partial gastrectomy, ccy,suture of periampullary artery, tube gastrostomy, divertizulization of duodenal stump and Hunt-[**First Name4 (NamePattern1) 487**] [**Last Name (NamePattern1) **] [**2123-4-16**]: Ex-lap with evacuation of clot, repair of mesenteric defect and repair of hunt-[**Hospital1 **] [**Hospital1 42265**] [**2123-4-19**]: ex-lap with abdominal wall closure using modified [**Location (un) 72954**] technique (stratus absorbable pigskin mesh unerlay and overlay of 12 x 14 inches marlex mesh) [**2123-4-29**]: Development of SBO requiring Ex-lap with LOA, Tracheostomy/T-tube cholangiogram [**2123-5-7**]: CT guided abscess drainage of 300ml bloody fluid . Past Medical History: - Hypertension - Hyperlipidemia - Coronary artery disease s/p 2 stents to LCx in [**11/2115**] - Aortic regurgitation - Hepatitis C (from blood transfusion), ? HBV - Remote h/o testicular cancer (Stage I seminoma testicular cancer, s/p left orchiectomy with radiation therapy in [**2099**]) - Osteoarthritis s/p left hip replacement x 2 c/b osteomyelitis Social History: Widowed. He lives independently downstairs from his daughter, who is a middle school teacher. He is a semi-retired produce seller. - Tobacco: Smoked as an adolescent but quit 60 years ago. - Alcohol: Rare. - Illicits: Denies. Family History: non-contributory Physical Exam: Vitals: T: BP: P: R: 18 O2: General: ill-appearing man, unresponsive with eyes open and head bobbing HEENT: Sclera anicteric, MMM, NGT in place Neck: supple, JVP not elevated, no LAD, trach collar in place Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, multiple drains in place including: colostomy, biliary drain, 3 JP drains, GJ tube GU: foley in place Ext: L foot heel ulcer, wrapped Pertinent Results: [**2123-5-14**] TTE: LA, RA normal in size. Mild symmetric LVH, LVEF>55%. RV normal. AV mildly thickened, no AS. Mild AR. MV normal. [**2123-5-14**]: Head CT w/o Contrast [**2123-5-14**] CT head: No acute intracranial process, including no hemorrhage. Hypodensity within the right frontal lobe is unchanged from [**2123-4-24**], and may represent sequelae of prior small vessel infarct. [**2123-5-14**]: CT Torso: 1. Contrast is tracking from bowel loops to the anterior abdominal wall in the lower right lower quadrant area. The findings are concerning for enterocutaneous fistula. 2. Status post multiple upper GI surgeries including Roux-en-Y gastrojejunostomy . No obstruction or leak is noted. 3. The previously noted fluid collection within the anterior abdominal wall has significantly improved. 4. 4.5 cm focus of hyperdense fluid collection adjacent to the acetabulum on the left side which may be related to the left total hip replacement and protrusio acetabulum. [**2123-5-14**]: RUQ Ultrasound with Doppler: 1. Patent hepatic vasculature. 2. 2.5 x 2.3 x 3.0 cm heterogeneous lesion within the left lobe of the liver, incompletely characterized, recommend contrast-enhanced multiphasic CT or MRI for further delineation. 3. Known midline collection with drainage tube, partially imaged, as more fully characterized on concurrent CT examination. 4. Coarsened echotexture of the liver, compatible with known cirrhosis. [**2123-5-16**]: PORTABLE ABDOMEN. The bowel gas pattern is nonspecific. There is an air-filled loop of bowel within the left upper abdomen of unclear etiology due to the lack of significant features. There is some stool seen within the right and left colon. No definite dilated small bowel loops are appreciated. [**2123-5-16**]: EEG SPIKE DETECTION PROGRAMS: These contained muscle and electrode artifact but no evidence of epileptiform discharges. SEIZURE DETECTION PROGRAMS: There was no evidence of electrographic seizures contained in these files. PUSHBUTTON ACTIVATIONS: There were no entries in these files. AUTOMATED TIME SAMPLES: This showed more sustained 8 Hz posterior dominant rhythm in the waking state which attenuated with eye opening. No areas of focal slowing, epileptiform discharges, or electrographic seizures were seen in these files. SLEEP: The patient progressed from wakefulness to sleep without additional findings. CARDIAC MONITOR: Showed a generally regular rhythm with an average rate of 84 bpm. IMPRESSION: This is a normal video EEG study in the sleeping and waking states. No focal, lateralized, or epileptiform features were seen in this study. This telemetry captured no pushbutton activations and contained no electrographic seizures. [**2123-5-17**]: EEG IMPRESSION: This is an abnormal video EEG study due to slowing and disorganization of the background rhythm consistent with a moderate encephalopathy. Note is made of several instances of rhythmic theta activity located in the posterior quadrant without obvious clinical correlate and in the context of a severely limited technical study associated with electrode artifact. These findings do suggest possible seizure activity in the right posterior quadrant; however, repeat EEG, if clinically indicated, would help clarify the above findings due to the limited technical nature of this study. [**2123-5-17**]: Abdominal Fluoro IMPRESSION: 1. Percutaneous duodenostomy tube with small leakage seen around the catheter entrance into the duodenum, with tracking along the catheter and liver. No definite biliary leak of contrast that refluxed into the biliary system, though a small contained leak at the T tube entrance site to the CBD can not be excluded. 2. Gastrojejunostomy was filled retrograde but unable to distend completely, a followup radiograph in 45- 60 minutes is recommended. [**2123-5-28**]: Gtube Study: Distention of the stomach [**Month/Day/Year 42265**] without filling of the gastrojejunostomy. Reflux into the esophagus is noted. No leak by the gastric tube injection. [**2123-5-29**]: R forearm: Mild swelling at the level of the wrist. Extensive vascular calcifications. No safe evidence of cortical disruptions indicative of fracture. Moderate degenerative changes at the level of the wrist in the proximal hand. [**2123-6-3**]: 1. No evidence of acute aortic dissection. No definite main pulmonary artery embolism is identified, within limits of the examination. 2. No new intra-abdominal collection is noted. There is no evidence of bowel obstruction. 3. Extensive fat stranding in the cholecystectomy bed and in the region surrounding the pancreatic head, likely relates to the recent surgery. 4. Aneurysmal dilation of the abdominal aorta just above the iliac bifurcation measuring up to 3.4 cm. 5. Bilateral atelectasis of the dependent lungs, associated with small pleural effusions, are new since the prior study. 6. Extensive retained barium within the colon. [**2123-6-14**]: T-tube study: Focal area of opacification near the area of the anastomosis, consistent with a contained leak. [**2123-6-22**]: CT torso: 1. Increased consolidative component within the left lower lobe lung is concerning for pneumonia. 2. Unchanged positioning of three surgical drains, G- and J-tubes, and internal biliary catheter. 3. Stable small focal fluid collection at the surgical bed. 4. No new focal fluid collections detected. 5. No change in fluid collection adjacent to the left acetabular component of the hip athroplasty. [**2123-6-24**]: CXR: no appreciable interval change. Culture Results: Pt. never had positive blood cultures at [**Hospital1 18**] [**2123-5-13**]: Bile Cx: klebsiella pneumoniae, E.coli, C albicans [**2123-5-13**]: peritoneal fluid from JP: E.coli, klebsiella, prob enterococcus [**2123-5-14**]: HCV viral load: undetectable [**2123-5-16**] and [**2123-6-3**]: Cdiff POSITIVE [**2123-5-17**]: CMV viral load 5620 copies [**2123-5-20**]: wound culture: C. albicans [**2123-6-5**]: UCulture: pseudomonas aeruginosa [**2123-6-22**]: UCulture: NEGATIVE [**2123-6-20**]: Sputum cx: oral flora [**2123-6-23**]: BAL: 2+PMNs, no microorganisms Brief Hospital Course: 74 yo male s/p multiple surgical interventions at an OSH now being transferred to [**Hospital1 18**] with concern for infected mesh, infected hematoma, enterocutaneous fistula and respiratory failure. Mr. [**Known lastname 107034**] had a very complicated hospital course marked by slow and steady improvement of every organ system and from an infectious disease perspective. Salient aspects of his hospital course will be summarized by problem below. In brief, he came to us critically ill and was for a time admitted to the Medical ICU. Care was eventually transferred to the SICU under Dr. [**Last Name (STitle) **]. He later made it to the floor, off ventilator assistance. On admission, he was continued on TPN, required ventilator assistance and was kept on broad spectrum antibiotics. As he improved clinically, he was started on tube feeds through his duodenostomy tube, which he was ultimately able to tolerate well and is now up to goal. His JP drains have remained in place and continue to drain various amounts of turbid fluid. As his liver function tests improved, his T-tube was able to be capped and his jaundice resolved. He initially required ventilator support but was able to be weaned from the vent over many days. He is now on trach collar with a passy-muir valve and is able to speak. On admission, his mental status was in question and EEGs were done to rule out seizure activity. No seizures were noted. As sedation was removed, the patient's mental status got progressively better. At discharge, he is lucid, alert, and interactive. His tube feeds have been advanced to goal and his TPN was stopped. For a time, due to excessive losses from his Gtube and from his biliary drain, he had difficulty with electrolyte imbalance which was treated prn. Hypernatremia was a problem and he was treated with [**Name (NI) 91806**] and later with H2O flushes through his duodenostomy tube with good result. His D-tube flushes were recently reduced to 100 cc q4h to reduce the amount of free water given in order to avoid fluid overload. Furthermore, his stomach and the duodenostomy were both studied and it appears that the stomach is currently not emptying well into the distal GI tract. For this reason, he has been primarily provided for nutritionally by tube feeds. His Gtube is treated with the following regimen: 3 hrs to gravity and one hour to low intermitted wall suction for 1 hour, which is then repeated. At the time of discharge, the patient was afebrile, tolerating tube feeds, alert and oriented and able to handle his own secretions. By problem: # Fever/ID: From an ID perspective, the patient was treated for a number of infections. Here are his culture results below. Of note, he never had a positive blood culture at [**Hospital1 18**]. [**2123-5-13**]: Bile Cx: klebsiella pneumoniae, E.coli, C albicans [**2123-5-13**]: peritoneal fluid from JP: E.coli, klebsiella, prob enterococcus [**2123-5-14**]: HCV viral load: undetectable [**2123-5-16**] and [**2123-6-3**]: Cdiff POSITIVE [**2123-5-17**]: CMV viral load 5620 copies [**2123-5-20**]: wound culture: C. albicans [**2123-6-5**]: UCulture: pseudomonas aeruginosa [**2123-6-22**]: UCulture: NEGATIVE [**2123-6-20**]: Sputum cx: oral flora [**2123-6-23**]: BAL: 2+PMNs, no microorganisms Lines were removed as pertinent. He now only has peripheral IV access. He was treated with various different antibiotic regimens for his various infections and infectious disease was consulted to help in antibiotic management. He was treated for the UTI, the infected bile and peritoneal fluid as well as for C. difficile. At discharge, the patient was afebrile, not having diarrhea and had completed a full course of Cdiff treatment. Shortly after the patient's admission, his surgical staples were removed. Soon thereafter, the superior portion of his abdominal incision began to breakdown with small amounts of bilious and purulent drainage. He was started on wet to dry dressing changes twice daily. This was changed to an ostomy bag. It continues to drain turbid fluid. The underlying mesh is almost certainly infected, however, the wound is adequately drained. The patient is now stable from this perspective. He was on the following antibiotics: [**5-13**]: vanc/zosyn/micafungin [**5-15**]: zosyn changed to meropenem [**5-16**]: flagy added [**5-22**]: vancomycin dc'd [**5-29**]: [**Last Name (un) 2830**] dc'd [**5-31**]: flagyl dc'd (off antibiotics, only on micafungin) [**6-6**]: micafungin dc'd, started PO vanc and ceftazidime [**6-14**]: ceftazidime dc'd [**6-20**]: PO vanc dc'd . # C. Difficile Infection The patient was noted to have a large increase in stool production and a c. diff antigen test was sent. This returned c. difficile positive and the patient was started on metronidazole IV. He was transitioned to PO vancomycin and completed a course through [**2123-6-20**]. . # Nutrition: The patient had been maintained on TPN at the outside hospital, and enteral feeding had not been attempted. After his tube studies there was concern over extravasation of fluid from the duodenostomy tube. We wanted to place [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]-intestinal tube distal to this duodenostomy tube for enteral feedings, but unfortunatey neither angio nor IR thought that a feeding tube could be passed through his duodenum. . The patient was started on tube feeds via existing duodenostomy tube with tube feeds based on nutrition recs of Vivonex TEN Full strength. He was finally transitioned to his current tube feeds, Impact with Fiber 3/4 strength at 105 cc/hr with free water flushes 100 cc q4h. He did well with this. He was transitioned off of TPN and had his last TPN on [**5-27**]. Of note, his duodenostomy tube had to be changed out twice as it was leaking and then clogged. The current tube is working well. . # Respiratory failure: The patient had undergone a tracheostomy at the outside hospital and was transferred to us on assist control. The patient was transitioned to PSV and then to trach collar. IP was able to place a smaller tracheostomy tube, and he subsequently had a PMV placed and is now talking in full sentences. . # Incision Drainage ?????? He now has an ostomy bag over the superior aspect of his incision, still draining purulent fluid, but controlled. # Hypernatremia: The patient had intermittent hypernatremia into the high 140s that responded well to D5W. No further hypernatremia with free H2O flushes in duodenostomy tube. He will need to be monitored for volume overload in the future and these free H2O flushes can be tapered off as tolerated. . #Melena: Patient with episodes of melena early during this hospitalization, ultimately, he received 3 units of red cells. His Hct stabilized and he required no further transfusions. . #Liver mass: During the patient's RUQ ultrasound, a 2.5 x 2.3 x 3.0 cm heterogeneous lesion within the left lobe of the liver was noted. This lesion will require more definitive imaging on an outpatient basis when the patient is more stable. AFP was sent and was normal. . # CMV +: The patient had CMV viral load sent that returned elevated. This was likely due to the large volume of blood products that he received while in the OSH. No intervention was thought necessary. . # Neurology: On the day of admission, the patient's daughter noticed head bobbing activity that was concerning for seizure activity. No history of seizures in the past, though decreased rhythmic activity overnight on HD 1. The patient had no further head bobbing or seizure like activity during his hospitalization. . He underwent multiple video EEGs that did not demonstrate evidence of seizure. . # Elevated LFTs: possibly due to hypoperfusion vs. hepatitis C infection vs TPN cholestasis. LFTs have trended down and are now back in normal range and his T-tube has been capped without elevation of his bilirubin. . # Acute Renal Failure: The patient had acute renal failure and his creatinine reached a peak of 1.9 from baseline of 1.0. This was thought to be due to volume depletion based upon exam and elevated sodium. The patient was initially given NS fluid boluses and D5W for hypernatremia with improvement of his creatinine to 0.8. . The patient's creatinine was monitored throughout the hospitalization and remained at or below his baseline level. . # CAD: on b-blocker, statin, aspirin at home, not continued at OSH # R arm pain: patient has osteoarthritis and complained intermittently of R arm pain. This was imaged and showed no fracture. The pain seems to be tolerable at this point. [**Month (only) 116**] consider gouty arthritis as the source? # Prior to discharge, the patient underwent a CT of the torso to make sure there was no major infection hiding. A left lower lobe consolidation was noted and so the patient underwent bronchoscopy on [**6-23**] with IP with findings of thick mucous plugging but no obvious infection. A BAL gram stain only showed PMNs, no microorganisms. This will be followed to ensure a negative culture. The patient remained stable from a respiratory perspective and is fit for discharge to rehab. Medications on Admission: Medications at Home: - Aspirin 325 mg daily - Atorvastatin 10 mg daily - Lisinopril 5 mg daily - Metoprolol Succinate SR 25 mg daily - Ranitidine HCl 150 mg [**Hospital1 **] - Nitroglycerin SL 0.4 mg prn . Medications on Transfer to [**Hospital1 18**] 1. Vancomycin 900mg IV Q 12 2. Lovenox 40mg SC daily 3. Reglan 10mg IV Q 6 hours 4. Erythromycin 500mg IV q 6hours 5. Zosyn 3.375gm IV q 6 hours 6. Tygacil 50mg IV q 12 hours 7. TPN 8. Fentanyl boluses for pain 9. Protonix 40mg IV q 12 hours 10. Caspofungin 50mg IV daily 11. Atrovent 2.5ml neb q 4 hours 12. Albuterol neb q 4 hours 13. Acetic Acid 1000ml [**Hospital1 **] Discharge Medications: 1. Acetaminophen 500 mg Tablet [**Hospital1 **]: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever. 2. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 3. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times a day) as needed for constipation. 4. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: 5000 (5000) units Injection TID (3 times a day). 5. Acetylcysteine 20 % (200 mg/mL) Solution [**Hospital1 **]: 1-10 MLs Miscellaneous Q8H (every 8 hours) as needed for thick secretions. 6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Last Name (STitle) **]: Three (3) mL Inhalation Q6H (every 6 hours) as needed for wheezing. 8. Metoprolol Tartrate 25 mg Tablet [**Last Name (STitle) **]: 0.5 Tablet PO BID (2 times a day). 9. Erythromycin 250 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: One (1) Tablet, Delayed Release (E.C.) PO Q6H (every 6 hours): for GI motility. 10. Metoclopramide 5 mg/mL Solution [**Last Name (STitle) **]: Ten (10) mg Injection Q6H (every 6 hours) as needed for motility. 11. Ondansetron HCl (PF) 4 mg/2 mL Solution [**Last Name (STitle) **]: Four (4) mg Injection Q8H (every 8 hours) as needed for nausea. 12. Nitroglycerin 0.4 mg Tablet, Sublingual [**Last Name (STitle) **]: One (1) tab Sublingual prn as needed for chest pain. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: acute cholecystitis s/p ERCP complicated by pancreaticoduodenal injury with gastroduodenal artery injury requiring emergent ex-lap, partial gastrectomy, cholecystectomy, suture of periampullary artery, tube gastrostomy, divertizulization of duodenal stump and Hunt-[**First Name4 (NamePattern1) 487**] [**Last Name (NamePattern1) **]. followed by ex-lap on following day with evacuation of clot, repair of mesenteric defect and repair of hunt-[**Hospital1 **] [**Hospital1 42265**]. e. coli sepsis s/p abdominal wall closure using modified [**Location (un) 72954**] technique (stratus absorbable pigskin mesh unerlay and overlay of 12 x 14 inches marlex mesh) small bowel obstruction s/p ex-lap with LOA, difficult weaning from ventilator s/p tracheostomy T-tube placement intraabdominal abscess Hepatitis C with cirrhosis malnutrition requiring TPN and tube feeds hypernatremia hyperbilirubinemia acute renal failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to [**Hospital1 18**] after being transferred from an ICU in [**Last Name (un) 33963**], FL. At [**Hospital1 18**] you were given supportive care and started on tube feeds through your duodenostomy tube. Please call your doctor or return to the Emergency Department for the following: - fever, chills, nausea, vomiting - increasing abdominal pain, hypotension - chest pain, shortness of breath Followup Instructions: Please call Dr.[**Name (NI) 1863**] office at ([**Telephone/Fax (1) 2300**] in order to schedule a follow up appointment in approximately 2 weeks. Please follow up with your primary care provider as needed.

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Discharge summary

report+addendum

Admission Date: [**2192-10-22**] Discharge Date: [**2192-11-28**] Date of Birth: [**2118-7-21**] Sex: F Service: SURGERY Allergies: Rofecoxib / Fluorescein Attending:[**First Name3 (LF) 5880**] Chief Complaint: Diarrhea Major Surgical or Invasive Procedure: [**2192-11-5**] 1. Flexible sigmoidoscopy. 2. Subtotal colectomy with ileosigmoid colostomy. 3. Repair of umbilical hernia. History of Present Illness: This is a 74 year old female with multiple medical problems including coronary artery disease and peripheral vascular disease who presented with 2 days of bloody diarrhea. The patient also has had nausea and vomitting and diffuse abdominal pain (throbbing in nature and in the right lower quadrant) during this period. She says she has had some fever and chills. She says she has not had these symptoms before, but according to her daughter she had had abdominal pain and diarrhea the week before. She has had no sick contacts and no recent travel. She denies a history of constipation . There is no hsitory of inflammatory bowel disease in the family. She had a colonoscopy in [**2190**] which showed a single small rectal polyp. Past Medical History: Severe COPD Peripheral Vascular Disease Venous Stasis ulcerations in bilateral lower extremities s/p appendectomy Osteoporosis Polycythemia Coronary Artery Disease (but with normal stress imaging) Renal insufficiency (thought to be caused by vioxx) Narcolepsy History of C. Diff History of MRSA on nasal swabs Social History: The patient lives with her daughter, [**Name (NI) **]. She does not leave her house much. She does not require assistance with activities of daily living but uses a walker to assist with ambulation. She denies recent tobacco or alcohol use. Family History: non-contributory Physical Exam: ON admission: v/s 96.2, 117, 123/77, 16, 99% on room [**Location (un) **] Gen: no acute distress, well-developed elderly female, alert/awake/oriented x 3 Neuro: CN 2-12 grossly intact HEENT: moist mucous membranes, PERRLA Pulm: mild expiratory wheezing biaterally CV: regular rate and rhythm, no murmurs Abd: soft, mildly distended, tender in the periumbilical region and right lower quadrant, no rebound/gaurding, normoactive bowel Rectal exam: blood-tinged, empty vault Extr: bilateral venous stasis changes with brawny edema, cellulitic changes in bilateral shins Pertinent Results: SEROLOGIES [**2192-10-22**] 02:15PM BLOOD WBC-19.4*# RBC-3.79* Hgb-14.3 Hct-43.0 MCV-113* MCH-37.8* MCHC-33.4 RDW-15.0 Plt Ct-361 [**2192-10-23**] 05:30AM BLOOD WBC-12.5* RBC-2.84*# Hgb-10.6*# Hct-32.1*# MCV-113* MCH-37.4* MCHC-33.1 RDW-14.6 Plt Ct-263 [**2192-10-24**] 05:50AM BLOOD WBC-10.3 RBC-2.67* Hgb-10.3* Hct-30.0* MCV-113* MCH-38.7* MCHC-34.4 RDW-14.3 Plt Ct-222 [**2192-10-25**] 06:00AM BLOOD WBC-8.5 RBC-2.56* Hgb-9.5* Hct-29.1* MCV-114* MCH-37.3* MCHC-32.8 RDW-14.7 Plt Ct-229 [**2192-10-27**] 05:00AM BLOOD WBC-12.8* RBC-2.78* Hgb-10.4* Hct-31.6* MCV-114* MCH-37.5* MCHC-33.0 RDW-14.3 Plt Ct-293 [**2192-10-29**] 10:38AM BLOOD WBC-10.3 RBC-2.81* Hgb-10.6* Hct-31.7* MCV-113* MCH-37.7* MCHC-33.4 RDW-14.3 Plt Ct-347 [**2192-11-1**] 04:25AM BLOOD WBC-10.9 RBC-2.66* Hgb-10.0* Hct-30.4* MCV-114* MCH-37.7* MCHC-32.9 RDW-14.0 Plt Ct-408 [**2192-11-2**] 04:24AM BLOOD WBC-10.1 RBC-2.60* Hgb-9.6* Hct-29.7* MCV-114* MCH-37.0* MCHC-32.3 RDW-14.1 Plt Ct-394 [**2192-11-5**] 10:09AM BLOOD WBC-14.2* RBC-2.95* Hgb-11.0* Hct-34.4* MCV-116* MCH-37.4* MCHC-32.1 RDW-13.9 Plt Ct-536* [**2192-11-5**] 07:00PM BLOOD WBC-17.4* RBC-3.15* Hgb-11.0* Hct-32.7* MCV-104*# MCH-34.8* MCHC-33.6 RDW-18.8* Plt Ct-422 [**2192-11-6**] 03:53AM BLOOD WBC-23.3* RBC-2.89* Hgb-9.8* Hct-30.2* MCV-105* MCH-33.9* MCHC-32.4 RDW-19.8* Plt Ct-504* [**2192-11-7**] 01:57AM BLOOD WBC-17.7* RBC-2.31* Hgb-8.0* Hct-23.9* MCV-103* MCH-34.4* MCHC-33.3 RDW-19.1* Plt Ct-293 [**2192-11-8**] 01:38AM BLOOD WBC-23.0* RBC-3.39*# Hgb-11.3*# Hct-33.4* MCV-98 MCH-33.3* MCHC-33.8 RDW-20.0* Plt Ct-314 [**2192-11-9**] 05:30AM BLOOD WBC-12.4* RBC-3.04* Hgb-10.2* Hct-30.6* MCV-101* MCH-33.6* MCHC-33.3 RDW-19.4* Plt Ct-286 [**2192-11-11**] 05:30AM BLOOD WBC-15.0* Hct-34.8* Plt Ct-339 [**2192-11-13**] 06:00AM BLOOD WBC-18.5* RBC-3.27* Hgb-10.7* Hct-33.4* MCV-102* MCH-32.8* MCHC-32.0 RDW-17.7* Plt Ct-365 [**2192-11-15**] 06:15AM BLOOD WBC-20.2* RBC-2.98* Hgb-9.9* Hct-30.5* MCV-102* MCH-33.0* MCHC-32.3 RDW-17.5* Plt Ct-424 [**2192-11-16**] 04:55AM BLOOD WBC-27.0* RBC-3.35* Hgb-10.8* Hct-34.4* MCV-103* MCH-32.3* MCHC-31.4 RDW-17.4* Plt Ct-545* [**2192-11-17**] 05:02AM BLOOD WBC-21.7* RBC-3.12* Hgb-10.3* Hct-31.4* MCV-101* MCH-33.0* MCHC-32.7 RDW-17.5* Plt Ct-519* [**2192-11-19**] 05:45AM BLOOD WBC-15.0* RBC-3.03* Hgb-9.8* Hct-30.7* MCV-102* MCH-32.4* MCHC-31.9 RDW-17.3* Plt Ct-554* [**2192-11-20**] 04:43AM BLOOD WBC-13.6* RBC-3.02* Hgb-9.8* Hct-30.4* MCV-101* MCH-32.5* MCHC-32.3 RDW-17.0* Plt Ct-621* [**2192-11-21**] 04:47AM BLOOD WBC-12.7* RBC-2.85* Hgb-9.5* Hct-29.0* MCV-102* MCH-33.3* MCHC-32.7 RDW-17.4* Plt Ct-565* [**2192-10-22**] 02:15PM BLOOD Neuts-78* Bands-1 Lymphs-7* Monos-13* Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0 [**2192-11-17**] 05:02AM BLOOD Neuts-89* Bands-2 Lymphs-1* Monos-5 Eos-1 Baso-0 Atyps-0 Metas-2* Myelos-0 [**2192-11-8**] 01:38AM BLOOD PT-13.0 PTT-30.4 INR(PT)-1.1 [**2192-10-22**] 05:15PM BLOOD PT-13.8* PTT-29.6 INR(PT)-1.2 [**2192-11-7**] 05:00AM BLOOD Fibrino-693* [**2192-10-22**] 02:15PM BLOOD Glucose-107* UreaN-41* Creat-1.7* Na-143 K-5.2* Cl-107 HCO3-22 AnGap-19 [**2192-10-23**] 05:30AM BLOOD Glucose-87 UreaN-35* Creat-1.3* Na-136 K-4.2 Cl-107 HCO3-19* AnGap-14 [**2192-10-24**] 05:50AM BLOOD Glucose-84 UreaN-20 Creat-1.0 Na-142 K-3.7 Cl-111* HCO3-21* AnGap-14 [**2192-10-25**] 06:00AM BLOOD Glucose-83 UreaN-13 Creat-0.9 Na-143 K-3.8 Cl-110* HCO3-23 AnGap-14 [**2192-10-29**] 10:38AM BLOOD Glucose-113* UreaN-22* Creat-0.8 Na-137 K-3.8 Cl-107 HCO3-23 AnGap-11 [**2192-11-3**] 04:20AM BLOOD Glucose-83 UreaN-49* Creat-1.3* Na-139 K-5.3* Cl-113* HCO3-18* AnGap-13 [**2192-11-5**] 07:00PM BLOOD Glucose-135* UreaN-43* Creat-1.1 Na-138 K-5.4* Cl-115* HCO3-13* AnGap-15 [**2192-11-6**] 03:53AM BLOOD Glucose-133* UreaN-39* Creat-1.3* Na-138 K-5.1 Cl-113* HCO3-17* AnGap-13 [**2192-11-6**] 09:00AM BLOOD Glucose-134* UreaN-38* Creat-1.4* Na-137 K-4.9 Cl-109* HCO3-19* AnGap-14 [**2192-11-7**] 12:42PM BLOOD Glucose-123* UreaN-36* Creat-1.5* Na-141 K-4.4 Cl-109* HCO3-24 AnGap-12 [**2192-11-9**] 05:30AM BLOOD Glucose-127* UreaN-34* Creat-1.1 Na-141 K-3.3 Cl-105 HCO3-28 AnGap-11 [**2192-11-12**] 04:15AM BLOOD Glucose-104 UreaN-31* Creat-1.0 Na-147* K-4.0 Cl-105 HCO3-35* AnGap-11 [**2192-11-15**] 06:15AM BLOOD Glucose-115* UreaN-28* Creat-0.9 Na-141 K-4.0 Cl-107 HCO3-27 AnGap-11 [**2192-11-20**] 04:43AM BLOOD Glucose-101 UreaN-9 Creat-0.9 Na-140 K-3.9 Cl-104 HCO3-28 AnGap-12 [**2192-11-21**] 04:47AM BLOOD Glucose-98 UreaN-9 Creat-1.0 Na-137 K-3.5 Cl-105 HCO3-26 AnGap-10 [**2192-10-22**] 02:15PM BLOOD ALT-10 AST-20 Amylase-621* TotBili-0.7 [**2192-11-5**] 10:09AM BLOOD ALT-15 AST-13 AlkPhos-123* Amylase-103* TotBili-0.2 [**2192-11-17**] 05:02AM BLOOD ALT-61* AST-37 AlkPhos-302* Amylase-84 TotBili-0.7 [**2192-10-22**] 02:15PM BLOOD Lipase-12 [**2192-11-5**] 10:09AM BLOOD Lipase-38 [**2192-11-17**] 05:02AM BLOOD Lipase-46 [**2192-10-22**] 02:15PM BLOOD Calcium-9.9 Mg-2.0 [**2192-11-5**] 10:09AM BLOOD Albumin-3.5 Calcium-9.7 Phos-4.9* Mg-2.6 [**2192-11-21**] 04:47AM BLOOD Calcium-8.2* Phos-3.6 Mg-1.9 [**2192-11-22**] 05:06AM BLOOD Calcium-8.4 Phos-4.0 Mg-2.1 [**2192-10-26**] 05:20AM BLOOD VitB12-314 Folate-12.5 [**2192-11-4**] 02:00PM BLOOD Triglyc-137 [**2192-10-22**] 05:52PM BLOOD Lactate-2.2* [**2192-10-22**] 06:54PM BLOOD Lactate-3.0* [**2192-10-22**] 10:38PM BLOOD Lactate-2.3* K-4.8 [**2192-11-5**] 03:00AM BLOOD Lactate-0.8 [**2192-11-5**] 03:20PM BLOOD Glucose-113* Lactate-1.5 Na-136 K-5.9* Cl-111 [**2192-11-5**] 04:24PM BLOOD Glucose-124* Lactate-2.4* Na-136 K-5.6* Cl-112 [**2192-11-6**] 12:10AM BLOOD Glucose-123* Lactate-1.3 [**2192-11-6**] 05:36AM BLOOD Glucose-149* Lactate-1.2 [**2192-11-7**] 07:48PM BLOOD Lactate-1.0 MICROBIOLOGY [**2192-10-22**] Blood Cx: negative [**2192-10-22**] Urine Cx: negative [**2192-10-23**] Stool Cx: negative [**2192-10-25**] Nasal Swab: MRSA + [**2192-10-28**] Stool C. Diff: negative [**2192-11-4**] Blood Cx: negative [**2192-11-8**] Blood Cx: negative [**2192-11-8**] Catheter Tip Cx: negative [**2192-11-10**] Sputum Cx: MRSA, yeast [**2192-11-12**] Urine Cx: VRE, yeast [**2192-11-13**] Blood Cx: negative [**2192-11-14**] Sputum Cx: MRSA [**2192-11-15**] Stool C.Diff: negative [**2192-11-15**] Wound Swab: MRSA, probable enterococcus [**2192-11-16**] Stool Cx: negative [**2192-11-19**] Urine Cx: yeast RADIOLOGY [**2192-10-22**] CT scan: 1. Thickened transverse colon and descending colon with mild pericolonic fat stranding. Potential etiologies include ischemia vs. infection. Inflammatory bowel disease is possible, but is considered less likely. 2. Emphysema. 3. Several tiny low attenuation liver lesions, too small to characterize on this study. 4. Left adrenal mass. This is incompletely characterized on this study and a dedicated adrenal CTA is recommended for further evaluation. 5. Low attenuation right kidney lesion, likely representing a simple cyst. 6. Enlarged left ovary. Further evaluation with pelvic ultrasound is recommended. 7. Pelvic free fluid. This is a nonspecific finding and may be related to the previously mentioned colonic abnormalities. 8. Small hiatal hernia. [**2192-10-25**] Abdominal Xray: no evidence of obstruction [**2192-10-26**] Abdominal CT: 1. Thickened transverse colon and descending colon, with pericolonic fat stranding. There has been some interval improvement with decreased involvement of the transverse colon. The appearance of the distal tranverse and proximal descending colon has not significantly changed. 2. Stable tiny low attenuation liver lesions. These are incompletely characterized. 3. Emphysema. 4. Stable left adrenal mass. 5. Small amount of free fluid in the pelvis, which is stable in the interval [**2192-11-6**] Abdominal CT: 1. No evidence of extravasation of contrast from the bladder. No definite extravasation from the urethra, although this evaluation is limited. 2. Moderate amount of free fluid in the abdomen and pelvis, but no focal walled-off collections. 3. Anasarca. 4. Emphysema. 5. Stable appearance to left adrenal lesion. [**2192-11-15**] Abdominal CT: Development of two new fluid collections along the surgical incision. Both are amenable to nonguided percutaneous drainage. The superior most collection underlies skin staples at approximately the L3 level. The second collection is at the level of the mid sacrum. [**2192-11-17**] Bilateral Lower Extrem Duplex: no DVT PATHOLOGY I. Ileocolectomy (A-K): 1. Stricture of colon, with submucosal fibrosis, transmural necrosis, and organizing pericolic fat necrosis. The features are most consistent with chronic ischemic colitis. 2. Dilation of proximal colon, without colitis. 3. Small adenoma of ascending colon. 4. Ileal segment, within normal limits 5. No carcinoma. II. Umbilical hernia: Fragment of fibroadipose tissue. Brief Hospital Course: This is a 74 year old female with peripheral vascular disease and polycythemia who was admitted with bloody diarrhea, abdominal pain, and an elevated white count on [**2192-10-22**]. The presumed diagnosis was ischemic colitis. A CT on admission did not show SMA or [**Female First Name (un) 899**] occlusion but demonstrated thickened transverse and descending colon. The patient was managed conservatively during her initial 2 weeks of hospitalization, with NPO/bowel rest, TPN initiatied for nutrition, and IV antibiotics (levoquin and flagyl) for treatment. She was examined serially and initially appeared to be improving, with her clinical examinations improving and an improving white cell count. However, after approximately 10 days she continued to have abdominal pain and diarrhea which then worsened and her white cell count and she had a slight metabolic acidosis. She was taken to the operating room on [**2192-11-5**]. Flex sigmoidoscopy demonstrated blanching of the proximal colon submucosa. Ex-lap revealed a markedly dilated colon, from the cecal area to the splenic flexure. A subtotal colectomy with ileosigmoid colostomy was performed. Pathology of the specimen revealed stricture consistent with chronic ischemic colitis. Post-operatively, the patient was transferred to the intensive care unit for close monitoring. She received volume resuscitation with LR and albumin and bicarbonate for metabolic acidosis and hyperkalemia. She had some hematuria with a normal renal ultrasound; it was determined that this was secondary to Foley catheter trauma and she was started on continuous bladder irrigation with resolution of her hematuria. She was transfused 2 units on post-operative day 2 and her hematocrits remained stable. She was extubated on post-operative day 3 and transferred to the floor on post-operative day 4. Her NGT was clamped and removed on post-operative day 8 and she was started on sips on post-operative day 9. She was advanced to a house diet by post-operative day 12 which she tolerated well and her TPN was weaned off. From an infectious diseases standpoint, the patient remained afebrile post-operatively but her white count trended upwards starting on post-operative day 10. She also had some diarrhea. A full infectious workup was negative for stool pathogens but revealed VRE in her urine and MRSA in her sputum (though chest xray was not indicative of pneumonia). CT scan demonstrated drainable fluid collections under her laparotomy incision and the incision was paritally opened at the bedside with drainage of fluid positive for MRSA. The patient was started on Linezolid/Zosyn/Flagyl for coverage of her MRSA/VRE and empiric C. diff and pneumonia coverage. These were converted to Linezolid/Levoquin/Flagyl on discharge (2 week total course) and wet--> dry dressing changes were started on her wound. Reglan was started which improved her diarrhea. The patient worked with physical therapy throughout her post-operative course and was found to be able to ambulate with assistance. In summary, this is a 74 year old female with ischemic colitis who underwent a subtotal colectomy with ileosigmoid colostomy who had urine and wound infections post-operatively. She was tolerating a regular diet on discharge and able to ambulate with assitance. She will require rehab placement for continued treatment of her infections and for assistance with returnt to baseline functional state. All questions were answered to her satisfaction on discharge. Medications on Admission: Actonel 35 mg Qweek [**Doctor First Name **] 80 mg oral daily Allopurinol 300 mg oral daily Aspirin Lipitor Combivent Hydroxyurea 1000 mg oral daily Synthroid 137 mg oral daily Lisinopril 40 mg oral daily Plavix 75 mg oral daily Protonix 40 mg oral daily Discharge Medications: 1. Promethazine HCl 25 mg/mL Solution Sig: Twenty Five (25) mg Injection Q6H (every 6 hours) as needed for nausea. 2. Metoclopramide HCl 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 3. Levothyroxine Sodium 137 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**11-25**] Puffs Inhalation Q6H (every 6 hours). 5. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 6. Bacitracin Zinc 500 unit/g Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 7. Risedronate Sodium 35 mg Tablet Sig: One (1) Tablet PO 1X/WEEK (ONCE PER WEEK). 8. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Diltiazem HCl 300 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). 10. Hydroxyurea 500 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 11. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 13. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 15. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 16. Linezolid 600 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. 17. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 6 days. 18. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Tablet(s) 19. Outpatient Lab Work Patient should have the follow labs checked daily: CBC (including white blood cell count) Chem 10 (including potassium and magnesium, which may require repletion) 20. Outpatient Physical Therapy Patient should be assisted with ambulation 3 times/day 21. [**Doctor First Name **] 60 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: Lifecare, [**Location (un) 3320**] Discharge Diagnosis: (1) Ischemic Colitis (2) Urinary Tract Infection (3) Bacteremia (4) Wound Infection (5) Venous Stasis Ulcers (6) Cellulities of lower extremities Discharge Condition: Fair Discharge Instructions: Please contact the office or come to the emergency room with any worsening abdominal pain, worsening diarrhea and/or bloody diarrhea, worsening nausea/vomitting not improved with standard treatments, or worsening drainage from the wound or redness around the incision. You should take antibiotics as prescribed. Your wound dressing should be changed with a saline wet-->dry dressing twice a day. Please call with any questions. Followup Instructions: Please contact the office of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] to set-up a follow-up appointment on [**2192-12-4**] ([**Telephone/Fax (1) 6439**]). Please contact Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 986**] (urology) to have an outpatient cystoscopy for evaluation of your post-operative hematuria ([**Telephone/Fax (1) 990**]) Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 9091**], MD Where: [**Hospital6 29**] [**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2193-1-30**] 10:40 Completed by:[**2192-11-22**] Name: [**Known lastname **],[**Known firstname 9188**] Unit No: [**Numeric Identifier 10690**] Admission Date: [**2192-10-22**] Discharge Date: [**2192-11-28**] Date of Birth: [**2118-7-21**] Sex: F Service: SURGERY Allergies: Rofecoxib / Fluorescein Attending:[**First Name3 (LF) 813**] Addendum: The patient was discharged on [**2192-11-28**]. Discharge Disposition: Extended Care Facility: Pavillion/[**Location (un) 10691**] [**First Name11 (Name Pattern1) 801**] [**Last Name (NamePattern4) 815**] MD [**MD Number(2) 816**] Completed by:[**2192-11-28**]

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icd9cm

[ [ [] ] ]

[ "00.14", "45.79", "48.23", "45.93", "53.49", "38.93", "99.15" ]

icd9pcs

[ [ [] ] ]

18813, 19034

11210, 14711

294, 420

17282, 17288

2408, 11187

17764, 18790

1787, 1805

15016, 17008

17113, 17261

14737, 14993

17312, 17741

1820, 1820

246, 256

448, 1180

1835, 2389

1202, 1513

1529, 1771

50,140

125,701

42763+58552

Discharge summary

report+addendum

Admission Date: [**2188-7-26**] Discharge Date: [**2188-8-25**] Date of Birth: [**2158-8-4**] Sex: F Service: MEDICINE Allergies: Nafcillin Attending:[**First Name3 (LF) 3853**] Chief Complaint: altered mental status Major Surgical or Invasive Procedure: Transesophageal echocardiogram x2 Intubation and mechanical ventilation Right IJ CVL placement PICC line placement Left iliopsoas abscess drain placement with removal History of Present Illness: This is a 29-year-old woman who is an active IV drug user, s/p tricuspid valve replacement(29mm [**Company 1543**] Mosaic), mitral valve repair (P2 resection,26mm CG Future Ring) for MSSA endocarditis on [**1-/2188**] (course complicated by septic emboli to the brain and lungs) who presents with relapse of drug abuse and septic shock. . The patient was reportedly last heard normal on [**2188-7-23**] when talking to her mother on the phone. She lives with her boyfriend [**Name (NI) **] and on [**2188-7-25**] he noticed "odd behavior" described as combative and aggressive thus called the paramedics. It is unclear when she restarted using IV drugs after admission this [**Month (only) 404**], likely since [**Month (only) 958**]. Per MICU note, she had been using cocaine and heroin on [**2188-7-24**]. When EMS arrived, the patient's HR was 150 and SBP 100, and she was given ativan x2 without effect. . Upon arrivival at [**Hospital6 3105**] ED, her BP was 89/73 with HR 118 (lowest recorded BP was 54/40). Labs were remarkable for creatinine of 5.2. WBC 2.4, Hct 38.2, Plt 32. Troponin I was 0.135, INR 3.9. She was given 1mg narcan, 750mg levaquin, 1g vancomycin, geodon 20mg and 25mg diphenhydramine and 100mg hydrocortisone. She was started on a levophed drip. Prior to transfer to [**Hospital1 18**], a right femoral central line was placed. She had a beside TTE that showed no pericardial effusion, intact TVR, no MR. ECG shows ventricular pacing at 104. . On arrival to the [**Hospital1 18**] MICU, the patient was reported to be quite agitated. Vitals were HR 122, BP 104/89, T 97.6, satting 99% RA on 0.12mcg/kg/min of norepinephrine. She was confused and thought that every person who entered the room was her boyfriend [**Name (NI) **] and was unable to answer any other questions. . During her stay in the MICU, she was continued on norepinephrine drip, bolused with fluids, and treated with vanc/cefepime initially then switched to gent/nafcillin for septic shock (blood cultures from OSH grew staph aureus, suspecitble to oxacillin, resistant to penicillin G.) TEE showed vegetation on tricuspid valve, normal valve otherwise, no vegetations on pacemaker, no abnormalities on mitral valve. She was seen by cardiothoracic surgery who did not think there was indication for surgical intervention. Given low urine output at OSH concerning for septic emboli (vs. pre-renal --> ATN), renal ultrasound was obtained (without Doppler) which was normal. Renal was consulted and thought etiology was likely ATN and recommended PRN lasix for volume overload. She had a stat head CT given AMS which showed possible new hypodensities in R parietal and L cerebellar areas (patient can't get MRI due to pacemaker). INR was 5 on admission thus [**Name (NI) **] was stopped and patient was given PO vitamin K 2.5 mg to reverse INR to try to prevent septic emboli bleeding in brain. She was intubated on [**7-26**], extubated on [**7-27**] without complications. Following extubation, she had [**10-22**] full-body pain and was put on [**Doctor Last Name **] scale with Librium. Speech and swallow cleared her for regular diet. Prior to transfer, mental status was near baseline and patient was hemodynamically stable (BPs 90s/60s). Past Medical History: 1. IVDA, s/p TVR and MVR [**2188-1-25**] for endocarditis: A. Tricuspid valve replacement with a size #29-mm [**Company 1543**] Mosaic tissue valve. B. Mitral valve repair with resection of P2 and repair with size #26 CG Future band. -completed 6wk course of nafcillin on [**3-5**] at [**Hospital1 **], post-op course c/b septic emboli to lungs and brain for which she was anticoagulated. 2. 3rd degree heart block: s/p pacemaker placement on [**2188-3-27**] with [**Company 2267**] Altrua model S606 dual-chamber pacemaker 3. Anxiety 4. Asthma Social History: patient lives with fiance [**Doctor Last Name **] (arrested on outstanding warrant after calling EMS) in [**Location 9583**]. Not working, use to be nanny. Active IVDA, last time was ? [**2188-7-24**]. Current smoker, does not report using EtOH. Family History: unable to obtain Physical Exam: Admission exam: General: Confused, incoherent, perseverating on a drug deal gone bad. HEENT: Sclera anicteric, dry mucus membranes, EOMI, PERRL, approximately 5mm, down to 3mm. Neck: supple, JVP at approximately 10, with diastolic flickering, no LAD CV: Regular rate and rhythm, normal S1 + S2, [**3-18**] diastolic murmur, heard best over right sternal border, no radiation to axilla. Chest: well healed midline scar. Lungs: clear anteriorly, although patient not cooperating with exam Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Confused, mumbling, asking for "please" over and over again. Patient did not cooperate with exam, although able to track eyes and attend to either side of room. Reflexes 2+ bilaterally patellar, downgoing babinski. No clonus Skin: numerous excoriations on upper forearms. Finger tips with violaceous flat petechiae. Lower extremities with 7mm escars scattered along legs. Discharge exam: General: AAOX3, pleasant and cooperative HEENT: OP clear, MMM CV: 3/6 systolic murmur, normal S1 and S2 Abdomen: NTND, active BS X$ Extremities: WWP, pulses 2+ and eqaul Neuro: MS [**First Name (Titles) **] [**Last Name (Titles) **] wnl, strength and sensation wnl Derm: no signs of embolic phenomenon Pertinent Results: [**2188-7-26**] 06:20AM BLOOD WBC-5.4 RBC-4.20# Hgb-10.9* Hct-34.6* MCV-83# MCH-25.8*# MCHC-31.3 RDW-15.7* Plt Ct-35*# [**2188-7-26**] 12:52PM BLOOD WBC-10.7# RBC-4.27 Hgb-11.1* Hct-35.5* MCV-83 MCH-25.9* MCHC-31.2 RDW-15.7* Plt Ct-56*# [**2188-7-27**] 04:40AM BLOOD WBC-8.4 RBC-4.11* Hgb-10.7* Hct-33.2* MCV-81* MCH-26.0* MCHC-32.2 RDW-15.8* Plt Ct-54* [**2188-7-27**] 02:37PM BLOOD WBC-8.1 RBC-4.13* Hgb-10.9* Hct-32.9* MCV-80* MCH-26.3* MCHC-33.1 RDW-15.9* Plt Ct-53* [**2188-7-28**] 02:11AM BLOOD WBC-12.8*# RBC-4.25 Hgb-10.9* Hct-33.5* MCV-79* MCH-25.6* MCHC-32.5 RDW-15.8* Plt Ct-48* [**2188-7-27**] 02:37PM BLOOD WBC-8.1 RBC-4.13* Hgb-10.9* Hct-32.9* MCV-80* MCH-26.3* MCHC-33.1 RDW-15.9* Plt Ct-53* [**2188-7-28**] 02:11AM BLOOD WBC-12.8*# RBC-4.25 Hgb-10.9* Hct-33.5* MCV-79* MCH-25.6* MCHC-32.5 RDW-15.8* Plt Ct-48* [**2188-7-28**] 09:00PM BLOOD WBC-12.2* RBC-3.94* Hgb-10.2* Hct-31.2* MCV-79* MCH-25.9* MCHC-32.7 RDW-16.1* Plt Ct-44* [**2188-7-29**] 02:26AM BLOOD WBC-10.8 RBC-4.10* Hgb-10.7* Hct-32.4* MCV-79* MCH-26.1* MCHC-33.0 RDW-16.2* Plt Ct-49* [**2188-7-30**] 05:05AM BLOOD WBC-11.6* RBC-3.89* Hgb-10.1* Hct-31.1* MCV-80* MCH-26.0* MCHC-32.5 RDW-16.3* Plt Ct-66* [**2188-7-31**] 05:32AM BLOOD WBC-13.0* RBC-3.87* Hgb-9.9* Hct-30.7* MCV-79* MCH-25.6* MCHC-32.3 RDW-16.4* Plt Ct-109*# [**2188-8-1**] 05:52AM BLOOD WBC-17.2* RBC-3.88* Hgb-9.8* Hct-31.1* MCV-80* MCH-25.2* MCHC-31.5 RDW-16.8* Plt Ct-133* [**2188-8-2**] 04:50AM BLOOD WBC-16.6* RBC-3.77* Hgb-9.6* Hct-30.2* MCV-80* MCH-25.6* MCHC-31.9 RDW-16.7* Plt Ct-139* [**2188-8-3**] 06:34AM BLOOD WBC-17.2* RBC-3.60* Hgb-9.1* Hct-29.4* MCV-82 MCH-25.3* MCHC-31.0 RDW-17.7* Plt Ct-139* [**2188-8-4**] 05:13AM BLOOD WBC-13.9* RBC-3.31* Hgb-8.6* Hct-26.8* MCV-81* MCH-26.0* MCHC-32.0 RDW-17.6* Plt Ct-174 [**2188-8-5**] 07:46AM BLOOD WBC-9.5 RBC-3.10* Hgb-8.1* Hct-25.3* MCV-82 MCH-26.1* MCHC-32.0 RDW-17.8* Plt Ct-210 [**2188-8-6**] 07:50AM BLOOD WBC-7.4 RBC-3.10* Hgb-8.0* Hct-25.2* MCV-81* MCH-25.8* MCHC-31.7 RDW-18.1* Plt Ct-196 [**2188-8-7**] 07:10AM BLOOD WBC-4.7 RBC-2.81* Hgb-7.3* Hct-22.9* MCV-82 MCH-25.9* MCHC-31.7 RDW-18.0* Plt Ct-182 [**2188-8-7**] 12:23PM BLOOD WBC-4.5 RBC-2.81* Hgb-7.2* Hct-22.9* MCV-82 MCH-25.7* MCHC-31.4 RDW-18.0* Plt Ct-196 [**2188-8-8**] 05:21AM BLOOD WBC-4.1 RBC-2.63* Hgb-6.8* Hct-21.6* MCV-82 MCH-25.9* MCHC-31.5 RDW-18.2* Plt Ct-180 [**2188-8-9**] 04:25AM BLOOD WBC-3.6* RBC-2.57* Hgb-6.6* Hct-21.0* MCV-82 MCH-25.7* MCHC-31.5 RDW-18.1* Plt Ct-188 [**2188-8-9**] 02:39PM BLOOD WBC-3.5* RBC-2.77* Hgb-7.2* Hct-22.6* MCV-82 MCH-25.9* MCHC-31.8 RDW-18.1* Plt Ct-208 [**2188-8-10**] 05:30AM BLOOD WBC-2.9* RBC-2.65* Hgb-7.0* Hct-21.8* MCV-82 MCH-26.5* MCHC-32.3 RDW-18.3* Plt Ct-174 [**2188-8-11**] 04:59AM BLOOD WBC-3.3* RBC-2.88* Hgb-7.6* Hct-23.7* MCV-82 MCH-26.3* MCHC-32.0 RDW-18.1* Plt Ct-195 [**2188-8-12**] 05:30AM BLOOD WBC-3.3* RBC-2.67* Hgb-6.9* Hct-21.9* MCV-82 MCH-25.9* MCHC-31.6 RDW-18.7* Plt Ct-181 [**2188-8-13**] 04:50AM BLOOD WBC-3.2* RBC-2.84* Hgb-7.4* Hct-23.3* MCV-82 MCH-25.9* MCHC-31.6 RDW-19.0* Plt Ct-205 [**2188-7-31**] 05:32AM BLOOD Neuts-86.4* Lymphs-10.5* Monos-1.8* Eos-1.0 Baso-0.2 [**2188-8-1**] 05:52AM BLOOD Neuts-81.8* Lymphs-14.1* Monos-2.9 Eos-0.8 Baso-0.5 [**2188-8-2**] 04:50AM BLOOD Neuts-80.9* Lymphs-16.1* Monos-2.2 Eos-0.4 Baso-0.4 [**2188-8-3**] 06:34AM BLOOD Neuts-80.9* Lymphs-16.5* Monos-1.7* Eos-0.3 Baso-0.6 [**2188-8-4**] 05:13AM BLOOD Neuts-81.3* Lymphs-16.0* Monos-2.1 Eos-0.4 Baso-0.2 [**2188-8-5**] 07:46AM BLOOD Neuts-78.0* Lymphs-18.1 Monos-3.1 Eos-0.7 Baso-0.2 [**2188-8-6**] 07:50AM BLOOD Neuts-79.7* Lymphs-16.8* Monos-2.6 Eos-0.6 Baso-0.3 [**2188-8-7**] 07:10AM BLOOD Neuts-73.3* Lymphs-23.0 Monos-3.0 Eos-0.5 Baso-0.2 [**2188-8-8**] 05:21AM BLOOD Neuts-63.5 Lymphs-32.4 Monos-2.8 Eos-0.9 Baso-0.4 [**2188-8-9**] 04:25AM BLOOD Neuts-59.6 Lymphs-34.9 Monos-3.1 Eos-1.7 Baso-0.7 [**2188-8-11**] 04:59AM BLOOD Neuts-63.3 Lymphs-31.6 Monos-2.0 Eos-2.9 Baso-0.2 [**2188-8-12**] 05:30AM BLOOD Neuts-62.0 Lymphs-34.1 Monos-1.6* Eos-2.2 Baso-0.3 [**2188-8-13**] 04:50AM BLOOD Neuts-59.2 Lymphs-35.2 Monos-2.7 Eos-2.6 Baso-0.4 [**2188-7-26**] 06:20AM BLOOD PT-49.3* PTT-32.7 INR(PT)-4.9* [**2188-7-26**] 12:52PM BLOOD PT-58.7* PTT-33.5 INR(PT)-5.9* [**2188-7-26**] 10:36PM BLOOD PT-42.3* PTT-33.7 INR(PT)-4.2* [**2188-7-27**] 04:40AM BLOOD PT-37.3* PTT-33.3 INR(PT)-3.6* [**2188-7-28**] 02:11AM BLOOD PT-66.6* PTT-39.7* INR(PT)-6.7* [**2188-7-28**] 09:00PM BLOOD PT-21.7* PTT-34.6 INR(PT)-2.1* [**2188-7-29**] 02:26AM BLOOD PT-18.4* PTT-31.0 INR(PT)-1.7* [**2188-7-30**] 05:05AM BLOOD PT-17.1* PTT-27.9 INR(PT)-1.6* [**2188-7-31**] 05:32AM BLOOD PT-14.6* PTT-28.0 INR(PT)-1.4* [**2188-8-1**] 05:52AM BLOOD PT-13.5* PTT-28.4 INR(PT)-1.3* [**2188-8-2**] 04:50AM BLOOD PT-12.5 PTT-28.2 INR(PT)-1.2* [**2188-8-3**] 06:34AM BLOOD PT-14.2* PTT-28.7 INR(PT)-1.3* [**2188-8-4**] 05:13AM BLOOD PT-14.5* PTT-30.7 INR(PT)-1.4* [**2188-8-5**] 07:46AM BLOOD PT-14.9* PTT-30.1 INR(PT)-1.4* [**2188-8-7**] 07:10AM BLOOD PT-14.5* PTT-30.2 INR(PT)-1.4* [**2188-8-8**] 05:21AM BLOOD PT-14.4* PTT-32.1 INR(PT)-1.3* [**2188-8-12**] 05:30AM BLOOD PT-13.6* PTT-30.8 INR(PT)-1.3* [**2188-8-13**] 04:50AM BLOOD PT-13.5* PTT-31.8 INR(PT)-1.3* [**2188-8-1**] 05:52AM BLOOD ESR-30* [**2188-8-10**] 05:30AM BLOOD Gran Ct-1480* [**2188-7-26**] 12:52PM BLOOD Fibrino-295 [**2188-7-29**] 02:26AM BLOOD Fibrino-301 [**2188-7-26**] 06:20AM BLOOD Glucose-90 UreaN-59* Creat-4.6*# Na-135 K-4.8 Cl-104 HCO3-13* AnGap-23* [**2188-7-26**] 12:52PM BLOOD Glucose-102* UreaN-64* Creat-4.8* Na-137 K-4.7 Cl-106 HCO3-15* AnGap-21* [**2188-7-26**] 06:30PM BLOOD Glucose-122* UreaN-69* Creat-4.7* Na-138 K-4.4 Cl-107 HCO3-16* AnGap-19 [**2188-7-26**] 10:36PM BLOOD Glucose-123* UreaN-68* Creat-4.7* Na-136 K-3.8 Cl-104 HCO3-19* AnGap-17 [**2188-7-27**] 04:40AM BLOOD Glucose-123* UreaN-68* Creat-4.7* Na-138 K-3.4 Cl-103 HCO3-21* AnGap-17 [**2188-7-27**] 02:37PM BLOOD Glucose-135* UreaN-69* Creat-4.4* Na-137 K-3.6 Cl-102 HCO3-23 AnGap-16 [**2188-7-28**] 02:11AM BLOOD Glucose-111* UreaN-65* Creat-4.1* Na-138 K-3.7 Cl-102 HCO3-21* AnGap-19 [**2188-7-28**] 09:00PM BLOOD Glucose-96 UreaN-62* Creat-3.6* Na-138 K-3.4 Cl-102 HCO3-24 AnGap-15 [**2188-7-29**] 02:26AM BLOOD Glucose-92 UreaN-59* Creat-3.4* Na-139 K-4.0 Cl-103 HCO3-24 AnGap-16 [**2188-7-30**] 05:05AM BLOOD Glucose-118* UreaN-58* Creat-2.8* Na-139 K-3.9 Cl-103 HCO3-25 AnGap-15 [**2188-7-31**] 05:32AM BLOOD Glucose-88 UreaN-46* Creat-2.3* Na-141 K-3.4 Cl-106 HCO3-24 AnGap-14 [**2188-8-1**] 05:52AM BLOOD Glucose-92 UreaN-35* Creat-1.6* Na-140 K-3.6 Cl-107 HCO3-25 AnGap-12 [**2188-8-2**] 04:50AM BLOOD Glucose-113* UreaN-28* Creat-1.3* Na-143 K-3.9 Cl-110* HCO3-26 AnGap-11 [**2188-8-3**] 06:34AM BLOOD Glucose-90 UreaN-22* Creat-1.3* Na-140 K-4.0 Cl-109* HCO3-25 AnGap-10 [**2188-8-4**] 05:13AM BLOOD Glucose-78 UreaN-20 Creat-1.2* Na-138 K-3.7 Cl-104 HCO3-27 AnGap-11 [**2188-8-5**] 07:46AM BLOOD Glucose-89 UreaN-19 Creat-1.1 Na-139 K-3.6 Cl-105 HCO3-28 AnGap-10 [**2188-8-6**] 07:50AM BLOOD Glucose-162* UreaN-18 Creat-1.1 Na-138 K-3.4 Cl-103 HCO3-26 AnGap-12 [**2188-8-7**] 07:10AM BLOOD Glucose-93 UreaN-15 Creat-1.0 Na-137 K-3.8 Cl-105 HCO3-26 AnGap-10 [**2188-8-8**] 05:21AM BLOOD UreaN-16 Creat-1.0 Na-139 K-3.8 Cl-106 HCO3-27 AnGap-10 [**2188-8-9**] 04:25AM BLOOD Glucose-91 Creat-1.0 Na-139 K-3.9 Cl-107 HCO3-27 AnGap-9 [**2188-8-10**] 05:30AM BLOOD Glucose-83 UreaN-15 Creat-1.0 Na-140 K-3.9 Cl-107 HCO3-27 AnGap-10 [**2188-8-12**] 05:30AM BLOOD Glucose-88 UreaN-15 Creat-1.0 Na-138 K-4.0 Cl-103 HCO3-27 AnGap-12 [**2188-8-13**] 04:50AM BLOOD Glucose-116* UreaN-18 Creat-1.0 Na-140 K-4.1 Cl-106 HCO3-26 AnGap-12 [**2188-7-26**] 06:20AM BLOOD ALT-45* AST-62* CK(CPK)-105 AlkPhos-206* TotBili-1.6* [**2188-7-26**] 12:52PM BLOOD CK(CPK)-115 [**2188-7-28**] 02:11AM BLOOD ALT-40 AST-39 AlkPhos-161* TotBili-2.3* [**2188-7-28**] 09:00PM BLOOD ALT-33 AST-24 LD(LDH)-250 AlkPhos-234* TotBili-3.8* [**2188-7-29**] 02:26AM BLOOD ALT-29 AST-22 LD(LDH)-226 AlkPhos-249* Amylase-19 TotBili-4.3* DirBili-3.5* IndBili-0.8 [**2188-7-30**] 05:05AM BLOOD ALT-20 AST-14 AlkPhos-221* TotBili-3.4* [**2188-7-31**] 05:32AM BLOOD ALT-13 AST-14 LD(LDH)-226 AlkPhos-169* TotBili-2.2* [**2188-8-1**] 05:52AM BLOOD ALT-14 AST-15 AlkPhos-149* TotBili-1.3 [**2188-8-2**] 04:50AM BLOOD ALT-12 AST-17 AlkPhos-129* TotBili-2.1* [**2188-8-3**] 06:34AM BLOOD ALT-11 AST-15 AlkPhos-110* TotBili-1.9* [**2188-8-4**] 05:13AM BLOOD ALT-9 AST-15 AlkPhos-96 TotBili-1.6* [**2188-8-5**] 07:46AM BLOOD ALT-9 AST-14 LD(LDH)-266* AlkPhos-90 TotBili-1.1 [**2188-8-6**] 07:50AM BLOOD ALT-9 AST-16 LD(LDH)-279* AlkPhos-89 TotBili-0.9 [**2188-8-7**] 07:10AM BLOOD ALT-7 AST-14 LD(LDH)-256* AlkPhos-79 TotBili-0.7 [**2188-8-8**] 05:21AM BLOOD ALT-7 AST-11 LD(LDH)-209 AlkPhos-72 TotBili-0.7 [**2188-8-9**] 04:25AM BLOOD ALT-7 AST-15 LD(LDH)-204 AlkPhos-68 TotBili-0.7 [**2188-8-10**] 05:30AM BLOOD ALT-7 AST-15 AlkPhos-71 TotBili-0.6 [**2188-8-12**] 05:30AM BLOOD ALT-7 AST-15 AlkPhos-70 TotBili-0.6 [**2188-8-13**] 04:50AM BLOOD ALT-8 AST-16 AlkPhos-78 TotBili-0.7 [**2188-7-26**] 12:52PM BLOOD D-Dimer-[**Numeric Identifier 92405**]* [**2188-8-9**] 04:25AM BLOOD Hapto-124 [**2188-7-26**] 12:52PM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE [**2188-8-1**] 05:52AM BLOOD CRP-50.2* [**2188-7-28**] 09:00PM BLOOD HIV Ab-NEGATIVE [**2188-7-28**] 10:07AM BLOOD Genta-1.2* [**2188-7-29**] 11:06AM BLOOD Genta-1.5* [**2188-7-29**] 01:00PM BLOOD Genta-5.4 [**2188-7-30**] 10:44AM BLOOD Genta-1.5* [**2188-7-31**] 05:31AM BLOOD Genta-0.8* [**2188-8-2**] 07:46AM BLOOD Genta-<0.3* [**2188-8-2**] 01:30PM BLOOD Genta-1.5* [**2188-8-3**] 07:37AM BLOOD Genta-1.4* [**2188-8-3**] 10:00AM BLOOD Genta-3.1* [**2188-8-5**] 07:45AM BLOOD Genta-1.7* [**2188-8-5**] 07:46AM BLOOD Genta-4.2* [**2188-8-5**] 07:46AM BLOOD Genta-4.1* [**2188-8-6**] 07:50AM BLOOD Genta-1.6* [**2188-8-9**] 08:00PM BLOOD Genta-0.4* [**2188-8-9**] 09:57PM BLOOD Genta-2.7* [**2188-8-12**] 05:33PM BLOOD Genta-0.3* [**2188-7-26**] 06:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2188-7-26**] 06:47AM URINE Blood-MOD Nitrite-NEG Protein-300 Glucose-TR Ketone-TR Bilirub-NEG Urobiln-2* pH-5.5 Leuks-LG [**2188-8-3**] 01:24PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [**2188-7-26**] 06:47AM URINE RBC-16* WBC->182* Bacteri-MANY Yeast-NONE Epi-0 Urine Culture: URINE CULTURE (Final [**2188-7-28**]): STAPH AUREUS COAG +. >100,000 ORGANISMS/ML.. OF TWO COLONIAL MORPHOLOGIES. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S NITROFURANTOIN-------- 32 S OXACILLIN------------- 0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S Outside Hospital Blood Cultures, re-grown in house: Time Taken Not Noted Log-In Date/Time: [**2188-8-8**] 10:12 am Isolate ISOLATE SENT FROM [**Hospital6 **] FOR RE-IDENTIFICATION AND SUSCEPTIBILITY TESTING. **FINAL REPORT [**2188-8-10**]** ISOLATE FOR MIC (Final [**2188-8-10**]): STAPH AUREUS COAG +. FINAL SENSITIVITIES. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN----------<=0.12 S OXACILLIN-------------<=0.25 S TRIMETHOPRIM/SULFA---- <=0.5 S All blood cultures while hospitalized from [**7-26**] to present are negative. [**2188-8-22**] 11:30 am JOINT FLUID RIGHT HIP JOINT . **FINAL REPORT [**2188-8-25**]** GRAM STAIN (Final [**2188-8-22**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2188-8-25**]): NO GROWTH. [**2188-8-22**] 11:30AM JOINT FLUID WBC-2900* RBC-1250* Polys-78* Lymphs-18 Monos-4 TEE [**7-26**]: No atrial septal defect is seen by 2D or color Doppler. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. No aortic valve abscess is seen. No aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. A mitral valve annuloplasty ring is present. No mass or vegetation is seen on the mitral valve. Trivial mitral regurgitation is seen. A bioprosthetic tricuspid valve is present. There is a small (0.7x0.3), linear, mobile echodensity attached to the septal tricuspid leaflet consistent with a vegetation. The body of the antero-lateral and septal leaflets of the bioprosthesis appear thickened (clips 122, 126) suggesting more extensive leaflet involvement by the infectious process. The mean transtricuspid mean gradient and peak velocity are slightly higher than expected for the type of valve. There are two pacer wires noted, one in the coronary sinus, and one in the right atrium. No mass or vegetation seen on the pacer wires. IMPRESSION: Small vegetation on the septal leaflet of the bioprosthetic tricuspid valve with thickening of the anterolateral and septal leaflets and slightly higher than expected transvalvular gradients. These findings are new compared with the prior study dated [**2188-3-5**] (images reviewed). CT Head [**7-26**]: IMPRESSION: Focal hypodensities in right parietal and left cerebellar hemispheres are new since [**2188-1-8**] exam, and may represent areas of infarction or infectious focus. Correlate with MRI Head without and with contrast if not CI. CT Chest and Abdomen [**8-5**]: IMPRESSION: 1. Interval development of small to moderate-sized intramuscular fluid collections involving both iliacus and psoas muscles, with the largest in the left iliacus with apparent connection to the underlying iliopsoas bursas. Suggestion of surrounding edema and hyperdense rim is concerning for underlying inflammation/infection. Differential considerations include abscess formation versus iliopsoas bursitis with developing infection. 2. Significant overall improvement of the intrapulmonary sequela of septic emboli with a few areas of [**Month/Year (2) **] nodularity and linear fibrosis. Previously seen peripheral nodules with intrinsic cavitation have mostly resolved. Moderate bilateral pleural effusions and basilar atelectasis persist. 3. Findings most consistent with subacute to chronic infarcts in the periphery of the spleen as detailed above. Vasculature is however grossly patent. TEE [**8-8**]: No masss/veg seen on pacer wires.The left atrium is normal in size. Overall left ventricular systolic function is normal (LVEF>55%). The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No masses or vegetations are seen on the aortic valve. No aortic regurgitation is seen. A mitral valve annuloplasty ring is present. There is a moderate to large sized vegetation on the mitral valve. Mild (1+) mitral regurgitation is seen. A bioprosthetic tricuspid valve is present. There is a large vegetation on the tricuspid valve. Moderate [2+] tricuspid regurgitation is seen. No vegetation/mass is seen on the pulmonic valve. IMPRESSION: Bioprosthetic tricuspid valve endocarditis. Mitral valve/annuloplasty ring endocarditis. Moderate tricuspid regurgitation. CT Chest and Abdomen [**8-11**]: IMPRESSION: 1. Near resolution of left psoas muscle fluid collection after drain placement. The drain could be removed if the output is less than 15 mL/day for a consecutive 48 hours. 2. Ill-defined fluid collections within the iliacus muscles have decreased in size from prior. 3. Significant volume overload marked by anasarca, gallbladder wall edema, mild ascites, bilateral moderate pleural effusions and intralobular septal thickening. 4. Unchanged intrapulmonary sequela of septic emboli with a few areas of [**Month/Year (2) **] nodularity and fibrosis. 5. Unchanged splenic infarctions without evidence of abscess formation. DISCHARGE LABS [**2188-8-25**] 05:21AM BLOOD WBC-3.5* RBC-2.94* Hgb-8.1* Hct-26.0* MCV-89 MCH-27.8 MCHC-31.3 RDW-22.6* Plt Ct-205 [**2188-8-19**] 04:58AM BLOOD PT-13.1* PTT-31.0 INR(PT)-1.2* [**2188-8-24**] 07:00AM BLOOD Glucose-83 UreaN-18 Creat-0.9 Na-144 K-4.0 Cl-109* HCO3-29 AnGap-10 [**2188-8-20**] 07:54AM BLOOD ALT-6 AST-17 AlkPhos-91 TotBili-0.6 [**2188-8-23**] 08:38PM BLOOD Calcium-9.0 Phos-3.6 Mg-1.9 Brief Hospital Course: 29-year-old woman, active IV drug user, s/p tricuspid valve replacement, mitral valve repair, MSSA endocarditis on [**1-24**] transferred from OSH to MICU for septic shock, continued drug abuse, altered mental status, ATN found with recurrent MSSA endocarditis. # Septic shock, bacteremia, and endocarditis: in the MICU, patient met SIRS criteria by HR and RR. She was placed on a norepinephrine drip in order to maintain adequate MAPs. The patient was initially treated with vancomycin and cefepime, but when OSH blood cultures grew out Staph aureus, susceptible to oxacillin, resistant to penicillin G., patient was switched to nafcillin and gentamicin, rifampin later added given has prostetic valve. TEE showed a vegetation on the bioprosthetic tricuspid valve, c/w endocarditis. The patient was extubated on [**7-27**] and was transferred to the medical floor after she had been hemodynamically stabilized. She remained stable on the floor, SBPs ranging from 90s to 110. We obtained blood cultures daily which were all negative. She had several issues with access including pulling PICC out, contaminating IJ, and PICC fragmenting inside right arm during repeat placement (not retrieved by surgery as unable to see on ultrasound). Imaging showed multiple septic emboli sequela, including bilateral psoas abscesses (see below). Due to the continuing burden of septic left sided emboli repeat TEE was performed after approximately 2 weeks of naf/gent/rif which showed interval progression of the tricuspid vegetation and a new large mitral vegetation. Due to the progression of her endocarditis in spite of appropriate antibiotic therapy, CT surgery was consulted who refused surgery due to her ongoing IV drug abuse issues (she was informed prior to her original surgery in [**Month (only) 404**] that if she used IV drugs again, that she would not be a surgical candidate at this institution). She was rejected for consultation at [**Hospital1 112**] and [**Hospital1 2025**] due to her ongoing IVDU. As her hospital course progressed she defervesced and her WBC count normalized and further cultures were negative of her blood; she complained of recurrent joint pain but CT scanning repeatedly showed no further abscess formation. A few days prior to discharge she developed a pruritic rash felt secondary to nafcillin so she was changed to cefazolin. She was discharged on cefazolin and rifampin to be continued until at least [**2188-9-9**], which is when her ID followup appointment is and they may be continued for longer; gentamicin was dc'ed prior to discharge per ID recommendations. She has an ID followup appointment after discharge at which it will be determined whether her course should be continued. She will be seen in infectious disease clinic on [**2188-9-9**] and will have TEE prior to the appointment as well to assess her vegetations. TEE is not yet scheduled, [**Hospital1 **] facility will be contact[**Name (NI) **] after scheduling. # Acute renal failure: the patient was given 8L fluid at OSH and only made 60ccs urine. There was concern for septic emboli causing ARF versus hypotension and prerenal etiology. Creatinine was initially 4.6, down from 5.2 at OSH. Renal was consulted who recommended continuing IVF and obtaining a renal u/s, which was unremarkable. Most likely etiology was septic shock --> pre-renal failure --> ATN. Her Cr continued to trend down and by discharge was normal. By this point, her Foley was out and she was making adequate urine. We trended her Cr daily and renally dosed all medications. # Pulmonary edema: patient became tachypneic on floor after being called out of MICU to 40s, CXR showed pulmonary edema. Ther was concern for ARDS vs. volume overload vs. valvular regurg in setting of endocarditis. Bedside TTE did not show any valvular abnormalities, EF was 55%. Cardiology was consulted who recommended diuresis, which was attemped until she became febrile and concern for repeat sepsis occured (see below). At time of discharge she was on room air without further diuresis needed. # Left Hip pain: as her course progressed she began spiking high temperatures (~7d into hospital course) with rigors and an elevated WBC count; she refused CT Torso for multiple days. Eventually when she allowed scanning bilateral psoas abscesses were discovered, left greater than right. Per ID's recommendation, IR placed a CT guided drain in the left iliopsoas abscess, which ultimately grew nothing but which resulted in normalization of her WBC count and defervescence. Repeat scan prior to drain removal showed near resolution of the left abscess and resolution of the right abscess. # right hip pain: etiology unclear, joint was tapped without growth of any organisms but does have evidence of osteoarthritis on CT scan. Patient was maintained on a regimen of dilaudid which was slowly downtitrated given her history of drug abuse. She will be discharged on PO dilaudid 2-4 mg Q6H PRN and should be downtitrated as tolerated. She should not be discharged with narcotics given history of drug abuse after rehab completed. If continues to have hip pain in [**1-14**] weeks, would consider re-evaluation and possibly further imaging. # Altered mental status with features of Wernickie's aphasia: on arrival to the MICU, patient was confused and incoherent. Of note, urine tox positive for cocaine and opiates, serum tox negative. There was a concern about resurfacing of prior neurological defecits from previous embolic stroke vs. new stroke. As per mother, patient did not have aphasia after her prior embolic stroke. CT scan showed new hypodensities in L cerebellum and R parietal lobe that were suspicious for ischemia, perhaps from septic emboli. MRI could not be performed due to the patient's pacemaker. Given her INR near 5 and her thrombocytopenia, she was given platelets and FFP to prevent hemorrhagic conversion. Haldol 1mg PRN was given for agitation. Her mental status was improved on [**7-27**] and [**7-28**] and on the medical floor, was A+O x 3, speaking coherently and fluently though she showed concerning behavior such as pulling out PICC line, defecating in cereal bowl. Ultimately this was attributed to delerium which resolved over the hospital course. # Pacemaker s/p 3rd degree block: pocket did not appear to be tender, Echo did not show any lead infection, but patient had several episodes of no V-pacing seen on tele and what appeared to be asystole. EP was consulted and this was thought was [**2-14**] intermittent capture likely caused by high capture thresholds of V lead, related to patient's position. They increased the voltage ventricular pace output to maximum and she had no further episodes. She will need follow-up with her electrophysiologist ([**First Name9 (NamePattern2) **] [**Last Name (un) **]) 2 weeks after discharge from rehab. # Thrombocytopenia: platelets were within normal range at 235,000 on [**2-24**]. Thrombocytopenia likely from marrow suppression secondary to septic shock. DIC was ruled out in MICU given normal PTT, normal fibrinogen (although INR was elevated). We obtained daily CBCs. Platelets continued to rise and on discharge, were normal. # Anion Gap: patient presented with elevated anion gap of 18. VBG with pH 7.23. Serum osms of 303 and calculated osms of 296 making other ingestion unlikely. Her anion gap was though likely secondary to renal failure as described above. Her anion gap closed as she was repleted with fluids. # Pulmonary emboli: Has history of septic emboli but also presented in [**2188-2-13**] with a large pulmonary emboli burden and discharged on warfarin. It is unclear from the CT chest with contrast whether this was septic emboli vs clot, warfarin was started empirically. As she was supratherapeutic, warfarin was held. Her INR trended to normal range during admission. [**Year (4 digits) 197**] continued to be held throughout the admission with a normal INR due to completion of 6 month course after first PE and concern for septic emboli given her history. It was held on discharge as well but could consider restarting after followup TEE if vegetation is decreasing in size and there are no signs of embolic disease. Heparin TID was continued throughout for DVT ppx. # IVDUA: patient continues to use cocaine and heroin. Social work followed her throughout her admission. Will require extensive services for substance abuse post discharge from rehab. Transitional Issues: - requires appointment to be set up with Dr [**Last Name (STitle) **] [**Name (STitle) **] of EP at ([**Telephone/Fax (1) 20575**] for 2 weeks post discharge - can restart lopressor during her rehab stay if she becomes hypertensive, otherwise would continue to hold until her outpatient cardiologist evaluates in [**Month (only) 216**]. - needs referral to substance abuse counselors after discharge - iron studies to work up anemia pending on discharge - antibiotics course for endocarditis to continue until at least [**2188-9-9**], course to be determined by infectious disease team - TEE will be scheduled prior to ID appointment and [**Hospital1 **] facility will be contact[**Name (NI) **] with the date and time when scheduled Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Warfarin 5 mg PO DAILY16 2. Metoprolol Tartrate 50 mg PO BID 3. Clonazepam 0.5 mg PO QHS 4. Quetiapine Fumarate 50 mg PO QHS Discharge Medications: 1. Acetaminophen 650 mg PO Q6H:PRN fever 2. Benzonatate 100 mg PO TID 3. CefazoLIN 2 g IV Q8H 4. Docusate Sodium 100 mg PO BID Hold if pt has BM 5. Heparin 5000 UNIT SC TID 6. 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. 7. Ibuprofen 400 mg PO Q8H:PRN pain 8. Multivitamins 1 TAB PO DAILY 9. Polyethylene Glycol 17 g PO DAILY constipation 10. Rifampin 300 mg PO Q8H 11. Senna 1 TAB PO BID:PRN constipation 12. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain 13. traZODONE 50 mg PO HS:PRN insomnia 14. HYDROmorphone (Dilaudid) 2-4 mg PO Q6H:PRN pain hold for sedation, RR<10 RX *Dilaudid 2 mg [**2-16**] tablet(s) by mouth every six (6) hours Disp #*30 Tablet Refills:*0 Discharge Disposition: Extended Care Facility: [**Hospital6 2222**] - [**Location (un) 538**] Discharge Diagnosis: Endocarditis Septic shock Acute renal failure Left iliopsoas abscesses s/p drainage Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 50463**], It was a pleasure taking care of you during your recent admission at [**Hospital1 18**]. You were transferred here from [**Hospital3 12748**] for treatment of your endocarditis leading to septic shock. You were stabilized in the MICU for several days prior to transfer to the floor. We treated your endocarditis with several antibiotics (gentamicin, nafcillin, rifampin) and obtained daily blood cultures. Your antibiotics were changed to cefazolin and rifampin on discharge since you may have had an allergic reaction to rifampin. You will be receiving these antibiotics until at least [**2188-9-19**], which is when you have your infectious disease appointment. You had pain in your hips which was due to an abscess in the muscles of your legs which we drained. Social work saw you to discuss strategies for stopping intravenous drug use. Do not ever use injection drugs again. Changes to your medications: START taking cefazolin 2 gm IV every 8 hours for your endocarditis START taking rifampin 300 mg by mouth every 8 hours for your endocarditis START taking dilaudid 2-4 mg by mouth every six hours as needed for pain START taking ibuprofen 400 mg every 8 hours as needed for pain START taking acetaminophen as needed for pain START taking benzonatate three times a day for cough START taking colace twice a day for constipation START taking heparin 5000 units subcutaneously three times a day to prevent blood clots START taking multivitamins daily START taking miralax daily for constipation START taking senna as needed for constipation START taking tramadol as needed for pain START taking trazodone as needed for insomnia STOP taking warfarin Followup Instructions: Department: CARDIAC SERVICES When: TUESDAY [**2188-9-2**] at 2:30 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2003**], NP [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: INFECTIOUS DISEASE When: FRIDAY [**2188-9-19**] at 10:30 AM With: [**Name6 (MD) 27568**] [**Name8 (MD) 27569**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Completed by:[**2188-8-27**] Name: [**Known lastname 14526**],[**Known firstname 634**] S Unit No: [**Numeric Identifier 14527**] Admission Date: [**2188-7-26**] Discharge Date: [**2188-8-25**] Date of Birth: [**2158-8-4**] Sex: F Service: MEDICINE Allergies: Nafcillin Attending:[**First Name3 (LF) 4665**] Addendum: PE addendum: MSK: Right hip has about 30-40% limit in ROM in both internal and external rotation as compared to left with some reproduction of pain, no warmth, erythema or crepitus on palpation of right hip joint, left hip joint is wnl, full rom and no warmth or erythema Discharge Disposition: Extended Care Facility: [**Hospital6 4356**] - [**Location (un) 164**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4666**] MD [**MD Number(2) 4667**] Completed by:[**2188-9-4**]

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icd9cm

[ [ [] ] ]

[ "38.93", "96.04", "96.71", "38.97", "38.91", "88.72", "54.91", "89.45" ]

icd9pcs

[ [ [] ] ]

37052, 37281

23364, 31836

291, 460

33873, 33873

5984, 23341

35749, 37029

4583, 4601

32870, 33649

33766, 33852

32619, 32846

34024, 34951

4616, 5645

5661, 5965

31857, 32593

34980, 35726

230, 253

488, 3733

33888, 34000

3755, 4302

4318, 4567

17,428

141,680

30401

Discharge summary

report

Admission Date: [**2146-2-2**] Discharge Date: [**2146-2-5**] Date of Birth: [**2069-9-1**] Sex: F Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 8850**] Chief Complaint: Hypotension. Major Surgical or Invasive Procedure: None. History of Present Illness: Mrs. [**Known lastname **] is a 76-year-old right-handed woman with a history of metastatic melanoma (metastases to brain, stomach, subcutaneous tissues, and lung) who was originally admitted to the [**Hospital Unit Name 153**] with urosepsis and is now being transferred to the OMED service for further managment. The patient was recently discharged from [**Hospital1 18**] on [**2146-1-27**] after an admission for seizures secondary to brain metastases. She was readmitted on [**2146-2-2**] for hypotension in the setting of UTI. She had been feeling a bit weak since discharge; went for her first episode of XRT [**2146-2-3**], then was noted to have a SBP in the 60's. ROS on admission: + loose stool x3, fatigue. Negative: F/C/NS, cough, N/V, abd pain, CP/SOB, LE edema, focal wakness/numbness/ paresthesias. In the ED, her vital signs were T 95.9, BP 92/54, HR 83. She was given 2L NS boluses, with improvement in BP to 115/50. She was also given Decadron 10 mg IV, ASA 325mg, and levofloxacin 500 mg IV. She was felt to need ICU care for overnight observation due to the hypotension. In the [**Hospital Unit Name 153**] the patient was treated with ciprofloxacin and IVF. Her ARF resolved with the administration of IVF. Stress dose steroids were discontinued and the patient was restarted on her home steroid regimen. Cardiac enzymes were checked given ST depressions on EKG (negative). She received XRT as scheduled on [**2146-2-3**]. After one night she remained normotensive and was called out to OMED. Past Medical History: 1. Mild hypertension. 2. Benign mitral regurgitation murmur with negative echocardiographic findings. 3. Osteoporosis. 4. Chronic benign hematuria that had been previously extensively investigated with negative findings. 5. Status post uncomplicated appendectomy [**2091**]. 6. Status post subtotal thyroidectomy in [**2103**] for benign nontoxic adenoma. 7. Status post fracture of her right ankle for which she underwent a surgical metal plate placed in [**2122**]. 8. metastatic melanoma; presented with episodes of slurred speech. Social History: She lives with her daughter in [**Name (NI) 27256**], MA. Her children are quite supportive, and they take turn to drive her to [**Hospital1 18**] for radiation. She never smoked and denies any alcohol use. She was a very active woman doing daily walks, swims, etc. Family History: There is pneumonia and hypertension in her family. One of her sisters died of melanoma. Her mother is healthy at age [**Age over 90 **]. Physical Exam: VITAL SIGNS: TEMPERATURE 96.5 F (Tmax 97.0 F and Tmin 95.9 F), blood pressure 119/51 (96-139/50-70), pulse 67 (60-99), respiratory rate 18, oxygen saturation 98% in room air. Her I/O: +3.5 L for LOS. GENERAL: Pleasant elderly female, NAD. HEENT: Minimal white patch in posterior OP, MMM. LUNGS: Chest clear to auscultation bilaterally. CARDIOVASCULAR: Regular w/ frequent ectopic beats. NL S1S2. No murmurs. ABDOMEN: Soft, NT, ND. Normoactive BS. No HSM. EXTREMITIES: No edema, with 2+ dorsalis pedis pulses bilaterally. NEUROLOGICAL EXAMINATION: Her Karnofsky Performance Score is 60. She is awake, alert, and oriented to person and place. There is no right-left confusion or finger agnosia. Calculation is intact. Her language is fluent with good comprehension, naming, and repetition. Her recent recall is fair. Cranial Nerve Examination: Her pupils are equal and reactive to light, 4 mm to 2 mm bilaterally. Extraocular movements are full. Visual fields are full to confrontation. Funduscopic examination reveals sharp disks margins bilaterally. Her face is symmetric. Facial sensation is intact bilaterally. Her hearing is intact bilaterally. Her tongue is midline. She has minimal slurring of her speech. Palate goes up in the midline. Sternocleidomastoids and upper trapezius are strong. Motor Examination: She does not have a drift. Her muscle strengths are [**3-26**] at all muscle groups. Her muscle tone is normal. Her reflexes are 2- and symmetric bilaterally. Her ankle jerks are absent. Her toes are down going. Sensory examination is intact to touch and proprioception. Coordination examination does not reveal appendicular or truncal ataxia. Pertinent Results: Initial labs: [**2146-2-2**] 04:30PM LACTATE-2.2* [**2146-2-2**] 04:15PM GLUCOSE-121* UREA N-71* CREAT-1.4* SODIUM-134 POTASSIUM-3.4 CHLORIDE-99 TOTAL CO2-23 ANION GAP-15 [**2146-2-2**] 02:32PM PT-11.5 PTT-22.1 INR(PT)-1.0 [**2146-2-2**] 02:32PM NEUTS-91.3* BANDS-0 LYMPHS-5.5* MONOS-2.4 EOS-0.2 BASOS-0.6 [**2146-2-2**] 02:32PM WBC-15.4* RBC-5.02 HGB-15.0 HCT-44.3 MCV-88 MCH-30.0 MCHC-34.0 RDW-13.3 [**2146-2-2**] 03:10PM URINE RBC-[**1-24**]* WBC-21-50* BACTERIA-MANY YEAST-NONE EPI-0-2 [**2146-2-2**] 03:10PM URINE BLOOD-TR NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-SM [**2146-2-2**] 04:15PM CALCIUM-7.9* PHOSPHATE-3.7 MAGNESIUM-2.7* [**2146-2-2**] 04:15PM cTropnT-<0.01 [**2146-2-2**] 04:15PM CK(CPK)-22* [**2146-2-2**] 10:59PM CK-MB-3 cTropnT-<0.01 [**2146-2-2**] 10:59PM CK(CPK)-38 Discharge labs: [**2146-2-5**] 07:55AM BLOOD WBC-6.1 RBC-3.72* Hgb-11.0* Hct-33.0* MCV-89 MCH-29.5 MCHC-33.3 RDW-12.8 Plt Ct-129* [**2146-2-5**] 07:55AM BLOOD Plt Ct-129* [**2146-2-5**] 07:55AM BLOOD Glucose-88 UreaN-27* Creat-0.7 Na-134 K-4.1 Cl-104 HCO3-23 AnGap-11 [**2146-2-3**] 05:56AM BLOOD CK-MB-4 cTropnT-<0.01 [**2146-2-5**] 07:55AM BLOOD Calcium-8.0* Phos-2.0* Mg-2.0 Imaging: CXR:Multiple lung nodules consistent with metastatic disease. Emphysema. Micro: UCx: URINE CULTURE (Final [**2146-2-4**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Trimethoprim/Sulfa sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ 4 S CIPROFLOXACIN--------- 1 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R 2 sets of blood cx NGTD Brief Hospital Course: A/P: This is a 76-year-old right-handed woman with past medical history significant for metastatic melanoma admitted for hypotension in setting of UTI and taking twice dose of HCTZ. (1) UROSEPSIS: Patient initially went to ICU because of hypotension. Blood pressure responded well to fluids and patient was called out of the ICU the next day. In addition, she was found to have E. Coli UTI which was sensitive to ciprofloxacin. Blood cultures are negative thus far. She was discharged on 14 day course of ciprofloxacin. She was afebrile and is hemodynamically stable on discharge. Patient's blood pressure medications were held. (2) ARF: Likely pre-renal in the setting of inadequate hydration in the setting of UTI. Resolved with IVFs. (3) HTN: Her blood pressure medications were held given hypotension and will hold on discharge as well given that patient is not eating and drinking as well and may be prone to dehydration. Will have VNA check BP and if elevated at home, should call Dr. [**Last Name (STitle) 724**] to restart. (4) METASTATIC MELANOMA: No chemotherapy at present. Tentative plan to enrolling her in the E2603 clinical trial with carboplatin, paclitaxel with and without sorafenib, following XRT of her brain mets. She will have 2 more sessions of XRT next week. (5) HISTORY OF SEIZURES: No episodes since last admission. We continued Keppra and dexamethasone. Dexamethasone should be tapered by radiation oncology. (6) ST DEPRESSIONS: patient had st depressions in setting of hypotension likely related to demand ischemia. Patient ruled out with 3 sets of negative enzymes. She was started on aspirin and this was continued on discharge. Medications on Admission: 1. Olmesartan 20 mg daily 2. Hydrochlorothiazide 12.5 mg PO DAILY 3. Prilosec OTC 20 mg PO once a day. 4. Benadryl 25 mg PO HS PRN 5. Levetiracetam 500 mg PO BID 6. Dexamethasone 4 mg PO Q12H Discharge Medications: 1. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*0* 2. Senna 8.6 mg Capsule Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*0* 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. Nystatin 100,000 unit/mL Suspension Sig: Ten (10) ML PO QID (4 times a day) as needed for thrush. Disp:*qs qs* Refills:*2* 5. Levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 11 days. Disp:*22 Tablet(s)* Refills:*0* 7. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*0* 8. Prilosec OTC 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 9. Benadryl 25 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: Caregroup VNA Discharge Diagnosis: UTI Hypotension Melanoma Discharge Condition: She was discharged with stable hemodynamics and without fever. Discharge Instructions: You were admitted with a urinary tract infection and low blood pressure. You were given antibiotics and IV fluids and did very well. Please take all medications as directed. You should not take any of your blood pressure medication on discharge. Please follow-up with all outpatient appointments. Please return to the ED or call your doctor if you experience any fever> 100.5, chest pain, difficulty breathing, abdominal pain, vomiting or any other concerning symptoms. Followup Instructions: You have the following appointments. Provider: [**Name10 (NameIs) 706**] MRI Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2146-2-28**] 10:00 Provider: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) 4861**], MD Phone:[**Telephone/Fax (1) 1844**] Date/Time:[**2146-2-28**] 11:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2146-2-28**] 1:30 You also have 2 more sessions of radiation on Monday [**2-7**] and Tuesday [**2-8**] at 7:30 am.

[ "197.0", "424.0", "276.1", "599.0", "041.4", "584.9", "780.39", "401.9", "198.3", "172.9", "197.8" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9993, 10037

6909, 8576

326, 333

10105, 10169

4596, 5453

10690, 11240

2739, 2879

8818, 9970

10058, 10084

8602, 8795

10193, 10667

5469, 6886

2894, 4577

274, 288

361, 1041

1055, 1881

1903, 2440

2456, 2723

7,181

170,381

47126

Discharge summary

report

Admission Date: [**2181-10-29**] Discharge Date: [**2181-11-10**] Date of Birth: [**2127-7-14**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2186**] Chief Complaint: Myalgias Major Surgical or Invasive Procedure: Tunneled hemodialysis catheter placement under radiographic guidance History of Present Illness: Pt is a 54 yo man with h/o polysubstance abuse (heroin, crack cocaine), initially presented to [**Hospital Unit Name 153**] on [**10-29**] after heroin/cocaine binge x days (used intranasally, denies current IVDU). By report, he wasn't feeling well, had myalgias, progressive difficulty walking with falls, and called out for help. Neighbor called 911 and pt brought to our ED. Upon arrival, he was hyperkalemic to 8.4 w/ EKG changes, Cr 9.8, CK >150K. He was given 4 amps of bicarb, calcium, and was emergently dialysed in the ED. CT of chest showed ? PNA so he was treated with levoflox and vanco. CT C-spine showed osseous fragment vs DJD but he refused collar. Past Medical History: 1. Depression 2. Polysubstance abuse 3. Anxiety 4. BPH 5. CRI (unknown baseline cr) Social History: Lives alone in apartment, has been homeless in past, contracts as an architect but currently not working, divorced, 1 child. Past IVDA, current intranasal heroin and crack cocaine (recently started after abstaining). Has heavy EtOH in past but denies any recently. Current smoker. Family History: non-contrib Physical Exam: 150/103 81 18 97% Ra GEN: comfortable, sleeping, easily arousable, A&O x 3 NAD HEENT: anicteric, MM dry, OP clear NECK: no tenderness, suppple SKIN: multiple abrasions over various parts of body, non tender, no rashes CV: RRR no m/r/g PULM: CTAB ABD: soft, mild RUQ tenderness; liver edge 3cm below costal margin, no splenomegaly, NABS EXT: no edema or track marks. Diffuse multiple stages of ecchymoses scattered along LE and forearms. Quinton catheter in place. NEURO: oriented x 3. limited exam as patient wished to sleep tonight. Pertinent Results: [**2181-10-29**] 11:00AM CREAT-9.8* POTASSIUM-8.4* [**2181-10-29**] 11:00AM CK(CPK)-[**Numeric Identifier 99887**]* [**2181-11-7**] 10:30AM CK(CPK)-581* . CT HEAD W/O CONTRAST ([**2181-10-29**]): No evidence of acute traumatic injury. . CT C-SPINE W/O CONTRAST ([**2181-10-29**]): 1. Small osseous fragment adjacent to the anteroinferior aspect of C6, which may represent either limbus vertebra, or an unusual appearance of a fracture fragment. 2. Mild degenerative changes. . CT CHEST, ABDOMEN, AND PELVIS W/O CONTRAST ([**2181-10-29**]): 1. Study limited by lack of IV contrast. 2. No evidence of any acute intra-abdominal injury. 3. Diffuse patchy ground-glass opacities seen in the lungs bilaterally, many more central in location. These could possibly represent inflammation, infection, or possibly edema. Clinical correlation suggested. . ABDOMEN U.S. ([**2181-10-30**]): No evidence of hepatic vein or portal vein thrombosis. Brief Hospital Course: 1) ARF: Oliguric renal failure likely secondary to rhabdomyolysis. He was emergently dialyzed in the ED, then admitted to the [**Hospital Unit Name 153**] where he received hemodialysis 3 days in a row. Pt was also noted to be hypocalcemic, requiring frequent supplementation and even a calcium drip while in the ICU. Pt's electrolytes eventually stabilized on HD three times a week, but without improvement in oliguria. He had a tunneled HD catheter placed by IR on [**11-2**]. He received HD on the day of discharge ([**11-10**]), with plan for outpatient HD on Tu, Th, Sa, to begin on Tuesday, [**11-13**]. . 2) Rhabdomyolysis: Pt presented with CK > 150k at admission in acute renal failure. He received dialysis as detailed above with normalization of his CK to <1K at the time of discharge. . 3) Transaminitis: Pt was noted to have elevated LFTs with AST peaking at 1601, and ALT at 473. He had a negative liver and abdominal ultrasound as detailed above, and hepatitis serologies were positive for HAV, HBV, and HCV (though HBV SAb SAg were negative, so likely in window period for HBV). LFTs were monitored during hospitalization and were noted to improve. Consent for an HIV test was attempted but refused by the patient. He stated that he last had a negative test 2 [**12-3**] yrs ago. He also noted having had hepatitis for a "long time". . 4) Substance abuse/Delirium: Pt had waxing and [**Doctor Last Name 688**] mental status initially during hospitalization. He had episodes of agitation w/ visual hallucinations. The delirium was thought likely from a combination of ARF, uremia, and cocaine/heroin withdrawal. His tox screen on admission was negative for EtOH, and he denied recent EtOH use. He was seen by addictions consult. Ativan was used PRN for agitation, but thought to have caused worsened mental status. Psychiatry consult, who had also been following the patient, recommended haldol for repeat agitation to which he responded well. He was also continued on reduced doses of Lamictal and Effexor. Multiple unsuccessful attempts were made to obtain records from [**Hospital1 2177**]. . 5) Ground glass opacities: Seen on CT chest as described above, thought likely to represent either "crack" lung and/or pulmonary edema. Pt was emperically started on levoflox and vancomycin in ED for PNA. However, abx were discontinued as infectious etiology was thought unlikely. Pt remained without respiratory complaints throughout hospitalization. Follow-up chest X-rays on [**10-31**] and [**11-1**] were read as normal. . 7) Cervical injury: CT showed possible C-spine injury. However, pt had no evidence of injury on exam and refused to wear cervical collar despite recommendations. He continued to have full range of motion and no spinal/paraspinal tendnerness. . CODE: FULL Discharge Medications: 1. Venlafaxine 75 mg Capsule, Sust. Release 24HR Sig: Two (2) Capsule, Sust. Release 24HR PO DAILY (Daily). Disp:*60 Capsule, Sust. Release 24HR(s)* Refills:*2* 2. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Lamotrigine 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 8. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Rhabdomyolysis Acute renal failure Hyperkalemia Discharge Condition: Stable Discharge Instructions: 1) Please take all your medications as directed. 2) Continue with dialysis, starting Tuesday, [**2181-11-13**] 3) Call if you have chest pain, shortness of breath, heart palpitations, lightheadedness, or any other concerns. Followup Instructions: Call [**Telephone/Fax (1) 250**] to establish a primary doctor [**First Name (Titles) **] [**Last Name (Titles) **] at [**Hospital1 18**] Completed by:[**2181-11-13**]

[ "600.00", "584.9", "276.7", "275.41", "305.60", "305.50", "585.6", "728.88", "070.54" ]

icd9cm

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39412

Discharge summary

report

Admission Date: [**2161-11-22**] Discharge Date: [**2161-11-24**] Date of Birth: [**2131-5-26**] Sex: M Service: SURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3223**] Chief Complaint: fevers Major Surgical or Invasive Procedure: Exploratory laparotomy with parital gastrectomy and placment of J tube [**2161-11-12**] History of Present Illness: HPI: Asked to see this 30 year old male known to ACS, who underwent ex-lap, partial gastrectomy and J tube placement on [**2161-11-12**] due to peritonitis from a dislodged G tube. He was discharged to rehab on [**2161-11-19**] and now returns with fevers to 102 F. Here in the ED he is [**Age over 90 **].4 F. Patient conversant, however not sure why he is here. He is unable to report any problems. During his last hospital stay, Mr. [**Known lastname 15499**] was reintubated once for aspiration and treated with a short course of antibiotics until he was afebrile Past Medical History: PMH: anoxic brain injury, SDH [**2161-8-29**], DVT, IVDA, MRSA in nares, respiratory failure, scabies PSH: Tracheostomy, PEG Social History: IVDA and tobacco use Family History: unknown Physical Exam: PHYSICAL EXAMINATION: upon admission [**2161-11-21**] Temp:95.7 HR:98 BP:144/82 O(2)Sat:99 normal Constitutional: Comfortable HEENT: Normocephalic, atraumatic Oropharynx within normal limits Chest: Clear to auscultation Cardiovascular: Regular Rate and Rhythm Abdominal: Soft, ? diffusely tender. no rebound, no gaurding. GU/Flank: No costovertebral angle tenderness Extr/Back: No cyanosis, clubbing or edema Skin: No rash Neuro: Speech fluent, Confused/baseline MAE Pertinent Results: [**2161-11-21**] 05:15PM URINE RBC-[**12-12**]* WBC-0 BACTERIA-FEW YEAST-NONE EPI-0-2 [**2161-11-21**] 05:15PM URINE BLOOD-LG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2161-11-21**] 05:50PM PT-50.6* PTT-43.2* INR(PT)-5.5* [**2161-11-21**] 05:50PM PLT COUNT-470* [**2161-11-21**] 05:50PM NEUTS-55.9 LYMPHS-34.8 MONOS-6.2 EOS-2.2 BASOS-0.8 [**2161-11-21**] 05:50PM WBC-8.0 RBC-3.05* HGB-8.7* HCT-26.3* MCV-86 MCH-28.6 MCHC-33.2 RDW-16.1* [**2161-11-21**] 05:50PM ALBUMIN-2.7* CALCIUM-8.5 PHOSPHATE-4.4 MAGNESIUM-1.7 [**2161-11-21**] 05:50PM LIPASE-20 [**2161-11-21**] 05:50PM ALT(SGPT)-14 AST(SGOT)-16 ALK PHOS-104 TOT BILI-0.4 [**2161-11-21**] 05:50PM GLUCOSE-100 UREA N-11 CREAT-0.5 SODIUM-133 POTASSIUM-4.6 CHLORIDE-97 TOTAL CO2-27 ANION GAP-14 [**2161-11-21**] 07:15PM LACTATE-0.6 [**2161-11-21**] 11:25PM FIBRINOGE-458* [**2161-11-22**] 04:51AM WBC-7.6 RBC-2.94* HGB-8.7* HCT-25.1* MCV-85 MCH-29.6 MCHC-34.6 RDW-15.9* [**2161-11-22**] 04:51AM CALCIUM-8.1* PHOSPHATE-3.3 MAGNESIUM-1.5* [**2161-11-22**] 04:51AM GLUCOSE-93 UREA N-11 CREAT-0.5 SODIUM-134 POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-24 ANION GAP-14 [**2161-11-22**] 04:51AM BLOOD WBC-7.6 RBC-2.94* Hgb-8.7* Hct-25.1* MCV-85 MCH-29.6 MCHC-34.6 RDW-15.9* Plt Ct-502* [**2161-11-23**] 02:16AM BLOOD WBC-4.8 RBC-2.74* Hgb-8.0* Hct-23.2* MCV-85 MCH-29.1 MCHC-34.4 RDW-16.0* Plt Ct-476* [**2161-11-23**] 02:16AM BLOOD Plt Ct-476* [**2161-11-23**] 02:47AM BLOOD PT-37.1* INR(PT)-3.8* [**2161-11-23**] 02:16AM BLOOD Glucose-90 UreaN-5* Creat-0.5 Na-134 K-3.2* Cl-99 HCO3-29 AnGap-9 [**2161-11-23**] 02:16AM BLOOD Calcium-8.5 Phos-4.6* Mg-1.9 [**2161-11-22**] 04:51AM BLOOD Calcium-8.1* Phos-3.3 Mg-1.5* [**2161-11-21**]: x-ray of abdomen: IMPRESSION: Contrast injected through J-tube courses into loop of small bowel most consistent with jejunum, with no evidence of extraluminal contrast [**2161-11-22**]: Chest x-ray: IMPRESSION: 1. NG tube with side port within the stomach. 2. Improved right pulmonary aeration. Persistent left lower lobe atelectasis with moderate pleural effusion [**2161-11-22**]: cat scan of abdomen and pelvis: IMPRESSION: 1. Left moderate pleural effusion is increased since prior. Adjacent opacification may be compressive atelectasis or consolidation in the correct clinical setting. 2. Intermediate density fluid surrounding spleen and along the anterior aspect of the left lobe of the liver appears more loculated compared to prior. Fluid along the liver causes some indentation of the left lobe of the liver. Fluid within the pelvis also appears more loculated compared to prior with mild wall enchancement noted, infection can't completely be excluded. 3. Small fluid collection within the subcutaneous tissue anteriorly in the midline (2, 69) is new and likely represents post operative changes; correlate clinically. 4. Sutures noted within a loop of the jejunum appears focally dilated but is unchanged from prior. 5. Foley catheter with balloon noted within the urethra, requires repositioning Brief Hospital Course: 30 year old gentleman who was admitted to the Acute Care Service on [**2161-11-21**] with fever and abdominal pain. Upon admission to the Intensive Care Unit, he was made NPO, given intravenous fluids and had an x-ray of his abdomen done to verify placement of his J tube. Once place verified, he had a cat scan of his abdomen and pelvis done which showed loculated fluid collections around the spleen, liver, and in the abdomen for which he is on a 10 day course of augmentin. He had blood, urine, and sputum cultures sent. He completed a 10 day course of meropenum on [**11-24**] which he was started for Acinetobacter in his sputum which was idenfified on a prior admission. He has since resumed his tube feedings via the J tube. He continues to have the left pleural effusion as reported on his cat scan of the chest. He is preparing for discharge back to his rehabilitation facility. He is tolerating his tube feedings via the J tube. His foley has been discontinued and he has a condom catheter in place. He has been afebrile with stable vital signs. His abominal staples have been removed and replaced with steri-strips. He has an abominal binder on to prevent him from removing his J tube. He is still mildy anemic and will need to have his complete blood count monitored as well as coagulation studies. His coumadin had been discontinued on [**11-19**] for elevated INR. He did not have it resumed. He did have repeat complete blood count and INR sent prior to his discharge and will need to have INR monitored prior to resuming his coumadin. He will follow up with the Acute Care Service in 2 weeks. Medications on Admission: [**Last Name (un) 1724**]: lansoprazole 30', neurontin 300", lisinopril 10', tylenol prn, quetiapine 50', divalproex 250", clonazepam 0.5 0.5-1 [**Hospital1 **], haldol 5"' prn, methadone 10"" Discharge Medications: 1. gabapentin 300 mg Capsule [**Hospital1 **]: One (1) Capsule PO TID (3 times a day): via J tube. 2. lisinopril 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily): via J tube. 3. quetiapine 25 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily): via J tube. 4. clonazepam 0.5 mg Tablet [**Hospital1 **]: 1-2 Tablets PO BID (2 times a day): via J tube. 5. valproic acid (as sodium salt) 250 mg/5 mL Syrup [**Hospital1 **]: Five (5) cc PO Q12H (every 12 hours): via J tube. 6. methadone 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO [**Hospital1 **] (4 times a day): via J tube. 7. Lorazepam 2-4 mg IV Q4H:PRN anxiety 8. lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily): via J tube. 9. amoxcillin-clavulate [**Last Name (STitle) **]: Five Hundred (500) mg PO three times a day: complete course on [**2161-12-2**]...suspension via J tube. Discharge Disposition: Extended Care Facility: [**Hospital 5503**] [**Hospital **] Hospital - [**Location (un) 5503**] Discharge Diagnosis: fever Discharge Condition: Mental Status: Oriented to name, place, but occasionally disoriented to time and place Level of Consciousness: Alert, answers questions Activity Status: Ambulatory - needs assistance, contracture left arm Discharge Instructions: You are being discharged from the hospital after you were admitted with fevers and abdominal pain. You are now being discharged to a rehabilitation facility with the following instructions: *Please look at the J tube site daily for signs of infection, increaseed redness or pain *Keep the insertion site clean and dry otherwise. *Make sure to keep the drain attached securely to your body Please return to the emergency room if you experience: *chest pain * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery Followup Instructions: Please follow up with the Acute Care Service in [**2-25**] weeks. You can schedule this appointment by calling #[**Telephone/Fax (1) 600**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**] Completed by:[**2161-11-24**]

[ "511.9", "V44.4", "780.60", "285.9", "482.83", "789.07" ]

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8912

Discharge summary

report

Admission Date: [**2132-11-5**] Discharge Date: [**2132-12-16**] Date of Birth: [**2072-3-29**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 15344**] Chief Complaint: fever, hypotension, diarrhea Major Surgical or Invasive Procedure: exploratory laparotomy, right colectomy, loop ileostomy, and distal transverse colon mucous fistula percutaneous cholecystostomy CT guided drainage of right paracolic fluid collection History of Present Illness: 60 yo male with a hx of metastatic bladder CA to liver and lung s/p bladder resection and nebladder, h/o renal stones and multiple UTI's, now receiving third round of gemcitibine who presented with fever following his last dose of chemo. Pt had chemotx on [**11-4**] and was feeling weak afterwards and went home to take a nap. Wife woke him up when she got home and he began rigoring. He measured temp to be 102.7 and decided to go to the ED. He first went to ED at [**Hospital3 30982**] and temp was 102.5 HR 140 and BP 98/56 and was given 1L NS and started on ceftazadime and levofloxacin, transferred to [**Hospital1 **]. In [**Hospital1 18**] ED T 102.5, BP 80/44, HR 140, RR 23, 100%RA. He was given 2L ns, RIJ placed placed, and he was started on sepsis protocol despite lactate 1.7. He also had a CVP of 14 but was given another 4L NS with poor SBP response and started on levophed continued on ceftriaxone and added vancomycin and transferred to the [**Hospital Unit Name 153**]. Over the next 24 hours he was quickly weaned off of levophed and SBP improved to the 150's with good urine output. He was fiven 1 unit PRBC's for a Hct of 25 and 1 bag of platelets for a platelet count in the 30's. Urine culture grew 10-25K of staph epi and blood cultures have remained negative to date. CXR was negative for infiltrates and sputum culture was contaminated with oral flora. Past Medical History: 1. Nephrolithiasis. 2. Metastatic bladder cancer-diagnosed in 7/00 when he has bladder resection and neobladder made from his ileum thought to be a curative operation with chemo of taxol and carboplatin and MVAD which he completed in [**12-20**]. Pt then represented in [**2128-12-20**] with rectal bleeding thought due to hemorrhoids. Rectal exam revealed nodular mass and follow-up CT showed disease recurrence with metastasis to lungs. Pelvic mass was treated with local radiation but otherwise was intially treated expectantly. Pt started on alimta/gemcitibine in [**2132-9-9**] and reports being hospitalized for neutropenic fever after his first two doses. 3. GERD 4. Hypertension. 5. Hypercholesterolemia. 6. OSA 7. Chronic UTI's-on Ciprofloxacin 250mg q3days with last UTI in [**2132**]3 Social History: SocHx-Pt is married to his wife of 33 years, has no children and works was a fund manager for a financial service. Quit tobacco use 3 years ago but prior to that has a 40 pack year smoking history, minimal EtOH 1-2 drinks/wk, no hx of illicit drug use Family History: Fam Hx-Father died of prostate CA at age 72, mother had DM and multiple [**Name (NI) 27141**] with first at age 68, no other hx fo CA, MI, HTN, DM or CVA Physical Exam: Temp 98.8 BP 124/55 Pulse 104 Resp 17 O2 Sat's 100% [**Female First Name (un) **] Gen - Alert, no acute distress HEENT - PERRL, anicteric, mucous membranes dry, no mucosal ulcerations Neck - no JVD, no cervical lymphadenopathy, thyroid nonpalp, Chest - Clear to auscultation bilat CV - Normal S1/S2, RRR, no murmurs, rubs, or gallops Abd - Soft, nontender, nondistended, with normoactive bowel sounds, no palpable masses Back - No costovertebral angle tendernes Extr - No clubbing, cyanosis, or edema, 2+ rad and dp pulses Neuro - Alert and oriented x 3, 5/5 strength in flexors and extensors of upper and lower extremiites Pertinent Results: [**2132-11-5**] 07:02AM BLOOD WBC-1.2* RBC-2.28* Hgb-7.4* Hct-21.1* MCV-92 MCH-32.5* MCHC-35.2* RDW-19.7* Plt Ct-33* [**2132-11-5**] 12:50AM BLOOD Neuts-82* Bands-6* Lymphs-8* Monos-1* Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-1* Hyperse-1* [**2132-11-5**] 06:00AM BLOOD PT-13.6 PTT-28.2 INR(PT)-1.2 [**2132-11-5**] 07:02AM BLOOD Gran Ct-1040* [**2132-11-5**] 06:00AM BLOOD Glucose-152* UreaN-27* Creat-1.1 Na-141 K-3.7 Cl-115* HCO3-19* AnGap-11 [**2132-11-5**] 12:50AM BLOOD ALT-119* AST-56* LD(LDH)-302* AlkPhos-126* TotBili-1.4 DirBili-0.9* IndBili-0.5 [**2132-11-5**] 06:00AM BLOOD Calcium-6.4* Phos-2.6* Mg-1.5* [**2132-11-4**] 01:08PM BLOOD Cortsol-23.9* [**2132-11-5**] 01:14AM BLOOD Lactate-1.7 [**2132-11-5**] 03:27AM BLOOD Lactate-1.1 [**2132-11-5**] 04:06AM BLOOD Lactate-0.8 [**2132-11-5**] 06:36AM BLOOD Lactate-1.2 [**2132-11-5**] 07:32AM BLOOD Lactate-1.0 Brief Hospital Course: The following is brief hospital course organized by problems. [**Name (NI) 30983**] the patient is a 60 year old man with history of metastatic bladder cancer initially admitted for fever, neutropenia, hypotension, and diarrhea after recent radiation and chemotherapy treatment. The patient then underwent exploratory laparotomy, right colectomy, loop ileostomy, distal transverse colon mucous fistula on hospital day number 10 ([**2132-11-14**]) for a large bowel obstruction that was complicated postoperatively by an ileus, acute renal failure, a right paracolic fluid collection, VRE cholecystitis, and unusually high ileostomy output. By post-operative day 32 all of these problems had resolved and the patient was discharged home with visiting nurses. 1) Sepsis: Patient presented to OSH ER with hypotension in the setting of febrile neutropenia. He was enrolled in the MUST sepsis protocol and managed initially with pressors (Levophed), fluid boluses, and broad spectrum antibiotics in the form of ceftazidime and vancomycin. Flagyl was added empirically, ceftazidime changed to cefepime, and patient given one unit of red cells. He defervesced and blood pressure improved quickly on this regimen, however no source could be identified. Patient was transferred from ICU to oncology service on hospital day number two. 2) Radiation proctitis and Ischemic Colon: Patient initially presented with chronic diarrhea and rectal urgency/frequency. Diarrhea became bloody early on in admission and on hospital day number three developed BRBPR. He had a sigmoidoscopy on hospital day number seven demonstrating radiation proctitis secondary to radiation therapy for bladder cancer. He then developed a large bowel obstruction following flexible sigmoidoscopy. Surgery was consulted on hospital day number 10, rectal tube placed, and CT revealed a stricture at rectosigmoid junction with transition point and cecum dilated to 11 cm. Patient then taken to operating room for right colectomy, ileostomy, and mucous fistula, and transferred to surgical intensive care unit. Much of the right colon appeared ischemic at the time of operation. Final pathology was also consistent with ischemic infarct with no evidence of metastatic disease. 3) Post-operative Ileus: Patient remained extubated for three days. He was started on Ampicillin, Levofloxacin, and Flagyl. Did not tolerate tube feeds initially and was started on TPN. He was transferred out of the SICU on postoperative day number 5. On post-operative day number five he began vomiting and a nasogastric tube was placed uneventfully. TPN was advanced to goal on postoperative day number seven and he remained on levofloxacin and Flagyl. Patient's ileus gradually resolved and NG tube was removed on postoperative day number ten. Diet was then advanced, TPN tapered, and antibiotics discontinued. 4) Atrial fibrillation: Patient developed rapid atrial fibrillation with a rapid ventricular response on hospital day number 6. Rate decreased with IV metoprolol and he spontaneously converted to NSR. Trans thoracic echo showed small pericardial effusion and TSH was WNL. Post-operatively, on hospital day number 14 patient again converted to rapid atrial fibrillation. Rate unable to be controlled with adenosine and Lopressor, required amiodarone bolus and continuous infusion. The patient was then cardioverted successfully on hospital day number 15, postoperative day number 4. The patient was discharged with 200 mg [**Hospital1 **] PO amiodarone and metoprolol 25 mg PO BID. He remained in NSR (with the exception of PVCs and a short run of non-sustained VT on postoperative day number 8) as documented by EKG and telemetry for the remainder of the admission. 5) VRE Cholecystitis: On postoperative day number seventeen the patient developed increasing right upper quadrant pain and fever. An ultrasound showed gallbladder wall edema and sludge and a CT scan demonstrated gall bladder distension. A HIDA scan performed the following day was equivocal. On postoperative day 18 ([**2132-12-1**]) a percutaneous cholecystostomy was performed. Patient's pain rapidly improved and he rapidly defervesced. CT scan from [**2132-12-5**] demonstrated interval decompression of the gall bladder. Culture from the percutaneous drainage however grew out vancomycin resistant enterococcus. Additionally, while the patient improved clinically quite rapidly, his white blood cell count continued to increase until [**12-8**], peaking at 25.8 before decreasing to 11.8 at the time of discharge. In consultation with the infectious disease team, the patient was treated with a total course of approximately three weeks of Linezolid (19 days exactly, including one week course to be completed after discharge). A T-tube cholangiogram on [**2132-11-9**] (postoperative day number 26) demonstrated drainage from the gallbladder and [**Date Range **] ducts into the duodenum. Given that removal of large quantities of [**Last Name (LF) **], [**First Name3 (LF) **] have been contributing to the patient's high ileostomy output via fat malabsorption, the cholecystostomy was capped following the T-tube cholangiogram. The patient was discharged with the cholecystostomy tube capped. 6) Acute renal failure: On [**2132-11-26**], postoperative day number 13, the patient's creatinine peaked at 1.5 from a baseline of approximately 1 and his potassium increased to 5.4. A general medicine consult was called the following day, given the patient's complex history. However, given rapid improvement following adequate fluid resuscitation, high BUN/Cr ratio, moderate hypotension, a fractional excretion of sodium equal to 0.7%, and the fact that the ARF coincided with the patient's increasing negative fluid balance, it was concluded that the patient's ARF was secondary to dehydration. At discharge creatinine was 1.2. 7) High ostomy output: The patient's ileostomy output began increasing gradually to over 2 liters, reached over 5.7 liters on postoperative day number 16 ([**2132-11-30**]), and continued to be high as late as postoperative day number 25 (4L). The etiology of the high output was never ascertained. He had three negative C. dif toxin assays, and a negative stool culture. However, a combination of opium drops, psyllium wafers, and Imodium all titrated up slowly, did decrease ostomy output and thicken the ostomy consistency. On [**2132-12-15**] (postoperative day number 32) output decreased to 2 liters and on the day of discharge output decreased to 1.3 L for 24 hours. 8) Difficulty with neobladder: The patient had a Foley catheter in place during the majority of his admission. The Foley catheter required frequent flushing and frequent changes due to mucous plugging. There was a brief period during which the urology team reactivated the patient's urethral sphincter. The Foley was replaced, however, because of high post void residuals and a need for closer monitoring of his fluid status. The patient had a brief trial of a condom catheter, which failed because of inadequate fixation. On the day of discharge the Foley was again removed and the sphincter reactivated by urology without difficulty. Medications on Admission: Celexa, MS Contin, Decadron, Ciprofloxacin, folate, B12, PPI, [**Doctor First Name 130**], atenolol Discharge Medications: 1. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. Amiodarone HCl 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 4. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 5. Zolpidem Tartrate 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Disp:*15 Tablet(s)* Refills:*0* 6. Loperamide HCl 2 mg Capsule Sig: Four (4) Capsule PO QID (4 times a day). Disp:*480 Capsule(s)* Refills:*0* 7. Hydromorphone HCl 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*45 Tablet(s)* Refills:*0* 8. Psyllium 1.7 g Wafer Sig: One (1) Wafer PO TID (3 times a day). Disp:*90 Wafer(s)* Refills:*0* 9. Erythromycin 5 mg/g Ointment Sig: 0.5 inches Ophthalmic QID (4 times a day). Disp:*1 tube* Refills:*1* 10. Opium 10 % Tincture Sig: Twenty Five (25) Drop PO Q6H (every 6 hours). Disp:*180 mL* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: bladder cancer radiation proctitis small bowel obstruction enterococcus cholecystitis acute renal failure high ostomy output Discharge Condition: good Discharge Instructions: Go to an Emergency Room if you experience new and continuing nausea, vomiting, fevers (>101.5 F), chills, or increasing abdominal pain not controlled by medications. Also go to the ER if your wound becomes red, swollen, warm, or produces pus. Please call urologist for any concerns related to urination. Please change ileostomy bag on mondays and thursdays and empty it as needed. Please change mucous fistula bag every other day. Please change dressing over the cholecystostomy tube every three days. Please handle this tube with care, it is important that it not be pulled. Please continue eating regular diet and supplement all meals with boost. Leave your midline abdominal incision open to air. If you experience clear drainage from your wounds, cover them with a clean dressing and stop showering until the drainage subsides for at least 2 days. No heavy lifting or exertion for at least 6 weeks. No driving while taking pain medications. Be sure to take your complete course of antibiotic call Linezolid. Please also take all other medications as prescribed. [**Month (only) 116**] restart citalopram (antidepressant) two weeks after stopping Linezolid, as these two medicaitions interact. You may take showers (no baths). Take a shower immediately before dressing changes by the visiting nurse. Please continue care of sphincter as instructed by urology. Followup Instructions: Please follow-up in one week with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. Please call ([**Telephone/Fax (1) 10820**] for appointment and directions. Please follow-up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 365**] of urology in one week. Please call ([**Telephone/Fax (1) 6441**] for appointment and directions

[ "276.5", "E879.2", "557.0", "560.89", "575.0", "196.8", "V10.51", "995.91", "288.0", "V09.80", "560.1", "038.9", "041.04", "601.8", "569.3", "599.0", "197.0", "427.1", "584.9", "E933.1", "287.5", "427.31", "197.7", "448.9" ]

icd9cm

[ [ [] ] ]

[ "88.72", "46.01", "38.93", "99.04", "45.43", "47.19", "87.54", "45.73", "45.24", "51.01", "46.11", "99.15" ]

icd9pcs

[ [ [] ] ]

13295, 13344

4764, 11950

353, 541

13513, 13519

3871, 4741

14945, 15322

3056, 3211

12100, 13272

13365, 13492

11976, 12077

13543, 14922

3226, 3852

285, 315

569, 1951

1973, 2771

2787, 3040

49,580

165,638

51778

Discharge summary

report

Admission Date: [**2199-9-10**] Discharge Date: [**2199-9-17**] Date of Birth: [**2160-5-7**] Sex: F Service: MEDICINE Allergies: Ampicillin / Penicillins / Morphine Hcl Attending:[**First Name3 (LF) 3918**] Chief Complaint: Chemotherapy Major Surgical or Invasive Procedure: Chemotherapy Dialysis History of Present Illness: 39-year-old woman with h/o type I diabetes since age 14 months, glomerulonephritis, kidney transplants in [**2174**] and [**2177**], and a double kidney and pancreas transplant on [**2188-11-20**], who has newly diagnosed EBV-driven CNS lymphoma. She was discharged on [**2199-8-30**] following an identical course of MTX and leucovorin- this admission required both HD and CVVH to manage toxicity in the setting of her renal transplant. Since discharge, the patient had a negative ROS and no issues. Past Medical History: PAST ONCOLOGIC HISTORY: ====================== Her neurological problems began in [**2199-3-22**] when her mother noted psychomotor slowing, short-term memory problems, inability to tolerate stress, and tremors in the hands. By [**2199-4-22**], she had additional symptoms including word-finding difficulty and slurred speech. Her mother took her to [**Hospital3 3583**], and she was released. Her mother then took her to see a neurologist at [**Hospital3 417**] Hospital, and he put her on Zoloft for possible depression. She was admitted to the [**Hospital1 827**] on [**2199-5-28**] for admitted [**2199-5-28**] for elective ventral hernia repair with mesh. She also had a workup for her mental status status change. A head MRI without gadolinium performed on [**2199-5-31**] showed moderate atrophy and mild periventricular hyperintensities. There was a question of mild communicating hydrocephalus. A spinal tap performed on [**2199-6-3**] showed 2 WBC, 49 protein, and 72 glucose, but she was positive for EBV PCR in the CSF. But HHV-6, HSV1 and 2, and [**Male First Name (un) 2326**] virus PCR were all negative. She was placed on 15 days of IV ganciclovir for meningoencephalitis with positive EBV PCR in CSF. A repeat lumbar puncture on [**2199-6-21**] yield negative EBV PCR, both qualitative and quantitative, in the CSF. But her memory function improved but it was still off. A repeat head MRI without gadolinium showed 3 hyperintense FLAIR lesions in the left caudate, right parietal periventricular region, and left frontal region near the surface of the brain. She underwent a stereotaxic brain biopsy by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. on [**2199-8-1**] and the pathology showed EBV-driven CNS lymphoma. Her cyclosporin was taken off subsequently. I saw her for the first time in the [**Hospital **] clinic on [**2199-8-13**], and her lumbar puncture that day showed 6 WBC, 61 protein, 56 glucose, atypical lymphocytes on cytology and negative flow cytometry. She also had an FDG-PET of the entire body on [**2199-8-14**]. It showed focal increased uptake in known right parietal (SUVmax 5.0) and left basal ganglia lesions (SUVmax 6.8), and there was no FDG avid disease outside the brain. She has just finished cycle 1 of MTX with leucovorin rescue. . PAST MEDICAL HISTORY: ==================== She had a history of diabetes, and it resolved after her double kidney and pancreas transplant on [**2188-11-20**]. She has hypertension and hypercholesterolemia, but no COPD. She was diagnosed with EBV encephalitis in [**2199-5-22**] and treated with gancyclovir. She had her first kidney transplant in [**2174**], and then a second kidney transplant in [**2177**], followed by a double kidney and pancreas transplant on [**2188-11-20**]. Social History: She lives with her parents in [**Location (un) 3320**], MA. She does not smoke cigarettes, drink alcohol, or use illicit drugs Family History: Her parents are healthy. Her two sisters are healthy. She does not have children. Her grandfather had NIDDM and her great grandmother apparently had IDDM. Physical Exam: Vitals - T: 97 BP:110/85 HR:88 RR:18 02 sat: 99RA GENERAL: NAD SKIN: warm and well perfused, [**Location (un) 4459**]: AT/NC, [**Location (un) 3899**], PERRLA, anicteric sclera, patent nares, MMM, good dentition, nontender supple neck, no LAD, CARDIAC: RRR, S1/S2, no mrg LUNG: CTAB ABDOMEN: nondistended, +BS, nontender in all quadrants, no rebound/guarding, no hepatosplenomegaly M/S: moving all extremities well, no cyanosis, or edema, no obvious deformities PULSES: 2+ DP pulses bilaterally NEURO: CN III-XII intact Pertinent Results: Discharge Labs: . . . . Reports: [**2199-9-14**] CXR: There is new development of bilateral vascular engorgement, upper zone redistribution of vasculature, interstitial extensive opacities and bilateral perihilar alveolar opacities continuing toward the lung bases, findings that are representing interstitial-alveolar pulmonary edema, at least moderate in severity. [**2199-9-15**] CXR: In comparison with study of [**9-14**], there has been a substantial decrease in the pulmonary vascular congestion. Bibasilar opacification persists, consistent with pleural effusion and compressive atelectasis. . Micro: [**2199-9-14**] Urine culture: no growht to date [**2199-9-14**] Blood culture x 4: no growth to date [**2199-9-15**] Blood culture: no growth to date Brief Hospital Course: This is a 39 year old female with ESRD s/p panc/kidney transplant, recently diagnosed with CNS lymphoma. Pt was admitted for methotrexate therapy and hemodialysis. . # EBV-Drived CNS Lymphoma: Patient tolerated IV high-dose methotrexate well; she was started on hemodialysis 6 hours later and simultaneously started on leucovorin rescue. She was dialyzed again on [**2199-9-12**]. She continued to get IV fluids to help clear MTX until [**2199-9-14**] when she developed flash pulmonary edema. She was transferred to the [**Hospital Unit Name 153**], but was quickly stabilized and transferred back. She was given Lasix 40mg IV BID and her oxygen requirement which was initially 4L. On transfer she was transitioned to po lasix and weaned off oxygen with improvement in CXR. . # Fever: The patient spiked to 101.5 on the same day as [**Hospital Unit Name 153**] transfer. She was empirically started on Meropenum and Vancomycin. Upon transfer to the floors, patient remained afebrile. Infectious work up was negative and so antibiotics were discontinued. . # Kidney Transplant: She was followed by the renal transplant team while in the hospital. She tolerated Hemodialysis well. The patient was maintained on prednisone. Mycophenolate was initially held and restarted at a reduced dose. . # Pancreas Transplant: Stable. Patient continued on prednisone and mycophenolate was restarted later during patient's hospitalization. . # Hypertension: In the [**Hospital Unit Name 153**] her atenolol was switched to carvedilol and her amlodopine was continued. Medications on Admission: 1. Sodium Chloride 0.9 % 0.9 % Syringe Sig: Ten (10) ML Injection PRN (as needed) as needed for line flush: Daily and then as needed. Disp:*1 box* Refills:*3* 2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 4. Bacitracin 500 unit/g Ointment Sig: One (1) Appl Ophthalmic [**Hospital1 **] (2 times a day) as needed for with dressing changes. Disp:*1 tube* Refills:*0* 5. Atenolol 100 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 7. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Sevelamer HCl 400 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for sleep/anxiety. 12. Citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day: Take [**11-23**] tablet daily for the next week and then take 1 tablet daily from then on. . Disp:*30 Tablet(s)* Refills:*2* 13. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day as needed for swelling. 14. Aranesp (Polysorbate) 100 mcg/0.5 mL Syringe Sig: 0.5 ML Injection once a week. 15. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. . Discharge Medications: 1. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Prednisone 1 mg Tablet Sig: Four (4) Tablet PO DAILY (Daily). 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. Folic Acid 1 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 Q24H (every 24 hours). 7. Sevelamer HCl 400 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 10. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Aranesp (Polysorbate) 100 mcg/mL Solution Sig: One (1) injection Injection once a week. 12. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day as needed for leg swelling. 13. Zofran 8 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. Disp:*90 Tablet(s)* Refills:*0* 14. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. Disp:*120 Tablet(s)* Refills:*0* 15. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 6 days. Disp:*6 Tablet(s)* Refills:*0* 16. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 17. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 18. Outpatient Lab Work Please have basic metabolic panel drawn thursday [**9-19**]. Send results to Dr.[**Name (NI) 6767**] office at fax [**Telephone/Fax (1) 107218**]. Thanks. Discharge Disposition: Home With Service Facility: [**Location (un) 511**] Home Therapies Discharge Diagnosis: Primary: 1. Central Nervous System Lymphoma 2. Diabetes Type I s/p kidney and pancreas transplant . Secondary: 1) Hypertension Discharge Condition: Stable Discharge Instructions: You were admitted the hospital for chemotherapy. You received methotrexate and shortly after received hemodialysis. You tolerated chemotherapy well. You developed subconjunctival hemorrhages in your eye likely secondary to temporarily high blood pressure. These will resolve on their own. You also developed fluid in your lungs as a complication of high blood pressure. You were transferred to the ICU but stabalized and soon returned to a regular bed. You were temporarily on supplemental oxygen, but this was decreased as we gave you medications to decrease the fluid in your lungs. You diuresed well with IV lasix. You can now return to your home doses. . We have made the following changes to your medication list: ******* 1) Zofran 8mg by mouth every 8 hours as needed for nausea 2) Compazine 10mg by mouth every 6 hours as needed for nausea 3) Cipro 500 mg daily for 7 days for a UTI 4) Cellcept [**Pager number **] mg [**Hospital1 **] 5) We switched your atenolol to carvedilol 12.5 mg [**Hospital1 **] . Please continue all your other home meds. . Please seek medical care if you develop nausea, vomiting, fevers/chills, shortness of breath, dizziness, fainting, chest pain, eye pain or vision changes. Followup Instructions: Provider: [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2199-9-27**] 10:10 . Please follow up with Dr. [**Last Name (STitle) 724**] as well as previously scheduled. You will be readmitted [**9-24**] for your next cycle. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 3922**] Completed by:[**2199-9-21**]

[ "V58.11", "518.81", "V42.83", "372.72", "428.31", "599.0", "428.0", "E878.0", "200.50", "272.0", "V58.65", "996.81", "139.8", "402.91", "348.39" ]

icd9cm

[ [ [] ] ]

[ "99.25", "39.95" ]

icd9pcs

[ [ [] ] ]

10224, 10293

5372, 6935

312, 336

10464, 10473

4586, 4586

11733, 12153

3871, 4029

8461, 10201

10314, 10443

6961, 8438

10497, 11710

4602, 5349

4044, 4567

260, 274

364, 870

3243, 3709

3725, 3855

61,248

117,808

39367

Discharge summary

report

Admission Date: [**2185-11-2**] Discharge Date: [**2185-11-19**] Date of Birth: [**2103-5-27**] Sex: F Service: MEDICINE Allergies: Erythromycin / Tramadol / Simvastatin Attending:[**First Name3 (LF) 2290**] Chief Complaint: Nausea/Vomiting Major Surgical or Invasive Procedure: Truncal vagotomy, antrectomy, retrocolic Billroth II gastrojejunostomy and omentectomy History of Present Illness: This is an 82 yo F transfered for workup of a stomach mass. She was admitted to OSH on [**10-26**] with 5 weeks of nausea and foreful brownish/blackish emesis, appx 1 pint/day. She associated this with recently starting warfarin, but symptoms returned even after stopping warfarin. She had no prior issues with nausea or vomiting. Also with 8-10# wt loss over this time. At OSH, noted to be in rapid afib. HR improved with IVF and dilt drip (now in 80s-90s). Warfarin was held and she was continued on enoxaparin. Underwent EGD which showed gastric mass. Biopsy performed with pathology "inconclusive". NG tube was refused (pt does not recall this). Surgery was consulted and recommended CT scan, with results below. She did require blood transfusions for anemia, as well. She was also on levofloxacin, then bactrim, for pansens E coli UTI. Sent to [**Hospital1 18**] for possible EUS with bx, and likely surgical intervention. Vitals from transfer call-in: T: AF BP: 132/91 HR: 80s-90s RR: 20 O2 Sat: 99% 2 L/min O2. . On the floor, patient notes that she has been on a regular diet, but not eating much solid. Her nausea is bad in the am, with spitting up phlegm, but abates after ~1pm. . . Past Medical History: Diabetes Hypertension Coronary artery disease s/p MI, 3 stents Osteoporosis Emphysema Atrial fibrillation Chronic back pain - spinal stenosis CHF? Anemia Hx of pancratitis Hx bilateral knee replacement and L shoulder replacement from OA Social History: Lives alone in [**Location (un) 5028**]. Former secretary. No tobacco, no etoh, no illicit drug use Family History: Father with [**Name2 (NI) 499**] cancer resected in his 80s; daughter diagnosed with breast cancer at age 48 Physical Exam: Vitals: T: 96.0 BP: 120/82 P: 101 R: 18 O2: 96,2L Glc: 142 General: Alert, no acute distress HEENT: MMM Neck: SCMs tight, no LAD Lungs: Crackles throughout left lung (patient lying with left lung down), otherwise clear CV: Irregularly irregular, no murmurs, rubs, gallops Abdomen: soft, mild LUQ and R mid abd TTP without rebound or guarding, mildly distended with tympany, bowel sounds present Ext: Warm, well perfused, no edema Pertinent Results: [**2185-11-3**] 06:10AM BLOOD WBC-5.5 RBC-3.44* Hgb-10.4* Hct-31.7* MCV-92 MCH-30.3 MCHC-32.9 RDW-13.2 Plt Ct-213 [**2185-11-3**] 06:10AM BLOOD PT-13.1 PTT-25.7 INR(PT)-1.1 [**2185-11-3**] 06:10AM BLOOD Glucose-122* UreaN-9 Creat-0.5 Na-136 K-3.9 Cl-96 HCO3-35* AnGap-9 [**2185-11-3**] 06:10AM BLOOD ALT-17 AST-18 AlkPhos-77 TotBili-0.4 [**2185-11-3**] 06:10AM BLOOD Albumin-3.4* Calcium-9.0 Phos-3.4 Mg-1.9 [**2185-11-3**] 06:10AM BLOOD PT-13.1 PTT-25.7 INR(PT)-1.1 [**2185-11-5**] 05:22AM BLOOD Triglyc-113 [**2185-11-7**] 06:13AM BLOOD PT-13.3 PTT-24.6 INR(PT)-1.1 [**2185-11-8**] 05:32AM BLOOD PT-13.3 PTT-28.3 INR(PT)-1.1 [**2185-11-10**] 02:37AM BLOOD PT-14.6* PTT-42.7* INR(PT)-1.3* [**2185-11-17**] 04:16AM BLOOD PT-13.9* INR(PT)-1.2* . Labs on discharge: [**2185-11-19**] 01:37PM BLOOD WBC-6.4 RBC-2.95* Hgb-8.9* Hct-26.9* MCV-91 MCH-30.2 MCHC-33.2 RDW-14.3 Plt Ct-327 [**2185-11-19**] 04:37AM BLOOD PT-15.4* INR(PT)-1.4* [**2185-11-19**] 04:37AM BLOOD Glucose-59* UreaN-12 Creat-0.5 Na-134 K-4.3 Cl-99 HCO3-31 AnGap-8 [**2185-11-19**] 04:37AM BLOOD Calcium-8.0* Phos-4.1 Mg-2.0 . [**2185-11-3**] 6:10 am SEROLOGY/BLOOD HELI ADDED TO ACC#[**Serial Number 87019**]Z. **FINAL REPORT [**2185-11-4**]** HELICOBACTER PYLORI ANTIBODY TEST (Final [**2185-11-4**]): NEGATIVE BY EIA. (Reference Range-Negative). . [**2185-11-4**] ECG: Atrial fibrillation with a ventricular rate of 126. Low voltage in the standard leads. Early transition. No other diagnostic abnormality. No previous tracing available for comparison. . [**2185-11-3**] EUS: Large amount of yellow liquid with large solid particles were noted in the stomach, it could not be completely suctioned out due to the large particles occluding suction channel An irregular, circumferential, friable mass was found in the antrum causing obstruction of the gastric outlet Cold forceps biopsies were performed for histology after EUS examination and FNA. EUS was performed using a radial echoendoscope at 7.5 MHz frequency, however, a full examination was not able to be performed due to the presence of large amount of fluid in the stomach: There was marked thickening of the stomach wall in the antrum, demarcation between mucosa, submucosa and muscularis propria was lost. These findings are consistent with an infiltrative type of gastric neoplasm, such as: linitis plastica, lymphoma, amyloidosis, syphillis, etc. Celiac axis was examined and no lympadenopathy was noted. . [**2185-11-4**] EUS Biopsy: Gastric mucosa, antrum: Antral mucosa with focal intestinal metaplasia. Note: Special stains for fungi are negative . [**2185-11-3**] Antrum wall cytology report: SUSPICIOUS FOR ADENOCARCINOMA. Scantly cellular specimen with scattered highly atypical glandular epithelial cells with high N:C ratio, prominent nucleoli, and vacuoles; one signet-ring appearing cell seen. . [**2185-11-19**] CXR: Left lower lobe opacity is a combination of pleural effusion and probably atelectasis. This is unchanged since [**11-4**]. Small right pleural effusion is probably unchanged. The right lobe otherwise is clear. There is no evidence of pneumothorax. Multiple thoracic vertebral body compression fractures are noted. . [**2185-11-19**] CTA chest: Final Report FINDINGS: There is a left trans-subclavian PICC in place with the tip in the junction ofSVC and right atrium. There is no sign of acute or chronic pulmonary embolism or pulmonary hypertension. There is no mediastinal, hilar or axillary adenopathy. There are diffuse three-vessel coronary calcifications. Cardiac [**Doctor Last Name 1754**] are unremarkable. Aorta demonstrates mild atherosclerotic burden without aneurysm with conventional branching of arch vessels. There is a left pleural effusion. There is consolidation in the left lower lobe adjacent to the pleural effusion which may be due to compressive atelectasis versus pneumonia. There is a smaller right pleural effusion. There is a 3.2 cm bulla in the right middle lobe. No nodule or mass. Bronchi and trachea are unremarkable. There are compression fractures in the T8 and T9 vertebra with approximately 50% height loss without breach of posterior cortex or retropulsion, stable from [**2185-11-4**]. There are also significant degenerative changes involving the right shoulder joint. IMPRESSION: No acute or chronic pulmonary embolism. Left pleural effusion with adjacent consolidation, atelectasis versus pneumonia. T8 and T9 vertebral body compression fractures with 50% height loss, stable from [**2185-10-12**]. Brief Hospital Course: This is an 82 yo F transferred for workup of a stomach mass, which presented with nausea and vomiting. The patient was initially admitted to general medicine, but was transferred to the Acute Care Service for a planned subtotal gastrectomy. Subsequently, a truncal vagotomy, antrectomy, retrocolic Billroth II, gastro-jejunostomy and omentectomy was performed on [**2185-11-8**]. The patient was transferred to the surgical intensive care unit post-operatively, where she remained stable. The patient was transferred to the surgical [**Hospital1 **] on Post-operative day #4. # Gastric mass: presented with mass from OSH. Partially obstructing, concerning for malignancy. EUS performed on [**11-4**] confirmed mass, with concern for linitis plastica vs. lymphoma. Was deemed H. pylori negative. Biopsies returned positive for intestinal metaplasia without any signs of overt malignancy. NGT was eventually needed for the pt as she began vomiting gastric secretions on [**2185-11-6**]. The patient was evaluated by surgery and deemed intermediate to high risk candidate based on her cardiovascular risk factors and history of an MI in the past. She was scheduled for surgery and a truncal vagotomy, antrectomy, retrocolic Billroth II gastrojejunostomy and omentectomy was performed on [**2185-11-8**]. Oncology was asked to evaluate the patient due to a final pathologic diagnosis of T4aN2. The patient will follow-up with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1852**] as an outpatient on [**2185-11-25**]. . # Afib: Pt. presented with atrial fibrillation with rapid ventricular response. Her warfarin was discontinued out of necessity for future surgical intervention. Her ASA was initially held but restarted on [**2185-11-7**] at 81 mg daily due to her risk of restenosis of her prior cardiovascular stents. Rate control was poorly achieved, initially with IV metoprolol and po diltiazem. However, after her NGT was placed, oral medications were stopped and the patient was continued on IV metoprolol 20 mg q4hr with her heart rate ranging between 80-90 BPM. However, on post-operative day # 5 the patient triggered for a sustained heart rate in the 130s. The patient received 5 mg of intravenous metoprolol x 3 with an improved heart rate into the 100s. The patient remained asymptomatic throughout the event. On post-operative day #6 her home regimen of po metoprolol and diltiazem was resumed. She remained in atrial fibrillation with a persistently elevated ventricular rate ranging between the 80's-120's. General medicine was consulted to optimize management. Recommendations included adjusting the timing of diltiazem with an increase in her atenolol dose. She was transfered to medicine for further rate control of her a fib and ultimately discharged on diltiazem 180mg sustained release and atenolol 50mg [**Hospital1 **]. She had a CT scan of your chest to look for a blood clot causing irritation of your heart. This was negative for evidence of a blood clot although the final read of this study is pending at your time of discharge. She was discharged on coumadin with an INR of 1.4 on the day of discharge. . # Anemia: Required transfusions at outside hospital. Upon transfer to [**Hospital1 18**] no further transfusions were needed. . # DM: Blood glucose levels were intermittenly elevated with a regular insulin sliding scale and glyburide early in the admission. At the time of transfer to medicine she has occasional low blood sugars and her glyburide was reduced to 2.5mg daily. # HTN: The patient came in on oral anti-hypertensives which were resumed once the patient was able to take po. Her systolic blood pressures ranged between 90-120s on diltiazem and atenolol. Her lisinopril 10mg daily was held in order to uptitrate her A fib medications. Her lisinopril should be restarted by your primary care doctor when her blood pressure allows. # Coronary artery disease s/p MI, 3 stents: She was initially off ASA for procedures but placed back on low dose ASA on [**2185-11-7**]. She was continued on her beta-blocker and statin. Her lisinopril was held as detailed above. . # Emphysema: She was continued on her fluticasone-salmeterol and nebs prn. . # Pain: Her standing APAP and methadone were converted to intravenous morphine and then a Dilaudid PCA while NPO. The patient resumed oral methadone and was transitioned to oral Percocet once tolerating po with well-controlled abdominal pain. She continued to have right shoulder and back pain throughout the course of her hospital stay. She also developed severe constipation during her hospitalization and was discharged on an aggressive bowel regimen of senna, colace, and miralax. . # FEN: The patient was kept NPO and maintained on total parenteral nutrition until her [**Last Name (un) **]-gastric tube was discontinued and tolerance to a regular diet was established. At discharge, the patient was tolerating a diabetic/ consistent carbohydrate diet. . # Prophylaxis: She was on heparin sc during her hospitalization. . # Rehabilitation: The patient was evaluated by both physical and occupational therapy prior to discharge. Physical therapy recommended home follow-up to improve endurance. Occupational therapy without recommendations. Medications on Admission: Home meds: ASA 81mg daily Glyburide 5mg daily Lipitor 10mg daily Lisinopril 10mg daily Atenolol 50mg daily Methadone 15mg qam, 10mg qnoon, 10mg qpm Combivent 2 puffs QID Advair 2 puffs daily Oxycodone APAP 5/325 prn . Medications (from [**Hospital3 26615**]): Atenolol 50mg [**Hospital1 **] Lisinopril 2.5mg daily Diltiazem CD 120mg daily Atorvastatin 10mg daily Lovenox 40 units daily Ferrous sulfate 325mg [**Hospital1 **] Insulin SS Methadone 15mg qam, 10mg qnoon, 10mg at 2200 Reglan 5mg IV TIDAC Zofran 8mg IV TIDAC Oxycodone APAP 1-2 tabs q6h prn pain Protonix 40mg daily Bactrim 1 tab [**Hospital1 **] Salmeterol Fluticasone 1 inh [**Hospital1 **] Discharge Medications: 1. Atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Methadone 5 mg Tablet Sig: Three (3) Tablet PO qam. 4. Methadone 10 mg Tablet Sig: One (1) Tablet PO q noon and qhs. 5. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 6. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for Pain. Disp:*40 Tablet(s)* Refills:*0* 7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*2* 8. diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). Disp:*30 Capsule, Sustained Release(s)* Refills:*2* 9. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 10. glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 11. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. Disp:*60 Tablet(s)* Refills:*0* 12. warfarin 1 mg Tablet Sig: Five (5) Tablet PO once a day: pls adjust as needed to maintain an INR of [**3-16**]. Disp:*150 Tablet(s)* Refills:*0* 13. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 14. diltiazem HCl 180 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO once a day. Disp:*30 Capsule, Sust. Release 24 hr(s)* Refills:*2* 15. Miralax 17 gram/dose Powder Sig: One (1) PO once a day as needed for constipation. 16. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: Obstructing gastric antral carcinoma with small notch of implants in the gastric colic omentum and the serosa of the first portion of the duodenum and the antrum. 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 transferred to the [**Hospital3 **] from an outside hospital and found to have gastric cancer. You had surgery which you are healing well from. You were seen by oncology and will follow up with them as an outpatient to determine your treatment plan. You remained in the hospital because you developed atrial fibrillation with a rapid heart rate. Your dose of atenolol was increased and you were started on diltiazem. You had a CT scan of your chest to look for a blood clot causing irritation of your heart. This was negative for evidence of a blood clot although the final read of this study is pending at your time of discharge. Please follow up with your primary care provider to obtain the final read of your chest CT scan. You have been started on a bowel regimen. Please contact your primary care doctor if you stop moving your bowels or if you stop passing gas. Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**6-20**] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. The following medications were started: -Diltiazem 180mg sustained release daily for a fib -colace 100mg twice a day as needed as a stool softner -senna 1 tab twice a day as needed for constipation -calcium 500mg twice a day The following medications were changed in dose: -atenolol was increased to 50mg twice a day -glyburide was decreased to 2.5mg daily The following medications were stopped: -lisinopril 10mg daily (should be restarted by your primary care doctor if your blood pressure is not too low) -pericolace (separate colace and senna was started) The following medications were continued at their previous doses: -ASA 81mg daily -Lipitor 10mg daily -Methadone 15mg in the am, 10mg at noon, 10mg before bed -Combivent 2 puffs four times a day -Advair 2 puffs daily -Oxycodone APAP 5/325 as needed for pain -Miralax as needed for constipatiion Followup Instructions: Please call the Acute Care Service at [**Telephone/Fax (1) 600**] to make an appointment within 2-3 weeks for surgical follow up. . Please call Dr. [**Last Name (STitle) 14879**] at [**Telephone/Fax (1) 32949**] to make an appointment within 3 days to have your INR checked and your heart rate checked. . Department: HEMATOLOGY/ONCOLOGY When: FRIDAY [**2185-11-25**] 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 Completed by:[**2185-12-23**]

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Discharge summary

report

Admission Date: [**2110-11-30**] Discharge Date: [**2110-12-10**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1234**] Chief Complaint: Abdominal aortic aneurysm. Major Surgical or Invasive Procedure: Aortic stent graft repair of abdominal aortic aneurysm with a Zenith device History of Present Illness: 85M pre-op for endovascular AAA (5.3 cm), Here for elective repair of AAA. Past Medical History: 1. Parkinson's Disease 2. Hypertension 3. NIDDM 4. h/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 329**] [**Doctor Last Name **] tear 5. Scoliosis/Kyphosis 6. Stable pericardial effusion, last echo [**10-28**] at [**Location (un) **] (followed by Kanam) 7. sleep disorder 8. h/o AAA Social History: lives with wife. [**Name (NI) **] [**Name2 (NI) 269**] used. Quit tobacco many years ago, but smoked [**2-27**] cigarettes/day x 10 years. Veteran. Retired, worked in advertising. Denies alcohol use Family History: NC Physical Exam: PE: AFVSS NEURO: PERRL / EOMI MAE equally Answers simple commands Neg pronator drift Sensation intact to ST 2 plus DTR Neg Babinski HEENT: NCAT Neg lesions nares, oral pharnyx, auditory Supple / FAROM neg lyphandopathy, supra clavicular nodes LUNGS: CTA b/l CARDIAC: RRR without murmers ABDOMEN: Soft, NTTP, ND, pos BS, neg CVA tenderness EXT: rle - palp fem, [**Doctor Last Name **], pt, dp lle - palp fem, [**Doctor Last Name **], pt, dp Pertinent Results: [**2110-12-6**] RENAL U.S. COMPARISON: CT of the abdomen dated [**2110-12-2**]. RENAL [**Month/Day/Year **]: The right kidney measures 10.1 cm. The left kidney measures 11.2 cm. There is no hydronephrosis, stone or solid renal mass identified. There are a couple of simple renal cysts of the left kidney, the largest of which is at the upper pole, measuring up to 4.0 cm in largest diameter. The bladder is collapsed. IMPRESSION: No hydronephrosis. Left renal cysts. [**2110-12-5**] Cardiology Report ECG Compared to the previous tracing the ventricular response rate to atrial fibrillation is slightly slower at 110. Intervals Axes Rate PR QRS QT/QTc P QRS T 112 0 84 368/434.42 0 31 -14 [**2110-12-2**] ECHO Study MEASUREMENTS: Left Atrium - Long Axis Dimension: 3.9 cm (nl <= 4.0 cm) Right Atrium - Four Chamber Length: 5.0 cm (nl <= 5.0 cm) Left Ventricle - Septal Wall Thickness: 0.9 cm (nl 0.6 - 1.1 cm) Left Ventricle - Inferolateral Thickness: 0.8 cm (nl 0.6 - 1.1 cm) Left Ventricle - Diastolic Dimension: 4.0 cm (nl <= 5.6 cm) Left Ventricle - Systolic Dimension: 2.2 cm Left Ventricle - Fractional Shortening: 0.45 (nl >= 0.29) Left Ventricle - Ejection Fraction: >= 60% (nl >=55%) Aorta - Valve Level: 3.3 cm (nl <= 3.6 cm) Aorta - Ascending: 3.3 cm (nl <= 3.4 cm) Aortic Valve - Peak Velocity: 1.0 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 0.9 m/sec Mitral Valve - A Wave: 0.3 m/sec Mitral Valve - E/A Ratio: 3.00 Mitral Valve - E Wave Deceleration Time: 287 msec TR Gradient (+ RA = PASP): *47 mm Hg (nl <= 25 mm Hg) Pericardium - Effusion Size: 2.8 cm INTERPRETATION: LEFT ATRIUM: Normal LA size. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function (LVEF>55%). False LV tendon (normal variant). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic root diameter. Normal ascending aorta diameter. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Moderate [2+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Significant PR. The end-diastolic PR velocity is increased c/w PA diastolic hypertension. PERICARDIUM: Large pericardial effusion. Effusion circumferential. No significant respiratory variation in mitral/tricuspid valve flows. Echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. Conclusions: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Right ventricular chambersize and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are structurally normal. Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. Significant pulmonic regurgitation is seen. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is a large, circumferential, echolucent pericardial effusion extending 2-2.8cm around the right and left ventricles. There is mild right ventricular diastolic invagination, but no respiratory accentuation of transmitral E wave velocity. Echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. Compared with the report of the prior study (tape unavailable for review) of [**2109-6-13**], the size of the pericardial effusion is larger, and mild right ventricular diastolic collapse is now seen. Based on [**2102**] AHA endocarditis prophylaxis recommendations, the echo findings indicate a moderate risk (prophylaxis recommended). Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. [**2110-12-2**] CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS CT ANGIOGRAM: Atheromatous plaque along the normal caliber included portion of the lower descending thoracic aorta, the upper abdominal aorta is normal in caliber measuring 2.3 cm. The common hepatic and splenic arteries have separate origins. Interval Endo stent repair of the infrarenal abdominal aortic aneurysm with the stent graft extending from less than 1 cm above the origin of the renal arteries,both of which are patent. The stented aorta measures less than 2 cm AP at the level of the renal artery origins. No evidence of endoleak. The infrarenal aneurysm sac at its largest measures up to 5.1 cm AP x 5 cm transverse (series 3A, image 93). Distal stent limbs extend to the mid right common iliac and distal left common iliac artery. Both internal and external iliac arteries are normal in caliber and patent. Minor retrograde filling of the [**Female First Name (un) 899**] noted. CT SCAN OF ABDOMEN WITH INTRAVENOUS CONTRAST: Large pericardial effusion measuring up to 4 cm in depth (larger than on the prior CT of [**2110-7-25**]). Small bibasilar pleural effusions, left lower lobe collapse and partial atelectasis of the posterior right lower lobe. Nasogastric tube in situ with the tip lying in the nondistended gastric body. The liver, spleen, pancreas, both adrenal glands appear normal. A small amount of free intraabdominal fluid mainly along the right pericolic gutter and mild circumferential thickening of the gallbladder wall. These findings with the appearances of the lung base may be secondary to cardiac congestion, for example. No intra- or extrahepatic biliary dilatation. Some vicarious excretion of contrast noted within the gallbladder. Some residual contrast noted in both kidneys on enhanced CT following recent angiography. Both kidneys show symmetric post-contrast enhancement. Hyopattenuating, partially exophytic renal cortical cyst arising from the left upper pole medially measures up to 3.9 cm. No abnormal large bowel loop dilatation or focal segmental stricture to strongly suggest ischemic bowel on the CT. CT SCAN OF PELVIS WITH INTRAVENOUS CONTRAST: No free pelvic fluid. Urinary catheter within the bladder, which is empty at the time of scanning. No bone lesions demonstrated. Degenerative change noted in the lumbar spine with moderate lumbar scoliosis convexed to the left side. CONCLUSION: 1. No abnormal bowel loop dilatation or segmental thickening to strongly suggest bowel ischemia on the current CT. Celiac and superior mesenteric artery are widely patent. 2. Interval Endo stent repair of the infrarenal abdominal aortic aneurysm. No evidence of endoleak. The infrarenal aneurysm sac measures up to a maximal diameter 5.1 cm AP. [**2110-11-30**] GLUCOSE-106* UREA N-46* CREAT-1.4* SODIUM-137 POTASSIUM-4.5 CHLORIDE-100 TOTAL CO2-22 ANION GAP-20 [**2110-11-30**] URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.011 [**2110-11-30**] PT-13.8* PTT-28.7 INR(PT)-1.3 [**2110-11-30**] PLT COUNT-135* [**2110-11-30**] WBC-7.1 RBC-4.25* HGB-12.8* HCT-37.2* MCV-88 MCH-30.1 MCHC-34.4 RDW-14.3 [**2110-11-30**] CALCIUM-9.8 PHOSPHATE-3.7# MAGNESIUM-2.2 Brief Hospital Course: Pt admittted 11/06/05admitted for preoperative hydration. [**2110-12-1**] Endovascular AAA repair with Zenith stent graft.Developed hypotension and acidosis with respiratory arrest post ativan sedation ( patient with history of sleep apnea). Patient intubated( for airway protection ) and transfered to ICU.Patient's cardiac enzymes ck/mb negative. elevated troponin 0.3 but patient with renal insuffiency (cr 1.9) EKG no acute changes.Patient required vasopressors for hemodymainac support.T max 103-102 WBC 17.3 CXR with volume overload. Patient diuresed. [**Date range (1) 96282**] cardology reconsulted for hypotension and bradycardia.Check TSH to r/o hypothyroism secondary to amiodarone.TSH 2.5 cortisol insuffiency. started on cortisone.Continued on broad spectrum antibiotics. [**Last Name (un) **] consullted for glycemic control. Transplant consultedfor ? abdominal sepsis. liver function tests normal.They did not feel there was an abdominal source for patient's elevated white count of fever. GI consulted for guiac positive stools and loose stools. CTA of abd negative for ischemic bowel.Sigmoidoscopy defered for concerns of seeding endovascular prothesis and lack of evidence for bowel ischemia ie rectal bleeding.C.diff sent x2 which have been negative.Patient will require continued diuresis over the next seven days with a potassium supplement. See patient's d/c rx. Patients amidarone is on a wean. Please see d/c rx for instructions.Patient will need to followup with Dr. [**Last Name (STitle) **] [**2-27**] weeks. please call for appointment. [**Telephone/Fax (1) 1241**]. [**2110-12-10**] Patient will d/c to rehab with foley inplace. Please d/c on arrival, Medications on Admission: Sinemet 25/100"', Mirapex 0.5"', Lopressor 50", triamterene 37.5 QOD, HCTZ 25 QOD Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 2. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 3. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): [**Month (only) 116**] DC on [**2110-12-15**]. 4. Pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 9. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 days: End of steroid taper. Stop on [**2110-12-10**]. 10. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: Abdominal aortic aneurysm atrial fibrillation respiratory distress,( reinbuated ) non-iorn gap metabolic acidosis cortisol non-responder postoperative hypootension secondary to adrenal insuffiency postoperative bradycardia history of Parkinsons's history of Dm2, noninsulin dependant history of [**Doctor First Name **] -[**Doctor Last Name **] tear history of scoliosis/kyphosis history of percardial effusion, stable, last echo [**10-28**] @ [**Location (un) 620**]( followed by Dr. [**Last Name (STitle) 8906**] history of sleep apnea Discharge Condition: Stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOLLOWING ENDOVASCULAR AORTIC ANEURYSM SURGERY . This information is designed as a guideline to assist you in a speedy recovery from your surgery. Please follow these guidelines unless your physician has specifically instructed you otherwise. Please call our office nurse if you have any questions. Dial 911 if you have any medical emergency. . ACTIVITY: . There are no specific restrictions on activity. You should be as active as is comfortable. Resume driving when you are comfortable without the need for pain medication. . PLEASE CALL US IMMEDIATELY FOR ANY OF THE FOLLOWING PROBLEMS: . Redness in or drainage from your incisions . . New pain, numbness or discoloration of your feet or toes . . New abdominal or back pain. . Watch for signs and symptoms of infection. These are: a fever greater than 101 degrees, chills, increased redness, or pus draining from the incision site. If you experience any of these or bleeding at the incision site, CALL THE DOCTOR. . Exercise: . Limit strenuous activity for 4 weeks. . Resume driving when you are comfortable without the need for pain medication. . No heavy lifting greater than 20 pounds for the next 7 days. . BATHING/SHOWERING: . You may shower immediately upon coming home. No bathing. Dissolving sutures, which do not have to be removed were probably used. Your wounds are covered with a clear, plastic dressing which should be left in place for three (3) days. Remove it after this time and wash your incisions gently with soap and water. . You may have staples. . WOUND CARE: . Sutures / Staples may be removed before discharge. If they are not, an appointment will be made for you to return for removal. . When the sutures / staples are removed the doctor may or may not place pieces of tape called steri-strips over the incision. These will stay on about a week and you may shower with them on. If these do not fall off after 10 days, you may peel them off with warm water and soap in the shower. . MEDICATIONS: . Unless told otherwise, you should continue taking all of the medications that you were on before surgery. You will be given a new prescription for pain medication, which should be taken every three (3) to four (4) hours if necessary. . Remember that narcotic pain meds can be constipating and you should increase the fluid and bulk foods in your diet. (Check with your physician if you have fluid restrictions.) If you feel that you are constipated, do not strain at the toilet. You may use over the counter Metamucil or Milk of Magnesia. Appetite suppression may occur; this will improve with time. Eat small balanced meals throughout the day. . CAUTIONS: . NO SMOKING! We know you've heard this before, but it really is an important step to your recovery. Smoking causes narrowing of your blood vessels which in turn decreases circulation. If you smoke you will need to stop as soon as possible. Ask your nurse or doctor for information on smoking cessation. . Avoid heavy lifting (over 10 pounds) for 4-6 weeks after surgery. . No strenuous activity for 4-6 weeks after surgery. . DIET: . There are no special restrictions on your diet postoperatively. Poor appetite is expected for several weeks and small, frequent meals may be preferred. . For people with vascular problems we would recommend a cholesterol lowering diet: Follow a diet low in total fat and low in saturated fat and in cholesterol to improve lipid profile in your blood. Additionally, some people see a reduction in serum cholesterol by reducing dietary cholesterol. Since a reduction in dietary cholesterol is not harmful, we suggest that most people reduce dietary fat, saturated fat and cholesterol to decrease total cholesterol and LDL (Low Density Lipoprotein-the bad cholesterol). Exercise will increase your HDL (High Density Lipoprotein-the good cholesterol) and with your doctor's permission, is typically recommended. You may be self-referred or get a referral from your doctor. . If you are overweight, you need to think about starting a weight management program. Your health and its improvement depend on it. We know that making changes in your lifestyle will not be easy, and it will require a whole new set of habits and a new attitude.. If interested you can may be self-referred or can get a referral from your doctor. . If you have diabetes and would like additional guidance, you may request a referral from your doctor. FOLLOW-UP APPOINTMENT: . Be sure to keep your medical appointments. The key to your improving health will be to keep a tight reign on any of the chronic medical conditions that you have. Things like high blood pressure, diabetes, and high cholesterol are major villains to the blood vessels. Don't let them go untreated! . You should be seen in the office approximately ten (10) days to two (2) weeks following discharge from the hospital. A CT scan of the abdomen will have to be preformed just prior to that visit and this will be scheduled with your visit when you call the office. . Please call the office on the first working day after your discharge from the hospital to schedule a follow-up visit. Normal office hours are 8:30-5:00 Monday through Friday. . PLEASE CALL THE OFFICE WITH ANY QUESTIONS OR CONCERNS THAT MIGHT DEVELOP. Followup Instructions: Call Dr [**Last Name (STitle) 27977**] office and schedule an appointment for 2 weeks. He can be reached at [**Telephone/Fax (1) 1241**]. Completed by:[**2110-12-10**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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Discharge summary

report

Admission Date: [**2144-1-17**] Discharge Date: [**2144-2-6**] Date of Birth: [**2089-4-29**] Sex: F Service: MEDICINE Allergies: Penicillins / Aspirin / Ciprofloxacin Attending:[**First Name3 (LF) 348**] Chief Complaint: transfer to ICU s/p stroke Major Surgical or Invasive Procedure: Tunnelled catheter placement Picc line placement History of Present Illness: The pt is a 54 year-old portuguese speaking woman with a PMH insulin dependent DM with nephropathy and neuropathy, HTN, PVD, and acute on chroni renal failure who was transferred from [**Hospital **] hospital after being found to have decreased movement of the left arm > left leg. . The patient was admitted to the OSH on [**2144-1-16**] with a CC of decreased PO intake. Per the patient's daughter, the patient was discharged from the hospital on [**2144-1-7**] after an admission for RLE wound related to her diabetes. She was discharged home with a woundvac, a PICC line and plan for 6 weeks of cefepime for osteomyelitis. She was somnolent at home and the daughter brought her Mother in because she felt that she was still ill. Importantly the daughter describes bilateral hand shaking - left prior to right that was occuring several times a day. Apparently the patient was aware of these movements and never lost consiousness during them. She was noted on admission to the OSH to have worsening renal failure with BUN61 and Cr 4.7. She underwent a swallow eval, at which time she choked, leading to respiratory distress, and was intubated. The patient was apparently evaluated by a "Stroke Team" and per the [**Location (un) **], the patient was supposed to go [**Hospital3 2576**] [**Hospital3 **], but there was no available ICU bed and so the patient was sent here. . At [**Hospital1 18**], pt had MRI/MRA and CT which showed a subacte infarct involving the R globus pallidus and internal capsule. She was not given TPA and instead started on plavix. Past Medical History: GERD DMII with neuropathy and renal failure. Renal Failure - chronic/acute HTN Right foot osteomyelitis. Peripheral Vascular Disease. anxiety/depression Social History: Patient is married, however she has been living with her daughter, [**Name (NI) **], who has been taking care of her. Family History: NC Physical Exam: Vitals: T:99.1 P:78 R:20 BP:147/69 SaO2:100% on assist control. General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx. Hirsuit. Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, soft, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, obese. Extremities: Severe wound on RLE - including necrotic deep wound. Pertinent Results: IMAGING: OSH-EKG: Sinus tach at 105, normal axis, normal intervals, no acute t-wave St-segment abnormalities. . OSH CT - with small vessle ischemic changes. Also a possibility for right basal ganglia/internal capsule hypodensity. . NCHCT - Subacute infarct involving the right globus pallidus and internal capsule. No intracranial hemorrhage is identified. . MRI - Diffusion and adc abnormalities in the area corresponding to the NCHCT. MRA was normal. . Renal U/S - Limited study without evidence of hydronephrosis or large mass. . Foot XR - no areas of bony erosion are seen to suggest osteomyelitis. . ECHO - the left atrium is normal in size. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. Suboptimal image quality - patient unable to cooperate. . NIAS - bilateral tibial arterial disease; vessels non-compressible . Carotid U/S - no significant stenosis . Vein Mapping - IMPRESSION: Patent bilateral basilic veins and left cephalic vein. Normal bilateral brachial arteries with triphasic Doppler waveforms. The right subclavian vein was visualized and is patent with preserved phasicity. . Bone Scan - IMPRESSION: Abnormal study with intense increased radiotracer uptake on all three phases in the right ankle region. This is a non-specific finding and infection vs fracture vs charcot joint or a combination of these entities remain within the differential. An indium labeled WBC scan may be obtained for further differentiation as clinically [**Name (NI) 9304**]. . [**2144-2-7**] p-MIBI: normal wall motion, no perfusion defect, no changes on EKG, no symptoms manifested with test. . MICRO: OSH Wound Cx - group B strep, pseudomonas aeruginosa OSH BCx - No growth UCx - enterococcous, R to Amp, S to Vanco WCx - strep, coag neg BCx - NGTD . IMPRESSION: No anginal symptoms or ECG changes from baseline. Nuclear report sent separately. . Labs on admission: [**2144-1-17**] GLUCOSE-142* UREA N-58* CREAT-4.8* SODIUM-148* POTASSIUM-5.6* CHLORIDE-119* TOTAL CO2-19* ANION GAP-16 CALCIUM-8.4 PHOSPHATE-4.5 MAGNESIUM-2.0 . WBC-8.2 RBC-3.11* HGB-8.5* HCT-28.2* MCV-91 MCH-27.4 MCHC-30.2* RDW-16.6* PLT COUNT-309 . PT-17.0* PTT-29.4 INR(PT)-1.5* TSH-2.1 CK-MB-4 cTropnT-0.05* ALT(SGPT)-10 AST(SGOT)-11 CK(CPK)-51 . URINE BLOOD-MOD NITRITE-NEG PROTEIN-100 GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-SM Brief Hospital Course: Ms. [**Known lastname 7563**] is a 54 year-old female with an extensive past medical history including DM, PVD, HTN, and nephropathy transferred for acute stroke and possible TPA. Based on the imaging there was no vascular cutoff on which to intervene despite a subacute infarct in the right thalmus/internal capsule. . The patient presented with a subacute CVA with residual left-sided upper extremity weakness. CT head ([**2144-1-17**]) revealed subacute infarct involving the right globus pallidus and internal capsule. MRI brain ([**2144-1-17**]) revealed correlated increased signal intensity in the posterior limb of the internal capsule. There was no hemorrhage. Given the subacute nature of the injury, the patient was not a candidate for lysis therapy. The patient was placed on clopidogrel and statin therapy. Aspirin therapy was deferred due to a history of an aspirin allegy. The patient's systolic blood pressue was targeted to 140-180 to maintain adequate watershed perfusion. On carotid ultrasound the patient had no significant stenosis. Lower extremity ultrasound did reveal bilateral tibial artery disease. Echo on [**2144-1-20**] was a limited study though revealed no intracardiac source of embolus and no PFO. The patient requires physical rehabilitation and will follow-up in the outpatient stroke clinic for further care. . # CV: The patient's EKG showed T wave flattening in I and aVL in the setting of negative serial cardiac enzymes. A TTE showed and EF > 55%. She was started on po Lopressor. . # Respiratory: The patient has a brief stay in the ICU including intubation for likely volume overload. She was extubated on [**1-18**] and slowly weaned to 3L O2 NC. On the medicine floor she desat'd x 2 to mid 70's and mid 60's -> however ABG was unchanged. CXR [**1-19**] showed fluid overload, and she was given Lasix 20mg IV and 0.5 in nitropaste for hypertension. She subsequently had continued improvement in respiratory function especially with establishment of scheduled hemodialysis to control volume overload. . # ID. The patient was admitted to [**Hospital6 8972**] 11.16.07-12.03.07 with complaints of right foot erythema, warmth and drainage from foot ulcer. She had a foot ulcer that probed to bone at that time and MRI revealed bony changes concerning for osteomyelitis. The patient underwent podiatric debridement at the OSH at that time and cultures from that procedure grew group B strep and pseudomonas. She was started on a 6 week course of vanc and cefepime with plans for outpatient podiatry follow-up. The patient was re-admitted and transferred to [**Hospital1 18**] prior to completion of this antibiotic course. On [**2144-1-24**] the patient was changed to vanc and ceftriaxone out of concern for cefepime induced AIN contributing to renal failure. He will complete a total of 6 week course as planned (to be completed on [**2144-2-4**]) with outpatient podiatry follow-up. She underwent bone scan on [**2144-1-23**] with signs of abnormal tracer uptake in the ankle of unclear significance possibly consistent with osteo, fracture or chacot foot. The patient had a repeat MRI while in the hospital at [**Hospital1 18**] revealing bony abnormalities consistent with osteomyelitis though also possibly consistent with charcot foot. The patient also underwent lower extremity vascular studies revealing no clear intervenable vascular deficits. The paitent was evaluated by the inpatient podiatry and vascular surgery consult services both of whom recommended no immediate intervention, instead favoring completion of 6 week antibiotic course and outpatient follow-up. The patient's urine also grew enterococcus and vancomycin therapy as above was continued to treat this infection. She will have follow-up with podiatry. She completed a course of antibiotics on [**2144-2-4**] with antiobitics being dosed with hemodialysis. She had frequent wound care. She remained afebrile for the remainder of her course. . # Renal: The patient was transferred with acute on chronic renal failure. Her prior baseline Cr was in the range of [**4-7**]. Her Cr continued to rise and in the setting of volume overload the patient was initiated on hemodialysis after right subclavian tunnelled HD catheter placement on [**2144-1-22**]. She underwent vein mapping for possible future fistula placement in the event of prolonged HD needs. The etiology of the patient's renal failure was felt multifactorial. On renal U/S on [**2144-1-17**] the patient had 10-11cm kidneys without hydronephrosis. UA was consistent with significant proteinuria and infection. Culture eventually grew enterococcus which was treated with vancomycin as described above. Ueos were positive and microscopy revealed sheets of WBC's concerning for AIN. At that time the patient's antibiotic regimen was changed fom vanc and cefepime to vanc and ceftazidime out of concen fo cefepime-induced AIN. Urine micoscopy also revealed muddy brown castst consistent with ATN possibly due to hypotension at the time of recent CVA. At the time of discharge, the patient is HD dependent. She likely has baseline diabetic nephropathy complicated by AIN and ATN. SPEP and UPEP showed polyclonal hypergammaglobulinemia and no Bence-[**Doctor Last Name **] protein. The renal team felt that this was unlikely to contribute to her renal failure. Of note, on [**2144-2-1**] the patient had an episode of hypotension, diaphoresis and nausea while on HD after removal of 1L of fluid. HD was discontinued, she was given IVF bolus and blood cultures were sent. Likely this represents hypovolemia due to overdialysis. Again, on [**2144-2-3**], she had an episode of hypotension with HD, which resolved with IVF. It was decided to keep the patient in house for a cardiac stress test prior to discharge as hypotension with HD may indicate underlying coronary artery disease. The p-MIBI was not concerning for ischemia (see above report). . # Shoulder pain: Tendonitis, tendon tears and labral tears were seen on MR. She was evaluated by the orthopedic team who felt that no acute intervention was warranted and she should continue antiinflammatory medications and physical therapy. She will follow-up in outpatient orthopedic clinic and should get repeat MRI in [**7-16**] months. . # Elevated INR: The patient received Vitamin K 5mg daily for 3 days. . # Anemia: Procrit was started with hemodialysis. Her anemia was felt to be secondary to her renal failure. She will need outpatient hemodialysis to be continued on a Monday, Wednesday, Friday scheduled. . # DM: She was maintained on an insulin sliding scale as well as standing dosages of humalog adjusted to 6 units TID with meals. We recommend increasing this standing dosage of humalog to 8 units TID with meals. She was admitted on a novolog sliding scale which will likely need to be adjusted at rehabilitation and as an outpatient. We recommend outpatient followup to optimize her blood sugar control. . # Diet: The patient was seen by speech and swallow and recommended thin liquids and soft solids. . Medications on Admission: Eucerin Cream Novolog sliding scale (46/32 of 70/30) Levemir - being held. Protonix 40IV daily Labetalol 100 [**Hospital1 **] Norvasc 500mg PO daily (suppose this is 50mg daily) Calcium/Tums x2 tablets TID Cefepime - 6 week course dose uncertain. Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Sevelamer 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 8. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 9. Collagenase 250 unit/g Ointment Sig: One (1) Appl Topical DAILY (Daily). 10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 11. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QHD (each hemodialysis). 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 13. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 14. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 15. Insulin Lispro 100 unit/mL Solution Sig: Eight (8) units Subcutaneous three times a day. 16. Humalog 100 unit/mL Solution Sig: SLIDING SCALE (SEE BELOW) Subcutaneous TID WITH MEALS: For blood sugars 151-200 mg/dL, please give 3 units of insulin; for blood sugar 201-250 mg/dL, please give 5 units of insulin; for blood sugar 251-300 mg/dL, give 7 units of insulin; for blood sugar 301-350 mg/dL, give 9 Units of insulin; for 351-400 mg/dL, give 11 units of insulin. If blood sugar> 400 mg/dL Notify M.D. . Discharge Disposition: Extended Care Facility: [**Hospital 8971**] Rehabilitation Center (at [**Hospital6 8972**]) - [**Location (un) 8973**] Discharge Diagnosis: Primary: Acute renal failure Osteomyelitis Cerebrovascular accident Secondary: Diabetes HTN Peripheral vascular disease Chronic kidney disease Discharge Condition: Stable Discharge Instructions: You were trasferred from another hospital for treatment of your stroke. You have been started on a number of new medications to reduce your future risk of stroke. You were found to have worsened function of your kidneys, requiring initiation of dialysis. It is difficulty to say how long you will need to remain on dialysis. You were also treated for an infection of your foot, which will require intravenous antibiotics which can be given at your dialysis. Take your medications as prescribed below and follow up with your doctors [**First Name (Titles) 3**] [**Last Name (Titles) 9304**] below. . You should seek medical attention if you develop fever>101, chills, nausea, vomiting, lightheadedness, weakness or numbness, or any other concerning symptoms. Followup Instructions: Follow up with Podiatry, Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) **]) Wednesday, [**2143-2-12**] 1PM [**Hospital Ward Name **] 3 [**Hospital Ward Name 517**] [**Hospital3 **] Deaconness. . Follow up in [**Hospital 4038**] Clinic, Dr. [**First Name (STitle) **] in [**3-9**] weeks after discharge. Phone # [**Telephone/Fax (1) 2574**]. . Follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 41488**] ([**Telephone/Fax (1) 41489**]). Please call to schedule an appointment when you leave rehabilitation. . Orthopaedics for shoulder pain with Dr. [**Last Name (STitle) 2719**] ([**Telephone/Fax (1) **]) [**2143-2-28**] 8:50AM [**Last Name (un) 469**] 2 [**Hospital Ward Name 516**] [**Hospital3 **] Deaconness.

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icd9cm

[ [ [] ] ]

[ "38.95", "39.95", "96.71" ]

icd9pcs

[ [ [] ] ]

14544, 14665

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2768, 4997

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Discharge summary

report+addendum

Admission Date: [**2142-4-25**] Discharge Date: [**2142-5-18**] Date of Birth: [**2094-7-8**] Sex: M Service: CARDIOTHORACIC Allergies: Norvasc Attending:[**First Name3 (LF) 165**] Chief Complaint: orthopnea, shortness of breath Major Surgical or Invasive Procedure: [**2142-5-1**] 1. Aortic valve replacement with a size 25-mm St. [**Male First Name (un) 923**] Regent mechanical valve. 2. Mitral valve repair with a size 30 GC Future ring. 3. Coronary artery bypass graft times 4 with left internal mammary artery to left anterior descending artery and saphenous vein grafts to diagonal obtuse marginal and right coronary arteries History of Present Illness: 47 yo M with ESRD on peritoneal dialysis awaiting kidney transplant presented to [**Hospital 16843**] hospital with profound orthopnea. On [**Holiday **] sunday he first began noting DOE and went to his PCP who prescribed Azithromycin. However his symptoms continued to worsen and he eventually went to [**Hospital 16843**] hospital ED for evaluationi. He denied chest pain, lightheadedness, palpitations and no weight gain. He also denied fevers, chills. However his trop was 5 in ED and he had ST-depression in lateral leads and he was treated for presumed NSTEMI with asa /metoprolol/statin and heparin gtt. He was also found to have bilateral lower infiltrates and started on empiric ceftriaxone/ azithromycin. An echo was performed that showed EF 40-45% and severe AI as well as possible aortic valve vegetation. He was also transfused 3U pRBCs for Hct 24. He was transfered to [**Hospital 498**] medical for TEE. At that time he was started on Vanc/ceftriaxone and heparin was stopped given high INR. He underwent a cath that showed boderline low cardiac output and elevated wedge pressures, mod pulm hypertension. He was found to have 95% left main stenosis and 90% LAD and 90% circumflex Cultures from [**Location (un) 16843**] until that point were negative. TEE showed 10X10mm vegetation on the non-coronary cusp with severe AI and hypokinetic RV as well as PFO and left-->right shunt. There was also mod-severe MR. [**First Name (Titles) **] [**Last Name (Titles) **] were changed to Gentamicin/Vancomycin and Ceftazidime (given LFT bump). . He underwent the placement of a dialysis catheter in the left internal jugular and thereafter received hemodialysis. He was dialysed daily for several days and was negative 3L per day. He received EPO with dialysis and Hct was stable. 6 blood cultures (4 at [**Location (un) **] and 2 at [**Hospital1 **]) were NGTD. He was transferred to [**Hospital1 18**] for surgical evaluation. Past Medical History: Outside Hospital: Non ST Elevation myocardial infarction Community acquired pneumonia Hemodialysis with temporary dialysis catheter placed at [**Hospital **] medical Dental extractions [**2142-4-19**] for tooth decay Short term memory loss Chronic back pain Mitral regurgitation Aortic regurgitation Aortic valve endocarditis Past Medical History: Chronic kidney disease stage 5 - on transplant list End stage renal disease on peritoneal dialysis- 1 year Anemia of chronic disease Hypertension Diabetes mellitus type 2 Barretts esophagus Colonic polyps Retinopathy/retinal hemorrhage Past Surgical History: Bilateral eye surgery due to bleeding Bilateral [**Last Name (un) 8509**] Surgery Tonsillectomy Peritoneal dialysis shunt placement Social History: -Tobacco history: none -ETOH: no alcohol in past 3 years, used to drink 6 beers/day -Illicit drugs: occasional marijuana use Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. . Mother died of MI at age 51; Father died of CVA at 59 Physical Exam: VS: T: 96.4 120/71 97 28 100%RA= GENERAL: anxious, breathing quickly but not in distress Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of ~15cm CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. systolic and diastolic murmur LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB except for mild crackles at bases. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: warm well perfused, bilateral toes appear erythematous at the distal end, no skin breaks, sensitive to touch and movement, no swelling noted around the toes, darkned appearance to dorsum of toes bilaterally. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [**2142-5-1**] Echo: PREBYPASS: Moderately decreased LV systolic function: LVEF = 30-35% with global HK. The left atrium is moderately dilated. No spontaneous echo contrast is seen in the left atrial appendage. A patent foramen ovale is present. There is severe symmetric left ventricular hypertrophy. The left ventricular cavity is severely dilated. The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. The diameters of aorta at the sinus, ascending and arch levels are normal. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is a moderate-sized vegetation on the aortic valve. Severe (4+) aortic regurgitation is seen. There is severe mitral annular calcification. Moderate to severe (3+) mitral regurgitation is seen. The mitral regurgitation vena contracta is >=0.7cm. There is no pericardial effusion.Coronary sinus is normal. POSTBYPASS: Improved LV systolic function with LEVF = 40-45% with paradoxical septal motion consistent with RV pacing. MV with no significant MR [**First Name (Titles) **] [**Last Name (Titles) **] after ring placed. AV with no significant AS or AI following 25mm [**First Name8 (NamePattern2) **] [**Male First Name (un) **] mechanical valve. RV function remains moderately to severely decreased despite milrinone, epinephrine and adequate ventialtion and oxygenation. [**2142-4-27**] Head CT: No acute intracranial process. If there is a high clinical concern for septic emboli, MRI can be considered, as it would be a more sensitive technique for the detection of small abscesses. [**2142-5-16**] CXR: Left pleural effusion is small. Cardiomegaly is stable. Right PICC remains in place in standard position. There are multifocal subsegmental left mid and lower atelectases. There is no evident pneumothorax. Sternal wires are aligned. [**2142-4-25**] 08:15PM BLOOD WBC-13.6* RBC-3.03* Hgb-9.4* Hct-28.3* MCV-93 MCH-31.1 MCHC-33.3 RDW-20.7* Plt Ct-82* [**2142-5-2**] 04:13AM BLOOD WBC-25.1* RBC-2.91* Hgb-9.1* Hct-25.6* MCV-88 MCH-31.2 MCHC-35.5* RDW-18.5* Plt Ct-178 [**2142-5-11**] 02:55AM BLOOD WBC-18.7* RBC-4.03* Hgb-11.8* Hct-35.5* MCV-88 MCH-29.2 MCHC-33.2 RDW-16.4* Plt Ct-157 [**2142-5-17**] 04:13AM BLOOD WBC-17.4* RBC-3.68* Hgb-10.7* Hct-31.7* MCV-86 MCH-29.2 MCHC-33.9 RDW-16.0* Plt Ct-237 [**2142-4-25**] 08:15PM BLOOD PT-15.8* PTT-26.5 INR(PT)-1.4* [**2142-5-9**] 06:28AM BLOOD PT-16.8* PTT-109.6* INR(PT)-1.5* [**2142-5-10**] 01:12AM BLOOD PT-28.5* PTT-96.8* INR(PT)-2.8* [**2142-5-12**] 02:26AM BLOOD PT-28.4* PTT-31.1 INR(PT)-2.7* [**2142-5-14**] 06:04AM BLOOD PT-25.7* INR(PT)-2.4* [**2142-5-15**] 05:45PM BLOOD PT-20.6* INR(PT)-1.9* [**2142-5-16**] 08:50AM BLOOD PT-23.5* PTT-32.7 INR(PT)-2.2* [**2142-5-17**] 04:13AM BLOOD PT-24.9* PTT-29.8 INR(PT)-2.4* [**2142-4-25**] 08:15PM BLOOD Glucose-125* UreaN-46* Creat-8.2* Na-138 K-4.6 Cl-102 HCO3-21* AnGap-20 [**2142-5-6**] 02:57AM BLOOD Glucose-120* UreaN-32* Creat-4.8*# Na-135 K-3.9 Cl-94* HCO3-29 AnGap-16 [**2142-5-17**] 04:13AM BLOOD Glucose-117* UreaN-83* Creat-8.5* Na-130* K-4.3 Cl-89* HCO3-25 AnGap-20 [**2142-4-25**] 08:15PM BLOOD ALT-593* AST-91* AlkPhos-111 TotBili-0.7 [**2142-5-7**] 02:53PM BLOOD ALT-18 AST-58* AlkPhos-264* TotBili-1.3 [**2142-5-17**] 04:13AM BLOOD Calcium-8.4 Phos-7.4* Mg-2.2 [**2142-5-18**] 04:02AM BLOOD PT-29.4* INR(PT)-2.9* Brief Hospital Course: Mr. [**Name14 (STitle) 88608**] was transferred from [**Hospital 498**] hospital for surgical management of his endocarditis and coronary artery disease. Upon admission he was appropriately medically managed, including multiple antibiotics and underwent extensive pre-operative work-up. This included usual lab work, echo, head ct and consultations for renal, ID, cardiology and neurology. In addition wound care specialist saw Mr. [**Name14 (STitle) 88608**] for a coccyx pressure ulcer pre and postoperatively. All consulted services followed him throughout his hospital course. On [**5-1**] he was brought to the operating room where he underwent an aortic valve replacement, mitral valve repair, and coronary artery bypass graft x 4. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring in critical but stable condition. Hemodynamics were augmented via pressors and inotropic support for several days immediately postop due to cardiogenic shock. Antibiotics for his endocarditis were recommended by ID. Per Renal recommendations CVVH was initiated until hemodynamics could tolerate HD. Mr.[**Known lastname 88609**] remained intubated until POD#6 due to volume overload. CVVH was discontinued and peritoneal dialysis was resumed. [**5-8**], pacing wires were discontinued, anticoagulation was initiated for his mechanical valve. He had an episode of VFib in which he was defibrillated and placed on an Amiodarone drip. Once weaned off all pressors and inotropy, beta-blocker/Statin and Aspirin were started. Postoperatively he had a persistent leukocytosis for which all lines were changed and he was repeatedly pan cultured. ID continued to follow. OR tissue culture showed no growth. No source identified for his elevated white count. Mr.[**Known lastname 88609**] had some agitation, confusion, and hallucinations postoperatively in which he was given Haldol. His mental status returned to baseline. He continued to slowly progress and on [**5-12**] he was transferred to the step down unit for further monitoring. Due to his deconditioning, Physical Therapy was consulted for evaluation of strength and mobility. ID/Renal/and the wound care consults followed with recommendations until Dr.[**First Name (STitle) **] cleared him for discharge on POD#17. Mr.[**Known lastname 88609**] was transferred to [**Hospital1 **], [**Location (un) 86**]. All follow up appointments were advised. Medications on Admission: MEDICATIONS (at home): Calcitriol 0.5mcg daily Epogen Folate 1mg daily Hydralazine 100mg TID Isosorbide dinitrate 10mg TID Lisinopril 40mg daily Lopressor 50mg [**Hospital1 **] Prilosec 20mg daily Phoslo 667 mg x4 TID . ' . Meds (on transfer): Lopressor 25mg [**Hospital1 **] Asa 81mg Daily Renagel 1600mg TID Heparin sc Colace Pepcid 20mg [**Hospital1 **] Bactroban/Peridex to the oral cavity [**Hospital1 **] Duonebs prn Nystatin powder to bilateral groin Oxycodone prn back/dental pain . Vancomycin 1500mg Q48hrs Ceftriaxone 2g after every dialysis Gentamicin Discharge Medications: 1. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 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 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-17**] Puffs Inhalation Q6H (every 6 hours) as needed for SOB. 6. calcium acetate 667 mg Capsule Sig: Three (3) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for sleep. 10. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 11. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 12. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 24H (Every 24 Hours): Discontinue [**2142-5-1**]. 13. cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection Q48H (every 48 hours): Discontinue [**2142-5-1**]. 14. epoetin alfa 2,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 15. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Continue until stopped by cardiologist. 16. warfarin 2 mg Tablet Sig: Two (2) Tablet PO once a day: Titrate for a goal INR of 2.5-3.0 for mechanical aortic valve and atrial fibrillation. 17. gentamicin in NaCl (iso-osm) 100 mg/100 mL Piggyback Sig: One (1) Intravenous every twenty-four(24) hours: If level <1 Discontinue [**5-1**]. 18. zinc sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily) for 7 days. 19. insulin glargine 100 unit/mL Cartridge Sig: 40 units Subcutaneous at breakfast. 20. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 21. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever/pain. 22. diphenhydramine HCl 12.5 mg/5 mL Elixir Sig: One (1) PO HS (at bedtime) as needed for sleep. 23. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2 times a day) as needed for constipation. 24. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. 25. Outpatient Lab Work Labs: PT/INR for Coumadin ?????? indication: Mechanical Aortic valve and atrial fibrillation Goal INR 2.5-3.0 First draw [**2142-5-19**]. Then every Monday, Wednesday and Friday 26. Outpatient Lab Work Please check weekly labs: CBC with differential/ Basal Metabolic Profile/ Gent trough/Vanco level, please fax results to #[**Telephone/Fax (1) 1419**] Discharge Disposition: Extended Care Facility: tbd Discharge Diagnosis: Aortic and Mitral valve endocarditis with valve regurgitation s/p Aortic valve replacement and mitral valve repair Coronary artery disease s/p Coronary artery bypass graft x 4 Past medical history: Non ST Elevation myocardial infarction Community acquired pneumonia Hemodialysis with temporary dialysis catheter placed at [**Hospital **] medical Dental extractions [**2142-4-19**] for tooth decay Short term memory loss Chronic back pain Past Medical History: Chronic kidney disease stage 5 - on transplant list End stage renal disease on peritoneal dialysis- 1 year Anemia of chronic disease Hypertension Diabetes mellitus type 2 Barretts esophagus Colonic polyps Retinopathy/retinal hemorrhage Past Surgical History: Bilateral eye surgery due to bleeding Bilateral [**Last Name (un) 8509**] Surgery Tonsillectomy Peritoneal dialysis shunt placement Discharge Condition: Alert and oriented x3 nonfocal Ambulating, deconditioned Incisional pain managed with oral analgesia Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. No edema Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**First Name (STitle) **] on [**6-8**] at 11:15AM Cardiologist: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] on [**5-21**] at 9:40AM. [**Hospital1 1559**] office ID: [**Doctor First Name **] [**Doctor Last Name **] on [**5-31**] at 11:50AM ID: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 9461**] on [**6-19**] at 2PM Please check weekly labs: CBC with differential/ Basal Metabolic Profile/ Gent trough/Vanco level, please fax results to #[**Telephone/Fax (1) 1419**] Please call to schedule appointments with your Primary Care Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 42305**] in [**3-20**] 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** Labs: PT/INR for Coumadin ?????? indication: Mechanical Aortic valve and atrial fibrillation Goal INR 2.5-3.0 First draw [**2142-5-19**]. Then every Monday, Wednesday and Friday [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2142-5-18**] Name: [**Known lastname 14070**],[**Known firstname 14071**] JR Unit [**Name2 (NI) **]: [**Numeric Identifier 14072**] Admission Date: [**2142-4-25**] Discharge Date: [**2142-5-18**] Date of Birth: [**2094-7-8**] Sex: M Service: CARDIOTHORACIC Allergies: Norvasc Attending:[**First Name3 (LF) 265**] Addendum: Last dose of Vanco 1000 mg IV was [**5-11**] with levels checked daily and >20. Gent level 0.9 on [**5-18**] and dose of 100 mg given (previously last dose had been [**5-13**]). All antibiotics to stop [**6-12**] (6 weeks from [**2142-5-1**] - date of surgery) Check daily Vanco/ Gent level - give Vanco dose for level <20 and Gent dose<1.0 until consistent dosing schedule can be arranged. Follow up labs as previously stated Discharge Disposition: Extended Care Facility: [**Hospital3 2215**] - [**Location (un) 42**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 266**] Completed by:[**2142-5-18**]

[ "414.01", "349.82", "263.9", "707.03", "285.1", "403.91", "599.0", "560.1", "286.9", "585.6", "785.51", "427.41", "416.8", "410.71", "396.3", "V45.11", "707.23", "285.21", "421.0", "276.69", "250.00", "518.5", "276.3", "V49.83" ]

icd9cm

[ [ [] ] ]

[ "38.91", "38.95", "36.15", "39.95", "96.04", "54.98", "38.93", "36.13", "99.62", "35.12", "39.61", "38.97", "96.72", "35.22", "89.64", "96.6" ]

icd9pcs

[ [ [] ] ]

18286, 18478

8216, 10686

303, 670

15096, 15323

4829, 6245

16246, 18263

3564, 3735

11300, 14149

14223, 14399

10712, 11277

15347, 16223

14942, 15075

3750, 4810

233, 265

698, 2640

6254, 8193

14683, 14919

3419, 3548

29,027

146,530

48372

Discharge summary

report

Admission Date: [**2168-1-6**] Discharge Date: [**2168-1-14**] Date of Birth: [**2099-3-16**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Doctor First Name 3290**] Chief Complaint: Altered mental status Major Surgical or Invasive Procedure: [**2168-1-6**]: Right internal jugular central catheter insertion [**2168-1-11**]: PICC line insertion History of Present Illness: 68 year old male with paraplegia complicated by osteomyelitis and neurogenic bladder with h/o chronic indwelling foley with recurrent UTIs (Pseudomonas, enterococcus) now with condom catheter, was noted by his VNA to have altered mental status along with hypothermia and hypotension to SBP of 90 by EMS on way to [**Hospital1 18**] ED. . In the ED, initial vitals were 86.3 58 120/82 18 100% RA. His CXR showed no acute process compared to previous CXR. EKG showed sinus bradycardia with [**Doctor Last Name **] wave. He subsequently became hypotensive with SBP in 80s which responded to 90s with IVF. He had RIJ place and placed on norepi with SBP in 130s. . His Labs were notable for potassium of 6.6 with creatinine of 1.9 (baseline creatinine of 1.2-1.4) for which he received Insulin 10U, D50, kayexalate and calcium gluconate. His labs were also notable for thrombocytopenia to 81 and WBC of 10.9. UA was consistent with UTI. Blood and urine culture were sent. He was given vancomycin/levaquin/flagyl for empiric coverage. He was transferred to MICU for futher evaluation and management. . On arrival to the MICU, patient reports having a little pain all over body. He was not able to verbalize, but was shaking his head yes/no. Found to have FSG in 30s. . On ROS, the patient reports having a little chest pain and abdominal pain. Denies having any pain in his legs. Could not further characterize his symptoms. Denies any respiratory symptoms, no cough or trouble breathing. Past Medical History: 1. Paraplegia (fell 16 years ago working on construction) complicated by osteomyelitis and requiring condom catheter (?neurogenic bladder) 2. Hepatitis C 3. Depression 4. Frequent Urinary tract infections (Enterobacter + Pseudomonas) 5. GERD 6. Anemia (Hct baseline 28-30) 7. Indwelling foley with persistent L sided hydronephrosis 8. sacral decubitus, stage IV, osteomyelitis, s/p approximately 11 wks of Vanc/Zosyn (completed [**2164-5-7**]), followed by Dr. [**First Name (STitle) 1075**] of ID and Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of Plastics. Social History: Has lived in [**Hospital3 2558**] in past but currently lives with son. [**Name (NI) **] smoking, no alcohol, no drug use. Pt born in [**Country 13622**] Republic and more comfortable speaking Spanish. Daughter, [**Name (NI) **], helps facilitate healthcare as well as son [**Name (NI) **] who he lives with. Family History: Father with essential tremor Physical Exam: ADMISSION PHYSICAL EXAM: General: eldery gentleman, noncommunicative and unable to verbalize, laying in bed, breathing heavily, looking uncomfortable HEENT: Sclera anicteric, dry mucous membranes, PERRL Neck: supple, JVP not appreciated CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Anteriorly clear to auscultation bilaterally, upper airway noises audible Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly Back: slight L CVA tenderness, but hard to elicit GU: + Foley with yellow urine with sediment, and occasional mucous and blood Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: no LE motor strength b/l, no LE sensation b/l, able to move UE spontaneously . DISCHARGE PHYSICAL EXAM: VS: 96.5 (98.4) 158/64 (128-158/64-82) 58 (58-91) 16 98%RA 97-100%RA 8-hr I/O: 30/incont x2 [**80**]-hr I/O: 600/1200 + incont x4, BMX1 FSBS: 114, 106, 108 General: Elderly black, bilingual (Spanish/English) male, appears comfortable, alert and awake, smiles and interacts with examiner, conversant with stronger voice and more energetic today HEENT: Sclera anicteric, dry mucous membranes, PERRL, clear oropharynx Neck: Supple, flat neck veins, no carotid bruits CV: RRR, normal S1/S2, no MRG Lungs: Coarse breath sounds at bases bilateral with bibasilar crackles. Abd: Normoactive bowel sounds, soft, non-distended, non-tender GU: no Foley, mild irritation on foreskin, no lesions Extr: No edema in forearms/hands. No LE edema. 2+ distal pulses. Warm, well-perfused. Neuro: Tremors with outstretched arms. Moving UE spontaneously, resistance on passive movement. Alert and awake. Smiling and interactive with examiner. Pertinent Results: ADMISSION LABS: [**2168-1-6**] 04:15PM BLOOD WBC-10.9# RBC-2.95* Hgb-8.3* Hct-28.9* MCV-98 MCH-28.1# MCHC-28.6*# RDW-15.9* Plt Ct-81*# [**2168-1-6**] 04:15PM BLOOD Neuts-85.4* Lymphs-11.8* Monos-2.0 Eos-0.4 Baso-0.3 [**2168-1-6**] 04:15PM BLOOD PT-12.7* PTT-47.8* INR(PT)-1.2* [**2168-1-6**] 10:02PM BLOOD Fibrino-563* [**2168-1-6**] 04:15PM BLOOD UreaN-54* Creat-1.9* [**2168-1-6**] 10:02PM BLOOD Glucose-28* UreaN-45* Creat-1.5* Na-140 K-5.9* Cl-117* HCO3-20* AnGap-9 [**2168-1-6**] 10:02PM BLOOD ALT-23 AST-17 LD(LDH)-87* CK(CPK)-87 AlkPhos-99 TotBili-0.1 [**2168-1-6**] 10:02PM BLOOD CK-MB-21* MB Indx-24.1* cTropnT-0.08* [**2168-1-6**] 10:02PM BLOOD Albumin-2.3* Calcium-8.1* Phos-2.5* Mg-2.0 [**2168-1-6**] 10:02PM BLOOD Hapto-122 [**2168-1-6**] 10:02PM BLOOD Cortsol-25.2* [**2168-1-6**] 04:32PM BLOOD Glucose-106* Lactate-1.5 Na-135 K-6.6* Cl-106 calHCO3-24 [**2168-1-6**] 10:08PM BLOOD freeCa-1.23 [**2168-1-6**] 06:00PM URINE Color-Straw Appear-Cloudy Sp [**Last Name (un) **]-1.006 [**2168-1-6**] 06:00PM URINE Blood-SM Nitrite-NEG Protein-TR Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG [**2168-1-6**] 06:00PM URINE RBC-21* WBC->182* Bacteri-MOD Yeast-NONE Epi-0 . RELEVANT LABS: [**2168-1-7**] 08:59AM BLOOD CK-MB-14* MB Indx-23.3* cTropnT-0.07* [**2168-1-9**] 06:50AM BLOOD CK-MB-15* MB Indx-9.4* cTropnT-0.15* [**2168-1-9**] 01:33PM BLOOD CK-MB-18* MB Indx-12.5* cTropnT-0.19* [**2168-1-10**] 06:40AM BLOOD CK-MB-11* MB Indx-15.9* cTropnT-0.19* [**2168-1-11**] 06:10AM BLOOD CK-MB-8 cTropnT-0.16* [**2168-1-8**] 04:09AM BLOOD calTIBC-190* Ferritn-431* TRF-146* [**2168-1-11**] 06:10AM BLOOD VitB12-1734* Folate-17.3 [**2168-1-7**] 11:28AM BLOOD %HbA1c-5.3 eAG-105 [**2168-1-11**] 10:45AM BLOOD TSH-3.5 [**2168-1-11**] 10:45AM BLOOD Cortsol-18.9 [**2168-1-7**] 08:28AM BLOOD Glucose-67* Lactate-1.3 K-4.2 calHCO3-13* [**2168-1-9**] 06:50AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-OCCASIONAL Macrocy-OCCASIONAL Microcy-OCCASIONAL Polychr-OCCASIONAL Schisto-OCCASIONAL Burr-OCCASIONAL [**2168-1-7**] 12:45AM URINE Hours-RANDOM UreaN-195 Creat-9 Na-81 K-17 Cl-74 [**2168-1-7**] 12:45AM URINE Osmolal-264 [**2168-1-9**] 10:27AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.007 [**2168-1-9**] 10:27AM URINE Blood-SM Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-LG [**2168-1-9**] 10:27AM URINE RBC-4* WBC-19* Bacteri-FEW Yeast-NONE Epi-0 [**2168-1-9**] 10:27AM URINE Hours-RANDOM UreaN-236 Creat-24 Na-101 K-11 Cl-89 [**2168-1-9**] 10:27AM URINE Osmolal-320 . DISCHARGE LABS: [**2168-1-13**] 06:11AM BLOOD WBC-7.6 RBC-3.47* Hgb-9.8* Hct-30.8* MCV-89 MCH-28.2 MCHC-31.8 RDW-16.4* Plt Ct-99* [**2168-1-13**] 06:11AM BLOOD UreaN-28* Creat-1.5* . MICROBIOLOGY: [**2168-1-6**] Blood cultures x2: no growth to date [**2168-1-6**] Urine culture: URINE CULTURE: PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 2 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S . IMAGING: [**2168-1-6**] EKG: Sinus bradycardia. Atrio-ventricular conduction delay. Early R wave transition. Prominent J point elevation. Compared to the previous tracing of [**2166-12-11**] the J point elevation is slightly more prominent and the ventricular rate has slowed. . [**2168-1-6**] Chest x-ray: Lung volumes remain low, with chronic moderate elevation of the right hemidiaphragm. There is crowding of bronchovascular markings and bibasilar atelectasis, but no focal consolidation. No significant pleural effusions or pneumothorax. Note is made of colonic interposition. IMPRESSION: Low lung volumes, without acute process. . [**2168-1-7**] EKG: Sinus rhythm. Compared to the previous tracing of [**2168-1-6**] the ventricular rate has increased and the prominent J point elevation is no longer appreciated. . [**2168-1-7**] Chest x-ray (AP portable): As compared to the previous radiograph, the patient shows increasing vascular diameters, an increasing left pleural effusion, small right pleural effusion and an increasing right and left basal atelectasis. Overall, these findings could reflect increasing fluid overload. No other relevant changes. The right-sided central venous access line is constant. . [**2168-1-7**] Portable renal ultrasound: FINDINGS: The right kidney measures 9.6 cm, and the left kidney measures 9.3 cm. Extensive bowel gas artifact limits visualization of both kidneys. Hydronephrosis and multiple cysts are noted bilaterally. No evidence of new perinephric fluid collection to suggest abscess. The urinary bladder wall is thickened as previously noted by CT, and an echogenic Foley catheter is noted in situ. IMPRESSION: 1. Bilateral multicystic kidneys and hydronephrosis, unchanged from prior CT. No evidence of perinephric abscess, although the study is severely limited by bowel gas artifact. 2. Thickening of the urinary bladder wall, grossly stable from prior CT though collapse of bladder about a Foley catheter limits assessment. . [**2168-1-8**] Chest x-ray (AP portable): Combination of left lower lobe consolidation and small-to-moderate left pleural effusion are stable since [**1-7**], increased since [**1-6**]. There is also more opacification at the right lung base which could be a second focus of pneumonia or atelectasis. There is no pulmonary edema. Heart size is normal. Right jugular line ends in the upper SVC. . [**2168-1-8**] Non-contrast head CT: FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or infarction. The ventricles and sulci are normal in size and configuration. No fracture is identified. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. IMPRESSION: No acute intracranial process. . [**2168-1-9**] Chest x-ray (PA/lat): The right internal jugular line has been discontinued. There is no change in low lung volumes, bibasilar consolidations, bilateral pleural effusions, left more than right. There is no evidence of overt edema, but mild vascular engorgement cannot be excluded. No pneumothorax is demonstrated. . [**2168-1-10**] EKG: Sinus rhythm with an atrial premature beat. Baseline artifact. Early transition. Compared to the previous tracing of [**2168-1-7**] the ventricular rate is slower. Atrial premature beat and artifact are new. . [**2168-1-11**] Chest x-ray (AP portable): 1. Left PICC tip in the mid SVC, curled at its distal end; if possible advancing 2 cm to confirm that is within the SVC is recommended; otherwise, this may be in the azygos [**Month/Day/Year 5703**], requiring repositioning. 2. Small bilateral pleural effusions with bibasilar atelectasis, right greater than left. . [**2168-1-11**] Chest x-ray (AP portable): As compared to the previous radiograph, the PICC line has been minimally advanced. The tip of the line now projects over the upper-to-mid SVC. The course of the line is unremarkable, there is no evidence of complications, notably no pneumothorax. Brief Hospital Course: Mr. [**Known lastname **] [**Known lastname 25067**] is a 68 year old gentleman with a PMH paraplegia c/b osteomyelitis and neurogenic bladder with indwelling Foley with recurrent UTIs (Pseudomonas, Enterococcus), admitted with altered mental status, treated in the MICU for urosepsis and pneumonia, with hospital course complicated by anemia with demand ischemia, acute kidney injury, thrombocytopenia, upper extremity rigidity and hypoglycemia. . . ACTIVE ISSUES: # Altered Mental Status: Patient was admitted after being found by health aides and family with altered mental status. This most likely secondary to his urinary tract infection and pneumonia, as described below. The patient was initially admitted to the MICU for hypotension and pressor requirement (see below), and as his infection cleared with IV antibiotics, his mental status gradually improved. There were no meningismal signs suggesting the need for an LP. After being transferred to the general medicine floor, his medications were also pared down to reduce risk of delirium. Family who visited during hospital course noted that he resolved to his baseline. In the context of resolving encephalopathy, the patient sometimes needs to be coaxed and physically stimulated to wake up. This has been his baseline from the end of his hospitalization. . # Urosepsis: The patient was admitted with altered mental status, hypothermia and left shift (85% PMNs), and was found to have urosepsis (initially hypotensive, hypothermic, and hypoglycemic), stabilized in the ICU with fluid resuscitation and brief treatment with pressors. On transfer out of the unit, the patient was no longer on pressors and maintained his blood pressures well. Urine culture grew Pseudomonas, with sensitivities as listed. Renal ultrasound ruled out perinephric abscess. He was treated with a ten-day course of IV cefepime (day 1 = [**1-6**]), which will be continued as an outpatient via PICC. Follow-up UA during this admission showed signs of clearing infection. . # Pneumonia: While in the ICU, chest x-ray revealed bilateral consolidations with effusions. The patient was started on empiric treatment for HCAP with vancomycin (for 7 days) and cefepime (day 1 = [**1-6**]). Treatment with cefepime is to be completed as an outpatient via PICC. There was also concern for aspiration, given that the patient developed difficulty with swallowing. He was initially NPO, then advanced slowly to soft/dysphagia diet with nectar-thick liquids, per Speech and Swallow. . # Acute on chronic anemia complicated by demand ischemia: Patient has chronic anemia with Hct baseline 28-30. On admission, Hct was 28.9, with a drop to nadir of 19.2 while in the ICU, with unknown etiology. There were no active signs of bleeding, stool Guaiac was negative, and hemolysis labs were unremarkable. He received one unit of PRBCs while in the ICU. After transferring to the medicine floor, he was noted to have Hct 23.5 with elevated CK-MB (peak 21), MB index (peak 24.1) and troponin (peak 0.19). There were no EKG changes. Elevated cardiac enzymes were thought to be secondary to demand ischemia in the setting of systemic infection and anemia. After transfusion of two units PRBCs, Hct appropriately bumped to 31.2 with downtrending cardiac enzymes (CK-MB 8, Troponin 0.16). . # Elevated cardiac enzymes: See above discussion of elevated cardiac enzymes in the setting of systemic infection and acute on chronic anemia. It is recommended that the patient have more cardiac evaluation in the outpatient setting after infections have resolved. He was started on aspirin 81 mg daily while hospitalized. . # Acute kidney injury: Creatinine was noted to be elevated to 1.9 on admission and while patient was in the ICU. He was provided with aggressive volume resuscitation, without much improvement in renal function. FEUrea was elevated with a high amount of sodium in the urine, less consistent with pre-renal azotemia; raised possibility of ATN. Renal ultrasound showed hydronephrosis, which was stable from past imaging. After transfusion of total 3 units PRBCs, creatinine improved to 1.5. Nephrotoxins were avoided, and medications were renally-dosed. . # Thrombocytopenia: Patient was admitted with platelets of 81. During course of admission, these trended down to 62. At the time of discharge, platelets were 99 and had been trending up. Thrombocytopenia was most likely multifactorial with acute decrease from myelosuppression in the setting of systemic illness, along with possible drug-suppression from linezolid and vancomycin. Platelets were monitored closely. . # Upper extremity rigidity: While in the ICU, patient was noted to have upper extremity rigidity with bilateral tremors. Per Neurology consult, his symptoms were most consistent with hypertonia in the setting of systemic illness, with superimposed essential tremor, which was familial and present before admission. As the patient improved clinically, his rigidity also improved. Coarse bilateral upper extremity tremor was present at the time of discharge. . # Hypoglycemia: Patient was initially severely hypoglycemic to glucose 28. Etiology was unclear. [**Name2 (NI) **] was aggressively treated with IV D5 in the ICU. Because his sugars kept dipping down, he was also started on a D10 drip briefly while in the unit. The patient's sugars were checked q1h. Initially, sugars were in the 100s while on the D10 drip. However, upon call out from the unit, the patient's D10 drip was stopped and he was able to maintain his sugars in the 200s. Random cortisol was within normal limits. His hypoglycemia likely related to both his infection and NPO status. Upon discharge, his sugars had stabilized. . # Disposition: Patient will need to be placed in rehabilitation after this hospitalization. Anticipated length of stay is less than 30 days. . . CHRONIC ISSUES: # Paraplegia: Has been a chronic problem for over 15 years, secondary to either fall or infection involving spine (differing accounts in medical records). Paraplegia is complicated by neurogenic bladder with frequent urinary tract infections, predisposing patient to infection on admission. Patient's urine output was monitored. He worked with PT on strength and endurance. He will continue PT in rehab. . . TRANSITIONAL ISSUES: # We stopped the patient's home medications (trazodone, Effexor XR, omeprazole, HCTZ - all doses unknown). Patient has been doing well off of these medications. PCP can readdress medications and restart as needed. # In context of resolving encephalopathy, patient sometimes needs to be coaxed to wake up. # CBC should be checked one week after discharge. # Cardiac enzymes were elevated in the setting of infection and acute on chronic anemia. There were no EKG changes. [**Month (only) 116**] consider more cardiac work-up as an outpatient. # Per Neurology recommendations, may consider starting topiramate 25 mg [**Hospital1 **] for treatement of tremors. # HCP: [**Name (NI) **] (daughter), [**Telephone/Fax (1) 101887**] # Code: Full (confirmed) Medications on Admission: omeprazole effexor senna trazodone HCTZ Discharge Medications: 1. cefepime 1 gram Recon Soln Sig: One (1) gram Injection Q24H (every 24 hours) for 2 doses. Disp:*2 grams* Refills:*0* 2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*0* 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 4. senna 8.6 mg Tablet Sig: One (1) Tablet PO bid prn as needed for constipation. Disp:*60 Tablet(s)* Refills:*0* 5. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) packet PO daily prn as needed for constipation. Disp:*30 packet* Refills:*0* 6. heparin, porcine (PF) 10 unit/mL Syringe Sig: Two (2) mL Intravenous PRN (as needed) as needed for line flush for 2 doses. Disp:*4 mL* Refills:*0* 7. sodium chloride 0.65 % Aerosol, Spray Sig: [**1-25**] Sprays Nasal QID:PRN as needed for nasal dryness. Disp:*1 bottle* Refills:*0* 8. phenol 1.4 % Aerosol, Spray Sig: One (1) Spray Mucous membrane Q4H (every 4 hours) as needed for sore throat. Disp:*1 bottle* Refills:*0* 9. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO daily PRN as needed for constipation. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Primary diagnosis: Pseudomonoas UTI . Secondary diagnoses: Pneumonia Thrombocytopenia Anemia complicated by demand ischemia 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 Mr. [**Known lastname **] [**Known lastname 25067**], It was a pleasure to participate in your care here at [**Hospital1 1535**]! You were admitted with a severe urinary tract infection that caused a change in your mental status. You were also found to have pneumonia. You were treated with antibiotics, cefepime and vancomycin, for your the infections in your urine and in your lungs. Additionally, your blood counts were low, and you required transfusion of three units of blood. While you were in the hospital, you had difficulty swallowing, but improved after a few days. Please note, the following changes have been made to your medications: - START cefepime, continue through [**2168-1-15**] - START aspirin 81 mg by mouth daily - START docusate sodium 100 mg by mouth twice daily - START polyethylene glycol 1 packet daily as needed for constipation Please continue to take all of your other medications as you had prior to your hospitalization. You will be followed by the doctor at your rehabilitation center. When you leave rehab, it will be important that you see your primary care physician, [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4334**]. Please make an appointment with him at that time, as instructed below. Wishing you all the best! Followup Instructions: You will be followed by the doctor at rehab. On leaving rehab, please contact Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4334**], [**Telephone/Fax (1) 45347**], to schedule an appointment.

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icd9cm

[ [ [] ] ]

[ "38.97" ]

icd9pcs

[ [ [] ] ]

20376, 20446

11947, 12398

326, 431

20614, 20614

4661, 4661

22136, 22352

2894, 2924

19127, 20353

20467, 20467

19063, 19104

20790, 22113

7214, 10392

2964, 3689

20526, 20593

18282, 19037

15300, 17833

265, 288

12413, 12423

459, 1943

10401, 11924

4677, 7198

20486, 20505

20629, 20766

17849, 18261

1965, 2551

2567, 2878

3714, 4642

53,151

150,192

193

Discharge summary

report

Admission Date: [**2182-10-17**] Discharge Date: [**2182-11-3**] Date of Birth: [**2104-4-10**] Sex: F Service: MEDICINE Allergies: Penicillins / Milk Attending:[**First Name3 (LF) 1253**] Chief Complaint: s/p ERCP with acute mental status changes/aspiration PNA Major Surgical or Invasive Procedure: ERCP with sphincteroplasty PEG tube placement (via Interventional Radiology) History of Present Illness: 77 y/o F with PMhx of Developmental Delay, COPD, HL, HTN and Mirizzi syndrome who presented today for elective ERCP. Pt was felt to be functionning at baseline prior to procedure with mild agitation, pulling at PIVs but interacting with staff. She was given fent/midaz for ERCP with stent placement and was transferred to the post-ERCP suite in stable condition. She had elevated BPs during the procedure requiring labetalol and metoprolol. She was found mildly tachypneic/wheezing with emesis on her gown. It was felt likely that she had an aspiration event with low grade temp However, she was still moving all four extremities and responding appropriately to questions though mildly sedated prior to transfer to the floor. . On arrival to the floor, pt was minimally responsive to sternal rub and did not withdraw to focal stimuli. She was notably tachypneic and eyes were deviated to right side. She was able to track to left with stimuli and would intermittently open eyes to command. Pt had an ABG 7.4/36/92 with lactate of 3.5 and CXR showed a right lower lobe infiltrate. Due to concern for acute intracranial hemmorrhage, she was taken down for a stat CT head. On return to the floor, pt was given narcan without any significant change in mental status. Neuro was consulted for possible acute stroke and within a few minutes, she became more responsive, opening eyes spontaneously. By the time neuro came to bedside, pt was able to verbalize her name and was noted to be using the right arm and had left sided deficit. A CODE stroke was called and pt was taken for urgent CTA head which did not show any vessel obstruction and TPA was felt unlikely to be helpful. Perfusion images confirmed right temporal hypoperfusion consistent with clinical exam and likely right MCA infarct. ICU consult was initiated and pt's guardian was notified. Pt was given Vanc/Cefepime and Aspirin 300mg PR while awaiting ICU transfer. She was lying flat per neuro recs and was noted to be spitting up bilious emesis. Head of bed was elevated and pt was suctionned prior to transferred to the ICU for closer monitoring of airway and management of acute pneumonia. Past Medical History: Hypertension Developmental Delay Mirizzi Syndrome COPD Social History: At baseline, pt lives at a nursing home and is able to feed herself, undress and can transfer from chair to bed but is otherwise wheelchair bound. No smoking/ETOH history documented. Family History: none relevant to this hospitalization. Physical Exam: Admission: T 101 BP 152/86 HR 86 RR 30 Sats 94% RA GEN: somnolent, open eyes to vigorous stimulous HEENT: Eyes deviated to right, tracks to left with startle CV: RRR no apprec m RESP: diffuse expiratory wheezes, moving air well ABD: soft, [**Month (only) **] BS, no rebound/guarding GU: foley in place EXTR: warm, minimal edema, toes upgoing NEURO: minimally responsive, eyes deviated, no withdrawal to painful stimuli Pertinent Results: [**2182-10-17**] 04:02PM BLOOD WBC-24.8*# RBC-6.40* Hgb-13.9 Hct-43.8 MCV-68* MCH-21.6* MCHC-31.6 RDW-14.3 Plt Ct-273 [**2182-11-2**] 05:55AM BLOOD WBC-8.1 RBC-5.33 Hgb-11.8* Hct-38.1 MCV-72* MCH-22.2* MCHC-31.0 RDW-14.8 Plt Ct-399 [**2182-11-1**] 06:05AM BLOOD Glucose-113* UreaN-4* Creat-0.5 Na-141 K-3.5 Cl-106 HCO3-27 AnGap-12 [**2182-10-28**] 06:05AM BLOOD Calcium-9.8 Phos-3.5 Mg-1.9 [**2182-10-17**] 04:02PM BLOOD ALT-92* AST-118* AlkPhos-247* TotBili-1.4 [**2182-10-18**] 04:42AM BLOOD ALT-145* AST-277* AlkPhos-136* Amylase-101* TotBili-0.5 [**2182-10-28**] 06:05AM BLOOD ALT-50* AST-46* LD(LDH)-170 AlkPhos-144* TotBili-0.3 [**2182-10-21**] 06:36AM BLOOD Triglyc-143 HDL-44 CHOL/HD-3.8 LDLcalc-93 [**2182-10-21**] 06:36AM BLOOD %HbA1c-9.4* eAG-223* . ERCP [**2182-10-17**] Procedures: A plastic stent was removed. Impression: 2 balloon sweeps were performed with a small stone, sludge and debris removed. A 1.5 cm biliary stricture in mid-CBD compatible with known cystic duct stone and mirrizi syndrome was visualized. A 10 F 5cm double pigtailed catheter was placed. Otherwise normal ercp to third part of the duodenum. CXR [**2182-10-17**] IMPRESSION: Right lower lobe pneumonia with atelectasis or pneumonia at the left base. . CTA HEAD W&W/O C & RECONS IMPRESSION: Moderate-to-severe intracranial atherosclerotic disease with findings suggestive of decreased perfusion to the right MCA/PCA watershed region. The findings may represent cerebral ischemia in the setting of hypovolemia, hypotension or other causes of decreased cardiac output. . Cardiac Echo: IMPRESSION: Small LV cavity size with mild symmetric LVH and hyperdynamic LV systolic function. Consequently, there is a mild to moderate LV outflow tract gradient. No pathologic valvular abnormality seen. . RUE LENI IMPRESSION: Partially occlusive thrombus in the right basilic and axillary veins at site of PICC line. Clot does not extend more centrally. . ABDOMEN (SUPINE ONLY) PORT IMPRESSION: Limited view of the abdomen demonstrating no evidence for obstruction. Bladder stone. Coags: [**2182-11-1**] 06:05AM BLOOD PT-13.4 PTT-29.7 INR(PT)-1.1 [**2182-11-2**] 05:55AM BLOOD PT-14.0* INR(PT)-1.2* (Started Warfarin 5 mg) Brief Hospital Course: 77 y/o F with PMhx of Developmental Delay, COPD, HL, HTN and Mirizzi syndrome who presented on [**10-17**] for elective ERCP. Pt was noted to have emesis on her gown in the post procedure suite with diffuse wheezes and low grade temp. It was thought likely that she had an aspiration event and when she was arrived on the floor, she had a profoundly depressed mental status, tachypnea and fever to 101.9. Further stat work up revealed evidence of aspiration PNA, leukocytosis and elevated lactate. Initial head imaging was unrevealing. However, she became more alert and was noted to have an acute left sided deficit. CODE STROKE was called and CTA/perfusion images confirmed right sided hypoperfusion likely consistent with right MCA stroke. Neuro felt there was no indication for TPA given patent intracranial vessels and on return to the floor, pt was noted to have bilious secretions that she was having difficulty clearing. She was transferred to the ICU for airway monitoring overnight. Pt was called out to the floor when she was able to cough and spit up secretions. She was noted to have a waxing and [**Doctor Last Name 688**] mental status, sometimes will respond to commands and other times will not. BP was allowed to autoregulate for the first 72 hrs post event and pt was continued on Aspirin 300mg daily. She was noted to have recovery of left arm function and was answering yes/no to questions. She was seen by PT/OT who recommended ongoing therapy upon return to NH. After discussion with HCP/guardian, decision was made to avoid follow up MRI as it was not likely to change care plan and pt was unlikely to tolerate the procedure. Echo was performed to rule out cardioembolic source which did not show any thrombus. Lipid panel showed LDL in the 93, and Hgb A1c 9.4. She was hyperglycemic during the hospitalization, and she was started on Lantus and sliding scale insulin. . Aspiration PNA: Pt was noted to have aspiration event s/p procedure and was monitored in the ICU for 24hrs given concern for her ability to protect airway . Leukocytosis, lactate and fevers resolved after initiation of Vanc/Cefepime/Flagyl. Respiratory status improved and pt had a PICC placed and she completed a course of antibiotics. Upper Extremity DVT- Patient was subsequently developed a DVT associated with the PICC line. The PICC line was discontinued and she was started on Lovenox. Once a PEG tube was placed, she was started on Warfarin for a goal INR of [**2-6**]. Please follow INR closely and titrate prn. She received her first dose of Warfarin 5 mg on [**11-2**]. Aspiration - Pt was seen by speach/swallow on multiple occasions, which she grossly failed with aspiration. She was kept strictly NPO, and she was maintained with IV medications and hydration. A dobhoff was placed for initiation of tube feeds, while waiting to see if she would regain her swallow function. It is/was hoped that her swallow function would improve, especially considering her significant recovery in her left arm movement, however, she did not show significant improvement on serial exams. In discussion with Speech and Swallow, however, there is some hope that she may recover her swallow on a long term basis, and Swallow therapy may help with this recovery. They suggested an approximate 50% chance of recovery to the point of safe oral intake in the long-term. . Diabetes-Pt with uncontrolled hyperglycemia after the initiation of tube feeds. Her lantus and insulin sliding scales were agressively increased. She is being discharged on 70 units of lantus, and a sliding scale. . Mirizzi Syndrome s/p ERCP: Pt with abnormal biliary anatomy who underwent stent and sphincteroplastyon [**10-17**] for recurrent abd pain. She was noted to have an acute rise in transaminases post procedure and these trended down with normal Tbili. Pt was followed by ERCP team while in house. . Developmental Delay: baseline confirmed with her guardian/mother and nursing home. . HTN: held BP meds to allow autoregulation s/p stroke. She was subsequently treated with IV metoprolol, clonidine patch, and IV lasix, with benefit. After obtaining access via PEG, a blood pressure medication regimen via PEG was begun. I expect that she will benefit from further titration of medications as an outpatient. Please note that she was also started on Lisinopril; please follow up lytes in 1 week to ensure she tolerates. . Hyperlipidemia: Patient's simvastatin was held while patient was NPO. This was resumed after obtaining access via PEG. This medication dose was increased to 40 mg for goal LDL <70 considering diabetes and stroke. Please follow up LFT's to ensure tolerating, and lipid profile to ensure she meets her targets. . CODE: DNR/DNI confirmed with guardian Medications on Admission: Aspirin 81mg daily Alendronate 70mg weekly Multivitamin Colace 100mg [**Hospital1 **] Calcium/Vit D Metoprolol 50mg [**Hospital1 **] Bisacodyl prn Simvastatin 20mg daily Vicodin/tylenol prn Discharge Medications: 1. enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) Inj Subcutaneous Q12H (every 12 hours): Please continue until INR [**2-6**] x 48 hrs, then discontinue. 2. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) packet PO DAILY (Daily): [**Month (only) 116**] hold for loose stools. 3. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for no bm x 2 days. 4. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM: Please follow INR closely, and titrate prn for INR goal [**2-6**]. Please continue lovenox until INR >2 x 48 hrs. 5. clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QMON (every Monday). 6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily): Please titrate prn. Started [**11-2**]. 8. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): Please titrate prn. Started [**11-2**]. 9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. acetaminophen 650 mg/20.3 mL Solution Sig: Six [**Age over 90 1230**]y (650) mg PO Q 8H (Every 8 Hours): would schedule q 8hr x 1 week, to treat for probable post-PEG procedure pain. (then prn). 11. alendronate 70 mg Tablet Sig: One (1) Tablet PO once a week. 12. Vitamin D-3 1,000 unit Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 13. simvastatin 40 mg Tablet Sig: One (1) Tablet PO at bedtime. 14. insulin glargine 100 unit/mL Solution Sig: Seventy (70) units Subcutaneous once a day: titrate prn. 15. Humalog 100 unit/mL Solution Sig: as per sliding scale units Subcutaneous four times a day: as per sliding scale provided. Discharge Disposition: Extended Care Facility: [**Hospital **] Healthcare Center - [**Location (un) 86**] Discharge Diagnosis: Primary: Biliary obstruction s/p sphincteroplasty Middle cerebral artery stroke Aspiration Pneumonia Dysphagia due to stroke . Secondary: Developmental Delay Hypertension Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: You were admitted for an ERCP and had a aspiration event after the procedure. It was discovered that you had a stroke on [**10-17**] and you will need to continue working with occupational therapy to continue recovering function. You were treated for an aspiration PNA with antibiotics, which you finished in the hospital. Your blood sugars were very elevated for this your insulin doses were increased. . Please note that there were many changes to your medications as a result of this hospitalization. Please follow your new medication list. Followup Instructions: Department: NEUROLOGY When: MONDAY [**2182-11-11**] at 4:30 PM With: DRS. [**Name5 (PTitle) 162**] & [**Hospital1 **] [**Telephone/Fax (1) 44**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ENDO SUITES When: THURSDAY [**2183-4-17**] at 8:00 AM Department: DIGESTIVE DISEASE CENTER When: THURSDAY [**2183-4-17**] at 8:00 AM With: [**Name6 (MD) 1948**] [**Last Name (NamePattern4) 1949**], MD [**Telephone/Fax (1) 463**] Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**] Campus: EAST Best Parking: Main Garage

[ "272.4", "V46.3", "434.91", "V49.86", "250.02", "496", "401.9", "997.39", "E879.8", "576.2", "997.2", "787.29", "507.0", "315.9", "453.83" ]

icd9cm

[ [ [] ] ]

[ "96.08", "51.10", "43.11", "38.97" ]

icd9pcs

[ [ [] ] ]

12346, 12431

5628, 10393

337, 416

12646, 12646

3403, 5605

13353, 14109

2909, 2949

10633, 12323

12452, 12625

10419, 10610

12782, 13330

2964, 3384

241, 299

444, 2613

12661, 12758

2635, 2692

2708, 2893

24,444

108,879

7977

Discharge summary

report

Admission Date: [**2168-8-16**] Discharge Date: [**2168-9-3**] Date of Birth: [**2104-9-5**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1267**] Chief Complaint: 63 y/o male s/p CABG on [**2168-7-26**], d/c'd to rehab on [**8-3**]. Re-admitted on [**8-16**] with sternal wound drainage. Major Surgical or Invasive Procedure: bedside excisional debridement of sternal wound History of Present Illness: s/p cabg, discharged to rehab, began to have sternal wound drainage, managed w/antibiotics, did not improve. re-admitted for IV antibiotics and wound debridement Past Medical History: CAD: [**2158**]- stent to prox RCA; [**2161**]-MI with 2 RCA stents; [**2164**] - MI with PTCA and stent to 90% mid LAD lesion and PTCA to D2; [**2-25**] - PTCA and brachytherapy to mid-LAD; stents to diag and OM1 branch; [**2166**] - at [**Hospital3 **] - 60% LAD stenosis, no stent placed. HTN morbid obesity CVA (right MCA) [**2154**] s/p RCEA NIDDM COPD OSA on CPAP Social History: Previous Hospitalization: none Suicide attempts: in [**2155**] after having a stroke, he placed a shotgun at his chin, pointing upwards, and pulled the trigger, but the safety was still on, for which he was later grateful. Assaultive behavior: none Current treaters: none in mental health Medication trials: none prior to zoloft SUBSTANCE ABUSE HISTORY: EtOH: denies ever using, abstinent his entire life secondary to hearing other people??????s problems with alcohol Smoked cigarettes x 20 years, quit 30 years ago Denies heroin, MJ, cocaine, and all other recreational drugs. Family History: non-contributory Physical Exam: Sternal wound with erythema, small area of dehiscence, 2+ peripheral edema, exam otherwise unremarkable Brief Hospital Course: Admitted on [**2168-8-16**], underwent excisional wound debridement at bedside, started on IV Vancomycin, and po Levofloxacin. Had remained hemodynamically stable, progressing with wound care and antibiotics, being diuresed. On [**2168-8-21**], he had a cardiac arrest, exhibited by bradycardia progressing rapidly to asystole. ACLS protocol was initiated, he was intubated, and transferred to the ICU. He did not wake up appropriately post-code, and a neurology consult was called. It was felt that he's suffered a significant CVA during the time of his arrest. He remained fully ventilated, and hemodynamically stable over the next few days, but showed no signs of neurologic improvement. The neurology service believed that he was at best to remain in a chronic vegetative state. This was discussed with patient's wife (and other family members). They initially wanted to give him some more time, an dnot withdraw support. But, as no neurologic improvement was seen, on [**9-3**], the patient's wife requested that his ventilator support and endotracheal tube be discontinued, and that no resuscitative measures be instituted. He was extubated at 1600, and became apneic a few hours later. He expired at 2055. Medications on Admission: Protonix ASA Lipitor Seroquel Zetia Albuiterol Atrovent Iron Vitamins Carvedilol Lasix Insulin Tylenol Levaquin Discharge Disposition: Extended Care Facility: [**Hospital3 11496**] - [**Location (un) **] Discharge Diagnosis: Sternal wound infection CVA anoxic brain injury Discharge Condition: expired Followup Instructions: n/a Completed by:[**2168-9-3**]

[ "410.92", "V45.81", "511.9", "250.00", "998.32", "998.59", "427.5", "348.1", "401.9", "496" ]

icd9cm

[ [ [] ] ]

[ "96.6", "38.93", "99.04", "99.69", "88.72", "96.72", "99.60", "86.22", "96.04", "86.28" ]

icd9pcs

[ [ [] ] ]

3239, 3310

1854, 3077

444, 493

3402, 3412

3435, 3469

1693, 1711

3331, 3381

3103, 3216

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280, 406

521, 685

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1095, 1677

28,788

127,535

32992

Discharge summary

report

Unit No: [**Numeric Identifier 76733**] Admission Date: [**2105-1-9**] Discharge Date: [**2105-1-14**] Date of Birth: [**2105-1-9**] Sex: M Service: Newborn service HISTORY: This is a full-term male infant born at 39-2/7 weeks gestational age to a 41-year-old G3 P2 mother via repeat C section with birth weight 3730 gm (8 lb 3 oz). The mother's prenatal labs were notable for blood type A positive, Hep B surface antigen negative, RPR nonreactive, antibody negative, Rubella immune. The baby was delivered via repeat C section with the mother's membranes intact at delivery. The baby's Apgars were 9 and 9. The mother was GBS unknown but as noted above, she had intact membranes at birth and there were no sepsis risk factors present. PHYSICAL EXAMINATION: On admission, birth weight 3730 grams (8 pounds 3 ounces). Length 20 inches. Head circumference 36 cm. The baby was [**Name2 (NI) 3584**] and well appearing. There were no rashes or lesions. The anterior fontanel was open and flat. The palate was intact. The lungs were clear to auscultation. The heart exam: Regular rate and rhythm without murmurs, 2+ femoral pulses bilaterally. The abdomen was soft with bowel sounds present and no hepatosplenomegaly. Testicles were descended bilaterally. The anus was normally placed. There were no spinal defects. The hips were stable and symmetric. The baby had good tone, good head control and positive grasp, Moro and suck reflexes. HOSPITAL COURSE: 1. Cardiovascular: The baby remained hemodynamically stable throughout his admission. 2. Respiratory: The baby remained stable on room air throughout his admission. 3. FENGI: The baby was exclusively breast fed by the mother, posting excellent weight gains with a discharge weight of 8 lb 4 oz. 4. Infectious disease: On [**2105-1-11**], day of life #2, the infant had an isolated fever spike to 101.1 rectal. This prompted a sepsis evaluation with blood cultures drawn and a CBC with differential. The baby's CBC was notable for a white count of 15.8 and a reassuring I to T ratio. Despite the reassuring CBC, in light of the fever spike, the baby was immediately started on ampicillin and gentamicin. As noted above, the mother's GBS status was unknown. In addition, she had no history of HSV or other STDs. In addition, it was noted that at the time the baby became febrile, he had a weight loss of approximately 8%. The mother continued exclusive breast feeding during this period of time. [**2105-1-11**] blood culture grew out gram negative diplococci at which time (dol #3) infectious disease at [**Hospital1 62374**] was contact[**Name (NI) **] who recommended adding cefotaxime to the antibiotic regimen, which was immediately done. In addition, a second blood culture was drawn on [**2105-1-12**] and an LP was drawn. The gram stain on the LP was negative and the white cell count on the CSF was 11 (67 rbc), diff w/ 1% polys, 16 % lymphs. On [**1-13**], day of life #4, microbiology reported the initial speciation of the gram negative rods on the first BCx ([**2105-1-11**]) as Neisseria, nonpathogenic species. At this time, [**Hospital3 1810**] infectious disease was formally consulted. Their assessment was that based on their literature survey, there have been no recorded cases of disease in a neonate caused by the nonpathogenic species of Neisseria. Specifically, microbiology had confirmed that this was not Neisseria meningitis or Neisseria gonococcus. As a result, infectious disease felt that antibiotics could be discontinued, the baby observed for a period of time inpatient and the baby thereafter discharged home with close followup by the primary care physician. [**Name10 (NameIs) **] baby's antibiotics were, therefore, discontinued in the late evening of [**2105-1-13**], by which time the baby had received approximately 3 days of ampicillin and gentamicin and two days of cefotaxime. The baby was thereafter monitored for a period of at least 12 hours, during which time he remained afebrile and continued with good p.o. Explicit fever instructions were provided to the mother by Dr. [**Last Name (STitle) **], including the recommendation to perform a rectal temperature on the infant if he felt hot or seemed sick and the instruction to immediately contact their pediatrician in the event that the baby's rectal temperature rose to 100 or higher as well as the recommendation to contact the pediatrician in the event that the baby displayed other signs of illness. As of the date of discharge on [**2105-1-14**], day of life #5, the blood culture from [**2105-1-12**] remained no growth to date and the CSF culture from [**2105-1-12**] remained no growth to date. CONDITION ON DISCHARGE: Good. DISPOSITION: Home. NAME OF PRIMARY PEDIATRICIAN: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3265**], [**Hospital3 2576**] [**Hospital3 **]. CARE RECOMMENDATIONS: 1. Continue breast feeds p.o. ad lib. 2. No medications. 3. Iron and vitamin D supplementation. All infants fed predominantly breast milk should receive vitamin D supplementation at 200 international units (may be provided as a multivitamin preparation) daily until 12 months corrected age. 4. State newborn screening sent [**2105-1-12**]. 5. Hepatitis B vaccine administered on [**2105-1-11**]. 6. Hearing screen status: [**Doctor Last Name 13674**] test bilaterally. 7. Immunizations recommended: Influenza immunization is recommended annually in the fall for all infants once they reach 6 months of age. Before this age (and for the first 24 months of the child's life), immunization against influenza is recommended for household contacts and out of home caregivers. FOLLOWUP: The baby should be seen by the primary care pediatrician 1 day after discharge from the hospital. DISCHARGE DIAGNOSES: 1. Full-term appropriate for gestational age male infant. 2. Sepsis evaluation with presumed blood culture contamination with a nonpathogenic species of Neisseria. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 71194**] Dictated By:[**Last Name (NamePattern1) 72910**] MEDQUIST36 D: [**2105-1-14**] 09:33:44 T: [**2105-1-14**] 10:30:10 Job#: [**Job Number 76734**]

[ "V30.01", "V05.3", "782.1", "778.8", "V29.0" ]

icd9cm

[ [ [] ] ]

[ "03.31", "99.55" ]

icd9pcs

[ [ [] ] ]

6031, 6509

1461, 4875

5092, 5580

768, 1444

5607, 6010

4900, 5070

8,896

113,604

52070

Discharge summary

report

Admission Date: [**2183-1-5**] Discharge Date: [**2183-1-11**] Date of Birth: [**2107-1-16**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Cardiac catheterization with DES to RCA and POBA to PDA History of Present Illness: 75 M h/o severe CAD s/p CABG [**2167**], s/p recent complicated admission ([**Date range (1) 107779**]/07) for NSTEMI with multiple interventions, presented to ED after calling EMS c/o increased SOB. Patient reports that he had noticed increased BLE edema over the last few days PTA. Yesterday, he noted more SOB and diaphoresis. Pt reported taking SLNTG x3 at home with some relief of these symptoms. BP 160/80, RR 36, O2sat 91-92% in field per MICU note. Patient reports being compliant with his medications and denies any change in diet recently. He did have 1 week of a nonproductive cough. In the ED, HR 63, BP 143/77, SaO2 85% RA, increasing to 90-92% on nonrebreather (no T recorded). Pt refused CPAP, stated that he would prefer intubation, and was ultimately intubated for increasing WOB/SOB. Pt then received furosemide 80 mg IV, nitro gtt, and ASA 300mg PR. TropT 0.03 noted on first set of CE. He put out only 200mL to the furosemide. He was transferred to the MICU. In the MICU, he received diuril 250mg and furosemide 100mg IV once. To this he has continually put out urine to over 2.5L negative thus far. He was awake and alert the morning after admission and was extubated at 9am. Since then, he has not received any more diuretics, but continues to make urine. He has been on room air with sats in the 90's. Currently, he complains of some bilateral leg pain secondary to the swelling. No CP, no SOB, no n/v, no f/c, no diarrhea or abdominal pain. +sore throat from intubation. Past Medical History: PAST MEDICAL HISTORY: 1. Coronary artery disease ---CABG ([**2167**]) - LIMA-->LAD - SVG-->RCA - SVG-->OM ---PCI ([**11/2176**]) - Ostial LIMA-LAD stent --> restenosis and brachytherapy ([**5-/2177**]) - Stenotic LIMA to the LAD stented - SVG to the PDA (patent) - SVG to the RCA (occluded) ---PCI ([**1-/2180**]) - SVG-RCA and SVG-OM (occluded) - LIMA-LAD (patent) - RCA and r-PDA stented (DES) ---PCI ([**3-/2180**]) - rPDA stented stented (Taxus) - r-PL balloon rescue - ostial RCA stented (DES) ---PCI ([**5-/2180**]) - LMCA-LCx stented (DES) - RCA stented (DES) ---PCI ([**5-/2181**]) - Left subclavian artery stented - [**Name (NI) 107781**] PTCA ---PCI ([**8-/2182**]) - RPDA POBA - RCA POBA ---PCI ([**8-/2182**]) - ostial LIMA stented (Cypher DES) . 2. Congestive heart disease - Systolic and [**Last Name (LF) 107778**], [**First Name3 (LF) **] 23% ([**9-16**]) 3. Valvular disease - 1+ AR - 2+ MR 4. Atrial fibrillation 5. Episode of atrial tachycardia ([**2181**]) 6. Episode of phase 4 block secondary to PVC ([**9-/2182**]) . Cardiac Risk Factors: (+) Diabetes (+) Dyslipidemia (+) Hypertension . OTHER PAST HISTORY 1. Peripheral [**Year (4 digits) 1106**] disease - Right CEA ([**7-/2168**]) - Left fem-bk [**Doctor Last Name **] w/ ISSVG ([**8-/2168**]) - Left fem-pt w/ vein ([**12-11**]) - Right CFA-ak [**Doctor Last Name **] w/ NRSVG ([**1-11**]) - Bilateral 5th toe amps ([**1-11**]) - Successful atherectomy of the right anterior tibial and popliteal arteries ([**3-14**]) - Successful cryoplasty of the L fem-[**Doctor Last Name **] graft ([**4-13**]) 2. Chronic kidney disease 3. Grade II internal hemrohrroids 4. Colonic diverticulosis 5. GERD 6. Acalculous cholecystitis s/p indwelling gallbladder catheter 7. Obstructive lung disease? 8. Low back pain Social History: No current tobacco use. 60+ pack-year history. Past heavy drinker. Lives alone, son lives upstairs from him. Family History: No family history of sudden cardiac death or early coronary artery disease. Physical Exam: Physical Exam: VS: T 97.3, BP 104/54 (99-120/41-58), HR 80 (76-90), O2sat 96% on RA RR 17. In 1030/Out 3476 net 2446 (LOS negative 2837mL) Gen: tired appearing male with eyes closed but awakens to answer questions appropriately HEENT: NCAT, dry MM, clear OP, PERRL, EOMI, anicteric sclera, non-injected conjunctiva. Neck: Elevated JVP to edge of jaw CV: difficult to hear secondary to upper airway secretions, but RRR, could not appreciate m/r/g Chest: clear bilaterally without w/r/r with mild crackles at R base. Anterior breath sounds obscured with upper airway secretion noises. Abd: Soft, NT, ND, BS+. Ext: 2+ BLE, very dry skin. Pertinent Results: [**2183-1-5**] 06:30PM BLOOD WBC-9.0 RBC-3.83* Hgb-10.8* Hct-34.7* MCV-91 MCH-28.3 MCHC-31.2 RDW-15.6* Plt Ct-217 [**2183-1-7**] 03:05AM BLOOD WBC-4.7 RBC-3.29* Hgb-9.3* Hct-28.5* MCV-87 MCH-28.3 MCHC-32.6 RDW-15.7* Plt Ct-167 [**2183-1-7**] 10:47AM BLOOD WBC-5.5 RBC-3.50* Hgb-10.1* Hct-30.4* MCV-87 MCH-28.8 MCHC-33.1 RDW-15.9* Plt Ct-171 [**2183-1-10**] 06:07AM BLOOD WBC-3.6* RBC-3.13* Hgb-8.8* Hct-27.3* MCV-87 MCH-28.1 MCHC-32.2 RDW-15.5 Plt Ct-164 [**2183-1-11**] 06:23AM BLOOD WBC-3.0* RBC-2.96* Hgb-8.1* Hct-25.8* MCV-87 MCH-27.4 MCHC-31.4 RDW-15.4 Plt Ct-129* [**2183-1-11**] 09:14AM BLOOD Hct-31.0* [**2183-1-5**] 06:30PM BLOOD PT-14.1* PTT-27.1 INR(PT)-1.2* [**2183-1-6**] 02:14AM BLOOD PT-12.7 PTT-20.7* INR(PT)-1.1 [**2183-1-11**] 06:23AM BLOOD PT-13.1 PTT-31.3 INR(PT)-1.1 [**2183-1-11**] 06:23AM BLOOD Ret Aut-2.1 [**2183-1-5**] 06:30PM BLOOD Fibrino-509* [**2183-1-11**] 06:23AM BLOOD calTIBC-316 Hapto-207* Ferritn-79 TRF-243 [**2183-1-5**] 06:30PM BLOOD Glucose-207* UreaN-30* Creat-2.5* Na-141 K-5.8* Cl-105 HCO3-20* AnGap-22* [**2183-1-5**] 09:35PM BLOOD Glucose-192* UreaN-31* Creat-2.5* Na-142 K-4.5 Cl-106 HCO3-22 AnGap-19 [**2183-1-8**] 06:00AM BLOOD Glucose-122* UreaN-44* Creat-2.9* Na-138 K-3.8 Cl-104 HCO3-24 AnGap-14 [**2183-1-11**] 06:23AM BLOOD Glucose-129* UreaN-32* Creat-2.6* Na-142 K-4.1 Cl-101 HCO3-28 AnGap-17 [**2183-1-5**] 06:30PM BLOOD CK(CPK)-146 Amylase-102* [**2183-1-6**] 02:14AM BLOOD CK(CPK)-188* [**2183-1-6**] 10:03AM BLOOD CK(CPK)-207* [**2183-1-6**] 04:02PM BLOOD CK(CPK)-194* [**2183-1-9**] 05:26AM BLOOD CK(CPK)-89 [**2183-1-11**] 06:23AM BLOOD LD(LDH)-247 TotBili-0.4 [**2183-1-5**] 06:30PM BLOOD CK-MB-4 cTropnT-0.03* [**2183-1-6**] 02:14AM BLOOD CK-MB-13* MB Indx-6.9* cTropnT-0.20* proBNP-8368* [**2183-1-6**] 10:03AM BLOOD CK-MB-11* MB Indx-5.3 cTropnT-0.24* proBNP-9154* [**2183-1-7**] 10:47AM BLOOD CK-MB-4 cTropnT-0.21* [**2183-1-5**] 09:35PM BLOOD Calcium-9.3 Phos-5.4*# Mg-2.3 [**2183-1-6**] 02:14AM BLOOD Calcium-9.6 Phos-4.4 Mg-2.4 [**2183-1-11**] 06:23AM BLOOD Calcium-9.4 Phos-4.2 Mg-2.2 Iron-37* Notable labs: 143 104 35 133 -------------< 3.6 25 2.6* (elevated from baseline 1.8) CK: 194 MB: 7 Trop-T: 0.25 * ([**2183-1-6**] 10am: CK: 207 MB: 11 MBI: 5.3 Trop-T: 0.24 [**2183-1-5**] 2am: CK: 188 MB: 13 MBI: 6.9 Trop-T: 0.20) Ca: 9.3 Mg: 2.1 P: 3.4 proBNP: 9154 WBC 5.5 Hgb 11.5 HCT 34.4 PLT 172 MCV 88 PT: 12.7 PTT: 20.7 INR: 1.1 EKG: Rate 100bpm, rhythm, Axis LAD, RBBB, ST depressions at V2-V3 new but ST depressions in V4-6 appear chronic. STUDIES: [**2183-1-5**] CXR: Cardiomegaly and moderate CHF [**2183-1-6**]: no more fluid overload. ETT tube in place . Echo [**2183-1-6**]: The left atrium is moderately dilated. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis with best preserved motion in the anteroseptum (LVEF = 25 %). [Intrinsic left ventricular systolic function is likely more depressed given the severity of valvular regurgitation.] Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size is normal. with mild global free wall hypokinesis. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis (area 1.6 cm2). Mild to moderate ([**12-11**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is borderline pulmonary artery systolic hypertension. Mild pulmonic regurgitation is seen. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2182-9-27**], regional left ventricular dysfunction now extends to the anterior and anterolateral walls. The overall ejection fraction is likely decreased. The severity of aortic regurgitation may have increased slightly. [**2183-1-8**] Cardiac Cath: FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Patent LIMA-LAD 3. Stenting of ostial and mid RCA with DES and POBA to ostial PDA. [**2183-1-8**] ECG: Sinus rhythm Ventricular premature complex Marked left axis deviation Left atrial abnormality RBBB with left anterior fascicular block Since previous tracing of the same date, no significant change Brief Hospital Course: 75 year old male with history of CAD s/p CABGx3 and multiple PCI's, CHF with EF 30%, diastolic and systolic HF, CRI, HTN, now presenting with SOB likely [**1-11**] CHF. Pt was intubated in ED and sent to the MICU. He was extubated the following day and transferred out to the Cardiology floor. # Respiratory distress: Respiratory distress likely combination of COPD and CHF, but more CHF given bilateral lower exttremity edema, CXR finding of fluid overload, and overload on exam initially. Mr. [**Known lastname 63208**] has a known LVEF of 25% based on ECHO here. Patient was intubated in the ED and transferred to the MICU. He was much improved the following day and was extubated successfully. He was treated with IV Furosemide during this time. He was transferred to the Cardiology Service and was placed on a Lasix drip for further diuresis. Given his new onset worsening left ventricular function, he was sent for cardiac cath which was significant for 3VD and is now s/p stenting of ostial and mid RCA with DES and POBA to ostial PDA. #CHF: Systolic acute on chronic CHF exacerbation as above. Patient was to continue carvedilol 12.5 mg [**Hospital1 **], isosorbide dinitrate 20mg TID. Furosemide was incresed to 80mg [**Hospital1 **] . #CAD: CABG x 3 in [**2167**] (LIMA-LAD, SVG-OM, SVG-PDA) with only LIMA-LAD patent multiple PCI's and multiple stents placed. Patient has tropopin leak up to 0.25 up from 0.03. This was thought to be due to demand ischemia as CK levels were not elevated. Patient was sent for Cardiac Cath as above. He is to continue home regimen of clopidogrel 75mg daily, ASA 325mg daily, simvastatin 80mg daily, isosorbide dinitrate 20mg TID. Pt started on Carvedilol 12.5 mg [**Hospital1 **]. # Rhythm: Atrial fibrillation: Pt not anticoagulated [**1-11**] massive GI bleed; rate controlled only with nondihydropyridine nifedipine at home. Switched to carvedilol this admission per cardiology. Patient was monitored for bronchospasm given hx of COPD. He did not have any adverse reaction and was discharged on Carvedilol for management of his A-fib and CHF. # COPD: Pt has known obstructive lung disease [**1-11**] extensive smoking history. He is to continue on his home Combivent. . # CRI: Baseline Cr (1.7-2.2), now elevated to 2.6 and remained there upon discharge. ACE-I was held and will be restarted by Dr. [**First Name (STitle) 437**] in clinic if kidney function improves. . # HTN: Patient is to continue Carvedilol, Isosorbide dinitrate, Amlodipine # Diabetes mellitus: Cont home glipizide . # Dyslipidemia: Continued simvastatin 80 daily. # Phase 4 Paroxysmal AV block: Patient has been seen by Dr. [**Last Name (STitle) **] regarding ICD/PM placement. This should be follow up by his PCP. Medications on Admission: MEDICATIONS ON ADMISSION: ([**First Name8 (NamePattern2) **] [**Doctor Last Name **] [**2182-12-16**] OMR note): Nifedipine 60 mg--one tablet by mouth once a day ASPIRIN 325MG--Take one by mouth every day Amlodipine 5 mg--one tablet by mouth once a day CLOPIDOGREL BISULFATE 75MG--One by mouth every day COMBIVENT 103-18 mcg/Actuation--take 2 puffs three times a day as needed for wheezing FUROSEMIDE 20 mg--three tablets by mouth once a day GLIPIZIDE 5 mg--take 1 tablet(s) by mouth once a day 1 hour after a meal ISOSORBIDE DINITRATE 20 mg--one tablet by mouth three times a day NITROGLYCERIN 400 MCG (1/150 GR)--Take as directed as needed for chest pain PROTONIX 40 mg--take 1 tablet(s) by mouth once a day (20 minutes before a meal) ROXICET 5 mg-325 mg--take 1 tablet(s) by mouth four times a day as needed for pain (twenty-eight day supply) SIMVASTATIN 80 mg--take 1 tablet(s) by mouth at bedtime ***** Pt does not appear to be on LISINOPRIL per PCP [**2182-12-16**] note, although he was discharged on lisinopril after his last hospital admission. ***** Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Isosorbide Dinitrate 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 5. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 6. Petrolatum Ointment Sig: One (1) Appl Topical TID (3 times a day) as needed. Disp:*1 tube* Refills:*2* 7. Glipizide 5 mg Tablet Sig: One (1) Tablet PO once a day: 1 hour after a meal. 8. Combivent 18-103 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation TID PRN as needed for shortness of breath or wheezing. 9. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 10. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual q5min PRN as needed for chest pain: one tablet every 5min for a total of 3 doses if needed for chest pain. 11. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. 12. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day. 13. Roxicet 5-325 mg Tablet Sig: One (1) Tablet PO QID prn as needed for pain. 14. Furosemide 80 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary: Systolic Heart Failure Exacerbation Coronary Artery disease s/p PCI with DES to RCA and POBA to PDA Secondary: - Coronary Artery Disease - Atrial Fibrillation, not anticoagulated due to massive GI bleed [**2176**] - PVD with B fem to distal bypass - Hypertension - Hypercholesterolemia - COPD - DM2 - GERD - Chronic renal insufficiency baseline 1.5 - 2.0 Discharge Condition: Stable Discharge Instructions: You were admitted into [**Hospital1 69**] for treatment of your Congestive Heart Failure. You were in severe respiratory distress on arrival and you were intubated and placed on a breathing machine for 24 hours. Your heart failure has been treated successfully with Intravenous Diuretics. An Ultrasound of the heart was done which showed worsening heart function. A cardiac catheterization was done to evaluate your arteries. You had a new occlusion of your right coronary artery which was opened with a drug eluting stent. A balloon was also used to open up a second artery. Please stop taking your Lisinopril for the time being. Your kidney function has slightly worsened with the diuresis and you should not take your Lisinopril as it may contribute to worsening kidney function. Your kidney function will be reevaluated by Dr. [**First Name (STitle) 437**] at your visit with him. Your Lasix has been increased from Lasix 60mg daily to Lasix 80mg twice per day. Please continue with your remaining regular home medications. Please attend recommended follow up below. If you experience worsening chest pain, shortness of breath, palpitations, nausea, vomiting, increased leg swelling, dizziness, lightheadedness, fainting or any other concerning symptoms then please call your doctor or report to the nearest emergency room. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Followup Instructions: Please call your new Cardiologist, Dr. [**First Name (STitle) 437**] at [**Telephone/Fax (1) 3512**] to set up an appointment to be seen on [**2183-1-23**]. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5377**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2183-1-22**] 8:20 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5377**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2183-3-5**] 8:20

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icd9cm

[ [ [] ] ]

[ "00.46", "96.04", "00.41", "36.07", "96.71", "00.66", "88.57", "88.56" ]

icd9pcs

[ [ [] ] ]

14339, 14396

9125, 11883

343, 401

14805, 14814

4623, 8736

16305, 16767

3874, 3952

12996, 14316

14417, 14784

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8753, 9102

14838, 16282

3982, 4604

283, 305

429, 1928

1972, 3730

3746, 3858

11,861

172,200

22422

Discharge summary

report

Admission Date: [**2133-6-11**] Discharge Date: [**2133-6-14**] Date of Birth: [**2105-5-5**] Sex: F Service: MEDICINE Allergies: Morphine / Prochlorperazine / Tramadol Attending:[**Doctor First Name 2080**] Chief Complaint: Nausea/diarrhea, hyperglycemia Major Surgical or Invasive Procedure: None History of Present Illness: 28 y/o F PMH IDDM (diagnosed at age 16)with multiple past admissions for DKA, proximal tibia fx s/p ORIF who presents with nausea and diarrhea for past couple of days along with increasing leg pain for past day decreased PO intake with some crampy abdominal pain. Denies any fevers, chills, cough, chest pain. Her initial vitals in the ED: T:99.1??????F P:108 RR:22 BP:119/77 O2Sat: 100. In the ED, her [**Doctor First Name **] glucose was 1052, K 6.8, WBC 8 (N:78.3), UA trace ketones, CXR No acute intrathoracic process. VBG after fluid resusciation 7.30/45/73/23 Lactate:4.1 EKG showed peaked T-waves. Given 10 units of insulin, started on insulin gtt at 6mg/hr, and calcium gluconate. Received 2L NS. In MICU T: 98.7 HR: 114 BP: 127/82 RR: 18 100% RA Her only complaint was some mild nausea. Past Medical History: - Diabetes mellitus type I: diagnosed age 16 in [**2120**] after her first pregnancy. followed at [**Last Name (un) 387**]. - Severe anxiety/panic attacks - Previous admissions for nausea/vomiting with h/o esophagitis and with concern for diabetic gastroparesis on metoclopramide - Esophagitis / H. Pylori [**6-/2128**] and again [**8-/2130**] - Stage I diabetic nephropathy (Baseline Cr 1.1) - Grade I esophageal varices seen on scope in [**2132-1-1**], negative liver ultrasound, normal LFTs, hep panel negative - Anxiety/panic attacks - [**Last Name (un) **] thought to be [**1-1**] lisinopril - Depression - Hyperlipidemia - S/P MVA [**5-4**] - lower back pain since then. - S/P MVA [**2130**], ex-lap - G2P1Ab1, s/p miscarriage in 06/00 3rd trimester, s/p C-section in [**2122**], not menstruating secondary to being on Depo-Provera - Genital Herpes - H pylori, s/p 2-week triple therapy on [**2132-1-24**] - left tibial plateau fracture s/p ORIF [**5-/2133**] Social History: Lives with her 9 y/o son. She is currently on disability. Tobacco: quit 10 years ago Alcohol: [**12-1**] glasses wine or champagne at holidays/special occasions (none recently) Illicits: none, denies IVDU Family History: diabetes in her grandmother and asthma. Physical Exam: Admission Exam: General: Alert, oriented x3, no acute distress Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: tachycardia, 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 , no CVA tenderness. Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Discharge Exam: Pertinent Results: Admission Labs: [**2133-6-11**] 07:15PM [**Month/Day/Year 3143**] WBC-8.2 RBC-3.66* Hgb-10.4* Hct-34.8*# MCV-95 MCH-28.4 MCHC-29.8* RDW-13.8 Plt Ct-285 [**2133-6-11**] 07:15PM [**Month/Day/Year 3143**] Neuts-78.3* Lymphs-18.3 Monos-2.2 Eos-1.0 Baso-0.2 [**2133-6-11**] 07:15PM [**Month/Day/Year 3143**] Glucose-1052* UreaN-49* Creat-2.2* Na-117* K-6.8* Cl-81* HCO3-19* AnGap-24* [**2133-6-11**] 11:11PM [**Month/Day/Year 3143**] CK-MB-1 cTropnT-<0.01 [**2133-6-11**] 11:11PM [**Month/Day/Year 3143**] Calcium-9.8 Phos-4.2 Mg-2.1 [**2133-6-11**] 10:14PM [**Month/Day/Year 3143**] Type-[**Last Name (un) **] pO2-73* pCO2-45 pH-7.30* calTCO2-23 Base XS--3 Comment-GREEN TOP [**2133-6-11**] 10:14PM [**Month/Day/Year 3143**] Lactate-4.1* [**2133-6-11**] 09:00PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.012 [**2133-6-11**] 09:00PM URINE [**Month/Day/Year **]-NEG Nitrite-NEG Protein-TR Glucose-1000 Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [**2133-6-11**] 09:00PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE Epi-0 UCx [**6-11**]: No growth (final) TWO VIEWS OF THE CHEST: The lungs are well expanded and clear. The cardiomediastinal silhouette, hilar contours, and pleural surfaces are normal. No pleural effusion or pneumothorax is present. IMPRESSION: No acute intrathoracic process. Brief Hospital Course: 27 y/o F h/o T1DM p/w 1d N/V/D and hyperglycemia. Active Issues ---------------- #DKA/DM1 uncontrolled with complications: Pt came in with N/V, hyperglycemia, electrolyte abnormalities, acidosis. No clear precipitating event for this presentation and pt states she was taking her insulin as prescribed. No evidence of underlying infection. Pt received insulin via drip and then was transitioned to insulin SC. She also received IV fluids. These measures corrected her lab abnormalities and [**Month/Year (2) **]. She was stable in the ICU and was transferred to the floor for continued adjustment of insulin regimen. She continued to do well. She was changed to Novolog mix 70/30: 28 qAM, 24 qPM, with HISS. - needs close follow up at [**Last Name (un) **] within 2 weeks # Presumed Gastroenteritis with N/V - Most likely multiple factorial with a strong component of diabetic gastroparesis vs gastroenteritis. Pt given Zofran 4 mg Q8 PRN and N/V resolved with resolution of DKA. #Anion gap acidosis - Likely [**1-1**] to lactic acidosis with lactate of 4.1 as well as diabetic ketoacidosis. Pt received IVF and elevated lactate and acidosis resolved prior to transfer to the floor. #[**Last Name (un) **] - Most likely pre-renal given h/o diarrhea and osmotic diuresis from hyperglycemia. Cr improving with fluid resuscitation.(baseline 1.3-1.4) Pt was seen as an outpatient on [**6-2**] with Cr. 1.7 thought to be [**1-1**] to lisinopril and told to d/c lisinoprol. However, due to her diabetic nephropathy and stability of her CKD with hydration, her ACE-I was resumed. Chronic Issues ------------------- #Anxiety/Psych: Was abused by uncle as a child, recently brought this up with her mother and this has been a source of much stress recently. She was continued on her home meds. #Chronic back/leg pain: Pain controlled with dilaudid initially, but soon changed oxycodone-acetominophen PRN. #HTN, CKD: Monitored. No active issue during this admission. Transitional Issues -Labile [**Month/Day (2) **] sugars, [**Last Name (un) **] following -Needs close followup with [**Last Name (un) **] -Cr downward trending Medications on Admission: novolog (70/30) 27 units QAM, 24 units QHS. Humalog 100 unit/mL Solution Sig: 1-15 units Subcutaneous three times a day: pls adjust per home sliding scale. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). ondansetron 4 mg Tablet mirtazapine 30mg QHS risperadone 2mg QHS lorazepam 0.5pm Q8H prn Reglan 10 mg Tablet Sig: One (1) Tablet PO four times a day. Discharge Medications: 1. risperidone 2 mg tablet Sig: One (1) tablet PO HS (at bedtime). 2. mirtazapine 30 mg tablet Sig: One (1) tablet PO HS (at bedtime). 3. omeprazole 20 mg capsule,delayed release(DR/EC) Sig: Two (2) capsule,delayed release(DR/EC) PO DAILY (Daily). 4. lorazepam 0.5 mg tablet Sig: One (1) tablet PO Q8H (every 8 hours) as needed for anxiety: please see your PCP for refills. 5. lisinopril 10 mg tablet Sig: One (1) tablet PO DAILY (Daily). 6. oxycodone-acetaminophen 5-325 mg tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: please see your PCP for refills. avoid with alcohol or driving. 7. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily) as needed for constipation: while taking percocet. 8. Humalog 100 unit/mL Solution Sig: 1-15 units Subcutaneous qACHS: according to the sliding scale provided, and your carb counting. Disp:*6 vials* Refills:*1* 9. FreeStyle Test Strip Sig: One (1) strip Miscellaneous five times a day: up to five times per day for [**Last Name (un) **] sugar monitoring. Disp:*1 box* Refills:*1* 10. FreeStyle Lancets Misc Sig: One (1) lancet Miscellaneous five times a day: for [**Last Name (un) **] glucose monitoring. Disp:*1 box* Refills:*1* 11. Novolog Mix 70-30 FlexPen 100 unit/mL (70-30) Insulin Pen Sig: as directed units Subcutaneous twice a day: 28 units in morning, 24 units at night. Disp:*6 vials* Refills:*1* Discharge Disposition: Home Discharge Diagnosis: Hyperglycemia/Diabetic ketoacidosis Diabetes mellitus type I, uncontrolled Anxiety Gastroenteritis Recent Tib-Fib fracture Discharge Condition: Stable. [**Last Name (un) **] sugars are labile. Discharge Instructions: Dear Ms. [**Known lastname **], You were admitted with elevated [**Known lastname **] sugars and abnormalities of your electrolytes (the salts in your [**Known lastname **]). We treated you with insulin and IV fluids and these abnormalities resolved. Your [**Known lastname **] sugars continued to be up and down while you were in the hospital and we recommend seeing your doctor [**First Name8 (NamePattern2) **] [**Last Name (Titles) **] in the next week to talk about your home insulin plan. Please take all medications as prescribed, and check your [**Last Name (Titles) **] sugar oftern. If you continue to take opiate medications, please note that due to excessive sedation, you must [**Last Name (un) **] take with alcohol, while driving, or while using machinery. Followup Instructions: Please call [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) 818**], MD who is your doctor at the [**Last Name (un) **] Diabetes Center at ([**Telephone/Fax (1) 19850**] to schedule your appointment some time in the next week. Name: [**Last Name (LF) 12933**], [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 5514**] A. MD - please see your PCP for follow up as well

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8242, 8248

4238, 6371

330, 337

8415, 8466

2898, 2898

9291, 9692

2398, 2439

6790, 8219

8269, 8394

6397, 6767

8490, 9268

2454, 2862

2879, 2879

260, 292

365, 1169

2914, 4215

1191, 2159

2175, 2382

82,565

196,861

10243

Discharge summary

report

Admission Date: [**2191-7-22**] Discharge Date: [**2191-8-5**] Date of Birth: [**2112-10-2**] Sex: F Service: MEDICINE Allergies: Sulfur-8 / ceftriaxone Attending:[**First Name3 (LF) 25936**] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: Embolization of artery for retroperitoneal bleed History of Present Illness: The patient is a 78F with h/o COPD, afib on coumadin, mild-mod mitral stenosis, Echo [**2187**] LVEF 60%, who presents from [**Hospital1 2292**] where she was there for eval of a rash. On further questioning, however, she noted that she has had a great deal of dyspnea on exertion recently. She says she had been feeling weak and miserable. At baseline, she can walk around and perform all ADL's but the 2-3 days before admission, she felt too weak and sick to do anything. Denies fevers/chills. No sick contacts/no recent illnesses. At [**Hospital1 **], they did an EKG there for hx of DOE and they found afib with rvr to 140. She received albuterol and combivent and 250cc bolus prior to arrival to ER. Of note patient stopped smoking 3 days before admission. She sats in the low 90's on room air at baseline. Past Medical History: . COPD (chronic obstructive pulmonary disease) Pseudophakia Macular Pucker SACRAL SPINE DISORDER ATRIAL FIBRILLATION paroxysmal HYPERCHOLESTEROLEMIA OSTEOPOROSIS, UNSPEC DEPRESSIVE DISORDER HYPOTHYROIDISM CVA at Age 18 with R sided hemiparesis since resolved History of Rheumatic Heart Disease of mitral valve . Social History: Smoking: Passive Smoker .5 ppd X40 years Smokeless Tobacco: Never Used Alcohol: No Family History: Brother [**Name (NI) 3730**]; Hypertension Mother [**Name (NI) 3730**] Sister Hypertension Physical Exam: ON ADMISSION . VS- T=97.9 BP=132/72 HR=130's irregular RR= 20 O2 sat= 94 3L GENERAL- in mild resporatory distress. Oriented x3. Mood, affect appropriate. HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK- Supple with JVP of 9 cm. CARDIAC- irregularly irregular,S1, S2, +S3. No appreciable murmurs but patient was tachycardic with distant heart sounds LUNGS- [**Month (only) **] breath sounds up to mid lung fields, diffuse exporatory wheezes ABDOMEN- mildly distended, non-tender, No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES- 1+ pitting edema up to mid ankle. SKIN- + stasis dermatitis LE 3 crusted lesions with erythematous base, pruritic but not tender, b/l upper arms and under L breast PULSES- Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ . ON DISCHARGE VS: 99.2 102/42 (100-115/40-60s) 95 (80-104) 18 98%RA I/O: yesterday 1360/-1200, last three shifts 1200/-2075 Gen: well-appearing pleasant elderly lady in NAD HEENT: NCAT EOMI MMM anicteric sclera Neck: Supple without LAD or JVD Pulm: CTA b/l without wheeze or crackles, improved air movement Cor: Irregular rate, (+)S1/S2 without m/r/g Abd: Soft, non-distended, non-tender, NABS Extrem: Trace edema in LE b/l, LE warm and well-perfused, cath site without bruit, c/d/i Neuro: AOx3, CNII-XII grossly intact, moving all extremities Lines: PIV Pertinent Results: ON ADMISSION . [**2191-7-22**] 04:30PM GLUCOSE-117* UREA N-30* CREAT-0.6 SODIUM-144 POTASSIUM-3.8 CHLORIDE-106 TOTAL CO2-29 ANION GAP-13 [**2191-7-22**] 04:30PM proBNP-3166* [**2191-7-22**] 04:30PM WBC-8.1 RBC-4.17* HGB-13.1 HCT-40.3 MCV-97 MCH-31.4 MCHC-32.5 RDW-13.4 [**2191-7-22**] 04:30PM NEUTS-68.2 LYMPHS-23.9 MONOS-5.4 EOS-1.4 BASOS-1.1 [**2191-7-22**] 04:30PM PLT COUNT-232 [**2191-7-22**] 04:30PM PT-61.7* PTT-44.6* INR(PT)-6.2* . CXR ([**7-22**]): 1. Pulmonary vascular congestion without effusion. 2. Rounded opacity in the right lung base is likely a nipple shadow, but follow-up radiograph with nipple markers may be obtained for confirmation after diuresis. . Echo ([**7-25**]): The left atrium is mildly dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is at least 15 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The estimated cardiac index is high (>4.0L/min/m2). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular cavity is mildly dilated with normal free wall contractility. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. The mitral valve shows characteristic rheumatic deformity. There is a minimally increased gradient consistent with trivial mitral stenosis. Mild (1+) mitral regurgitation is seen. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . IMPRESSION: Minimal mitral stenosis. Normal left ventricular cavity size with preserved regional and global lar systolic function. Moderate pulmonary artery hypertension. Right ventricular cavity enlargement with preserved free wall motino. Moderate tricuspid regurgitation. . CT Chest ([**7-28**]):As shown on a previous serial chest radiographs, mild pulmonary edema is improving. Centrilobular emphysema is moderate. A few less than 5 mm nodules are scattered throughout the lungs. A chest CT followup should be done in six months. . Cardiac cath ([**7-29**]): Active bleeding from superior branch of right lumbar artery. Successful placement of microspheres followed by coil embolization of the lumbar artery . CTAP ([**7-29**]): Large 9.8 x 12.1 cm right retroperitoneal hematoma with evidence of active arterial extravasation, the largest of which is in the right iliacus. An IR consult should be obtained. Moderate multifocal stenosis of the right common iliac, external iliac and common femoral artery with possible focal areas of high grade stenoses. Likely moderate focal stenosis in the distal left common iliac artery. Diffuse calcific atherosclerosis in the the distal external iliac arteries is also noted bilaterally. . Renal U/S ([**8-3**]): Large right heterogenous retroperitoneal hematoma with mild displacement of the right peri-renal space. However, no evidence of resulting mass effect, compression or hydronephrosis on the right kidney. . LABS ON DISCHARGE [**2191-8-5**] 05:16AM BLOOD WBC-11.1* RBC-3.82* Hgb-11.9* Hct-36.8 MCV-96 MCH-31.3 MCHC-32.5 RDW-15.8* Plt Ct-310 [**2191-8-5**] 05:16AM BLOOD Glucose-106* UreaN-32* Creat-0.7 Na-137 K-4.6 Cl-96 HCO3-34* AnGap-12 [**2191-8-5**] 05:16AM BLOOD Calcium-9.3 Phos-3.1 Mg-1.9 Brief Hospital Course: 78 year old female with a PMHx of AFib presents short of breath and found to have AFib with RVR, pulmonary edema, and some component of COPD exacerbation. The patient's stay was complicated by a right sided retroperitoneal bleed that was embolized on [**7-29**] (right lumbar artery). . # Retroperitoneal bleed: Unclear nidus of injury. s/p successful embolization of right lumbar [**Last Name (un) **] on [**7-29**]. Pt noted to have spontaneous retroperitoneal bleed [**2191-7-29**] AM on CT scan likely began [**2191-7-28**] PM as pt at that time complained of sudden onset right hip pain. No history of trauma, falls or procedures other than cardioversion on [**7-26**]. - Her INR was supratherapeutic on admission(6.5 on [**7-22**]) and was allowed to trend down during the course of her admission. Restarted warfarin 5mg and heparin bridge on [**7-27**]. INR on 8/30PM = 1.2, [**7-29**] AM = 1.5. PTT was supratherapeutic 8/30AM then 8/30PM PTT 68. On [**7-29**] AM PTT=68.9. LAST warfarin dose on [**7-28**] 4pm. On [**7-29**] pt transferred to CCU after above events and Hct drop from 32 to 23, and her SBPs 60s-70a. She received 2U RBC and 2U FFP with BPs returning to 100s/60s prior to emobilization of right lumbar artery by interventional cardiology. After embolization patients received 4U RBC, and 2U FFP. Hct remained stable x 24 hours and patient returned back to floor. She received one additional unit of PRBCs on the floor after a drop in hematocrit overnight, but has had a stable hematocrit greater than 30 since [**2191-8-2**] 05:00. The patient continues to report unchanged RLE/hip pain, likely a result of the bleed. All anticoagulation has been held since the day of the bleed. . Shortness of Breath/Weakness Patient with significant SOB beyond baseline up admission with significant smoking history and COPD. It was thought that she had an acute exacerbation of COPD complicating her CHF. Her initial CXR demonstrated some vascular congestion, but no true effusions, and hyperinflation. The patient had not required hospitalization for COPD exacerbation previously. She was continued on her home fluticasone-salmeterol regimen with L-albuterol and ipratropium nebulizers added. She was also started on prednisone for 5 days. She was started on lasix and achieved variable diuresis throughout her stay. Her lung exams improved clinically during her course, but the patient still had an oxygen requirement for much of her stay. A CT chest was obtained given her smoking history which did not identify any specific causes for her SOB, though some pulmonary nodules were found. By the end of her stay, her oxygen requirement was weaned and she was satting well on room air. . #Atrial Fibrillation Patient presented with supratherapeutic INR, thought to be [**12-30**] poor PO intake during the days before admission. Her rates were not controlled, initially in the 120's-130's. Became hypotensive initially in ED with IV Diltiazem and has since received calcium- BP's normalized. Anticoagulation held upon admission. She was triggered for a high heart rate and given metoprolol, but then started on diltiazem 60mg QID. This was then transitioned to 240mg of XR diltiazem. She was initially tried on digoxin but was not fully loaded. She was then started on amiodarone for DCCV. It was thought that the patient's atrial fibrillation was contributing to her deteriorating respiratory status. The patient was cardioverted on [**7-26**] and remained in sinus rhythm for about 36 hours. She then returned to afib. She was continued on diltiazem and amiodarone until the bleed at which time all atrial fibrillation medications were discontinued. The diltiazem was restarted after embolization and and she maintained HR 90s-100s. . #Rash Patient had rash at admission that appeared like a zoster infection, but patient reports she has had vaccine and the pattern of distribution was not consistent. However, given recent time course (developed over 72 hours), it was decided that she would receive a 7 day course of valacyclovir. Her rash resolved without further complaint. . CHRONIC ISSUES #Hypertension Has history of hypertension, controlled at home with lisinopril. Pressures while inpatient have been in the 100-110 systolic range. Her lisinopril has been held. She will be discharged with lisinopril held until she's evaluated by her cardiologist. . #Depression Patient had a history of depression, her venlafaxine was continued while inpatient. Estimated length of rehab stay is <30 days. . #CAD Patient endorses in teh past she had exertional chest pain that resolved with SL nitro. No other known history of CAD at this time. Her aspirin will be continued, but SLNG held. . #Hypothyroid Patient had a history of hypothyroidism, TSH found to be mildly elevated this admission. Her home dose of levothyroxine was continued. Her TSH should be rechecked in four weeks after discharge. . TRANSITIONAL ISSUES #Patient's anticoagulation has been held for atrial fibrillation given her bleed. She should follow-up with her cardiologist to discuss restarting warfarin. #Antihypertensives were also held; these should be discussed with cardiology before restarting. #Respiratory status has improved over course of hospitaliation, but patient may still require occasional lasix for fluid overload and supplemental oxygen while walking for desaturations. #The patient should continue to have a daily CBC/hematocrit to monitor for signs of continued bleeding. #Patient was found to have nodules on her chest CT. Radiology recommended follow-up with another CT in 6 months. #Patient found to have an elevated TSH on admission, with history of hypothyroidism. She should have a repeat TSH in four weeks. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Atrius. 1. Simvastatin 40 mg PO DAILY 2. Reclast *NF* (zoledronic acid-mannitol&water) 5 mg/100 mL Injection as directed 3. Warfarin 5 mg PO DAILY16 As Directed 4. Venlafaxine XR 75 mg PO DAILY Do not stop without consulting clinician 5. Levothyroxine Sodium 88 mcg PO DAILY 6. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH DAILY 7. Atenolol 37.5 mg PO DAILY Hold for HR<55, SBP<100 8. Lisinopril 10 mg PO DAILY Hold for SBP<90 9. calcium carbonate-vitamin D3 *NF* 600 mg(1,500mg) -400 unit Oral [**Hospital1 **] 10. Calcitonin Salmon 200 UNIT NAS DAILY 11. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv with min-lycopene-lutein;<br>mv-min-folic acid-lutein) 0.4-300-250 mg-mcg-mcg Oral Daily 12. Aspirin 81 mg PO DAILY 13. Vitamin D 1000 UNIT PO DAILY 14. Nitroglycerin SL 0.3 mg SL PRN chest pain Discharge Medications: 1. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH [**Hospital1 **] 2. Levothyroxine Sodium 88 mcg PO DAILY 3. Venlafaxine XR 75 mg PO DAILY Do not stop without consulting clinician 4. Vitamin D 1000 UNIT PO DAILY 5. Digoxin 0.125 mg PO DAILY 6. Docusate Sodium 100 mg PO BID 7. Senna 1 TAB PO HS:PRN constipation please hold for loose stools and abdominal cramping. thanks 8. calcium carbonate-vitamin D3 *NF* 600 mg(1,500mg) -400 unit Oral [**Hospital1 **] 9. Calcitonin Salmon 200 UNIT NAS DAILY 10. Centrum Silver *NF* (multivitamin-minerals-lutein;<br>mv with min-lycopene-lutein;<br>mv-min-folic acid-lutein) 0.4-300-250 mg-mcg-mcg Oral Daily 11. Reclast *NF* (zoledronic acid-mannitol&water) 5 mg/100 mL Injection as directed 12. Simvastatin 40 mg PO DAILY 13. Aspirin 81 mg PO DAILY 14. Levalbuterol Neb *NF* 0.63 mg/3 mL Inhalation q4 hr PRN SOB Reason for Ordering: pt with COPD and afib 15. Ipratropium Bromide Neb [**11-29**] NEB IH Q6H:PRN Wheeze, SOB 16. Diltiazem Extended-Release 240 mg PO DAILY 17. Nitroglycerin SL 0.3 mg SL PRN chest pain 18. Polyethylene Glycol 17 g PO DAILY 19. oxygen please provide supplemental oxygen (2-3L via NC) on ambulation Discharge Disposition: Extended Care Facility: [**First Name4 (NamePattern1) 533**] [**Last Name (NamePattern1) **] for Extended Care - [**Location 1268**] Discharge Diagnosis: Atrial Fibrillation with RVR COPD Exacerbation CHF Exacerbation Spontaneous retroperitoneal bleed 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: Ms. [**Last Name (Titles) 34124**], you came to the hospital with shortness of breath and a fast heart rate. You were found to be in atrial fibrillation with a fast heart rate. Your breathing troubles were likely from fluid overload and a COPD exacerbation. During your stay, you were found to have an internal bleed. You went briefly to the ICU for management and then were transferred back to the general medicine floor. We gave you several medicines to help your breathing including steroids and IV water pills. To help your heart rates and irregular heart rhythm, you were given medications called amiodarone, metoprolol, and digoxin. Some of these were continued, others were not. Cardioversion was attempted, but you did not stay in normal rhythm. Please see the medication sheet for any changes to your medication regimen. Please follow-up with your cardiologist within 1 week of your discharge: It is important that you keep this appointment to discuss whethere you should restart your blood-thinner (warfarin) and medications to control your high blood pressure (atenolol and lisnopril). Thank you for choosing [**Hospital1 18**], it was a pleasure participating in your care. Followup Instructions: We are working on a follow up appointment for your hospitalization in Cardiology with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. You need to be seen within 1-2 weeks of discharge. The office will contact you or your husband with the appointment information. If you have not heard within 2 business days please call the office at [**Telephone/Fax (1) 2258**].

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icd9cm

[ [ [] ] ]

[ "39.79", "99.61", "88.42", "88.49" ]

icd9pcs

[ [ [] ] ]

14783, 14918

6916, 12635

303, 354

15060, 15060

3269, 6893

16458, 16848

1647, 1742

13587, 14760

14939, 15039

12661, 13564

15243, 16435

1757, 3250

244, 265

382, 1196

15075, 15219

1218, 1531

1547, 1631

19,059

183,594

48190

Discharge summary

report

Admission Date: [**2127-4-22**] Discharge Date: [**2127-5-1**] Date of Birth: [**2065-11-22**] Sex: F Service: MEDICINE Allergies: Penicillins / Clindamycin / Celery / apple / bees Attending:[**First Name3 (LF) 613**] Chief Complaint: Malaise, shortness of breath, lower extremity pain Major Surgical or Invasive Procedure: none. History of Present Illness: Ms [**Known firstname **] [**Known lastname **] is a 61 year old female with morbid obesity, obesity-hypoventilation syndrome and obstructive sleep apnea complicated by pulmonary hypertension, cor pulmonale who is presenting with worsening volume overload in the past two weeks. She also has a history of polyarticular gout, recently on prednisone taper, and chronic renal insufficiency. Ms [**Known lastname **] [**Last Name (NamePattern1) 60251**] presented to [**Hospital1 18**] in [**2126-11-28**] for hypercarbic respiratory failure requiring intubation and tracheostomy. She was discharged to [**Hospital1 700**] and she was successfully weaned off the ventilator; currently she has been managed at rehab with red capping during the day and Passy-Muir valve at night with humidified air that she uses inconsistently. Her current admission was prompted after a routine visit to her PCP; she was sent to the ED for worsening volume overload. In the ED, she had transient and questionable hypotension to 80s systolic with immediate improvement without intervention. She was triaged to MICU for diuresis in the presence of this transient episode of hypotension. Her pulmonary hypertension is multifactorial - she has a history of Fen-Phen use in the past; she also has obstructive sleep apnea which was previously managed by CPAP. She is currently oxygen dependent on 2 liters nasal cannula. Recently, she was diagnosed with a DVT in her right upper extremity; she has been on coumadin and lovenox bridge - however it seems according to the last pulmonary note coumadin is being held until tracheostomy tube is changed in early [**Month (only) 116**]. She is also complaining of joint pain in her left ankle especially; she has a history of polyarticular gout affecting sacroiliac joints, PIPs, ankles on recent prednisone taper. Her lasix dose at home is 20 mg daily; she reports being compliant with a gradual increase in lower extremity swelling and pain over the past couple months. During this time, her prednisone was also being tapered. She is coughing up clearish sputum, but denies feeling much more short of breath than normal; denies orthopnea, chest pain, chest pressure, paroxysmal nocturnal dyspnea. Not ambulating at rehab given pain in her ankles. Past Medical History: 1. Morbid obesity (s/p gastric bypass [**2113**]) 2. Obstructive sleep apnea (noctural BiPAP 18/15, home O2 3-4L via nasal cannula) 3. Obesity hypoventilation syndrome 4. Severe pulmonary artery hypertension (attributed to OSA) 5. Cor pulmonale attributed to severe pulmonary hypertension 6. Asthma 7. Osteoarthritis (bilateral knees) 8. Diastolic heart failure (2D-Echo [**1-/2124**] showing LVEF 70-80%, PAP 64 mmHg) 9. Chronic kidney disease (stage III-IV, baseline creatinine 1.8-2.2) 10. Rosacea 11. Hypertension 12. Iron deficiency anemia 11. s/p ventral hernia repair with mesh and component separation ([**5-/2119**]) 12. s/p debridement of anterior abdominal wall and complex repair ([**6-/2119**]) Social History: She has 2 adult children and adopted 3 so total of 5 children. She notes no tobacco use, rare alcohol use currently but notes a former heavy alcohol history in the distant past. She denies recreational substance use. Family History: Notable for diabetes mellitus in her mother and sister, hypertension in siblings, mother and throughout the maternal family as well as kidney disease. Physical Exam: Admission PE: Vitals: BP is 115/70, HR is 97 and regular, respiratory rate is 18, 90% on humidifed trach mask, temp 98 Gen: Black female, in mild respiratory distress Cardiac: Nl s1/s2 RRR no murmurs appreciable Pulm: lungs clear bilaterally, intermittent wheezes Abd: distended and full of stool; no tenderness, normoactive bowel sounds Ext: [**1-31**]+ edema up to sacrum extending from both feet; no active synovitis, dorsum of left foot mildly tender without erythema Discharge PE: PE: VS: 98.3 102/59 (100-126/62-80) 93 (87-102) 20 97 on 1.5L (94-97 on 1.5L) 8h: -1025 General: pleasant, obese woman, with trach, NAD, in bed watching television neck: could not assess for JVP CV: RRR, S1, S2, no murmurs/rubs/gallops appreciated lungs: bibasilar inspiratory crackles, poor air movement back: 10 cm x 5cm soft, tender and hard, with overlying ecchymoses-> overall continues to decrease in size abdomen: obese, +BS, soft, nontender, nondistended extremities: warm, well perfused, 2+ DP pulses, significant pedal edema, with 1-2+ LE pitting edema b/l--> improving Neuro: normal muscle strength and sensation throughout, AAOx3 Pertinent Results: Admission labs: [**2127-4-22**] 08:00PM URINE COLOR-Yellow APPEAR-Hazy SP [**Last Name (un) 155**]-1.011 [**2127-4-22**] 08:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-LG [**2127-4-22**] 08:00PM URINE RBC-2 WBC-60* BACTERIA-MANY YEAST-NONE EPI-7 [**2127-4-22**] 08:00PM URINE HYALINE-7* [**2127-4-22**] 08:00PM URINE MUCOUS-RARE [**2127-4-22**] 07:23PM TYPE-[**Last Name (un) **] PO2-71* PCO2-46* PH-7.46* TOTAL CO2-34* BASE XS-7 COMMENTS-GREEN [**2127-4-22**] 07:23PM LACTATE-1.0 [**2127-4-22**] 07:15PM GLUCOSE-133* UREA N-18 CREAT-1.3* SODIUM-140 POTASSIUM-4.8 CHLORIDE-99 TOTAL CO2-29 ANION GAP-17 [**2127-4-22**] 07:15PM estGFR-Using this [**2127-4-22**] 07:15PM cTropnT-<0.01 proBNP-4108* [**2127-4-22**] 07:15PM CALCIUM-8.4 PHOSPHATE-2.0* MAGNESIUM-1.7 URIC ACID-3.8 [**2127-4-22**] 07:15PM WBC-12.0* RBC-3.75*# HGB-10.2*# HCT-37.0# MCV-99*# MCH-27.1 MCHC-27.4*# RDW-16.8* [**2127-4-22**] 07:15PM NEUTS-86.6* LYMPHS-8.6* MONOS-2.2 EOS-2.3 BASOS-0.3 [**2127-4-22**] 07:15PM PLT COUNT-301 [**2127-4-22**] 07:15PM PT-20.3* PTT-37.7* INR(PT)-1.9* Discharge labs: [**2127-4-30**] 05:50AM BLOOD WBC-7.4 RBC-3.81* Hgb-10.3* Hct-37.3 MCV-98 MCH-27.0 MCHC-27.6* RDW-17.0* Plt Ct-269 [**2127-5-1**] 06:05AM BLOOD WBC-8.9 RBC-3.66* Hgb-10.0* Hct-35.9* MCV-98 MCH-27.4 MCHC-27.9* RDW-17.0* Plt Ct-243 [**2127-5-1**] 06:05AM BLOOD PT-22.7* PTT-42.9* INR(PT)-2.2* [**2127-4-29**] 06:00AM BLOOD LMWH-0.25 [**2127-5-1**] 06:05AM BLOOD Glucose-131* UreaN-14 Creat-1.3* Na-145 K-3.8 Cl-97 HCO3-43* AnGap-9 [**2127-5-1**] 06:05AM BLOOD Calcium-8.2* Phos-2.3* Mg-2.1 Upper back u/s: FINDINGS: A hypoechoic tubular fluid collection is noted in the region marked, 11 mm below skin surface, measuring 1.1 x 0.6 x 2.9 cm. ECHO: IMPRESSION: Suboptimal image quality. Right ventricular cavity dilation with free wall hypokinesis. Pulmonary artery hypertension. Normal left ventricular cavity size and global systolic function. No intracardiac shunt suggested at rest. Compared with the prior study (images reviewed) of [**2126-12-3**], the estimated PA systolic pressure is now lower (may not reflect a true change due to suboptimal technical quality of the current study acquired with the patient sitting up in a chair). CT abd/pelvis: IMPRESSION: 1. No acute intra-abdominal or intrapelvic process. 2. Mild bibasilar atelectasis. 3. Post-gastric bypass. No bowel obstruction. Brief Hospital Course: This 61 year old female with a history of pulmonary hypertension and cor pulmonale secondary to obesity-hypoventilation syndrome and obstructive sleep apnea presents with worsening volume overload. # hypoxia [**1-30**] OSA, pulmonary HTN, and obesity hypoventilation: Initially the patient was admitted to the MICU. She was seen by both sleep medicine and IP. As per IP, it was recommended that the patient con't to uncap the trachestomy tube at night and place a trach mask with humidifier around that. The patient was doing well on this regimen while in the unit and was called out to the floor. The patient was initially doing well while on the floor, but she then triggered for hypoxia on the floor and returned to MICU on [**2127-4-25**]. During this unit stay, hypoxia resolved with uncapping of her tracheostomy. She was placed on a ventilator on the first night as she appeared somnolent and monitored for another night using red cap during the day and passy muir valve at night without any oxygen desaturations. Multiple attempts were made to re-address code status as pt periodically requested that she no longer be put on a ventilator. Of note, the patient was also restarted on her Sildenafil for her pulmonary hypertension. The patient was also continued on her ipratropium, albuterol, and fluticasone On transfer back to the floor, the patient was doing well on 1.5L NC, maintaining O2 sats between 88-92%. It will also be VERY important to maintain her O2 sats between 88-92%, as the patient is a chronic CO2 retainer and O2 saturations that are too high can lead to hypercarbia. The patient will have a repeat outpatient sleep study as well (see transitional issues). # volume overload: The etiology of the patient's volume overload is multifactorial, given her history of cardiopulmonary disease. In the MICU, diuresis was initiated for her volume overload (lasix 80 mg IV BID) with good immediate response. Given her severe pulmonary hypertension, we repeated her echo with bubble study to look for shunt; no shunt was visualized. At night, we kept her on oximetry while using a Passy-Muir valve which was used for humidified air without any desaturation. Her sats remained in the low 90s. Her sildenafil was restarted. While on the floor, the patient was continued on Lasix. It was held in the setting of her acute renal failure, but once her creat was trending down, Lasix 40 mg daily was restarted. # acute renal failure: While in the unit the patient' creat began to rise (1.7). Her lasix was stopped and medications were renally dosed and nephrotoxic agents were avoided. Upon discharge, her creat was trending down, back to 1.3 and diuresis was restarted. # RUE DVT: Otherwise, her anticoagulation for her upper extremity DVT was continued (lovenox) with coumadin being held given plan by IP to exchange out the tracheostomy tube in early [**Month (only) 116**]. After IP decided that they were going to hold off on this procedure, Lovenox was discontinued and the patient was restarted on coumadin with daily INRs being checked. # back pain: The patient was complaining of upper back pain and was noted to have an ecchymosis overlying a tender mass. An ultrasound of the upper back showed a hematoma. It was unclear whether she had any trauma to the area. The hematoma was decreasing in size upon discharge. # Hypotension: The patient was transiently hypotensive in the ED; remained normotensive while in the unit and while on the medicine floor. # E. coli UTI: The patient completed seven day course of ceftriaxone for her E.coli UTI. # increased secretions from trach: While in the unit, noted to have increased secretions from trach. She was noted to have GNRs in culture, likely colonization # Cor pulmonale/right sided heart failure: Most recent ECHO shows EF >60% with right ventricular cavity dilation with free wall hypokinesis, consistent with her known R sided heart failure in the setting of OSA and pulmonary HTN. The patient was initially volume overloaded and diuresed as described above. She was discharged home on Lasix 40 mg daily. # pulmonary HTN: The patient was restarted on her sildenafil. # L ankle pain: The patient was complaining of ankle pain; films with evidence of soft tissue swelling. She was given allopurinol and colchicine, as well as prednisone 5 mg daily. Her colchicine was held in the setting of her acute renal failure. Upon discharge, the patient was continued on prednisone 5 mg, as per rheum note. # DM2: The patient has not required long acting insulin in the past, as per OMR and she was maintained on a humalog insulin sliding scale while in house. Transitional Issues: - sleep follow up: The patient has a sleep study on [**2127-6-14**] with the sleep doctors; if there are cancellations, the sleep doctors [**Name5 (PTitle) **] contact the patient with a sooner appt for sleep study. The patient has a follow up appt with the sleep doctors [**Last Name (NamePattern4) **] [**2127-7-1**] at 10:30 AM with Dr. [**Last Name (STitle) **]. - Given her obesity hypoventilation and high baseline levels of Co2, the pt is a chronic retainer and maintaining O2 sats in the high 80/low 90 range should be her goal in order to preserve her respiratory drive. PLEASE maintain O2 sats in the low 90s; avoid sats any higher in order to prevent hypercarbia. - Please check daily INRs until they are stable. Medications on Admission: ALLOPURINOL - 300 mg Tablet - 1 Tablet(s) by mouth daily in combination with 100 mg tablet for total of 400 mg daily ALLOPURINOL - 100 mg Tablet - 1 Tablet(s) by mouth daily in combination with 300 mg daily for total of 400 mg BIPAP - - as directed for sleep apnea COMMODE - - For home use. Needed indefinitely. Dx: gout. RID# [**Telephone/Fax (5) 101573**] EPINEPHRINE - (Not Taking as Prescribed) - 0.3 mg/0.3 mL (1:1,000) Pen Injector - use as directed prn FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 2 puffs inhaled twice a day FUROSEMIDE - (Prescribed by Other Provider) - 20 mg Tablet - Tablet(s) by mouth INVACARE TUB SEAT - - as directed qd; diag: 428.0 OXYCODONE - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth Q4 hours as needed for pain OXYGEN - - 4 liters nasal cannula via concentrator continuous portable oxygen required for daily appointments & errands [**3-4**] hours per day. Oxygen sat 60-70%RA. Dx hypoxemia / respiratory fail OXYGEN CONCENTRATOR - - use 3 litres via nasal prongs continuous flow at rest and with exertion DX: CHF, pulmonary HTN. Life time need POLYETHYLENE GLYCOL 3350 - (Prescribed by Other Provider) - Dosage uncertain WARFARIN - (Prescribed by Other Provider) - 6 mg Tablet - Tablet(s) by mouth WATER AEROBICS - - 1-3 times weekly Pulmonary HTN; to improve pulmonary function ACETAMINOPHEN [TYLENOL] - (Prescribed by Other Provider) - Dosage uncertain ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day BIPAP 18/15 WITH 4L SUPPLEMENTAL O2 WHILE ASLEEP - (OTC) - Dosage uncertain BISACODYL - (Prescribed by Other Provider) - 5 mg Tablet, Delayed Release (E.C.) - 2 Tablet(s) by mouth at bedtime CLOTRIMAZOLE [DESENEX] - (Prescribed by Other Provider) - Dosage uncertain CODEINE-GUAIFENESIN [CHERATUSSIN AC] - 100 mg-10 mg/5 mL Liquid - [**12-30**] teaspoon(s) by mouth twice a day as needed for cough DOCUSATE SODIUM [COLACE] - 100 mg Capsule - 1 Capsule(s) by mouth [**Hospital1 **] - tid prn constipation FERROUS SULFATE - 325 mg (65 mg Iron) Tablet - 1 Tablet(s) by mouth every morning SODIUM CHLORIDE [SALINE SPRAY] - 0.9 % Aerosol, Spray - [**2-1**] sprays at least 4 times a day use more frequently for nasal congestion Discharge Medications: 1. allopurinol 300 mg Tablet [**Month/Day (3) **]: 0.5 Tablet PO once a day. 2. fluticasone 110 mcg/actuation Aerosol [**Month/Day (3) **]: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 3. furosemide 40 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 4. sildenafil 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO TID (3 times a day). 5. polyethylene glycol 3350 17 gram Powder in Packet [**Hospital1 **]: One (1) Powder in Packet PO DAILY (Daily) as needed for constipation. 6. warfarin 2 mg Tablet [**Hospital1 **]: Three (3) Tablet PO Once Daily at 4 PM. 7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Hospital1 **]: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze. 8. aspirin 81 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO once a day. 9. docusate sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO twice a day as needed for constipation. 10. ferrous sulfate 325 mg (65 mg iron) Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 11. prednisone 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital1 **]-[**Location (un) 701**] Discharge Diagnosis: primary diagnosis: acute on chronic right heart failure acute on chronic diastolic heart failure obesity hypoventiliation syndrome obstructive sleep apnea pulmonary hypertension secondary diagnosis: right upper extremity deep venous thrombosis urinary tract infection chronic kidney disease stage II-III 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 **], It was a pleasure taking care of you while you were hospitalized at [**Hospital1 18**]. You were admitted to the hospital because your primary care doctor thought that you were retaining a lot of fluid. While you were in the emergency room, your pressures were low and you were initially admitted to the intensive care unit. While on the medicine floor, your blood pressures remained in a good range. Your oxygenation levels were varying, and you required a return to the intensive care unit for one night. You have been doing better since then. It will be VERY important that your oxygen levels stay in the range of 88-92%. We made the following changes to your medications: INCREASE Lasix to 40 mg by mouth daily DECREASE allopurinol to 150 mg daily RESTART sidenafil 20 mg by mouth three times daily Followup Instructions: Department: WEST [**Hospital 2002**] CLINIC When: TUESDAY [**2127-5-6**] at 11:15 AM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 3020**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: RHEUMATOLOGY When: FRIDAY [**2127-5-23**] at 2:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 34216**], MD [**Telephone/Fax (1) 2226**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 861**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: MEDICAL SPECIALTIES When: TUESDAY [**2127-7-1**] at 10:30 AM With: DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3172**] [**Telephone/Fax (1) 612**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage You will need a sleep study soon. The tentative date for this is [**6-14**]. The sleep lab will call you to confirm this date and time. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2127-5-1**]

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Discharge summary

report

Admission Date: [**2162-3-23**] Discharge Date: [**2162-3-26**] Service: MEDICINE Allergies: Aspirin / Ibuprofen Attending:[**First Name3 (LF) 106**] Chief Complaint: etoh septal ablation Major Surgical or Invasive Procedure: Alcohol septal ablation Implantable pacemaker placement History of Present Illness: 81F with concentric cardiomyopathy s/p etoh septal ablation [**8-/2159**] who presents to [**Hospital1 18**] for re-ablation. She first was diagnosed with hypertrophic obstructive cardiomyopathy in [**2155**] after having years of unexplained chest pain and shortness of breath with edema. [**Year (4 digits) **] showed gradient of 40mmHg and near cavity obliteration. She was medically managed with diuretics and verapamil but eventually required etoh ablation 9/[**2158**]. She slowly had symptomatic improvement and her resting gradient was 25mmHg in 3/[**2160**]. During [**2162-2-2**], she had a series of problems including a fall, pneumonia and a oral infection. Subsequently, she had signficant worsening of her dyspnea such that she could barely walk across the kitchen before feeling short of breath. TTE [**2162-2-4**] demonstrated symmetric LVH with an excellent LVEF (78%) and normal regional wall motion but a resting LVOT gradient of 23mmHg that increased to >100mmHg with Valsalva and a gradient of 106mmHG of her outflow tract. Given her recurrence of symptoms and the gradient, elective ablation was performed. Past Medical History: HOCM, s/p ethanol ablation [**2158**] [**11-7**]: Pneumonia s/p mechanical [**2162**] Hypothyroidism Borderline Hyperlipidemia Remote Migraines DJD Hx of colon polyps Osteoporosis Tonsillectomy Several Basal cell carcinoma excisions, most recent from [**12-9**]- left foot 3 C-sections [**2161-12-5**]-infected torus palatinus, requiring oral surgery Social History: Non-smoker, non-drinker. Lives at home w/ husband. She previously worked as [**Name8 (MD) **] RN in a NICU in [**Location (un) **] [**State 2748**]. She is married with four children, one of whom lives in [**Location 1110**]. Family History: n-c Physical Exam: bp 90/45 hr 80 rr 16 GEN: female in bed NAD HEENT: PERRL, MMM CV: normal S1/S2 PUL: CTA B/L ABD: Soft, NT, ND Ext: No edema Pertinent Results: [**2162-3-23**] 11:47AM TYPE-ART PO2-82* PCO2-43 PH-7.40 TOTAL CO2-28 BASE XS-0 INTUBATED-NOT INTUBA COMMENTS-ROOM AIR [**2162-3-23**] 08:15AM WBC-11.5* RBC-4.03* HGB-12.5 HCT-35.2* MCV-87 MCH-30.9 MCHC-35.5* RDW-13.0 [**2162-3-23**] 11:47AM HGB-11.8* calcHCT-35 O2 SAT-95 [**2162-3-23**] 08:15AM PLT COUNT-365# [**2162-3-26**] 07:35AM BLOOD WBC-9.0 RBC-3.11* Hgb-9.7* Hct-27.3* MCV-88 MCH-31.2 MCHC-35.5* RDW-13.5 Plt Ct-200 [**2162-3-26**] 07:35AM BLOOD Glucose-94 UreaN-12 Creat-0.8 Na-140 K-3.8 Cl-106 HCO3-26 AnGap-12 [**2162-3-24**] 03:34PM BLOOD CK(CPK)-371* ECG: [**3-26**]: Demand A-V sequential and ventricular pacing Since previous tracing, A-V paced rhythm CXR: 1) Permanent pacemaker leads in satisfactory position with no pneumothorax. 2) Small bilateral pleural effusions and discoid atelectasis. 3) Compression fracture in mid-thoracic spine. ECHO [**3-24**]: There is moderate symmetric left ventricular hypertrophy with normal cavity size and dynamic systolic function (LVEF >70%). Regional left ventricular wall motion is normal. No valvular [**Male First Name (un) **] is seen, but a moderate (peak 50mmHg) LVOT gradient is identified. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened. No aortic regurgitation is seen. The mitral leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. There is an anterior space which most likely represents a fat pad. Brief Hospital Course: A/P: 81F w/ HOCM s/p etoh septal ablation 1) Cardiac: a) ischemia: given etoh has caused a controlled infarction she was equiv of a post-MI patient, although she has no coronary artery disease. Cath showed only lumenal irregularities. CKs trended downward post-procedure. She had some residual chest pain after the procedure that was treated with fentanyl and then oxycodone, this was attributed to bruising after she received chest compressions briefly during her procedure. b) pump: pt has followup with Dr. [**Last Name (STitle) 696**] for followup [**Last Name (STitle) 461**]. EF~75% We continued lasix,aldactone, pindolol and verapamil. c) rhythm: pt had CHB during procedure with asystole. She received several chest compressions. Transvenous pacer placed perioperatively and CHB has resolved. On [**3-24**], the pt went back into complete heart block. A permanent implantable pacemaker was placed. 2) Endocrine: h/o hypothyroidism, contine synthroid 3) PPX: heparin sq, bowel regimen, anti-emetics 4) Code: Full 5) Comm: patient, husband [**Name (NI) **], grandson. Medications on Admission: Verapamil 80mg three times a day Pindolol 5mg daily Lasix 160mg daily (hold the morning of the procedure) Synthroid 100mcg six days a week, 50mcg on Monday's KCL 20meq every day Evista 60mg daily Fosomax 70mg once a week (Tuesdays) Aldactone 25mg twice a day Vitamin supplements (E, C, zinc, calcium) Discharge Medications: 1. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO 6X/WEEK ([**Doctor First Name **],TU,WE,TH,FR,SA). 2. Levothyroxine Sodium 50 mcg Tablet Sig: One (1) Tablet PO QMON (every Monday). 3. Raloxifene HCl 60 mg Tablet Sig: One (1) Tablet PO daily (). 4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Tramadol HCl 50 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 8. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day) as needed. 9. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 10. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY (Daily). 11. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 12. Alendronate Sodium 70 mg Tablet Sig: One (1) Tablet PO QTUES (every Tuesday). 13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 14. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 15. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*14 Tablet(s)* Refills:*0* 16. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 17. Spironolactone 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Pindolol 5 mg Tablet Sig: One (1) Tablet PO QDAY (). 19. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 20. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 5 days. Disp:*20 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Hypertrophic cardiomyopathy Discharge Condition: Good Discharge Instructions: Please seek medical attention for fevers>101.4, chest pain, or for anything else medically concerning. Please take your medications as directed. Followup Instructions: 1) Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2162-4-6**] 1:00 3) Provider: [**Name10 (NameIs) **] Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 128**] Date/Time:[**2162-6-17**] 1:00 4) Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 10464**] Date/Time:[**2162-6-24**] 11:30

[ "997.1", "244.9", "414.8", "426.0", "E878.8", "272.0", "414.01", "425.4" ]

icd9cm

[ [ [] ] ]

[ "37.83", "37.23", "37.27", "37.72", "37.26", "37.34" ]

icd9pcs

[ [ [] ] ]

6999, 7005

3758, 4845

247, 305

7077, 7083

2265, 3735

7277, 7775

2101, 2106

5197, 6976

7026, 7056

4871, 5174

7107, 7254

2121, 2246

187, 209

333, 1465

1487, 1839

1855, 2085

29,869

197,263

15669

Discharge summary

report

Admission Date: [**2106-8-29**] Discharge Date: [**2106-9-2**] Date of Birth: [**2054-5-7**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7223**] Chief Complaint: CP and SOB Major Surgical or Invasive Procedure: Right heart catheterization; pericardialcentesis History of Present Illness: Patient is a 52 y/o male with a history of dyslipidemia and DM who presented to an OSH w/ complaints substernal chest pain with associated shortness of breath over the last two days. Pain described as constant, stabbing 10/10 chest pain without radiation. Found that pain is worse with position. He denies any assoicated nausea/vomiting or diaphoresis. While in the OSH ED, patient's vitals were 94/68, HR 107, RR 16, T 100.4, and 89% on RA. Patients CP was not relieved by SLNG x 3. EKG showed ST depressions in lead I, aVL, and 1mm ST elevations in I. The patient had a CTA which revieled a large pericardial effuison, as well as a question of atelectasis verus infiltrate at the left base. The patient was transfered to [**Hospital1 18**] for possible pericardialsentesis. Of note, on the day prior the presentation, the patient endorses a 101.4 degree fever, ear pain, and loose, non-bloody stools. He has not any new joint pain, and has no history of rheumatologic, thyroid , or renal disease. He had a colonoscopy two years prior, which he reports as negative. He denies any recent cough, hemopytsis, night sweats, or history of smoking. He was experiencing chest pain one month prior to presentation, and had a stress test, which he reports as normal. On review of symptoms, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, recent black stools or red stools. He denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. . Past Medical History: Cardiac Risk Factors: Diabetes, Dyslipidemia Social History: Social history is significant for the absence of tobacco use. There is no history of alcohol abuse. There is no family history of premature coronary artery disease or sudden death. His father passed away from [**Name (NI) 2481**] and mother is also deseased from gastric cancer. Physical Exam: VS: T 99.4, BP 149/88, HR 126, RR 21, O2 99% on 15L Gen: Middle aged male, laying flat on bed, wearing O2 mask. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple, no JVP noted CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. ? + S3 vs fixed split s2 Chest: Patient laying flat and difficult to asses. Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi heard anteriorally. Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial bruits. +BS Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Pertinent Results: Conclusions: The left atrium is normal in size. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The right ventricular cavity is unusually small. Right ventricular systolic function is normal. The aortic valve leaflets appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is a moderate to large sized pericardial effusion primarily anterior to the right atrium and right ventricle (2.1cm) and inferolateral left ventricle (1.2cm) with relatively less (<1cm) around the left ventricular apex and inferior wall. There is right ventricular diastolic collapse, consistent with impaired fillling/tamponade physiology. There is significant, accentuated respiratory variation in mitral/tricuspid valve inflows, consistent with impaired ventricular filling. IMPRESSION: Moderate to large partially loculated pericardial effusion with evidence of hemodynamic compromise/tamponade physiology. Pericardial fluid: NEGATIVE FOR MALIGNANT CELLS. CXR: Pericardial drain remains in place. Cardiomediastinal contours are stable in appearance. Lung volumes remain low but slightly increased compared to the previous study. Left retrocardiac opacity, likely a combination of atelectasis and effusion, appears unchanged. Right lung is grossly clear. [**2106-8-29**] 08:46PM TSH-2.2 [**2106-8-29**] 08:46PM CEA-1.1 [**2106-8-29**] 08:46PM WBC-19.4* RBC-4.68 HGB-13.9 HCT-40.0 MCV-85 MCH-29.8 MCHC-34.8 RDW-13.7 [**2106-8-29**] 07:00PM OTHER BODY FLUID TOT PROT-5.7 GLUCOSE-183 LD(LDH)-436 ALBUMIN-3.4 [**2106-8-29**] 07:00PM OTHER BODY FLUID WBC-[**Numeric Identifier 45204**]* RBC-144* POLYS-93* LYMPHS-0 MONOS-5* MACROPHAG-2* [**2106-8-29**] 04:28PM ALT(SGPT)-30 AST(SGOT)-21 LD(LDH)-277* CK(CPK)-103 ALK PHOS-63 AMYLASE-17 TOT BILI-0.8 Brief Hospital Course: #) Cardiac: Ischemia: While the patient complained of chest pain, seemed more pleuritic in nature. CE negative x 2 and negative while at OSH. Patient with recent stress test one month ago with supposed normal findings. Cardiac cath in [**2100**] showing no CAD. Do no believe that patient complains of CP/SOB is ischemic in nature. However, patient had CP 2-4 weeks ago, and given new pericardial effusion with possibly some restrictive componenent given incomplete resolution, possibilitys of a Dressler's type syndrome cannot be overlooked. Patient was continued on home dose of lipitor. . Pump: Patient w/ a large pericardial effusion on CT, and hemodynamic pressures consistent with tamponade. Of note, however, is that patient hypertensive at presentation. Patient s/p pericardiacentesis with removal of 600cc of staw color fluid w/ high WBC and PML predominance. Fluid culture failed to grow organisims, and no malignant cells were seen on cytlogic exam. The etiology for the effusion is unclear. Pt was HIV and PPD negative, no evidence of myocardial infarction, no known hx of causative drugs and toxins, no metabolic disorders (especially uremia, dialysis, and hypothyroidism.) The patient had no description of symptoms consistent with lupus, although had midly elevated levels of RF and [**Doctor First Name **]. The patient described recent syndroms consistent with a viral podrome, which lends itself to a viral etiology. However, the simulaneous onset of both symptoms is less podromal in nature. CT negative for lung pathology. The patient remained clinicaly stable throughout hospitalization, and BP and HR returned to [**Location 213**] levels within hours of removal of pericardial fluid. Serial f/u TTE showed an absence of fluid reaccumulation. The patient was started on both ibuprofin for pain and cochicine. He was discharged due to continue ibuprofin for 2 week course and cochicine for 6 weeks. . #) Dyspnea: Most likely secondary to poor cardiac function in the setting of tamponade, and patient discharged without O2 requirment and adequate O2 sats. CXR showed b/l pleural effusions, lending itself to a seriousitis etiology. As pericardial fluid was analysed, no thoracentesis was performed. Patient was discahred with instructions for f/u CXR in 1 week to evaluate effusions. Sputum Cx were negative and patient afebrile. . #) DM: Patient w/ DM diagnosed three years ago. Was maintained on home regimen of metformin/glipize w/ Humalong ISS. . #) Hiatal Hernia: Kept on outpatient regimen of ranitidine and protonix. Medications on Admission: Ranitidine 300mg qhs Lipitor 10mg daily Glipizide 5mg daily Protonix one taplet daily Metformin 1000mg [**Hospital1 **] ASA 81mg qday Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 6 months. Disp:*360 Tablet(s)* Refills:*0* 4. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) for 2 weeks. Disp:*56 Tablet(s)* Refills:*0* 5. Metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Tablet(s) 6. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. PA/Lateral Chest XRay Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Pericardial Effusion Cardiac Tamponade Secondary Diagnosis: Diabetes Discharge Condition: Stable Discharge Instructions: You were admitted with a pericardial effusion, which is a collection of fluid around your heart. This fluid was removed and we followed you with a series of echocardiograms to make sure that it was not reaccumulating. We also did some tests to find an explanation for why the fluid accumulated, and everything came back negative. 1. Please take all medications as prescribed. 2. Please attend all follow-up appointments. You should see Dr. [**Last Name (STitle) 45205**] in clinic in one week, and should make that appoinment upon discharge. 3. Have a chest x-ray in one weeks time to evaluate for change of fluid on the lung. 4. If you develop chest pain, shortness of breath, lightheadedness, confusion, palpiations, or any other concerning symptoms, call your cardiologist or go straight to the emergency room. Followup Instructions: Please Schedule an outpatient follow up with your cardiologist Dr. [**Last Name (STitle) 45205**] in 1 week. At that time, have a Chest X-Ray as prescribed below.

[ "401.9", "518.0", "420.90", "423.2", "250.00", "553.3", "511.9", "272.4" ]

icd9cm

[ [ [] ] ]

[ "37.21", "88.55", "37.0" ]

icd9pcs

[ [ [] ] ]

8796, 8802

5430, 7994

324, 375

8934, 8943

3393, 5407

9808, 9975

8179, 8773

8823, 8823

8020, 8156

8967, 9785

2521, 3374

274, 286

403, 2142

8902, 8913

8842, 8881

2164, 2210

2226, 2506

27,058

177,309

46998

Discharge summary

report

Admission Date: [**2189-1-6**] Discharge Date: [**2189-1-23**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1162**] Chief Complaint: Abdominal pain, dysuria. Major Surgical or Invasive Procedure: Central line placement [**2189-1-6**]: History of Present Illness: 83yo man w/ Alzheimers, BPH h/o UTIs, s/p recent R hip fx & ORIF with gamma nail on [**2188-12-28**] who presented w/ "shaking chills & abd pain x 1 day. In the ER, temp 103.3, rectal temp >104, HR 120, BP 140s/40s and lactate 4.4. Sepsis protocol was initiated and a RIJ was placed. He was started on vanc, zosyn and flagyl and recieved 3 L of fluid. UA showed evidence of UTI. CT abdomen was negative for acute pathology. CT head did not show an ICH. CXR film did not show an infiltrate. Lactate subsequently came down to 2.1. . He was initially admitted to the [**Hospital Unit Name 153**] for urosepsis. 4 out of 4 blood cultures returned Ecoli (R to pcn, unasyn) otherwise pan-sensitive. Vanco,Zosyn discontinued. Started on Cipro antibiotics. Repeat surveillance cultures from [**1-7**], [**1-9**] negative to date. Also started on flagyl and PO vancomycin empirically for cdiff (cdiff negative x 2 thus far [**1-6**] and [**1-8**]). . [**Hospital Unit Name 153**] course also complicated by new afib with RVR, felt to be in setting of infection. Treated initially with dig load, and diltiazem, b-blocker for rate control. digoxin, dilt subsequently discontinued due to hypotension. Currently controlled on PO lasix, in normal sinus rythm . Given HD stability, called out to floor on [**2189-1-10**]. Past Medical History: bladder diverticulum renal cysts BPH recurrent UTIs (pansensitive Klebsiella and E. Coli) TIA '[**79**] depression [**1-7**]+ AR/1+ MR, EF >55% on echo from [**6-9**] Social History: Italian speaking, understands and speaks some english. Lives at home with his wife. [**Name (NI) **] 3 children. Denies tob/drug use. Drinks [**1-7**] glass wine per day. Family History: NC Physical Exam: VS: T 98.6, BP 112/57, HR 82, RR 20, 95% 3L O2 NC GEN: awake, alert, primary italian speaking, no acute distress HEENT: EOMI. MMM. OP clear NECK: supple. no jvd RESP: CTA b/l with good air movement throughout CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: right lower extremity with echymosis extending from hip laterally down entire leg to dorsum of foot. also w/ 2+ dorsal edema b/l NEURO: no focal deficits Pertinent Results: [**2189-1-6**] 11:28PM HCT-24.2* [**2189-1-6**] 10:21PM TYPE-ART PO2-102 PCO2-32* PH-7.38 TOTAL CO2-20* BASE XS--4 [**2189-1-6**] 10:21PM LACTATE-2.2* [**2189-1-6**] 09:09PM TYPE-ART TEMP-36.7 O2-50 O2 FLOW-15 PO2-95 PCO2-34* PH-7.36 TOTAL CO2-20* BASE XS--5 INTUBATED-NOT INTUBA VENT-SPONTANEOU COMMENTS-SHOVEL [**2189-1-6**] 09:09PM freeCa-1.05* [**2189-1-6**] 09:55AM GLUCOSE-129* UREA N-23* CREAT-1.0 SODIUM-142 POTASSIUM-4.1 CHLORIDE-107 TOTAL CO2-23 ANION GAP-16 [**2189-1-6**] 09:57AM HGB-9.5* calcHCT-29 [**2189-1-6**] 05:47PM WBC-30.6*# RBC-2.33* HGB-7.2* HCT-22.0* MCV-95 MCH-31.1 MCHC-32.9 RDW-14.5 CT Abd/Pelvis with IV contrast [**2189-1-15**]: IMPRESSION: 1. No CT evidence of colitis, as clinically questioned. No evidence of intra-abdominal infection. 2. Increasing liquefaction of right thigh hematoma; superinfection cannot be excluded. 3. New patchy opacities in the right middle lobe and the lingula, raising the possibility of aspiration. 4. Multiple bilateral renal cysts. CT abd/pelvis [**2189-1-6**]: IMPRESSION: 1.9-cm hematoma in the medial compartment of the right thigh, likely related to right femoral neck fracture and ORIF. 2.Mild anasarca. 3. No evidence for intra-abdominal infection. 4. Multiple bilateral renal cysts. 5. Bibasilar atelectasis. CT head [**2189-1-6**]: IMPRESSION: No acute intracranial hemorrhage and no evidence of acute intracranial process. Brief Hospital Course: Problem list 1) E.coli Bacteremia/Urosepsis) 2) ducubitus ulcer 3)c. diff infection 4) delirium Please see HPI for brief summary of ICU events. E.coli was sensitive to cipro and patient was to complete a 2 week course of cipro to be stopped on [**2189-1-21**]. Unfortunately he was persistently delirious despite antibiotic treatment for the urosepsis as well as his c. diff infection. He developed intermittent oligoarthritis that was aspirated by orthopedics. The initial aspiration revealed no evidence of infection or arthropathy. Repeat aspiration showed evidence of pseudogout. The patient cotinued to spike fevers with intermittent episodes of hypotension and no improvement in his mental status with low grade fevers and leukocytosis. Due to the patient's poor mental status his nutritional intake was poor. The family refused NGT or J-tube placement for intermittent feedings. Multiple family meetings were held and it was decided by the entire family with myself and his PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 665**], in attendance that the patient would be made CMO per his previously stated wishes. The patient was placed on a morphine gtt and passed away peacefully later that day. Medications on Admission: 1. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 2. Memantine 5 mg Tablet Sig: One (1) Tablet PO qd (). 3. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 5. Paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed. 7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): Continue until [**2189-1-28**]. 8. Vancomycin 250 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours): Continue until [**2189-1-28**]. 9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID 10. Enoxaparin 40 mg/0.3 mL Syringe Sig: One (1) Subcutaneous Q24H 11. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 12. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 13. Ciprofloxacin 400 mg/40 mL Solution Sig: One (1) bag Intravenous Q12H (every 12 hours): Continue until [**2189-1-21**]. Stop on [**2189-1-21**]. 14. Docusate 100 mg po bid Senna one tab po bid prn Bisacodyl 10 mg supp prn Tylenol 650 mg po q6 prn Oxycodone 5 mg o q 6h prn Discharge Disposition: Expired Discharge Diagnosis: Urosepsis with E.coli bacteremia Clostridium Difficile decubitus ulcer Discharge Condition: expired

[ "600.00", "331.0", "V54.13", "712.36", "427.31", "285.1", "401.9", "995.91", "276.52", "707.03", "008.45", "294.10", "038.42", "293.0", "599.0", "275.49" ]

icd9cm

[ [ [] ] ]

[ "81.91", "99.04" ]

icd9pcs

[ [ [] ] ]

6525, 6534

4005, 5232

286, 327

6648, 6658

2557, 3982

2060, 2064

6555, 6627

5258, 6502

2079, 2538

222, 248

356, 1665

1687, 1855

1871, 2044

16,511

191,603

14472+14473

Discharge summary

report+report

Admission Date: [**2194-10-6**] Discharge Date: [**2194-10-8**] Service: CARDIOTHOR HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 13783**] is a 79-year-old gentleman with some dyspnea on exertion that was admitted to at one-half blocks for 10 years. He has also complained of a chronic cough and has a smoking history of one pack per day times 65 years. He currently has a past medical history of emphysema. A chest x-ray in [**3-/2194**] showed a small lung nodule. Follow-up CT scan showed a lingular mass which appeared to be lung cancer. He was admitted to hospital on [**2194-10-6**] for a limited thoracotomy and lingular wedge resection. PAST MEDICAL HISTORY: 1. Arthritis. 2. Peptic ulcer disease. 3. Duodenal ulcers. 4. Coronary artery disease/myocardial infarction in [**2170**]. 5. Hypertension. 6. Chronic obstructive pulmonary disease. PAST SURGICAL HISTORY: No significant past surgical history. MEDICATIONS AT HOME: Nortriptyline. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Mr. [**Known lastname 13783**] is a retired auto salesman who has a 90-pack-year smoking history. PHYSICAL EXAMINATION: On examination Mr. [**Known lastname 13783**] appeared well. He had no palpable lymph nodes on head and neck exam. He had some clubbing of his fingers noticed. His lungs were clear to auscultation. He had regular heart rate and normal heart sounds. His abdominal exam was benign. His abdomen was soft and nontender to palpation. HOSPITAL COURSE: On [**2194-10-6**] Mr. [**Known lastname 13783**] was admitted to the hospital for limited thoracotomy and lingular wedge resection. He was placed under general anesthesia and intubated. He tolerated the procedure well with no complications and awoke in the Recovery Room. In the OR because of respiratory distress he was bronchoscoped and successfully extubated in the Recovery Room. The epidural was replaced, as well in the Recovery Room due to insufficient pain analgesia. The estimated blood loss of the surgery was 220 cc. Postoperatively a chest tube was placed on the left side. Postoperatively he was afebrile with stable vital signs and had an epidural for pain analgesia. He had clear lung fields and a regular heart rate. His abdomen was benign, and his extremities were warm with no edema. His course in hospital was uneventful. On postoperative day one he remained afebrile with stable vital signs. He remained on the epidural with the chest tube in place. On [**2194-10-8**], postoperative day two, he continued to do well. He remained afebrile with stable vital signs. The chest tube developed a small leak. The chest tube was subsequently removed. The epidural was also removed, as well as the Foley on this day. The patient tolerated everything well and voided after the Foley was removed. Mr. [**Known lastname 13783**] has been ambulating well independently. He has voided since the removal of the Foley and has been tolerating p.o. intake well. His pain has been well controlled on oral medications. The patient was seen by Physical Therapy in the hospital and deemed independent in his activity. However, it was suggested that he would benefit from a few sessions of physical therapy prior to discharge. The patient is currently stable for discharge home and has been advised to call Dr.[**Name (NI) 14732**] office to arrange a follow- up appointment in one week. He has also been advised that the outer dressing can be removed two days after discharge and that he may shower. He has also been advised not to drive a vehicle until off pain medications and he has been seen in the [**Hospital 702**] clinic. DISCHARGE MEDICATIONS: 1. Albuterol sulfate 0.083% solution one to three puffs q. 6 hours p.r.n. 2. Percocet 5/325 3 mg tabs, one to two tablets p.o. q. 4 h. p.r.n. 3. Colace 100 mg capsules, one capsule p.o. twice a day. PRIMARY DIAGNOSIS: Lung cancer. [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 178**], M.D. [**MD Number(1) 179**] Dictated By:[**Last Name (NamePattern1) 31577**] MEDQUIST36 D: [**2194-10-8**] 15:50 T: [**2194-10-9**] 15:14 JOB#: [**Job Number 42786**] Admission Date: [**2194-10-6**] Discharge Date: [**2194-11-6**] Service: MEDICINE ADMISSION DIAGNOSIS: Lung tumor. POSTOPERATIVE DIAGNOSIS: Lung tumor. PROCEDURES PERFORMED: Left upper lobe limited resection via a thoracotomy and biopsy of left lower lobe. HISTORY OF THE PRESENT ILLNESS: This is a 79-year-old man with a history of chronic cough, dyspnea on exertion, status post old MI, history of interstitial lung disease who presented with a mass in the medial aspect of the left lower lobe. The patient had a PET scan which was positive in this region as well as a clarifying CAT scan. HOSPITAL COURSE: He was taken to the OR for the procedure above. He did well immediately perioperatively from this procedure and was getting ready to be discharge home on postoperative day number two; however, he had low saturations and dyspnea on the evening of postoperative day number two and had to be transferred to the Intensive Care Unit. From this point on, he spent approximately ten days in the Cardiothoracic Surgical Intensive Care Unit where he started to become progressively more hypoxic, eventually requiring intubation. He had a picture that blossomed into ARDS and after various modes of ventilatory therapy, including antibiotics and pulmonary toilet, he was noted not to be progressing in the ARDS. He was transferred to the Medical Intensive Care Unit Service on postoperative day number ten and continued to undergo various modes of ventilatory weaning. Eventually, despite multiple modes of therapy and the inability to make progress on his ARDS with a worsening PF ratio, family discussions with the service were had and the patient was made DNR comfort care only. He expired on [**2194-11-8**] with no autopsy allegedly performed. ADMISSION DIAGNOSIS: Left-sided lung tumor. DISCHARGE DIAGNOSIS: Limited thoracotomy with biopsy of the above with multisystem organ failure and Adult Respiratory Distress Syndrome occurring postoperatively. [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 178**], M.D. [**MD Number(1) 179**] Dictated By:[**Name8 (MD) 12027**] MEDQUIST36 D: [**2195-1-7**] 12:56 T: [**2195-1-7**] 13:19 JOB#: [**Job Number 42787**]

[ "410.71", "785.51", "518.5", "515", "162.3", "197.2", "428.0", "584.9", "482.1" ]

icd9cm

[ [ [] ] ]

[ "32.29", "96.04", "37.23", "33.24", "96.72", "98.15", "33.43", "88.56", "99.20", "96.6", "33.23", "36.01", "36.06", "40.11" ]

icd9pcs

[ [ [] ] ]

3687, 3890

6050, 6458

4834, 5980

962, 1016

901, 940

1155, 1490

6003, 6027

123, 666

3910, 4297

688, 877

1033, 1132

21,765

115,834

46601+58926

Discharge summary

report+addendum

Admission Date: [**2161-11-16**] Discharge Date: [**2161-11-28**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 759**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: trans-esophageal echo and dccv [**2161-11-25**] - no complications History of Present Illness: 86 yo woman with multiple medical conditions here with 3-4 days of weakness and acute onset of short of breath. Otherwise, no chest pain, palpitation, lightheadedness or dizziness. No orthopnea or PND. No nausea, vomiting, diarrhea or abdominal pain. No [**Month/Day/Year 5162**], chills, cough or other URI symptoms. No dysuria or frequency. No change in appetite or bowel habit. ED: Afib with rapid ventricular rate up to 130s, EKG with lateral ST depressions, CXR with multifocal infiitrates and blood tests revealed hyperglycemia and elevated Cr. Past Medical History: PMHx: 1. Heart block, junctional rhythm - pacemaker placed 2. CHF - EF 30% 3. PVD - followed by Dr. [**First Name (STitle) **] 4. Significant bilateral carotid disease 99% 5. Hx of PE in [**2144**] 6. DM 7. MR [**First Name (Titles) **] [**Last Name (Titles) **] 8. Iron deficiency anemia 9. Osteoporosis 10. Eczema 11. Basal cell CA Social History: widowed, no children, lives alone, smoked 2 packs per day, quit in 89, no drinking or drug use. Family History: non-contributory Physical Exam: PE: 99.5, 110, 100/61, 24, 100%6L (88%RA) Gen: cachectic elderly woman, NAD HEENT: anicteric, OP clear, dry MMM CV: IRIR, tachy Lungs: diffuse coarse breath sounds Abd: soft, NT Ext: no edema Skin: diffuse rashes, dry skin Neuro: nonfocal Pertinent Results: Labs on Admission: CK: 242 MB: 8 Trop-*T*: 0.09 Vit-B12:347 Folate:18.4 Other Blood Chemistry: Iron: 19 calTIBC: 211 Ferritn: 334 TRF: 162 135 102 61 ------------< 468 4.8 24 1.3 Mg: 2.1 MCV=96 WBC=7.9 HgB=9.5 Plt=140 Hct=27.7 PT: 14.0 PTT: 28.8 INR: 1.2 Other Urine Chemistry: UreaN:575 Creat:66 Na:17 UA: negative CT Chest: 1) Confluent areas of consolidation right upper lobe and patchy nodular areas of consolidation in the right lower lobe most consistent with multifocal pneumonia. 2) Likely element of superimposed pulmonary edema. 3) Left greater than right small pleural effusions. Brief Hospital Course: 86F PMH of CAD, CHF--EF 30% with severe MR, Dermatomyositis, DM, presented on [**11-16**] c/o generalized weakness for 1 week, with acute onset of SOB on the evening of [**11-15**], both at rest and with exertion. Pt also noted to have had loose stools for the past week, but no other symptoms. 1. PNA: On admission CXR, pt was noted to have a multifocal pneumonia and was started on azithromycin and ceftriaxone. She was also noted on admission to have ARF and hyperglycemia. She was placed on O2NC and given steroids and albuterol/ipratropium nebs. She remained afebrile, and appeared to have a stable leukocytosis. Influenza was considered, but no washing was obtained at the lab; the patient was placed on droplet precautions. On the floor, the patient continued to develop SOB, and required ICU transfer. Respiratory decompensation at that time thought secondary to super-imposed pulmonary edeam. In the ICU, she continued on ceftriaxone/azithromycin for community-acquired PNA. CT chest showed interstitial lung disease with persistent RUL PNA. She clinically improved and was transferred to the floor where antibiotic treatment was continued (D1=[**11-17**]). She is currently scheduled to complete her antibiotics on [**12-1**] and has picc line in place for this. As mentioned above, sputum was not obtained. It is unclear as to the etiology of this multi-focal PNA. Given h/o dermatomyositis, there were concerns of underlying lung dz. However, no formal PFTs were ever documented prior to this PNA. Her oxygen requirements have decreased through-out her stay but she was advised to f/u Pulmonary for an outpt managemnt. She has been asked to call radiology to for repeat CXR in 4 weeks time to re-assess interval progression. Her oxygen requirement has improved, but she still remains on 2-4L NC. This should be weaned as tolerated to keep sats 93%-95%. 2. Afib: On admission, pt found to be in rapid Afib, which apparently had occurred 1 time before. She was started on a heparin drip for anticoagulation, lopressor PO for rate control, and was scheduled for an Echo which was not performed prior to transfer. While on the floor, HR were 90s - 110s, with BP 115/58. It is thought that her transfer to the ICU was the result of CHF in the setting of rapid afib. In the ICU, she was eventually rate controlled w/ beta blockade and dig. Following transfer back to the floor, she underwent TEE (no thrombus) followed by DCCV on [**2161-11-26**]. She will continue on digoxin and beta blockade and her goal inr will be 2.0-3.0. At the time of dishcarge, she remains in sinus rhythm. She should have f/u w/ dr. [**Last Name (STitle) **] as outlined in discharge instructiions and also w/ device clinic for interoggation of pacer. 3. ARF: On admission, BUN/Cr was 63/1.7, up from baseline Cr of 1.1-1.3. The FENa was 0.3% indicating likely prerenal. She was given gentle hydration and her ACEI (lisinopril) was initially held (restarted after renal failure resolved). While on the floor, her Cr decreased to baseline. As mentioned above, she was felt to be in failure necessitating transfer to the icu. She has tolerated aggressive diuresis w/o bumps in creatinine. 4. CHF: On admission, the patient had no evidence of CHF. ACEI and norvasc were held due to decreased BP (90/60). As noted from her PMH, she has a history of EF 30% with severe MR [**First Name (Titles) **] [**Last Name (Titles) 1192**] AR. Trop were mildly elevated and stable at 0.1-0.09, with negative MBs, and felt to be [**12-23**] ARF. She was continued on ASA, lipitor, but plavix was held. She was started on heparin drip, and ACEI and imdur were gradually added back. Repeat Echo showed severe MR, [**Month/Day (2) 1192**] AR, and worsened EF compared with an Echo from [**12-25**]. As mentioned above and below, pt had episode of acute resp decompensation necessitating transfer to MICU early in hospital course. At this point, CXR c/w worsening pulmonary edema. At the time, she was also in rapid afib. In the ICU, she did not require invasive resp support and was aggressively diuresed w/ iv lasix 40 iv bid. She was negative 6 liters total upon transfer from the ICU. Gentle diuresis was continued on the floor. Rate control will be crucial for her and she will continue on Toprol 150 qd and remains on Lisinopril 40 qd. The morning following her dccv, she had a brief acute hypoxic resp decompensation. She was quickly stabilized. It was felt that this may have been secondary to transient worsening CHF in the setting of recent cardioversion. Pt stabilized w/ continued diuresis and she will be discharged on oral lasix 80 mg qd. 5. Mental status: The patient had one episode of sun-downing during her ICU stay, it resolved in the morning. 6. DM: Initially placed on Insulin GTT, then changed to Insulin SS with NPH. Her NPH was increased during her admission for hyperglycemia. Current regimen is NPH 25 units qam and NPH 6 units qpm. 7. CAD: continued ASA, toprol, lipitor, ACEI. The initial troponin leak was thought to be in the setting of CHF flare with some renal failure. Pt has refused catheterization in the past. 8. Carotid artery disease: continued ASA 9. Anemia: Pt was initially transfused 1 U PRBC which ?precipitated CHF flare. Hematocrit was kept >28 during hospitalization. ***10. Code: Should be addressed w/ PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. Still remains vague. At this point, pt does not wish for heroic measures to prolong her life. However, she was not against intubation. Based upon discussions w/ PCP and pt, pt is DNR but ok for intubation. Obviously, prolonged course on vent would need to be discussed further. Medications on Admission: Insulin 70/30 31 UQAM, [**3-26**] U QPM Amlodipine 5 mg Miacalon NS QD Doxepin 25 mg qhs ASA 81 Flonase 2 sprays QD Lasix 80 mg Imdur 60 mg Lipitor 20 mg Lisinopril 40 mg Plavix 75 mg Toprol XL 100 mg ALL: NKDA Discharge Medications: 1. Calcitonin (Salmon) 200 unit/Actuation Aerosol, Spray Sig: One (1) spray Nasal DAILY (Daily). 2. Doxepin HCl 25 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 3. Beclomethasone Diprop Monohyd 0.042 % Aerosol, Spray Sig: Two (2) Spray Nasal QD (). 4. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 6. Ipratropium Bromide 0.02 % Solution Sig: One (1) puff Inhalation Q6H (every 6 hours) as needed. 7. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) [**Hospital1 **] PO BID (2 times a day). 9. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 11. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 12. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 13. Furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily). 15. Digoxin 125 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 16. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. 17. Ceftriaxone Sodium in D5W 20 mg/mL Piggyback Sig: One (1) infusion Intravenous Q24H (every 24 hours) for 3 days: thru [**2161-12-1**]. 18. Guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO Q6H (every 6 hours). 19. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed). 20. Lidocaine HCl 2 % Solution Sig: One (1) ML Mucous membrane TID (3 times a day). 21. Outpatient Lab Work please check INR on [**2161-11-30**] - goal inr is 2.0-3.0 22. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: see below units Subcutaneous twice a day: NPH 25 units SC qam and 6 units of NPH SC qpm. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Presumed multi-focal PNA improving CHF exacerbation, resolving New onset atrial fibrillation s/p successfull DCCV Acute renal failure resolved Anemia Discharge Condition: stable Discharge Instructions: please return to ed or [**Name8 (MD) 138**] md [**First Name (Titles) **] [**Last Name (Titles) 5162**], chills, shortness of breath, coughing, chest pain, decreased mentation. please do not drink more than 2 liters of fluid per day. please [**Name8 (MD) 138**] md if weight gain is greater than 3 lbs please take medications as directed. Followup Instructions: please call pulmonary clinic at [**Telephone/Fax (1) 612**] for appt in 1 months time after cxr repeated. please call radiology at [**Telephone/Fax (1) 327**] to schedule repeat CXR (pa and lateral) in 3 weeks time. Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2161-12-28**] 1:00 Provider: [**First Name11 (Name Pattern1) 610**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2161-12-28**] 1:30 Provider: [**First Name11 (Name Pattern1) 674**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2162-1-5**] 10:20 Completed by:[**2161-11-28**] Name: [**Known lastname 15814**],[**Known firstname 1073**] Unit No: [**Numeric Identifier 15815**] Admission Date: [**2161-11-16**] Discharge Date: [**2161-11-28**] Date of Birth: [**2075-9-13**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2544**] Addendum: NOTE: PATIENT JUST DISCHARGED EARLIER TODAY, BUT WAS NOT DISCHARGED ON COUMDADIN (AND SHOULD HAVE BEEN). I CALLED [**Hospital3 **], SPOKE W/ NURSE SUPERVISOR ([**Telephone/Fax (1) 15816**]) AND RELAYED THAT PATIENT NEEDS TO BE ON COUMADIN 2 MG QHS WITH INR CHECK AT START OF NEXT WEEK. Discharge Disposition: Extended Care Facility: [**Hospital3 901**] - [**Location (un) 382**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2545**] MD [**MD Number(2) 2546**] Completed by:[**2161-11-28**]

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icd9cm

[ [ [] ] ]

[ "38.93", "88.72", "99.04", "99.62" ]

icd9pcs

[ [ [] ] ]

12645, 12875

2366, 7003

283, 352

10696, 10704

1729, 1734

11092, 12622

1437, 1455

8310, 10409

10523, 10675

8074, 8287

10728, 11069

1470, 1710

224, 245

380, 939

1749, 2343

7018, 8048

961, 1308

1324, 1421

31,252

116,108

34323+57921

Discharge summary

report+addendum

Admission Date: [**2111-6-16**] Discharge Date: [**2111-6-28**] Date of Birth: [**2057-4-5**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 348**] Chief Complaint: Antifreeze ingestion Major Surgical or Invasive Procedure: Hemodialysis Endotracheal intubation RIJ central line placement History of Present Illness: Mr. [**Known lastname 78991**] is a 54 year old male who presents with antifreeze ingestion. Per report, the patient ingested 1.5-2L of antifreeze at 6 pm on [**2111-6-16**]. He vomited four times and EMS was called. He told the woman he was living with, [**First Name4 (NamePattern1) 2152**] [**Last Name (NamePattern1) **], that he would like to jump in front of a car, but didn't want to upset the driver. He initially complained of some burning in his throat and some slurred speech per report. He was transferred to [**Hospital3 **]. There he was given 2L 5%EtOH, Vitamin B1 100 mg POx1, Vitamin B6 100 mg POx1. He had diarrhea x 1 at the OSH which reportedly looked like antifreeze. He was then sent to BIMDC for consideration of HD. At [**Hospital1 18**], VS Temp 99.8, HR 50-60, BP 147/91, R 20. the patient was intermittently apneic. To sternal rub, he would wake up and call out "I want to die, let me die," and would not answer history questions. He was intubated in the [**Hospital1 18**] ED and was given a dose of 15 mg/kg fomepizole at toxicology recommendations. His pH was 7.19 and renal was consulted for consideration of HD. He was given 3 liters normal saline Past Medical History: Depression h/o ETOH abuse Social History: Divorced; 1 son- doesn't keep in touch with family. Lives with [**First Name4 (NamePattern1) 2152**] [**Last Name (NamePattern1) **] (listed as next of [**Doctor First Name **])- she is his landlord. history of ETOH abuse, sober for 12 yrs. Extent of ETOH unknown. No tobacco. no drugs. History of marijuana & cocaine use ~ 20 years ago. Currently works as a delivery driver for the [**Location (un) 86**] Globe. Family History: NC Physical Exam: VS: 97.5 121/62 71 22 100 AC 550/14/5/50% Gen: intubated, sedated, does not follow commands HEENT: conjunctival erythema bilaterally. pupils equal round and reactive to light. approx 2 mm Car: RRR no murmur Resp: coarse BS bilaterally Abd: soft, mildly distended, tympanic to percussion, hypoactive BS, no guarding Ext: no LE edema, 2+ DP/PT bilaterally Pertinent Results: [**2111-6-16**] 11:00PM BLOOD WBC-14.2* RBC-4.26* Hgb-13.5* Hct-41.4 MCV-97 MCH-31.7 MCHC-32.6 RDW-13.7 Plt Ct-269 [**2111-6-16**] 11:00PM BLOOD Neuts-92.6* Bands-0 Lymphs-5.3* Monos-1.7* Eos-0.2 Baso-0.1 [**2111-6-17**] 02:45AM BLOOD PT-13.6* PTT-22.5 INR(PT)-1.2* [**2111-6-16**] 11:00PM BLOOD Plt Ct-269 [**2111-6-18**] 03:42AM BLOOD Ret Aut-2.1 [**2111-6-16**] 11:00PM BLOOD Glucose-549* UreaN-8 Creat-1.1 Na-135 K-4.3 Cl-101 HCO3-11* AnGap-27* [**2111-6-16**] 11:00PM BLOOD ALT-14 AST-14 LD(LDH)-177 AlkPhos-62 TotBili-0.6 [**2111-6-16**] 11:00PM BLOOD Albumin-4.5 Calcium-8.5 Phos-2.3* Mg-2.1 [**2111-6-19**] 03:15AM BLOOD calTIBC-190* VitB12-147* Folate-GREATER TH Ferritn-799* TRF-146* [**2111-6-16**] 11:00PM BLOOD Osmolal-461* [**2111-6-19**] 03:15AM BLOOD Osmolal-296 Relevant Imaging: 1) CT [**2111-6-19**] IMPRESSION: 1. Very small amount of stranding and fluid in the right retroperitoneum, most consistent with a small retroperitoneal hemorrhage, likely related to right femoral central venous catheter placement. Amount of blood does not appear large enough to explain clinical hematocrit drop from 40 to 24. 2. Dense bilateral lung base consolidations, concerning for aspiration or infection. 2) CXR [**2111-6-22**] Brief Hospital Course: Mr. [**Known lastname 78991**] is a 54 year old male with depression s/p ethylene glycol ingestion for suicide attempt, acidotic with hospital course c/b fevers, hypotension, anemia, and difficult weaning from ventilator secondary to AMS. 1)Ethylene glycol ingestion: Patient was admitted to the MICU after an ethylene glycol ingestion. He had been started on an ethanol gtt at the OSH. Upon transfer to [**Hospital1 18**], renal was consulted and he was started on fomepizole and access was established for hemodialysis. He underwent two hemodialysis sessions and the ethylene glycol level was montiored until it was no longer detectable. The HD line was then removed. 2)Fevers: During his hospital stay, the patient spiked high fevers. The cause was thought to be a pneumonia given his sputum which grew staph aureus and the cxray which suggested a possible LLL infiltrate. He was started on Vancomycin Zosyn but he continued to spike through antibiotics. The decision was made to stop the antibiotics given lack of clear source of infection. He continued to have fevers but lower than they had been. Cultures remained negative. 3)Respiratory Failure: Patient was intubated initially for airway protection given changes in his mental status. There was also some thought that there was a component of PNA vs. volume overload. He was treated briefly for hospital aquired pneumonia (which were then stopped) and he was also diuresed with Lasix. He was successfully extubated and his mental status slowly improved. 4) Anemia: Patient had a significant drop in his hematocrit from admission. He was guaiac negative. He also underwent a CT abdomen/pelvis which was negative for an RP bleed. He did received 2 units of pRBCs during his stay in the MICU. 5)Depression: Patient presented with ethylene glycol ingestion as part of suicide attempt. Pscyhiatry and social work were consulted once patient was extubated. Medications on Admission: None Discharge Medications: 1. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Disposition: Extended Care Facility: [**Hospital1 **] 4 Discharge Diagnosis: Primary Diagnoses: 1. Ethylene Glycol ingestion (Suicide attempt) 2. Acute Renal Failure 3. Bradycardia 4. Depression Secondary Diagnoses 1. Recovering Alcoholism Discharge Condition: Medically Stable Discharge Instructions: You have been admitted to the hospital after an ingestion of Ethylene glycol. While you were here you were in the Intensive Care Unit. Please take all medications as directed. Please return to the Emergency Room for Chest Pain, Shortness of Breath or any other medical concern. Followup Instructions: In-patient psychiatric Care Name: [**Known lastname 12730**],[**Known firstname **] Unit No: [**Numeric Identifier 12731**] Admission Date: [**2111-6-16**] Discharge Date: [**2111-6-28**] Date of Birth: [**2057-4-5**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1408**] Addendum: Patient was found to have fevers to 101 once daily for 2 days after initial transfer date to Psychiatry. CXR, U/A and blood cultures were negative. On the second day of fevers, the patient was noted to have swollen and tender Right MCP joints. Rheumatology was consulted for a arthocentesis and the fluid was positive for crystals consistent with gout. The patient was started on a prednisone taper and daily colchicine. Discharge Disposition: Extended Care Facility: [**Hospital1 **] 4 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1410**] MD [**MD Number(2) 1411**] Completed by:[**2111-6-28**]

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icd9cm

[ [ [] ] ]

[ "38.91", "39.95", "96.72", "96.04", "38.95" ]

icd9pcs

[ [ [] ] ]

7288, 7490

3759, 5676

334, 399

6076, 6095

2498, 3278

6424, 7265

2104, 2108

5731, 5800

5889, 6055

5702, 5708

6119, 6401

2123, 2479

274, 296

3296, 3736

427, 1608

1630, 1658

1674, 2088

81,888

143,112

7925

Discharge summary

report

Admission Date: [**2130-12-19**] Discharge Date: [**2130-12-22**] Date of Birth: [**2048-2-26**] Sex: F Service: NEUROSURGERY Allergies: Prednisone / Codeine Attending:[**First Name3 (LF) 1835**] Chief Complaint: Headache Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname 28466**] is an 82 year old right handed woman fell off her chaor and may have had a syncopal event. She lost conscioussness. She reports she was watching TV and does not recollect much after that. She was unable to get to a phone for sometime and as a result was a delayed presentation to [**Hospital6 **]. She has no recollection of how she fell. She had a head CT scan around 0400 which showed a large acute SDH. As a result, she was trasnferred to [**Hospital1 18**] for further management. She complained of diffuse headaches with mild nausea. She denies any neck pain, paresthesia, numbness or other pain. Neurosurgery consulted for further management. Past Medical History: COPD, asthma, bronchitis, pneumonia, Depression (req 3 hospitalizations), EtOH abuse c/b ?GTC sz [**2-15**] EtOH w/d, CAD, hypercholesterolemia, constipation, GERD, anemia, emphysema, hypothyroid, scoliosis, osteoporosis, psoriasis, insomnia Social History: widow, lives alone, nonsmoker, denies ETOH abuse Family History: NC Physical Exam: On Admission: O: T:97.3 BP: 151/81 HR: 72 R 20 O2Sats - 86% 2L Gen: WD/WN, comfortable, NAD. HEENT: head traumatic with periorbital eccymosis, no battle sign; eyes - clear, no exudate; ears: HOH, no otorrhea, nose: patent, throat Pupils: perrl EOMs - full Neck: Supple. Lungs: CTA bilaterally, slight wheeze on forced expiration, prolong expiratory phase. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused, right knee abrasion Neuro: GCS 15 Pleasant, wearing a Hard collar she aox3, perrl, EOM intact, no otorrhea, Motor exam is: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**5-18**] on right; 5-/5 on the left upper. slight left pronator drift, LEs are [**5-18**] bilaterally Sensation: Intact to light touch Reflexes 2+ throughout, no clonus Toes downgoing bilaterally At Discharge: NF Pertinent Results: [**2130-12-19**] 07:00AM GLUCOSE-152* UREA N-5* CREAT-0.6 SODIUM-131* POTASSIUM-4.1 CHLORIDE-95* TOTAL CO2-28 ANION GAP-12 [**2130-12-19**] 07:00AM estGFR-Using this [**2130-12-19**] 07:00AM cTropnT-<0.01 [**2130-12-19**] 07:00AM TSH-4.7* [**2130-12-19**] 07:00AM WBC-16.0*# RBC-4.11* HGB-13.0 HCT-37.4 MCV-91 MCH-31.6 MCHC-34.7 RDW-12.5 [**2130-12-19**] 07:00AM NEUTS-92.7* LYMPHS-6.0* MONOS-1.1* EOS-0.1 BASOS-0.2 [**2130-12-19**] 07:00AM PLT COUNT-310 [**2130-12-19**] 07:00AM PT-12.1 PTT-28.9 INR(PT)-1.1 CT head [**2130-12-19**] 1. A 1.5 cm right frontoparietal subdural hematoma with leftward midline shift by about 7 mm. No evidence of transtentorial or tonsillar herniation. A few hypodense foci within may relate to ongoing hemorrhage- correlate for coagulopathy. Small focus of acute hemorrhage in the left insular region. 2. No definite underlying fracture. Right cheek bruising. 3. Bilateral paranasal sinus disease. CT head [**2130-12-19**] [**2130-12-19**] Echocardiogram The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Vigorous biventricular systolic function without outflow tract obstruction. Mild pulmonary hypertension. [**2130-12-19**] Ct C-spine 1. No definite evidence of cervical spine fracture. 2. Severe multilevel cervical spine degenerative disease with canal narrowing and neural foraminal narrowing. This predisposes patient to cord or ligamentous injury in the setting of trauma, which can be evaluated by MRI if not CI, if necessary. 3. Paranasal sinus disease. 4. Severe biapical emphysema. 5. Incomplete assessment of a moderate right hemispheric subdural hematoma, to be correlated with head CT [**2130-12-19**] CT head 1. Interval stability and acute right subdural hematoma with no change in the degree of mass effect within the limitations of technique differences. 2. Evidence of possible active hemorrhage or old subdural hematoma, admixed with new blood. Investigation into possible causes of ongoing hemorrhage such as coagulopathy or anticoagulants is recommended. Close follow up with subsequent head CT is recommended if no surgical intervention is planned. 3. Additional small focus of cortical hemorrhage near the left sylvian fissure/adjacent cortex which has demonstrated interval stability withs lightly decreased density but should be followed closely on subsequent examinations. [**12-21**] Carotid Duplex: Impression: Right ICA no stenosis. Left ICA <40% stenosis. [**12-21**] EEG: preliminary no seizure activity Brief Hospital Course: Ms. [**Known lastname 28466**] was admitted to [**Hospital1 18**] neurosurgery under the care of Dr. [**Last Name (STitle) **] for Acute SDH. She was loaded with Dilantin and then started on 100mg po TID. Platelets were 301 and Dr. [**Last Name (STitle) **], recommend platelet trasnfusion. She was admited to the neuro ICU for frequent neuro check, Due to her syncopal event, Echocardiogram was done as well as an EEG and ECG. Her Troponin was normal and Aspirin was held. SBP goal was < 140, nicardipine gtt as needed, hydralazine PRN. The patient remained neurologically stable therefore it was decided to wait until [**12-20**] to undergo a craniotomy and evacuation of the SDH. On [**12-20**] the patient developed respiratory distress and and copious amounts of tan/brown sputum. She was started on Levaquin, sputum was sent for culture and her surgery was canceled. On [**12-21**] she was again neurologically well and had improved from a respiratory standpoint. She was opting not to undergo surgery at this point. It was decided that it would be best for her to go to a rehab and return in a few weeks when her respiratory status had improved and the blood products have broken down. She was cleared for transfer to the floor at this point and PT/OT were consulted for assistance with discharge planning. As part of the syncope work up a carotid duplex was obtained (no significant stenosis) and an EEG was performed (prelim no seizure activity). On [**12-22**] she was ambulating with assistance to the bathroom and had much better pain control. Dilantin level was therapeutic at 12.3. PT and OT recommended discharge to inpatient rehab facility. Family was updated of the plan and she was cleared for discharge. Medications on Admission: - Advair discus INH 250/50 2 inh [**Hospital1 **] - [**Doctor First Name **] 180mg daily - Citalopram 60mg daily - trazodone 25mg daily - lipitor 20mg QHS - MVI daily - Ocean nasal spray 45mL .65% 2 sprays each nostirl [**Hospital1 **] - percolace 2 tab qhs - preservation eye vitamins 1 tab [**Hospital1 **] - omeprazole 40mg daily - ferrous sulfate SR 160mg [**Hospital1 **] - Spiriva handihaler 18mcg/cap inh daily - synthroid .05 daily - vitamin D 400 units daily - flonase one spray each nostril twice daily Discharge Medications: 1. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: Two (2) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 2. fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 4. trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 5. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 6. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 10. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze, SOB. 12. phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO TID (3 times a day). 13. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal [**Hospital1 **] (2 times a day). 14. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 16. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 18. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection TID (3 times a day). 19. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 20. oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for pain. 21. Levaquin 750 mg Tablet Sig: One (1) Tablet PO once a day for 4 days. Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: Right Acute Subdural Hematoma Pneumonia 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: General Instructions ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you were on a medication such as Coumadin (Warfarin), or Plavix (clopidogrel), or Aspirin, prior to your injury, do not resume taking them until cleared by your surgeon. ?????? You have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. Followup Instructions: Follow-Up Appointment Instructions ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **], to be seen in 6 weeks. ??????You will need a CT scan of the brain without contrast. Completed by:[**2130-12-22**]

[ "492.8", "852.26", "244.9", "311", "486", "493.90", "733.00", "E884.2", "272.0", "530.81" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9560, 9632

5345, 7072

296, 302

9716, 9716

2269, 5322

11014, 11275

1365, 1369

7636, 9537

9653, 9695

7098, 7613

9899, 10991

1384, 1384

2245, 2250

248, 258

330, 1016

1398, 2231

9731, 9875

1038, 1282

1298, 1349

23,755

130,920

8168+8169

Discharge summary

report+report

Admission Date: [**2155-7-29**] Discharge Date: [**2155-8-8**] Date of Birth: [**2091-3-5**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 64-year-old female with a significant past medical history for diabetes mellitus x 15 years, hypertension, end-stage renal disease with hemodialysis for the last three years, no known coronary disease, who presented to the [**Hospital6 **] patient's preoperative work-up included a stress thallium to rule out any significant myocardial ischemia. This was noted to be negative. The test was performed in [**2154-2-6**]. She additionally had a preoperative chest x-ray which showed mild interstitial edema and cardiomegaly but no effusions or pneumonia, no pneumothorax. This was performed on the night of admission. She had an electrocardiogram on admission, axis deviation. There was questionable change in the anteroseptal leads showing evidence of an old myocardial infarction. There were also noted diffuse ST-T wave changes thought to be secondary to a metabolic or drug effect. HOSPITAL COURSE: The patient went to the operating room on [**2155-7-30**] where she underwent cadaveric renal transplant with a kidney that was noted to have a 26-hour ischemic time, and there was 0 antigen mismatch. Postoperatively the patient was discharged to the intensive care unit where she was rapidly extubated. Within the first 24 hours postoperatively she failed to put out any urine. She underwent a renal ultrasound on postoperative day one. The ultrasound showed no evidence of hydronephrosis. There were normal intrarenal arterial wave forms with persistive indices .74 to .83. She had normal venous inflow and there was no perinephric fluid collections. As a consequence of her anuria and rising potassium and her positive fluid balance of 7 liters postoperatively, she did go to hemodialysis on postoperative day one. On postoperative day two the patient's pulmonary artery catheter was discontinued and she was transferred to floor status. Her urine output was noted to be 62 cc over this 24-hour interval. Her diet was advanced to her renal [**Doctor First Name **] 1800 kilocalorie diet with low sodium being one of its parameters as well, to help with volume restriction. On postoperative day three she continued her Solu-Medrol taper. Prograf was not started as her renal function and delayed graft function became more apparent. On postoperative day four she had finished her five-day course of Thymoglobulin, the first dose being given on postoperative day zero. Her urine output was noted to increase to 225 cc on postoperative day five, 250 cc on day six, and by day seven she had put out 500 cc. However due to the persistent elevation in her phosphate, which was 14 on postoperative day seven, as well as her BUN greater than 100, she went to hemodialysis. On postoperative day eight the patient was noted to have urine output of greater than 700 cc. Her BUN on postoperative day eight was 77 with a creatinine of 5.9, potassium was 4.3. Her phosphate was 11, therefore Amphojel 30 cc p.o. t.i.d. with meals x 72 hours was instituted to help with intestinal phosphate binding and decreased absorption. Throughout her entire hospital stay she remained afebrile. Her immunosuppression by postoperative day eight included rapamycin 5 mg p.o. once daily, prednisone 20 mg p.o. once daily, and CellCept 1 gram p.o. b.i.d. A rapamycin level from [**2155-8-6**] after a three-day course of 10 mg p.o. once daily showed a level of 32. Her rapamycin dose of 5 mg p.o. once daily that was begun on [**2155-8-6**] was not changed. By postoperative day nine the patient was continuing to do well. Her renal function was slightly improved. She continued to make urine. She was tolerating her renal [**Doctor First Name **] diet with fluid restriction of 1.5 liters per day and a low-sodium diet of less than 2 grams per day. She was getting Percocet as needed for pain. Her saturations on room air were 95-96% and she was continued on incentive spirometry and chest physiotherapy. She was ambulating and out of bed. Cardiovascular: Her blood pressures were controlled in the 140s on no antihypertensives. Her heart rate was in the 80s to 90s on amiodarone 200 once daily and digoxin .125 q. week. She was tolerating her enteric-coated aspirin 325 mg once daily. She had a triple-lumen catheter in the right internal jugular vein that was discontinued on postoperative day nine. Hematology/Infectious Disease: She had a stable hematocrit of 29, a white count of 8, a platelet count of 144. She was on prophylaxis with Mycelex Troche 1 tablet p.o. q.i.d., Bactrim single strength once daily, and ganciclovir 500 mg p.o. once daily. DISCHARGE PLAN: 1. Amiodarone 200 mg p.o. once daily 2. Enteric-coated aspirin 325 mg p.o. once daily 3. Digoxin .125 mg p.o. q. week given on Thursdays. 4. Mycelex Troche 1 tablet p.o. q.i.d. 5. Zantac 150 mg p.o. once daily 6. Renagel 800 mg p.o. t.i.d. with meals. 7. NPH 40 units subcutaneous q.a.m., 8 units subcutaneous q.p.m., and a sliding scale of insulin with Humulin. 8. CellCept 1 gram p.o. b.i.d. 9. Rapamycin 5 mg p.o. once daily with a level to be checked in 48 hours, next level would be [**2155-8-9**]. 10. Prednisone 20 mg p.o. once daily 11. Bactrim single strength 1 tablet p.o. once daily. 12. Amphojel 30 cc p.o. t.i.d. with meals x 72 hours, started on [**2155-8-7**], for a total of three days. 13. Ganciclovir 500 mg p.o. once daily. 14. Percocet 5\325, 1-2 tablets p.o. q. 4-6 hours p.r.n.. 15. Colace 100 mg p.o. t.i.d. 16. Dulcolax suppositories 1 tablet per rectum p.r.n. constipation. 17. Coumadin 3 mg p.o. once daily for atrial fibrillation. She will be discharged to a skilled nursing facility where she will receive medication teaching and administration of her medications, as well as she will be required to have laboratory draws every other day from the time of discharge. Copies of laboratory data should be sent to Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **], telephone [**Telephone/Fax (1) 29057**]. Also Dr. [**Last Name (STitle) 8605**], the patient's outpatient nephrologist, should receive reports of the aforementioned laboratory data. His office number is [**Telephone/Fax (1) 15173**]. FOLLOW UP: She will have follow up with Dr. [**Last Name (STitle) **] early next week after the Labor Day holiday, as well as with Dr. [**Last Name (STitle) **] on the same day. She will call for an appointment at [**Telephone/Fax (1) 60**], and also Dr. [**Last Name (STitle) 8605**] should see the patient which the next 1-2 weeks, [**Telephone/Fax (1) 15173**]. DIET: She will be on a renal [**Doctor First Name **] 1800, low-sodium (that being less than 2 grams) diet. She will have her coagulation panel profile checked, prothrombin and international normalized ratio checked as well as her digoxin levels checked with her laboratory draws, and those results should be sent to Dr.[**Name (NI) 29058**] office for management. Strict measurement of daily urine outputs and weights should be recorded so that they can be brought to the transplant physicians at follow up. The patient's blood sugar levels should be checked every six hours in a strict manner, considering the fact that her NPH is being titrated for effect, given the steroids. The next rapamycin blood level should be checked on [**2155-8-10**], and these results should also be sent to Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] so that they may then titrate her appropriate dosage. CONDITION ON DISCHARGE: The patient is status post a cadaveric renal transplant with delayed graft function. DISCHARGE STATUS: She is to go to the skilled nursing facility with the previously described follow-up instructions. Addendum: Patient was not discharged due to fluid overload, delayed-graft function and the need for dialysis. See next discharge summary. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3598**], MD [**MD Number(1) 3599**] Dictated By:[**Last Name (NamePattern4) 3204**] MEDQUIST36 D: [**2155-8-7**] T: [**2155-8-7**] 12:48 JOB#: [**Job Number 29059**] Admission Date: [**2155-7-29**] Discharge Date: [**2155-8-15**] Date of Birth: [**2091-3-5**] Sex: F Service: TRANSPLANT ADMISSION DIAGNOSIS: End stage renal disease. DISCHARGE DIAGNOSIS: End stage renal disease status post cadaveric renal transplant on [**7-30**] with renal biopsy. [**Hospital1 69**] along with her Nephrologist, Dr. ............, at [**Hospital **] Hospital since [**2152**] when she was evaluated for kidney transplant. In brief, she has past medical history significant for Type 2 diabetes diagnosed when she was 52 years old with no known history of cardiac disease, retinopathy or gastropathy. She is status post left AV fistula placement in 09/99 and has been on significant for hyperlipidemia and hypertension but denies any peripheral vascular disease or chronic obstructive pulmonary disease or pancreatitis. She has no history of angina. She has no known drug allergies. MEDICATIONS AT ADMISSION: 1. Epogen given with dialysis. 2. Diltiazem 240 mg a day. 3. Norvasc 2.5 mg a day. 4. NPH 30 units in the morning and 10 units in the p.m. with a Humalog sliding scale. 5. Digoxin 0.125. 6. Coumadin 3 mg a day. 7. Phos-Lo. 8. Renogel. 9. Amiodarone 200 a day. 10. Nephrocaps. All preoperative clearance done without complications. She underwent an uncomplicated cadaveric renal transplant on [**2155-7-30**]. The kidney was noted to be well perfused with good Dopplerable signal throughout the entire operation. It was noted that her blood pressure, however, during the case was in the mid to upper 80's which was of some concern for overall kidney perfusion although the kidney appeared well during the case. The patient was placed on immunosuppression with Solu-Medrol taper, CellCept postoperatively and was restarted on her preoperative Amiodarone with the addition of Bactrim single strength and Ganciclovir. Her postoperative course was notable for low urine output. She was recovered and spent the first few postoperative days in the Surgical Intensive Care Unit requiring blood pressure support with pressors, but these were weaned successfully although it was of concern what her overall poor hemodynamics would be to this newly transplanted kidney. When she was transitioned to the Transplant Unit Floor, she was on hemodialysis temporarily, and then started on Lasix infusion to help continue good perfusion through the kidney and to inspire the kidney to have more urine output. These interventions seemed somewhat successful. The patient was transitioned off the Lasix strip to a daily dose of Lasix with Zaroxolyn, and was followed very closely. Off the Lasix strip, her urine output went from approximately 1200 cc a day to about 500 cc a day with elevated BUN in the low 100's and creatinine of 7. For this reason, given the patient's intermittent nausea, it was discussed with the Nephrology Team and Surgical Team perhaps restarting dialysis would be a good option. The patient was dialyzed successfully for two sessions during this course, postoperative day 13 and 15 and this was successful. Following this, the patient's mental status which had been clear throughout even improved, her volume status improved and she was no longer short of breath with ambulation and her BUN decreased successfully which was accompanied by a decrease in nausea. The patient at the time of discharge had improved/recovered urine output to the 1200 cc range. It had been postulated before this urine output recovered as to whether the patient needed a repeat renal biopsy ultrasound but as her kidneys seemed to be recovering a hold was placed on this plan, especially since the patient had been on Coumadin and aspirin which had only been held two days prior to the proposed biopsy time. The patient's last kidney ultrasound was on [**8-8**] which showed that she had some decreased flow and no real antegrade diastolic flow but as the patient's urine output had improved with just the use of Zaroxolyn and a daily dose of Lasix, the surgeons were very encouraged. The patient was discharged to rehabilitation with very close follow-up and would need to have strict I's and O's, for her follow-up visit. The patient was going to return with the log of daily urine output to be able to present to Dr. [**Last Name (STitle) **]. and the Nephrology Team so that an educated discussion of her kidney function could be had. The patient was discharged on the following medications. DISCHARGE MEDICATIONS: 1. CellCept [**Pager number **] mg q.i.d. which had been changed from 1 gram b.i.d. with the thought that the smaller doses more frequently would hopefully decrease overall nausea. 2. Rapamune. at 2 mg q.d. and this had been decreased a few days prior to discharge with the thought that her level had been 29, a little bit on the high side and could be decreased. 3. Prednisone 20 mg a day. 4. Epogen 5000 units given q. Tuesday and Thursday. 5. Amiodarone 200 mg q. day. 6. Bactrim single strength q. day. 7. Ganciclovir 500 mg q.d. 8. Zaroxolyn 5 mg q.d. 9. Lasix 160 mg q. day. The patient will continue to have her Coumadin and aspirin held because at a follow-up visit a renal biopsy may be in order depending upon the log of her urine output displayed. The patient would not need hemodialysis from her rehabilitation facility. The patient was discharged to rehabilitation in good condition and comfortable with this discharge plan. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3598**], MD [**MD Number(1) 3599**] Dictated By:[**Name8 (MD) 15477**] MEDQUIST36 D: [**2155-8-15**] 09:23 T: [**2155-8-15**] 10:40 JOB#: [**Job Number 29060**]

[ "458.2", "997.5", "788.29", "427.31", "276.6", "403.91", "285.21", "250.40", "276.7" ]

icd9cm

[ [ [] ] ]

[ "88.75", "38.91", "89.64", "55.24", "55.69", "39.95" ]

icd9pcs

[ [ [] ] ]

12705, 13917

8430, 12682

1083, 4745

6314, 7584

8382, 8408

157, 1065

4761, 6302

7609, 8360

14,565

145,485

1503

Discharge summary

report

Admission Date: [**2164-8-28**] Discharge Date: [**2164-9-6**] Date of Birth: [**2127-12-2**] Sex: F Service: MEDICINE Allergies: Penicillins / Erythromycin Base / Keflex / Sulfa (Sulfonamide Antibiotics) / Compazine / Valium / Fentanyl / Flecainide / Tape [**1-8**]"X10YD / Midodrine / Topamax / Clindamycin / Ferrlecit / Linezolid / Levaquin in D5W / Vancomycin / Ciprofloxacin / Avelox / Droperidol / Nut Flavor / Peanut / Epinephrine / Shellfish Attending:[**First Name3 (LF) 2195**] Chief Complaint: hypotension, altered mental status Major Surgical or Invasive Procedure: Removal of tunneled line Placement of PICC line History of Present Illness: 36 yo F w/ h/o neuropathic dysautonomia on fludrocortisone at home, bacterial overgrowth syndrome, and hypothyroidism, who presents with hypotension and altered mental status. Per health care proxy, patient was in USOH on [**Name (NI) 766**]. Went for dental cleaning that morning after taking azithromycin (also took a dose post-procedure) and during procedure received xylocaine, subsequently became hypertensive and tachycardic. Was sent to [**Hospital1 3278**] ED where received a beta blocker with some response in HR. Discharged home and was tachy to 150s, which improved after a 1 L NS bolus (of note, patient typically gets 1L NS w/ K at home daily). Patient "felt crappy" but without focal complaints, but improved after fluids. Later in night continued to feel abnormal, and went to bathroom with cramping and loose stools. No [**Hospital1 **] noted. Was dizzy and felt pre-syncopal in bathroom and per HCP had a brief syncopal episode w/ LOC of about 1 sec. Recovered and was agitated but oriented. Was brought to ED given refractory hypotension and concern for sepsis. . In the ED, initial vs were: HR70 BP72/27 RR12 O2 sat 100%. Patient triggered on arrival for hypotension and was given 1L NS w/ mild improvement of her pressure. She complained of head and ear pain (per HCP these are typical symptoms for her when she is septic) as well as muscle cramps. She was also noted to be somewhat drowsy and confused. Pt and HCP reported these are typical symptoms for her when septic and refused LP w/o sedation. She received a total of 4L of NS bringing her pressures to 90s systolically. She was started on levophed for additional support as well as gentamicin and daptomycin for empiric coverage given her multiple allergies. She was also give 80 mEQ K for potassium of 2.0 on arrival, toradol 30 mg IV x2, and zofran. Given report of increased abdominal discomfort and diarrhea, she underwent CT abd/pelvis and RUQ U/S w/o focal findings. . On arrival to the ICU, patient was somnolent and not following commands. . Review of systems: (+) Unable to obtain secondary to patient's mental status. Past Medical History: 1. Postural orthostatic tachycardia [**Hospital1 8820**]: longstanding, gives self IVF boluses 5 days a week, given over 2 hours depending on dose of Florinef taken that day. She says her baseline HR is usually in the 120's. 2. Hypokalemia: requires potassium in IVF 3. Tachycardia induced cardiomyopathy: most recent ECHO [**1-17**] with EF 45-50% and mild LV global hypokinesis with no valve abnormalities. 4. Recurrent sinusitis. 5. Hypothyroidism. 6. Hypoglycemia - says episodes come at random, not medicated. 7. Status post three laminectomies as a child. 8. Anorexia nervosa: reports not active. 9. History of enterococcal (Vanc susceptible) sepsis, coag negative staph, and non-fermenter, nonpseudomonas infections related to Hickmann catheter. 10. GERD: hiatal hernia on most recent EGD on [**2162-2-26**], reflux to level of vocal cords. 11. Status post-appendectomy. 12. Congenital strabismus. 13. Hyperprolactinemia and pituitary adenoma by MRI. 14. Depression. 15. Post-traumatic stress disorder. 16. History of CNS sepsis [**2157-1-6**]. 17. History of anemia. 18. CNS sepsis in [**2157-1-6**]. 19. Serratia hickman line infection on the left (only wound culture not [**Year (4 digits) **] culture was positive) 20. Abdominal wall discoloration with distention/lipi dystrophy and livedo reticularis. 21. Bacterial overgrowth syndrome- takes rifaximin at times Social History: Disabled due to POTS, stays at home with PCA. Denies tobacco, EtOH use, no IVDU or illicit substances. Family History: Grandfather (maternal) had pheochromocytoma and autonomic dysfunction similar to her syndrome. Grandfather had pheochromocytoma and coronary artery disease. A maternal grandmother had lung cancer. There was breast cancer in a maternal grandmother and aunt. There is hypothyroidism in the family. Physical Exam: Phyisical Exam on Admission: Vitals: T:99.1 BP: 100/69 P: 104 R: 16 O2: 99% on RA General: Thin, chronically ill appearing woman, somnolent, moaning to verbal stimuli, but not following commands HEENT: R pupil 2 mm and reactive, L pupil 4 mm and reactive; sclera anicteric Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally anteriorly, no wheezes, rales, rhonchi CV: Tachycardic, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, diffusely tender (grimaces when palpate), non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Labs on Admission: [**2164-8-28**] 02:52AM WBC-1.3*# RBC-2.91*# HGB-9.8*# HCT-27.4*# MCV-94 MCH-33.6* MCHC-35.7* RDW-12.4 [**2164-8-28**] 02:52AM NEUTS-80.0* LYMPHS-15.7* MONOS-2.1 EOS-1.9 BASOS-0.2 [**2164-8-28**] 02:52AM ALBUMIN-2.3* CALCIUM-5.6* PHOSPHATE-1.5* MAGNESIUM-1.1* [**2164-8-28**] 02:52AM LIPASE-27 [**2164-8-28**] 02:52AM ALT(SGPT)-19 AST(SGOT)-28 ALK PHOS-35 TOT BILI-0.7 [**2164-8-28**] 02:55AM HGB-9.8* calcHCT-29 [**2164-8-28**] 02:55AM GLUCOSE-86 LACTATE-2.5* K+-2.2* [**2164-8-28**] 03:44AM RET AUT-1.4 [**2164-8-28**] 03:44AM PT-17.4* INR(PT)-1.6* [**2164-8-28**] 03:44AM WBC-1.5* RBC-3.63* HGB-12.2 HCT-34.1* MCV-94 MCH-33.5* MCHC-35.7* RDW-12.4 [**2164-8-28**] 03:44AM NEUTS-79* BANDS-1 LYMPHS-15* MONOS-5 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2164-8-28**] 03:44AM GLUCOSE-93 UREA N-9 CREAT-0.8 SODIUM-142 POTASSIUM-3.4 CHLORIDE-113* TOTAL CO2-18* ANION GAP-14 [**2164-8-28**] 03:51AM GLUCOSE-88 LACTATE-3.7* K+-3.5 [**2164-8-28**] 11:29AM CORTISOL-30.7* [**2164-8-28**] 04:15AM URINE [**Month/Day/Year 3143**]-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-TR [**2164-8-28**] 04:15AM URINE RBC-1 WBC-<1 BACTERIA-FEW YEAST-NONE EPI-0 [**2164-8-28**] 04:15AM URINE HYALINE-14* [**2164-8-28**] 04:15AM URINE MUCOUS-RARE . Micro . [**2164-8-28**] 4:20 am [**Month/Day/Year 3143**] CULTURE FROM CENTRAL LINE. [**Month/Day/Year **] Culture, Routine (Preliminary): GRAM NEGATIVE ROD(S). PRELIMINARY SENSITIVITY. These preliminary susceptibility results are offered to help guide treatment; interpret with caution as final susceptibilities may change. Check for final susceptibility results in 24 hours. STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES PERFORMED ON REQUEST.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ GRAM NEGATIVE ROD(S) | CEFTAZIDIME----------- S CIPROFLOXACIN--------- S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ S Aerobic Bottle Gram Stain (Final [**2164-8-28**]): GRAM NEGATIVE ROD(S). Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ON [**2164-8-28**] @ 520 PM. Anaerobic Bottle Gram Stain (Final [**2164-8-29**]): GRAM POSITIVE COCCI IN CLUSTERS. Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 8827**] [**2164-8-29**] @ 9:00 AM. [**2164-8-28**] 4:15 am [**Month/Day/Year 3143**] CULTURE FROM CENTRAL LINE. [**Month/Day/Year **] Culture, Routine (Preliminary): GRAM NEGATIVE ROD(S). IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 329-0551M [**2164-8-28**]. Aerobic Bottle Gram Stain (Final [**2164-8-28**]): GRAM NEGATIVE ROD(S). Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ON [**2164-8-28**] @ 520 PM. [**2164-8-28**] 4:15 am URINE Site: NOT SPECIFIED CHM S# [**Serial Number 8828**]M UCU ADDED [**8-28**]. **FINAL REPORT [**2164-8-31**]** URINE CULTURE (Final [**2164-8-31**]): HAFNIA ALVEI. >100,000 ORGANISMS/ML.. Hematology/Chemistry specimen, possibly contaminated. INTERPRET RESULTS WITH CAUTION. Piperacillin/tazobactam sensitivity testing available on request. ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ HAFNIA ALVEI | ESCHERICHIA COLI | | AMPICILLIN------------ 4 R 4 S AMPICILLIN/SULBACTAM-- 4 R 4 S CEFAZOLIN------------- =>64 R <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- 4 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S LEVOFLOXACIN----------<=0.12 S MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- <=16 S 32 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S [**2164-8-29**] 11:42 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. FECAL CULTURE (Pending): CAMPYLOBACTER CULTURE (Pending): OVA + PARASITES (Final [**2164-8-30**]): NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. FECAL CULTURE - R/O VIBRIO (Final [**2164-8-31**]): NO VIBRIO FOUND. FECAL CULTURE - R/O YERSINIA (Pending): FECAL CULTURE - R/O E.COLI 0157:H7 (Pending): CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2164-8-30**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). [**2164-8-30**] 4:57 am [**Month/Day/Year 3143**] CULTURE Source: Line-CVC. [**Month/Day/Year **] Culture, Routine (Pending [**2164-8-30**] 10:32 pm STOOL CONSISTENCY: SOFT Source: Stool. **FINAL REPORT [**2164-8-31**]** OVA + PARASITES (Final [**2164-8-31**]): NO OVA AND PARASITES SEEN. This test does not reliably detect Cryptosporidium, Cyclospora or Microsporidium. While most cases of Giardia are detected by routine O+P, the Giardia antigen test may enhance detection when organisms are rare. . Imaging . CXR [**8-28**]: FINDINGS: AP and lateral chest radiographs were obtained. The lungs are clear with no evidence of consolidation. No effusion or pneumothorax is present. Blunting of the right costophrenic angle and hemidiaphragm elevation are chronic and unchanged. No effusion or pneumothorax is present. A left subclavian line terminates at the low SVC. The heart and mediastinal contours are normal. IMPRESSION: No acute cardiopulmonary process. . CT head [**8-28**]: FINDINGS: No acute intracranial hemorrhage, edema, or mass effect is present. The ventricles and sulci are normal in size and configuration. The basal cisterns are not compressed. The visualized paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: No evidence of an acute intracranial process . CT abdomen/pelvis [**8-28**]: FINDINGS: The visualized lung bases are free of nodules, consolidations, or effusions. The liver has a heterogeneous appearance. Diffuse periportal edema is present. Small amount of perihepatic ascites is seen. There is a large amount of pericholecystic fluid which collapses the gallbladder lumen centrally. No intra- or extra-hepatic biliary dilatation is seen. The main portal vein and branches are patent. The IVC is distended. The pancreas, spleen, and adrenal glands are normal. The kidneys enhance and excrete contrast symmetrically. No mesenteric or retroperitoneal adenopathy is present. The stomach, small and large bowel are of normal caliber and appearance. PELVIS: The remainder of bowel is unremarkable, the appendix is not visualized, there are no secondary signs of appendicitis. The bladder and uterus are normal. BONE WINDOWS: There are no concerning lytic or sclerotic lesions. IMPRESSION: Diffuse periportal edema, perihepatic ascites and pericholecystic fluid most consistent with recent aggressive fluid resuscitation; however, right upper quadrant ultrasound can be performed to confirm these findings. . RUQ US [**8-28**]: INDICATION: 66-year-old woman with abdominal pain and abnormal CT, question cholecystitis. FINDINGS: Limited ultrasound was performed of the right upper quadrant. The liver has a homogeneous echotexture with no focal lesions identified. The main portal vein is patent. The gallbladder wall is markedly edematous, measuring a maximum of 1.4 cm, compressing the gallbladder lumen. No stones are identified. The common bile duct is normal in caliber measuring 3 mm. Negative son[**Name (NI) 493**] [**Name2 (NI) 515**] sign. IMPRESSION: Massive gallbladder wall edema, which compresses the gallbladder lumen, likely secondary to vigorous volume resuscitation. . Elbow X-ray [**8-28**]: INDICATION: Dog bite six days ago complicated by septic shock. Three views of the left elbow are normal. There is no fracture, effusion, bony destruction or dislocation. There is no definite soft tissue mass or fluid collection. Discharge Labs: [**2164-9-4**] 02:04PM WBC-5.6 RBC-3.27* Hgb-10.8* Hct-29.7* MCV-91 Plt Ct-249# [**2164-9-6**] 05:49AM Glucose-82 UreaN-6 Creat-0.6 Na-140 K-3.4 Cl-106 HCO3-28 [**2164-9-6**] 05:49AM Phos-3.5 Mg-2.1 Brief Hospital Course: 36 year old woman w/ h/o neuropathic dysautonomia, bacterial overgrowth syndrome, and hypothyroidism presenting with hypotension and altered mental status concerning for sepsis and found to be bacteremic with pseudamonas [**2-8**] long term central line infection. Of note, team communicated closely with patient's outpatient providers thoughout the hospital stay. # Septic Shock- Patient w/ POTS with baseline SBPs in the 90s-100s as well as diarrhea and also with altered mental status. Remained hypotensive despite aggressive fluid boluses and required pressor support with Levophed for approximately 24 hours. In the ICU she was fluid resuscitated further. Her lactate trended down and [**Month/Day (2) **] pressure normalized. Given patient is on chronic steroids at home, considered adrenal insufficiency contributing to hypotension. [**Last Name (un) **] stim stest was performed and was normal. Sources of infection considered were pulmonary, abdominal, urinary, central line (in for 1 year as patient self administers normal saline daily at home), CNS given AMS, and oral in the setting of recent dental work. Also, patient gave history of recent dog bite on her left elbow. In ED, patient was broadly covered with antibiotics with Daptomycin/Gentamycin given extensive allergies to multiple antibiotics. Infectious disease team was following closely. Patient was continued on Daptomycin/Gentamycin and Doxycycline/Flagyl were added because of concern for dental infection as well as concern for Pasturella in the setting of recent dog bite. Source of infection was investigated. In setting of diarrhea, obtained CT abdomen/pelvis and RUQ US as well as sent stool cultures for O&P, vibrio, yirsinia, campylobacter, c.dif all of which were negative and did not demonstrate a source of infection. CXR with no pneumonia. X-ray of the left elbow did not show any abnormality [**2-8**] dog bite. Urine cultures grew out pan sensitive E. Coli as well as Hafnia alvei resistant only to ampicillin and cefazolin. [**Month/Day (2) **] cultures grew out pseudomonas sensitive to cefazadime, ciproflox, zosyn, gentamycin, tobramycin. Two days into hospital stay, area surrounding patient's central line (in for 1 year) became erythematous and tender. Decision was made to remove the line as this was the likely nidus of infection. New PICC was placed instead. Shortly after removal of line, patient's condition improved. She was changed from gentamycin to tobramycin given shortage of gentamycin. She will complete a total of two weeks of Gentamycin, dated since the removal of her central line, to be completed on [**2164-9-13**]. # Altered mental status- Differential included included secondary change from septic picture vs. primary CNS process such as meningitis or encephelitis. CT head was negative for acute process. As hypotension resolved, mental status returned to normal and thus lumbar puncture was deferred. # Pancytopenia- Likely secondary to septic picture particularly given rapid development of leukopenia and thrombocytopenia compared to normal values on [**8-20**]. Does have a slight anemia compared to recent baseline in 40s, though true baseline is unclear. FDPs were mildly elevated, but fibrinogen/d-dimer wnl not indicative of active DIC. [**Name (NI) 3674**] Baseline unclear, but in mid 30s to 40s. Most recently was 47.6 in clinic on [**8-20**] and currently 34.1. No signs of active bleeding on exam. Stool was guaic negative. Did not require [**Month/Year (2) **] transfusion. Hct stabilized at 30 and platelets returned to [**Location 213**]. # POTS- Long history of autonomic dysregulation which has been treated with gabapentin and fluorinef. Has baseline BPs in 90s-110s and HR in 90s-100s. Patient was continued on her home florinef; [**Last Name (un) 104**] stim was negative as noted above. Initially held home gabapentin and ritalin in setting of sepsis and altered mental status, but re-started them once patient improved. # Diarrhea: Worsened several days into antibiotic therapy; thought to be antibiotic associated diarrhea. All stool cultures negative, as well as a stool PCR for C.difficile. Her diarrhea resolved with increasing her dose of Immodium. She was also given a five day course of Rifaximin. She was seen in consultation by the GI service, and should continue to follow-up with Dr.[**First Name (STitle) 1356**] as an outpatient. # Hypokalemia: Is a chronic issue for the patient. She was repleted on a once-to-twice daily basis over the last several days of her hospitalization, and is being discharged with orders for NS with 50 mEq of potassium, as she has taken in the past. Her electrolytes will be re-checked daily for two days following discharge, then again two days later. Subsequent need for electrolyte checks to be determined by her PCP at her [**Name9 (PRE) 702**] visit on [**9-12**]. Medications on Admission: AMPHETAMINE-DEXTROAMPHETAMINE [ADDERALL] - 30 mg Tablet - 1 (One) Tablet(s) by mouth twice a day - No Substitution AMPHETAMINE-DEXTROAMPHETAMINE [ADDERALL] - 10 mg Tablet - 1 Tablet(s) by mouth three times a day - No Substitution AZITHROMYCIN - 500 mg Tablet - 1 Tablet(s) by mouth 1/2 hour prior to procedure AZITHROMYCIN - 500 mg Recon Soln - 500 mg IV 1/2 hour prior to procedure CHLORZOXAZONE [PARAFON FORTE DSC] - (per old records) - 500 mg Tablet - 1 Tablet(s) by mouth twice a day as needed for neck pain CLOBETASOL - 0.05 % Cream - apply affected areas twice a day Do not use on face or folds EPINEPHRINE [EPIPEN JR] - 0.15 mg/0.3 mL (1:2,000) Pen Injector - use as directed for anphylaxis as directed disp 1 2-pack ERGOCALCIFEROL (VITAMIN D2) - 50,000 unit Capsule - 1 Capsule(s) by mouth monthly FLUDROCORTISONE - (Dose adjustment - no new Rx) - 0.1 mg Tablet - 2 Tablet(s) by mouth twice a day GABAPENTIN [NEURONTIN] - 800 mg Tablet - 1 Tablet(s) by mouth three times a day I.V FLUIDS - (Dose adjustment - no new Rx) - - 50 meq potassium added LEVOTHYROXINE [SYNTHROID] - 112 mcg Tablet - 1 (One) Tablet(s) by mouth once a day - No Substitution LIDOCAINE - 5 % (700 mg/patch) Adhesive Patch, Medicated - [**1-9**] topically for 12 hours as needed for pain LIOTHYRONINE - 5 mcg Tablet - 1 Tablet(s) by mouth once a day ONDANSETRON HCL - 8 mg Tablet - 1 Tablet(s) by mouth once a day as needed for nausea RABEPRAZOLE [ACIPHEX] - (per old records) - 20 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth twice a day SODIUM FLUORIDE-POT NITRATE [PREVIDENT 5000 SENSITIVE] - 1.1 %-5 % Paste - use as directed twice a day . Medications - OTC CETIRIZINE - 10 mg Tablet - 1 Tablet(s) by mouth once a day RANITIDINE HCL - (OTC) - 150 mg Capsule - 1 Capsule(s) by mouth once a day Allergies: Avelox, Ciprofloxacin, Clindamycin, Compazine, Erythromycin Base, Fentanyl, Ferrlecit, Flecainide, Keflex, Levaquin in D5W, Linezolid, Midodrine, Nut Flavor, Peanut, Penicillins, Sulfa (Sulfonamide Antibiotics), Tape [**1-8**]"X10YD, Topamax, Vancomycin, Droperidol, Valium, epinephrine Discharge Medications: 1. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. liothyronine 5 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. fludrocortisone 0.1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. gabapentin 400 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 5. chlorzoxazone 500 mg Tablet Sig: One (1) Tablet PO BID PRN () as needed for neck pain. 6. lidocaine-prilocaine 2.5-2.5 % Cream Sig: One (1) Appl Topical PRN (as needed) as needed for muscle pain. 7. ascorbic acid 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. dextroamphetamine 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 9. dicyclomine 10 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*1 month's supply* Refills:*0* 10. alum-mag hydroxide-simeth 200-200-20 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed for Nausea, stomach upset. 11. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 12. loperamide 2 mg Capsule Sig: Two (2) Capsule PO QID (4 times a day) as needed for diarrhea. 13. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) inhalation Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 14. famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 15. gentamicin 40 mg/mL Solution Sig: Three [**Age over 90 **]y (320) mg Injection Q24H (every 24 hours) for 7 doses. Disp:*7 doses* Refills:*0* 16. Zofran 8 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for nausea. Disp:*1 month's supply* Refills:*0* 17. Outpatient Lab Work Please have a Chem 10 checked on [**2164-9-7**], [**2164-9-8**], and [**2164-9-10**] and have the results sent to Dr.[**Last Name (STitle) 3707**]. 18. IV fluids Please provide patient with 1L NS with 50 mEq of potassium, IV, to be given 5x/week. Please give two week's supply with no refills. 19. IV fluids Please provide patient with 1L NS, IV, to be given 2x/week. Please give two week's supply with no refills. Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Sepsis Pseudomonal bacteremia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with low [**Last Name (STitle) **] pressure and were found to have bacteria in your [**Last Name (STitle) **], likely from your line. Your tunneled line was removed and you had a PICC line placed. Your symptoms improved. You will need to continue to take IV antibiotics through [**2164-8-13**]. Please weigh yourself every morning, and call your doctor if your weight goes up more than 3 lbs. Followup Instructions: Department: [**State **]When: WEDNESDAY [**2164-9-12**] at 10:00 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 3747**], MD [**Telephone/Fax (1) 2205**] Building: [**State **] ([**Location (un) **], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: On Street Parking Department: GASTROENTEROLOGY When: TUESDAY [**2164-10-2**] at 9:00 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 1983**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: GERONTOLOGY When: THURSDAY [**2164-12-6**] at 1 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8708**], M.D. [**Telephone/Fax (1) 719**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

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Discharge summary

report

Admission Date: [**2128-10-25**] Discharge Date: [**2128-11-8**] Date of Birth: [**2052-5-17**] Sex: F Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 1481**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Laparotomy, lysis of adhesions, small bowel resection. History of Present Illness: Patient is a 73 year old female who awoke the morning of presentation with abdominal pain, generalized, inability to pass flatus. Past Medical History: DM-2 cervical CA s/p total hyterectomy breast mass schizophrenia copd with co2 retention CAD CRI (baseline Cr=0.8-1) Social History: retired, no EtOH, smokes. lives with sister Family History: DM-2, CAD Physical Exam: Temp 97.3, HR 99, BP 96/43, RR 12, SaO2 100% Alert and oriented, NAD CTAB RRR Distended, diffuse tenderness, midline scar noted with concern for incarcerated hernia, +rebound tenderness, +guarding Palp fem pulses b/l No femoral hernia Guiac negative stool Pertinent Results: [**2128-10-25**] 09:30AM WBC-10.4 RBC-5.27 HGB-14.9 HCT-43.1 MCV-82 MCH-28.3 MCHC-34.6 RDW-14.8 [**2128-10-25**] 09:30AM NEUTS-85.0* BANDS-0 LYMPHS-10.8* MONOS-2.6 EOS-1.2 BASOS-0.3 [**2128-10-25**] 09:30AM ALT(SGPT)-9 AST(SGOT)-15 LD(LDH)-208 ALK PHOS-102 AMYLASE-44 TOT BILI-0.4 [**2128-10-25**] 09:30AM LIPASE-13 [**2128-10-25**] 09:30AM GLUCOSE-292* UREA N-17 CREAT-1.1 SODIUM-128* POTASSIUM-4.8 CHLORIDE-87* TOTAL CO2-26 ANION GAP-20 Brief Hospital Course: The patient was admitted to the surgical service and an NG tube was placed for decompression. A CT scan showed signs of a complete obstruction with some loops of small bowel which had some retained delayed intravenous contrast suggesting some sort of vascular compromise. She was taken to the operating room for an exploratory laparotomy and approximately 3 feet of small bowel was resected (see op note for details). Intraoperatively, the patient had hypotension requiring pressors. Postoperatively, she was transferred, still extubated, to the SICU and was vigorously resuscitated. The patient was extubated on post op day 3. The patient did well and was transferred to the floor on post op day 5. She remained NPO awaiting return of bowel function. The morning of post op day 6, the patient developed a rapid heart rate (160-180), hypotension, and diaphoresis. She was immediately resuscitated and transferred to the SICU. EKG showed A-fib with rapid ventricular response. She was cardioverted with Amiodarone after which she remained in sinus rhythm with a normal blood pressure. Anticoagulation was initiated with a heparin drip and Coumadin, aspirin and Diltiazem were also started. The patient began passing flatus on post op day 8 and was given a diet of clear liquids. She continued to do well and was transferred back to the floor on post op day 10. Her psychiatric medications were restarted on post op day 10. She was deemed ready for discharge to rehabilitation on post op day 14. She was discharged on Lovenox until a therapeutic INR is reached on warfarin. Medications on Admission: ASA, Atenolol 25, Atrovent, Cogentin 5, Flovent, Metformin 500, NTG, Risperdol, Zantac 150 Discharge Medications: 1. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 2. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 3. Albuterol 90 mcg/Actuation Aerosol Sig: 2-4 Puffs Inhalation Q6H (every 6 hours) as needed. 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): Dosing: 400mg PO BID through [**11-10**], then decrease to 400mg PO QD from [**11-11**] through [**11-17**], then decrease to 200mg QD ongoing. 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Benztropine 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Haloperidol 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 11. Risperdal 4 mg Tablet Sig: One (1) Tablet PO once a day for 1 days: [**11-9**]: 5mg [**11-10**]: 6mg (ongoing). 12. Risperdal 1 mg Tablet Sig: One (1) Tablet PO once a day for 1 days: [**11-9**]: 5mg [**11-10**]: 6mg (ongoing). 13. Risperdal 4 mg Tablet Sig: One (1) Tablet PO once a day: Starting [**11-10**]. 14. Risperdal 2 mg Tablet Sig: One (1) Tablet PO once a day: Starting [**11-10**]. 15. Warfarin 2.5 mg Tablet Sig: One (1) Tablet PO at bedtime: Monitor INR and adjust Coumadin for level 2.0-3.0. 16. Lovenox 100 mg/mL Solution Sig: Fifty (50) mg Subcutaneous twice a day: To be given at the SAME TIME as Warfarin. Discontinue once therapeutic INR (2.0-3.0) reached with Warfarin. 17. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 19. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Strangulated small bowel obstruction Discharge Condition: Stable Discharge Instructions: Please do not lift anything heavier than a gallon of milk for 6 weeks. Please resume prior home medications. You may shower, pat incision dry. Leave steri strips on, they will fall off on their own. You may resume a regular diet. Please call or return if you have a fever >101.4, surrounding redness or drainage from the incision, persistent nausea, vomiting, constipation, or diarrhea. Followup Instructions: Please see Dr. [**Last Name (STitle) **] in 2 weeks. Call [**Telephone/Fax (1) 2981**] for an appointment. Completed by:[**2128-11-8**]

[ "295.62", "560.2", "458.29", "557.0", "427.31", "568.0", "496", "V10.41", "585.9", "414.01" ]

icd9cm

[ [ [] ] ]

[ "45.62", "54.59" ]

icd9pcs

[ [ [] ] ]

5128, 5207

1496, 3069

287, 344

5288, 5297

1023, 1473

5732, 5870

721, 732

3210, 5105

5228, 5267

3095, 3187

5321, 5709

747, 1004

233, 249

372, 503

525, 643

659, 705

24,512

188,843

24872

Discharge summary

report

Admission Date: [**2166-10-14**] Discharge Date: [**2166-10-18**] Date of Birth: [**2145-6-6**] Sex: F Service: MEDICINE Allergies: Benadryl / Morphine / Iodine Attending:[**First Name3 (LF) 2186**] Chief Complaint: Pulmonary embolism Major Surgical or Invasive Procedure: None History of Present Illness: 21 F transferred from [**Hospital3 22439**] for R-sided chest wall tenderness/PE. Symptoms started 5d PTA, with R calf cramp which resolved. The same night, the pt developped R chest wall pain: constant/sharp, along right side going to the R shoulder. Worse with deep inspiration, lying down and at night. Relieved slightly w/Advil and NyQuil. No cough. Pt thought that leg cramp was from electrolyte imbalance from her Diamox and stopped taking it. Feels no SOB now. No other CP. Had T 100.5 in the [**Hospital1 6687**] ED. Denies C/N/V/constipation/diarrhea/HA. No recent travel. Back in [**Month (only) **], she was travelling from [**State 8780**] and had swollen feet, which resolved but bothered her on-off occasionally since. O/w, has never had similar symptoms before. No recent travel. . PMHx: Pseudotumor cerebri, diagnosed at the age of 14. Had 1 LP at that time, and none since. Was treated with Diamox at that time, her symptoms resolved and she stopped the Diamox. Her symptoms recurred last [**Month (only) 956**], and she restarted the Diamox. . Meds: - Diamox, as above. - Orthotricyclen, started at age of 17, stopped briefly earlier this year and then restarted. - Centrum. . All: Benadryl. . SHx: Married. Never been pregnant, never tried to become pregnant. Has 4 sisters, 1 brother, all apparently healthy. Works taking caring of a lady w/Alzheimer's. Denies tob/EtOH/illicit drugs. . FHx: Mother had 2 miscarriages and died at age of 46 from ?sepsis. No known FHx of DVT/PE. Father alive, healthy. . PE: Vs: 96.6, 119, 128/64, 20, 99% RA NAD, obese. Difficult to appreciate JVD. RRR, no loud P2. No MRG Lungs: R base crackles. Abd: Obese, S/NT Trace [**Location (un) **] R>[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5813**] negative. No calf tenderness. . A/P: 21 F on OCPs, p/w PE. . - PE: On heparin gtt (subtherapeutic for now. Will rebolus and increase heparin rate). Check LENIs in the am (? IVC filter candidate if large DVT burden?). Will transition to coumadin. . - Pain control: NSAIDs standing, morphine prn. . - Hypercoagulability w/u: Check factor V Leiden and prothrombin gene mutations, lupus anti-coagulant. . - Thrombocytopenia: Unclear etiology. Pt has no Hx of prior exposure to heparin, before today. Will follow. . - Outpt Pap smear. . - House diet. . - Proph: On IV heparin. . - Dispo: To the floor Past Medical History: Pseudotumor cerebri, dx age 14. Had LP at time of diagnosis, none since then. Treated with Diamox at the time, her symptoms resolved and she stopped the medication. Her symptoms recurred last [**Month (only) 956**] and she restarted the Diamox, stopped after PE's were diagnosed. Social History: Married, no hx of pregnancy, never tried to become pregnant. Has 4 sisters, 1 brother, all healthy. Works taking care of an elderly woman with Alzheimer's. Denies tobacco/etoh/drugs. Family History: Mother had 2 miscarriages and died at 46 y.o. from ? sepsis. No known hx of DVT/PEs. Father alive, healthy Physical Exam: 97.8 140/80 103 18 100% RA Gen- Well appearing lady resting in bed. NAD. Cardiac- RRR. S1 S2. No m,r,g. Pulm- CATB. No wheezes, rales, or rhonchi. Abdomen- Obese. Soft. NT. ND. Positive bowel sounds. Extremities- No c/c/e. Pertinent Results: [**2166-10-14**] 02:45PM BLOOD WBC-10.3 RBC-4.20 Hgb-12.0 Hct-33.5* MCV-80* MCH-28.5 MCHC-35.7* RDW-12.4 [**2166-10-14**] 02:45PM BLOOD Neuts-79.1* Bands-0 Lymphs-14.9* Monos-4.3 Eos-0.6 Baso-1.1 [**2166-10-18**] 09:24AM BLOOD PT-18.9* PTT-87.5* INR(PT)-2.5 [**2166-10-14**] 02:45PM BLOOD PT-13.0 PTT-26.8 INR(PT)-1.1 [**2166-10-15**] 04:15AM BLOOD Thrombn-150* [**2166-10-14**] 02:45PM BLOOD D-Dimer-4480* [**2166-10-14**] 02:45PM BLOOD Glucose-101 UreaN-8 Creat-0.8 Na-137 K-4.4 Cl-103 HCO3-23 AnGap-15 [**2166-10-15**] 04:15AM BLOOD Calcium-8.9 Phos-3.6 Mg-2.2 Iron-40 [**2166-10-15**] 04:15AM BLOOD calTIBC-351 VitB12-163* Folate-15.7 Ferritn-153* TRF-270 [**2166-10-15**] 04:15AM BLOOD HCG-<5 [**2166-10-18**] 09:24AM BLOOD PT-18.9* PTT-87.5* INR(PT)-2.5 CT 100CC NON IONIC CONTRAST [**2166-10-14**] 5:05 PM IMPRESSION: Large bilateral pulmonary emboli with right lower lobe wedge- shaped opacity consistent with an infarction with surrounding hemorrhage. At the immediate conclusion of this examination, these findings were discussed with the ordering physician and relayed to the Emergency Department dashboard at 5:40 p.m. CHEST (PA & LAT) [**2166-10-14**] 5:49 PM IMPRESSION: No evidence of pneumonia or CHF. Please refer to the chest CT report of the same day. Brief Hospital Course: 21 y/o female with PMH significant for pseudotumor cerebri transferred from the [**Hospital Unit Name 153**] for further care of a PE. EKG unchanged from prior, no acute changes. Chest x-ray showed a patchy opacity at the right base better seen on CT (see above), a small focus of retrocardiac opacity and a trace right pleural effusion. . 1. [**Name (NI) 10952**] Pt with large, bilateral PE in addition to wedge shaped infarction in the right lower lobe. Unclear cause of PE in this pt- she is on OCPs but has no other know risk factors for a hypercoagulable state. Patient was continued on anticoagulation on a heparin drip and transition to coumadin. Patient was not a candidate for lovenox so she stayed until her INR was therapeutic between 2 to 2. Percocet for pain control. Pt will need outpatient hypercoagulable work up. Breast exam normal. Last Pap was two years ago and was normal. Will need repeat PAP as an outpatient. Her mother did have two miscarriages so may have had an unknown clotting disorder. . 2. [**Name (NI) 3674**] Pt with anemia of unclear etiology. Guiac'd all stools which were negative. Iron studies and folate were wnl. B12 was low. Started repleting and will need to continue as outpatient. Followed Hct closely and transfused for Hct of 27 or less. 3. FEN- Regular diet. Electrolyte replacement as needed. . 4. Proph- Heparin drip until therapeutic on coumadin; bowel regimen Medications on Admission: 1. Diamox- As above, pt self discontinued following the leg cramp. 2. Orthotricyclen 3. Centrum multivitamin 1 tab daily Discharge Medications: 1. Outpatient Lab Work Please check PT/INR on [**Name (NI) 766**] [**2166-10-20**] 8am at [**Hospital3 42943**]. Please fax results to Dr. [**First Name4 (NamePattern1) 2431**] [**Last Name (NamePattern1) **] at [**Hospital1 18**] Fax #[**Telephone/Fax (1) 62567**] and Dr. [**First Name8 (NamePattern2) 3403**] [**Last Name (NamePattern1) **]. 2. Coumadin 1 mg Tablet Sig: Three (3) mg PO at bedtime: Please take 3 mg of coumadin (three of the 1 mg tabs) on the evenings of [**10-18**] and [**10-19**]. You will have you labs checked Mon and your dose will be adjusted as needed. Disp:*120 0* Refills:*2* 3. Cyanocobalamin 500 mcg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 5 days. Disp:*10 Tablet(s)* Refills:*0* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Disp:*16 Tablet(s)* Refills:*0* 5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for 4 days. Disp:*8 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary diagnosis: 1. Large bilateral PEs 2. Right DVT Discharge Condition: Stable, pain controlled with Percocet, not hypoxic, hemodynamically stable, INR therapeutic. Discharge Instructions: 1. Please keep all follow up appointments. 2. Please take all medications as prescribed. 3. Seek medical attention for fevers, chills, chest pain, shortness of breath, abdominal pain, or any other concerning symptoms. 4. Please go to [**Hospital6 18346**] admission desk have your blood drawn by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 62568**] on [**Last Name (NamePattern1) 766**] morning [**10-20**] at 8AM SHARP. The results will be forwarded to Dr. [**Last Name (STitle) **] and to [**Hospital1 18**]. We will contact you on [**Name (NI) 766**] as to any necessary adjustments to your coumadin dosage. 5. Do not resume taking your birth control pills. They are the main risk factor we know about at this time that could have contributed to you having a blood clot. In the future, you should let all of your doctors know that [**Name5 (PTitle) **] had a blood clot in your leg and lungs while taking birth control pills. 6. You will need further workup for the reason you had a blood clot as an outpatient. You will need to have a breast exam and Pap smear by your primary care physician. [**Name10 (NameIs) **] addition, they will probably draw labs to look for other reasons your blood clotted. 7. Please refrain from overexertion and going to work until you see your PCP. Followup Instructions: 1. Please schedule a follow-up appointment with Dr. [**First Name8 (NamePattern2) 3403**] [**Last Name (NamePattern1) **] within 1 week of discharge by calling [**Telephone/Fax (1) 52946**]. 2. Please go to [**Hospital6 18346**] admission desk have your blood drawn by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 62568**] on [**Last Name (NamePattern1) 766**] morning [**10-20**] at 8AM SHARP. The results will be forwarded to Dr. [**Last Name (STitle) **] and to [**Hospital1 18**]. We will contact you on [**Name (NI) 766**] as to any necessary adjustments to your coumadin dosage. Completed by:[**2166-12-23**]

[ "E932.2", "281.1", "453.40", "415.19", "V58.61" ]

icd9cm

[ [ [] ] ]

[ "99.19" ]

icd9pcs

[ [ [] ] ]

7468, 7474

4895, 6309

309, 316

7573, 7668

3595, 4872

9025, 9662

3226, 3336

6481, 7445

7495, 7495

6335, 6458

7692, 9002

3351, 3576

251, 271

344, 2704

7514, 7552

2726, 3010

3026, 3210

4,718

134,323

19699

Discharge summary

report

Admission Date: [**2169-3-26**] Discharge Date: [**2169-4-13**] Date of Birth: [**2096-6-30**] Sex: F Service: SURGERY/GOLD HISTORY OF PRESENT ILLNESS: A 72-year-old female, with a history of hypertension, COPD, renal cell carcinoma, status post left renal nephrectomy in [**2167**], sigmoid disorder, who was admitted to [**Hospital3 **] on the [**3-24**] after having one day of severe abdominal pain associated with nausea and vomiting. Per report, the patient's symptoms were associated with eating [**Male First Name (un) 19450**] candy. An ER amylase was 1,977 and a lipase was 7,508. Right upper quadrant ultrasound revealed gallstones, 5 mm normal CBD. The patient's white count was 16.2, crit elevated at 46, blood glucose 213, AST 217, ALT 224. T-bili was reportedly normal. Chest x-ray was normal. EKG revealed frequent PVCs, an old MI. A KUB revealed small calcifications in the right side of the abdomen, ?stones. HOSPITAL COURSE: The patient was admitted to the ICU for pancreatitis, after physical evaluation was requested. The patient received vigorous IVF hydration, Zosyn, morphine prn pain control. Dilantin was given and the patient was made NPO for bowel rest and had Foley placed for careful I's and O's. By hospital day #2, the patient's white count had risen from 16.2 to 23. Crit was stable at 45. Calcium was 7.3. Amylase and lipase were at 1,345 and 5,865, respectively. The patient had low urine output, around 30 cc/h, with good pain control, and no further nausea and vomiting. The orders and plans for lap-chole once the pancreatitis resolved were put into place. By the [**3-26**], the patient was started on BiPAP secondary to increased respiratory rate, and increased O2 necessary secondary to 7.29, 4,562 blood gas. No signs of CHF per interval. Intermittent chest x-ray revealed moderate left pleural effusions and small lung volume, as the patient was noted to be 5-liter positive secondary to aggressive IVF hydration. The patient was subsequently intubated secondary to increased respiratory rate and PA to 50 even on BIPAP. CT scan of the abdomen on [**2169-3-26**] showed a nonenhancing tail and a portion of the body of the pancreas consistent with necrosis, a large fluid collection at [**Location (un) 6813**] pouch, and bilateral atelectasis with pleural effusions. The patient was transferred to the [**Hospital1 **] for management of necrotizing pancreatitis and hypoxic respiratory failure. PAST MEDICAL HISTORY: 1. Hypertension. 2. Chronic obstructive pulmonary disease 3. Renal cell carcinoma status post resection in [**2167-2-10**]. 4. Appendectomy. 5. Liver hemangioma. 6. Breast cyst. MEDICATIONS AT HOME: 1. Dilantin 100 mg po tid. 2. Norvasc. ALLERGIES: No known drug allergies. SOCIAL HISTORY: A 50-pack year history of smoking. No ethanol use. Seven children. Divorced. Works at school cafeteria. PHYSICAL EXAM: Temperature 100.7, 99, normal sinus rhythm, frequent PVCs, 150/54 blood pressure. Generally, obese, sedate heart. HEENT - no scleral icterus. Cardiac revealed normal S1, S2, no murmurs, rubs or gallops. Lungs were clear to auscultation bilaterally. Abdomen was positive for epigastric pain, no rebound, guarding. Extremities had no clubbing, cyanosis or edema. LABS UPON PRESENTATION: White count 23, crit 45, 222 platelets. Chem-7 - 148/4.2, 116/22, 29/1.1, 218 glucose. INR 1.1, PT 13.2, PTT 20.2, AST 52, ALT 85, T-bili 0.8, amylase from 1,977 to 1,345, now 901. Lipase from 7,508 to 5,856, now 2,672. Albumin at 2.5, total protein of 5.5. ASSESSMENT AND PLAN: A 72-year-old female, with hypertension, COPD, renal cell carcinoma, presenting with necrotizing pancreatitis with increased white count, increased hematocrit, decreased calcium, and hypoxic respiratory failure. The plan was to vigorously hydrate the patient with continuous boluses, check venous lactates. The patient was to be placed on goal-directed protocol, meropenem. ICU COURSE AS FOLLOWS: The patient was intubated for airway protection and was finally extubated and remained as such. Her nutritional status was addressed by TPN while she was NPO, which she is continuing on currently, being supplemented with PO intake. Otherwise, her tenderness resolved while in the unit. Upon transferring to the floor, the patient's LFTs were as follows: T-bili 0.6, alk phos 265, ALT 56, amylase 90, AST 102. The patient received physical therapy beginning during her unit course, and it was continued while on the floor. On the floor, the patient gradually increased her PO intake, and her TPN was decreased from an initial 2 liters to 1 liter upon discharge. The patient will be discharged to an acute rehab facility where she will receive continued physical therapy, and she will be followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in approximately 2-3 weeks. Until that time, the patient is to remain on a clear liquid diet, and to continue her 1 liter bags of TPN, with adjustment as needed for electrolyte changes. DISCHARGE MEDICATIONS: 1. Heparin subcu 5,000 q 8 h. 2. Albuterol 4 puffs IH q 4 h prn. 3. Tylenol 325-650 mg PR q 4-6 prn fever and pain. 4. Insulin sliding scale. 5. Tegretol 100 mg po tid. 6. Protonix 40 mg po q 24 h. 7. Lopressor 50 mg po bid with holding parameters. FOLLOW-UP: The patient will be followed by Dr. [**Last Name (STitle) **] on [**4-28**] in his office and an appointment has already been made. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 8275**] Dictated By:[**Name8 (MD) 8276**] MEDQUIST36 D: [**2169-4-13**] 11:19 T: [**2169-4-13**] 11:47 JOB#: [**Job Number 53288**]

[ "577.0", "518.81", "574.91", "V10.52", "496", "780.39", "401.9" ]

icd9cm

[ [ [] ] ]

[ "99.15", "89.64", "38.93", "96.72", "51.85", "51.88", "51.14" ]

icd9pcs

[ [ [] ] ]

5087, 5741

975, 2482

2704, 2782

2924, 5064

174, 957

2504, 2683

2799, 2908

23,451

134,463

20066

Discharge summary

report

Admission Date: [**2171-12-21**] Discharge Date: [**2172-1-16**] Date of Birth: [**2116-5-23**] Sex: M Service: Medicine, [**Location (un) **] Firm HISTORY OF PRESENT ILLNESS: The patient is a 55-year-old gentleman with a history of peripheral vascular disease and recently diagnosed acquired immunodeficiency syndrome who was transferred from an outside hospital for further evaluation. The patient was originally admitted to an outside hospital on [**2171-12-3**] with complaints of vomiting, weakness, and weight loss. He was found on admission to be pancytopenic. A computed tomography scan revealed a fatty liver. He subsequently developed a right upper lobe infiltrate. He was ruled out for tuberculosis with sputum cultures times three, but he remained febrile and was started on ceftriaxone and azithromycin. A bronchoscopy done at the outside hospital on [**12-11**] showed erythema in the left main stem bronchus of unclear significance. Also, at the outside hospital, the patient was found to be human immunodeficiency virus positive with a CD4 count of 2. He was also hepatitis B positive. The patient was started on Bactrim for Pneumocystis carinii pneumonia prophylaxis. A bone marrow biopsy done at the outside hospital showed a myelodysplastic pattern of cells. The patient was transferred to [**Hospital1 188**] for further evaluation. PAST MEDICAL HISTORY: (The patient also has a past medical history of) 1. Cholelithiasis. 2. Peripheral vascular disease; status post two femoral-to-popliteal bypass grafts on the right lower extremity. MEDICATIONS ON TRANSFER: (His medications on transfer from the outside hospital included) 1. Azithromycin 500 mg by mouth every day. 2. Bactrim double strength one tablet by mouth every day. 3. Protonix 40 mg by mouth once per day. 4. Simethicone. 5. Vancomycin 1 gram twice per day. 6. Diflucan. 7. Prednisone 20 mg by mouth once per day. 8. Nystatin swish-and-swallow. ALLERGIES: SOCIAL HISTORY: The patient has smoked one-third of a pack of cigarettes for the past 35 years. No current alcohol use, but heavy alcohol use 20 to 30 years ago. No drug abuse. The patient denies any homosexual contact. [**Name (NI) **] has a history of unprotected heterosexual contact years ago. FAMILY HISTORY: His father died of a myocardial infarction at the age of 49. His mother had breast cancer. PHYSICAL EXAMINATION ON PRESENTATION: The patient's physical examination on admission revealed his temperature was 99.6 degrees Fahrenheit, his heart rate was 120, his blood pressure was 120/64, his respiratory rate was 22, and his oxygen saturation was 91% to 93% on 3 liters. His head, eyes, ears, nose, and throat examination revealed temporal wasting. He had some erythema around the nose. He had some thrush in the oral cavity. His pupils were equal, round, and reactive to light. His extraocular muscles were intact. The neck was supple. The patient had no lymphadenopathy. Jugular venous distention was not appreciated. He had no wheezes on pulmonary examination. He did have some diffuse crackles on the right greater than left. Cardiovascular examination revealed tachycardia. Normal first heart sounds and second heart sounds. No murmurs, rubs, or gallops. The patient's abdomen was soft and nontender. The abdomen was mildly distended. Extremity examination revealed he had 2+ pitting edema in the right lower extremity and 1+ on the right side. The dorsalis pedis pulses were 2+ on the left and 1+ on the right. On neurologic examination, the patient was alert and oriented times three. His cranial nerves II through XII were intact. His motor strength was [**6-17**] in the upper extremity. Motor strength was 4+/5 in the lower extremity. PERTINENT LABORATORY VALUES ON PRESENTATION: The patient's laboratory values revealed his white blood cell count was 1.6, his hematocrit was 24.9, and his platelets were 57. The patient's sodium was 135, his potassium was 4.3, his chloride was 109, his bicarbonate was 21, his blood urea nitrogen was 15, his creatinine was 0.4, and his blood glucose was 106. His liver function tests revealed a normal alanine-aminotransferase of 36, his aspartate aminotransferase was 86, his lactate dehydrogenase was 446, his alkaline phosphatase was 112, and his total bilirubin was 0.7. His calcium was 7.5, his magnesium was 1.9, and his phosphate was 3.9. The patient's thyroid-stimulating hormone was 2.5. He was hepatitis B surface antigen positive. His hepatitis B core antibody was positive. His hepatitis B surface antibody was negative. His human immunodeficiency virus test was positive while here. He had urine cultures which did not grow out any bacteria. His blood cultures did not grow out bacteria. His rapid plasma reagin was nonreactive. His cryptococcal antigen was undetectable. PERTINENT RADIOLOGY/IMAGING: The patient's chest x-ray on admission showed diffuse ground-glass opacities throughout the right lung and in the left lower lobe. No definite pleural effusion. This was most likely consistent with Pneumocystis carinii pneumonia. He had a computed tomography scan on admission of the chest which showed diffuse areas of consolidation involving both lungs as well as sparing of the left upper lobe; again consistent with Pneumocystis carinii pneumonia. He had a moderate right pleural effusion. He also had ascites in his abdomen. CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: Impression revealed a 55-year-old gentleman with newly diagnosed human immunodeficiency virus and a history of peripheral vascular disease who now presented hypoxic, requiring a significant amounts of oxygen, and also with pancytopenia, and most likely with a Pneumocystis carinii pneumonia infection. 1. HUMAN IMMUNODEFICIENCY VIRUS ISSUES: Initially, the patient was started on highly active antiretroviral therapy treatment for his advanced human immunodeficiency virus/acquired immunodeficiency syndrome. His highly active antiretroviral therapy was started on hospital day two; including efavirenz 600 mg by mouth at hour of sleep and lamivudine/zidovudine one tablet by mouth twice per day. On hospital day three, the lamivudine/zidovudine was discontinued, and lamivudine by itself was added on at 150 mg by mouth twice per day, and stavudine 30 mg by mouth q.12h. Was added to the regimen. A discussion ensued regarding whether or not the patient had a possible immune reconstitution reaction worsening his Pneumocystis carinii pneumonia, and it was decided that his highly active antiretroviral therapy treatment would be temporarily placed on hold until his opportunistic infections improved. Subsequently, his highly active antiretroviral therapy treatment was discontinued on hospital day twelve and had not been restarted at the time of this dictation. 2. PNEUMOCYSTIS CARINII PNEUMONIA ISSUES: The patient was essentially diagnosed with Pneumocystis carinii pneumonia on admission via a chest x-ray, elevated lactate dehydrogenase, and computed tomography scan. A Pulmonary Service consultation was obtained on hospital day two. A bronchoscopy which they performed showed a normal oropharynx and a normal larynx. In the airway, there was mild erythema and a discrete erythematous area seen in the left main stem bronchus of unclear significance. Subsequently immunofluorescence test for Pneumocystis carinii pneumonia performed from the bronchial lavage was positive for Pneumocystis carinii. The patient was started on treatment level dosage of Bactrim for his Pneumocystis carinii pneumonia which was 250 mg intravenously q.8h. for 21 days. He was also started on prednisone for a 21-day course with a taper in place. 3. CYTOMEGALOVIRUS ISSUES: The patient had a cytomegalovirus viral load sent on hospital day ten which came back with 57,000 copies. The test was repeated on hospital day eighteen and came back 21,000 copies. In the interim, the patient was being treated with ganciclovir at 250 mg intravenously q.12h. The latest cytomegalovirus viral load performed on hospital day twenty-four revealed a viral load of 7000. The patient is currently still being treated with treatment doses of ganciclovir at 250 mg intravenously q.12h. The patient will need to have his white blood cell count and red blood cell count monitored while being on this medication, as it can cause pancytopenia. 4. NUTRITIONAL ISSUES: The patient was found to be very cachectic and wasted on admission. He was started on Boost Plus supplements three times per day on hospital day two and was continued on that throughout the course of his admission. On hospital day twenty-four, a nasogastric tube was placed and the patient was begun on tube feeds with ProMod with fiber with a goal rate of 55 cc per hour. The patient is currently still being treated with the tube feeds. Of note, his albumin on admission was 1.6. 5. MYCOBACTERIUM AVIUM-INTRACELLULARE PROPHYLAXIS ISSUES: Mycobacterium avium-intracellulare prophylaxis was started with azithromycin 1200 mg by mouth every week on hospital day eleven. 6. FUNCTIONAL STATUS ISSUES: Physical Therapy worked with the patient since he was admitted and felt that he was significantly deconditioned and would benefit from continued physical therapy as an inpatient. 7. CONGESTIVE HEART FAILURE ISSUES: The patient had an echocardiogram several days after admission which revealed an ejection fraction of approximately 35%. The patient was begun on a low-dose ACE inhibitor as management. Throughout the course of his hospitalization, he was diuresed as needed for decreases in his oxygen saturations and clinical appearance of volume overload. 8. HYPONATREMIA ISSUES: The patient had a persistent hyponatremia with serum sodium levels frequently in the range of 120. He was treated with 500-cc boluses of normal saline as needed. Urine studies were drawn on him that were somewhat equivocal but were consistent with a syndrome of inappropriate secretion of antidiuretic hormone picture and also slight hypovolemic state. Toward the end of his hospital stay, the patient's sodium did trend up. On the day of discharge, his sodium was 134. 9. ORAL THRUSH ISSUES: The patient was found to have oral thrush on admission and was placed on Nystatin oral suspension swish-and-swallow. Clinically, the thrush did improve throughout the course of his admission; however, it was still present, and the treatment will need to be continued. 10. MAJOR EVENTS: On hospital day six, the patient was transferred to the Medical Intensive Care Unit for persistent hypotension with a systolic blood pressure down to the 70s. The cause was thought to be overly aggressive antihypertensive treatment with an ACE inhibitor. The patient was volume resuscitated and was transferred back out to the floor two days later. On hospital day nine, the patient was again transferred to the Medical Intensive Care Unit for hypotension and slight hypoxia. He was again volume resuscitated with approximately four liters of fluid and was transferred back to the floor two days later. CONDITION AT DISCHARGE: Condition on discharge was stable; normotensive and slightly tachycardic (with heart rates generally between 100 and 110). His oxygen requirement was approximately 99% on 4 liters. He had minimal strength likely due to poor nutritional status and deconditioning. He was able to walk approximately 10 feet without assistance. DISCHARGE STATUS: Discharge status was to [**Hospital **] Hospital for further care. DISCHARGE DIAGNOSES: 1. Acquired immunodeficiency syndrome. 2. Cytomegalovirus pneumonitis. 3. Pneumocystis carinii pneumonia. 4. Malnutrition. 5. Hospital-acquired pneumonia. MEDICATIONS ON DISCHARGE: 1. Bactrim double strength one tablet by mouth every day. 2. Triamcinolone cream 0.025% one application to the forehead once per day. 3. Sarna lotion to the forehead once per day. 4. Ganciclovir 250 mg intravenously q.12h. 5. Insulin as per sliding-scale. 6. Azithromycin 1200 mg by mouth every week (on Tuesday). 7. Multivitamin one tablet by mouth every day. 8. Nystatin oral suspension 5 mg by mouth four times per day as needed. 9. Protonix 40 mg by mouth q.24h. DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was instructed to follow up in the Infectious Disease Clinic upon discharge from the outside hospital. [**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D. [**MD Number(1) 4521**] Dictated By:[**Last Name (NamePattern1) 54023**] MEDQUIST36 D: [**2172-1-16**] 13:02 T: [**2172-1-16**] 13:30 JOB#: [**Job Number 54024**]

[ "136.3", "284.8", "070.30", "789.5", "042", "484.1", "428.0", "261", "112.0" ]

icd9cm

[ [ [] ] ]

[ "03.31", "96.6", "33.24" ]

icd9pcs

[ [ [] ] ]

2305, 5456

11612, 11773

11799, 12276

12310, 12711

5489, 11160

11175, 11591

198, 1385

1618, 1985

1408, 1592

2002, 2288

9,593

122,283

19158

Discharge summary

report

Admission Date: [**2102-7-29**] Discharge Date: [**2102-8-18**] Service: CARDIAC SURGERY HISTORY OF PRESENT ILLNESS: This is an 89-year-old female presenting with 10-16 hours of substernal chest pain radiating to arm and shoulder on the left side associated with nausea and vomiting. Patient presented to [**Hospital6 3426**] and was subsequently transferred to [**Hospital1 346**] for further evaluation and cardiac catheterization. PAST MEDICAL HISTORY: 1. Hypothyroid. 2. Osteoporosis. 3. Osteoarthritis. 5. Paget's disease. 6. Status post hysterectomy. 7. Status post polypectomy. ALLERGIES: No known drug allergies. PREOPERATIVE MEDICATIONS: 1. Fosamax 10 mg po q day. 2. Synthroid 50 mcg po q day. 3. Tylenol prn. 4. Multivitamins. INITIAL PHYSICAL EXAMINATION: Patient was awake, alert, oriented x3 in no apparent distress upon arrival to [**Hospital1 **] [**First Name (Titles) 2142**] [**Last Name (Titles) **]. Pulse was 66 in sinus rhythm, blood pressure was 149/54, respiratory rate 19, and oxygen saturation of 98%. Neurologically, awake, alert, cooperative, and oriented x3. HEENT: Pupils are equal, round, and reactive to light and accommodation. Extraocular movements are intact. Normocephalic, atraumatic. Neck was without jugular venous distention or masses. Lungs were clear to auscultation bilaterally. Heart was regular, rate, and rhythm, S1, S2. There was a 3/6 systolic murmur heard loudest at the right second intercostal space. Abdomen: Positive bowel sounds, soft, nontender, nondistended. No costovertebral tenderness. Extremities are without clubbing, cyanosis, or edema. ELECTROCARDIOGRAM: Electrocardiogram showed T-wave inversions in V2-V3. X-RAYS: Chest x-ray at the outside hospital was reported to show mild congestive heart failure. HOSPITAL COURSE: The patient was admitted on [**2102-7-29**]. Patient ruled in for a non-ST elevation myocardial infarction with a peak troponin of 1.58. Patient was taken to the cardiac catheterization laboratory on [**2102-7-31**] and in the cardiac catheterization laboratory the patient was found to have a left ventricular ejection fraction at 50%, a 50% left main coronary artery lesion, 90% long mid LAD lesion, 80% ostial OM-1 lesion, and 80% proximal right coronary artery lesion with a pulmonary capillary wedge pressure of 18, and a LVEDP of 16. Patient had an echocardiogram subsequent to her cardiac catheterization which showed a depressed ejection fraction at 35% with anterior wall hypokinesis. The patient was referred to Cardiac Surgery for evaluation. The patient was determined to be a surgical candidate. The patient was taken to the operating room on [**2102-7-31**] for a CABG x3, LIMA to LAD, saphenous vein graft to OM, and saphenous vein graft to distal right coronary artery with Dr. [**Last Name (STitle) 70**]. Please see operative note for further details. The patient was transferred to the Intensive Care Unit in stable condition on milrinone and Neo-Synephrine. The patient was weaned and extubated from mechanical ventilation on postoperative day #1. On postoperative day #1, the patient was noted to be increasingly lethargic, initially attributed to narcotics. Narcotics were reversed with Narcan, however, the patient continued to be lethargic. On postoperative day #3, the patient went for a STAT head CT scan without contrast due to her continued lethargy. The CT scan showed a large area of hypoattenuation within the distribution of the right middle cerebral artery and the right posterior cerebral artery with foci of high attenuation in the region of the temporal [**Doctor Last Name 534**] of the right lateral ventricle that represented associated intraparenchymal hemorrhage. There was evidence of significant mass effect with effacement of the sulci on the right and significant right to left shift. No evidence of uncal or cerebellar herniation. No evidence of hydrocephalus. Neurosurgery was consulted upon evaluation of the CT scan for evaluation of the swelling and mass effect seen on CT scan. Neurosurgery recommended IV Decadron. Felt that there was not a need for any surgical intervention, and recommended serial CT scans. At this time, the patient was noted on physical examination to not be following commands, was positive for doll's eyes. Had purposeful movement of her right upper extremity. Minimal movement of her left lower extremity to painful stimuli. Toes are upgoing on left lower extremity. Patient was noted to have a slight gag. Neurology consult recommended serial neurological examinations and serial CT scans. It was also recommended to maintain patient's systolic blood pressure in the 140-160 range. On postoperative day #4, patient's neurologic examination began to improve. The patient continued to have a left facial droop. Patient had gross motor movement of her left upper and left lower extremity and purposeful movement with fine motor movement of right upper and lower extremities. It was recommended to continue on the Decadron. CT scan of the head showed no change. No significant bleed, and no evidence of herniation. Patient's neurological status continued to improve over the next several days. It was noted that the patient had an elevated white blood cell count thought to be attributed to the steroids, however, the patient was pancultured and all cultures were negative for any infectious process. On postoperative day #5, the patient continues to improve from a neurologic standpoint. Neurology felt that it was appropriate to discontinue the Decadron. Patient had a feeding tube placed for nutritional supplementation. Postoperative day #6, the patient underwent a PEG with Dr. [**Last Name (STitle) 952**]. Patient tolerated this procedure well with no postoperative complications. Patient was started on tube feeds. Urinalysis from postoperative day #5 showed evidence of trace leukocyte esterase. Patient was started on levofloxacin and completed a five day course. On postoperative day #8, the patient underwent a video fluoroscopic swallowing evaluation by the speech pathologist which showed overall mild oropharyngeal dysphagia characterized by reduced bolus control and formation with premature spill-over of liquids, oral residue and a mild delay in swallow initiation. No aspiration occurred during the study. It was felt that the patient was safe to start taking po nutrition. They recommended a diet of soft solids, thin liquids, whole pills with liquids, basic aspiration precautions. It is recommended that patient remain upright for all meals and followup Speech Therapy services. The patient was continued on tube feeding as patient was unable to take full adequate nutrition. On postoperative day #11, the patient underwent a carotid ultrasound which showed no flow limiting stenosis in either the right or left carotid arteries. The patient's pacing wires were removed on postoperative day #9 without complication. By postoperative day #11, patient had progressed to significantly increased fine and gross motor movement of her left upper extremity and lower extremities with significant improvement in speech. The Neurology Service felt the patient was stable from a neurologic point-of-view and signed off. Recommended that patient follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12544**] upon discharge from rehabilitation. Patient began having episodes of diarrhea. A culture for Clostridium difficile was sent. Patient was empirically started on Flagyl. The Clostridium difficile culture subsequently came back negative and the Flagyl was stopped. On postoperative day #12, patient began complaining of nausea and refused to take po. Patient was medicated with Zofran and Tigan with some improvement in her nausea. Patient underwent a CT scan of her abdomen to rule out intraabdominal process. CT scan showed no evidence of pancreatitis. Normal bowel and no evidence of any intraabdominal process. The GI service was consulted and recommended symptomatic treatment. Thought that the nausea was multifactorial. Patient's nausea continued to improve over the next several days and had disappeared by postoperative day #14, was able to eat and tolerate tube feedings without complaints of nausea. On postoperative day #14, patient was able to ambulate with assistance and with a walker approximately 100 feet, and on postoperative day #15, the patient was cleared for discharge to rehabilitation. CONDITION ON DISCHARGE: Temperature max 98.2, pulse 67, sinus rhythm, blood pressure 115/43, respiratory rate 15, oxygen saturation on 1 liter nasal cannula 95%. The patient is awake, alert, following commands. Strength in the left upper and left lower extremity is [**4-29**]. Strength in the right upper and right lower extremity is [**5-29**]. Patient has a left visual field neglect, but has some compensation with cueing. Cardiovascular: Regular, rate, and rhythm, no rub and no murmur. Lungs are clear bilaterally, decreased at the left base. GI: Abdomen was soft, nontender, nondistended. The patient has not complained of any nausea over 36 hours. The patient is tolerating full strength tube feeds via her PEG tube and taking recreational po nutrition. LABORATORY DATA: White blood cell count 13.9, hematocrit 31.6, platelet count 419. Urinalysis from [**8-17**] was negative. Chemistries: Sodium 136, potassium 4.4, chloride 104, bicarb 25, BUN 9, creatinine 0.7, blood glucose 240, ALT 13, AST 34, alkaline phosphatase 60, amylase 101, total bilirubin 0.4, lipase 103. Culture data: Patient had a [**1-28**] blood cultures drawn on [**2102-8-14**] that was positive for coag-negative Staph. This was felt to be a contaminant. The patient had a urine culture from [**8-14**] which showed Enterococcus species. The patient had been on a course of levofloxacin at a time with a subsequently negative urinalysis. Patient's stool was negative for Clostridium difficile. Patient has a chest x-ray pending, and the patient was cleared for discharge to rehabilitation. DISCHARGE DIAGNOSES: 1. Status post coronary artery bypass graft x3. 2. Perioperative right PCA and MCA infarct. 3. Status post PEG for postoperative pancreatitis. 4. Status post leukocytosis now resolving. DISCHARGE MEDICATIONS: 1. Lopressor 12.5 mg po bid. 2. Tylenol 325 mg po q4-6h prn. 3. Ibuprofen 400 mg po q4-6h prn. 4. Colace 100 mg po bid. 5. Zantac 150 mg po q day. 6. Enteric coated aspirin 325 mg po q day. 7. Synthroid 50 mcg po q day. 8. Fosamax 10 mg po q day. 9. Multivitamin one po q day. 10. Calcium carbonate 500 mg po bid. FOLLOW-UP INSTRUCTIONS: The patient is to followup with Dr. [**Last Name (STitle) 70**] upon discharge from rehabilitation. The patient is to followup with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12544**] upon discharge from rehabilitation. Patient is to followup with Dr. [**Last Name (STitle) **] upon discharge from rehabilitation. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Last Name (NamePattern1) 1541**] MEDQUIST36 D: [**2102-8-18**] 09:59 T: [**2102-8-18**] 09:58 JOB#: [**Job Number 52271**]

[ "997.02", "787.2", "787.02", "997.01", "288.8", "518.5", "414.01", "410.71" ]

icd9cm

[ [ [] ] ]

[ "36.15", "39.61", "37.22", "88.56", "36.12", "88.53", "43.11" ]

icd9pcs

[ [ [] ] ]

10133, 10320

10343, 10658

1824, 8516

665, 765

788, 1806

130, 449

10683, 11327

471, 639

8541, 10112

41,034

158,061

35039

Discharge summary

report

Admission Date: [**2129-3-26**] Discharge Date: [**2129-4-8**] Date of Birth: [**2100-8-14**] Sex: M Service: NEUROSURGERY Allergies: Meropenem Attending:[**First Name3 (LF) 78**] Chief Complaint: Ventriculoperitoneal shunt malfunction with likely meningitis and peritonitis. Major Surgical or Invasive Procedure: Shunt tap performed [**2129-3-26**] followed by removal of a VP shunt with removal of proximal catheter, shunt valve, distal shunt catheter including peritoneal portion of the previously placed shunt. 2. Placement of new external ventricular drain. 3. Drainage of abdominal csf collection. History of Present Illness: The patient is a 28-year-old male who was recently admitted in [**2128-11-20**] for a ruptured Acom aneurysm. The patient underwent first open coiling and decompression through a ventriculostomy. The patient later on needed a craniectomy and subsequent a cranioplasty. The patient has had multiple previous infections. The patient now represents with unclear fever from rehabilitation. Was sent to the [**Hospital **] [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] ER. Past Medical History: ACommA aneurysm rupture secondary to cocaine use PSH: [**2128-11-26**] Ventriculostomy, A-Comm Aneurysm coiling, decompressive craniectomy R [**2128-12-2**] Cerebral angiogram [**2128-12-8**] IVC filter/Tracheostomy/Peg [**2128-12-15**] VP shunt placement [**2129-2-4**] cranioplasty Social History: Per mother: no Tobacco [**Month/Day/Year 80077**] use At [**Hospital1 **] for inpatient rehab Family History: Non contributory Physical Exam: Admition Exam: PHYSICAL EXAM: O: T: 101.6F BP: 130/84 HR: 80 R: 16 O2Sats: 95% RA Gen: WD/WN, comfortable, NAD. HEENT: NCAT. Surgical wound well-healed without erythema. Shunt function intact. Neck: Supple. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Negative Brudzinski's and Kernig's signs. Neuro: Mental status: Lethargic, opens eyes briefly to voice. Does not answer questions. Cranial Nerves: Pupils equally round and reactive to light, 4 to 2 mm bilaterally. EOMI. Face symmetric. Motor: Normal bulk and tone bilaterally. Mild tremor of both hands. Withdraws to noxious stimuli throughout. Sensation: Intact to light touch throughout. Reflexes: B T Br Pa Ac Right 1 1 1 1 0 Left 1 1 1 1 0 Toes downgoing bilaterally Discharge exam: Unchaged from above with the exception of the absence of fevers. Wounds: C/D/I both on head at the site for placement of ventricular portion of the VPS and the abdominal portion of the vps. Pertinent Results: [**2129-3-26**] 01:20AM PLT COUNT-569*# [**2129-3-26**] 01:20AM NEUTS-84.3* LYMPHS-11.7* MONOS-3.5 EOS-0.2 BASOS-0.2 [**2129-3-26**] 01:20AM WBC-27.4*# RBC-3.99* HGB-11.2* HCT-33.9* MCV-85 MCH-28.1 MCHC-33.1 RDW-14.4 [**2129-3-26**] 01:20AM LIPASE-38 [**2129-3-26**] 01:20AM ALT(SGPT)-88* AST(SGOT)-30 ALK PHOS-157* AMYLASE-36 TOT BILI-0.7 [**2129-3-26**] 01:20AM estGFR-Using this [**2129-3-26**] 01:20AM GLUCOSE-113* UREA N-14 CREAT-0.7 SODIUM-137 POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-27 ANION GAP-12 [**2129-3-26**] 01:31AM LACTATE-1.0 [**2129-3-26**] 01:54AM URINE RBC-0-2 WBC-[**3-24**] BACTERIA-FEW YEAST-NONE EPI-0 [**2129-3-26**] 01:54AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-NEG [**2129-3-26**] 01:54AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.022 [**2129-3-26**] 12:24PM CEREBROSPINAL FLUID (CSF) WBC-480 RBC-0 POLYS-83 LYMPHS-5 MONOS-12 [**2129-3-26**] 12:24PM CEREBROSPINAL FLUID (CSF) PROTEIN-25 [**2129-3-26**] 12:25PM CEREBROSPINAL FLUID (CSF) WBC-330 RBC-0 POLYS-83 LYMPHS-7 MONOS-10 [**2129-3-26**] 01:42PM PT-17.8* PTT-32.4 INR(PT)-1.6* [**2129-3-26**] 09:10PM PT-16.1* PTT-27.9 INR(PT)-1.4* [**2129-3-26**] 09:10PM PLT COUNT-365 [**2129-3-26**] 09:10PM NEUTS-83.2* LYMPHS-12.4* MONOS-3.5 EOS-0.7 BASOS-0.2 [**2129-3-26**] 09:10PM WBC-12.9*# RBC-3.40* HGB-9.7* HCT-28.8* MCV-85 MCH-28.6 MCHC-33.8 RDW-14.2 [**2129-3-26**] 09:10PM CALCIUM-8.9 PHOSPHATE-3.6 MAGNESIUM-1.7 [**2129-3-26**] 09:10PM GLUCOSE-89 UREA N-5* CREAT-0.5 SODIUM-138 POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-26 ANION GAP-13 [**2129-3-26**] 11:13PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2129-3-26**] 11:13PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.012 3/7/09CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Final Report COMPARISON: Outside hospital CT from [**2129-3-15**]. CT ABDOMEN WITH CONTRAST: The lung bases are clear and there is no pericardial or pleural effusion. A few tiny hepatic hypodensities are too small to characterize, but may represent small cysts or hamartomas. The gallbladder, spleen, pancreas, adrenal glands are normal. The kidneys enhance symmetrically and excrete contrast normally without hydronephrosis or hydroureter. The stomach is decompressed with the G-tube tract noted anteriorly. Intra-abdominal loops of small bowel are of normal caliber and orally administered contrast has traversed through to the transverse colon. A rim-enhancing fluid collection at the tip of the VP shunt in the right mid to lower abdomen measures 6.8 x 5.2 x 7.4 cm compared to 6.4 x 3.2 x 6.8 cm on [**3-15**]. Abutting the inferior aspect of this collection is a second rim- enhancing fluid collection measuring 6.1 x 4.5 x 6.0 cm compared to 3.8 x 2.2 x 5.6 cm. These fluid collections are closely related to the cecum and ascending colon with marked surrounding inflammatory fat stranding. Reactive mesenteric lymph nodes measure up to 10 mm. The abdominal aorta is of normal caliber. An inferior vena cava filter is in position. CT PELVIS WITH CONTRAST: The rectum, sigmoid colon, bladder, and prostate are unremarkable. There is no free pelvic fluid or pathologically enlarged pelvic or inguinal lymph nodes. Heterotopic ossification is noted along the anterior aspect of the left acetabulum. The osseous structures are otherwise unremarkable. IMPRESSION: Increase in size of two moderately large rim-enhancing fluid collection adjacent to the tip of the ventriculoperitoneal shunt in the right lower quadrant. Findings are concerning for abscess. HEAD CT [**2129-3-26**] FINDINGS: A ventriculostomy catheter extends from the left frontal cortex superiorly and extends into the left lateral ventricle. The catheter terminates at the septum pellucidum in the left lateral ventricle, slightly displacing the septum pellucidum into the right lateral ventricle. A small amount of hyperdense material layers posteriorly in the left lateral ventricle, consistent with a small amount of hemorrhage. There is a small focus of pneumocephalus and small focus of air in the left lateral ventricle anteriorly. Soft tissue changes are seen overlying the left frontal burr hole site. Unchanged is an aneurysm coil in the anterior communicating artery territory. Also stable is a low-density subdural collection, measuring 14 mm in depth maximally, overlying the right frontal cortex. Encephalomalacia in the bilateral inferior frontal lobes is unchanged. Bilateral basal ganglia lacunes are stable. There is no other new focus of intracranial hemorrhage. There is no edema, shift of normally midline structures, or evidence of new infarct. Mild ventriculomegaly is stable. The [**Doctor Last Name 352**]-white differentiation is preserved. The basilar cisterns are patent. Post-surgical changes are present in the bony calvarium, without other acute abnormality. The paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: Left frontal approach ventriculostomy catheter terminates in the anterior left lateral ventricle, somewhat displacing the septum pellucidum to the right. Small focus of hemorrhage layering within the left lateral ventricle. Small amount of pneumocephalus related to procedure. Unchanged 14 mm subdural low-density fluid collection overlying the right frontal cortex, adjacent to right frontal craniotomy. Stable appearance of bilateral inferior frontal encephalomalacia. [**2129-3-29**] NON-CONTRAST HEAD CT: A ventriculostomy catheter remains in place from a left frontal approach, with tip terminating just to the right of midline, and again indenting the septum pallucidum. A small amount of layering intraventricular hematoma in the left occipital [**Doctor Last Name 534**] is not changed. However, there is new increased size of the lateral ventricles. There has been interval resolution of gas within the left lateral ventricle. Again the patient has had coiling of an anterior communicating artery aneurysm. Encephalomalacic changes in the bifrontal lobes as previously seen, in the expected distribution of the anterior cerebral arteries. Bilateral basal ganglia lacunes are unchanged also unchanged.. No new large vascular territory infarction is seen. Again post-surgical changes are noted from right frontotemporal craniotomy. 12-mm hypoattenuating extra-axial collection underlying the right temporal region is slightly smaller than that previously seen (14 mm). Associated with this is linear high-density, likely representing thickened dura, which is unchanged. No evidence of new intracranial hemorrhage is seen. A small amount of subcutaneous gas remains in the left frontal region where surgical skin staples remain in place. The visualized paranasal sinuses and mastoid air cells remain well aerated. IMPRESSIONS: 1. Left frontal ventriculostomy remains in place, with interval increase in size of lateral ventricles, including their temporal horns and atria, corresponding to clinical impression of hydrocephalus; there is no definite evidence of transependymal migration of CSF. 2. Bifrontal encephalomalacic changes are as previously seen after anterior communicating artery aneurysm coiling. 3. Hypodense extra-axial collection underlying right craniotomy site slightly decreased in size. COMMENT: Findings were initially posted as a "wet-read" via CCC, and should be correlated with clinical assessment of shunt placement, s/p adjustment. [**2129-3-30**] NON-CONTRAST HEAD CT: A left frontal approach ventriculostomy catheter remains in place with its tip touching the septum pellucidum just to the right of midline. Again seen is a small amount of layering intraventricular hemorrhage in the left occipital [**Doctor Last Name 534**]. The lateral ventricles have not increased in size from the previous day's study. There is evidence of coiling of the anterior communicating artery aneurysm. There are persistent in encephalomalacic changes in the bifrontal lobes. There is no evidence of new hemorrhage. Bilateral basal ganglia lacunes are unchanged. No large vascular territory infarct is seen. IMPRESSION: Again seen are post-surgical changes in the right frontotemporal craniotomy. There is an unchanged approximately 12 mm hypoattenuating extra- axial collection underlying the right frontal area. Brief Hospital Course: The patient is a 28-year-old male admitted with unclear fever from rehabilitation. Was sent to the [**Hospital **] [**Hospital **] [**First Name (Titles) **] [**Last Name (Titles) **] Emergency Department on [**2129-3-26**]. We performed a shunt tap and obtained a stat Gram stain which revealed bacteria.The patient was therefore taken emergently to the operating room and followed by removal of a VP shunt with removal of proximal catheter, shunt valve, distal shunt catheter including peritoneal portion of the previously placed shunt and placement of new external ventricular drain. There was also an abdominal fluid collection at the site of VPS insertion that was drained in IR. Patient came to the Step down unit with a Ventricular drain and under the direction ID he was placed on a course of antibiotics for presumed meningitis and shunt infection. After 10 days of antibiotic therapy, as advised by ID, the patient was taken back to the OR for a new VPS. Post Operative course was uncomplicated, and on POD #2 the patient is ready for discharge back to rehab. Medications on Admission: amantadine 100mg [**Hospital1 **] albuterol neb prn propanolol 80mg q8h diltiazem 90mg q6h methylphenydate 5 mg [**Hospital1 **] bacitracin prn chlorhexidine prn bowel regimen Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Propranolol 40 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 6. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 7. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day) as needed. 9. Methylphenidate 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Shunt failure/infection Discharge Condition: Stable. Discharge Instructions: General Instructions ?????? Have a friend/family member check your incision daily for signs of infection. ?????? Take your pain medicine as prescribed. ?????? Exercise should be limited to walking; no lifting, straining, or excessive bending. ?????? You may wash your hair only after sutures and/or staples have been removed. If your wound closure uses dissolvable sutures, you must keep that area dry for 10 days. ?????? You may shower before this time using a shower cap to cover your head. ?????? Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, and Ibuprofen etc. ?????? If you have been prescribed Dilantin (Phenytoin) for anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing in one week. This can be drawn at your PCP??????s office, but please have the results faxed to [**Telephone/Fax (1) 87**]. If you haven been discharged on Keppra (Levetiracetam), you will not require blood work monitoring. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. ?????? Make sure to continue to use your incentive spirometer while at home, unless you have been instructed not to. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. Followup Instructions: Follow-Up Appointment Instructions ??????Please return to the office in 10 days for removal of your staples or sutures or you may have them removed at rehab. ??????Please call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**First Name (STitle) **], to be seen in ___4____weeks. ??????You will need a CT scan of the brain without contrast. Completed by:[**2129-4-8**]

[ "331.4", "320.9", "V12.59", "E878.1", "996.63", "567.22" ]

icd9cm

[ [ [] ] ]

[ "86.09", "96.6", "54.91", "02.42", "54.21" ]

icd9pcs

[ [ [] ] ]

13247, 13317

11075, 12149

351, 655

13385, 13395

2671, 8209

15350, 15740

1612, 1630

12376, 13224

13338, 13364

12175, 12353

13419, 15327

1676, 2001

2460, 2652

232, 313

683, 1175

2100, 2444

10212, 11052

2016, 2084

1197, 1484

1500, 1596

10,446

196,578

2685+2686

Discharge summary

report+report

Admission Date: [**2158-2-10**] Discharge Date: Date of Birth: [**2086-10-17**] Sex: M Service: ADDENDUM: The patient was discharged with the Foley placed to leg back with gravity drainage and with a prescription for Flomax 0.4 mg p.o.q.d. 30 minutes before meals for the next five days, with plans for the Foley to be removed at the rehabilitation facility, as the patient had failure to void after Foley with a history of previous failures to void after Foley discontinuation during previous hospitalizations. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Last Name (NamePattern1) 13391**] MEDQUIST36 D: [**2158-2-14**] 14:57 T: [**2158-2-14**] 14:21 JOB#: [**Job Number 13392**] Admission Date: [**2158-2-10**] Discharge Date: [**2158-2-14**] Date of Birth: [**2086-10-17**] Sex: M Service: CAR [**Doctor First Name 147**] ADMITTING DIAGNOSIS: Coronary artery disease. DISCHARGE DIAGNOSES: 1. Status post coronary artery bypass graft times three vessels. 2. Coronary artery disease. 3. Osteoarthritis of the spinal column, hips, and knees. CONSULTATIONS: Physical Therapy. PROCEDURE: Coronary artery bypass graft times three vessels. HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 13393**] is a 71 -year-old man with a past medical history significant for coronary artery disease, congestive heart failure, and atrial fibrillation, as well as hypertension, hypercholesterolemia, and previous peripheral vascular disease and transient ischemic attacks, who presented after a percutaneous transluminal coronary angioplasty with a complaint of unstable angina. He was catheterized on [**2-7**]. This demonstrated a diffuse moderate hypokinesis of the left ventricle and an ejection fraction of 30% to 35%. He also had mild mitral regurgitation at the mitral valve and 85% stenosis in the left circumflex, 80% stenosis in the left anterior descending, 90% stenosis in the diagonal, 80% stenosis in the right coronary artery, and 90% stenosis in the posterior left ventricular. PAST MEDICAL HISTORY: Includes hypothyroidism, diabetes mellitus, hypercholesterolemia, hypertension, peripheral vascular disease, previous transient ischemic attacks, atrial fibrillation, congestive heart failure, and coronary artery disease. PAST SURGICAL HISTORY: Includes an appendectomy and carotid endarterectomy in [**2152**]. ALLERGIES: Quinidine, shellfish, and IV contrast material. ADMITTING MEDICATIONS: Captopril 75 mg [**Hospital1 **], Coumadin 4.0 mg on Monday, Wednesday, Friday, 3.0 mg on Tuesday, Thursday, Saturday, and Sunday, Lasix 20 mg po q day, Humulin 70/30, and nifedipine 90 mg po q day, Prevacid, Celexa, and Lipitor. SOCIAL HISTORY: He has a prior smoking history, he quit nine years ago. He denies any alcohol use or any recreational drug use. PHYSICAL EXAMINATION: He was 5 foot, 8 inches tall with a weight of 210 pounds. His blood pressure was 178/74 with a pulse of 45. He was in no apparent distress. He was alert and oriented times three. On chest examination he was clear to auscultation bilaterally. His cardiac examination demonstrated an irregular rate and rhythm, but there were no murmurs, rubs, or gallops. His abdomen was soft, nontender, nondistended. HOSPITAL COURSE: On [**2-10**], he was admitted for a coronary artery bypass grafting where he underwent a left internal mammary artery to left anterior descending, a saphenous vein graft to diagonal, a saphenous vein graft to posterior descending artery, and to posterior left ventricular with a jump graft. He tolerated this procedure well and was transferred from the Operating Room to the Cardiothoracic Intensive Care Unit with an A-V paced rhythm of 91 beats per minute, a mean arterial pressure of 78, a central venous pressure of 15, a PAD of 23, and [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 1052**] of 31. He was on epinephrine, Neo-Synephrine, and propofol drips. He was extubated by postoperative day one when his Coumadin was restarted and he was transferred to the floor. On postoperative day two his tubes were removed, his wires were capped, his central line was removed, his Foley was removed, and he began to diurese. He was again treated with Coumadin for his atrial fibrillation. He was also evaluated by Physical Therapy for ambulation monitoring and found to be rather slow to ambulate and rehabilitation planning was initiated. On postoperative day three it was felt that he was going to require a significant amount of this pulmonary toilet and the preceding diuresis. The patient's physical examination had improved by postoperative day four. At this point he had a high temperature of 99.3 F, current of 99.3 F, his blood pressure was 122/70, his pulse was 66, respirations 18, and his O2 saturation was 93% on two liters. He had diuresed approximately one liter the evening before of free fluid. He was started on Vioxx for his osteoarthritis in order to help control the osteoarthritis and promote ambulation. His BUN was 33 and his creatinine was 1.0. These were down from the day before and the patient was doing well. A bed became available and plans were made to transfer the patient to [**Hospital 1474**] Hospital. DISCHARGE CONDITION: Fair. DISPOSITION: Discharged to [**Hospital 1474**] Hospital. DISCHARGE MEDICATIONS: Lasix 20 mg po q day times seven days, K-Dur 20 mEq po q day times seven days, Vioxx 25 mg po q day times two days, then 12.5 mg to 25 mg po q day for osteoarthritis, Coumadin 4.0 mg po q Monday, Wednesday, Friday, 3.0 mg po q Tuesday, Thursday, Saturday, and Sunday, Prilosec 20 mg po q day, Captopril 75 mg po q day, Celexa 30 mg po q day, and aspirin 81 mg po q day, as well as NPH insulin 45 units subcutaneous q AM and 25 units subcutaneous q PM. The regular insulin sliding scale is as follows: 0 to 60, give 1 amp of D50 or juice, 61 to 150 - do nothing, 151 to 200 - 2 units, 201 to 250 - 4 units, 251 to 300 - 6 units, 301 to 350 - 8 units, 351 to 400 - 10 units, 401 to 450 - 12 units, 451 and up - 15 units and call the house officer. FOLLOW UP: The patient to return to Far Six for wound evaluation in approximately one week. The patient is also to follow up with his primary care physician in one to two weeks and to call for an appointment to follow up with Dr. [**First Name8 (NamePattern2) 892**] [**Last Name (NamePattern1) 1537**] in his office at [**Telephone/Fax (1) **] for an appointment in approximately four weeks. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Last Name (NamePattern1) 13391**] MEDQUIST36 D: [**2158-2-14**] 14:40 T: [**2158-2-14**] 15:16 JOB#: [**Job Number 13394**]

[ "278.00", "424.0", "428.0", "443.9", "427.31", "242.90", "411.1", "788.20", "414.01" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

5366, 5432

1050, 1301

5456, 6204

3382, 5344

2418, 2802

6216, 6882

2956, 3364

1330, 2148

1003, 1029

2171, 2394

2819, 2933

11,473

116,361

12810

Discharge summary

report

Admission Date: [**2192-11-3**] Discharge Date: [**2192-11-15**] Service: CCU HISTORY OF PRESENT ILLNESS: The patient is a 77 year old man with a history of diabetes mellitus, coronary artery disease, status post three vessel coronary artery bypass grafting and status post mitral valve replacement, who presented to an outside hospital with ventricular tachycardia, progressing to a ventricular fibrillation arrest, with chronic defibrillation times two. The patient reports he was driving his car when he began to note some lightheadedness. He pulled over to the side of the road and then lost consciousness. Prior to this, he had no symptoms of chest pain, shortness of breath, diaphoresis or any other anginal equivalent at that time. He was found a short time later, he does not know how long. Emergency medical service was called and an electrocardiogram at that time reportedly revealed supraventricular tachycardia at a rate of 200 to 210, although no strips are available for review. The patient was given 6 mg of Adenosine en route to an outside hospital, which had essentially no effect. Upon arrival to the outside hospital, he was found to be in a tachycardia to approximately 200, of unknown etiology. He then rapidly progressed to monomorphic ventricular tachycardia, became pulseless and cyanotic, for which he was rapidly defibrillated at 200 joules, with an immediate resumption of normal sinus rhythm. The patient again went into ventricular tachycardia a short time later, with degeneration into ventricular fibrillation and was again defibrillated, this time with 300 joules, again returning to normal sinus rhythm immediately. At this time, he was given a 100 mg Lidocaine bolus and a 2 mg/minute continuous intravenous drip was started. The patient remained in normal sinus rhythm after that and was transferred to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] for further management. Of note, the patient denies ever having had an anginal equivalent or chest pain in the past. His initial coronary artery disease was picked up on a routine workup for another medical illness that he does not recall, ultimately resulting in stress, cardiac catheterization and then coronary artery bypass grafting. Upon arrival to [**First Name4 (NamePattern1) 3867**] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **], the patient was without complaint. He had no chest pain or shortness of breath. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post three vessel coronary artery bypass grafting in [**2183**]; also performed at the same time was a mitral valve repair which failed; patient then had a mitral valve replacement with a mechanical valve approximately in [**2184**]. 2. Abdominal aortic aneurysm repair. 3. Diabetes mellitus times ten years, controlled with Glynase after diet management failed. 4. Peptic ulcer disease. MEDICATIONS ON ADMISSION: Adalat 30 mg p.o.q.d., Lopressor 50 mg p.o.b.i.d., Lipitor 10 mg p.o.q.d., Glynase 3 mg p.o.q.d., Accupril 20 mg p.o.q.d., Lanoxin 0.125 mg p.o.b.i.d. (patient verifies that his dosing is b.i.d.), Coumadin 2.5 mg p.o.q.d., Prevacid 30 mg p.o.q.d., Zantac 150 mg p.o.q.d. ALLERGIES: Penicillin (rash). SOCIAL HISTORY: The patient does not currently smoke, he quit 20 years ago, and denies any alcohol intake. He lives with his wife in [**Name (NI) **]. He is a retired police officer. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: On physical examination on admission, the patient had a blood pressure of 143/103, pulse 69 and regular, respiratory rate 18 and oxygen saturation 98% in room air. General: Well appearing, in no acute distress. Head, eyes, ears, nose and throat: Anicteric sclerae, oropharynx clear with moist mucous membranes. Neck: Jugular venous pressure to 6 cm, estimated central venous pressure of approximately 14. Respiratory: Lungs clear to auscultation bilaterally. Cardiovascular: Regular rate and rhythm, mechanical S1, normal S2, soft crescendo-decrescendo systolic murmur best heard at left sternal border, nonradiating. Abdomen: Old surgical scars, soft, benign. Rectal: Brown guaiac negative stool. Extremities: No cyanosis, clubbing or edema, 2+ pulses bilaterally. LABORATORY DATA: Electrocardiogram on admission showed normal sinus rhythm at 71 beats per minute, normal axis, normal intervals, borderline first degree A-V block, partial right bundle branch block, T wave inversions in II, III, V5 and V6. HOSPITAL COURSE: 1. Cardiovascular: Given the patient's extensive history of coronary artery disease, it was suspected that he had had a primary arrhythmic event and this is what led to his monomorphic ventricular tachycardia and his need for defibrillation. The patient was continued on Lidocaine overnight, which was stopped on hospital day number two, after he had been stable. He was scheduled to go to the electrophysiology laboratory for an electrophysiology study. Cardiac enzymes were cycled and revealed CKs of 187, 228 and 215 with MBs of 14, 18 and 16. We believed that this was a troponin leak secondary to his tachycardia and not a primary event. However, given the patient's extensive history, we could not rule out a primary cardiac vent leading to the arrhythmia. The plan was for the patient to go to the cardiac catheterization laboratory and, following his catheterization, go to the electrophysiology laboratory for an electrophysiology study and, most likely, an ICD placement. On hospital day number two, however, the patient began to develop increasing blood pressure to approximately 200 systolic. He then developed rales bilaterally, approximately one-half way up, and his oxygen requirement began to increase. It was believed that the patient had flashed into pulmonary edema and he was diuresed with Lasix. On hospital day number three, the patient's lungs were clear and his oxygen requirement had returned to [**Location 213**], however, the patient's BUN and creatinine had risen. His creatinine on hospital day two was in the mid-2s compared with 1.6 on admission. Because of this rise in creatinine, it was believed it was not safe at the current time to send him to the catheterization laboratory, so catheterization was delayed. The electrophysiology service offered, in light of his delayed catheterization, to take the patient to the electrophysiology for an electrophysiology study to see if he had an ablatable focus. On [**2192-11-7**], the patient was taken to the electrophysiology laboratory. A focus of atrial tachycardia was found, which was ablated during the electrophysiology study. A plan was made for the patient to have a pacemaker and ICD placement after his catheterization. On the same day, an echocardiogram was performed which revealed mild symmetric left ventricular hypertrophy, normal left ventricular cavity size, severely depressed left ventricular function with a left ventricular ejection fraction of 25% to 30% and sever global left ventricular hypokinesis. The patient also showed a depressed right ventricular function, moderate tricuspid regurgitation, mitral valve prosthesis with normal function, no mitral regurgitation. The patient continued to be stable following his electrophysiology study and was transferred to the floor awaiting his catheterization. Catheterization was performed and revealed a 100% occluded right coronary artery, left anterior descending artery and left circumflex. The patient also had three saphenous vein grafts. The superior saphenous vein graft to the obtuse marginal two was patent. Saphenous vein graft to the distal right coronary artery was patent but the saphenous vein graft to the left anterior descending artery was occluded proximally with a mid- left anterior descending artery and distal graft filling via right-to-left collaterals. At the time, the decision was made to do no intervention and that medical management only would be preferred. The patient was sent back to the floor and, the following day, had an electrophysiology study in which an ICD was implanted with DDD mode pacing capabilities. The procedure was uncomplicated and the patient was returned back to the floor in stable condition. Upon returning back to the floor, the patient's Coumadin was restarted, although he was continued on heparin for his mechanical valve. The patient remained in house for four days awaiting his INR to become therapeutic. On the day of discharge, his INR was 2.1 and it was deemed safe to send him home. The patient will have no medications make. I will tell him to return to his 2.5 mg daily of Coumadin and he will follow up with his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 24717**], the day following discharge. Additionally, per patient's discussion with the electrophysiology team, electrophysiology will see him today before he leaves and then, one month from now, he will be seen by Dr. [**Last Name (STitle) 1911**] for follow-up on his ICD pacemaker implantation. DISCHARGE DIAGNOSIS: Ventricular fibrillation. Coronary artery disease. Flash pulmonary edema. Anticoagulation for mechanical mitral valve. DISCHARGE MEDICATIONS: Adalat 30 mg p.o.q.d. Lopressor 50 mg p.o.b.i.d. Lipitor 10 mg p.o.q.d. Glynase 3 mg p.o.q.d. Accupril 20 mg p.o.q.d. Lanoxin 0.125 mg p.o.b.i.d. Coumadin 2.5 mg p.o.q.d. Prevacid 30 mg p.o.q.d. Zantac 150 mg p.o.q.d. DISCHARGE STATUS: To home. DISCHARGE CONDITION: Stable. FOLLOW-UP: The patient will follow up with Dr. [**Last Name (STitle) 24717**], his primary care physician. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. [**MD Number(1) 1014**] Dictated By:[**Last Name (NamePattern1) 1213**] MEDQUIST36 D: [**2192-11-15**] 10:21 T: [**2192-11-19**] 07:28 JOB#: [**Job Number **] cc:[**Numeric Identifier 39461**]

[ "250.00", "427.5", "V45.81", "427.1", "428.0", "414.02", "427.41", "599.0", "V43.3" ]

icd9cm

[ [ [] ] ]

[ "88.56", "37.26", "88.53", "37.94", "37.34", "37.23" ]

icd9pcs

[ [ [] ] ]

9589, 10017

3534, 3552

9319, 9567

9176, 9296

3026, 3330

4617, 9155

3575, 4599

117, 2546

2569, 2999

3347, 3517

68,128

189,927

25204

Discharge summary

report

Admission Date: [**2145-10-12**] Discharge Date: [**2145-10-19**] Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 301**] Chief Complaint: 86 F Patient initially presented s/p syncopal event with fall but gave hx of BRBPR with loose bloody stools. Major Surgical or Invasive Procedure: [**2145-10-13**] Colonoscopy History of Present Illness: HPI: 86 F who initially presented to ED s/p syncopal event with fall but gave hx of BRBPR with loose bloody stools. Ct performed showed colitis of the splenic flexure to sigmoid with adjacent stranding in the abscence of diverticular disease. PT gives history of 3 days of abdominal pain and severe constipation and straining prior to BRBPR. Pt took stool softeners and self digitalized just prior to her first bloody BM. Since then she has had 3 BM that were red, but did not turn the toilet water red. Mild nausea, had 2 episodes of vomiting with saliva mainly. PT had decreased Po intake but ate a lite lunch this afternoon. She has history of hemorrhoids in the bast and 6 months ago was worked up for ? melena. She cant recall her last colonoscopy, EGD performed [**12-18**] endoscopy showed bx proven [**Doctor Last Name 15532**] esophagus . PT hct is 33 on ED labs, baseline hct 33 per prior records had 1 bloody bm in ED w repeat hct 30.9. CR increased at 2.1 baseline 1.4 [**7-18**] echo shows preserved Ef of >55%. Pt states that she takes 2 ibuprofen daily. Denies fevers, chills, hematemesis, sick contacts, + [**Name2 (NI) 63155**] loss 145-131. Past Medical History: HTN HL Reflux Hypothyroid Hyponatremia Depression Arthritis Right hip replacement [**2135**] Total knee replacement [**2-15**] Migraine Social History: Normally uses cane for ambulation. Lives in [**Hospital3 **]. No etoh. No smoking. Family History: Not obtained Physical Exam: Vitals: T: 98F BP: 187/67 P: 75 R: 13 O2: 100% on RA Gen: Pale appearing elderly female in NAD CVS: RRR No murmurs rubs or gallops Pulm: CTAB Abd: Soft, NT, ND Rectal: Small amount of bright red blood on glove, Guiac positive. Pertinent Results: [**2145-10-12**] 10:40AM BLOOD WBC-17.1*# RBC-3.86* Hgb-11.6* Hct-33.0* MCV-86 MCH-29.9 MCHC-35.0 RDW-14.4 Plt Ct-228 [**2145-10-13**] 04:59AM BLOOD WBC-18.0* RBC-4.06* Hgb-11.4* Hct-34.3* MCV-85 MCH-28.0 MCHC-33.1 RDW-14.6 Plt Ct-176 [**2145-10-14**] 03:33AM BLOOD WBC-12.5* RBC-3.48* Hgb-10.2* Hct-29.6* MCV-85 MCH-29.2 MCHC-34.4 RDW-14.7 Plt Ct-162 [**2145-10-17**] 07:55AM BLOOD WBC-7.1 RBC-3.47* Hgb-10.6* Hct-30.6* MCV-88 MCH-30.5 MCHC-34.6 RDW-14.8 Plt Ct-198 [**2145-10-12**] 10:40AM BLOOD PT-13.3 PTT-23.1 INR(PT)-1.1 [**2145-10-12**] 10:39PM BLOOD PT-14.9* PTT-24.0 INR(PT)-1.3* [**2145-10-17**] 07:55AM BLOOD Plt Ct-198 [**2145-10-12**] 10:40AM BLOOD Glucose-186* UreaN-38* Creat-2.1* Na-132* K-4.7 Cl-99 HCO3-19* AnGap-19 [**2145-10-15**] 06:50AM BLOOD Glucose-124* UreaN-14 Creat-1.1 Na-134 K-3.8 Cl-103 HCO3-23 AnGap-12 [**2145-10-12**] 10:39PM BLOOD Calcium-8.5 Phos-2.9 Mg-1.6 [**2145-10-16**] 07:45AM BLOOD Calcium-8.6 Phos-2.7 Mg-1.5* [**2145-10-18**] 09:15AM BLOOD Calcium-8.2* Phos-3.1 Mg-1.7 [**2145-10-12**] 10:42AM BLOOD Lactate-3.3* [**2145-10-13**] 05:23AM BLOOD Lactate-1.6 CT Scan 1. Extensive mural thickening of the descending and sigmoid colon with adjacent stranding, indicative of colitis. Etiologies are non-specific, though given the [**Female First Name (un) 899**] distribution, [**Female First Name (un) 1106**] causes (e.g. ischemia) are favored. Infectious etiologies remain diagnostic considerations with inflammatory causes felt much less likely. 2. Small amount of perihepatic free fluid. 3. Extensive degenerative changes in the spine. Brief Hospital Course: Patient admitted through emergency room status post fall and bright red blood per rectum. CT scan performed showing ischemic colitis. Patient admitted to Surigical ICU where she recieved several units of blood. A colonoscopy was performed showing sigmoid colitis. Her labs were monitored closely and she was transferred to the regular floor when she was stable. Her diet was slowly advanced to a regular diabetic diet. Her sodium was noted to be low, this is thought to be due to the amount of stool output. We repleted her with normal saline. Last sodium before discharge is 128 with follow up planned with her primary care provider for recheck. Her blood pressure has been elevated during hospital course. She is being discharged home on her prior dose of beta blocker and will have pcp follow up on this as well. I have called Dr. [**First Name (STitle) 6624**] and discussed hospital course as well as pending problems: IE hypertension and hyponatremia. She will follow up with these issues. Medications on Admission: ASA 81mg po qd, simvastatin 20mg qd, citalopram 30mg qd, levothyroxine 50mcg qd, omeprazole 20mg qd, metoprolol tartrate 100mg qd, HCTZ 12.5mg qd (stopped recently), lisinopril 5mg qd, xalatan 0.005% eye drops qd, wellbutrin. Discharge Medications: 1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:*10 Tablet(s)* Refills:*0* 2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*30 Tablet(s)* Refills:*0* 3. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Citalopram 20 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 6. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 7. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metoprolol Tartrate 25 mg Tablet Sig: Five (5) Tablet PO DAILY (Daily). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 10. Bupropion HCl 100 mg Tablet Sig: One (1) Tablet PO AT NIGHT (). Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary Diagnosis: Ischemic Colitis Discharge Condition: Stable Discharge Instructions: Please call your doctor or return to the emergency room if you have any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. Followup Instructions: Provider: [**Name10 (NameIs) 357**] follow up with your primary care provider in one to two weeks. Please have them check your sodium level and blood pressure. (Dr. [**First Name (STitle) 6624**] Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2145-11-16**] 8:00 Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2145-11-16**] 9:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2145-11-16**] 9:30 Completed by:[**2145-10-19**]

[ "780.2", "V43.65", "440.1", "276.2", "V43.64", "403.90", "557.9", "276.1", "530.81", "530.85", "585.9", "584.9" ]

icd9cm

[ [ [] ] ]

[ "45.23", "99.04" ]

icd9pcs

[ [ [] ] ]

5900, 5958

3759, 4758

372, 403

6038, 6047

2154, 3736

6881, 7470

1877, 1891

5034, 5877

5979, 5979

4784, 5011

6071, 6858

1906, 2135

223, 334

431, 1600

5998, 6017

1622, 1760

1776, 1861

3,078

103,639

21243

Discharge summary

report

Admission Date: [**2175-10-12**] Discharge Date: [**2175-10-16**] Date of Birth: [**2128-2-22**] Sex: M Service: SURGERY Allergies: Vitamin K Attending:[**First Name3 (LF) 668**] Chief Complaint: Leakage of clear fluid from umbilicus. Major Surgical or Invasive Procedure: No repair to hernia Resuscitation with intubation [**2175-10-13**] History of Present Illness: 47M with h/o ESRD on HD, ESLD [**2-17**] hepatitis C, alcoholic cirrhosis, encephalopathy who presents with leakage of clear fluid from his umbilicus. This was first noticed last evening ([**10-11**]). The leakage soaked his clothes and bed by his report. He spoke with his PCP, [**Name10 (NameIs) 1023**] recommended he go to the ED to be evaluated, which he did not do until today. He is seen now in dialysis. The leakage has decreased throughout today. He notes that this could be secondary to his belt frequently rubbing on his large umbilical hernia. He denies F/C/N/V/C/D. He reports feeling generally well recently, with the exception of this new complaint. Past Medical History: # Cirrhosis - hep C + EtOH abuse - c/b esophageal varices s/p banding in [**12-26**] - EGD [**2175-4-28**]: 4 cords of grade II varices, nonbleeding GE jctn ulcer - has not been treated for hepatitis C - has nodular lesions on US -> no MRI to eval for HCC, AFP 4.3 - h/o SBP in [**9-21**], ? SBP during last hospitalization (empiric) # ESRD on HD T/Th/Sat # Anemia of chronic disease # Left Lower extremity wound # h/o major depression # schizotypal personality disorder Social History: Lives with wife. Denies tobacco, ETOH, or drug use currently. Heavy ETOH use in the past, prior IV drug use in early 80s (last [**4-21**]). Family History: Maternal aunt with DM Physical Exam: T: 96.6 88 119/67 28 GEN: NAD. Awake and alert. Pleasant. HEENT: Icteric sclera. MMM. OP clear. NECK: Supple, JVP ~ 10 cm H2O. CV: RRR. nl S1, S2. No MRG LUNGS: Diminished BS at bases bilaterally. No rales or rhonchi. ABD: + Accessory muscle use. Mild work of breathing. ABD: Softly distended. Large umbilical hernia. Very small drops of serous fluid on superior aspect of umbilical hernia. There is no obvious skin defect where the leak was coming form. Hernia easily reeducible. Abdomen is nontender. Dullness to percussion on dependent flanks. Hypoactive BS. Otherwise soft. No rigidity. EXT: Warm. 1+ LE edema. SKIN: Mild jaundice. No spider angiomas. R chest ecchymosis. NEURO: Oriented x3. Pertinent Results: On Admission: [**2175-10-12**] WBC-11.3* RBC-2.97* Hgb-10.6* Hct-33.7* MCV-114* MCH-35.6* MCHC-31.4 RDW-19.3* Plt Ct-100* PT-19.2* PTT-41.9* INR(PT)-1.8* Glucose-90 UreaN-56* Creat-7.6* Na-134 K-5.2* Cl-99 HCO3-27 AnGap-13 ALT-28 AST-60* LD(LDH)-418* AlkPhos-157* Amylase-92 TotBili-4.0* Lipase-95* Albumin-2.7* Calcium-8.3* Phos-2.9 Mg-2.5 Ammonia-65* Brief Hospital Course: Initial plan for patient was to go to OR for repair of the umbilical hernia. He has a new onset of ascites and there is concern for erosion of hernia and/or infection. He was admitted following hemodialysis. On the morning of the intended surgery, his INR was 1.8 and PTT 42. Plan was to give Vitamin K pre-op and have FFP on call to OR. During the infusion of the Vitamin K the patient suffered an apparent anaphylactic reaction to the IV Vitamin K and he required resuscitation to include intubation. He was transferred to the ICU where he was stablized, and ultimately extubated. He was transferred back to the surgical floor. However it was felt that the risk of the operative procedure would outweight the benefit of fixing the hernia, so it was determined to send the patient home without the hernia repair. He is to wear an abdominal binder at all times, one was provided to the patient prior to discharge. He will continue on his usual home medications and be followed by the liver team as he has been prior to this admission. He will also continue his hemodialysis per outpatient schedule. Medications on Admission: Rifaximin 400 mg PO TID, Nadolol 20 mg DAILY, Lactulose 45) ML PO QID, Thiamine 100 mg DAILY, Folic Acid 1 mg DAILY, Protonix 40 mg once a day, Sevelamer 1600 mg TID Discharge Medications: 1. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 2. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lactulose 10 g/15 mL Syrup Sig: Forty Five (45) ML PO QID (4 times a day). 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Sevelamer 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Hydromorphone 2 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Umbilical hernia with fluid leakage: stable Discharge Condition: Fair Discharge Instructions: Please call Dr [**Last Name (STitle) 56228**] office at [**Telephone/Fax (1) 2422**] if you experience increased abdominal pain, fevers > 101, nausea, vomiting, or other concerning symptoms. Continue medications as prescribed Wear the abdominal binder at all times. Please call Dr [**Last Name (STitle) 10285**] if you feel you need to be seen sooner than your previously scheduled appointment Continue Hemodialysis schedule per your outpatient clinic schedule PLease call [**Telephone/Fax (1) 673**] and ask for [**First Name8 (NamePattern2) 5969**] [**Last Name (NamePattern1) 5970**] to help with discussion about dialysis access Other dialysis clinics: fresenius, Dialysis Care Incorporated Followup Instructions: [**Name6 (MD) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2176-2-29**] 11:30 Completed by:[**2175-10-16**]

[ "301.22", "789.59", "427.5", "V64.1", "585.6", "571.2", "070.44", "E934.3", "995.0", "553.1" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

4893, 4899

2883, 3983

311, 380

4987, 4994

2506, 2506

5738, 5895

1745, 1768

4200, 4870

4920, 4966

4009, 4177

5018, 5715

1783, 2487

231, 273

408, 1076

2520, 2860

1098, 1570

1586, 1729

30,183

177,306

32875

Discharge summary

report

Admission Date: [**2154-3-31**] Discharge Date: [**2154-4-2**] Date of Birth: [**2120-11-19**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 30**] Chief Complaint: Nausea/vomiting Major Surgical or Invasive Procedure: none History of Present Illness: 33M PMH ESRD on HD, HTN p/w epigastric abdominal pain, nonradiating, nausea/vomiting starting one day prior to admission. The patient has been unable to tolerate PO, including his home medications. He complains of loose stools for one day, now resolved. The patient's mother and sister have had similar symptoms. The patient also complains of orthopnea, DOE, and nonproductive cough, consistent with his prior episodes of fluid overload due to missing dialysis. The patient missed HD Friday due to a friend's funeral. . In the ED, initial VS: T: 97.1 BP: 186/48 HR: 78 RR: 20 O2: 100%RA. EKG with new TWI V5-V6, although consistent with reciprocal changes from patient's known LVH, and no evidence of peaked T waves. The patient's blood pressure increased to up to 256/162. The patient received Ondansetron 4 mg, Insulin 10 units with dextrose, Calcium gluconate 1 amp IV, Kayexalate 30 gm, NIFEdipine CR 60 mg, Labetolol 10 mg IV x 2. The patient's blood pressure remained elevated and the patient was started on Labetolol gtt. Chest x-ray showed mild congestion. The patient was thought to be lethargic and CT head performed and negative. . On arrival to the floor, the patient denies abdominal pain, nausea. . ROS: Negative for fevers, chills, chest pain, headache, weakness, numbness. Otherwise negative in detail. Past Medical History: 1. ESRD on HD thought due to hypertensive nephropathy, started on dialysis in [**12/2152**]; going to [**Location (un) **] Dialysis Unit at [**Location (un) 76539**], and follows with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 76540**]; saw Dr. [**Last Name (STitle) **] here in [**2153-11-29**]. 2. Hypertension, diagnosed in [**2147**] when he had a medical exam during incarceration. 3. Status post appendectomy. 4. Recent admission for right flank pain 1/[**2153**]. 5. Medication noncompliance. Social History: He used to work as a plasterer, but is now on disability. tobacco - 1PPD x 14 years, recently decreased to two cigarettes a day. + alcohol use, + cocaine - last use [**2153-11-27**], denies any intravenous drugs. Family History: Father - dead at age 36 from unknown cancer Mother - alive, 56, + HTN maternal grandmother - on hemodialysis for end-stage renal disease. - The patient has a younger sister and an older brother, both alive and well. - son - 7, alive and well Physical Exam: T: 97 BP: 165/114 (equal bilaterally) P: 82 RR: 20 SaO2: 100% 4L NC General: NAD HEENT: Sclera anicteric, PERRL, OP clear without lesions NECK: Supple, JVD 5 cm, RIJ tunnelled catheter without erythema CV: RRR, no MRG Pulm: CTAB Abd: NABS, soft, NTND, no HSM, no masses Ext: No CCE Skin: Warm, no rashes Neuro: AAOx3, CN II-XII intact, MAEW Pertinent Results: EKG: NSR at 77, axis 0, NI with QTc 433. LVH per voltage criteria. TWI III and aVF (old), JPE V2-V4 (old), TWI V5-V6 (old) but c/w reciprocal changes from LVH. . CHEST (PA & LAT) Study Date of [**2154-3-31**] IMPRESSION: Cardiomegaly, mild congestion. . CT HEAD W/O CONTRAST Study Date of [**2154-3-31**] (my read) No ICH or mass effect. Brief Hospital Course: 33M PMH ESRD on HD presenting with hypertensive urgency, nausea/vomiting after missing dialysis. . # Hypertensive urgency: Hypertension in the setting of inability to tolerate his medications due to nausea and the patient missing his last session of dialysis. Initially started on labetalol gtt in the MICU. Without evidence of end organ ischemia, with negative CT head, no ECG changes, cardiac enzymes negative. He was continued on his outpt regimen (BB, ACEI), CCB was titrated up prior to discharge. . # Hyperkalemia: Resolved with Kayexalate. Rreceived Insulin 10 units with dextrose, Calcium gluconate, Kayexalate 30 gm in ED. He underwent HD per his outpt regimen. . # ESRD on HD: Thought to be secondary to due to hypertensive nephropathy. Resumed on outpt schedule of MWF HD. . # Nausea/Vomiting: Resolved. Recent sick contacts suggesting viral gastroenteritis. Also likely component of uremia. LFT and lipase unremarkable (laboratories slighly hemolyzed). Ruled out for MI with enzymes. Symptoms improved on discharge. Medications on Admission: Calcium Acetate 667 mg TID Lisinopril 40 mg [**Hospital1 **] Metoprolol Succinate 100 mg DAILY Nifedipine 60 mg SR [**Hospital1 **] Sevelamer HCl 1600 mg TID Terazosin 1 mg QHS Discharge Medications: 1. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. Terazosin 1 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 3. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. Sevelamer HCl 800 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*90 Tablet(s)* Refills:*2* 5. Nifedipine 90 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO once a day. Disp:*60 Tablet Sustained Release(s)* Refills:*2* 6. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Discharge Disposition: Home Discharge Diagnosis: Primary Hypertensive urgency End stage renal disease on hemodialysis Hyperkalemia Discharge Condition: stable Discharge Instructions: You were admitted with high blood pressures. You were treated initially with intravenous blood pressure medications. You were then started on oral blood pressure medications that you normally take at home. You also had hemodialysis on Monday. Please note that your nifedipine was increased. Also note that your sevelamer was increased as well. Please take all of your other medications as directed. In addition, we have made several appointments for you. It is important that you attend these appointments. Please see below. It is also extremely important that you take all of your blood pressure medications. If you have any of the following symptoms, please return to the emergency room or see your PCP: [**Name10 (NameIs) **] pain, shortness of breath, palpitations, or any other serious concerns. Followup Instructions: We have set you up with a primary care doctor in our clinic because you did not have one. We have also set up an appointment for you to be evaluated by Dr. [**First Name (STitle) **] for evaluation for hemodialysis access placement: Dr. [**First Name (STitle) **]: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2154-5-2**] 3:40 . Your new primary care doctor appointment: [**2154-5-8**] 02:00p [**Last Name (LF) 6401**],[**First Name8 (NamePattern2) 488**] [**Last Name (NamePattern1) **] [**Hospital6 29**], [**Location (un) **] [**Hospital 191**] MEDICAL UNIT . Please attend your dialysis tomorrow as previously scheduled. Completed by:[**2154-5-6**]

[ "276.7", "585.6", "403.01" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

5399, 5405

3478, 4514

329, 336

5531, 5540

3112, 3455

6401, 7152

2492, 2735

4741, 5376

5426, 5510

4540, 4718

5564, 6378

2750, 3093

274, 291

364, 1697

1719, 2244

2260, 2476

59,227

138,122

544

Discharge summary

report

Admission Date: [**2160-12-15**] Discharge Date: [**2160-12-24**] Service: MEDICINE Allergies: Ibuprofen / Percocet / Naprosyn / Percodan Attending:[**First Name3 (LF) 1515**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Valvuloplasty History of Present Illness: [**Age over 90 **] yo female with 3VD CAD s/p MI in [**2156**], POBA LCX, CHF with EF 25% with worsening RV function, dyslipidemia, HTN, rheumatic heart disease, AV stenosis s/p valvuloplasty x2 with recent CHF exacerbation c/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]. Patient had been doing well at rehab. Bumex was restarted [**12-12**]. Last night developed SOB and was sent to [**Hospital **] Hosp ER where they felt she was hypovolemic and treated with 2L IVF and sent her back to [**Location (un) **]. This am, the patient experienced worsening SOB. She was treated with Morphine, Bumex 1mg x 2, and [**2-2**] of a 1/150 SL nitro x 2 b/c pt c/o chest tightness. After taking nitro the pt's BP dropped to 90/s the later returned to baseline 100s. At time of transfer her O2 sat was 94% on 2Lnc but will dip down to 88% with talking or sips of water. . On the floor the patient was complaining of dry mouth and thirst and drinking water. She denied SOB, chest pain, or any other discomfort. She denies cough, fever, chills. However, she stated she had had some delirium at the rehab due to double dose of morphine but was unclear about the exact events. She is aware that she is at [**Hospital1 **]. . The patient has severe aortic stenosis with low output (EF = 25%), and she underwent a valvuloplasty in [**Month (only) 216**]. She also has diffuse disease of the LAD and RCA. Cardiac catheterization confirmed significant gradient in setting of low EF, so another valvuloplasty was performed, which dropped the gradient from 31 to 23 mmHg. The patient tolerated the procedure well and was stable afterwards. She was given Lasix. Her groin site was closed. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -PERCUTANEOUS CORONARY INTERVENTIONS: [**2160-9-25**]: 3VD; Successful POBA to proximal circumflex lesion; successful balloon aortic valvuloplasty 3. OTHER PAST MEDICAL HISTORY: Severe AS s/p aortic balloon valvuloplasty on [**9-25**] and again on [**2160-12-17**] CAD s/p MI in [**2156**]; recent POBA to LCx, 3VD CHF HTN HL CKD Pneumonia Iron deficiency Psoriasis Nephrolithiasis Appendectomy Thrombocytopenia s/p TAH s/p L hip fracture and repair Social History: Lives independently in [**Hospital1 **]. Still drives. Walks with cane. Husband died 15 years ago. She has 2 children - son [**Name (NI) 4468**] in Ca. Daughter [**Name (NI) 4051**] in [**Name (NI) 3844**] (HCP). Still volunteers at [**Hospital3 **]. -Tobacco history: none -ETOH: none -Illicit drugs: none Family History: Brother had rheumatic heart disease. Children are healthy. No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Admission Exam: GENERAL: WDWN in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of *** cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: 2+ pitting edema bilaterally SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ . Pertinent Results: [**12-17**] Echo: FOCUSED VIEWS AFTER AORTIC VALVULOPLASTY: The left atrium is dilated. Overall left ventricular systolic function is severely depressed (LVEF= 20-25 %). The aortic valve leaflets are severely thickened/deformed. Moderate to severe (3+) mitral regurgitation is seen. After initial valvuloplasty inflation: Trace to mild aortic regurgitation. After final valvuloplasty inflation: Mild to moderate aortic regurgitation. Gradient across aortic valve consistent with moderate to severe aortic stenosis. Compared to study from [**2160-12-3**], the gradient across the aortic valve is reduced (mean gradient 35 mm Hg to 25 mm Hg). The severity of aortic regurgitation is slightly increased. [**12-18**] Echo: The left atrium is dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Overall left ventricular systolic function is severely depressed (LVEF= 20-25 %). There is no ventricular septal defect. The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. There are three aortic valve leaflets. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (valve area 0.8-1.0cm2). Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. Severe pulmonic regurgitation is seen. There is a small pericardial effusion. There are no echocardiographic signs of tamponade. Echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. Compared with the prior study (images reviewed) of [**2160-12-3**], the degree of aortic regurgitation has probably increased. The velocity across the aortic valve is similar but some of this velocity is due to increased aortic regurgitation. The degree of stenosis across the valve is probably slightly less (although is calculated as the same). The other findings are similar. . [**12-20**] CXR MPRESSION: AP chest compared to [**12-4**] through 19: Severe enlargement of the cardiac silhouette has not improved. Left lower lobe is still collapsed. Right basal atelectasis has worsened, but previous small right pleural effusion has decreased. There is no pulmonary edema or pneumothorax. . [**12-20**] CT ab/pelvis: ] 1. Hematoma along right medial pelvic wall extending from right groin with retroperitoneal extension on the right. 2. Bilateral small pleural effusions with adjacent opacities at the lung bases, likely atelectasis, cannot exclude superinfection. 3. Small pericardial effusion similar to prior. 4. Moderate atherosclerotic changes in the aorta and iliac vessels. 5. Cholelithiasis with no evidence of cholecystitis. Brief Hospital Course: [**Age over 90 **] yo female with 3VD CAD s/p MI in [**2156**], POBA LCX, CHF with EF 25-30%, dyslipidemia, HTN, rheumatic heart disease, AV stenosis s/p valvuloplasty x2 with recent admission for CHF exacerbation c/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **]. Pt now represents for increased SOB and hypervolemia, partially [**3-4**] recent fluid boluses in OSH ED. She is s/p valvuloplasty [**12-17**] and continues undergoing diuresis and pain control for pelvic hematoma. On [**12-20**] patient decided definitively to become hospice/comfort measures only, and discussed with her family who suported her decision. She also also began experiencing decreased urine output and worsening creatinine. She became increasingly delirious and agitated with significant discomfort and was discharged to [**Hospital 4470**] Rehab for end of life care. . # GOALS OF CARE: Patient decided that she wanted to transition to hospice, have comfort measures only, and does not want to continue planning for valve replacement. She spoke to her daughter and expressed these wishes. She has stated on multiple occasions that "I know I'm dying, I just want to be comfortable." She became increasingly dyspneic and delirious with chest pain. We attempted to diurese for comfort but her kidney function is also decreasing and she has very minimal uop with increasing morphine requirement. Palliative care consulted and recommended the addition of zyprexa. We are also treating empirically for uti as the patient was complaining of bladder pain. She should receive cipro 250mg daily x3days (day 1 = [**12-23**]). The patient's course has recently been complicated by a paranoid delirium. She sometimes refuses PO medications though has been taking concentrated oral morphine and zydis. She had been agitated by delusions that her children have died or been killed. She is intermittently placated by staff presence, but also becomes paranoid that we are trying to harm her. Her daughter visited and was a calming presence. On day of discharge the patient was increasingly lethargic and non-verbal. She has become anuric. She will be transferred to Alliance [**Location (un) 38**] for end of life care. . # Congestive heart failure/severe aortic stenosis: On admission patient was s/p aortic balloon valvuloplasty x 2, with recent admission for CHF exacerbation. Has already been evaluated by cardiac surgeons who deem her extreme risk for conventional aortic valve replacement and has been managed medically in an attempt to bridge to percutaneous valve replacement. The patient was diuresed on previous admission to a 2L O2 requirement. However, diuresis was held on discharge due to creatinine increase(1.4-->3.6). She was discharged on Bumex PRN SOB. At rehab Bumex was restarted on [**12-12**]. On previous admission it was felt that valvuloplasty would not provide significant improvement of functional status or renal perfusion, however, given failure of medical management, valvuloplasty was done to perpetuate cardiac function until percutanous valve replacement becomes available at [**Hospital1 18**]. Compared to prior echo before valvuloplasty, the degree of aortic regurgitation has probably increased. The velocity across the aortic valve is similar but some of this velocity is due to increased aortic regurgitation. The degree of stenosis across the valve is probably slightly less (although is calculated as the same). However, patient now has deteriorating course and has elected to be comfort measures only. . # Pelvic hematoma: [**3-4**] perc valvloplasty. Pt is experience significant pain. pain management as above. . # Coronary Artery Disease: Continued ASA and atorvastatin. Now dced [**3-4**] goals of care. . # Chronic Kidney Disease: Cr increasing. Urine output decreasing. Will not monitor [**3-4**] goals of care. . # Gout: dced allopurinol [**3-4**] goals of care. . # GERD: dced pantoprazole [**3-4**] goals of care. . # CODE: DNR/DNI, COMFORT MEASURES ONLY. Medications on Admission: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 6. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 7. allopurinol 100 mg Tablet Sig: One (1) Tablet PO EVERY 3 DAYS (Every 3 Days). 8. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical 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. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) dose PO DAILY (Daily) as needed for constipation. 12. morphine 15 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for chest pain. 13. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. 14. bumetanide 1 mg Tablet Sig: One (1) Tablet PO as instructed: Give one dose if patient gains 3lbs or develops shortness of breath not relieved with PO morphine. . 15. Outpatient Lab Work Please check Chem 10 on Friday [**2160-12-12**]. 16. calcium carbonate 500 mg (1,250 mg) Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO BID (2 times a day). 2. ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. 3. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. 4. morphine concentrate 20 mg/mL Solution Sig: 5-10 mg PO Q1H (every hour) as needed for pain, discomfort. 5. morphine concentrate 20 mg/mL Solution Sig: Five (5) mg PO Q4H (every 4 hours). Discharge Disposition: Extended Care Facility: [**Hospital 4470**] HealthCare Center at [**Location (un) 38**] Discharge Diagnosis: End stage CHF, Severe aortic stenosis. Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mrs. [**Known lastname 4471**], It was a pleasure participating in your care. You were admitted for severe aortic stenosis and heart failure. You underwent aortic valvuloplasty however did not have improvement of your heart function. You decided to become comfort measures only, meaning you will only be treated symptomatically, you no longer want to pursue life-prolonging therapies. You have been having a significant amount of delirium, agitation and pain, which we are attempting to treat with morphine and zyprexa. You also have complained of bladder pain concerning for urinary tract infection and so we will treat you with a 3 day course of cipro. You are being discharged to Alliance in [**Location (un) 38**] where you will continue your comfort care. Followup Instructions: none

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icd9cm

[ [ [] ] ]

[ "37.23", "35.96", "88.56" ]

icd9pcs

[ [ [] ] ]

12868, 12958

6841, 10830

260, 275

13041, 13041

3911, 6818

14019, 14027

2876, 3051

12343, 12845

12979, 13020

10856, 12320

13225, 13996

3066, 3892

2083, 2230

213, 222

303, 1989

13056, 13201

2261, 2535

2011, 2063

2551, 2860

25,696

179,042

11471

Discharge summary

report

Admission Date: [**2169-2-6**] Discharge Date: [**2169-2-22**] Date of Birth: [**2118-2-1**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 9598**] Chief Complaint: scrotal edema Major Surgical or Invasive Procedure: IVC venogram, thrombectomy, tPA X 2 History of Present Illness: Mr. [**Known lastname **] is a 50-year-old African-American male with hormone refractory metastatic prostate cancer status post multiple previous treatments, OSA, hypercholesterolemia, and h/o bilateral LE DVTs c/b bilateral PE with placement of IVC filter who presents with complaints of increased scrotal swelling. Of note, the pt has been hospitalized twice this month for c/o increased LE edema. On his most recent hospital course, he had a CT scan that showed clot cranially and caudally from the IVC filter extending down the iliac veins b/l. The pt was initially treated with thrombectomy and local tPA which produced minimal result and then was given systemic tPA with resolution of the pt's LE edema. He was placed on a heparin gtt and transitioned to enoxaparin 120 mg [**Hospital1 **] by time of discharge. He reports feeling better at the time of discharge and was able to walk without difficulty. Since then, the pt has noted increasing scrotal edema and increasing R leg pain X 3 days. Denies prior h/o scrotal edema. Swelling is associated with b/l achy pain. He also reports R upper thigh pain that is intermittent. His wife reports a slight increase in his RLE edema. Denies fevers, chills, SOB, chest pain. . ROS is remarkable for new L sided temporal headaches over the past week. Denies neck stiffness, photophobia, visual changes, new weakness or numbness. Takes Tylenol at home with relief. Otherwise extensive ROS negative. Past Medical History: PAST ONCOLOGIC HISTORY: Metastatic prostate cancer to bone refractory to hormone therapy s/p cycle 1 of Carboplatin and Taxotere [**2168-12-15**]. Dx in [**2163**] as [**Doctor Last Name **] 8 s/p surgical prostatectomy with XRT to t9 spinal metastasis in [**11-11**] followed by hormonal therapy, Taxotere (2 cycles), ketoconazole, hydrocortisone, mitoxantrone, and DES. He was recently noted to have a rise in his PSA to the 400 range, and a L-spine MRI on [**11-14**] showed multiple spine metastatic foci (no prior MRI L-spine for comparison, bone scan in [**6-/2168**] without clear spine metastases). He received his first cycle of Carboplatin and Taxotere on [**2168-12-15**]. . PAST MEDICAL HISTORY: 1. Metastatic prostate cancer to bone refractory to hormone therapy (see above) 2. Bilateral LE DVTs complicated by bilateral PE [**4-/2168**], treated with enoxoparin then warfarin, and status post IVC filter placement 04/[**2168**]. Last with DVT on [**2169-1-7**], now on enoxoparin 120 mg daily. 3. Psoriasis 4. Hypercholesterolemia 5. Seasonal allergies 6. Obstructive sleep apnea on CPAP at home Social History: He lives at home with his wife and his 12 year-old son. [**Name (NI) **] does not smoke. Family History: Father had prostate cancer. He has noother relatives with psoriasis and denies thyroid disease,rheumatoid arthritis and lupus in his family. Physical Exam: VITALS: T 99.7 BP 110/70 HR 112 RR 20 O2 sat 91-92% on RA GEN: Pleasant, NAD, AAO X 3 HEENT: EOMI. sclera anicteric. PERRL. MMM. OP clear. NECK: No cervical lymphadenopathy. Unable to appreciate JVD secondary to body habitus. RESP: CTA b/l CVS: RRR, +s1/s2, no m/r/g GI: Obese, soft, non-tender. normoactive bowel sounds. Genitalia: +3 scrotal swelling EXT: [**2-11**]+ symmetric pitting edema in lower extremities to knees. +1 DP pulses b/l. Negative [**Last Name (un) 5813**] sign on RLE. SKIN: No rashes. Venous stases changes in b/l LE NEURO: CN II-XII intact. Strength 5/5 in upper and lower extremities. Reflexes 2+ and symmetric at bicep, patella, brachioradialis, Achilles. No sensory deficits. Pertinent Results: [**2169-2-6**] 06:35PM WBC-7.1# RBC-3.06* HGB-8.2* HCT-25.9* MCV-85 MCH-26.7* MCHC-31.5 RDW-18.6* [**2169-2-6**] 06:35PM PLT COUNT-265 [**2169-2-6**] 06:35PM PT-13.6* PTT-30.0 INR(PT)-1.2* [**2169-2-6**] 06:35PM CALCIUM-8.8 PHOSPHATE-3.1 MAGNESIUM-1.9 [**2169-2-6**] 06:35PM GLUCOSE-102 UREA N-6 CREAT-1.1 SODIUM-141 POTASSIUM-3.7 CHLORIDE-105 TOTAL CO2-28 ANION GAP-12 [**2169-2-6**] 09:56PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.008 [**2169-2-6**] 09:56PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-NEG [**2169-2-6**] 09:56PM URINE RBC-6* WBC-0 BACTERIA-RARE YEAST-NONE EPI-0 . Scrotal US [**2-6**]: The right testicle measures 3.1 x 2.0 x 2.6 cm. The left testicle measures 3.0 x 2.4 x 1.9 cm. Both testicles are normal and homogeneous in echotexture. Arterial and venous color flow and Doppler waveforms are demonstrated. There are small bilateral hydroceles. Bilateral epididymi are normal. There is massive subcutaneous and interstitial edema within the surrounding soft tissues. IMPRESSION: 1. Normal appearing testicles. 2. Large subcutaneous edema. . CXR (PA and lat) [**2-7**]: The cardiac silhouette, mediastinal and hilar contours are normal and stable. The pulmonary vasculature is normal and there is no pneumothorax. The lungs are clear without consolidations or effusions. The surrounding soft tissue and osseous structures are unchanged. IMPRESSION: No acute cardiopulmonary process. . RELEVANT IMAGING DATA: [**2168-12-30**] MRI L-spine: Bony metastases are visualized in the lumbar vertebral bodies, sacrum and both iliac bones. No significant change is seen. No epidural abscess identified or new epidural mass seen. . [**2168-12-6**] MRI L-spine: Numerous metastatic tumor deposits, with possible small epidural lesions seen anterior to the thecal sac at the L4 and L5 levels, versus distended epidural veins secondary to a moderate posterior disc protrusion at L4-5. . [**6-/2168**] Bone scan: Widespread metastatic disease in multiple ribs, right iliac crest, and vertebra L4. . [**2169-1-6**] BLE U/S: 1. Noncompressible deep venous thrombosis in left common femoral vein almost occluding the lumen. No clot demonstrated distal to superficial femoral vein. 2. Clot in the left greater saphenous vein. 3. No evidence of DVT on the right. Brief Hospital Course: The patient was admitted to the OMED service for complaints of scrotal edema and increasing R leg pain. Given his past history, it was thought that his scrotal edema was secondary to known IVC clot extending down to the bilateral iliac veins. A scrotal ultrasound was significant for no signs of torsion, normal doppler studies, and massive amounts of subcutaneous edema. Vascular surgery was consulted and it was felt that the patient would not be a candidate for surgical management of his clot. The patient underwent IR guided repeat IVC venogram with repeat thrombectomy and systemic administration of tPA on hospital day 2. He was admitted to the the MICU for observation. IR had placed vascular sheath which were removed on [**2169-2-8**]. He was restarted on IV heparin after sheath removal and discharged from the ICU back to the floor. He was kept on a heparin drip for several days as he had previously clotted off his IVC after his prior thrombectomy. Although it was noted that his lower extremity and scrotal edema improved slightly after the repeat thrombectomy and tPA, it was agreed upon by the medical, oncologic, and radiology teams that a repeat IVC venogram with repeat thrombectomy and tPA would be performed to help evaluate IVC flow and to improve the pt's chances of post-procedure success. The repeat venogram revealed good flow through the IVC from the prior thrombectomy and a repeat thrombectomy with tPA administration was performed. This was complicated by an episode of epistaxis that resolved spontaneously and an episode of hematuria, which also subsequently resovled. During these episodes, his heparin was held and then restarted once all signs of bleeding had stopped. . The [**Hospital 228**] hospital course was complicated by intermittent fevers. No clear sources of infection were found initially and antibiotics were not started for a week and a half. However, a UA that was sent for culture studies did come back positive, and the patient was started on cipro. The following day, it was noted that the patient's Cr climbed from 1.1 to 1.7. The patient was given IVF as it was thought his renal failure may have been secondary to dye load from the IVC venogram the day prior or from pre-renal causes. The subsequent day the pt's Cr continued to increase up to 2.3 and renal was consulted. A urine sediment showed many WBC and WBC casts and was thought to be consistent with AIN. Cipro was discontinued and switched to ceftriaxone and the pt was placed on steroids. A renal US was negative for renal vein thrombosis as well as a MRI/MRA of the kidneys. . Due to the patient's fevers without a clear source of infection, ID was consulted for FUO. After further work-up, it was thought that the pt's fevers were secondary to the patient's clot burden rather than an infectious process or an allergic reaction to his other medications. . The patient also complained of tremors and twitching. His electrolytes were within normal limits and a PCO2 was wnl as well. Neurology was consulted who felt that the pt's tremors were more consistent with asterixis. LFTs and an ammonia level were wnl. His neurontin was tapered down from 900 mg to 300 mg tid with a significant improvement in his symptoms. . His hospital course was also complicated by several episodes of chest pain. Cardiac enzymes remained negative and multiple EKGs were without ischemic changes. Given his large clot burden, intermittent fevers and intermittent episodes of hypoxia with O2 sats down to the 80s on RA, the possibility was considered. Initially, the pt was not imaged given his ARF and the fact that he was already on a heparin drip. A V/Q scan was performed that showed a low likelihood of PE. . The patient also complained of neck pain during the hospital course without other meningeal signs, including headaches, photophobia, elevated WBC, altered mental status. It was thought to be musculoskeletal in nature as the neck pain resolved with acetaminophen and toradol. . He was transitioned to lovenox 120 mg SQ [**Hospital1 **] from heparin gtt once renal vein thrombosis was ruled out definitively with the MRI and was discharged home in good condition with follow-up with his oncologist and renal. Medications on Admission: 1. Gabapentin 900 mg TID 2. Amitriptyline 50 mg qhs 3. Docusate Sodium 100 mg [**Hospital1 **] 4. Lidocaine 5 %(700 mg/patch) Adhesive Patch qd 5. Morphine SR 75 mg q8h 6. Hexavitamin qd 7. Senna 1 tab [**Hospital1 **] prn 8. Ferrous Sulfate 325 qd 9. Folic Acid 1 mg qd 10. Lovenox 160 mg q12h 11. Hydromorphone 4 mg Tablet Sig: 2-4 Tablets PO Q3H (every 3 hours) as needed for pain. Discharge Medications: 1. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 2. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Ferrous Sulfate 325 (65) 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. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical QDAILY (). Disp:*30 Adhesive Patch, Medicated(s)* Refills:*0* 7. Morphine 100 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q8H (every 8 hours). Disp:*180 Tablet Sustained Release(s)* Refills:*0* 8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). Disp:*180 Capsule(s)* Refills:*2* 9. Enoxaparin 120 mg/0.8 mL Syringe Sig: One [**Age over 90 **]y (120) mg Subcutaneous Q12H (every 12 hours). Disp:*7200 mg* Refills:*2* 10. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3 to 4 Hours) as needed for for pain. Disp:*30 Tablet(s)* Refills:*0* 11. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*40 Tablet(s)* Refills:*0* 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Disp:*60 Tablet(s)* Refills:*0* 13. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: IVC filter clot Acute Interstitial Nephritis [**2-10**] ciprofloxacin Tremor Secondary Diagnosis: Metastatic Prostate Cancer Bilateral DVTs OSA Discharge Condition: Good, breathing well on room air, eating regular diet, ambulating. Discharge Instructions: You were admitted for increasing lower extremity edema and scrotal edema. Two seperate thrombectomies with tPA administration were performed to restore flow through the inferior vena cava and leg veins. Please take all medication as prescribed. You will need to continue to take lovenox 120 mg subcutaneously twice a day. Due to your resolving renal failure, we started you on a steroid called prednisone. You will need to take this daily and have your kidney function tests checked within 1 week of discharge. If your kidney function continues to improve, the steroids will be tapered slowly as an outpatient. You have an appointment to follow-up with a kidney doctor, Dr. [**Last Name (STitle) 4883**]. We also decreased your neurontin dose to 300 mg three times a day, which we believe were the primary cause of your tremors. Call your doctor or return to the emergency room if you experience any of the following: fever > 100.5, chills, night sweats, increased burning on urination, decreased urine frequency or output, shortness of breath, chest pain, increasing lower extremity and scrotal edema. Followup Instructions: You have the following appointments: Kidney Doctor: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2169-3-7**] 9:00 Provider [**Last Name (NamePattern4) **]. [**First Name (STitle) **]/DR. [**First Name (STitle) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2169-3-9**] 9:00 Please call ([**Telephone/Fax (1) 31457**] to make an appointment to follow-up with Dr. [**Last Name (STitle) **] within 1 week. [**Name6 (MD) **] [**Last Name (NamePattern4) 9601**] MD, [**MD Number(3) 9602**] Completed by:[**2169-2-22**]

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icd9cm

[ [ [] ] ]

[ "88.51", "88.66", "99.10", "39.79" ]

icd9pcs

[ [ [] ] ]

12600, 12606

6384, 10603

327, 365

12814, 12883

3990, 6361

14038, 14661

3102, 3245

11038, 12577

12627, 12627

10629, 11015

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3260, 3971

274, 289

393, 1844

12745, 12793

12646, 12724

2575, 2979

2995, 3086

78,882

147,158

52810

Discharge summary

report

Admission Date: [**2133-1-5**] Discharge Date: [**2133-1-10**] Date of Birth: [**2073-5-6**] Sex: F Service: UROLOGY Allergies: Sulfa (Sulfonamide Antibiotics) / Lipitor / Penicillins Attending:[**First Name3 (LF) 1232**] Chief Complaint: CC: elective admission for right adrenal mass removal. REASON FOR [**Hospital Unit Name 20719**]: close respiratory monitoring, wheezing. Major Surgical or Invasive Procedure: Right adrenalectomy ([**1-5**]). Right-sided chest tube placement ([**1-5**]). Right internal jugular central venous catheter placement ([**1-5**]). Right arterial line placement ([**1-5**]). History of Present Illness: A 59-year-old woman who was admitted initially to the urology service for elective right adrenalectomy for pheochromocytoma. Per report, patient underwent uncomplicated procedure in which the right adrenal gland was approached through the diaphram on the right side. Post-operatively, the patient was transiently on pressors. She was extubated and noted to have wheezes; per report she had splinting and labored breathing. An ABG at this time showed slight respiratory acidosis with 7.24/56/91. Patient then underwent chest x-ray that showed no pneumothorax and no evidence of focal infiltrate. Per report, there was concern about worsening respiratory status which is why the patient was transferred to the ICU. Currently, she has central access via an IJ line, and also peripheral access. There is a chest tube on the right, and an NG tube that should be placed to low-wall suction overnight. Per report, she is alert and oriented to person and place, but slightly delirious. Her vitals at time of transfer are HR 79, BP 113/57, satting 98% 10L, breathing at 35/m. ROS: currently, patient endorses mild pain at the surgical site. Her breathing feels okay. She denies fever, chills, or sputum production. Past Medical History: - Pheochromocytoma - resection [**2133-1-5**] - Polychondritis - Mild COPD - Hypertension - Hypercholesterolemia - Appendectomy - Tubal Ligation Social History: Ms. [**Known lastname **] lives with her husband in [**Name (NI) 3844**]. They have three children. Her daughter is a nurse. She has been smoking long term, but stopped smoking the day prior to this visit and has a desire to quit. She drinks up to four beers daily. Family History: Mother had cancer, unknown primary. Daughter, benign breast mass. Physical Exam: General: sleeping but arousable, oriented, no respiratory distress Vitals: T 96.6, HR 81, BP 123/46, satting 99% on CVP: [**11-3**] HEENT: non-icteric sclera, moist mucus membranes Neck: supple, no jugular venous distention Heart: regular rate and rhythm, normal s1/s2 Lungs: diffuse coarse inspiratory sounds, good air movement, faint scattered expiratory wheezes Abdomen: moderate tenderness over right upper quadrant, near area of surgical site Extremities: warm, well-perfused, non-edematous Pertinent Results: Labs at Admission: [**2133-1-5**] 12:37PM BLOOD WBC-7.5 RBC-3.13*# Hgb-9.9*# Hct-29.4* MCV-94 MCH-31.5 MCHC-33.6 RDW-13.7 Plt Ct-233 [**2133-1-5**] 06:31PM BLOOD PT-11.9 PTT-21.6* INR(PT)-1.0 [**2133-1-5**] 12:37PM BLOOD Glucose-114* UreaN-13 Creat-0.5 Na-144 K-3.9 Cl-114* HCO3-24 AnGap-10 [**2133-1-5**] 06:31PM BLOOD proBNP-385* [**2133-1-5**] 06:31PM BLOOD Calcium-8.2* Phos-4.5 Mg-2.0 [**2133-1-5**] 10:22AM BLOOD Glucose-150* Lactate-1.2 Na-140 K-4.1 Cl-107 [**2133-1-5**] 10:22AM BLOOD Hgb-11.6* calcHCT-35 O2 Sat-97 [**2133-1-5**] 10:22AM BLOOD freeCa-1.21 Imaging: Chest x-ray ([**2133-1-5**]): In comparison with study of [**11-13**], there is now an endotracheal tube in place with its tip approximately 4 cm above the carina. Nasogastric tube extends well into the stomach. Right IJ catheter extends to the lower portion of the SVC. There is a right chest tube in place and no evidence of pneumothorax. Patchy area of increased opacification at the left base most likely represents atelectasis, though in the appropriate clinical situation, pneumonia would have to be considered. Of incidental note is subcutaneous gas along the right lateral chest and upper abdomen wall. Multiple surgical clips in the upper abdomen on the right, and a well-marginated apparent lesion in the proximal humerus that is probably of no clinical significance. Brief Hospital Course: In summary a 59-year-old woman with history of mild COPD and right pheochromocytoma admitted to urology service after undergoing right adrenalectomy. Please see operative not for full detail. She was admitted to the medical ICU post-operatively for close respiratory monitoring given concern of worsening hypercarbia post-extubation. # Hypercarbia, wheezing on exam: patient with wheezes on exam. Ddx includes COPD versus cardiogenic wheezes from pulmonary edema, likely compounded by splinting related to pain from recent surgery. Suspect COPD and splinting as the main causes for impaired ventilation given her relatively normal echocardiogram in [**2123**] and no signs of decompensated CHF on exam. Notably, the patient is 6 liters positive after perioperative fluid resuscitation. BNP was checked and was less than 400. Patient was treated with albuterol and ipratropium nebs at scheduled dosing and fluticasone inhaler twice daily. A repeated arterial blood gas after one treatment with bronchodilators showed improved ventilation with resolution of the respiratory acidosis. She was monitored overnight in the medical ICU and there were no significant events. A repeat chest x-ray in the morning showed evidence of atelectasis. Her respiratory function improved throughout the hospitalization and she will continue flovent and albuterol inhalers and follow up with Dr. [**Last Name (STitle) **] in [**3-27**] weeks. # S/p right adrenalectomy: Pain control with morphine PCA overnight, with Tylenol and ketorolac as needed. Patient was treated with four doses of prophylactic clindamycin post-operatively. Her blood pressure was within normal limits and was stable throughout hospitalization. Her blood pressure medications were held. # Hyperlipidemia: no active issues. Home pravastatin was resumed when patient's diet was advanced. At discharge, patient's pain was controlled on oral pain meds, tolerating a regular diet, and was ambulating. She will have follow up with Dr. [**Last Name (STitle) **], Dr. [**Last Name (STitle) **], Dr. [**Last Name (STitle) 3540**], and her PCP. Medications on Admission: - prazosin 5 mg q6h - diet supplemented with 2g NaCl daily - Amlodipine 10 mg daily - Metoprolol tartrate 100 mg [**Hospital1 **] - Pravastatin 40 mg HS - Was on long term steroid for Polychondritis, but she has been off prednisone for about two years. Discharge Medications: 1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever. 2. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*1 inhalers* Refills:*3* 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for Constiation. Disp:*60 Capsule(s)* Refills:*2* 4. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:*14 Patch 24 hr(s)* Refills:*2* 5. pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*45 Tablet(s)* Refills:*0* 7. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheezing. Disp:*1 inhalers* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Right adrenal tumor Discharge Condition: stable A+Ox3 ambulates independently Discharge Instructions: -You may shower but do not bathe, swim or immerse your incision. -Do not lift anything heavier than a phone book (10 pounds) or drive until you are seen by your Urologist in follow-up -Tylenol should be your first line pain medication, a narcotic pain medication has been prescribed for breakthough pain >4. Replace Tylenol with narcotic pain medication. Max daily Tylenol dose is 4gm, note that narcotic pain medication also contains Tylenol (acetaminophen) -Do not drive or drink alcohol while taking narcotics -Colace has been prescribed to avoid post surgical constipation and constipation related to narcotic pain medication, discontinue if loose stool or diarrhea develops. -Resume all of your home medications, except hold blood pressure medications. -Call your Urologist's office to schedule/confirm your follow-up appointment in 3 weeks AND if you have any questions. -If you have fevers > 101.5 F, vomiting, or increased redness, swelling, or discharge from your incision, call your doctor or go to the nearest ER -Do not eat constipating foods for 2-4 weeks, drink plenty of fluids Followup Instructions: -Call Dr.[**Name (NI) 1233**] office ([**Telephone/Fax (1) 4276**] ‎for follow-up AND if you have any questions (page Dr. [**Last Name (STitle) 261**] at [**Telephone/Fax (1) 2756**]). -Call Dr.[**Name (NI) 84946**] office for pulmonary follow up. -Call Dr.[**Name (NI) 108896**] office for endocrinology follow up. -Call your primary care physician for [**Name9 (PRE) **] follow up.

[ "780.62", "227.0", "272.0", "496", "401.9", "458.29", "518.5" ]

icd9cm

[ [ [] ] ]

[ "38.93", "38.91", "34.04", "07.22" ]

icd9pcs

[ [ [] ] ]

7586, 7592

4324, 6425

451, 644

7656, 7695

2945, 4301

8846, 9241

2347, 2414

6728, 7563

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6451, 6705

7719, 8823

2429, 2926

274, 413

672, 1880

1902, 2048

2064, 2331

21,613

191,356

3840

Discharge summary

report

Admission Date: [**2197-3-29**] Discharge Date: [**2197-4-8**] Date of Birth: [**2161-10-16**] Sex: F Service: MEDICINE Allergies: Penicillins / Erythromycin Base / Codeine / Tape / Sulfa (Sulfonamides) / Dipentum Attending:[**First Name3 (LF) 30**] Chief Complaint: fevers, foot infection Major Surgical or Invasive Procedure: Central line placement (left subclavian) Debridement and hardware removal from left foot History of Present Illness: 35 year old female with long standing DMI c/b triopathy and h/o VRE bacteremia ([**Date range (1) 17248**]) who is a direct admit from [**Hospital **] clinic for fevers, foot infection. . She had a recent admission [**Date range (1) 17249**] presented with ARF and hyperkalemia, found to have VRE septicemia and left foot infection. TTE and TEE were negative for endocarditis, her portocath (which had been in place for 17 yrs) was removed on [**2-16**]. She had follow-up blood cultures obtained at an outside facility on [**2-23**], which reportedly were negative at 5 days. Zyvox was restarted by her podiatrist (Dr. [**Last Name (STitle) **] on [**3-7**], given chronic sinus formation at foot wound; there was a plan to to excise the sinus and remove the anchor although held off [**2-3**] fever. Pt completed this course of antibiotics ~ 1 week ago. . She then developed fevers to 103 x1 week, nausea, non-biliary, non-bloody emesis, watery diarrhea (no BRBPR/black tarry stools). She reports tolerating a po diet with good UOP. She also reports a dry cough. No sick contacts. . She presented to the [**Hospital **] clinic for a regularly scheduled appointment and was found to have a foot odor and discharge. She was admitted to the floor for further management. She denies dysuria, abdominal pain, CP, SOB. She uses a insulin pump and blood glucose runs 130s-150s. Past Medical History: 1)DM type I x34 years c/b triopathy 2)CRI - baseline Cr 2.5-3.0 3)Depression 4)Iron def anemia on EPO 5)gastroparesis 6)multiple foot surgeries c/b infections s/p L TMA 7)hypercholesterolemia 8)ulcerative collitis 9)hx of MRSA 10)legally blind due to retinopathy 11) h/o meningitis [**8-7**] 12) h/o VRE bacteremia - [**2-8**] Social History: Lives with her husband. [**Name (NI) **] smoking, occasional alcohol, no drug use. Family History: Numerous family members with type 2 DM (grandmother, aunt, 2 great uncles). History of CAD (great-grandfather), breast cancer, and colon cancer. Primary pulmonary hypertension (mother). Physical Exam: VS: Temp: T 96.9 BP 110/60 HR 88 RR 16 100% RA GEN: pleasant, comfortable, NAD HEENT: PERRL, EOMI, anicteric, MMM, op without lesions RESP: CTA b/l with good air movement throughout CV: RR, S1 and S2 wnl, no m/r/g. ABD: nd, +b/s, soft, nt EXT: [**2-4**]+ pitting edema BL LE up to knees, no clubbing or cyanosis, right foot wrapped and in boot NEURO: CNII-XII grossly intact Pertinent Results: Labs: [**2197-3-29**] 03:00PM BLOOD WBC-11.9*# RBC-3.26* Hgb-8.6* Hct-27.0* MCV-83 MCH-26.3* MCHC-31.7 RDW-17.8* Plt Ct-585* [**2197-3-29**] 03:00PM BLOOD Neuts-80* Bands-1 Lymphs-9* Monos-5 Eos-0 Baso-1 Atyps-1* Metas-2* Myelos-1* [**2197-4-7**] 04:28AM BLOOD ESR-41* [**2197-3-29**] 03:00PM BLOOD Glucose-297* UreaN-89* Creat-5.5*# Na-130* K-6.6* Cl-102 HCO3-15* AnGap-20 [**2197-4-7**] 04:28AM BLOOD CRP-35.0* [**2197-3-29**] 07:29PM URINE Blood-MOD Nitrite-NEG Protein-500 Glucose-250 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD . U Cx- Klebsiella pneumoniae Bl Cx- KLEBSIELLA PNEUMONIAE | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CEFUROXIME------------ <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S IMIPENEM-------------- <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S . Wound cx - STAPH AUREUS COAG + | ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- =>4 R PENICILLIN------------ =>0.5 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- S VANCOMYCIN------------ <=1 S . Renal US [**2197-3-30**]: IMPRESSION: Compared to prior ultrasound from [**2197-2-15**], there is increased echogenicity of bilateral kidneys, which may represent a diffuse parenchymal process related to patient's acute renal failure. There is no hydronephrosis or renal mass. . Left ankle 2 views [**2197-3-30**]: IMPRESSION: 1. The cuboid is not well seen due to patient positioning. 2. The arthrodesis screw, calcaneal anchor, and transmetatarsal amputation again seen. 3. The fragmentation of the navicular and calcaneal fracture are unchanged from [**3-7**]. 4. [**Month/Day (4) **] calcifications and surgical clips are noted. . TTE: LVEF 60-70% The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 60-70%). 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. No masses or vegetations are seen on the aortic valve. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. There is moderate pulmonary artery systolic hypertension. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2197-2-14**], the apparent pulmonary artery pressure is significantluy increased. If clinically suggested, the absence of a vegetation by 2D echocardiography does not exclude endocarditis. . MRI cervical, thoracic, lumbar spine [**2197-4-1**] 1. Study is somewhat limited due to patient motion, as well as the lack of IV contrast. 2. No definite evidence of discitis, vertebral osteomyelitis or epidural abscess, fluid collection. 3. Epidural lipomatosis in the posterior spinal canal from T1-T12 levels. 4. 1.6 cm focus of increased signal intensity in the posterior aspect of L2 vertebral body, likely representing an "atypical" hemangioma. 5. Normal appearing spinal cord. . Foot plain film [**2197-4-4**]: Unchanged appearance of postoperative left foot. No definite evidence of osteomyelitis. . Brief Hospital Course: This is a 35 yo female with a PMH of DMI c/b triopathy, recent VRE bacteremia, who presents as a direct admit from [**Hospital **] clinic with left foot ulcer and fevers and found to have klebsiella urosepsis and MRSA from wound culture. . 1. Hypotension: The patient is hypotensive in the setting of fever and GNR bacteremia, indicating likely sepsis and required MICU care. She grew GNR in blood from [**3-29**] and [**3-30**]. UA is dirty, with culture growing klebsiella. Foot ulcer with MRSA. Lactate was 0.6 with mixed venous O2 of 71. She was initially treated with ciprofloxacin, cefepime and daptomycin and once sensitivities were known, coverage was changed to ciprofloxacin and vancomycin. Podiatry was involved and removed hardware from the patient's foot. The patient became stable on antibiotic regimen and was discharged to complete a course of ciprofloxacin and linezolid. She was discharged on a 2 week course of linezolid with outpatient follow up with ID who plant to reevaluate the patient and may extend antibiotic course. . 2. Acute on Chronic Renal Failure: Cr 5.5 on admission, with BL Cr of [**2-4**]. Renal U/S negative for obsturction. Volume overload by exam, continue lasix. Renal US without evidence of hydronephrosis. Renal following and feel that patient is heading for hemodialysis although currently no acute indication. Patient refused renal diet. Outpatient follow up with renal. . 3. Hyperkalemia: Hyperkalemia in the setting of acute on chronic renal failure. She has a history of hyperkalemia per OMR. Patient resistant to taking kayexalate, especially in the evening (when hyperkalemia was first discovered) but eventually agreed. No peaked T waves on EKG. . 4. L found wound: Pt has had chronic infections of this TMA of her L foot c/b VRE and MRSA infections, during this hospital course growing out MRSA. She has screws and hardware in place and podiatry involved and removed some hardware during the admission. Treated with daptomycin, then linezolid for outpatient. . 5. DMI: Patient has a history of diabetes with multiple complications, now on insulin pump. [**Last Name (un) **] recs helped to adjust insulin pump. . 6. Anemia: Hct at baseline of 26, ACD by iron studies likely due to renal failure. Given iron. Received blood transfusions as HCT trended down. Outpatient follow up with renal. Medications on Admission: metoprolol 50mg po BID celexa 40mg po daily lipitor 40mg po daily insulin pump Nabicarb 1300mg po TID lasix 20mg po BID-held ASA 81mg po daily synthroid 40mcg po daily Vit D - unknwown dose vicoden 1-2tabs q8H prn pain Discharge Medications: 1. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 8 days. Disp:*8 Tablet(s)* Refills:*0* 2. Outpatient Lab Work CBC [**2197-4-13**] 3. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 4. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain: not to exceed 2grams in 24 hour period. 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 9. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Sodium Bicarbonate 650 mg Tablet Sig: Three (3) Tablet PO QID (4 times a day). 12. Insulin Pump Eng/French R1000 Misc Sig: as directed Miscellaneous as directed: as directed. 13. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 14. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 6136**] Home Care Discharge Diagnosis: Primary: 1. Septic Shock. 2. Klebsiella UTI - Bacteremia. 3. Left Foot MRSA Hardware-Soft tissue abscess. Secondary: 1. Chronic Kidney Disease Stage V - Nephrotic Syndrome. 2. Anemia of Chronic Kidney Disease. 3. Diabetes Mellitus Type I - Insulin Pump. 4. Peripheral Neuropathy - Retinopathy. 5. Ulcerative Colitis. 6. Hypertension. 7. Hyperlipidemia. 8. Depression. 10.Hypothyroidism, 11.MRSA/VRE Discharge Condition: Good Discharge Instructions: Please be sure to keep your appointment with Dr. [**First Name (STitle) **] in the Department of Infectious Disease to discuss the need to continue your antibiotics. You will need to have your complete blood counts checked next Friday [**2197-4-14**] . Return to the Emergency department or call you PCP if you have fever, chills or feel ill. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 1037**] [**Last Name (NamePattern4) 2335**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2197-4-14**] 1:00 Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**2197-4-18**] at 2:40 Phone: [**Telephone/Fax (1) 543**] Provider: [**First Name8 (NamePattern2) 8031**] [**Last Name (NamePattern1) 10314**], MD Phone:[**Telephone/Fax (1) 2664**] Date/Time:[**2197-5-1**] 2:00 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2197-5-1**] 4:30 Make a follow up appointment with your primary care physician [**Last Name (NamePattern4) **] [**Telephone/Fax (1) 250**].

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icd9cm

[ [ [] ] ]

[ "78.68" ]

icd9pcs

[ [ [] ] ]

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2231, 2318

107

174,162

4832

Discharge summary

report

Admission Date: [**2122-5-14**] Discharge Date: [**2122-5-18**] Date of Birth: [**2052-4-2**] Sex: M Service: MEDICINE Allergies: cefazolin / Penicillins Attending:[**First Name3 (LF) 2009**] Chief Complaint: hypotension, Hct drop Major Surgical or Invasive Procedure: EGD [**2122-5-15**] Blood transfusion [**5-14**] History of Present Illness: 70-year-old man status post kidney transplant now on HD initially presented with dyspnea and epigastric pain. Patient reports symptoms began suddenly yesterday while watching TV, with sudden SOB and mild epigastric discomfort. Pt reports that at some point today he had mild chest discomfort, similar to that he has regularly, and took a nitroglycerin. He denies nausea, vomiting, hematemesis, hematochezia or melena. He denies history of recent bleeding, dizziness, or light headedness. . In the ED, initial vital signs were:97.6 76 107/93 18 99%. CXR was clear. While he was in the ED he became hypotensive to the 80s and received several IVF totalling to 750cc. He had an episode of melena and coffee ground emesis. He was lavaged which resulted in bright blood (thought to be traumatic) that cleared quickly with few coffee grounds, no bile was drawn back. CTA torso showed no PE or abdominal perforation. EKG also showed no ST depressions in lateral leads, but troponin 0.06. Renal was consulted and concerned about K of 6.1 and recommended urgent dialysis. During his ED stay he received 5mg IV morphine for epigastric pain, started on a protonix drip. Pt was transfered to MICU with 2PIVs and stable vital signs. . In the MICU, patient reports continued epigastric discomfort, but no further nausea, emesis, or melena. . ROS: Denies fevers, chills, change in weight, headache, dizziness, orthopnea/PND or palpitations, urine production, lower extremity edema, new pains, rash. Past Medical History: [**7-/2121**]: Rx allergy: Cephalosporins (cefazolin), s/p graft embolect - Subdural Hematoma: ER [**Hospital1 18**] [**6-19**] - ESRD s/p kidney transplant and rejection, now on hemodialysis - Glomerulonephritis - CAD: cardiac cath [**2119-9-26**]: completely occluded LCx (unchanged since [**2113**]), 50% lesion LAD (vs 30% prior) & completely stenotic RCA - Cath [**2119-9-28**] s/p 2 Xience [**Year (4 digits) **] to RCA after rotablation of heavily calcified artery - Hyperparathyroidism - Anemia - Gout - Hyperlipidemia - Hypertension - Eosinophilia (? 2o Strongloides) - Multiple lung nodules of unknown etiology - Hypogonadism - Obesity - Bronchospasm - Hx PPD positive but ruled out for pulmonary TB recently - chronic SDH s/p [**2119**] - [**2121-8-25**] Left IJ tunnelled catheter placement . PAST SURGICAL HISTORY: - Cardiac catherization on [**2119-9-28**] s/p 2 Xience [**Year (4 digits) **] to RCA after rotablation of heavily calcified artery. - [**2113**] - Left brachial artery to cephalic vein primary AV fistula. - [**2114**] - Revision of AV fistula with ligation of side branches - [**2114**] - Creation of left upper arm arteriovenous graft, brachial to axillary. - [**2115**] - Thrombectomy with revision of left arm arteriovenous (AV) graft - [**2115-4-11**] Cadaveric kidney transplant, right iliac fossa. (Dr. [**First Name (STitle) **] - [**2117-8-13**] - Right upper arm brachial - axillary graft (Dr. [**First Name (STitle) **] - [**2119**] - RUE AVG Fistulogram, angioplasty of intragraft partially occluding clot - [**2120**] - RUE AVG Thrombectomy, fistulogram, arteriogram, 8-mm balloon angioplasty of outflow stenoses. - [**2121**] RUE graft thrombectomy - [**2121**] [**2121-12-12**] tunneled HD catheter placement and AV fistula ligation Social History: -Tobacco: smoked for a few years as a teenager -EtoH: denies -Illicits: denies -Lives alone w Cat; has three sons that are not very involved in his life; walks with a cane. Has VNA once a month and meals on wheels. -Previously worked as a zoo keeper [**Last Name (NamePattern1) 20122**] Zoo Family History: No history of kidney disease, + history for DM, HTN Physical Exam: ADMISSION EXAM: GENERAL - well-appearing gentleman, sedated, in NAD, no respiratory distress, warm to touch. HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple 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/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, trace edema bilaterally., 2+ peripheral pulses (radials, DPs) NEURO - awake, A&Ox3, CNs II-XII grossly intact Discharge exam O: 98.0 136/88 75 18 100%ra GENERAL - obese latino male in NAD HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear NECK - supple LUNGS - CTA bilat, no r/rh/wh, good air movement, resp unlabored, no accessory muscle use. Hematoma on back is unchanged. HEART - PMI non-displaced, RRR, no MRG, nl S1-S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, trace edema bilaterally, 2+ peripheral pulses (radials, DPs) NEURO - awake, A&Ox3, CNs II-XII grossly intact Pertinent Results: Admission labs [**2122-5-14**] 02:45PM BLOOD WBC-11.6* RBC-3.17*# Hgb-8.5*# Hct-29.4*# MCV-93 MCH-26.9* MCHC-29.0* RDW-19.5* Plt Ct-183 [**2122-5-14**] 09:48PM BLOOD WBC-13.6* RBC-2.59* Hgb-7.1* Hct-23.9* MCV-92 MCH-27.3 MCHC-29.6* RDW-19.4* Plt Ct-168 [**2122-5-14**] 02:45PM BLOOD Glucose-144* UreaN-137* Creat-8.7*# Na-137 K-6.1* Cl-97 HCO3-20* AnGap-26* [**2122-5-14**] 02:45PM BLOOD ALT-25 AST-20 AlkPhos-107 TotBili-0.2 [**2122-5-14**] 02:45PM BLOOD Albumin-3.4* Calcium-7.5* Phos-3.1# Mg-2.9* . Cardiac labs [**2122-5-14**] 02:45PM BLOOD CK-MB-4 cTropnT-0.06* proBNP-4103* [**2122-5-14**] 09:48PM BLOOD cTropnT-0.05* [**2122-5-15**] 02:26AM BLOOD CK-MB-3 cTropnT-0.10* [**2122-5-15**] 09:53AM BLOOD CK-MB-4 cTropnT-0.15* . Discharge labs [**2122-5-18**] 06:30AM BLOOD WBC-8.5 RBC-2.96* Hgb-8.5* Hct-28.1* MCV-95 MCH-28.8 MCHC-30.3* RDW-19.0* Plt Ct-153 [**2122-5-18**] 06:30AM BLOOD Glucose-119* UreaN-49* Creat-8.1*# Na-135 K-4.4 Cl-94* HCO3-27 AnGap-18 [**2122-5-18**] 06:30AM BLOOD Calcium-7.8* Phos-3.7 Mg-2.3 . EKG [**2122-5-14**]: Sinus rhythm. Left atrial abnormality with a change in atrial morphology compared to the previous tracing of [**2122-1-20**]. There are new ST-T wave changes recorded in leads I and aVL as compared with prior tracing which may represent active lateral ischemic process. Followup and clinical correlation are suggested. . EKG [**2122-5-15**]: Sinus rhythm. Compared to the previous tracing of [**2122-5-15**] there is further improvement inthe inferolateral ST-T wave abnormalities. Followup and clinical correlation are suggested. . CXR [**2122-5-14**]: No acute cardiopulmonary process. Persistent increased interstitial markings in the lungs compatible with chronic interstitial disease. Interval resolution of the right mid lung opacity since prior. . CTA [**2122-5-14**]: 1. No evidence of acute pulmonary embolism or acute aortic dissection. 2. Extensive atherosclerotic disease involving the aorta, major visceral arteries and coronary arteries. 3. No evidence of bowel perforation or other acute abdominal pathology. 4. Scattered colonic diverticulosis without evidence of acute diverticulitis. . EGD [**2122-5-15**]: Esophagus: Lumen: A medium size hiatal hernia was seen. Mucosa: A salmon colored mucosa distributed in a segmental pattern, suggestive of long segment Barrett's Esophagus was found. Stomach: Mucosa: Localized erythema and erosion of the mucosa with no bleeding were noted in the antrum. These findings are compatible with Moderate gastritis. Duodenum: Mucosa: Diffuse continuous friability, erythema and congestion of the mucosa with no bleeding were noted in the duodenal bulb compatible with Moderate duodenitis. Excavated Lesions Five ulcers ranging in size from 4 mm to 6 mm were found in the duodenal bulb. Two of these had visible vessel in center. 6 cc epinephrine was injected in one and 4 cc in the other. 2 Endoclips were placed on the the larger ulcer successfully. IMPRESSION: Medium hiatal hernia Moderate gastritis Moderate duodenitis Ulcers in the duodenal bulb Mucosa suggestive of Barrett's esophagus Otherwise normal EGD to third part of the duodenum Brief Hospital Course: 70 yom with history of ESRD on HD, CAD s/p [**Month/Day/Year **] in [**2120**], p/w epigastric pain, hematemesis, melena, and dyspnea X 1 day, found to have duodenal ulcers, s/p clipping and epinephrine, with course complicated by demand ischemia. . # Hematemesis/Melena, GI bleeding, acute bood loss anemia: Pt with Hct drop to 23.9 from 29.4 on admission. He received 2 units of PRBC transfused on [**2122-5-14**]. He was briefly intubated for EGD performed on [**5-15**] which showed multiple duodenal ulcers, two with visible vessels. Both were injected with epinephrine, and 2 Endoclips were placed on the the larger ulcer successfully. He was quickly extubated without complication. HCT remained stable thereafter. His diet was advanced to clears, and he was maintained on [**Hospital1 **] PPI. Low dose aspirin 81mg was restarted given his CAD, and decision to restart plavix was made. His Cardiologist was [**Name (NI) 653**], and [**Name2 (NI) 20207**] a note from [**2120**]: . "This patient has a drug-eluting stent placed in [**2121-1-8**] for recurrent in-stent restenosis inside a prior drug-eluting stent from [**2119-9-9**]. He should be on uninterrupted aspirin for life as well as lifelong clopidogrel (or equivalent anti-platelet) therapy given the anatomical substrate of a bilayer of drug-eluting stents that puts him at very high risk for late and very late stent thrombosis. Late stent thrombosis carries significant mortality and morbidity risks. The only circumstance for which we would consider stopping dual anti-platelet therapy would be intracranial bleeding." . He was put back on aspirin 325mg daily and plavix 75mg daily. He was started on low dose BB, and as he tolerated this well his home metoprolol succinate 100mg daily was restarted. Because he is high-risk to bleed, and remains on dual-anti-platelet therapy, he should have several hct checks in the near future. His home PPI was also increased. . Additionally, an H pylori serology was checked, and came back equivocal. As this is a potentially reversible risk factor, it was decided to treat him with PPI, metronidazole x 10 days (he has PCN allergy), and clarithromycin x10 days. . # Hypotension: In the setting of his GIB. This resolved, and he remained normotensive. We continued to hold his home antihypertensives in the MICU and these were restarted on the floor, where his pressures remained stable. # Demand Ischemia: Pt with EKG on admission showing ischemic appearing T waves in I and aVL, as well as ST-T wave flattening in leads V5-V6 andII and aVF. This was concerning for ischemia, but eventually resolved on subsequent EKG. Thought to be demand related to the setting of hypotension and anemia. Aspirin 325 and plavix 75 daily were restarted. He was continued on his home pravastatin 10mg daily, and his LDL was at goal <70. He was symptomc free on discharge. . # Interstitial lung diseae: Initially maintained on IV methylprednisolone in the setting of his NPO status, and once diet was advanced he was restarted on home dose of prednisone 30mg, with bactrim PPX. Given his upper GI bleed, his pulmonologist was [**Name (NI) 653**], and felt that his prednisone could be lowered to 20mg daily. He will f/u w/ pulmonary on [**5-21**] . # CKD on HD: MWF dialysis sessions. Dialysis was deferred on Friday [**5-15**] given hypotension, but was restarted the following day. He was continued on sevelemer, calcinet, and nephrocaps, though sevelemer dose was decreased, and calcium acetate started, per renal recommendations. Last dialysis sessions was Monday [**5-18**]. . # CAD, s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **]: As above, initially held ASA, plavix, BB given that patient was bleeding and hypotensive. He was maintained on his pravastatin 10mg daily. Eventually, all CAD meds (see above) were restarted. His aspirin and plavix should NEVER be stopped, except in setting of truly life-threatening bleed, given the way this pt is stented puts him at very high risk for in-stent thrombosis. Per Dr [**Last Name (STitle) **]: "need to balance the risk and consequences of recurrent GI bleeding vs. the risks and consequences of stent thrombosis in his RCA. Patients with stent thrombosis carry a 20-40% mortality and a 30-40% chance of a large non-fatal MI" . # Gout: Continued allopurinol. . # Code status: full (confirmed) =================================== TRANSITIONAL ISSUES # needs to have hct checked frequently in near future to ensure no recurrent bleeding # Repeat EGD 4-6 weeks, per GI. Medications on Admission: allopurinol 100 mg qod B complex-vitamin C-folic acid 1 mg daily clopidogrel 75 mg daily metoprolol succinate 100 mg daily sevelamer carbonate 800 mg 5 tabs tid pravastatin 10 mg daily aspirin 325 mg daily cinacalcet 30 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). oxycodone 5 mg Tablet q6h prn pain fluticasone 50 mcg/Actuation Spray daily albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler prn docusate sodium 100 mg daily Bactrim DS [**Name (NI) 20208**] (unclear if taking) Discharge Medications: 1. allopurinol 100 mg Tablet Sig: One (1) Tablet PO every other day. 2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 4. sevelamer carbonate 800 mg Tablet Sig: Three (3) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 5. pravastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. 6. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. cinacalcet 30 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 8. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1) Nasal once a day. 9. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: One (1) Inhalation PRN as needed for shortness of breath or wheezing. 10. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO M/W/F (). 11. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 12. calcium acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). Disp:*90 Capsule(s)* Refills:*2* 13. prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 14. 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* 15. clarithromycin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days. Disp:*20 Tablet(s)* Refills:*0* 16. metronidazole 500 mg Tablet Sig: One (1) Tablet PO twice a day for 10 days. Disp:*20 Tablet(s)* Refills:*0* 17. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO once a day. 18. Outpatient Lab Work [**2122-5-20**]: Hematocrit - Please fax results to Dr. [**First Name (STitle) **]. Phone: [**Telephone/Fax (1) 608**] Fax: [**Telephone/Fax (1) 4647**] Discharge Disposition: Home Discharge Diagnosis: duodenal ulcers, gastrointestinal bleed Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr [**Known lastname 20118**], It was a pleasure taking care of you at [**Hospital1 18**]. You were admitted for a gastrointestinal bleed. This was found to be from ulcers in your stomach. For this, you had an endoscopy, and the bleeding was stopped. Changes were made to your medications, which should also help prevent more bleeding. Your duodenal ulcers may be related to a stomach infection from Helicobacter pylori. This is a common infection that can pre-dispose you to ulcers. You will receive 10 days of antibiotics to treat this infection. Please have your blood counts (Hematocrit) checked at dialysis on Wednesday. You will follow-up with the GI doctors and [**Name5 (PTitle) **] likely need another endoscopy in 4 - 6 weeks. The following changes were made to your medications: ** DECREASE sevalamer to 800mg tablets, take THREE (3) tablets THREE (3) times a day (you had previously been taking 5 tablets 3 times a day) ** DECREASE prednisone to 20mg once daily (you had been on 30mg once daily) ** START pantoprazole 40mg by mouth twice daily (You will take this instead of the 20 mg daily dose you were previously taking) ** START calcium acetate 667mg tablet, 1 tablet three times a day with meals ** START metronidazole 500mg by mouth twice a day for 10 days [antibiotic] ** START clarithromycin 500mg by mouth twice a day for 10 days [antibiotic] Followup Instructions: Department: BIDHC [**Location (un) **] When: MONDAY [**2122-5-25**] at 10:45 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 607**], MD [**Telephone/Fax (1) 608**] Building: 545A Centre St. ([**Location (un) 538**], MA) None Campus: OFF CAMPUS Best Parking: Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [**2122-6-3**] at 2:30 PM With: [**Name6 (MD) 2606**] [**Name8 (MD) 2607**], MD [**Telephone/Fax (1) 463**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage Department: PFT When: THURSDAY [**2122-5-21**] at 1 PM Department: PULMONARY FUNCTION LAB When: THURSDAY [**2122-5-21**] at 1 PM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: GZ [**Hospital Ward Name **] BUILDING (FELBEERG/[**Hospital Ward Name **] COMPLEX) [**Location (un) 3971**] Campus: EAST Best Parking: Main Garage Department: MEDICAL SPECIALTIES When: THURSDAY [**2122-5-21**] at 2:00 PM With: DR. [**Last Name (STitle) 11071**]/DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "252.00", "530.85", "V45.82", "276.7", "553.3", "585.6", "996.81", "535.50", "532.91", "403.91", "274.9", "458.9", "285.1", "V45.11", "535.60", "272.4", "515" ]

icd9cm

[ [ [] ] ]

[ "45.13", "44.43", "39.95" ]

icd9pcs

[ [ [] ] ]

15254, 15260

8307, 12888

305, 355

15344, 15344

5138, 8284

16893, 18186

4010, 4063

13420, 15231

15281, 15323

12914, 13397

15495, 16870

2735, 3684

4078, 5119

244, 267

383, 1883

15359, 15471

1906, 2712

3700, 3994

67,719

174,201

22292

Discharge summary

report

Admission Date: [**2144-10-7**] Discharge Date: [**2144-10-14**] Date of Birth: [**2074-4-9**] Sex: M Service: [**Last Name (un) **] HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old with a chief complaint of six weeks of weight loss and jaundice. The weight loss occurred throughout the majority of this Summer and is felt to be up to 25 pounds. The patient has had no abdominal pain but became overtly jaundiced in early [**Month (only) 216**]. This was accompanied by dark urine during this time. An endoscopic retrograde cholangiopancreatography procedure was performed, and a stent was placed initially. However, the jaundice was not relived. He went on to develop fevers and chills two weeks after this procedure. An endoscopic retrograde cholangiopancreatography was then performed on [**2144-9-22**] which showed migration of the stent which was replaced, and his jaundice subsequently abated. A follow-up ultrasound and computerized axial tomography scan and dedicated computed tomography angiogram was performed. This demonstrated a complex large cystic mass in the head of the pancreas; consistent with an intraductal papillary mucinous tumor. It should also be noted that the findings of Dr.[**Name (NI) 12202**] endoscopy also corroborate that diagnosis with distinct mucin production through the pancreatic duct orifice. PAST MEDICAL HISTORY: Significant for hypertension and non- insulin-dependent diabetes mellitus for the past three years. PAST SURGICAL HISTORY: He has had no surgical history. PHYSICAL EXAMINATION ON PRESENTATION: The patient's vital signs were within normal limits. He was a well-appearing elderly gentleman in no apparent distress. Awake, alert and oriented times three. The patient had residual scleral icterus. There was no lymphadenopathy or masses or thyromegaly in the neck. His cardiac examination revealed a regular rate and rhythm. There were no murmurs, rubs, or gallops. Pulmonary examination revealed the lungs were clear to auscultation bilaterally. Abdominal examination revealed the abdomen was nondistended with normal active bowel sounds. The abdomen was soft and nontender with firm abdominal wall musculature. There were no evidence of Courvoisier gallbladder. The inguinal region showed no evidence of hernias or masses. Rectal examination was deferred at this time. SUMMARY OF HOSPITAL COURSE: On [**2144-10-7**] the patient was preoperatively prepared. He was consented by both the Anesthesia and Surgical team and brought to the Operating Room for laparotomy. The patient tolerated the procedure well, and an open cholecystectomy was performed in addition to a pylorus preserving Whipple procedure. The surgical findings indicated right hepatic artery high off of the superior mesenteric artery with masses and tumor adherence to that area. The procedure was done under general anesthesia, and the patient did not require any blood products. The patient's condition was stable at the conclusion of the operation, and he was brought to the Post Anesthesia Care Unit. The plan at this point was to keep the patient intubated until the next morning, and replete electrolytes as needed, and to continue expectant management. An arterial blood gas was performed at that time that was reassuring with a pH of 7.37. On postoperative day one, the patient was extubated that morning and progressed well. On postoperative day two, the patient's blood sugars were noted to be somewhat elevated during this time. The [**Last Name (un) **] Diabetes Service was consulted, and the sliding-scale insulin was adjusted accordingly. Throughout this time, the standard Whipple protocol was followed. On postoperative day three, the patient's nasogastric tube was removed. The patient continued to be followed by the [**Last Name (un) **] Diabetes Service staff. On postoperative day four, the patient's Foley catheter was removed. The patient was voiding independently and was out of bed to the chair at this point. A peripheral intravenous line and the central line was removed. The patient was placed of sips of clears and tolerated this well. On postoperative day five, the patient was started on Reglan 10 mg q.6h. and was started on Percocet. At the same time, the patient's analgesia was discontinued. The patient was also given Ambien as a sleep aid at night. [**Last Name (un) **] weighed in again at this point and stated that the patient would likely need insulin at home, but would wait to see how he progressed on a full diet before making this decision. DISCHARGE DISPOSITION: On postoperative day seven - [**2144-10-14**] - the patient was stable. Vital signs were within normal limits. Physical examination was within normal limits. The patient was able to be discharged to home with services for blood glucose draws and blood pressure checks on a daily basis. DISCHARGE INSTRUCTIONS: The patient to be discharged to home with a visiting nurse aide for help with blood glucose draws and blood pressure checks. The patient to call his medical doctor if having any increase in abdominal pain, fevers, chills, nausea, vomiting, redness or drainage about the wound, or if there were any questions or concerns. The patient was to follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in one to two weeks in his office and to follow up with the [**Hospital **] Clinic the day after discharge, with an appointment already set up for [**2144-10-15**]. CONDITION ON DISCHARGE: Stable. MEDICATIONS ON DISCHARGE: 1. Reglan 10 mg by mouth four times per day. 2. Percocet 5/325 by mouth q.4-6h. as needed (for pain). 3. Metoprolol 25 mg by mouth twice per day. 4. Colace 100 mg by mouth twice per day. 5. Ambien 5 mg by mouth at hour of sleep as needed (for sleep). 6. Tylenol 325 mg by mouth q.4-6h. as needed. 7. Insulin sliding scale as directed. 8. Lantus 4 units subcutaneously at that time. 9. Protonix 40 mg by mouth once per day. DISCHARGE STATUS: Discharged to home. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 11162**] Dictated By:[**Last Name (NamePattern1) 15912**] MEDQUIST36 D: [**2144-10-21**] 14:45:47 T: [**2144-10-21**] 15:13:03 Job#: [**Job Number 56267**]

[ "575.11", "576.1", "401.9", "250.00", "577.1", "211.6" ]

icd9cm

[ [ [] ] ]

[ "52.7", "51.22" ]

icd9pcs

[ [ [] ] ]

4609, 4899

5577, 6320

4924, 5517

1521, 2379

2408, 4585

183, 1373

1396, 1497

5542, 5551

20,546

174,445

52941+59487

Discharge summary

report+addendum

Admission Date: [**2138-3-26**] Discharge Date: [**2110-2-24**] Date of Birth: [**2076-12-15**] Sex: M Service: MEDICAL ICU/[**Location (un) **] Date of discharge to be determined by the next team taking care of this patient. CHIEF COMPLAINT: Hypotension, shortness of breath, emesis. HISTORY OF PRESENT ILLNESS: This is a 61 year old male with multiple medical problems who is a resident at [**Hospital3 537**], who reportedly had a witnessed episode of emesis some time during the night prior to admission. On the morning of admission, the patient was found by staff to be tachypneic with a respiratory rate in the 40s and oxygen saturation 78% on three liters nasal cannula. The patient was brought to the [**Hospital1 69**] Emergency Department for further evaluation. Upon arrival, he was found to be hypoxic with oxygen saturation at 80% on 100% nonrebreather. The patient was then placed on nasal BiPAP with 10 liters of oxygen. The patient denied any pain, cough, shortness of breath, at that time. He was found to be febrile to 102.4 with an elevated white blood cell count, tachypneic and a lactate of 4.5. The patient was subsequently started on MUST protocol while in the Emergency Department. A right subclavian was placed with mixed oxygen saturation of 50 to 61%. The patient was aggressively fluid resuscitated with three liters of normal saline with CVP in the range of 3.0 to 5.0 and a SVP that was low to the 90s. Levophed was initiated and the patient was transferred to the Medical Intensive Care Unit for further management. The patient reversed his code status when questioned by the Emergency Department staff and requested to be intubated should he be needed to intubated. PAST MEDICAL HISTORY: 1. History of syphilis initially treated with Penicillin in [**2103**], complicated by neurosyphilis treated with Penicillin times two weeks in [**2137-12-26**]. History of lumbar puncture with negative VDRL and positive FTA. 2 Cerebrovascular accident in [**2131**], and [**2132**], with three in total. 3. Chronic aspiration, status post percutaneous endoscopic gastrostomy tube. 4. Hypertension. 5. History of gastrointestinal bleed. 6. History of Methicillin resistant Staphylococcus aureus pneumonia. 7. History of seizure disorder. 8. History of depression. 9. Osteoarthritis. 10. Gender identity disorder. 11. Hypercholesterolemia. ALLERGIES: Percodan. MEDICATIONS ON ADMISSION: 1. Zinc 220 mg p.o. once daily. 2. Subcutaneous Heparin 5000 units q12hours. 3. Baclofen 10 mg p.o. three times a day. 4. Vitamin 500 mg p.o. twice a day. 5. Colace 100 mg p.o. once daily. 6. Aspirin 325 mg p.o. once daily. 7. Atenolol 100 mg p.o. once daily. 8. Celexa 60 mg p.o. once daily. 9. Zantac 150 mg p.o. once daily. 10. Neurontin 300 mg p.o. twice a day to three times a day. 11. Percocet one tablet p.o. three times a day. 12. Dilantin 200 mg p.o. twice a day. 13. Jevity tube feeds. 14. Ativan p.r.n. 15. Ultram p.r.n. 16. Trazodone p.r.n. 17. Dulcolax p.r.n. 18. Chlorpromazine p.r.n. SOCIAL HISTORY: The patient lives in [**Hospital3 537**] as a resident. History of remote alcohol and tobacco use. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: Temperature 102.4, heart rate 86, blood pressure 134/48, respiratory rate 46, breathing 83% on nonrebreather and 93% on BiPAP with pressure support of 10 and PEEP of 5. Generally, this is an elderly chronically ill appearing male in no apparent distress using accessory muscles of respiration. Head, eyes, ears, nose and throat - Extraocular movements are intact. Mucous membranes are dry. Jugular venous pressure is approximately four to five centimeters. Poor dentition. Heart - Distant heart sounds bilaterally. Lungs - bronchial breath sounds at the left base. Decreased breath sounds at the right base. The abdomen is soft, percutaneous endoscopic gastrostomy tube site without erythema, decreased bowel sounds. Extremities contracted bilaterally with no edema, cool extremities, left foot two to three centimeters shallow ulcer, no fluctuance or pus. LABORATORY DATA: Potassium 4.6, creatinine 0.8, INR 1.2, lactate 4.5. White blood cell count 11.3, 40% polys, 41% bands, hematocrit 37.3, platelet count 341,000, MCV 100. Urinalysis showed moderate leukocytes, positive nitrites, 21-25 white blood cells. Arterial blood gas on 100% nonrebreather 7.45/33/52. On BiPAP 7.39/35/84. HOSPITAL COURSE: 1. Septic shock - The patient likely presented with septic shock and the patient was initially started on MUST protocol. The likely source was aspiration pneumonia from episodes of emesis and aspiration as a chronic risk plus/minus urine which showed positive nitrites and moderate leukocytes. The patient's other sources include skin from the percutaneous endoscopic gastrostomy site which looked clean, sacral decubitus ulcer which did not probe to bone, as well as a left superficial ulcer in the left lower extremity, which did not have any evidence of fluctuance or pus. The patient was aggressively fluid hydrated with lactated ringer's to maintain a SCVP greater than 10 and the patient did not qualify for Zygres on this admission. The patient was initially started on Levophed drip for improvement of his hemodynamics to maintain a MAP greater than 65. Cortrosyn stimulation test was performed which showed that the patient had a cortisol in the 50 range, 58.2, which was not consistent with adrenal insufficiency. Serial lactate levels trended and the patient's lactate continued to trend down with improvement of his anion gap and metabolic acidosis. The patient was initially started on Vancomycin for history of Methicillin resistant Staphylococcus aureus pneumonia and Ceftriaxone and Clindamycin empirically for aspiration pneumonia and consolidation on the left lower lobe. On hospital day three, the patient had a repeat spike temperature of 101 and was pancultured. Urine culture was growing Staphylococcus aureus greater than 100,000 organisms and the patient was continued on Vancomycin dosed by levels. Aspiration pneumonia was continued empirically with coverage by Ceftriaxone and Clindamycin. The patient had an ultrasound of his chest which showed no fluid collection in the lungs and therefore there was nothing to tap. 2. Hypoxic respiratory failure - Likely due to aspiration pneumonia. The patient was placed on a ventilator on admission to the Medical Intensive Care Unit after failure to tolerate CPAP with worsening acidemia. The patient was maintained on AC 500/22 and his FIO2 was weaned down. The patient was sedated. An echocardiogram was performed to assess ejection fraction which was essentially normal at 55%. 3. Neurology - The patient was minimally functional at baseline. Calls to [**Hospital3 537**] revealed the patient was wheelchair bound at baseline. The patient's Dilantin level was checked and was low normal. Even adjusting for his low albumin, the patient was subsequently restarted on Dilantin bolus times one and change of his Dilantin to intravenous while he was intubated. Baclofen was given p.r.n. for leg pain. 4. FEN - The patient was restarted on tube feeds for improvement of his nutritional status. 5. Endocrinology - The patient had cortisol levels that were stable. The patient was maintained on insulin drip to improve his glucose control. 6. Metabolic acidosis - Likely due to lactic acidosis which had resolved with improvement of his hemodynamics. 7. Metabolic alkalosis - The patient was likely volume contracted. Urine chloride was 33 and this had resolved with improvement of his fluid status with lactated ringer's. 8. Renal - The patient's renal function was stable throughout the hospital course. However, his FNA on admission was 0.2%, likely prerenal which subsequently resolved with improvement of his intravenous fluids. 9. Anemia - The patient initially presented with a hematocrit drip. The patient was transfused two units of packed red blood cells, however, since the patient was intubated, there was an effort to try and identify patient for consent. The patient prior to intubation had noted that he had no immediate family and had no health care proxy and therefore should have whatever medical procedures would be necessary to his care. Attempts to contact his emergency contact both at [**Hospital3 537**] revealed that the emergency contact was a neighbor and that the patient had a sister who had moved to [**Name (NI) 108**], whose telephone number was no longer working. At this time, the patient does not have a health care proxy. 10. Code - The patient reversed his code status on admission and is now a full code. 11. Prophylaxis - The patient was maintained on subcutaneous Heparin and Sucralfate during his hospitalization. The remainder of the hospital course and discharge information will be dictated by the next intern who will be covering for this patient. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**] Dictated By:[**Last Name (NamePattern1) 5227**] MEDQUIST36 D: [**2138-3-29**] 20:27 T: [**2138-4-1**] 20:09 JOB#: [**Job Number 109135**] Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 17897**] Admission Date: Discharge Date: [**2138-4-4**] Date of Birth: Sex: M Service: ADDENDUM: HOSPITAL COURSE CONTINUED: 1. SEPSIS: The patient's blood cultures remained negative. He was weaned off pressors. Continued ceftriaxone, clindamycin and vancomycin administered for a total of eight days. Upon discontinuation of antibiotics his white blood count was stable, and he remained afebrile. Cause of sepsis remained likely aspiration. The patient underwent a bedside swallow evaluation with recommendation for video evaluation for a history of silent aspiration. The video evaluation revealed the patient was back to baseline. Recommend PEG tube as primary source of nutrition; however, the patient permitted honey-thickened liquids with ground solids for his own pleasure. 1. HYPOXIC RESPIRATORY FAILURE: The patient's sedation was weaned, and he was converted to pressure support ventilation. He was stable on a spontaneous breathing trial and subsequently extubated without difficulty on [**2138-4-1**]. Aggressive chest physical therapy and suctioning was administered to aid with copious secretions. At the time of discharge, the patient was saturating 92 percent on 3 liters nasal cannula with a range anywhere 92 percent to 100 percent. His respiratory failure was thought to be secondary to shunting associated with his aspiration event. 1. NEUROLOGIC: The patient's Dilantin level still subtherapeutic. He was again loaded with 400 mg of intravenous Dilantin for a presumed history of seizure activity documented on an admission in [**2137-10-26**] with a Dilantin level of 9.3. However, his Dilantin level still remains subtherapeutic. Nevertheless, he exhibited no seizure activity. Thus, he was converted to an increased oral dose of 300 mg by mouth twice per day with no plan for further loading doses. 1. FLUIDS, ELECTROLYTES AND NUTRITION: The patient underwent a video evaluation with recommendation to resume PEG feedings as his primary source of nutrition but to allow honey-thickened liquids with ground solids for the patient's pleasure. 1. FOOT ULCERATION: The patient presented with a severe foot ulceration. Plastics was consulted and indicated to need for debridement. Followup as an outpatient. DISCHARGE DIAGNOSES: 1. Aspiration pneumonia. 2. Septic shock. 3. Hypoxic respiratory failure; likely secondary to pulmonary shunt. CONDITION ON DISCHARGE: Fair; the patient saturating well on 4 liters nasal cannula; tolerating tube feedings; blood pressure stable; and afebrile. DISCHARGE STATUS: The patient was discharged to [**Hospital3 10159**]. MEDICATIONS ON DISCHARGE: 1. Baclofen 10 mg by mouth three times per day. 2. Celexa 60 mg by mouth once per day. 3. Gabapentin 300 mg by mouth q.8h. 4. Aspirin 325 mg by mouth once per day. 5. Combivent 103/18 mcg 1 to 2 puffs inhaled q.4.h. 6. Lansoprazole 30 mg by mouth once per day. 7. Phenytoin 300 mg by mouth q.12h. 8. Guaifenesin 10 mL by mouth q.4.h. (times five days). 9. Miconazole powder one application three times per day as needed (for axillary rash). 10. Nystatin cream one application topically four times per day as needed (for groin rash). DISCHARGE FOLLOWUP: Follow up with your primary care doctor in one week. [**First Name8 (NamePattern2) **] [**Name8 (MD) 781**], [**MD Number(1) 782**] Dictated By:[**Last Name (NamePattern1) 5234**] MEDQUIST36 D: [**2138-8-3**] 17:16:10 T: [**2138-8-3**] 18:02:56 Job#: [**Job Number 17902**]

[ "518.81", "578.9", "276.2", "785.52", "285.9", "707.0", "995.92", "780.39", "507.0" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.72", "96.6" ]

icd9pcs

[ [ [] ] ]

3196, 3214

11722, 11838

12087, 12634

2452, 3061

4454, 11701

3237, 4437

262, 305

12655, 12960

334, 1730

1752, 2426

3078, 3179

11863, 12061

46,603

130,423

53254

Discharge summary

report

Admission Date: [**2166-3-29**] Discharge Date: [**2166-4-11**] Date of Birth: [**2097-3-17**] Sex: F Service: MEDICINE Allergies: Levofloxacin / Lisinopril / Diphenhydramine Attending:[**First Name3 (LF) 3531**] Chief Complaint: S/p arrest in the OR during IP stent procedure. Major Surgical or Invasive Procedure: Left main stem stent placement. Endotracheal intubation. Left femoral tripple lumen catheter placement. History of Present Illness: 69 y/o F with PMHX of COPD and Small Cell Lung Cancer (diagnosed [**2159**]) s/p XRT/chemo/tumor debridement/R mainstem bronchus stent placement ([**2164**]) and recent LUE DVT on Coumadin who initially presented to [**Hospital 1474**] hospital on [**3-27**] with 3-4 episodes of hemoptysis, increased cough, wheezing and shortness of breath. She was started on IV SoluMedrol 125mg IV q6hrs, Nebs and tessalon pearles. She was supratherapeutic with an INR of 4.1 and Coumadin was held. CTA was negative for PE and revealed right mainstem stent with distal intraluminal narrowing or tumor effusion, mediastinal and subcarinal confluent metastatic lymphadenopathy. Decision was made for transfer to [**Hospital1 18**] for bronch and IP evaluation. . Pt was admitted to [**Hospital1 18**] and was continued on steroids, nebs and cough suppressants. She went for flexible bronchoscopy on [**3-30**] which revealed normal trachea, extensive tumor at carina obstructing both mainstem bronchi, extrinsic mediastinal compression of L mainstem and unable to visualize stent in right mainstem due to intraluminal tumor. Pt was taken to the OR on [**4-1**] and had stent placed in the left mainstem with good result. There was attempted argon plasma coagulation inside of the right stent to remove intraluminal obstruction. During this procedure, pt became progressively hypoxic, bradycardic and loss of pulse at approx 3:38pm. CPR was started immediately and pt received a total of 2mg of epi. After approximately 2-3minutes of CPR, rhythm was checked and there was a palpable pulse with HR >100 and sbp >180. TEE was performed and showed bubbles in the right atrium suggestive of APC related air embolism but no RV dilation suggestive of acute PE. Oxygen sats recovered into the 90s, right femoral a-line and left femoral CVL was placed. Pt was given an additional bolus of Midazolam and some neosynephrine for BP support prior to transfer to the ICU. . On arrival to the ICU, pt was intubated and sedated with HR >100 and BP 140/90s. Sedation was rapidly weaned and pt was clearly responding to commands and moving all extremities. Past Medical History: 1. Small Cell lung cancer - diagnosed in [**2159**] and recurred in [**2161**]. Initially started 6 weeks of XRT, followed by multiple regimens of chemo. Has been off chemo for the last 4 months "because CT scans have been stable." Last bronchoscopy was in [**2165-12-23**] - small amounts of granulation tissue seen in stent. 2. Recent LUE DVT (mid-[**2166-2-20**]) - L arm port was changed, after which she developed dramatic swelling from shoulder to wrist; UENIs confirmed LUE DVT. Coumadin 5mg was started. 3. COPD - longstanding, unknown date of diagnosis 4. Lupus - diagnosed 8 years ago after work-up for painful knee and finger joints (L finger joints > R finger joints) - treated with "pills" but not prednisone 5. Shingles infection in T10 dermatome in [**10/2165**] - treated with acyclovir and recovered within 1 week 5. Anxiety/Insomnia PAST SURGICAL HISTORY: 1. Right eye cataract surgery 2. Bronchial stent placement in [**2165-2-20**] by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] 3. Lung cancer tumor debridement and ablation in [**2165-2-20**] by Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] Social History: She lives in [**Hospital1 1474**] with her husband. She has 4 children and 7 grandchildren who live within a mile of her house. She worked as a homemaker. She smoked tobacco for approximately 20 pack years (1 pack per day for 20+ years) and quit in the [**2145**]. She does not know of any asbestos exposure. She drinks alcohol only on social occasions and uses no other drugs. Family History: She reports no family history of lung cancer, SLE, or CAD. Her mom died of "stomach cancer" at 51yo and her niece has breast cancer. Her son has [**Name2 (NI) **]. Physical Exam: Vitals: T: 98.1 BP: 130/84 P: 117 R: 22 O2: 98% on 3 L General: Alert, oriented, not in acute respiratory distress, sitting upright in bed watching TV with audible upper airway inspiratory and expiratory stridor. HEENT: Sclera anicteric, pupils equal round & reactive to light, mucous membranes moist, no jugular venous distention, mucous membranes moist, oropharynx clear without thrush, no oropharyngeal source of bleeding seen Neck: supple, JVP not elevated, no lymphadenopathy, no carotid bruits, loud and harsh inspiratory upper airway stridor heard, trachea not deviated Lungs: Nasal cannula intact, patient sitting upright with audible upper airway inspiratory and expiratory stridor. Patient appears comfortable and is not using any accessory muscles of inspiration. Respiratory rate is mildly elevated. Scattered anterior inspiratory and expiratory wheezes. Left-sided bronchial breath sounds bases>apices. Right-sided bronchial breath sounds with fine crackles at bases. Scattered inspiratory and expiratory wheezes but not consistently. CV: Tachycardic with regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, well perfused, no clubbing, cyanosis or edema Skin: No skin rash or ecchymoses noted, dressing over left anterior pectoral region covering old PortaCath. Neuro: Alert & oriented x 3, extraocular movements intact, CNs II-XII grossly intact and patient moving all four extremities spontaneously On Discharge: vs: 98.8 126/70 108 18 95% 2L Gen: ill appearing female, appearing older than stated age. CV: tachycardic, no rubs, gallops, murmurs. Lungs: diffuse rhonchi, few wheezes, scant basilar rales on the left. moderate [**Location (un) **] movement Abd: soft, ND, NT ABS Ext: wwp with palpable DP pulses Neuro: alert and oriented, EOMI, patient moving all extremities spontaneously Pertinent Results: [**2166-3-29**] 09:50PM WBC-9.8# RBC-3.21* HGB-10.0* HCT-28.9* MCV-90 MCH-31.1 MCHC-34.5 RDW-18.7* [**2166-3-29**] 09:50PM NEUTS-94.3* LYMPHS-3.6* MONOS-1.9* EOS-0.1 BASOS-0.1 [**2166-3-29**] 09:50PM PLT COUNT-256 [**2166-3-29**] 09:50PM PT-24.0* PTT-34.8 INR(PT)-2.3* [**2166-3-29**] 09:50PM GLUCOSE-224* UREA N-30* CREAT-1.0 SODIUM-138 POTASSIUM-4.6 CHLORIDE-102 TOTAL CO2-24 ANION GAP-17 [**2166-3-29**] 09:50PM CALCIUM-8.6 PHOSPHATE-2.1* MAGNESIUM-1.8 . [**2166-4-9**] Radiology CHEST (PORTABLE AP) Known treated right upper lobe mass with expected post-treatment change and soft tissue density seen in a right paramediastinal location is stable. New mild bilateral pleural effusions. Otherwise no significant interval change with no focal consolidation, and pulmonary vascularity within normal limits. No new abnormality involving cardiomediastinal contours. Stable appearance of bilateral bronchial stents and port with tip terminating within the upper SVC. No evidence of pneumothorax. [**2166-4-7**] Radiology MR HEAD W & W/O CONTRAS There is a linear region of decreased diffusion within the right frontal lobe, predominantly involving the cortex and subcortical white matter, as well as multiple additional punctate foci of decreased diffusion within the biparieto-occipital lobes, including extending into the splenium of the corpus callosum on the right. There is an additional focus of abnormal slow diffusion within the inferior aspect of the right cerebellar hemisphere, measuring 1.5 cm, with associated brisk enhancement. There is [**Doctor Last Name **] enhancement over the right frontal lobe signal abnormalities described above. All of the regions of decreased diffusion have associated T2 signal abnormality. There are no regions of abnormal marrow replacement, despite limitations by motion artifact. Focus of susceptibility artifact along the posterior focus likely represents a small calcified dural plaque. There are multifocal regions of punctate post-embolic encephalomalacia within the left cerebellar hemisphere suggesting chronic embolic disease. IMPRESSION: 1. Multifocal regions of abnormally decreased diffusion, most prominent within the right frontal lobe, which has an appearance suggestive of watershed infarction. The more punctate foci of decreased diffusion posteriorly suggest multiple small emboli. 2. Well-defined 15 mm focus of enhancement and decreased diffusion within the right cerebellar hemisphere may represent a subacute enhancing infarct, but is more concerning for a metastatic lesion in this patient with lung cancer. Consideration could be given to neck MRA or CTA to evaluate the cervical circulation, though the pattern suggests a proximal source. [**2166-4-2**] Radiology BILAT LOWER EXT VEINS P Grayscale and color Doppler images of bilateral common femoral, superficial femoral, and popliteal veins were performed. There is normal compressibility, flow and augmentation. [**2166-4-2**] Cardiology ECHO [**2166-4-2**] The estimated right atrial pressure is 10-15mmHg. Left ventricular systolic function is hyperdynamic (EF>75%). Right ventricular chamber size is normal with mild global free wall hypokinesis. There is a small to moderate sized pericardial effusion. There are no echocardiographic signs of tamponade. [**2166-4-1**] Cardiology ECHO No atrial septal defect is seen by 2D or color Doppler. Right ventricular chamber size is normal. with borderline normal free wall function. The aortic valve leaflets (3) are mildly thickened. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Mild (1+) TR. Upon initial placement small air bubbles visualized in ascending aorta. No air visualized in LA/LV. No LV wall motion abnormalities. No thrombus visualized in RA, RV, PA. Right PA appears compressed by large mass but still patent. Arrest possibly secondary to left sided intracardiac air/coronary air embolism but unable to determine given time between event and images. PE also on the differential but no signs of significant RV failure, however inotropes (epinephrine) were administered. [**2166-4-1**] Pathology Tissue: Bronchus Intermedius. Small cell carcinoma [**2166-3-31**] Radiology VENOUS DUP EXT UNI (MAP Grayscale, color and Doppler images were obtained of the left subclavian IJ axillary, brachial, basilic, and cephalic veins. There is normal flow, compression and augmentation seen in all of the vessels. . Brief Hospital Course: 69 y/o F with PMHx of large mediastinal SCC s/p right mainstem stenting who presented with recurrent compressive symptoms who underwent OR placement of left mainstem stent and right mainstem APC complicated by hypoxia and PEA arrest. . Pt thought to have had PEA arrest after rigid bronchoscopy was removed, subsequent to L main stent placement for SCLC and use of argon anticoagulation. She underwent CPR immediately for <1 minute. The etilogy was thought to be air emboli secondarely to argon coagulation vs. hypoxia. TEE was not done during procedure due to technical difficulties secondarely to the mediastinal mass. However, TEE done after arrest showing air bubbles in L atrium. On admission the A-a gradient with pO2 was of >450 on 100% Fi02 and lactate was 1.7. She was moving all extremities and following commands. CE were negative x2. Repeat TTE was normal. Anticoagulation was initially held (For DVT) and patient was extubated succesfuly 3 days after initial intubation. Her ventilatory support was minimal, RISBI was <105 with air leak and she was extuabted 24 hours after procedure. Unfortunately, she developped stridor and increase number of secretions in the upper airways with respiratory rate in the 40s and SpO2 in 70s. She required emergent re-intubation. High-dose steroids (methylprednisolone 125 mg q 6hrs) were started and continued for 48 hours and patient was succesfully extubated on day 3. Steroids were slowly down-tapered. Due to long standing disease with e/o hyperinflation on CXR and report of bronchospasm on presentation, she was also treated for COPD exacerbation with standing and prn nebulizers. After several days on the medical floor, patient's respiratory status was not improving. Interventional pulmonology was reconsulted. Pt was taken for flexible bronchoscopy which showed significant mucus, some of which was removed, and [**Female First Name (un) **] on the vocal cords. Thoracentesis was also performed. 800cc were removed and sent for culture. Culture was still pending at time of discharge. LUE DVT: Per PSH report, pt had portacath associated upper extremity DVT and has been on Coumadin, p/w supratherapeutic INR. However, ultrasound on [**3-31**] did not show any DVT. LENIs were negative. Anticoagulation was held prior to procedure and re-started 24 hours afterwards (with lovenox) given her malignancy and higher bleeding risk. During her hospitalization there was concern of a cerebellar metastasis of SCLC. Per radiology, pt should undergo a repeat MRI in 6 weeks for further characterization. Due to h/o DVT and atrial fibrillation as well as evidence of embolic stroke, anticoagulation was continued upon discharge. Primary oncologist, Dr. [**Last Name (STitle) 65126**] was informed of this and he agreed with the plan. Tachycardia / SVT : Pt has remained tachycardic since admission, suspect some component of dehydration and underlying malignancy. CTA neg for PE at OSH prior to transfer. LENIs were negative. Patient was hydrated and tachycardia did not improve. Then, she had episodes of atrial fibrillation up to 140-150 BPM with stable BP. She was started on metoprolol and it was titrated up to 50 mg TID which maintained a HR of 100 as monitored on telemetry. Metoprolol was not further uptitrated as sinus tachycardia was thought to be secondary to her illness. She was discharged on this regimen. Would consider uptitration of metoprolol if rate requies better control. She was diltiazem prior to this admission, but it did not control her heart rate adequately. SCLC: Pt with SCLC s/p chemo/radiation and now with L and R main bronchus metal stents. Given that she has already received max radiation doses plan is to do brachitherapy and chemo as outpatient. She will need follow up MRI in 6 weeks for further charactization of a potential brain metastasis. Outpatient providers will also have to reassess whether or not to continue anticoagulation. Plan for patient to follow up with Dr. [**Last Name (STitle) **] [**Name (STitle) 109613**] ([**Hospital **] [**Hospital 3278**] Medical Center) for HDR ?????? brachytherapy in the Bronchus intermedius in the next week. Follow up with primary oncologist within 2-3wks with a repeat MRI head and CT chest. And follow up with Dr. [**Last Name (STitle) **] in IP in 4 wks for return visit and flex bronch. Bacteremia: Pt grew STAPHYLOCOCCUS, COAGULASE NEGATIVE from a-line, which was removed <24 after positive blood culture and started on Vancomycin (Day 1 [**4-2**]). Then, patient grew MRSA from sputum and plan was to treat with Vanc for 2 weeks given endovascular infection. . UTI: Pts urine was growing GNRs so ciprofloxacin was started. Speciation showed ENTEROBACTER CLOACAE pan-sensitive. She was switched to bactrim to continue treatment for 7 days (D1 [**4-5**]). Medications on Admission: Aspirin 81 mg PO daily Warfarin 5 mg PO daily Diltiazem 240 mg PO daily Magnesium oxide 400 mg PO daily Lorazepam 0.5 mg PO bid Benzonoatate 100 mg PO 1 tab tid Spiriva inhaler (tiotropium) Discharge Medications: 1. Magnesium Oxide 400 mg Tablet Sig: One (1) Tablet PO once a day. 2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for anxiety. 3. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily): for two days then reduce to 20 mg daily for two days, then reduce to 10mg daily for 2 days. 4. Enoxaparin 60 mg/0.6 mL Syringe Sig: One (1) [**Last Name (un) 74210**] syringe Subcutaneous Q12H (every 12 hours). 5. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 6. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 7. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day): pt should also gargle with this medication for treatment of her sore throat ([**Female First Name (un) **]). 8. Guaifenesin 1,200 mg Tab, Multiphasic Release 12 hr Sig: One (1) Tab, Multiphasic Release 12 hr PO BID (2 times a day). 9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb neb neb Inhalation Q6H (every 6 hours). 10. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb neb Inhalation Q2H (every 2 hours) as needed for SOB. 11. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation every six (6) hours as needed for SOB. 12. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for sleep. 13. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed) as needed for sore throat. 14. Sulfamethoxazole-Trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): last dose is evening of [**2166-4-12**]. 15. Vancomycin 1,000 mg Recon Soln Sig: One (1) gram Intravenous twice a day: please resume on [**4-13**] after checking vanco trough to ensure level is not supratherapeutic. Goal 15-20. Last day of treatment is [**4-16**]. 16. Outpatient Lab Work Please check vanco trough every third dose. Please check on trough on [**4-12**] prior to resuming vancomycin administration. 17. Port a cath Please deaccess permanent catheter after antibiotic regimen is complete. 18. Heparin Flush (10 units/ml) 5 mL IV PRN line flush Indwelling Port (e.g. Portacath), heparin dependent: Flush with 10 mL Normal Saline followed by Heparin as above daily and PRN per lumen. 19. Heparin Flush (100 units/ml) 5 mL IV PRN DE-ACCESSING port Indwelling Port (e.g. Portacath), heparin dependent: When de-accessing port, instill Heparin as above per lumen. 20. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: 1 and half tablet daily Tablet Sustained Release 24 hr PO once a day: 150mg daily. 21. Outpatient Lab Work Please check weekly CBC and chem 10 to ensure no major abnormalities Discharge Disposition: Extended Care Facility: [**Hospital6 **] Discharge Diagnosis: primary: small cell lung cancer PEA arrest COPD exacerbation pulmonary effusion atrial fibrillation MSSA bacteremia Enterobacter UTI secondary: hypertension h/o DVT anxiety 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: Ms. [**Known lastname **] - It was pleasure to care for you during your hospitalization. You were admitted for hematemesis. You were to have one of your stents reopened and have another stent placed in your lungs. However, shortly after the procedure you developed very low blood pressure and required ICU hospitalization. You were intubated twice. Upon extubation you had swelling in your neck impairing your breathing, as well as severe wheezing. You were treated with steroids and nebulizers. Unfortunately your breathing did not improve so you underwent another bronchoscopy which showed alot of mucus, some of which was removed. You had fluid removed from your lungs also. Your vocal cords show a candidal infection (thrush) so you should continue to gargle with nystatin swish and swallow. You will require oxygen for some time until your lung function improved. Also during your hospitalization you were found to have Staph aureus infection of your blood stream and possibly a Staph aureus pneumonia. You will complete a 14 day course of Vancomycin (antibiotic). You were also found to have a urinary tract infection for which you are on a second antibiotic called Bactrim. You were also treated for atrial fibrillation (irregular heart rhythm) which requires medication to control the heart rate and continuation of blood thinners to prevent strokes. You were previously on coumadin and this is being switched to lovenox. Unfortunately, to complicate this matter, a small abnormality was found in your brain that may be a metastasis of the lung cancer. This is not entirely clear. If it is, you could potentially have a bleed in the brain. On the other hand, if you do not continue with the lovenox treatment, you could have a stroke from a blood clot formed in the heart, which you may have already had in the past. The present plan is to continue you on blood thinners until we can obtain a repeat MRI to confirm a metastatic brain tumor. At that time, the matter of continuing blood thinners can be readdressed. Regarding treatment - you should discuss further treatment of your lung cancer with your pulmonologists and your primary oncologist. Many medications were changed during this hospitalization: - you will start prednisone taper, ipratropium and albuterol for treatment of COPD - guifenessin has been added to break up mucus - bactrim and vancomycin have been added for treatment of urinary tract infection and blood stream infection - nystatin swish and swallow for treatment of oral and vocal throat [**Female First Name (un) **] infection (yeast). Please gargle with this medication for most effective treatment. - metoprolol has been started for better heart rate control. stop taking diltiazem - lovenox has been started to thin the blood. stop taking coumadin. - aspirin has been discontinued due to increased risk of bleeding. - lorazepam may be used as frequently as every 6 hrs as needed. Followup Instructions: Please make the following appointments. Name: [**Last Name (LF) **],[**First Name3 (LF) 5445**] Address: [**Hospital1 **], [**Hospital1 **],[**Numeric Identifier 93461**] Phone: [**Telephone/Fax (1) 37687**] Appointment: Thursday [**2166-4-24**] 11:15am Department: INTERVENTIONAL PULMONARY When: TUESDAY [**2166-5-13**] at 11:30 AM [**Telephone/Fax (1) 3020**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: CHEST DISEASE CENTER When: TUESDAY [**2166-5-13**] at 12:00 PM [**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 We are working on a follow up appointment with Dr. [**Last Name (STitle) **] [**Name (STitle) 109613**] in the Pulmonary Department at [**Hospital 3278**] Medical Center within 2 weeks. The office will be contacting you at home with an appointment. If you have not heard or have any questions please call [**Telephone/Fax (1) 32678**]. Completed by:[**2166-4-11**]

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Discharge summary

report

Admission Date: [**2113-3-19**] Discharge Date: [**2113-3-25**] Date of Birth: [**2038-2-1**] Sex: M Service: [**Doctor Last Name **]-INT M HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 5850**] is a 75 year old male with a history of coronary artery disease, ischemic cardiomyopathy, and atrial fibrillation, who presented to [**Hospital 8641**] Hospital on [**2113-3-16**], complaining of five days of melena and diffuse abdominal discomfort. His initial hematocrit was 33 and on upper endoscopy he was found to have Barrett's Grade I erosion. There were plans to do colonoscopy for further evaluation of sources for gastrointestinal bleeding and the patient was given a GoLYTELY bowel prep at [**Hospital 8641**] Hospital. However, the patient developed emesis and ten out of ten abdominal pain during this time, with an episode bradycardia to 30 to 50s range and decrease in blood pressure to systolic blood pressure in the 90s in the setting of having had a bowel movement and getting up from the commode. An arterial blood gas was done after this event and the patient was found to have a serum pH of 7.24, pCO2 of 27 and pAO2 of 100 on two liters nasal cannula. There was initial concern for a possible colonic acute mesenteric ischemia given the abdominal pain and hypotension and history of melena, but abdominal CT scan done at the outside hospital did not show any evidence of such. A temporary pacer was placed secondary to the bradycardic event. The patient was started on intravenous heparin given concern for acute mesenteric ischemia with a history of atrial fibrillation. The patient was transferred from the outside hospital for further GI work-up and evaluation. PAST MEDICAL HISTORY: 1. Duodenal ulcer treated with Pepcid; history of H. pylori, treated. 2. History of colonic polyps/AVMs. 3. History of atrial fibrillation on Coumadin. 4. History of coronary artery disease with a history of myocardial infarction in [**2098**]; status post coronary artery bypass graft, left ventricular ejection fraction of 45%; moderate mitral regurgitation and severe pulmonary hypertension. 5. Spinal degenerative joint disease with right shoulder contraction. 6. Type 2 diabetes mellitus, diet controlled. 7. Peripheral vascular disease. 8. Question of chronic obstructive pulmonary disease. ALLERGIES: No known drug allergies. MEDICATIONS ON TRANSFER: 1. Protonix 40 mg p.o. q. day. 2. Heparin 1000 units per hour. 3. Zocor 40 mg p.o. q. day. 4. Levofloxacin 500 mg p.o. q. day. 5. Flagyl 500 mg intravenous q. six. 6. Regular insulin sliding scale. 7. Isordil 40 mg p.o. three times a day. 8. Avapro 300 mg p.o. q. day. 9. Neurontin 100 mg p.o. three times a day. OUTPATIENT MEDICATIONS: 1. Zocor 40 mg p.o. q. day. 2. Isordil. 3. Neurontin 100 mg p.o. three times a day. 4. Lasix 60 mg p.o. q. a.m. 5. Avapro. 6. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**]. 7. Atenolol 50 mg p.o. twice a day. SOCIAL HISTORY: Former smoker, quit since [**2079**]. Former alcohol, quit [**2079**]. Lives in [**Hospital3 **] facility. Daughter [**Name (NI) **] is in open care. PHYSICAL EXAMINATION: In general, a pleasant male in no acute distress. Vital signs with temperature 99.3 F.; heart rate 75; blood pressure 128/88; respiratory rate 23; saturation O2 98%. HEENT: Normocephalic, atraumatic. Dry mucous membranes. Pupils are equal, round and reactive to light. Extraocular movements intact. Neck: Left cordis in place. Cardiac examination: Regular rate and rhythm, no murmurs, rubs or gallops. Lung examination: Clear to auscultation bilaterally. Abdomen soft, with suprapubic and bilateral lower quadrant tenderness but no rebound. Extremities with no cyanosis, clubbing or edema. Chronic venous stasis changes. Neurological: Alert and oriented times three. Cranial nerves intact, grossly non-focal. LABORATORY: From [**3-19**] in the morning, white blood cell count 6.0, hematocrit 28.0, platelets 98 down from 134, MCV 98 to 103. Chemistry panel with sodium 143, potasium 4.1, chloride 109, bicarbonate 22, BUN 31, creatinine 1.8, glucose 104. PT 22.8, PTT 42.3, fibrin 233, negative D-Dimer and negative fibrin degradation products. CK 142, MB fraction 2.2, troponin 0.5. Chest x-ray showed cardiomegaly, no infiltrates, no effusion. CT scan of the abdomen showed gallstones but no evidence of cholecystitis. Right intestinal opacity/adhesions. Open celiac supra-mesenteric and common iliac arteries. SUMMARY OF HOSPITAL COURSE: The patient was initially admitted to the Medical Intensive Care Unit for close monitoring given history of bradycardia, placement of temporary pacemaker and history of recent gastrointestinal bleeding. Hospital course was notable for the following: 1. Gastrointestinal Bleeding: The patient had a known history of arteriovenous malformations and polyps with gastrointestinal bleeding in [**2111-3-23**]. EGD done at the outside hospital showed Grade I esophagitis and CT scan of the abdomen had already patent mesenteric vessels; no valve thickening or obstruction. The patient had had hematocrits checked after blood transfusion at the outside hospital (at least one unit of packed red blood cells and two units of fresh frozen plasma). The GI consultation service was consulted for help in managing the patient's history of gastrointestinal bleeding. The patient was placed on intravenous Protonix, fluids and initially n.p.o. with serial abdominal examinations. After review of the data, history and CT scan, it was felt that acute mesenteric ischemia was unlikely to have been responsible and heparin was discontinued. On [**3-21**], the patient underwent a colonoscopy and esophagogastroduodenoscopy. The EGD showed medium hiatal hernia; otherwise a normal EGD to second part of duodenum. Erosions were seen inside the hernia. These erosions were thought to have been the cause for patient's melena and the GI Consult Service advised keeping patient on Protonix 40 mg p.o. twice a day times one week, then 40 mg p.o. q. day for 60 days. The patient's colonoscopy on [**2113-3-21**], showed polyps in the transverse colon, otherwise normal colonoscopy to the cecum. Polypectomy was recommended at a future date and follow-up when gastrointestinal bleeding and cardiac issues resolved. The patient was subsequently monitored with serial checks with hematocrit which were stable with an initial trend downward. He did have hematocrit of around 27 to 28 when transferred from the Medical Intensive Care Unit to the regular medical [**Hospital1 **] and given his history of coronary artery disease, it was felt that he would benefit from blood transfusion. He received one unit of packed red blood cells and his subsequent hematocrits rose from 29 to 31 range and have remained stable there since. 2. Cardiovascular: The patient has a known history of coronary artery disease and atrial fibrillation. His serial cardiac enzymes were sent to rule out myocardial infarction given recent episode of hypotension and bradycardia. These returned negative. He did have a temporary pacer placed at the outside hospital for symptomatic bradycardia and Cardiology consulted on this matter as well. After review of the patient's history and hematocrit, it was felt that his bradycardia was likely due to a combination of vasovagal episode in the setting of bowel movement during bowel preparation for colonoscopy and beta blockade with Atenolol with the possibility of enhanced effects in the setting of acute renal insufficiency. His beta blockers were initially held and the patient had no further episodes of bradycardia. His blood pressure remained stable and his temporary pacemaker was discontinued. Because he did have a history of atrial fibrillation and did need rate control, low dose beta blockers were restarted with Metoprolol and have been titrated up with good rate control and no further episodes of bradycardia or hypotension. His history of atrial fibrillation had prompted use of anti-coagulants in the past, but given the acute episodes of gastrointestinal bleeding his Coumadin was initially held, but when his hematocrit stabilized, his Coumadin was restarted and should be continued with goal INR of 2.0 to 3.0. Also, his anti-hypertensive medications were held in the setting of hypotensive event, however, when his blood pressure stabilized and his renal function improved, his angiotensin receptor blocker and Lasix were restarted. 3. Hypoxia: The patient developed an O2 requirement during the course of his hospital stay. This was in the setting of transfusion and intravenous fluid and holding of his Lasix. His physical examination and chest x-ray findings were consistent with congestive heart failure and the patient has been restarted on his Lasix and his angiotensin receptor blocker for treatment of this with subsequent improvement in his hypoxia. It is anticipated that with further therapy, his O2 requirements will resolve. He will need continued monitoring of his daily weights and intakes and outputs until his hypoxia resolved and his cardiovascular status becomes stable. 4. Diabetes mellitus: The patient has a known history of type 2 diabetes mellitus that was formerly controlled on diet. He was started on Regular insulin sliding scale and was on fingersticks while in the hospital and may benefit from started an oral [**Doctor Last Name 360**] if he continues to have periodic elevated blood sugars. 5. Deconditioning: After a prolonged hospital stay, the patient was deconditioned and after Physical Therapy evaluation was felt to be someone who could benefit from Physical Therapy in a Rehabilitation setting. DISPOSITION: The patient was subsequently stable fro discharge and is awaiting transfer to Rehabilitation facility. DISCHARGE DIAGNOSES: 1. Gastrointestinal bleeding, likely secondary to esophageal erosions, Barrett's Type I esophagus. 2. Bradycardic event; question vasovagal; question secondary to enhanced effects of beta blocker in the setting of acute renal insufficiency. 3. Acute renal insufficiency; prerenal etiology with creatinine of 1.8 on presentation to [**Hospital1 190**] and improvement to baseline creatinine of 0.9 after intravenous fluid hydration. 4. Anemia secondary to gastrointestinal bleed. 5. History of coronary artery disease. 6. History of type 2 diabetes mellitus. 7. History of atrial fibrillation. 8. Colon polyps; needs GI follow-up for polypectomy once gastrointestinal bleeding issues and cardiovascular status stabilize. 9. Peripheral vascular disease. 10. History of spinal degenerative joint disease. 11. Questionable history of chronic obstructive pulmonary disease. DISCHARGE MEDICATIONS: 1. Protonix 40 mg p.o. twice a day times two weeks, then change to 40 mg p.o. q. day times 60 days. 2. Metoprolol 25 mg p.o. twice a day; continue to monitor heart rate and blood pressure and adjust for rate control. 3. Ibesartan 300 mg p.o. q. day. 4. Atorvastatin 40 mg p.o. q. day. 5. Warfarin 4 mg p.o. q. day; adjust to goal INR of 2.0 to 3.0. 6. Lasix 60 mg p.o. q. a.m. 7. Potassium chloride 10 mEq p.o. q. day. 8. Neurontin 100 mg p.o. three times a day. 9. Isordil 10 mg p.o. three times a day. DISCHARGE INSTRUCTIONS: 1. The patient will be discharged to Rehabilitation. 2. He will need follow-up with his primary care physician on an ongoing basis. 3. He will INR checked two days following discharge and adjust Coumadin to goal INR of 2.0 to 3.0. 4. The patient will also need to follow-up monitoring of his hematocrit to insure stability, given history of gastrointestinal bleeding. 5. The patient will also need follow-up colonoscopy for polypectomy given findings of transverse colon polyps during hospital stay. 6. Discharge diet, cardiac, two gram salt. CONDITION ON DISCHARGE: Stable. [**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D. [**MD Number(1) 4521**] Dictated By:[**Last Name (NamePattern1) 6614**] MEDQUIST36 D: [**2113-3-24**] 17:18 T: [**2113-3-24**] 23:14 JOB#: [**Job Number 40586**]

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Discharge summary

report

Admission Date: [**2142-11-14**] Discharge Date: [**2142-11-23**] Date of Birth: [**2094-8-31**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 898**] Chief Complaint: Back pain. Right sided sensory loss. Major Surgical or Invasive Procedure: OPERATION: 1. Corpectomy of T1 and T2. 2. Fusion C7-T3. 3. Cage placement. 4. Anterior instrumentation C7-T3. 5. Autograft, allograft and bone morphogenic protein. History of Present Illness: This is a 48 y.o. woman with pmh significant for metastatic thyroid cancer, s/p median sternotomy, T1 & T2 Corpectomy w/ T1-T3 Fusion/Cage, with subsequent bilateral pulmonary embolism, being transferred to medicine for optimization of anticoagulation. The patient presented on [**2142-11-14**] complaining of right sided back pain, along with weakness and diminshed sensation on the right side of her body. Imaging at the time revealed tumor infiltration of her thopracic spine, and she underwent median sternotomy, T1 & T2 Corpectomy w/ T1-T3 Fusion/Cage. Her post-operative course was complicated by bilateral pulmonary emboli. She was begun on anticoagulation and is now s/p IVC filter placement. Past Medical History: papillary Thyroid Cancer diagnosed 10yrs ago, s/p thyroidectomy, 4 radioactive iodine trwatments. . Thyroidectomy. Social History: lives with husband and 4 kids. Alcohol [**3-10**] drinks a week. Smoking 5 cig day - 5 years Family History: father with [**Name2 (NI) 499**] cancer Physical Exam: Vitals: T:98.0 P:72 BP:124/76 R:16 SaO2:94%RA General: Awake, alert, NAD. Hard Cervical collar on HEENT: NC/AT, PERRL, EOMI without nystagmus, no scleral icterus noted, MMM, no lesions noted in OP Neck: Hard collar Pulmonary: Lungs CTA bilaterally Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Skin: no rashes or lesions noted. Neurologic: -mental status: Alert, oriented x 3. Able to relate history without difficulty. -cranial nerves: II-XII intact -motor: normal bulk, strength and tone throughout. No abnormal movements noted. -sensory: No deficits to light touch throughout. -cerebellar: No nystagmus, dysarthria, intention or action tremor Pertinent Results: [**2142-11-13**] 05:10PM BLOOD WBC-12.1* RBC-3.41* Hgb-11.1*# Hct-33.5* MCV-98 MCH-32.7* MCHC-33.3 RDW-13.6 Plt Ct-481* [**2142-11-22**] 07:40AM BLOOD WBC-11.0 RBC-3.33* Hgb-10.5* Hct-31.7* MCV-95 MCH-31.6 MCHC-33.2 RDW-14.7 Plt Ct-355 [**2142-11-23**] 07:30AM BLOOD WBC-13.1* RBC-3.18* Hgb-10.3* Hct-29.3* MCV-92 MCH-32.3* MCHC-35.0 RDW-14.9 Plt Ct-336 [**2142-11-13**] 05:10PM BLOOD Neuts-94.1* Bands-0 Lymphs-4.6* Monos-0.4* Eos-0.8 Baso-0.1 [**2142-11-18**] 12:05PM BLOOD Neuts-88.7* Lymphs-5.7* Monos-5.0 Eos-0.5 Baso-0 [**2142-11-21**] 12:50AM BLOOD PT-12.1 PTT-83.8* INR(PT)-1.0 [**2142-11-21**] 12:50PM BLOOD PT-13.5* PTT-103.9* INR(PT)-1.2* [**2142-11-21**] 09:00PM BLOOD PT-16.5* PTT-68.6* INR(PT)-1.5* [**2142-11-22**] 04:55AM BLOOD PT-23.2* PTT-76.5* INR(PT)-2.3* [**2142-11-22**] 07:40AM BLOOD PT-24.9* PTT-80.9* INR(PT)-2.5* [**2142-11-22**] 12:50PM BLOOD PT-29.7* PTT-68.9* INR(PT)-3.1* [**2142-11-23**] 07:30AM BLOOD PT-39.1* PTT-34.4 INR(PT)-4.4* [**2142-11-13**] 05:10PM BLOOD Glucose-113* UreaN-15 Creat-1.0 Na-140 K-4.8 Cl-103 HCO3-27 AnGap-15 [**2142-11-23**] 07:30AM BLOOD Glucose-94 UreaN-19 Creat-0.6 Na-141 K-4.0 Cl-106 HCO3-27 AnGap-12 [**2142-11-16**] 07:05AM BLOOD ALT-20 AST-17 AlkPhos-76 [**2142-11-16**] 07:05AM BLOOD GGT-48* [**2142-11-13**] 05:10PM BLOOD Calcium-9.7 Phos-4.5 Mg-2.3 [**2142-11-21**] 07:15AM BLOOD Calcium-7.8* Phos-3.3 Mg-2.0 [**2142-11-18**] 04:14AM BLOOD TSH-0.32 [**2142-11-19**] 03:57PM BLOOD freeCa-1.10* [**2142-11-14**] 05:34PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-TR [**2142-11-14**] 05:34PM URINE RBC-0 WBC-0-2 Bacteri-FEW Yeast-NONE Epi-[**12-25**] . [**2142-11-14**] 5:34 pm URINE Source: CVS. **FINAL REPORT [**2142-11-15**]** URINE CULTURE (Final [**2142-11-15**]): GRAM POSITIVE BACTERIA. >100,000 ORGANISMS/ML.. Alpha hemolytic colonies consistent with alpha streptococcus or Lactobacillus sp. . [**2142-11-19**] 7:36 am MRSA SCREEN Source: Nasal swab. **FINAL REPORT [**2142-11-22**]** MRSA SCREEN (Final [**2142-11-22**]): No MRSA isolated. . [**2142-11-19**] 7:36 am MRSA SCREEN Source: Rectal swab. **FINAL REPORT [**2142-11-22**]** MRSA SCREEN (Final [**2142-11-22**]): No MRSA isolated. . [**2142-11-19**] 7:35 am SWAB Source: Rectal swab. **FINAL REPORT [**2142-11-21**]** R/O VANCOMYCIN RESISTANT ENTEROCOCCUS (Final [**2142-11-21**]): No VRE isolated. . CT T-SPINE W/O CONTRAST [**2142-11-13**] 7:41 PM CT T-SPINE W/O CONTRAST Reason: please eval for progression of met disease, spine integrity [**Hospital 93**] MEDICAL CONDITION: 48 year old woman with known metastatic thyroid cancer to T2 and lungs with new b/l UE and LE 4/5 weakness and tingling and numbness REASON FOR THIS EXAMINATION: please eval for progression of met disease, spine integrity CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 48-year-old female with metastatic thyroid cancer to the T2 vertebral body and lungs with weakness and tingling in the upper and lower extremities. Evaluate for metastatic disease. COMPARISON: [**2142-9-25**]. TECHNIQUE: Axial CT images of the thoracic spine were obtained without IV contrast. Bone algorithm and sagittal and coronal reformations were performed. FINDINGS: The extension of the lytic metastatic lesion, primarily within the T2 vertebral body, into the T1 vertebral body has increased in size in the interval. There is persistant vertebral plana with a focal kyphosis of the T2 vertebral body with more extensive lytic lesions of the right T2 pedicle and lamina. The soft tissue mass along the right posterior aspect of the T2 vertebral body, extending into the bony spinal canal appears slightly increased in size, causing severe canal stenosis. There has been slight interval increase in size of the lucent lesion along the right superior endplate of T3 indicating this likely represents extension of the metastatic lesion. There are multiple scattered pulmonary nodules throughout the lungs similar in size and number, consistent with diffuse metastatic disease. Surgical clips are seen within the thyroid bed. IMPRESSION: Progression of osseous metastatic disease involving the T1-T3 vertebral bodies with associated increase in size of the soft tissue lytic lesion at the level of the T2 causing worsened (severe) spinal canal stenosis. An MRI would provide much better evaluation of soft tissue extension and cord and nerve root compression. . CHEST (PA & LAT) [**2142-11-14**] 7:11 PM CHEST (PA & LAT) Reason: please evaluate for pulmonary infiltrates [**Hospital 93**] MEDICAL CONDITION: 48 year old woman with metastatic ca to spine, presenting with low grade fever and elevated WBC REASON FOR THIS EXAMINATION: please evaluate for pulmonary infiltrates TWO-VIEW CHEST [**2142-11-14**] COMPARISON: [**2142-8-23**]. INDICATION: Metastatic cancer. Fever and elevated white blood cell count. Heart size, mediastinal and hilar contours are normal. Multiple small nodules are present throughout both lungs, most prominent in the mid and lower lungs, measuring up to about a centimeter in diameter. In retrospect, a few of these nodules may have been present on the previous examination but the overall size and number appears increased. Biapical thickening appears unchanged. No pleural effusions are identified. Known metastatic disease to the upper thoracic spine is not well demonstrated radiographically. IMPRESSION: Multiple small pulmonary nodules, highly suspicious for metastatic disease. . MR THORACIC SPINE W/O CONTRAST [**2142-11-14**] 5:07 AM MR THORACIC SPINE W/O CONTRAST Reason: eval for cord compression [**Hospital 93**] MEDICAL CONDITION: 48 year old woman with recent surgeyr, inc pain REASON FOR THIS EXAMINATION: eval for cord compression CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Evaluate for cord compression. Additional information from the online medical record indicates that the patient has a history of metastatic disease with cancer to the T2 vertebral body. COMPARISON: Comparisons were made to CT of the thoracic spine, [**2142-11-13**] and MR thoracic spine, [**2142-10-5**]. TECHNIQUE: Multiplanar MR imaging of the thoracic spine was performed without intravenous contrast. The following sequences were obtained: sagittal T1, T2, IR. and axial T2. FINDINGS: Redemonstrated is vertebra plana of the T2 vertebral bony with abnormal low signal on T1-weighted imaging within the marrow of the T1 vertebral body and superior portion of the T3 vertebral body secondary to metastatic involvement. Abnormal signal extends into the posterior elements at these levels and there is a large soft tissue component extending posteriorly along the right side of the spinal canal. Both the osseous involvement and the soft tissue components have worsened from [**10-5**]. Although the axial images are degraded by patient motion, they still demonstrate severe compression of the spinal cord at the T2 level and severe compression of the exiting neural foramen at these levels. Spinal cord compression has increased from [**2142-10-5**] though the cord maintains normal signal characteristics. Inversion recovery images demonstrate abnormal high signal within the T3 vertebral body and posterior soft tissues from T1 to T3 that represent reactive changes. Rocal kyphosis at this level has also worsened from [**2142-10-5**]. The multiple pulmonary metastases are not well visualized on this study. IMPRESSION: Metastatic vertebra plana of T2 and additional metastases involving T1 and T3 with worsening severe spinal cord compression secondary to an enlarging large soft tissue component. Close observation is recommended given the extent of spinal cord compression. Accurate assessment of the extent of disease is limited due to lack of IV contrast, which was not given as the indication mentioned was cord compression. To consider IV contrast study, based on clinical discretion. . ROUTINE MRI OF THE CERVICAL AND LUMBAR SPINE WAS PERFORMED WITHOUT AND WITH GADOLINIUM. Comparison is made with multiple prior studies including [**2142-11-13**] and [**2142-10-5**]. FINDINGS: As noted on the prior examination from [**2142-11-14**], there is metastatic vertebra plana of T2 with extensive epidural tumor causing circumferential narrowing and encasement of the spinal cord. Tumor involves the posterior elements, particularly on the right. There is mild cord compression at this level, without abnormal cord signal present. Metastatic involvement of T1 and T2 vertebral bodies is also noted. There are mild spondylotic changes in the cervical spine. Tumor extends into the neural foramen at T2, on the right. Evaluation of the lumbar spine demonstrates no evidence for abnormal marrow signal or pathologic compression. There is no abnormality within the thecal sac. IMPRESSION: Severe vertebra plana at T2 with cord compression. Also evidence for metastatic involvement at T1 and T3. . Pathology Examination Name Birthdate Age Sex Pathology # [**Hospital1 18**] [**Known lastname 18269**],[**Known firstname **] [**2094-8-31**] 48 Female [**-8/3998**] [**Numeric Identifier 18270**] Report to: DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] Gross Description by: DR. [**Last Name (STitle) **]. [**Doctor Last Name 395**]/mtd SPECIMEN SUBMITTED: 1. FS T 2 BONE/SOFT TISSUE, 2. FS T 4 BONE, 3. T4 TUMOR Procedure date Tissue received Report Date Diagnosed by [**2142-11-16**] [**2142-11-16**] [**2142-11-22**] DR. [**Last Name (STitle) **]. [**Doctor Last Name 2336**],DR. [**Last Name (STitle) **]. [**Doctor Last Name **]/cma?????? Previous biopsies: [**Numeric Identifier 18271**] LEFT & RIGHT THYROID LOBE, MODIFIED RADICAL NECK [**Numeric Identifier 18272**] LEFT LYMPH NODE CERVICAL/jf/3. DIAGNOSIS: Thoracic vertebrae: I. T2 bone and soft tissue (A-B): Poorly differentiated carcinoma with squamous features, see note. II. T4 bone (C-D): Poorly differentiated carcinoma with squamous features, see note. III. T4 tumor (E): Poorly differentiated carcinoma with squamous features, see note. Note: Immunoperoxidase studies, performed on both parts II and III show the carcinoma to be strongly positive for CK7 and TTF-1 (nuclear pattern) and negative for CK20 and thyroglobulin. These findings (in particular, positive nuclear TTF-1 and negative for thyroglobulin) are not typical of a thyroidal primary and suggest a lung origin for this metastasis. Clinical correlation is indicated. Previous slides are unavailable for comparison. Clinical: Specimen submitted: 1. FS T2 Bone and soft tissue. 2. FS T4 bone. 3. T4 Tumor. Gross: The specimen is received fresh in two parts, in the O.R., each container labeled with the patient's name, "[**Known firstname 1743**] [**Known lastname 14218**]" and the medical record number. Part 1 is additionally labeled "T2 bone and soft tissue". It consists of fragments of bone and soft tissue measuring 0.5 x 0.4 x 0.3 cm in aggregate. A portion was frozen. Frozen section diagnosis by Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] is: "Bony and soft tissue with reactive changes; no malignancy identified; sampling very limited because of bone content". The specimen is entirely submitted as follows: A=frozen section remnant, B=remainder of tissue. Part 2 is additionally labeled "T4 bone". It consists of fragments of bone and soft tissue measuring 1.5 x 1.0 x 0.5 cm in aggregate. A portion was frozen with a frozen section diagnosis by Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **] of: "Epithelial aggregate admixed with dense reactive tissue consistent with metastatic carcinoma; this tumor does not look like typical papillary thyroid carcinoma. Permanent section is needed for diagnosis". The specimen is entirely submitted as follows: C=frozen section remnant, D=remainder of tissue. A-D were decalcified at the bench. Part 3 is additionally labeled "T4 tumor". It consists of a reddish fragment of tissue measuring 0.9 x 0.4 x 0.3 cm. The specimen is entirely submitted into cassette E. . CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2142-11-17**] 8:10 PM CTA CHEST W&W/O C&RECONS, NON- Reason: 48 F w/ metastatic thyroid CA, s/p T1-T3 corpectomy for meta [**Hospital 93**] MEDICAL CONDITION: 48 year old woman with thyroid CA, mets to thoracic spine REASON FOR THIS EXAMINATION: 48 F w/ metastatic thyroid CA, s/p T1-T3 corpectomy for metastatic lesion, POD 2, now w/ acute O2 desaturation, r/o PE CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 48-year-old woman with thyroid cancer and metastatic disease to the thoracic spine. Status post T1-T3 corpectomy for metastatic lesion, POD 2, now acute O2 desaturation, rule out PE. TECHNIQUE: CTA CHEST WITHOUT AND WITH CONTRAST: COMPARISONS: No prior chest CTs are available for comparison. CTA CHEST: There are multiple bilateral PEs. There are partially occlusive thrombi in both main pulmonary arteries. Multiple clots cause near occlusion of the right lower lobe branches. There is near occlusive thrombosis of a segmental right middle lobe branch and the right upper lobe branch. On the left, there is partial occlusion of all lower lobe pulmonary artery branches as well as lingular segmental branch and a clot at the origin of the left upper lobe branches with patency distally. There is bilateral dependent atelectasis and there is a small right-sided pleural effusion. A drain is seen traversing anterior to the liver cranially to the left lung apex and then descending into the left hemithorax and terminating at the left lateral costophrenic angle. The patient is intubated with the ETT tip about 3-1/2 cm above the carina. The airways are patent to the subsegmental bronchi level. Heart size is within normal limits. There is no pericardial effusion. Multiple pulmonary metastases are seen throughout all lobes of the lung with lower lobe predominance. The largest one is located in the right middle lobe measuring 11 mm (3:52). The patient is status post T1- T3 corpectomy for metastases and there is a fixation plate with screws in T3 and T1 vertebral bodies transbridging T2. A round stabilization column is seen in between. A large metastatic mass causes destruction of nearly the entire T2 vertebral body and posterior elements and partially also of T3 and T1. There is invasion of the mass into the spinal canal and encasement of the spinal cord at these levels. There is a 2 x 2 cm area of abnormal soft tissue superior to the aortic knob in the left apical mediastinum likely representing a small hematoma related to the recent surgery. The patient is status post midline sternotomy with intact wires. Multiple surgical clips are seen along the thyroid bed and in the left apical mediastinum. Several small bubbles of air are seen adjacent to the midline sternotomy and there is some stranding in the adjacent chest wall soft tissues, expected post-surgical changes. No acute pathology is seen in the partially visualized abdominal organs. IMPRESSION: 1. Massive bilateral PEs with involvement of branches to all lobes. Partially occlusive thrombi in the main pulmonary arteries. 2. Bilateral dependent atelectasis and small right pleural effusion. No apparent pulmonary infarcts. 3. Innumerable metastatic nodules in both lungs. 4. Status post T1-T3 corpectomy for a metastatic mass that causes encasement of the spinal cord at these levels. There is a small left apical mediastinal hematoma. . BILAT UP EXT VEINS US PORT [**2142-11-18**] 10:19 AM BILAT UP EXT VEINS US PORT Reason: BILAT PE [**Hospital 93**] MEDICAL CONDITION: 48 year old woman with massive bilateral PE REASON FOR THIS EXAMINATION: ?DVT LEFT UPPER EXTREMITY VENOUS ULTRASOUND INDICATION: 48-year-old woman with massive bilateral PE. Rule out DVT. COMPARISON: Not available. FINDINGS: Grayscale and color Doppler images of right internal jugular, subclavian, axillary, brachial veins were obtained. These demonstrate hyperechoic material and absent color flow in the left internal jugular vein and no normal color flow in the subclavian vein. Normal flow and augmentation were present in the axillary and brachial veins. Compressibility was not tested as study was terminated per request of the clinician. IMPRESSION: Left internal jugular vein thrombosis. Findings concerning for left subclavian vein thrombosis. . CHEST (PORTABLE AP) [**2142-11-20**] 6:30 AM CHEST (PORTABLE AP) Reason: evaluate for pneumothorax [**Hospital 93**] MEDICAL CONDITION: 48F with h/o recently diagnosed metastatic thyroid carcinoma to the lung and T spine. Now w/ bilateral PE. CT removed yesterday REASON FOR THIS EXAMINATION: evaluate for pneumothorax AP CHEST 6:41 A.M. ON [**11-20**] HISTORY: Metastatic thyroid carcinoma. Bilateral PE. Chest tube removed exclude pneumothorax. IMPRESSION: AP chest compared to [**11-18**] through 15: Left lower lobe atelectasis and small left basal pleural effusion have increased since [**11-19**]. Right lung is clear. Cardiomediastinal silhouette is midline and unremarkable. No endotracheal tube is seen below C7, the upper margin of this film and a right internal jugular line tip projects over the superior cavoatrial junction. No pneumothorax. Multiple nodules seen in the right lower lung presumably metastases. Dr. [**Last Name (STitle) **] [**Last Name (STitle) **] paged to report these findings at the time of dictation. Brief Hospital Course: Assessment and Plan: 48 y.o. woman with pmh significant for metastatic thyroid cancer, s/p median sternotomy, T1 & T2 Corpectomy w/ T1-T3 Fusion/Cage, with bilateral pulmonary embolism, being transferred to medicine for optimization of anticoagulation. . #)Pulmonary Embolism: Patient was found to have bilateral PE after surgery, is s/p IVC filter and being anticoagulated with coumadin after bridged with heparin drip. She received 5mg Coumadin on [**11-20**] and [**11-21**], 2.5mg on [**11-22**]. INR has increased over this period 1.2->2.5->3.1, and was 4.4 the day of discharge. Coumadin was therefore held, and she was sent home with instructions to take 2.5mg on saturday, and 2.5mg on Sunday. The patient has follow-up with her PCP on [**Name9 (PRE) 766**] to have an INR measured. Patient will need at least 3 months of anticoagulation. . #)Papillary thyroid cancer s/p thyroidectomy: The patient was continued on levothyroxine. The patient has an appointment scheduled with her outpatient oncologist after discharge. . #)Thoracic Spine Surgery: The pathology sample from thoracic spine surgery is most sugestive of a primary lung cancer, rather than a metastatic thyroid cancer as previously thought at presentation. She has an appointment to meet with her oncologist after discharge. Patient was instructed to wear her hard collar at all times when she was out of bed. She has an appointment to follow-up with her orthopedic spine surgeon, Dr. [**Last Name (STitle) 363**] after discharge. . #)Cord Compression: After surgery, the patient no longer had focal neurological signs on exam, and strength and sensation returned to her right side. She was immediately placed on dexamethasone 4mg IV q6h as soon as spinal compression was discovered. She was switched to prednisone 50mg [**Hospital1 **] after surgery. She was discharged on a prednisone taper, with a regimen of 50mg daily for 4 days, then 25mg daily for 4 days, then 10mg for 4 days, then stop. Medications on Admission: Levoxyl 150 Ibuprofen 800 q6h Vicodin 5mg/500mg q6h prn pain prednisone 10 mg daily Discharge Medications: 1. Levothyroxine 50 mcg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 2. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain for 5 days. Disp:*40 Tablet(s)* Refills:*0* 3. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. Disp:*15 Tablet(s)* Refills:*0* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 7. Outpatient Lab Work Please have your PT/INR measured. Results should be faxed to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. at [**Telephone/Fax (1) 11038**] 8. Prednisone 50 mg Tablet Sig: One (1) Tablet PO once a day for 4 days: Take 50mg each morning for four days, from [**11-24**] to [**11-27**]. Disp:*4 Tablet(s)* Refills:*0* 9. Prednisone 50 mg Tablet Sig: .5 Tablet PO once a day for 4 days: Take 25mg each morning for four days from [**11-28**] through [**12-1**]. Disp:*2 Tablet(s)* Refills:*0* 10. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for 4 days: Take 10mg each morning for four days, from [**12-2**] through [**12-5**]. Disp:*4 Tablet(s)* Refills:*0* 11. Ambien 5 mg Tablet Sig: 1-2 Tablets PO at bedtime as needed for insomnia for 4 days: Take 1-2 tablets each night for insomnia. Disp:*8 Tablet(s)* Refills:*0* 12. Warfarin 1 mg Tablet Sig: Two (2) Tablet PO once a day for 1 months: Take two tablets daily beginning on [**2142-11-25**]. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital6 486**] Discharge Diagnosis: Metastatic Thyroid Cancer Spinal Cord Compression Discharge Condition: Good 97.0 97.0 146/92 58 16 96RA Discharge Instructions: You were admitted to the hospital after experiencing back pain and right sided weakness and numbness. Evaluation revealed that you had tumor invasion of your thoracic spine with compression of your spinal cord. You underwent surgery to remove the tumor and stabilize your spinal column. You will need further surgery on your spine in the future. . Please follow up as described below. . Please call your primary care physician or return to the hospital if you experience any further weakness, numbness or tingling, back pain, chest pain, shortness of breath, difficulty breathing, or fever. Followup Instructions: You have an appointment with your PCP [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 1579**] on [**2142-11-26**] at 2:10pm. . You have an appointment with your Orthopedic Surgeon [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 363**] [**Telephone/Fax (1) 3573**] on [**12-6**], at 1:30pm at [**Hospital Ward Name 23**] clinical center floor 2. . Provider: [**First Name11 (Name Pattern1) 312**] [**Last Name (NamePattern4) 3015**], M.D. Phone:[**Telephone/Fax (1) 1803**] Date/Time:[**2142-12-4**] 11:30 . Please call to confirm all appointments

[ "998.12", "415.11", "198.5", "722.0", "E849.7", "V10.87", "E878.8", "197.0", "599.0", "041.01" ]

icd9cm

[ [ [] ] ]

[ "77.79", "81.62", "81.02", "80.99", "38.7", "84.51", "84.52" ]

icd9pcs

[ [ [] ] ]

23775, 23825

20032, 22006

353, 519

23919, 23957

2379, 5107

24597, 25201

1514, 1555

22141, 23752

19103, 19231

23846, 23898

22032, 22118

23981, 24574

2149, 2360

1570, 2053

277, 315

19260, 20009

547, 1249

2068, 2132

1271, 1387

1403, 1498

11,952

152,440

22153

Discharge summary

report

Admission Date: [**2115-3-7**] Discharge Date: [**2115-4-30**] Date of Birth: [**2062-9-7**] Sex: F Service: MEDICINE Allergies: Codeine / Demerol Attending:[**First Name3 (LF) 9554**] Chief Complaint: 52 yo female known by the transplant service, sp OTL on [**2115-1-27**]. DC home on [**2115-3-2**]. Readmitted on [**2115-3-7**] from nursing facilty with diagnosis of hypotension and increasing liver function tests Major Surgical or Invasive Procedure: Post pyloric feeding tube [**2115-3-8**] Transjugular biopsy History of Present Illness: 52 yo female known by the transplant service, sp OTL on [**2115-1-27**]. DC'd to home on [**2115-3-2**]. Readmitted on [**2115-3-7**] from nursing facilty with diagnosis of hypotension, increasing liver function test. Past Medical History: 1. Heavy ETOH abuse since age 20 for about 30 years. Used to drink pint a day. Unsuccessful detox treatment in the past. No h/o DTs, or seizures. 2. Liver cirrhosis with portal HTN, thrombocytopenia, coagulopathy. (hepatologist Dr. [**Last Name (STitle) 497**] 2. H/o upper and lower GI bleeding in [**2111**] with EGD positive for varices which were ?banded . 3. h/o HTN 4. h/o low back pain 5. s/p tubal ligation [**2093**] 6. Ectopic pregnancy [**2099**] Social History: Tobacco ?????? [**3-15**] cigarettes/dayEtOH ?????? Stopped drinking on [**3-15**], previously [**4-12**] vodka drinks per day for 30 years.IVDU ?????? denies. Lives w/husband. Family History: Strong hx of alcohol abuse and cirrhosis. Father died from MI at 53. Mother died at 57 from alcohol abuse, brother died in the last two years from alcohol abuse Physical Exam: bp 96-100/50-60 hr 45 rr 20 sao2 2l 100% RRR S1 S2 SEM III/VI lungs:CTA Abd: soft, mildly distended extremities:edema to knees b/l Chronic brawny skin changes in both lower extremities Pertinent Results: CHEST (PORTABLE AP) [**2115-4-29**] 7:07 AM IMPRESSION: 1. Interval removl of pericardial drain with stable appearance of the mediastinal and cardiac contours. 2. Persistent bilateral pleural effusions. ECHO Study Date of [**2115-4-28**] Conclusions: The left atrium is dilated. The right atrium is dilated. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is severely depressed. There is severe global right ventricular free wall hypokinesis. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. There are three aortic valve leaflets. No aortic regurgitation is seen. Moderate to severe (3+) mitral regurgitation is seen. Severe [4+] tricuspid regurgitation is seen. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. ECHO Study Date of [**2115-4-25**] Conclusions: There is a moderate to large sized pericardial effusion. The effusion appears circumferential. There is brief right atrial diastolic collapse; although there is no frank diastolic collapse of the right ventricle, this chamber appears compressed. Echocardiographic signs of tamponade may be absent in the presence of elevated right sided pressures. C.CATH Study Date of [**2115-4-25**] COMMENTS: 1. Selective coronary angiography was performed which revealed a right dominant system. There was no angiographically apparent CAD in the LMCA, LAD, LCX, or RCA. 2. Hemodynamics on entry showed markedly elevated right and left heart filling pressures (RVEDP 21 mm Hg, PCWP mean 30 mm Hg), depressed cardiac index (1.6), and mild pulmonary hypertension (PASP 47 mm Hg). 3. Endomyocardial biospy was performed with removal of 5 specimens. The procedure was tolerated well. 4. After the completion of the RV biopsy, right heart cath, and coronary angiograms, the 5 F right FA sheath was pulled in the cath lab. The patient became hypotensive to SBP in the 70s by noninvasive measurement with a HR of 105. Her pressure did not respond to atropine. An emergent echo was done, which showed a large pericardial effusion with signs worrisome for tamponade. The patient was reprepped for an emergent pericardiocentesis. The patient was mentating throughout. 5. Pericardiocentesis was performed via the subxyphoid approach with removal of approximately 700 cc of bloody fluid. RA pressure fell from fell from 31 mm Hg to 22 mm Hg and SBP increased from 80 to 120 mm Hg after the pericardiocentesis was performed. FINAL DIAGNOSIS: 1. Coronary arteries are normal. 2. Endomyocardial biopsy was performed. 3. Post procedure, patient developed severe pericardial tamponade. 4. Mild pulmonary hypertension, elevated filling pressures, low cardiac output. CT CHEST W/O CONTRAST [**2115-4-10**] 9:16 AM IMPRESSION: 1) Unchanged appearance of 9-mm noncalcified nodule in the right lower lobe, please follow in 3 months. 2) Increase of bilateral pleural effusion and pericardial effusion, associated with atelectasis. 3) Focal area of consolidative opacity in the posterior segment of right upper lobe, which probably is representing atelectasis, however, pneumonia cannot be excluded. 4) Cardiomegaly. 5) Decreased ascites and splenomegaly in this patient status post liver transplant. 6) Extensive diffuse subcutaneous edema. US ABD LIMIT, SINGLE ORGAN [**2115-3-13**] 10:16 AM FINDINGS: Targeted grayscale examination of the abdomen reveals a moderate volume of ascites, increased since the prior study. A dedicated assessment of the liver was not performed. IMPRESSION: Moderate volume of ascites. WBC HB HCT [**2115-4-22**] 6:15A 5.4 3.14* 10.4* 32.0* 102* 33.2* 32.6 22.3* [**2115-4-21**] 6:30A 5.7 3.28* 10.4* 34.3* 105* 31.7 30.3* 22.5* (2) LINE:PICC BASIC COAGULATION (PT, PTT, PLT, INR) (BLOOD) DATE PT 11.6-13.6 sec PT [**Name (NI) **] sec PTT 22.0-35.0 sec PTT Mea sec Plt Smr Plt Ct 150-440 K/uL BLEED T 2-8 MINUTES FIBRINO 200-400 MG/DL FSP 0-10 UG/ML INR(PT) MPV 7.2-9.4 fL LPlt PltClmp [**2115-4-22**] 6:15A 197 [**2115-4-22**] 6:15A 17.0* 31.7 1.8 [**2115-4-21**] 6:30A (4) 210 (4) LINE:PICC [**2115-4-21**] 6:30A (6) 15.9* 30.8 1.6 (6) LINE:PICC BASIC COAGULATION (FIBRINOGEN, DD, TT, REPTILASE, BT) (BLOOD) DATE Fibrino 150-400 mg/dL [**Last Name (un) **] Fib 150-325 mg/dL FDP 0-10 ug/mL D-Dimer 0-500 ng/mL Thrombn 16-20 sec Control sec Reptlas 15-25 sec Rept Ct sec Bleed T 2-8 min [**2115-4-22**] 6:15A 282 [**2115-4-21**] 6:30A (8) 294 (8) LINE:PICC RENAL & GLUCOSE (BLOOD) DATE Glucose 70-105 mg/dL UreaN 6-20 mg/dL Creat .4-1.1 mg/dL Na 133-145 mEq/L K 3.3-5.1 mEq/L Cl 96-108 mEq/L HCO3 22-29 mEq/L AnGap [**9-28**] mEq/L [**2115-4-22**] 6:15A 110* 22* 0.6 138 3.7 101 31* 10 03/DATE ALT 0-40 IU/L AST 0-40 IU/L LD(LDH) 94-250 IU/L CK(CPK) 26-140 IU/L AlkPhos 39-117 IU/L Amylase 0-100 IU/L TotBili 0-1.5 mg/dL DirBili 0-.3 mg/dL IndBili mg/dL [**2115-4-22**] 6:15A 17 22 244 379* 17 0.6 [**2115-4-21**] 6:30A (12) 18 25 269* 338* 21 0.6 (12) LINE:PICC OTHER ENZYMES & BILIRUBINS (BLOOD) DATE HLAP 21-85 IU/L HSAP 6-48 IU/L Lipase 0-60 IU/L LAP 27-59 IU/L GGT 5-36 IU/L AcdPhos 0-5.4 IU/L ProsFx 0-1.2 IU/L NonPros 0-5.4 IU/L 5'ND [**3-21**] U/L Uncon B MG/DL Delta/D MG/DL Conj [**Hospital1 **] NBil 0-1.5 mg/dL Dlta [**Hospital1 **] MG/DL N-DBil mg/dL N-IBil mg/dL [**2115-4-22**] 6:15A 9 [**2115-4-21**] 6:30A (14) 10 (14) LINE:PICC CHEMISTRY (BLOOD) DATE TotProt 6.4-8.3 g/dL Albumin 3.4-4.8 g/dL Globuln [**3-15**] g/dL Calcium 8.4-10.2 mg/dL Phos 2.7-4.5 mg/dL Mg 1.6-2.6 mg/dL UricAcd 2.4-5.7 mg/dL Iron 30-160 ug/dL Cholest 0-199 mg/dL [**2115-4-22**] 6:15A 2.8* 8.4 4.1 1.9 [**2115-4-21**] 6:30A (16) 2.7* 8.4 4.3 2.3 (16) LINE:PICC PITUITARY (BLOOD) DATE FSH [**3-23**] mIU/mL LH 2-100 mIU/mL Prolact [**8-8**] ng/mL [**Hospital1 **] ng/dL ACTH ng/L MacrPRL 60-100 % TSH .27-4.2 uIU/mL [**2115-4-21**] 6:30A (18) 2.6 (18) LINE:PICC 13/05 6:30A (10) 29* Brief Hospital Course: Patient admitted with hypotension, increasing liver enzymes, for evaluation for rejection. Underwent liver biopsy that showed:Liver, allograft, transjugular biopsy: 1. Small fragmented biopsy with few portal areas showing no significant inflammation. 2. Moderate predominantly microvesicular steatosis. 3. No features of acute cellular rejection seen 4. No intracytoplasmic hyalin seen. 5. Trichrome and reticulin stains show no significant fibrosis. 6. Iron stain: No stainable iron seen. Echocardiogram showed:The left atrium is mildly dilated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis. The right ventricular cavity is dilated. There is severe global right ventricular free wall hypokinesis. 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. Moderate (2+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the findings of the prior study (tape reviewed) of [**2114-8-14**], contractile function of the left and right ventricular function is profoundly depressed. ABDOMINAL DOPPLER US DONE SHOWED:Flow is identified within the main hepatic artery, but no definite intrahepatic arteries were visualized with flow. Although this could be technical, this is a concerning finding and was discussed with Dr. [**Last Name (STitle) **] in the morning of [**2115-3-9**]. Persistent non-occlusive thrombus in the extrahepatic portal vein. Patient was transferred to SICU for further management, cardiology heart failure was involved in patient care, recommended gentle diuresis. Patient at that point with mean bp 55-60 and SBP 80's. Was placed on dopamine drip, to increase the cardiac out put. Swan catheter was placed on arrival to the intensive care unit for further management of the CHF, and to obtain more info about the cardiac function. Patient was managed with milrinone and IV lasix. Later, a Natrecor drip was started. Her fluid status slowly improved. Patient finally was weaned off the Natrecor drip and the dopamine, and was left on Lasix drip. At that point the bp of the patient did not tolerate Lasix bolus. Patient remain in the SICU until the Lasix drip was successfully wean off, and was placed on Lasix IV bolus. Post pyloric tube feedings were started during her SICU stay. Once on the floor the diuretics were started per mouth, aggressive physical therapy was installed, and more nutrition po, cycling the Tube feedings at night and increasing po intake. Feeding tube was removed prior to discharge, patient remains with good po intake. *** Large pericardial effusion**** On [**2115-4-25**], the patient underwent a cardiac catheterization for right ventricular biopsy to assess the cause of her biventricular heart failure. Her cardiac index in the cath lab was 1.6 with an output of 3.1 with the following pressures: RA 28/26/23 RV 47/21 PA 47/28/37 Wedge mean 29 SVR 1832 The results of her cardiac biopsy are still pending. She has no coronary artery disease. Her catheterization was complicated by a right ventricular perforation which resulted in a large pericardial effusion with evidence of right ventricular diastolic collapse and tamponade. As a result, a pericardial drain had to be placed and the patient was transferred to the CCU. Repeat serial echos showed, with the drain in place, resolved pericardial effusion. The drain was then removed on [**2115-4-27**] without further accumulation of the pericardial effusion. The last echocardiogram was performed on [**2115-4-28**] and should be repeated on [**2115-5-1**] with monitoring daily of a pulsus and signs of tamponade. *****Congestive heart failure, EF <10%****** Unclear etiology. A swan was placed and showed an index of 1.83 before inotropy was initiated. She was placed on milrinone 0.375 with an index of 2.42 which was titrated up to 0.4 with an index of 2.69, SVR of 880. She was given 60 mg IV lasix [**Hospital1 **] with minimal diuresis. The patient was then diuresed with diuril 250 mg and 500 mg IV BID in addition to bumex 4 mg IV BID which provided much diuresis -1.5 to 2.6 liters a day. In addition, she was maintained on spironolactone 25 mg daily, carvedilol 3.125 mg [**Hospital1 **] and digoxin 0.125 mg. The swan was discontinued and the patient was diuresed with diuril and bumex. She developed a slight contraction alkalosis on the day of discharge. As a result, our plan is to slow down her diuresis and give her diamox for her alkalosis. Of note, we performed a trial of a low-dose ACE which the patient did not tolerate. Her blood pressure dropped and thus the ACE was discontinued. This has been her experience in the past with an ACE as well. ****Fever, UTI***** The patient spiked the first day in the CCU on [**2115-4-25**]. She was pancultured. Her CXR shows severe CHF and thus an infiltrate cannot be excluded. She does admit to chronic yellowish sputum which she feels his sinusitis. Her urine grew E.coli. The patient had been on vancomycin per transplant surgery empirically. She was also on Bactrim DS [**Hospital1 **] for PCP prophylaxis as she's in an immunocompromised state. We started her on Zosyn 4.5 gm IV Q8 on [**2115-4-26**] for a total of 5 days. Her last day is [**2115-5-1**]. Her E. coli proved to be sensitive to Bactrim which we continued. Transplant surgery indicated that they no longer feel that she needs empiric vancomycin. This may be discontinued. **** Liver transplant**** The patient has end-stage liver disease secondary to EtOH. She had a transplant as described above. She was maintained on rapamycin, MMF, and prednisone per the transplant surgery service who followed her daily in the CCU and discussed her care with the CCU team daily. ***** H/o Ventricular tachycardia***** The patient was being followed by electrophysiology who planned to place an ICD originally. However, after she developed tamponade post RV ***** IV access**** A double-lumen PICC was placed on [**2115-4-29**] for IV access. Her cordis will be pulled so she may be transferred to floor level of care on milrinone. *** Elevated blood sugars**** The patient does not have a history of diabetes. However, while on prednisone, her blood sugars have been elevated. She was followed while an inpatient by our diabetic specialists at the [**Hospital **] Clinic who recommended maintaining her on lantus QHS and a sliding scale of insulin. Medications on Admission: Sulfameth/Trimethoprim SS 1 TAB PO DAILY Fluconazole 400 mg PO/NG Q24H Sulfameth/Trimethoprim SS 1 TAB PO DAILY Heparin 5000 UNIT SC TID Docusate Sodium 100 mg PO BID Insulin SC (per Insulin Flowsheet) Sliding Scale Pantoprazole 40 mg PO Q24H Mycophenolate Mofetil 1000 mg PO BID Prednisone 15 mg PO DAILY Start: In am [**2-6**] am traMADOL 50 mg PO Q4-6H:PRN Valganciclovir HCl 450 mg PO BID Start: In am start [**2-11**] Sarna Lotion 1 Appl TP QID:PRN Risperidone 0.5 mg PO BID CycloSPORINE Modified (Neoral) 125 mg PO Q12H Duration: 2 Doses give 125mg for pm dose 1/4 and am dose [**2-13**] Furosemide 20 mg PO DAILY Discharge Medications: 1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 2. Epoetin Alfa 20,000 unit/2 mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 3. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed. 4. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 6. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical QID (4 times a day) as needed. 7. Mineral Oil-Hydrophil Petrolat Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 8. Multivitamin Capsule Sig: Five (5) ML PO DAILY (Daily). 9. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Levothyroxine Sodium 200 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Mycophenolate Mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Sirolimus 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 16. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 17. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 19. Bumetanide 4 mg IV BID 20. 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 21. Milrinone 0.26-0.5 mcg/kg/min IV INFUSION 22. Piperacillin-Tazobactam Na 4.5 gm IV Q8H Duration: 5 Days 23. Hydromorphone 0.5-2 mg IV Q4-6H:PRN 24. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 25. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 26. Dolasetron Mesylate 12.5 mg IV Q8H:PRN Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Admitted for Hypotension,lethargy, Dehydration s/p Orthotopic Liver Transplant [**2116-1-27**] Final diagnosis :Dilated Cardiomyopathy with EF 10%, CHF, 3+MR/TR regurgitation Multiple bilateral Pulmonary Emboli R pulmonary LLL 9mm nodule Steroid induced DM Hypothyroidism PEA Atrial Fibrillation VTach Drug Rash Decubitus UTI, enterococcus sensitive only to vanco Malnutrition PMH: ESLD sec ETOH cirrhosis,PE, h/o enceph, ascites, portal htn, sbp, h/o GI bleed, esoph varices, htn, sp ectopic preg/tubal ligation, LBP Discharge Condition: stable/fair. Self feeding ambulates with help. Discharge Instructions: The facility needs to call transplant service immediately at [**Telephone/Fax (1) 673**] if any fevers, chills, nausea, vomiting, lethargy, sustained arrythmia, abdominal pain, or discharge, reddness from incision Labs need to be drawn every Monday and Thursday for cbc, chem 10, ast, alt, alk phos, T Bili, albumin and trough rapamycin level. Results need to be fax'd to [**Hospital1 18**] Transplant Office attn: [**First Name8 (NamePattern2) 1022**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 697**] Followup Instructions: Please call ([**Telephone/Fax (1) 7179**] to schedule an appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], your cardiologist, in 4 weeks. Please call ([**Telephone/Fax (1) 3618**] to schedule an appointment with Dr. [**Last Name (STitle) **], your liver transplant surgeon, in 1 month. Please call ([**Telephone/Fax (1) 5862**] to schedule an appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 284**], your electrophysiologist, in 1 month for possible ICD placement if you do not receive a heart transplant. [**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2139**]

[ "998.2", "E932.0", "790.4", "427.1", "599.0", "785.51", "707.03", "428.43", "428.0", "584.9", "423.0", "996.82", "251.8", "425.4", "415.19", "285.1", "263.9", "427.5" ]

icd9cm

[ [ [] ] ]

[ "37.0", "50.11", "99.04", "99.60", "89.64", "96.6", "88.56", "37.25", "00.13", "38.93", "00.17" ]

icd9pcs

[ [ [] ] ]

17610, 17689

8018, 14799

492, 555

18252, 18300

1884, 4451

18863, 19572

1500, 1664

15469, 17587

17710, 18231

14825, 15446

4468, 7995

18324, 18840

1679, 1865

237, 454

583, 802

824, 1290

1306, 1484

17,362

161,205

25228

Discharge summary

report

Admission Date: [**2174-10-13**] Discharge Date: [**2174-10-19**] Date of Birth: [**2126-4-6**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 695**] Chief Complaint: Orthotopic Liver Transplant Major Surgical or Invasive Procedure: liver transplant [**2174-10-13**] History of Present Illness: 58 y/o male with PMH ESLD secondary to HCV cirrhosis presents for OLT. Feeling well, no fever, chills, recent infections. Did have MVA 5 days ago with bruised ribs, no other complications. Past Medical History: Hep C cirrhosis s/p MVA 5 days ago (bruised ribs) HTN Colonic Polyps Incarcerated Umbilical Hernia Social History: His last IV drug use was in [**2171-1-5**] and last alcohol use in [**2167**]. He has had two tattoos in the past. He is a genotype 3. He lives alone but has good support in his brother and sister. Family History: n/a Physical Exam: VS: 98, 160/77, 16, 99%RA Gen: A+Ox3, NAD Lungs: CTA bilaterally Card: RRR, no M/R/G Abd: Distended, non-tender. Extr: No edema, + pulses Pertinent Results: On Admission:[**2174-10-13**] 03:17AM GLUCOSE-88 UREA N-16 CREAT-1.1 SODIUM-133 POTASSIUM-3.7 CHLORIDE-98 TOTAL CO2-31 ANION GAP-8 ALT(SGPT)-48* AST(SGOT)-110* ALK PHOS-82 TOT BILI-2.3* ALBUMIN-2.3* CALCIUM-8.2* PHOSPHATE-3.4 MAGNESIUM-1.8 WBC-5.7 RBC-3.63* HGB-11.9* HCT-34.7* MCV-96 MCH-32.8* MCHC-34.3 RDW-15.1 PLT COUNT-101* PT-22.1* PTT-39.5* INR(PT)-2.2 FIBRINOGEN-98* Brief Hospital Course: 48 y/o male with h/o Hep C cirrhosis is admitted for OLT. Patient found to have ascites, diagnostic paracentesis with cell count performed and found to be acceptable results for OLT. Liver from a DCD donor, please see operative note for surgical detail. Patient extubated on POD 1. Liver U/S on POD 1 demonstrated patent arterial and venous flow. U/S repeated on POD 3 with good arterial and venous flow, however hepatic artery was not visulaized, and a repeat U/S was performed later in the day with good visualization of the HA. Liver function tests improved daily over the post op course. Bilirubin on discharge was 1.2. Patient was afebrile throughout with all VSS. Pain management achieved initially with IV dilaudid and then PO Oxycodone with good results. Routine intra-op and post op immunosuppression were used, which patient tolerated without difficulty. Discharged on 3 [**Hospital1 **] of Tacro, MMF [**12-5**], Pred 20 Medications on Admission: Nadolol 40', Spironolactone 100'', Lasix 80 AM, 40 PM, Lactulose 15''' Discharge Medications: 1. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). 2. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Mycophenolate Mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 5. Albuterol 90 mcg/Actuation Aerosol Sig: 1-8 Puffs Inhalation Q4H (every 4 hours) as needed for SOB. 6. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Disp:*45 Tablet(s)* Refills:*2* 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO every 4-6 hours as needed for breakthrough pain. Disp:*40 Tablet(s)* Refills:*0* 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Valganciclovir 450 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Insulin Glargine 100 unit/mL Solution Sig: Twelve (12) Subcutaneous at bedtime. Disp:*1 * Refills:*2* 14. Insulin Regular Human 100 unit/mL Solution Sig: follow sliding scale Injection four times a day. Disp:*1 * Refills:*0* 15. glucometer please provide One Touch Ultra 16. Test Strips PLease provide One Touch Ultra Test Strips 1 Box Refills: 2 17. syringes Insulin syringes 1 box refill: 1 18. Tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO BID (2 times a day) for 2 doses. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare VNA Discharge Diagnosis: HCV cirrhosis, now s/p OLT [**2174-10-13**] h/o substance abuse Discharge Condition: good Discharge Instructions: Call Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 673**] if fever, chills, nausea, vomiting, inability to take medications, incision redness/bleeding/drainage, increased abdominal distention or jaundice Labs every Monday and Thursday with results fax'd to [**Telephone/Fax (1) 697**] Chem 10, AST, ALT, ALk Phos, T Bili, Albumin, CBC, Trough Prograf level. PLease start with these lab draws on Thursday [**10-20**] Followup Instructions: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 156**] TRANSPLANT SOCIAL WORK Date/Time:[**2174-10-26**] 1:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2174-10-26**] 3:20 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 673**] Date/Time:[**2174-11-2**] 9:40 [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2174-10-26**]

[ "401.9", "250.00", "V11.3", "V12.72", "305.90", "789.5", "070.54", "571.5" ]

icd9cm

[ [ [] ] ]

[ "99.06", "99.07", "99.04", "00.93", "99.05", "50.59" ]

icd9pcs

[ [ [] ] ]

4185, 4247

1529, 2462

342, 378

4355, 4362

1129, 1129

4833, 5449

951, 956

2583, 4162

4268, 4334

2488, 2560

4386, 4810

971, 1110

275, 304

406, 596

1142, 1506

618, 718

734, 935

42,545

148,513

28659

Discharge summary

report

Admission Date: [**2181-2-25**] Discharge Date: [**2181-3-1**] Date of Birth: [**2097-12-20**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7651**] Chief Complaint: Shoulder pain/hypertensive emergency Major Surgical or Invasive Procedure: Cardiac cathterization History of Present Illness: Ms. [**Known lastname **] is an 83 year old female with HTN, IDDM, CRI, and no prior cardiac history who presents with left shoulder pain, SOB, and chest tightness. Pt had flipped a mattress the previous night, and experienced b/l shoulder achiness that evening. She also had chest tightness that she associated with an ongoing cold, and tightness was relieved with [**Last Name (un) 18774**] Vapor Rub. This am, she thought she felt cold symptoms coming on, took a dose of Robitussin, and proceeded to have SOB with vomiting of clear/white phlegm, non-radiating substernal chest tightness, and bilateral shoulder pain. Pain/SOB was not worsened or relieved with by any factors. Patient had symptoms at rest. There is no history of PND, orthopnea, presyncope, syncope, or palpitations. Daughter was concerned, and called EMS. On arrival, EMS found bs to be 404. BP was found to be 264/98. Pt was given ASA 324mg and taken to the ED. . Of note, pt reports missing only her Lisinopril dose this am. One week ago, she self titrated down her Humalog 75/25 to 42u qam, 20u qpm, as she had been having bs in the 60s-80s. She is followed at [**Last Name (un) **]. She has noted having decreased exercise tolerance over the past week. She is normally very active with her ADLs at home. Daughter is concerned that pt may be over-exerting herself. Pt has been admitted for hypertensive ?urgency in [**6-4**] after inadvertantly holding all her BP and insulin/anti-glycemic medications prior to cataract surgery. BP at time of admission then had been systolic 180s, and FS mid-300s. . In the ED, initial vitals were T:98.2 HR:74 BP:264/98 RR:24 O2Sat:98%RA. EKG was found to have 1mm STE in avR and V1, 1-2mm STD in II, II, V4-V6. Pt was started on a Labetalol gtt at 1mg/min and given Zofran 4mg IV x 1. CODE STEMI was activated, and pt was received 4L O2 NC, NG 0.4mg x 3, Plavix 600mg PO x 1, Heparin bolus 3600u IV x 1, Integrillin 11mg IV x 1, and Morphine 2mg IV x 1, and IVF x 1L. Pain had completely resolved from [**3-6**]->0/10 after Labetalol gtt and Morphine. Troponin was elevated at 0.17. CXR prelim read showed mild heart failure, with moderate cardimegaly and small bilateral pleural effusions and bibasilar atelectasis. She was evaluated by the cardiology fellow in the ED, and EKG was interpreted as LVH with strain rather than acute STEMI. She was admitted to the CCU for further evaluation and management. . In the CCU, pt's chest tightness had completely resolved. She was still having some mild SOB at rest. Pain in shoulders had also resolved. The patient denies any palpitations or syncope, claudication-type symptoms, melena, rectal bleeding, or transient neurologic deficits. No change in weight, bowel habit or urinary symptoms. No cough, fever, night sweats, arthralgias, myalgias, headache or rash. All other review of systems negative. Past Medical History: Hypertension Type II DM w/ eye complications (macular edema, Non Proliferative Diabetic Retinopathy) Paget's disease Cataract extraction Hypercholesterolemia CRI, creatinine 1.3 ([**2179-11-8**]), stage III Osteoporosis Rickets, as a child OA/ knees h/o Carpal tunnel syndrome h/o Lipodystrophy h/o DVT ~ [**2147**], s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] LE neuropathy s/p Burn bilat FA, [**2141**]'s ? h/o Heart murmur . Cardiac Risk Factors: +Diabetes, ?Dyslipidemia, +Hypertension . Cardiac History: CABG n/a . Percutaneous coronary intervention: n/a . Pacemaker/ICD: n/a . Other Past History: see above Social History: Denies smoking, alcohol, drug history. Lives with 21 year old grandson, is independent with all [**Name (NI) 5669**]. Gets support from family and neighbors as needed. Currently driving. There is no family history of premature coronary artery disease or sudden death. Family History: non contributory Physical Exam: VS - 97.0 69 160/65 15 100%4L Gen: WDWN middle aged female in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. Neck: Supple with JVP to angle of mandible. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal soft S1, nml S2. No m/r/g. No thrills, lifts. No S3 or S4. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Occasional bibasilar crackles; otherwise CTAB with no other crackles, wheezes or rhonchi. Abd: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Neuro: CN2-12 intact grossly; sensation intact diffusely, strenght [**5-1**] diffusely in UE/LE muscles bilaterally Pertinent Results: Admission Labs [**2181-2-25**] WBC-7.9 RBC-3.74* Hgb-10.8* Hct-32.1* MCV-86 MCH-28.9 MCHC-33.7 RDW-14.9 Plt Ct-294 [**2181-2-25**] PT-17.2* PTT-150* INR(PT)-1.6* [**2181-2-25**] Glucose-378* UreaN-24* Creat-1.3* Na-133 K-4.3 Cl-96 HCO3-25 AnGap-16 [**2181-2-25**] CK(CPK)-184* [**2181-2-25**] Calcium-8.8 Phos-4.2 Mg-1.4* Iron-37 Cholest-216* [**2181-2-25**] Triglyc-58 HDL-94 CHOL/HD-2.3 LDLcalc-110 [**2181-2-25**] Triglyc-58 HDL-94 CHOL/HD-2.3 LDLcalc-110 [**2181-2-25**] calTIBC-278 VitB12-577 Folate-GREATER TH Ferritn-154* TRF-214 [**2181-3-1**] 06:55AM BLOOD Calcium-8.8 Phos-4.6* Mg-2.0 Biomarkers [**2181-2-25**] cTropnT-0.17* [**2181-2-25**] CK-MB-26* MB Indx-5.1 cTropnT-1.52* [**2181-2-26**] CK-MB-20* MB Indx-4.7 cTropnT-1.45* [**2181-2-25**] CK(CPK)-184* [**2181-2-25**] ALT-29 AST-91* CK(CPK)-512* AlkPhos-135* TotBili-0.4 [**2181-2-26**] BLOOD CK(CPK)-428* Other Labs [**2181-3-1**] Glucose-63* UreaN-44* Creat-1.7* Na-138 K-4.1 Cl-103 HCO3-28 AnGap-11 [**2181-3-1**] PT-13.8* PTT-29.1 INR(PT)-1.2* [**2181-3-1**] WBC-5.8 RBC-2.86* Hgb-8.5* Hct-24.6* MCV-86 MCH-29.6 MCHC-34.3 RDW-15.1 Plt Ct-277 U/A [**2181-2-26**] 11:57PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.012 [**2181-2-26**] 07:47PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.011 [**2181-2-26**] 11:57PM URINE Blood-LGE Nitrite-NEG Protein-30 Glucose-1000 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2181-2-26**] 07:47PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [**2181-2-26**] 07:47PM URINE RBC-30* WBC-9* Bacteri-NONE Yeast-NONE Epi-1 [**2181-2-26**] 07:47PM URINE CastHy-3* Reports/Imaging [**2181-2-25**] CXR: The heart size is mildly enlarged. The aorta is tortuous. The hilar contours are normal. Small bilateral pleural effusion and bibasilar atelectasis are noted. Mild pulmonary vascular congestion is visualized. Severe degenerative changes of the thoracic spine are noted. A sclerotic lesion of the right humeral head most likely represents a bone island. IMPRESSION: Mild pulmonary vascular congestion and small bilateral pleural effusions. [**2181-2-26**]: ECHO The left atrial volume is increased. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with mild hypokinesis of the mid to distal inferolateral wall. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([**12-29**]+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with mild hypokinesis of the mid to distal inferolateral wall. Diastolic dysfunction. Mild to moderate mitral regurgitation. Moderate pulmonary artery systolic hypertension. RENAL DUPLEX IMPRESSION: 1. No hydronephrosis. 2. Bilateral pleural effusions and a scant trace of ascites. 3. No evidence of renal artery stenosis. Cardiac Cath COMMENTS: 1. Selective coronary angiography of this right dominant system revealed severe diffuse 3 vessel CAD. The LMCA had a distal 20% stenosis. The LAD was heavily calcified and had a diffuse calcified proximal-mid stensosis COMME% spanning the origin of D1. There was diffuse disease in the distal/apical LAD to 70%. D1 had a proximal tubular 80% stenosis. The LCX was heavily calcified with a proximal 30% stenosis, diffuse 60% stenosis in the mid portion, and distal stenosis to 80% at the LPL. All OMs were small and diffusely diseased. There were distal CX collaterals to the RPL. The Ramus was moderately calcified with a mid tubular 85% stenosis. The RCA was heavily calcified with a proximal 80%, mid diffuse 70% and distal 65% stenosis. The RPDA had a 40% proximal and 80% distsal stenosis, with distal competitive flow from collaterals. There was diffuse disease in a small RPL1 and modest RPL2. 2. Limited resting hemodyanamics revealed elevated left sided filling pressures with a LVEDP of 20mm Hg (respiratory variation ranged from 12 to 26mm Hg). There was no transvalvular aortic gradient on careful pullback of the catheter from the LV to the aorta. There was severe systemic arterial hypertension despited TNG at 200mcg/min IV. 3. Abdominal aortography demonstarted a smooth aorta with singla patent renal arteries bilaterally. There was mild atherosclerosis of a tortuous left iliac artery. FINAL DIAGNOSIS: 1. Extensive 3 vessel coronary artery disease. 2. Moderate left ventricular hypertensive diastolic heart failure. 3. Severe systemic systolic arterial hypertension. 4. MIld atherosclerosis of the left iliac artery. 5. No angiographic evidence of flow-limiting renal artery stenosis. Brief Hospital Course: Patient is an 83 y/o F with HTN, DM2 on insulin, CKI, no prior CAD hx who presents with L shoulder pain and EKG changes in setting of hypertensive emergency. # Hypertensive emergency: Patient initially on nitro gtt then weaned off as BP improved on PO medications. Hypertensive emergency was thought to be multifactorial and secondary to med noncompliance. She did not have evidence of renal artery stenosis on cath or duplex. Metoprolol was changed to labetalol with improved control. Amlodipine was also added. She was continued on lisinopril. # Chronic diastolic heart failure: Satting high 90s on room air. Started on lasix 40mg daily which she tolerated well with slight bump in creatinine on day of discharge. She should have repeat labs as outpatient. Continued ACEI and BB . # CAD: Pt had NSTEMI in setting of hypertensive emergency. Cath showing 3VD, with cardiac surgery not planning to intervene. Continued ASA, Lisinopril, and changed metoprolol to labetalol. Continued statin . # DM2: Labile sugars, ranging 88 to 342 o/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] following. She was continued on Humalog 75/25, 30 units qam and 20 units qpm with HISS. She will have outpateint follow up with [**Last Name (un) **]. . # Stage III CRF: Cr on admission 1.3 (baseline at or above this level), now 1.7 after gentle diuresis with lasix. [**Month (only) 116**] also be elevated on [**2181-3-1**] from cath. She should have repeat labs as na outpatient for further monitoring while on lasix. # Hyperlipidemia: Added high dose simvastatin given CAD. . # Anemia: Hct stable in high 20s. . # Code: presumed FULL . Medications on Admission: Lisinopril 40mg PO daily (last dose 2/28) Metoprolol 100mg PO daily Metformin 500mg PO bid Aspirin 81mg PO qhs Humalog 75-25 KiwkPen 100units/ml 54units SC qam (has been taking 42u) Humalog 75-25 KiwkPen 100units/ml 22 units SC qpm (has been taking 20u). Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: [**12-30**] Tablet, Sublinguals Sublingual PRN (as needed) as needed for chest pain: Take 5 minutes apart, call 911 if you still have chest pain after 3 doses. Disp:*1 bottle* Refills:*1* 3. Lisinopril 40 mg Tablet Sig: One (1) Tablet PO once a day. 4. Amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 5. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Insulin Lispro Protam & Lispro 100 unit/mL (75-25) Insulin Pen Sig: Forty (40) units Subcutaneous once a day. 8. Insulin Lispro Protam & Lispro 100 unit/mL (75-25) Insulin Pen Sig: Twenty (20) units Subcutaneous before dinner. 9. Labetalol 200 mg Tablet Sig: Two (2) Tablet PO twice a day. Disp:*120 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Non ST Elevation Myocardial Infarction Hypertensive Urgency Acute on Chronic Diastolic Dysfunction Chronic Kidney Disease Diabetes Mellitus Type 2 Discharge Condition: stable. Discharge Instructions: You have very high blood pressure that caused your heart to be enlarged and stiff. Your uncontrolled blood pressure caused a heart attack with some heart damage. It is of the utmost importance that your blood pressure be well controlled to prevent further heart damage. Please get a blood pressure cuff at home and check your blood pressure every day at different times. Keep a log of these blood pressures and bring with you to every doctor's appt. You may be set up with a home telemonitoring system that will send your weights and blood pressures to your doctor's office. Please also check your blood sugars daily to see if your insulin needs to be adjusted. You will need to see Dr.[**Name (NI) 3733**] in a few weeks to check your heart status and he recommend that you go to cardiac rehabilitation near your home. This will help with exercise and will give you information about your diet. New medicines: 1. Labetolol: to lower your blood pressure 2. Furosemide: to lower your blood pressure and prevent build up of fluid in your lungs. 3. Amlodipine: to lower your blood pressure 4. Simvastatin: to lower your cholesterol and keep your heart arteries from further narrowing and causing another heart attack. 5. Nitroglycerin: to take if you have chest pain at home. Take 5 minutes apart while you are sitting down. If you still have chest pain after 3 doses, call 911. . Please call Dr.[**Name (NI) 3733**] or Dr. [**First Name (STitle) **] if you have any chest pain, trouble breathing, low blood pressure, fevers, dizziness or any other unusual symptoms. Please get a blood pressure cuff at home and check your blood pressure daily, keep a log to give to your doctors at office [**Name5 (PTitle) 2176**]. Please call [**First Name4 (NamePattern1) 1258**] [**Last Name (NamePattern1) 69336**] if you have any questions about your medicines or discharge. Followup Instructions: Primary Care: [**Last Name (LF) **],[**First Name3 (LF) **] E. [**Telephone/Fax (1) 18145**] Date/time: Friday [**3-9**] at 1:30pm. . Cardiology: Provider: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] Phone: [**Telephone/Fax (1) 62**] [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 436**] Date/Time:[**2181-3-6**] 3:40 Completed by:[**2181-3-1**]

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icd9cm

[ [ [] ] ]

[ "88.53", "37.22", "88.56", "88.42" ]

icd9pcs

[ [ [] ] ]

13294, 13352

10349, 11990

352, 377

13543, 13553

5185, 10024

15464, 15847

4225, 4243

12296, 13271

13373, 13522

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