ChanBeDu/relevant_section_length · Datasets at Hugging Face

8,799

118,529

18749+18750

Discharge summary

report+report

Admission Date: [**2139-8-22**] Discharge Date: [**2139-9-8**] Date of Birth: [**2104-9-10**] Sex: F Service: MEDICINE Allergies: Tape [**1-25**]"X10YD / Augmentin / Hydrocodone / Levofloxacin / Ciprofloxacin Attending:[**Doctor First Name 2080**] Chief Complaint: throat swelling Major Surgical or Invasive Procedure: Thoracentesis done on [**2139-8-28**] History of Present Illness: 34 yo F with history type 1 DM, HTN, CKD, recent admission for DKA found to have cellulitis versus osteomyelitis of right foot who presents with facial swelling and foreign body sensation in back of throat. Patient was discharged from [**Hospital1 18**] on [**8-17**] after a 4 day stay for DKA and was found to have cellulitis. She was sent home with instructions to complete a 7 day course of levofloxacin. Took total of 3 or 4 days of levofloxacin. On [**8-18**] developed full body itchiness without presence of rash and on [**8-19**] developed severe diarrhea. Patient called PCP who changed her to ciprofloxacin. She then began having facial swelling on [**8-21**] with a foreign body sensation in back of throat. Also had difficulty opening eyes. Called PCP's office today who advised patient to go to ED. . In ED, initial vitals were 98.4 104 133/79 16 96%. Exam was notable for facial swelling however a clear oropharnyx. Patient was tolerating secretions and was without stridor. Lungs were significant for wheezes. Patient was given benadryl, methylprednisolone 125mg x 1, albuterol neb x 1, acetaminophen 1g, and metoprolol succinate 25mg. Per ED signout, ID was consulted who recommended that she be given vancomycin 1g and aztreonam 2g Q8h. Prior to transfer, lung exam was significant for crackles. CXR was then taken and was concernign for increased fluid and patient was given albuterol neb and lasix 20mg. Patient recieved 1200cc of fluid. There was initially no reported increase in o2 requirement however after reassessment patient desatted to 88%. Patient was then placed on a NRB. Also prior to transfer, patient had right ankle film for concern of worsening cellulitis. Last vitals were Temp 100.1 HR 93 BP 143/97 sating 100% NRB. . In MICU, patient was resting comfortably. Denied SOB or difficulty tolerating secretions. Complained of being hungry. . Review of systems: (+) Per HPI and nonproductive cough (but no hemoptysis), chills, diarrhea, lower extremity redness and edema (-) Denies fever, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, or weakness. Denies nausea, vomiting, constipation, abdominal pain, or changes in bowel habits. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Denied orthopnea/PND Past Medical History: 1. Type 1 diabetes complicated by retinopathy and likely nephropathy, diagnosed at age 11. Poorly controlled per recent records, with the exception of during her pregnancy when she required TPN (with insulin it) for hyperemesis. She has had multiple episodes of diabetic ketoacidosis. Aic was 15.1 [**10-30**] appt with her [**Last Name (un) **] attending Dr. [**Last Name (STitle) 9978**]. No visits since then. Last eye exam [**5-1**] - "quiescent" PROLIFERATIVE diabetic retinopathy. 2. Depression 3. Severe hyperemesis requiring TPN. 4. Status post C section at 33 weeks because of hyperemesis. 5. Migraines 6. Accquired hemophilia (FVIII inhibitor in [**2132**]) treated with steroids and rituximab 7. Anti-E and warm autoantibody 8. GERD, antral ulcer 9. Hypertension 10. Hydronephrosis 11. - Osteoporosis ([**2138-11-12**] T-score lumbar spine -2.2, femoral neck -3.1) . Past Surgical History: - Cesarean section ([**2132**]) - Laparoscopic appendectomy ([**2132**]) - TAB [**3-31**] - Proximal gastroduodenal artery embolization - Excision of a skin mole - Achilles avulsion repair Social History: The patient does not smoke or drink alcohol, had piercing of ears, a transfusion in [**2132**]. Married, living with her husband and one son. A homemaker currently. On disability since [**2132**]. Exercises regularly at a gym. Family History: Has 1 sister, no hx of cancer or bleeding/ blood disorders in family but positive IBD history in grandfather and [**Name2 (NI) 12232**]. Physical Exam: ADMISSION PE: Vitals: 97.1 137/66 96 96% 4LNC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, difficulty to assess oropharynx [**2-25**] Grade III Mallampati, no palatal petechiae Neck: supple, JVP not elevated, no LAD, no stridor Lungs: Crackles 1/3rd up bases, no wheezes CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, R>L edema, morbilophorm rash on bilateral pre-tibial areas (R>L), right LE slightly more edematous than left Pertinent Results: ADMISSION LABS: [**2139-8-22**] 02:50PM BLOOD WBC-6.1 RBC-2.69* Hgb-8.0* Hct-24.4* MCV-91 MCH-29.9 MCHC-33.0 RDW-14.7 Plt Ct-376 [**2139-8-22**] 03:00PM BLOOD WBC-7.1 RBC-2.64* Hgb-7.9* Hct-23.9* MCV-90 MCH-29.9 MCHC-33.2 RDW-14.7 Plt Ct-373 [**2139-8-22**] 02:50PM BLOOD Neuts-65.6 Lymphs-25.2 Monos-5.1 Eos-3.5 Baso-0.6 [**2139-8-22**] 03:00PM BLOOD Neuts-65.7 Lymphs-25.9 Monos-5.0 Eos-3.0 Baso-0.4 [**2139-8-23**] 02:45AM BLOOD PT-12.5 PTT-23.5 INR(PT)-1.1 [**2139-8-22**] 03:00PM BLOOD Glucose-244* UreaN-27* Creat-1.7* Na-134 K-4.8 Cl-96 HCO3-29 AnGap-14 [**2139-8-23**] 02:45AM BLOOD Glucose-220* UreaN-25* Creat-1.3* Na-136 K-3.8 Cl-100 HCO3-25 AnGap-15 [**2139-8-22**] 03:00PM BLOOD LD(LDH)-335* [**2139-8-23**] 02:45AM BLOOD ALT-49* AST-23 AlkPhos-271* TotBili-0.1 [**2139-8-22**] 03:00PM BLOOD proBNP-2278* [**2139-8-23**] 02:45AM BLOOD Albumin-2.8* Calcium-8.3* Phos-3.8 Mg-2.2 [**2139-8-22**] 03:00PM BLOOD Hapto-374* [**2139-8-22**] 09:04PM BLOOD Lactate-1.1 . DISCHARGE LABS: [**2139-9-8**] 06:39AM BLOOD WBC-6.5 RBC-2.71*# Hgb-8.3*# Hct-25.3* MCV-94 MCH-30.8 MCHC-32.9 RDW-16.2* Plt Ct-413 [**2139-9-4**] 05:35AM BLOOD Neuts-53.0 Lymphs-35.2 Monos-5.2 Eos-5.7* Baso-0.8 [**2139-9-8**] 06:39AM BLOOD Plt Ct-413 [**2139-9-2**] 04:58AM BLOOD ESR-75* [**2139-9-4**] 05:35AM BLOOD Ret Aut-5.9* [**2139-9-4**] 04:53PM BLOOD ACA IgG-4.4 ACA IgM-3.2 [**2139-9-8**] 06:39AM BLOOD Glucose-242* UreaN-31* Creat-1.6* Na-138 K-5.2* Cl-102 HCO3-30 AnGap-11 [**2139-9-2**] 04:58AM BLOOD ALT-18 AST-14 LD(LDH)-207 AlkPhos-167* TotBili-0.1 [**2139-9-2**] 04:58AM BLOOD GGT-106* [**2139-9-7**] 09:16PM BLOOD Calcium-8.6 Phos-5.1* Mg-2.2 [**2139-9-4**] 05:35AM BLOOD calTIBC-276 VitB12-600 Folate-10.7 Ferritn-39 TRF-212 [**2139-8-25**] 05:20AM BLOOD TSH-3.8 [**2139-9-3**] 05:08PM BLOOD Free T4-0.89* [**2139-9-3**] 05:08PM BLOOD Cortsol-13.2 [**2139-9-4**] 04:51PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [**2139-9-4**] 04:53PM BLOOD [**Doctor First Name **]-POSITIVE * Titer-1:640 Cntromr-NEGATIVE [**2139-9-2**] 04:58AM BLOOD [**Doctor First Name **]-POSITIVE * Titer-1:160 dsDNA-NEGATIVE [**2139-9-2**] 04:58AM BLOOD CRP-5.7* [**2139-9-4**] 04:53PM BLOOD b2micro-4.2* [**2139-9-2**] 04:58AM BLOOD C3-154 C4-54* [**2139-9-2**] 12:09PM BLOOD HIV Ab-NEGATIVE [**2139-8-31**] 06:06AM BLOOD Vanco-11.5 . Micro: - Blood cultures ([**9-3**]): negative . [**2139-9-2**] 1:44 pm URINE Source: CVS. **FINAL REPORT [**2139-9-3**]** Legionella Urinary Antigen (Final [**2139-9-3**]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, in infected patients the excretion of antigen in urine may vary. . [**2139-9-2**] 1:44 pm URINE Source: CVS. **FINAL REPORT [**2139-9-3**]** URINE CULTURE (Final [**2139-9-3**]): NO GROWTH. . [**2139-8-28**] 2:03 pm PLEURAL FLUID PLEURAL. GRAM STAIN (Final [**2139-8-28**]): 2+ (1-5 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [**2139-8-31**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2139-9-3**]): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [**2139-8-29**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. . IMAGING: CXR PA and lateral [**9-4**]: IMPRESSION: Improved bilateral atelectasis and edema after diuresis. . CARDIAC MRI [**9-3**]: Impression: 1. Normal left ventricular cavity size with normal global and regional systolic function. The LVEF was normal at 61%. The effective forward LVEF was mildly reduced at 52%. No CMR evidence of prior myocardial scarring/infarction. 2. Normal right ventricular cavity size with normal global and regional systolic function. The RVEF was normal at 61%. 3. Mild mitral regurgitation. 4. The indexed diameters of the ascending and descending thoracic aorta were normal. The indexed diameter of the main pulmonary artery was mildly dilated. 5. No evidence of pericardial constriction found. 6. There was a small circumferential pericardial effusion. 7. A note is made of large bilateral pleural effusions with associated compressive atelectasis. Multiple small mediastinal lymph nodes, measuring less than 1 cm, likely reactive but better evaluated on prior CT 2 days prior. Embolization coils in the region of the pancreas which result in artifact. . CT CHEST without contrast [**9-1**]: IMPRESSION: 1. Reaccumulation with increased extent of a right moderate-to-severe simple non-loculated pleural effusion since the pre-thoracentesis examination from [**2139-3-27**]. 2. Increased now moderate left simple pleural effusion. 3. Interval progression of disease with new left-sided nodular opacification and increased in extent, peribronchiolar soft tissue and nodular opacities. . In the absence of clinically suspected malignancy, these findings are likely attributed to an infectious etiology. . CTA CHEST [**2139-8-27**]: IMPRESSION: No pulmonary embolism. Mild interstitial edema. Right upper lobe consolidation and peribronchial opacities are suggestive of infection. Large bilateral effusions with atelectasis of the adjacent lungs. Brief Hospital Course: 34 y/o F with history of DM, HTN, CKD, recent admission for cellulitis presenting with facial swelling and foreign body sensation concerning for drug reaction, subsequently found to be with dyspnea and hypoxia, felt to be from pleural effusions related to serum sickness and hypoalbuminemia. . Please see below for hospital course by problem list. . # Hypoxia: Patient's initial hypoxia concerning for drug reaction from quinolone. No airway compromise. There is evidence for systemic allergic reaction given facial swelling and skin rash, though. She was monitored in the ICU for this concern and showed improvement with IV steroids, benadryl, and famotidine. She was called out to the medicine floor. She subsequently developed dyspnea and hypoxia again, with imaging suggestive of pneumonia. She completed 7 days of vancomycin and cefepime for HAP. On re-imaging, she also developed pulmonary edema. Her clinical picture appeared most consistent with increased capillary permeability leading to increase capillary leak. Rheumatology and renal teams were consulted and felt that diagnosis was most consistent with serum sickness and possibly hypoalbuminemia. Thoracentesis was performed and was transudative with negative culture data. Echo was performed, and initially showed diastolic dysfunction, but this report was addended to state that cardiac systolic and diastolic function was normal. In addition, cardiac MRI was within normal limits during this admission. To review prior records, patient does not carry diagnosis of CHF and last Echo did not show evidence of dysfunction. Her EKG also does not reveal any concerning findings (ischemia, LVH, or afib). PE was ruled out on [**2139-8-27**] CTA chest. Patient was diuresed with 20 mg IV lasix [**Hospital1 **], per pulmonary recommendations, with improvement in her O2 saturation. She was oxygenating well on room air and had ambulatory O2 saturation > 94% on discharge. She was discharged with lasix 20 mg daily with follow-up. There was a question of peribronchiolar soft tissue and nodular opacities on [**2139-9-1**] CT chest, which pulmonary felt was related to fluid and edema; however, f/u imaging in [**4-29**] weeks is recommended. Patient will also f/u with rheumatology re: pending labs, and to see whether there is a rheumatologic cause for her pleural effusions, particularly given her strongly positive [**Doctor First Name **]. However, as above, diagnosis appears to be most consistent with serum sickness, despite normal complement levels. . # Facial swelling: C/w drug reaction. CXR not revealing for mediastinal or neck mass to cause SVC syndrome. Patient already received steroids and benadryl. Unable to fully assess OP given Mallampati score, however, there was some concern for angioedema and capillary leak syndrome. Already received famotidine and steroids in ED. Maintained airway well in ICU, and was inactive issue after hospital day 1. . # Acute renal failure: renal team was consulted and reviewed sediment, which was consistent with nephrotic range proteinuria, without superimposed process. No evidence for ATN. Renal team agreed with lasix 20 mg daily on discharge, with follow-up with her [**Hospital1 1774**] nephrologist. On discharge, she was felt to be near her new baseline renal function. Patient will have outpatient lab work on [**Last Name (LF) 2974**], [**9-11**]. Valsartan is also on hold post discharge, and will be addressed at upcoming PCP [**Name Initial (PRE) **]. . # Hyperglycemia/Diabetes: Patient with several admissions for DKA in past. Most recently admitted last week with DKA. No evidence for DKA during admission. [**Last Name (un) **] was consulted regarding poorly controlled diabetes. Patient was discharged with lantus 3 units at breakfast and 7 units at bedtime, along with SSI. She has f/u with [**Last Name (un) **] as noted, and is considering transitioning to insulin pump. . # Hypertension: patient was continued on amlodipine. [**Last Name (un) **] was held given elevated Cr above baseline. . # Anemia: felt to be a hypoproliferative anemia, per hematology oncology consult. She also required transfusion of pRBC on one occasion for Hct ~ 21. No evidence for hemolysis or blood loss. She was guaiac negative. She was discharged with supplemental iron. Inpatient hematology team offered bone marrow diagnosis, but patient declined. She has outpatient f/u with hematology on discharge. . # Hyperlipidemia: continued simvastatin . # Depression: continued citalopram . # Transitional issues: - f/u CXR post discharge after 4-6 weeks re: nodular opacities on [**2139-9-1**] CT chest, which pulmonary felt was related to fluid and edema - EPO level pending on discharge - rheumatology labs pending on discharge - PCP to address lasix titration and possible [**Last Name (un) **] re-initiation - Outpatient Lab Work Please obtain bloodwork for chemistry 7 on [**Last Name (LF) 2974**], [**2139-9-11**] and send results to PCP, [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **] at [**Telephone/Fax (1) 250**]. Indication - acute renal failure - appointments with hematology, [**Last Name (un) **], nephrology, pulmonary, and [**Hospital 1944**] clinic Medications on Admission: Medications: 1. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) 2. citalopram 40 mg Tablet Sig: One (1) Tablet PO once a day. 3. gabapentin 600 mg Tablet Sig: One (1) Tablet PO at bedtime. 4. valsartan 160 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 8. Lantus 100 unit/mL Solution Sig: One (1) 9 Units Subcutaneous at bedtime. 9. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a week. 10. colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day as needed for pain. 11. insulin lispro 100 unit/mL Solution Sig: One (1) Per sliding scale Subcutaneous three times a day. Discharge Medications: 1. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Disp:*30 Capsule(s)* Refills:*0* 2. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 3. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for headache. 4. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 6. amlodipine 10 mg Tablet Sig: One (1) Tablet PO once a day. 7. Celexa 40 mg Tablet Sig: One (1) Tablet PO once a day. 8. gabapentin 300 mg Capsule Sig: Two (2) Capsule PO at bedtime. 9. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 10. Ambien 5 mg Tablet Sig: One (1) Tablet PO HS as needed for insomnia. 11. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a week for AS DIRECTED weeks: take as directed per PCP . 12. Outpatient Lab Work Please obtain bloodwork for chemistry 7 on [**Last Name (LF) 2974**], [**2139-9-11**] and send results to PCP, [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **] at [**Telephone/Fax (1) 250**]. Indication - acute renal failure. 13. Humalog 100 unit/mL Cartridge Sig: sliding scale as [**First Name8 (NamePattern2) **] [**Last Name (un) **] units Subcutaneous three times a day. 14. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 15. Lantus 100 unit/mL Solution Sig: 3 units at breakfast and 7 units at bedtime units Subcutaneous once a day. Disp:*1 bottle* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnoses: 1) Pulmonary effusions felt to be from serum sickness and hypoalbuminemia 2) Allergic drug reaction from quinolone (urticaria/hives, wheeze) 3) Right lower extremity cellulitis 4) Type I diabetes mellitus 5) Acute kidney injury . Secondary diagnoses: 1) Hypertension 2) Depression 3) Migraines 4) Chronic kidney disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Last Name (Titles) **], . It was a pleasure taking care of you at the [**Hospital1 771**]. . You were admitted on [**2139-8-22**] for close monitoring after an antibiotic related allergic drug reaction. You had been taking the antibiotic Ciprofloxacin for your recent right lower extremity cellulitis, when you developed significant facial swelling. The swelling has now resolved and your foot looks well-healed at this time having completed your full treatment of Vancomycin and Cefepime for this infection. . While you were in the hospital, you also became short of breath and had oxygen saturation levels that reached as low as 60%. Given this sudden decrease in your respiratory function, you were placed on oxygen and received a chest X-ray on [**2139-8-26**] that revealed significant fluid around your lungs, known as pleural effusions. A CT scan of your chest on [**2139-8-27**] was also obtained that confirmed the findings from your X-ray, and suggested the possibility of an infection as well. Given the effect the fluid was having on your breathing, the interventional pulmonary team was consulted to remove some of the effusion to relieve your symptoms and also to send it for analysis. Approximately 1.5 liters were removed from around your right lung on [**2139-8-28**], and the fluid was sent for studies which revealed that it was largely free of protein and cells. . As your breathing did not significantly improve after the removal of the effusion, you had a repeat chest X-ray on [**2139-8-31**] which showed that much of the fluid had reaccumulated. Thus, rather than remove the fluid again, we initiated you on intravenous diuretic therapy (Lasix) at 20 MG twice a day. You responded well to the medication, putting out nearly 2L more that you were taking in. Your breathing improved significantly where you no longer needed oxygen, and on a follow-up chest X-ray on [**2139-9-4**], your pleural effusions had decreased significantly. Your oxygen saturation while walking remained above 95%. . Due to the nature of the fluid around your lungs, we were concerned that your heart may not be pumping effectively resulting in the back up of fluid. Therefore, we obtained ultrasound imaging of your heart on [**2139-9-1**], which was read as showing significant dysfunction of the relaxing phase of your heart. To follow-up this finding, you had a Cardiac MRI on [**2139-9-3**] which revealed no dysfunction with your heart whatsoever. Your previous ultrasound study was also reread by a Cardiology attending on [**2139-9-3**] and he confirmed that there was no dysfunction seen on this modality either. In other words, your heart is functioning well. . You had some elevated blood sugars which were may have been from recent steroids given in the emergency room for controlling your allergy symptoms. These hyperglycemic readings improved slowly. We had a diabetes specialist from [**Last Name (un) **] Diabetes Center come to see you here in the hospital and some adjustments were made to your home insulin doses. You have been set up with your diabetes specialist as outlined below. . Lastly, the team noted a low red blood cell count or anemia that has been worsening in recent weeks. Given your history of GI bleeding and recent use of ibuprofen you should continue taking a daily anti-acid medication called omeprazole and stop using any ibuprofen as this medicine can promote GI bleeding and worsen kidney function. Please use Tylenol as a safer alternative for headaches and joint pains. . Please see below for upcoming appointments. On discharge, your kidney function is slightly worse than your baseline. Please hold valsartan for now, until your next appointment. On this appointment, you can discuss whether to resume valsartan. Please have renal function checked on [**Last Name (un) 2974**], [**9-11**] as per script. . MEDICATION CHANGES/INSTRUCTIONS: 1) Decrease usual simvastatin to 20mg daily (this is due to possible interaction with amlodipine) 2) Please do not take ibuprofen, instead take Tylenol 650mg q6hrs as needed for headaches and/or leg pain 3) Continue glargine at 3 Units in morning and 7 Units at bedtime and see attached full Humalog Sliding Scale insulin dosing schedule which is [**First Name8 (NamePattern2) **] [**Last Name (un) **] 4) Please restart omeprazole 40mg daily 5) Please start ferrous sulfate 325mg iron tablets twice daily 6) If you develop constipation on iron, please take over the counter colace 100mg [**Hospital1 **] as needed to help soften stools 7) Hold valsartan on discharge 8) Increase metoprolol tartrate to 37.5 mg twice a day . Otherwise, please continue taking your usual home medications as previously prescribed. Followup Instructions: Please follow-up with Dr. [**First Name4 (NamePattern1) 553**] [**Last Name (NamePattern1) 818**] at [**Last Name (un) **] Diabetes Center on [**10-13**] at 10:30am. Office location is on the [**Location (un) **]. Phone # ([**Telephone/Fax (1) 4847**]. . Department: [**Hospital3 249**] When: Monday [**2139-9-14**] 12:00pm With: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Address: [**Location (un) 830**] [**Location (un) 86**], [**Numeric Identifier 718**] Location: [**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 250**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Central [**Hospital **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage This appointment is with a hospital-based doctor as part of your transition from the hospital back to your primary care provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary care doctor in follow up. . Department: RHEUMATOLOGY When: WEDNESDAY [**2139-9-16**] at 10:30 AM With: [**First Name8 (NamePattern2) 11595**] [**Last Name (NamePattern1) 11596**], 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: PULMONARY FUNCTION LAB When: MONDAY [**2139-9-21**] at 2:10 PM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Department: MEDICAL SPECIALTIES When: MONDAY [**2139-9-21**] at 2:30 PM With: DR. [**Last Name (STitle) 51373**]/DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 612**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [**2139-9-23**] at 1 PM With: [**First Name11 (Name Pattern1) 2295**] [**Last Name (NamePattern4) 11222**], MD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage . Please follow-up with your nephrologist at [**Hospital1 1774**] within the next week. Completed by:[**2139-9-11**] Admission Date: [**2139-9-12**] Discharge Date: [**2139-9-21**] Date of Birth: [**2104-9-10**] Sex: F Service: MEDICINE Allergies: Tape [**1-25**]"X10YD / Augmentin / Hydrocodone / Levofloxacin / Ciprofloxacin / morphine / fentanyl Attending:[**Doctor First Name 2080**] Chief Complaint: Dyspnea, Hypoxia Major Surgical or Invasive Procedure: Ultrasound-guided renal biopsy CPR (cardiopulmonary resuscitation) History of Present Illness: Ms. [**Name13 (STitle) **] is a 35 y/o F with a h/o Type I DM, HTN, CKD, warm autoimmune hemolytic anemia, depression, and osteoperosis who was recently on the SIRS service on [**2139-9-15**] when she had a 2 minute cardiac arrest, requiring 5 rounds of CPR, immediately following a renal biopsy prompting a 1-day admission to the MICU, who now presents back to the SIRS service with hypoxia, continuing bilateral pleural effusions, and concern for mixed respiratory acidemia/metabolic alkalemia of multi-factorial etiology. . The patient was discharged from the SIRS service following presentation for anaphylactic response to fluoroquinolones, with subsequent hypoxia due to bilateral pleural effusions of unclear etiology, a normocytic anemia, and nephrotic syndrome on [**2139-9-8**]. At that time, the patient was breathing comfortably on room air following aggressive diruesis, with consistent O2Sats > 95%. She was discharged on Lasix 20 MG PO QD, and soon redeveloped shortness of breath, LE edema and lethargy prompting her re-presentation to [**Hospital1 18**] on [**2139-9-12**]. A CXR confirmed the presence of recurrent bilateral pleural effusions. She had a desat into the 80s on RA, which resulted in her transfer to the MICU. She was aggressively diuresed with IV Lasix 40 MG [**Hospital1 **] overnight, and was then transferred to the SIRS service on [**2139-9-14**] after a noticeable improvement in her breathing. . Given the presence and recurrent nature of her bilateral pleural effusions, we continued IV Lasix 40 MG [**Hospital1 **] and consulted the Rheumatology and Renal teams. Both teams agreed that the patient should pursue a renal biopsy, which was performed on [**2139-9-15**], and subsequently she had a cardiac arrest. During the procedure, the patient received Versed 100 MG and Fentanyl 100 MG, and was conscious and able to follow instructions during the procedure. Immediately afterwards though, she became unresponsive during her transit to the recovery room, exhibiting some involuntary jerking activity and was found to not have a pulse. She received 2 minutes of CPR and subsequently regained responsivness. At this point she was placed on telemetry where she a normal sinus rhythm and a palpable pulse. No medication was administered during the event and she was placed on O2 and then transfered to the MICU. . In the MICU, she was monitored and was stable other than one episode of hypoglycemia with a blood sugar of 14 on the [**2139-9-16**], that was immediately managed with IV D50 and she responded appropriately with improved alertness and appropriate mental status. A CTA ruled out pulmonary embolus. She was observed for a few hours and was then transfered to the SIRS service. . On the floor, the patient was found in acute respiratory distress, with an initial O2Sat in the 40s. The patient was immediately placed on 4L NC and her O2Sats increased back to the 90s. She exhibited significant somnolence and altered mental status. An ABG taken on 4L gave results of 7.37/62/67/37 and a following one on RA was 7.39/61/47/38. . Past Medical History: 1. Type 1 diabetes complicated by retinopathy and likely nephropathy, diagnosed at age 11. Poorly controlled per recent records, with the exception of during her pregnancy when she required TPN (with insulin it) for hyperemesis. She has had multiple episodes of diabetic ketoacidosis. Aic was 15.1 [**10-30**] appt with her [**Last Name (un) **] attending Dr. [**Last Name (STitle) 9978**]. No visits since then. Last eye exam [**5-1**] - "quiescent" PROLIFERATIVE diabetic retinopathy. 2. Depression 3. Severe hyperemesis requiring TPN. 4. Status post C section at 33 weeks because of hyperemesis. 5. Migraines 6. Accquired hemophilia (FVIII inhibitor in [**2132**]) treated with steroids and rituximab 7. Anti-E and warm autoantibody 8. GERD, antral ulcer 9. Hypertension 10. Hydronephrosis 11. Osteoporosis ([**2138-11-12**] T-score lumbar spine -2.2, femoral neck -3.1) . Past Surgical History: - Cesarean section ([**2132**]) - Laparoscopic appendectomy ([**2132**]) - TAB [**3-31**] - Proximal gastroduodenal artery embolization - Excision of a skin mole - Achilles avulsion repair Social History: The patient does not smoke or drink alcohol, transfusion in [**2132**]. Married, living with her husband and one son. A homemaker currently. On disability since [**2132**]. Exercises regularly at a gym. Family History: Has 1 sister, no hx of cancer or bleeding/ blood disorders in family but positive IBD history in grandfather and [**Name2 (NI) 12232**]. Physical Exam: EXAM on ADMISSION Vitals: T: 97.3 BP: 118/62 P: 64 RR: 18 O2: 92% on 2L General: In NAD HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple, no LAD Lungs: Crackles bilaterally, with decreased breath sounds at the bases CV: Normal rate and regular rhythm, with split S2 best heard at the LUSB, no M/R/G Abdomen: Soft, non-tender, mildly distended, bowel sounds present, no rebound tenderness or guarding, no hepatosplenomegaly GU: Deferred Ext: 1+ pitting edema, R>L in lower extremities, warm, well perfused, 2+ pulses Neuro: AOx3, Sensory and motor grossly intact EXAM on DISCHARGE: improved LLL, decreased BS over RLL; small and superficial left dorsal foot ulceration Pertinent Results: ADMISSION LABS: [**2139-9-12**] 10:00PM BLOOD WBC-6.4 RBC-3.26* Hgb-10.1* Hct-30.8* MCV-94 MCH-31.0 MCHC-32.8 RDW-17.0* Plt Ct-438 [**2139-9-12**] 10:00PM BLOOD Neuts-69.2 Lymphs-23.2 Monos-4.8 Eos-1.7 Baso-1.0 [**2139-9-12**] 10:00PM BLOOD Glucose-326* UreaN-41* Creat-1.5* Na-136 K-6.0* Cl-101 HCO3-24 AnGap-17 [**2139-9-13**] 06:15AM BLOOD Glucose-414* UreaN-39* Creat-1.4* Na-139 K-4.2 Cl-102 HCO3-25 AnGap-16 Pertinent trends: Cr and K+ [**2139-9-16**] 02:41AM BLOOD Creat-1.3* K-4.2 [**2139-9-17**] 05:50AM BLOOD Creat-2.6*# K-4.6 [**2139-9-19**] 06:45AM BLOOD Creat-1.5* K-4.8 [**2139-9-20**] 06:45AM BLOOD Creat-1.4* K-5.4* [**2139-9-21**] 05:15AM BLOOD Creat-1.4* K-5.6* [**2139-9-14**] 02:25PM BLOOD [**Doctor First Name **]-POSITIVE * Titer-1:640 dsDNA-NEGATIVE [**2139-9-19**] 06:45AM BLOOD AMA-NEGATIVE [**2139-9-14**] 06:25AM BLOOD C3-121 C4-48* [**2139-9-15**] 11:50AM BLOOD Type-ART pO2-114* pCO2-42 pH-7.49* calTCO2-33* Base XS-8 [**2139-9-16**] 04:22PM BLOOD Type-ART pO2-47* pCO2-61* pH-7.39 calTCO2-38* Base XS-8 Microbiology: Blood cultures - negative x2 Imaging: CXR ([**9-12**]): SINGLE AP UPRIGHT PORTABLE CHEST RADIOGRAPH: There are interval bilateral basilar opacity, right slightly worse than left, representing combination of bilateral pleural effusions with atelectasis. Superimposed infections cannot be excluded. There is no pneumothorax. The cardiomediastinal silhouette, hilar contours, and pulmonary vasculature are normal. There is interval removal of the left-sided PICC line. IMPRESSION: Interval moderate bibasilar opacities, likely combination of pleural effusions and atelectasis, but cannot exclude superimposed infection. CXR ([**2139-9-16**]): As compared to the prior examination, there is improved aeration at the lung bases with improvement in atelectasis and effusions as well as vascular congestion. No pneumothorax is seen. The cardiomediastinal silhouette is unchanged. . CT CHEST ([**2139-9-15**]): 1. No evidence of pulmonary embolism. 2. Persistent moderate bilateral pleural effusions with compressive atelectasis. 3. Interval improvement of scattered areas of peri-bronchovascular opacities. 4. Two splenic hypodensities, the anterior lesion subcentimeter in size and stable, the second 14-mm lesion along the hilum demonstrates increase in size since [**2136-11-2**]. Differential includes but not limited to cysts, hamartoma, hemangioma, or lymphangioma. These can be followed by ultrasound. 5. Left pectoral subcutaneous emphysema and soft tissue induration likely related to instrumentation. Recommend clinical correlation to identify the catheter-like structure terminating in the subcutaneous soft tissue. . ABDOMINAL U/S ([**2139-9-14**]): 1. Nondistended gallbladder with marked wall edema, nonspecific, but may relate to liver dysfunction or hypoproteinemia. No pericholecystic fluid or son[**Name (NI) 493**] [**Name2 (NI) 515**] sign. No intra- or extra-hepatic biliary dilatation. 2. Bilateral pleural effusion. No free fluid is seen. 3. 1.5 cm septated right renal cyst without internal vascularity, with thin septations measure no greater than 1 mm. Arterial and venous flow is seen to both kidneys. No hydronephrosis bilaterally. 4. Along the anterior cortex of the mid to lower pole of the right kidney, there is an echogenic focus, measuring 1.4 x 0.6 x 1.0 cm, which is avascular, and not definitively within the kidney- most likely perinephric fat. Attention at follow-up imaging. Brief Hospital Course: 35 year old female with a PMH for DMI, hypertension, warm antibody, hemolytic anemia, depression, and osteoperosis who presents with a chief complaint of dyspnea. Active issues: # Code blue/arrest: The patient underwent renal biopsy and received fentanyl/versed for the procedure. When she was being wheeled to recovery she was noted to become ashen and lost a pulse. CPR was performed for 2 minutes following which she had spontaneous return of circulation. BP was in the 160s and HR in the 70s. She was not given epinephrine. CTA showed no PE and labs were unrevealing. She did not have abnormalities on EKG. It was thought that she had a vagal episode triggering the unresponsive/pulseless episode. She was monitored overnight in the ICU without any problems other than hypoglycemia the next morning in the setting of being NPO and receiving NPH insulin. This resolved with dextrose. . # Dyspnea hypoxemia with hypercarbia: Thought to be from pleural effusions, which were seen on CXR. Patient was recently admitted with negative work up for the pleural effusions except for a positive [**Doctor First Name **] and anti SS-A antibody. Cardiogenic pulmonary edema was thought to be unlikely given her recent normal echo and cardiac MRI. Pt did not have any signs of infection. The effusions was ultimately felt to be secondary to her hypoalbuminemia resulting from her nephrotic range proteinuria/diabetic nephropathy. She received antibiotics in the ED and these were stopped upon admission to the ICU. She had no fevers, tachycardia, or signs of infection and was diuresed 3L of fluid with improvement of her O2 saturations to the mid 90s on 2L NC O2. She was transferred to the floor and continued to improve on IV Lasix 40 MG [**Hospital1 **] when she was sent for a renal biopsy per the recommendation of both the Renal and Rheumatology teams. This is when the patient had a cardiac arrest (as above), was transferred back to the MICU, and was returned to the SIRS service. On presentation, she had an acute desaturation into the 40s. ABGs obtained on 4L and RA revealed a picture of hypercarbia likely from narcotic medication administration and poor inspiratory effort from pleural effusions, chest pain due to CPR and healing rib fractures, in addition to hypoxemia likely from V/Q mismatch given elevated A-a gradient and improvement on oxygen. The patient was given IV Lasix and kept on 4L of O2 and was slowly weaned off until she was stable on room air with appropriate ambulatory sats, over approximately 3-4 days. . # Acute on chronic renal failure: According to notes from prior admission, she had nephrotic range proteinuria and the underlying cause was thought to be due to her diabetes. This was confirmed by renal biopsy which took place on [**2139-9-15**]. The patient's creatinine on admission was 1.6, which improved initially following diuresis, but then became elevated to 2.6, 48h after a CT scan, likely due to contrast-induced nephropathy. The patient was not given IV fluids and instead was encouraged to take in PO fluids allow for self-regulation. Within 3 days, her creatinine downtrended to 1.3 and she was subsequently started on torsemide 40 MD QD instead of Lasix, and the following day back on her home dose of valsartan 160 MG PO QD. After an acute rise in her creatinine to 1.5 in the setting of the valsartan, we chose to discontinue it upon discharge along with a dose adjustment of torsemide to 20mg qd. # Hyperkalemia: The patient presented with a K+ of 5.9, which was managed by administration of Kayexylate. The etiology of this elevation was unclear. Repeat K+ after administration of Kayexylate gave a repeat [**Location (un) 1131**] of 4.2 and the patient had a stable K+, with occasional need for repletion with potassium chloride following initiation of diuresis. However, a few days prior to discharge, the patient's K+ was elevated to > 5.0 following initiation of valsartan and thus we administered Kayexylate and discontinued the patient's valsartan. Her K+ continued to be elevated on discharge but the EKG did not show any acute changes. Her electrolytes will be followed closely in [**1-25**] days by her PCP. . # Diabetes, type 1 poorly controlled: The patient was continued on her home dose of lantus and sliding scale insulin. She was given a diabetic diet. Her blood sugars in the hospital were somewhat variable, with a many readings above 400 and a low in the MICU of 14, that was managed with 50% Dextrose. She was placed on her ISS as [**First Name8 (NamePattern2) **] [**Last Name (un) 9718**] recommendations and plans to follow-up with them regarding an insulin pump upon discharge. . # Hypertension: The patient was continued on her home regimen of amlodipine and metoprolol. Her blood pressures were generally well-controlled in the hospital and no changes were made to her regimen, apart from the valsartan as described above. . # Anemia: The patient's Hct range of 29-30 represents an improvement from discharge range of 24-25. However, the value is still lower than her previous baseline levels and was seen by Hematology at her last admission who commented on her hypoproliferative state. Given her improved value and her other pressing issues, we did not pursue a work-up in the hospital and we advised she continue to follow-up as planned with the [**Hospital **] clinic as an out-patient. # Rib pain: As a result of chest compressions, the patient noted a very sore chest, with pain managed adequately by tramadol. A limited supply of tramadol was provided to her at discharge. . Transitional issues: # Follow-up: She has numerous follow-up appointments with her PCP, [**Name10 (NameIs) **], hematology, pulmonary, and [**Last Name (un) **]. Her PCP will be following her hyperkalemia closely with outpatient lab draws prior to these appointments. [**Last Name (un) **] will be discussing the option of an insulin pump as an outpatient. # Incidental kidney finding on imaging: Per abdominal U/S report - "Along the anterior cortex of the mid to lower pole of the right kidney, there is an echogenic focus, measuring 1.4 x 0.6 x 1.0 cm, which is avascular, and not definitively within the kidney - most likely perinephric fat. Attention at follow-up imaging." Medications on Admission: 1) Amlodipine 10 mg PO/NG DAILY 2) Insulin SC 3) Citalopram 40 mg PO/NG DAILY 4) Ferrous Sulfate 325 mg PO/NG DAILY 5) Metoprolol Tartrate 37.5 mg PO/NG [**Hospital1 **] 6) Furosemide 40 mg IV ONCE 7) Omeprazole 40 mg PO DAILY 8) Gabapentin 600 mg PO/NG HS 9) Senna 1 TAB PO BID:PRN Constipation 10) Simvastatin 20 mg PO/NG DAILY 11) Heparin 5000 UNIT SC TID 12) Ambien 5 MG PO QHS PRN for insomnia 13) Ergocalciferol 50,000U QWeekly Discharge Medications: 1. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. torsemide 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: 1-2 Tablets PO DAILY (Daily). 7. metoprolol tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). 8. gabapentin 600 mg Tablet Sig: One (1) Tablet PO at bedtime. 9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 10. Ambien 5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 11. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO once a week. 12. Lantus 100 unit/mL Solution Sig: Three (3) Units Subcutaneous QAM. 13. Lantus 100 unit/mL Solution Sig: Seven (7) Units Subcutaneous QPM. 14. Humalog 100 unit/mL Solution Sig: ISS Subcutaneous QIDACHS. 15. tramadol 50 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for pain. Disp:*24 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: PRIMARY: 1. Pleural effusions, Hypoxia, Hypercarbia 2. Cardiac Arrest 3. Acute Renal Failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Last Name (Titles) **], It was a pleasure taking care of you at the [**Hospital1 771**]. You were admitted on [**2139-9-12**] to the ICU with shortness of breath and fluid overload in the lungs. You were given intravenous furosemide (lasix) to help remove the fluid and you appropriately responded to the medication. When you were stable, you were transfered to the floor and were seen by the Rheumatology and Renal teams, who both recommended a renal biopsy. You received a renal biopsy on [**2139-9-15**], which went well, but immediately following the procedure, you had what was presumed to be a cardiac arrest for 2 minutes. A code was called and you received 5 rounds of CPR. You recovered following the CPR and did not require any medications during the code. Once stable, you were transferred to the MICU for monitoring and evaluation. When transfered back to the floor on [**2139-9-16**], you had an additional acute oxygen desaturation, but were placed on 4L of oxygen and given intravenous Lasix and you recovered well. We closely watched your oxygen levels and you appropriately came off oxygen and had appropriate levels on room air and on the day of discharge. With regards to your kidneys, the biopsy results revealed that your disease is almost entirely related to your diabetes. On [**2139-9-17**], your kidney function acutely declined as indicated by an increase in your creatinine level, likely due to the contrast you received a few days earlier during your CT scan. We conservatively managed this, encouraging you to take in sufficient fluids orally and your creatinine appropriately came down on the day of discharge. Once improved, we started you a new diuretic known as Torsemide once a day for continual removal of fluid at a dose of 20 MG per day. You also have a mild elevation in your potassium. Please AVOID high potassium foods until follow up. Please have your potassium level checked on follow up. MEDICATION CHANGES: 1) CONTINUE Torsemide 20 MG once a day 2) STOP valsartan for now . Please seek medical attention for any worsening symptoms. Please attend your follow-up appointments below. Followup Instructions: We have scheduled the following appointments for you: Name: [**Last Name (LF) **], [**Name8 (MD) **] MD When: Wednesday, [**2138-9-23**]:00am Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Location: [**Hospital1 **] **Please have your blood drawn on Tuesday or Wednesday before this appointment. Name: [**Last Name (LF) 20556**], [**First Name7 (NamePattern1) 553**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Last Name (un) **] DIABETES CENTER Address: ONE [**Last Name (un) **] PLACE, [**Apartment Address(1) 20557**], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2490**] Appointment: Thursday [**2139-10-1**] 1:00pm Department: WEST [**Hospital 2002**] CLINIC When: MONDAY [**2139-10-19**] at 4:00 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 721**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [**2139-9-23**] at 1 PM With: [**First Name11 (Name Pattern1) 2295**] [**Last Name (NamePattern4) 11222**], MD [**Telephone/Fax (1) 22**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 249**] When: MONDAY [**2139-11-16**] at 1 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 250**] Specialty: PULMONARY, CRITICAL CARE & SLEEP MEDICINE Address: [**Location (un) **], E/KS-B23, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 612**] We are working on a follow up appointment with the Pulmonary Department within 1-2 weeks. You will be called at home with the appointment. If you have not heard from the office within 2 days or have any questions, please call the number above.

[ "276.7", "585.3", "283.0", "403.90", "285.21", "362.02", "536.3", "346.90", "511.89", "581.89", "999.5", "784.2", "427.5", "E931.3", "250.43", "482.9", "799.02", "311", "273.8", "272.4", "V58.67", "250.53", "E944.4", "707.15", "E932.0", "288.60", "584.9", "285.8", "581.81", "511.9", "530.81", "682.7", "733.00", "708.0", "787.99" ]

icd9cm

[ [ [] ] ]

[ "55.23", "88.73", "38.97", "99.60", "34.91" ]

icd9pcs

[ [ [] ] ]

43425, 43431

35414, 35578

26545, 26614

43568, 43568

31927, 31927

45898, 47891

31072, 31211

42180, 43402

43452, 43547

41722, 42157

43719, 45680

6047, 8538

30641, 30831

31226, 31801

18855, 18926

8725, 10632

8571, 8689

41031, 41696

2318, 2860

45700, 45875

26489, 26507

35594, 41009

26642, 29720

31820, 31908

31943, 35391

43583, 43695

15176, 15858

29742, 30618

30847, 31056

20,077

169,009

22438

Discharge summary

report

Admission Date: [**2101-8-18**] Discharge Date: [**2101-8-24**] Date of Birth: [**2030-12-10**] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old gentleman has had symptoms of shortness of breath and fatigue for approximately one year prior to admission. He underwent a cardiac echocardiogram on [**2101-5-5**] revealing a moderately enlarged left atrium with a torn chordae of the anterior mitral valve leaflet. There was also [**4-7**]+ mitral regurgitation, mild to moderate pulmonary hypertension. The patient was admitted to the [**Hospital1 188**] on [**2101-8-18**] for a cardiac catheterization. This revealed normal left ventricular ejection fraction of 65 percent as well as normal coronary arteries. It also showed moderate pulmonary hypertension with pulmonary artery pressures of 45/16 and the patient was referred for mitral valve repair versus replacement with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **]. PAST MEDICAL HISTORY: 1. Hypercholesterolemia. 2. Mitral regurgitation. 3. Esophageal donut placed approximately 15 years ago. 4. Rectal fissure repair. 5. Back surgery in [**2056**]. ALLERGIES: The patient states allergies to Klonopin and all antidepressant medications which resulted in nausea and fatigue. PREOPERATIVE MEDICATIONS: 1. Lasix 20 mg p.o. q.d. 2. Potassium 10 mEq p.o. q.d. 3. Aspirin 81 mg p.o. q.d. LABORATORY DATA: The laboratory values preoperatively were unremarkable. PHYSICAL EXAMINATION: The patient's physical examination was unremarkable. SOCIAL HISTORY: The patient denied alcohol intake and was a cigar smoker for 20 years but quit three months prior to admission. HOSPITAL COURSE: The patient was taken to the Operating Room on [**2101-8-19**] with Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] where he underwent a mitral valve repair with a #28 CE anuloplasty band. Postoperatively, the patient was on a nitroglycerin drip and transported to the Cardiac Surgery Recovery Unit in good condition. The patient was successfully weaned from mechanical ventilation and extubated the night of surgery. He was in normal sinus rhythm with stable hemodynamic parameters. On postoperative day number one, beta blockers were initiated. His Swan-Ganz catheter was removed. On postoperative day number two, diuresis was initiated. The patient remained hemodynamically stable and was ready to be transferred to the telemetry floor. The patient, on postoperative day number three, had a number of hours of atrial fibrillation, was treated with increasing beta blockers as well as Amiodarone and before the following morning had converted to sinus rhythm with no further episodes of atrial fibrillation. Today, postoperative day number five, he remains hemodynamically stable and ready to be discharged home. Condition today: Neurologically, he was grossly intact with no apparent deficits. The pulmonary examination revealed that his lungs were clear to auscultation bilaterally. Coronary examination revealed a regular rate and rhythm. Sternal incision was clean with Steri-Strips clean, dry, and intact. His abdomen was benign. His extremities were warm without edema. DISCHARGE MEDICATIONS: 1. Amiodarone 200 mg p.o. b.i.d. for one week and then 200 mg p.o. q.d. for three weeks or until discontinued by Dr. [**Last Name (STitle) **]. 2. Lopressor 25 mg p.o. b.i.d. 3. Aspirin 325 mg p.o. q.d. 4. Zantac 150 mg p.o. b.i.d. 5. Colace 100 mg p.o. b.i.d. 6. Dilaudid 2 mg p.o. q. 4-6 hours p.r.n. pain. 7. Lasix 20 mg p.o. b.i.d. times seven days. 8. Potassium chloride 20 mEq p.o. b.i.d. times seven days. DISCHARGE DIAGNOSIS: Mitral regurgitation, status post mitral valve repair. CONDITION ON DISCHARGE: Good. FOLLOW UP: The patient is to follow-up with Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] in one to two weeks, his cardiologist. He is also to follow-up with his primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 17996**], in one to two weeks. He is to follow-up with his cardiac surgeon, Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **], in three to four weeks. [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**] Dictated By:[**Last Name (NamePattern1) 5664**] MEDQUIST36 D: [**2101-8-24**] 16:59:55 T: [**2101-8-24**] 17:46:57 Job#: [**Job Number 58312**]

[ "416.9", "272.0", "424.0", "427.31", "429.5", "997.1", "E878.9" ]

icd9cm

[ [ [] ] ]

[ "37.22", "88.56", "88.53", "39.61", "35.12" ]

icd9pcs

[ [ [] ] ]

3240, 3661

3683, 3739

1714, 3217

3783, 4488

1330, 1489

1512, 1566

166, 991

1013, 1304

1583, 1696

3764, 3771

51,585

136,598

22609

Discharge summary

report

Admission Date: [**2133-8-25**] Discharge Date: [**2133-8-31**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 759**] Chief Complaint: Diarrhea, fall Major Surgical or Invasive Procedure: None History of Present Illness: 85 yo M with PMH of CAD s/p recent STEMI on [**8-19**] with BMS to RCA presents with diarrhea, vomiting and weakness. Also with nonproductive cough and chills. He has been SOB since prior to his STEMI last week. Pt denies abdominal pain, fever, chest pain, back pain, BRBPR. Per niece, patient has been unsteady since leaving hospital. Also with poor po intake and dizziness. He has fallen at home without head trauma. In the ED, VS: 67 123/60 18 97 RA. Labs notable for elevated lipase to 1485, Tn elevated to 3.94 with normal CK MBI, Cr of 6.2, WBC count of 16.2. EKG was unchanged from prior. Stool was guaiac negative. He received Vanco, Zosyn for possible biliary sepsis, and 2L IVFs. Patient was transferred to [**Hospital Unit Name 153**] for further management. Past Medical History: Emphysema gastric ulcers h/o bilateral inguinal hernia repair recent STEMI as outlined above Social History: Past history of heavy 2ppd tobacco use for 30 plus years, quit 12-15 years ago per his niece; no recent etoh use, no drugs. Lives at home alone. His wife died in [**2125**] , had been caring for her by himself, she had bad dementia. He has a wood stove at home that he uses every day. He is a retired carpenter and was in the army in WWII. Family History: Noncontributory Physical Exam: VS:HR 69, BP 135/70, 92% on RA GEN: Elderly in NAD, Sitting up in bed HEENT: EOMI, PERRL, anicteric NECK: Supple, no JVD CHEST: CTABL, distant BS throughout, no w/r/r CV: RRR, S1S2, no m/r/g ABD:Soft, NT, ND, +BS, no organomegaly EXT: warm, no c/c/e SKIN: ecchymoses on bilateral hands, LUE, L flank NEURO: AAOx 3(place: hospital- [**Location (un) **]), CN ii-xii intact; strength and sensation grossly intact Pertinent Results: [**2133-8-25**]: CXR: Large opacity in the right perihilar region extending to the lateral hemithorax on the right. Density highly suggestive of airspace disease although smaller underlying mass lesion cannot be entirely excluded. A neoplasm is suspect. [**2133-8-25**]: Liver/ Gallbladder U/S: Cholelithiasis, no evidence acute cholecystitis. Prominent common bile duct, cannot exclude distal choledocholithiasis. [**2133-8-25**]: CT HEAD: No significant interval change with no acute intracranial pathology identified. [**2133-8-25**]: CT C-spine: 1. Limited examination due to multilevel degenerative changes as described above with no definite acute fracture. The kyphotic angulation results in canal narrowing, which increases risk of cord injury. If high clinical suspicion, a dedicated MRI can be used for better evaluation of ligamentous and cord pathology. 2. Atherosclerotic disease and centrilobular emphysema. [**2133-8-26**]: Renal U/S: HISTORY: 85-year-old man with acute renal failure. Please evaluate for obstruction. COMPARISONS: None. FINDINGS: The aorta is of normal caliber and diameter throughout. There is no evidence for aneurysm or focal dilatation. The right kidney measures 10.4 cm and the left kidney measures 11.3 cm. Within the right kidney, there are no stones, masses or hydronephrosis. Within the lower pole of the left kidney, there is a 2.7 x 1.4 x 1.1 cm multiseptated hypoechoic structure likely representing a multiseptated parapelvic cyst. There are no other masses identified. There is no hydronephrosis. There is a Foley present within the bladder, which is decompressed. There is limited arterial vascular evaluation of the left and right kidneys. However, waveforms are normal in appearance and there is normal-appearing flow. IMPRESSION: 1. No evidence for hydronephrosis. 2. Right-sided parapelvic cyst. 3. Limited evaluation of the renal vasculature, however, flow appears normal. 4. No abdominal aortic aneurysm. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 13879**] [**Name (STitle) 13880**] DR. [**First Name8 (NamePattern2) 7722**] [**Last Name (NamePattern1) 7723**] Approved: [**Doctor First Name **] [**2133-8-27**] 2:58 PM [**2133-8-26**]: CT chest without contrast: 1. Large right upper lobe mass abutting the major fissure, encapsulating and narrowing right upper lobe airways. Postobstructive pneumonitis is seen adjacent to the lesion. Several pulmonary nodules are seen in the superior segment of the right lower lobe, in the right middle lobe, and left lower lobe. 2. Multiple heterogeneous, predominantly sclerotic lesions in spine, consistent with metastatic disease. 3. Hypodense lesion in the right lobe of the liver, incompletely evaluated on this non-contrast study, consistent with metastatic disease. Further evaluation with MRI is recommended. 4. Previously described pancreatic duct abnormalities are not well evaluated on this study, and MRI is recommended for further evaluation. 5. Multiple right-sided calcified pleural plaques and multiple foci of left-sided pleural thickening suggesting prior asbestos exposure. 6. Mediastinal and hilar lymphadenopathy. Brief Hospital Course: 85 year old male with CAD s/p STEMI on [**2133-8-19**] here with diarrhea x1 day, dizziness, possible acute pancreatitis, and acute renal failure. #. Acute renal failure: FeNA 2.8 consistent with ATN. Renal was consulted and felt this was likely multifactorial from cholesterol emboli, recent initiation of an ACEI, and volume depletion. Abdominal ultrasound with renal flow with no evidence of aortic dissection or obstruction. Urine eosinophils negative. His creatinine was monitored and should continue to be closely watched for resolution at rehab. He maintained good urine output with 1100 cc in the 24 hrs prior to discharge. Please avoid nephrotoxic medications, including ACE-inhibitors for the time being. Continue to monitor urine output and ensure patient does not become dehydrated. Cr on day of discharge 7.3, BUN 53, K 3.6 #. Pancreatitis: Chemical elevation of Lipase and ALT sensitive and specific for acute pancreatitis though history not typical with minimal symptoms. [**Last Name (un) 5063**] score approximately 3 at admission and 0-1 at 48 hours. Given that LFTs are decreasing and lipase is falling, it appears that the patient likely passed the obstructing stone. GI (ERCP team) involved initially but decided against ERCP acutely given his improvement and he was on Plavix; Consider ERCP in [**7-7**] weeks as an outpatient if desired by patient/family. Zosyn was started to cover possible developing biliary sepsis, but there was no sign of this subsequently. He was eventually resarted on clears. Statin held given transaminitis. ## bloody stools: The patient started having liquid stools, + for blood, since starting clears, ?related to PO intake as he has had a substantial amount of PO fluids over the first 24 hours of clear liquid diet. However, he remained symptom-free, hemodynamically stable, and with stable Hct (~35). Diarrhea improved overnight as his diet was restricted again to sips, and he was restarted on clears again, with no red liquids. He had another loose bowel movement that was green and guaiac negative and he reported to me on the day of anticipated discharge that the diarrhea was slightly improved. If this continues, you may consider checking C. difficile. Hct 34 on day of discharge. Diarrhea described as green in color, occult blood negative on the day of discharge. #. Right lung mass: Given his smoking history, the mass is concerning for lung cancer. The plan as of his last discharge was to defer biopsy for one month given that he is on Plavix. However, given the likely metastatic nature of the disease, it is unclear what benefit a biopsy might provide as the patient and his niece are reluctant at this time to consider chemotherapy. CT chest during this admission showed a post-obstructive pneumonitis; given the potential for an infectious component, he was covered with Zosyn for postobstructive pneumonia for seven days (ends [**2133-9-2**]). Noncontrast chest CT also indicates likely metastatic disease with spread to liver and spine. #. CAD s/p recent STEMI: Elevated CK and troponins likely due to acute renal failure and were trending down. No EKG changes. Continued cardiac regimen of ASA, Plavix, beta-blocker. Lisinopril held [**12-27**] renal failure; statin held given LFTS as above. On the day of discharge, I updated his niece at his request and her questions were answered to her apparent satisfaction. Medications on Admission: 1. Aspirin 325 mg Tablet PO DAILY 2. Clopidogrel 75 mg Tablet PO DAILY 3. Atorvastatin 80 mg Tablet PO DAILY 4. Lisinopril 5 mg Tablet PO DAILY 5. Metoprolol Succinate 25 mg PO once a day Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Piperacillin-Tazobactam 2.25 gram Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours): continue through [**2133-9-2**] and discontinue. 6. Acetaminophen 500 mg Capsule Sig: [**11-26**] Capsules PO TID PRN as needed for fever or pain. 7. Outpatient Lab Work Chem-7 with BUN/Cr, Na, Cl, K, CO3, glucose every day until renal function plateaus and electrolytes are stable. [**Name8 (MD) **] MD with results. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] and Rehab Centre Discharge Diagnosis: Primary: pancreatitis, acute renal failure Secondary: coronary artery disease, lung mass Discharge Condition: Fair Discharge Instructions: You were admitted for evaluation of diarrhea and dehydration and found to have pancreatitis and acute renal failure. You improved with IV fluids and antibiotics. If you have fevers, chills, chest pain, abdominal pain, inability to tolerate food or liquids, or any other concerning symptoms, seek medical attention immediately. Followup Instructions: Follow up with the nephrologists (kidney doctors) after you are discharged from rehab. You may call Dr. [**First Name (STitle) 4102**] [**Name (STitle) **] office at [**Telephone/Fax (1) 60**] to make an appointment. Follow up with your primary care physician in one month. You may consider a biopsy of the lung mass after you are off Plavix, which she can arrange for you. Call Dr.[**Name (NI) 41811**] office at [**Telephone/Fax (1) 5763**] to make an appointment.

[ "584.9", "V45.82", "786.6", "577.0", "492.8", "414.01", "410.72" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9611, 9672

5246, 8650

276, 282

9805, 9812

2034, 2468

10188, 10659

1572, 1589

8888, 9588

9693, 9784

8676, 8865

9836, 10165

1604, 2015

222, 238

310, 1082

2477, 5223

1104, 1198

1214, 1556

71,072

190,731

54779

Discharge summary

report

Admission Date: [**2175-7-23**] Discharge Date: [**2175-8-4**] Date of Birth: [**2102-9-2**] Sex: M Service: MEDICINE Allergies: Sulfa(Sulfonamide Antibiotics) / Cipro / Codeine / morphine Attending:[**First Name3 (LF) 943**] Chief Complaint: abdominal pain Major Surgical or Invasive Procedure: Diagnostic paracentesis x2 Therapeutic paracentesis x2 Temporary dialysis line placement History of Present Illness: This is a 72 year old man with a history of alcoholic cirrhosis, recent hospitalization ERCP with ampullary sphincterotomy for a finding of CBD dilation, who presents with worsening of abdominal pain and constipation. The wife reports that he was doing very well after his discharge from the hospital on [**2175-7-18**]. However, yesterday morning ([**2175-7-22**]) he developed worsening abdominal pain that he reports is "gassy." His wife gave him 30 mL of lactulose and performed a fleet enema, which usually helps him when he is constipated. However, he was not able to move his bowels and his pain persisted. He requires high doses of oxycontin/oxycodone at baseline for management of his chronic pain and DJD. During his last hospital admission, he underwent an ERCP with sphincterotomy due to an elevated AlkP and a CT finding at an LGH of a [**Month/Day/Year 6878**] CBD to 28mm. While in the hospital ([**7-20**] discharge) he was on a lower dose of narcotics and he was moving his bowels regularly with a bowel regimen. His abdominal pain had improved even prior to the ERCP and sphincterotomy. The sphincterotomy was uncomplicated and he was discharged home feeling well. Initial VS in the ED: 99.8 92 158/75 18 95% RA. Tmax in the ED was 99.9. A CT abdomen scan was performed that showed mild interval increase in ascites (not clinically appreciable). No obstruction noted or other acute abdominal process noted. It was determined through bedside ultrasound that there was not enough ascites for diagnostic paracentesis. Patient was given ceftriaxone 2g for possible SBP. Notable labs ALT: 17 AP: 235 (decreased from prior admission) Tbili: 1.4 Alb: 3.8 AST: 31 Lip: 16. WBC (Neut 80.6%) 9.5 Hgb 11.5 Hct 33.6 Plt 86. Ammonia 40. His VS prior to transfer: 98.2, 83, 148/78, 18, 96%RA On the floor, he continues to have difficulty moving his bowels and complains of abdominal pain. He appears distracted by pani and his wife provides most of the history. Review of systems: (+) Per HPI + cough + anorexia + constipation + arthralgias (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea. No recent change in bladder habits. No dysuria. Denied myalgias. Past Medical History: - alcoholic cirrhosis: stopped drinking 20 years ago, c/b variceal bleed (in [**2175-3-28**]), ascites and hepatic encephalopathy. On EGD in [**Month (only) 116**], noted to have "ulcerated" stomach. (at [**Location (un) 1468**]) - pancreatitis: a long time ago - hypertension - NIDDM on Metformin - anemia requiring blood transfusions and iron infusions in the past, followed by H/O Dr. [**Last Name (STitle) 4680**] at [**Location (un) 1468**] - s/p cholecystectomy - bilateral knee replacements, c/b left prosthetic knee infection in [**2170**] (with bacterial seeding after colonoscopy), at [**Hospital6 2910**], s/p antibiotic spacer in that knee. Followed by ID Dr. [**Last Name (STitle) 8362**] at [**Hospital1 **]. - s/p 8 lower back lateral disc surgeries - s/p 3 cervical disc surgeries - prosthetic L eye: was hit in a fight - incarc hernia R groin - ventral hernia - chronic right shoulder OA Social History: -living situation: lives with wife, daughter and daughter's fiance -Work: used to manage a nightclub, then managed a PT clinic, -Tobacco: former, quit 50 years ago -Alcohol: former alcohol abuse, quit 20 years ago -Drugs: none ever Family History: Brother and father deceased from lung cancer (both smokers). Mother with CAD in her 80s. Non-Hodgkins lymphoma in his son. SLE in daughter. Another daughter T cell lymphoma. Physical Exam: ADMISSION PE: Vitals: T: 100.4 BP: 150/70 P: 95 R: 18 O2: 95% on RA General: Somulent elderly man with appreciable discomfort, going to the bathroom to unsuccessfully attempt to pass stool twice during the interview, oriented to person, place (knows he is in hospital but not [**Hospital1 18**]). With regard to time, he thought it was [**2164**], Saturday (it is Sunday). He knew we were in the month of [**Month (only) **]. He was inattentive throughout the exam and was not able list the months of the year forward or backward. HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, interespersed PVCs, normal S1 + S2, I/VI systolic murmur heard best at RUSB. Abdomen: distended, diffusely tender, no rebound tenderness, no guarding, BS present. hepatosplenomegaly difficult to assess due to distension. Veins appreciated on abdomen, although not noticably distended Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: - no spider rashes or lesions Lymph: - no cervical, axillary, or inguinal LAD Neuro - somulent, A&Ox2 as above, + asterixis, CNs II-XII grossly intact, although left eye is prosthesis, muscle strength 5-/5 in UE and [**4-1**] in lower extremities, sensation grossly intact throughout, DTRs 2+ and symmetric, cerebellar exam intact, wide based gait Rectal: guaiac positive Discharge PE: VS: T 98, Tm 98.8, HR 50-70s, BP 150s/70-80s, 20, 95-100% RA I/O: UOP 1225cc GENERAL: A&Ox3, sitting up in bed, in NAD HEENT: L eye prosthesis in place, sclera anicteric. CARDIAC: RRR, systolic murmur heard throughout LUNGS: CTAB ABDOMEN: soft, distended non-tender to palpation, +BS. EXTREMITIES: trace LE edema b/l. Warm and well perfused. NEUROLOGY: no asterixis Pertinent Results: ADMISSION LABS: [**2175-7-23**] 08:40AM BLOOD WBC-9.5# RBC-3.67* Hgb-11.5* Hct-33.6* MCV-92 MCH-31.3 MCHC-34.3 RDW-16.4* Plt Ct-86* [**2175-7-23**] 08:40AM BLOOD PT-15.5* PTT-31.1 INR(PT)-1.5* [**2175-7-23**] 08:40AM BLOOD Glucose-179* UreaN-15 Creat-0.7 Na-140 K-3.8 Cl-98 HCO3-32 AnGap-14 [**2175-7-23**] 08:40AM BLOOD ALT-17 AST-31 AlkPhos-235* TotBili-1.4 [**2175-7-23**] 08:40AM BLOOD Albumin-3.8 Cholest-125 [**2175-7-24**] 06:30AM BLOOD Albumin-3.2* Calcium-8.3* Phos-4.9* Mg-2.0 . RELEVANT LABS: [**2175-7-26**] 08:30AM BLOOD Type-[**Last Name (un) **] pO2-43* pCO2-70* pH-7.23* calTCO2-31* Base XS-0 Intubat-NOT INTUBA [**2175-7-26**] 08:30AM BLOOD Lactate-2.2* [**2175-7-26**] 04:51PM BLOOD Lactate-1.5 [**2175-7-23**] 10:20AM BLOOD Ammonia-40 [**2175-7-23**] 08:40AM BLOOD Triglyc-79 HDL-45 CHOL/HD-2.8 LDLcalc-64 [**2175-7-24**] 11:22AM URINE Color-DkAmb Appear-Cloudy Sp [**Last Name (un) **]-1.035 [**2175-7-24**] 11:22AM URINE Blood-MOD Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG [**2175-7-24**] 11:22AM URINE RBC-26* WBC-20* Bacteri-FEW Yeast-NONE Epi-<1 TransE-<1 [**2175-7-24**] 11:22AM URINE CastHy-41* CastWBC-3* [**2175-7-24**] 11:22AM URINE Hours-RANDOM Creat-261 Na-15 K-70 Cl-10 [**2175-7-24**] 11:22AM URINE Osmolal-351 [**2175-7-26**] 11:21AM URINE Color-Yellow Appear-Cloudy Sp [**Last Name (un) **]-1.021 [**2175-7-26**] 11:21AM URINE Blood-MOD Nitrite-NEG Protein-600 Glucose-TR Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG [**2175-7-26**] 11:21AM URINE RBC-15* WBC-23* Bacteri-FEW Yeast-NONE Epi-1 TransE-1 [**2175-7-26**] 11:21AM URINE CastHy-9* [**2175-7-24**] 09:15AM ASCITES WBC-800* RBC-[**Numeric Identifier **]* Polys-11* Lymphs-18* Monos-36* Mesothe-6* Macroph-29* [**2175-7-24**] 09:15AM ASCITES TotPro-1.8 Glucose-130 LD(LDH)-76 Albumin-1.0 . MICROBIOLOGY: ucx [**7-26**]: neg Bl cx [**7-23**], [**7-26**]: no growth C diff [**7-26**]: neg swab HD cath [**2175-7-30**]: no growth Peritoneal fluid cx [**7-24**]: no growth Peritoneal fluid cx [**7-28**]: no growth Peritoneal fluid cx [**8-1**]: NGTD, final pending Peritoneal fluid cx [**8-3**]:NGTD, final pending . IMAGING: TTE [**2175-7-28**]: The left atrium is moderately [**Month/Day/Year 6878**]. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are borderline/low normal (LVEF 55%). There is no ventricular septal defect. The right ventricular cavity is mildly [**Month/Day/Year 6878**] with borderline normal free wall function. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. RUQ U/S [**2175-7-27**]: 1. Small volume ascites. 2. Patent hepatic vasculature. 3. Residual central intrahepatic and extrahepatic bile duct dilatation, but less than on the CT of [**2175-7-15**], following sphincterotomy on [**2175-7-17**]. CXR [**2175-7-27**]: As compared to the previous radiograph, the signs suggesting pulmonary edema have decreased in severity. However, edema is still present. Moderate cardiomegaly, no pleural effusions. Mild retrocardiac atelectasis. CT abd/pelvis [**2175-7-26**]: 1. Moderately increased amount of ascites. 2. Increased amount of intraperitoneal fat stranding. 3. Unchanged evidence of cirrhosis and portal hypertension including a small nodular liver, splenomegaly, gastroesophageal and splenic varices, ascites, and diffuse intraperitoneal fat stranding. 4. Sigmoid diverticulosis without evidence of diverticulitis. 5. Left indirect inguinal hernia. 6. No abscess is identified. Renal U/S [**2175-7-25**]: Bilateral simple-appearing renal cysts. Mild cortical thinning of the left upper pole. Otherwise, normal renal son[**Name (NI) **] with no evidence of obstruction. . Discharge labs: [**2175-8-4**] 06:05AM BLOOD WBC-2.7* RBC-2.91* Hgb-8.6* Hct-27.1* MCV-93 MCH-29.4 MCHC-31.6 RDW-17.4* Plt Ct-98* [**2175-8-4**] 06:05AM BLOOD PT-14.2* INR(PT)-1.3* [**2175-8-4**] 06:05AM BLOOD Glucose-137* UreaN-50* Creat-2.5* Na-146* K-3.4 Cl-111* HCO3-26 AnGap-12 [**2175-8-4**] 06:05AM BLOOD ALT-13 AST-24 AlkPhos-108 TotBili-0.4 [**2175-8-4**] 06:05AM BLOOD Albumin-4.3 Calcium-8.6 Phos-3.2 Mg-1.8 Brief Hospital Course: 72M alcoholic cirrhosis complicated by varices, encephalopathy, recent hospitalization for ERCP and ampullary sphincterotomy, chronic pain and DJD on high dose narcotics, admitted with abdominal pain, low grade fevers, and [**Last Name (un) **] requiring ICU transfer for hypotension and confusion. # Sepsis: Fevers, hypotension, and leukocytosis to 18.5 concerning for sepsis with likely abdominal source given acute epigastric pain, combination of which prompted transfer to MICU. Patient initially admitted with dull abdominal pain and distention, concerning for SBP, initially treated with ceftriaxone, broadened to zosyn + vanc on transfer to MICU. Sepsis most likely [**12-29**] SBP, but other possibilities included pancreatitis, cholangitis given recent ERCP. CXR without evidence of PNA. Given diffuse bilateral patchy opacities on CXR, also considered acute pulmonary process as source. Patient may also have had an aspiration event in the setting of altered mental status. Culture data negative to date. Pt with diagnostic para [**7-24**] and [**7-28**], not entirely c/w SBP (144 polys, 195 polys respectively), but SBP thought most likely in setting of abd pain, distention and fat stranding on CT abd. BPs improved during MICU stay. Leukocytosis resolved. Lactate normalized. MICU callout. Pt continued on zosyn + Vanc (day 1 [**7-26**]) with plan for 7d of broad coverage and then converted to cipro SBP ppx on [**2175-8-2**]. Pt with documented cipro allergy in our OMR but pt and his wife were not aware of this allergy. Called PCP office to see if documented there and it was not, so we started Cipro for SBP ppx, which pt tolerated without difficulty. Pt started on stress dose steroids in MICU, which were tapered and transitioned back to PO prednisone 10mg QD (home dose for PMR). # Acute kidney injury, initiated on HD [**2175-7-29**]: Creatinine uptrended from baseline 0.7 during admission. BUN/Cr peaked [**2175-7-29**] at 115/8. In MICU, appeared total body fluid overloaded, but likely intravascularly depleted. Urine electrolytes and UNa consistent with ATN, with muddy brown casts noted by nephrology. However, also concern for HRS s/p volume challenge and octreotide/midodrine. D/c'ed midodrine [**2175-7-30**]. Lisinopril held. UOP improved and pt making approx 1L urine daily. Cr downtrending. Temp HD catheter pulled prior to discharge. # Cirrhosis w/ acute hepatic encephalopathy: Encephalopathy increased with the onset of fevers, then persisted until closer to discharge when pt's MS returned to baseline. No evidence of portal vein thrombosis on CT abd w/ contrast. Pt confused with asterixis during MICU stay and for a few days post MICU callout. - H/o varices: H/H stable without signs of active bleeding. Nadolol held in MICU for hypotension and restarted on the floor. - Encephalopathy: continued lactulose, started rifaximin ([**7-29**]). - Ascites, SBP on adm: Pt had therapeutic tap with removal of 5L of fluid on [**8-1**] with albumin replacement. Pt with reaccumulation and repeated therapeutic para [**8-3**] with removal of 1L. Pt will likely need repeated OP therapeutic taps as an OP. When renal function stabilizes, pt will need diuretic regimen. # AMS: Pt confused with asterixis. Could be from cirrhosis or uremia. Monitored for improvement with HD. Continued lactulose, rifaximin per above. Pt MS improved after callout from MICU and was at baseline prior to discharge, confirmed by pt's wife. # Bilateral shoulder pain: Acute pain posterior to left shoulder in MICU with wide differential. Likely musculoskeletal as patient has been immobilitzed in bed for the past 2 days. However, given acute epigastric pain, concern for referred pain from abdominal process. Considered cardiac pain from demand ischemia. However, no other cardiac symptoms. Pain improved with IV tylenol PRN; held narcotics for confusion and hypotension. Pt then started to complain on the floor of bilateral shoulder pain most likely related to PMR. Pt on high dose narcotic regimen at home (80mg oxycontin TID with 30mg oxycodone for breakthrough). We restarted pt on regimen of 40 oxycontin [**Hospital1 **] and 10mg oxycodone for breakthrough, which adequately controlled the pt's pain without changes in mental status. We discharged the pt home on this pain regimen. # NIDDM: well-controlled on metformin at home which was held during admission and replaced with SSI. Pt discharged home on SSI because of contraindication to metformin in the setting of renal and liver dysfunction. Spoke with [**Last Name (un) **] and got pt f/u appt on Mon, [**2175-8-7**] in their transition clinic for further assistance in insulin management. Pt and wife had insulin teaching by nursing prior to discharge. # Polymyalgia Rheumatica: On prednisone 10mg as an outpatient. Started on stress dose steroids during admission which was tapered back down to his home regimen. # Hypertension: Lisinopril held during admission for [**Last Name (un) **]. BPs uptrended post MICU stay. Pt discharged off of lisinopril. # Hyperlipidemia: Continued on home statin. # Insomnia: Chronic. Held diazepam to minimize risk of confusion. Restarted trazadone. Transitional Issues: # Pt will be discharged to home with PT and 24hr care from family. # Pt will need biweekly labs, which will be faxed to Dr. [**Last Name (STitle) 497**] in liver clinic. Pt will f/u with Dr. [**First Name (STitle) **] in renal clinic in 2mo. # Pt will need repeated therapeutic paracenteses as an OP as reaccumulated quite rapidly during admission. If renal function continues to improves and stablizes, pt will need diuretic regimen to help control ascites. Pt to be set up with therapeutic paracentesis in radiology before appt in liver clinic on [**2175-8-10**]. Dr. [**Last Name (STitle) 497**] [**Name (NI) 653**] liver clinic to assist in setting up this paracentesis. # Pt discharged on Cipro SBP ppx. # Pt discharged on SSI with close f/u in [**Last Name (un) **] transition clinic. Pt on metformin on admission but contraindicated in setting of renal and liver dysfunction. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from PatientFamily/Caregiver[**Name (NI) 581**]. 1. Bisacodyl 20 mg PO BID 2. Docusate Sodium 200 mg PO BID hold for loose stool, patient may refuse 3. Lactulose 30 mL PO TID Hold for loose stool. 4. Lisinopril 10 mg PO DAILY hold for SBP < 100 5. Multivitamins 1 TAB PO DAILY 6. Nadolol 40 mg PO DAILY hold for SBP < 100, HR < 60 7. OxycoDONE (Immediate Release) 30 mg PO Q4H:PRN breakthrough pain 8. Oxycodone SR (OxyconTIN) 80 mg PO Q8H 9. traZODONE 50 mg PO HS:PRN insomnia 10. Vitamin D 400 UNIT PO DAILY 11. Simvastatin 40 mg PO DAILY 12. PredniSONE 10 mg PO DAILY 13. Omeprazole 40 mg PO DAILY 14. Polyethylene Glycol 17 g PO DAILY:PRN constipation 15. Senna 1 TAB PO BID:PRN constipation 16. Caltrate-600 Plus Vitamin D3 *NF* (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit Oral daily 17. Glucosamine-Chondroitin-MSM *NF* (gluc-[**Doctor Last Name 2871**]-MSM#2-C-D3-[**Last Name (un) **]-born; gluc-[**Doctor Last Name 2871**]-msm#1-vit C - m a n g - b o r; glucosam-msm-chond-hrb149-hyal; glucosam-msm-chondr-vit C-hyal) 500-500-66.7 mg Oral daily 3 tablets 18. MetFORMIN XR (Glucophage XR) 750 mg PO BID Do Not Crush 19. Lorazepam 0.5 mg PO Q8H:PRN anxiety 20. Diazepam 5 mg PO QHS:PRN insomnia Discharge Medications: 1. Nadolol 40 mg PO DAILY hold for SBP < 100, HR < 60 2. Omeprazole 40 mg PO DAILY 3. PredniSONE 10 mg PO DAILY 4. Simvastatin 40 mg PO DAILY 5. Lactulose 30 mL PO TID Hold for loose stool. 6. Bisacodyl 20 mg PO BID 7. Caltrate-600 Plus Vitamin D3 *NF* (calcium carbonate-vitamin D3) 600 mg(1,500mg) -400 unit Oral daily 8. Docusate Sodium 200 mg PO BID hold for loose stool, patient may refuse 9. Glucosamine-Chondroitin-MSM *NF* (gluc-[**Doctor Last Name 2871**]-MSM#2-C-D3-[**Last Name (un) **]-born; gluc-[**Doctor Last Name 2871**]-msm#1-vit C - m a n g - b o r; glucosam-msm-chond-hrb149-hyal; glucosam-msm-chondr-vit C-hyal) 500-500-66.7 mg Oral daily 3 tablets 10. Multivitamins 1 TAB PO DAILY 11. Polyethylene Glycol 17 g PO DAILY:PRN constipation 12. Senna 1 TAB PO BID:PRN constipation 13. Vitamin D 400 UNIT PO DAILY 14. Ciprofloxacin HCl 500 mg PO Q24H RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 15. Rifaximin 550 mg PO BID RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice daily Disp #*60 Tablet Refills:*0 16. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain hold for sedation or RR <10 RX *oxycodone 10 mg 1 tablet(s) by mouth every 3-4 hours Disp #*40 Tablet Refills:*0 17. Oxycodone SR (OxyconTIN) 40 mg PO Q12H hold for sedation or RR <10 RX *oxycodone [OxyContin] 40 mg 1 tablet(s) by mouth every 12 hours Disp #*30 Tablet Refills:*0 18. Outpatient Lab Work Please collect chem7, albumin, INR, CBC every Monday and Thursday for 1 month and fax results to Dr. [**Last Name (STitle) 497**] at [**Telephone/Fax (1) 4400**]. 19. Insulin SC Sliding Scale Fingerstick Q6H Insulin SC Sliding Scale using HUM Insulin RX *blood-glucose meter [FreeStyle System Kit] 1 kit Disp #*1 Kit Refills:*0 RX *insulin lispro [Humalog] 100 unit/mL Up to 10 Units per sliding scale three times a day Disp #*10 Vial Refills:*0 RX *insulin syringe-needle U-100 [BD Insulin Syringe] 28 gauge X [**11-28**]" 1 syringe three times a day Disp #*90 Syringe Refills:*0 20. FreeStyle System Kit *NF* (blood-glucose meter) 1 kit Miscellaneous once 21. BD Ultra-Fine Nano Pen Needles *NF* (insulin needles (disposable)) 32 x 5/32 Miscellaneous TID RX *insulin needles (disposable) [BD Ultra-Fine Nano Pen Needles] 32 gauge X 5/32" 1 needle three times a day Disp #*90 Unit Refills:*0 22. BD Syringe *NF* (syringe (disposable)) 1 syringe TID RX *syringe (disposable) [BD Syringe] 1 syringe three times a day Disp #*90 Syringe Refills:*0 23. traZODONE 50 mg PO HS:PRN insomnia Discharge Disposition: Home With Service Facility: [**Hospital1 3894**] Health VNA Discharge Diagnosis: Primary diagnosis: Sepsis Acute tubular necrosis Secondary diagnosis: Alcoholic cirrhosis Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: Dear Mr. [**Known lastname 90284**], It was a pleasure taking care of you in the hospital. You were admitted with abdominal pain and distention. You were treated with IV antibiotics. Your blood pressures were low so you were transferred to the intensive care unit. Your blood pressures improved while you were treated with broad-spectrum antibiotics. You were then transferred to the regular floor. During your hospital stay, your kidney function worsened and you required hemodialysis. Your urine output improved which was a good sign of improvement in kidney function. Please follow-up at the appointments listed below. Please see the attached list for changes to your home medications. # Of note, you will be taking a medication called ciprofloxacin, which you will take long term to help prevent infections in your abdomen. # You should also continue taking lactulose for a goal of 3 bowel movements daily. # You will also be using insulin for your diabetes instead of metformin. # Please throw out your old oxycontin and oxycodone prescriptions. You have an attached prescriptions for the new doses of these medications. Followup Instructions: To follow-up on your diabetes management with insulin, we would like you to follow-up at [**Last Name (un) **] in the diabetes clinic. You have an appt with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at 2pm on Mon, [**2175-8-7**]. The phone number is [**Telephone/Fax (1) 25521**]. Your Primary Care office is working on getting you an appointment for approximately one week. They will be calling you Monday with the appointment. If you have not heard please call the office. Name: [**Last Name (LF) **],[**First Name3 (LF) 31893**] Location: [**Hospital1 **] HEALTH Address: [**Street Address(2) 31894**], [**Location (un) **],[**Numeric Identifier 6086**] Phone: [**Telephone/Fax (1) 31895**] Department: LIVER CENTER When: THURSDAY [**2175-8-10**] at 3:40 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 3723**], MD [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: WEST [**Hospital 2002**] CLINIC When: THURSDAY [**2175-10-5**] at 1 PM With: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. [**Telephone/Fax (1) 721**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Completed by:[**2175-8-5**]

[ "572.3", "303.93", "272.4", "789.59", "338.29", "567.23", "576.8", "572.2", "715.90", "725", "V43.65", "584.5", "038.9", "995.91", "250.00", "V15.82", "285.9", "456.21", "571.2", "780.52", "401.9" ]

icd9cm

[ [ [] ] ]

[ "54.91", "38.95", "39.95" ]

icd9pcs

[ [ [] ] ]

20581, 20643

10577, 15749

332, 423

20778, 20778

6036, 6036

22116, 23573

3999, 4174

18013, 20558

20664, 20664

16680, 17990

20963, 22093

10150, 10554

4189, 5635

15770, 16654

2440, 2805

5649, 6017

278, 294

451, 2421

20735, 20757

6052, 10134

20683, 20714

20793, 20939

2827, 3734

3750, 3983

5,383

162,316

27195

Discharge summary

report

Admission Date: [**2199-6-15**] Discharge Date: [**2199-6-27**] Service: CARDIOTHORACIC Allergies: Verapamil / Digoxin / Amiodarone Analogues / Sotalol / Cardizem Attending:[**First Name3 (LF) 1283**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2199-6-17**] - Mitral Valve Replacement(29mm [**Company 1543**] Mosaic Porcine Valve) and Single Vessel CABG(Left internal mammary artery to the left anterior descending artery) History of Present Illness: Mrs. [**Known lastname 17029**] is an 81 year old female with congestive heart failure. She has been medically managed but has gradually experienced worsening symptoms of dyspnea on exertion and paroxysmal nocturnal dyspnea. An echocardiogram in [**2198-11-6**] showed moderate to severe mitral regurgitation and depressed LV function. Subsequent cardiac catheterization in [**2199-4-6**] confirmed moderate to severe MR with an LVEF of 34%. Coronary angiography revealed a 50-60% lesion in the mid left anterior descending artery. Based upon the above results, she was referred for cardiac surgical intervention. Given her history of chronic atrial fibrillation and Warfarin anticoagulation, she was admitted severals days prior to operative date for Warfarin reversal and heparinization. Past Medical History: Congestive Heart Failure, Mitral Regurgitation, Coronary artery Disease, Hypertension, Type II Diabetes Mellitus, Chronic atrial fibrillation, Left Breast Cancer - s/p Lumpectomy and XRT, s/p Chole, s/p Knee Arthroscopy, s/p Ankle Surgery Social History: Lives alone, very independent. Denies history of tobacco and ETOH. She is a retired bookkeeper. Family History: No history of premature CAD. Physical Exam: Vitals: BP 126/62, HR 65, RR 18, SAT 98% on room air General: elderly female in no acute distress HEENT: oropharynx benign, Neck: supple, no JVD, slight decreased ROM Heart: regular rate, normal s1s2, holosystolic murmur at apex Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, no edema, no varicosities Pulses: 1+ distally Neuro: nonfocal Pertinent Results: [**2199-6-16**] 02:50AM BLOOD WBC-6.1 RBC-4.35 Hgb-13.6 Hct-40.0 MCV-92 MCH-31.3 MCHC-34.0 RDW-15.4 Plt Ct-208 [**2199-6-16**] 02:50AM BLOOD PT-14.4* PTT-62.0* INR(PT)-1.3* [**2199-6-16**] 02:50AM BLOOD Glucose-106* UreaN-27* Creat-0.9 Na-140 K-3.5 Cl-102 HCO3-26 AnGap-16 [**2199-6-16**] 02:50AM BLOOD ALT-15 AST-23 LD(LDH)-252* AlkPhos-72 TotBili-0.7 [**2199-6-16**] 02:50AM BLOOD %HbA1c-6.4* [Hgb]-DONE [A1c]-DONE [**2199-6-23**] 04:43AM BLOOD WBC-10.7 RBC-3.10* Hgb-9.6* Hct-28.4* MCV-92 MCH-31.0 MCHC-33.8 RDW-15.2 Plt Ct-228 [**2199-6-27**] 05:40AM BLOOD PT-20.6* INR(PT)-2.0* [**2199-6-26**] 06:30AM BLOOD PT-19.0* INR(PT)-1.8* [**2199-6-25**] 10:00AM BLOOD PT-20.1* INR(PT)-1.9* [**2199-6-24**] 05:50AM BLOOD PT-17.5* INR(PT)-1.6* [**2199-6-23**] 04:43AM BLOOD PT-17.0* INR(PT)-1.6* [**2199-6-27**] 05:40AM BLOOD UreaN-18 Creat-1.0 K-4.6 [**2199-6-24**] 05:50AM BLOOD K-4.6 [**2199-6-23**] 04:43AM BLOOD UreaN-19 Creat-0.9 Na-132* K-3.9 Cl-95* HCO3-27 AnGap-14 [**2199-6-27**] 05:40AM BLOOD Mg-2.3 [**Last Name (NamePattern4) 4125**]ospital Course: On [**6-15**], Mrs. [**Known lastname 17029**] was admitted for routine preoperative evaluation and heparinization. Workup was unremarkable and she was cleared for surgery. On [**6-17**], Dr. [**Last Name (Prefixes) **] performed a mitral valve replacment and single vessel coronary artery bypass grafting. For surgical details, please see seperate dictated operative note. Following the operation, she was brought to the CSRU for invasive monitoring. Within 24 hours, she awoke neurologically intact and was extubated. She experienced episodes of rapid atrial fibrillation(up to 160 bpm)which was initially treated with Amiodarone and beta blockade. Despite medical therapy, she continued to experience episodes of rapid atrial fibrillation. When in a normal sinus rhythm, she exhibited sinus node dysfunction. Pronestyl therapy was attempted but without much success. Given her multiple drug allergies, inability to adequately control her atrial fibrillation and sinus node dysfunction, the EP service was consulted. Based on EP recommendations, Digoxin therapy was initiated and beta blockade was advanced as tolerated. Warfarin anticoagulation was eventually resumed. Once her atrial fibrillation was adequately controlled, she eventually transferred to the SDU for further care and recovery. Beta blockade was advanced as tolerated. Warfarin was dosed for a goal INR between 2.0 and 3.0. Over several days, her atrial fibrillation rate improved. She continued to experience intermittent tachycardia(up to 120 bpm) mostly with exertion. Toprol XL was eventually advanced to her preoperative dose of 200 mg [**Hospital1 **]. She tolerated low dose Digoxin as well. As medical therapy was optimized, she continued to make clinical improvements with diuresis and made steady progress with physical therapy. She was medically cleared for discharge on postoperative day 10. At discharge, her oxygen saturations were 94-96% on room air and chest x-ray showed stable mild to moderate left pleural effusion and atelectasis. Her BP was 108/50 with a HR of 85. All surgical wounds were clean, dry and intact. Medications on Admission: Diovan 40 qd, Lasix 40 qd, Avandia 4 qd, Toprol XL 200 qd, Arimidex 1 qd, Lipitor 20 qd, Warfarin, Neurontin 300 qid, Glucosamine, Calcium, Vitamins, Folate, Vitamin E Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Rosiglitazone 2 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 7. Anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily (). Disp:*30 Tablet(s)* Refills:*2* 8. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR Sig: Two (2) Tablet Sustained Release 24HR PO BID (2 times a day). Disp:*120 Tablet Sustained Release 24HR(s)* Refills:*2* 9. Warfarin 2 mg Tablet Sig: 1.5 Tablets PO qpm: Take as directed by Dr. [**First Name (STitle) **]. Daily dose may vary according to INR. Disp:*60 Tablet(s)* Refills:*2* 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: s/p MVR(#29 [**Company 1543**] porcine)CABGx1(LIMA-LAD)[**6-17**] Chronic Atrial Fibrillation Postop Pleural Effusion PMH: DM2, HTN, Breast CA s/p lumpectomy/XRT, s/p CCY, Rt knee arthroscopy Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased. 2) Report any fever greater then 100.5. 3) Report any weight gain of 2 pounds in 24 hours or 5 pounds in 1 week. 4) No lifting greater then 10 pounds for 10 weeks. 5) No driving for 1 month. 6) Coumadin for atrial fibrillation and tissue mitral valve. Goal INR is 2.0 - 3.0. Please check INR with 48-72 hours of discharge. [**Last Name (NamePattern4) 2138**]p Instructions: Dr. [**Last Name (Prefixes) **] in 4 weeks Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **] in [**2-8**] weeks Dr. [**Last Name (STitle) 20222**] or [**Last Name (un) **] in [**2-8**] weeks Completed by:[**2199-6-27**]

[ "E849.8", "250.00", "V10.3", "424.0", "414.01", "427.31", "E878.8", "511.9", "458.29" ]

icd9cm

[ [ [] ] ]

[ "35.23", "39.61", "36.15" ]

icd9pcs

[ [ [] ] ]

6762, 6811

297, 480

7047, 7054

2135, 3142

1691, 1721

5515, 6739

6832, 7026

5323, 5492

7078, 7490

7541, 7772

1736, 2116

3193, 5297

238, 259

508, 1300

1322, 1562

1578, 1675

1,987

105,158

52806

Discharge summary

report

Admission Date: [**2102-3-20**] Discharge Date: [**2102-4-3**] Date of Birth: [**2056-10-25**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 297**] Chief Complaint: diahhrea Major Surgical or Invasive Procedure: paracenteisis central line placement History of Present Illness: 45M with hx of DM type I, ESRD on HD, HTN who presents with 6 days of watery, nonbloody diarrhea. Of note, patient finished 14 day course of vanc/levo/ceftaz for foot ulcer (MRSA and Enterobacter positive). Then 2 days later (approx 8 days ago), he started to develop diarrhea. He was started on flagyl 6 days ago and diarrhea at first improved, but has now worsened. He states that he has approximately 3 diarrheal BM per day. These are watery, smell like medication and non bloody. denies f/c, abd pain, recent travel or ill contacts. Also denies any recent URIs. Denies any chest pain, SOB, abdominal pain. Past Medical History: 1)DM type 1 2)Primary sclerosing cholangitis - biopsy at OSH on [**2102-1-15**] was strongly suggestive of PSC; also patient had secondary hemosiderosis diagnosed by stainable iron laden Kuppfer cells. No evidence of malignancy was seen at this time. No evidence of cirrhosis 3)ESRD on HD - gets dilyzed at "The Dialysis Center" at [**Location (un) 108889**] 4)HTN 5)Peripheral vascular disease 6)Foot Ulcers - s/p recent debridement - gangrene and osteomyelitis. Previous to this, he was found to be growing out MRSA and Enterobacter 7) MRSA bacteremia . Social History: - denies smoking or drinking history - immigrant from [**Location (un) 4708**] Family History: Mother - died 5 months ago; she had diabetes w/ renal involvement Sister with diabetes Physical Exam: PE: Admission vitals to ED VS: T: 99.3 HR: 112 BP: 161/85 RR: 16 GEN: Jaundiced middle aged male HEENT: Sclera icteric. Tongue yellow underneath; no lesions in mouth CHEST: Lungs CTA B/L. Old fistual in R subclavian region. CV: +s1+s2 SEM heard at RUSB and LUSB ABD: +BS. Soft NT. Mildly distended. Areas of shifting dullness noted on percussion. (-) [**Doctor Last Name 515**] sign. EXT: Several fingers on both hands have dry gangrene and are deformed; Multiple lesions on both arms - look excoriated. Others look like tophi. HD Fistula on L arm. Pertinent Results: RUQ USG: 1. Gallbladder filled with sludge with no definite shadowing stones. There is an apparent common duct stent. Please correlate with patient's history. No intrahepatic biliary ductal dilatation is seen. 2. Ascites. 3. Possible echogenic right renal medulla . EKG: NSR; LAD; TWI: I, AVL - both old; Late R wave progression . [**2102-3-23**] IMPRESSION: Large soft tissue defect in the second toe with irregularity at the second metatarsal bone, periosteal reaction, as well as heterotopic bone formation with cortical irregularity. The findings are suspicious for osteomyelitis, however, correlation with time course from the surgery is recommended. . [**2102-3-23**]: US of Abdomen: CONCLUSION: 1. Distended gallbladder with sludge and small [**Doctor Last Name 5691**] like stones as well as edema in the wall. In the presence of massive ascites, wall edema cannot be used as a sign of acute cholecystitis and there were no other findings to suggest this, but if clinical concern remains, a radionuclide biliary scan would be recommended for further evaluation. 2. Massive ascites. An appropriate spot was marked in the right lower quadrant for paracentesis by the clinical team. 3. Atrophic kidneys and heavily calcified hepatic and splenic arteries suggestive of underlying diabetic vasculopathy. . [**2102-3-23**]: Scrotal US: CONCLUSION: The findings suggest chronic ischemia on the right testis with minimal detectable flow but slightly diminished testicular volume compared to the normally vascularized left side. This would be atypical for torsion and raises the possibility of arterial insufficiency, possibly related to underlying diabetic vascular disease. The findings were relayed to the urologists shortly after completion of the study. . [**2102-3-29**]: 1. Extensive intraabdominal ascites, unchanged appearance. 2. No evidence of bowel perforation. No evidence of obstruction. 3. Marked vascular calcifications in the heart and through the abdomen and pelvis including the subcutaneous tissues. 4. Small-to-moderate left pleural effusion with continued left greater than right perihilar ground-glass opacity suggesting CHF 5. Addendum: Distal ileum and proximal colonic edema - DDx ischemia, infection or inflammation Brief Hospital Course: INITIAL ASSESSEMENT AND HOSPITAL COURSE BY THE FLOOR TEAM: 45 yo on HD for ESRD, primary sclerosing cholangitis s/p vanco/Levo/Ceftaz presents with diarrhea x 1 week. On [**3-27**] with increased confusion and somnolence. . On [**2102-3-27**], patient developed increased somnolence and confusion. This occurred shortly after dialysis. A trigger was called; his ABG was OK - 7.51/39/126 on RA with HCO3 of 32 -> since this was shortly after dialysis, renal service indicated that his acid base status was not equilibriated at this time. - Head and Abd CT (especially in light of hiccups - considered whether blood or other sources for diaphragmatic irritation) - head CT did not find any masses or bleeds; extensive intracranial calcifications were found. - Abd CT was negative for retroperitoneal bleed; it did show layering high density material in the GB and extensive ascites, but a pocket could not be found to tap via US. - stopped baclofen which has high incidence of AMS particulary in renal failure patients - CXR showed improving paramediastinal haziness and LLL opacity ? atelectasis or fluid collection. - patient got 1g IV of Vancomycin - concern here was for subtherapeutic vanco levels. . On [**2102-3-28**]: patient was sent for US guided paracentesis - cultures and chemistries were sent. . # Diarrhea - from admission to - [**3-28**] patient has continued to have diarrhea - C Diff negative x 3 - sent a 4th - C Diff B toxin pending as of [**2102-3-28**] - [**3-23**]: had whitish diarrhea - [**3-24**]: 2 green diarrheal episodes o/n . - patient was intially treated with with flagyl. Through he was receiving flagyl as outpatient, it may not have been adequately dosed. Hence, we increased his flagyl dose to 500mg PO BID. ([**2102-3-24**] is day # 5 of Flagyl at this dose) . - on [**3-24**], with his rising WBC count despite Levo/unasyn/flagyl, we started him on PO vanco 250 PO Q 6 for likely flagyl resistant C Diff. On [**2102-3-27**], the vanco dose was increased to 500mg PO Q6 because of the high WBC count an inability to curb his diarrhea. . - also must consider that this could be secondary to his sclerosing cholangitis/?UC as patient has been having on and off diarrhea since diagnosis past [**Month (only) **]. . - [**3-24**]: stopped flagyl and started PO vanco. Sent for vanco level. Also changed Unasyn over to Meropenem - given patient's history of Enterobacter and MRSA. . # Leukocytosis: - unclear etiology at this time - potential sources include his gall bladder, MRSA bacteremia, abscess, foot, C Diff (B toxin), drug reaction - [**2102-3-28**]: getting US guided paracentesis for diagnostic and therapeutic purposes . # ESRD: ? [**2-23**] diabetes - on M, W , F hemodialysis . # Chronic Cholangiolitis: - reevaluation of pathology here revealed chronic cholangiolitis adn obstructive biliary disease - patient had stent placed on [**2102-3-22**] because of a dominant stricture near the ampulla via ERCP . Dx at OSH: PSC: - suggested by ---- prominent ductal proliferation ---- intra and extracellular cholestasis ---- hepatocyte "feathery degeneration ---- fibrosis by trichrome stain with architectural distortion ---- [**Doctor First Name **], AMA, SMA negative ---- also patient had secondary hemosiderosis diagnosed by stainable iron laden Kuppfer cells. No evidence of malignancy was seen at this time. No evidence of cirrhosis. . - On admission, since patient was s/p biliary stent, he was started on 5 days of Unasyn - also because of his foot ulcer infection - discontinued once sensitivities arrived from OSH. - stopped colestipol and ursodiol on [**2102-3-24**] . # ESRD / Cirrhosis: - patient is being evaluated for combined hepatorenal transplant - his cousin is potential match - he has an appointment at [**Hospital1 2025**] - also determining if he would like to be evaluated here. . - ? etiology of cirrhosis: denies EtOH, ? PSC, Ischemia, ? R heart failure . # Abdominal pain: - improved after 1L taken off by paracentesis - US of abdomen and testicles - > showed decreased blood flow to his right testicle which is likely chronic in nature -> and could be accounting for his pain -> appreciate urology recs: do not feel that thsi is epididymitis or orchitis at this time. - s/p ERCP - Hct stable . # Foot: - s/p surgery and 2 weeks of abx for ? osteomyelitis at OSH Vanco/Ceftaz/Levo - wet to dry dressing changes. - podiatry took to OR on [**2102-3-24**] -> partial debridement - poor bleeding - vascular surgery holding on angiography + intervention [**2-23**] increased WBC ct - [**2102-3-28**] at this time, podiatry does not think that his leukocytosis is due to foot infection . # MRSA Bacteremia: - Cx Positive at OSH - blood cultures pending here - Start on Vancomycin ([**3-28**] is day #9) - IV with HD. - checking Vanco level - also on PO vanco for the ? C Diff -> increased on [**2102-3-27**] - pt missed some vanco doses with HD/multiple procedures . # HTN: - started on metoprolol - added ACE-I on [**2102-3-25**] for continued HTN - consider adding nifedipine, hydral for acute HTN that is hard to ctrl . # DM - started on NPH 8 qAm, 8 qPm as well as SSI - FS QID - renal, diabetic diet ~2:30 AM of [**2102-3-31**], A code blue was calld after the patient was found pulseless and unresponsive. Per nursing report he was confused earlier in the day with NGT draining dark bloody material but had stable vitals and was mentating. He has a h/o cirrhosis, ESRD on HD, SBP, type 1 DM, PVD, bacteremia, poss CDiff, and recent diarrheal epidose. . Chest compressions were started, he was intubated, and a cordis was placed in his R groin. He received IVF's wide open and 2 of Epi and 2 of Atropine were given for Asystolic code which turned into PEA. The patient was then noted to have a pulse but was bradycaric. He was pulseless for at least 15 mins. He was also given 1 amp of bicarb and calium. He was then transferred to SICU. . Upon arrival to the SICU the patient was again noted to be pulseless, and chest compressions were resumed and he was given IVF's and Atropine x1, then started on a Dopamine drip and resumed a pulse. He was given several amps of bicarb and several grams of Calcium. He subsequently had another PEA arrest when chest compressions were resumed for several minutes and pulse was regained after IVF's. An A-line was placed and after labs returned pt was given 4U of PRBC's, 2U FFP, and Vasopressin was added for BP support. . CXR was noted to have diffuse pulmonary edema/infiltrates, trach was noted to have pink frothy fluid from it. His NGT was suctioned with blood, which did not clear with lavage and GI was called for possible UGIB +/- aspiration and subsequent asystolic arrest. Given pulm edema on CXR IVF's were held and pressors were titrated for MAP of 60-65. He was also noted to have a temp of 90 and was placed on a bear hugger. The patient's family was notified, as well as the ICU attending on call who evaluated the patient. . Patient required 2 pressors for hypotension. He had fixed dilated pupils and remained unresponsive. ICU attending met with the family and a decision was made that given patient's neurologic exam CPR was not indicated. Family requested to maintain patient on ventillator and pressors for ~2-3 days to see if there is any improvement. Neurologic exam remained unchanged, the only sign of brainstem function was episodic intermittent spontaneous breathing. After a family meetint evening of [**4-2**], CT scan of head was performed which showed bilateral thalamic infarct and moderate edema consistent with anoxic brain injury. Family requested that patient be extubated and taken off pressors with goals of care changed towards comfort measures. He expired [**2102-4-3**]. Medications on Admission: . Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Anoxic brain injury ESRD Primary sclerosing cholangitis htn Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired Completed by:[**2102-4-3**]

[ "250.81", "785.52", "250.71", "572.2", "995.92", "440.24", "731.8", "008.45", "578.0", "570", "250.41", "789.5", "576.1", "403.91", "575.8", "997.69", "730.07", "608.83", "427.5", "348.1", "038.9", "286.6", "275.0", "576.2", "585.6", "786.8", "518.81" ]

icd9cm

[ [ [] ] ]

[ "54.91", "99.04", "86.22", "99.60", "45.13", "51.14", "96.34", "00.17", "38.93", "99.07", "51.87", "39.95", "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

12435, 12444

4629, 12354

323, 361

12547, 12556

2363, 4606

12612, 12649

1691, 1779

12406, 12412

12465, 12526

12380, 12383

12580, 12589

1794, 2344

275, 285

389, 1000

1022, 1579

1595, 1675

22,108

139,778

46493

Discharge summary

report

Admission Date: [**2175-12-23**] Discharge Date: [**2175-12-26**] Date of Birth: [**2114-5-29**] Sex: F Service: MEDICINE Allergies: Penicillins / Ampicillin / Gentamicin / Optiray 300 Attending:[**First Name3 (LF) 3552**] Chief Complaint: fever, lethargy Major Surgical or Invasive Procedure: 1. placement of left nephrostomy tube, in place 2. placement of left subclavian line, removed [**12-26**] History of Present Illness: Ms. [**Known lastname **] is a 61 year-old female NH resident with advanced Alzheimer's dementia, recently treated for Klebsiella UTI (0105/05) with subsequent post-treatment urine growing Providentia ([**2175-12-7**]) sensitive to Bactrim. Per NH, she had abdominal pain in the past week, accompanied by nausea and vomiting. She developed a fever to 101.6, with leukocytosis as well as guaiac positive stools. She was noted to be somewhat lethargic. She was transferred to the [**Hospital1 18**] ED for further evaluation and care. Past Medical History: 1. Advanced Alzheimer's dementia since age 50. 2. Hypertension 3. History of nnephrolithiasis with stent/lithotripsy/sepsis in [**2173-9-24**]. 4. Seizure disorder Social History: She is a resident at the [**Hospital3 **] center. At baseline, she wanders around on the floor, and is non-verbal. No history of tobacco or EtOH consumption. Family History: Non-contributory. Physical Exam: On admission: T 101.6 130/80 (went to 107/50) 68 (went to 120) 16 (went to 22) 100% NRB Gen: somnolent, unresponsive, slightly increased work of breathing HEENT: PERRL, NG tube CV: Reg, tachy, distant S1/S2, no murmurs Pulm: rhonchi anteriorly, decreased air movement Abd: soft, NT/ND, nephrostomy tube on L flank Ext: warm, no clubbing/cyanosis/edema, + distal pulses Neuro: somnolent, winces slightly to sternal rub Physical examination on transfer to floor: VITALS: Tm in ICU 100.8 on [**12-23**] at 0500, Tc 97, BP 120-150/40s-60s, HR 40s-60s, RR teens and stauraion 95-97% on room air. GEN: In NAD. Non-verbal. Awake. HEENT: PERRL. Anicteric. NECK: JVP not elevated. Left SCL in place. RESP: Chest CTA bilaterally. CVS: RRR. Normal S1, S2. No S3, S4. No murmur or rub. GI: BS normoactive. Nephrostomy tube in place, draining clear urine. Foley also in place. Abdomen soft, does not appear tender. EXT: No pedal edema. Vital signs on morning of discharge: 98.7 110/72 84 20 96% RA Pertinent Results: Admission labs: [**2175-12-22**]: UA Clear, SP [**Last Name (un) 155**] 1.026, pH 6.5, lg blood, tr protein, neg glucose/bili/urobili/leuk/nitrite RBC 0-2, WBC [**5-3**], occ bact, no yeast or epi CBC: WBC-28.4* (diff NEUTS-61 BANDS-18* LYMPHS-14* MONOS-6 EOS-0 BASOS-0 ATYPS-1* METAS-0 MYELOS-0) HGB-12.8 HCT-35.8* MCV-89 MCH-31.6 MCHC-35.8* RDW-13.1 PLT COUNT-173 Chemistry: GLUCOSE-97 UREA N-24* CREAT-1.1 SODIUM-140 POTASSIUM-5.1 CHLORIDE-100 TOTAL CO2-26 ANION GAP-19 LFTs: ALT(SGPT)-12 AST(SGOT)-26 AMYLASE-26 TOT BILI-0.3 LIPASE-15 LACTATE-3.5* Relevant laboratory data on transfer: CBC: WBC-12.5* (down from 28.4) RBC-3.35* Hgb-10.2* Hct-30.0* MCV-90 MCH-30.4 MCHC-33.9 RDW-12.9 Plt Ct-132* No differential ordered today. Yesterday, 18-->14% bands. Coagulation: PT-14.0* PTT-29.1 INR(PT)-1.2 Chemistry: Glucose-101 UreaN-16 Creat-0.6 Na-143 K-4.3 Cl-111* HCO3-28 AnGap-8 Calcium-8.5 Phos-2.7 Mg-1.9 [**2175-12-23**] 03:30AM Cortsol-193.1* [**2175-12-23**] 08:06PM Lactate-1.1 (down from 3.5 on admission) Microbiology: [**2175-12-23**] URINE Contaminated [**2175-12-22**] URINE GRAM NEGATIVE ROD(S) ~[**2170**]/ML. [**2175-12-22**] BLOOD CULTURE Pending [**2175-12-22**] BLOOD CULTURE Pending Relevant imaging data: [**2175-12-23**] CXR: There is now evidence of a left nephrostomy tube. The NG tube is within the stomach. There are low lung volumes. There is linear atelectasis in the left mid lung zone. Stable cardiac and mediastinal contours. No effusions or pulmonary edema. IMPRESSION: No acute disease [**2175-12-23**] CT OF THE ABDOMEN WITH CONTRAST: There is bibasilar atelectasis. An NG tube is seen coursing below the diaphragm into the stomach. There is moderate hydronephrosis of the left kidney which is enhancing, although not excreting intravenous contrast. There is an obstruction at the left ureteral pelvic junction by an apparent 14 mm calcified stone. There is a moderate amount of perinephric stranding, although no evidence of rupture. There are at least three small calcifications identified in left kidney, including a 5 mm upper pole stone, 8 mm mid pole stone, and 6 mm lower pole stone. These stones are nonobstructing. The right kidney enhances and excretes contrast without evidence of obstruction. There are multiple, hypoattenuating lesions throughout the liver which are too small to definitively characterize, but likely represent simple cysts or hemangiomas. The largest is within the left lobe and measures 17 mm. The pancreas, spleen, and adrenal glands are unremarkable. There is no free air within the abdomen. CT OF THE PELVIS WITH IV CONTRAST: A Foley catheter is seen within the bladder with a small amount of iatrogenic air. No free fluid is seen within the pelvis. BONE WINDOWS: There are no suspicious lytic or sclerotic osseous lesions. IMPRESSION: 1) 14 mm stone obstructing the left ureteropelvic junction with moderate left-sided hydronephrosis and perinephric stranding. Smaller, noncalcified stones identified within the left renal collecting system. 2. Multiple, tiny scattered hypoattenuating lesions throughout the liver which are not definitively characterized but likely represent simple cysts. OSH data: Urine Cx ([**2175-12-7**]): > 100K Providencia. Sensitivities: Resistant to Amp, Augmentin, Cefazolin, Cipro, Levo, Tetracycline, Indeterminate to Aztreonam, Nitrofurantoin. *Sensitive to Bactrim, Gentamicin, Ceftriaxone. Urine Cx ([**2175-11-29**]): > 100K Klebsiella pansensitive Brief Hospital Course: 1. urosepsis - Pt had recently been treated for a Klebsiella UTI, and post-treatment urine cultures from outside data revealed growth of Providencia, which was sensitive to Bactrim. Pt was noted to have obstrutive nephrolithiasis on CT, which was thought to be the source of infection. In the ED, after nephrostomy tube placement (see below), pt's SBP dropped into the 80s and she had increased O2 requirements, transiently requiring a nonrebreather mask. She did not respond fully to fluid boluses x4. Pt was given IV levofloxacin, flagyl, and vancomycin; the latter was discontinued due to diffuse flushing. A left subclavian line was placed, and the MUST protocol was begun in the setting of sepsis. Pt was admitted to the MICU for early goal directed therapy. Her sepsis resolved and she was hemodynamically stable with these interventions. She was transferred to the floor the following day and remained hemodynamically stable. She was treated with IV Bactrim (due to the sensitivity data of Providencia), and levofloxacin, presumably as it was unclear if there were other pathogens involved prior to culture data. Urine cultures did not grow a significant number of organisms for identification. She will be discharged on Bactrim alone, as there is no microbiological data at this time to necessitate the use of levofloxacin, as well. 2. obstructive nephrolithiasis - pt was seen to have obstructing stones on CT. She was taken to interventional radiology for placement of a left sided percutaneous nephrostomy tube on [**2175-12-23**]. She tolerated the procedure well and had good drainage of urine. Urology continued to follow pt throughout her hospital stay. She will need outpatient followup about 10 days after the procedure, and has an appointment with Dr. [**Last Name (STitle) 986**] for this on [**2176-1-1**]. 3. seizure disorder - pt did not undergo any seizures while in the hospital. She was maintained on valproic acid. 4. allergic reaction - Pt had some type of allergic reaction after infusion of vancomycin, with diffuse flushing. Other possibilities include a reaction to dye administration. She was given famotidine, Benadryl, and methylprednisolone without further incident. 5. dementia - Pt remained with baseline dementia, and was unable to communicate verbally with the team. However, she was able to communicate discomfort with facial expressions. She was placed in soft restraints to prevent her from pulling at lines or getting out of bed without supervision; this was discontinued as pt did not seem agitated. 6. [**Name (NI) 5**] - pt was maintained on [**Hospital1 **] H2 blocker, SC heparin, and was given a bowel regimen. She was placed on aspiration precautions. 7. Code - DNR/DNI. Code discussion was had with family during the MICU stay, and they agreed to placing a central line and giving pressors if needed. Further discussions about longer-term issues of goals of therapy are ongoing between pt's daughter and Dr. [**Last Name (STitle) 986**], particularly in the setting of repeated episodes of obstructing nephrolithiasis and recurrent infections. Medications on Admission: valproic acid 500mg po bid colace bactrim [**Hospital1 **] tylenol prn Discharge Medications: 1. Heparin Sodium (Porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 4. Valproate Sodium 250 mg/5 mL Syrup Sig: Five Hundred (500) mg PO Q12H (every 12 hours). 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 6. Acetaminophen-Codeine 300-30 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 7. Bactrim DS 160-800 mg Tablet Sig: One (1) Tablet PO twice a day for 11 days: course ends [**2175-12-6**]. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - LTC Discharge Diagnosis: Primary: 1. urosepsis 2. obstructive nephrolithiasis, status post placement of left nephrostomy tube Secondary: 1. Alzheimer's dementia, severe 2. seizure disorder Discharge Condition: hemodynamically stable, afebrile, tolerating po Discharge Instructions: Please take all of your medications and inform the staff if you have pain with urination or other complaints. Followup Instructions: You have an appointment with Dr. [**Last Name (STitle) 986**] (your urologist) on [**2176-1-1**] at 2:45PM, on the [**Location (un) 10043**] of the [**Hospital Ward Name 23**] Building at [**Hospital1 **]. The phone number is ([**Telephone/Fax (1) 93948**] to reach Dr. [**Last Name (STitle) 986**]. [**Name6 (MD) 1592**] [**Name8 (MD) 1593**] MD, [**MD Number(3) 3555**]

[ "780.39", "294.10", "331.0", "599.0", "782.62", "785.52", "401.9", "038.9", "E930.8", "592.0", "591", "995.92" ]

icd9cm

[ [ [] ] ]

[ "38.93", "55.03" ]

icd9pcs

[ [ [] ] ]

9859, 9924

5929, 9061

330, 440

10132, 10181

2436, 2436

10339, 10744

1382, 1401

9182, 9836

9945, 10111

9087, 9159

10205, 10316

1416, 1416

275, 292

468, 1004

2452, 5906

1430, 2417

1026, 1191

1207, 1366

20,370

125,347

48624

Discharge summary

report

Admission Date: [**2192-12-1**] Discharge Date: [**2192-12-6**] Service: MEDICINE Allergies: Ace Inhibitors Attending:[**First Name3 (LF) 689**] Chief Complaint: Confusion and fever Major Surgical or Invasive Procedure: Central line placement History of Present Illness: [**Age over 90 **] y.o. woman presenting with fever and hypotension. She was discharged yesterday from the neurology service where she was admitted for focal weakness. She had presented on [**11-29**] with right-sided weakness. MRI showed new lacunar infarct in left thalamus but not thought to be related to her right-sided weakness. It was thought this may have been due to seizure or TIA. During that admission, she had some clinical evidence of pulmonary edema which improved with lasix. She ruled out for MI. . Pt was discharged home, and now represents with fever and confusion. Per family, pt walked out of the hospital last night. This morning, she was more lethargic and not ambulating on her own as usual. She did not have any other specific complaints such as dyspnea, cough, chest pain. . In [**Name (NI) **], pt initially was normotensive with mild hypoxia (mid 90s on RA). BP then dropped in 70s with minimal response to fluids. Started on ceftriaxone, azithromycin, and clindamycin for possible aspiration pneumonia. Due to persistent hypertension, the CODE SEPSIS was called, central line was placed, and levophed was started for BP support. Pt received total of 5L NS in ED. She was then transferred to MICU. Past Medical History: 1) Hearing loss 2) Dementia: dx'd by her PCP x 3 years requiring 24 hr care 3) HTN 4) CHF--no TTE results available, neg ETT in '[**88**] 5) CRI--b/l Cr in mid 1's 6) hypothyroidism 7) colonic polyps 8) anemia 9) depression,s/p inpatient psych admission and ECT most recently 3 years ago 10) renal mass, not being worked up, suggestive of cancer per family 11) basal cell carcinoma 12) hip fracture 1.5 years ago 13) gallstones 14) ? CVA Social History: Lives in an elderly home with 24 hour caregivers, widowed, 3 kids, no tob/etoh/drugs, former clerk. Family History: Non-contributory. Physical Exam: VS: 96.6 (102.4)---114/37----74----20----99% on FM. GEN: Lethargic, nonverbal, but responds to simple commands HEENT: PERRL, anicteric, conj noninjected. OP clear with dry MM. NECK: supple, LUNGS: pt not taking deep breaths, but CTA anteriorly. CV: RRR, nml s1s2, 2/6 systolic murmur at RUSB ABD: soft, NT, distended (per family chronic), naBS. EXT: no edema, no cords. NEURO: awake but not alert or oriented. Moves all 4 ext. Pertinent Results: [**2192-12-1**] 04:00PM WBC-17.4*# RBC-4.59 HGB-13.8 HCT-38.8 MCV-85 NEUTS-83* BANDS-2 LYMPHS-3* MONOS-11 EOS-1 BASOS-0 PLT COUNT-315 . GLUCOSE-143* UREA N-42* CREAT-1.7* SODIUM-144 POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-23 ANION GAP-17* LACTATE-2.7* CALCIUM-9.8 PHOSPHATE-2.2* MAGNESIUM-1.9 . PT-12.2 PTT-20.7* INR(PT)-1.0 . [**2192-12-1**] 04:00PM CK(CPK)-169* [**2192-12-1**] 04:00PM CK-MB-5 [**2192-12-1**] 04:00PM cTropnT-0.02* . [**2192-12-1**] 04:30PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.011 BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG . [**2192-12-1**] 09:47PM ABG: 7.36/36/257 . CXR: no infiltrate or CHF . ECG: poor baseline, sinus tach at 102. Nml axis, IVCD. TWI in I, avL (old). . Head CT: 1) No acute intracranial hemorrhage. 2) Left temporal encephalomalacia. 3) Small focal hypodensity in the left thalamus, corresponding to the punctate area of restricted diffusion on the prior MRI. 4) No CT evidence to suggest acute major vascular territorial infarction, though MRI would be more sensitive. . [**2192-12-6**] 06:10AM BLOOD WBC-9.4 RBC-3.51* Hgb-10.8* Hct-30.4* MCV-87 MCH-30.7 MCHC-35.4* RDW-15.0 Plt Ct-283 [**2192-12-1**] 09:25PM BLOOD Neuts-83.4* Bands-0 Lymphs-12.3* Monos-3.4 Eos-0.4 Baso-0.5 [**2192-12-6**] 06:10AM BLOOD PT-11.6 PTT-26.5 INR(PT)-0.9 [**2192-12-6**] 06:10AM BLOOD UreaN-9 Creat-0.9 K-3.7 [**2192-12-1**] 09:25PM BLOOD ALT-16 AST-17 AlkPhos-79 Amylase-24 TotBili-0.3 [**2192-12-1**] 09:25PM BLOOD Lipase-18 [**2192-12-6**] 06:10AM BLOOD Mg-1.9 [**2192-12-1**] 09:25PM BLOOD Cortsol-7.3 Brief Hospital Course: [**Age over 90 **] y.o. woman with fever, hypotension, and hypoxia. This occurred 1 day after discharge from neurology service for ? seizure vs TIA. Pt did not have any focal complaints and CXR, U/A, cultures did not indicate clear source of infection. However, given hypoxia, pneumonia was the most likely possibility. 1) Septic Shock: Likely due to pneumonia. Treated empirically with ceftriaxone/azithro for 3 days w/ marked improvement in oxygenation to 94% on RA and stable BP at time of discharge. Plan to continue w/ levofloxacin for total 10 day course of abx. Had CVL line placed in the ER to maintain CVP around 12 (after 5 liters of fluid) and MAPs above 60 with transient use of levophed. [**Last Name (un) **] 7.3 but BP improved off pressors so stim not performed in ICU. Strict glucose control maintained. Leukocytosis and fever quickly resolved. Urine with GBS and gram positive bacteria but blood cultures did not grow any organisms. .. 2) MS change: Pt has baseline dementia but had increased agitation in setting of infection and sepsis. We continued outpatient psych meds--increased zyprexa to 2.5mg tid (from 5mg qhs), and continued buproprion. .. 3) CHF: Mild b/l pleural effusions s/p volume resusitation. No evidence of CHF at admission. Held lasix and valsartan until BP was stable off pressors. Diovan and home dose lasix restarted on [**12-5**]. ECHO planned as outpatient. .. 4) Hypothyroidism: We continued levoxyl. .. 5) CKD/Azotemia: After hydration, creatinine is back to below baseline of 1.0. .. 6) Metabolic acidosis: Lactate has returned to [**Location 213**], and this is a non-gap acidosis. Likely caused by large amount of NS pt has received. Switched resuscitation fluids to LR. This MA resolved during her hospitalization. . 7) Anemia: Pt baseline Hct in 30s--now 29. This occurred after hydration and was accompanied by proportional drop in all cell lines; likely hemodilutional. Guiaic (-) stools. Followed Hct, did not receive a transfusion. . 8) F/E/N: Fluids as above. Speech and swallow eval recommended thin liquids and pureed solids. Re-consulted for video swallow which showed that she was able to tolerate the abovementioned foods w/o any aspiration risk. 9) Proph: SC heparin for DVT ppx. .. 10) CODE FULL, discussed with patient and multiple family members. .. 11) ACCESS: left subclavian CVL [**Date range (1) 39125**]. Then had peripheral line. .. 12) Comm: Daughter [**Name (NI) 24606**] .. 13) Dispo: Dischrged to rehab Medications on Admission: Lasix 40mg [**Hospital1 **] Valsartan 80mg daily ASA 325mg daily Levothyroxine 88mcg daily Olanzipine 5mg qhs Bupropion 75mg daily Atrovastatin 20mg daily Oxybutynin 2.5mg tid Lactulose 30ml daily Senna KCl 20meq [**Hospital1 **] Discharge Medications: 1. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). [**Hospital1 **]:*60 Tablet(s)* Refills:*2* 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. [**Hospital1 **]:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 6. Bupropion 75 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 7. Levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours. [**Hospital1 **]:*60 Tablet(s)* Refills:*2* 9. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 8 days. [**Hospital1 **]:*8 Tablet(s)* Refills:*0* 10. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. [**Hospital1 **]:*300 ML(s)* Refills:*0* 11. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO TID (3 times a day). [**Hospital1 **]:*45 Tablet, Rapid Dissolve(s)* Refills:*2* 12. K-Dur 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO every twelve (12) hours. [**Hospital1 **]:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2* 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day. [**Hospital1 **]:*60 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Hospital1 599**] of [**Location (un) 55**] Discharge Diagnosis: Septic Shock Urinary Tract Infection Dementia Hypertension Discharge Condition: stable with oxygen sats of 94% on Room Air Discharge Instructions: Please notify doctors [**First Name (Titles) **] [**Last Name (Titles) 2449**] of fevers, chills, lightheadedness, shortness of breath, chest discomfort or other symptoms of concern. Pt should continue on levofloxacin for 7 more days. Followup Instructions: Please follow-up with Dr. [**First Name (STitle) **] [**Name (STitle) 1395**] [**Telephone/Fax (1) 2936**] within 2 weeks of leaving rehab Completed by:[**2192-12-6**]

[ "294.8", "281.9", "486", "276.2", "785.52", "599.0", "428.0", "593.9", "403.91", "244.9", "V12.59", "995.92", "038.9" ]

icd9cm

[ [ [] ] ]

[ "00.17", "38.93" ]

icd9pcs

[ [ [] ] ]

8826, 8898

4272, 6783

241, 266

9001, 9046

2623, 3412

9330, 9500

2130, 2149

7064, 8803

8919, 8980

6809, 7041

9070, 9307

2164, 2604

182, 203

294, 1535

3422, 4249

1557, 1996

2012, 2114

65,883

107,382

8819

Discharge summary

report

Admission Date: [**2116-4-26**] Discharge Date: [**2116-5-3**] Date of Birth: [**2067-10-28**] Sex: M Service: MEDICINE Allergies: Zidovudine Attending:[**First Name3 (LF) 3624**] Chief Complaint: found down Major Surgical or Invasive Procedure: Endoscopy History of Present Illness: 48M HIV+ on HAART CD4 228, DM on insulin pump, s/p kidney xplant ([**2114**]) on Tacro/Prednisone 5/Bactrim, found down at home after taking Ativan/narcotics for pain [**2-19**] colonoscopy 4 days ago. Pt reports that yesterday afternoon he took 3 pills of what he thought were ativan per his daily routine and sat down to watch TV as his last memory. Mother called 911 EMS gave narcan pt woke then vomited reported coffee ground emesis per EMS after he had ate he ate meatball sub for diner. Seen initially at [**Hospital1 1562**] where he had Cr 2.7 from 1.8, K 7.1 and trop 0.14 and he recieved Kayexalate 30mg, CaGluc 1 amp, 6U humulin and Reglan 10mg, Protonix 80mg, and 1L NS + 2 amps bicarb. CXR there showed multifocal infiltrates by report. Reported epigastric pain. Guiaic neg. HR 105 and 73/44 at OSH In ED 98.4 91 111/70 18 96% 2L and remained normotensive. NG lavage was negative, guaiac + with mix brown stool and BRB. Review of symptoms: denies fever, chills,abd pain, chest pain, diaphoresis, black or bloody stools, nausea, vomiting, suicidal ideation, tylenol ingestion. Denies headache, 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: HIV diagnosed in [**2093**], no AIDS defining illness, last CD4 341 DM type I, c/b neuropathy CVA [**2108**], mild, lateral 3 digits on right hand affected Hypertension Pilonidal cyst, abscess drainage Kidney transplant [**2114**] Lt 4th metatarsal osteotomy [**2113**] Social History: There is a distant smoking in the past. No history of drug use or alcohol abuse. The patient lives with his mother and is currently disabled. Single MSM. No pets, previously worked as a painter. Family History: NC Physical Exam: Vitals: 100.1, 102, 116/65, 18, 99%RA General: Alert, orientedx 3, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: distant heart sounds, Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley, no CVA tenderness Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, well healing ulcer on left foot without erythema or drainage. Pertinent Results: Labs on Admission: [**2116-4-26**] 11:06PM tacroFK-4.9* [**2116-4-26**] 08:45PM GLUCOSE-483* UREA N-36* CREAT-3.0*# SODIUM-141 POTASSIUM-5.6* CHLORIDE-101 TOTAL CO2-24 ANION GAP-22* [**2116-4-26**] 08:45PM estGFR-Using this [**2116-4-26**] 08:45PM ALT(SGPT)-29 AST(SGOT)-28 CK(CPK)-852* ALK PHOS-64 TOT BILI-0.4 [**2116-4-26**] 08:45PM LIPASE-21 [**2116-4-26**] 08:45PM cTropnT-0.08* [**2116-4-26**] 08:45PM CK-MB-11* MB INDX-1.3 [**2116-4-26**] 08:45PM CALCIUM-8.2* PHOSPHATE-5.4*# MAGNESIUM-1.8 [**2116-4-26**] 08:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2116-4-26**] 08:45PM WBC-8.2 RBC-3.70* HGB-13.1* HCT-39.5* MCV-107*# MCH-35.3* MCHC-33.1 RDW-16.1* [**2116-4-26**] 08:45PM NEUTS-70 BANDS-1 LYMPHS-22 MONOS-7 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2116-4-26**] 08:45PM HYPOCHROM-OCCASIONAL ANISOCYT-OCCASIONAL POIKILOCY-OCCASIONAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-OCCASIONAL TEARDROP-OCCASIONAL [**2116-4-26**] 08:45PM PLT COUNT-188 [**2116-4-26**] 08:45PM PT-12.5 PTT-25.3 INR(PT)-1.1 Labs on Discharge: [**2116-5-3**] 06:25AM BLOOD WBC-5.2 RBC-3.23* Hgb-11.5* Hct-32.2* MCV-100* MCH-35.5* MCHC-35.6* RDW-16.4* Plt Ct-192 [**2116-5-3**] 06:25AM BLOOD PT-12.8 PTT-23.3 INR(PT)-1.1 [**2116-5-3**] 06:25AM BLOOD Glucose-190* UreaN-29* Creat-3.0* Na-138 K-3.5 Cl-105 HCO3-25 AnGap-12 [**2116-5-1**] 06:20AM BLOOD ALT-27 AST-21 AlkPhos-57 TotBili-0.5 [**2116-4-30**] 05:40AM BLOOD CK-MB-3 cTropnT-0.10* [**2116-4-29**] 06:30AM BLOOD cTropnT-0.10* [**2116-4-27**] 11:24AM BLOOD CK-MB-9 cTropnT-0.14* [**2116-5-3**] 06:25AM BLOOD Calcium-8.0* Phos-2.2* Mg-1.8 [**2116-5-3**] 06:25AM BLOOD tacroFK-5.8 Microbiology: [**2116-4-26**] Blood cultures x 2 No growth [**2116-4-27**] MRSA Screen No MRSA isolated [**2116-4-27**] Urine Culture No growth [**2116-4-29**] VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Preliminary): No Herpes simplex (HSV) virus isolated Imaging: - ECG Study Date of [**2116-4-27**] 12:47:16 AM Sinus tachycardia. Low limb lead QRS voltage. Modest ST-T wave changes. Findings are non-specific. Since the previous tracing of [**2114-8-1**] sinus tachycardia and modest ST-T wave changes are both now present. - CHEST (PA & LAT) Study Date of [**2116-4-27**] 3:06 AM IMPRESSION: Cavitating right lower lobe pneumonia. - RENAL TRANSPLANT U.S. Study Date of [**2116-4-27**] 8:52 AM IMPRESSION: 1. Increased resistive indices within the transplanted kidney, which are elevated compared to [**2114-7-18**] ultrasound. 2. Mild pelvocaliectasis of the transplanted kidney. - CT CHEST W/O CONTRAST Study Date of [**2116-4-28**] 5:03 PM IMPRESSION: 1. Multifocal pneumonia. No cavitation or obstruction. 2. A 9-mm upper tracheal nodule contiguous with possible esophageal mass. I would suggest a repeat CT scan, after vigorous coughing to clear the trachea of any debris, utilizing oral contrast [**Doctor Last Name 360**] to reassess both the trachea and the esophagus. - ESOPHAGUS Study Date of [**2116-4-30**] 2:47 PM IMPRESSION: 1. Esophageal dysmotility, as described above. 2. No evidence of esophageal stricture, intraluminal mass, or mucosal abnormality. - EGD [**2116-5-1**] Procedure: The procedure, indications, preparation and potential complications were explained to the patient, who indicated his understanding and signed the corresponding consent forms. A physical exam was performed. The patient was administered moderate sedation. The patient was placed in the left lateral decubitus position and an endoscope was introduced through the mouth and advanced under direct visualization until the third part of the duodenum was reached. Careful visualization of the upper GI tract was performed. The procedure was not difficult. The patient tolerated the procedure well. There were no complications. Findings: Esophagus: Normal esophagus. Stomach: Normal stomach. Duodenum: Normal duodenum. Brief Hospital Course: Mr. [**Known lastname 20083**] is a 48yo M with history of HIV and diabetic nephropathy s/p living-related transplant [**7-25**] who was found down at home and was found down with improvement after narcan and found to have acute kidney injury, elevated K that was treated and hypotension with report of coffee ground emesis. # Acute kidney injury: The patient normally has a creatinine around 1.8 s/p living related transplant, but after being found down had a creatinine of 3, which rose during the course of his admission initally; he was thought to have ATN secondary to volume depletion in setting or recent bowel prep as well as dehydration. His creatinine improved over the course of his admission with IV fluids back down to 3, but not completely back to his baseline. He was discharged with a decrease in his Truvada to 1 tablet every 72 hours secondary to his continued but improving renal damage. # GI bleed: Pt guaiac positive in ED likely related to recent colonoscopy or prior rectal exam at OSH. Concern for UGI bleed given report of dark emesis, but pt HCT is stable, GI lavage is neg and he denies abdominal pain, bloody stool, black stool or lightheadedness. The patient had a table HCT within the hospital that did not require any blood transfusions. An endoscopy was performed which was completely normal, without any sign of mass or bleed. #Multivocal infiltrate: Multifocal infiltrate found on CXR after being altered and vomiting with EMS. Initially endorsed low grade fevers, cough, and brown productive sputum. Was initially covered with Vanc/cefepime cover for possible aspiration PNA. A CT of the Chest was shown to be consistent with multifocal pneumonia, but also incidentally commented on an esophgeal/tracheal mass. The patient's antibiotics were later transition to moxifloxacin. He had completed a 7 day course of antibiotics by the time of his discharge. UPon discharge he was not short of breath and satting well on room air, as compared to his initial presentation when he had required 4 L O2. #Esophageal mass: On CT scan, the patient was noted to have an esophageal mass with some possible connection to a very small tracheal infiltrate, concerning for malignancy. A barium swallow was performed, which only showed some esophageal dysmotility, but no signs of a mass or fistula. The EGD for presumed UGIB also did not reveal any signs of mass or fistula. Given the fact it was presumed the patient had an aspiration event, the tracheal infiltrate was presumed to be aspirated content from his aspiration event. # Hyperglycemia: Pt with insulin pump at home wtih fingersticks ranging 100-200 usually presenting with hyperglycemia. His hyperglycemia was though to be secondary to the stress response of infection. He was controlled in house with SSI, with recommendations from the [**Last Name (un) **] team. Upon discharge, he was re-started back on his insulin pump. # s/p Renal transplant: Renal ultrasound was not thought to reflect rejection. The patient's tacrolimus level was elevated in the hospital, and thus his dose was halved to 1.5 mg [**Hospital1 **] from 3 mg [**Hospital1 **], with Tacro levels on discharge in the appropriate range. # HIV: on HAART. HAART medication dosing decreased secondary to known renal dysfunction; upon discharge, he was still taking less than his usual home dose of Truvada; this will need to be uptitrated to his normal home dose once his kidneys fully recover. # Substance abuse: It came to light during this admission that the patient had purposefully taken all of the narcotics prescribed to him post his anoscopy simultaneously in order to "get high." Social work and psychiatry was consulted; psychiatry did not find any acute issues, and recommended continuing the patient's current dosing of psychoactive medication. PCP was [**Name (NI) 653**], and will help to make arrnagement for further outpateint psychiatric help. Medications on Admission: AMLODIPINE - 5 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) AZATHIOPRINE - 50 mg Tablet - 1 Tablet(s) by mouth once a day EMTRICITABINE-TENOFOVIR [TRUVADA] - 200 mg-300 mg Tablet - 1 Tablet(s) by mouth every day ETRAVIRINE [INTELENCE] - 100 mg Tablet - 2 Tablet(s) by mouth twice daily INSULIN ASPART [NOVOLOG PENFILL] - (Prescribed by Other Provider) - 100 unit/mL Cartridge - LORAZEPAM [ATIVAN] - (Prescribed by Other Provider) - 1 mg Tablet - 2 Tablet(s) by mouth at bedtime METOCLOPRAMIDE - 10 mg Tablet - 1 Tablet(s) by mouth three times a day PANTOPRAZOLE [PROTONIX] - (Prescribed by Other Provider) - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth daily PREDNISONE - 5 mg Tablet - 1 Tablet(s) by mouth once a day RALTEGRAVIR [ISENTRESS] - 400 mg Tablet - 1 Tablet(s) by mouth twice daily SULFAMETHOXAZOLE-TRIMETHOPRIM [BACTRIM] - 400 mg-80 mg Tablet - 1 Tablet(s) by mouth once a day TACROLIMUS - (restarted) - 1 mg Capsule - 2 Capsule(s) by mouth twice a day VENLAFAXINE - (Prescribed by Other Provider) - 75 mg Capsule, Ext Release 24 hr - 1 Capsule(s) by mouth once a day Discharge Medications: 1. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO DAILY (Daily). 2. etravirine 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO every twenty-four(24) hours. 6. tacrolimus 0.5 mg Capsule Sig: Three (3) Capsule PO Q12H (every 12 hours). Disp:*180 Capsule(s)* Refills:*2* 7. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. insulin aspart 100 unit/mL Cartridge Sig: 0.85 U Subcutaneous every hour: via insulin pump, titrate according to your blood glucose. 10. Truvada 200-300 mg Tablet Sig: One (1) Tablet PO every seventy-two (72) hours. 11. Outpatient Lab Work Chem 7, CBC, serum tacrolimus level. Send to Dr. [**Last Name (STitle) **] at Office Phone:([**Telephone/Fax (1) 3618**], Office Fax:([**Telephone/Fax (1) 12146**] 12. amlodipine 5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Aspiration pneumonia Acute Tubular necrosis (kidney injury) Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 20083**], You were admitted to the hospital after you had overdosed on pain medications given to you for your anoscopy and sigmoidoscopy. You were unconscious and developed a pneumonia from inhaling some of your stomach contents. You were treated with antibiotics for seven days. You also developed kidney failure afterwards, which has since improved. However, it has not returned back to normal and because of this the doses of some of your medications have changed. On one of your CT scans, there was a concern for an esophageal mass. You had an endoscopy that showed no problems. The following changes have been made to your medications: Tacrolimus - DECREASE to 1.5mg twice daily Truvada - DECREASE to 1 tablet every 72 hours. You should RESTART your insulin pump at 0.85U/hour starting 11pm tonight [**2116-5-3**]. Followup Instructions: Please make an appointment with Dr. [**Last Name (STitle) **] within the next 2 weeks. His phone number is [**Telephone/Fax (1) 673**]. Also, you should see your primary care doctor, Dr. [**First Name (STitle) 1557**] as well. Her phone number is [**Telephone/Fax (1) 30782**]. You will need to have your labs checked sometime next week and sent to Dr. [**Last Name (STitle) **]. You have been given a prescription for those. You have the following other appointments scheduled. Department: PODIATRY When: FRIDAY [**2116-5-29**] at 1:20 PM With: [**First Name11 (Name Pattern1) 3210**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **], DPM [**Telephone/Fax (1) 543**] Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: TRANSPLANT CENTER When: MONDAY [**2116-8-17**] at 1 PM With: [**Name6 (MD) 2105**] [**Name8 (MD) 2106**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**First Name4 (NamePattern1) 971**] [**Last Name (NamePattern1) 970**] MD [**MD Number(1) 3629**]

[ "E850.8", "584.5", "V42.0", "362.01", "276.7", "965.8", "401.9", "250.41", "792.1", "250.51", "507.0", "V45.85", "357.2", "V12.54", "583.81", "250.61", "V08", "530.5", "305.90" ]

icd9cm

[ [ [] ] ]

[ "45.13" ]

icd9pcs

[ [ [] ] ]

13143, 13149

6867, 10782

282, 294

13253, 13253

2934, 2939

14283, 15543

2288, 2292

11936, 13120

13170, 13232

10808, 11913

13404, 14260

2307, 2915

232, 244

4023, 6844

322, 1766

2953, 4004

13268, 13380

1788, 2059

2075, 2272

63,746

161,622

9806

Discharge summary

report

Admission Date: [**2169-11-26**] Discharge Date: [**2169-12-6**] Date of Birth: [**2109-2-1**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 165**] Chief Complaint: Severe chest pain Major Surgical or Invasive Procedure: [**2169-11-26**] Replacement of Ascending Aorta and Hemiarch and Aortic Valve Resuspension History of Present Illness: Mr. [**Known lastname 33019**] is a 60 year old male who developed sudden onset chest pain which radiated to his neck and jaw. He was found to be hypotensive and grey while at home. En route to another hospital he was given intravenous fluids and found to have significant blood pressure difference between his two arms. A chest CTA revealed a Type A aortic dissection with extension into the right subclavian artery and occlusion of the right common carotid artery. There was no extension into the abdominal aorta. Given the above findings, he was emergently transferred to the [**Hospital1 18**] for surgical intervention. Past Medical History: Hypertension GERD Appendectomy Melanoma resection - radical left groin dissection [**Doctor Last Name 9376**] Syndrome hypercholesterolemia Social History: Denies tobacco. Admits to only social ETOH. Works long hours in government position and teaches at night. Family History: Admits to coronary artery disease - unknown ages. Physical Exam: Discharge exam: Vitals- 98.6 104/60 82sinus 92%3L NC General- pleasant to speak with HEENT- PERRLA Neck- supple, full ROM Chest- Lungs clear bilaterally Heart- Irregular rhythm, sternum stable Abdomen- Soft, nontender without rebound or guarding. Normoactive bowel sounds Ext- warm with 1+ bilateral edema Neuro- alert, oriented, non-focal Pulses- 2+ Incisions- clean, dry Pertinent Results: [**2169-11-26**] Intraop TEE: Pre Bypass: The left atrium and right atrium are normal in cavity size. No atrial septal defect is seen by 2D or color Doppler. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is moderately dilated. There are simple atheroma in the descending thoracic aorta. A mobile density is seen in the ascending aorta, aortic arch, and descending aorta that is consistent with an intimal flap/aortic dissection. It arises at the level of the sino-tubular junction. It continues for approximately 10 cm beyond the left subclavian. There is no pericardial collection. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. Post Bypass: Left and right ventricular function is preserved. An aortic graft is in place. There is mild aortic regurgitation. The descending aortic dissection is unchanged. [**2169-12-6**] 05:43AM BLOOD WBC-12.2* RBC-3.05* Hgb-9.4* Hct-28.1* MCV-92 MCH-30.8 MCHC-33.5 RDW-14.4 Plt Ct-544* [**2169-11-26**] 06:07PM BLOOD WBC-13.0* RBC-4.07* Hgb-13.6* Hct-36.6* MCV-90 MCH-33.3* MCHC-37.1* RDW-13.1 Plt Ct-240 [**2169-12-6**] 05:43AM BLOOD PT-31.5* PTT-40.3* INR(PT)-3.3* [**2169-12-4**] 09:20AM BLOOD PT-41.5* INR(PT)-4.6* [**2169-12-6**] 05:43AM BLOOD UreaN-19 Creat-1.2 K-4.3 [**2169-12-4**] 09:20AM BLOOD Glucose-149* UreaN-20 Creat-1.0 Na-138 K-4.5 Cl-103 HCO3-26 AnGap-14 [**2169-11-26**] 06:07PM BLOOD Glucose-104 UreaN-17 Creat-1.0 Na-142 K-3.7 Cl-107 HCO3-26 AnGap-13 [**2169-11-28**] 01:49AM BLOOD ALT-18 AST-53* LD(LDH)-308* AlkPhos-34* Amylase-67 TotBili-1.4 [**2169-11-26**] 06:07PM BLOOD CK(CPK)-147 [**2169-11-28**] 01:49AM BLOOD Lipase-10 [**2169-12-6**] 05:43AM BLOOD Mg-2.2 [**2169-11-27**] 08:44AM BLOOD Calcium-6.6* Phos-2.5* Mg-1.9 Brief Hospital Course: Mr. [**Known lastname 33019**] was emergently brought to the operating room where Dr. [**First Name (STitle) **] performed an aortic dissection repair. For surgical details, please see seperate dictated operative note. Following the operation, he was brought to the CVICU for invasive monitoring. He was initially maintained on intravenous Nitro to maintain MAP less than 85mmHg and SBP in the 100-120mmHg. On postoperative day one, he awoke neurologically intact and was extubated without incident. He required several units of PRBC to help maintain a hematocrit near 30%. Over several days, he gradually weaned from intravenous Nitro and was transitioned to beta blockade. He maintained stable hemodynamics and eventually was transferred to the SDU on postoperative day three. He remained stable with good BP control on oral agents. A CTA was done to assess his repair and any residual aortic pathology. He was ambulating and neurologically intact. He continued to be in and out of atrial fibrillation so he was discharged on amiodarone and low dose coumadin. He passed physical therapy on post-op day 8 and was cleared to be discharged to rehab. Medications on Admission: HCTZ 25 qd, Prilosec 20 qd, Aspirin 81 qd Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*0* 5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. Disp:*30 ML(s)* Refills:*0* 7. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. Disp:*30 Suppository(s)* Refills:*0* 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 7 days. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 11. Menthol-Cetylpyridinium 3 mg Lozenge Sig: One (1) Lozenge Mucous membrane PRN (as needed). Disp:*90 Lozenge(s)* Refills:*0* 12. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). Disp:*270 Tablet(s)* Refills:*0* 13. Diltiazem HCl 60 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*0* 14. Camphor-Menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed. Disp:*qs qs* Refills:*0* 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 16. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed. Disp:*50 Tablet(s)* Refills:*0* 17. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: Two (2) Spray Nasal DAILY (Daily). Disp:*qs qs* Refills:*2* 18. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours). Disp:*qs qs* Refills:*2* 19. Chlorpheniramine-Hydrocodone 8-10 mg/5 mL Suspension, Sust.Release 12 hr Sig: Five (5) ML PO Q12H (every 12 hours) as needed. Disp:*qs ML(s)* Refills:*0* 20. furosemide Sig: Twenty (20) milligrams Intravenous twice a day for 1 weeks. Disp:*qs qs* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital3 12564**] Health Network Discharge Diagnosis: Type A Aortic Dissection s/p Replacement of Ascending Aorta and Hemiarch,Aortic Valve Resuspension Hypertension [**Doctor Last Name 9376**] Syndrome gastric reflux hypertension hypercholesterolemia irritable bowel syndrome Discharge Condition: Good Discharge Instructions: No driving for one month and off all narcotics No lifting more than 10 lbs for 10 weeks from surgery date. Shower daily, no baths or swimming Do not apply creams, lotions or powders to any surgical incision. report any redness of, or drainage from incisions report any fever greater than 100.5 report any weight gain greater than 2 pounds a day or 5 pounds a week take all medications as directed Followup Instructions: Dr. [**First Name (STitle) **] in [**5-20**] weeks ([**Telephone/Fax (1) 170**]) Dr. [**Last Name (STitle) 713**] in [**3-19**] weeks Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**] in [**2-15**] weeks. ([**Telephone/Fax (1) 1989**]) Please call for appointments [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2169-12-6**]

[ "782.3", "272.0", "277.4", "427.31", "530.81", "564.1", "441.01", "493.90", "401.9", "433.10" ]

icd9cm

[ [ [] ] ]

[ "38.45", "99.04", "38.93", "88.72", "39.61" ]

icd9pcs

[ [ [] ] ]

7718, 7781

3900, 5055

338, 431

8048, 8055

1850, 3877

8500, 8911

1387, 1438

5147, 7695

7802, 8027

5081, 5124

8079, 8477

1453, 1453

1469, 1831

281, 300

459, 1085

1107, 1248

1264, 1371

76,812

152,711

12420

Discharge summary

report

Admission Date: [**2163-4-24**] Discharge Date: [**2163-5-4**] Date of Birth: [**2097-1-13**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 38616**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: -Thoracentesis -Paracentesis -Pleurex Catheter Placement. History of Present Illness: The patient is a 66 year old male with PMHx HTN and recently diagnosed follicular lymphoma who presents with dyspnea. The patient has been undergoing workup of lymphoma since [**Month (only) 404**] when he developed night sweats and weight loss. He started noting increase in abdominal girth in [**Month (only) 958**], which progressed to include DOE as well. Imaging showed ascites, pleural effusion, and diffuse LAD. On [**4-15**], he had a paracentesis with 3L removed. He was admitted to BIDN on [**2163-4-18**] for expedited workup given his symptoms. During that admission, he underwent a lymph node biopsy w/ Dr. [**First Name (STitle) 2819**] on [**4-19**], and on [**4-20**] had ultrasound-guided paracentesis done of 2300 mL and a thoracentesis was done of 1200 mL. He was seen by Dr. [**Last Name (STitle) 3274**] of Oncology with plans for follow up visit next week to discuss the results of the biopsies. He was sent home on lasix 20mg daily which he has been taking. Since his discharge though, he has felt increasingly unwell, with fatigue, worsening shortness of breath, and increased abdominal girth since then as well. He has had persistent leg edema as well, left greater than right - an ultrasound during his last admission was negative for DVT. He initially presented to [**Location (un) 620**] where CXR showed large pleural effusion. He was initially hypotensive which improved after 1LNS, then he was transferred to [**Hospital1 18**] for further workup. In the ED, initial VS were: 97.3 100 117/67 24 99%. Labs showed leukocytosis to 13, Cr of 1.3, lactate of 2.6. ABG showed 7.41/40/343/26. He was given 1 additional liter NS, ceftriaxone/azithromycin as pneuomnia could not be excluded, nebs, and was placed on CPAP which gave him marked improvement in his respiratory status. On transfer, vitals were systolic 105, RR 24, O2 100% on NIVVP, 86. On arrival to the MICU, patient's VS. Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denies shortness of breath, cough, dyspnea or wheezing. Denies chest pain, chest pressure, palpitations. Denies constipation, abdominal pain, diarrhea, dark or bloody stools. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: 1. Hypertension. 2. Depression. 3. Migraine. 4. Bladder dysfunction. 5. Laminectomy 6. Arthroscopy 7. Sinus reconstruction 8. Varicocele Social History: He is married. He has 2 grown children. 1 of his sons is getting married in [**Name (NI) **]. He was a non cigarette smoker but he was a regular marijuana user particularly over the last 3 to 4 years, often daily, although he quit in [**Month (only) 958**]. No significant alcohol. He is a retired electrical engineer, retiring about a year and a half ago. He lives in [**Location 620**] with his wife. [**Name (NI) **] had been quite active going to a gym and doing some water aerobics until the last 3 to 4 weeks. Family History: NC - Father: Bladder cancer - Sister: Breast cancer - No history of lymphoma or immune disorders Physical Exam: Admission Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-distended, bowel sounds present, no organomegaly, no tenderness to palpation, no rebound or guarding GU: no foley Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. Discharge Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Left lung reduced air entry to mid-chest. Left pleurex catheter in place. right lung clear to air entry with reduced air entry at the lung base. Abdomen: distended, no leakage at paracentesis sites, 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. Mild edema bilaterally, left worse than right. Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred. Pertinent Results: Admission Labs: [**2163-4-24**] 02:40AM BLOOD WBC-13.4* RBC-4.70 Hgb-13.3* Hct-42.6 MCV-91 MCH-28.3 MCHC-31.2 RDW-16.2* Plt Ct-225 [**2163-4-24**] 02:40AM BLOOD Neuts-72.8* Lymphs-18.8 Monos-6.7 Eos-1.0 Baso-0.7 [**2163-4-24**] 02:40AM BLOOD PT-11.2 PTT-26.9 INR(PT)-1.0 [**2163-4-24**] 02:40AM BLOOD Glucose-97 UreaN-23* Creat-1.3* Na-136 K-4.3 Cl-100 HCO3-22 AnGap-18 [**2163-4-24**] 02:40AM BLOOD ALT-12 AST-31 LD(LDH)-244 AlkPhos-73 TotBili-0.5 [**2163-4-24**] 02:40AM BLOOD Lipase-35 [**2163-4-24**] 02:40AM BLOOD Albumin-3.5 Calcium-8.8 Phos-3.2 Mg-2.1 UricAcd-6.3 [**2163-4-24**] 03:01AM BLOOD Lactate-2.6* [**2163-4-24**] 05:18AM BLOOD Type-ART Temp-36.7 PEEP-5 FiO2-100 pO2-343* pCO2-40 pH-7.41 calTCO2-26 Base XS-1 AADO2-336 REQ O2-61 Intubat-NOT INTUBA [**Hospital3 **]: [**2163-4-24**] 02:40AM BLOOD Triglyc-274* [**2163-4-24**] 02:40AM BLOOD HBsAb-PND [**2163-4-24**] 02:40AM BLOOD b2micro-PND Ascites: [**2163-4-24**] 01:59PM ASCITES WBC-[**Numeric Identifier 38617**]* RBC-4000* Polys-3* Lymphs-95* Monos-2* [**2163-4-24**] 01:59PM ASCITES TotPro-2.8 Glucose-91 Creat-1.1 LD(LDH)-108 Albumin-2.2 Triglyc-379 [**2163-4-24**] 01:59PM OTHER BODY FLUID IPT-PND [**2163-4-24**] 04:48PM BONE MARROW [**Doctor Last Name 4427**]-PND Discharge Labs: [**2163-5-4**] 06:10AM BLOOD WBC-8.0 RBC-4.22* Hgb-12.0* Hct-37.6* MCV-89 MCH-28.5 MCHC-32.0 RDW-16.8* Plt Ct-365 [**2163-5-3**] 06:06AM BLOOD Neuts-74.6* Lymphs-14.7* Monos-6.4 Eos-3.4 Baso-0.9 [**2163-5-4**] 06:10AM BLOOD Plt Ct-365 [**2163-5-4**] 06:10AM BLOOD PT-10.9 PTT-30.0 INR(PT)-1.0 [**2163-5-4**] 06:10AM BLOOD Fibrino-414* [**2163-5-4**] 06:10AM BLOOD [**2163-5-4**] 06:10AM BLOOD Glucose-98 UreaN-18 Creat-1.0 Na-138 K-4.4 Cl-104 HCO3-27 AnGap-11 [**2163-5-4**] 06:10AM BLOOD ALT-11 AST-18 LD(LDH)-137 AlkPhos-49 TotBili-0.2 [**2163-5-4**] 06:10AM BLOOD Calcium-8.7 Phos-4.4 Mg-2.1 UricAcd-5.5 [**2163-4-28**] 03:00PM PLEURAL WBC-5040* RBC-9900* Polys-7* Lymphs-81* Monos-4* Meso-5* Macro-3* [**2163-4-25**] 04:45PM PLEURAL WBC-4075* RBC-[**Numeric Identifier 34864**]* Polys-4* Lymphs-84* Monos-0 Macro-12* [**2163-4-28**] 03:00PM PLEURAL Glucose-126 Creat-1.1 LD(LDH)-122 Triglyc-75 [**2163-4-25**] 04:45PM PLEURAL TotProt-2.9 Glucose-144 LD(LDH)-93 Albumin-2.3 Cholest-53 Triglyc-62 [**2163-5-3**] 03:44PM ASCITES WBC-8389* RBC-3167* Polys-6* Lymphs-85* Monos-2* Mesothe-1* Macroph-3* Other-3* [**2163-4-28**] 09:06AM ASCITES WBC-6125* RBC-[**Numeric Identifier 30005**]* Polys-4* Lymphs-4* Monos-0 Mesothe-1* Macroph-1* Other-90* [**2163-4-24**] 01:59PM ASCITES WBC-[**Numeric Identifier 38617**]* RBC-4000* Polys-3* Lymphs-95* Monos-2* [**2163-5-3**] 03:44PM ASCITES TotPro-2.4 Glucose-107 LD(LDH)-99 Albumin-1.9 [**2163-4-28**] 09:06AM ASCITES TotPro-2.5 Glucose-163 Creat-1.1 LD(LDH)-84 Amylase-29 TotBili-0.2 Albumin-2.1 [**2163-4-24**] 01:59PM ASCITES TotPro-2.8 Glucose-91 Creat-1.1 LD(LDH)-108 Albumin-2.2 Triglyc-379 [**2163-4-24**] 01:59PM OTHER BODY FLUID CD23-DONE CD45-DONE HLA-DR[**Last Name (STitle) 7735**] [**Name (STitle) 38618**] CD10-DONE CD19-DONE CD20-DONE Lamba-DONE CD5-DONE [**2163-4-24**] 01:59PM OTHER BODY FLUID CD3-DONE [**2163-4-24**] 01:59PM OTHER BODY FLUID IPT-DONE [**2163-4-24**] 04:48PM BONE MARROW [**Doctor Last Name 4427**]-DONE Microbiology: [**2163-4-24**] 1:59 pm PERITONEAL FLUID GRAM STAIN (Final [**2163-4-24**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Preliminary): ANAEROBIC CULTURE (Preliminary): HBV Viral Load (Final [**2163-4-27**]): HBV DNA not detected. Blood and urine cultures pending . [**2163-5-3**] 3:44 pm PERITONEAL FLUID PERITONEAL FLUID. GRAM STAIN (Final [**2163-5-3**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2163-5-6**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. Imaging: [**4-26**] TTE: Conclusions 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%). The estimated cardiac index is high (>4.0L/min/m2). 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. 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 hypertension. Dilated ascending aorta. No pericardial effusion. Bilateral pleural effusions. [**4-26**] LENIs: IMPRESSION: No evidence of DVT in the right or left leg. Enlarged lymph nodes in the inguinal regions bilaterally. [**4-27**] CXR: IMPRESSION: 1. Stable large left pleural effusion and small right pleural effusion. 2. Atelectasis at the left base [**4-24**] Bone Marrow Biopsy SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY: DIAGNOSIS: Hypercellular bone marrow with extensive involvement by follicular lymphoma MICROSCOPIC DESCRIPTION Peripheral Blood Smear: The smear is adequate for evaluation. Red blood cells are normochromic and normocytic with anisopoikilocytosis including frequent burr cells, occasional elliptocytes, and macrocytes are seen. Rare nuclear RBC's are seen. The white blood cell count appears normal. A subset of lymphocytes are atypical and display a cleaved nuclear morphology. Platelet count appears normal and giant forms are not seen. Differential shows 74% neutrophils, 8% monocytes, 17% lymphocytes, 1% eosinophils. Aspirate Smear: The aspirate material is suboptimal for evaluation due to paucity of spicules. M:E ratio is 2:1. Erythroid precursors are normal in number and exhibit dyspoietic forms with irregular nuclear contours, asymmetric nuclear budding. Myeloid precursors appear normal in number and show normal maturation. Occasional abnormal nuclear lobation and pseudo Pelger [**Doctor Last Name **]??????t forms are seen. Megakaryocytes are present in normal; abnormal forms are seen including several hypolobated forms, micromegakaryocytes, forms with disjointed nuclei. Small cleaved lymphocytes are seen; no large lymphoid cells are seen. A 500 cell differential shows: 1% Blasts, 2% Promyelocytes, 6% Myelocytes, 5% Metamyelocytes, 30% Bands/Neutrophils, 1% Plasma cells, 35% Lymphocytes, 20% Erythroid. Clot Section and Biopsy Slides: The core biopsy material is adequate for evaluation. It consists of a 0.9 cm core biopsy, trabecular marrow with a cellularity of over 90%. Approximately 70% of marrow cellularity is comprised of atypical lymphocytes with scant cytoplasm and irregularly shaped nuclei; focal areas (<10%) of larger cells (centroblasts) with more open chromatin and nucleoli are seen. In the remaining cellularity, M:E ratio estimate is normal. Erythroid precursors exhibit overall normoblastic maturation. Myeloid precursors have complete maturation to neutrophilic stage. Megakaryocytes are present and are loosely clustered focally. ADDITIONAL STUDIES: Flow cytometry: See separate report - shows involvement by Follicular lymphoma. [**4-24**] Peritoneal fluid cytology Peritoneal fluid: ATYPICAL. Numerous monomorphic small atypical lymphocytes. [**4-24**] Peritoneal Fluid flow Cytometry FLOW CYTOMETRY IMMUNOPHENOTYPING The following tests (antibodies) were performed: HLA-DR, FMC-7, Kappa, Lambda, and CD antigens 3, 5, 10, 19, 20, 23, 45. RESULTS: Three color gating is performed (light scatter vs. CD45) to optimize blast/lymphocyte yield. Lymphoid cells comprise 83% of total analyzed events. B cells comprise 66% of lymphoid gated events and have a slight Kappa predominance (Kappa gain). They co-express pan B-cell markers CD19, 20, along with CD10, FMC-7. They do not express any other characteristic antigens including CD5, CD23. T cells comprise 28% of lymphoid gated events and express mature lineage antigens (CD3, CD5). INTERPRETATION Immunophenotypic findings consistent with involvement by follicular lymphoma. Correlation with clinical findings and morphology (see S12-20136K) is recommended. [**4-25**] Pleural fluid cytology Pleural fluid: Numerous lymphoid cells. Please also see corresponding flow cytometry report (S12-[**Numeric Identifier **]). Mesothelial cells and macrophages are also present. [**2163-4-25**] Cytogenetics KARYOTYPE: nuc ish(MYCx2)[100],(IGH@,BCL2)x4(IGH@ con BCL2x3)[78/100] Culture of this peritoneal fluid did not yield metaphase cells for analysis, therefore the chromosome analysis could not be performed. FISH analyses of interphase nuclei with the IGH@/BCL2 and MYC probes were interpreted as ABNORMAL for the IGH@/BLC2 probes, consistent with rearrangement of these loci with an additional fusion signal seen. The MYC probe hybridization was interpreted as normal. Please see below for details of the FISH analyses. FISH DETAILS: FISH evaluation for an IGH@-BCL2 rearrangement was performed on nuclei with the LSI IGH@/BCL2 Dual Color, Dual Fusion Translocation Probe ([**Doctor Last Name 7594**] Molecular) for IGH@ at 14q32 and BCL2 at 18q21 and is interpreted as ABNORMAL. Rearrangement was observed in 78/100 nuclei, which exceeds the normal range (up to 1%) established for these probes in the Cytogenetics Laboratory at [**Hospital1 18**]. An additional fusion signal was seen in all abormal cells. IGH@-BCL-2 rearrangement is a typical cytogenetic aberration in a subset B-cell lineage non-Hodgkin's lymphoma of follicular center cell origin. FISH evaluation for a MYC rearrangement was performed on nuclei with the LSI MYC Dual Color Break Apart Rearrangement Probe ([**Doctor Last Name 7594**] Molecular) at 8q24 and is interpreted as NORMAL. No rearrangement was observed in 100/100 nuclei, which is within the normal range established for this probe in the Cytogenetics Laboratory at [**Hospital1 18**]. Up to 4% of cells in normal samples can show apparent MYC rearrangement using this probe set. A normal MYC FISH finding can result from absence of a MYC rearrangement, from an atypical MYC rearrangement, or from an insufficient number of neoplastic cells in the specimen. These FISH tests were developed and their performance determined by the [**Hospital1 18**] Cytogenetics Laboratory as required by the CLIA '[**38**] regulations. They have not been cleared or approved by the U.S. Food and Drug Administration. The FDA has determined that such clearance or approval is not necessary. These tests are used for clinical purposes. This study was necessary for the analysis of this specimen. This study was necessary for the analysis of this specimen. This study was necessary for the analysis of this specimen. This study was necessary for the analysis of this specimen. [**2163-4-29**] Immunophenotyping FLOW CYTOMETRY REPORT FLOW CYTOMETRY IMMUNOPHENOTYPING The following tests (antibodies) were performed: HLA-DR, FMC-7, Kappa, Lambda, and CD antigens 3,5,10,19,20,23,45. RESULTS Three color gating is performed (light scatter vs. CD45) to optimize lymphocyte yield. Lymphoid cells comprise 1% of total analyzed events. B cells are scant in number precluding evaluation of clonality. Within the monocytoid cell / large cell gate, there is a small population of CD10 positive events, which shows dim CD20 gain (an artifact cannot be excluded). These events do not express CD19. In addition, they do not have light chain (bright) expression. T cells comprise 80% of lymphoid gated events,and express mature lineage antigens CD3,CD5). INTERPRETATION: Diagnostic immunophenotypic features of involvement by B cell lymphoma are not seen in specimen. Correlation with clinical findings is recommended. Flow cytometry immunophenotyping may not detect all lymphomas due to topography, sampling or artifacts of sample preparation. [**2163-5-3**] Paracentesis Uneventful diagnostic and therapeutic paracentesis with removal of 4 liters of milky ascitic fluid. [**2163-5-4**] CXR In comparison with study of [**5-1**], there has been placement of a left Pleurx catheter with removal of substantial amount of pleural fluid. No definite pneumothorax. Atelectatic changes persist at the bases and there is mild blunting of the right costophrenic angle. Brief Hospital Course: 66 y/o male with new diagnosis of follicular lymphoma who p/w dyspnea, found to have recurrent large pleural effusion. . ACTIVE ISSUES: . # Respiratory distress - The likely cause of his respiratory distress is the large left pleural effusion, which is likely due to lymphoma. He also had significant ascites causing increased diaphragmatic pressure. Paracentesis successfully removed 2L of fluid and relieved his breathing, although he remained on oxygen support. Thoracentesis was performed on [**4-25**] with about 1.2L of fluid removal; no antibiotics were initiated. One Light's criteria was met but was borderline (Pleural fluid protein / Serum protein >0.5), likely c/w exudate [**1-20**] lymphoma. Given the rapid reaccumulation of fluid from malignant etiology (confirmed by flow cytometry of pleural fluid), the patient needed more definitive therapy either via initiation of treatment for lymphoma or eradication of pleural space. He subsequently received treatment with bendamustine and rituximab as below, but continued to reaccumulate pleural effusions requiring recurrent thoracentesis. We eventually decided to place a left-sided pleurx catheter to allow frequent drainage of his malignant pleural effusions. . # Lymphoma - Paracentesis from [**Location (un) 620**] showed cells c/w follicular lymphoma, his lymph node biopsy was also c/w follicular lymphoma. CT torso from [**Location (un) 620**] showed substantial lymphadenopathy throughout the abdomen. He was initiated on dexamethasone [**4-24**] for a planned 4 day course. Tumor lysis labs were followed and the patient was provided aggressive hydration. Allopurinol was also provided to avoid hyperuricemia. Provided acyclovir to prevent HSV reactivation, particularly given history of post-herpetic neuralgia in legs. Bone marrow biopsy performed [**4-24**] was consistent with follicular lymhpoma. The patient was transferred to the Oncology service with the intention of initiating chemotherapy, and started on bendamustine as well as rituximab. On first receiving rituximab, he developed a bas reaction, with tachycardia, hypertension and rigors. Infusion was stopped. The patient was temporarily transferred to the intensive care unit to receive rituximab via a 24 hour desensitization protocol. During the desensitization, he had a mild episode of tightness in his chest with no decrease on O2 saturation. He improved with nebilizers and was able to be transferred back to floor immediately after the infusion. He did however, continue to rapidly reaccumulate both pleural effusions and ascites, with multiple thoracenteses and paracenteses, and eventual placement of a pleurx catheter as above. He will followup with Dr. [**Last Name (STitle) 3759**] and Dr. [**Last Name (STitle) 3274**] for further care as an outpatient. # Ascites: Malignant ascites consistent with follicular lymphoma. He underwent three diagnostic and therapeutic paracenteses during his hospital stay, the first two on the floor and the third with IR-guidance and removal of 4L ascitic fluid. He will need to followup for furtehr therapeutic paracenteses. # Lower extremity edema (L>R) - ultrasound of the LLE ([**Hospital1 **] [**Location (un) 620**]) showed no DVT. On exam he has L>R lymphadenopathy. CT showed massive abdominal and pelvic lymphadenopathy that likely caused venous compression leading to asymmetric edema. Repeat RLE USS also showed no evidence of DVT. His inguinal lymphadenopathy and lower extremity edema had improved somewhat following chemotherapy. . #Paroxysmal AVT - Patient had multiple episodes of SVT to the 170s during his time in the [**Hospital Unit Name 153**]. He complained only of palpitations and remained hemodynamically stable. He broke spontaneously and did not require vagal maneuvers or pharmacologic agents. The patient had experienced these episodes at home as well, however they had become more frequent since his admission to [**Hospital1 18**] and initiation of chemo. He was started on a low dose of metoprolol 12.5mg [**Hospital1 **] in an attempt to suppress these episodes. . # Hypertension - Patient was hypotensive on initial presentation to [**Location (un) 620**] which improved with fluids. He was normotensive on transfer to [**Hospital1 18**]. . Transitional Issues: - He weill require close outpatient followup with Drs [**Last Name (STitle) 3759**] and [**Name5 (PTitle) 3274**] for ongoing management of his follicular lymphoma. He will also need to followup with interventional pulmonology for management of his pleurx catheter and recurrent pleural effusions. Dr. [**Last Name (STitle) 3274**] will also arrange for recurrent therapeutic paracenteses as needed. Medications on Admission: Allopurinol 300 mg daily Diovan daily Lipitor 20 mg daily Lasix 20mg daily ProAir as needed multivitamin magnesium B12 fish oil Discharge Medications: 1. allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*0* 2. Lipitor 20 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*90 Tablet(s)* Refills:*0* 3. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 4. ProAir HFA 90 mcg/actuation HFA Aerosol Inhaler Sig: One (1) Inhalation every six (6) hours as needed for shortness of breath or wheezing. Disp:*qs * Refills:*0* 5. multivitamin Capsule Sig: One (1) Capsule PO once a day. 6. Fish Oil 300 mg Capsule Oral 7. cyanocobalamin (vitamin B-12) Oral 8. escitalopram 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 9. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) for 30 days. Disp:*qs Tablet(s)* Refills:*0* 10. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*0* 12. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 13. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO every eight (8) hours as needed for nausea. Disp:*14 Tablet, Rapid Dissolve(s)* Refills:*0* 14. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig: 1.5 Tablet Extended Release 24 hrs PO once a day. Disp:*45 Tablet Extended Release 24 hr(s)* Refills:*2* 15. oxycodone 5 mg Capsule Sig: [**12-20**] Capsules PO every 4-6 hours as needed for pain: do not take if drowsy. Do not drive or operate heavy machinery while taking this medication. Disp:*10 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Follicular Lymphoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname **], It was a pleasure taking care of you at the [**Hospital1 771**]. You were admitted with shortness of breath and abdominal distension from fluid accumulating in your abdomen and lungs due to follicular lymphoma. We performed multiple taps to drain the fluid from your lungs and abdomen, and placed a catheter in your left chest to allow frequent drainage of the pleural effusions. Analysis of the fluid was consistent with follicular lymphoma, and no other malignant or infectious process was identified. While you were here, we also treated you with bendamustine and rituximab. You initially developed a reaction to rituximab, but subsequently underwent uneventful desensitization in the ICU. Please followup with Drs. [**Last Name (STitle) 3759**] and [**Name5 (PTitle) 3274**] following discharge, for ongoing management of your follicular lymphoma. During your hospitalization, you had a number of episodes of a fast heart rate. We started you on medication (metoprolol) to slow down your heart. Please continue taking this medication following discharge. We made the following changes to your medications: STOPPED -Valsartan STARTED -Escitalopram for anxiety -Acyclovir and Bactrim to prevent infections -Metoprolol for blood pressure and heart rate -Senna and Sodium Docusate to help move your bowels -Ondansetron for nausea Please continue taking your other medications as usual. Followup Instructions: Department: HEMATOLOGY/BMT When: FRIDAY [**2163-5-6**] at 2:00 PM With: [**First Name11 (Name Pattern1) 3750**] [**Last Name (NamePattern4) 3885**], NP [**Telephone/Fax (1) 3886**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: FRIDAY [**2163-5-6**] at 2:00 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3884**], MD [**Telephone/Fax (1) 3237**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: MONDAY [**2163-5-9**] at 2:00 PM [**Telephone/Fax (1) 38619**] Building: [**Street Address(2) 3001**] ([**Location (un) 620**], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: Thoracic Where: SC [**Hospital Ward Name **] CLINICAL CTR, [**Location (un) **] MULTI-SPECIALTY THORACIC UNIT-CC9 When: [**2163-5-19**] at 11:00a With: Dr. [**First Name4 (NamePattern1) 1151**] [**Last Name (NamePattern1) 3373**] [**Name6 (MD) 11021**] [**Name8 (MD) 11022**] MD [**MD Number(2) 38620**] Completed by:[**2163-5-7**]

[ "427.0", "705.1", "789.51", "202.00", "202.08", "300.00", "518.0", "518.81", "401.9", "511.81", "311", "782.3" ]

icd9cm

[ [ [] ] ]

[ "34.91", "54.91", "99.25", "41.31", "34.04" ]

icd9pcs

[ [ [] ] ]

24353, 24411

17716, 17837

312, 372

24475, 24475

5040, 5040

26076, 27353

3485, 3584

22609, 24330

24432, 24454

22456, 22586

24626, 25744

6299, 8615

3624, 4236

22028, 22430

25774, 26053

2346, 2768

265, 274

17852, 22007

400, 2327

5056, 6283

9056, 17693

24490, 24602

2790, 2928

2944, 3469

8647, 8647

4261, 5021

30,678

197,019

15018

Discharge summary

report

Admission Date: [**2103-10-10**] Discharge Date: [**2103-10-20**] Date of Birth: [**2033-9-7**] Sex: M Service: MEDICINE Allergies: Univasc / Lipitor / Vitamin E / Ambien Attending:[**First Name3 (LF) 398**] Chief Complaint: hematemesis Major Surgical or Invasive Procedure: Intubation Central line placement History of Present Illness: Mr. [**Known lastname **] is a 70 yo man with a history of COPD with approximately thrice yearly hospitalizations for exacerbations, HTN, CHF, CVA, lung CA s/p resection, and AAA s/p repair [**1-20**] presenting with hematemesis. Of note he was discharged from [**Hospital1 18**] [**10-4**] for URI/COPD exacerbation. This am noted he felt weak/lightheaded upon arising from bed, fell to floor. Had 1x episode of vomiting maroon blood. Continued to have sx of lightheadedness. At time of presentation to ED, was HD stable with VS 98.6 88 156/85 18 100% 2L. Reported some CP day prior to admission, currently resolved. Did have some elevated LFTs on initial testing with RUQ tenderness. A RUQ u/s was done which showed some evidence of GB swelling without CBD dilitation. Got 2L IVF in ED as well as nebs and IV PPI. Pt guaiac negative on exam. CXR was negative for evidence of new infiltrate. ECG unchanged. . On ROS pt notes that he did fall and hit head this morning, does not think he lost consciousness. Had also fallen a few weeks ago and hit his coccyx, has some pain there when he sits. Denies recent chest discomfort or shortness of breath. Does endorse worsening cough over past week productive of sputum. States that he had ~500cc of maroon hematemesis after falling, says this happened before in [**Month (only) **] when he had an UGIB at an OSH but it was a higher volume then. No nausea. No abd pain, no constipation or diarrhea. Last BM earlier today. Past Medical History: 1. Hypertension 2. Hyperlipidemia 3. Peripheral vascular disease with right SFA atherectomy and left external iliac artery stenting in [**2101**]. 4. Cardiomyopathy - likely non-ischemic from Chemo 5. Carotid stenosis - likely d/t parotid XRT, s/p stenting to the left common carotid and internal carotid in [**2100**] 6. AAA (thoracoabdominal) s/p endovascular repair 7. Small-cell carcinoma of the parotid gland s/p chemo and XRT 8. History of lung carcinoma s/p wedge resection left upper lobe on and right lower lobe superior segmentectomy on [**11-17**] 9. History of supraventricular tachycardia 10. Depression 11. COPD with an FEV-1 of 42% 12. Chronic kidney disease, stage II to III (Cr 1.4-1.9) 13. UGIB in early [**7-28**]. CHF secondary to cardiomyopathy Social History: Patient smoked for 50 years, quit 3 years ago. quit drinking 24 year ago. he is now retired but had his own business prior to retiring. Lives at [**Doctor Last Name **] House which is [**Hospital3 **] where he is independent except for med administration and meals. Family History: Father and sister have [**Name (NI) 2320**]. mother and brother have [**Name2 (NI) 499**] CA. Physical Exam: Vitals: T: 96 BP:147/102 P:71 R:12 SaO2: 100% General: Drowsy, easily arousable, frail appearing elderly gentleman in NAD HEENT: small tender pink swelling on occiput, ttp on right mastoid process. Thrush. MMM. conjunctiva not pale or injected. no scleral icterus. Neck: s/p radiation. No bruits. Pulmonary: Diminished air exchange b/l, slight rhonchi, clear with coughing. wheezes on forced expiration. diminished bs right base with pneumonectomy scar. Cardiac: RR, nl S1 S2, no murmurs, rubs or gallops appreciated Abdomen: s/p AAA repair scar. No HSM. negative [**Doctor Last Name **]. No abdominal bruit. + BS, soft ND/NT Extremities: No edema. cool. 1+ TP pulses. Small ecchymosis with excoriation to right of coccyx. No midline tenderness. Skin: no rashes or lesions noted. Neurologic: Drowsy. Oriented x 3. Falling asleep during conversation but easily arousable. Follows all commands. Poor short term memory. CN II- XII intact. Moving all extremities symetrically. Pertinent Results: RUQ u/s: Preliminary Report THICKENING AND EDEMA OF THE WALL OF THE GALLBLADDER WITHOUT INTRA OR EXTRA HEPATIC BILIARY DILATATION. HIDA SCAN RECOMENDED TO EXCLUDE ACALCULOUS CHOLECYSTITIS . CXR:Unchanged, no acute process. . EKG: NSR at 66, LBBB, LVH, LAD, RA abnormality. No change from prior. Brief Hospital Course: 70 yr old man with severe COPD on (steroids high dose) and course of azithromycin, HTN, CHF (cardiomyopathy s/p chemo) lung cancer s/p resection, AAA in [**10-21**] presented with chief compliant of hematemesis. The morning of admission at NH, s/p fall reaching from nightstand with head trauma -- shortly thereafter reports of vomiting blood. Initial evaluation significant for lactate 2.8, abnormal gallbladder on US thickened wall with edema. Overnight became cold, clammy, hypotensive with tachypnea and chest pain. Initially negative cardiac enzymes. Received femoral A-line, venous access, started dopamine peripheral changed to levophed with subsequent tachycardia. Switched to dopamine and dobutamine. He received 3L fluid. Cards TTE preliminary global hypokinesis. Gas 7.12/42, lactate 7.7. CT abdomen with PO contrast edematous gallbladder no other significant findings. TEE unremarkable for dissection, empirically started on heparin for concern of primary cardiac etiology vs PE. Morning of [**10-12**] developed bright red blood per ETT tube. [**2025-10-10**], able to wean dopamine and dobutamine; however during the day of [**10-13**] he required further dopamine. RUQ U/S negative for portal vein thrombosis, gall bladder mildly edematous. LENIs negative for DVTs. Given 500cc bolus without any change in UOP. Received platelets [**10-12**] for platelet count 51 in setting of hemoptysis. Renal consulted for initiation of hemodialysis as his shock was complicated by ATN with persistent renal failure, now on HD, has temporary left IJ dialysis line. Of note, the patient was also found to have enterobacter in his sputum so was treated with IV cefepime for presumed VAP. After discussion with family, patient was made do-not-reintubate. Patient was successfully extubated on [**2103-10-19**] and on nasal cannula but with tachypnea and tenuous respiratory status when moved. Patient also not tolerating any POs and extremely weak. We had conversation with patient's HCP on [**2103-10-20**] and decision was made to make patient CMO and to have goal to keep patient comfortable. All medications were discontinued except for IV morphine for comfort. The patient passed away comfortably at 5:40pm on [**2103-10-20**]. Medications on Admission: 1. Fluticasone-Salmeterol 250-50 mcg [**Hospital1 **] 2. Pantoprazole 40 mg Tablet daily 3. Fluoxetine 20 mg Capsule daily 4. Simvastatin 40 mg Tablet daily 5. Multivitamin 1 daily 6. Folic Acid 1 mg DAILY 7. Docusate Sodium 100 mg PO BID 8. Acetaminophen 325 mg Tablet1-2 Q6H PRN 9. Gabapentin 200mg daily 10. Aspirin 325 mg Tablet daily 11. Guaifenesin prn 12. Isosorbide Mononitrate 30 mg Tablet Sustained Release daily 13. Metoprolol Tartrate 50 mg Tablet PO Q8H 14. Lisinopril 10 mg Table PO DAILY 16. Prednisone 20 mg Tablet Sig: 1-3 Tablets PO DAILY (Daily) for 8 days: Please take 60 mg ([**10-5**], [**10-6**], [**10-7**], [**10-8**]), followed by 40 mg ([**10-9**], [**10-10**]), followed by 20 mg ([**10-11**], [**10-12**]). 15. Prednisone 5 mg Tablet Sig: 1-2 Tablets PO once a day for 4 days: Please take 10 mg ([**10-13**], [**10-14**]) followed by 5 mg ([**10-15**], [**10-16**]). 17. Albuterol 18. Hydrochlorothiazide 25 mg Tablet daily Discharge Medications: Patient expired Discharge Disposition: Expired Discharge Diagnosis: Patient expired Discharge Condition: Patient expired Discharge Instructions: Patient expired Followup Instructions: Patient expired

[ "785.51", "530.81", "786.3", "272.0", "428.0", "578.9", "V10.11", "425.4", "403.90", "584.9", "999.9", "286.6", "585.3", "428.22", "518.5", "410.71", "496", "E879.8", "112.0" ]

icd9cm

[ [ [] ] ]

[ "88.72", "38.93", "38.91", "96.04", "39.95", "96.72", "38.95" ]

icd9pcs

[ [ [] ] ]

7663, 7672

4376, 6618

311, 346

7731, 7748

4056, 4353

7812, 7830

2941, 3036

7623, 7640

7693, 7710

6644, 7600

7772, 7789

3051, 4037

260, 273

374, 1850

1872, 2641

2657, 2925

21,597

179,456

51013+51014

Discharge summary

report+report

Admission Date: [**2181-5-29**] Discharge Date: [**2181-6-5**] Date of Birth: [**2111-1-28**] Sex: M Service: HISTORY OF PRESENT ILLNESS: This is a 70-year-old white male with known coronary artery disease, status post myocardial infarction times three and status post percutaneous transluminal coronary angioplasty and stent in [**2179**]. He also has a history of non-insulin-dependent diabetes mellitus, hypertension, and hyperlipidemia. He presented to [**Hospital6 3622**] on [**5-25**] with intermittent chest pain and increased lower extremity edema. The patient ran out of Lasix two weeks prior to admission and had progressively worsening dyspnea on exertion with chest pressure. At [**Hospital6 33**], he was diuresed with Lasix, and his electrocardiogram revealed congestive heart failure. He had lateral ST depressions. He underwent cardiac catheterization which revealed 3-vessel coronary artery disease, and a reduced an ejection fraction, with an occluded stent. He had a normal left main. He ruled out for a myocardial infarction and presented to [**Hospital1 346**] for coronary artery bypass graft. PAST MEDICAL HISTORY: (Past medical history is significant for) 1. Status post myocardial infarction times three. 2. History of colon cancer; status post colectomy in [**2176**] with colostomy takedown. 3. History of non-insulin-dependent diabetes mellitus. 4. History of gastroesophageal reflux disease. 5. History of hyperlipidemia. 6. History of hypertension. 7. History of diverticulosis. 8. Status post appendectomy. 9. Status post percutaneous transluminal coronary angioplasty and stent in [**2179**]. 10. Status post right shoulder rotator cuff repair. MEDICATIONS ON ADMISSION: 1. Glipizide 10 mg p.o. once per day. 2. Glucophage 850 mg p.o. twice per day. 3. Zestril 40 mg p.o. once per day. 4. Isosorbide 60 mg p.o. once per day. 5. Lipitor 20 mg p.o. once per day. 6. Norvasc 10 mg p.o. once per day. 7. Atenolol 25 mg p.o. once per day. 8. Glucotrol 5 mg p.o. three times per day. 9. Iron. 10. Multivitamin one tablet p.o. every day. 11. Avandia 4 mg p.o. once per day. 12. Aspirin 81 mg p.o. once per day. ALLERGIES: The patient has no known drug allergies. SOCIAL HISTORY: He is married and lives with his wife. [**Name (NI) **] quit smoking in [**2169**] and does not drink alcohol. REVIEW OF SYSTEMS: His review of systems was unremarkable. PHYSICAL EXAMINATION ON PRESENTATION: On physical examination, he was well-developed and well-nourished white male in no apparent distress. Vital signs were stable. Afebrile. Head, eyes, ears, nose, and throat examination revealed normocephalic and atraumatic. Extraocular movements were intact. The oropharynx was benign. The neck was supple with full range of motion. No lymphadenopathy or thyromegaly. Carotids were 2+ and equal bilaterally without bruits. The lungs had bibasilar rales. Cardiovascular examination revealed a regular rate and rhythm. Normal first heart sounds and second heart sounds. No murmurs, rubs, or gallops. The abdomen was obese and soft with a large reducible ventral hernia. The abdomen was nontender with positive bowel sounds. Extremities had bilateral trace pedal edema. The pulses were 2+ and equal bilaterally throughout. Neurologic examination was nonfocal. PERTINENT LABORATORY VALUES ON DISCHARGE: His laboratories on discharge revealed hematocrit was 28.4, white blood cell count was 12,700, and platelets were 355. Sodium was 139, potassium was 4, chloride was 101, bicarbonate was 28, blood urea nitrogen was 26, creatinine was 1.2, and blood glucose was 167. HOSPITAL COURSE: On [**5-30**], he underwent a coronary artery bypass graft times four with a left internal mammary artery to the left anterior descending artery and reversed saphenous vein graft to obtuse marginal, first diagonal, and the posterior descending artery. Cross-clamp times was 71 minutes. Total bypass times was 83 minutes. He was transferred to the Cardiothoracic Surgery Recovery Unit on Neo-Synephrine and propofol in stable condition. He had a stable postoperative night and was extubated. He was transfused one unit of packed red blood cells. On postoperative day one, he had some bradycardia and was atrioventricularly paced. He also had decreased urine output requiring increasing Lasix doses and eventually required dopamine and responded to this very well. He had the chest tubes discontinued on postoperative day two. His dopamine was weaned off, and he had diuresis on his own. He continued to progress and was transferred to the floor. On postoperative day five, he had his wires discontinued that day. DISCHARGE DISPOSITION: On postoperative day six, he was discharged to rehabilitation in stable condition. MEDICATIONS ON DISCHARGE: 1. Plavix 75 mg p.o. three times per day. 2. Glipizide 5 mg p.o. four times per day. 3. Glucophage 850 mg p.o. twice per day. 4. Avandia 4 mg p.o. once per day. 5. Pravachol 20 mg p.o. once per day. 6. Multivitamin one tablet p.o. every day. 7. Prilosec 20 mg p.o. once per day. 8. Lasix 20 mg p.o. twice per day (times one week) then decrease to 10 mg p.o. once per day. 9. Potassium chloride 20 mEq p.o. twice per day (times one week) then discontinue. 10. Lopressor 25 mg p.o. twice per day. 11. Zestril 20 mg p.o. once per day. DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was to be followed by Dr. [**Last Name (STitle) **] in one to two weeks and by Dr. [**Last Name (STitle) **] in four weeks. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Last Name (NamePattern1) 11726**] MEDQUIST36 D: [**2181-6-5**] 12:59 T: [**2181-6-5**] 13:37 JOB#: [**Job Number **] Admission Date: [**2181-5-29**] Discharge Date: [**2181-6-5**] Date of Birth: [**2111-1-28**] Sex: M Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: This 70-year-old white male has known coronary artery disease and is status post myocardial infarction in [**2179**]. He also has a history of diabetes, hypertension and hyperlipidemia. He presented to [**Hospital6 105982**] emergency room on [**2181-5-25**] with intermittent chest pain and increased lower extremity edema. He reports that he ran out of Lasix two weeks prior to admission and had progressively worsening dyspnea on exertion with chest pressure. At [**Hospital3 **] he was diuresed with Lasix and an EKG revealed lateral ST depressions. He underwent cardiac catheterization which revealed an occluded stent in a dominant right coronary and a normal left main. He underwent cardiac catheterization at [**Hospital6 **] and was transferred for coronary artery bypass grafting. He did rule out for a myocardial infarction at that time. PAST MEDICAL HISTORY: 1. Status post myocardial infarction x 2. 2. History of colon carcinoma. 3. History of noninsulin dependent diabetes mellitus. 4. History of gastroesophageal reflux disease. 5. History of hyperlipidemia. 6. History of hypertension. 7. History of diverticulosis. 8. Status post appendectomy. 9. Status post colectomy in [**2176**] with colostomy takedown. 10. Status post percutaneous transluminal coronary angioplasty and stent in [**2179**]. 11. Status post right shoulder rotator cuff repair. MEDICATIONS ON ADMISSION: 1. Lasix 10 mg p.o. q.d. 2. Glucophage 850 mg p.o. b.i.d. 3. Zestril 40 mg p.o. q. day. 4. Isosorbide 60 mg p.o. q. day. 5. Lipitor 20 mg p.o. q. day. 6. Prilosec 20 mg p.o. q. day. 7. Norvasc 10 mg p.o. q. day. 8. Atenolol 25 mg p.o. q. day. 9. Glucotrol INCOMPLETE DICTATION. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Last Name (NamePattern1) 11726**] MEDQUIST36 D: [**2181-6-5**] 12:49 T: [**2181-6-5**] 13:25 JOB#: [**Job Number 105983**]

[ "411.1", "428.0", "412", "401.9", "250.00", "414.01", "V45.82", "272.0", "530.81" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

4744, 4828

4855, 5407

7449, 8015

3697, 4720

5441, 6007

3411, 3678

2415, 3396

6036, 6893

6916, 7422

2281, 2394

19,306

175,785

16797

Discharge summary

report

Admission Date: [**2188-5-19**] Discharge Date: [**2188-6-20**] Date of Birth: [**2166-7-20**] Sex: M Service: [**Doctor First Name 147**] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1**] Chief Complaint: Pt presents on [**2188-5-19**] for one-stage Ileopouch-anal anastomosis. Major Surgical or Invasive Procedure: 1. Ileopouch-Anal Anastomosis 2. Exploratory Laparotomy with diverting ileostomy 3. Primary Incision CLosure History of Present Illness: Pt has an established history of ulcerative colitis. He has been on chronic steroids, at a dose of 5mg/d upon admission. Due to recurrent symptoms, pt wishes for surgical therapy. Past Medical History: ulcerative colitis. No other significant medical history. Social History: 21yo Graduate student. Family History: Positive for IBD. Father died of colon CA at 43yo. Physical Exam: Thin, healthy-appearing young man. Abdominal exam reveals no masses, tenderness, ascites. Physical exam otherwise unremarkable. Brief Hospital Course: Patient had long, complicated hospital course. In overview, pt tolerated initial procedure well. On [**5-25**], pt began having copious bilious vomiting as well as copious bowel movements. Later that evening he became hypotensive and severely tachycardic, with declining mental status. Pt transferred to SICU, intubated, and taken to OR for exploratory laparotomy and diverting ileostomy; primary incision left open due to abdominal compartment syndrome. Pt continued to be hypotensive requiring pressure support for several days, with significant accompanying electrolyte abnormalities. Pt stabilized and normotensive in SICU, abdomen closed with open superficial layers on [**5-28**]. Pt remained in SICU until [**6-5**], transferred to floor. On floor, pt had an erratic course with fluctuations in fluid status and severe fluctuations in heart rate. In consultation with renal and endocrine services, electrolyte and fluid status issues were resolved, and patient discharged home with midline venous catheter for prn fluid support, and appropriate VNA services. In greater depth, consider hospital course by system: Neuro: Pt admitted in excellent neuro condition, continued until [**5-25**] during suspected hypoadrenal crisis when pt experienced significant decline in mental status. Pt underwent appropriate rapid sequence induction for intubation in SICU, and due to his open abdomen was maintained on propofol and fentanyl until [**5-31**]. When these drips were stopped, pt recovered normal mental status and was noted to have no neurologic deficits throughout the rest of his hospital course. Cardiovascular: Unremarkable until [**5-25**], when as noted pt became hypotensive to 80s/40s and tachycardic to 180s. This continued despite aggressive fluid resuscitation. Upon transfer to SICU, patient started on levophed and pitressor to maintain blood pressures. Gradually weaned off thsee drips with appropriate recovery of blood pressure, pt essentially normotensive by [**5-31**]. Upon transfer to floor on [**6-5**], pt continued to have erratic HR. Although pt denied any orthostatic symptoms, he would have HRs of 80-90 at rest, and 160-170 upon standing or walking. BPs remained on the low end of normal and were stable. As patient's fluid status gradually stabilized, his HR also stabilized, with modest changes in HR most likely due to deconditioning after a [**Hospital 47424**] hospital stay. Respiratory: Pt on vent while in SICU. Pt extubated [**5-29**]. Excellent use of incentive spirometer. On [**6-2**] pt was found to have left pnuemothorax, and a chest tube was placed. Appropriate suction therapy, wound healed and sealed and pneumothorax resolved by [**6-17**]. Endocrine: A hypoadrenal crisis is believed to be the central insult giving rise to pt's rapid decompensation and subsequent arduous course. On night of [**5-25**] was administered stress dose steroids in response to tachycardia unresponsive to fluid resuscitation. In SICU pt noted to have bizarre electrolyte abnormalities, including sodiums up to 160, with concomitant concentrated urine. Electrolytes stabilized in SICU, and upon transfer to floor pt remained eunatremic despite significant fluid shifts and fluctuating urine osmolarity. Pt tried on Florinef to assist mineralocorticoid function, but this was of minimal help. Renal: Initially no renal issues were suspected. However, late in hospital course as it appeared that pt was unable to concentrate urine despite net fluid loss, a more intensive renal workup was pursued. Diagnosis of DI was considered and rejected in the face of concentrated urine under light fluid load. Also considered was a diagnosis of solute diuresis, powered by excess urea creation from steroid therapy and increased protein intake. 24hr-urine studies argued against this, as urine osmolarity was low. Renal team decided that, under stress of past month, pt had simply washed out his interstitial gradient and in the presence of polydipsia would be unable to appropriately concentrate urine. As pt is otherwise quite healthy, they are quite confident that he will recover this gradient through liberal administration of salt. ID: Although pt never had a confirmed infectious process contributing to his condition, he was started empirically on IV Levo/Flagyl on [**5-25**]. He subsequently developed oral thrush and Fluconazole was added to his regimen. Levo/Flagyl discontinued on [**6-5**], Fluconazole discontinued on [**6-8**]. FEN: After [**5-25**], pt's electrolytes fluctuated considerably, with sodiums in the 160s while in the SICU. He had a complex diuresis with confusing urine osmolarities, further complicated by concomitant administration of pitressor. Pt nutrition status while on the floor, although supplemented early in his hospital course with TPN, continued to be poor, and he lost a significant amount of weight. As he began tolerating more po intake, the pt's diet was supplemented with Boost. Although there was concern from Renal that excess protein may be driving a solute diuresis, the opinion of the surgical team was that in the setting of a large healing wound, a new ostomy, and general post-operative condition, the pt needed significant protein intake and as a compromise he was continued on a moderate protein diet. Of note, pt was discharged home with a Midline for prn IV fluids until his renal issues (as discussed above) could be resolved. GI: Pt with total colectomy and ileoanal pouch for UC. Pouch output finally begun on [**5-25**], however the triumph of this was overshadowed by darker events that evening. Due to abdominal compartment syndrome of 6.27, pt was given diverting ileostomy and open abdomen to assist recovery. [**Name (NI) 47425**] pt was found to be in a profound ileus with copious dark fluid in the small intestine, though the anastomosis remained quite secure. Although abdomen was closed with resolution of intra-abdominal pressure, ileostomy takedown will not be for a while. On the floor, pt gradually began having good flow from his ostomy, and in fact output became so high he was started on significant doses of loperamide, as his ostomy output was felt to be contributing to his general hypovolemia. Medications on Admission: 6-Mercaptopurine Prednisone 5mg qd Discharge Medications: 1. Loperamide HCl 2 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) as needed for diarrhea for 30 days. Disp:*120 Capsule(s)* Refills:*2* 2. Sodium Chloride 1 g Tablet Sig: One (1) Tablet PO TID (3 times a day) for 30 days. Disp:*90 Tablet(s)* Refills:*2* 3. Florinef Acetate 0.1 mg Tablet Sig: Three (3) Tablet PO once a day: Taper as per endocrine doctor's recommendation. Disp:*90 Tablet(s)* Refills:*2* 4. Prednisone 2.5 mg Tablet Sig: Five (5) Tablet PO every twelve (12) hours for 4 weeks: You are one a steroid TAPER. Take 5 tablets in the morning and evening. Do this for 4 days. Then take 5 tablets in the morning and 4 in the evening for 4 days. Then take 4 and 4 for 4 days. Then take 4 and 3 for 4 days. Then take 3 and 3 for 4 days. Then take 3 and 2 for 4 days. Then take 2 and 2 (10mg total per day), and stay on this dose until you see the Endocrine doctor (Dr [**Last Name (STitle) **] to assess how best to continue. You will be in regular contact with Dr [**Name (NI) **] throughout this time, and he may change your dosages. In that case, follow his instructions exactly, and disregard these. Disp:*200 Tablet(s)* Refills:*2* 5. Prednisone 1 mg Tablet Sig: One (1) Tablet PO once a day: DO NOT TAKE THESE UNLESS SPECIFICALLY INSTRUCTED BY DR [**Last Name (STitle) **] OR DR [**Last Name (STitle) 13645**]! These are being supplied to you so that, in case they change your steroid taper, you will have smaller-dosage pills available. Disp:*150 Tablet(s)* Refills:*2* 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for chest pain. Disp:*15 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: Ulcerative Colitis Dehydration Hypoadrenal crisis Renal Disorder Not Otherwise Specified, Polyuria Discharge Condition: Good. Discharge Instructions: No heavy lifting for 6 weeks. You may eat and shower as normal. Please try to drink plenty of fluids, as you are at increased risk for dehydration. Follow instructions on care for your Mid line, your osotmy, and your wound care. Please follow up with Renal service per their instructions, and follow up with Dr [**Last Name (STitle) **] in 2 weeks. Pay attention to signs of dehydration. If you feel unusually weak, tired, or dizzy upon standing, you may need supplemental fluids. If you notice your heart rate climbing, this may also be a sign you need supplemental fluids. Hot weather and significant sun exposure can cause you to be dehydrated more quickly, so be sure to rehydrate often when outside. Followup Instructions: Pt to follow-up with Dr [**Last Name (STitle) **] in 2 weeks. Please call Dr[**Name (NI) 47426**] office [**Telephone/Fax (1) 1803**] to set up an appt with her. Please tell the receptionist she specifically wanted to see you when your prednisone dose was 10mg/day. Please call the [**Hospital 2793**] Clinic at [**Telephone/Fax (1) 60**] to set up an appt with Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1860**]. She will see you in conjunction with Dr [**Last Name (STitle) **].

[ "789.5", "512.1", "997.4", "556.0", "560.1", "E878.8", "276.0", "255.4", "112.0" ]

icd9cm

[ [ [] ] ]

[ "89.61", "99.07", "96.71", "96.04", "99.15", "54.25", "46.21", "45.8", "96.07", "38.91", "89.64", "99.04", "34.04", "38.93" ]

icd9pcs

[ [ [] ] ]

9042, 9125

1081, 2175

405, 516

9267, 9274

10028, 10541

862, 914

7375, 9019

9146, 9246

7316, 7352

9298, 10005

2203, 7290

929, 1058

292, 367

544, 725

747, 806

822, 846

77,947

192,699

35788

Discharge summary

report

Admission Date: [**2115-4-24**] Discharge Date: [**2115-5-4**] Date of Birth: [**2049-9-11**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 613**] Chief Complaint: Reason for MICU Transfer: Hypotension Major Surgical or Invasive Procedure: [**2115-4-29**] Temporary HD line placement [**2115-5-3**] Permanent HD tunneled line placement History of Present Illness: 65M with history of DM, CPOD on 2L home O2, and CKD (recently started on HD 2.5 wks ago), and currently at rehab after admission for cellultis, worsening renal impairment and who presents now from rehab with subjective fevers for the last [**1-7**] days, malaise, and hypotension with SBP to 80s. Baseline SBP in 110s, however earlier today was noted to be in 80s per rehab staff. Per report, patient was mentating at baseline at the time. ? of fevers per EMS but none documented. Was transferred to ED for further evaluation. On arrival to the ED, 98.8F, 98, RR: 25,O2Sat: 94, O2Flow: 3lnc. SBP was in mid-80s with MAP 55. He received 2 500cc fluid boluses, with improvement in MAP to 65. Has now received a total of 1.5L NS. Temp 98.8. His labs were notable for leukocytosis with WBC 11.7 with 86% neutr and 11% bands. K was 5.8; EKG did not show any acute changes. . Patient is not anuric, and UA showed few bacteria, 8 WBCs, 2epi, small leuk, neg nitr. CXR did not show clear evidence of PNA, but given concern for possible HCAP patient was given vancomycin/cefepime. ED also also noted redness at line site. Was guiac negative. ED spoke with renal, want to hold off on dialysis. Gave 40IV lasix for K. . On arrival to the ICU, patient VS: [**Age over 90 **]F, 102 107/63/23/98%on 2L. Pt denied any dyspnea or chest pain or cough. Denied recent dysuria states does make some urine. Only notes he had some redness and itchiness at line insertion site. He does note has had itchiness throughout his body since starting dialysis 2 weeks ago, no other complaints. Patient notes the redness at his lower extremities from his previous admissions has improved. . 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. Past Medical History: -diabetes mellitus type II -HTN -dCHF/right heart failure (EF>55%), -s/p open chest surgery for "dot" on lung at [**Doctor Last Name 1263**] -rheumatoid arthritis -COPD on 2L home O2 -Depression -Bipolar Disorder -Schizoaffective disorder -Glaucoma -stage 5 chronic kidney disease -peripheral vascular disease s/p RLE bypass -history of pulmonary embolism on Coumadin -Obesity hypoventilation syndrome -OSA on bipap/cpap -chronically elevated left hemidiaphragm Social History: Lives in [**Hospital3 2558**], Uses electric wheelchair at baseline. -Tobacco history: smoked 1PPD for 43 years quit several years ago -ETOH: quit drinking 4-5 years ago, used to drink socially -Illicit drugs: Denies Family History: Mother: [**Name (NI) 3730**] (unknown type) Father: [**Name (NI) 3495**] disease Physical Exam: Admission Physical Exam: Vitals: 98F, 102 107/63/23/98%on 2L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Rales in bilateral lung bases L>R. Chest: R sided tunneled HD line, erythematous, hot to touch, no drainage CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis or edema. Lowever extremities with darkened skin, not hot touch, no redness. Dry flaxy skin throughout body. . Discharge Physical Exam: VS Tm/c 98.7 111/60 78 95%4L General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Lungs: Clear to auscultation bilaterally. CV: Regular rate and rhythm though distant heart sounds, normal S1 + S2, no murmurs appreciated Abdomen: soft, non-distended, non-tender, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: Warm, chronic discoloration bilaterally, 1+ pulses, no appreciable edema. Left lateral malleolus with Stage II ulcer. Skin: Chronic hyperpigmentation of BLEs Pertinent Results: ADMISSION LABS: [**2115-4-24**] 11:40AM BLOOD WBC-11.7*# RBC-3.24* Hgb-8.9* Hct-30.6* MCV-95 MCH-27.6 MCHC-29.2* RDW-16.2* Plt Ct-151 [**2115-4-24**] 11:40AM BLOOD Neuts-86* Bands-11* Lymphs-3* Monos-0 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 NRBC-2* [**2115-4-24**] 11:40AM BLOOD PT-42.1* PTT-48.6* INR(PT)-4.1* [**2115-4-24**] 11:40AM BLOOD Glucose-99 UreaN-49* Creat-6.0*# Na-137 K-5.8* Cl-96 HCO3-25 AnGap-22* [**2115-4-24**] 11:40AM BLOOD ALT-10 AST-20 AlkPhos-74 TotBili-0.1 [**2115-4-24**] 11:40AM BLOOD CK-MB-2 proBNP-5344* [**2115-4-24**] 11:40AM BLOOD cTropnT-0.04* [**2115-4-25**] 04:29AM BLOOD CK-MB-3 [**2115-4-24**] 11:40AM BLOOD Albumin-3.4* Calcium-8.8 Phos-5.7*# Mg-2.0 [**2115-4-25**] 06:05PM BLOOD Cortsol-20.2* [**2115-4-24**] 11:50AM BLOOD Lactate-2.5* . RELEVANT LABS: [**2115-4-27**] 04:44AM BLOOD Lactate-0.8 [**2115-5-2**] 04:24AM BLOOD Valproa-25* . DISCHARGE LABS: [**2115-5-3**] 02:41AM BLOOD WBC-5.7 RBC-3.13* Hgb-8.8* Hct-30.4* MCV-97 MCH-28.2 MCHC-29.1* RDW-16.6* Plt Ct-289 [**2115-5-3**] 02:41AM BLOOD PT-16.1* PTT-39.6* INR(PT)-1.5* [**2115-5-3**] 02:41AM BLOOD Glucose-80 UreaN-57* Creat-4.8*# Na-138 K-4.9 Cl-98 HCO3-29 AnGap-16 [**2115-5-3**] 02:41AM BLOOD Calcium-9.2 Phos-6.4*# Mg-2.2 [**2115-5-3**] 06:06AM BLOOD Vanco-17.7 . . MICROBIOLOGY: [**2115-4-24**] 11:40 am BLOOD CULTURES x2: **FINAL REPORT [**2115-4-28**]** Blood Culture, Routine (Final [**2115-4-28**]): STAPH AUREUS COAG +. FINAL SENSITIVITIES. 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. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. STAPH AUREUS COAG +. 2ND MORPHOLOGY. Consultations with ID are recommended for all blood cultures positive for Staphylococcus aureus, yeast or other fungi. 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. FINAL SENSITIVITIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | STAPH AUREUS COAG + | | CLINDAMYCIN-----------<=0.25 S <=0.25 S ERYTHROMYCIN---------- =>8 R =>8 R GENTAMICIN------------ <=0.5 S <=0.5 S LEVOFLOXACIN---------- 4 R 4 R OXACILLIN------------- =>4 R =>4 R RIFAMPIN-------------- <=0.5 S <=0.5 S TETRACYCLINE---------- <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S <=0.5 S VANCOMYCIN------------ <=0.5 S <=0.5 S . [**2115-4-24**] 3:58 pm CATHETER TIP-IV Source: tunneled HD line. **FINAL REPORT [**2115-4-26**]** WOUND CULTURE (Final [**2115-4-26**]): STAPH AUREUS COAG +. >15 colonies. 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-----------<=0.25 S ERYTHROMYCIN---------- =>8 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 4 R OXACILLIN------------- =>4 R RIFAMPIN-------------- <=0.5 S TETRACYCLINE---------- <=1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ 1 S . [**2115-4-24**] 11:30 am URINE CHM S# [**Serial Number 81393**]B UCU ADDED [**4-24**]. **FINAL REPORT [**2115-4-26**]** URINE CULTURE (Final [**2115-4-26**]): Culture workup discontinued. Further incubation showed contamination with mixed fecal flora. Clinical significance of isolate(s) uncertain. Interpret with caution. GRAM NEGATIVE ROD(S). 10,000-100,000 ORGANISMS/ML.. . [**2115-4-25**] Blood culture: no growth [**2115-4-26**] Blood culture: no growth [**2115-4-27**] Blood culture: no growth [**2115-4-27**] Urine culture: no growth [**2115-5-1**] Blood culture: no growth . Reports: . [**2115-4-24**] ECG: Sinus rhythm. Right bundle-branch block. [**2115-4-24**] ECG: Sinus rhythm. Right bundle-branch block. Compared to the previous tracing of [**2115-4-6**] the heart rate is increased. There are no other significant diagnostic changes. . [**2115-4-24**] CXR: Frontal and lateral views of the chest were obtained. Right-sided central venous hemodialysis catheter is again seen, terminating in the right atrium. Persistent elevation of the left hemidiaphragm is again seen with subsequent shift of the mediastinum/cardiac silhouette to the right. The cardiac silhouette may be enlarged although the left aspect is not well assessed due to the elevated left hemidiaphragm. No pleural effusion or pneumothorax is seen. Patient is status post median sternotomy. . [**2115-4-26**] TTE: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The aortic valve leaflets are mildly thickened (?#). The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Moderate tricuspid regurgitation with thickened septal leaflet. If the clinical suspicion for endocarditis is moderate or high, a TEE is suggested to better define the valves. Compared with the prior study (images reviewed) of [**2113-8-23**], the septal tricuspid leaflet thickening and tricuspid regurgitation is increased. However, given the very poor image quality, these findings are less definitive. . [**2115-4-24**] CHEST (PA & LAT): Right-sided central venous hemodialysis catheter is again seen, terminating in the right atrium. Persistent elevation of the left hemidiaphragm is again seen with subsequent shift of the mediastinum/cardiac silhouette to the right. The cardiac silhouette may be enlarged although the left aspect is not well assessed due to the elevated left hemidiaphragm. No pleural effusion or pneumothorax is seen. Patient is status post median sternotomy. . [**2115-4-25**] CHEST (PORTABLE AP): In comparison to the prior radiograph, there has been little significant overall change. Elevation of the left hemidiaphragm is once again seen. Cardiac silhouette is difficult to evaluate given the hemidiaphragm elevation, however, does appear to be enlarged. No focal opacities are noted concerning for an infectious process. Patient is status post median sternotomy. Right-sided hemodialysis catheter has been removed. . [**2115-4-26**] TTE: The left atrium is normal in size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). The right ventricular cavity is mildly dilated with mild global free wall hypokinesis. The aortic valve leaflets are mildly thickened (?#). The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Moderate tricuspid regurgitation with thickened septal leaflet. If the clinical suspicion for endocarditis is moderate or high, a TEE is suggested to better define the valves. Compared with the prior study (images reviewed) of [**2113-8-23**], the septal tricuspid leaflet thickening and tricuspid regurgitation is increased. However, given the very poor image quality, these findings are less definitive. . [**2115-5-3**] Tunneled HD Line Placement: Successful uncomplicated placement of a 15.5F 27-cm tip-to-cuff tunneled hemodialysis with tip in the right atrium. The line is ready to use. Right sided temporary HD catheter was removed. Brief Hospital Course: 65 y/o male with DM II, COPD, and CKD stage V, started on hemodialysis approximately 2.5 weeks prior to admission, who presented with sepsis due to MRSA bacteremia/ HD catheter infection. . . ACTIVE ISSUES # Sepsis due to MRSA Bacteremia: He presented without documented fevers but with leukocytosis with left shift and bandemia > 10%, HR>90, RR>20 and hypotension. UA revealed 8 WBCs but was otherwise unremarkable. CXR revealed a chronically elevated left hemidiaphragm but no clear infiltrate. Given recent HD line placement there was concern for sepsis from bacteremia. He received Vancomycin and Cefepime in the ED for possible HCAP. Although a urinary source was considered less likely, he was changed to Vancomycin and Meropenem (Meropenem due to prior UTI sensitivities). Blood cultures ultimately revealed MRSA bacteremia. Urine culture eventually revealed 10K-100K GNRs but was contaminated so Meropenem was discontinued. ID was consulted early in his hospitalization and recommended HD line removal with a line holiday. IR removed the HD line the day following admission and he was given approximately 48 hours without a line. Catheter tip culture also grew MRSA. A TTE was unremarkable for endocarditis. TEE for further evaluation was not pursued, as the decision was made to treat with vancomycin IV for 6 weeks empirically. The patient's blood pressure slowly trended down from systolics of 120s to 80s. A temporary femoral line was placed into the right groin for better access. He received several 250-500 cc boluses but was never required vasopressors. His blood pressure then slowly improved at which time he was transferred to the floor. On the medicine floor, the patient continued vancomycin dosed with HD. He was hemodynamically stable and afebrile. Femoral line was removed and a RIJ temporary dialysis line was placed on [**4-29**], while awaiting permanent line, which was placed on [**5-3**]. The patient tolerated these procedures well. The patient will need to continue vancomycin IV for 6 weeks, dosed with dialysis. He should have weekly labs drawn and sent to the [**Hospital 18**] [**Hospital **] clinic. . # CKD stage V: Patient was started on dialysis approximately 2.5 weeks prior to presentation. Dialysis was not performed during his ICU stay due to removal of the HD line and tenuous blood pressures. He initially required fluid boluses for hypotension but his fluid balance was subsequently managed with Lasix boluses. He also received several doses of Kayexalate (in addition to Lasix) for hyperkalemia without EKG changes. Renal followed him throughout his hospitalization. A temporary HD line was placed on [**2115-4-29**] as noted above. Patient required several units of FFP and doses of vitamin K to reverse INR enough for placement of a permanent HD catheter, which was done on [**2115-5-3**]. . # Anemia: Hematocrit was 30.6 on admission, down from 33.5 on [**2115-4-12**]. There were no acute signs of bleeding and he was guaiac negative. He ultimately received 4 units pRBCs for repeated hematocrits of high 20s-30, but also for hemodynamic support to avoid using crystalloid fluids exclusively. His hematocrit remained stable for the rest of his admission. . . CHRONIC ISSUES: # COPD on 2L home O2: Patient presented on 2L of oxygen with saturations in the high 90s. His oxygen requirement increased to 4L during his ICU stay and was attributed to his volume status. He had several episodes of respiratory distress that resolved with non-invasive positive pressure ventilation and was breathing comfortably throughout most of his ICU stay and on the floor. He continued to receive his home Fluticasone, Albuterol and Tiotropium throughout his stay. . # Bipolar disorder/Schizoaffective disorder: Patient's affect was stable during this admission, and he had no signs or symptoms of psychosis. Efforts were made to obtain more information about his diagnoses, as it is perplexing to have both an affective and psychotic disorder diagnosed. On evaluation by our inpatient Psychiatry team, they recommended no changes to his complex psychiatric medication regimen, since he is so stable at this time. He continued his home divalproex, oxcarbazepine, and risperdone. . # Diabetes mellitus II: He was managed on a Humalog ISS during his ICU stay. He was continued on this on the floor, but required no insulin. . # HTN/dCHF/right heart failure (EF>55%): His Metoprolol and Aspirin 81 mg were continued initially. Metoprolol was held for hypotension but was restarted prior to floor transfer. . # Rheumatoid arthritis: Continued hydroxychroloquine. . # Depression/Bipolar Disorder/Schizoaffective disorder: Continued divalproex, oxcarbasezpine, risperdone . # Pulmonary Embolism on Coumadin: He presented with INR of 4.0 and Coumadin was held. He recieved 4 units of FFP for femoral line placement in the unit. For permanent HD line placement, desired INR was less than 1.5. The patient received several units of FFP and doses of vitamin K while on the floor prior to this procedure. On discharge his latest INR is 1.1, he will be continued on home regimen of 3mg daily, with INR to be checked by rehab and titrated for INR goal of [**2-8**]. . # Obesity hypoventilation syndrome and OSA: He was continued on BiPap throughout his ICU stay and on the floor at night, and intermittently as needed for respiratory distress. . . TRANSITIONAL ISSUES: # Vancomycin IV to continue for 6 weeks, dosed with HD. Patient should have labs checked weekly while on this antibiotic: CBC with differential, BUN/Cr, AST/ALT, Alk Phos, Total bili, ESR/CRP, vancomycin level. Fax results to ([**Telephone/Fax (1) 4591**]. Contact ID RN's at ([**Telephone/Fax (1) 21403**] with any questions regarding antibiotics. # Would consider further Psychiatric evaluation, and adjustment of medications to simplify regimen. # CODE: Full Code Medications on Admission: 1. aspirin 81 mg Tablet PO DAILY (Daily). 2. calcitriol 0.25 mcg Capsule Sig: PO DAILY 3. divalproex 250 mg Tablet, Delayed Release (E.C.) PO QAM 4. divalproex 500 mg Tablet, Delayed Release (E.C.) PO QPM 5. docusate sodium 100 mg Capsule [**Hospital1 **] 6. metoprolol tartrate 25 mg Tablet PO BID 7. cholecalciferol (vitamin D3) 1,000 unit PO DAILY (Daily). 8. cholecalciferol (vitamin D3) 400 unit once a day. 9. calcium carbonate 500 mg calcium (1,250 mg) PO once a day. 10. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 11. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation twice a day as needed for shortness of breath or wheezing. 12. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation once a day. 13. hydroxychloroquine 400 mg PO BID 14. insulin lispro 100 unit/mL Solution Sig: Sliding scale units Subcutaneous three times a day. 15. risperidone 2.5 mg Tablet PO HS (at bedtime). 16. tamsulosin 0.4 mg Capsule PO HS (at bedtime). 17. oxcarbazepine 300 mg [**Hospital1 **] 18. sevelamer carbonate 1600 mg Tablet Sig: PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 19. Eucerin Cream Sig: One (1) application Topical four times a day as needed for itching. 20. camphor-menthol [**11-16**] % Cream Sig: Topical twice a day as needed for itching. 21. warfarin 3 mg 4PM daily. Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QAM (once a day (in the morning)). 4. divalproex 500 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO QPM (once a day (in the evening)). 5. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Vitamin D3 1,000 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Vitamin D3 400 unit Tablet Sig: One (1) Tablet PO once a day. 9. calcium carbonate 500 mg calcium (1,250 mg) Capsule Sig: One (1) Capsule PO once a day. 10. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 11. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 12. hydroxychloroquine 200 mg Tablet Sig: Two (2) Tablet PO twice a day. 13. insulin lispro 100 unit/mL Solution Sig: One (1) unit Subcutaneous four times a day: with meals and before bed, as directed by sliding scale. 14. risperidone 1 mg Tablet Sig: 2.5 Tablets PO HS (at bedtime). 15. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO HS (at bedtime). 16. oxcarbazepine 300 mg Tablet Sig: One (1) Tablet PO twice a day. 17. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO three times a day: with meals. 18. camphor-menthol 0.5-0.5 % Lotion Sig: One (1) Appl Topical TID (3 times a day) as needed for itching. 19. white petrolatum-mineral oil Cream Sig: One (1) Appl Topical QID (4 times a day) as needed for itching. 20. vancomycin in D5W 1 gram/200 mL Piggyback Sig: One (1) g Intravenous HD PROTOCOL (HD Protochol): day 1 = [**2115-4-24**] , for six weeks. 21. warfarin 3 mg Tablet Sig: One (1) Tablet PO once a day. 22. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for SOB/ wheezing. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Primary diagnosis: MRSA septicemia from HD catheter . Secondary diagnoses: -chronic kidney disease stage V, on HD -COPD on home O2 -OSA on CPAP -HTN -dCHF/right heart failure (EF>55%) -rheumatoid arthritis -Depression -Bipolar Disorder -Schizoaffective disorder -Glaucoma -peripheral vascular disease s/p RLE bypass -history of pulmonary embolism on Coumadin 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 4587**], It was a pleasure to participate in your care here at [**Hospital1 1535**]! You were admitted with low blood pressure, and you were found to have a bacterial infection in your blood. We think this infection was caused by your dialysis catheter. This catheter was removed. You were treated with antibiotics for your infection. After you improved, yoru dialysis catheter was replaced. You will continue antibiotics (Vancomycin) for six weeks for continued treatment. Please note, the following changes were made to your medications: - START vancomycin 1 g IV with hemodialysis through [**6-6**] (for total duration of 6 weeks) Continue all of your other medications as you had prior to this hospitalization Please weigh yourself every morning, and call your doctor if your weight goes up more than three pounds. You will have weekly labs checked at [**Hospital3 2558**]. Results should be faxed to the [**Hospital1 **] Infectious Disease Clinic at ([**Telephone/Fax (1) 4591**]. If there are any questions regarding your vancomycin, please call ([**Telephone/Fax (1) 21403**] to speak with an Infectious Disease Registered Nurse. Wishing you all the best! Followup Instructions: Department: INFECTIOUS DISEASE When: TUESDAY [**2115-5-14**] at 9:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4593**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: INFECTIOUS DISEASE When: TUESDAY [**2115-5-14**] at 11:45 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 456**], MD [**Telephone/Fax (1) 457**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: TRANSPLANT CENTER When: THURSDAY [**2115-5-16**] at 1:30 PM With: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

[ "276.7", "403.91", "V15.82", "295.70", "E879.7", "995.91", "428.32", "285.21", "250.00", "428.0", "714.0", "327.23", "707.22", "585.6", "996.62", "V58.61", "296.50", "V12.55", "707.06", "278.03", "038.12" ]

icd9cm

[ [ [] ] ]

[ "39.95", "38.95" ]

icd9pcs

[ [ [] ] ]

22770, 22840

13311, 16522

340, 438

23243, 23243

4653, 4653

24638, 25760

3298, 3381

20621, 22747

22861, 22861

19196, 20598

23419, 24615

5542, 13288

3421, 4071

22936, 23222

18702, 19170

2146, 2562

263, 302

466, 2127

4669, 5526

22880, 22915

23258, 23395

16538, 18681

2584, 3048

3064, 3282

4096, 4634

14,864

175,255

22943

Discharge summary

report

Admission Date: [**2168-12-24**] Discharge Date: [**2168-12-30**] Date of Birth: [**2126-6-18**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2698**] Chief Complaint: dizzyness, presyncope, chest pain Major Surgical or Invasive Procedure: cardiac catheterization with stent (cypher) to RCA and PDA History of Present Illness: 42 yo man with pmh sig for hypertension on four antihypertensive medications, had three days of intermittent [**4-18**] left sided chest "pressure" associated with dizziness all occurring at rest but dizziness worse with standing. After three days of symptoms pt went to PCP's office, while there felt "so dizziy (he) might pass out" and was taken to the OSH ED. He noted that he discovered that he had been taking double his Tiazac dose for the past two days mistakenly. In OSH ED found to have bp 90s/60s, inferior STEMI with first degree AV block, was started on Heparin and Integrilin, as was found to be asymptomatic at time. As he also had an increased creatinine, he was admitted with plans to transfer to [**Hospital1 18**] at later date for cardiac catheterization. However, upon becoming symptomatic with AV dissociation he was immediately transferred to [**Hospital1 18**] for catheterization. At [**Hospital1 18**] he was found to have disease of the RCA and PDA, received cypher stents at each site, was also found to be in third degree AV block and was transferred to the CCU. Past Medical History: Hepatitis C Hypertension Social History: Lives with wife and daughter [**Name (NI) 1403**] for moving company Smokes marijuana Lat used cocaine three weeks ago Family History: CVA in parents Physical Exam: BP 100/70 HR 60s RR 14 O2 97% RA No acute distress No JVD Cardiac exam with regular rate and rhythm, nl s1s2, no mrg Lungs clear Abdomen soft nontender nondistended nabs Extremity wwp, co cce Groin site cdi Pertinent Results: [**2168-12-24**] 08:26PM PT-13.7* PTT-32.1 INR(PT)-1.2 [**2168-12-24**] 08:26PM PLT COUNT-344 [**2168-12-24**] 08:26PM WBC-13.8* RBC-4.47* HGB-12.5* HCT-37.8* MCV-85 MCH-27.9 MCHC-33.0 RDW-13.8 [**2168-12-24**] 08:26PM TRIGLYCER-141 HDL CHOL-33 CHOL/HDL-5.1 LDL(CALC)-108 [**2168-12-24**] 08:26PM CALCIUM-9.0 PHOSPHATE-2.4* MAGNESIUM-1.8 CHOLEST-169 [**2168-12-24**] 08:26PM CK-MB-8 cTropnT-1.46* [**2168-12-24**] 08:26PM ALT(SGPT)-33 AST(SGOT)-42* CK(CPK)-214* ALK PHOS-78 AMYLASE-114* TOT BILI-0.5 [**2168-12-24**] 08:26PM LIPASE-26 [**2168-12-24**] 08:26PM GLUCOSE-143* UREA N-17 CREAT-1.1 SODIUM-136 POTASSIUM-4.2 CHLORIDE-98 TOTAL CO2-32* ANION GAP-10 . . Cardiac Catheterization: PROCEDURE: Left Heart Catheterization: was performed by percutaneous entry of the right femoral artery, using a 6 French left [**Last Name (un) 2699**] catheter, advanced to the ascending aorta through a 6 French introducing sheath. Coronary Angiography: was performed in multiple projections using a 6 French JL4 and a 6 French JR4 guiding catheter, with manual contrast injections. Percutaneous coronary revascularization was performed using placement of drug-eluting stent(s). Conscious Sedation: was provided with appropriate monitoring performed by a member of the nursing staff. HEMODYNAMICS RESULTS BODY SURFACE AREA: m2 HEMOGLOBIN: gms % ENTRY **PRESSURES LEFT VENTRICLE {s/ed} 112/20 AORTA {s/d/m} 112/81/96 **CARDIAC OUTPUT HEART RATE {beats/min} 65 RHYTHM JUNCTIONAL **ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM **RIGHT CORONARY 1) PROXIMAL RCA NORMAL 2) MID RCA DISCRETE 100 **ARTERIOGRAPHY RESULTS MORPHOLOGY % STENOSIS COLLAT. FROM **LEFT CORONARY 5) LEFT MAIN NORMAL 6) PROXIMAL LAD NORMAL 6A) SEPTAL-1 NORMAL 7) MID-LAD DISCRETE 40 8) DISTAL LAD NORMAL 9) DIAGONAL-1 NORMAL 12) PROXIMAL CX NORMAL 13) MID CX DISCRETE 30 13A) DISTAL CX NORMAL 14) OBTUSE MARGINAL-1 NORMAL 15) OBTUSE MARGINAL-2 NORMAL **PTCA RESULTS RCA PDA **BASELINE STENOSIS PRE-PTCA 100 100 **TECHNIQUE PTCA SEQUENCE 1 2 GUIDING CATH 6FJR4 6FJR4 GUIDEWIRES CPTXS CPTXS INITIAL BALLOON (mm) 2.0 2.0 FINAL BALLOON (mm) 2.5 2.5 # INFLATIONS 4 5 MAX PRESSURE (PSI) 270 210 **RESULT STENOSIS POST-PTCA 0 0 SUCCESS? (Y/N) Y Y PTCA COMMENTS: Initial angiography revealed a total occlusion of the mid RCA at the origin of what was felt to be a bifurcaiton point of the mid RCA and an acute marginal branch. We planned to treat the RCA with thrombectomy and stenting with rescue of the marginal branch if necessary. Eptifibatide was continued. A 6 French JR4 guiding catheter provided adequate support for the intervention. A ChoICE PT XS wire was easily directed pst the occlusion and into what was felt to be the distal RCA. A 2.0 x 20 mm Maverick balloon was uded to dotter through the occlusion and then dilate the stenotic area using 2 inflations of 8 ATM just distal to what was felt to be the acute marginal branch. This provided some restoration of flow which revealed significant thrombus. Thrombectomy was performed with a PercuSurg Export catheter. A 2.5 x 28 mm Cyoher DES was then deployed across the stenosis with good result. We then turned our attention to what we thoight was an acute marginal. After crossing into the vessel with the ChoICE PT xs wire, it became apparent that this acute marginal branch was really a sizeable PDA. After dottering with the 2.0 x 20 mm balloon and then dilating a significant proximal stenosis with inflaitons of 12, 12, 10, and 10 ATM. A 2.5 x 28 mm Cy[her DES was deployed across the stenosis at 14 ATM. Final angioraphy revealed no residual stenosis, no apparent dissection, and normal flow. The patient left the lab free of angina and in stable condition. TECHNICAL FACTORS: Total time (Lidocaine to test complete) = 41 minutes. Arterial time = 39 minutes. Fluoro time = 11.6 minutes. Contrast: Non-ionic low osmolar (isovue, optiray...), vol 190 ml Premedications: ASA 325 mg P.O. Clopidogrel 300 mg po Eptifibatide gtt Anesthesia: 1% Lidocaine subq. Anticoagulation: Heparin [**2163**] units IV Other medication: Atropine 2 mg iv Eptifibatide gtt TNG 600 mcg ic Cardiac Cath Supplies Used: .014 [**Company **], CHOICE PT XS, 300CM .014 [**Company **], CHOICE PT XS, 300CM 2.0 [**Company **], MAVERICK, 20 6F CORDIS, JR 4 SH 6F [**First Name8 (NamePattern2) **] [**Male First Name (un) **], ANGIOSEAL, 6F 200CC MALLINCRODT, OPTIRAY 200CC 2.5 CORDIS, CYPHER OTW, 28 2.5 CORDIS, CYPHER OTW, 28 3F [**Company **], EXPORT ASPIRATION CATHETER COMMENTS: 1. Selective coronary angiography of this right dominant system revealed one vessel disease. The LMCA had mild luminal irregularities. The LAD likewise had mild luminal irregularities and a 40% lesion in the mid vessel. The LCX had mild diffuse disease with a more focal 30% stenosis in its mid-segment. The RCA was totally occluded in its mid-segment 2. Limited resting hemodynamice revealed moderately elevated left-sided filling pressures (LVEDP 20 mmHg). Systemic areterial pressures were normal and there was no gradient noted on catheter pull back across the aortic valve. 3. Successful PTCA and stenting of the distal RCA with a 2.5 x 28 mm Cypher DES. Final angiography revealed no residual stenosis, no apparent dissection and normal flow (see PTCA comments). 4. Successful PTCA and stenting oh the rPDA with a 2.5 x 28 mm Cypher DES. Final anigoraphy revealed no residual stenosis, no apparent dissection, and normal flow (see PTCA comments). 5. Successful deployment of a 6 French Angioseal device in the right femoral arteriotomy. FINAL DIAGNOSIS: 1. One vessel coronary artery disease. 2. Successful placement of a drug-eluting stent in the distal RCA. 3. Successful placement of a drug-eluting stent in the rPDA. 4. Successful Angioseal. . . ECHO: EF 40-45% The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with severe hypokinesis of the basal half of the inferior and inferolateral walls. The remaining segments contract well. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. There is no mitral valve prolapse. Mild to moderate ([**12-11**]+) mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Regional left ventricular systolic dysfunction c/w CAD. Mild-moderate mitral regurgitation c/w papillary muscle dysfunction Brief Hospital Course: After catheterization with stent placement to the RCA and PDA pt was stable, continued to be in third degree AV block for several days but asymptomatic, hemodynamically stable, without elevation in creatinine or QT prolongation. On the third hospital day he began to show signs of return of AV function with periods of first degree AV block. On the fourth hospital day he developed chest pain which was relieved with nitro drip. By the fifth hospital day his rhythm wa predominantly first degree AV block, and he was asymptomatic and hemodynamically stable. Echo showed EF 40-45%, no akinesis or requirement for coumadin. He was discharged on the seventh hospital day with an appointment set up for follow up with PCP and Cardiology. Medications on Admission: Tiazac 420 mg po qd Diovan 160 mg po qd Atenolol 100 mg po qd HCTZ 25 mg po qd Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 3 months. Disp:*30 Tablet(s)* Refills:*2* 3. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Inferior wall myocardial infarction Complete heart block, followed by intermittent first degree heart block Discharge Condition: stable Discharge Instructions: Please return to the ER or call your doctor if you have any further chest pain, difficulty breathing, any weakness, numbness, or bleeding. . Please take all your medications as directed. Followup Instructions: 1)CARDIOLOGIST - Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1523**], MD Where: [**Hospital 4054**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 4022**] Date/Time:[**2169-1-19**] 8:30 [**Hospital Ward Name 23**] Center is at [**Location (un) **]. [**Location (un) 86**] - at [**Hospital Ward Name 516**] of [**Hospital1 18**] 2) Dr.[**Name (NI) 59264**] office - covered by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] appointment [**2169-1-3**] at 9am Completed by:[**2168-12-30**]

[ "401.9", "414.01", "426.11", "410.41", "305.60", "426.0", "070.70", "424.0" ]

icd9cm

[ [ [] ] ]

[ "37.22", "36.07", "36.05", "88.52", "99.20", "88.55" ]

icd9pcs

[ [ [] ] ]

10261, 10267

8878, 9616

351, 412

10419, 10427

1996, 5750

10662, 11204

1738, 1754

9745, 10238

10288, 10398

9642, 9722

7788, 8855

10451, 10639

1769, 1977

5769, 7771

278, 313

440, 1538

1560, 1586

1602, 1722

59,016

129,536

39860

Discharge summary

report

Admission Date: [**2116-1-22**] Discharge Date: [**2116-1-22**] Date of Birth: [**2045-3-24**] Sex: M Service: MEDICINE Allergies: Celebrex Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: abdominal pain, diarrhea, vomiting Major Surgical or Invasive Procedure: Intubation History of Present Illness: 70 yo M PMH HTN,s/p radical prostatectomy, s/p pacemaker who presented to an OSH early this am with severe abdominal pain, diarrhea, nausea and vomiting. Per his wife, symptoms began on [**Name (NI) 766**] evening. Pt was passing multiple loose brown stools at home. Some stools may have been black. He was also vomiting and complaining of severe abd tenderness. She does not believe he had fevers or chills. At the OSH he was hypothermic to 96.6 and hypotensive to 48/15. RR was 24-30. Admission labs were notable for metabolic acidosis, ABG 7.14/32/56/10.9. CEs were elevated. Creatinine also elevated at 2.7. CT ABD showed fluid throughout the colon. Given tender abdomen there was concern for ischemic bowel. Pt was transferred to the ICU where he was started on dopamine and a bicarbonate gtt. He was transferred to [**Hospital1 18**] MICU for additional work-up. . En route pt's MAPs maintained in the 70's on max dose levophed and neosynephrine. . Review of systems: unable to obtain Past Medical History: h/o prostate cancer dysplipidemia BPH s/p pacemaker for syncopal episode htn spinal stenosis, s/p spinal fusion s/p ccy Social History: - Tobacco: quit many years ago - Alcohol: occasional - Illicits: none Family History: unknown Physical Exam: Tmax: 36.3 ??????C (97.3 ??????F) Tcurrent: 36.3 ??????C (97.3 ??????F) HR: 95 (93 - 99) bpm BP: 110/69(85) {86/63(-16) - 112/78(127)} mmHg RR: 11 (11 - 28) insp/min SpO2: 100% General: Intubated and sedated, not responding to commands HEENT: Sclera anicteric, dry mucous membranes Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: regular, no murmurs appreciated Abdomen: soft, non-distended, no bowel sounds present GU: foley in place Ext: cool, no edema Pertinent Results: I. Labs A. OSH LABS [**2116-1-21**]: 7.08/60/78/17 lactate 7.6 total protein 5.1 alb 2.7 AST 2316 ALT 1719 Alk Phos 293 amylase 1385 lipase 87 CK 517 Trop 0.56 WBC 9.1 Hgb 13.4 Hct 40 plt 181 INR 1.5 PT 15.4 PTT 42.8 B. Admission Labs [**2116-1-22**] 01:32AM BLOOD WBC-2.3* RBC-5.21 Hgb-14.9 Hct-45.6 MCV-88 MCH-28.5 MCHC-32.6 RDW-14.5 Plt Ct-208 [**2116-1-22**] 01:32AM BLOOD Neuts-59 Bands-2 Lymphs-23 Monos-5 Eos-0 Baso-0 Atyps-0 Metas-3* Myelos-3* Promyel-5* [**2116-1-22**] 01:32AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-2+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Burr-2+ [**2116-1-22**] 01:32AM BLOOD PT-20.7* PTT-43.6* INR(PT)-1.9* [**2116-1-22**] 01:32AM BLOOD Fibrino-446* [**2116-1-22**] 01:32AM BLOOD Glucose-209* UreaN-62* Creat-3.2* Na-137 K-4.1 Cl-100 HCO3-17* AnGap-24 [**2116-1-22**] 01:32AM BLOOD ALT-2752* AST-4291* LD(LDH)-3010* CK(CPK)-778* AlkPhos-249* Amylase-700* TotBili-1.2 [**2116-1-22**] 01:32AM BLOOD Lipase-197* [**2116-1-22**] 01:32AM BLOOD CK-MB-24* MB Indx-3.1 cTropnT-0.28* [**2116-1-22**] 01:32AM BLOOD Albumin-2.6* Calcium-8.1* Phos-6.0* Mg-2.2 [**2116-1-22**] 04:31AM BLOOD Vanco-14.5 [**2116-1-22**] 01:21AM BLOOD Type-ART pO2-75* pCO2-51* pH-7.18* calTCO2-20* Base XS--9 [**2116-1-22**] 01:21AM BLOOD Lactate-5.9* [**2116-1-22**] 02:12AM BLOOD O2 Sat-93 [**2116-1-22**] 01:21AM BLOOD freeCa-1.09* C. Last set of labs [**2116-1-22**] 04:31AM BLOOD WBC-1.9* RBC-4.60 Hgb-13.3* Hct-39.5* MCV-86 MCH-28.9 MCHC-33.7 RDW-14.5 Plt Ct-191 [**2116-1-22**] 04:31AM BLOOD Neuts-28* Bands-3 Lymphs-22 Monos-4 Eos-2 Baso-0 Atyps-7* Metas-6* Myelos-2* Other-26* [**2116-1-22**] 04:31AM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-3+ Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL Burr-3+ [**2116-1-22**] 04:31AM BLOOD Plt Smr-NORMAL Plt Ct-191 [**2116-1-22**] 04:31AM BLOOD Glucose-105* UreaN-59* Creat-2.8* Na-141 K-3.8 Cl-105 HCO3-18* AnGap-22 [**2116-1-22**] 04:31AM BLOOD ALT-2840* AST-4650* LD(LDH)-2910* CK(CPK)-758* AlkPhos-201* TotBili-1.2 [**2116-1-22**] 04:31AM BLOOD Calcium-6.6* Phos-4.6* Mg-1.7 [**2116-1-22**] 08:41AM BLOOD Type-ART pO2-96 pCO2-40 pH-7.20* calTCO2-16* Base XS--11 Intubat-INTUBATED [**2116-1-22**] 08:41AM BLOOD Lactate-7.0* II. Radiology A. CXR - final report pending B. OSH hospital imaging - not available III. Microbiology A. [**Hospital6 19155**] Blood culture: Gram positive cocci in clusters (resembles Staph sp.), positive in [**2-11**] blood cultures. Blood cultures pending B. [**Hospital1 18**] [**2116-1-22**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2116-1-22**] URINE NOT PROCESSED INPATIENT [**2116-1-22**] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT [**2116-1-22**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT ### Pending studies: Microbiology as above and final CXR report Brief Hospital Course: # Septic shock with possible Staph bacteremia 70-year-old male with severe sepsis, multiorgan failure, with initial presentation of N/V/abd pain and possible LGIB who presented to an [**Hospital6 19155**] with a GI syndrome with prominent severe abdominal pain component. His admission labs were notable for severe metabolic acidosis (pH 7.140 pCO2 32 pO2 56 HCO3 10.9, lactate on admission at [**Hospital1 18**] 5.9) and hypotension with cardiac biomarkers suggesting strain/ischemia consistent with septic shock from probable GI etiology. CT abdomen at the OSH performed but report not available. Given clinical history, suspected GI infection as etiology of severe sepsis with multi-organ dysfunction from questionable translocation or aggressive colitis. Given the patient's lactate, there may be some component of ischemic bowel/mesenteric ischemia associated with process or secondary to initial under-resuscitation or delay in seeking medical attention with a fulminant process. Preliminary blood cultures ([**2-11**]) grew gram positive cocci in clusters (resembles staph sp) per [**Hospital6 19155**] lab. In addition, there may be a component of cardiogenic shock given ECHO at the OSH showed EF 40 % and elevated cardiac biomarkers although myocardial depression from sepsis cannot be excluded. The patient was started on broad spectrum antibiotics on arrival at [**Hospital1 18**] consisting of zosyn, vancomycin, and ciprofloxacin in addition to pressor support with levophed and continued ventilatory support. Given progressively worsening clinical status, wife decided to make [**Name (NI) 3225**] and patient expired. In course of septic shock, he had multiple organ failure in setting of septic shock including shock liver, renal failure, coagulopathy, and cardiac strain/ischemia . # RESPIRATORY FAILURE: Patient was intubated in setting of significant metabolic acidosis and continued on ventilation until made [**Name (NI) 3225**]. Medications on Admission: Fosamax 70mg weekly Detrol 4mg daily Lopid 600mg [**Hospital1 **] Tofranil 10mg daily Home medications: Lipitor 80mg daily Paxil 30mg daily Trazadone 50mg qHS Zetia 10mg daily Flexeril 10mg TID Prilosec 20mg daily Caltrate-VitD Vitamin C ASA 325mg daily Lupron Inj every 3 weeks Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Primary diagnosis: Severe sepsis secondary to presumed gastrointestinal etiology, respiratory failure, metabolic acidosis, Secondary: acute renal failure, coagulopathy, secondary to sepsis, prostate cancer Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "V10.46", "518.81", "V45.01", "286.9", "276.2", "785.52", "272.4", "995.92", "038.10", "584.5", "V45.4", "785.51", "V45.89", "401.9", "570", "276.52", "600.00" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

7285, 7294

4969, 6927

311, 324

7544, 7554

2154, 4946

7610, 7757

1591, 1600

7256, 7262

7315, 7315

6953, 7039

7578, 7587

1615, 2135

7057, 7233

1326, 1345

237, 273

352, 1307

7334, 7523

1367, 1488

1504, 1575

9,096

166,910

4366

Discharge summary

report

Admission Date: [**2160-2-26**] Discharge Date: [**2160-3-1**] Date of Birth: [**2104-7-14**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: Encephalopathy, GI Bleed Major Surgical or Invasive Procedure: EGD [**2160-2-27**] Paracentesis [**2160-2-26**] History of Present Illness: Mr. [**Known lastname 18823**] is a 55 year old Male with Alcoholic Cirrhosis with recent admission to the MICU for fever and hypotension with abbreviated course of antibiotics given no focus of infection was found. The patient was ruled out for SBP, blood, urine cultures negative and CXR without infiltrate. Patient was guaiaic positive without frank bleeding and impression likely source is known portal gastropathy. Yesterday, the patient is reported to have undergone a dental cleaning without event at 10:00 a.m. Later in the afternoon, near 1:00 pm the patient started expiriencing increasing confusion and seemed restless at night. This a.m., after eating [**12-5**] English Muffin the patient vomited which included small quarter sized blood clot. The patient has otherwise had no episodes of hematemesis. He denies BRBPR, melena, or other episodes of frank hematemesis. . The patient otherwise has been afebrile (temps taken at home) without subjective fevers/chills. He has had some abdominal bloating and discomfort and stooling with lactulose. Today, the patient was seen in follow up in the liver clinic. A diagnostic paracentesis was performed which was not consistent with SBP. The patient is now transferred to the ICU for ongoing management of encephalopathy and evaluation for possible GI bleed. . Past Medical History: #. Alcoholic cirrhosis, not on transplant list - complicated by ascites and hepatic encephalopathy - doses of his diuretics reduced due to hypotension - undergoes paracentesis approximately every 2 weeks - intermittently nadolol due to hypotension previously #. Hepatic sarcoidosis #. Abdominal and inguinal hernia (s/p bilateral inguinal herniorrhaphies) #. CKD #. history of HSP #. Anemia #. Gout #. History of colon adenoma - 6mm adenomatous polyp by biopsy [**3-8**] Social History: Patient lives with wife but is not working, lives in [**Name (NI) 745**]. He performs all ADLs but does not drive. He is married with a good social support system. He has two children living in [**State **]. Tobacco: None ETOH: Prior alcoholic, No Etoh since [**Month (only) **] (6 months) Illicts: No drug use Family History: Father w/ HTN, early CAD, alcoholism. Brother with alcoholism. Mother w/ HTN. Physical Exam: 98.4 F, 98 115/62 21 100% RA General: Patient appears stated age, chronically ill, jaundiced, NAD HEENT: wearing glasses, sclera icteric. OP: Hypereremic gingiva, now frank bleeding Neck: JVP visible to 6cm Chest: Breath sounds equal bilaterally, good air movement. No rhonchi, wheezes, rales Cardiac: Tachycardic, regular. No M/R/G Abdomen: Moderately distended, + fluid wave. +bowel sounds, soft, mild tenderness to palpation in right upper quadrant. Rectal: Scant thin yellow stool/mucous in rectal vault, guaiac positive Extremities: warm, well-perfused, 2+ edema LLE, no edema RLE, 2+ DP Neuro: A&O x2 (to person and place), MAEW, strength equal bilaterally + mild asterixis Pertinent Results: [**2160-2-26**] 01:00PM BLOOD WBC-4.1 RBC-2.12* Hgb-6.7* Hct-20.1* MCV-95 MCH-31.4 MCHC-33.1 RDW-17.5* [**2160-2-26**] 08:15PM BLOOD Neuts-59.3 Bands-0 Lymphs-28.3 Monos-11.1* Eos-0.9 Baso-0.3 [**2160-2-29**] 10:30AM BLOOD WBC-6.5 RBC-3.50* Hgb-10.8* Hct-31.6* MCV-90 MCH-30.8 MCHC-34.1 RDW-16.6* [**2160-2-26**] 01:00PM BLOOD PT-19.7* INR(PT)-1.8* [**2160-2-29**] 05:05AM BLOOD PT-17.8* PTT-37.3* INR(PT)-1.6* [**2160-2-26**] 01:00PM BLOOD Glucose-117* UreaN-36* Creat-1.3* Na-137 K-4.2 Cl-104 HCO3-24 AnGap-13 [**2160-2-29**] 05:05AM BLOOD Glucose-111* UreaN-25* Creat-1.2 Na-133 K-4.0 Cl-104 HCO3-19* AnGap-14 [**2160-2-26**] 01:00PM BLOOD ALT-17 AST-50* LD(LDH)-139 AlkPhos-129* TotBili-2.8* DirBili-1.0* IndBili-1.8 [**2160-2-29**] 05:05AM BLOOD ALT-20 AST-46* LD(LDH)-152 AlkPhos-111 TotBili-3.5* [**2160-2-27**] 10:00AM BLOOD Lipase-46 [**2160-2-26**] 08:15PM BLOOD Albumin-2.7* Calcium-8.8 Phos-3.8 Mg-2.2 [**2160-2-29**] 05:05AM BLOOD Albumin-2.7* Calcium-8.5 Phos-3.6 Mg-1.8 [**2160-2-26**] 01:00PM BLOOD Hapto-<20* [**2160-2-26**] 08:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2160-2-26**] 08:20PM BLOOD freeCa-1.09* [**2160-2-26**] 03:35PM ASCITES WBC-43* RBC-37* Polys-2* Lymphs-31* Monos-49* Mesothe-6* Macroph-12* RADIOLOGY Final Report LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2160-2-26**] 10:32 PM LIVER OR GALLBLADDER US (SINGL Reason: please eval for biliary dilation, portal vein flow [**Hospital 93**] MEDICAL CONDITION: 55 year old man with ETOH cirrhosis, hx of varices, here with ams and ?GI bleed, Hct 20 REASON FOR THIS EXAMINATION: please eval for biliary dilation, portal vein flow INDICATION: Alcoholic cirrhosis and known history of portal hypertension, presents with GI bleed. Evaluate for biliary dilatation and portal flow. RIGHT UPPER QUADRANT ULTRASOUND: Comparison is made to [**2159-9-27**] examination. There is unchanged appearance to a shrunken, nodular, cirrhotic-appearing liver with coarsened echogenicity and mild-to-moderate surrounding ascites. No intrahepatic mass lesions are identified. There is no intrahepatic ductal dilatation and the common bile duct measures approximately 0.6 cm. There is mild gallbladder wall thickening likely related to third spacing but no evidence of choledocholithiasis. Limited evaluation of the right kidney is unremarkable. The spleen remains enlarged measuring approximately 17 cm sagittally. Doppler interrogation of the main portal vein was difficult due to underlying cirrhosis and difficulty with breath holding, but the main portal vein remains patent with appropriate hepatopetal flow. Main hepatic artery displays appropriate waveforms. IMPRESSION: Unchanged appearance of cirrhotic-appearing liver. Mild-to-moderate surrounding ascites. No intrahepatic ductal dilatation and patent main portal vein with appropriate hepatopetal flow. RADIOLOGY Final Report CHEST (PORTABLE AP) [**2160-2-26**] 7:31 PM CHEST (PORTABLE AP) Reason: Eval for consolidation [**Hospital 93**] MEDICAL CONDITION: 55 year old man with history of cirrhosis, presents with encephalopathy. Lungs generally clear but need to exclude infectious sources REASON FOR THIS EXAMINATION: Eval for consolidation AP CHEST, 7:45 P.M. [**2160-2-26**] HISTORY: Cirrhosis and encephalopathy. Rule out infection. IMPRESSION: AP chest compared to [**2160-1-29**]: Vague opacification in the left mid lung at the level of the eighth posterior rib is probably due to healing rib fractures at that level and associated pleural thickening. I see no good evidence for pneumonia. Heart size is normal, hilar, and mediastinal contours are unremarkable and aside from a left lower lateral pleural surface, which is excluded from the examination, the other pleural margins are normal. RADIOLOGY Final Report ABDOMEN (SUPINE & ERECT) PORT [**2160-2-29**] 9:54 AM ABDOMEN (SUPINE & ERECT) PORT Reason: eval for free air, obstruction [**Hospital 93**] MEDICAL CONDITION: 55 year old man with EtOH cirrhosis, varices, here w/ GIB, now s/p paracentesis w/ increased abd distention, tympanitic abd, rebound tenderness on exam. REASON FOR THIS EXAMINATION: eval for free air, obstruction HISTORY: 55-year-old man with ethanol cirrhosis, varices, GI bleed. Having abdominal distension and rebound tenderness after paracentesis. COMPARISON: Right upper quadrant ultrasound of [**2160-2-26**]. THREE VIEWS OF THE ABDOMEN: Multiple dilated air-filled loops of small bowel are identified. Air is identified in the cecum, which is not abnormally distended. The colon is apparently collapsed. There is no evidence of air- fluid levels or free air on upright radiograph. Osseous structures are unremarkable. IMPRESSION: Dilated, air-filled loops of small bowel suggestive of ileus; less likely early obstruction. [**1-28**] EGD: Varices at the lower third of the esophagus with stigmata of recent bleeding. Successful band ligation performed Portal hypertensive gastropathy Brief Hospital Course: 55 year old Male with Alcoholic Cirrhosis with ? encephalopathy, GI bleed. . # Encephalopathy - Presumed to be due to UGIB. No evidence of infection, blood, urine and ascites fluid cultures negative, no evidence for SBP, no PNA seen on CXR. Tox screen negative. Pt's encephalopathy cleared after treatment for UGIB and lactulose. On day of discharge pt was mentating and back to his baseline without evidence for confusion or asterixis. #.UGIB: Pt underwent EGD on admisson which revealed 2 cords of grade II-III varices with stigmata of recent bleeding believed to be culprit for patients UGIB. He received a total of 5 units of PRBCs, 5 units of FFP and 1 unit of platelets. He was treated with octreotide drip initially as well as an IV PPI. His nadolol and diuretics were held while hospitalized for hypotension. He was transitioned to PO PPI for discharge. At time of release the patient's hematocrit was stable and he had no further bleeding diatheses. His nadolol and diuretics were restarted on discharge. #. ETOH/Sarcoid Cirrhosis - maintained on Rifaximin and lactulose. Pt in process of being listed for transplant in [**State **]. Only awaiting dental clearance for listing. Pt has refractory ascites, gets routine paracentesis Q 2 weeks. Had 6L removed on [**2-26**], no evidence for SBP. Will return for routine therapeutic para as outpatient. On day of discharge pt was afebrile with stable vital signs and hematocrit. Discharged home with wife with plan for completion of dental workup on [**3-3**], follow up in liver transplant clinic on [**3-11**], will have follow up EGD and therapeutic paracentesis on same day. Medications on Admission: Medications outpatient: Furosemide 20 mg daily Spironolactone 50 mg daily Lactulose 10 gram/15 mL:30 ML PO TID Rifaximin 400 mg PO tid Sucralfate 1 gram PO qid Nadolol 20 mg daily Vitamin A Oral Zinc Oral Nexium 80 mg daily Acetaminophen PRN Albuterol 90 mcg 1-2 Puffs Inhalation Q6H Calcium Carbonate 500 mg PO bid Cholecalciferol (Vitamin D3) 400 unit daily Ferrous Sulfate 325 mg [**Hospital1 **] Hexavitamin 1 cap daily . Allergies: NKDA Discharge Medications: 1. Rifaximin 200 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 2. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 4. Sucralfate 1 gram Tablet Sig: One (1) Tablet PO QID (4 times a day) for 7 days. Disp:*7 Tablet(s)* Refills:*0* 5. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO Q2H (every 2 hours) as needed: Take as needed for a goal of [**3-8**] bowel movements a day. . 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. 7. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 10. Zinc Sulfate Oral 11. Vitamin A Oral 12. Calcium Carbonate 500 mg Capsule Sig: One (1) Capsule PO twice a day. 13. Cholecalciferol (Vitamin D3) 400 unit Capsule Sig: One (1) Capsule PO once a day. 14. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO twice a day. 15. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. 16. Tessalon Perles 100 mg Capsule Sig: One (1) Capsule PO three times a day as needed for cough for 7 days. Disp:*30 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Variceal bleed Discharge Condition: Good, ambulating independently, vital signs and hematocrit stable. Discharge Instructions: You were admitted with confusion and an upper GI Bleed. Your blood counts are stable. Take all medications as directed. Please follow-up with all outpatient appointments. Please call your doctor or return to the hospital if you have any dizziness, chest pain, difficulty breathing, bloody or black stools or any other concerning symptoms. Followup Instructions: You also are scheduled for an upper endoscopy to follow up on the one you had while hospitalized. This will be at 1:00pm With Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 2305**], [**Location (un) **] ([**Hospital1 18**] [**Hospital Ward Name **]) [**Hospital Ward Name 1950**] building, [**Location (un) 470**]. Nothing to eat after midnight on the day of the procedure. Please call [**Telephone/Fax (1) 463**] if you have questions regarding this procedure. You also are scheduled for a therapeutic paracentesis on [**2160-3-11**], please present to the radiology department at 10:00am, [**Hospital Unit Name **], [**Location (un) 470**]. Please call [**Telephone/Fax (1) 327**] with any concerns or questions. Provider: [**Name10 (NameIs) **] [**Last Name (NamePattern4) 2424**], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2160-3-11**] 8:00 Provider: [**First Name11 (Name Pattern1) 1730**] [**Last Name (NamePattern4) 2301**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2160-3-11**] 2:00

[ "285.9", "348.30", "135", "789.59", "456.20", "571.2", "572.3" ]

icd9cm

[ [ [] ] ]

[ "54.91", "42.33" ]

icd9pcs

[ [ [] ] ]

11903, 11909

8350, 9999

339, 389

11968, 12037

3373, 4822

12427, 13460

2577, 2657

10492, 11880

7334, 7487

11930, 11947

10025, 10469

12061, 12404

2672, 3354

275, 301

7516, 8327

417, 1736

1758, 2231

2247, 2560

51,374

108,433

21394

Discharge summary

report

Admission Date: [**2130-5-16**] Discharge Date: [**2130-5-27**] Date of Birth: [**2050-4-5**] Sex: F Service: NEUROSURGERY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1271**] Chief Complaint: SAH Major Surgical or Invasive Procedure: Right Extenral Ventricular drain History of Present Illness: Patient is an 80 yo F with hx of HTN/HL who presents with headache as transfer from OSH with SAH. Per patient, yesterday she had the abrupt onset of posterior/occipital HA at around 5pm that lasted 30 minutes and then resolved on own. No associated neurological changes with headache. Today, at around 4pm she had again the sudden onset of posterior/occipital HA with radiation down neck. This time the headache was much more severe and associated with a worsening of her baseline tinnitus. No N/V. No weakness or numbness sensation. No visual changes. She was taken to an OSH where a CT head was performed which showed a SAH in the basal cistern without hydrocephalus. She was transferred to [**Hospital1 18**] for Neurosurgical evaluation. Neuro exam at OSH on presentation intact with baseline L facial droop. Past Medical History: Past Medical History: hypertension hypercholesterolemia asthma on advair history of GI bleed felt likely [**1-4**] ischemic colitis per [**2126**] DC summary from [**Location (un) **] depression (on bupropion) T10 left discectomy on [**9-6**]. Social History: Lives at home alone without services. She has 5 children, several grandchildren and 8 great grandchildren. Retired behavioral optometry assistant. Never smoked. Rare etoh Family History: Noncontributory Physical Exam: On admission: PHYSICAL EXAM: GCS E: 4 V: 5 Motor 6. Hunt and [**Doctor Last Name 9381**] 2. [**Doctor Last Name 957**] 2 O: T: 97.4 BP: 152/71 HR: 92 R 15 O2Sats 98%2L Gen: WD/WN, comfortable, NAD. HEENT: Pupils: R surgical 4-3 L [**2-1**] 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: mildly sleepy but appropriate and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, R pupil surgical but reactive 4-3mm, L 3-2mm. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: L facial droop (baseline) 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 [**4-6**] throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Reflexes: B T Pa Ac Right 2 2 2 2 Left 2 2 2 2 Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin Upon discharge: Expired Pertinent Results: [**2130-5-16**] CTA Head/Neck: 1. Hemorrhage in the collicular cister with extension into the ventricles is likely secondary to ruptured AVM in the cerebellar vermis. 2. 17-mm x 11 mm arteriovenous malformation with high-flow feeding from the bilateral posterior cerebral and superior cerebellar arteries and draining into the deep cerebral venous system. 3. 2-mm left cavernous ICA aneurysm. 4. No evidence of an acute infarction. [**2130-5-17**] CT Head: No evidence for hydrocephalus, with grossly stable intraventricular and small subarachnoid hemorrhage. [**5-17**] Cerebral Angiogram - 1. Mrs. [**Known lastname 8029**] underwent diagnostic cerebral angiogram which demonstrates an arteriovenous malformation within the anterior superior cerebellum predominantly supplied by the bilateral superior cerebellar arteries and to a lesser extent the right PICA and left AICA-PICA complex. There may be a questionable 1.5- 2mm aneurysm at the anterior aspect of the arteriovenous malformation immediately adjacent to the nidus. Venous drainage is central, to the straight sinus without stenosis or aneurysm. No active extravasation of contrast demonstrated. 2. 3-mm broad-based aneurysm along the posterior wall of the proximal cavernous left internal carotid artery. 3. Short segment of corrugated appearance of the left distal cervical internal carotid artery wall without flow-limiting stenosis may represent a short segment of fibromuscular dysplasia. 4. Severe tortuosity of the cervical vessels noted. This anatomy may complicate future intervention. [**2130-5-18**] CT head: 1. New focus of left parietal subarachnoid hyperdensity and increased hyperdense material layering in the left occipital [**Doctor Last Name 534**], which may represent redistribution of blood products, but slight new hemorrhage cannot be excluded. 2. Evolving blood products in the third and fourth ventricles, aqueduct and foramina of Luschka without evidence for hydrocephalus. [**5-18**] CT Head repeat - 1. Interval development of hydrocephalus compared to seven hours prior, with new dilation of the lateral and third ventricles, likely secondary to hemorrhage within the fourth ventricle. 2. No definite evidence of new intracranial hemorrhage. Some redistribution of blood products into the right occipital [**Doctor Last Name 534**] is noted. [**5-19**] CT Head - no change [**5-20**] Ct head - no change MR HEAD W & W/O CONTRAST [**2130-5-23**] 1. Multiple areas of small acute infarctions involving the left centrum semiovale, parasagittal frontal cortex, splenium of corpus callosum, and posterior midbrain. 2. Interval reduction in the size of ventricles and stable position of the right transfrontal ventriculostomy catheter. 3. Hemorrhage in the superior vermis with blood products from ruptured AVM Brief Hospital Course: 80F who presented after a sudden onset of headache, CT revealed a SAH at the OSH and she was transferred to [**Hospital1 18**]. A CTA was performed which showed a question of a venous anomaly in the cerebellar vermis. She was admitted to the Neuro ICU under Neurosurgery. She was started on Nimodipine and Keppra. She was monitored closely overnight, as patient was becoming more lethargic. The family had expressed that if she decompensated, they did not want to intubate and would want DNR/DNI. A repeat head CT was done on [**5-17**] which showed no evidence for hydrocephalus, with grossly stable intraventricular and small subarachnoid hemorrhage. An Angiogram was recommended and they reversed the DNI order for procedures. She was intubated for an angiogram with Dr. [**Last Name (STitle) **]. and this showed an AVM possibly being fed by left SCA aneurysm. She was not able to be extubated and she was trasnfered to the SICU intubated. On [**5-18**] she was following commands and opening eyes. The SICU felt that her left side was weaker and she had a CT which was stable. Her exam did not improve however and an EVD was placed. On, [**5-19**] CT of the head showed that the lateral ventreicles were slightly smaller and the EVD was lowered to 10 and pulled back 2cm. She had some decreased Sats to 90 with decreased breathe sounds at the right anterior lung base with suggestion of right middle lobe consolidation on CXR. She also had some thick secretions and sputum cultures were sent. She required Lasix 20mg. CPAP was increased. Her PICC line was malpositioned ordered IR to reposition, will do monday so PICC used as mid-line for now. pt became oliguric in afternoon and required IVF bolus, started LR @ 75 w/ good response On [**5-18**] pt had a brief rise in ICP to 28 after turning and repeat CT showed no new hemorrhage. A CXR on [**5-21**] RLL infiltrate and a Bronchoscopy was performed w/ no secretions for BAl, and results came back + for MRSA. On [**5-22**], Vancomycin started for MRSA in sputum/VAP. Rhythmic twitching of LUE noted, concerning for seizure. Resolved w/ ativan 2mg IV. Neuro consulted and they recommended starting Keppra and titrating accordingly. EEG was obtained which showed PLEDS and dilantin was started per Neurology. She had an MRI on [**5-23**] which showed a brainstem infarct. Her exam worsened and she did not open her eyes. She only WD to deep noxious. On [**5-24**] exam worsened, her dilantin level was 12.8 and patient recieved ativan for pled. [**5-25**], no changes were seen in exam. On [**5-26**], a family meeting was held to discuss goals of care. Since patient's exam has not improved, the family has decided to make patient CMO. Her EVD was removed and she was extubated. On [**2130-5-27**] at 0602 she expired. Medications on Admission: Lipitor 10mg' Advair 250/50 1puff daily Senna 8.6mg [**Hospital1 **] Cartia XT 120mg q24 Calcium 500mg [**Hospital1 **] Cyclobenzaprine 10mg TID Colace 100mg po BID oxycodone 5mg po q4prn Aleve 220mg po PRN Gabapentin 400mg TID Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Subarachnoid hemorrhage Intraventricula hemorrhage AV Malformation cavernous left internal carotid artery aneurysm Hydrocephalus Respiratory failure LLL Pneumonia MRSA - sputum culture Malnutrition Seizures Brainstem infarct Discharge Condition: expired Discharge Instructions: Expired Followup Instructions: EXPIRED [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2130-5-27**]

[ "041.12", "430", "997.31", "272.0", "434.91", "437.3", "V49.86", "263.9", "780.39", "431", "331.4", "518.81", "401.9", "493.90", "272.4" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.6", "02.39", "96.71", "38.91", "96.04", "96.72", "88.41", "33.24", "38.97" ]

icd9pcs

[ [ [] ] ]

9202, 9211

6106, 8891

311, 346

9480, 9490

3274, 3723

9546, 9680

1673, 1690

9170, 9179

9232, 9459

8917, 9147

9514, 9523

1734, 2091

268, 273

3246, 3255

374, 1197

2367, 3230

4860, 6083

1719, 1719

2106, 2351

1241, 1468

1484, 1657

59,945

170,691

5218+55651

Discharge summary

report+addendum

Admission Date: [**2181-7-1**] Discharge Date: [**2181-7-6**] Date of Birth: [**2115-3-11**] Sex: M Service: CARDIOTHORACIC Allergies: Allopurinol Attending:[**First Name3 (LF) 1505**] Chief Complaint: abnormal stress test Major Surgical or Invasive Procedure: [**2181-7-2**] Coronary Artery Bypass Graft x 4 History of Present Illness: 66 year old male that recently underwent stress testing as part of a renal transplant workup. He exercised 5 minutes [**Known firstname **] protocol reaching 99% max PHR, stopping due to a 60 mmHg drop in systolic blood pressure and shortness of breath. He denied chest or back discomfort. EKG was notable for 1mm upsloping ST segment/J point depression in leads 2, 3, avF, V5-V6 and 1mm slow upsloping in leads V1, avR starting early in exercise and returning back to baseline by the end of recovery. These ST changes were noted in conjunction with the development on a non-specific IVCD, rendering the changes as non-specific, but possibly ischemic. Imaging was notable for a severe partially reversible defect involving the apex and distal anterior wall. There was also a moderate reversible defect involving the inferior wall. Transient ischemic dilatation of the LV was noted with stress. LVEF was 32%. He was referred for cardiac catheterization that revealed coronary artery disease and is referred for surgical evaluation. Past Medical History: Alports syndrome with renal failure (glomerulonephritis, proteinuria)and hearing loss (bilateral hearing aids) Hypertension Hyperlipidemia [**2181-5-23**]: syncope- unclear etiology Gastroesophageal reflux disease Gouty attacks due to renal insufficiency 2 stable pulmonary nodules Elevated PSA with normal biopsy Anemia d/t renal failure Colonic polyps Gallstone Social History: Race: caucasian Last Dental Exam: 4 weeks ago Lives with: spouse Occupation: physician, [**Name10 (NameIs) 21339**] [**Name11 (NameIs) 1139**]: denies ETOH: 3 glasses of wine per year Family History: Brother had atypical back pain at age 58, diagnosed with an MI, s/p CABG. Father had an MI in his late 70s Physical Exam: Pulse: 72 Resp: 16 O2 sat: 98 RA B/P Right: 159/75 Left: 154/91 General: no acute distress Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [sx] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur none Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] no palpable masses Extremities: Warm [x], well-perfused [x] Edema none Varicosities: none Neuro: Grossly intact Pulses: Femoral Right: +2 Left: +2 DP Right: +2 Left: +2 PT [**Name (NI) 167**]: +2 Left: +2 Radial Right: +2 Left: +2 No carotid bruits Pertinent Results: [**2181-7-2**] Echo: PREBYPASS: No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated with normal free wall contractility. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. POSTBYPASS: Biventricular systolic function is preserved. The remaining study is otherwise unchanged from prebypass. Brief Hospital Course: Dr. [**Known lastname 2805**] was admitted one day prior to surgery for gentle hydration, given renal insufficiency. He underwent usual pre-operative work-up and was brought to the operating room on [**7-2**] where he underwent a coronary artery bypass graft x 4. Please see operative report for surgical details. Following surgery he was transferred to the CVICU for invasive monitoring. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. Chest tubes and pacing wires were removed per protocol. His betablocker, ace and statin were resumed. On POD# 2 Dr. [**Known lastname 2805**] was transferred from the ICU to the stepdown unit. He was evaluated by physical thrapy for strength and conditioning. Dr. [**Known lastname 2805**] was diuresed with IV lasix and was followed closely by nephrology during his hospital course. On POD#4 his BUN/Creat were 96/6.3 - IV diuresis was discontinued per Dr.[**Name (NI) 12913**] recommendation. It was recommended that Dr. [**Known lastname 2805**] stay in the hospital until [**2181-7-7**] to have his BUN and CREAT drawn however, Dr. [**Known lastname 2805**] decided to go home on [**2181-7-6**] and have the VNA check his BUN/Creat on monday [**2181-7-9**] and communicate closely with Dr. [**Last Name (STitle) 4883**] and Dr. [**Name (NI) 6149**] office. Dr. [**Last Name (STitle) **] was made aware of the discharge plan. Dr. [**Known lastname 2805**] was discharged on 20mg po lasix daily with labs to be drawn on monday [**2181-7-9**] and sent to Dr. [**Last Name (STitle) 4883**]. All follow up appointments were advised. Medications on Admission: Amlodipine 5mg daily lipitor 80mg daily calcitriol 0.25mg 5x/week lopressor 25mg [**Hospital1 **] prednisone prn gout *used quick taper last week for tenosynovitis (40, 40, 20)* asa 81mg daily Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Disp:*135 Tablet(s)* Refills:*2* 6. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO 5X/WK (). 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*65 Tablet(s)* Refills:*0* 8. Outpatient Lab Work To be Drawn on [**2181-7-9**]: Bun/Creat and potassium and fax results to Dr. [**Last Name (STitle) 4883**] [**Telephone/Fax (1) 9420**] otr call [**Telephone/Fax (1) 721**] 9. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 1376**] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 Past medical history: Alports syndrome with renal failure (glomerulonephritis, proteinuria)and hearing loss (bilateral hearing aids) Hypertension Hyperlipidemia [**2181-5-23**]: syncope- unclear etiology Gastroesophageal reflux disease Gouty attacks due to renal insufficiency 2 stable pulmonary nodules Elevated PSA with normal biopsy Anemia d/t renal failure Colonic polyps Gallstone Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with percocet Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. 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 until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr. [**Last Name (STitle) **] on [**2181-8-9**] at 1PM Please call to schedule appointments with your Primary Care Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) **] in [**11-25**] weeks Cardiologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**11-25**] weeks nephrologist Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4883**] 1-2 weeks [**Telephone/Fax (1) 721**] **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: chemistry- Bun, Creat, potassium. Please call results to Dr. [**Last Name (STitle) 4883**] [**Telephone/Fax (1) 721**]; Fax [**Telephone/Fax (1) 9420**] Completed by:[**2181-7-6**] Name: [**Known lastname 3544**],[**Known firstname 2147**] E Unit No: [**Numeric Identifier 3545**] Admission Date: [**2181-7-1**] Discharge Date: [**2181-7-6**] Date of Birth: [**2115-3-11**] Sex: M Service: CARDIOTHORACIC Allergies: Allopurinol Attending:[**First Name3 (LF) 741**] Addendum: Dr. [**Known lastname **] also had a post-operative ileus which was resolving by clinical exam upon discharge and was tolerating a regular diet, passing flatus and stool. Discharge Disposition: Home With Service Facility: [**Hospital1 3546**] [**Name6 (MD) **] [**Name8 (MD) 747**] MD [**MD Number(2) 748**] Completed by:[**2181-7-6**]

[ "389.9", "414.01", "V49.83", "414.2", "997.4", "V12.72", "E878.2", "272.4", "403.91", "518.89", "585.5", "759.89", "560.1", "530.81", "285.21" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

9249, 9422

3487, 5097

297, 346

6880, 7098

2774, 3464

7851, 9226

2011, 2119

5340, 6316

6411, 6472

5123, 5317

7122, 7828

2134, 2755

237, 259

374, 1407

6494, 6859

1810, 1995

30,884

183,821

49702

Discharge summary

report

Admission Date: [**2167-8-12**] Discharge Date: [**2167-10-5**] Date of Birth: [**2112-7-5**] Sex: F Service: ORTHOPAEDICS Allergies: Meperidine Attending:[**First Name3 (LF) 11415**] Chief Complaint: s/p motorcycle crash with injuries Major Surgical or Invasive Procedure: [**2167-8-12**]: ORIF left tibia shaft fx, ORIF left tibia plateau fracture [**2167-8-19**]: Closed reduction, external fixator placement right elbow and ORIF Left [**1-18**] metatarsal and 3 metatarsal head resection [**2167-9-7**]: I&D left tibia with VAC placement [**2167-9-10**]: Split thickness skin graft by plastic surgery Dr. [**First Name (STitle) **] [**2167-9-12**]: PICC placement [**2167-9-24**]: External fixator right elbow and K wires Left foot removed [**2167-10-5**]: Remaining K wires left foot removed History of Present Illness: Ms. [**Known lastname **] is a 55 year old female who was involved in a motorvehicle crash. She was taken to [**Hospital6 5016**] and then transferred to the [**Hospital1 18**] for further evaluation. Past Medical History: History of pericarditis s/p appy s/p ccy s/p TAH s/p cervical spine surgery Social History: Lives alone in [**Location (un) 7661**] +smoker Estranged from family Family History: n/a Physical Exam: Upon admission Alert and oriented Cardiac: Regular rate rhythm Chest: Lungs clear bilaterally Abdomen: Soft non-tender non-distended Extremities: c-collar in place. Abrasion on bilateral arms, R arm sensation/movement intact, + pulses. LLE ecchymosis of thigh/calf and foot unstable L ankle, deformity left calf, compartments soft, + sensation/movement, + pulses. Pertinent Results: [**2167-9-29**] 03:50AM BLOOD WBC-6.8 RBC-3.19* Hgb-9.4* Hct-28.0* MCV-88 MCH-29.5 MCHC-33.6 RDW-14.6 Plt Ct-266 [**2167-9-25**] 04:13AM BLOOD WBC-6.8 RBC-3.14* Hgb-9.4* Hct-27.4* MCV-87 MCH-30.0 MCHC-34.3 RDW-14.6 Plt Ct-255 [**2167-9-24**] 09:15AM BLOOD WBC-5.6 RBC-3.16* Hgb-9.3* Hct-27.9* MCV-88 MCH-29.5 MCHC-33.4 RDW-14.6 Plt Ct-259 [**2167-9-7**] 09:14AM BLOOD PT-13.1 PTT-30.3 INR(PT)-1.1 [**2167-9-24**] 09:15AM BLOOD Glucose-98 UreaN-14 Creat-0.8 Na-140 K-4.6 Cl-104 HCO3-29 AnGap-12 [**2167-9-24**] 04:20AM BLOOD Glucose-100 UreaN-15 Creat-0.8 Na-141 K-4.0 Cl-105 HCO3-27 AnGap-13 [**2167-8-12**] 04:50PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG Brief Hospital Course: Ms. [**Known lastname **] presented to the [**Hospital1 18**] on [**2167-8-12**] via transfer from [**Hospital6 5016**] after being involved in a motorcycle crash. She was evaluated by the trauma and orthopaedic surgery services. She was found to have a left tibia plateau and shaft fracture, a left foot metatarsal fractures, and a right elbow fracture. She was admitted, prepped, and then taken to surgery by orthopaedics. She underwent and ORIF of her tibia shaft and plateau fractures. She tolerated the procedure well and was then taken to the trauma ICU for further care. On [**2167-8-13**] she was weaned and extubated. She was transferred to the floor but unfortunately her uncooperative behavior and nursing requirements were too high and she was transferred back to the Trauma ICU for care. On [**2167-8-14**] and on [**2167-8-15**] she was transfused with 2 units of packed red blood cells due to acute post operative anemia each day. On [**2167-8-15**] she was also intubated to acute agitation, confusion, and poor respiratory status. On [**2167-8-16**] she was transfused with 4 units of packed red blood cells due to acute post operative anemia. On [**2167-8-17**] she self extubated. On [**2167-8-18**] she was transferred to the floor. On [**2167-8-19**] she returned to the OR for and ORIF of her left [**1-18**] metatarsal fractures and closed reduction of her right elbow with external fixator placement. She tolerated the procedure well. On [**2167-8-24**] she returned to the operating room for I&D of her left leg wound which required VAC placement due to extensive debridement. Cultures from the I&D grew enterococcus sensitive to Vancomycin. She was also seen by psychiatry to recommended 1:1 sitters and medication to help with agitation and confusion. On [**2167-8-28**] she returned to the operating room for an I&D with VAC change which tolerated well. On [**2167-9-3**] she returned to the operating room for an I&D with VAC change, which she tolerated well. On [**2167-9-7**] she returned to the operating room for an I&D with VAC change which she tolerated well. On [**2167-9-9**] she fell out of bed. X-rays were done which showed no new fracture. On [**2167-9-10**] she was taken to the operating room by plastic surgery for a split thickness skin graft on her left tibia. She tolerated the procedure well, was extubated, transferred to the recovery room, and then to the floor. On [**2167-9-12**] a PICC line was placed for long term antibiotics and due to poor peripheral access. On [**2167-9-15**] her distal radial external fixator was broken. The external fixator remained intact and was supported by an orthoplast splint. On [**2167-9-17**] her VAC over her split thickness skin graft was removed and revealed that the graft had took well. On [**2167-9-24**] her right elbow external fixator was removed along with some K-wires from her left foot. On [**2167-10-5**] the remaining K wires were removed from her left foot. The rest of her hospital stay was uneventful with her lab data and vital signs within normal limits, and her pain controlled. She is being discharged today in stable condition. Medications on Admission: denies Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO every six (6) hours. 2. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Olanzapine 2.5 mg Tablet Sig: One (1) 12.5mg PO twice a day. 7. Nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 8. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 9. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Discharge Disposition: Extended Care Facility: [**Hospital 103931**] Hospital Discharge Diagnosis: s/p motorcycle crash Left tibia shaft fracture Left tibia plateau fracture Right elbow fracture Left [**1-18**] metatarsal fractures Acute post operative anemia Discharge Condition: Stable Discharge Instructions: Continue to be nonweight bearing on your right arm and left leg Continue your lovenox injections as instructed You may resume your home medications as prescribed If you notice any increased redness, drainage, swelling, or if you have a temperature greater than 101.5, please call the office or come to the emergency department. Physical Therapy: Activity: As tolerated Left lower extremity: Partial weight bearing R elbow passive and active ROM Treatment Frequency: Take off boot daily to inspect skin Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 1005**] in 6 weeks, please call [**Telephone/Fax (1) 1228**] to schedule that appointment Please follow up with Plastic Surgery, Dr. [**First Name (STitle) **], next weeks, please call [**Telephone/Fax (1) 5343**] to schedule that appointment. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**] Completed by:[**2167-10-6**]

[ "E878.8", "E849.7", "E849.5", "825.25", "E812.2", "998.13", "823.32", "826.0", "832.09" ]

icd9cm

[ [ [] ] ]

[ "79.72", "86.69", "79.66", "78.68", "93.59", "86.22", "99.04", "98.27", "79.36", "97.12", "86.04", "83.45", "78.18", "79.37", "38.93" ]

icd9pcs

[ [ [] ] ]

6474, 6531

2400, 5574

310, 842

6735, 6743

1686, 2377

7297, 7750

1275, 1280

5631, 6451

6552, 6714

5600, 5608

6767, 7098

1295, 1667

7116, 7216

236, 272

870, 1073

7237, 7274

1095, 1172

1188, 1259

20,190

137,000

1752

Discharge summary

report

Admission Date: [**2139-5-8**] Discharge Date: [**2139-6-9**] Date of Birth: [**2085-1-5**] Sex: F Service: [**First Name9 (NamePattern2) **] [**Last Name (un) **] HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old woman who developed Hodgkin's disease and was treated with mantle irradiation in [**2110**]. She did well with regard to her Hodgkin's disease but developed congestive heart failure and was found to have constrictive pericarditis and underwent a pericardectomy at the [**Hospital 9940**] Clinic in the early [**2126**]'s. In [**2133**] she developed worsening shortness of breath and ultimately was admitted to the [**Hospital1 188**] in [**2138-4-7**] with respiratory distress and was found to have bilateral fibrothoraces. On [**2138-6-11**], she underwent a left thoracotomy with decortication of the severe left fibrothorax with an excellent anatomic result. Her postoperative course was complicated requiring tracheostomy and a feeding tube. After being discharged to rehabilitation she suffered a respiratory arrest from a mucus plug and was resuscitated and transferred back. Since that time she has had recurrent admissions for respiratory insufficiency requiring multiple bronchoscopies and an extensive workup. It appears clear that she has severe restrictive physiology resulting in severe respiratory insufficiency as a result of recurrent fibrothorax with a pleural RIND. She also appears to have some trapped lung due to this fibrothorax which is resulting in chronic ventilatory dependence. She is being admitted for right-sided decortication. PAST MEDICAL HISTORY: 1. Hodgkin's disease as above status post splenectomy and radiation therapy in [**2110**]. 2. Congestive heart failure. 3. Status post cardiac arrest. 4. Status post pericardectomy. 5. Status post hysterectomy. 6. Hypothyroidism. 7. History of depression. 8. History of Clostridium difficile. MEDICATIONS ON ADMISSION: 1. Metoprolol 25 mg p.o. q. day. 2. Guaifenesin 15 mg p.o. q. 6h. p.r.n. 3. Folic acid 1 mg p.o. q. day. 4. Lasix 20 mg p.o. q. day. 5. Lorazepam 0.5 mg p.o. q. 4h. p.r.n. 6. Albuterol nebs q. 2h. 7. Ipratropium nebs q. 2h. 8. Lactulose 20 mg p.o. q. day. 9. Multivitamin one q. day. 10. Ascorbic acid 500 mg p.o. b.i.d. 11. Ferrous sulfate 325 mg p.o. b.i.d. 12. Levothyroxine 125 mcg p.o. q. day. 13. Lansoprazole 30 mg p.o. q. day. 14. Zolpidem 5 mg p.o. q. hs. 15. Sertraline 150 mg p.o. q. day. 16. Levofloxacin 500 mg p.o. q. day. ALLERGIES: IV contrast which results in anaphylaxis. SOCIAL HISTORY: She is single, has no children and is a retired professor [**First Name (Titles) **] [**Last Name (Titles) 9929**] at a local college. She is a nonsmoker. PHYSICAL EXAMINATION: She was alert and oriented with normal vital signs. She was breathing through her trach mask without distress and talking without any problems. [**Name (NI) **] signs: Temperature 99.1, heart rate 87, blood pressure 90/69, 99% sats on the trach mask. Sclerae anicteric. Her neck has no cervical adenopathy. Lungs are clear to auscultation bilaterally without crackles or wheezes. Her heart is regular without any murmurs. She has a well-healed left thoracotomy scar. Abdomen is benign. Extremities have no clubbing or edema. RADIOLOGY: Chest CT scan shows pulmonary fibrosis on the medial aspect of both lungs from the mediastinal and radiotherapy. She has chronic scarring in both lungs from recurrent infections. There are no pleural effusions. There are no significant areas of atelectasis. HOSPITAL COURSE: On [**2139-5-8**], the patient was taken to the Operating Room for a right lung decortication. This was a prolonged surgery which was technically very difficult and the patient required eight units of fresh frozen plasma, nine units of packed red blood cells and 18 units of platelets for an estimated blood loss of four liters. She tolerated the procedure and was transferred to the Surgical Intensive Care Unit postoperatively where she was closely monitored on the ventilator and required pressor support. On [**5-14**] she returned to the Operating Room for a evacuation of a right-sided hemothorax and washout. She had no further return trips to the Operating Room and had a prolonged one month hospitalization which will be summarized by systems. 1. Neurologic: The patient did well. Her pain was initially controlled on intravenous narcotics and has now been weaned to p.o. hydromorphone which she appears to be tolerating well. She also continues on her Zoloft for her chronic depression. 2. Cardiac: All of her pressors were weaned after her postoperative resuscitation. She now remains hemodynamically stable with a systolic blood pressure in the 100 range and a heart rate of approximately 100. Her beta blocker had not been restarted but we are considering restarting that now. 3. Pulmonary: She underwent chest tube drains of her right hemothorax until the chest tube drainage decreased and the tubes were all eventually removed. She was gradually weaned from the ventilator and she currently tolerates being off the ventilator for a 24 hour period but as a means of assuring expansion of her lung and expression of any excess of fluid, she is placed on the ventilator for two hour periods twice a day on vent settings with very high peak inspiratory pressures as per the protocol outlined by respiratory therapists. Her respiratory status has been stable and her sats are 95% on the 50% face mask. She had an excellent re-expansion of her lung postoperatively and should do well long term. 4. Gastrointestinal: The patient has been experiencing prolonged nausea and it is unclear what the etiology of her nausea is. She has no evidence for any intra-abdominal ileus or obstruction. She is being fed via a nasogastric feeding tube at a goal rate of 70 cc/hour but due to the fact that she has ongoing nausea, she has not been taking a p.o. diet although there is no reason why she cannot. She continues on Pepcid 20 mg b.i.d. and Zofran around the clock. 5. Genitourinary: The patient has been aggressively diuresed to her baseline weight. At the time of discharge her BUN and creatinine are at her baseline of 17/0.5. She is not currently on any diuretics. 6. Hematology: Her hematocrit has been stable at 35 as are her coags with a PT of 12.9 and PTT of 49.9 and INR of 1.1. She continues on subcutaneous heparin for DVT prophylaxis and has had no problems with any ongoing bleeding since the time of her initial operation. 7. Infectious Disease: The patient has been maintained on broad spectrum intravenous antibiotics throughout her hospitalization. Her cultures from the Operating Room have grown methicillin-resistant Staphylococcus aureus and __________________________ and [**Female First Name (un) 564**] torulopsis. She has also tested positive for Clostridium difficile, as she has in the past. She is currently being treated on intravenous vancomycin, intravenous Bactrim, intravenous fluconazole and p.o. vancomycin. The plan is to keep her on this regimen for a total of a three week course which will be completed on [**2139-6-14**]. After that date she will continue on her p.o. vancomycin for two more weeks due to her recurrent Clostridium difficile. She has no active infectious problems with a temperature of 97.4 and a white count of 12.7. 8. Endocrine: The patient has hypothyroidism and is currently on Synthroid which will be increased to 125 mcg a day as this is her standard dose. Throughout her hospitalization she has been treated with steroids to try to minimize the fibrotic reaction within her right lung. Due to the fact she has improved and she is now one month out from surgery, the plan is to wean her off of her steroids. On [**6-8**], we obtained an Endocrinology consult who outlined a tapering for her prednisone from 30 mg p.o. q. day down to 20 mg p.o. q. day for two days, then 10 mg p.o. q. day for two days, then 5 mg p.o. q. day. After weaning her down to 5 mg for approximately one week, the patient will require repeat Cortrosyn stimulation test. Based on the results of this, if the cortisol rises to above 18-20, then they would decrease the prednisone to 2.5 mg per day for two days and then stop it. If the cortisol does not exceed 18-20, then she needs to continue on prednisone at 5 mg per day and should arrange for an Endocrinology follow up at [**Telephone/Fax (1) 9941**] for further evaluation. DISCHARGE DIAGNOSES: 1. Right-sided fibrothorax status post open decortication on [**2139-5-8**]. 2. Right hemothorax status post VATS with hematoma evacuation on [**2139-5-14**]. 3. Clostridium difficile being treated on oral vancomycin. 4. Right hemothorax methicillin-resistant Staphylococcus aureus and yeast currently being treated on broad spectrum antibiotics. 5. Chronic nausea with nasogastric feeding requirement. DISCHARGE MEDICATIONS: 1. Pepcid 20 mg p.o. b.i.d. 2. Regular insulin sliding scale. 3. Zoloft 150 mg p.o. q. day. 4. Synthroid 125 mcg p.o. q. day. 5. Subcu heparin 5000 mg p.o. b.i.d. 6. Atrovent inhalers. 7. Albuterol inhalers. 8. Ipratropium inhalers. 9. Zofran 4 mg IV q. 4h. p.r.n. 10. Prednisone as outlined in discharge summary 30 mg on [**2139-6-8**], then 20 mg p.o. q. day from [**6-9**] until [**6-10**], then 10 mg p.o. q. day from [**6-11**] to [**6-12**], then 5 mg p.o. q. day from [**6-13**] onwards with follow up with [**Hospital 6091**] Clinic at [**Telephone/Fax (1) 9941**]. 11. Hydromorphone p.r.n. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**] Dictated By:[**Last Name (NamePattern1) 9942**] MEDQUIST36 D: [**2139-6-8**] 17:21 T: [**2139-6-8**] 16:38 JOB#: [**Job Number 9943**]

[ "292.81", "201.90", "244.9", "E878.8", "511.0", "515", "008.45", "428.0", "998.12" ]

icd9cm

[ [ [] ] ]

[ "96.72", "34.09", "34.51", "38.93" ]

icd9pcs

[ [ [] ] ]

8530, 8939

8962, 9847

1962, 2564

3589, 8509

2761, 3571

214, 1612

1634, 1936

2581, 2738

80,523

147,471

5918

Discharge summary

report

Admission Date: [**2183-6-17**] Discharge Date: [**2183-6-20**] Date of Birth: [**2101-9-28**] Sex: F Service: MEDICINE Allergies: Nsaids / Sulfa (Sulfonamide Antibiotics) / Aspirin Attending:[**First Name3 (LF) 23347**] Chief Complaint: weakness Major Surgical or Invasive Procedure: Transfusion History of Present Illness: 81F with h/o baseline dementia, prior CVA on coumadin, sent from nursing home with lethargy, AMS, tachypnea found to be severely anemic (HCT 15) and hypoxic with a leukocytosis (13K). Of note, her INR was supertherapeutic to 5.7. She was reportedly guiac negative and CT head, torso failed to localize any bleeding. She was given 2u pRBCs with resultant hypoxia (90% on NRB) c/f TRALI v TACO. Given this concern, she received solumedrol, benadryl, H2 blockade and CPAP with improvement. She was admitted to the MICU where she was noted to be hypothermic and hypotensive. She was started an an IV PPI [**Hospital1 **] and given vitamin K. A family discussion surrounding goals of care ensued which resulted in patient being DNR/I without plan for EGD unless the patient acutely re-bleeds at which time the family would want her to have an urgent EGD with known high likelihood that she would end up intubated thereafter. . While in the unit, she had 2 large black BMs with a 5 point Hct drop for which she was transfused 1 u pRBCs. She remained hemodynamically stable. The overall plan at time of discharge from the MICU was to stabilize the patient and send her back to the NH with hospice if logistically able to do so. Palliative care was involved. . ROS: + pain in right foot but otherwise unable to obtain Past Medical History: - HTN - DM2 - h/o CVA with residual right side weakness and left peripheral visual field loss - breast cancer - s/p dual chamber [**Company **] pacemaker implantation for unclear indication with recent battery replacement - depression - chronic back pain - h/o CAD - h/o duodenal ulcer per son Social History: Lives in [**Hospital1 **]. Was a home maker. Has three children. Family History: Unable to obtain from patient. Physical Exam: Upon admission to MICU: General: pale, lethargic, wearing CPAP. HEENT: Sclera anicteric, MM dry Neck: supple, no LAD Lungs: Clear to auscultation anteriorly, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: cool, weakly dopplerable LE pulses . Upon transfer to the floor: Vitals: T: 96.2 BP: 118/50 P: 71 R: 25 O2: 93% RA, 99% 2L General: pale, lethargic, tachypneic although NAD. HEENT: Sclera anicteric, MM dry Neck: supple, no LAD, no JVD although limited exam Lungs: Clear to auscultation anteriorly, no wheezes, rales, ronchi CV: V-paced on monitor, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: cool, weakly dopplerable LE pulses; 1 * 1 cm dry ulceration on lateral malleolus Pertinent Results: [**2183-6-17**] 05:57PM TYPE-[**Last Name (un) **] PH-7.22* COMMENTS-GREEN TOP [**2183-6-17**] 05:57PM LACTATE-1.5 [**2183-6-17**] 05:57PM freeCa-1.01* [**2183-6-17**] 05:39PM HCT-34.2* [**2183-6-17**] 05:39PM PT-16.8* PTT-25.2 INR(PT)-1.5* [**2183-6-17**] 01:45PM HCT-34.9*# [**2183-6-17**] 01:45PM PT-18.6* PTT-26.4 INR(PT)-1.7* [**2183-6-17**] 05:00AM ALT(SGPT)-22 AST(SGOT)-25 CK(CPK)-82 ALK PHOS-135* TOT BILI-0.2 [**2183-6-17**] 05:00AM CK-MB-NotDone cTropnT-0.06* [**2183-6-17**] 05:00AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0 LEUK-TR [**2183-6-17**] 05:00AM URINE RBC-0-2 WBC-[**3-13**] BACTERIA-RARE YEAST-NONE EPI-0 [**2183-6-17**] 01:40AM WBC-11.6* RBC-1.85* HGB-4.6* HCT-14.9* MCV-81* MCH-25.0* MCHC-31.1 RDW-16.6* [**2183-6-17**] 01:40AM PLT COUNT-476* [**2183-6-17**] 01:40AM PT-50.2* PTT-31.3 INR(PT)-5.7* [**2183-6-16**] 11:45PM GLUCOSE-196* UREA N-67* CREAT-1.3* SODIUM-135 POTASSIUM-4.9 CHLORIDE-104 TOTAL CO2-23 ANION GAP-13 [**2183-6-16**] 11:45PM WBC-13.0*# RBC-1.89*# HGB-4.8*# HCT-15.0*# MCV-80* MCH-25.5* MCHC-31.9 RDW-17.6* [**2183-6-16**] 11:45PM NEUTS-71.3* LYMPHS-23.4 MONOS-4.5 EOS-0.5 BASOS-0.4 [**2183-6-16**] 11:45PM PLT COUNT-530*# [**2183-6-16**] 11:45PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-0.2 PH-5.0 LEUK-SM [**2183-6-16**] 11:45PM URINE RBC-0 WBC-[**3-13**] BACTERIA-RARE YEAST-NONE EPI-0-2 . CT Head [**6-17**]: 1. Slightly motion-limited study without evidence of acute intracranial abnormalities. If there is a clinical concern for an acute infarction, MRI would be a more sensitive study. 2. Extensive chronic small vessel ischemic disease. . CT Torso [**6-17**]: 1. No retroperitoneal hematoma or fluid collection in the abdomen or pelvis to explain hematocrit drop. 2. No bowel abnormality. 3. Large diaphragmatic defect with herniation of stomach and transverse colon, as fully imaged on concurrently obtained chest CT. 4. Evidence of prior granulomatous disease. 5. Extensive atherosclerotic calcifications. . CXR [**6-17**]: No evidence of fluid overload. Increased opacity at the right lung base likely reflects increased fluid within herniated loops of bowel. However, small right pleural effusion cannot be excluded. . MICRO: MRSA SCREEN (Final [**2183-6-19**]): POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. . URINE CULTURE (Final [**2183-6-18**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. . URINE CULTURE (Final [**2183-6-19**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. Brief Hospital Course: 81 YO F w dementia, depression, CVA on coumadin, h/o duodenal ulcer who presented on [**6-17**] with GI bleeding, anemia from blood loss, and lethargy in the setting of a supertherapeutic INR s/p stabilization with blood products and vitamin K. . # GI bleed. Likely upper GI bleeding (duodenal ulcer?). Dual antiplatelet therapy, coumadin, and SSRI (antiplatelet property) have also contributed to the bleeding tendency. She should be off antiplatelet and anticoagulation therapy, considering that her immediate risk of rebleeding seems higher than her risk of stroke. No EGD was done, considering her goals of care. Her hematocrit remained stable for 48 hours prior to discharge. She should remain off aspirin, plavix and coumadin and should continue to take protonix [**Hospital1 **]. . # UTI. Given foley placement in the ICU, patient should complete a 7 day course of cipro to finish on [**6-25**]. . # Pressure ulcer and arterial ulcer. Followed as an outpatient in vascular clinic. Seen by wound care with recs provided elsewhere in this document. . # Delirium and dementia. Delirium resolved. But she remains at risk for delirium and should refrain from risky medications such as narcotics. She should receive standing tylenol for pain control as well as lidocaine patch and should refrain from narcotics as much as possible. She should also receive a stable bowel regimen and frequent reorientation. . # Depression. She has long standing depression and flat affect at baseline. SSRI was stopped given anti-platelet effect. Remeron and abilify may be continued. She should have further outpatient evaluation and treatment of her depression to improve her overall quality of life. Medications on Admission: fentanyl 25mcg/hr patch q72hr fluoxetine 40mg po qdaily levothyroxine 25mcg po qdaily lidoderm 5% patch qdaily (on 9am, off 9pm) lovastatin 20mg po qdaily mirtazapine 45mg po qdaily mvi abilify 2mg po qdaily aspirin 325mg po qdaily diovan 160mg po bid oxycodone 5/325mg x 2tabs qhs pindolol 10mg po bid plavix 75mg po qdaily bisacodol 10mg pr prn combivent inhaler q4hr prn colace prn oxycodone 5/325 2 tabs po tid prn pain trazadone 25mg po qhs NPH 8U SC BID RISS coumadin 3.5 or 2.5 mg po qdaily Discharge Medications: 1. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 2. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for back pain: 12 hours on, 12 hours off. Adhesive Patch, Medicated(s) 4. Lovastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 5. Mirtazapine 45 mg Tablet Sig: One (1) Tablet PO once a day. 6. Multivitamin Tablet Sig: One (1) Tablet PO once a day. 7. Abilify 2 mg Tablet Sig: One (1) Tablet PO once a day. 8. Diovan 160 mg Tablet Sig: One (1) Tablet PO twice a day: hold for SBP < 100 . 9. Pindolol 10 mg Tablet Sig: One (1) Tablet PO twice a day: hold for SBP < 100 or HR <55. 10. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO every 4-6 hours as needed for pain. 11. Bisacodyl 10 mg Suppository Sig: One (1) supp Rectal once a day as needed for constipation. 12. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: [**1-10**] Puffs Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 14. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO at bedtime as needed for insomnia. 15. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Eight (8) u Subcutaneous twice a day. 16. Insulin Lispro 100 unit/mL Solution Sig: 1-8 units Subcutaneous ASDIR (AS DIRECTED): as needed per sliding scale . 17. Ciprofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 11 doses. 18. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Discharge Disposition: Extended Care Facility: [**Hospital1 **] Discharge Diagnosis: Primary: GI bleed Urinary Tract Infection Secondary: Dementia Depression CVA with residual right-sided weakness Discharge Condition: Fair. Hemodynamically stable. Alert and oriented times three. Discharge Instructions: You were admitted to the hospital for fatigue and decreased alertness. You were found to have severe, profound anemia. You were given blood products and your anemmia improved. Given your wishes relayed through your healthcare proxy, an EGD was not done so the exact location of your bleed is unknown. You should stop taking aspirin, plavix and coumadin given the life-threatening nature of your bleed. You were also noted to have a urinary tract infection. You were started on an antibiotic called ciprofloxacin which you should continue for a total of seven days (day 1 = [**6-18**]). . Your two new medications are cipro (for urine infection) and protonix (to protect your stomach and prevent further bleeding). . Medications like fluoxetine have been shown to increase bleeding risk so this medication was stopped. You should discuss this further with your nursing home providers. You may otherwise continue your other mood related medications. . Please discuss with your nursing home care providers or return to the hospital should you experience shortness of breath, worsening fatigue, chest pain or pressure, cough or throw up blood, notice dark tarry or bright red blood in your stool or from your rectum, pain with urination or any other concerning symptoms. Followup Instructions: Dr [**Last Name (STitle) **] is aware of your hospitalization and will follow up with you at your nursing home. Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2183-7-9**] 9:30 [**Name6 (MD) **] [**Last Name (NamePattern4) 23348**] MD, [**MD Number(3) 23349**]

[ "707.03", "799.02", "V64.2", "578.9", "437.0", "599.0", "V58.61", "707.07", "790.92", "785.59", "707.22", "311", "707.21", "707.06", "532.70", "290.40", "288.60", "250.00", "285.1", "V45.01", "401.9", "707.23", "V10.3" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9818, 9861

5838, 7528

321, 334

10018, 10082

3107, 5815

11397, 11733

2089, 2121

8076, 9795

9882, 9997

7554, 8053

10106, 11374

2136, 3088

273, 283

362, 1673

1695, 1991

2007, 2073

25,303

116,159

5018

Discharge summary

report

Admission Date: [**2197-6-5**] Discharge Date: [**2197-6-14**] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Positive ETT Major Surgical or Invasive Procedure: [**2197-6-7**] Three Vessel Coronary Artery Bypass Grafting(LIMA to LAD with vein grafts to Ramus and PLV) and Aortic Valve Replacement utilizing a 23 millimeter CE pericardial tissue valve. History of Present Illness: Mr. [**Known lastname 1683**] is a pleasant 82 year old gentleman with known coronary artery disease, prior MI and PCI in the past. An ETT in [**2197-5-22**] depressions but negative for chest pain. Nuclear imaging showed a dilated LV with an ejection fraction of 24%. There was a large inferior and inferolateral fixed defect with a large reversible apical defect. Based upon the above results, he was referred for repeat cardiac catheterization. On admission, he denied chest pain, SOB, fatigue, syncope, palpitations and pedal edema. He reported one episode of dizziness which lasted only several seconds approximately one week prior to this admission. Past Medical History: Ischemic Cardiomyopathy, EF 24% CAD and AS History of MI and RCA stent [**2188**] Hyperlipidemia HTN BPH Prior Hernia repairs Social History: Married with 3 children. He denies tobacco and excessive ETOH. Family History: Denies premature CAD. Physical Exam: Vitals: BP 127/76, HR 75, RR 14, SAT 97%on room air General: well developed elderly male in no acute distress HEENT: oropharynx benign, Neck: supple, no JVD, Heart: regular rate, normal s1s2, 3/6 systolic murmur Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, no edema, no varicosities Pulses: 2+ distally Neuro: alert and oriented, nonfocal Pertinent Results: [**2197-6-5**] 11:20AM BLOOD WBC-8.4 RBC-4.24* Hgb-13.0* Hct-38.1* MCV-90 MCH-30.6 MCHC-34.0 RDW-12.7 Plt Ct-234 [**2197-6-5**] 11:20AM BLOOD PT-15.5* PTT-65.0* INR(PT)-1.4* [**2197-6-5**] 11:20AM BLOOD Glucose-174* UreaN-12 Creat-0.9 Na-134 K-3.9 Cl-102 HCO3-22 AnGap-14 [**2197-6-5**] 11:20AM BLOOD ALT-14 AST-24 CK(CPK)-71 AlkPhos-61 Amylase-81 TotBili-0.8 [**2197-6-5**] 11:20AM BLOOD %HbA1c-5.9 [Hgb]-DONE [A1c]-DONE [**2197-6-13**] 07:10AM BLOOD Hct-36.9* [**2197-6-11**] 04:55AM BLOOD WBC-13.4* RBC-3.90*# Hgb-11.9* Hct-34.0* MCV-87 MCH-30.6 MCHC-35.1* RDW-14.4 Plt Ct-108*# [**2197-6-13**] 07:10AM BLOOD UreaN-23* Creat-1.3* K-3.9 [**2197-6-11**] 04:55AM BLOOD Glucose-104 UreaN-21* Creat-1.0 Na-133 K-3.7 Cl-95* HCO3-26 AnGap-16 [**2197-6-10**] 08:53AM BLOOD HEPARIN DEPENDENT ANTIBODIES- negative Brief Hospital Course: Mr. [**Known lastname 1683**] was admitted and underwent cardiac catheterization which was significant for severe three vessel coronary artery, including left main disease, and severe ischemic cardiomyopathy. Coronary angiography demonstrated a right dominant system with an 80% left main lesion; 60% mid LAD stenosis; diffuse diagonal disease; 85% lesion in the first OM; and 95% PLV stenosis. The RCA stents were widely patent. Left ventriculography showed an LVEF of 25% and no mitral regurgitation. Angiography was also notable for a self limited retrograde dissection of the commom iliac artery which required no intervention. Based on the above results, cardiac surgery was consulted for surgical revascularization and further evaluation was performed. An echocardiogram showed moderate to severe aortic stenosis with [**First Name8 (NamePattern2) **] [**Location (un) 109**] of 0.7cm2 with peak and mean gradients of 35 and 19 mmHg respectively. The LVEF was estimated between 35-40%. A carotid ultrasound demonstrated minimal disease of both internal carotid arteries. The rest of his preoperative hospital course was unremarkable except for occasional runs of asymptomatic NSVT. He remained pain free on medical therapy. On [**6-7**], Dr. [**Last Name (STitle) **] performed three vessel coronary artery bypass grafting and a pericardial aortic valve replacement. Following the operation, he was brought to the CSRU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated. Initially hypoxic, required steady diuresis. He maintained stable hemodynamics and was gradually weaned from inotropic support. He was intermittently transfused with PRBC to keep hematocrit near 30%. Amiodarone was initially utilized to prevent atrial arrhythmias. His CSRU course was otherwise uneventful and he transferred to the SDU on postoperative day three. His platelet count dropped as low as 70K. HIT assays were checked and negative for heparin PF4 antibodies. Throughout his hospital stay, he remained thrombocytopenic but his platelet count did improve prior to discharge. He experienced some urinary retention for which he was started on Flomax. Prior to discharge, his foley was *****. His postoperative course was otherwise uneventful. He continued to maintain stable hemodynamics and remained in a normal sinus rhythm. Given no occurence of atrial arrhythmias, Amiodarone was eventually discontinued. Given his depressed LV function, he was maintained on Coreg, Captopril and diuretics. He tolerated medical therapy. Due to continued clinical improvements, he was cleared for discharge on postoperative day 7. He had a 400cc residual and had a foley catheter placed prior to d/c. He will follow up with Dr. [**Last Name (STitle) 770**] of urology in 1 week for foley removal. Medications on Admission: Zocor 40qd, Captopril 25 qd, Terazosin 5 qd, Aspirin 325 qd, MVI, Vit E, Vit C Discharge Medications: 1. Terazosin 5 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Disp:*30 Capsule(s)* Refills:*2* 2. Tamsulosin 0.4 mg Capsule, Sust. Release 24HR Sig: One (1) Capsule, Sust. Release 24HR PO HS (at bedtime). Disp:*30 Capsule, Sust. Release 24HR(s)* Refills:*2* 3. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*60 Cap(s)* Refills:*2* 5. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*60 Capsule(s)* Refills:*2* 6. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(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. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 9. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 10. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*1 MDI* Refills:*2* 11. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day). Disp:*1 MDI* Refills:*2* 12. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 13. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 14. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day for 14 days. Disp:*14 Tablet(s)* Refills:*0* 15. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 14 days. Disp:*14 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: CAD and AS - s/p CABG and AVR History of MI and RCA stent [**2188**] Hyperlipidemia HTN BPH Right Iliac Dissection Prior Hernia repairs NSVT Urinary Retention Thrombocytopenia Discharge Condition: Good Discharge Instructions: Patient may shower, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Monitor wounds for signs of infection. Please call with any concerns or questions. Followup Instructions: Dr. [**Last Name (STitle) **], cardiac surgeon in [**4-26**] weeks Dr. [**Last Name (STitle) 6700**], PCP [**Last Name (NamePattern4) **] [**2-24**] weeks Dr. [**Last Name (STitle) **], cardiologist in [**2-24**] weeks [**Hospital Ward Name 121**] 2 in 2 weeks for wound check Completed by:[**2197-6-14**]

[ "443.22", "424.1", "600.01", "287.5", "V45.82", "401.9", "414.01", "412", "427.89", "272.4" ]

icd9cm

[ [ [] ] ]

[ "57.94", "39.61", "35.21", "88.53", "36.15", "99.07", "57.95", "37.22", "88.72", "36.12", "99.04", "88.56" ]

icd9pcs

[ [ [] ] ]

7466, 7521

2676, 5489

280, 473

7741, 7748

1845, 2653

8066, 8374

1404, 1427

5618, 7443

7542, 7720

5515, 5595

7772, 8043

1442, 1826

228, 242

501, 1158

1180, 1308

1324, 1388

81,432

190,359

40461

Discharge summary

report

Admission Date: [**2128-5-30**] Discharge Date: [**2128-6-15**] Date of Birth: [**2087-3-5**] Sex: M Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 618**] Chief Complaint: R thalamic hemorrhage Major Surgical or Invasive Procedure: None History of Present Illness: The pt is a 41 year-old primarily Spanish speaking man with no reported PMH who is transferred from an OSH for a right thalamic hemorrhage. He reports that he was sitting at his computer earlier today when he developed sudden onset of the feeling of dizziness, followed quickly by weakness and loss of sensation in the left side of his body. He was able to get to the telephone and called his friend who took him to [**Hospital6 23267**]. There he was found to have a blood pressure of 197/129. He was given metoprolol 5mg x2, then started on a nitroglycerin drip, which brought him down to 155/90. He had a NCHCT which showed a 1.8x2.5cm right thalamic hemorrhage, at which point the decision was made to transfer him to [**Hospital1 18**] for further evaluation. The patient denies headache currently, though reports that he does often get headaches, which he describes as a diffuse non-specific pain that happens several times/month. He will usually take aspirin for these, with some relief, but the last headache was several days ago. On neuro ROS, the pt denies loss of vision, blurred vision, diplopia, dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or hearing difficulty. Denies difficulties producing or comprehending speech. No bowel or bladder incontinence or retention. On general review of systems, the pt denies recent fever or chills. No night sweats or recent weight loss or gain. Denies cough, shortness of breath. Denies chest pain or tightness, palpitations. Denies nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denies arthralgias or myalgias. Denies rash. Past Medical History: - ? HTN (patient denies when asked) - Headaches, several times/month, last was several days ago, usually takes aspirin with resolution. Social History: Lives in [**Hospital1 487**] with his girlfriend. [**Name (NI) 1403**] in a restaurant. Smokes [**2-15**] cigarettes/week. Drinks occasional EtOH. No illicits. Family History: her died at age 74 of CAD. Father is deceased, but he does not remember from what. Physical Exam: Vitals: T: 99.3 P: 87 R: 18 BP: 147/94 SaO2: 98% on RA General: Awake, cooperative, NAD. HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: 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 pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -Mental Status: Alert, oriented x 3 though somewhat slow to respond. Able to relate history without difficulty with the help of a Spanish interpretor. Language is fluent with intact repetition and comprehension. Normal prosody. There were no paraphasic errors. Pt. was able to name both high and low frequency objects. Speech was not dysarthric. Able to follow both midline and appendicular commands. -Cranial Nerves: I: Olfaction not tested. II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: EOMI without nystagmus. Normal saccades. V: Facial sensation intact to light touch and pinprick on the right, absent on the left VII: Left sided facial droop VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [**Doctor First Name 81**]: 5/5 strength in trapezii on the right, [**4-17**] on left. XII: Tongue protrudes in midline. -Motor: Normal bulk, tone throughout. Has difficulty controlling the left arm, and is not able to position it appropriately to assess for pronator drift. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB L 3 4+ 4 4+ 5 4+ 5- 4+ 5 4 4 5 4 4 R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 -Sensory: Decreased light touch, pinprick, temperature and proprioception on the left side of face arm and leg, extending into the torso. Decreased vibration in the left hand and foot. -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 2 2 2 2 2 R 2 2 2 2 1 Plantar response was flexor on the right, extensor on the left. -Coordination: No dysmetria on FNF on the right, unable to perform on the left. -Gait: Deferred given left leg weakness Pertinent Results: Laboratory Data on admission: 142 | 103 | 12 ---------------< 92 4.3 | 27 | 0.8 15.8 13.7 >------< 228 45.6 PT: 12.4 PTT: 22.7 INR: 1.0 IMAGING: [**2128-6-8**] NCHCT: 1. Stable right thalamic hemorrhage, surrounding edema and mild mass effect. 2. No evidence of new intracranial abnormalities. [**2128-6-6**] NCHCT: Unchanged right thalamic hemorrhage. Decreased density of intraventricular blood. [**2128-6-4**] NCHCT: Stable appearance of the right thalamic hemorrhage without evidence of progression or new intracranial hemorrhage. [**2128-5-31**] NCHCT: Stable size of right thalamic hemorrhage, with effacement of third ventricle and atrium, but no significant mass effect. [**2128-5-30**] NCHCT: Acute right thalamic hemorrhage measuring 1.8 x 2.5 cm with mild surrounding edema. [**2128-6-2**] Renal US: 1. Normal son[**Name (NI) 493**] appearance of the kidneys with no hydronephrosis. Limited renal Doppler ultrasound as described with no evidence for renal artery stenosis. 2. Echogenic liver consistent with fatty infiltration. Other forms of liver disease and more advanced liver disease including significant hepatic fibrosis/cirrhosis cannot be excluded on this study. [**2128-6-2**] CXR: Mild tortuosity of the thoracic aorta, no mediastinal or hilar abnormalities. Brief Hospital Course: Brief summary: The pt is a 41 year-old Spanish speaking man with no reported PMH (though likely hypertension) presenting following acute onset of dizziness followed by left sided weakness and numbness, found to have a 1.8 x 2.5 cm right thalamic hemorrhage. Exam is notable for weakness and poor control of the left face, arm and leg, as well as loss of sensation to all modalities over the left face, arm and leg. Given the initial blood pressure of 197/129 on arrival to the OSH, and location of the hemorrhage, suspect the most likely etiology is hypertensive. Neurologic: - Patient was admitted to Neuro ICU and then transferred to the floor. While on the floor he did have 1 brief generalized seizure lasting less than 1 minute in time. He was started on Keppra, however the etiology of the seizure was unclear and may have been related to EtOH withdrawl. There was no subsequent seizure activity. Last head CT in AM [**6-6**] Stable right thalamic hemorrhage, surrounding edema and mild mass effect without significant change. He was started Fluoxetine for depression and Trazadone for sleep. Cardiovascular: - He was initially kept an SBP<160. Has become relatively hypotensive. Amolodipine decreased from 10 mg to 5 mg. He was continue coreg 12.5mg [**Hospital1 **]. His trop x3 neg on admission and Orthostatics negative. Nutrition: - He was kept on a low calorie diet (1800 calories) and given a bowel regimen Endocrine: - Blood glucose was controlled with an insulin sliding scale and his goal BS<150. He was kept on the following prophylaxis: - DVT: boots / Heparin 5000 UNIT SC TID - Stress ulcer: Famotidine 20 mg PO/NG [**Hospital1 **] Medications on Admission: - Aspirin PRN for headaches, last several days ago. Discharge Medications: 1. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 2. famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day. 3. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. levetiracetam 750 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. tizanidine 2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Discharge Disposition: Extended Care Facility: [**Hospital3 4339**] Discharge Diagnosis: Right thalamic hemorrhage 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 **], You were admitted for a right thalamic bleed. This was thought to be secondary to your hypertension. Your stroke risk factors were checked. You should not smoke. Your cholesterol was 180. You were checked for blood glucose control with a HgB A1c. The level was 6.2. You need to continue your blood pressure control. You should continue to eat a low fat healthy diet, and follow up with your primary care physician. It was a pleasure taking care of you. Followup Instructions: Please follow-up with your primary care doctor as needed. [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**] Completed by:[**2128-6-15**]

[ "311", "458.29", "342.90", "305.1", "348.5", "401.9", "780.39", "305.00", "E942.6", "431" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8452, 8499

6172, 7841

325, 331

8569, 8569

4842, 4858

9267, 9448

2388, 2474

7943, 8429

8520, 8548

7867, 7920

8745, 9244

3427, 4823

2489, 3003

264, 287

359, 2033

4873, 6149

8584, 8721

2055, 2192

2208, 2372

14,386

128,762

18210

Discharge summary

report

Admission Date: [**2145-8-17**] Discharge Date: [**2145-8-28**] Date of Birth: Sex: Service: CCU MED HISTORY OF PRESENT ILLNESS: The patient is an 83 year old female with diabetes, hypertension, dyslipidemia admitted to outside hospital for COPD flareup. The patient initially did well with nebulizers, but on [**8-12**] became acutely short of breath with ABG of 7.13 and was intubated. The patient had been started on doxycycline for right lower lobe infiltrate and then started on IV ceftriaxone and azithromycin. CTA was negative for PE. EKG demonstrated atrial fibrillation and concern regarding biphasic T waves. The patient was started on IV hydration and nitroglycerin. The patient was ruled out for MI by negative enzymes. The patient with episodes RAF, PAT, ST, heart rate of 130. Treated with IV Lopressor and Cardizem. Echo on [**8-12**] demonstrated mildly depressed LV function with an ejection fraction of 55 percent. Aortic stenosis valve area 0.6, mean gradient 25, peak gradient 50. BMP was moderately elevated at the outside hospital. The patient was transferred for COPD exacerbation. PAST MEDICAL HISTORY: Dyslipidemia,, hypertension, RA, diabetes type 2, COPD, osteoporosis. ALLERGIES: Codeine, quinolones. MEDICATIONS: Ceftriaxone, azithromycin, albuterol, Atrovent, Solu-Medrol, RISS, aspirin, Norvasc, Singular, heparin, Flovent. SOCIAL HISTORY: The patient lives at home. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: Vital signs 96, 145/53, 57 on assist control 600, 14, 0.5, CVP 20, PAP 40/30, 33 to 15 now. In general, sedated and intubated. HEENT right pupil surgical. Left was reactive to light. Chest bibasilar crackles. CV irregular, [**2-4**] holosystolic murmur at the apex. Abdomen soft, nondistended, nontender, positive bowel sounds. Extremities 1+ edema bilaterally. Lines right Swan IJ. LABORATORY DATA: On admission d-dimer was greater than 1000. Hematocrit 30.7. EKG showed atrial tachycardia. HOSPITAL COURSE: 1. Coronaries. Coronaries were clean by recent catheterization. The patient was on aspirin, but was changed to Plavix given history of COPD and a reaction to aspirin causing COPD to flare. The patient was held on all beta blockers, given beta agonists for COPD. However, the patient was continued on ACE inhibitors. 2. Myocardium. Ejection fraction 50 percent. The patient's ACE inhibitor was titrated upward and the patient had a Swan in and volume status was titrated accordingly. 3. Aortic stenosis. The patient's valvular disease was severe, but not critical which was likely contributing to her CHF. There were no active issues during that time. 4. Rhythm. MAT occasional COPD with enlarged right atrium. The patient's rate was controlled with diltiazem drip which was changed to p.o. diltiazem as the patient tolerated. 5. Pulmonary. The patient was on the CCU service and at the end of hospitalization was transferred to the MICU service. The patient came in with COPD exacerbation, intubated and sedated. The patient was started on methylprednisolone, inhalers and nebs as scheduled. The patient was then extubated successfully, however, was transferred to the MICU because the patient had worsening COPD exacerbation on steroids and scheduled albuterol and Atrovent q.two hours. In the MICU the patient's COPD exacerbation continued to worsen despite maximal therapy with nebulizers and steroids. MICU intern documented that the patient was changed to comfort measures only after discussion with the family. At that time, three hours later, at 3:51 in the morning, the patient was found with cease of respirations. The patient's likely cause of death was COPD exacerbation. 6. ID. The patient had vent acquired pneumonia and was treated with antibiotics. 7. Aortic stenosis. The patient was not a surgical candidate throughout this hospitalization. DISPOSITION: The patient died on the MICU service, cause being COPD exacerbation. DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-953 Dictated By:[**Dictator Info **] MEDQUIST36 D: [**2145-10-14**] 08:22 T: [**2145-10-14**] 08:35 JOB#: [**Job Number 50308**]

[ "427.89", "518.81", "038.9", "491.21", "482.41", "428.30", "428.0", "112.0", "424.1" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.72", "33.22", "38.91", "88.53", "88.56", "99.15", "37.23" ]

icd9pcs

[ [ [] ] ]

1467, 1485

2027, 4225

1508, 2010

161, 1149

1172, 1405

1422, 1450

11,860

148,412

22989

Discharge summary

report

Admission Date: [**2200-6-11**] Discharge Date: [**2200-8-29**] Date of Birth: [**2134-9-28**] Sex: F Service: MEDICINE Allergies: Dapsone / Cyclosporine / Cefepime Attending:[**First Name3 (LF) 3913**] Chief Complaint: Allogenic transplant for lymphoma. Major Surgical or Invasive Procedure: Hickman placement-changed over wire on [**2200-8-19**] Chemotherapy Stem cell infusion Bronchoscopy Intubation x2 History of Present Illness: This is a 65 year old woman with recurrent large cell lymphoma first diagnosed in [**6-10**], s/p 6 cycles of R-CHOP in [**12-12**], recurrence in fall of [**2198**], s/p ICE x 3 and ESHAP ([**1-13**]). She was recently discharged from our [**Month/Year (2) 3242**] for auto-[**Month/Year (2) 3242**] in [**3-13**] (CBV), but showed residual disease on PET with a large retroperiotneal mass (bx c/w follicular lymphoma). The pt has been undergoing radiation to that area and is being admitted now to the [**Date Range 3242**] for allogenic transplant with a sibling matched donor (her brother [**5-13**] match). She had occasionally hot flashes last typically 1-2 mins, when she was here in [**3-13**], which has gotten better the past two weeks. She denied any fever, chill, night sweats, headache, visual changes, skin rashes, mucosities, chest pain, SOB, cough, abdominal pain, N/V/D, constipation or any other urinary symptoms, and claimed to be pretty healthy all her life other than her lymphoma. . ROS: per HPI, otherwise negative Past Medical History: Oncologic History: Patient was initially diagnosed with lymphoma in [**2198-6-14**], when she noted a preauricular swelling. Patient was seen by her PCP, [**Name10 (NameIs) **] had a biopsy of the node c/w non-Hodgkin's lymphoma, diffuse large B-cell type, and underwent therapy with R-CHOP, with six cycles completed in [**2198-12-8**]. Her disease responded initially, but in [**2199-9-7**], patient noted increase in size of the lymph nodes in her neck and preauricular area, with a follow up PET scan positive for disease recurrence. Patient then underwent treatment with three cycles of ICE. Her 2nd cycle of ICE was complicated by E. coli bacteremia. After completion of her ICE, patient had a PET scan performed, which showed presence of persistent disease, with no change in aortocaval lymph nodes and increased uptake in the parotid area. Her most recent chemotherapy was ESHAP in [**1-/2200**] with stem cell mobilization. She tolerated chemotherapy treatments well, with no significant toxicity. She received an auto-[**Year (4 digits) 3242**] in [**3-13**], and tolerated chemotherapy quite well with complications that included diarrhea, mucositis, bullae on hands, mild nausea, and febrile neutropenia (see below). Hydration, antiemetics, and supportive care were give per [**Month/Year (2) 3242**] protocol. She received her cells on [**2200-3-4**] without complications. She started G-CSF as scheduled on D+4 and she demonstrated improvement of counts around D8-9. A repeat PET scan revealed a large retroperitoneal mass (bx c/w follicular lymphoma). The patient has been undergoing radiation to that area and is admitted now for allogenic transplant. . Other Past Medical History: High cholesterol (was on statin, held since [**2-9**]) Thyroid mass, benign on biopsy, thyroidectomy in [**1-12**], on synthroid. Social History: She smoked for approximately 18 years, quit 30 years ago. At that time she was smoking 1 pack per day. She describes moderate alcohol use with wine occasionally. Married with two daughters. She used to work in the human resources department at [**Last Name (un) 59330**]; however, she has not worked since [**2198-6-7**]. She lives in the [**Location (un) 10059**] area. Family History: Her mom died at the age of 87 of cerebral hemorrhage. Her father died at the age of 48 of malignant hypertension. Her aunt had breast cancer. Her brother died of a massive MI at the age of 66. She has another brother with hypertension and emphysema. Physical Exam: Admission: . VS: T 98.1, BP 130/70, HR 64, RR 18, O2 sat 99% on RA, wt 127lbs, ht 62" Gen: very pleasant women, lying comfortably in bed, in NAD HEENT: PERRL, EOMI, MMM, OP clear w/o erythema or exudate. Neck: Supple. No lymphadenopathy, no JVD, no carotid bruits CV: RRR, Nl s1 and s2. No M/R/G. Lungs: CTAB, no wheezing, rales, or rhonchi. Abd: Soft, NT, ND, NABS, no HSM Ext: 2+ pulses bilateraly, no CCE. Neuro: A&O x 3; 5/5 strength throughout, no focal neuro signs. Pertinent Results: Admission Labs: . [**2200-6-11**] 12:12PM BLOOD WBC-3.0* RBC-2.62* Hgb-9.8* Hct-26.5* MCV-101* MCH-37.5* MCHC-37.0* RDW-18.6* Plt Ct-57* [**2200-6-11**] 12:12PM BLOOD Neuts-69.0 Lymphs-21.0 Monos-8.1 Eos-1.6 Baso-0.4 [**2200-6-11**] 12:12PM BLOOD Anisocy-2+ Poiklo-1+ Macrocy-3+ [**2200-6-11**] 12:12PM BLOOD PT-11.8 PTT-33.9 INR(PT)-1.0 [**2200-6-10**] 12:09PM BLOOD Gran Ct-1760* [**2200-6-11**] 12:12PM BLOOD Glucose-112* UreaN-16 Creat-1.1 Na-144 K-4.1 Cl-107 HCO3-28 AnGap-13 [**2200-6-11**] 12:12PM BLOOD ALT-16 AST-20 LD(LDH)-155 AlkPhos-64 TotBili-0.7 [**2200-6-11**] 12:12PM BLOOD Albumin-4.4 Calcium-9.1 Phos-3.3 Mg-2.0 UricAcd-4.3 . Radiology: CXR ([**2200-6-11**]): The heart size is normal. Mediastinum has normal contour and width. The lungs are clear. The pleural surfaces are smooth with no pleural effusion. Impression: 1. Standard position of two central venous line catheters. 2. No acute cardipulmonary process. . [**7-27**] CXR - Diffuse bilateral hazy patchy opacities with blunting of diaphragms and CP angles. Cardiomegaly. Left hickman terminating in R subclavian. . [**7-25**] CXR - There is increasing radio opacity generally overlying a background of micro nodular opacities suggesting some pulmonary edema. As far as I can see, there has been no CT for the evaluation of questions of small lung nodules raised on prior interpretations of plain radiographs since [**7-7**]. Interval changes probably due to pulmonary edema, but the possibility of disseminated infection is still of concern. Mild cardiomegaly is stable. Tip of a left supraclavicular central venous dual channel catheter projects over the SVC. There is no pneumothorax or appreciable pleural effusion. A right supraclavicular line ends at the superior cavoatrial junction. Findings were discussed by telephone with Dr. [**Last Name (STitle) **]. . CT chest [**7-27**]: Diffuse confluent ground-glass and airspace opacities are seen within the entire lungs bilaterally, with peripheral sparing at the lung bases. Diagnostic considerations include diffuse infectious process from fungal or atypical etiologies, ARDS, or alveolar hemorrhage.With the absence of effusions, failure is thought to be less likely. Multiple lines and ET tube as described above. The ET tube tip is just above the carina. . TTE [**7-7**]: EF 55%. Small circumferential pericardial effusion, without echocardiographic signs of tamponade. Preserved global and regional biventricular systolic function. . TTE [**2200-8-4**]: The left atrium is normal in size. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is probably grossly normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is a very small pericardial effusion. Compared with the prior study (images reviewed) of [**2200-7-7**], mitral regurgitation is probably slightly increased. Aortic regurgitation is unchanged. Images are technically suboptimal for comparison of regional wall motion. . Renal US [**2200-8-10**]: Very limited examination. Visualized intrarenal arteries show no parvus et tardus waveforms, with resistive indices mostly of approximately 0.69-0.74. Mild right-sided hydronephrosis, presumably due to ureteral obstruction by known right-sided retroperitoneal mass. . Chest CT [**2200-8-13**]: Significant interval improvement of diffuse interstitial and alveolar opacities; given the current CT findings and prior comparison studies, findings may represent partially resolving alveolar hemorrhage or ARDS. An improving diffuse infectious process is less likely but remains in the differential. Persisting small bilateral pleural effusions with possible mild component of volume overload. . CT chest/abdomen/pelvis: There are faint diffuse ground-glass opacities bilaterally, but much improved from [**2200-8-13**]. A discrete irregular pulmonary nodule is present within the left upper lobe measuring 10 mm of unclear etiology. This may represent a small focus of persistent inflammatory disease, but malignancy is also a diagnostic consideration. Continued followup (three months) is advised. Bibasilar scarring is again identified. Right Port-A-Cath catheter tip terminates in the right atrium. A left subclavian central venous catheter tip also terminates in the right atrium. The heart is unremarkable. The descending aorta is normally dilated measuring 3.7 cm, but stable from [**2200-5-29**]. No pathologic axillary, hilar, or mediastinal adenopathy is identified, though multiple small hilar lymph nodes are again noted, unchanged. The patient is status post thyroidectomy. CT ABDOMEN WITHOUT CONTRAST: No focal lesions are identified within the non-contrast liver. The gallbladder, pancreas, spleen, stomach, small bowel loops are unremarkable. Again seen is a soft tissue mass encasing the right renal hilum extending to the right psoas muscle, which is not well evaluated on this non-contrast study but has decreased in size compared to [**7-29**], [**2199**]. Though difficult to measure, the mass roughly measures 3.2 x 2.4 cm. There are bilateral parapelvic renal cysts. There is no free air or free fluid. Small bowel loops are normal caliber. CT PELVIS WITHOUT CONTRAST: The rectum is normal. There is diverticular disease of the sigmoid. The large bowel is otherwise unremarkable. The distal ureters and bladder are normal. There are bilateral fat-containing inguinal hernias. No pathologic adenopathy, free air, or free fluid is identified. Brief Hospital Course: This is a 65 year old woman with recurrent NHL, first diagnosed with large cell lymphoma in [**6-10**], s/p 6 cycles of R-CHOP in [**12-12**], recurrence in fall of [**2198**], s/p ICE x 3 and ESHAP ([**1-13**]), s/p auto-[**Month/Year (2) 3242**] in [**3-13**], found to have new lymphoma by PET (bx c/w follicular lymphoma) and radiation, admitted to [**Date Range 3242**] unit for reduced intensity-allogenic [**Date Range 3242**]. Her hospital course for this admission is as follows: . # Lymphoma: Follicular type (less aggressive type than the one she had before Large cell lymphoma) by bx. Patient was readmitted to the [**Date Range 3242**] unit [**2200-6-11**] for allogenic transplant with a sibling matched donor (her brother [**5-13**] match). She underwent allo-[**Month/Day (4) 3242**] with day 0 [**2200-6-18**]. Continued allogenic [**Month/Day/Year 3242**] protocol per Dr [**Last Name (STitle) **]. - Cyclocporin started day 0, then Mon, Wed, Fri. Eventually discontinued due to toxicity - MTX 10mg/m2 IVB day +1, +3, +5 - GCSF 300mcg/day started on day +6, discontinued when ANC was >1000 - Patient was on cyclosporin [**Hospital1 **] dosing, discontinued due to DAH thought to be [**1-9**] cyclosporin - ANC started trending up on [**7-5**], now engrafted ANC 3880 [**2200-8-29**] - CT on [**8-27**] showed interval decrease in size of mass. -Patient now engrafted. -Patient currently on Cellcept for immunosuppression. Will need to be tapered per Dr.[**Name (NI) 3930**] recommendation. . # Fever- Her post-[**Name (NI) 3242**] course was relatively uneventful until [**6-27**], when she started spiking fevers with unclear source. Spiked first fever [**6-27**]. started Cefepime, continued on Fluconazole, and acyclovir; spiked again on [**7-1**], vanc started; spiked again on [**7-2**], vori started; spiked [**Last Name (un) 59331**] on [**7-2**] and [**7-3**] am, new non-blanching petechia noted on [**2200-7-3**], flagyl started on [**7-3**]; continued to spike on [**7-4**] to 103.5, a hypotensive episode on [**7-4**] am, responsive to IV fluids (500ml resuscitation), BP stabilized throughout the day, received >4gm tylenol for fever, rash worsened, CXR clear, RUQ showed no evidence of VOD; [**7-5**]: Rash worse on the chest, face and arms, GVHD vs drug rash, d/C'ed cefepime, and started aztreonam; Cxs continued to be negative to date, CXR has been clear to date, currently on Aztreonam, vanc, acyclovir (PO per ID), vori, flagyl, chest CT (non contrast) on [**7-5**] showed no evidence of infections . On [**7-7**] she became dyspnic and febrile, and CXR demonstrated new central bilateral ground glass and alveolar opacities suggestive of pulmonary edema vs. engraftment syndrome. She became hypoxic and was transferred to the ICU where she was intubated. She was then found to have diffuse alveolar hemorrhage by bronchoscopy on [**7-10**]. She recieved multiple antibiotics including levofloxacin, voriconazole, vancomycin, aztreonam, bactrim, and fluconazole. At the time she received solumedrol 100mg IV x 2d and lasix for possible engraftment syndrome, but had no improvement. She was then placed on solumedrol 1gm IV x 4d for DAH, respiratory status improved, and she was extubated on [**7-15**]. CSA was held given possible DAH [**1-9**] this. She was tranferred to the floor on [**7-22**] and started back on the Cyclosporin. She initially did well and then again dropped her sats into the 70s and had increased mucous/secretions with hemoptysis. She was transferred back to the ICU for hypoxia/hypercarbia where she was intubated for a second time. Her CSA was held again. . While in the ICU her steroids were tapered and she was diuresed as needed with improvement in her oxygenation. She was continued on Acyclovir, Caspofungin and Bactrim for prophylaxis. She was started on Cellcept 500mg tid for immunosuppression given possible DAH [**1-9**] CSA. She was extubated for a second time but continued to have a high oxygen requirement and intermittantly required BIPAP. Her O2 requirements were eventually weaned down enough to come back to the floor on [**8-11**]. Initially on the floor the patient continued to require 4L NC to maintain sats in 90s and with diuresis she was eventually weaned off oxygen. Initially her sats would drop into high 80s with activity but with incentive spirometry and reconditioning her oxygenation imroved. CT chest on [**8-13**] showed significant improvement in her intersitial disease. Her Solumedrol was slowly tapered and now she is on oral Prednisone, 10mg daily. Currently denies SOB and O2 sats 95-98% on RA. . # HTN: While in the ICU Patient's BP began running very high into the 170s. It was thought that it may have been related to cyclosporin, but this has been discontinued 2 weeks prior. Initially her HTN was refractory to medication and she required a labetolol drip for about 20 hours. She was then continued on Clonidine patch, Norvasc 10mg daily, Metoprolol 100mg tid and Hydralazine 10mg tid. Because the patient's hypertension had been so refractory, there was a question of the possibility of renal artery stenosis secondary to past radiation versus extension of known retroperitoneal mass involving the right renal hilum. Renal duplex to check for renal artery stenosis was performed [**8-10**] but was a suboptimal study and could not rule out the possibility of RAS. Renal consult was obtained to evaluate for cause of malignant HTN. Renal thought that the high blood pressure was more likely caused in the setting of ARF while in ICU. She had a bump in her creatinine around the same time as her HTN started. Additionally, renal thought that the presence of her mass near the renal hilum may have also contributed to her malignant hypertension. Cyclosporin is also known to cause HTN but this had been off for 2 weeks. BP on the floor was well-controlled. Hydralazine was discontinued and metoprolol was changed to [**Hospital1 **] dosing and her BP remained stable. MRA to evaluate the renal arteries was deferred as the renal team thought that ARF was more likely cause than stenosis of the renal arteries since her BP noprmalized. -Cont. Clonidine 1 patch, Norvasc, metoprolol 100mg [**Hospital1 **] -[**Month (only) 116**] decrease antihypertensive meds as tolerated. . # Hypercholesterolemia: The patient's statin was held since [**2-10**]. . # Hypothyroidism: Continued synthroid per home regimen. . # Deconditioning: After a prolonged hospital course and long-term steroids the patient became very deconditioned and weak. Once on the floor physical therapy was consulted to assist with her rehabilitation. Initially the patient was very weak and was unable to stand. With the help of PT daily she was eventually able to walk and stand with minimal assistance. She will require more agggressive PT/OT upon discharge but has made progress daily in her strength. Specific attention will need to be placed on endurance training, muscle strength and gait training. . # Thrombocytopenia: After engraftment, the patient's counts came up, however she remained persistantly thrombocytopenic requiring platelet transfusion every 1-2 weeks when her platelets would decrease to less than 20 (she was kept highr than 20 given her h/o DAH). The etiology of her thrombocytopenia was unclear, however BM biopsy on [**8-19**] did show reduced megakaryocytes in her marrow. In addition, it was felt that her Bactrim may also have been contributing so this was changed to Dapsone. On dapsone the patient's LDH increased and her hct dropped, concerning for hemolysis so she was put back on Bactrim but on a M,W,F schedule. Platelets currently 36 and stable. . # FEN: Patient was initially placed on a low bact diet. TPN was started on [**6-26**] due to mucositis. After transfer to the floor the patient began taking more PO and TPN was continued until [**8-21**], at which point her PO intake was sufficient. Her electrolytes were monitored daily and repleted based on the oncology sliding scale. She is currently tolerating her diet with . # Access; Left Hickman (3ports). Changed over a wire by IR on [**2200-8-19**]. . # Code: Full Medications on Admission: synthroid 100mcg PO qday Acyclovir 400mg PO bid (was reduced recently from tid) Discharge Disposition: Extended Care Facility: [**Hospital3 **] Discharge Diagnosis: Primary diagnosis: NHL s/p allogenic stem cell transplant Diffuse alveolar hemorrhage-resolving Secondary Diagnosis: Hypothyroidism HTN Neutropenic fever ARF-now resolved Cyclosporin toxicity Discharge Condition: Pt is in good condition at the time of discharge. afebrile, experiencing no symptoms of chest pain, shortness of breath, dizziness, N/V/D, taking POs, O2 sat 95-98% on RA. Hct 26.2, Plt 36, ANC 3880 Discharge Instructions: If you experience any symptoms of chest pain, shortness of breath, dizziness, fever>100.5F, shaking chills with or withour fever, painful or burning urination, productive cough, sore throat, unusal bleeding or bruising, blood in urine or stool, severe constipation or diarrhea, nausea or vomiting, soreness of the intravenous site or pain at portachath or hickman site, any unusal swelling, sputum production, rash or mouth sores or difficulty swallowing, or any other concerning medical symptoms, please seek medical attention immeidately and call you Hematology/Oncology doctor (call [**Telephone/Fax (1) 8717**]) ask for [**Telephone/Fax (1) 3242**] physician on call Please take all of your medications as prescribed. Please follow up your appointments as scheduled. Followup Instructions: Please follow up with your primary Oncologist Dr. [**Last Name (STitle) **] on [**2200-9-4**]. Please report to [**Hospital Ward Name 23**] 9 by noon for your appointment. Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3920**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2200-9-4**] 12:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], MD Phone:[**Telephone/Fax (1) 3237**] Date/Time:[**2200-9-4**] 12:30 Provider: [**Name10 (NameIs) 3242**] [**Apartment Address(1) 6044**] Date/Time:[**2200-9-4**] 12:30

[ "693.0", "528.0", "516.8", "285.22", "244.1", "584.9", "518.81", "288.0", "202.80", "V15.3", "V58.65", "789.5", "272.0", "E933.1", "401.0" ]

icd9cm

[ [ [] ] ]

[ "99.28", "93.90", "99.15", "96.71", "96.6", "41.03", "00.91", "38.93", "96.72", "96.04", "33.24", "99.05", "99.04", "41.31" ]

icd9pcs

[ [ [] ] ]

18781, 18824

10482, 18650

330, 446

19061, 19263

4541, 4541

20086, 20664

3779, 4034

18845, 18845

18676, 18758

19287, 20063

4049, 4522

255, 292

474, 1517

18963, 19040

4557, 10459

18864, 18942

3243, 3375

3391, 3763

32,180

161,533

33793

Discharge summary

report

Admission Date: [**2171-4-28**] Discharge Date: [**2171-5-2**] Date of Birth: [**2108-8-31**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 348**] Chief Complaint: Transfer from [**Hospital1 **] Detox Center for Alcohol Withdrawal Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 78139**] is a 62 year old male with a history of hypertension and alcohol abuse who presents from [**Hospital1 **] detox center for management of alcohol withdrawal. The patient initially presented to [**Hospital3 10310**] Hospital requesting detoxification. He was transferred to [**Hospital1 **]. On arrival there he was found to be tremulous, tachycardic in the 120s to 130s and hypertensive at 157/97. He received librium 200 mg PO x 1 and was transferred here for more acute management given his hemodynamic instability. He reports that his last drink was on [**2171-4-27**]. He denies a history of withdrawal seizures. He has been admitted to the hospital for alcohol withdrawal more times than he can remember. His most recent admission was a few weeks ago. He has had alcohol associated visual hallucinations and was experiencing these at [**Hospital1 **]. The patient reports that he has been drinking heavily since age 15. He drinks a quart of rum daily and sometimes drinks wine. He has quit for periods of up to 6 months in the past but always resumes drinking because "it is easier to drink." He has tried AA in the past but feels as if this is too big a committment and has lost touch with his sponsors. He also has tried day programs and does not wish to try this option again. He reports that his primary care physician [**Last Name (NamePattern4) **]. [**First Name (STitle) **] is located in [**Location (un) **]. He has not seen this provider in some time and does not wish for Dr. [**First Name (STitle) **] to be contact[**Name (NI) **] about this admission. In the emergency room his initial vitals were T: 99.1, HR: 111, BP: 157/97, RR: 24, 100%. He had a CXR which showed no acute cardiopulmonary process. His EKG showed sinus tachycardia at 102 beats per minute with normal axis, normal intervals and no acute ST segment changes. CBC and electrolytes were within normal lmiits. His serum ethanol level was 76. His toxicology screen was positive for benzodiazepines. His AST was 82 and his ALT was 61. He received valium 10 mg IV x 2, ativan 6 mg x 1 and received erythromycin ointment for his eyes out of concern for conjunctivitis. He also was started on a banana bag. He was transferred to the ICU for further management. In the ICU he was placed on a valium CIWA scale Q3H. He lorazepam 6 mg IV and valium 190 mg PO over a period of 24 hours. He was noted to be tachycardic and tremulous but otherwise was hemodynamically stable. He was evaluated by physical therapy and cleared for discharge home. He is now transferred to the floor for further management. On review of systems he currently denies lightheadedness, dizziness, chest pain, shortness of breath, nausea, vomiting, abdominal pain. He recently had an isolated episode of diarrhea. He denies dysuria, hematuria, leg pain or swelling. He endorses tremulousness which has improved since admission. He denies visual hallucinations since admission. Past Medical History: Hypertension (receives medications from hospital physicians) ETOH abuse depression Social History: Unmarried. Lives alone in an apartment. He has no children. He lost his job for a medical gas company one year ago. Receives small disability check (? spinal cord injury leading to right hand paralysis) and performs odd jobs to support himself. He has been drinking since age 15. Currently drinks 1 quart of rum per day. He has a 20 pack year smoking history and quit 20 years ago. He denies IVDU. He has two siblings but does not get along with them. Family History: Father is alive at age [**Age over 90 **] and has dementia. His mother died at age 86 of a "stomach ulcer operation." There is no family history of alcohol abuse. Physical Exam: Vitals: T: 98.7 BP: 120/84 HR: 100 RR: 18 O2: 98% on RA General: Middle aged male, tremulous, alert, oriented, no acute distress HEENT: sclera mildly injected, clear occular discharge, PERRL, EOMI, MMM, poor dentition, oropharynx clear CV: RRR, S1 + S2, no murmurs, rubs, gallops Resp: clear to ausculation bilaterally, no wheezes, rales, ronchi GI: soft, non-tender, non-distended, +BS, no palpable organomegaly GU: no foley Ext: WWP, 2+ pulses, no c/c/e Neurologic: strength 5/5 throughout, sensation intact across all dermatomes. Finger to nose dysmetria bilaterally. Gait not tested. Pertinent Results: Chemistries: [**2171-4-28**] 04:55AM GLUCOSE-91 UREA N-10 CREAT-0.9 SODIUM-139 POTASSIUM-3.4 CHLORIDE-97 TOTAL CO2-23 ANION GAP-22* [**2171-4-28**] 04:55AM ALT(SGPT)-61* AST(SGOT)-82* LD(LDH)-198 ALK PHOS-48 TOT BILI-1.0 [**2171-4-28**] 04:55AM LIPASE-44 [**2171-4-28**] 04:55AM CALCIUM-8.6 PHOSPHATE-1.3* MAGNESIUM-2.3 Hematology: [**2171-4-28**] 04:55AM WBC-9.3 RBC-4.08* HGB-14.4 HCT-40.3 MCV-99* MCH-35.2* MCHC-35.6* RDW-13.4 [**2171-4-28**] 04:55AM NEUTS-83.8* LYMPHS-12.5* MONOS-2.4 EOS-0.7 BASOS-0.6 [**2171-4-28**] 04:55AM PLT COUNT-197 Toxicology: [**2171-4-28**] 04:55AM ASA-NEG ETHANOL-76* ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG tricyclic-NEG [**2171-4-28**] 04:55AM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEG Urinalysis: [**2171-4-28**] 04:55AM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.026 [**2171-4-28**] 04:55AM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-50 BILIRUBIN-SM UROBILNGN-4* PH-5.0 LEUK-NEG [**2171-4-28**] 04:55AM URINE RBC-0-2 WBC-0-2 BACTERIA-FEW YEAST-NONE EPI-0-2 [**2171-4-28**] 04:55AM URINE HYALINE-0-2 [**2171-4-28**] 04:55AM URINE MUCOUS-MOD EKG: Sinus tachycardia. Non-specific ST-T wave changes. No previous tracing available for comparison. Imaging: AP SEMI-UPRIGHT CHEST: Lung volumes are slightly low. There is mild tortuosity of the thoracic aorta. The heart size is at the upper limits of normal. There is elevation of the right hemidiaphragm. No consolidation is identified. Pulmonary vascularity is not engorged. There are no pleural effusions seen. No displaced fractures are identified. Brief Hospital Course: 62 year old male with a history of hypertension and alcohol abuse who presents with alcohol withdrawal. Alcohol Withdrawal: The patient's last drink was on [**2171-4-27**]. He drinks a quart of rum daily. He has a history of hallucinations but not seizures. He was originally taken to [**Hospital1 **] detoxification center but was noted to have elevated blood pressures and tacycardia and was transferred here for closer medical monitoring. He was originally admitted to the MICU and placed on a valium CIWA scale. His home antihypertensive regimen was restarted. He received multivitamins, thiamine and folate. He showed no further signs of hemodynamic instability. His valium was tapered over the next three days. At the time of discharge he had not required valium for over 24 hours. He was seen and evaluated by physical therapy who was concerned for gait instability and recommended home physical therapy and a walker for balance assistance. He was seen by social work and declined assistance for his alcohol abuse. He will follow up with his primary care physician. Hypertension: The patient's blood pressures were initially elevated on presentation but decreased to baseline once his home antihypertensive regimen was restarted. No changes were made to his outpatient regimen. He was encouraged to see his primary care physician [**Last Name (NamePattern4) **]. [**First Name (STitle) **] to ensure that these medications are being provided by a single physician. Thrombocytopenia: His platelets were noted to nadir at 130 during this admission. The rest of his blood counts were stable. This was felt to be related to his chronic alcohol abuse. At the time of discharge his platelet count was 156. Conjunctivitis: On presentation to the emergency room the patient was reported to have purulent occular discharge. This had improved upon arrival to the general medical floor but he was continued on a five day course of topical erythromycin gel. He completed this course in house. Depression: The patient was noted to have a flat affect during this hospitalization and slightly depressed mood. He did not endorse any homicidal or suicidal ideations. He was continued on his home dose of seroquel and encouraged to follow up with his primary care physician Prophylaxis: He received subcutaneous heparin for DVT prophylaxis. Medications on Admission: Lisinopril 20 mg daily Verapamil 240 mg daily Seroquel 100 mg qhs Discharge Medications: 1. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO Q24H (every 24 hours). 3. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Primary: Alcohol Withdrawal Hypertension Bacterial Conjunctivitis Depression Discharge Condition: Stable. Not showing signs of active withdrawal. Ambulating without assistance. Discharge Instructions: You were seen and evaluated for your alcohol withdrawal. You were treated with valium until it was felt that you were safe to go home. You were counselled regarding the importance of staying sober. You also were treated with topical antibiotics for conjunctivitis. Please take all your medications as prescribed. No changes were made to your medication regimen. Please keep all your follow up appointments as scheduled. Please seek immediate medical attention if you experience any fevers > 101 degrees, chest pain, difficulty breathing, hallucinations, seizures or any other concerning symptoms. Followup Instructions: Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 2398**] [**Last Name (NamePattern1) **] within one week of this hospitalization. His office phone number is [**Telephone/Fax (1) 51661**].

[ "287.5", "401.9", "787.91", "372.30", "311", "291.81", "303.01" ]

icd9cm

[ [ [] ] ]

[ "94.62" ]

icd9pcs

[ [ [] ] ]

9209, 9258

6449, 8810

381, 388

9379, 9462

4793, 6426

10114, 10370

4003, 4168

8927, 9186

9279, 9358

8836, 8904

9486, 10091

4183, 4774

274, 343

416, 3405

3427, 3511

3527, 3987

50,362

187,852

31279+57739+57754

Discharge summary

report+addendum+addendum

Admission Date: [**2181-11-6**] Discharge Date: [**2181-11-17**] Date of Birth: [**2117-12-19**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1406**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: 1.Coronary artery bypass grafting x4 with the left internal mammary artery to left anterior descending artery and reverse saphenous vein graft to the first obtuse marginal artery, second obtuse marginal artery, and diagonal artery. 2. Mitral valve repair with a Medtronics CG Future annuloplasty ring, size 28 mm, model #638R. History of Present Illness: This is a 63-year-old male with a non-ST-elevation myocardial infarction back in 08/[**2181**]. He had ventricular fibrillatory arrest and was defibrillated and intubated. The outside echocardiogram showed anterior hypokinesis and a large left ventricular thrombus. The hypothermic protocol was initiated and he was transferred to [**Hospital1 **] where he underwent a cardiac catheterization and left anterior descending artery stent was placed. He had arrested multiple times which required CPR and defibrillation. He is on maximum pressors and intra- aortic balloon pump was inserted. Eventually a tandem heart was inserted. He recovered from this incident and was discharged on [**2181-9-25**], and presents now with recurrent angina. He subsequently underwent a cardiac catheterization which demonstrated an 80% stenosis of his left main coronary artery and also a 50% mid stenosis of his left anterior descending artery. He had 30% of his right coronary artery. His echocardiogram demonstrated mild lesion or left ventricular systolic dysfunction with hypokinesis of the mid and distal anterior septal and inferior septal segments. He had trivial mitral regurgitation. Dr.[**Last Name (STitle) **] was consulted for coronary artery bypass. He also had developed a right groin pseudoaneurysm which had been stable, and vascular surgery was consulted who felt that this could be managed electively Past Medical History: Anxiety attacks GERD SEIZURES HTN Social History: Married, wife [**Name (NI) **]. -[**Name2 (NI) 1139**] history: unknown -ETOH: recent heavy use -Illicit drugs: unknown Family History: pt unable to provide Physical Exam: Admission Physical Exam Pulse:57 Resp:17 O2 sat:96/RA B/P Right:118/61 Left: 128/72 Height: 5'[**82**]" Weight:169 lbs General: Skin: Dry [] intact [] HEENT: PERRLA [] EOMI [] Neck: Supple [] Full ROM [] Chest: Lungs clear bilaterally [] Heart: RRR [] Irregular [] Murmur Abdomen: Soft [] non-distended [] non-tender [] bowel sounds + [] Extremities: Warm [], well-perfused [] Edema Varicosities: None [] Neuro: Grossly intact Pulses: Femoral Right: Left: DP Right: Left: PT [**Name (NI) 167**]: Left: Radial Right: Left: Carotid Bruit Right: Left: Pertinent Results: [**2181-11-13**] 04:46AM BLOOD WBC-19.3* RBC-3.49* Hgb-10.7* Hct-30.4* MCV-87 MCH-30.7 MCHC-35.2* RDW-16.2* Plt Ct-128* [**2181-11-6**] 06:58PM BLOOD WBC-7.8 RBC-4.14* Hgb-12.3* Hct-38.2* MCV-92 MCH-29.6 MCHC-32.1 RDW-15.2 Plt Ct-182 [**2181-11-12**] 02:54PM BLOOD PT-15.1* PTT-44.1* INR(PT)-1.3* [**2181-11-6**] 06:58PM BLOOD PT-27.3* PTT-150* INR(PT)-2.7* [**2181-11-13**] 04:46AM BLOOD Glucose-104* UreaN-14 Creat-0.9 Na-139 K-4.2 Cl-108 HCO3-24 AnGap-11 [**2181-11-6**] 06:58PM BLOOD Glucose-100 UreaN-12 Creat-1.1 Na-144 K-4.8 Cl-107 HCO3-30 AnGap-12 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 73783**] (Complete) Done [**2181-11-12**] at 11:56:04 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 18**] - Department of Cardiac S [**Last Name (NamePattern1) 439**], 2A [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2117-12-19**] Age (years): 63 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Chest pain. Coronary artery disease. Left ventricular function. Mitral valve disease. Preoperative assessment. ICD-9 Codes: 414.8, 424.0, 424.2 Test Information Date/Time: [**2181-11-12**] at 11:56 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 168**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2010AW2-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: 1.1 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: 1.0 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.5 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 35% to 45% >= 55% Aorta - Annulus: 1.9 cm <= 3.0 cm Aorta - Sinus Level: 2.8 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.5 cm <= 3.0 cm Aorta - Ascending: 2.7 cm <= 3.4 cm Aorta - Descending Thoracic: 1.9 cm <= 2.5 cm Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal interatrial septum. No ASD by 2D or color Doppler. LEFT VENTRICLE: Normal LV wall thickness. Moderate regional LV systolic dysfunction. Moderately depressed LVEF. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending aorta diameter. AORTIC VALVE: Mildly thickened aortic valve leaflets (3). Trace AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate (2+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets. Physiologic (normal) PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. Results were 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. Left ventricular wall thicknesses are normal. There is moderate regional left ventricular systolic dysfunction with akinesis of the apex and distal anterior, inferior, septal and lateral wall. There is hypokinesis of the mid anteroseptal, ineferoseptal and inferior walls.. Overall left ventricular systolic function is moderately depressed (LVEF= 40 %). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The MR [**First Name (Titles) **] [**Last Name (Titles) **] and increased to 3+ from probable mild ischemia. After treatment the MR decreased to less than 2+ Dr. [**Last Name (STitle) **] was notified in person of the results. [**Name (NI) 33958**] The pt is receiving epinephrine at 0.02 uck/kg/min There is a slight improvement in LV function in the presence of inotropes. RWMA's persist however the base of the heart is more hyperdynamic. There is a well seated ring prosthesis in the mitral position. MR is no longer visualized. The remaining study is unchanged from prebypass. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 168**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2181-11-12**] 13:21 ?????? [**2174**] CareGroup IS. All rights reserved. Brief Hospital Course: [**2181-11-12**] Mr.[**Known lastname **] was taken to the operating room and underwent Coronary artery bypass grafting x4 with the left internal mammary artery to left anterior descending artery and reverse saphenous vein graft to the first obtuse marginal artery, second obtuse marginal artery, and diagonal artery. Mitral valve repair with a Medtronics CG Future annuloplasty ring, size 28 mm, with Dr.[**Last Name (STitle) **]. Please refer to operative report for further details. He tolerated the procedure well and was transferred to the CVICU intubated and sedated in critical but stable condition. He awoke neurologically intact, extubated and was weaned off pressors. Beta-Blocker/Statin/ASA and diuresis were initiated. On POD 2 he was transferred to the step down unit for further monitoring. Physical Therapy was consulted for evaluation of strength and mobility. It was felt that the patient would benefit from a short rehab stay. He was thrombocytopenic and plavix was discontinued. A heprain induced thrombocytopenia assay was negative. He was discharged to [**Hospital3 **] on postoperative day 4. He will follow-up with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 171**] as an outpatient. An appointment has also been made for for him to follow-up with Dr. [**Last Name (STitle) **] regarding his femoral pseudoaneurysm. Medications on Admission: Medications at home: AMIODARONE - (Prescribed by Other Provider) - 200 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 80 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) CLOPIDOGREL [PLAVIX] - (Prescribed by Other Provider) - 75 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) Take every day with aspirin for at least one month, do not stop taking unless Dr. [**Last Name (STitle) 171**] says it is OK DULOXETINE [CYMBALTA] - (Prescribed by Other Provider) - 20 mg Capsule, Delayed Release(E.C.) - 2 Capsule(s) by mouth twice a day FOLIC ACID - (Prescribed by Other Provider) - 1 mg Tablet - 1 Tablet(s) by mouth once a day LEVETIRACETAM - (Prescribed by Other Provider) - 500 mg Tablet - 1 Tablet(s) by mouth twice a day METOPROLOL SUCCINATE - (Prescribed by Other Provider) - 25 mg Tablet Sustained Release 24 hr - 1 Tablet(s) by mouth DAILY (Daily) VALSARTAN [DIOVAN] - (Dose adjustment - no new Rx) - 40 mg Tablet - 1 Tablet(s) by mouth daily WARFARIN - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth Once Daily at 4 PM goal INR 2.0-3.0 ASPIRIN - (Prescribed by Other Provider) - 325 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) CALCIUM CARBONATE - (Prescribed by Other Provider) - 200 mg (500 mg) Tablet, Chewable - 1 Tablet(s) by mouth three times a day give with meals THIAMINE HCL - (Prescribed by Other Provider) - 100 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) --------------- --------------- --------------- --------------- Plavix - last dose: [**2181-11-8**] 75mg Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime. 4. duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 5. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. 10. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. 11. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: 1. Coronary artery disease. 2. Mitral regurgitation Past Medical History Hyperlipidemia, Hypertension Coronary aretery disease s/p LAD stent andvfib arrest Anxiety attacks GERD Seizures- last one 10 years ago Migraine Afib s/p cardioversion Past Surgical History s/p knee arthroscopy s/p laser eye surgery Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Incisions: Sternal - healing well, no erythema or drainage Leg Right/Left - healing well, no erythema or drainage. Discharge Instructions: 1)Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage 2)Please NO lotions, cream, powder, or ointments to incisions 3)Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart 4)No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive 5)No lifting more than 10 pounds for 10 weeks 6)Lasix and potassium daily for 7 days then re-evaluate. Monitor and replete electrolytes while on lasix. 7)Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments: Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 170**] [**2181-12-12**] 1:00pm Cardiologist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2181-11-26**] 2:40 Follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 1241**]. Surgery scheduled for [**12-17**] for repair of pseudoaneurysm. Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] M. [**Telephone/Fax (1) 27541**] in [**1-13**] 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** Other Scheduled Appointments: Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2181-11-27**] 10:40 Provider: [**Name10 (NameIs) **] CLINIC Phone:[**Telephone/Fax (1) 3009**] Date/Time:[**2181-11-27**] 11:00 Completed by:[**2181-11-16**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 12228**] Admission Date: [**2181-11-6**] Discharge Date: [**2181-11-17**] Date of Birth: [**2117-12-19**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 135**] Addendum: The patient was to be discharged on POD#4 but had shortness of breath. His pain medication had been discontinued the night before because of hallucinations and he was in pain. He had a clear CXR and was started on combivent and vicodin. He improved dramatically and was discharged to [**Hospital3 1933**] in stable condition on POD#5. Discharge Medications: 1. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO at bedtime. 4. duloxetine 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 5. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. 10. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day for 7 days. 11. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 12. lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 13. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation q 4 hours PRN as needed for shortness of breath or wheezing. 14. hydrocodone-acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Discharge Disposition: Extended Care Facility: [**Hospital3 1933**] Discharge Diagnosis: 1. Coronary artery disease. 2. Mitral regurgitation Past Medical History Hyperlipidemia, Hypertension Coronary aretery disease s/p LAD stent andvfib arrest Anxiety attacks GERD Seizures- last one 10 years ago Migraine Afib s/p cardioversion Right groin pseudoaneurysm Past Surgical History s/p knee arthroscopy s/p laser eye surgery Discharge Condition: Alert and oriented x3 nonfocal Ambulating with steady gait Incisional pain managed with Ultram Incisions: Sternal - healing well, no erythema or drainage Leg Left - healing well, no erythema or drainage. Discharge Instructions: 1)Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage 2)Please NO lotions, cream, powder, or ointments to incisions 3)Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart 4)No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive 5)No lifting more than 10 pounds for 10 weeks 6)Lasix and potassium daily for 7 days then re-evaluate. Monitor and replete electrolytes while on lasix. 7)Please call with any questions or concerns [**Telephone/Fax (1) 1477**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 1477**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments: Surgeon: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 1477**] [**2181-12-12**] 1:00pm Cardiologist: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1582**], MD Phone:[**Telephone/Fax (1) 337**] Date/Time:[**2181-11-26**] 2:40 Follow-up with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 4749**]. Surgery scheduled for [**12-17**] for repair of pseudoaneurysm. Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) 12229**],[**First Name3 (LF) 77**] M. [**Telephone/Fax (1) 12230**] in [**1-13**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 1477**]. Answering service will contact on call person during off hours** Other Scheduled Appointments: Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 809**] Date/Time:[**2181-11-27**] 10:40 Provider: [**Name10 (NameIs) **] CLINIC Phone:[**Telephone/Fax (1) 12231**] Date/Time:[**2181-11-27**] 11:00 [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 137**] MD [**MD Number(2) 138**] Completed by:[**2181-11-17**] Name: [**Known lastname **],[**Known firstname **] Unit No: [**Numeric Identifier 12228**] Admission Date: [**2181-11-6**] Discharge Date: [**2181-11-17**] Date of Birth: [**2117-12-19**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 135**] Addendum: Lisinopril 2.5mg daily was added on discharge. [**Month (only) 412**] be advanced as blood pressure tolerates. Creatinine 1.3. Discharge Disposition: Extended Care Facility: [**Hospital3 1933**] [**First Name11 (Name Pattern1) 77**] [**Last Name (NamePattern4) 137**] MD [**MD Number(2) 138**] Completed by:[**2181-11-16**]

[ "401.9", "292.12", "346.90", "414.01", "E935.9", "411.1", "564.00", "E879.0", "997.2", "300.00", "345.40", "530.81", "V45.82", "442.3", "287.5", "424.0" ]

icd9cm

[ [ [] ] ]

[ "35.33", "88.56", "39.61", "37.22", "36.13", "38.93", "36.15" ]

icd9pcs

[ [ [] ] ]

19739, 19944

7821, 9180

335, 665

16846, 17052

2997, 6109

18012, 19716

2325, 2347

15132, 16399

16490, 16825

9206, 9206

17076, 17989

9227, 10779

6158, 7798

2362, 2978

284, 297

693, 2110

2132, 2168

2184, 2308

9,643

120,205

14958

Discharge summary

report

Admission Date: [**2124-8-27**] Discharge Date: [**2124-9-5**] Date of Birth: [**2062-1-2**] Sex: M Service: CARDIAC SURGERY PAST MEDICAL HISTORY: 1. Coronary artery disease status post silent myocardial infarction. 2. Hypertension. 3. Chronic renal insufficiency. 4. Hyperlipidemia. 5. Cataracts. 6. Diabetes mellitus type 2. PAST SURGICAL HISTORY: Status post cataract surgery. ALLERGIES: Questionable shellfish/dye. MEDICATIONS ON ADMISSION: Aspirin 81 mg q.d., Atenolol 100 mg q.d., Lantus insulin 32 units q bed time, Avapro 150 mg q.d., Glyburide 10 mg b.i.d., Lipitor 20 mg q.d., Imdur 60 mg q.d., Neurontin 900 mg t.i.d., multivitamin one tab q.d., Timolol and Zalatan eye drops q.d. HISTORY OF PRESENT ILLNESS: The patient is a 62 year-old diabetic man with known cardiac disease referred to [**Hospital1 1444**] for repeat catheterization and potential coronary artery bypass graft. On [**2123-7-21**] the patient underwent a cardiac catheterization at [**Hospital3 **]. Angiography revealed 20 to 30% distal eccentric plaque, which seemed to involve the origin of left anterior descending coronary artery. The left anterior descending coronary artery had 60 to 70 proximal stenosis. Obtuse marginal had 70% osteal stenosis. Right coronary artery had 60% proximal narrowing. EF was noted to be 70%. The patient's son stated the patient was seen by cardiac surgeon at [**Hospital3 **] who did not feel the patient was a good candidate for a coronary artery bypass graft at that time. The patient has now come back for a second opinion from Dr. [**Last Name (STitle) 70**] who is referring him for repeat catheterization and possible surgery. The patient has occasional symptoms on exertion, which manifests as chest pain and shortness of breath. The patient states that he has been feeling better since placed on Atenolol. He denies any other symptoms. PHYSICAL EXAMINATION: The patient is pleasant, cooperative and in no acute distress. Cardiovascular regular rate and rhythm. No murmurs. Respirations clear to auscultation bilaterally. Abdomen soft, nontender, nondistended. Bowel sounds positive. Extremities warm and well perfuse. No edema. LABORATORIES ON ADMISSION: White blood cell 8.9, hematocrit 38.8, platelets 218, sodium 138, potassium 5.1, chloride 107, bicarb 24, BUN 33, creatinine 1.7, blood sugar 194. HOSPITAL COURSE: The patient was admitted to the Medicine Service on [**2124-8-28**]. He underwent a cardiac catheterization, which showed an ejection fraction of 60%. Left main had distal 60 to 65% stenosis into left anterior descending coronary artery. Left anterior descending coronary artery had 80% osteal stenosis with high D1, 80% stenosis distal, 90% stenosis of the apex, left circumflex predominant vessel with obtuse marginal one, obtuse marginal two 90% proximal disease, right coronary artery predominant vessel with osteal 80% lesion and moderate diffuse disease in the mid segment. Preoperatively the patient remained asymptomatic and pain free. He was taken to the Operating Room on [**8-30**] with a coronary artery bypass graft times four with left internal mammary coronary artery to left anterior descending coronary artery, saphenous vein graft to the right coronary artery, saphenous vein graft to ramus intermedius, saphenous vein graft to obtuse marginal two was performed. The operation went without complications. Pacing wires as well as mediastinal pleural tubes were placed intraoperatively. The patient was transported to CSIU in stable condition. Postoperative day number one the patient had a temperature of 38.9. Sputum blood cultures were sent, otherwise stable. On postoperative day number two the patient was extubated without complications. He was started on Levofloxacin. He had a fever of 39.2. He continued aggressive pulmonary toilet. Postoperative day number three the patient continued to run a fever of 38.9. He continued pulmonary toilet. Continued Levofloxacin. White blood cell count remained stable on postoperative day number four. Blood sugar went down and the patient remained 37 to 38 range. Ambulating white blood cell count 8.7, continues on Levofloxacin. Postoperative day number five the patient is stable, afebrile and continues on Levofloxacin, white blood cell count 7.8. The patient is ambulating with physical therapy. Breath sounds were decreased at the bases, otherwise occasional rhonchi, few scattered rales. The patient is transferred to the floor. On the floor the patient remained febrile, ambulating with physical therapy. No O2 requirements on ambulation. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: The patient should follow up with Dr. [**Last Name (STitle) 70**] in six weeks for postoperative follow up. The patient should follow up with his primary care physician in two to three weeks, follow up questionable upper respiratory infection, blood pressure control. The patient should undergo extensive physical therapy with a goal of transition to outpatient rehab. MEDICATIONS: 1. Lopressor 125 mg po b.i.d. 2. Docusate 100 mg po b.i.d. 3. Zantac 150 mg po b.i.d. 4. Aspirin enteric coated 325 mg po q.d. 5. Oxazepam 15 to 30 mg po q.h.s. prn. 6. Gabapentin 100 mg po t.i.d. 7. Levofloxacin 250 mg q 24 hours stop on [**2124-9-11**]. 8. Glyburide 5 mg po b.i.d. 9. Atorvastatin 20 mg po q.d. 10. Insulin _________ 32 units at bedtime, insulin flow sheet (see inside sheet). 11. ______________ .5% ophthalmic one drop OU b.i.d. 12. Latanoprost .005% one drop OU q.h.s. DISCHARGE DIAGNOSIS: 1. Coronary artery disease prior myocardial infarction status post coronary artery bypass graft times four. 2. Hypertension. 3. Hyperlipidemia. 4. Cataract. 5. Diabetes mellitus. 6. Status post cataract surgery. [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 75**] Dictated By:[**Last Name (STitle) 7487**] MEDQUIST36 D: [**2124-9-4**] 22:43 T: [**2124-9-5**] 07:07 JOB#: [**Job Number 43798**]

[ "997.3", "E878.2", "412", "401.9", "465.9", "355.8", "414.01", "411.1", "250.00" ]

icd9cm

[ [ [] ] ]

[ "37.22", "36.13", "39.61", "88.56", "88.53", "36.15" ]

icd9pcs

[ [ [] ] ]

5610, 6127

482, 730

2407, 4638

383, 455

1935, 2226

759, 1912

2241, 2389

169, 359

4663, 5589

73,292

131,870

40773

Discharge summary

report

Admission Date: [**2165-4-18**] Discharge Date: [**2165-4-21**] Date of Birth: [**2086-7-3**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2108**] Chief Complaint: Diarrhea Major Surgical or Invasive Procedure: None History of Present Illness: HPI: 78 year old male with history of rheumatic heart disease s/p AVR/MVR at [**Hospital1 2025**] in [**2163**], HTN, DM who had onset of nausea early this morning followed by developed abdominal pain and diarrhea. He denied vomiting, fevers, chills, abdominal distention. Also denies chest pain, SOB. Denies recent antibiotics or sick contacts or travel. Denies melena or BRBPR. He continued to take his anti-hypertensives and diuretics at home. In EMS, his SBP noted to be 75-88 and he recieved 500cc IVF. In the ED, intial vitals were: 73 79/50 18 100% 4L NC. Appeared dry on exam. Given 4L IVF and SBP 120s. Abdomen was diffusely tender. Giving Vanco/Zosyn and then sent for CT which showed enteritis and ? diverticulitis. Labs returned with WBC 22, Creatinine 4.7, Troponin 0.37. EKG abnormal but no acute ST changes. Cardiology was consulted and stated to give him aspirin and unlikely to be ACS. Patient remained afebrile, on transfer 108/46 HR 79 16 100% on 3L. Access 2x PIV. Past Medical History: - Atrial fibrillation not on coumadin because of non compliance and concerns with warfarin - Pulmonary embolism - Rheumatic heart disease with MR, MS and AS status post bioprosthetic MVR and AVR [**2164-4-11**] - DMII - Atypical chest pain syndrome without obstructive coronary disease - BPH - HLD - Chronic dyspnea attributed to HF with preserved EF Social History: Lives in [**Location **] with his wife. Disabled. Used to work in a grocery store. He is a lifelong nonsmoker, does not drink alcohol and does not use ilicit drugs. Family History: History: noncontributory Physical Exam: VS: Temp:97 BP: 100/48 HR:85 RR:18 O2sat: 98% on 2L GEN: obese male, NAD HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules 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: no c/c/e SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. No pass-pointing on finger to nose. 2+DTR's-patellar and biceps Pertinent Results: Admission Labs: [**2165-4-17**] 08:15PM BLOOD WBC-22.1* RBC-4.95 Hgb-13.7* Hct-41.0 MCV-83 MCH-27.6 MCHC-33.3 RDW-15.5 Plt Ct-259 [**2165-4-17**] 08:15PM BLOOD Neuts-80* Bands-2 Lymphs-10* Monos-4 Eos-0 Baso-1 Atyps-2* Metas-1* Myelos-0 [**2165-4-17**] 08:15PM BLOOD PT-12.7 PTT-23.0 INR(PT)-1.1 [**2165-4-17**] 08:15PM BLOOD Glucose-177* UreaN-75* Creat-4.7* Na-138 K-3.3 Cl-94* HCO3-26 AnGap-21* [**2165-4-17**] 08:15PM BLOOD ALT-16 AST-29 CK(CPK)-291 AlkPhos-78 TotBili-0.3 [**2165-4-17**] 08:15PM BLOOD Lipase-26 [**2165-4-17**] 08:15PM BLOOD CK-MB-14* MB Indx-4.8 cTropnT-0.37* [**2165-4-18**] 01:43AM BLOOD Calcium-7.5* Phos-5.4* Mg-2.2 [**2165-4-17**] 08:27PM BLOOD Lactate-2.0 Additional Labs: [**2165-4-18**] 01:43AM BLOOD CK-MB-17* MB Indx-6.0 cTropnT-0.43* [**2165-4-18**] 07:56AM BLOOD CK-MB-12* cTropnT-0.56* [**2165-4-18**] 03:45PM BLOOD CK-MB-13* MB Indx-5.0 cTropnT-0.73* [**2165-4-18**] 10:30PM BLOOD CK-MB-14* MB Indx-5.2 cTropnT-0.87* [**2165-4-19**] 05:21AM BLOOD CK-MB-12* MB Indx-4.3 cTropnT-0.86* [**2165-4-19**] 05:21AM BLOOD calTIBC-295 VitB12-432 Folate-11.3 Ferritn-211 TRF-227 [**2165-4-20**] 06:11AM BLOOD Hapto-276* [**2165-4-19**] 05:21AM BLOOD Digoxin-0.6* Discharge Labs: [**2165-4-21**] 05:55AM BLOOD WBC-12.4* RBC-3.84* Hgb-11.0* Hct-31.9* MCV-83 MCH-28.7 MCHC-34.6 RDW-15.4 Plt Ct-209 [**2165-4-21**] 05:55AM BLOOD Glucose-62* UreaN-36* Creat-1.4* Na-145 K-3.5 Cl-101 HCO3-34* AnGap-14 [**2165-4-21**] 05:55AM BLOOD Calcium-8.6 Phos-2.7 Mg-1.8 Microbiology: Blood cultures x 2 no growth to date at time of discharge. [**2165-4-18**] 3:40 am STOOL CONSISTENCY: WATERY Source: Stool. **FINAL REPORT [**2165-4-20**]** FECAL CULTURE (Final [**2165-4-20**]): NO SALMONELLA OR SHIGELLA FOUND. CAMPYLOBACTER CULTURE (Final [**2165-4-20**]): NO CAMPYLOBACTER FOUND. OVA + PARASITES (Final [**2165-4-19**]): 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. Cryptosporidium/Giardia (DFA) (Final [**2165-4-19**]): NO CRYPTOSPORIDIUM OR GIARDIA SEEN. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2165-4-18**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). Studies: [**2165-4-17**] EKG Probable atrial fibrillation but baseline artifact makes assessment difficult. Inferolateral myocardial infarction of indeterminate age. ST-T wave abnormalities. Cannot exclude myocardial ischemia. Clinical correlation is suggested. No previous tracing available for comparison. [**2165-4-17**] Radiology CHEST (PORTABLE AP) [**Last Name (LF) 2922**],[**First Name3 (LF) 1730**] 1. Moderate cardiomegaly with bibasilar opacities, which likely represent atelectasis. 2. No free intraperitoneal air. [**2165-4-17**] Radiology CT ABD & PELVIS WITH CO [**Last Name (LF) 2922**],[**First Name3 (LF) 1730**] Approved 1. Probable early sigmoid diverticulitis. 2. Fluid-filled small and large bowel loops, possibly reflecting gastroenteritis. 3. Cholelithiasis. 4. Renal atrophy. [**2165-4-18**] Cardiology ECHO [**2165-4-18**] The left atrium is elongated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. No aortic regurgitation is seen. A bioprosthetic mitral valve prosthesis is present. The mitral prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Mild symmetric left ventricular hypertrophy with normal global and regional biventricular systolic function. Normally-functioning aortic and mitral valve bioprostheses. [**2165-4-19**] Radiology CHEST (PORTABLE AP) FINDINGS: Moderately severe pulmonary edema is stable. Bilateral moderately large pleural effusions, moderate cardiomegaly, median sternotomy wires, and an aortic valve replacement device are unchanged since [**2165-4-18**]. IMPRESSION: Stable moderately severe pulmonary edema. Brief Hospital Course: Mr. [**Known firstname 2319**] [**Known lastname **] is a 78 year old male with significant cardiac history s/p CABG AVR/MVR who presented with acute onset abdominal pain and diarrhea and was found to have a low-normal blood pressure, acute kidney injury, and elevated troponins. #. Diarrhea and Abdominal Pain: Patient had an elevated WBC count and evidence of diverticulitis on CT scan and was treated with ciprofloxacin and flagyl with resolution of his symptoms. He was discharged with prescriptions to complete a 10 day course. Surgery was consulted on admission and felt there were no acute surgical issues. Stool testing was negative for C. difficile and other pathogens. #. Acute Renal Failure: The patient's creatinine was elevated to 4.7 on admission (up from reported baseline of 1.5). This elevation was likely due to hypotension and volume depletion from diarrhea with underlying chronic kidney disease. All antihypertensives, including irbesartan, and diuretics (lasix and metolazone) were held on admission and he was given several liters of fluid for volume resuscitation. Lasix and metolazone were subsequently restarted and he was given several doses of IV lasix with good response and removal of extra fluid. His creatinine was decreased to 1.4 on the day of discharge. #. Acute pulmonary edema: In the setting of hodling diuretics and broad antihypertensive regimen, the patient developed acute pulmonary edema on the night of [**2165-4-18**], and he responded well to lasix, morphine, and nitro paste. Antihypertensives were slowly restarted and additional lasix was given the following day and the patient's oxygen requirement finally resolved. # Elevated cardiac enzymes: Per cardioloy, the elevation in cardiac enzymes on presentation was likely demand ischemia in the setting of hypotension and impaired troponin clearance in the setting of [**Last Name (un) **]. An old EKG obtained from the PCP's office confirmed no new inferior MI and Q-waves were confirmed to be old. Cardiac enzymes remained stable and trended down after 2 days. # Hypertension: The patient was initially admitted to the MICU due to hypotension. Antihypertensives were initially held in the setting of diarrhea and hypotension. Following volume resuscitation, he became hypertensive and metoprolol, isordil, and diuretics were restarted and he was eventually called out to the medical floor where additional diuretics were given. He was advised to wait to restart his irbesartan until he saw his PCP in [**Name9 (PRE) 702**]. # Chronic dyspnea attributed to HF with preserved EF: Digoxin was intially held in the setting of renal failure and restarted the following day. His irbesartan was held in the setting of acute renal failure. His diuretics and beta-blocker were restarted as above. # Type 2 diabetes mellitus: The patient was continued on his home dose of insulin 70/30 and also placed on an insulin sliding scale with reasonable control of blood sugars. # Atrial fibrillation: The patient is not anticoagulated per his outpatient notes. He was maintained on aspirin. # Hyperlipidemia: The patient was continued on simvastatin. # Possible history of COPD: The patient was continued on albuterol and fluticasone inhalers. # GERD: Ranitidine was held initially in the ICU and restarted several days later. Code: Full Medications on Admission: Lasix 40mg [**Hospital1 **], Metolazone 5mg daily, Digoxin 0.125mg daily, Insulin Aspart 70/30 30 units [**Hospital1 **], Metoprolol 100mg daily, Simvastatin 40mg daily, Isordil 10mg TID, ASA 325mg daily, Albuterol prn, Clonazepam 0.5mg prn, Flovent 220mcg [**Hospital1 **] prn, Irbesartan 150mg daily, Ranitidine 150mg [**Hospital1 **] Discharge Medications: 1. furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 2. metolazone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. insulin NPH & regular human 100 unit/mL (70-30) Suspension Sig: Thirty (30) units Subcutaneous twice a day. 5. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily). 6. isosorbide dinitrate 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Tablet(s) 7. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. 10. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO once a day as needed for anxiety. 11. Flovent HFA 220 mcg/Actuation Aerosol Sig: One (1) Inhalation twice a day as needed for shortness of breath or wheezing. 12. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 14. Flagyl 500 mg Tablet Sig: One (1) Tablet PO every eight (8) hours for 7 days. Disp:*21 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Care Group Home Care Discharge Diagnosis: Primary Diagnoses: 1. Diverticulitis 2. Hypotension Secondary Diagnoses: 1. Chronic heart failure with preserved EF 2. Type 2 diabetes mellitus 3. Hypertension 4. Benign prostatic hypertrophy 5. Atrial fibrillation 6. Status post bioprosthetic mitral and aortic valve replacements 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 because of inflammation in your colon known as diverticulitis. You were treated with antibiotics and will need to continue them for another week. You also had a low blood pressure and received a lot of IV fluids. We then temporarily increased your lasix dose to remove the extra fluid but you are now back on your home doses. The following changes were made to your medications: - Please stop irbesartan. Please see your primary care physician within the next week to have blood tests of your kidney function checked so he can decide if it is safe for you to resume taking this medication. - Please start ciprofloxacin and flagyl for an additional 7 days to treat your diverticulitis (Last dose 5/8 am) Followup Instructions: Please follow-up with your primary care physician within the next week. You will need to have labs of your electrolytes and kidney function checked.

[ "562.11", "600.00", "428.0", "V43.3", "272.4", "787.91", "530.81", "398.90", "427.31", "250.00", "401.9", "V45.81", "584.9", "458.8", "285.9", "V12.51", "428.32", "518.4" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12386, 12437

7264, 8953

312, 318

12763, 12763

2570, 2570

13679, 13832

1909, 1935

11001, 12363

12458, 12511

10640, 10978

12914, 13656

3777, 7241

1950, 2551

12532, 12742

8970, 10614

264, 274

346, 1334

2586, 3761

12778, 12890

1356, 1710

1726, 1893

7,673

188,671

50731

Discharge summary

report

Admission Date: [**2177-8-30**] Discharge Date: [**2177-9-2**] Date of Birth: [**2108-7-31**] Sex: M Service: [**Hospital Unit Name 196**] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 9554**] Chief Complaint: syncope Major Surgical or Invasive Procedure: PPM implantation History of Present Illness: 69 yo man with h/o of hypercholesterolemia and renal ca > 20 years PTA who p/w syncope on AM off admission. Pt was in USOH until AM on DOA when he awoke gasping for air. He got up out of bed, became dizzy and fell into the nightstand next to his bed, hitting his face in the process and lacerating his nose and lip. The fall was unwitnessed. He came to, his wife called the EMS and the pt was BIBA to the ER. On the way to the hospital, the EMTs noted his HR to be in the 40s with CHB, then he dropped his HR into the 20s and had two 10-second seizures. He received 1mg atropine and 350cc NS with good effect, his HR and BP increasing. In the ED he remained stable in CHB, a Cordis sheath was inserted, and he came to the CCU with external pacing pads on and ready if needed. Past Medical History: Hypercholesterolemia Renal cell CA s/p nephrectomy 20y PTA Social History: Insurance lawyer; married, lives with his wife in [**Name (NI) 86**]; h/o smoking in the past though he quit; social etoh, 1-2 drinks, 2 times per week; no other drug use; walks regularly Family History: noncontributory; no CAD Physical Exam: Vitals: HR 48, BP 120/66, RR 20, O2 sat 99% on 2LNC, afebrile Gen: older man, lying on stretcher, NAD HEENT: R IJ line in neck; lacerations on nose and upper lip; MMM; OP clear CV: irreg irreg rhythm; nl s1s2 no m/g/r; no carotid bruits Lungs: CTA b/l, no w/r/r Abd: soft, NT, ND, +BS Ext: no LE edema, FROM x 4, 2+ DP pulses Neuro/Psych: nonfocal; approp affect, linear TP Pertinent Results: [**2177-8-30**] 05:10AM BLOOD WBC-13.3* RBC-4.39* Hgb-14.0 Hct-42.2 MCV-96 MCH-31.9 MCHC-33.2 RDW-13.5 Plt Ct-305 [**2177-9-2**] 05:40AM BLOOD WBC-14.5* RBC-4.21* Hgb-13.9* Hct-39.4* MCV-94 MCH-33.1* MCHC-35.4* RDW-13.1 Plt Ct-263 [**2177-8-30**] 05:10AM BLOOD Neuts-20* Bands-0 Lymphs-70* Monos-4 Eos-2 Baso-0 Atyps-4* Metas-0 Myelos-0 [**2177-8-30**] 05:10AM BLOOD Plt Smr-NORMAL Plt Ct-305 [**2177-8-31**] 06:20AM BLOOD PT-13.0 PTT-25.4 INR(PT)-1.1 [**2177-9-2**] 05:40AM BLOOD Plt Ct-263 [**2177-8-30**] 02:40PM BLOOD ESR-4 [**2177-8-30**] 10:55AM BLOOD Parst S-NEG [**2177-8-30**] 05:10AM BLOOD Glucose-241* UreaN-31* Creat-1.4* Na-143 K-3.5 Cl-107 HCO3-22 AnGap-18 [**2177-9-2**] 05:40AM BLOOD Glucose-82 UreaN-20 Creat-1.0 Na-140 K-4.0 Cl-102 HCO3-25 AnGap-17 [**2177-8-30**] 05:10AM BLOOD CK(CPK)-86 [**2177-8-30**] 02:40PM BLOOD ALT-47* AST-22 AlkPhos-47 TotBili-1.2 [**2177-8-31**] 06:20AM BLOOD CK(CPK)-109 [**2177-8-30**] 05:10AM BLOOD cTropnT-<0.01 [**2177-8-31**] 06:20AM BLOOD CK-MB-2 [**2177-8-31**] 06:20AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.0 [**2177-9-2**] 05:40AM BLOOD TotProt-6.1* Calcium-9.2 Phos-4.1 Mg-1.9 [**2177-8-30**] 05:10AM BLOOD TSH-5.0* [**2177-8-30**] 02:40PM BLOOD T4-6.0 [**2177-9-2**] 05:40AM BLOOD PEP-ABNORMAL B IgG-730 IgA-50* IgM-14* IFE-MONOCLONAL Brief Hospital Course: In the CCU: 1. CHB/Rhythm Pt arrived in CCU in NSR in 70s. Etiology of CHB thought to be fibrous change c/w pt's known prior conduction disease. Lyme, Ehrlichiosis and Babesiosis serologies were sent which were ultimately negative. Monospot negative. Pt received PPM without complications. PPM was [**Company 1543**] EnPulse DDDR. Pt was transferred to floor after receiving his PPM then d/c'd on his 2nd post-procedure day. 2. Elevated WBC Pt noted to have WBC of 13.3 without fever but with malaise for 2 months; pt's family reported that his WBC has been elevated "all summer" with no workup performed to date. Smudge cells were seen on pt's smear, common in malignancy (CLL?), though ESR was low at 4. Heme/Onc consulted to evaluate, recommended flow cytometry to r/o CLL and want to see pt in one month for further eval as outpatient. Pt given the contact info and instructed to set up the appointment. 3. Renal Pt has h/o Renal Cell CA s/p nephrectomy, Cr 1.4 on admission. No issues on this admission. 4. Derm Skin lacerations from fall; Plastics consulted to evaluate, they sutured the wounds and prescribed antibiotic cream. They removed the sutures prioor to pt's discharge. Medications on Admission: ASA 325mg po qd Lipitor 20mg po qd Discharge Medications: 1. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 2. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*2* 3. Keflex 500 mg Capsule Sig: One (1) Capsule PO four times a day for 4 days. Disp:*16 Capsule(s)* Refills:*0* 4. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 5. Percocet 5-325 mg Tablet Sig: One (1) Tablet PO every [**4-8**] hours as needed for pain for 4 days. Disp:*16 Tablet(s)* Refills:*0* 6. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day for 4 days: To keep stool soft while taking Percocet. Disp:*8 Capsule(s)* Refills:*0* 7. Ativan 1 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia for 4 days: Please take only as needed for sleep; do not take prior to activity or operating heavy machinery. Disp:*4 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Complete Heart Block Discharge Condition: left pocket wound, no hematoma Discharge Instructions: Please contact the Hematology Division in one week to set up a follow up appointment. Please keep your skin incision site clean and dry. Followup Instructions: Please call the Hematology Division in one week to set up an appointment. Device Clinic [**Hospital Ward Name 23**] 7 [**2177-9-9**] 9:30am Device Clinic [**First Name8 (NamePattern2) 1439**] [**Last Name (NamePattern1) 4949**], [**First Name8 (NamePattern2) 11320**] [**Last Name (NamePattern1) **] Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2178-2-11**] 2:00 Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 677**], M.D. Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 2934**] Date/Time:[**2178-2-11**] 2:30 [**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2139**]

[ "E884.4", "V15.82", "780.2", "780.39", "V53.31", "426.0", "873.21", "078.89", "873.43" ]

icd9cm

[ [ [] ] ]

[ "37.83", "27.51", "37.72", "37.78", "21.81", "89.45" ]

icd9pcs

[ [ [] ] ]

5454, 5460

3219, 4409

342, 360

5525, 5557

1908, 3196

5743, 6510

1471, 1496

4494, 5431

5481, 5504

4435, 4471

5581, 5720

1511, 1889

295, 304

388, 1168

1190, 1250

1266, 1455

81,318

186,441

41337

Discharge summary

report

Admission Date: [**2169-3-27**] Discharge Date: [**2169-3-30**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 613**] Chief Complaint: Weakness, nausea Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **] YO F HTN, HLD with 3 weeks of abdominal pain and 1 day of nausea and weakness who was found to have anterior ST elevations [**Hospital 90006**] transferred from [**Hospital3 **] for possible cardiac catheterization. The patient presented to [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] on [**3-27**] at which time she was found to have a narrow complex regular tachycardia with rate in the 130s-140s and SBP in the 80s. The patient was also noted to initially be "non-verbal". Due to concern for SVT, the patient was given 6mg IV adenosine as well as IV metoprolol. She "converted" to sinus rhythm with SBP in the 130s. An EKG was done and showed ST elevations in V2-V4 so IV heparin was started (guiac + brown stool), rectal aspirin was given and she was transferred to the [**Hospital1 18**] ED for possible cardiac catheterization. . Upon arrival to the ED, a code STEMI was called. Her initial VS were 134/85 RR 17 100% on 2L NC. She was alert and oriented. Her labs were quite concerning given pH reported as 7.05 with lactate of 7.9, leukocytosis to 22K. Trop 0.07. Her u/a showed >100 WBCs and + leuk esterase. Two 18g PIVs were placed and she was given 2L NS. Interventional cardiology declined urgent cath. The CCU fellow was contact[**Name (NI) **] and felt the patient was more appropriate for MICU admission. . Upon arrival to the MICU, the patient denies complaints. Her nausea has abated and she denies any abdominal pain today. She denies fevers, cough, dysuria or rashes. She only endorses "post-nasal drip." She has had several days of diarrhea for which she believes her doctor gave her a "purple pill." Past Medical History: hypertension hyperlipidemia hypothyroidism left hip replacement tonsillectomy right tibial plateau fracture Social History: The patient lives alone. She ambulates with a walker. She denies tobacco, alcohol or illicit drugs. Family History: Non-contributory Physical Exam: ADMISSION EXAM: Vitals: T: 95.6 117/61 82 99% on 2L --> 88% on RA while sleeping General: Alert, oriented, no acute distress, cachectic HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: + [**Known lastname **] Ext: + venous dermatitis, non-pitting edema . DISCHARGE EXAM: Vitals: T: 98.2 BP 148-160/72-76 RR 18 General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: Supple, prominent hyoid but no thryomegaly, no carotid bruits. Lungs: Mild crackles at right base CV: S1, S2, no murmurs auscultated Abdomen: Soft, non-tender, non-distended, bowel sounds present Ext: + venous dermatitis, non-pitting edema, ecchymoses on arms Pertinent Results: ADMISSION LABS: [**2169-3-27**] 07:54PM BLOOD WBC-14.7* RBC-3.80* Hgb-12.3 Hct-36.2 MCV-95# MCH-32.4* MCHC-34.0# RDW-14.8 Plt Ct-161 [**2169-3-27**] 07:54PM BLOOD Neuts-82* Bands-4 Lymphs-5* Monos-6 Eos-0 Baso-0 Atyps-1* Metas-2* Myelos-0 [**2169-3-27**] 07:54PM BLOOD PT-15.3* PTT-78.1* INR(PT)-1.3* [**2169-3-27**] 07:54PM BLOOD Glucose-116* UreaN-24* Creat-1.1 Na-141 K-4.5 Cl-107 HCO3-23 AnGap-16 [**2169-3-27**] 07:54PM BLOOD ALT-444* AST-563* CK(CPK)-215* AlkPhos-217* TotBili-0.4 [**2169-3-27**] 07:54PM BLOOD Calcium-8.8 Phos-4.3 Mg-2.2 [**2169-3-27**] 07:54PM BLOOD TSH-1.6 . PERTINENT LABS: [**2169-3-27**] 07:54PM BLOOD CK-MB-12* MB Indx-5.6 cTropnT-0.60* proBNP-1093* [**2169-3-28**] 02:14AM BLOOD CK-MB-12* MB Indx-5.7 cTropnT-0.43* [**2169-3-27**] 08:01PM BLOOD Lactate-1.2 . DISCHARGE LABS: . MICROBIOLOGY: [**2169-3-27**] Blood Cx: pending [**2169-3-27**] Urine Cx: pending [**2169-3-28**] Urine Cx: pending [**2169-3-28**] Stool Cx: pending . IMAGING: [**3-27**] CRX: Baseline artifact. Sinus rhythm. P-R interval prolongation. Left axis deviation. Consider left anterior fascicular block. Small R waves versus Q waves in leads V1-V2. Consider anteroseptal myocardial infarction, especially with mild ST segment elevation in leads V1-V2. Other ST-T wave abnormalities. No previous tracing available for comparison. [**2169-3-27**] CXR: Cardiac silhouette is within upper limits of normal in size given the portable AP technique. There is mild tortuosity of the aorta. Lungs are essentially clear. . [**2169-3-27**] KUB: Non-obstructive bowel gas pattern. No free air. . [**2169-3-27**] RUQ U/S: No intra- or extra-hepatic biliary dilatation. Cholelithiasis without definite evidence of cholecystitis. [**3-28**] CXR: In comparison with the study of [**3-27**], there is little overall change. Cardiac silhouette is at the upper limits of normal without vascular congestion or pleural effusion. Mild tortuosity of the descending aorta with calcification in its wall is again seen. [**3-28**] Echo: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity is small. Overall left ventricular systolic function is normal (LVEF 75%). There is no ventricular septal defect. The right ventricular free wall is hypertrophied. The right ventricular cavity is dilated with severe global free wall hypokinesis. There are complex (>4mm) atheroma in the aortic arch. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. Mild-to-moderate ([**1-8**]+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is borderline/mild bileaflet mitral valve prolapse. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. The estimated pulmonary artery systolic pressure is normal (normal pulmonary artery pressure in the presence of right ventricular pump dysfunction should not be taken to indicate normal pulmonary vascular resistance). There is a small pericardial effusion. There are no echocardiographic signs of tamponade. [**3-28**] LENIS: 1. 4.1 x 1.1 x 2.7 cm right [**Hospital Ward Name 4675**] cyst. 2. No evidence of DVT in bilateral lower extremities . [**3-28**] CTA: IMPRESSION: 1. Bilateral acute pulmonary emboli with mild straightening of the intraventricular septum suggesting right heart strain. 2. Right lower lobe consolidation which in the setting of acute pulmonary embolism could represent infarction. 3. Extensive atherosclerotic calcification of the thoracic aorta which is normal in caliber. . Brief Hospital Course: [**Age over 90 **]F with HTN, HLD, presenting with abdominal pain, nausea and weakness found to have anterior ST elevations, leukocytosis, and transaminitis. Her CTA demonstrated bilateral pulmonary embolisms. . #. Pulmonary embolism: The patient found to have bilateral PEs on CTA chest, and had evidence of RV dilation and free wall hypokinesis on TTE. She was continued on heparin gtt, and it was felt that patient's hypoxia was likely secondary to PE and possible RLL infarct seen on chest imaging. The patient's INR was not therapeutic on the day of discharge, so she will continue Lovenox at the rehabilitation facility until her INR is therapeutic. . # ST elevations: ST elevations in V1-V3, ST depressions in V5-V6, with troponin leak were concerning for STEMI. Troponin peaked at 0.6 and was downtrending. Patient was continued on ASA, metoprolol, and heparin gtt. Echo showed a dilated RV cavity with severe global free wall hypokinesis. Cardiology was consulted and felt EKG changes more suggestive of RV strain than STEMI. CTA chest confirmed presence of bilateral PEs. Patient continued on heparin gtt, though given lower concern for ACS, plavix was not started. Patient remained CP free, and ST elevations on EKG resolved. . # Leukocytosis/bandemia, likely secondary to UTI: The patient was initially broadly covered with vanc/zosyn/flagyl. U/A was suggestive of UTI, so antibiotics were narrowed to ciprofloxacin. RUQ revealed gallstones but no evidence of cholecystitis. No clinical or laboratory evidence of pancreatitis. Patient with chronic loose stools, but no recent antibiotics or hospitalizations. Stool was negative for C. diff. The patient will complete a seven-day course of ciprofloxacin. . # Transaminitis/Abdominal Pain: U/S negative for acute pathology. Recent abdominal CT at [**Hospital1 **] negative for acute process. Patient may have had an obstructing gallstone and then passed it, though no biliary dilatation seen on U/S. No history of ETOH abuse. Hepatitis A/B/C serologies negative. Was likely component of shock liver secondary to hypotension that contributed, and transaminases trended down over time. Abdominal pain may also have secondary to gram negative UTI, which was treated with cipro as above. The patient's abdominal pain had completely resolved by time of transfer from the MICU to the floor. . # Hypoxia: O2 sats in the high 90s on 2L, but drop to the low 90s on RA. Was most likely seconary to PE as above. No infiltrate or effusion on CXR. No history of pulmonary disease. Patient with severe kyphosis which is likely contributing. BNP elevated at 1093, but patient euvolemic on exam and CXR without evidence of pulmonary edema. . # Hypothyroidism: TSH was normal. Continued home levothyroxine dosing. Medications on Admission: Omeprazole 20 mg daily, Metoprolol 12.5 mg [**Hospital1 **], Synthroid 88 mcg daily, Aspirin 81 mg daily, Calcium/Vit D Discharge Medications: 1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 2. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 3. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days. 6. Calcium 500 + D (D3) 500-125 mg-unit Tablet Sig: One (1) Tablet PO once a day. 7. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 8. Lovenox 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous twice a day: Until INR is therapeutic. Discharge Disposition: Extended Care Facility: [**Doctor First Name 391**] Bay Skilled Nursing & Rehabilitation Center - [**Hospital1 392**] Discharge Diagnosis: Pulmonary embolism RV strain UTI 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 8389**], It was a pleasure participating in your care at [**Hospital1 771**]. . You were hospitalized becaused you had clots in your lungs, called pulmonary emboli. These pulmonary emboli were probably responsible for your weakness and nausea. You also had a urinary tract infection, which may have casued your abdominal pain. You will be sent to rehab on medications, Lovenox and Coumadin, to help prevent any future clots from forming. You will also receive an antibiotic, ciprofloxacin, to treat your urinary tract infection. . You will go to a rehabilitation facility in order to get stronger. . START Coumadin. START Lovenox. START ciprofloxacin. . Followup Instructions: Please see your Primary Care Physician following your stay at the rehabilitation center. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

[ "244.9", "V43.64", "599.0", "415.19", "272.4", "401.9", "429.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10543, 10663

6908, 9673

268, 274

10740, 10740

3254, 3254

11624, 11837

2233, 2251

9843, 10520

10684, 10719

9699, 9820

10923, 11601

4060, 6885

2266, 2819

2835, 3235

211, 230

302, 1967

3270, 3839

10755, 10899

3855, 4044

1989, 2099

2115, 2217

10,612

119,309

15230

Discharge summary

report

Admission Date: [**2133-12-7**] Discharge Date: [**2133-12-11**] Date of Birth: [**2064-1-19**] Sex: F Service: [**Hospital1 212**] HISTORY OF PRESENT ILLNESS: The patient is a 69 year old female with a history of coronary artery disease, end stage renal disease on hemodialysis and congestive heart failure, who presented from home to the Emergency Department and was unresponsive. Per the patient's husband, the patient had been at home in her usual state of health, independent of activities of daily living until the morning of admission, when she felt lethargic with shortness of breath. Her cardiologist, Dr. [**Last Name (STitle) 12923**] was called who instructed them to go right to the Emergency Department. In the Emergency Department, the patient was initially stable but then had an acute episode of unresponsiveness and low blood pressure. The episode was described as a thumping over to the left. There was no shaking, stiffening or eye rolling. Neurology was called and head CT without contrast was found to be negative. She was intubated for hypoxia. After receiving oxygen, through the intubation, the patient was able to wake up and cooperate with a neurologic examination. Per report from the husband, the patient had no complaints, no recent fever, chills, nausea, vomiting, diarrhea or constipation. No bright red blood per rectum. No melena, urinary symptoms. No chest pain or her anginal equivalent which is described as heavy arms. PAST MEDICAL HISTORY: 1. Coronary artery disease, status post coronary artery bypass graft, aortic stenosis, 3+ mitral regurgitation. 2. End stage renal disease on hemodialysis times one year. 3. Diabetes mellitus on insulin. 4. History of gastrointestinal bleed. 5. Peripheral vascular disease. 6. Congestive heart failure, ejection fraction of 20%. 7. DDD pacer secondary to complete heart block. 8. Asthma. 9. Glaucoma. 10. Hypertension. 11. Hypercholesterolemia. 12. History of Heparin induced thrombocytopenia, type II. 13. Alcohol use. MEDICATIONS ON ADMISSION: 1. Amitriptyline 25 mg q.h.s. 2. Nephrocaps two once daily. 3. PhosLo two three times a day. 4. Lipitor 20 mg once daily. 5. Protonix 40 mg once daily. 6. Imdur 30 mg once daily. 7. Aspirin 81 mg once daily. 8. Lopressor 100 mg twice a day. 9. Plavix 75 mg once daily. 10. Xalatan. 11. Alphagan. 12. Digoxin three times weekly. 13. Advair one twice daily. 14. NPH 20 units in the morning and 10 units at night. ALLERGIES: She reports allergy to Aspirin leading to gastrointestinal bleed, intravenous dye leading to the cause of her renal failure, Penicillin causing swelling and hives. SOCIAL HISTORY: She lives with her husband who helps care for her and her two daughters. She quit drinking alcohol a number of years ago and has no history of tobacco use or illicit use. FAMILY HISTORY: Her father died of acute myocardial infarction at age 59. Her mother died of a cerebrovascular accident at age 68. PHYSICAL EXAMINATION: On admission, vital signs were temperature 99.8, blood pressure 100/40, pulse 70, oxygen saturation 100%, and respiratory rate of 12. In general, she was a pleasant woman with no apparent distress. She had slight scleral icterus. Cardiovascular - regular rate and rhythm, normal S1 and S2, III/VI systolic murmur. Chest showed decreased breath sounds at her bases bilaterally. She had a soft, nontender, nondistended abdomen with normal bowel sounds. She had no edema of her extremities and no calf tenderness. Neurologically, she was sedated so cranial nerves could not be assessed. LABORATORY DATA: Blood gas shortly after intubation was 7.35, 31, 126. White blood cell count was 9.7, hematocrit 41.4, platelet count 233,000. Sodium 130, potassium 6.3, chloride 85, bicarbonate 24, blood urea nitrogen 33, creatinine 5.6, glucose 219. Ammonia was 118. Lactate was 14.2. Digoxin level was 2.6. ALT 43, AST 157, amylase 2.2, total bilirubin 2.9, CK 88, MB 4.0, troponin 0.35. INR 1.3. White blood cell count differential had a 1% bandemia and 86% neutrophils. Urinalysis revealed negative nitrite, negative leukocyte esterase. CT of the head as said showed no hemorrhage and chronic microvascular changes. Chest x-ray showed cardiomegaly with congestive heart failure that improved after intubation. Right upper quadrant ultrasound showed no ductal dilatation and normal portal venous flow. CTA showed no pulmonary embolus, bilateral pleural effusions and moderate ascites in the abdomen. IMPRESSION: This was a 69 year old woman with a history of coronary artery disease, congestive heart failure, end stage renal disease and diabetes mellitus with pacemaker, who presented with unresponsiveness. Number one thought was syncope. The patient was put on telemetry and ruled out for myocardial infarction. Respiratory failure that was seen during a mixture of mental status changes and hypoxemia. Chest x-ray revealed congestive heart failure resolving quickly and oxygenation and ventilation adequate. Elevated lactate level thought to be due to hypotension in the setting of liver dysfunction. There were no obvious medications leading to elevated lactate and acidosis was not striking. End stage renal disease was concerning for the cause, however, the patient was not overdue for dialysis. Renal was consulted and dialysis was planned for the next day. Final [**Location (un) 1131**] of right upper quadrant ultrasound revealed a cirrhotic liver with interval reversal of flow in the portal vein since one year ago when the last study was done. This was consistent with a worsening of cirrhosis. There was cholelithiasis without any evidence of cholecystitis. On day one of Medical Intensive Care Unit admission, the patient remained intubated and sedated. She ruled out for myocardial infarction. She had dialysis and 2.5 liters removed. Electrophysiology saw the patient and was concerned about an electrical dysfunction as the etiology. Initially her potassium was found to be 7.0 and her Digoxin level was 2.6 and supratherapeutic. Electrophysiology interrogated her pacer and found no electrical etiology to her syncopal episode. Over the first three days of admission, her systolic blood pressure was stable and the patient extubated herself. When the patient was stable to be transferred to the floor, at that time the impression was that her episode of unresponsiveness was thought to be due to a transient ischemic attack versus encephalopathy due to uremia or hepatic source. Her mental status is improved back to her baseline within two days. Neurology consultation evaluated her and felt that there was no neurologic etiology to her syncopal episode. The patient was maintained on Lactulose and had hemodialysis on a regular schedule. CT of her head did reveal a wedge shaped infarct pattern concerning for a cerebrovascular accident. The patient was not eligible to have a magnetic resonance scan given that she had a pacer in place. The patient's neurologic status continued to improve. The patient's Amitriptyline was discontinued. She was instructed not to take it again for fear that it would interact with her other medications and somehow contribute to further episodes of unresponsiveness or syncope. The patient's mental status continued to improve. She continued to have hemodialysis. She had a physical therapy consultation who felt that she was better than her baseline and she was discharged home to be with VNA services. Regarding the patient's initial event of hypoxia, on day two, she extubated herself. She required minimal oxygen on nasal cannula. She was diuresed given the picture of congestive heart failure. She was treated with ten days of Levaquin due to retrocardiac opacity that was found and thought possible pneumonia complicated the picture of hypoxia. On the day of discharge, the patient was breathing 95% in room air and had no episodes of shortness of breath. During her stay, the patient also had a temperature spike. Sources were thought to be due to her lung or pneumonia post intubation. Sputum was checked and it was nonspecific. The patient had a groin line that was discontinued. She was given Vancomycin and Levofloxacin. Blood cultures never grew any organism. Vancomycin was discontinued and Levofloxacin was continued for the entire ten day course as stated above. For the patient's cirrhosis and ascites present, Lactulose was continued. Vitamin K was given. Synthetic function of the liver was monitored. The patient did have transaminase elevation and INR increased to 2.0, total bilirubin increased to 2.9. This was thought to be due to hypotension and poor cardiac function at baseline. These values decreased towards normal at the time of discharge. For end stage renal disease, the patient had renal consultation. Hemodialysis was continued per routine. Renal followed closely. She was given a renal diet and her electrolytes were monitored very carefully with no further events. For fluids, electrolytes and nutrition - The patient was maintained on a renal, cardiac, diabetic two gram sodium diet. She received no intravenous fluids. Electrolytes were monitored carefully and were within normal range. Prophylaxis was maintained throughout admission with a proton pump inhibitor, aspiration precautions. The patient was given no subcutaneous Heparin given her history of thrombocytopenia on Heparin. She was given pneumatic boots, and she was put up into bed and ambulated regularly. Code Status - The patient was full code throughout her stay, however, it needs to be addressed further with the patient and her husband, their family and the primary care physician given that this was the patient's second intubation in a six week period with multiple chronic illnesses. Throughout her stay, the patient progressively began to eat more towards her baseline. NPH was increased back to her home dose. The patient had anemia that was found to be combined B12 or folate deficiency and chronic renal insufficiency. It was found to be stable and unchanged and she was at her baseline. At the end of hospital stay, the impression was that her syncopal event was due to a combination of encephalopathy, hypoxia and volume overload due to congestive heart failure and end stage renal disease and severe cirrhosis, all of which resolved with dialysis and Lactulose. The patient was discharged home with instructions to weigh herself daily, call her medical doctor if she weighed more than three pounds increase, adhere to a two gram sodium diet, 1500cc fluid restriction, to take all her medications as prescribed. She was told to not take her Digoxin or Amitriptyline any more given her impaired renal function and delicate neurologic status. The patient was instructed to follow-up with her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 44325**], in one to two weeks, as well as with her cardiologist, Dr. [**Last Name (STitle) 12923**]. CONDITION ON DISCHARGE: The patient was ambulating well with her walker, breathing in room air, eating and drinking well and euvolemic with an ejection fraction of 20%. DISCHARGE STATUS: She was discharged to home with VNA services. PRIMARY DIAGNOSES: 1. Chronic renal failure. 2. Systolic heart failure. 3. Critical aortic stenosis. 4. Encephalopathy. 5. Cirrhosis. 6. Liver failure. 7. Hypoxia. 8. Hypokalemia. 9. Hyperkalemia. 10. Digoxin toxicity. 11. Coronary artery disease. 12. Diabetes mellitus type 2 complicated by nephropathy. 13. Asthma. 14. Glaucoma. 15. Peripheral vascular disease. 16. Hypertension. MEDICATIONS ON DISCHARGE: 1. Plavix 75 mg one once daily. 2. Famotidine Tartrate 2.2% drops, one drop twice a day. 3. Calcium Acetate 667 mg tablets, take three p.o. three times a day with meals. 4. Aspirin 81 mg one once daily. 5. Lipitor 20 mg p.o. once daily. 6. Multivitamin two p.o. once daily. 7. Latanoprost 0.005% drops one drop h.s. 8. Tylenol p.r.n. 9. Salmeterol 50 mcg one inhalation q12hours. 10. Flovent 110 mcg inhaler two puffs twice a day. 11. Lactulose 10 grams/15ml syrup, take 30ml p.o. three times a day. 12. Levofloxacin 250 mg tablet, take one tablet p.o. q48hours for a total duration of ten days. 13. Colace 100 mg take one tablet p.o. twice a day. 14. Senna take one tablet p.o. twice a day. 15. Bisacodyl take two tablets p.o. once daily as needed for constipation. 16. Trazodone 50 mg p.o. q.h.s. 17. Insulin NPH 20 units in the morning and 10 units at night. 18. Lopresor 12.5 mg p.o. twice a day. 19. Protonix 40 mg p.o. once daily. 20. The patient was instructed not to take Amitriptyline or Digoxin any more. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4561**] Dictated By:[**Last Name (NamePattern1) 6374**] MEDQUIST36 D: [**2134-1-25**] 15:28 T: [**2134-1-27**] 19:24 JOB#: [**Job Number 44326**]

[ "250.40", "276.7", "518.81", "403.91", "571.2", "572.2", "276.8", "789.5", "398.91" ]

icd9cm

[ [ [] ] ]

[ "96.04", "39.95", "93.96", "96.71" ]

icd9pcs

[ [ [] ] ]

2867, 2984

11678, 12975

2062, 2660

3007, 11023

178, 1484

1506, 2036

2677, 2850

11048, 11652

22,816

174,094

56366+56367

Discharge summary

addendum+addendum

Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 6987**] Admission Date: [**2192-2-4**] Discharge Date: [**2192-2-10**] Date of Birth: [**2134-6-25**] Sex: M Service: TRAUMA [**Last Name (un) **] HISTORY OF THE PRESENT ILLNESS: The patient is a 57-year-old male, unrestrained passenger, ? driver, in a high-speed motor vehicle accident versus a tree. The patient was ejected from the vehicle. There was significant damage to the car. The patient was found unresponsive at scene with GCS of 5 improving to 14. Upon treatment with the paramedic, the patient was initially thought to have alcohol on board. Upon arrival in the trauma bay, the patient was hemodynamically stable. Investigation revealed negative trauma series. Head CT was negative. Chest CT was negative. The CT of the cervical spine revealed no fractures. The CT of his abdomen and pelvis was without organ injury, however, the patient was noted to have a left acetabular fracture, femoral neck fracture and a posterior hip dislocation. The patient was also noted to have significant facial lacerations and degloving injury to his face. Based on these injuries, the patient was taken immediately to the operating room, where his hip was reduced and the fractures underwent open reduction and internal fixation. Plastic surgery was consulted intraoperatively for repair of his facial lacerations and degloving injury, which extended into his soft palate. Postoperatively, the patient remained intubated in the Surgical Intensive Care Unit with a relatively fast ventilatory wean. In the Intensive Care Unit, the patient was started on total parenteral nutrition due to edema of the soft palate and question of a swallowing mechanism. However, he continued to do very well, and on hospital day #3 he was extubated successfully. The patient was watched in Surgical Intensive Care Unit for an additional day and then transferred to the floor. On the floor, he continued to do well. He was afebrile. However, one of his sputum cultures grew some gram-negative rods, which speciated as Hemophilus influenzae. He was started on Levofloxacin 500 mg p.o.q.d. for this. His pulmonary consolidation resolved by the physical examination. He was slowly advanced to a regular, which he was tolerating. The total parenteral nutrition was discontinued. He will be discharged to a rehabilitation facility. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: The patient was discharged to rehabilitation. DISCHARGE MEDICATIONS: 1. Norvasc 5 mg p.o.q.d. 2. Ativan 0.5 mg p.o.q.6h.p.r.n. 3. Boost, one can p.o.t.i.d. 4. Tylenol #3, 1 to 2, q.4 to 6h.p.r.n. 5. Multivitamin p.o.q.d. 6. Levofloxacin 500 mg p.o.q.d., which should be discontinued on [**2192-2-13**]. 7. Prozac 20 mg p.o.q.d. 8. Bacitracin ointment to face wounds b.i.d. 9. Zantac 150 mg p.o.b.i.d. 10. Albuterol, Atrovent MDI one to two puffs q.4h.p.r.n. 11. Peridex mouth wash swish and spit t.i.d. 12. Lovenox 30 mg subcutaneously b.i.d. 13. Sliding scale insulin. DIET: Regular. We expect that his insulin requirement is related to his TPN and will probably not require insulin once off the TPN in rehabilitation on a regular diet. The patient's right shoulder has been radiologically studied. There are no fractures, however, there is significant bruising in the humeral head. He will have a right shoulder sling just p.r.n. His fractures of the lower extremity require him to not adduct his knees together at any point. He should not flex his left leg to greater than 45 degrees at any time for six weeks. He will be strict nonweightbearing and should followup with the Department of Orthopedic Surgery. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 845**], M.D. [**MD Number(1) 846**] Dictated By:[**Last Name (NamePattern1) 6453**] MEDQUIST36 D: [**2192-2-10**] 09:24 T: [**2192-2-9**] 11:24 JOB#: [**Job Number 6988**] Name: [**Known lastname **], [**Known firstname **] Unit No: [**Numeric Identifier 6987**] Admission Date: [**2192-2-4**] Discharge Date: [**2192-2-10**] Date of Birth: [**2134-6-25**] Sex: M Service: TRAUMA [**Last Name (un) **] HISTORY OF THE PRESENT ILLNESS: The patient is a 57-year-old male, unrestrained passenger, ? driver, in a high-speed motor vehicle accident versus a tree. The patient was ejected from the vehicle. There was significant damage to the car. The patient was found unresponsive at scene with GCS of 5 improving to 14. Upon treatment with the paramedic, the patient was initially thought to have alcohol on board. Upon arrival in the trauma bay, the patient was hemodynamically stable. Investigation revealed negative trauma series. Head CT was negative. Chest CT was negative. The CT of the cervical spine revealed no fractures. The CT of his abdomen and pelvis was without organ injury, however, the patient was noted to have a left acetabular fracture, femoral neck fracture and a posterior hip dislocation. The patient was also noted to have significant facial lacerations and degloving injury to his face. Based on these injuries, the patient was taken immediately to the operating room, where his hip was reduced and the fractures underwent open reduction and internal fixation. Plastic surgery was consulted intraoperatively for repair of his facial lacerations and degloving injury, which extended into his soft palate. Postoperatively, the patient remained intubated in the Surgical Intensive Care Unit with a relatively fast ventilatory wean. In the Intensive Care Unit, the patient was started on total parenteral nutrition due to edema of the soft palate and question of a swallowing mechanism. However, he continued to do very well, and on hospital day #3 he was extubated successfully. The patient was watched in Surgical Intensive Care Unit for an additional day and then transferred to the floor. On the floor, he continued to do well. He was afebrile. However, one of his sputum cultures grew some gram-negative rods, which speciated as Hemophilus influenzae. He was started on Levofloxacin 500 mg p.o.q.d. for this. His pulmonary consolidation resolved by the physical examination. He was slowly advanced to a regular, which he was tolerating. The total parenteral nutrition was discontinued. He will be discharged to a rehabilitation facility. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: The patient was discharged to rehabilitation. DISCHARGE MEDICATIONS: 1. Norvasc 5 mg p.o.q.d. 2. Ativan 0.5 mg p.o.q.6h.p.r.n. 3. Boost, one can p.o.t.i.d. 4. Tylenol #3, 1 to 2, q.4 to 6h.p.r.n. 5. Multivitamin p.o.q.d. 6. Levofloxacin 500 mg p.o.q.d., which should be discontinued on [**2192-2-13**]. 7. Prozac 20 mg p.o.q.d. 8. Bacitracin ointment to face wounds b.i.d. 9. Zantac 150 mg p.o.b.i.d. 10. Albuterol, Atrovent MDI one to two puffs q.4h.p.r.n. 11. Peridex mouth wash swish and spit t.i.d. 12. Lovenox 30 mg subcutaneously b.i.d. 13. Sliding scale insulin. DIET: Regular. We expect that his insulin requirement is related to his TPN and will probably not require insulin once off the TPN in rehabilitation on a regular diet. The patient's right shoulder has been radiologically studied. There are no fractures, however, there is significant bruising in the humeral head. He will have a right shoulder sling just p.r.n. His fractures of the lower extremity require him to not adduct his knees together at any point. He should not flex his left leg to greater than 45 degrees at any time for six weeks. He will be strict nonweightbearing and should followup with the Department of Orthopedic Surgery. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 845**], M.D. [**MD Number(1) 846**] Dictated By:[**Last Name (NamePattern1) 6453**] MEDQUIST36 D: [**2192-2-10**] 09:24 T: [**2192-2-9**] 11:24 JOB#: [**Job Number 6989**]

[ "E823.1", "820.09", "305.00", "873.43", "355.3", "487.1", "808.0", "873.41", "840.9" ]

icd9cm

[ [ [] ] ]

[ "27.59", "38.93", "79.39", "79.35", "99.15", "96.71", "96.04", "86.59" ]

icd9pcs

[ [ [] ] ]

6599, 8033

6501, 6576

59,924

183,401

40026

Discharge summary

report

Admission Date: [**2175-11-16**] Discharge Date: [**2175-11-25**] Date of Birth: [**2107-8-31**] Sex: F Service: SURGERY Allergies: Nifedipine / amlodipine Attending:[**First Name3 (LF) 5569**] Chief Complaint: Hartmann's reversal Major Surgical or Invasive Procedure: [**2175-11-16**] Hartmann's reversal, small bowel resection, bladder repair, liver biopsy History of Present Illness: 68-year-old female with a history of a AAA repair complicated by ischemic colitis requiring an emergent sigmoid colectomy with end colostomy on [**2175-4-2**]. She has done quite well in her recovery and presents for reversal of her Hartmann's procedure. She has a history of cirrhosis of unclear etiology, so a liver biopsy has also been requested by her treating hepatologist. The risks and benefits of the procedure were discussed in detail with the patient and her daughter. Consideration was also given to open cholecystectomy as the patient has a small gallbladder polyp. We discussed that if there were any concerns we would place a diverting ileostomy and would not proceed with the cholecystectomy given the multiple procedures planned. Past Medical History: PMH: left thalamic ICH [**10-16**], HTN, COPD, thyroid disease, CAD, type 2 diabetes mellitus, previous smoker PSH: Open infrarenal AAA repair w/ dacron [**2175-3-31**] (Dr. [**Last Name (STitle) 43078**]; sigmoid colectomy end colostomy [**2175-4-2**] (Dr [**Last Name (STitle) **]; TAH and BSO Social History: Does not report a substance use history. Says that she is a social drinker and does not drink very often. Had long smoking history but stopped smoking 5 years ago. Family History: Father died age [**Age over 90 **] w/complications of Alzheimer's. Mother is aged 96 w/mild memory issues and is retired RN Pertinent Results: [**2175-11-16**] 02:32PM WBC-6.0 RBC-3.75* HGB-10.2*# HCT-30.7* MCV-82 MCH-27.2 MCHC-33.2 RDW-16.0* [**2175-11-16**] 02:32PM PLT COUNT-134* [**2175-11-16**] 02:32PM GLUCOSE-112* UREA N-21* CREAT-0.8 SODIUM-140 POTASSIUM-3.8 CHLORIDE-107 TOTAL CO2-24 ANION GAP-13 [**2175-11-16**] 02:32PM ALT(SGPT)-28 AST(SGOT)-45* ALK PHOS-81 TOT BILI-0.8 [**2175-11-16**] 02:32PM ALBUMIN-2.9* CALCIUM-8.3* PHOSPHATE-4.3# MAGNESIUM-1.4* Brief Hospital Course: Patient was admitted for an elective Hartmann's reversal procedure on [**2175-11-16**]. In the operating room a significant amount of adhesions were found in the abdomen and during the procedure a small bowel resection and a bladder repair needed to be performed, leaving a diverting loop ileostomy to allow full healing of the sigmoid anastomosis (see report). Postoperatively, patient received 2U of RBCs for labile blood pressures in the PACU, EBL 250 and a Hct of 25.5 postop, rising appropriately to 34 and with no evidence of bleeding. She was initially managed with an epidural, but given labile blood pressures and inadequate pain management, this was changed to a PCA and the epidural pulled on POD1. On POD2 her NGT output was minimal, the ostomy looked pink and putting out minimal serous fluid. NGT was removed, pain was controlled with a PCA. On POD3 patient was feeling well, OOB ambulating, pain was controlled. She was advanced to a clear liquid diet. On POD4 patient has 2 episodes of emesis, requiring replacement of the NGT. A KUB showed dilated loops of small bowel consistent with ileus. On POD5 the ostomy started to have 300 cc of stool and gas and by POD6 the NGT was removed. The foley catheter was kept for 6 days postop given the bladder repair and then removed without complications. By POD7 she was tolerating clears again with ostomy output >1L and on POD8 tolerating a regular diet. She was seen by physical therapy and cleared to go home. She was discharged on POD9, tolerating a regular diet, ambulating independently, with adequate pain control on po pain meds and with adequate ostomy output. She will have VNA at home and follow up with Dr. [**Last Name (STitle) **] as an outpatient. Medications on Admission: Citalopram 10', Lopressor 50', HCTZ 25', Home oxygen 2.5 L at night, and sometimes during the day, Symbicort 160 mcg-4.5 mcg [**Hospital1 **], ProAir prn, ipratropium-albuterol 0.5 mg-3 mg, omeprazole 20', simvastatin 20', valsartan 160', ASA 81', vit D3 1000', mvi, fish oil Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 3. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every eight (8) hours as needed for pain. Tablet(s) 4. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 5. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 6. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 9. oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* *** Diovan was not restarted postop in the hospital as BP was 120-130's without it and it was never restarted after surgery. VNA should follow BP & it she's running higher, then it can get restarted. Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: History of AA repair, ischemic colitis s/p Hartmann's procedure Now s/p Hartmann's reversal, small bowel resection, bladder repair, liver biopsy Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent Discharge Instructions: Please call the Transplant Office [**Telephone/Fax (1) 673**] if you have any of the warning signs. Monitor your ostomy output and measure it. If this is more than 1.5 liters a day you must call the office for advise. Monitor your incision, if there are signs of worsening redness, induration or drainage call the office Followup Instructions: Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2175-12-1**] 2:20 Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2175-12-21**] 2:00 Completed by:[**2175-11-29**]

[ "V15.82", "575.6", "276.69", "V55.3", "496", "401.9", "568.0", "458.29", "998.2", "E870.0", "571.5", "560.1", "276.8" ]

icd9cm

[ [ [] ] ]

[ "45.62", "54.59", "46.52", "57.81", "50.12", "03.90", "46.01" ]

icd9pcs

[ [ [] ] ]

5413, 5464

2290, 4014

305, 396

5652, 5652

1835, 2267

6146, 6453

1690, 1816

4340, 5390

5485, 5631

4040, 4317

5801, 6123

246, 267

424, 1173

5667, 5777

1195, 1492

1508, 1674

25,113

109,484

13004

Discharge summary

report

Admission Date: [**2141-6-19**] Discharge Date: [**2141-6-22**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 338**] Chief Complaint: melena Major Surgical or Invasive Procedure: blood transfusion History of Present Illness: The patient is an 81 year old male with a history of CAD status post CABG times x4 and ICD, atrial fibrillation on coumadin, hypertension, diabetes type I, and CHF who presented to [**Hospital **] Hospital on [**6-19**] as the patient noticed that his ICD had fired x 2 in the past 24 hours. At the OSH, the patient was noted to have a Hct of 30 with BUN/Cr of 100/2.2. His baseline Hct is 38. He then reported that he had noticed 3 days of black, tarry loose stool. He has never had gastrointestinal bleeding nor has he had a prior colonoscopy. He denied any bright red blood per rectum, hematemesis, nausea or vomiting. He was transferred to the [**Hospital1 18**] as he receives cardiac care here. In the ED, he was found to have a Hct of 32.4 with a positive NG lavage that did not clear (by report) and an INR of 2.2. His Cr was 2.1 (baseline 1.1-1.5), WBC of 13 with 78% PMNs. His HR was 116, SBP 134/57 after 250 cc IVF at the OSH. He was reported as being 88/51 en route to [**Hospital1 18**]. In the ED, the patient received 4 units FFP, 2 units PRBC with 40 IV lasix between units, 10 mg SC Vitamin K and 40 mg IV protonix. GI and EP evaluated the patient in the ED. EP increased his set rate for his ICD to 150-160 bpm and felt his ICD was otherwise working well but was set off from his rapid afib with widened QRS. GI planned for EGD when INR reversed. Past Medical History: 1. DMI, for 30 years c/b neuropathy 2. CAD: s/p Cath ([**2128**]) with clean coronary arteries, ETT Persantine study ([**12-21**]) with fixed, and Cath ([**2-22**]) with distal RCA 60% lesion, left main 30% discrete lesion, mid LAD 90%, D1 80%, proximal circ 80%, OM1 70% and wedge of 17 s/p 4v-CABG ([**2-22**]) with LIMA to LAD, vein graft to PDA, vein graft to OM1 and radial artery to diag 3. CHF, EF 30% s/p ICD for primary prevention of sudden cardiac death (did not place [**Hospital1 **]-v ICD because QRS duration was under 120 msec) 4. Chronic AF, asymptomatic, ICD interrogated by [**Doctor Last Name **] [**3-25**] and showed an isolated episode of atrial fibrillation with a rapid ventricular response in his ventricular tachycardia zone 5. Right ICA stenosis > 70%, asymptomatic 6. HTN 7. s/p removal of malignant bladder tumor 8. Gout 9. Varicose veins 10. CABG complicated by mediastinitis treated with antibiotics. The patient left AMA from that hospitalization Social History: Patient lives with his wife. [**Name (NI) **] has two children, a daughter who is a nurse. He is retired post office worker. He quit smoking 30 years ago and does not drink alcohol. Family History: Father died of an MI at 60, his brother had a CABG at age 60 and his other brother an MI at age 70. Physical Exam: Tc = 96.5 P=97 BP=181/72 RR=16 100% on NC Gen - NAD, AOX3, slow to answer questions but answers appropriately HEENT - Mildly pale conjuctiva, anicteric, dry MMM Heart - Irregular, Grade II/VI SEM throuhout precordium best heard at RUSB with bilateral carotid bruits Lungs - CTAB Abdomen - Soft, NT, ND, + BS Ext - Chronic venous stasis dermatitis near ankles bilaterally with +1 d. pedis bilaterally, trace edema bilaterally Skin - Multiple seborrheic keratoses on back/chest Pertinent Results: CXR [**2141-6-19**]: Stable cardiomegaly. No CHF or pneumonia. EKG [**2141-6-9**]: Afib with LBBB, LVH, TWI I, avL, [**Street Address(2) 1766**] elevations with LBBB discordant with QRS [**2141-6-19**] 09:59PM GLUCOSE-170* UREA N-119* CREAT-1.7* SODIUM-142 POTASSIUM-4.4 CHLORIDE-110* TOTAL CO2-22 ANION GAP-14 [**2141-6-19**] 09:59PM ALT(SGPT)-17 AST(SGOT)-23 LD(LDH)-160 ALK PHOS-52 AMYLASE-76 TOT BILI-0.4 [**2141-6-19**] 09:59PM LIPASE-46 [**2141-6-19**] 09:59PM ALBUMIN-3.6 CALCIUM-9.4 PHOSPHATE-2.9# MAGNESIUM-2.0 CHOLEST-129 [**2141-6-19**] 09:59PM TRIGLYCER-277* HDL CHOL-29 CHOL/HDL-4.4 LDL(CALC)-45 [**2141-6-19**] 07:52PM HCT-28.0* [**2141-6-19**] 07:52PM PT-17.5* PTT-28.1 INR(PT)-2.0 [**2141-6-19**] 01:20PM GLUCOSE-195* UREA N-138* CREAT-2.1* SODIUM-141 POTASSIUM-5.5* CHLORIDE-106 TOTAL CO2-21* ANION GAP-20 [**2141-6-19**] 01:20PM WBC-13.0* RBC-3.52*# HGB-11.1*# HCT-32.4*# MCV-92 MCH-31.6 MCHC-34.3 RDW-14.5 [**2141-6-19**] 01:20PM NEUTS-78.4* LYMPHS-18.3 MONOS-2.7 EOS-0.5 BASOS-0.2 [**2141-6-19**] 01:20PM PLT COUNT-191 [**2141-6-19**] 01:20PM PT-18.3* PTT-27.2 INR(PT)-2.2 Brief Hospital Course: The patient is an 81 year old male with a history of CAD s/p CABG, ICD with afib on coumadin, and DMII who presented with melenotic stools and a 8 point Hct drop from baseline with rapid afib. 1. UGIB; received a total of 3 Units of PRBC's. Hct now stable. - The patient underwent an EGD on [**6-19**] that showed a gastric ulcer in the proximal body of the stomach that proved to be the source of his UGIB. In addition, there was a visible clot in the distal esophagus. There were ulcers in the stomach but not the duodenum. The crater in the proximal stomach was injected with epinephrine and cauterized. GI suggests that if Hct remains stable, he return for another EGD in [**6-28**] weeks to re-evaluate healing of the current gastric ulcers and question the utility of a biopsy to assess for possible malignancy. - He was found to have H. pylori and started on a 2 week course of therapy with protonix, clarithromycin, and azithromycin. - He was initially kept NPO, however his diet was advanced as tolerated once hct was stable. 2. Afib s/p ICD - The patient was taking coumadin 5 mg as an outpatient with a goal INR [**2-23**]. On admission he was given Vitamin K 10 mg SQ x 1 and FFP for reversal of an initial INR of 2.2. His coumadin was held during his stay however was restarted at discharge. - He was discharged on Toprol XL 150 mg for rate control - His digoxin was continued - The patient had a St. [**Male First Name (un) 923**] ICD placed for primary prevention of sudden cardiac death given his ischemic cardiomyopathy. His ICD has been evaluated by EP on [**6-19**] and felt to be working effectively. It was most likely triggered by the rapid ventricular rate in the setting of afib with a baseline LBBB. 3. DMI. His oral meds were initially held while he was NPO. He was covered with a SSI while he is hospitalized His glyburide 6 mg and Metformin 500 mg [**Hospital1 **] were restared prior to discharge. 4. HTN - The patient takes Toprol XL 150 mg and Zestril 40 mg at home. His BP remained stable throughout his stay and his oupatient anti-HTN medications were restarted. 5. CHF, EF 30% - He was given maintenance fluids while kept NPO with lasix between blood transufions. He was discharged home on Lasix 40 mg [**Hospital1 **]. 6. Acute on chronic renal failure (baseline Cr 1.3-1.5). Cr improved to 1.5 from 2.1 with IV hydration. - Most likely pre-renal in nature in the setting of loose stools with melena in the past few days. 7. CAD - Discharged home on Bblocker and ACE. His ASA was held given GI bleed. - lipid profile WNL, pt does not need statin (LDL 45). 8. CODE: DNR but agrees to resuscitation including CPR and defibrillation (he has an ICD in place). We discussed how this is difficult to respect as protecting one's airway and protecting their heart in an emergency are both necessary for complete CPR but he reiterated his desire not to be intubated but agrees to resuscitation. Medications on Admission: Metformin 500 [**Hospital1 **] Lasix 40 [**Hospital1 **] glyburide 6mg daily Toprol XL 150 allopurinol 5 mg QD Zestril 40 Digetek .125 Aspirin 81 Coumadin 5 mg Discharge Medications: 1. Clarithromycin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 14 days. Disp:*28 Tablet(s)* Refills:*0* 2. Amoxicillin 500 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours) for 14 days. Disp:*28 Capsule(s)* Refills:*0* 3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours for 1 doses. 4. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day: except sunday. 5. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: Three (3) Tablet Sustained Release 24HR PO DAILY (Daily). 6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for 2 weeks. Disp:*28 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 7. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day: pantoprazole is available over the counter or as a generic. 8. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. Metformin HCl 500 mg Tablet Sig: One (1) Tablet PO twice a day. 11. Glyburide 1.25 mg Tablet Sig: Four (4) Tablet PO twice a day. 12. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) 13. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO three times a day. Discharge Disposition: Home Discharge Diagnosis: Upper GI bleed secondary to peptic ulcer disease H. pylori induced peptic ulcer disease Discharge Condition: stable and improved Discharge Instructions: Please seek immediate medical attention if you experience fever greater than 101, shaking chills, lightheadedness, palpitations, chest pain, or have black/tarry stools, or bloody stools. Please resume your other home medications except please do not take aspirin. You are on a 2 week course of therapy for treatment of H. pylori (protonix, clarithromycin, azithromycin). Followup Instructions: 1. Please follow up with your PCP [**Last Name (NamePattern4) **] 2 weeks. 2. Please have your blood work checked on Monday and have the results sent to your PCP. 3. Please follow up with Dr. [**Last Name (STitle) **] in GI to obtain a repeat endoscopy in [**6-28**] weeks. Call ([**Telephone/Fax (1) 8892**] to make a clinic appointment.

[ "414.8", "V58.61", "V53.32", "V45.81", "250.00", "428.0", "427.31", "285.1", "041.86", "584.9", "412", "401.9", "531.40", "414.00" ]

icd9cm

[ [ [] ] ]

[ "89.49", "99.04", "44.43" ]

icd9pcs

[ [ [] ] ]

9149, 9155

4664, 7597

268, 288

9287, 9308

3521, 4641

9729, 10072

2903, 3005

7811, 9126

9176, 9266

7623, 7788

9332, 9706

3020, 3502

222, 230

316, 1685

1707, 2688

2704, 2887

3,703

179,102

45054

Discharge summary

report

Admission Date: [**2173-8-12**] Discharge Date: [**2173-8-15**] Service: MEDICINE Allergies: Bactrim / Procardia Attending:[**First Name3 (LF) 458**] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: None History of Present Illness: 87yo M with hx of DM, HTN, diverticulosis,s/p partial colectomy, depression, CKD, parkinson's vascular dementia, s/p pacemaker, who has been experiencing night desaturation for the past few days, worse this evening. At [**Hospital 100**] Rehab, he had awoken with SOB, satting 89% on 3L NC, improved to 95% on mask at 5L. Pt was given Lasix 40 mg po and 81 mg ASA. Pt had a second episode of SOB overnight, satting 70-80% on mask at 8L and was transferred to [**Hospital1 18**]. RR was 28, BP 150/80, HR 64, T 98 ax. Patient was non-communicative at time of exam and history was obtained from medical record and from family report. . On arrival to [**Hospital1 18**] ED, SpO2 76% on NRB, ABG of 7.34/66/53. He was started on BiPap (FiO2 60%, PEEP 5, PS 10) with improvement of O2 sat to 90-100%. He received a nitro gtt, Lasix 60 mg IV, levofloxacin 750 mg IV, and albuterol nebulizer. . 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, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He has a chronic raspy cough per the daughter. [**Name (NI) **] of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, palpitations. Daughter is not aware of any dyspnea on exertion, orthopnea. She has noted that he had ankle edema ("elephant legs") in the late winter and early spring and had asked [**Hospital1 100**] Senior Life to start the patient on Lasix. Daughter denies any syncope or presyncope. He has poor functional capacity at baseline. Past Medical History: PAST MEDICAL HISTORY: 1. Type 2 DM 2. Thoracic pseudoaneursym of aorta, 4.3 cm in diameter 3. HTN 4. Diverticulosis, s/p partial colectomy 5. Depression 6. CRI (baseline Cr 1.3-1.7) 7. Parkinson's disease 8. Vascular dementia 9. Pacemaker c/b lead thrombus. Previously followed by Dr [**Last Name (STitle) **] for "episodic unreponsiveness." This resolved with pacemaker adjustment. Recently seen by Dr. [**Last Name (STitle) **]/[**Doctor Last Name **] for the thrombus, anticoagulation deferred for h/o falls, unsteady gait, and confusion. 11. s/p hip fracture requiring ORIF in [**3-/2172**] with a complicated medical course including hypoxic respiratory failure. 12. Chronic diastolic dysfunction. Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. Patient resides at [**Hospital 100**] Rehab. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: VS: T 95.7 ax, BP 130/85, HR 79, RR 16, O2 95% on BiPap Gen: Fatigued older male in NAD. Oriented to self only, "[**2138**]", "[**Hospital1 100**]." Per daughter, mental status at baseline. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. MMM. Neck: Supple with JVP of 7 cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. ?S3. No murmurs noted. Chest: No accessory muscle use. Decreased breath sounds throughout, diffuse rhonchi. No crackles, wheezes. Abd: Normoactive, soft, NT/ND, No HSM. No abdominial bruits. Ext: No femoral bruits. Trace pedal edema bilaterally. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Neuro: PERRL, EOMI. Resting tremor. . Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP/PT [**Name (NI) 2325**]: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP/PT Pertinent Results: ADMISSION LABS: [**2173-8-12**] 04:05AM BLOOD WBC-10.8 RBC-4.64# Hgb-13.5*# Hct-41.4# MCV-89 MCH-29.1 MCHC-32.6 RDW-14.3 Plt Ct-146* Neuts-84.1* Lymphs-10.8* Monos-2.3 Eos-2.6 Baso-0.2 PT-14.0* PTT-27.7 INR(PT)-1.2* Glucose-208* UreaN-22* Creat-1.5* Na-145 K-3.5 Cl-101 HCO3-37* AnGap-11 [**2173-8-12**] 04:05AM BLOOD ALT-16 AST-19 LD(LDH)-200 CK(CPK)-85 AlkPhos-70 TotBili-0.4 CK-MB-NotDone proBNP-1203* Albumin-4.2 Mg-2.0 . [**2173-8-12**] 04:20AM BLOOD Type-ART pO2-53* pCO2-66* pH-7.34* calTCO2-37* Base XS-6 Intubat-NOT INTUBA . [**2173-8-12**] 05:37AM TYPE-ART PO2-70* PCO2-68* PH-7.32* TOTAL CO2-37* BASE XS-5 INTUBATED-NOT INTUBA . [**2173-8-12**] 10:51AM TYPE-ART PEEP-5 O2-60 PO2-130* PCO2-66* PH-7.35 TOTAL CO2-38* BASE XS-8 INTUBATED-NOT INTUBA . [**2173-8-12**] 01:44PM CK-MB-NotDone cTropnT-0.02* [**2173-8-12**] 01:44PM CK(CPK)-67 . [**2173-8-13**] 04:28AM Triglyc-163* HDL-34 CHOL/HD-4.1 LDLcalc-72 . [**Hospital1 18**] [**Numeric Identifier 96306**]Portable TTE (Complete) Done [**2173-8-12**] at 2:12:50 PM FINAL The left atrium is dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. The ascending aorta is moderately dilated. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a fat pad. . Compared with the prior study (images reviewed) of [**2173-5-25**], the previously suspected thrombus on the pacing wire is not apparent on the current study. However, the suboptimal image quality precludes close examination of the pacing wrie. The other findings are similar. . Radiology Report CHEST (PORTABLE AP) Study Date of [**2173-8-12**] 4:03 AM UPRIGHT PORABLE CHEST Streaky linear atelectasis is noted extending from the region of the right hila and at the left base in this patient with persistent low lung volumes. No evidence of interstitial pulmonary edema, pneumothorax, or consolidation to suggest pneumonia. The cardiomediastinal silhouette is unchanged with stable appearance to abnormal contour projecting above the aortic knob consistent with the patient's known pseudoaneurysm. Positioning of pacemaker leads is unchanged. . Radiology Report CHEST (PA & LAT) Study Date of [**2173-8-14**] 1:55 PM Lateral views are not well penetrated. The right hemidiaphragm is elevated, as before. The lungs appear clear except for streaky density in the retrocardiac area, which is suboptimally evaluated. The cardiac silhouette appears large but may be exaggerated by AP technique. A 4.5 cm round density projected adjacent to the aortic knob, consistent with a known aortic pseudoaneurysm is unchanged. Mediastinal structures are unchanged in appearance, and the bony thorax is grossly intact. A bipolar transvenous pacemaker remains in place. IMPRESSION: Streaky density in the retrocardiac area that may represent partial atelectasis or consolidation. Elevation of the right hemidiaphragm. No definite interval change. Brief Hospital Course: The patient is an 87yo man with a history of Diabetes, Hypertension, diastolic CHF, s/p pacemaker, CKD, Parkinson's, and vascular dementia who presented for SOB/hypoxia and found to be in hypercarbic/hypoxic respiratory failure requiring BiPap. . # Hypercarbic/hypoxic respiratory failure: The patient was hypoxic on admission with SpO2 76% on NRB and an arterial blood gas of 7.34/66/53. He was started on BiPap (FiO2 60%, PEEP 5, PS 10) with improvement of O2 sat to 90-100% which was weaned over several hours. The patient had no history of COPD or asthma. His acute hypoxia was felt to be due to diastolic heart failure, although CXR appeared to have mild pulmonary edema without significant change from [**4-22**]. The patient was afebrile, without cough, fever or leukocytosis. PE was considered given a previously noted thrombus in the RA and the patient's poor functional capacity at baseline. However, repeat ECHO was without evidence of thrombus and there was no evidence of DVT on physical exam. The patient received Lasix boluses for diuresis and was slowly switched back to his home dose of PO Lasix. Over the course of hospitalization the patient had marked improvement in his supplemental oxygen requirements and at the time of discharge he was sating well on 4L of oxygen. . # Diastolic CHF: The patient had an Echocardiogram in [**Month (only) **] with evidence of mild pulmonary artery systolic hypertension and diastolic dysfunction. On presentation this admission, the patient lacked overt volume overload on arrival and chest xray was not remarkably changed from previous exams. However, BNP was elevated at 1203. Blood pressure was noted to be 150/80 and the patient was given IV Lasix boluses and started on a Nitro gtt for blood pressure control. Repeat ECHO showed little change since previous exam. We would encourage daily weights and a low sodium diet in this patient. Should his weight increase greater than 3 pounds, he should be given an extra PM dose of Lasix. . # HTN: The patient was noted to be hypertensive during admission, with systolic blood pressures to the 160's/170's. He was initially started on a Nitro drip for immediate blood pressure control. He was then transitioned to oral medications. His home dose of metoprolol was increased from 12.5mg daily to 100mg and he was started on Imdur 30mg daily with a good response in BP. At the time of discharge, his blood pressure was in an acceptable range of 110's systolic. . # CAD/Ischemia: The patient had an episode of chest pain. Cardiac enzymes were unremarkable with troponin was slightly elevated in setting of chronic renal failure, possible demand ischemia from diastolic CHF. The patient had no known history of CAD and no evidence of acute ischemic changes on EKG. . # DM: The patient was maintained in glipizide and an insulin sliding scale for extra coverage. . # CRI (baseline Cr 1.3-1.7): The patient had a history of chronic renal insufficiency and on arrival, his creatinine was at baseline. Following Lasix diuresis, the patient's creatinine increased to a peak of 1.9 but was trending down at the time of discharge. The patient was discharged on his home dose of Lasix (60mg). His renal function should be carefully monitored and his Lasix dosing adjusted accordingly. . # Parkinson's disease/Vascular Dementia/Depression: The patient was maintained on his normal regiment of donepezil, Mirapex, bupropion HCl, and Celexa 20 mg. His nightly trazodone dose was increased to 25mg QHS. . # Code status: Full code, confirmed with daughter. . Medications on Admission: CURRENT MEDICATIONS: Furosemide 60 mg daily, started in [**4-22**] Metoprolol XL 12.5 mg daily KCl 10 meq MWF Glipizide 5 mg daily Acetaminophen 975 mg q 6 hrs Bupropion Hcl 75 mg [**Hospital1 **] Celexa 20 mg daily Donepezil 10 mg daily Mirapex 0.25 mg TID Trazodone 12.5 mg qhs Keflex 500 mg daily for chronic suppressive therapy Ferrous sulfate 325 mg daily Vitamin D 1000 units daily Calcium carbonated 650 mg [**Hospital1 **] Vitamin C Vitamin B12 1000 mcg IM monthly Melatonin 4 mg qhs Discharge Medications: 1. Bupropion 75 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 3. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Donepezil 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 6. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 9. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 11. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 12. Glipizide 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed. 14. Isosorbide Mononitrate 10 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 16. Potassium Chloride 10 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO MWF. 17. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). 18. Iron (Ferrous Sulfate) 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO once a day. 19. Vitamin C 100 mg Tablet Sig: One (1) Tablet PO once a day. 20. Vitamin B-12 1,000 mcg/mL Solution Sig: One (1) Injection once a month. 21. Melatonin 1 mg Tablet Sig: Four (4) Tablet PO qHS. 22. Lasix 20 mg Tablet Sig: Three (3) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - LTC Discharge Diagnosis: Primary: diastolic Heart Failure HTN Type 2 DM CRI (1.3-1.7) Secondary: Diverticulosis, s/p partial colectomy Depression Parkinson's disease Dementia-vascular on MRI [**2162**] Pacemaker Discharge Condition: The patient was hemodynamically stable, afebrile and without pain. He was sating 96% on 3L NC oxygen. Discharge Instructions: You were admitted for evaluation of shortness of breath. It was felt that your symptoms were realated to poor heart function. You were treated with diuretics and oxygen with a significant improvement in your symptoms. During your hospitalization, it was noted that your blood pressure was elevated. We have increased your dose of metoprolol to 100mg daily and we have also added an additional medication (Imdur). You should take both medications as prescribed. We have also increased your dose of trazadone from 12.5 to 25mg every evening. Please take all medications as prescribed. You should follow-up with your primary care doctor with regards to your kidney function. You should be weighed daily. If you have a weight gain > 3lbs, you should take an EXTRA dose of Lasix (40 mg) in the evening. Please call your doctor or return to the hospital if you develop chest pain, increased shortness of breath, numbness or tingling in your arm, nausea, vomiting, fevers, chills or any other symptoms of concern. Followup Instructions: Appointments scheduled prior to admission: . Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2173-12-2**] 1:00 . Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2173-12-2**] 1:45 Completed by:[**2173-8-15**]

[ "404.91", "332.0", "441.7", "518.81", "428.30", "437.0", "562.10", "428.0", "290.40", "311", "250.00", "V45.01", "585.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

13312, 13377

7346, 10919

246, 252

13608, 13713

3832, 3832

14778, 15111

2855, 2937

11461, 13289

13398, 13587

10945, 10945

13737, 14755

2952, 3813

187, 208

10966, 11438

280, 1940

3849, 7323

1984, 2668

2684, 2839

66,723

152,202

16295

Discharge summary

report

Admission Date: [**2191-6-14**] Discharge Date: [**2191-6-17**] Date of Birth: [**2112-1-30**] Sex: F Service: ORTHOPAEDICS Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 7303**] Chief Complaint: right hip pain Major Surgical or Invasive Procedure: Revision R total hip arthroplasty from [**3-29**] for acetabular fracture and nonunion History of Present Illness: 79 y/o woman who underwent THA in [**2191-3-14**] and in the post operative period developed an acetabular fracture which went on to non [**Hospital1 **]. Treatment options were discussed and it was decided by all parties to proceed with revision of her acetabular component only. Past Medical History: Hypertension Osteoporosis Right hip severe osteoarthritis s/p right hip replacement in [**3-/2191**] Right hip and pelvis insufficiency fractures Hyperlipidemia s/p TAH/USO in [**2149**] for ? endometrial cancer Asthma H. Pylori Polymyalgia rheumatica on chronic prednisone Social History: She lives in the same building as her daughter. She is divorced. She is a non-smoker and denies alcohol or illicit drug use. Family History: Father died at age 51 of an accident but had coronary artery disease. Mother had asthma and died in her 70s. Physical Exam: Vitals: T: 98.6 BP: 122/46 P: 81 R: 26 O2: 100% on 2L (while asleep demonstrates 15 to 30 second episodes of apnea with desaturations to the 60s) General: Alert, mildly somnolent, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley draining clear yellow urine Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema, right hip wound with pressure dressing in place Pertinent Results: Hematology: [**2191-6-14**] 06:02PM BLOOD WBC-15.7*# RBC-2.70*# Hgb-8.6*# Hct-25.0*# MCV-93 MCH-31.7 MCHC-34.2 RDW-13.2 Plt Ct-308 [**2191-6-15**] 05:37AM BLOOD WBC-10.6 RBC-2.54* Hgb-8.3* Hct-23.3* MCV-92 MCH-32.8* MCHC-35.6* RDW-13.2 Plt Ct-251 [**2191-6-14**] 06:02PM BLOOD Neuts-79.9* Lymphs-16.3* Monos-3.3 Eos-0.4 Baso-0.1 [**2191-6-15**] 05:37AM BLOOD PT-12.0 PTT-26.4 INR(PT)-1.0 Chemistries: [**2191-6-14**] 06:02PM BLOOD Glucose-148* UreaN-17 Creat-0.7 Na-137 K-3.4 Cl-105 HCO3-23 AnGap-12 [**2191-6-15**] 05:37AM BLOOD Glucose-116* UreaN-14 Creat-0.7 Na-134 K-4.2 Cl-105 HCO3-23 AnGap-10 [**2191-6-15**] 05:37AM BLOOD Calcium-7.8* Phos-3.8# Mg-1.6 [**2191-6-14**] 06:02PM BLOOD TSH-3.0 Blood Gas: [**2191-6-14**] 11:47PM BLOOD Type-ART Temp-37.2 pO2-161* pCO2-34* pH-7.46* calTCO2-25 Base XS-1 Images: CXR PA and Lateral [**2191-6-10**]: The cardiac, mediastinal and hilar contours are within normal limits. Lungs are clear with no focal consolidation or pleural effusion. Incidental note is made of marked coronary artery calcifications in both right and left coronary arteries. The visualized osseous structures show diffuse demineralization. EKG [**2191-6-10**]: Baseline artifact. Sinus bradycardia. Low limb lead voltage. Indeterminate axis. Early R wave progression. Brief Hospital Course: The patient was admitted to the orthopaedic surgery service and was taken to the operating room for above described procedure. Please see separately dictated operative report for details. The surgery was uncomplicated and the patient tolerated the procedure well. Patient received perioperative IV antibiotics. In the postoperative period,she experienced oxygen desaturization and was admitted to the [**Hospital Unit Name 153**] overnight for observation. On POD 1 she was stable on room air after reducing her narcotic intake. Otherwise, pain was controlled with oral pain medications. The patient received lovenox for DVT prophylaxis starting on the morning of POD#1. Also on POD 1, the pt recieved 2 U PRBC without issue. The surgical dressing was changed on POD#2 and the surgical incision was found to be clean and intact without erythema or abnormal drainage. The patient was seen daily by physical therapy. Labs were checked throughout the hospital course and repleted accordingly. At the time of discharge the patient was tolerating a regular diet and feeling well. The patient was afebrile with stable vital signs. The patient's hematocrit was acceptable and pain was adequately controlled on an oral regimen. The operative extremity was neurovascularly intact and the wound was benign. At time of discharge, patient was deemed stable for safe discharge to rehab. The patient's weight-bearing status is 50 % weight bearing on the operative extremity for 6 weeks with posterior hip precautions. Medications on Admission: Albuterol PRN Alendronate 70 mg qweek Fluticasone nasal Lisinopril 10 mg daily Toprol XL 12.5 mg daily Omeprazole 20 mg daily Prednisone 5 mg daily Simvastatin 20 mg daily Triamterene-Hydrochlorothiazide 37.5-25 mg daily Aspirin 81 mg daily Calcium 500 mg TID Vitamin D 400 IU daily Multivitamin daily Discharge Medications: 1. Lovenox 40 mg/0.4 mL Syringe Sig: One (1) Subcutaneous once a day for 3 weeks: once finished, start aspirin 325mg twice a day for 3 weeks. Disp:*21 * Refills:*0* 2. Aspirin, Buffered 325 mg Tablet Sig: One (1) Tablet PO twice a day for 3 weeks. Disp:*42 Tablet(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 5. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Multivitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 7. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*2* 8. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily). 9. Triamterene-Hydrochlorothiazid 37.5-25 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 10. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). 11. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: One (1) Puff Inhalation Q6H (every 6 hours) as needed for SOB. 12. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Prednisone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): until [**6-22**] then stop. 14. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for CP. 15. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). Discharge Disposition: Extended Care Facility: [**First Name8 (NamePattern2) 3075**] [**Last Name (NamePattern1) **] Ctr Discharge Diagnosis: revision non [**Hospital1 **] Right THA 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: 1. Please return to the emergency department or notify your physician if you experience any of the following: severe pain not relieved by medication, increased swelling, decreased sensation, difficulty with movement, fevers greater than 101.5, shaking chills, increasing redness or drainage from the incision site, chest pain, shortness of breath or any other concerns. 2. Please follow up with your primary physician regarding this admission and any new medications and refills. 3. Resume your home medications unless otherwise instructed. 4. You have been given medications for pain control. Please do not drive, operate heavy machinery, or drink alcohol while taking these medications. As your pain decreases, take fewer tablets and increase the time between doses. This medication can cause constipation, so you should drink plenty of water daily and take a stool softener (such as colace) as needed to prevent this side effect. 5. You may not drive a car until cleared to do so by your surgeon or your primary physician. 6. Please keep your wounds clean. You may shower starting five days after surgery, but no tub baths or swimming for at least four weeks. No dressing is needed if wound continues to be non-draining. Any stitches or staples that need to be removed will be taken out by the visiting nurse or rehab facility two weeks after your surgery. 7. Please call your surgeon's office to schedule or confirm your follow-up appointment in four weeks. 8. Please DO NOT take any non-steroidal anti-inflammatory medications (NSAIDs such as celebrex, ibuprofen, advil, aleve, motrin, etc). 9. ANTICOAGULATION: Please continue your lovenox for three weeks to help prevent deep vein thrombosis (blood clots). After completing the lovenox, please take Aspirin 325mg TWICE daily for an additional three weeks. 10. WOUND CARE: Please keep your incision clean and dry. It is okay to shower five days after surgery but no tub baths, swimming, or submerging your incision until after your four week checkup. Please place a dry sterile dressing on the wound each day if there is drainage, otherwise leave it open to air. Check wound regularly for signs of infection such as redness or thick yellow drainage. Staples will be removed by the visiting nurse or rehab facility in two weeks. 11. VNA (once at home): Home PT/OT, dressing changes as instructed, wound checks,staple removal 2 weeks after surgery, replace with steri strips. 12. ACTIVITY: 50 % weight bearing on the operative extremity for 6 WEEKS. No strenuous exercise or heavy lifting until follow up appointment. Physical Therapy: 50% WEIGHT BEARING FOR 6 WEEKS posterior hip precautions Treatments Frequency: staple removal 2 weeks from date of surgery dressing changes as needed 50% weight bearing for 6 WEEKS Followup Instructions: We recommend that you be evaluated at the sleep clinic and undergo a sleep study for further evaluation of your apneas. Please call ([**Telephone/Fax (1) 513**] to schedule an appointment. Provider: [**First Name4 (NamePattern1) 6100**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2191-7-13**] 12:00 [**First Name4 (NamePattern1) 6100**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 7305**] Completed by:[**2191-6-17**]

[ "V43.64", "996.41", "E878.1", "725", "493.90", "401.9", "272.4", "733.00" ]

icd9cm

[ [ [] ] ]

[ "81.52" ]

icd9pcs

[ [ [] ] ]

6737, 6837

3358, 4873

334, 422

6921, 6921

2045, 3335

9904, 10401

1192, 1304

5226, 6714

6858, 6900

4899, 5203

7104, 8924

1319, 2026

9699, 9756

9778, 9881

280, 296

8936, 9681

450, 733

6936, 7080

755, 1031

1047, 1176

14,796

108,573

22082+22083

Discharge summary

report+report

Admission Date: [**2103-9-19**] Discharge Date: [**2103-9-27**] Date of Birth: [**2045-12-29**] Sex: F Service: CSU HI[**Last Name (STitle) 2710**]OF PRESENT ILLNESS: This is a 57-year-old woman who was referred into the Medical Center as a patient of Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5874**] of Cardiology and Dr. [**First Name (STitle) **] [**Last Name (Prefixes) **] of Cardiac Surgery. She reported that she had a heart murmur since childhood and her primary care physician had recently referred her for a routine echocardiogram. This showed mild MR with normal LV chamber size and function and a thickening in the descending portion of the aortic arch. She was then referred for further testing. On [**2103-7-20**], she had an MRI at [**Hospital1 18**] which showed a large irregular mass at the proximal descending aorta with an abnormal pretracheal lymph node. The differential diagnosis includes neoplasm versus thrombus. She has since been seen by Dr. [**Last Name (Prefixes) **] and Oncology at [**Hospital1 **] and is referred now for cardiac catheterization. This was the note recorded prior to her cardiac catheterization done on [**2103-8-15**], one month prior to her admission. The patient denied any symptoms at the time. Her only complaint was of episodic indigestion. She was normally quite active, participating in aerobics and swimming without any difficulties. She denied any claudication, edema, orthopnea, PND, lightheadedness, and admitted to rare palpitations. PAST MEDICAL HISTORY: 1. Aortic mass. 2. Heart murmur. 3. Hypertension. 4. Hypercholesterolemia. 5. Positive family history with her father having an MI at 62 and mother with coronary disease in her late 60s. Her mother also had an abdominal aortic aneurysm. The patient's older brother had an MI at 45 and another MI and CABG at 54 and another brother had a CVA at age 48, all contributing to a very positive family history. 6. Grave's disease. 7. An episode of bilateral pneumococcal pneumonia in [**2086**]. PAST SURGICAL HISTORY: 1. Tonsillectomy and adenoidectomy. 2. Appendectomy. 3. Ectopic pregnancy surgery in [**2068**]. ALLERGIES: The patient has no known drug allergies. MEDICATIONS AT THE TIME OF CARDIAC CATHETERIZATION: 1. Tapazole 10 mg p.o. daily. 2. Atenolol 50 mg p.o. daily. 3. Hydrochlorothiazide 25 mg p.o. daily. 4. Aspirin 81 mg p.o. daily. SOCIAL HISTORY: The patient admitted to smoking 1 1/2 packs per day for 40 years. She cut back in [**Month (only) **] to three- quarters of a pack in that year and quit approximately two weeks prior to her cardiac catheterization. The patient is divorced and lives alone. The patient has two children. She works as a project manager for a demolition company. She denied any history of emotional, physical, or sexual abuse or threats of abuse. HOSPITAL COURSE: She came in for cardiac catheterization on [**2103-8-15**]. A preoperative echocardiogram done in [**2103-5-24**] showed a mild MR, trace TR, trace TI, ejection fraction 60 percent, and a thickening in the descending portion of the aortic arch. DICTATION ENDED [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2103-11-6**] 10:42:17 T: [**2103-11-6**] 11:27:43 Job#: [**Job Number 57736**] Admission Date: [**2103-9-19**] Discharge Date: [**2103-9-27**] Date of Birth: [**2045-12-29**] Sex: F Service: CSU ADDENDUM: Preop laboratory work obtained on [**2103-8-31**] showed a white count of 6.1, hematocrit of 37.1, platelet count 206,000. Prothrombin time 12.6, PTT 32.5. INR 1.0. Sodium 136, K 3.4, chloride 96, bicarbonate 28, BUN 13, creatinine 0.8 with a blood sugar of 83. ALT 16, AST 21. LDH 208. Alkaline phosphatase 100, amylase 93, total bilirubin 0.5, HBA1C 5.3 percent. Electrocardiogram performed on [**2103-8-14**] showed a sinus bradycardia at 52 and otherwise unremarkable examination but please refer to the final report. Cardiac catheterization performed on [**2103-8-14**] showed an right coronary artery lesion at 50 percent, and left anterior descending coronary artery lesion of 40 percent and a first diagonal lesion at 50 percent. Please refer to the final catheter report dated [**2103-8-14**]. On [**2103-8-6**] preop cardiac magnetic resonance imaging showed a chunky irregular calcified mass of 2 cm 1.5 cm at the base of aortic arch distal to left subclavian. There appeared to be no dissection or aneurysms. . There was increased in size of the lymph nodes in her chest also was noted a thyroid goiter, a left lower lobe granuloma and moderate diffuse emphysema. Please refer to the MRI of the chest on [**2103-8-6**]. Cardiac MR was performed on [**2103-7-20**] which showed an LVEF of 76 percent, a RVEF of 59 percent, abnormal pre-tracheal lymph node and a 32 mm long by 20 mm deep irregular mass noted in the arched aortic distal to the left subclavian. Please refer to the final MR report dated [**2103-7-20**] The patient did go home after all these procedures. Also had a preoperative chest X-ray done that showed a calcification in the aortic knob and no acute cardiopulmonary disease. Th[**Last Name (STitle) 1050**] was admitted to the hospital on [**2103-9-19**] to Dr. [**Last Name (Prefixes) **] service where she underwent resection of the aortic mass and replacement of the aortic arch as well as the proximal descending aorta with re-implantation of the cephalic vessels. The patient also had a flexible bronchoscopy done by Dr. [**Last Name (STitle) **], a 20 mm [**Doctor First Name **] Weave graft. Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] also assisted Dr. [**Last Name (Prefixes) **] on the procedure. The patient was transferred to the Cardiothoracic intensive care unit in stable condition on a Neo-Synephrine titrated drip and a Propofol titrated drip. Dr. [**First Name4 (NamePattern1) 919**] [**Last Name (NamePattern1) 57737**] also saw the patient intraoperatively. Postop day one, the patient had some [**Street Address(2) 1766**] elevations, Cardiology was consulted. The patient was paced at 87 on the morning of the 28th with a T-max of 100, blood pressure 108/57, she remained intubated and sedated on a Diltiazem drip at five. Insulin drip at 1 unit per hour. Nitroglycerine drip at 0.25 mcg per kg and a Propofol drip of 35 mg. LABORATORY FINDINGS: Postop labs: White count 7.9, hematocrit 27.2, platelet count 148,000. PT 13.6, PTT 37.2 with an INR 1.2, sodium 145, K 4.1, chloride 112, bicarb 27, BUN 16, creatinine 1.0, blood sugar 71. The patient regular rate and rhythm of the heart. Lungs were clear bilaterally. Abdomen was soft and nontender. The patient had 1 plus peripheral edema. The patient also had a repeat 12 lead Electrocardiogram this morning. Diltiazem was continued. There was a question of whether or not this was spasm in the right coronary artery and plans were to try and wean the ventilator during the day. Please refer to the cardiology note. The patient was also seen by rehabilitation services and physical therapy. I would defer further evaluation at this time. On postop day two the patient had been extubated. Swann Ganz Catheter had been removed. Diltiazem was off. The patient was started on Lopressor, beta-blockade and Lasix diuresis. Nitroglycerin was weaned off. Creatinine remained stable at 1.1 as did hematocrit and white blood cell count. The patient had bilateral expiratory wheeze and 1 plus peripheral edema, otherwise the patient was alert and oriented in no acute distress with unremarkable examination. The patient continued diuresis, chest tubes were kept in with plan to try and wean O2 and hopefully get the patient out to the floor later in the afternoon. On postop day three, the patient had been restarted on Norvasc and Captopril for tighter blood pressure control. Blood pressure was 143/61 with a heart rate of 63 in sinus rhythm sating 94 percent on 5 liters nasal cannula. She was alert and oriented moving all four extremities. Her lungs were clear bilaterally. Her heart was regular rate and rhythm. Incisions were clean, dry and intact. Chest tubes were removed. The patient was transferred out to the floor to get out of bed and start ambulating with the nurses and physical therapist. . The patient was transferred out to the floor on postop day three in the afternoon where she was again re-evaluated and started to work with physical therapy on ambulation. The patient continued to be followed by daily by Vascular Surgery service for Dr. [**Last Name (STitle) **] and also seen by Case Management. The patient did have some desaturation with activity to the 80 on postop day five, she remained in sinus rhythm at 60 with a blood pressure of 110/60, sating 89 percent on four liters. The patient had decreased breath sounds bilaterally at the basis but her examination was otherwise unremarkable. Central venous line pacing wires had been removed. The patient had a pulmonary rehabilitation screen and had some nebulizers, Norvasc was decreased from twice a day to once daily dosing. The patient continued to work with physical therapy. Percocet p.o meds were given for pain. The patient was repeatedly encouraged to cough, deep breath and use her incentive spirometer on postop day six. Hematocrit remained stable at 27.9, sating 92 percent on room air now The patient had decreased breath sounds at left base halfway up. Sternum was stable. The left subclavian incision was also clean and dry. Repeat chest x-ray was done. The Lasix dosing was decreased from twice a day to once daily. The patient also continued on her aspirin, Atenolol, Captopril and Lasix. The patient was also receiving Imdur 60 mg p.o. once daily and Methimazole and was covered by sliding scale regular insulin. Pulmonology consultation was obtained on [**2103-9-25**]. Diagnosis of left pleural effusion was made with a question about whether or not this might need to be performed under ultrasound guidance, please refer to the consultation note. The patient was also re-evaluated every day for her improvement and her ambulation status by case management. The patient had on postop day seven increasing left effusion, she had an episode of brief bradycardia with some hypertension late in the day on [**2103-9-25**]. She had some complaints of dysuria, her blood pressure was stable. She remained in sinus rhythm in the 60's. Captopril was stopped. She had the significant decreased breath sounds at her left lung, otherwise her examination was unremarkable. Follow-up urinalysis and chest x-ray were ordered. The patient had a thoracentesis of the left chest performed on [**2103-9-26**] by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 57738**]. Approximately one liter of serosanguineous fluid was removed. The patient was given additional Percocet for pain management. The patient had a little bit of confusion over the night time confusing about 12 noon versus 12 midnight, this appeared to be resolved though rapidly. The patient continued to work with physical therapy to improve her ambulation status and was doing quite well and was deemed ready to go home with VNA services on [**2103-9-27**], postop day 8 and that was the day of discharge. Th[**Last Name (STitle) 1050**] was instructed to follow-up with Dr. [**Last Name (STitle) **] [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] in the office for a postop surgical visit at approximately four weeks post discharge. Was also instructed to see Dr. [**Last Name (STitle) 38852**] [**Name (STitle) 57739**] her primary care physician. [**Name10 (NameIs) **] in approximately three weeks and to return to the [**Hospital 409**] Clinic on Far Two for postop evaluation of her surgical wounds approximately two weeks after discharge. EXAMINATION ON DISCHARGE: Sinus rhythm 73, blood pressure 110/54, respiratory rate 20, sating 92 percent on room air. Weight was 60 kg at the time. Her hematocrit was stable at 27. DISCHARGE MEDICATIONS: 1. Aspirin 81 mg p.o. once daily. 2. Atenolol 25 mg p.o. once daily 3. Colace 100 mg p.o. twice a day 4. Lasix 20 mg p.o. twice daily times one week and then 20 mg p.o. once daily times two weeks. 5. Methimazole 10 mg tablets one p.o. daily. 6. Albuterol-Ipratropium 103-18 mcg aerosol one to two puffs inhalation q 6 hours. 7. Levofloxacin 500 mg p.o. once daily. 8. Percocet 5/325 mg one tablet p.o. p.r.n. q 4 to 6 hours for pain. 9. Potassium chloride 20 mEq packet once daily times one week. 10. Imdur 30 mg once daily. 11. Ibuprofen 400 mg p.o. every 8 hours times two weeks. DISCHARGE DIAGNOSIS: 1. Status post resection of aortic mass with placement of aortic arch and proximal descending aorta re-implantation of cephalic vessels. Also status post flexible bronchoscopy. 2. Hypertension. 3. Hypercholesterolemia. 4. Positive family history for cardiovascular disease. 5. [**Doctor Last Name 933**] disease. 6. Hypertension. 7. Status post bilateral pneumococcal pneumonia in [**2086**]. 8. Status post tonsillectomy and adenoidectomy as a child. 9. Appendectomy. 10. Ectopic pregnancy surgery. The patient was discharged to home with VNA services on [**2103-9-27**]. [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2103-11-6**] 11:17:22 T: [**2103-11-6**] 12:33:11 Job#: [**Job Number 57740**]

[ "E878.2", "458.29", "440.0", "272.0", "997.3", "444.1", "511.9", "242.00", "496", "401.9" ]

icd9cm

[ [ [] ] ]

[ "39.59", "39.62", "39.61", "88.72", "38.45", "33.22", "34.91" ]

icd9pcs

[ [ [] ] ]

12202, 12808

12829, 13671

2911, 12007

2106, 2443

12022, 12179

1575, 2083

2460, 2893

665

152,089

16124

Discharge summary

report

Admission Date: [**2119-2-25**] Discharge Date: [**2119-2-27**] Date of Birth: [**2052-5-20**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3705**] Chief Complaint: LE weakness Major Surgical or Invasive Procedure: none History of Present Illness: 66 yo male CAD, PVD, hypertension who took his BP meds this morning and several hours later felt nauseated, he dropped himself to the ground and felt dizzy, weak, couldn't get off the floor for 30 minutes. He believes he took his medications as prescribed this morning but can't name his meds and doesn't know for sure that he didn't take the wrong meds. Denies any associated chest pain, palpitations, fever, chills, vomiting, diarrhea, headache, vision change, myalgias, arthralgias, rash. Patient denies sick contacts, but he notes over the past few months he has had weight loss, decrease in PO intake, mild nausea. . In the ED, 97.4 62 90/54 18 100% on RA. Patient's BP dropped into the 80s and remained 80s-90s with HR in the low 60s. BP equal on both arms and a smaller cuff and larger cuff were tried. Received Cefepime, 4L IVF with only mild improvement. He received calcium and glucagon which did not improve his BP. EKG showed T wave flattening diffusely. Patient continued to mentate well throughout with reported good urine output. . On the floor, the patient reports feeling well and denies dizziness, chest pain, palpitations or confusion. He notes that he had some abdominal pain with the abdominal ultrasound today. . Review of systems: (+) Per HPI (-) Denies fever, chills, night sweats. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. No recent change in bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: -Hypertension. -Hyperlipidemia, last LDL 55 and HDL 52 ([**1-6**]). -History of gout. -Tobacco abuse, ongoing. -History of prostate cancer treated with CyberKnife radiation therapy. -Coronary artery disease, status post right coronary artery drug-eluting stent in [**2113**], complicated by VF. -Left ventricular systolic dysfunction, EF 40%. -Peripheral [**Year (4 digits) 1106**] disease status post bilateral lower extremity revascularizations s/p PTA of b/l SFA in [**2113**], atherectomy of peroneal artery and PTA on the R in [**2116**]. -Ectatic infrarenal aorta, 2.8 cm greatest diameter -Stage III kidney disease. Social History: Smokes ciggarettes, attempting to quit, smoke [**4-3**] cigarettes/ week Family History: no lung disease Physical Exam: Exam on admission to MICU [**2119-2-25**]: not documented electronically Exam on transfer to floor [**2119-2-26**]: Vitals: T:98.4 BP:131/58 P:73 R:22 O2: 93% RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding Ext: warm, well perfused, 2+ pulses, no edema Exam on discharge *** Pertinent Results: Labs on admission [**2119-2-25**]: WBC-7.2 RBC-3.53* Hgb-9.7* Hct-30.6* MCV-87 MCH-27.6 MCHC-31.8 RDW-15.2 Plt Ct-124* Neuts-81.0* Lymphs-11.7* Monos-3.7 Eos-3.5 Baso-0.2 Glucose-176* UreaN-29* Creat-1.7* Na-142 K-4.0 Cl-104 HCO3-29 AnGap-13 Lactate-1.6 Cardiac enzymes negative x3 [**2119-2-26**] Iron studies : calTIBC-189* Hapto-386* Ferritn-384 TRF-145* Iron-35* [**2119-2-26**] LFTs: Albumin-3.1* ALT-9 AST-11 LD(LDH)-141 CK(CPK)-46* AlkPhos-51 TotBili-0.2 Lipase-41 [**2119-2-26**] PSA-0.1 Labs on discharge: [**2119-2-27**] 05:55AM BLOOD WBC-5.6 RBC-3.79* Hgb-10.2* Hct-32.1* MCV-85 MCH-26.8* MCHC-31.7 RDW-15.4 Plt Ct-125* [**2119-2-27**] 05:55AM BLOOD Plt Ct-125* [**2119-2-27**] 05:55AM BLOOD Glucose-72 UreaN-14 Creat-1.0 Na-141 K-4.2 Cl-108 HCO3-24 AnGap-13 Micro: [**2119-2-25**] BCx: negative [**2119-2-26**] MRSA: negative [**2119-2-26**] H. pylori: negative Imaging: [**2119-2-25**] CXR: Probable underlying emphysema without superimposed acute process. [**2119-2-26**] CT Torso: Small amount of perihepatic and abominal ascites. Trace right pleural effusion. No metastatic disease. Mildly enlarged heart. AAA (infrarenal) measures 2.8cm (TV) x 2.7 cm (AP) not significantly changed compared with US from [**2115**]. Bilateral common iliac artery aneurysms not significanlty changed. No bowel obstruction. [**2119-2-27**] Echo: The left atrium and right atrium are normal in cavity size. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The estimated cardiac index is normal (>=2.5L/min/m2). Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated at the sinus level. The aortic arch is mildly dilated. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2114-7-6**], regional left ventricular systolic function is now normal. The severity of aortic regurgitation is increased (but remains mild). The aortic arch is now mildly dilated. Brief Hospital Course: 66 year old male with CAD, PVD, HTN, h/o prostate CA, gout who presented with extreme weakness this morning, found to be hypotensive. . Pt looked okay on admission to MICU. He never needed pressors and BP remained stable. His hypotension was attributed to meds and poor PO intake. BP improved with fluids so adrenal insufficiency was felt less likely and cortisol not checked. CT Torso done for 5 lb weight loss and intermittent nausea to evaluate for metastatic disease but no lytic lesions noted. He was started on PPI in ICU for possible ulcer for nausea/vomiting, though H. pylori titers were negative. His anti-hypertensives were held and highest SBP was 140. . He was called on to the floor on [**2119-2-26**]. There he had a CT torso to evaluate a possible malignancy, which came back negative. His PSA was normal and his iron studies were suggestive of anemia of chronic disease. He was normotensive, so none of his antihypertensives were restarted, except for doxazosin to avoid urinary retention. An echocardiogram showed normal LV function. His creatinine continued to improve back to his baseline. In terms of his anemia and weightloss, he had no further drop in his hematocrit, and it was decided that he would continue to have work-up as an outpatient with close follow-up with his PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 11616**]. He should have an outpatient EGD and titration of his blood pressure medications. He was discharged off of omeprazole because there was no convincing evidence that his symptoms were caused by peptic ulcer disease. Medications on Admission: Clonidine 0.1 mg Tablet 1 Tablet(s) by mouth twice a day [**2119-2-20**] Colchicine 0.6 mg Tablet 1 Tablet(s) by mouth once a day [**2118-4-7**] Doxazosin [Cardura] 4 mg Tablet 1 Tablet(s) by mouth twice a day Lisinopril 40 mg Tablet 1 Tablet(s) by mouth once a day Metoprolol Succinate [Toprol XL] 100 mg Tablet Sustained Release 24 hr 1 Tablet(s) by mouth once a day Nifedipine [Procardia XL] 90 mg Tablet Extended Rel 24 hr 1 Tab(s) by mouth once a day Sildenafil [Viagra] 100 mg Tablet one Tablet(s) by mouth as needed for 2 to 3 hours before sex take this medication on an empty stomach Simvastatin 80 mg Tablet 1 Tablet(s) by mouth once a day [**2118-8-12**] Terazosin 2 mg Capsule 1 Capsule(s) by mouth once a day Aspirin 325 mg Tablet 1 Tablet(s) by mouth once a day [**2118-4-7**] Discharge Medications: 1. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Terazosin 2 mg Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary diagnosis: Hypotension, dehydration Secondary diagnoses: h/o prostate cancer, coronary artery disease, systolic CHF. Discharge Condition: Mental Status: Clear and coherent Level of Consciousness: Alert and interactive Activity Status: Ambulatory - Independent Discharge Instructions: You were admitted with low blood pressures and weakness. Your symptoms improved with intravenous fluids, and we think that you're safe to go home. We are concerned, however, about your recent weight loss and poor appetite. You should talk to your primary care doctor about these symptoms. . While you were here you had low blood pressure. We therefore want you to stop some of your blood pressure lowering medications, at least until you see Dr. [**Last Name (STitle) 11616**] this Friday. - STOP lisinopril, metoprolol, clonidine, nifedipine, doxazosin - CONTINUE Aspirin, Simvastatin and Terazosin . It is very important that you see your primary care doctor, Dr. [**Last Name (STitle) 11616**], this Friday. He will check your blood pressure and adjust your blood pressure medications if needed. You can also talk to him about the weight loss you've been having. Followup Instructions: Please see your primary care doctor, Dr. [**First Name8 (NamePattern2) 3924**] [**Last Name (NamePattern1) 11616**], at [**Hospital1 46097**]Clinic this Friday [**3-3**] at 10:30am. It is very important that you make it to that appointment. Completed by:[**2119-3-13**]

[ "428.0", "V45.82", "V58.66", "428.22", "274.9", "276.51", "272.4", "443.9", "285.9", "585.3", "584.9", "403.90", "V10.46", "414.01", "458.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8325, 8383

5682, 7271

328, 334

8552, 8552

3297, 3798

9595, 9867

2645, 2662

8112, 8302

8404, 8404

7297, 8089

8699, 9572

2677, 3278

8470, 8531

1617, 1892

276, 290

3817, 5659

362, 1598

8423, 8449

8567, 8675

1914, 2538

2554, 2629

15,542

153,238

6512

Discharge summary

report

Admission Date: [**2140-2-1**] Discharge Date: [**2140-2-8**] Service: MEDICINE Allergies: Lisinopril / Metformin Attending:[**First Name3 (LF) 689**] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: none History of Present Illness: [**Age over 90 **] F, HTN, DM2, breast ca., hypercholesterolemia and history of LGIB (diverticuli and internal hemmorhoids) presenting with bright red blood per rectum. Pt. reports BRBPR at baseline (spotting 1-2 times a day). Last night, passed increased amount of blood with stool that took a bit longer than normal to stop, In the morning she had some BRBPR without stool so she decided to come. She has had some gassy abdominal pain and chronic baseline rectal pain from rectal prolapse, but been otherwise asymptomatic. She denies lightheadedness, palpitations, chest pain, shortness of breath, fevers, chills, melena, diarrhea, constipation. . On ROS: pt. only reports some L leg pain over the last month or so. she denies any weakness, and ambulates, but she states that at times the pain migrates to her left knee and limits her mobility. . In ED, she received one L NS and had a hct of 34, which is down 3 points from her latest in [**2139-10-25**], though her chronic baseline over the last two years seems to bump between 32 and 37. Past Medical History: - Noninsulin-dependent diabetes, followed by the [**Last Name (un) **] Diabetes Center; hgbA1c 7.0 ([**2139-10-28**]) - Hypertension. - Hypercholesterolemia - [**12/2136**] Total Chol 142, HDL 63,LDL 45, TG 169 - Anemia: - Lower GI Bleed - [**2135**] 2nd to diverticulosis seen on endoscpy in [**2135**] (last in system). - Breast cancer - s/p R lumpectomy, recurrence with recurrence in L breast, free excision in [**1-/2139**], considering local therapy with Dr. [**Last Name (STitle) 2036**] currently - Hemorrhoids - s/p banding, continued internal hemmorhoids - Hysterectomy - Restrictive Lung Disease - PFTs ([**12/2136**]): normal FEV1, decreased FVC, with FEV1/FVC 135% predicted - Anginal symptoms - [**6-2**] chest tightness during stress MIBI ([**12/2136**]) however nuclear study showed normal perfusion; LVEF in [**2135**] ECHO >55% . Social History: Lives at [**Hospital3 **] on her own. cooks her own meals, administers her own meds. Denies current alcohol/tobacco use. Distant tobaco history of a few years of [**3-27**] cigs/wk. history Family History: Positive for coronary artery disease. No history of colon cancer. Physical Exam: Vitals: T 98.1 BP 102/68 P81 RR16 sat99% RA FSBG 131 Gen: Well appearing, NAD HEENT: anicteric, PERRL, EOMI no EGN, OP clear, no lesions; MMM Neck: no [**Doctor First Name **] Pulm: CTAB, no wheezes CV: RRR, nls1s2, no MRGs Abdm: Soft, NTND, increased BS Back: R CVA tenderness Extrem: sl. cool, no tenting, 2+ pulses, no C/C/E, 2+ DP pulses bilaterally Skin: scars in R axilla, L breast from prior surgery Neuro: CNII-XII intact, nl strength, sensation B Pertinent Results: [**2140-2-1**] 04:09PM GLUCOSE-234* [**2140-2-1**] 04:09PM HGB-12.2 calcHCT-37 [**2140-2-1**] 03:58PM GLUCOSE-248* UREA N-28* CREAT-1.3* SODIUM-138 POTASSIUM-4.0 CHLORIDE-101 TOTAL CO2-27 ANION GAP-14 [**2140-2-1**] 03:58PM estGFR-Using this [**2140-2-1**] 03:58PM WBC-6.4 RBC-3.99* HGB-12.1 HCT-34.3* MCV-86 MCH-30.2 MCHC-35.1* RDW-14.6 [**2140-2-1**] 03:58PM NEUTS-64.9 LYMPHS-25.5 MONOS-6.0 EOS-2.7 BASOS-0.9 [**2140-2-1**] 03:58PM PLT COUNT-238 [**2140-2-1**] 03:58PM PT-11.1 PTT-21.1* INR(PT)-0.9 [**2140-2-2**] 12:30AM BLOOD Hct-30.2* [**2140-2-2**] 05:45AM BLOOD WBC-5.1 RBC-3.15* Hgb-9.6* Hct-26.9* MCV-85 MCH-30.5 MCHC-35.7* RDW-14.9 Plt Ct-200 [**2140-2-2**] 10:45AM BLOOD Hct-29.3* Hct on discharge 33.0 last colonoscope [**2135**]: diverticulosis throughout last EGD [**2135**]: duodenitis, otherwise wnl. [**Numeric Identifier 7536**] EMBO NON NEURO [**2140-2-4**] 3:14 AM Reason: Mesenteric angiogram with possible atheroembolization Contrast: VISAPAQUE [**Hospital 93**] MEDICAL CONDITION: [**Age over 90 **] year old woman with h/o hemmorrhoids, diverticulosis with lower GI bleed, tagged scan shows bleeding at distal left colon REASON FOR THIS EXAMINATION: Mesenteric angiogram with possible atheroembolization INDICATION: Patient with history of hemorrhoids and diverticulosis with lower GI hemorrhage. Tagged red blood cell scan shows bleeding at the distal left colon. Please perform arteriogram and possible embolization. RADIOLOGISTS: Dr. [**Last Name (STitle) 4686**] and Dr. [**Last Name (STitle) **] performed the procedure. Dr. [**Last Name (STitle) 4686**], the attending radiologist, was present and supervising throughout. PROCEDURE AND FINDINGS: Informed consent was obtained. A preprocedure timeout was performed. The patient was placed supine on the angiography table, and the right groin was prepped and draped in sterile fashion. 5 cc of 1% lidocaine was used for local anesthesia. By palpation, a 19-gauge Seldinger needle was advanced into the right common femoral artery directly over the femoral head. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7648**] wire was advanced into the abdominal aorta and the puncture needle was exchanged for a 5-French sheath. A 4-French Sos Omni selective catheter was utilized to access the orifice of the superior mesenteric artery. A superior mesenteric arteriogram was performed demonstrating the SMA and its branches to be widely patent without evidence of extravasation. Attempts to cannulate the orifice of the [**Female First Name (un) 899**] with the Sos selective catheter were unsuccessful. Thus, the Omni selective catheter was exchanged for an Omniflush catheter, and an aortogram was performed. The aortogram demonstrated patent bilateral renal arteries, an accessory renal artery on the left, the inferior mesenteric artery and lumbar arteries. Using this arteriogram as a guide, the orifice of the inferior mesenteric artery was then cannulated with a 5-French Mickaelson catheter. The [**Female First Name (un) 899**] arteriogram was performed in frontal and oblique projections, demonstrating a focus of active arterial extravasation at the junction of the descending and sigmoid colon. A Tracker microcatheter was advanced into the inferior mesenteric artery, selctively into a distal branch of the left colic artery. Contrast injection at this locale confirmed extravasation from this branch. Based on the diagnostic findings, it was decided that the patient would benefit from and was a good candidate for embolization. Two 1 cm x 2 mm coils were deployed at this level. Subsequent superselective arteriogram from the [**Female First Name (un) 899**] demonstrated occlusion of the arterial branch responsible for the bleeding. The catheters were removed and the angiographic sheath was pulled. Manual compression was applied to the right groin until complete hemostasis was achieved. The patient tolerated the procedure well and there were no immediate complications. Moderate sedation was provided by administering divided doses of Versed and fentanyl throughout the total intraservice time of 2 hours, during which the patient's hemodynamic parameters were continuously monitored. A total both of 25 mcg of fentanyl and 0.5 mg of Versed were administered. Approximately 180 cc of Visipaque contrast was administered throughout the procedure. IMPRESSION: 1. Superselective arteriogram from the [**Female First Name (un) 899**] demonstrated a focus of active arterial extravasation near the junction of the descending and sigmoid colon. 2. Coil embolization of a left colic [**Last Name (un) **] of the [**Female First Name (un) 899**], with a good angiographic result. Brief Hospital Course: # GI Bleed On the floor she was initially hemodynamically stable with stable hematocrits. She had a colonoscopy which showed diverticulosis of the sigmoid colon, descending colon, transverse colon and ascending colon and blood distal to the distal transverse colon. [**2-3**] EGD showed gastritis, duodenal ulceration and a clot in the fundus. She then returned to the floor and several hours later started having cupfuls of BRBPR. She remained hemodynamically stable. She had a central line placed and was sent to tagged RBC scan. Per report, she had some bleeding in the distal colon. GI bleeding showed findings consistent with a lower GI bleed. The origin was placed within the descending/sigmoid colon junction. She had selective angiogram by IR with coil emblization of a branch of [**Female First Name (un) 899**]. She received 5 total units during this time with stabilization of hct. on discharge, hct was 33.0 and stable > 48h. She was placed on [**Hospital1 **] PPI on discharge with need for colonoscopy as outpt 1 month after discharge. . * DM: sugars slightly elevated - held glyburide in house and placed on sliding scale. Sugars well controlled here. . * CRI: Baseline appears to be 1.1-1.3 and pt within baseline throughout stay . * Chest Pain: pt had transient L sided chest pain [**2-4**] at 7:30 AM. Resolved w/in 5 min. No assoc dyspnea, nausea, diaphoresis. -EKG obtained: primary AVB (old), T wave flattening V1 (old), V2 (new), V6 (new); change in axis (? lead placement). CEs were negative . * Rectal prolapse/hemmorhoids: anusol PRN, bowel regimen to keep stools soft. . * Hypecholesterolemia: Continued pravachol. . * HTN: held cartia and hctz, but restarted when hct stable We lowered your cardizem XL dose to 120mg per day, which may have to be increased by your PCP. Medications on Admission: Glyburide 5mg [**Hospital1 **] HCTZ 25mg qd ranitidine 150mg [**Hospital1 **] Dilt. XL 300mg qd Feso4 325mg qd Colace 100mg [**Hospital1 **] pravachol 10mg qhs Lantus 12U qAM novolog pen 2U qmeal Discharge Medications: 1. Pravastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Tablet(s) 2. Centrum Silver Tablet Sig: One (1) Tablet PO once a day. 3. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 5. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*2* 6. Pramoxine-Mineral Oil-Zinc 1-12.5 % Ointment Sig: One (1) Appl Rectal [**Hospital1 **] (2 times a day) as needed for rectal pain. Disp:*1 qs* Refills:*2* 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*1* 9. Glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day. 10. Insulin Glargine 100 unit/mL Solution Sig: Fourteen (14) units Subcutaneous qAM. 11. Novolog Flexpen 100 unit/mL Insulin Pen Sig: Two (2) units Subcutaneous QAC. 12. Diltiazem HCl 120 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). Disp:*30 Capsule, Sustained Release(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: [**Doctor Last Name **] GI bleed Blood loss Anemia Gastritis Diverticulosis _________________ Diabetes Mellitus Discharge Condition: good, ambulating without assistance, tolerating POs, no fresh blood per rectum, satting <95% on room air Discharge Instructions: Please seek medical attention should you develop further GI bleeding, especially bright red blood, or should you continue to hav dark tarry stools. Please also seek medical attention should you develop lightheadness, dizziness, chest pain, shortness of breath, or any other concernign symptoms such as fever, nausea, abdominal pain or decreased urine output. Please take all medications exactly as prescribed. We have started you on protonix, which you should take twice a day for at least a month. In addition, you should take stool softeners colace and senna twice a day to keep your stools soft. You may also take other over the counter products such as metamucil or prune juice to keep your stools soft. You can also hold your iron pills for now and check with your PCP with regards to when to restart them. We have also lowered your cardizem XL dose to 120mg per day. You may need to have this increased by your PCP on follow up. Follow up as below. Followup Instructions: You should follow up with your PCP in the next week. His number is [**Telephone/Fax (1) 24989**]. You should have your hematocrit checked at this visit. You have been discharged with a hematocrit of ~31. He should also measure your blood pressure as we have decreased your cardizem dose You should also follow up with the GI service in 1 month ([**Telephone/Fax (1) 19233**]. You need to have a colonoscopy scheduled for 1 month from now. You can have that scheduled through your PCP or through the GI group. You also have the following appointments which you should attend. Provider: [**Name10 (NameIs) 706**] Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2140-3-24**] 1:30 Provider: [**Name11 (NameIs) **] [**Name12 (NameIs) **], MD Phone:[**Telephone/Fax (1) 17898**] Date/Time:[**2140-3-24**] 2:40

[ "V10.3", "455.0", "272.0", "535.51", "496", "562.12", "285.1", "585.6", "250.00", "584.9", "403.91" ]

icd9cm

[ [ [] ] ]

[ "38.93", "88.47", "39.79", "45.23", "99.04", "44.43" ]

icd9pcs

[ [ [] ] ]

11127, 11133

7702, 9511

233, 239

11289, 11396

2973, 3963

12407, 13220

2411, 2480

9758, 11104

4000, 4141

11154, 11268

9537, 9735

11420, 12384

2495, 2954

188, 195

4170, 7679

267, 1313

1335, 2186

2202, 2395

23,261

131,254

13394

Discharge summary

report

Admission Date: [**2141-3-27**] Discharge Date: [**2141-5-2**] Date of Birth: [**2092-10-30**] Sex: F Service: CHIEF COMPLAINT: Epigastric pain. HISTORY OF PRESENT ILLNESS: The patient is a 48-year-old female with no significant past medical history who was in her usual state of health until one day prior to admission to an outside hospital. She developed severe epigastric pain and vomiting which she tried to sleep off for several hours. The pain continued to worsen, and she ultimately presented to [**Hospital **] [**Hospital 1459**] Hospital. In the Emergency Room she was tachycardiac in the 130s to 140s with variable systolic blood pressures ranging from 90 to 180. She was transferred to the Intensive Care Unit and required a large amount of intravenous fluids for hemodynamic stabilization up to a total of 5 L. She received bicarbonate for a pH of 7.1 and a metabolic acidosis, and her urine output was 350 cc over 24 hours there. Her outside labs included an amylase of 188, lipase of 892, ALT 59, AST 123, alkaline phosphatase 111, total bilirubin 1.3, white count 26.4. Ultrasound was negative for gallstones, and a CT demonstrated severe pancreatitis with partial necrosis of the pancreatic head. She was then transferred to the [**Hospital6 1760**] for resuscitation and further evaluation. On further review of history, she has no history of gallstones, diabetes. She drinks "socially," and per her husband, her alcohol consumption had recently increased as she was laid off from work. She has been asymptomatic with no nausea, vomiting, fevers, chills, change in bowel habits, prior to this episode of epigastric pain. PAST MEDICAL HISTORY: Significant for cervical laminectomy in [**2139**]. Uterine fibroids. MEDICATIONS ON ADMISSION: Past steroid injections for hand pain. ALLERGIES: NO KNOWN DRUG ALLERGIES. SOCIAL HISTORY: The patient lives with her husband. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION: General: On transfer from the outside hospital to [**Hospital6 256**] the patient was a sleepy but responsive woman in mild distress. Vital signs: Temperature 98??????, heart rate 149, blood pressure 133/85, respirations 24, oxygen saturation 96% on 5 L nasal cannula. HEENT: Pupils equal, round and reactive to light. Lungs: Clear to auscultation bilaterally. Cardiovascular: Tachycardiac but regular with no murmurs, rubs or gallops. Abdomen: Distended with abdominal wall edema and extreme tenderness in the upper epigastric area. Extremities: There were distal pulses. Feet were warm bilaterally. Neurological: She has no focal deficits. LABORATORY DATA: On admission white count was 16.4, hematocrit 38.3, platelet count 77; sodium 132, potassium 4.5, chloride 99, bicarb 21, BUN 29, creatinine 1.4, glucose 324; PT 15.9, PTT 46.3, INR 1.8; admission arterial blood gas was 7.82, 38, 141, 19, -7; ALT 99, AST 77, alkaline phosphatase 50, amylase 218, lipase 1520, total bilirubin 1.6; ionized calcium 0.88, lactate 6.1. CAT scan from outside hospital showed severe pancreatitis, severe extensive inflammatory changes, patchy heterogenous enhancement, necrosis at the head and tail of the pancreas. Ultrasound showed no gallstones per outside hospital report. HOSPITAL COURSE: Respiratory: The patient was transferred to the Surgical Intensive Care Unit where she was continued with aggressive fluid hydration. Her most pressing issue was her respiratory status, and throughout her early hospital course on hospital day #1 and #2, the patient's arterial blood gases began to deteriorate. Initially her blood gas showed a pO2 of 141 as above, but by 6 a.m. on hospital day #2, her blood gas was 7.36, pCO2 40, pO2 66, bicarbonate 24, with a base excess of -2. She was tachypneic. On hospital day #2, the patient was intubated without incident. With ventilatory control, her blood gases immediately improved. Her pO2 upon intubation was 91. Hemodynamic status: The next issue was her hemodynamic status. Her blood pressure remained labile with episodes of systolic blood pressure dropping down into the 90s. Early in her hospitalization, the patient did require Neo-Synephrine GTT to maintain the mean arterial pressures above 60. This was very brief and occurred only during the first and second hospital days. Otherwise she did remain hemodynamically stable, although tachycardiac essentially for her entire hospitalization. The tachycardia was not aggressively addressed due to her stable blood pressure status after that initial Neo-Synephrine pressor support. The patient was also aggressively hydrated receiving several liters of fluid to maintain adequate urine output. An NG tube was placed to suction, and thick bilious contents were aspirated from the GI tract. The patient was also started on Imipenem. The patient's coagulopathy was corrected with FFP for her INR of 1.8. After intubation, the patient was kept comfortable on Ativan and Dilaudid GTTs. ICU course: Neurologically the patient was continued to be sedated while intubated. She was arousable, and as her condition improved, the sedation was weaned. Late in her Intensive Care Unit stay, the patient began to show signs of agitation and confusion. This was managed with Haldol. She has subsequently become oriented and has had no episodes of agitations after being discharged from the Intensive Care Unit. She has shown no focal or neurologic deficits. The patient's respiratory status remained stable. She remained on ventilatory support for several weeks during her Intensive Care Unit stay. She underwent a slow wean and eventually was extubated on hospital day #23 without incident. She has tolerated extubation well and has been able to manage her secretions and maintain high oxygen saturations. Cardiovascular status: As described as above, she continued to remain stable. She remained tachycardiac for most of her hospitalization. She was recently started on beta-blockade and is currently tolerating Lopressor with good heart rate control and adequate blood pressure. GI issues: Included nasogastric placement. Initially the patient was placed to suction, and then several attempts at tube feedings were made. She began with .................. tube feeds and had several episodes of high residuals. She eventually tolerated tube feeds at goal which was Peptamen at 60 cc/hr. During the time when she was only on ................... tube feeds or no tube feeds, she was on TPN which eventually was weaned when she was tolerating tube feeds at goal. Her amylase and lipase quickly normalized, and her most recent lipase was 30, and her amylase was 22. During her hospitalization, she also developed multiple, frequent, loose stools which were sent for C-diff, and the patient was started on intravenous Flagyl empirically. All C-diff cultures have returned as negative. The frequency of loose stools has decreased substantially. GU: Issues include diagnosed urinary tract infection on [**4-15**] with diagnosed E. coli greater than 100,000 colonies. She was started on a five-day course of Floxacillin which she completed. Infectious disease: Issues included multiple temperature spikes early during her hospital course with temperatures up to 103??????. She was pancultured multiple times which resulted in no positive blood cultures. The patient's central lines and peripheral lines were all changed appropriate after each temperature spike. She had been started on Imipenem and completed a 14-day course, and more recently, the patient has been afebrile for a significant period of time with at least seven days. Also when the patient had begun to spike fevers on [**2141-4-2**], she underwent a CAT scan of the abdomen to rule out abscess. No abscesses were found, but it was noted that 60% of the pancreas was necrotic at that time. She also had bilateral effusion and patent portal and splenic veins. Hematologic: The patient's coagulopathies were corrected earlier. The patient's hematocrit remained ultimately stable. There were two episodes where the patient required transfusion for a decrease in her hematocrit, but the patient did not have any active signs of bleeding. The patient was found to have a right upper extremity DVT after noticing right arm edema. The patient was started on Heparin and then switched to Lovenox subcue for anticoagulation. Endocrine: Her endocrine status included a labile blood sugar. She required Insulin drip to control blood sugars in the 300s at the time. She otherwise responded well to an Insulin sliding scale. Currently her Insulin has been under well control which has not required any Insulin recently, although she will be closely monitored for diabetes due to the extensive pancreatic mass. In summary, the patient's SICU course remained progressively to improve. After extubation, the patient remained stable, tolerated her tube feeds at goal, was evaluated by Physical Therapy and was begun on conditioning, and she became ready for discharge to the floor on hospital day #33. Her course on the Surgical Floor has remained uneventful. She had a speech and swallow study which had originally categorized her as a poor candidate for aspiration. She was going to be continued on tube feeds, but then a repeat swallow evaluation demonstrated that the patient could tolerate thickened liquids and pureed diets. She tolerated this without any evidence of aspiration and has been now advanced to a diabetic diet which she is tolerating. The patient has been ambulating with Physical Therapy, and although her activity level is improved, she will truly benefit from rehabilitation for conditioning. The patient's respiratory status has remained stable with oxygen saturations in the high 90s on room air. Her secretions have dramatically decreased and essentially is none. The patient has remained afebrile. The patient continues to have some loose bowel movements, but otherwise the frequency has not increased, and all C-diff toxin assays have remained negative. The patient did have a CAT scan on [**2141-4-19**], with aspiration of fluid collection which has not grown any organisms to date. The CAT scan also demonstrated a decrease in fluid collections from the one done early which earlier which was slightly improved. The patient is stable and is now ready for discharge to rehabilitation. DISCHARGE DIAGNOSIS: Necrotizing pancreatitis. DISCHARGE MEDICATIONS: Protonix 40 mg p.o. q.d., ASA 81 mg p.o. q.d., Lovenox 70 mg subcue b.i.d., Clonidine TTS 3 patch 0.2 mg q.week on Thursday's, Lopressor 50 mg p.o. t.i.d., Tylenol 650 mg p.o. q.6 hours p.r.n., Albuterol MDI [**12-21**] q.6 hours p.r.n., Insulin sliding scale. CONDITION ON DISCHARGE: Stable. The [**Hospital 228**] rehabilitation potential is good. FOLLOW-UP: The patient will follow-up with Dr. [**Last Name (STitle) 1305**] in two weeks unless clinically necessary to follow-up earlier. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 1306**], M.D. [**MD Number(1) 1307**] Dictated By:[**Last Name (NamePattern1) 3835**] MEDQUIST36 D: [**2141-5-1**] 19:57 T: [**2141-5-1**] 20:09 JOB#: [**Job Number 40670**]

[ "599.0", "276.2", "577.0", "453.8", "287.5", "518.81" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.72", "96.04", "96.6", "99.15" ]

icd9pcs

[ [ [] ] ]

1945, 1963

10482, 10744

10431, 10458

1796, 1874

3284, 10409

1986, 3266

149, 167

196, 1674

1697, 1769

1891, 1928

10769, 11257

1,371

109,490

25316

Discharge summary

report

Admission Date: [**2197-2-19**] Discharge Date: [**2197-3-15**] Date of Birth: [**2125-8-5**] Sex: M Service: MEDICINE Allergies: Demerol / Vicodin / Zosyn Attending:[**First Name3 (LF) 30**] Chief Complaint: S/P Fall with multiple fx Major Surgical or Invasive Procedure: R humerus closed reduction R humerus ORIF History of Present Illness: 71 M c CAD/CHF, AICD c BiV pacer, Afib on coumadin, DM on insulin who presents after a mechanical fall onto R side. History from wife who is at patient's bedside; pt. somnolent. Pt. squatting to feed cat and on rising had mechanical fall with twisting motion onto R side. Unwitnessed. Denies LOC. Wife found patient down complaining of pain at R shoulder and R hip. Also denies any preceding CP, SOB, lightheadedness, dizziness, palpitations, bowel/bladder incontinence. . Presented to [**Hospital1 1474**] ED and found to have R transverse humeral neck fracture and R acetabular fracture and pubic ramus fracture. Transfered to [**Hospital1 18**] ED. . In ED, VSS and AF. Seen by ortho; closed reduction performed on R humeral fracture and felt to require ORIF for acetabular fracture. Recommended hold on all anti-coagulation. Pain well controlled with IV Dilaudid 1 mg * 2 though pt. somewhat somnolent. Noted to have Cr 2.5 in ED; baseline is unknown. . Per conversation today with PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3314**], (OSH records pending), pt is CRF with baseline creat 2.5-2.7. Per conversation, PCP has old notes that indicate baseline O2 sats in high 80s - low 90s. Pt had angiograms of legs recently by vascular which worsened his renal function (now returned to baseline CRF). . ROS: No recent orthopnea, PND, urinary problems. Wife does report two recent hospitalizations; first at [**Hospital3 417**] for lower extremity pain thought [**12-30**] PVD. Pt. underwent angiography c intervention as per wife with some relief of symptoms. Second at [**Hospital 1474**] hospital 1 week prior for lower extremity pain and SOB; found to have O2 sat 84% RA; thought [**12-30**] URI and pt. treated with a prednisone taper; however, pt. lacks a formal diagnosis of COPD. Wife mentions that pt's potassium level was high on that admission but unclear etiology of this. Normally the patient is able to walk about 50 feet across his ranch house, prepares his own meals, dresses himself, and occasionally drives. Past Medical History: 1. Congestive Heart Failure - EF 15% by previous notes 2. CAD s/p CABG [**2184**] and AICD c [**Hospital1 **]-V pacer in [**2194**] 3. PVD s/p b/l fem-[**Doctor Last Name **] bypass and TMA; CEA [**2186**] 4. Diabetes on insulin 5. Atrial fibrillation on coumadin 6. Hypothyroidism 7. Hyperlipidemia 8. Obstructive Sleep Apnea 9. Restless Leg Syndrome Social History: 70 pack year smoking history, drinks a cup of wine each night. Lives with his wife. Used to work in Community Dev. Program for [**Location (un) 3320**] MA until 2 yrs prior Family History: No hx kidney disease or CAD. Sister c CVA in 70s, Father and mother lived into mid 90s. Physical Exam: VS: 97.3 150/80 77 14 90% RA GEN: elderly man appears older than stated age, somnolent HEENT: conjunctivae pink, JVP flat, MMM RESP: CTA b/l with good air movement throughout CV: RR, [**1-3**] SM at apex c/w MR. [**First Name (Titles) **] [**Last Name (Titles) **] ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: bilateral TMA. cold to touch. pulses not palpable. + chronic venous stasis changes. Denuded. Small 2 mm in diameter ulcer on plantar surface L foot; no purulence/erythema at this area. 2+ pitting edema over tibia b/l. SKIN: no rashes/no jaundice Pertinent Results: Labs: Cr 2.5, BUN 77, HCT 33.5, INR 4.5. U/A [**5-7**] RBC, lg bld, prot . EKG: Paced rhythm at 80 bpm . Imaging: CXR [**2-20**] - Cardiomegaly. No acute cardiopulmonary process. BiV pacer leads noted. Multiple surgical clips. No focal consolidations. . Shoulder XR [**2-19**] - Fracture of surgical R humeral neck. . Hip XR [**2-19**] - Comminuted fracture of the right acetabulum and nondisplaced right superior pubic ramus fracture. . Knee XR [**2-19**] - No fracture or dislocation . TTE [**2-20**] - EF 25-30%. Mild symmetric left ventricular hypertrophy with regional systolic dysfunction c/w CAD (proximal LAD lesion). Severe tricuspid regurgitation. Moderate pulmonary artery systolic hypertension. Mild aortic regurgitation. Brief Hospital Course: A/P: 71 y/o M h/o CAD, CHF (EF 25-30%), Severe TR, AICD w/ [**Hospital1 **]-V pacer, DM2, chronic renal failure, who presents with right hip and humerus fractures, MICU callout for respiratory failure [**12-30**] nosocomial pneumonia and volume overload. Now respiratory status is stable on nasal cannula. s/p R humerus ORIF. R hip not repaired given surgical risks. Pt was made CMO and passed away . # Hypoxia: combination of vol overload and aspiration PNA> for the vol overload the pt was diuresed with torsemide and lasix. he aspirated twice leading to desatt and tranfer to ICU. he was weaned down to O2 by NC and transferred back to the floor. he was treated with vanco nad aztreonam (zosyn was d/c'ed because of the concern for AIN). also received nebs. . # Systolic/Diastolic Heart Failure: TTE on [**2197-2-20**] showed EF 25-30%, also w/ 4+ TR. SvO2 54%. Clinically volume overload. continued carvedilol 25mg po bid. planned to start ACE/[**Last Name (un) **] once ARF resolves. had a BIV pacer and AICD . # Fractures: s/p humerus ORIF. Surgical repair of R hip fracture was on hold given surgical risk. OOB to chair, NWB R arm and RLE. continued PT . # Acute on Chronic Renal Failure: Cr rose from 2.4. Thought initially to be [**12-30**] diuresis however creatinine continued to rise despite holding diuresis. FeNa 0.67% indicating a prerenal process also +urine eos indicated AIN. AIN most likely [**12-30**] zosyn and changed to aztreonam. Renally dosed meds and antibiotics. held ACE in setting of ARF . # CAD: No evidence for active CAD. S/p CABG in [**2184**]. continued beta [**Last Name (LF) 7005**], [**First Name3 (LF) **]. held ACE in setting of [**Doctor First Name 48**]. EP interrogated AICD . # Afib: Currently paced; unknown what current underlying rhythm is. Continue anticoagulation with coumadin. held digoxin in setting of ARF . # PVD: was on pentoxiphylline. vascular saw the pt and did not feel that there was an acute need for an invasive procedure. pt was to f/u with his outpt vascular surgeon . # DM/hypoglycemia: continued sliding scale insulin . #. Hyperlipidemia - Continued home regimen of lipitor . # Hypothyroid - Continued home regimen of levothyroxine . # OSA: home regimen of CPAP 5 cm H20 + 2Lpm O2 . # FEN: diabetic/heart healthy diet. replete lytes . # Communication: With pt and wife [**Telephone/Fax (1) 63336**]; PCP: [**Name Initial (NameIs) 3314**] ([**Location (un) 1475**]) [**Telephone/Fax (1) 3183**] (Secretary [**Doctor First Name **] [**Telephone/Fax (1) 63337**]), Outpt Cards: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Hospital1 18**] Cards: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] . # Access: PIV, R IJ CVL . # PPx: anticoagulated, pneumoboots, Protonix . # Code: DNR/I Medications on Admission: 1. Trental 400 mg tid 2. Coreg 25 mg [**Hospital1 **] 3. Digoxin 125 mcg daily 4. Lasix 60 mg [**Hospital1 **] 5. Coumadin 6 mg daily 7. Synthroid 112 mcg daily 8. Lipitor 40 mg daily 9. Xalatan gtt daily 10. Klonopin 0.5 mg qhs 11. Phoslo 667 mg tid 12. Folate 1 mg daily 13. Colace/Senna 14. Fluticasone 1 spray daily both nostrils 15. Serevent 1 puff [**Hospital1 **] 16. Albuterol 2 puffs qid PRN 17. Insulin - Novolog 70/30 26 u breakfast, 14 u dinner Discharge Medications: none Discharge Disposition: Extended Care Discharge Diagnosis: Primary Diagnosis: 1. Right humerus fracture s/p repair 2. Right acetabular fracture s/p ORIF 3. Right pubic ramus fracture 4. CAD Native Vessel s/p CABG [**2184**] 5. Severe LVSD 6. AICD with biventricular pacer 7. Atrial Fibrillation 8. Ventricular Tachycardia 9. Aspiration Pneumonia 10. Acute Renal Failure 11. Anemia of Chronic Renal Disease 12. Osteoporosis. . Secondary Diagnosis: 1. Diabetes mellitus, insulin-dependent 2. Chronic kidney disease stage III/IV 3. PVD s/p bilateral fem-[**Doctor Last Name **] BPG and TMA 4. Hypothyroidism 5. Hyperlipidemia 6. Obstructive Sleep Apnea 7. Restless leg syndrome 8. Chronic Obstructive Pulmonary Disease Discharge Condition: none Discharge Instructions: none Followup Instructions: none Completed by:[**2197-3-24**]

[ "276.1", "E885.9", "272.4", "333.94", "244.9", "440.20", "585.6", "599.7", "812.00", "414.00", "427.1", "327.23", "518.81", "808.0", "425.4", "403.91", "V45.02", "287.5", "808.2", "285.21", "428.0", "V58.67", "584.9", "250.40", "507.0", "790.92", "285.1", "428.40", "707.05", "263.9", "250.80", "427.31", "V45.81", "V66.7" ]

icd9cm

[ [ [] ] ]

[ "89.49", "93.90", "79.31", "38.93", "79.01" ]

icd9pcs

[ [ [] ] ]

7796, 7811

4465, 7259

309, 353

8529, 8535

3706, 4442

8588, 8623

3008, 3097

7767, 7773

7832, 7832

7285, 7744

8559, 8565

3112, 3687

244, 271

381, 2426

8229, 8508

7851, 8208

2448, 2802

2818, 2992

56,317

120,741

2961

Discharge summary

report

Admission Date: [**2164-1-13**] Discharge Date: [**2164-1-19**] Date of Birth: [**2082-4-5**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Known firstname 5552**] Chief Complaint: hypoxia Major Surgical or Invasive Procedure: none History of Present Illness: 81 y/o M w/ Lung Ca, recent MI, emphysema with home O2 2L, over past 1-week has had increasing dyspnea. No f/c/ns/chest pain. Saw PCP [**Name Initial (PRE) 7790**]. Sat was low 80's on 2L. On Chemo currently. Baseline WBC count elevation with chemotherapy with alimta. . In the ED, initial vs were: 98.3, 104, 151/78, RR30-35, O2 Sat 99% NRB. Exam was notable for mild wheeze. CXR was read as negative. Patient got CTA for question PE -> negative. Was treated as COPD flare. . On arrival, patient was tachypneic to 28-30 with O2 sat of 97% on NRB. T98.2, Bp 151/78, HR 96 Past Medical History: 1) CAD s/p MI in [**2140**] by EKG diagnosis, no admission, no symptoms, ETT/MIBI [**2159**] showing partially reversible defect in RCA distribution. No interventions performed. 2) HTN 3) Hyperlipidemia 4) COPD 5) DJD 6) Thoracic artery aneursym, stable 7) Nonsmall cell lung cancer (see below) ONCOLOGIC HISTORY: Mr. [**Known lastname 14194**] was in his USOH until [**2163-7-25**] when he presented with hemoptysis and weight loss of 10 pounds over previous 1-2 months. He had a CT scan of the chest on [**8-21**] and it showed a 4.1 x 4.0 right hilar mass with subcarinal lymphadenopathy, 19 mm right axillary lymph node as well as multiple right lower lobe and left lower lobe nodules concerning for lung cancer. On [**2163-8-28**], he was admitted to [**Hospital1 771**] with chest pain and ruled out for a non-ST elevation MI. He was seen by the hematology-oncology consult service while in the hospital and underwent FNA of the right axillary lymph node, the pathology of which showed nonsmall cell cancer, squamous cell type. He was discharged on the third of [**Month (only) 359**] and then on [**2163-8-30**], he had a bronchoscopy done for evaluation of his hemoptysis as well as bronchial biopsy and the cytology confirmed metastatic nonsmall cell lung cancer. He has subsequently completed 2 cycles of Navelbine. Social History: He lives in [**Location 3146**]. He is married and has a daughter and a son. [**Name (NI) **] has two grandchildren. He is here today with his wife & son. [**Name (NI) **] smoked for at least 50 years, stopped smoking 3-4 years ago. He drinks occasional alcohol. He used to work as a carpenter, it is unclear if he has had asbestos exposure. Family History: Father died at age 43 of unknown causes. Mother died of breast cancer complications at age 53. Sister had breast cancer and lung cancer and died at age 80 Physical Exam: Tmax: 36.8 ??????C (98.2 ??????F) Tcurrent: 36.8 ??????C (98.2 ??????F) HR: 91 (91 - 99) bpm BP: 162/85(104) {151/70(97) - 163/85(108)} mmHg RR: 25 (24 - 29) insp/min SpO2: 96% O2 Delivery Device: Medium conc mask SpO2: 96% ABG: 7.45/31/140//0 Physical Examination General Appearance: Well nourished, No(t) Overweight / Obese, Diaphoretic Eyes / Conjunctiva: PERRL Head, Ears, Nose, Throat: Normocephalic Cardiovascular: (S1: Normal), (S2: Normal), No(t) S3, No(t) S4, No(t) Rub Peripheral Vascular: (Right radial pulse: Present), (Left radial pulse: Present), (Right DP pulse: Not assessed), (Left DP pulse: Not assessed) Respiratory / Chest: (Expansion: Symmetric), (Breath Sounds: Diminished: occasional wheezes, rare) Abdominal: Soft, Non-tender, Bowel sounds present, No(t) Distended Extremities: Right: Absent, Left: Absent Musculoskeletal: No(t) Muscle wasting Skin: Not assessed Neurologic: Attentive, Follows simple commands Pertinent Results: Labs on Admission: [**2164-1-13**] 03:45PM BLOOD WBC-63.7*# RBC-3.50* Hgb-10.6* Hct-30.5* MCV-87 MCH-30.4 MCHC-34.8 RDW-17.7* Plt Ct-329 [**2164-1-13**] 03:45PM BLOOD Glucose-107* UreaN-23* Creat-0.9 Na-132* K-4.7 Cl-98 HCO3-22 AnGap-17 [**2164-1-14**] 03:14AM BLOOD Calcium-8.9 Phos-5.0* Mg-2.2 [**2164-1-13**] 07:23PM BLOOD Type-ART pO2-140* pCO2-31* pH-7.45 calTCO2-22 Base XS-0 Lactic Acid:2.0 mmol/L . Imaging: CTA [**2164-1-14**]: 1. No pulmonary embolism or secondary signs of embolism. 2. While the right hilar mass, multiple parenchymal lung masses, and thoracic lymphadenopthy have deacreased in size, intra-abdominal metastases, including hepatic metastases, have increased in size. L1 lucent lesion, worrisome for metastasis, is more conspicuous today. 3. Emphysema with upper lobe predominant ground- glass opacity which may represent respiratory bronchiolitis-associated interstitial lung disease. 4. Decreased right pleural effusion. . CXR on Admission: No appreciable change compared to torso [**2163-10-27**]. Known right hilar and right lower lobe masses re-demonstrated with persistent interstitial abnormality of the right lung concerning for possible lymphangitic carcinomatosis. No evident new superimposed acute abnormality. . CXR [**2164-1-17**]: In comparison with the study of [**1-14**], there is persistent enlargement of the right hilum consistent with the mass seen on CT. Increasing opacification in the right upper lobe just above the minor fissure consistent with developing pneumonia. Suggestion of a similar area of opacification in the left upper zone. Mild atelectatic changes are seen at the left base. Brief Hospital Course: 81 y/o M w/ long smoking history, emphysema, metastatic non-small cell lung cancer, CAD, who p/w respiratory distress from COPD flare. Initially admitted to MICU, improved on steroids & azithromycin and transferred to OMED. [**Hospital 2035**] hospital course according to active problem list. . #Respiratory distress: Secondary to COPD exacerbation. Initially treated in ICU requiring 50% face mask. Transferred to OMED once oxygen requirement stable on NC. Stable on 4 L NC (patient's baseline is 2 L NC). Patient was discharged on prednisone taper and inhalers. Patient was treated with Azithromycin for total of 7 days. . #Leukocytosis: Stable at WBC 40K. Was as high as 63K on admission. Discussed with Heme/Onc to evaluate his leukocytosis and eosinophilia, which was thought likely [**12-26**] underlying cancer and unlikely related to tx with Alimta. . # Lung Ca: Hepatic metastases. Care per primary oncologist Dr. [**Last Name (STitle) **]. . # Hyperkalemia: Resolved following kayexylate. Captopril was discontinued (started during admission for elevated blood pressure). . #Hypertension: Atenolol held during acute exacerbation, re-started prior to discharge. . # Urinary retention: Patient demonstrated urinary retention in ICU. Refused foley and discharge on BPH medication. Improved prior to discharge. . #CAD: Not active during admission. Discharged on statin and Atenolol. Patient did not tolerate captopril due to hyperK. - Patient should discuss ASA use with primary care doctor Medications on Admission: 1. Citalopram 10 mg Tablet Sig: One (1) Tablet PO once a day. 2. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. 4. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 5. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 7. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. 8. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 9. Salmeterol 50 mcg/Dose Disk with Device Sig: One (1) puff Inhalation Q12H (every 12 hours). 10. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 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. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO BID (2 times a day). 4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 6. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 7 days: Take 2 tablets daily for 3 days then take 1 tab daily for 7 days. Disp:*13 Tablet(s)* Refills:*0* 7. Azithromycin 250 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days: Take for 3 more days for total 7 days. . Disp:*3 Tablet(s)* Refills:*0* 8. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. 9. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: [**11-25**] Inhalation twice a day. Disp:*1 inhaler* Refills:*3* 10. Citalopram 10 mg Tablet Sig: One (1) Tablet PO once a day. 11. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Non-small cell lung cancer COPD Coronary artery disease Discharge Condition: Good, ambulating, on 3 L NC. Discharge Instructions: You were admitted for difficulty breathing due to a COPD flare. You will be discharged on antibiotics, new inhalers, and steroids. THIS IS VERY IMPORTANT - DO NOT TAKE YOUR SCHEDULED DEXAMETHASONE (as scheduled prior to chemotherapy with Dr. [**Last Name (STitle) **] [**2164-1-24**]). We are discharging you on another type of steroids (prednisone) and if you take both Prednisone and Dexamethasone your blood sugar will elevate to a critical level which is dangerous to your health. . Please contact Dr.[**Name (NI) 8949**] office regarding plans for your chemotherapy. . Attend all your follow-up appointments: Provider: [**Known firstname **] [**Last Name (NamePattern1) 593**], MD Phone:[**0-0-**] Date/Time:[**2164-1-24**] 9:30 Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2164-1-24**] 9:30 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10384**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2164-1-24**] 10:30 . We have made the following changes to your medication: # ADDED: New inhalers to treat your COPD: Advair. Continue to take the Albuterol as needed for shortness of breath. # ADDED: Prednisone. You will take 20 mg (2 tablets) once a day for 3 days, then 10 mg for 7 days. DO NOT TAKE YOUR SCHEDULED DEXAMETHASONE. If you take both Prednisone and Dexamethasone your blood sugar will elevate to a critical level which is dangerous to your health. # ADDED: Antibiotic Azithromycin 250 mg once a day for three more days # STOPPED: Salmeterol inhaler - instead you will take Advair # STOPPED: Captopril because your potassium was too high while on this. . Return to the ER if you experience fever, chills, increased difficulty breathing, chest pain or other concerning symptoms. Followup Instructions: Provider: [**Known firstname **] [**Last Name (NamePattern1) 593**], MD Phone:[**0-0-**] Date/Time:[**2164-1-24**] 9:30 Provider: [**First Name8 (NamePattern2) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2164-1-24**] 9:30 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 10384**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2164-1-24**] 10:30 Completed by:[**2164-2-1**]

[ "162.9", "715.90", "E932.0", "788.20", "272.4", "288.60", "162.2", "276.7", "197.7", "518.82", "600.01", "162.5", "465.9", "441.2", "401.9", "491.21", "412" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9117, 9174

5483, 6984

321, 327

9274, 9305

3816, 3821

11147, 11582

2668, 2824

7943, 9094

9195, 9253

7010, 7920

9329, 9920

2839, 3797

9944, 11124

274, 283

355, 942

4786, 5460

964, 2292

2308, 2652

20,769

183,005

50279

Discharge summary

report

Admission Date: [**2142-1-12**] Discharge Date: [**2142-1-17**] Date of Birth: Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is an 82-year-old woman with a past medical history significant for chronic lymphocytic leukemia with recent central nervous system involvement who was recently admitted to [**Hospital1 346**] between [**12-2**] and [**1-8**] with sepsis secondary to pneumonia. Her hospital course was complicated by leukemic meningitis and respiratory failure leading to a tracheostomy, cardiomyopathy, poor mental status, and percutaneous endoscopic gastrostomy tube placement. She also had an acute myocardial infarction in the setting of hypotension with her ejection fraction falling from 70% to 25%. Lastly, she had Clostridium difficile colitis. Please see the full Discharge Summary for discharge date [**2142-1-8**] for further details. At the end of this admission, the patient was discharged to rehabilitation. She was at rehabilitation for three days, at which time she spiked a temperature to 101, became tachycardic, appeared ill, and was transferred to [**Hospital1 188**] on [**1-12**]. PAST MEDICAL HISTORY: 1. Chronic lymphocytic leukemia diagnosed in [**2132-5-16**]. Had Prolymphocytic leukemiz as well in '[**36**] was rx'd successfully with short cycles of fludarabine. Over last several months PLL has recurred ? malig transformation of CLL. Last hosp complicated by with central nervous system involvement, leukemic meningitis, and also non-Hodgkin lymphoma (beta cell kappa restricted). Received cycle of fludarabine. She is followed by Dr. [**Last Name (STitle) 104852**] at the [**Hospital6 8862**]. Receives Monthly IVIG as outpt. 2. Bronchiectasis with recurrent pneumonias. 3. Status post Clostridium difficile colitis diagnosed on [**2141-12-7**]. 4. Status post tracheostomy on [**2141-12-29**]. 5. Coronary artery disease; status post acute myocardial infarction in [**2141-11-15**]. 6. History of idiopathic thrombocytopenic purpura; status post splenectomy. She receives monthly intravenous immunoglobulin, and her last infusion was on [**1-10**]. 7. Rheumatoid arthritis. 8. Status post percutaneous endoscopic gastrostomy tube placement on [**2142-1-1**]. 9. s/p small cva at [**Hospital1 112**], MEDICATIONS ON TRANSFER: 1. Folic acid 1 mg by mouth once per day. 2. Aspirin 325 mg by mouth once per day. 3. Lasix 40 mg by mouth once per day. 4. Percocet one to two tablets by mouth q.4-6h. as needed. 5. Heparin 5000 units subcutaneously q.8h. 6. Lansoprazole 30 mg by mouth once per day. 7. Metoprolol 50 mg by mouth twice per day. 8. Flagyl 500 mg by mouth three times per day. 9. Ritalin 12.5 mg by mouth twice per day. 10. Fluoxetine 40 mg by mouth once per day. 11. Prednisone 10 mg by mouth once per day. 12. Albuterol meter-dosed inhaler 2 puffs inhaled q.4h. as needed. 13. Ipratropium 2 puffs inhaled q.4h. as needed. 14. Salmeterol 2 puffs inhaled twice per day. 15. Beclomethasone 2 puffs inhaled four times per day. 16. Colace 100 mg by mouth twice per day. 17. Lisinopril 20 mg by mouth once per day. 18. NPH insulin 18 units subcutaneously in the morning and 14 units subcutaneously at hour of sleep. 19. Regular insulin sliding-scale. ALLERGIES: TINAZOLINE, CLONIDINE, CODEINE, QUININE, EFFEXOR, PENICILLIN, ERYTHROMYCIN, and SULFA. SOCIAL HISTORY: The patient lived with her husband before her multiple hospitalizations. Her children are very involved in her care. She has no history of smoking or alcohol use. PHYSICAL EXAMINATION ON PRESENTATION: The patient's temperature was 103 degrees Fahrenheit, her heart rate was 110, her respiratory rate was 33 to 40, her blood pressure was 120s/70s, and her oxygen saturation was 99% on 40% tracheostomy mask. In general, she was on the tracheostomy mask, following commands, and answering question appropriately. In no respiratory distress. Her oral mucosa were very dry. The neck was supple with a tracheostomy clean, dry, and intact. She had coarse breath sounds throughout anteriorly. Her abdomen was soft with positive bowel sounds. The percutaneous endoscopic gastrostomy tube was clean, dry, and intact. She had no peripheral edema. On neurologic examination, the patient was able to move her extremities passively but not against resistance. PERTINENT LABORATORY VALUES ON PRESENTATION: Relevant laboratories on admission revealed the patient's white blood cell count was 8.4. Her lactate was 4. PERTINENT RADIOLOGY/IMAGING: A chest x-ray showed continued left lower lobe atelectasis/consolidation and a pleural effusion. CONCISE SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The patient was admitted to the [**Hospital Ward Name 332**] Intensive Care Unit for respiratory distress and concern regarding sepsis; although, the patient maintained her blood pressure throughout her admission. She was called out to the regular Medicine floor on the ACOVE Medicine Service the following day. The following is a brief summary of her hospital course. 1. LEFT LOWER LOBE PNEUMONIA ISSUES: The patient has a history of bronchiectasis with recurrent left lower lobe pneumonias. She was initially started on vancomycin and cefepime in the Emergency Department awaiting sputum culture results. Her sputum culture grew methicillin-resistant Staphylococcus aureus and sparse growth of gram-negative rods, but no further identification. When this result returned the patient was continued on vancomycin, but the cefepime was changed to Levaquin for continued coverage of Pseudomonas if that was in fact the organism found in the sputum culture. None of her other cultures, including blood cultures, grew out anything throughout her hospital stay. 2. BRONCHIECTASIS ISSUES: As the patient has baseline bronchiectasis with an increased risk of recurrent pulmonary infections, she was continued on her outpatient regimen of Ceftin 500 mg by mouth twice per day for seven days the first week of every other month alternating with ciprofloxacin 500 mg by mouth twice per day the first week of every other month. She was to continue taking all of her inhalers and albuterol nebulizers as needed. 3. CHRONIC LYMPHOCYTIC LEUKEMIA ISSUES: The patient is seen by Dr. [**Last Name (STitle) 104852**] at the [**Hospital6 8865**] concerning her cancer treatment. Current treatment was deferred during this admission until the resolution of her acute medical issues. It should be known that the patient receives monthly intravenous immunoglobulin infusions with the last one being on [**2142-1-10**]. Please call the [**Hospital6 8865**] to set up further infusions. 4. DIABETES MELLITUS ISSUES: The patient has type 2 diabetes mellitus and takes NPH insulin twice per day as well as a regular insulin sliding-scale. Her blood sugars remained in the high 100s to low 200s throughout her hospital stay. On the day of discharge, her NPH regimen was increased by one unit both in the morning and at bedtime. Please adjust this as needed. 5. CORONARY ARTERY DISEASE ISSUES: The patient had an acute myocardial infarction during her last admission secondary to hypotension in the setting of sepsis. A repeat echocardiogram was done during this hospitalization which showed a return of her ejection fraction to greater than 55%. She was to continue on her metoprolol, lisinopril, aspirin, etcetera. 6. RHEUMATOID ARTHRITIS ISSUES: The patient was asymptomatic throughout this admission. She was to continue on her outpatient regimen of 10 mg by mouth every day. 7. HISTORY OF CLOSTRIDIUM DIFFICILE COLITIS ISSUES: The patient was diagnosed with Clostridium difficile colitis in [**Month (only) 359**] of this year. Stool samples sent during this admission were negative for Clostridium difficile colitis; however, she was still having loose stools. As she has been getting antibiotics for the past seven days for her pneumonia, we will continue her Flagyl for the next five days to help prevent a recurrence of Clostridium difficile colitis. 8. DEPRESSION ISSUES: We were unsure if the patient has an official diagnosis of depression, but she seemed to be doing well on Prozac 40 mg by mouth once per day. However, Ritalin was started during her last one or two admissions, and the indication was not clear. Therefore, we are tapering off the Ritalin. Currently, she is getting 5 mg by mouth twice per day, and this should be tapered per her medication list (see below). 9. TRACHEOSTOMY CARE ISSUES: The patient has had a tracheostomy in place since [**2141-12-29**]. The indication for placing the tracheostomy was difficulty weaning from the ventilator. The patient was doing extremely well, breathing 100% on room air through her tracheostomy. During the past two days, she has been tolerating a PMV valve for indefinite periods of time. In terms of removing her tracheostomy, the next step would be to use the red-cap mechanism. This can be done at her rehabilitation place if she is able to maintain the cap without respiratory distress for two days straight, the process of decannulation can be begun with a goal to remove the tracheostomy completely. 10. NUTRITIONAL ISSUES: The patient has been nothing by mouth for the past two to three weeks secondary to the severity of her medical illness; however, she seemed to be recovering very nicely. She had a video swallow done on [**2142-1-16**] which showed that the patient had silent aspiration to thin liquids. The recommendation was that the patient was to initiate a by mouth diet with a pureed consistency, and she should be eating only nectar-thickened liquids. She was to tuck her chin to her chest when swallowing liquids and solids. She should maintain aspiration precautions. She should swallow two times per bite or sip and should alternate between bites and sips. She should follow up with Speech and Swallow therapy at [**Hospital1 **]. She should have a repeat video swallow in one to two weeks, as it was thought that her aspiration to thin liquids was likely due to fatigue, and this should improve with rehabilitation. Lastly, the PMV valve should be worn at all meals while the tracheostomy is still present. She is also to continue her tube feeds as they are at goal until a Nutrition consultation is done with recommendations for how to combine her oral intake with her tube feeds recommendations. The goal is for her to be taking adequate oral intake so that the percutaneous endoscopic gastrostomy tube can be reversed. DISCHARGE DIAGNOSES: 1. Methicillin-resistant Staphylococcus aureus pneumonia. 2. Weaning from tracheostomy; now with PMV valve. 3. Bronchiectasis. MEDICATIONS ON DISCHARGE: 1. Folic acid 1 mg by mouth once per day. 2. Aspirin 325 mg by mouth once per day. 3. Lansoprazole 30 mg by mouth once per day. 4. Heparin 5000 units subcutaneously q.8h. 5. Prozac 40 mg by mouth once per day. 6. Zinc 220 mg by mouth every day. 7. Vitamin C 500 mg by mouth twice per day. 8. Albuterol nebulizer 1 nebulizer q.4h. as needed. 9. Flovent 2 puffs inhaled twice per day. 10. Oxycodone 5 mg to 10 mg by mouth q.4-6h. as needed. 11. Tylenol 325 mg to 650 mg by mouth q.4-6h. as needed. 12. Prednisone 10 mg by mouth once per day. 13. Lisinopril 20 mg by mouth once per day. 14. Metoprolol 50 mg by mouth twice per day. 15. Combivent 2 puffs q.6h. 16. Ambien 5 mg by mouth at hour of sleep as needed (for insomnia). 17. NPH insulin 19 units subcutaneously in the morning and 15 units subcutaneously at hour of sleep. 18. Regular insulin sliding-scale. 19. Simethicone 40 mg to 80 mg by mouth as needed. 20. Ritalin 5 mg by mouth twice per day; with titration down on [**1-17**] to [**1-19**] to 5 mg by mouth twice per day; on [**1-20**] to [**1-24**] to 5 mg by mouth once per day; and on [**1-25**] off. 21. Flagyl 500 mg by mouth three times per day (for five days). 22. Ciprofloxacin 500 mg by mouth twice per day for the first week of this month, alternating with Ceftin 500 mg by mouth twice per day for the first week of next month and alternating months. CONDITION AT DISCHARGE: Condition on discharge was stable. The patient has a tracheostomy and percutaneous endoscopic gastrostomy tube in place. She was breathing well on room air. DISCHARGE STATUS: To [**Hospital3 **]. [**Doctor First Name 306**] C- [**Name8 (MD) 308**], M.D. [**MD Number(1) 11871**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2142-1-17**] 10:37 T: [**2142-1-17**] 10:42 JOB#: [**Job Number 104856**] eo

[ "V09.0", "V44.0", "202.80", "250.00", "714.0", "482.41", "204.10", "276.5", "494.0" ]

icd9cm

[ [ [] ] ]

[ "96.6" ]

icd9pcs

[ [ [] ] ]

10590, 10721

10748, 12161

4707, 10569

12176, 12654

155, 1162

2334, 3391

1184, 2308

3408, 4673

69,806

197,579

39006

Discharge summary

report

Admission Date: [**2107-5-25**] Discharge Date: [**2107-5-26**] Date of Birth: [**2069-6-17**] Sex: M Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 2817**] Chief Complaint: Airway obstruction. Major Surgical or Invasive Procedure: Change tracheostomy tube. History of Present Illness: 37 yo male with a history of osteogenesis imperfecta, GERD, tracheostomy s/p seizure presenting to [**First Name8 (NamePattern2) 1495**] [**Hospital3 6783**] Medical Center from his longterm care facility with respiratory distress. The patient had a bronchoscopy done on the day of presentation which showed granulation tissue and thick secretions around his tracheostomy tube. Some of the granulation tissue was removed and the secretions appeared clear at that time. The patient appeared to be doing well and was sent back to his longterm facility. Upon return to his [**Hospital1 1501**], the aptient was found to have intermittent SOB and airway obstruction that seemed positional. He was transferred back to the emergency room at [**Hospital2 **] [**Hospital3 6783**] and noted to have profuse coughing at that time. At that time, his vital signs were significant for T: 99.5, BP: 110/55, HR: 104-124, RR: 14-20 with ventilator settings of AC rate of 14, PEEP: 5, FiO2: 50%, tidal volume: 350. The patient was admitted to the MICU at [**Hospital2 **] [**Hospital3 6783**] and then transferred to [**Hospital1 18**] for consideration of laser bronchoscopy. . Upon arrival to [**Hospital1 18**], the patient was noted to be cyanotic. The interventional pulmonary team was called. At bedside, they noted extensive supraglottic edema, thought secondary to GERD and extensive granulation tissue at the site of the tracheostomy. His secretions were suctioned and the patient was no longer hypoxic. His tracheostomy was replaced and a longer tracheostomy that bypassed the granulation tissue was placed 1.5 cm above the carina. After that intervention, the patient was no longer in distress. . At the time of interview, the patient only states that he has some burning at his trachea. Past Medical History: -osteogenesis imperfecta complicated by multiple fractures including a recent humeral fracture -GERD -diverticular disease -seizure in [**3-/2107**] (? alcohol associated) and chronic intubation with tracheostomy after this seizure -h/o EtOH abuse -h/o cocaine abuse -heart murmur Social History: - Tobacco: tobacco history - Alcohol: history of abuse, none currently - Illicits: history of cocaine, marijuana - Living: Lives at [**Hospital **] nursing home. Prior, he lived alone Family History: Unknown Physical Exam: Admission Physical Vitals: T: 100.6 BP: P: 130/72 105 R: 18 O2: Pressure support General: Alert, oriented, no acute distress. Patient is trached with a soft whisper. HEENT: Sclera blood, dry mucous membranes Neck: supple, JVP not elevated, no LAD. trach site clean. Lungs: Wheezing throughout all lung fields anteriorly. No ronchi or crackles. Pectus excavatum CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding. GU: no foley Ext: warm, well perfused, no clubbing, cyanosis or edema Pertinent Results: [**2107-5-25**] 09:00PM GLUCOSE-88 UREA N-21* CREAT-0.5 SODIUM-139 POTASSIUM-4.6 CHLORIDE-101 TOTAL CO2-26 ANION GAP-17 [**2107-5-25**] 09:00PM CALCIUM-9.3 PHOSPHATE-4.6* MAGNESIUM-2.0 [**2107-5-25**] 09:00PM WBC-10.5 RBC-3.18* HGB-10.4* HCT-30.0* MCV-95 MCH-32.6* MCHC-34.5 RDW-14.5 [**2107-5-25**] 09:00PM PLT COUNT-316 Brief Hospital Course: This is a 37 yo male with a history of osteogenesis imperfecta, GERD, tracheostomy s/p seizure presenting with respiratory distress who was found to have granulation tissue at trachea site, s/p placement of longer tracheostomy. . # Airway obstruction: On arrival to the MICU, the patient indicated in writing that he felt he needed to be suctioned. Shortly thereafter, the patient became hypoxic, unresponsive and lost pulses. After a brief period of BVM and aggressive suctioning, the patient recovered. Interventional pulmonary was paged and upon [**Last Name (un) 1066**] found extensive granulation tissue around his prior trach site with supraglottic stenosis. The trach was replaced with a longer one which bypassed the granulation tissue (1.5 cm above the carina) and was sutured in place. The patient was ventilated without issue for the remainder of his ICU stay. The pt will need a f/u appointment with Dr. [**Last Name (STitle) **] of interventional pulm within 2 wks post discharge in the [**Hospital **] clinic. Will need a CT of the trachea without contrast beforehand. . # Respiratory distress: Per OSH reports, the patient had respiratory distress, which was likely related to his granulation tissue. On presentation to [**Hospital1 18**], had respiratory arrest due to mucous plug as described above. the patient has been stabilized with a longer tracheostomy tube. He did not show any sign of infection that could be complicating his ventilation. . # Supraglottic swelling: The patient was noted to have supraglottic swelling on scope, thought likely due to underlying GERD. Hew as started on [**Hospital1 **] PPI, and H2 blocker at night, and dexamethasone 5 mg IV q6h for the swelling. . # GERD: Continued PPI. . # Chronic pain- Continued home oxycodone, tylenol. . # Anxiety- Continued home ativan, quetiapine. . # Osteogenesis imperfecta: No current issues at this time. . The patient was transferred back to his LTAC facility on HD#2. Medications on Admission: -Ativan 1 mg q6HR -oxycodone IR 5 mg per PEG q6HR:PRN pain -combivent 2 puffs PRN -enoxaparin 30 units SQ dialy -Jevity 1.2% at 30 ml per hour -thiamine 100 mg daily -quetiapine 50 mg in the morning and 25 mg at night -water flushes 200 mL q8HR -multivitamin daily -aspirin 325 mg daily -pantoprazole 40 mg daily -chlorhexidine -metoprolol 12.5 mg [**Hospital1 **] -Docusate [**Hospital1 **] -Senna dialy:PRN -bisacodyl 10 mg PR PRN -tylenol 650 mg q6HR:PRN pain/fever Discharge Medications: 1. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Tablet(s) 2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 3. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO QAM (once a day (in the morning)). 5. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 6. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Five (5) ML Mucous membrane [**Hospital1 **] (2 times a day). 8. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 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 DAILY (Daily) as needed for constipation. 11. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 13. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for SOB, wheezing. 14. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Pantoprazole 40 mg IV Q12H Discharge Disposition: Extended Care Facility: [**Location (un) 32674**] - [**Location (un) **] Discharge Diagnosis: Clogged tracheostomy tube. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: You were treated in the hospital after having respiratory arrest related to clogging of your tracheostomy tube. Your tube was changed to a longer size and your breating returned to baseline. Your medications have not changed in any way. Please go to all of your follow up appointments. Seek urgent medical advice if your experience- Any difficulty breathing, increasing clogging of your trach tube, chest pain, fever or chills, any other new or concerning symptoms. Followup Instructions: You are scheduled for a tracheal CT scan at 8:30 am on [**6-16**]. At 9 am on [**6-16**] you have a follow up appointment with Dr. [**Last Name (STitle) **] and at 10 am you are scheduled for a flexible bronchoscopy. You may contact the office at ([**Telephone/Fax (1) 17398**] with questions. you should have your facility call prior to your appointment if you are still on the ventilator at that time.

[ "518.83", "934.0", "519.02", "530.81", "478.74" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.6", "97.23" ]

icd9pcs

[ [ [] ] ]

7443, 7518

3678, 5642

316, 343

7589, 7589

3324, 3655

8218, 8626

2678, 2687

6162, 7420

7539, 7568

5668, 6139

7724, 8195

2702, 3305

257, 278

371, 2157

7604, 7700

2179, 2461

2477, 2662

8,857

103,729

20850

Discharge summary

report

Admission Date: [**2182-6-11**] Discharge Date: [**2182-6-17**] Date of Birth: [**2104-9-2**] Sex: F Service: MED Allergies: Penicillins / Aspirin Attending:[**First Name3 (LF) 2181**] Chief Complaint: Respiratory Distress Major Surgical or Invasive Procedure: Intubation History of Present Illness: Patient is a 77 year old female with COPD, ESRD on HD, CAD, MVR, who was tranferred from an outside hospital ED already intubated for respiratory failure. Also with hyperkalemia. She was afebrile ane hemodynamically stable. According to family, the patient had progressive SOB yesterday,despite increasing chronic home O2 from 2L to 4+L. No cough/fever/chills/CP. Of note, she has a h/o intubations for COPD flares. She was also due for HD. Patient was treated for recent bronchitis 4 weeks ago with Z-Pack. She reports being well until [**Month (only) **] of last year when she was first hospitalized for COPD exacerbation and was intubated. Since then she has been intubated 3 times. She reports that she has been on dialysis since [**11-29**]. Patient was admitted from the ED to the MICU. She received kayexalate, insulin, D5 and calcium carbonate for high potassium. She was kept on solumedrol for 24 hours. She was started on Levofloxacin. She was extubated on [**6-13**]. Past Medical History: 1. COPD on chronic O2 (most recent intubation x 1yr ago) 2. ESRD on HD (T, TH, Sat) thought to be secondary to XRT for uterine ca 3. Uterine ca x 16 yrs ago s/p chemo/xrt 4. CAD s/p CABG x 3 [**10-30**] 5. MVR on coumadin (PCP believes this is porcine and goal INR is 1.5-2.5; no valve seen on CXR) 6. s/p cholecystectomy 7. anxiety 8. GERD 9. restless legs. Social History: Lives with supportive husband. [**Name (NI) **] 5 children. Ambulatory. Uses 2L oxygen at home when active. Quit smoking one year ago. Prior to that smoked 1 pack every two days. Does not drink alcohol. Family History: Non contributory Physical Exam: VS: T 97.8 HR 68 BP 151/60-184/77 RR 24 EDW: 58 kg GEN: Elderly female seen at dialysis, in NAD. HEENT: Anicteric sclera. EOMI. Moist mucous membranes. No erythema or edema of oropharynx. LUNGS: Crackles bilaterally R>L [**12-28**] way up. No wheezes. CV: Regular. [**3-2**] holosystolic murmur at apex. ABD: Soft, non tender, non distended, active bowel sounds. EXT: No clubbing, or edema. Blue discoloration of toes with some healed sores. 1+ posterior tibialis pulses bilaterally. AVF of left arm with palpable thrill and good bruit. NEURO: Alert and oriented x 3. CN II-XII intact and symmetric bilaterally. Strength is [**5-1**] in upper and lower extremities bilaterally. Labs: 8.7>32.1<191 143| 95 | 54 3.2| 30 | 6.3 Glucose 78 Ca 7.9 Mg 2.1 P 8.3 INR 1.5 PTT 69.4 Blood culture negative. Sputum gram stain: 3+ gram positive cocci in pairs/chains/cluters 2+ gram negatvie rods Sputum culture: moderate orophayngeal flora with sparse pseudomonas Pertinent Results: ECG: Normal sinus rhythm. First degree AV block. Probable anterior infarct - age undetermined. Lateral ST-T changes offer additional evidence of ischemia. Repolarization changes may be partly due to rate. Clinical correlation is suggested No previous tracing. Rate: 120. Intervals: PR 0 QRS 72 QT/QTc 330/401.42 Axis: P 0 QRS 0 T 113 CXR: The heart is enlarged. There are increased interstitial markings and perihilar haziness, consistent with congestive heart failure. Small left pleural effusion is also likely present. The patient is post median sternotomy and mitral valve replacement. An endotracheal tube terminates just proximal to the carina. An NG tube is seen coarsing below the diaphragm into the proximal stomach. IMPRESSION: Cardiomegaly with congestive heart failure. Low lying endotracheal tube which could be pulled back several centiimeters. CXR: The heart shows slight left ventricular enlargement. There is evidence of a prosthetic valve and prior CABG surgery. The pulmonary vessels are slightly prominent and appear slightly blurred. Slight left heart failure may be present. There is also evidence of patchy atelectasis at the left lung base behind the heart and some minor atelectasis is also noted in the right lower lobe. Interstitial changes are present in both lungs, mainly in the mid and upper zones. The endotracheal tube, the right IJ central line, and the NG line are in good position. IMPRESSION: Findings are consistent with slightly improving left heart failure. Bibasilar atelectasis is noted. Background CABG and prosthetic valve surgery. Brief Hospital Course: Assessment and Plan: 77 year old woman with ESRD, COPD, CAD, MVR admitted with COPD exacerbation/CHF, initially intubated. Now extubated, afebrile and hemodynamically stable. 1. Respiratory failure: Likely COPD flare with possible component of CHF. Patient was extubated with no event after 48 hours and maintained on 4L O2. She was given solumedrol for 24 hours and then transitioned to prednisone taper, serevent, flovent, albuterol and atrovent. She was started on levofloxacin for COPD flare as she had bronchitis recently and was treated with azithromycin and did not improve. Sputum culture was obtained and showed sparse growth of pseudomonas aeruginosa thought to be a colonizer. As the patient was not febrile and not producing much sputum she was not started on antibiotics. After hemodialysis with fluid removal patient was euvolemic. She was continued on ACE I for afterload reduction. 2. ESRD: Patient received dialysis Tuesday, Thursday, Saturday and Monday. To have next session Thursday at [**Location (un) 4265**] [**Location (un) 3786**]. She was dialyzed to her 59 kg on day of discharge. On Tuesday 1.9 kg was removed, on Thursday 2.8 kg was removed, on Saturday 3.3 kg was removed adn on Monday 2.9 kg was removed. 3. MVR: Patient was maintained on coumadin. 4. CAD: Patient was contined on lipitor, beta blocker and Ace inhibitor. 5. Hyperkalemia: Resolved with insulin, D5, kayexalate. Now on dialysis. 6. FEN: Heart friendly diet, 2 gm sodium, 1 liter fluid restriciton. No elevation of blood glucose while on prednisone. 7. Lines: Right internal jugular central line placed in intensive unit and removed on the floor. 8. family: Husband is health care proxy. 10. code status: full code. Medications on Admission: Coumadin 3 mg PO qhs Lisinopril 5 po qd Coreg 12.5 po bid lipitor 10 po qd folate 1 po qd zinc advair albuterol ativan prn 2L oxygen via NC Discharge Medications: 1. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD (once a day). 2. Warfarin Sodium 1 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime). 3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day) as needed for constipation. 4. Prednisone 10 mg Tablet Sig: as directed Tablet PO once a day for 9 days: 3 tablets PO for 3 days, 2 tablets po for 3 days, 1 tablet PO for three days. Disp:*18 Tablet(s)* Refills:*0* 5. Combivent 103-18 mcg/Actuation Aerosol Sig: One (1) inh Inhalation every six (6) hours. Disp:*2 cannisters* Refills:*2* 6. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. 7. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 8. Coreg 12.5 mg Tablet Sig: One (1) Tablet PO twice a day. 9. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 10. Advair Diskus 250-50 mcg/DOSE Disk with Device Sig: One (1) inhalation Inhalation twice a day. 11. oxygen 2L oxygen by nasal cannula Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Chronic obstructive pulmonary disease exacerbation Congestive heart failure Discharge Condition: Stable with improved oxygen saturation and improved clinical exam. Discharge Instructions: Take your medications as prescribed. Call your primary care physician if you experience shortness of breath, cough, chest pain or wheezing. Take the same medications that you were taking before this hospitalization. You are also now taking prednisone for the next 18 days and combivent four times a day every day. Followup Instructions: Follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], in one week. Call [**Telephone/Fax (1) 55519**] for an appointment. Patient will have INR checked by VNA on Tuesday, [**2182-6-18**] and called into [**Location (un) 4265**] [**Location (un) 3786**] Dialysis center at [**Telephone/Fax (1) 55520**].

[ "E879.2", "300.00", "V45.1", "414.00", "491.21", "585", "518.81", "428.1", "276.7" ]

icd9cm

[ [ [] ] ]

[ "38.93", "39.95", "96.71" ]

icd9pcs

[ [ [] ] ]

7514, 7571

4597, 6321

297, 309

7691, 7759

2992, 4574

8121, 8517

1938, 1956

6511, 7491

7592, 7670

6347, 6488

7783, 8098

1971, 2973

237, 259

337, 1320

1342, 1702

1718, 1922

71,083

140,525

44274

Discharge summary

report

Admission Date: [**2180-9-19**] Discharge Date: [**2180-9-28**] Date of Birth: [**2099-2-22**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5129**] Chief Complaint: "found unresponsive" Major Surgical or Invasive Procedure: Intubation, extubated. History of Present Illness: Ms. [**Known lastname **] [**Known lastname 22924**] is an 81 yof who was found unresponsive in her nursing home bed. Per report, she was hypoglycemic (glucose 50) and was noted to be "acting inappropriately." The patient remembers "passing out," and experiencing right arm stiffness/numbness, but no other details surrounding the incident. On arrival of EMS, her Blood Glucose was found to be 20, she was given 1mg glucagon/1 amp D50 and was brought to the ED. Vital signs were all stable and she remained afebrile, O2 Sat was 99% 10L NRB, FSG 150. On presentation, EKG was without acute ischemic changes. The patient was responsive to pain, w/o response to narcan, and intubated for airway protection. CT head was negative; RIJ placed for access. Repeat BS 21, given D10 gtt and 2 bolus dextrose. She was then given 100mg hydrocortisone x 1, vanc and zosyn, and was admitted to the ICU. Past Medical History: - CHF - DM2 - AF on coumadin - CRI - Chronic Hep B - gout - glaucoma Social History: Denies any history of smoking, EtOH, or other drug use Was born in [**Location (un) 6847**] and has been living in the United States for the past 30 years. She is married; her husband is 88, lives with her, and is in good health. She has three sons. Family History: Significant for DM and HTN. Physical Exam: VS: Afebrile, satting well on room air. GEN: NAD. Alert, conversive not in english. HEENT: + periorbital edema; PERRL, EOMi b/l, conjunctivae clear, sclera anicteric; OP moist without masses/petechiae; uvula midline; dentition in poor repair NECK: + thyromegaly; no carotid bruits; no [**Doctor First Name **]; CV: Irregularly irregular; + 3/6 systolic murmur loudest at L sternal border, radiating to axilla CHEST: good air movement throughout; ABD: distended, hepatomegaly w/palpable liver edge; mildly tender; + fluid wave; +BS EXT: WWP; no clubbing/cyanosis; trace edema in LE; palpable pulses in extremities; gouty tophus at right third digit DIP SKIN: no rashes, excoriations; no jaundice NEURO: Mental status: Pt. A/O; cooperative with exam CN: II-XII grossly intact Motor: [**3-18**] in upper extremities Sensory: LT grossly intact in upper/lower extremities Pertinent Results: CBC: [**2180-9-19**] 01:40AM BLOOD WBC-6.0 RBC-2.65* Hgb-8.3* Hct-26.4* MCV-100* MCH-31.2 MCHC-31.3 RDW-18.2* Plt Ct-141* [**2180-9-28**] 05:05AM BLOOD WBC-4.8 RBC-2.63* Hgb-8.2* Hct-25.9* MCV-99* MCH-31.1 MCHC-31.5 RDW-18.5* Plt Ct-185 Coags: [**2180-9-19**] 01:40AM BLOOD PT-34.2* PTT-50.2* INR(PT)-3.6* [**2180-9-28**] 05:05AM BLOOD PT-39.8* PTT-52.8* INR(PT)-4.3* Chemstry: [**2180-9-19**] 09:45AM BLOOD Glucose-253* UreaN-68* Creat-2.6* Na-136 K-4.5 Cl-96 HCO3-29 AnGap-16 [**2180-9-28**] 05:05AM BLOOD Glucose-129* UreaN-67* Creat-2.1* Na-143 K-4.1 Cl-100 HCO3-34* AnGap-13 [**2180-9-20**] 04:01AM BLOOD Calcium-9.1 Phos-8.1*# Mg-2.7* [**2180-9-27**] 07:27AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.0 LFTs: [**2180-9-19**] 01:40AM BLOOD ALT-16 AST-32 LD(LDH)-242 CK(CPK)-37 AlkPhos-129* TotBili-1.3 [**2180-9-27**] 07:27AM BLOOD ALT-18 AST-31 AlkPhos-92 TotBili-1.1 Albumin-3.3* Albumin-2.9* Lipase: [**2180-9-19**] 01:40AM BLOOD Lipase-154* CE: [**2180-9-19**] 01:40AM BLOOD CK-MB-3 cTropnT-0.03* [**2180-9-19**] 09:45AM BLOOD CK-MB-NotDone cTropnT-0.04* Iron studdies: [**2180-9-19**] 09:45AM BLOOD calTIBC-272 VitB12-444 Folate-10.1 Ferritn-102 TRF-209 TFTs: [**2180-9-19**] 01:40AM BLOOD TSH-0.53 [**2180-9-19**] 01:40AM BLOOD T4-6.5 T3-82 Hep serologies: [**2180-9-19**] 09:45AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-POSITIVE [**2180-9-26**] 02:42AM BLOOD Digoxin-0.4* [**2180-9-19**] 09:45AM BLOOD HCV Ab-NEGATIVE Blood tox screen: [**2180-9-19**] 01:40AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG ECHO: The left atrium is mildly dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). The right ventricular cavity is markedly dilated with mild global free wall hypokinesis. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. Severe [4+] tricuspid regurgitation is seen. Pulmonary hypertension cannot be reliably assessed given degree of TR. There is a small pericardial effusion. CT HEAD: CT OF THE HEAD WITHOUT CONTRAST: There is no intracranial mass effect, edema, hydrocephalus, shift of normally midline structures, major vascular territorial infarct, or acute hemorrhage. The [**Doctor Last Name 352**]-white matter differentiation is preserved. Hypodensities are present in the supratentorial white matter and the inferior right lentiform nucleus, likely related to chronic microvascular ischemic disease in a patient of this age. Intracranial vascular calcifications are seen. The surrounding osseous and soft tissue structures are unremarkable. The visualized paranasal sinuses are clear. IMPRESSION: 1. No evidence of acute intracranial abnormalities. 2. Chronic small vessel ischemic disease. CXR: FINDINGS: Portable AP view of the chest in upright position was obtained. There is marked cardiomegaly. Tortuous aorta with calcifications. The pulmonary vasculature is normal. There is no pneumothorax or consolidation. Opacity in the left lung base may represent atelectasis, pleural effusion or penumonia. The osseous structures demonstrate diffuse demineralization. CT AB/PELV: IMPRESSION: 1. There is no free air in the abdomen to suggest a bowel perforation. There is no evidence of bowel obstruction. 2. There is a moderate amount of ascites fluid within the abdomen, which measures up to 20 Hounsfield units in density. The fluid could be proteinaceous or serosanguineous given this density. Please correlate clinically, as the etiology of ascites is indeterminate on this study. 3. Marked atherosclerotic disease involving the abdominal aorta and extending into the SMA. Vascular patency cannot be assessed on this study. 4. Marked cardiomegaly and a moderate-to-large pericardial effusion. Brief Hospital Course: Ms. [**Known lastname **] [**Known lastname 22924**] is an 81 yof with h/o DM2, CHF, CKD, AF (on coumadin), p/w unresponsiveness and found to be hypoglycemic (BG<20). She was intubated for respiratory failure [**1-15**] CHF exacerbation and admitted to the MICU. Her MICU course was significant for diuresis and treatment of UTI (CFX). Patient transferred to floor in a stable condition. . # CHF/tricuspid regurgitation/pulmonary HTN - Based on patient's report, her CHF had been exacerbated over the past few months, with an increase in weight and swelling of her LE/abdomen. The history of her heart failure is not completely clear from history, but is likely a longstanding issue. She typically receives care at [**Hospital1 336**]. Echo from [**9-19**] revealed dilated right ventricle with mild systolic dysfunction, preserved left ventricular global and regional systolic function, severe tricuspid (+4) regurgitation, and small pericardial effusion. She was diuresed slowly over her hospitalization. We kept her torsemide dose at 40mg to prevent from overdiuresing her. Her aldactone was restarted and her digoxin was restarted. She was able to be weaned off oxygen and was satting well on room air. # DM: Pt. with episode of hypoglycemia precipitating admission, with acute mental status changes. Unclear as to why patient became hypoglycemic - poor po intake, change in medications, CHF exacerbation, etc. Now with elevated glucoses post-extubation, presumably from improving renal function and increased clearance of insulin. Fasting glucose range in 200s, with this am at 234. Pt. is receiving Lantus 20U and Humulin per ISS. Her lantus was changed back to Humalin (75/25) twice a day as per her son they could not get lantus paid for by insurance. Her blood sugars then became low and she was decreased to 33U with breakfast and 30U with dinner. . # CKD - Patient's baseline Cr is 1.6 to 2.2, and it has been elevated upon admission, trending downward with diuresis and equillibration of fluid status. MICU team had been re-initiating standing diuretics with caution. Her creatinine trended town to her baseline at 2.2. Her ACE inhibitor was initially held, then restarted when creatinine normalized. . # AFib - Patient is on Coumadin (2mg MWFSat, 1mg TuThurSun), with target [**1-16**] INR. Also on Metoprolol for rate control. Her INR became elevated to 5. Coumadin was held. Restart when INR < 2.2 with goal of [**1-16**]. . # Anemia ?????? Hct has been 24-26 since admission, macrocytic; blood transfusions given. Stools have been guaiac+, noted to have blood in stool PM of transfer [**9-26**], with hct to 23.4, lowest since admit, but within range of error of draw. GI was consulted for possible colonoscopy, but as her INR was elevated and her HCT stabalized they opted to wait until her INR came down. Did not want to give FFP in setting of diuresing for heart failure. We reccomend obtaining an outpatient colonoscopy over the next few months. . # Hypernatremia - Na has been elevated, 149 to 142 on am of transfer, with this am at 145. Patient has had minimal PO intake and was initiated on D5W@125cc/hr by MICU team. Pt increased her PO intake and Na normalized. . # UTI - +proteus UTI, cipro resistant, completed course of ceftriaxone. . # AMS ?????? reportedly stable, as per family. . # Gout/RUE pain and weakness - Per family, the pain is old. The patient is reporting an increase in weakness since this hypoglycemic episode, but it does not seem to be worsening. Her colchicine was continued. . # Multinodular goiter: Her TSH was normal. She was not having any symptoms in house. Continue workup as previously directed. . # Code: FULL . # contacts: [**Name (NI) 22924**], W. (son) [**Telephone/Fax (1) 94947**], [**Known lastname 22924**], Y. (dt) [**Telephone/Fax (1) 94948**] # Medication changes: 1) Torsemide decreased to 40mg [**Hospital1 **] 2) Toprol increased to 150mg daily 3) Insulin Humalin 33U with breakfast, 30U with dinner. Medications on Admission: acetaminophen coumadin 1/2mg qod digoxin 0.125mg qod colchicine 0.6mg qod toprol XL 100mg daily lisinopril 20mg daily INSULIN: -- Novolin SS -- Humulog 75-25 45 untis [**Hospital1 **] ISMN 60mg daily torsemide 80mg [**Hospital1 **] aldactone 25mg ??TID flovent 220mcg 2 puffs [**Hospital1 **] xalatan eye gtt 1 gtt OU qHS ranitidine 150mg qHS KCl 20 mEq daily senna colace fleets enema prn MoM prn Dulcolax prn Discharge Medications: 1. Acetaminophen 325 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q6H (every 6 hours) as needed. 2. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 3. Docusate Sodium 100 mg Capsule [**Hospital1 **]: One (1) Capsule PO BID (2 times a day). 4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 5. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Last Name (STitle) **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 6. Magnesium Hydroxide 400 mg/5 mL Suspension [**Last Name (STitle) **]: Thirty (30) ML PO Q6H (every 6 hours) as needed. 7. Colchicine 0.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 8. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr [**Last Name (STitle) **]: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 9. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: Two (2) Puff Inhalation QID (4 times a day). 10. Acetylcysteine 20 % (200 mg/mL) Solution [**Last Name (STitle) **]: One (1) ML Miscellaneous Q6H (every 6 hours) as needed. 11. Digoxin 125 mcg Tablet [**Last Name (STitle) **]: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 12. Spironolactone 25 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 13. Torsemide 20 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times a day). 14. Lisinopril 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 15. Multivitamin Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 16. Insulin NPH & Regular Human 100 unit/mL (70-30) Cartridge [**Last Name (STitle) **]: One (1) Subcutaneous twice a day: Before breakfast and dinner. . 17. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr [**Last Name (STitle) **]: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). 18. Latanoprost 0.005 % Drops [**Last Name (STitle) **]: One (1) Drop Ophthalmic HS (at bedtime). 19. Ranitidine HCl 150 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital1 2670**] - [**Location (un) **] Discharge Diagnosis: Hypoglycemia Acute diastolic heart failure Discharge Condition: Stable. Discharge Instructions: You were admitted to the hospital with low blood sugar and change in mental status. You intially had to go to the intensive care unit and required intubation to protet your airway. You were succesfully extubated and transferred to a medical floor. Your blood glucose levels were difficult to control. You at times had high blood glucose and other times low blood glucose. You were stable to go back to your discharge facility. Medication changes: 1) Torsemide dose decreased to 40mg twice a day 2) Torpol XL dose increased to 150mg daily 3) Insulin Humalin (70/25) decresed to 33U at breakfast and 30U at dinner. Followup Instructions: weight gain. Monitor fingerstick blood sugar qid and adjust insulin to maintain in 100-150 range. Follow up with your PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] 1-2 years after you leave the nursing home.

[ "275.41", "041.6", "585.9", "789.59", "274.9", "397.0", "599.0", "250.82", "518.81", "787.21", "428.23", "792.1", "790.92", "428.0", "241.1", "427.31", "584.9", "E934.2", "V58.67", "276.0", "403.90", "E932.3", "416.8", "365.9", "280.9", "V12.09" ]

icd9cm

[ [ [] ] ]

[ "96.04", "38.93", "96.6", "96.72", "93.90" ]

icd9pcs

[ [ [] ] ]

13323, 13393

6688, 10518

336, 361

13480, 13490

2589, 4934

14157, 14386

1656, 1685

11140, 13300

13414, 13459

10704, 11117

13514, 13947

1700, 2403

13967, 14134

276, 298

389, 1279

4943, 6665

2418, 2570

1301, 1372

1388, 1640

15,952

180,799

26893

Discharge summary

report

Admission Date: [**2195-1-13**] Discharge Date: [**2195-2-4**] Date of Birth: [**2145-5-20**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 6169**] Chief Complaint: Leg pain,relapsed AML Major Surgical or Invasive Procedure: Bone Marrow Biopsy, [**2195-1-14**] Intubation History of Present Illness: 49 yo female with AML s/p MRD allogeneic transplant 1 year ago complicated by chronic GVHD involving the skin, oral mucosa and liver maintained on prednisone and cellcept, presenting with L leg pain and 3-6% blasts on peripheral smear. . Pt called clinic yesterday night ([**2195-1-12**]) complaining of acute left leg/knee/foot pain without any joint swelling, fevers, weakness,or trauma. Pt is able to walk and is denying any weakness or bowel/bladder incontinence. Pt has chronic GVHD as above and mild numbness of the left leg though this is not worse. Developed back pain 4 days ago which resolved with tylenol. Pt was seen in clinic yesterday AM and was advised to increase her prednisone to 40mg and stop Cellcept with plans to undergo repeat BM bx tomorrow ([**1-14**]) given the rise in peripheral blasts, 6%, and worsening anemia (Hct 30.4). She was advised patient to go to local ER in [**Location (un) **] Valley, as [**Hospital1 18**] is 1 hour away, and had an ultrasound performed of her leg which was negative for DVT. This morning, she came into clinic with [**10-14**] pain in her leg, and she was given Dilaudid 2mg IV and Solumedrol 100mg IV this AM and then admitted for pain control and preparation for BMBx tomorrow ([**1-14**]). . Currently, patient in mild ([**3-14**]) pain in L distal thigh, no worse with movement than at rest. No back pain, chest pain, shortness of breath, fevers, chills, night sweats, diarrhea, or worsening skin rash. She notes stable to improving rash on back as well as stable to improving ulcers in the back of her throat. No odynophagia. . Past Medical History: Onc History: *[**9-/2193**]- Developed progressive lethargy -> elevated WBC count -> BMBx -> diagnosis of M5b AML. Underwent 7+3 (with mitoxantrone) -> followed by 3 cycles of AraC consolidation. *Admitted [**2194-1-24**] for allogeneic transplant from brother with cytoxan and TBI. Hospital course complicated by diarrhea thought [**2-6**] GVHD of gut and intubation/transfer to unit for hypoxia of unknown etiology. ICU course required pressors, complicated by renal failure on temp HD, shock liver, ?TTP with plasmapharesis, multiple small cortical infarcts in watershed pattern, seizures requiring phenobarb to control- all of unknown etiology; thought [**2-6**] SIRS with multi-organ failure. Discharged [**2194-4-3**] in stable condition. *[**2194-6-26**]- Neuro f/u with no evidence of residual symptoms from stroke or epilepsy- tapered off AED. *[**2194-8-19**]- developed back/abdomen rash c/w GVHD of skin, started on pred 20 *[**2194-9-9**]- developed oral ulcers c/w GVHD of oral mucosa, started on Famvir *[**2194-10-2**]- elevated LFT's c/w GVHD of liver *[**2194-11-11**]- increased Cellcept to 250 tid for persistent elevated LFTs . PMHx: 1. Cholecystectomy: during induction chemotherapy 2. Wisdom teeth extraction x 2 ([**1-10**]) . Social History: She notes exposure to a number of chemicals including organic solvents and possibly benzene. She did have a history of a one to two pack a day cigarette smoking for approximately 10 years, and she stopped smoking 10 years ago. She drinks alcohol socially. Married with 2 adult children Family History: Mother: [**Name (NI) **] Ca Father: heart disease - she believes both of her parents died from clots. Physical Exam: T: Afebrile Pulse Ox: 98% RA P: 64 BP: 120/76 RR:18 Gen: Middle aged woman in NAD HEENT: posterior oropharynx and tonsils with non-exudative shallow ulcers bilaterally. MMM, EOMI, PERRL CV: +s1+S2 RRR No M/R/G Resp: Bibasilar dry crackles Back: Hyperpigmented macular rash diffusely over back, no raised lesions Abd: Soft, NT ND Ext: No pretibial edema Neuro: CN 2-12 grossly intact, speech appropriate, strength 5/5 in BLE. Gait deferred. . Pertinent Results: Admission labs: 138 101 20 --------------< 117 4.3 28 0.9 Ca: 9.4 Mg: 2.6 P: 3.1 . 10.4 4.6 >----< 107 30.4 . [**2195-1-15**]- CXR: IMPRESSION: New small right pleural effusion and adjacent subtle peripheral right lower lobe opacity. The latter may be due to an early focus of pneumonia given the history of fever. . [**2195-2-3**]- CXR: A right internal jugular central venous catheter, endotracheal tubes, and Dobbhoff catheters are in unchanged position. Allowing for slight differences in technique, there no change in the appearance of interstitial and alveolar opacities in bilateral lungs, consistent with ARDS. . [**2195-1-16**]- Echo: IMPRESSION: Normal biventricular systolic function. . [**2195-1-14**]- BMBx: Relapsed acute myelogenous leukemia with monocytic differentiation (FAB AML-M5a). . Micro: [**2195-1-29**] blood cx: ENTEROCOCCUS FAECIUM | AMPICILLIN------------ =>32 R DAPTOMYCIN------------ S LINEZOLID------------- 1 S PENICILLIN------------ =>64 R VANCOMYCIN------------ =>32 R Brief Hospital Course: 49 yo female with AML s/p MRD allogeneic transplant 1 year prior to admission (complicated by chronic GVHD involving the skin, oral mucosa and liver- maintained on prednisone and cellcept), presented with leg pain and 6% blasts on peripheral smear. A bone marrow biopsy was done showing relapse of AML and she was treated with MEC, after which she was transferred to the ICU for hypoxic respiratory distress. She was intubated for worsening hypoxemia and increasing work of breathing. Chest imaging was c/w infection as well as ARDS. She grew out VRE in blood cultures. She also remained pancytopenic so was treated with broad spectrum antibiotics and antifungals, including daptomycin, ampho, azithro, atovoquone, and meropenem. She was difficult to ventilate so was switched to a kinetic bed for lung recruitment. We increased her PEEP and decreased her tital volumes but were unable to provide adequate oxygenation. She also was intermittently hypotensive and required frequent fluid boluses. The patient did not have improvement in her oxygenation or ventilation despite aggressive measures. In the setting of her pancytopenia, GVHD, sepsis, and respiratory failure, the primary heme/onc attending, ICU team, and family met on [**2195-2-4**] to discuss goals of care and prognosis. It was determined that she was in an incurable stage of her disease and the family decided to change the goals of care to focus on no escalation of care (no pressors, no IV fluids, no resuscitation). Over the course of that evening, the patient became increasingly hypoxemic and had a drop in her blood pressure. The family requested that the ventilator be removed and the patient expired at 8:32pm on [**2195-2-4**]. The husband and family requested a post-mortem. Medications on Admission: Cellcept 500mg [**Hospital1 **] Prednisone 10mg qd Lasix 20mg qd Famvir 500mg [**Hospital1 **] Folic Acid 1mg qd Mepron (Atovaquone) 750mg [**Hospital1 **] Nizorel 1% shampoo daily Discharge Medications: none Discharge Disposition: Expired Discharge Diagnosis: Primary Diagnosis: AML Respiratory Failure ARDS GVHD Discharge Condition: expired Discharge Instructions: none Followup Instructions: none

[ "782.1", "729.5", "338.3", "995.92", "038.0", "571.8", "996.85", "V58.65", "E933.1", "528.00", "518.84", "205.00", "284.8" ]

icd9cm

[ [ [] ] ]

[ "96.6", "41.31", "38.93", "99.25", "33.24", "99.05", "96.04", "00.17", "99.15", "99.04", "96.72", "38.91" ]

icd9pcs

[ [ [] ] ]

7299, 7308

5270, 7038

336, 384

7405, 7415

4185, 4185

7468, 7476

3603, 3707

7270, 7276

7329, 7329

7064, 7247

7439, 7445

3722, 4166

275, 298

412, 2007

4201, 5247

7348, 7384

2029, 3282

3298, 3587

55,921

192,708

33078

Discharge summary

report

Admission Date: [**2178-4-1**] Discharge Date: [**2178-4-8**] Date of Birth: [**2136-1-30**] Sex: F Service: MEDICINE Allergies: Atripla / Morphine Attending:[**First Name3 (LF) 949**] Chief Complaint: Pleural effusion Major Surgical or Invasive Procedure: Thoracentesis Blood Transfusions Central Line Placement Pigtail Catheter Placement History of Present Illness: This is a 42 year-old woman with history of HIV, Hepatitis C cirrhosis on the transplant list presenting from clinic with right pleural effusion. She was recently admitted ([**Date range (1) 76893**]) for right pleural effusion and 1.2L were removed. It was consistent with a transudate and no malignant cells were seen. ECHO showed EF >55% and no liver lesions seen on MRI. The effusion was thought to be a sympathetic effusion from ascites. The patient did not receive a paracentesis at that time. She states that in the interim her breathing improved and she was comfortable. However, 1-2 weeks prior to admission she began to become short of breath. She went to her physican in [**Hospital1 789**] and a CXR was performed. The was not a large effusion present on that CXR. However, she continued to worsen and states that over the weekend her breathing worsened further. She is unable to sleep because she needs to sleep propped up due to SOB when supine. She also reports increasing lower ext edema and increase in her abdominal girth. She denied any abdominal pain, N/V/D/F/C. She does report a cough with clear sputum. She returned to her doctor [**First Name (Titles) **] [**Last Name (Titles) 789**] and repeat CXR showed a "large" effusion. She saw Dr. [**Last Name (STitle) 497**] in clinic today and was admitted directly for further management. . Review of sytems otherwise unremarkable. She denies urinary symptoms. She denies changes in bowel habits, denies melenotic stools or hematochezia. Past Medical History: 1. HIV (CD4 670, vL ND [**1-/2178**]) - diagnosed in [**2157**], presumed from IVDU versus sexual transmission from husband, who was long-term IV drug user - started ART 1 year ago d/t elevated vL, low CD4 in setting of acute illness, per patient not diagnosed with OI 2. Hepatitis C cirrhosis (HepC vL 1,090,000 [**3-/2177**]) - diagnosed in [**2176**] - on transplant list - complicated by ascites, encephalopathy, grade 1 varices - history of elevated AFP without focal liver lesions 3. History of necrotizing fascitis [**2163**] Social History: The patient lives with her mother and does not work due to diability. She very occasionally used to smoke tobacco and last smoked two years ago. The patient reported that she stopped consuming alcohol two years ago and prior to that only consumed very occasionally. History of other substance use includes IVDU (stopped [**2156**]), cocaine and mushrooms, no current use. Family History: Her mother is currently alive and doing well but suffers from high blood pressure. The patient's father reportedly died in [**2173**] from Parkinson's disease. Physical Exam: Admission: VS: T 97, BP 114/76, HR 92, RR 18, 98% RA GEN: middle-aged women, generally well appearing with appropriate affect and behavior, who is lying in bed and speaking comfortable in no apparent distress, not dyspenic or tachypneic HEENT: moist mucous membranes NECK: supple, no JVD, no LAD CV: S1&S2 RRR, 2/6 SEM CHEST: decreased breath sounds on the right to [**Date range (1) 55744**] up the lung field with dullness to percussion in the same region. No R/W. Good breath sounds on the left ABD: soft, slightly distended; non-tender, +BS, no rebound no gaurding EXT: +1 pitting edema; feet warm and well-perfused with 2+ DP pulses Pertinent Results: [**2178-4-1**] 03:35PM BLOOD WBC-8.1 RBC-3.01* Hgb-10.2* Hct-31.6* MCV-105* MCH-34.0* MCHC-32.3 RDW-17.9* Plt Ct-100* [**2178-4-1**] 03:35PM BLOOD PT-24.3* PTT-44.0* INR(PT)-2.4* [**2178-4-1**] 03:35PM BLOOD Glucose-89 UreaN-10 Creat-0.9 Na-129* K-3.3 Cl-98 HCO3-25 AnGap-9 [**2178-4-1**] 03:35PM BLOOD ALT-95* AST-189* LD(LDH)-328* AlkPhos-341* TotBili-7.4* [**2178-4-1**] 03:35PM BLOOD Albumin-2.4* Calcium-7.8* Phos-2.6* Mg-1.8 [**2178-4-7**] 06:00AM BLOOD calTIBC-267 Ferritn-258* TRF-205 Iron-75 [**2178-4-8**] 05:55AM BLOOD WBC-6.4 RBC-2.85* Hgb-9.4* Hct-28.8* MCV-101* MCH-33.0* MCHC-32.6 RDW-21.3* Plt Ct-84* [**2178-4-8**] 05:55AM BLOOD PT-20.7* PTT-36.2* INR(PT)-2.0* [**2178-4-8**] 05:55AM BLOOD Glucose-66* UreaN-14 Creat-1.0 Na-136 K-4.3 Cl-99 HCO3-30 AnGap-11 [**2178-4-8**] 05:55AM BLOOD ALT-65* AST-119* LD(LDH)-256* AlkPhos-197* TotBili-6.7* [**2178-4-7**] 06:00AM BLOOD Albumin-3.0* Calcium-8.7 Phos-1.8* Mg-1.8 [**2178-4-4**] 12:44PM URINE Osmolal-325 [**2178-4-4**] 12:44PM URINE Hours-RANDOM Creat-23 Na-87 [**2178-4-4**] 12:49PM PLEURAL WBC-5222* Hct,Fl-22* Polys-63* Lymphs-20* Monos-17* [**2178-4-2**] 06:00PM PLEURAL WBC-420* RBC-780* Polys-2* Lymphs-47* Monos-21* Meso-9* Macro-21* [**2178-4-4**] 12:49PM PLEURAL Glucose-77 LD(LDH)-310 Albumin-1.7 [**2178-4-2**] 06:00PM PLEURAL TotProt-0.5 LD(LDH)-83 Albumin-LESS THAN [**2178-4-2**] 6:00 pm PLEURAL FLUID **FINAL REPORT [**2178-4-8**]** GRAM STAIN (Final [**2178-4-2**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2178-4-5**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2178-4-8**]): NO GROWTH. Cytology Pleural Fluid: NEGATIVE FOR MALIGNANT CELLS. CXR: [**4-1**] IMPRESSION: Large right pleural effusion, increased in size since prior study. CXR: [**4-2**] IMPRESSION: AP chest compared to [**2-4**] and [**4-1**]: Right lung base is still elevated but there has been a substantial decrease in the volume of right pleural effusion. How much subpulmonic effusion persists is difficult to say, and might be detectable by decubitus views. Substantial right lower lobe atelectasis persists, though improved. Left lung is clear, heart size normal. No appreciable pneumothorax. CXR: [**4-2**] IMPRESSION: AP chest compared to [**4-2**] at 6:31 p.m. Elevation of the right lung base due in part to subpulmonic pleural effusion has worsened, and volume of right pleural fluid layering posteriorly and collecting in fissures has increased. Severe atelectasis in the right middle and lower lobe persists. Left lung is clear, but mediastinum remains shifted to the left. No pneumothorax. CT [**4-3**] IMPRESSION: 1. Large right pleural effusion. No evidence of acute hemothorax. 2. Complete right lower lobe and partial right middle lobe collapse likely secondary to the adjacent large right pleural effusion. 3. 6-mm peribronchovascular nodule in the superior segment of the left lower lobe which is new compared to the prior study and is most likely infectious or inflammatory in etiology. However, a small iatrogenic vascular malformation cannot be excluded (e.g., if the patient has undergone Swan Ganz catheter placement) and a followup contrast enhance CT is recommended in three months to ensure resolution or to further characterize if persistent. 4. Stable 2-mm right upper lobe nodule. 5. Stable compression fracture, of T10 vertebral body, unchanged since chest x-ray of [**2178-1-18**]. CXR [**4-4**] The right internal jugular line tip is at the level of mid SVC. The upper portion is kinked but it's most likely external but should be evaluated clinically. There is no change in the right pigtail catheter. There is no change in the position of the right hemidiaphragm and the degree of aeration of the right lung base. The left basal atelectasis is new since [**2178-4-3**], chest radiograph but is not included in the field of view of the study obtained on [**2178-4-4**], at 4:24 p.m. No pneumothorax is present. Cardiomediastinal silhouette is unchanged and no failure is seen. CT Chest [**4-5**] IMPRESSION: 1. Significant decrease in right pleural effusion. Small to moderate right pleural effusion remains. There is new minimal pneumothorax on the right following pigtail catheter placement. 2. New atelectasis at the left lung base. 3. Moderate loss of aeration in the right lower lobe. This could be due to atelectasis or pneumonia. 4. Indeterminate nodule in the superior segment of the left lower lobe. This measures about 7 mm. Followup to resolution with repeat scan in three months is recommended. CXR [**4-7**] FINDINGS: In comparison with the study of [**4-6**], the pigtail catheter has been removed. No change in the appearance of the right pleural effusion and no evidence of pneumothorax. The mild opacification in the retrocardiac area has reduced since the previous study. Brief Hospital Course: 42 y.o. female with HIV, Hep C., on the transplant list, transferred to the ICU with hemothorax and dropping Hct as well as hypoxia. . # Hemothorax: The patient was found to have reaccumulation of her right pleural effusion over a 4 week period. A CXR on admission showed right effusion likely a sympathetic effusion secondary to ascites. The patient's INR was 2.2 and she recieved 4U of FFP and underwent thoracentesis at the bedside and 1.6L were removed [**4-2**]. The fluid was consistent with a transudate, cultures negative and cytology negative for malignant cells. During the night the patient became hypoxic requiring 2-3L NC and Hct drop to 22.8 from 27.2 . Repeat CXR showed reaccumulation of some fluid, but the patient remained stable and was able to be weaned to room air in the AM. The patient under CT scan of the chest that showed large right pleural effusion that was not consistent with hemothorax. The patient remained stable, but again became hypoxic on [**4-4**] requiring NRB and continued Hct drop to 17. A repeat diagnostic thorocentesis revealed bloddy fluid. The patient was transferred to the MICU and pigatail catheter was placed and drained via chest tube. The patient was also given 3 units PRBC, 5 units FFP, and 1 plt. The patient respiratory status improved, Hct remained stable and catheter stopped draining fluid. Repeat CT scan and CXRs showed continued small right pleural effusion. On [**4-5**] the patient came out of the ICU. Her pigatil catheter was clamped and then removed after CXR did not show reaccumulation. She recieved 1U FFP prior to removal and 1U FFP post-removal. Her Hct remained stable and respiratory status remained >95% on room air. She was continued on lasix 40mg and spironolactone 100mg daily. Her pain was controled with demerol and oxycodone. She was discharged on percocet. She will follow-up with her PCP. . # Acute Renal Failure: The patient's creatinine peaked at 1.5 in the setting of acute bleed. Her creatinine improved to 1.0 after blood products. . # Hepatitis C: Currently on the transplant list. She was continued on lactulose. P . # HIV. CD4 670, VL ND 03/[**2177**]. She was continued on Emtricitabine-Tenofovir, Raltegravir . #. Lung Nodule: CT-scan showed indeterminate nodule in the superior segment of the left lower lobe, measures about 7 mm. Followup to resolution with repeat scan in three months is recommended. # FEN: Low sodium . # Access: PIV . # PPx: Heparin SC . # Code: FULL Medications on Admission: Emtricitabine-Tenofovir [Truvada] 200 mg-300 mg QHS Raltegravir [Isentress] 400 mg [**Hospital1 **] Spironolactone 100 mg DAILY Lasix 60mg daily Lactulose 30 mL 2-3 times a day Clotrimazole 10 mg troche five times per day Calcium Carbonate-Vitamin D3 600 mg-400 unit [**Hospital1 **] Fe supplements Discharge Medications: 1. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). 2. Raltegravir 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 6. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane 5X A DAY (). 7. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Percocet 10-325 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain for 1 weeks: Do not drive while taking this medication. This medication can make you constipated. Disp:*25 Tablet(s)* Refills:*0* 9. Calcium 600 + D(3) 600-400 mg-unit Tablet Sig: One (1) Tablet PO twice a day. 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day: This is over the counter. It is recommended while you are taking percocet. . Discharge Disposition: Home Discharge Diagnosis: Right Pleural effusion Hemothorax Seconadry: HCV HIV Discharge Condition: stable, O2 sat >95% on room air, ambulationg, normotensive Discharge Instructions: It was a pleasure taking care of you while you were in the hospital. You were admitted to [**Hospital1 18**] because of fluid in your lungs. You underwent a procedure to remove fluid that was complicated by bleeding. You were in the ICU for low oxygentation, closer monitoring and given blood products. You had a catheter in your chest for drainage. It was pulled out and your respiratory status remained stable. You improved and are breathing well on room air. Please follow the medications prescribed below. Please follow up with the appointments below. Please call your PCP or go to the ED if you experience chest pain, palpitations, shortness of breath, nausea, vomiting, fevers, chills, or other concerning symptoms. Followup Instructions: You have an appointment with your PCP on [**4-20**] @ 11:30am PCP: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 76894**] [**Telephone/Fax (1) 76895**] It is recommended that you have a repeat CT-scan in 3months to re-evaluate a small lung nodule. Dr.[**Name (NI) 948**] office will contact you with an appointment time for next week. Completed by:[**2178-4-8**]

[ "998.11", "518.89", "584.9", "276.1", "511.9", "511.89", "285.1", "070.54", "571.5", "V08" ]

icd9cm

[ [ [] ] ]

[ "34.09", "99.04", "34.91", "38.93" ]

icd9pcs

[ [ [] ] ]

12575, 12581

8652, 11138

293, 378

12679, 12740

3712, 8629

13519, 13895

2877, 3038

11488, 12552

12602, 12658

11164, 11465

12764, 13496

3053, 3693

237, 255

406, 1915

1937, 2472

2488, 2861

59,076

167,800

15745

Discharge summary

report

Admission Date: [**2189-6-24**] Discharge Date: [**2189-6-29**] Date of Birth: [**2130-1-7**] Sex: F Service: NEUROSURGERY Allergies: Aspirin Attending:[**First Name3 (LF) 1835**] Chief Complaint: progressive Right sided hearing loss, right sided tinnitus Major Surgical or Invasive Procedure: Right suboccipital craniotomy for resection of vestibular schwannoma History of Present Illness: Patient presents to clinic in referral from Dr [**Last Name (STitle) **] in neurology. Patient complains of tinnitus in her rigth ear x 10 years which she can trace back to an event where she heard a loud popping sound. She also complains of recent progressive right sided hearing loss which on formal audiogram testing confirms as severe. She also reports that she has balance issues and difficutly with short term memory. MRI was obtained prior to the visit and shows a right sided CP angle lesion. She denies headaches, nausea, vomiting, dizziness, blurry vision, or difficulty hearing with her left ear. She presents for elective resection of CPA tumor. Past Medical History: Appendicitis, ectopic pregnancy Social History: Works as a CNA Family History: Denies family history of brain tumor Physical Exam: On Admission: Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERRL EOMs full without nystagmus 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. 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, 4mm to 3mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength intact and symmetric. Slightly decreased sensation on the upper right face in the V1 and V2 distribution. VIII: unable to hear out of right ear. 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 [**6-18**] throughout. No pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Toes downgoing bilaterally Coordination: normal on finger-nose-finger, rapid alternating movements, heel to shin On Discharge: CN VII defecit, Right Facial Droop with incomplete lid closure; House-Brackmann IV-V Stable decreased sensation in the Right V1-2 distributions. Other exam stable. Pertinent Results: MRI brain [**6-24**] - right cerebellopontine angle mass lesion with partial extension into the right internal auditory canal, likely consistent with a vestibular schwannoma, meningioma is a more remote consideration, no new lesions are identified. Fiducial markers are in place. CT brain [**6-24**] - Status post right suboccipital craniotomy. Expected postoperative changes in the posterior fossa. No postoperative hemorrhage. Extensive pneumocephalus is seen tracking throughout the sulci of the bilateral cerebral convexities MRI Brain [**6-25**] - 1. Status post resection of a large right cerebellopontine angle tumor, with a few enhancing nodules, largest measuring 5mm, within the cistern and in the right internal auditory canal possibly representing residual tumor. Continued followup to this region is recommended to assess for residual tumor and diff. from reactive changes and assess stability. A small focus of decreased diffusion is of uncertain etiology- ? small infarct/ blood products/tumor. Attention on close follow up with complete brain MRI study. 2. Post-right suboccipital craniotomy changes, including fluid within the right mastoid air cells and post-surgical soft tissue swelling and edema, all within expected post-procedure limits. Brief Hospital Course: Pt underwent elective resection of a right-sided cerebellopontine angle tumor under general anesthesia with facial nerve monitoring. Frozen pathology revealed schwannoma. Postoperatively she was transferred to the ICU for Q1 hour neuro checks and systolic blood pressure control less than 140. She was started on steroids, dexamethasone 4mg Q6hrs with a plan for a 1 week taper to off. Postop CT head showed post operative changes. Postoperatively, she had a right facial droop and as a result she remained on dexamethasone. She remained stable during her ICU course and was transferred to the floor. She had headaches, incisional pain, nausea and dizziness but improved with medications and conservative management. Her diet was advanced in routine fashion. She tolerated advances. She was evaluated by PT/OT and speech therapy during her course. She has CN VIII deficit on the right at baseline and new CN VII deficit on the right. Plastic surgery consult was called for patient's inability to close her right eye. They recommended nothing to do at this time as the patient was seeing small improvements daily in lid closure. They recommend reconsulting after several weeks if deficit persists. On [**6-29**] she was started on a dexamethasone taper over 1 week to off. At the time of discharge she is tolerating a dysphagia diet, ambulating with a cane or walker, afebrile with stable vital signs. Medications on Admission: buspar (unknown dose), naproxen (held 10 days prior to surgery), percocet PRN Discharge Medications: 1. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for PAin. 2. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for Constipation. 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for Pain or fever . 5. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 7. cyclobenzaprine 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day) as needed for spasm. 8. white petrolatum-mineral oil 56.8-42.5 % Ointment Sig: One (1) Appl Ophthalmic HS (at bedtime). 9. polyvinyl alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed) as needed for dryness: Right eye. 10. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 11. meclizine 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed for PRN Dizziness. 12. dexamethasone 1 mg Tablet Sig: Two (2) Tablet PO Daily () for 2 days: For 2 Days Start: After 2 mg Q 12 hrs tapered dose. Stop after 2mg daily. 13. dexamethasone 1 mg Tablet Sig: Two (2) Tablet PO 12 hrs () for 2 days: Duration: 2 Days Start: After 2 mg Q8 hrs tapered dose. Stop after 2mg daily . 14. dexamethasone 1 mg Tablet Sig: Two (2) Tablet PO 8 hrs () for 2 days: Duration: 2 Days Start: After 3 mg Q8hrs tapered dose. Stop after 2mg daily . 15. dexamethasone 0.5 mg Tablet Sig: Six (6) Tablet PO 8 hrs () for 2 days: Duration: 2 Days Start: After 4 mg tapered dose. Stop after 2mg daily. 16. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO 8 hrs () for 2 days: Duration: 2 Days Stop after 2mg daily. Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: Right Vestibular schwannoma RIGHT CRANIAL NERVE VIII DEFICIT RIGHT CRANIAL NERVE VII DEFICIT Right CN V / BRANCHES II AND III DEFICIT DYSPHAGIA 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 ?????? 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. 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 call ([**Telephone/Fax (1) 88**] to schedule an appointment with Dr. [**Last Name (STitle) **], to be seen in 4 weeks. ??????You will need an MRI of the brain with contrast Completed by:[**2189-6-29**]

[ "E878.8", "389.15", "386.12", "997.09", "388.30", "716.90", "951.4", "338.18", "225.1", "V12.71", "388.5" ]

icd9cm

[ [ [] ] ]

[ "02.39", "01.59" ]

icd9pcs

[ [ [] ] ]

7450, 7520

4083, 5498

330, 401

7708, 7708

2794, 4060

9446, 9698

1194, 1232

5626, 7427

7541, 7687

5524, 5603

7891, 9423

1247, 1247

2610, 2775

232, 292

429, 1089

1724, 2596

1261, 1472

7723, 7867

1111, 1145

1161, 1178

32,193

170,840

9449

Discharge summary

report

Admission Date: [**2166-3-27**] Discharge Date: [**2166-4-4**] Date of Birth: [**2096-5-8**] Sex: F Service: MEDICINE Allergies: Tetracycline Analogues / Atenolol / Tegaderm Attending:[**First Name3 (LF) 2387**] Chief Complaint: Nausea, vomiting, hypotension Major Surgical or Invasive Procedure: Left heart catheterization Central Line Placement Arterial Line Placement Hemodialysis History of Present Illness: 69 yo W with DM, ESRD on HD, CAD s/p multiple PCIs w/ most recent DES x2 to LCX, CHF w/EF 20-25%, COPD on 2L home O2, PVD (R foot [**First Name3 (LF) **]), OSA, Afib (not on coumadin [**2-6**] GIB) who presents w/ chills, malaise, fever and n/v. . Pt. was in USOH, until the day of evaluation at 3pm, when she developed a sensation of malaise, chills, sweats followed by nausea and vomiting while cooking dinner. Due to fatigue, she decided to lay down and hand an episode of emesis (non bilious, whitish colored). Her daughter noted that she looked diaphoretic and pale while laying in bed as well as c/o of "twingy" chest dyscomfort. Temp at home was 101.8 at which time EMS was called. Pt. denies any other preceeding sx, and infact was seen by her cardiologist earlier and told that she was doing well. She denies fevers, cough, worsening SOB/DOE, PND or orthopnea. She did report intermittent substernal discomfort, similar to her prior admission (see below). She notes some sacral pain at area of her prior cyst. Also notes that her right foot [**Month/Day (2) **] has not been healing and reports having had an injection of "stem cells" into the [**Month/Day (2) **] by her podiatrist. No dysuria, loose bms, arthralgias or myalgias. Notes intermittent HA w/o photophobia. Reports neck discomfort, unchanged from prior. No sick contacts. Of note, pt. was admitted last [**2082-1-27**] to [**Hospital1 1516**] for CP, w/ lateral STd and flat CEs, s/p cath w/ LCX occlusion, s/p DESx2 for instent-restenosis, right ischemic foot [**Hospital1 **] consistent w/ chronic osteomyelitis (RLE angiogram w/ poor perfusion but no distal targets and given poor BF surgical intervention was not felt feasible. While in EMS, pt. was given zofran and Nitro spray. Initial VS in ED were 102.5F 122 170/80 20 100% 12L. Pt. was felt to be tachypneic w/ increased WOB and somewhat confused. Labs were notable for WBC of 14K w/ left shifts and 4 bands, BNP 8K (prior 62K), Trop of 0.16, Cr 3.7 and lactate of 1.8. ECG showed STd I, V5-6, and in II, aVF along w/ STe V1-2. ED team d/w cardiology who felt this was demand ischemia in setting of increased demand. She received Zofran/Reglan IV, Acetaminophen 650mg, ASA 300PR and 750mg IV Levofloxacin as well as 1L NS. Although her HR decreased to 110s, SBP was in 90s and she was admitted to MICU for hypotension. VS on transfer were 110 92/41 23 97% 4L. . On arrival to the MICU, pt. appeared somewhat somnolent, but easily arousable and appropriately responsive. C/o some discomfort in her sacrum that is unchanged over the past month. Per daughter, her mother appears much improved in terms of color and alertness. Past Medical History: - CAD s/p 4V CABG '[**51**] (LIMA to LAD, SVG to diag, SVG to Cx, SVG to RCA), DES x3 to OM1 ([**2164-8-11**]), BMS to OM1 ([**2164-5-1**]), BMS x3 to LCX/OM ([**1-/2165**]) and DESx2 to LCX [**1-16**]. - TIA `97 or `98 - paroxysmal afib/flutter s/p multiple cardioversions '[**55**]/'[**56**]; d/c'd coumadin ~4yrs ago [**2-6**] GIB - ESRD - COPD on 3L home O2 (non compliant) - Morbid obesity - Hypertension - Hyperlipidemia - PVD s/p angioplasty of anterior tibial artery ([**9-12**]), s/p angioplasty of right dorsal pedis ([**11-12**]) - s/p L5 amp & [**4-10**] metatarsal head resections - GIB from PUD ~4 yrs ago - OSA - Chronic anemia (baseline ~ 32) - C. diff colitis, toxin positive, in the absence of diarrhea - Hypothyroidism - Asthmatic bronchitis - Sciatica - Vertigo - MRSA hx - should PRESERVE HER LEFT ARM for future fistula placement Social History: Lives in [**Location 86**], at home with her son, [**Name (NI) **]. She uses a wheelchair at baseline and is on 2 liters O2. She formerly worked as a homemaker and in meat wrapping. -Tobacco history: quit smoking 30 years ago, smoked 2.5 ppd x 25yrs -ETOH: no current alcohol use, none in past that she reports -Illicit drugs: denies Family History: Mother died of breast cancer at age 60; sister died at 60 of glioblastoma; father died of lung cancer at 73; and sister died at 60 of heart disease; son died at [**Hospital1 18**], diabetic, of massive MI in [**2160**] Physical Exam: Admission physical exam: General: Awakens easily to voice, obese, fatigued and slightly diaphoretic. HEENT: Sclera anicteric, pale, dMM, oropharynx clear Neck: supple, head wag test negative, JVP 8, no LAD, tunneled line is NTTP. CV: Regular rate, normal S1 + S2, [**2-10**] SM best at 2LICS w/o radiation no gallops Lungs: Crackles b/l at bases, no wheezing or rhnonchi Abdomen: obese, soft, non-tender, non-distended, bowel sounds present GU: no foley Ext: warm, 1+ edema b/l, well perfused, diminished PT pulses b/l, L > R, no clubbing. There is a sacral cyst 8x6cm, erythematous, TTP. R foot wrapped w/ gauze. Neuro: Awakens easily to voice, follows appendicular and axial commands. Oriented to location, person, month, year, not day. DOWb intact, MOYb over 45 secs w/ one error. Intact repetition, naming and writing. CNs: VFF, EOMI, no nystagmus, symmetric face, palate elevates symmetrically, tongue is midline. Normal tone, no pronator drift. UEs [**Last Name (LF) 23490**], [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 32190**]. Deferred gait. DISCHARGE EXAM: VSS, SBP 100-110, O2 sats 100% on 2L NC Gen: AOx3, in good spirits, NAD Heart: Irregularly irregular, normal S1, loud S2, 2/6 systolic murmur at apex with radiation to axilla, difficult to assess JVD based on obesity Lungs: CTAB, no wheezes, crackles, rhonchi Abd: obese, soft, NT, ND Ext: chronic stasis changes, 1+ edema BL, R foot wrapped with Aquofor, large sacral cyst Pertinent Results: Admission labs: [**2166-3-27**] 08:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-2* PH-5.0 LEUK-MOD [**2166-3-27**] 08:15PM URINE HYALINE-72* [**2166-3-27**] 08:15PM WBC-14.8*# RBC-4.33 HGB-12.7 HCT-41.3 MCV-95 MCH-29.4 MCHC-30.8* RDW-16.1* [**2166-3-27**] 08:15PM NEUTS-80* BANDS-4 LYMPHS-8* MONOS-6 EOS-1 BASOS-1 ATYPS-0 METAS-0 MYELOS-0 [**2166-3-27**] 08:15PM PT-11.7 PTT-31.9 INR(PT)-1.1 [**2166-3-27**] 08:15PM ALBUMIN-4.0 [**2166-3-27**] 08:15PM ALT(SGPT)-25 AST(SGOT)-35 ALK PHOS-159* TOT BILI-0.3 [**2166-3-27**] 08:15PM cTropnT-0.16* [**2166-3-27**] 08:15PM GLUCOSE-158* UREA N-25* CREAT-3.7* SODIUM-135 POTASSIUM-4.9 CHLORIDE-96 TOTAL CO2-30 ANION GAP-14 [**2166-3-27**] 08:21PM LACTATE-1.8 . Cardiac labs: [**2166-4-2**] 05:18AM BLOOD CK-MB-3 cTropnT-2.49* [**2166-4-1**] 04:06AM BLOOD CK-MB-4 cTropnT-2.16* [**2166-3-31**] 02:17PM BLOOD CK-MB-4 cTropnT-2.11* [**2166-3-31**] 03:29AM BLOOD CK-MB-5 cTropnT-2.31* [**2166-3-30**] 02:44PM BLOOD CK-MB-5 cTropnT-2.16* [**2166-3-30**] 05:13AM BLOOD CK-MB-6 cTropnT-2.06* [**2166-3-29**] 10:30PM BLOOD CK-MB-7 cTropnT-1.69* [**2166-3-29**] 03:30PM BLOOD CK-MB-9 cTropnT-1.61* [**2166-3-29**] 03:57AM BLOOD CK-MB-16* MB Indx-10.7* cTropnT-1.61* [**2166-3-28**] 10:20PM BLOOD CK-MB-21* MB Indx-10.6* cTropnT-1.68* [**2166-3-28**] 01:28PM BLOOD CK-MB-25* MB Indx-9.4* cTropnT-1.35* [**2166-3-28**] 05:01AM BLOOD CK-MB-16* MB Indx-10.5* cTropnT-0.54* [**2166-3-27**] 08:15PM BLOOD cTropnT-0.16* [**2166-3-27**] 08:15PM BLOOD proBNP-8330* . [**2166-3-27**] CXR: CONCLUSION: Loculated fluid right base and chronic fluid in left base. There is probably a small amount of increased fluid over the prior radiograph. There is cardiomegaly and unusually orientated sternal wires probably reflecting sternal dehiscence. . [**2166-3-30**] CXR: FINDINGS: In comparison with the study of [**3-29**], the monitoring and support devices remain in place. Continued substantial enlargement of the cardiac silhouette with bilateral pleural effusions, compressive basilar atelectasis, and moderate pulmonary edema. . Cardiac catheterization [**2166-3-30**]: FINAL DIAGNOSIS: 1. Severe native three vessel coronary artery disease. 2. Patent LIMA to LAD and SVG to OM2. 3. New total occlusion of SVG to RCA. 4. Successful POBA of OM1 with a 2.0 x 12 mm balloon. 5. Successful RFA AngioSeal. 6. Admit to the CCU with medical management. . [**3-27**] Echocardiography: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is top normal/borderline dilated. There is severe regional left ventricular systolic dysfunction with near-akinesis of the septum and anterior wall. There is milder hypokinesis of the remaining segments (LVEF = 25-30%). No masses or thrombi are seen in the left ventricle. The right ventricular cavity is moderately dilated with mild global free wall hypokinesis. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets are moderately thickened. There is at least mild aortic valve stenosis (valve area 1.2-1.9cm2). Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Moderate (2+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . IMPRESSION: Mildly hypertrophied and borderline dilated left ventricle with severe regional and global systolic dysfunction. At least mild aortic stenosis. Moderate mitral regurgitation. Moderate pulmonary hypertension. . Compared with the limited prior study (images reviewed) of [**2165-9-10**], the findings are similar. =============================== EKG [**4-1**]: Sinus rhythm. Compared to the previous tracing cardiac rhythm is now sinus mechanism. TRACING #3 =========================== DISCHARGE LABS [**2166-4-4**] 06:21AM BLOOD WBC-6.2 RBC-3.49* Hgb-10.7* Hct-33.9* MCV-97 MCH-30.6 MCHC-31.4 RDW-16.2* Plt Ct-133* [**2166-3-31**] 03:29AM BLOOD PT-13.3* PTT-29.1 INR(PT)-1.2* [**2166-4-4**] 06:21AM BLOOD Glucose-68* UreaN-25* Creat-4.6*# Na-133 K-4.0 Cl-93* HCO3-30 AnGap-14 [**2166-4-2**] 05:18AM BLOOD CK(CPK)-14* [**2166-4-4**] 06:21AM BLOOD Calcium-9.3 Phos-4.2 Mg-2.2 ============================= URINE CULTURE (Final [**2166-3-29**]): KLEBSIELLA OXYTOCA. 10,000-100,000 ORGANISMS/ML.. Piperacillin/tazobactam sensitivity testing available on request. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA OXYTOCA | AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- =>64 R CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 64 I TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: 69 yo W with DM, ESRD on HD, CAD s/p multiple PCIs w/ most recent DES x2 to LCX, CHF w/EF 20-25%, COPD on 2L home O2, PVD (R foot [**Month/Day/Year **]), OSA, Afib (not on coumadin [**2-6**] GIB) who presents w/ chills, malaise, fever and hypotension, found to have a UTI but also NSTEMI s/p cardiac cath and POBA of OM1. . 1. Hypotension: Likely multifactorial, but mostly cardiogenic shock and UTI, possible pneumonia. In setting of fever, n/v and malaise w/ leukocytosis and relative bandemia concerning for sepsis. The patient grew Klebsiella from her urine culture, but had negative blood cultures during her admission. She did not have physiology of cardiogenic shock, however, her EKG had demand changes and she had positive enzymes. The patient's hypotension resolved with continued supportive care. She will continue Levofloxacin 250mg Qday x 6 days for a total 14 day course. . 2. NSTEMI: The patient was initially free from chest pain, though her EKG was concerning for ischemia. Her cardiac enzymes suggested that she was indeed experiencing ischemia. Due to previous GI bleeds, heparin could not be started on patient. As patient became more stable, she had an episode of chest pain, which resulted in cardiac catheterization that showed severe native three vessel coronary artery disease, patent LIMA to LAD and SVG to OM2, and a new total occlusion of SVG to RCA. The patient received successful POBA of OM1 with a 2.0 x 12 mm balloon and successful RFA AngioSeal. She was discharged on Plavix, Aspirin, Metoprolol, Statin, and Nitroglycerin PRN. . 3. Acute Systolic Heart Failure Exacerbation: Pulmonary congestion worsened during early MICU stay, but was able to remove fluid via ultrafiltration. The patient initially was unable to undergo a full dialysis schedule due to hypotension, but she then underwent 3 consecutive successful sessions with improvement in her weight and subjective dyspnea. She was able to be discharged on her home O2 requirement. She was discharged on low dose metoprolol, aspirin, and statin. She does not tolerate an ACEI. 4.. RLE [**Month/Day (2) **] with dx of chronic osteo: Arterial by description from prior podiatry notes. Unable to examine as pt. refusing at this time. PVD not amendable to intervention per pt. cardiologist. Podiatry evaluated patient, felt infection not likely and left wound care recommendations. . 5. ESRD, due to DM/HTN: Continued hemodialysis and sevelamer/nephrocaps. . 6. Atrial fibrillation: The patient was not on anticoagulation secondary to history of GI bleeds. During ICU stay, her atrial fibrillation was difficult to control due to holding metoprolol due to hypotension. As she stabilized, the patient's home metoprolol was returned and she received amiodarone in loading dose and continued at 400mg Qday. By discharge, the patient had good rate control. . 7. COPD: on home 2-3L, currently at baseline. No wheezing on exam. Continued albuterol and ipratropium. . 8. DM: Continued home NPH and SS. . 9. Hypothyroidism: Continued home levothyroxine. . TRANSITIONAL ISSUES: - The patient met with palliative care while she was here and there was some discussion about goals of care and possible hospice. The patient will continue to have this discussion with her family - The patient can have uptitration of many of her cardiac meds as needed, depending on her SBP. The patient can go up on her midodrine to TID as needed as well. Medications on Admission: -- albuterol/ipratropium 2 puffs daily -- amiodarone 200 mg daily -- atorvastatin 40 mg daily -- B complex-vitamin C-folic acid 1 mg -- bupropion HCl 150 mg ER daily -- clopidogrel 75 mg daily -- folic acid 400mcg -- fluticasone 50 mcg nasa daily -- gabapentin 300 mg daily -- levothyroxine 100 mcg daily -- isosorbide mononitrate 30 daily -- metoprolol tartrate 12.5 mg [**Hospital1 **] -- midodrine 10 mg [**Hospital1 **] -- sevelamer carbonate 1600 mg tid w/ meals -- torsemide 100 mg [**Hospital1 **] -- aspirin 325 mg daily -- docusate sodium 100 mg [**Hospital1 **] -- insulin NPH & regular human (70-30) (32) units am daily -- Flaxseed oil 1200mg daily -- NTG prn Discharge Medications: 1. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 2. bupropion HCl 150 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO QAM (once a day (in the morning)). 3. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. folic acid 400 mcg Tablet Sig: One (1) Tablet PO once a day. 5. fluticasone 50 mcg/actuation Spray, Suspension Sig: One (1) Spray Nasal once a day as needed for allergy symptoms. 6. levothyroxine 100 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. midodrine 10 mg Tablet Sig: One (1) Tablet PO twice a day. 8. sevelamer carbonate 800 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 9. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. insulin NPH & regular human 100 unit/mL (70-30) Insulin Pen Sig: Thirty Two (32) units Subcutaneous once a day. 11. levofloxacin 250 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 6 days. Disp:*6 Tablet(s)* Refills:*0* 12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN as needed for chest pain. 14. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. 15. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily) as needed for constipation. 16. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. amiodarone 400 mg Tablet Sig: One (1) Tablet PO once a day. 18. metoprolol tartrate 25 mg Tablet Sig: 0.25 Tablet PO BID (2 times a day). 19. gabapentin 300 mg Capsule Sig: One (1) Capsule PO once a day. 20. Combivent 18-103 mcg/actuation Aerosol Sig: 1-2 puffs Inhalation every 4-6 hours as needed for shortness of breath or wheezing. Discharge Disposition: Home With Service Facility: [**Hospital **] Home Health Care Discharge Diagnosis: NSTEMI UTI Acute Systolic Heart Failure Exacerbation COPD DM2 Cardiogenic Shock 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 because you had fever, chills, and fatigue at home. In the ED, you had low BP and signs of infection, so they stabilized you in the ICU before you were transfered to the cardiology service. While you were in the ICU, you had chest pain and positive cardiac enzymes and we found during a catheterization that you had a blockage of one of your coronary vessels, however, no intervention was undertaken. We continued to get fluid off with dialysis, which was initially limited due to hypotension. Your hypotension resolved, and we were able to get you on your heart failure medications and perform multiple dialysis to get the extra fluid off. We treated you for a UTI. Our podiatry colleagues evaluated your foot [**Hospital **] and would like to follow up with you as an outpatient. Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. MEDICATION CHANGES: Stop Isosrbide mononitrate Stop Torsemide Increase Lipitor from 40mg to 80mg once a day Increase Amiodarone from 200mg to 400mg once a day Decrease Metoprolol from 12.5mg to 6.25mg twice a day Start Levofloxacin 250mg once day for 6 days Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] J. Location: [**Hospital **] MEDICAL ASSOCIATES Address: [**Location (un) **], [**Street Address(1) 4323**],[**Numeric Identifier 4325**] Phone: [**Telephone/Fax (1) 5457**] Appointment: Friday [**2166-4-11**] 9:15am Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Doctor Last Name **] BLDG, [**Apartment Address(1) 17383**] Address: [**Last Name (NamePattern1) 8541**], [**Location (un) **],[**Numeric Identifier 8542**] Phone: [**Telephone/Fax (1) 7960**] Appointment: Thursday [**2166-4-24**] 2:30pm Department: PODIATRY When: WEDNESDAY [**2166-4-16**] at 9:10 AM With: [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM [**Telephone/Fax (1) 543**] Building: Ba [**Hospital Unit Name 723**] ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage

[ "250.60", "412", "416.8", "V46.2", "272.4", "585.6", "V45.82", "038.9", "414.01", "785.59", "041.3", "V49.86", "414.02", "278.01", "287.5", "428.0", "276.1", "440.23", "327.23", "730.17", "995.92", "V58.67", "599.0", "410.71", "707.15", "V49.72", "V45.11", "427.31", "496", "244.9", "403.91", "428.23", "357.2" ]

icd9cm

[ [ [] ] ]

[ "88.57", "00.40", "39.95", "00.66" ]

icd9pcs

[ [ [] ] ]

17123, 17186

11164, 14204

333, 422

17310, 17310

6081, 6081

18682, 19709

4369, 4590

15305, 17100

17207, 17289

14609, 15282

8254, 11141

17493, 18400

4630, 5671

5687, 6062

14225, 14583

18420, 18659

264, 295

450, 3125

6097, 8237

17325, 17469

3147, 4002

4018, 4353

25,164

175,940

96

Discharge summary

report

Admission Date: [**2132-3-28**] Discharge Date: [**2132-4-9**] Date of Birth: [**2054-2-21**] Sex: M Service: ORTHOPAEDICS Allergies: Levaquin Attending:[**First Name8 (NamePattern2) 1103**] Chief Complaint: Hip and patellar fracture Major Surgical or Invasive Procedure: ORIF of right patella fx ORIF of right femoral neck fracture History of Present Illness: Briefly, Mr. [**Known lastname 1104**] is a 78 year old male with extensive medical history, who uses a RLE prosthesis for ambulation s/p R BKA from PVD, who presents s/p fall when his prosthesis slipped out of place, found to have R patellar and non-displaced fracture of the R femoral neck, here for possible orthopedic surgery. His medical problems notably include CAD s/p CABG in [**2117**], MI [**2123**], MIBI with fixed and reversible defects in [**2129**], CHF with EF 20%, PVD s/p R BKA with b/l iliac stents, AAA found to be 5.4 x 5.0 cm on recent abdominal US, paroxysmal atrial fibrillation, bovine AVR, and CRI, on coumadin for his iliac stents and PAF. Patient reports that at baseline he is able to walk about 2 blocks, and activity is limited by SOB. He feels SOB getting out of bed in the morning. He is able to climb a flight of stairs without difficulty. He denies orthopnea or LE edema. No recent weight gain. Past Medical History: 1) CAD s/p CABG [**2117**], MI [**2123**] 2) AS s/p AVR [**2123**] (bovine) 3) PVD s/p R BKA and b/l iliac artery stents 4) Carotid stenosis s/p R CEA 5) h/o C. Diff 6) h/o MRSA 7) CHF class [**Last Name (LF) 1105**], [**First Name3 (LF) **] 30% 8) AAA 5 x 5.4 cm 9) S/P AICD 10) Hypercholesterolemia 11) CRI (baseline approx. 1.3) 12) PAF Social History: Lives at home alone, independent. Quite smoking 8 years ago but 50 pack year smoking hx. Family History: Non-contributory Physical Exam: 98.2, 68, 100/48, RR15, 98% on RA Gen: Cachectic appearing elderly male, resting comfortably in bed, appearing in pain with movement. Neck: No JVD. Cor: RR, normal rate, no m/r/g. Lungs: CTA b/l. Abd: NABS, soft, NT/ND Extr: No c/c/e. R BKA. Swollen, erythematous R knee, exquisitely tender. Trace PT on the L. Pertinent Results: [**3-28**] AP, LATERAL AND SUNRISE VIEWS OF THE PATELLA: No prior studies are available for comparison. There is a horizontal fracture through the patella with 1.2 cm of displacement of the fragments anteriorly. There is a small joint effusion. There are changes from prior BKA, and extensive [**Month/Year (2) 1106**] calcifications are present. IMPRESSION: Horizontal patellar fracture with 1.2 cm of displacement anteriorly. [**3-28**] PELVIS AND RIGHT HIP, THREE VIEWS: There is a transverse lucency through the femoral neck, which may represent a nondisplaced fracture. No other fractures or dislocations are identified. Degenerative changes of the SI and hip joints are noted. There is diffuse demineralization. Extensive [**Month/Year (2) 1106**] calcifications and iliac stents are noted. IMPRESSION: Transverse lucency through the femoral neck, which may represent a nondisplaced fracture. [**3-28**] CT PELVIS: There is a nondisplaced fracture of the proximal right femoral neck. No other fractures or dislocations are identified. There is diffuse osteopenia. There is a small amount of high attenuation fluid within the right hip joint space, which may represent a small amount of hemorrhage. Extensive [**Month/Year (2) 1106**] calcifications are seen as are bilateral iliac stents. Visualized portions of the pelvis are unremarkable. Soft tissue structures are within normal limits. IMPRESSION: Nondisplaced fracture of the right femoral neck. Brief Hospital Course: 78 year old male with extensive medical history, notably including CAD s/p CABG in [**2117**], MI [**2123**], MIBI with fixed and reversible defects in [**2129**], CHF with EF 20%, PVD s/p R BKA with b/l iliac stents, AAA found to be 5.4 x 5.0 cm on recent abdominal US, paroxysmal atrial fibrillation, who uses a RLE prosthesis for ambulation s/p R BKA, who presents s/p mechanical fall with R patellar and R femoral neck fractures, here for orthopedic surgery. 1) Ortho: Patient is high risk for surgery, however per ortho, surgery will not be extensive, could be completed in relatively short time frame, possibly under spinal anesthesia only. Awaiting cardiolgy consult for estimate of operative risk given recent MIBI with reversible defects in all territories, and cath with 3VD. Patient willing to accept 25-30% chance of operative mortality. [**Year (4 digits) **] has seen patient and says o.k. for surgery. Limiting factor may be INR, as still 2.9 with 5 mg Vitamin K. Another 5 mg given, but may need FFP/platelets, and given EF 30%, would likely need to be done under controlled setting in ICU in case of respiratory distress. [**Month (only) 116**] defer until tomorrow. Needs patellar surgery one way or another in order to ever be able to use prosthesis again. 2) AAA: Seen by [**Month (only) 1106**]. Will try to get CTA during hospitalization at some point, though not now in setting of worsened creatinine. [**Month (only) 116**] just be able to get abdominal US. Appreciate [**Month (only) 1106**] consult. Outpatient repair of AAA. 3) CHF: Class [**Last Name (LF) 1105**], [**First Name3 (LF) **] 20% in past, though 30% on most recent cath, currently dry on exam, therefore holding lasix. If patient doesn't go to surgery tonight, will order food and will likely order lasix then. Also will need lasix with any FFP/platelets. -Coumadin for goal INR [**1-10**] 4) PVD: Bilateral iliac stents, on coumadin, therefore once INR below 2, will have to start heparin drip. --recheck INR post second dose of vitamin K, if < 2.0, will start heparin, and d/c prior to surgery 5) A-fib: As above, holding coumadin. 6) CRI: Slightly above baseline. Holding ACE-I. 7) FEN: K borerline therefore holding ACE-I. No fluids. Will order food if pt. doesn't go to OR. 8) Code: Full. 9) PPx: Heparin drip then transfer to coumadin, senna, colace. Removed RIJ CVL and placed peripheral IV on [**2132-4-9**]. Hct 29.7 on discharge. Needs daily Hct and INR. Transfuse Hct<28 and keep INR [**1-10**]. Medications on Admission: Coumadin Lipitor 10 mg daily Lasix 20 mg alternating with 40 mg folate Toprol 25 mg daily Zestril 2.5 mg daily Tylenol PRN Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): Per slide scale. 5. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 6. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**12-9**] Sprays Nasal QID (4 times a day) as needed. 7. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 10. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Oxycodone HCl 5 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 13. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 14. Coumadin 5 mg Tablet Sig: One (1) Tablet PO once a day: Please adjust dose to keep INR 2.0-3.0. Tablet(s) Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] [**Hospital 1108**] Rehab Unit at [**Hospital6 1109**] - [**Location (un) 1110**] Discharge Diagnosis: Right Patella fracture Right femoral neck fracture Post-op anemia AAA CHF ARF DM PVD Discharge Condition: stable Discharge Instructions: Please cont with non-weight bearing left leg. Coumadin for anti-coagulation goal INR 2.0-3.0. Oral pain medication as needed. Please keep incision clean/dry. Please call/return if any fevers, increased discharg from incision, or trouble breathing. Please check Hct, coags on arrival. Check daily Hct. If Hct <28, then transfuse. Last Hct [**2132-4-8**] 29.7. Followup Instructions: Provider: [**Name10 (NameIs) 1111**],[**First Name7 (NamePattern1) 1112**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] SURGERY Where: [**Last Name (NamePattern4) **] SURGERY Date/Time:[**2132-8-4**] 11:00 Follow-up with Dr.[**First Name (STitle) **] 2weeks after discharge, please call this week for appt. [**Telephone/Fax (1) 1113**] Provider: [**Name10 (NameIs) 251**] [**Last Name (NamePattern4) 1114**], M.D. Where: [**Hospital6 29**] [**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2132-5-28**] 10:00

[ "584.9", "443.9", "427.31", "414.01", "820.8", "E878.4", "E888.9", "E878.8", "250.00", "V49.75", "428.0", "V42.2", "441.4", "996.4", "822.0" ]

icd9cm

[ [ [] ] ]

[ "79.36", "79.35" ]

icd9pcs

[ [ [] ] ]

7674, 7819

3675, 6203

308, 371

7948, 7956

2190, 3652

8364, 8910

1822, 1840

6376, 7651

7840, 7927

6229, 6353

7980, 8341

1855, 2171

243, 270

399, 1336

1358, 1699

1715, 1806

23,829

185,247

4852

Discharge summary

report

Admission Date: [**2175-7-7**] Discharge Date: [**2175-7-17**] Date of Birth: [**2105-3-31**] Sex: F Service: MEDICINE Allergies: Reglan / Bee Sting Kit Attending:[**First Name3 (LF) 1148**] Chief Complaint: Altered Mental Status Major Surgical or Invasive Procedure: None History of Present Illness: Pt is 70yo F w/ MMP including DM type II, HTN, and ESRD on HD, who presents with episode of mental status changes, hypotension, and hypoxia. Pt was dialyzed as per her usual routine today, then taken back home by EMS. Pt then reportedly had mental status changes and agitation, and was taken back to OSH ED, where she was found to have SBP in 60's and O2sat in 60's on RA. Pt was given 20mg etomidate, 10mg vecuronium and intubated for hypoxic resp failure. She was given Zosyn 3.375mg for ? diverticulits seen on CT abd. She reportedly was ruled out for PE at OSH, but this was a non-contrast CT. Prior to leaving OSH [**Name (NI) **], pt became hypertensive to the 200s and was started on a nitro gtt. She was then transferred to [**Hospital1 18**] ED for further management. In the [**Hospital1 18**] ED, VS were: T99.8, HR75, BP187/66, RR12, 100% on vent (AC650x12, PEEP5, fi02 100%). Pt was given Vanc 1g x1, 10mg IV decadron, and a right femoral line was placed. Past Medical History: Hypertension Type II DM ESRD on HD ([**1-26**] DM2) MWF LGIB s/p cauterization/capping in ([**2-27**]) CAD, s/p NSTEMI PVD s/p R fem-[**Doctor Last Name **] bypass ([**2172**]) & s/p R AKA; L bypass ([**2163**]) Hypothyroidism PAF Depression GERD s/p fistula ligation in the left arm after becasue of contracture h/o C.dif toxin B positivity Social History: Lives with her husband [**Name (NI) **] and her mother-in-law. Is usually in a wheelchair, but able to do many ADLs in wheelchair (does dishes, cleans herself). Family History: Non-contributory Physical Exam: Vitals: Gen: Sedated, not responsive to voice, moving ext spontaneously HEENT: Pupils reactive. Anicteric. Neck: No elev JVP Cardio: Regular, nml s1,s2. No murmurs. Resp: CTAB anteriorly. no c/w/r. Abd: Soft, NTND. +BS Ext: R AKA. Ext cold to touch, pulses not palpable; able to doppler R radial pulse. Neuro: Sedated, spont moving ext, not responsive to voice Pertinent Results: CTA chest prelim read: No PE; bilat large pleural effusions increased in size; bilateral consolidations at bases ? PNA vs atelectasis. ECG [**2175-7-7**]: Sinus rhythm. Consider left atrial abnormality. Extensive ST-T changes may be due to myocardial ischemia Since previous tracing, rate faster compared to the study of [**2175-6-7**] which showed: Sinus bradycardia. P-R interval prolongation. Early transition. Q-T interval prolongation with ST-T wave abnormalities. Since the previous tracing of [**2175-5-23**] the Q-T interval is longer with more prominent ST-T wave abnormalities. Clinical correlation is suggested. EKG: NSR 65. Nml axis. QTc 510. <1mm ST depressions in I,II,V5-V6 (V5-V6 new). No TWIs. [**2175-7-12**] 10:02PM URINE RBC-21-50* WBC-21-50* Bacteri-FEW Yeast-NONE Epi-0 TransE-0-2 [**2175-7-8**] 03:33AM BLOOD WBC-11.9*# RBC-2.60* Hgb-8.4* Hct-27.0* MCV-104* MCH-32.5* MCHC-31.3 RDW-20.8* Plt Ct-178 [**2175-7-17**] 08:30AM BLOOD WBC-5.4 RBC-3.02* Hgb-9.7* Hct-30.1* MCV-100* MCH-32.2* MCHC-32.3 RDW-23.4* Plt Ct-132* Brief Hospital Course: Pt is 70 yo female with multiple medical problems including DM type II, HTN, and ESRD on HD, who presented with episode of mental status changes, hypotension, and hypoxic resp failure. The patient was admitted to the MICU. Hypoxic resp failure: most likely due to pulm edema [**1-26**] fluid shifts s/p dialysis. Differential on admission included PE, PNA, and sepsis. The patient had CT-angiogram that was negative for pulmonary embolism, sputum cultures that only grew oral flora and no growth on any of her blood cultures. Of note the patient had ECG's during this admission that were consistent with prior ECGs without new findings and cardiac enzymes failed to show an elevation of her Ck or CKMB. The patient did have an elevation in her troponin, but this low level elevation was to be expected in a patient on chronic hemodialysis. It remained unclear what the etiology of her hypoxia was. Nevertheless, the patient's oxygen requirement resolved despite repleting fluids and subsequent chest x-rays demonstrated resolution of the patient's pulmonary congestion. Hypotension: The patient was hypotensive on arrival at [**Hospital1 18**] with SBPs in the 70s. Ddx includes overaggressive volume removal at HD, sepsis, MI. Pt with elevated lactate on admission to 2.7. Sepsis, though intitially treated empirically, and MI were ruled out based on negative blood cultures and reassuring cardiac enzymes/ECG as above. Volume repletion was sufficint to restore normal blood pressures. The patient never required pressers. She was given stress dose steroids based on an insufficient response to a cortisol stimulation test. Antihypertensives were intially held, but were restarted per her outpatient regimen by the time of discharge. The patient's altered mental status continued in the MICU and after transfer to the floor. It was characterized by a florid delerium that was notable for auto discontinuation of her NG tube and various IV lines. She was combative with examiners and would not respond to questions. In the MICU she required soft restraints on the upper extremities. On the floor she continued to behave erratically and a psychiatry consult was ordered. They suggested 7.5mg TID Haldol standing with 5-10mg Haldol PRN breakthrough. The patient was very pleasant by her second day ([**2175-7-13**]) on the floor and no longer required Haldol. She occaisionally recieved ambien for sleep. By the end of her hospitalization she was refusing her physical therapy and was threatening to leave AMA because of a persistent desire to go home. She refused discharge to rehab. She was convinced to stay from [**Date range (1) 20270**] to recieve physical therapy, even though she was medically clear to go home. She continued to scream at night and refuse physical therapy. She was ultimately discharged home with increased services even though she was advised that a rehabilitation facility would likely be in her best interest. On the [**2175-7-12**] a UTI was diagnosed - see labs above. Mrs. [**Known lastname 18995**] was put on a 7 day course of ciprofloxacin. She was discharged with two days left and a prescription for her antibiotics. Medications on Admission: Levothyroxine 125 mcg (1) Tablet PO DAILY Paroxetine HCl 20 mg (1) Tablet PO DAILY Aspirin 81 mg (1) Tablet, Chewable PO DAILY Folic Acid 1 mg (1) Tablet PO DAILY Amiodarone 200 mg (1) Tablet PO DAILY Atorvastatin 40 mg (1) Tablet PO DAILY Zinc Sulfate 220 mg (1) Capsule PO DAILY Lansoprazole 30 mg (1) Capsule PO DAILY Gabapentin 300 mg (1) Capsule PO QHD Calcium Acetate 1334 mg (2) Capsules PO TID W/MEALS Ascorbic Acid 500 mg (1) Tablet PO BID Acetaminophen 325 mg 1-2 Tablets PO Q4-6H PRN Epoetin Alfa 6000 Units QHD Docusate Sodium 100 mg (1) Capsule PO BID Senna 8.6 mg (1) Tablet PO BID PRN B Complex-Vitamin C-Folic Acid 1 mg (1) Cap PO DAILY Benzonatate 100 mg (1) Capsule PO TID Toprol XL 50 mg (1) tab PO DAILY Insulin NPH (30) Units SC QAM Discharge Medications: 1. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Paroxetine HCl 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 7. Zinc Sulfate 220 mg Capsule Sig: One (1) Capsule PO once a day. 8. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO QHD. 9. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. Calcium Acetate 667 mg Capsule Sig: Two (2) Capsule PO once a day. 11. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO twice a day. 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 13. Epoetin Alfa 2,000 unit/mL Solution Sig: Three (3) Injection QHD as needed. 14. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. Capsule(s) 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 16. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Capsule PO once a day. 17. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 days. Disp:*2 Tablet(s)* Refills:*0* 18. Benzonatate 100 mg Capsule Sig: One (1) Capsule PO three times a day. 19. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 20. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: 30units Subcutaneous QAM. Discharge Disposition: Home With Service Facility: [**Location (un) 2203**] VNA Discharge Diagnosis: Hypotension, hypoxia. Discharge Condition: Vital stigns are stable. Continent of bowel. Anuric. Tolerating PO nutrition. Discharge Instructions: Please take your medications as prescribed. Please follow up with your scheduled follow up appointments - note that you have a scheduled visit with a gastroenterologist. Please note that we highly recommend that you go to a rehabilitation facility to improve your strength and ability to move from bed to chair and back again. However, in light of your opting to go home, we have made arrangements for some home physical therapy. Please return to the hospital if you have any shortness of breath, severe light headedness, or chest pain. Followup Instructions: Provider: [**Name10 (NameIs) **] WEST,ROOM FIVE GI ROOMS Date/Time:[**2176-1-2**] 9:00 Provider: [**First Name11 (Name Pattern1) 2671**] [**Last Name (NamePattern4) 10485**], MD Phone:[**Telephone/Fax (1) 2986**] Date/Time:[**2176-1-2**] 9:00 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 20271**] [**Telephone/Fax (1) 20264**] Call to schedule appointment Completed by:[**2175-7-19**]

[ "250.00", "599.0", "427.31", "412", "518.81", "428.0", "585.6", "V49.76", "403.91", "244.9", "530.81" ]

icd9cm

[ [ [] ] ]

[ "96.04", "99.04", "38.93", "96.71", "39.95" ]

icd9pcs

[ [ [] ] ]

8996, 9055

3376, 6554

304, 310

9121, 9203

2300, 3353

9789, 10185

1877, 1895

7360, 8973

9076, 9100

6580, 7337

9227, 9766

1910, 2281

243, 266

338, 1316

1338, 1682

1698, 1861

4,641

144,190

18222+56920

Discharge summary

report+addendum

Admission Date: [**2189-2-14**] Discharge Date: [**2189-2-18**] Date of Birth: [**2137-4-17**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3984**] Chief Complaint: Diaphoresis with ventilator alarms. Major Surgical or Invasive Procedure: none History of Present Illness: 51 yo Spanish speaking quadraplegic male with ALS on a ventilator from rehab who was taken to the ED for ventilator alarms. He was noted to be diaphoretic. The patient reports that his shortness of breath started around the evening of the day before admission. He reports that he felt very air hungry and diaphoretic. He denies any increased secretion or a cough. He denies any fevers, chills or nightsweats. He also denies any CP, abdominal pain or dysuria. The patient answeres questions with yes or no by blinking with his eyes and further information is difficult to obtain. . In the ED, his VS: T 100.6 BP 123/70 HR 105 RR 14 98% He tolerated the ventilator in the ED without any problems on AC 600 x 14 with FiO2 0.6, 5 PEEP. Prelim CXR showed ventilator-associated pneumonia. EKG showed sinus tachycardia. He was given IVFs, Zosyn and Levofloxacin for VAP. He received a total of 2L of NS. . Currently, he continues to feel more uncomfortable on the ventilator and air hungry but it is already improved from prior. . ROS: negative for CP, abdominal pain, diarrhea, constipation, f/c/ns, weight loss, changes in the color of the urine or stool. Past Medical History: *ALS. Dx [**4-13**]. Home O2 requirement. *Quadraplegic. *Respiratory failure (FVC 40% predicted). *Hx L common femoral vein DVT [**5-15**]. *Hypertension. *Migraines. *Arthritis. *Actinic keratosis. Social History: No tobacco, etoh, drugs. Lives with family. Has 2 kids ages 5 and 10. Former custodian. Spanish is preferred language. Family History: *Mother: DM. *Father: MI at 70. Physical Exam: T 100.6 BP 123/70 HR 105 RR 14 98% GENERAL: NAD but reports respiratory discomfort HEENT: unable to open mouth due to spasm, pt unable to tolerate testing for pupillary reflex NECK: JVP low, trach collar in place, neck spastic CARDIAC: S1S2, no murmur/rub or gallop, regular rate rhythm LUNG: decreased and bronchial breath sounds in the L base ABDOMEN: tense (according to family at baseline), non tender, +BS EXT: +DP, no edema NEURO: quadriplegic, following commands, CN 2-7 intact, negative Kernig and Brudzinkis sign SKIN: no open wounds Pertinent Results: **LABS** [**2189-2-14**] 05:03PM BLOOD WBC-33.6*# RBC-4.76# Hgb-14.1# Hct-43.4# MCV-91 MCH-29.5 MCHC-32.4 RDW-13.5 Plt Ct-268# [**2189-2-14**] 05:03PM BLOOD Neuts-74* Bands-8* Lymphs-8* Monos-8 Eos-0 Baso-0 Atyps-2* Metas-0 Myelos-0 [**2189-2-14**] 05:03PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [**2189-2-14**] 05:03PM BLOOD Plt Smr-NORMAL Plt Ct-268# [**2189-2-14**] 05:03PM BLOOD Glucose-275* UreaN-27* Creat-0.5 Na-139 K-3.9 Cl-100 HCO3-25 AnGap-18 [**2189-2-15**] 04:04AM BLOOD Calcium-9.3 Phos-2.4* Mg-2.0 [**2189-2-14**] 09:36PM BLOOD Cortsol-31.4* [**2189-2-14**] 09:47PM BLOOD Type-ART Temp-38.0 pO2-183* pCO2-36 pH-7.46* calTCO2-26 Base XS-2 [**2189-2-14**] 05:06PM BLOOD Lactate-3.4* . **IMAGING** CXR [**2189-2-14**]: Left lower lobe collapse and associated small pleural effusion. Brief Hospital Course: # Sepsis: Most likely secondary to ventilator associated pneumonia seen on CXR. Elevated WBC with bandemia. UA negative. Treated initially with broad spectrum antibiotics: Vancomycin, Ceftazidime and Levofloxacin. Subsequently blood cultures positive [**3-13**] for Staph coag negative. Antibiotic coverage reduced to Vancomycin alone for 2 week course. Subsequent blood cultures negative. TTE negative for vegetations. Pt initially required fluid resuscitation but never required vasopressors. No more fluid resuscitation needed after 2L in ED and subsequent 2L on the floor. DFA and urine legionella and urine culture negative. Sputum culture with oropharyngeal flora. Blood cultures negative to date, final results still pending. Lactate initially elevated at 3.4, subsequently improved. [**Last Name (un) **] stim test adequate. . # Respiratory failure: due to to ventilator associated pneumonia and associated left lower lobe collapse. On baseline settings, absolute ventilator dependent due to ALS. Treatment of PNA and bactermia with Vancomycin as above. DFA and urine legionella negative. . # ALS: continued on Baclofen and Lorazepam . # Psychiatric: continued on Sertraline, Mirtazapine and Trazodone . # GLucose intolerance: started on insulin sliding scale . # FEN: restarted on tube feeds . # PPX: Heparin SQ, PPI, bowel regimen . # ACCESS: PIV x2 . # CODE: full (reversed from DNR prior per wife) Medications on Admission: Hydrocortisone Cream 1% 1 Appl TP [**Hospital1 **] Albuterol-Ipratropium 4 PUFF IH Q6H Levofloxacin 750 mg IV DAILY Aspirin 325 mg PO DAILY Lorazepam 0.5 mg PO Q8H:PRN Baclofen 5 mg PO TID Mirtazapine 15 mg PO HS CeftazIDIME 2 g IV Q8H Senna 1 TAB PO BID:PRN Sertraline 150 mg PO DAILY Desenex *NF* 2 % Topical [**Hospital1 **] Docusate Sodium (Liquid) 100 mg PO BID traZODONE 50 mg PO HS Tylenol ELixir 1000mg QID Lopressor 37.5mg Q8h Heparin sc TID Nexium 40mg Qdaily Discharge Medications: 1. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. Cortisone 1 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 4. Miconazole Nitrate 2 % Cream Sig: One (1) Topical [**Hospital1 **] (2 times a day). 5. Ipratropium-Albuterol 18-103 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q6H (every 6 hours). 6. Sertraline 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 7. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 9. Baclofen 10 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 10. Mirtazapine 15 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 11. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed. 12. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 14. Vancomycin 1000 mg IV Q 12H day 1 = [**2189-2-14**] for 14 days 15. Heparin Flush PICC (100 units/ml) 2 mL IV DAILY:PRN 10 ml NS followed by 2 mL of 100 Units/mL heparin (200 units heparin) each lumen Daily and PRN. Inspect site every shift. 16. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane [**Hospital1 **] (2 times a day). 17. Nexium 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 18. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: ASDIR Subcutaneous ASDIR: per sliding scale. Discharge Disposition: Extended Care Facility: [**Hospital3 672**] Hospital Discharge Diagnosis: Ventilator associated pneumonia Left lower lobe collapse Acute renal failure likely from ischemic ATN Discharge Condition: conversant through eye blinking, quadriplegic Discharge Instructions: Admitted for ventilator associated pneumonia. Treated initially with broad spectrum antibiotics: Vanco, Ceftazidime and Levofloxacin. Subsequently blood cultures positive for Staph coag negative. Antibiotic coverage reduced to Vancomycin alone for 2 week course. Subsequent blood cultures negative. TTE negative. Pt also found to have rising creatinine, likely due to initial hypotension in the context of GPC sepsis. Never on vasopressors, however initially needed fluid resuscitation. Continue to hold Metoprolol for now. [**Month (only) 116**] restart once renal function recovered. Respiratory settings unchanged from baseline. Patient with copious secretions, will need frequent suctioning. Patient will need: -Ventilator treatment, Mouthcare, Chlorhexidine mouthwash -Continue Vancomycin for a 14 day course, first day [**2189-2-14**] -Daily labs to monitor creatinine -Cardiopulmonary assessment, restart Metoprolol once MAP > 65 continously for 2days Followup Instructions: With physicians at rehab on daily basis [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**] Name: [**Known lastname 9292**],[**Known firstname **] Unit No: [**Numeric Identifier 9293**] Admission Date: [**2189-2-14**] Discharge Date: [**2189-2-18**] Date of Birth: [**2137-4-17**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1807**] Addendum: * Elevation in creatinine: Patient's creatinine increased to 1.2 on [**2-18**] up from 0.5 on admission. Likely related to transient hypotension on admission leading to tubular necrosis. Patient's creatinine should be rechecked daily for several days following discharge from [**Hospital1 8**] to ensure that it is improving. Urine output should similarly be monitored closely. If urine output decreases, could consider hypovolemia though further rise in creatinine should prompt investigation of acute renal failure. Discharge Disposition: Extended Care Facility: [**Hospital3 **] Hospital [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 1809**] Completed by:[**2189-2-18**]

[ "V12.51", "335.20", "564.00", "V46.11", "702.0", "038.19", "584.5", "486", "E879.8", "V44.1", "346.90", "V44.0", "716.90", "999.9", "401.9", "518.84", "344.00", "995.92", "271.3" ]

icd9cm

[ [ [] ] ]

[ "96.6", "99.21", "38.93", "96.72" ]

icd9pcs

[ [ [] ] ]

9335, 9538

3404, 4816

351, 357

7179, 7227

2529, 3381

8235, 9312

1916, 1950

5336, 6955

7054, 7158

4842, 5313

7251, 8212

1965, 2510

276, 313

385, 1540

1562, 1763

1779, 1900

26,553

109,889

29718

Discharge summary

report

Admission Date: [**2168-3-13**] Discharge Date: [**2168-3-15**] Date of Birth: [**2131-1-20**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2186**] Chief Complaint: bloody stool Major Surgical or Invasive Procedure: Colonscopy with injection and ligation History of Present Illness: The patient is a 37M with colon cancer s/p resection 8 years ago and recent PE, who presented with marroon stools and clot. The patient was found to have a PE approximately 4 months ago when he presented with severe inspiratory chest pain. He was started on coumadin and lovenox. A colonoscopy was done at that time and he was found to have 2 polyps. However, the pt was being anticoagulated at that point with coumadin, so polypectomy was deferred. The plan was for continuation of coumadin for 3 months, and then pt would undergo polypectomy. Three days ago, pt underwent polypectomy off the coumadin. Per the patient, the gasteroenterologist said his polyps had grown significantly in size over the three months. He was started on lovenox at that time. Since Friday night (day after the colonoscopy), he developed maroon, mucousy stools, 3-4x/day, with clotted blood. A few stools were black. The patient called his gastereoenterologist who advised that the patient go to the ED. The patient states that he usually has [**1-31**] BMs per day since his colonic resection. He denied BRBPR. Pt denies chest pressure, lightheadedness, dizziness with standing, or SOB. Denies abdominal pain, fevers, or hematemesis. . In the ED, the pt was given Golytely 4L po. He underwent colonoscopy this morning which demonstrated clot over the transverse colon polypectomy site without active bleeding. Patient underwent surgical ligation. Past Medical History: - Stage III colon Ca - s/p partial colectomy (14-18in of transverse and descending colon) followed by 5FU/Leucovorin and localized XRT ([**2158**]) - RLL subsegmental pulmonary embolism [**12-6**] - GERD Social History: Lives with wife and 2 children (3y/o and 6y/o) in [**Location (un) 56138**]. Works at [**Company 2267**] selling IVC filters and other vascular products. Smoked about 0.5-1 packs per week, quit in [**12-6**]. Drinks socially on the weekends, up to 10 beers/week. No IVDU. Family History: Father with ureteral, liver, and renal Ca. Mother healthy. [**Name2 (NI) **] FH of PE or miscarriages in women. Physical Exam: VS: 97.4, 68, 10, 100/54, 5500/2100 Gen: well appearing, conversant, NAD HEENT: PERRL, EOMI, OP clear, MMM, no conjunctival pallor CV: RRR, nl S1/S2, no m/r/g Pulm: CTAB, no w/r/r Abd: soft, NT/ND, +BS, no masses Ext: no c/c/e Pertinent Results: [**2168-3-13**] 09:00PM PT-10.9 PTT-25.1 INR(PT)-0.9 [**2168-3-13**] 09:00PM PLT COUNT-251 [**2168-3-13**] 09:00PM WBC-10.1 RBC-4.50* HGB-13.4* HCT-37.9* MCV-84 MCH-29.8 MCHC-35.4* RDW-14.2 [**2168-3-13**] 09:00PM GLUCOSE-85 UREA N-20 CREAT-0.8 SODIUM-135 POTASSIUM-4.2 CHLORIDE-99 TOTAL CO2-23 ANION GAP-17 . IMAGING: [**2168-3-2**] PET: negative . [**2168-1-5**] COLONOSCOPY: Two sessile 15mm non-bleeding polyps of benign appearance were found in the transverse colon and cecum. 3 1 cc.[**Country 11150**] ink submucosal injections were applied for tattooing of area around the polyp in the cecum. . [**2168-3-10**] COLONOSCOPY: A single sessile 20 mm polyp of benign appearance was found in the cecum. A single-piece polypectomy was performed using a hot snare. The polyp was subsequently cut in half and completely removed. Two endoclips were deployed across the base of the polypectomy site to prevent future bleeding. A single sessile 15 mm polyp of benign appearance was found in the transverse colon. A piece-meal polypectomy was performed using a hot snare. The polyp was completely removed. . [**2168-3-14**] COLONOSCOPY: The cecal polypectomy site had an endoclip in place and there was no evidence of bleeding. The transverse polypectomy site had a clot over the site. The clot could not be flushed off with lavage. (injection, ligation) Otherwise normal colonoscopy to cecum. Brief Hospital Course: Mr. [**Known lastname **] is a 37 year old male with a history of colon cancer who underwent resection, chemotherapy and radiation. He recently presented with bilaterally PEs and it was thought that this may represent disease recurrence. He was started on Coumadin and Lovenox for PE and underwent colonoscopy in [**Month (only) 956**] which demonstrated 2 polyps. Intervention was deferred at that time as he was being anti-coagulated. . His Coumadin was recently held such that he could undergo colonoscopy and polypectomy in early [**Month (only) 547**]. After his procedure he was restarted on Coumadin and Lovenox and subsequently presented with bloody bowel movements. He was admitted to the MICU and prepped for colonoscopy. Anti-coagulation was held. On colonoscopy, clot overlying one of the polypectomy sites was identified. He received injection and ligation of this site. There was no active bleeding. The patient remained hemodynamically stable during this admission. . He was restarted on anti-coagulation with Lovenox bridge prior to discharge. He was asked to follow up in the [**Hospital 197**] Clinic the Friday after discharge. Medications on Admission: lovenox 80mg SC bid coumadin 3.75 mg 5 day per wk, 5mg 2 day per wk prilosec Discharge Medications: 1. Enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe Subcutaneous [**Hospital1 **] (2 times a day) for 10 days. Disp:*20 syringes* Refills:*1* 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Coumadin Please resume your home regimen of coumadin. 3.75 mg for 5 days each week and 5mg on the remaining 2 days. 4. Outpatient [**Name (NI) **] Work PT/INR check twice weekly beginning on Thursday [**2168-3-18**]. Results should be FAXED to Dr.[**Name (NI) 40905**] office/[**Hospital 18**] [**Hospital 197**] Clinic (Phone: [**Telephone/Fax (1) 2173**]). Discharge Disposition: Home Discharge Diagnosis: Primary: - lower GI bleed . Secondary: - Stage III colon Ca - s/p partial colectomy (14-18in of transverse and descending colon) followed by 5FU/Leucovorin and localized XRT ([**2158**]) - RLL subsegmental pulmonary embolism [**12-6**] - GERD Discharge Condition: Good. Tolerating PO. Hct stable. Afebrile. Discharge Instructions: You were admitted to the hospital for a GI bleed. You underwent colonoscopy and were to have a blood clot overlying the recent polypectomy site in your colon. You should return to the ER or call your doctor if you experience any of the following symptoms: fever > 101.4, weakness/fatigue, chest pain, bright red blood in your stool, black stool or any other concerning symptoms. . Please take all medications as prescribed. You should restart your coumadin tonight. . Please follow up with all appointments as instructed. Followup Instructions: 1. Please follow up with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in 2 weeks. 2. Please have your INR checked at the [**Hospital 18**] [**Hospital 197**] Clinic on Friday [**2168-3-19**]. 3. Please have your INR checked twice weekly when you are traveling beginning Monday [**2168-3-22**]. A prescription has been provided for this. Results should be FAXED to Dr.[**Name (NI) 40905**] office/[**Hospital 197**] Clinic (Phone: [**Telephone/Fax (1) 2173**]).

[ "530.81", "V10.05", "V12.51", "E878.8", "998.11" ]

icd9cm

[ [ [] ] ]

[ "45.43" ]

icd9pcs

[ [ [] ] ]

6141, 6147

4154, 5302

328, 369

6434, 6479

2732, 4131

7049, 7537

2357, 2470

5429, 6118

6168, 6413

5328, 5406

6503, 7026

2485, 2713

276, 290

397, 1825

1847, 2052

2068, 2341

68,280

128,071

7141

Discharge summary

report

Admission Date: [**2175-12-5**] Discharge Date: [**2176-1-1**] Date of Birth: [**2105-12-9**] Sex: F Service: ORTHOPAEDICS Allergies: Percocet / Codeine / Penicillins / Iodine Containing Agents Classifier / Iron Attending:[**First Name3 (LF) 11415**] Chief Complaint: Left ankle fracture with exposed hardware Major Surgical or Invasive Procedure: [**2175-12-7**]: 1. Irrigation and debridement of left lateral wound down to the level of the plate and bone. 2. Placement of vacuum sponge. [**2175-12-8**]: 1. Ultrasound-guided puncture of the right common femoral artery. 2. Contralateral third-order catheterization of the left popliteal artery. 3. Abdominal aortogram. 4. Serial arteriograms of the left lower extremity. 5. Balloon angioplasty of the left superficial femoral artery. 6. Stenting of the left superficial femoral artery for dissection [**2175-12-13**]: 1. Removal of hardware, left ankle 2. Irrigation and debridement of left lateral wound 3. Placement of external fixator 4. Placement of vacuum sponge [**2175-12-19**]: 1: I&D left ankle wound 2. Placement of vacuum sponge [**2175-12-22**]: 1: Bedside VAC change [**2175-12-25**]: 1: Bedside VAC change [**2175-12-28**]: 1: Bedside VAC change [**2175-12-31**]: 1: Bedside VAC change History of Present Illness: Ms. [**Name14 (STitle) 26562**] is a 70 year old female who suffered a left ankle fracture/dislocation on [**2175-11-10**]. Skin around medial ankle did not allow ORIF and fibula was plated on [**2175-11-10**]. She presented to orthopaedic clinic on [**2175-12-5**] with exposed hardware. She was then admitted to the [**Hospital1 18**] for further care. Past Medical History: DM2 HTN renal insufficiency hyperlipidemia tension headache s/p Tonsillectomy s/p cholecystectomy s/p fibroid tumor removal cervical spondylosis DJD Social History: No tobacco, rare Etoh, no illicits. Works at attorney's office. Family History: NC Physical Exam: Upon admission Alert and oriented Cardiac: Regular rate Chest: Lungs clear Abdomen: Soft non-tender non-distended Extremities: LLE lateral incision with dehisiance and eschar + hardware visiable, Pertinent Results: [**2176-1-1**] 05:55AM BLOOD WBC-10.6 RBC-3.00* Hgb-9.1* Hct-28.8* MCV-96 MCH-30.3 MCHC-31.6 RDW-18.2* Plt Ct-560* [**2175-12-18**] 05:37AM BLOOD Neuts-90* Bands-0 Lymphs-3* Monos-4 Eos-3 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2175-12-29**] 03:50AM BLOOD PT-14.5* PTT-32.9 INR(PT)-1.3* [**2176-1-1**] 05:55AM BLOOD Glucose-142* UreaN-28* Creat-3.4* Na-138 K-4.5 Cl-102 HCO3-29 AnGap-12 [**2175-12-9**] 07:50AM BLOOD ALT-7 AST-51* LD(LDH)-347* AlkPhos-574* TotBili-0.4 [**2175-12-7**] 02:23AM BLOOD GGT-858* [**2176-1-1**] 05:55AM BLOOD Calcium-7.2* Phos-2.8 Mg-1.6 [**2175-12-7**] 02:23AM BLOOD calTIBC-208* VitB12-GREATER TH Folate-GREATER TH Ferritn-770* TRF-160* [**2175-12-7**] 02:23AM BLOOD TSH-0.93 [**2175-12-7**] 02:23AM BLOOD T4-10.7 [**2176-1-1**] 05:55AM BLOOD Vanco-14.3 Brief Hospital Course: Ms. [**Known lastname **] was directly admitted from the orthopaedic clinic to [**Hospital1 18**] on [**2175-12-5**] for a left ankle wound break down. Pre-operatively, she was consented, prepped, and received hemodialysis in the evening in preparation for surgery the next day. She brought to the operating room for an I&D of her ankle wound and placement of VAC dressing on [**2175-12-6**]. Intra-operatively, she was closely monitored and remained hemodynamically stable, although she was hypertensive and had ST segment depression. She otherwise tolerated the procedure well without. Post-operatively, she was transferred to the PACU where medicine was consulted for her EKG changes. She was transferred to the medicine service and admitted to the MICU for observation overnight. She was transferred to the floor on [**2175-12-7**]. Vascular surgery was consulted to evaluate the vascular integrity of her left leg. She was taken to angiography on [**2175-12-8**]. During the procedure, there was concern of rupture of an AV fistula and she was transferred to the vascular sugery service and taken to the VICU for observation. Her hematocrit remained stable and she was transfered to the floor on the orthopaedics service for continued managment of her ankle wound. They recommended Plavix for 30 days. On [**2175-12-13**], the patient returned to the OR for hardware removal and placement of external fixator. She tolerated this procedure without complication and was transferred to the floor with a VAC dressing in place. Plastic surgery was consulted during this procedure for possible wound closure. They said that no closure would be attempted at this time, although flap closure was not out of the question in the future. Infectious Disease was consulted for assistance managing her infections. Her wound infection was MSSA and she was given IV Vanco dosed around dialysis. She was also found to have C. difficile and was started on PO vancomycin and IV flagyl per their recommendations. WBC count and fever curve were trended to monitor signs of infection. She returned to the OR on [**2175-12-19**] for another I&D and VAC change. The wound showed some signs of healthy granulation. She tolerated the procedure well with complication and returned to the floor after a brief stay in PACU. On [**2175-12-22**] her VAC was changed at the bedside without difficulty. She continued to have every 3 day VAC changes while in the hospital. Due to continued diarrhea GI was consulted and recommended to start probiotics. Throughout her hospital stay she was seen by renal and had dialysis. She was also seen by physical therapy to improve her strength and mobility. Medications on Admission: Nifedipine, HCTZ, Lantus, Humalog, ASA Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. Disp:*60 Tablet(s)* Refills:*0* 3. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 4. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 6. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QHS (once a day (at bedtime)). 7. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for anxiety. 9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 12. Calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO MO WE FR (). 13. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) 1000mg Intravenous HD PROTOCOL (HD Protochol): To continue until [**2176-2-19**] per Infectious Disease. 14. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day): Apply to area under pannus. 15. Cholestyramine-Sucrose 4 gram Packet Sig: One (1) Packet PO TID (3 times a day): Give 1 packed before each meal. 16. Outpatient Lab Work Please draw weekly, CBC with diff, Chem 7, Vanco trough, and fax results to Infectious Disease at [**Telephone/Fax (1) 432**] 17. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 19. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 2 weeks: Start date [**2175-12-29**] End date [**2176-1-12**] Please check ua after Cipro course is complete. 20. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for Pain. 21. Fixed and Sliding Scale Insulin See attached 22. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours): Continue until at least [**2176-3-4**], to be determined by Infectious Disease. 23. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for gas. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Left ankle fracture Non healing ankle wound/infection Peripheral artery disease End stage renal disease Discharge Condition: Mental Status:Clear and coherent Level of Consciousness:Alert and interactive Activity Status:Ambulatory - requires assistance or aid (walker or cane) Discharge Instructions: If you experience any shortness of breath, new redness, increased swelling, pain, or drainage, or have a temperature >101, please call your doctor or go to the emergency room for evaluation. You may not bear weight on your left leg. Please use your crutches/walker for ambulation. Please resume all of the medications you took prior to your hospital admission. Take all medication as prescribed by your doctor. You have been prescribed a narcotic pain medication. Please take only as directed and do not drive or operate any machinery while taking this medication. There is a 72 hour (Monday through Friday, 9am to 4pm) response time for prescription refil requests. There will be no prescription refils on Saturdays, Sundays, or holidays. Please plan accordingly. Feel free to call our office with any questions or concerns. Followup Instructions: Please follow up with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], Orthopaedics NP, in 2 weeks. You can call [**Telephone/Fax (1) 1228**] to schedule that appointment. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2235**] MD, [**MD Number(3) 11417**] Completed by:[**2176-1-2**]

[ "996.67", "721.0", "272.0", "V45.11", "403.91", "285.21", "585.6", "730.06", "008.45", "518.0", "E878.1", "583.81", "998.32", "041.12", "272.4", "250.42", "707.13", "996.1", "041.11", "E879.2", "998.59", "440.23" ]

icd9cm

[ [ [] ] ]

[ "00.41", "39.95", "77.67", "86.22", "79.06", "86.28", "77.47", "93.59", "00.40", "39.50", "88.42", "84.72", "78.17", "00.46", "39.90", "88.48", "99.04", "78.67", "88.77", "00.45" ]

icd9pcs

[ [ [] ] ]

8332, 8398

3009, 5692

384, 1309

8546, 8546

2206, 2986

9583, 9933

1966, 1970

5781, 8309

8419, 8525

5718, 5758

8723, 9560

1985, 2187

303, 346

1337, 1696

8560, 8699

1718, 1869

1885, 1950

22,335

116,007

14169

Discharge summary

report

Admission Date: [**2185-2-21**] Discharge Date: [**2185-2-24**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 106**] Chief Complaint: Admitted from clinic for cardiac tamponade. Major Surgical or Invasive Procedure: Pericardial drainage. History of Present Illness: [**Age over 90 **] yo male w no significant past medical history, who was seen in clinic this a.m. and scheduled for ECHO. Was in his usual state of health until a few weeks prior to admission when he had an episode of shaking chills at his home in [**State 108**] and was taken to the hospital. At the [**Hospital 108**] Hospital, he was admitted for two nights and apparently told that he had a "big heart" on (x-ray) and lower extremity edema and was discharged on 40mg PO lasix. Of note, pt. reports that he had two previous episodes of shaking chills a few months ago while he was in [**Location (un) 86**] which resolved overnight without medical intervention. Also reports a non-productive cough over the same timeline. He denies any chest pain, no shortness of breath, no orthopnea, no PND, no decrease in exercise tolerance, no history of malignancy and no sick contacts. [**Name (NI) **] returned to [**Location 86**] and daughter had him see Dr. [**First Name (STitle) 437**] in clinic on the morning of admission. Was tachycardic in clinic with distant heart sounds and elevated JVP. Had ECHO which demonstrated 3 cm pericardial effusion, evidence of R ventricular collapse and tamponade physiology. Was taken to the cath lab for pericardial drainage with removal of 2L of brownish fluid and insertion of pericardial drain. Pt was then transferred to the CCU for further management. Past Medical History: hx of GI bleeds Right colon adenoma s/p R hemicolectomy in [**2180**] Anemia DM II - on oral hypoglycemics umbilical hernia s/p appendectomy s/p TURP h/o nephrolithiasis Social History: No tobacco, Occasional alcohol. Widowed, lives alone in [**State 108**] part of the year. Family History: Non-contributory Physical Exam: Vitals: T - 98.4, HR - 99, BP - 120/66, SpO2 - 99% on 2L NC. . PE: General: Pleasant gentleman, looks younger than stated age. In bed lying flat, looks comfortable, in NAD HEENT: PERRLA, sclera anicteric, MMM NECK: No carotid bruits. CHEST: CTAB, decreased breath sounds at bases, no w/r/r CARDIAC: RRR, nl. S1 S2, 2/6 SEM @ L upper sternal border. JVP not elevated. Pericardial drain present. ABDOMEN: Soft, NT, ND, + BS, R lateral vertical scar in abdomen w healed osotomy scar. EXT: No edema, warm, well-perfused NEURO: Alert & Oriented X 3 Pertinent Results: Admission labs: 141 102 38 AGap=16 ------------< 4.3 27 2.1 estGFR: 30/36 (click for details) RheuFac: 4 . 11.7 6.8>---<269 34.1 . PT: 14.8 PTT: 27.3 INR: 1.3 . Pericardial fluid: TotProt: 4.2 Glucose: 97 LD(LDH): 1110 Amylase: 21 Albumin: 3.0 WBC: 3700 Hct,Fl: 5.0 Polys: 2 Lymphs: 95 Monos: 2 Atyps: 1 Plasma: 0 . [**Doctor First Name **]: Negative . EKG: Sinus tach @ 100bpm, low voltages, no ST changes. . Imaging: [**2185-2-21**] ECHO:Large circumferential pericardial effusion with echocardiographic findings c/w tamponade physiology. At least mild aortic stenosis. Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. EF - 55% . Cardiac Cath ([**2185-2-21**]) 1. Pericardial tamponade. 2. Successful removal of 2050cc dark, bloody fluid. 3. No significant residual pericardial fluid at the conclusion of the procedure. . Hemodynamics: Pre-Cath: Baseline resting hemodynamics revealed tamponade physiology with a mean RA of 20mmHg, RVED of 22mmHg, mean PCWP of 23mmHg, PAD of 27mmHg, and a pericardial pressure of 23mmHg. The pulsus paradoxus was approximately 31mmHg. Initial femoral artery systolic pressure was 118mmHg. The cardiac index was depressed at 2.0l/min/m2. . Post-Cath: Post procedure hemodynamics revealed a mean RA of 9mmHg, PCWP of 11mmHg, and pericardial pressure of -5mmHg. The femoral systolic pressure increased to 144mmHg and the cardiac index increased to 3.8l/min/m2. . CXR [**2185-2-23**]: Pericardial drainage catheter has been removed. There has been no change in the cardiomediastinal contour. Small bilateral pleural effusions are still present. No pneumothorax. Left basal atelectasis is stable. Lungs, otherwise clear. Brief Hospital Course: A/P: 93-yo gentleman with no significant PMH, admitted with large chronic pericardial effusion and tamponade, of unknown etiology, stable s/p cardiac cath with drainage of 2L of dark, bloody fluid. . 1. Pericardial Effusion/Tamponade: s/p drainage of large chronic pericardial effusion with pericardial drain. Etiology is unclear at this time but could most likely be secondary to malignancy (no clear source at this time), occult infection given his h/o shaking chills although no fevers/white count, uremia/ renal failure or connective tissue disease or idiopathic. The pericardial drain put out minimal fluid after initial placement and was uneventfully removed. Pulsus remained low after initial drainage. Cultures were pending with NGTD at time of discharge. ECHO post catheter removal showed trivial pericardial effusion. The evening of catheter placement he was febrile to 101.4. He was cultured (blood and urine) and started on ceftriaxone and vanco out of concern for catheter related infection. Since all cultures were negative these were stopped after 72 hours. . 2. Pump: Has an EF of 55% by ECHO. Decreased cardiac index probably due to tamponade with good recovery post-drainage. Did not require diuresis after pericardial drainage. . 3. Acute on Chronic Renal Insufficiency: Likely pre-renal secondary to poor cardiac output due to tamponade physiology. Baseline creatnine is ~1.3, improved on this hospital stay to 1.4-1.6. . 4 Normocytic Anemia: Has prior history of anemia and GI bleeds, hematocrit is 34.1,which is around his baseline with no obvious source of bleeding. iron studies consistent with mixed anemia of chronic disease and iron deficiency. . 5 Diabetes: Has a history of NIDDM, possibly on glyburide in the past, blood glucose monitored here and <150, no sliding scale was needed so discharged off medication. . 6 Code: FULL Medications on Admission: asa 81 mg qd lasix 40 mg qd Folate/B12 glyburide ? . Allergies: NKDA Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*90 Tablet, Delayed Release (E.C.)(s)* Refills:*3* 3. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Pericardial effusion. Discharge Condition: Good. Discharge Instructions: Please take all medications as prescribed. Please keep all follow-up appointments. Please notify your primary care doctor, Dr. [**First Name8 (NamePattern2) **] [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 42160**] ([**Telephone/Fax (1) 42161**], or your cardiologist, Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**], or return to the Emergency Department if you experience fevers, chills, shortness of breath, chest pain or pressure, light-headedness, feeling faint, nausea, vomitting, diarrhea, or any symptoms that concern you. Followup Instructions: Please follow-up with your primary care doctor, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Last Name (NamePattern1) 42160**] within 1-2 weeks of discharge. Please call [**Telephone/Fax (1) 42162**] for this appointment. . Please follow-up with Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 437**] of cardiology within 1 week of discharge. Please call [**Telephone/Fax (1) 4451**] to schedule this appointment.

[ "285.9", "585.9", "584.9", "420.99", "250.00" ]

icd9cm

[ [ [] ] ]

[ "37.0", "37.21" ]

icd9pcs

[ [ [] ] ]

6925, 6931

4423, 6282

305, 329

6997, 7005

2669, 2669

7629, 8095

2071, 2089

6402, 6902

6952, 6976

6308, 6379

7029, 7606

2104, 2650

222, 267

357, 1754

2685, 4400

1776, 1948

1964, 2055

79,538

184,967

42555

Discharge summary

report

Admission Date: [**2184-4-4**] Discharge Date: [**2184-4-12**] Date of Birth: [**2161-8-8**] Sex: F Service: NEUROLOGY Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 618**] Chief Complaint: Left sided plegia, dysarthria. Major Surgical or Invasive Procedure: PICC line placement. History of Present Illness: The pt is a 22 year-old right-handed female with history of ADHD on stratera who presents with onset of slurred speech and left sided speech this afternoon. She was in her usual state of health until this afternoon/this morning when she was with friends in a car smoking [**Name (NI) 92100**]. She felt like she was having an "anxiety attack" and went home. [**Doctor First Name **] describes shortness of breath, palpitations and says she "felt like [she] was going to die of a heart attack". She went home and tried to take deep breaths, count backwards from 10, take a drink of cold water which helped a little. The history is then unclear as to when she developed the slurred speech and weakness. . Per the history mom was given, her friend was at her apartment with her and she came out of her room some time around 2 or 3pm. At that time her speech was slurred and she had difficulty standing up. He had her sit on the couch and she fell to the ground. This friend then called her boyfriend who was at work and unable to come see her. He called another friend who picked her up and took her to the ED in [**Location (un) 5450**]. Per mom, she thinks she was left at the ED without much of a history being given. . In the ED at [**Hospital3 17921**] Center, she was combative and agitated. Unable to perform NIHSS due to agitation. There she had a CT head which was reportedly unremarkable. MRI performed after ativan. Past Medical History: ADHD Bipolar Disorder (?) Borderline personality traits (?) Social History: Was adopted at the age of 3. Mom states she has always been an "obstinate" child. She lives with her boyfriend currently who mom says is a bit delayed. Mom is her [**Social Security Number 92101**]social security payee. She does work for housekeeping at an [**Hospital3 **] facility. Per mom, she feels that although [**Name (NI) **] denies other ilicit drug use, she may use many other drugs. [**Doctor First Name **] denies all other drugs, including prescribed medication, aside from marijuana. First time use of K2 was today. Per mom, [**Name (NI) **] did bring her a medication planner on Friday that was empty but should not have been. She is unsure how reliably she takes her medications. Family History: Patient is adopted. Physical Exam: ADMISSION EXAM . Physical Exam: 99.1 ??????F (37.3 ??????C), Pulse: 79, RR: 14, BP: 127/99, O2Sat: 100 RA, Pain: 0. General: Drowsy, dozes off to sleep but arouseable easily. HEENT: NCAT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: Supple, no carotid bruits appreciated. No nuchal rigidity Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, no M/R/G noted Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or HSM. Extremities: No C/C/E bilaterally, 2+ radial, DP pulses bilaterally. LLE cool to touch but with strong pulse Skin: no rashes or lesions noted. . Neurologic: -Mental Status: Alert, oriented to name, "hospital", [**Month (only) **] [**2184**]. Able to relate history with constant stimulation and repetitive questioning. Continuously dozes off to sleep but wakes with minimal tactile stimulation. Inattentive, able to name DOW backward without difficulty. Language is fluent with intact. Following commands, with repetition. There were no appreciated paraphasic errors. Pt. was able to name high frequency objects. Speech was mildly dysarthric. Able to follow both midline and appendicular commands. -Cranial Nerves: I: Olfaction not tested. II: PERRL 4 to 2mm and brisk. VFF unable to be assessed. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. III, IV, VI: EOMI unreliably tested due to sedation, appears to have full horizontal gaze. Normal saccades. V: Facial sensation intact to light touch. VII: Dense L facial droop in upper motor neuron pattern. VIII: Hearing intact to finger-rub bilaterally. IX, X: Palate elevates symmetrically. [**Doctor First Name 81**]: 5/5 strength in trapezii and SCM bilaterally. XII: Tongue protrudes with deviation to the left. . -Motor: Normal bulk, tone throughout. No pronator drift bilaterally. No adventitious movements, such as tremor, noted. No asterixis noted. Delt Bic Tri WrE FFl FE IO IP Quad Ham TA [**First Name9 (NamePattern2) 2339**] [**Last Name (un) 938**] EDB L 2 2 2 0 0 0 0 0 2 2 0 0 0 0 R 5 5 5 5 5 5 5 5 5 5 5 5 5 5 . -Sensory: Diminished sensation to all modalities. Extinction to DSS. . -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 3 3 3 3 2 R 3 3 3 3 2 Plantar response was upgoing on L, withdrawal on the R. . -Coordination: No intention tremor, no dysdiadochokinesia on the R. No dysmetria on FNF or HKS bilaterally. . -Gait: deferred. PERTINENT FINDINGS ON DISCHARGE: Patient demonstrated wakefulness, attention, and improved speech daily. She remains hemiplegic on the left with no movement on the L side even to noxious stimuli. There is a left facial droop. Reflexes are brisk, and upgoing on the left plantar. She is inattentive to her left side. Mentation and mood are off for the circumstance. Pertinent Results: LABS ON ADMISSION: ------------------ [**2184-4-4**] 08:50AM %HbA1c-5.3 eAG-105 [**2184-4-4**] 08:50AM TRIGLYCER-62 HDL CHOL-54 CHOL/HDL-3.4 LDL(CALC)-117 [**2184-4-4**] 08:50AM CRP-1.4 [**2184-4-4**] 08:50AM SED RATE-3 [**2184-4-4**] 02:02AM ASA, ETHANOL, ACETMNPHN, bnzo, barbit, tricyc = NEG [**2184-4-4**] 01:50AM URINE bnzo, bbit, opiat, cocain, amphetmn, mthdone = NEG [**2184-4-4**] 01:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG [**2184-4-4**] 01:50AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.007 . PERTINENT LABS DURING WORK-UP: [**2184-4-4**] 08:50AM BLOOD ACA IgG-2.2 ACA IgM-4.4 [**2184-4-4**] 08:50AM BLOOD AT-108 ProtCFn-77 ProtSFn-96 [**2184-4-4**] 08:50AM BLOOD Lupus-NEG [**2184-4-4**] 08:50AM BLOOD ALT-10 AST-15 LD(LDH)-140 AlkPhos-39 TotBili-0.2 [**2184-4-4**] 02:02AM BLOOD CK(CPK)-85 [**2184-4-4**] 02:02AM BLOOD cTropnT-<0.01 [**2184-4-4**] 02:02AM BLOOD CK-MB-2 [**2184-4-4**] 08:50AM BLOOD %HbA1c-5.3 eAG-105 [**2184-4-4**] 08:50AM BLOOD Triglyc-62 HDL-54 CHOL/HD-3.4 LDLcalc-117 [**2184-4-5**] 06:29AM BLOOD TSH-1.4 . [**2184-4-9**] 04:21AM BLOOD BETA-2-GLYCOPROTEIN 1 ANTIBODIES (IGA, IGM, IGG)-PND [**2184-4-4**] 08:50AM BLOOD PROTHROMBIN MUTATION ANALYSIS-PND [**2184-4-4**] 08:50AM BLOOD FACTOR V LEIDEN-PND . LABS ON DISCHARGE: ------------------ [**2184-4-12**] 04:34AM BLOOD WBC-8.7 RBC-4.36 Hgb-12.9 Hct-39.4 MCV-90 MCH-29.5 MCHC-32.6 RDW-14.1 Plt Ct-227 [**2184-4-12**] 04:34AM BLOOD PT-11.7 PTT-35.3 INR(PT)-1.1 [**2184-4-12**] 04:34AM BLOOD Glucose-84 UreaN-15 Creat-0.6 Na-138 K-4.0 Cl-100 HCO3-28 AnGap-14 [**2184-4-12**] 04:34AM BLOOD Calcium-9.7 Phos-4.8* Mg-1.8 [**2184-4-12**] 04:34AM BLOOD Osmolal-285 . IMAGING: -------- CTA HEAD/NECK [**2184-4-4**]: IMPRESSION: 1. Very large relatively acute infarct involving much of the right middle cerebral arterial distribution, with only slight mass effect upon the overlying gyri and subjacent body of the right lateral ventricle, and no subfalcine or more central herniation. 2. No evidence of hemorrhagic conversion. 3. Abrupt occlusion of the right MCA at its mid-M1 segment, which may relate to thrombosis, given the hyperattenuating material in the immediately more distal portion as seen on the NECT or, alternatively, to focal dissection or vasospasm, or some combination of these. There is minimal distal flow, largely provided by meningeal collateral vessels. 4. Otherwise, unremarkable intracranial circulation and cervical vessels; specifically, there is a normal appearance to the right common and internal carotid arteries, without significant plaque or flow-limiting stenosis. . NCHCT [**2184-4-5**]: IMPRESSION: 1. New mild (4 mm) leftward parafalcine herniation, with associated mild effacement of the right lateral ventricle. 2. Evolving large right MCA territory infarct, with no evidence of hemorrhagic conversion. 3. The suprasellar and quadrigeminal cisterns remain preserved. . ECHOCARDIOGRAM [**2184-4-6**]: The left atrium and right atrium are normal in cavity size. A patent foramen ovale is present. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Patent foramen ovale. Normal global and regional biventricular systolic function. . NCHCT [**2184-4-6**]: IMPRESSION: Unchanged appearance of a large right MCA territory infarct, with continued mild effacement of the right lateral ventricle. Slight deformity on the right uncus. Consider close followup. No new mass effect or hemorrhagic conversion. Asymmetry in the lateral atlanto-axial distances is likely positional and can be correlated clinically for significance. . BILATERAL LOWER EXTREMITY DOPPLER U/S [**2184-4-6**]: IMPRESSION: No evidence of lower extremity deep vein thrombosis. . NCHCT [**2184-4-7**]: IMPRESSION: There is expected further evolution of the large right MCA territorial infarct with a minimal increase in leftward shift of normally midline structures and no evidence of significant central herniation. . NCHCT [**2184-4-8**]: IMPRESSION: Stable appearance of large right MCA infarct with leftward shift of normally midline structures. . MRV PELVIS [**2184-4-8**]: IMPRESSION: 1. No evidence for a pelvic venous thrombus. 2. 3.6 cm minimally complex right ovarian cyst, probably within physiologic allowance in a patient of this age, followup pelvic ultrasound suggested in six weeks to ensure stability or resolution. . MR HEAD [**2184-4-9**]: IMPRESSION: Redemonstration of the extensive subacute right middle cerebral arterial territorial infarction, with similar degree of subfalcine but no more central herniation. There is evidence of hemorrhagic conversion in the involved deep [**Doctor Last Name 352**] matter structures of the striatum, as well as likely early dystrophic mineralization related to cortical pseudo-laminar necrosis. Brief Hospital Course: This is the brief hospital course for a 22 year old woman with ADHD on atomoxetine, on oral contraceptive therapy, and a history of tobacco use who presented with dysarthria and left sided weakness with a subsequent finding of a large right MCA territory. This notably occurred in the setting of synthetic cannabis abuse (smoking K2). She was found to have a mid-M1 occlusion of unknown etilogy with otherwise normal blood vessels of the neck and head. She was initially admitted to the SDU but overnight developed a headache. An NCHCT revealed 4mm of parafalcine herniation and she was started on hyperosmolar therapy with mannitol. She was transferred to the ICU for closer monitoring. . Her NCHCTs remained stable for the next few days (except for small amounts of hemorrhagic transformation), and her exam continued to improve with more wakefulness, attention, and improved speech. She remains hemiplegic with no movement on the LEFT side, including to noxious stimuli. . She was found to have a PFO on her TTE, but negative lower extremity dopplers and an MRI of her pelvic region did not reveal any venous clots (anticoagulation is not an option for her at this time). Hypercoagulability labs were sent, and some remain pending at the time of discharge (see above results section). These can be followed up at her appointment with Dr. [**Last Name (STitle) **] in a few weeks. . She conditionally passed her bedside dysphagia screen but requires 1:1 supervision and soft consistency solids. She was left-sided plegic when initially starting physical and occupational therapy, and remained this way throughout her stay with us. . At discharge, she will be continued on ASA 325mg daily, a daily statin, and prozac. Until she is more mobile, Heparin SC 5000U TID should be continued. . She was discharged to rehab for rigorous physical, speech, and occupational therapy when medically stable by the neurology team. She will have follow-up with Dr. [**Last Name (STitle) **] on [**2184-6-8**]. Medications on Admission: -Stratera 50mg -Minessa (OCP) Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) injection Injection TID (3 times a day). 2. aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Discharge Diagnosis: Right middle cerebral artery stroke. Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Lethargic but arousable. Activity Status: Out of Bed with assistance to chair or wheelchair. . Neuro examination at discharge: Patient demonstrated wakefulness, attention, and improved speech daily. She remains hemiplegic on the left with no movement on the L side even to noxious stimuli. There is a left facial droop. Reflexes are brisk, and upgoing on the left plantar. She is inattentive to her left side. Mentation and mood are off for the circumstance. Discharge Instructions: Dear [**Known firstname **], You were admitted to [**Hospital1 69**] after imaging done at your local hospital showed that you had suffered a large stroke. The stroke was in the middle cerebral artery in your brain on the right side. This is a very serious medical condition, and your recovery will likely be a long one, but since you are so young, your prognosis to regain some functioning is very good. . It is very important that you take all of your medications as prescribed especially the aspirin. Additionally, you MUST stop smoking. It places you at a very high risk of having another stroke. People who are trying to quit smoking have the best success when they surround themselves with supportive people who also do not smoke. If you need a Nicotine patch, Nicorette gum, or other nicotine supplements, please ask your doctor at rehab to help you attain some. . When you were medically stable to leave the hospital, you were discharged to a rehab facility where you can have more intensive physical, occupational, and speech therapy. . It was very nice to meet you and your family. We wish you the very best in your recovery. Followup Instructions: Department: NEUROLOGY When: TUESDAY [**2184-6-8**] at 4:00 PM With: [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**Telephone/Fax (1) 2574**] Building: [**Hospital6 29**] [**Location (un) 858**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**] Completed by:[**2184-4-12**]

[ "305.90", "314.01", "438.20", "348.4", "620.2", "434.01", "745.5" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

13383, 13430

10938, 12935

333, 355

13511, 13511

5551, 5556

15218, 15597

2621, 2642

13015, 13360

13451, 13490

12961, 12992

14057, 15195

3840, 5185

2689, 3281

13699, 14033

5199, 5532

263, 295

6911, 10915

383, 1808

5570, 6892

13526, 13685

1830, 1891

1907, 2605

21,975

181,841

8746

Discharge summary

report

Admission Date: [**2105-12-2**] Discharge Date: [**2105-12-11**] Date of Birth: [**2036-8-7**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 69 year old male with a complicated past medical history. He initially presented to [**Hospital1 69**] in [**Month (only) **], complaining of constipation and vague abdominal pain, associated with nausea and vomiting. The patient also reported a ten pound weight loss at that admission. The patient underwent CT of the abdomen, which showed a markedly abnormal pancreas with an ectatic duct and possible filling defect. The patient was suspected to have IPMT disease; however, MRCP of the pancreas was more consistent with a calculus disease of the pancreas with an additional finding of acute cholecystitis. During that admission, the patient successfully underwent endoscopic retrograde cholangiopancreatography with sphincterotomy, resulting in removal of multiple gallstones and drainage of pus from the biliary system. After discharge from the hospital, the patient was followed up with the hepatobiliary surgical office and was seen by Dr. [**First Name (STitle) **] Vomer, who had initially been consulted during the prior admission. With the successful resolution of the calculous disease of the pancreas, the patient agreed to undergo elective laparoscopic cholecystectomy and presented to the operating room on [**2105-12-2**]. PAST MEDICAL HISTORY: Significant for diabetes mellitus; coronary artery disease; chronic renal insufficiency with baseline creatinine level of 2.6; hypertension and paroxysmal atrial fibrillation, documented during the last admission. (It is not clear whether this was an acute onset or a chronic onset that was recently detected). Benign prostatic hypertrophy. PAST SURGICAL HISTORY: Status post coronary artery bypass graft in [**2102**]; status post left carotid endarterectomy in [**2099**] and status post prostate surgery in [**2086**]. REVIEW OF SYSTEMS: Anemia secondary to chronic renal insufficiency, otherwise all other medical history was reported previously and review of systems was otherwise noncontributory. FAMILY HISTORY: Noncontributory. MEDICATIONS AT HOME: 1. Cardura 6 mg p.o. q. a.m. and 4 mg p.o. q. p.m. 2. Lopressor 100 mg p.o. twice a day. 3. Cozaar 100 mg p.o. q. day. 4. Aspirin p.o. q. day. 5. Lasix 40 mg p.o. q. day. 6. Rocaltrol 0.25 mg p.o. q. day. 7. Procrit 4000 units q. four days. 8. Lipitor 10 mg p.o. q. day. 9. NPH 42 units in the a.m. and 12 units q h.s. with Humalog sliding scale. 10. Cardizem CD 240 mg p.o. q. day. 11. Multi-vitamins. 12. Folate. 13. Nasonex and Clarinex. PHYSICAL EXAMINATION: The patient was afebrile; temperature 96.8; heart rate of 67; blood pressure 179/78; saturating 97% on room air. Fingerstick was 199. The patient was alert and oriented times three without jaundice or icteric sclera; not in apparent distress. HEAD, EYES, EARS, NOSE AND THROAT examination was otherwise normal. Cardiovascular examination: Regular rate and rhythm with S1 and S2, no murmurs were appreciated. Respiratory examination: Clear to auscultation bilaterally. Abdominal examination: Bowel sounds present; obese, soft, nontender, nondistended. HOSPITAL COURSE: The patient underwent laparoscopic cholecystectomy but at the very end of the procedure, the patient had intraoperative hemorrhage from the liver bed, upon separation of the gallbladder from the liver. Because of the profuse bleeding, the procedure was converted to open cholecystectomy for management of the hemorrhage. The estimated blood loss was 800 cc. The patient received 5.5 liters of Crystalloid and 2 units of packed red blood cells and was transferred to the Intensive Care Unit at the end of the case for postoperative management. The patient was followed with serial hematocrit levels, which remained stable, above the level of 30 and there was no further evidence of bleeding postoperatively. During his Intensive Care Unit admission, the patient was found to have atrial fibrillation postoperatively. Cardiology consult was obtained, given the patient's history of cardiac disease and that his cardiologist was a [**Hospital1 188**] cardiologist. With cardiology consult, the patient was started on Amiodarone bolus and was continued on Amiodarone drip. The patient spontaneously came out of atrial fibrillation, only to return again and the patient was continued on Amiodarone as per cardiology consult. The patient left the Intensive Care Unit on postoperative day number four, only to return promptly again with rapid atrial fibrillation. The patient was continued to be treated with Lopressor and Amiodarone with conversion of his cardiac rhythm. After conversion of the cardiac rhythm to sinus rhythm, the patient was transferred to the floor and his cardiac rhythm was monitored by telemetry. He was found to have several episodes of paroxysmal atrial fibrillation. Again, cardiology consult was obtained and the patient was restarted on his home regimen as noted above. The patient had several episodes of nausea and vomiting and with appropriate medication, the patient's nausea improved and the patient was slowly advanced on his diet, which he tolerated without difficulty. Nausea and vomiting had been resolved within a time period of 24 hours and after further consultation with cardiology, the patient was discharged on [**2105-12-11**] on postoperative day number nine, having passed flatus and having had bowel movement. DISCHARGE CONDITION: Stable. DISCHARGE STATUS: Discharged to home. DISCHARGE DIAGNOSES: 1. History of calculus disease of the pancreas. 2. Acute cholecystitis. 3. Coronary artery disease status post coronary artery bypass graft. 4. Diabetes mellitus. 5. Chronic renal insufficiency. 6. Atrial fibrillation. 7. Hypertension. 8. Benign prostatic hypertrophy. 9. Liver hemangioma. DISCHARGE MEDICATIONS: 1. Patient is to continue on all his preadmission medications and is to add the following: 2. Amiodarone 200 mg p.o. q. day. 3. Coumadin 4 mg p.o. q h.s. 4. Tylenol with codeine 30/300 mg one to two tablets p.o. every four hours prn for pain. 5. Colace 400 mg p.o. twice a day. FOLLOW-UP: The patient is to follow-up with Dr. [**Last Name (STitle) **] in his office one week from discharge. The patient is to see his cardiologist, Dr. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) **], and is to follow-up on his arrhythmia which will be monitored at home with [**Doctor Last Name **] of Hearts monitoring. The patient is to see his primary care physician and [**Name9 (PRE) 702**] with him to check the INR with a goal of 2 to 3. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 8275**] Dictated By:[**Last Name (NamePattern1) 30603**] MEDQUIST36 D: [**2105-12-24**] 07:42 T: [**2105-12-24**] 19:43 JOB#: [**Job Number 30604**]

[ "285.21", "V64.41", "593.9", "574.10", "427.31", "401.9", "250.00", "428.0", "998.11" ]

icd9cm

[ [ [] ] ]

[ "51.22", "99.04", "50.69" ]

icd9pcs

[ [ [] ] ]

5552, 5600

2169, 2187

5621, 5925

5948, 6995

3265, 5530

2208, 2663

1810, 1969

2686, 3247

1989, 2152

160, 1421

1444, 1786

23,680

141,859

47297+47298+47299

Discharge summary

report+report+report

Admission Date: [**2170-6-13**] Discharge Date: [**2170-6-29**] Date of Birth: [**2111-4-12**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 59 year old male with a past medical history significant for coronary artery disease, status post coronary artery bypass graft times three, aortic valve replacement, (ejection fraction of 25%), history of thoracic aneurysm, status post Bentyl/[**Doctor Last Name 10010**] procedure, who was scheduled to be admitted to vascular surgery for angioplasty of his right leg when he tripped and broke his right hip. The patient underwent right hip open reduction and internal fixation on [**2170-6-14**] with estimated blood loss of 1 liter. Postoperatively the patient had a vague episode of chest pain associated with a new T wave inversion in V2 and biphasic T in V3 on electrocardiogram, compared with electrocardiogram from [**2170-3-29**]. The electrocardiogram changes appeared to be secondary to lead placement and no ST changes were noted. Cardiac enzymes were cycled. The patient had an elevated troponin to 7.5 but MB fraction was flat. The patient was transferred from the Orthopedic Service to the Coronary Care Unit for further evaluation. Cardiac consult was obtained. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17872**], M.D. [**MD Number(1) 17873**] Dictated By:[**First Name3 (LF) 100120**] MEDQUIST36 D: [**2170-6-29**] 13:26 T: [**2170-6-29**] 15:30 JOB#: [**Job Number 100121**] Admission Date: [**2170-6-13**] Discharge Date: [**2170-6-29**] Date of Birth: [**2111-4-12**] Sex: M HISTORY OF PRESENT ILLNESS: The patient is a 59 year old male with a past medical history significant for coronary artery disease, status post coronary artery bypass graft times three, aortic valve replacement, ischemic thoracic aneurysm status post Bentall/[**Doctor Last Name 10010**] procedure, who was scheduled to be admitted to Vascular Surgery for angioplasty on the day of admission when he tripped and broke his right hip. The patient underwent right hip open reduction and internal fixation on [**2170-6-14**] with estimated blood loss of 1 liter. During the case and postoperatively the patient was hemodynamically stable. pain. The electrocardiogram was obtained and showed new T wave inversion in V2 and biphasic T wave in V3 when compared to previous electrocardiogram. Cardiac enzymes were cycled and the patient was found to have an elevated troponin of 7.5 but a negative MB fraction. Cardiac consult was obtained and recommended medical management at the time. At the time of admission to Coronary Care Unit the patient was without complaints of chest pain, shortness of breath, nausea and vomiting or diaphoresis. PAST MEDICAL HISTORY: 1. Coronary artery disease, myocardial infarction in [**2169-4-24**]. At the time the patient underwent a Bentall procedure with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 10010**] aortic root replacement with Carbometrics valve and coronary artery bypass graft times three with left internal mammary artery to left anterior descending, saphenous vein graft to obtuse marginal, saphenous vein graft to diagonal. Myocardial infarction in [**2169-10-25**], the patient underwent cardiac catheterization at that time which showed occluded saphenous vein graft to obtuse marginal, tight saphenous vein graft to diagonal 1 which was stented at that time. The left internal mammary artery was patent and a leak was seen at the site of the [**Doctor Last Name 10010**] procedure. Computerized tomography scan confirmed a pseudoaneurysm. The patient went for review coronary artery bypass graft at that time with saphenous vein graft to diagonal 1 and revision of the [**Doctor Last Name 10010**] anastomosis. Echocardiogram [**2169-11-24**] showed ejection fraction of 30%. 2. Peripheral vascular disease, [**2169-1-24**] the patient is status post left femoral artery to dorsalis pedis bypass with a nonreverse saphenous vein graft for a left heel ulceration and claudication [**2169-7-25**], graft stenosis. The patient underwent a left femoral-popliteal dorsalis pedis bypass revision with an arm vein as a jump graft from the lower graft to the [**Doctor Last Name **] of the old graft at the dorsalis pedis anastomosis. 3. Type 2 diabetes, insulin dependent complicated by peripheral neuropathy, baseline creatinine .8 to 1.0. 4. Hypertension 5. Hypercholesterolemia; lipid profile in [**2170-1-25**], total cholesterol 123, LDL 59, HDL 35. 6. Anxiety. MEDICATIONS ON ADMISSION: 1. Lopressor 50 mg b.i.d. 2. Captopril 25 mg t.i.d. 3. Avandia 4 mg q. AM 4. Lipitor 10 mg q.d. 5. Lasix 40 mg b.i.d. 6. Kayciel 10 mEq p.o. b.i.d. 7. Celexa 20 mg q.d. 8. Clonazepam 2 mg b.i.d. 9. Neurontin 300 mg q. AM, 300 mg in the day, 400 mg q. PM 10. OxyContin 30 mg SR p.o. b.i.d. 11. Coumadin 2 mg, 5 mg 12. NPH 56 units q. AM, 16 units q. PM 13. Zantac 150 mg p.o. b.i.d. 14. Percocet one to two tabs p.o. q. 6 hours prn pain ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient lives with his wife and children. The patient has a history of intravenous drug abuse, positive tobacco in the past, denies alcohol use. PHYSICAL EXAMINATION: Physical examination on admission to Coronary Care Unit revealed vital signs with temperature maximum of 102, temperature current 100.8, heartrate 92, blood pressure 157/61, PA 44/16, PCWP 17, CVP 5, cardiac output 9.28, cardiac index 4.69, SVR 590. In general the patient was awake, alert and responded appropriately to questions in no acute distress. Head, eyes, ears, nose and throat revealed pupils equal and nonreactive to light. Extraocular movements intact. Oral mucosa dry. Neck supple, unable to appreciate jugulovenous distension. Chest: Diffuse rhonchi on the anterior chest. Heart: Regular rate and rhythm. Mechanical S2 with II/VI systolic ejection murmur at the base. Abdomen was nontender, nondistended with normoactive bowel sounds. Extremities with 1+ lower extremity edema. Right hip was bandaged. LABORATORY DATA: Laboratory data on admission to the Coronary Care Unit on [**6-15**], white blood count was 5.0, hematocrit 26.5, platelets 94, electrolytes within normal limits. CPK-441 to 695 to 697 to 607. CPK 22 on discharge. Chest x-ray [**6-13**], stable cardiac enlargement, pulmonary parenchyma unchanged from prior examination. Persantine [**First Name9 (NamePattern2) 1608**] [**2170-6-21**], the patient denied arm, neck, back or chest discomfort, no ST segments were noted. Rhythm was sinus with a rare isolated ATVs. Stress images show a moderate defect of the inferior wall, inferior portion of the lateral wall as well as a moderate defect of the inferior portion of the septum with the left ventricular cavity dilated. Ejection fraction was calculated to be 36%. There is global hypokinesis most prominent at the apex and lateral wall. Computerized tomography scan of the abdomen and pelvis on [**2170-6-18**], hemorrhage within the right gluteus muscle which tracked into the right lateral thigh. No retroperitoneal hemorrhage. Small bilateral pleural effusions. Cardiac catheterization [**2170-6-26**], performed for positive Persantine [**Year (4 digits) 1608**], right posterior descending artery 90% stenosis, right posterior lateral 50% stenosis, left main 70% stenosis, proximal left anterior descending 90% stenosis, mid left anterior descending 40% stenosis, distal left anterior descending 100% stenosis, diagonal 1 100% stenosis, distal circumflex 100% stenosis, obtuse marginal 1 and 2 100% stenosis. The proximal right posterior descending artery was treated with successful percutaneous transluminal coronary angioplasty. Due to the patient's difficult anatomy, the patient received 600 cc of contrast. At the time the saphenous vein graft to V1 graft and the left internal mammary artery to left anterior descending were not engaged. Cardiac catheterization [**2170-6-28**], left internal mammary artery to left anterior descending was patent and final report is pending. HOSPITAL COURSE: 1. Cardiovascular - The patient remained hemodynamically stable throughout this admission. Cardiac enzymes and electrocardiograms were cycled. The patient was continued on his Aspirin, Lopressor, Captopril and Lipitor. The patient was ruled out for acute myocardial infarction with flat MBs and no ST segment changes on electrocardiogram. On hospital day #9 the patient underwent Persantine [**Year (4 digits) 1608**] showing reversible defects. On hospital day #14 and 16 the patient went to the cardiac catheterization laboratory and underwent percutaneous transluminal coronary angioplasty and stenting of the right posterior descending artery. The patient reported chronic chest discomfort since the time of his coronary artery bypass graft in [**Month (only) 116**] and [**2169-11-24**]. A cardiothoracic surgery consult was obtained. Surgery consult was obtained to evaluate chronic substernal chest discomfort and chronic unstable sternal separation. It was reported that the sternal separation will eventually form fibrous [**Hospital1 **] and does not need to be addressed. Recurrence of the Bentall conduit pseudoaneurysm was ruled out at the time of cardiac catheterization. During the hospitalization the patient's Lopressor was changed to Atenolol 25 mg q.d. and Captopril 25 mg t.i.d. was changed to Mavik 2 mg q.d. for once a day dosing. 2. Hematology - Postoperatively the patient had a hematocrit of 26.7 in a setting of estimated blood loss of 1 liter. The patient was transfused 1 unit of packed red blood cells with a post transfusion hematocrit of 28.6. The Heparin was started on postoperative day #1 for the patient's mechanical aortic valve with Coumadin begun when Heparin was therapeutic. On postoperative day #3 the patient's hematocrit decreased to 25.5 in a setting of an INR of 4.4. The patient's Coumadin dose was decreased and the patient again received 1 unit of packed red blood cells. On postoperative day #4 the post transfusion hematocrit was 22.6 in the setting of an INR of 6.7. The patient was asymptomatic at the time with no complaint of chest pain, shortness of breath or lightheadedness. The patient was not actively bleeding from his wound. On rectal examination the patient was guaiac negative. The patient was given 2 units of FFP, Vitamin K 1 mg intravenously and transfused 7 units of packed red blood cells. Postoperative day #5 the patient's hematocrit was 29.7 with an INR of 1.8. Computerized tomography scan was done to rule out a retroperitoneal bleed. Computerized tomography scan showed no evidence of retroperitoneal bleed. The patient was restarted on Heparin prior to discharge for his mechanical aortic valve. 3. Infectious disease - Postoperatively the patient was febrile to 103.8. The patient never developed leukocytosis during the admission. The patient was asymptomatic without complaints of headache, cough, shortness of breath, chest pain, abdominal pain or diarrhea. Chest x-ray was done and showed no evidence of pneumonia. Blood cultures were done on postoperative day #1 and 3 which all showed no growth. Urine cultures showed no growth as well. The patient became afebrile on postoperative day #4. Cefazolin was started postoperatively for prophylaxis and was continued to postoperative day #9, given the patient's bleed into his thigh. 4. Endocrine - The patient was continued on his NPH and Avandia, morning blood sugars were high running in the 200s. The patient's NPH PM dose was increased from 16 units to 25 units. It was also noted in the patient's record the patient was noted to have a TSH of 7.5 on [**2170-2-21**]. TSH and free T4 were repeated on [**2170-6-25**] with TSH of 1.4 and free T4 of 1.1. 5. Gastrointestinal - Protonix was given for gastrointestinal prophylaxis and the patient's history of heartburn. Colace was given for constipation. 6. Neurological - The patient was continued on his home dose of OxyContin and Percocet for his history of chronic pain. 7. Psyche - The patient with a history of anxiety. The patient was continued on a home dose of Clonazepam. DISCHARGE STATUS: Stable, discharged to rehabilitation facility. DISCHARGE MEDICATIONS: 1. Celexa 20 mg p.o. q.d. 2. Neurontin 300 mg q. AM and 300 mg in the day, 400 mg q PM 3. Lipitor 10 mg p.o. q.d. 4. Aspirin 325 mg p.o. q.d. 5. Avandia 4 mg p.o. q. AM 6. NPH 56 units subcutaneously q. AM, NPH 25 units subcutaneously q. PM 7. Zantac 150 mg p.o. b.i.d. 8. Multivitamin one tablet p.o. q.d. 9. Colace 100 mg p.o. b.i.d. 10. Atenolol 25 mg p.o. q.d. 11. Clonazepam 2 mg p.o. b.i.d. 12. Lasix 40 mg p.o. b.i.d. 13. Mavik 2 mg p.o. q.d. 14. Heparin 1300 units/hour 15. Coumadin 3 mg p.o. q.d. DISCHARGE DIAGNOSIS: 1. Right hip fracture status post open reduction and internal fixation of right hip 2. Coronary artery disease status post percutaneous transluminal coronary angioplasty of right posterior descending artery [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 17872**], M.D. [**MD Number(1) 17873**] Dictated By:[**First Name3 (LF) 100120**] MEDQUIST36 D: [**2170-6-29**] 14:10 T: [**2170-6-29**] 15:53 JOB#: [**Job Number 100122**] 1 1 1 R Name: [**Known lastname 100123**], [**Known firstname **] A Unit No: [**Numeric Identifier 100124**] Admission Date: [**2170-6-13**] Discharge Date: [**2170-6-29**] Date of Birth: [**2111-4-12**] Sex: M Service: ADDENDUM: The state facility to which the patient is going is [**Hospital6 85**] in [**Location (un) 86**], [**State 350**]. DR.[**Last Name (STitle) 100125**],[**First Name3 (LF) **] 12-906 Dictated By:[**Last Name (NamePattern4) 100126**] MEDQUIST36 D: [**2170-6-29**] 14:48 T: [**2170-6-29**] 18:04 JOB#: [**Job Number **]

[ "997.1", "410.71", "414.01", "285.1", "820.09", "V45.81", "250.61", "E885.9", "357.2" ]

icd9cm

[ [ [] ] ]

[ "88.56", "89.44", "92.05", "81.52", "36.01", "37.22" ]

icd9pcs

[ [ [] ] ]

12368, 12884

12905, 14008

4630, 5114

8170, 12345

5305, 8153

1691, 2803

2825, 4604

5131, 5282

27,983

190,484

50814+59293

Discharge summary

report+addendum

Admission Date: [**2192-10-19**] Discharge Date: [**2192-11-10**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2297**] Chief Complaint: Sepsis Respiratory failure Major Surgical or Invasive Procedure: endotracheal intubtation central venous catheter placement History of Present Illness: The patient is a [**Age over 90 **] y.o. female with pmh of hypertension and dementia who was brought in from [**Last Name (un) 1188**] house NH with 1 week of lethargy, poor PO intake, and hypernatremia. She was given IVFs and IV cipro x 3 days for UTI. Urine eventually grew enterococcus. 1 day prior to admission, she is reported to have aspirated, and given nebs/O2. The morning of admission, whe was more somnolent and hypotensive to the 80s. She was sent to the [**Hospital1 18**] ED. . In the [**Hospital1 18**] ED, T 101.6, BP initially 70s systolic, improved to 100 after 4L IVFs. She was somnolent with RR 16 and O2 sats ranging from 86% NRB to 92% RA. She was intubated for airway protection. Labs revealed leukocytosis (18.5), ARF, lactate 2.6, and Troponin of 0.16. ECG neg for acute ischemic abnormalities (no old). U/A was dirty and CXR with patchy bibasilar infiltrates concerning for pneumonia (? aspiration). She was given Levoflox 750, Vanco 1gm, Flagyl 500mg, and ASA 325PR. A R subclavian central line was placed. . Of note, a CXR on [**2192-10-14**] showed clear lungs. Urine from [**2192-10-14**] grew enterococcus but sensitivites could not be performed. Labs on [**2192-10-14**] showed WBC 10.3, Hct of 34, Plt 314, Na- 161, K-4.1, Cl-131, CO2- 21, BUN 46, and Cr 1.2. . ROS: Unable to obtain. Past Medical History: Lung cancer s/p resection [**2178**] Dementia w/agitation HTN Recent UTIs Social History: Was living with her daughter until [**2192-7-4**], but then was hospitalized for agitation/worsening dementia, and has been in [**Hospital1 1501**] ever since. >50 pack year smoking hx, quit in [**2178**]. No etoh or illicits. At baseline, AAO x1 and recognizes daughter. Usually is agitated when medical care given. Family History: Noncontributory Physical Exam: VS: T 97.4 BP 104/61, HR 90, RR 23, 100% on AC/1.00/400/16/5 Gen: intubated, sedated HEENT: dry mucous membranes Neck: flat JVP Lungs: bilateral rhonchi, R >L Abd: soft, ND/NT Ext: no edema Skin: erythema over sacral region, no skin breakdown Neuro: sedated but responds to pain (a-line placement) Pertinent Results: CXR [**10-19**]: 1. ET and NG tubes in satisfactory position. 2. Patchy bibasilar consolidations, left more than right, which, in this setting, may represent aspiration pneumonitis. 3. Mild CHF with interstitial edema. . CXR [**11-7**] FINDINGS: In comparison with the study of [**11-3**], there has been some reduction in the left pleural effusion, possibly related to a thoracentesis. Little change in the effusion on the right. Enlargement of the cardiac silhouette with vascular congestion is again seen. Nasogastric tube has been pulled back and lies within the distal esophagus. . CT head [**10-19**]: No hemorrhage . CT head [**10-27**]: IMPRESSION: No significant change since the previous study of [**2192-10-19**]. No acute hemorrhage identified. Moderate-to-severe ventriculomegaly suggestive of normal pressure hydrocephalus is seen. . MRI/MRA head [**10-28**]: Ventricles diffusely enlarged out of proportion to the sulci with extensive deep and periventricular white matter T2 hyperintensities. Above findings may represent communicating hydrocephalus versus central atrophy. There is fluid within the mastoid air cells bilaterally, and there is prominence of the adenoidal tissue, which is unusual for the patient's age. Normal MRA of the head. . EEG [**10-28**] and [**10-31**]: Encephalopathy. No seizure activity. . [**2192-10-19**] 12:40PM WBC-18.5* RBC-3.92* HGB-10.0* HCT-31.8* MCV-81* MCH-25.5* MCHC-31.4 RDW-17.1* [**2192-10-19**] 12:40PM ALT(SGPT)-18 AST(SGOT)-28 CK(CPK)-602* ALK PHOS-88 AMYLASE-60 TOT BILI-0.4 [**2192-10-19**] 12:40PM GLUCOSE-327* UREA N-101* CREAT-3.6* SODIUM-161* POTASSIUM-5.7* CHLORIDE-130* TOTAL CO2-18* ANION GAP-19 [**2192-10-19**] 12:44PM LACTATE-2.6* [**2192-10-19**] 05:02PM PLT COUNT-185 [**2192-10-19**] 05:02PM PT-19.4* PTT-41.4* INR(PT)-1.8* Brief Hospital Course: [**Age over 90 **]F h/o HTN, dementia, admitted to MICU given hypotension likely [**1-6**] sepsis from urine Proteus, sputum Proteus; also respiratory failure requiring intubation and ICU admission. Pt was extubated [**10-31**] but remained only responsive only to pain off sedation. Neuro workup unrevealing and pt eventually became more responsive. Pt remained HD stable and afebrile after initial resuscitation. . 1. Sepsis: On admission, pt noted to be hypotensive to 70s in ED with respiratory distress, prompting intubation. Pt was started on vanc for h/o vanc-sensitive enterococcal UTI. Urine and sputum grew Proteus sensitive to pip-taz; pip-taz therefore started on [**10-22**]. Sputum grew OSSA, vanc d/c'd [**10-25**] and nafcillin started to continue abx course for PNA. Pt completed 10 day courses of Zosyn and nafcillin on [**11-1**].and remained afebrile and hemodynamically stable. . 2. Respiratory failure: Pt initially intubated for airway protection given somnolence and decreased O2sat during episode of hypotension in ED, as well as suspected aspiration PNA per CXR on admission. Sedation discontinued [**10-24**] with haloperidol PRN for agitation, but pt continued to have depressed mental status. Pt therefore maintained on intubation for airway protection given altered mental status, however, tolerating progressive weaning of ventilator settings. Pt was extubated [**10-31**] without difficulty. . 3. Altered mental status: Slowly improved over time. CT head demonstrated no acute bleed, but moderate ventriculomegaly possibly indicating normal pressure hydrocephalus. H2 blocker removed for possible MS effects, and PPI started. Pt demonstrated gaze preference to L per neuro consult exam. Encephalitis was entertained, and toxic metabolic workup initiated: TSH normal, RPR NR, UA unrevealing, EEG (demonstrating encephalopathy), MRI brain w/ and w/o contrast (demonstrating communicating hydrocephalus vs. volume loss, LFTs (unrevealing). After discussions with family, it was decided to defer an LP at this time but to repeat EEG which did not show any new findings. Pt became somewhat more alert on [**11-2**]. It was felt that her AMS is likely only slowly recovering given underlying severe dementia. . 4. Melanotic stools- Transient episode. Pt was placed on PPI IV bid and ASA 325 was held. Hct remained stable. . 5. AF: Pt had episodes of PAF with associated RVR. Has responded very well to 12.5 mg PO metoprolol [**Hospital1 **]. Metoprolol was eventually increased to 25 mg TID with good effect and continued at this dose. . 6. Anemia: Pt noted to have decreased hct to 21.5 on [**10-24**], with hemolysis and iron studies nondiagnostic for hemolysis. Pt received 2units PRBCs and has maintained hct. In addition, episode of melanotic stools as above. However, Hct remained stable around 25 without any further transfusions. . 7. Acute renal failure: On admission, pt's creatinine 3.6 considered likely [**1-6**] to either prerenal vs sepsis-related ATN etiology. Pt received IVF during intial resuscitaiton and ARF resolved over the course of her MICU stay. . 8. Hypernatremia: Na 161 on admission, considered possibly [**1-6**] dehydration, and corrected with free water and intermittent D5W boluses. Na trended down to low 140s. . 9. Coagulopathy: On admission, INR 1.7 likely [**1-6**] poor nutritional status given low albumin; received vit K PO x 3 days with improvement. Remained stable. . 10. Hyperglycemia: NPH titrated to maintain FS <150; Hyperglycemia at night. Increased qHS Lantus to 12 units from 10. ....................... On the floor, the patient spiked another temperature and was restarted on vancomycin and Zosyn. Additional discussions were had with the family, who wished to place a feeding tube for nutrition. Plans were made for IR placement on [**2192-11-9**]. During the procedure, after receiving 1mg IV Versed, the patient's blood pressures dropped. It was initially attributed to sedation, but repeat CBC demonstrated a lower hematocrit. A sub-clavian central line was placed and a stat CT scan of the abdomen and pelvis demonstrated perforation of an abdominal aortic aneurysm. She remained stable for approximately twelve hours and was supported with transfusions and IV fluid, but on the morning of [**11-10**] acutely dropped her blood pressure; it was felt secondary to acute rupture of the already compromised AAA, and she expired shortly afterward with her daughter at her side. The medical examiner has accepted the case. Medications on Admission: Ciproflox 250mg PO TID started [**10-16**], d/c'd [**10-7**] Ciproflox 400mg IV Q12 started [**10-14**], d/c [**10-16**] Ferrous sulfate 325 po daily Catapres TTS 3 patch - apply 1 patch qWeek on WED Depakote sprinkles: 375mg PO daily (9PM) Lexapro taper 10mg daily (([**Date range (1) 40579**]), then 5mg daily ([**Date range (1) 42404**]) Remeron 7.5 QHS Zydis 5mg PO every other day Zydis 5mg QHS Colace 100mg daily Albuterol nebs prn ASA 81mg daily MV daily Trazadone 25mg PO QHS prn Nystatin S&S QID x 5 days ([**Date range (1) 11357**]) Senna 2 tabs QHS Fleet enema pnr Bisacodyl prn MOM prn Acetaminophen 650mg q4H Prn . Allergies: NKDA Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Primary: Septicemia secondary to urinary tract infection Community Acquired Pneumonia Hypoxic Respiratory Distress Multifactoral encephalopathy AAA rupture Acute blood loss anemia Secondary: Chronic blood loss anemia Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired Name: [**Known lastname 400**],[**Known firstname 1194**] W. Unit No: [**Numeric Identifier 17221**] Admission Date: [**2192-10-19**] Discharge Date: [**2192-11-10**] Date of Birth: [**2099-4-17**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5448**] Addendum: Of note, vascular surgery was consulted for the ruptured abdominal aneurysm. Her aortic anatomy was not conducive to percutaneous intervention, and Ms. [**Known lastname **] daughter did not wish to pursue surgery; the decision between the medical team, vascular team, and family was to manage conservatively with blood transfusions. Discharge Disposition: Expired [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5451**] MD [**MD Number(2) 5452**] Completed by:[**2192-11-10**]

[ "599.0", "038.49", "482.41", "578.1", "V10.11", "441.3", "785.52", "584.9", "507.0", "285.1", "250.00", "427.31", "276.0", "518.81", "331.5", "348.31", "782.3", "294.8", "933.1", "995.92", "458.29", "286.9" ]

icd9cm

[ [ [] ] ]

[ "99.04", "96.72", "96.04", "46.32", "38.93" ]

icd9pcs

[ [ [] ] ]

10685, 10852

4361, 5798

291, 352

9860, 9869

2516, 4338

9925, 10662

2164, 2181

9557, 9566

9619, 9839

8889, 9534

9893, 9902

2196, 2497

225, 253

380, 1714

5813, 8863

1736, 1811

1827, 2148

3,676

108,930

22397

Discharge summary

report

Admission Date: [**2167-10-22**] Discharge Date: [**2167-11-6**] Date of Birth: [**2099-10-27**] Sex: F Service: SURGERY Allergies: Zosyn / Quinolones / Penicillins Attending:[**Doctor First Name 5188**] Chief Complaint: Unresponsive and seizing Major Surgical or Invasive Procedure: Subtotal colectomy Endotracheal intubation End-ileostomy Splenectomy Dobhoff feeding tube Foley catheter Orogastric tube History of Present Illness: 67 year old female with mild retardation was transferred from [**Hospital6 **] after being found lying down on her bathroom floor at her nursing facility seizing and unresponsive. Approximately two days prior to this event, she was noted to have aspiration pneumonia, shortness of breath and chest tightness and bilateral upper and lower extremity stasis dermatitis and scabies. Vitals signs at the time of her arrival to [**Hospital3 **] showed a hypotensive, bradycardic patient who was tachypneic. Patient was transferred to the [**Hospital1 18**] ED where she was intubated prior to arrival, appeared septic and still found to be hypotensive with a SBP in the 50-60s. Her abdomen was tense, greatly distended and tympanic. Past Medical History: Mild mental retardation Atrial fibrillation Hypertension Congestive heart failure Post-traumatic stress disorder h/o Right calf deep venous thrombosis s/p Pulmonary embolus s/p IVC filter placed h/o Endometrial cancer s/p TAH/BSO Social History: Lives in [**Hospital3 2558**] (a long-term care facility) Has a brother, [**Name (NI) **] [**Name (NI) **]. Family History: Non-contributory Physical Exam: On addmision to [**Hospital1 18**] patient's physical exam was as follows: Vitals: T=34.6 C, BP=67/37, P=61, R=18, SpO2=100% on CMV (VT=400cc, RR=14, FiO2=100%, PEEP 5) Gen: intubated, sedated, in acute distress HEENT: NC/AT, PERRL CVS: RRR Pulm: coarse bilaterally Abd: greatly distended, tympanic, no BS Rectal/Anoscopy: mucosa wnl, no ulcers Skin: scaly, dry Ext: no edema Pertinent Results: WBC-33.3* RBC-2.73* HGB-6.2* HCT-25.0* MCV-92 MCH-22.7* MCHC-24.7* RDW-21.2* PLT COUNT-442* PT-21.5* PTT-36.5* INR(PT)-2.9 GLUCOSE-227* UREA N-55* CREAT-1.5* SODIUM-146* POTASSIUM-4.9 CHLORIDE-122* TOTAL CO2-11* ANION GAP-18 CORTISOL-32.9* CRP-1.15* CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST [**2167-10-22**] 6:30 PM 1. Free intraperitoneal air and distended gas-filled colon. Although no bowel wall defect can be seen, the source of the free air is likely colonic. 2. Large hiatal hernia. Brief Hospital Course: Ms. [**Known lastname **] was taken to the OR the evening of her arrival to [**Hospital1 18**] for an exploratory laparotomy. Intra-operatively, she was found to have a pan-ischemic colon with evidence of perforation midway along the transverse colon. At that point she underwent a subtotal colectomy and end-ileostomy. She also underwent a splenectomy for a capsule tear as an intra-operative complication. For details of the procedure, please see operative note. Post-operatively, she was transferred to the SICU for monitoring where she was agressively fluid resuscitated with crystalloid and blood products and given pressors. She was also maintained on IV antiobiotics and treated for her scabies. She was slow to become responsive and a head CT was done on POD #1 but was within normal. Her mental status slowly improved to near baseline by POD#7 On POD#2, her hemodynamic status improved and she had no further pressor requirement. On POD#2, total parenteral nutrition was started. Her bowel function slowly returned and she started tube feeds on POD#5. ON POD#8, she was doing well and was extubated, a Dobhoff feeding tube was placed and all antibiotics were stopped. She was then transferred out of the SICU on POD#10. Follow-up CT done on [**2167-10-31**] for an elevated WBC showed no identifiable fever source, but, a small amount of free fluid within the abdomen and bilateral pleural effusions and lower lobe atelectasis. On [**2167-11-3**], for concerns of aspiration, a bedside swallowing evaluation was done as was a video swallow the following day. Results showed mild to moderation aspiration and no cough reflex. However, recommendations were for pureed solids and nectar-thickened liquids with one-to-one assistance. She continued to have difficulty with adequate blood glucose control and was maintained on a stringent insulin sliding scale. On [**2167-11-6**], she was doing well, eating with assistance and mvoing from her bed to the chair with assistance. She was transferred to [**Hospital3 **] facility on [**2167-11-6**]. She is asked to follow-up with Dr. [**Last Name (STitle) 5182**] on [**2167-11-17**] in the morning. Medications on Admission: Zyprexa 10 PO QD Docusate sodium 100 PO BID Lopressor 50 PO BID Coumadin Iron sulfate 325 PO QD Fluoxetine 20 PO QD Lasix 40 PO QD Protonix 40 PO QD MVI Discharge Medications: 1. Urea 10 % Lotion Sig: One (1) Appl Topical ASDIR (AS DIRECTED). Disp:*1 1* Refills:*2* 2. Diltiazem HCl 30 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). Disp:*120 Tablet(s)* Refills:*2* 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 4. Sertraline HCl 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 5. Olanzapine 10 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO DAILY (Daily). Disp:*60 Tablet, Rapid Dissolve(s)* Refills:*2* 6. Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*60 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 8. Hydromorphone 0.5-2 mg IV Q4-6H:PRN 9. Hydralazine HCl 10 mg IV Q6H:PRN for sbp > 160 Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: Perforated, necrotic colon Sepsis Hypovolemia Blood loss anemia Respiratory failure Hypertension Hypernatremia Atrial fibrillation Congestive heart failure Thrombocytopenia Diabetes mellitus Bilateral pleural effusions Dysphagia/aspiration Scabies Discharge Condition: Good Discharge Instructions: You may restart any home medications you were taking prior to your hospitalization. You may shower. You may ambulate with assistance. You may eat only pureed solids and nectar thickened liquids with supervision/assistance. Followup Instructions: Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. SURGICAL SPECIALTIES CC-3 (NHB) Where: SURGICAL SPECIALTIES CC-3 (NHB) Date/Time:[**2167-11-17**] 9:15 [**Name6 (MD) **] [**Last Name (NamePattern4) **] MD, [**MD Number(3) 5190**]

[ "557.0", "317", "285.1", "427.31", "428.0", "569.83", "E878.8", "553.3", "276.5", "995.91", "309.81", "518.5", "038.9", "998.2", "287.5", "401.9" ]

icd9cm

[ [ [] ] ]

[ "46.20", "45.8", "41.5", "38.93" ]

icd9pcs

[ [ [] ] ]

5857, 5927

2545, 4719

320, 443

6219, 6225

2027, 2522

6496, 6795

1597, 1615

4923, 5834

5948, 6198

4745, 4900

6249, 6473

1630, 2008

256, 282

471, 1203

1225, 1456

1472, 1581

29,595

164,001

34005

Discharge summary

report

Admission Date: [**2159-7-1**] Discharge Date: [**2159-8-11**] Date of Birth: [**2115-4-25**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1666**] Chief Complaint: overdose Major Surgical or Invasive Procedure: Central venous line placement Hemodialysis Fasciotomy History of Present Illness: 40 yo M w/ unknown PMH p/w drug overdose. The patient was found down with empty bottles of tramadol, fiorcet (butalbital, APAP, caffeine), and lorazepam. He was intubated in the field. . In the emergency department he was hypotensive to 60-80s SBP. He received 5L IVF, and SBP came up to 100-110s/60s; his heart rate was in the 110s and came down to 90s with fluids. He was afebrile. Tox screen was positive for acetaminophen (5.6) and benzodiazepines, negative for ethanol. Toxicology service was consulted. He also had cool LLE, and vascular was consulted for compartment syndrome. He had 18g IVs placed, and was given charcoal via NGT. He also received vancomycin and zosyn for hypotension and elevated wbc count. . Past Medical History: PMH: HTN . Psych hx: Depression. Pt admits to prior overdose ~10 yrs ago, when asked about past psych admissions he says 'I don't remember'. He was seeing a therapist in [**Last Name (LF) 2199**], [**First Name4 (NamePattern1) **] [**Known firstname **], but stopped about 1 mo ago. Seroquel had been prescribed by PCP. Social History: Please see Social Work notes for full details. In brief, the patient's wife informed the social worker that the patient had been having a long struggle with substance abuse and depression, and had been taking marijuana, benzodiazepines, and Percocet, as well as "possibly suboxone". Patient had been kicked out of his house by his wife and was living next door with his 22 year old daughter and her boyfriend when he made his suicide attempt. The family owns an engraving business. Family History: unknown Physical Exam: 95.9 135/85 106 98% on AC 100% 550x14 5 sedated, NAD PERRL, EOMI, no LAD, MM dry Skin: scratch marks on forehead, groin, leg Chest: CTABL HEart: RRR, no M/R/G, nl S1 S2 Abd: soft, NT, ND, no HSM, BS + Extr: LLE in bandage s/p fasciotomy, RLE dusky, distal pulses doppleable b/l Pertinent Results: Admission labs: [**2159-7-1**] 06:00PM WBC-30.2* RBC-6.65* HGB-20.8* HCT-61.3* MCV-92 MCH-31.4 MCHC-34.0 RDW-12.9 [**2159-7-1**] 06:00PM PLT COUNT-466* [**2159-7-1**] 06:00PM GLUCOSE-160* UREA N-30* CREAT-3.6* SODIUM-137 POTASSIUM-7.4* CHLORIDE-103 TOTAL CO2-7* ANION GAP-34* [**2159-7-1**] 06:00PM CALCIUM-8.1* [**2159-7-1**] 06:00PM ALT(SGPT)-538* AST(SGOT)-1523* ALK PHOS-80 TOT BILI-0.6 [**2159-7-1**] 06:00PM AMYLASE-131* [**2159-7-1**] 06:00PM PT-13.6* PTT-31.1 INR(PT)-1.2* [**2159-7-1**] 06:20PM CK(CPK)-[**Numeric Identifier 78500**]* [**2159-7-1**] 06:00PM ASA-NEG ETHANOL-NEG ACETMNPHN-5.9 bnzodzpn-POS barbitrt-NEG tricyclic-NEG [**2159-7-1**] 06:20PM URINE bnzodzpn-POS barbitrt-POS opiates-NEG cocaine-NEG amphetmn-NEG mthdone-POS . . Liver enzymes and CK course in the first portion of admission: [**2159-7-1**] 06:20PM BLOOD CK(CPK)-[**Numeric Identifier 78500**]* [**2159-7-1**] 09:10PM BLOOD CK(CPK)-[**Numeric Identifier 78501**]* [**2159-7-2**] 06:01AM BLOOD CK(CPK)-[**Numeric Identifier 78502**]* ALT-553* AST-1454* LD(LDH)-3040* AlkPhos-46 TotBili-0.2 [**2159-7-2**] 03:59PM BLOOD CK(CPK)-[**Numeric Identifier 78503**]* ALT-510* AST-1371* LD(LDH)-2628* AlkPhos-46 TotBili-0.4 [**2159-7-3**] 03:16AM BLOOD CK(CPK)-[**Numeric Identifier 78504**]* ALT-524* AST-1383* LD(LDH)-2332* AlkPhos-51 TotBili-0.3 [**2159-7-3**] 03:16AM BLOOD CK(CPK)-[**Numeric Identifier 78504**]* ALT-524* AST-1383* LD(LDH)-2332* AlkPhos-51 TotBili-0.3 [**2159-7-3**] 04:31PM BLOOD CK(CPK)-[**Numeric Identifier 78505**]* [**2159-7-3**] 09:30PM BLOOD CK(CPK)-[**Numeric Identifier 78506**]* [**2159-7-4**] 05:30AM BLOOD CK(CPK)-[**Numeric Identifier 78507**]* ALT-514* AST-1379* LD(LDH)-2227* AlkPhos-62 Amylase-91 TotBili-0.5 [**2159-7-6**] 06:40AM BLOOD CK(CPK)-[**Numeric Identifier 78508**]* ALT-383* AST-733* LD(LDH)-1441* AlkPhos-71 TotBili-0.4 [**2159-7-8**] 06:32AM BLOOD CK(CPK)-[**Numeric Identifier 23344**]* ALT-303* AST-359* LD(LDH)-955* AlkPhos-106 Amylase-121* TotBili-0.3 [**2159-7-10**] 05:11AM BLOOD CK(CPK)-7544* ALT-208* AST-174* LD(LDH)-726* AlkPhos-90 TotBili-0.3 [**2159-7-11**] 10:09AM BLOOD CK(CPK)-5785* ALT-167* AST-123* LD(LDH)-690* AlkPhos-73 TotBili-0.3 [**2159-7-17**] 04:03AM BLOOD CK(CPK)-790* ALT-60* AST-30 LD(LDH)-375* AlkPhos-50 TotBili-0.2 [**2159-7-23**] 05:30AM BLOOD CK(CPK)-306* ALT-19 AST-24 AlkPhos-93 TotBili-0.2 Brief Hospital Course: This is a 44 year old man who was found down and brought in by ambulance after a poly-pharmacy overdose suicide attempt, with his subsequent course complicated by initial respiratory failure and intubation in the field, followed by compartment syndrome, rhabdomyolysis, and renal failure. The patient is 44 year old male c severe depression s/p drug overdose suffering from rhabdo causing a resolving ARF, now hyperCa resolving, s/p fasciotomies for compartment syndrome, healing well. . #Overdose (medical issues): It was not clear exactly which drugs the patient overdosed on. Reportedly benzo/fiorecet/tramadol were found. Tox screen was positive for benzo/barbs/tylenol/methadone. After obtaining collateral info, it appears that the pt was taking large quantities of benzodiazepines and percocet/subuxone daily. Tylenol level in the ED was elevated at 5.9. The patient was started on a NAC protocol in ED (150mg/kg over 1hr, then 50mg/kg over 4hrs, then 100mg/kg over 16hrs). Pt was also found to be tachycardic and hypertensive and was started on a CIWA scale with valium for suspected benzodiazepine withdrawal. The patient was also started on a fentanyl patch with taper for possible narcotic withdrawal. He was supplemented with thiamine, folic acid, pyridoxine. Psychiatry was consulted and followed him throughout the admission (see below). . # Severe Depression, Suicide Attempt: During much of the admission, the patient was sleepy (early on, to the point of ongoing sedation in the context of a fair amount of pain and pain medication), flat of affect, and not particularly communicative. As the admission progressed in mid-[**Month (only) **] the patient was more awake and mildly communicative. He had poor appetite and in the context of trying to improve his PO intake, we started Remeron. The patient's appetite and mood appeared to improve slightly although this was doubtlessly also associated with resolution of some of his medical and surgical issues. . Mr [**Known lastname **] required a 1:1 sitter throughout much of his admission and continued to express his concern that he would not be safe alone without a sitter. However as he improved from a medical standpoint, he made gradual strides in his mood and concern for his own safety. For the last week of his hospital stay, he continued to state that he felt safe without 1:1 observation. He was started on Remeron in part for appetite and also for mood; psychiatry followed along. Per recommendation of the psychiatry consult service, he should be followed in the rehab facility for additional psychiatry support and medication titration. He no longer requires a 1:1 sitter, and has been discontinued, as per psych recs. . At the time of discharge, he was on Mirtrazipine 30mg PO QD and lorazapam 1mg PO Q6H prn anxiety as per psych recs. . #Compartment syndrome in BLE: Vascular surgery was consulted in the ED and performed LLE fasciotomy in 4 compartments on night of admission as well as a RLE fasciotomy on [**7-2**]. He received perioperative vancomycin for prophylaxis. He developed significant rhabdomyolysis with the CK trend detailed above in the "labs" section, which was likely the major contributor to his acute renal failure (see below). Vascular surgery continued to follow this patient closely, with the following notable interventions: [**7-1**]: LLE fasciotomy in 4 compartments night of admission ([**7-1**]) [**7-2**]: RLE fasciotomy [**7-2**] [**7-13**]: Bilateral additional lateral fasciotomies and additional debridement. [**7-17**]: Additional debridement, with some dead muscle seen but appeared to be mostly well. Placement of wound vacs. Was kept overnight in the Vascular Intensive Care Unit for monitoring for concern for effects of reperfusion of possible necrotic tissue; was stable overnight and transferred back to the medicine service in the morning. He remained stable on the medical floor thereafter. [**7-20**]: Vac change. [**7-24**]: Repeat vac change. [**7-26**]: Skin grafting to all but one fasciotomy site (lateral left). [**8-1**]: Removal of vacs and evaluation of grafts. [**8-2**]: Skin grafting of the remaining fasciotomy site. All skin grafts were taken from regions of thigh skin. He should follow-up in the vascular surgery clinic as recommended in the discharge instructions. Wound care for the incisions include Adapetec dressings and ACE bandages. The incisions were clean, dry, and intact, at the time of discharge. - Pain management has been an issue as the patient has significant tolerance to opiates and benzos. On discharge, the patient was on a Fentanyl 100mcg patch and Oxycodone 15mg PO Q3H, with the patient requesting around 40mg daily and still in visible distress upon movement. . - daily dressings, adaptec, ACE bandages. -pain - the pain is well controlled at every time i ask, con't current medications - oxycodone -fentanyl 100mcg -morphine was d/c'ed to reduce polypharmacy -morphine 2mg X1 was given this morning, oxycodone 40 was taken over the day yesterday and 20mg this morning, the PRN dose was increased to 15mg Q3H. . #Acute renal failure: Clinical course most consistent with ATN secondary to rhabdomyolysis, possibly also with an element of overdose drug-related injury; and dehydration likely contributing a prerenal element. Renal was consulted and followed closely. Mr [**Known lastname **] was on hemodialysis through [**7-27**]. He was kept on sevalamer for phosphate. Gradually he experienced renal recovery and no longer needed hemodialysis. His discharge serum creatinine was 1.7. It is expected that this may be the patient's new baseline as it is unlikely that the patient will recovery complete renal function. . # Hypercalcemia: The patient developed hypercalcemia during his period of renal recovery. This was attributed to mobilization of precipitated calcium salts in the inflammed muscles during his rhabdomyolysis. The patient received calcitonin in addition to IV fluids and lasix. - as per renal recs today, d/c lasix and calcitonin and to continue fluids for one more day. ensure that cr and ca levels are stable or dropping. reconsider lasix and fluids if cr and ca levels being to rise. - as the kidney function improves, the patient should be able to independently maintain a negative fluid balance. . #C diff colitis: C diff B detected; enterobacter detected from a tissue culture from a debridement; and pan-sensitive E coli was seen in his urine on the 24th. Otherwise all of his repeated cultures were negative. In the MICU, while febrile and critical, he was treated with vancomycin and cefepime empirically. He was treated empirically and perioperatively with vancomycin starting on [**7-2**]. His E Coli was treated with ciprofloxacin from [**Date range (1) 22999**]; this was changed to cefepime because of fever. On [**7-16**] cefepime was changed to meropenem after his enterobacter was detected, with concern for likelihood of development of ESBL on a cephalosporin. Meropenem and vancomycin were discontinued on [**7-31**]. He was on initially empiric flagyl from [**7-7**] because of abdominal pain and loose stools in the setting of broad-spectrum antibiotics, and now is scheduled to stop on [**8-7**] (7 days after the discontinuation of vancomycin and meropenem). He was on and off PO vanc; we found after several attempts that when we pulled PO vanc he was more likely to be febrile, more likely to have an elevated white count, and more likely to have abdominal pain; furthermore, C diff B toxin was detected on [**7-9**] and gave further argument for aggressive C. diff treatment. PO vanc was stopped on [**8-7**]. At discharge, the patient had solid stools and was afebrile. . The sources of his fevers were generally not clear; some may have been secondary to tissue trauma and reperfusion, or to drug effects. After meropenem and vancomycin were discontinued on [**7-31**], he has had fewer fevers since. . #Transaminitis: This is likely from hepatic injury from OD including tylenol and shock liver from hypotension (it was unclear how long the patient was down). Hepatitis serologies for B and C returned negative. This resolved over the earlier part of the admission. His coags began elevating around [**7-7**] and his INR reached a peak of 3.5; this resolved, lagging behind his resolving liver enzymes, confirming the observation of a brief time of liver dysfunction followed by resolution. . #Hypertension and tachycardia: Mr [**Known lastname **] was hypertensive early in the admission as well as tachycardic. This was initially thought perhaps secondary to benzo withdrawal but continued beyond an expected course for this; pain may have been the more significant contributor. He was started on metoprolol which was titrated up to 75 TID. He had no ectopy. He was normotensive with high normal heart rates on metoprolol. As his pain resolves and his mood lightens, it will likely be useful to titrate this down. . #Shock: Initially the patient was hypotensive to 60s in the ED. This was likely secondary to dehydration--SBP came up with IVFs--as well as ingestion of sedative agents. He was not clearly infected. He did receive vancomycin and zosyn in ED and vanco for prophylaxis for fasciotomy. BCxs, UCx were all ngtd. CXR was without infiltrate. . #Metabolic acidosis: Initially, AG = 27, with delta:delta about 1, suggesting pure anion gap metaboic acidosis. This was likely secondary to renal failure. Osmolal gap was 3, so methanol and ethylene glycol poisoning was felt to be unlikely. This resolved with aggresive IVF resuscitation with isotonic bicarbonate. . #GI Bleed: Bright red blood per rectum was observed on [**7-11**] and on [**7-13**]. GI was consulted. He had a rectal tube at the time and subsequent clinical observations, most especially the eventual resolution of bleeding after pulling the rectal tube on [**7-12**], suggested that a tissue ulceration associated with the rectal tube was most likely to be responsible. This issue has been resolved prior to discharge. . #Anemia: Anemia of Chronic Disease. Most consistent with anemia of inflammation combined with blood loss from graft sites, and briefly from GI bleeding. He was transfused with a total of 5 units of PRBCs over the admission. He was transfused for Hct <21 or at dialysis for values close to 21. He was started on iron supplementation and epoeitin for support of blood cell production starting on [**8-2**]. His need for epogen would be expected to decrease as he continues to experience renal recovery. - as per renal rec and iron studies Epoetin Alfa and ferritin was d/c'ed on [**8-11**]. . #PPX: Heparin SC. Bowel regimen as needed. . #FEN: From [**7-13**] to [**7-30**], he was on TPN; his ileus, sedation and pain seemed to preclude him tolerating much PO intake. Eventually he was able to eat more and we decreased and then eliminated TPN. He was tolerating a full diet with supplements. . #SOCIAL: Social work followed closely. Mr [**Known lastname **] wanted his parents to be the main contacts and also decisionmakers when he did not have the capacity to make decisions. . #CODE: Full . #COMMUNICATION: with parents and patient . Medications on Admission: unknown Discharge Medications: 1. Line care PICC line care per protocol 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day) as needed. 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 5. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 6. Lorazepam 2 mg/mL Syringe Sig: One (1) Injection Q4H (every 4 hours) as needed for nausea. 7. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical QID (4 times a day) as needed. 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. Fentanyl 100 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: Two (2) Tab Sust.Rel. Particle/Crystal PO ONCE (Once) for 1 doses. 12. Oxycodone 5 mg Tablet Sig: Three (3) Tablet PO Q3H (every 3 hours) as needed for pain. 13. PICC line care protocol 14. Furosemide 10 mg/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 15. Mirtazapine 15 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 16. Multivitamins Tablet, Chewable Sig: One (1) Cap PO DAILY (Daily). 17. Prochlorperazine Maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. 18. Ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for breakthru nausea. 19. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. Discharge Disposition: Extended Care Facility: [**Hospital1 **] Discharge Diagnosis: Primary: Drug overdose Suicide attempt Rhabdomyolysis Bilateral lower leg compartment syndrome Acute renal failure requiring hemodialysis Depression C. dif colitis Secondary: hypertension Discharge Condition: stable. improving renal function. not requiring 1:1 observation. max assist on transfers. Discharge Instructions: if cr >1.4, send to nephro service, steimnan [**Numeric Identifier 78509**] You were admitted with drug overdose causing your compartment syndrome requiring surgery for your calves and causing your kidneys to shut down. To help your kidneys, you were placed on hemodialysis, but since, you have recovered function and no longer need diaylsis. Your volume overload and hypercalcemia issues are resolving as your kidney functions improves. Please do not use illicit substances and comply with your medications. Please go to all scheduled follow up appointments with your physicians. If you feel that your condition is worsening or acutely ill, contact your PCP or go to the emergency room. Followup Instructions: Vascular Surgery Clinic: Please have someone call ([**Telephone/Fax (1) 78510**] to inquire about a follow-up appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1391**] within 4-6 weeks. [**Hospital 10701**] Clinic: Please have someone call ([**Telephone/Fax (1) 773**] to schedule a follow-up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] within 4-6 weeks. Please also see your PCP as scheduled and inform of the updates to your medical history. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**] Completed by:[**2159-8-11**]

[ "276.51", "728.89", "599.0", "518.81", "969.4", "967.0", "570", "965.4", "584.5", "728.88", "296.30", "E950.0", "292.0", "401.9", "275.42", "285.29", "008.45", "276.2", "304.10", "E950.3", "965.02", "E950.1", "729.72" ]

icd9cm

[ [ [] ] ]

[ "83.45", "39.95", "93.59", "99.15", "86.69", "38.93", "83.09", "96.71" ]

icd9pcs

[ [ [] ] ]

17676, 17719

4709, 15882

323, 378

17952, 18044

2311, 2311

18785, 19468

1988, 1997

15940, 17653

17740, 17931

15908, 15917

18068, 18762

2012, 2292

275, 285

406, 1126

2327, 4686

1148, 1473

1489, 1972

26,926

154,304

820

Discharge summary

report

Admission Date: [**2103-12-21**] Discharge Date: [**2103-12-23**] Date of Birth: [**2063-8-23**] Sex: F Service: MEDICINE Allergies: Iodine; Iodine Containing / Morphine / Oxycontin Attending:[**First Name3 (LF) 477**] Chief Complaint: Facial Numbness Major Surgical or Invasive Procedure: Mechanical Ventilation History of Present Illness: Ms. [**Known lastname 3444**] is a 40 yo woman with metastatic breast CA to bone direct admitted to the floor for metastasis of the sphenoid encoroaching on the posterior wall of the L orbit & mandibular mets causing orbital pain, periorbital and mental numbness. She has noted these symptoms since about [**12-16**] and they have progressed from tingling to numbness. She is also seeing black spots on her vision. She also notes for the past 2 weeks she has had weakness &numbness of her LLE, for the past 1 week she has been unable to flex her hip, extend her knee, or dorsiflex her foot. She also complains of low back pain. This morning she had difficulty holding her urine to make it to the bath room. Denies any peri-anal numbness. . She presented to the ED on [**12-19**] with a few days of numbness in L side of face, down her body, etc. CT scan was non-diagnostic and she left AMA. Open MRI (see below) showed bony disease of the greater wings of sphenoid, extending into the optic canal, and bony involvement of the mandible approaching the inferior alveolar nerve canal. Past Medical History: Metastatic breast cancer with verterbral metastasis s/p XRT to thoracic spine & chemotherapy HTN Morbid Obesity Depression Anemia Post partum cardiomyopathy- EF now improved to 45-50% h/o peritonsillar abscess [**2101**] s/p I&D ?transfusion reaction recently ?anxiety Social History: Lives at home with husband and children. smoking [**1-17**] cigarettes per day Family History: Aunt with [**Name2 (NI) 499**] cancer at 46. Grandmother had leukemia. Mother: diabetes. [**Hospital 5772**] medical history unknown to patient. Physical Exam: T 97.5 HR 95 BP 130/95 RR 16 100%RA GENERAL: NAD, AOX3, Speaking in full sentences HEENT: PEERLA, No scleral icterus. CV: S1 S2 No M/R/G PULM: Clear to ausculation bilaterally ABDOMEN: Morbid Obesity, soft, Non-Tender, Non-Distended, BS+ EXTREMITY: No cyanosis, clubbing or edema NEURO: Alert and Oriented x3. Pt unable to move L eye up and lateral without discomfort. Left sided V1-V3 lacking sensation. Bilateral mental area lacking sensation. Mild left facial droop. Right V1-V2 WNL. 5/5 Strength and Sensation in Upper Extremities Bilaterally. 5/5 Strength and sensation R LE. 1/5 Strength in LLE extensors. No sensation on mid and anterior thigh. Sacral area with normal sensation bilaterally. Anal wink intact. Equivocal 1+ reflexes due to pt's habitus. Equivocal babinski signs bilaterally. Pertinent Results: Admission Labs: [**2103-12-20**] 10:22AM WBC-4.9 RBC-3.01* HGB-8.7* HCT-26.0* MCV-86 MCH-29.0 MCHC-33.6 RDW-19.5* [**2103-12-20**] 10:22AM PLT COUNT-245 [**2103-12-20**] 10:22AM GRAN CT-3332 [**2103-12-20**] 10:22AM CEA-100* CA27.29-3139* [**2103-12-20**] 10:22AM ALBUMIN-3.8 CALCIUM-9.7 PHOSPHATE-4.9* MAGNESIUM-1.8 [**2103-12-20**] 10:22AM ALT(SGPT)-36 AST(SGOT)-94* LD(LDH)-608* ALK PHOS-108 TOT BILI-0.6 [**2103-12-20**] 10:22AM UREA N-9 CREAT-0.8 SODIUM-143 POTASSIUM-4.3 CHLORIDE-105 TOTAL CO2-28 ANION GAP-14 [**2103-12-20**] 12:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-NEG . EXAM: MRI of the cervical, thoracic, and lumbar spine. CLINICAL INFORMATION: Patient with left lower extremity weakness and urinaryincontinence, rule out cord compression. CERVICAL SPINE: TECHNIQUE: T1, T2 and inversion recovery sagittal and gradient-echo axial images of cervical spine were acquired. FINDINGS: Diffuse metastatic lesions are identified in the cervical vertebral bodies on the partially visualized upper thoracic region. Mild compression of the inferior endplate of C7 vertebra and mild anterior wedging of T4 vertebra are identified. There is no cord compression seen or epidural mass. The post-gadolinium cervical images are somewhat limited by motion. There is no abnormal signal seen within the spinal cord. Endotracheal tube is visualized with retained secretions in the nasopharynx. IMPRESSION: Diffuse bony metastatic disease. No cord compression seen. THORACIC SPINE: TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial images were obtained before gadolinium. T1 sagittal and axial images were obtained following the administration of gadolinium. FINDINGS: Diffuse bony metastatic lesions are identified in the thoracic region. No evidence of epidural mass or spinal cord compression seen. Mild wedging of the T4, T6, T10, and T12 vertebral bodies noted. There is no evidence of intrinsic spinal cord signal abnormalities identified. No acute compression fracture seen. Diffuse metastatic lesions are identified in the liver and also an area of atelectasis seen in the left lower lung. IMPRESSION: Diffuse bony metastasis. No abnormal intraspinal enhancement. No cord compression. LUMBAR SPINE: TECHNIQUE: T1, T2 and inversion recovery sagittal and T2 axial images were obtained before gadolinium. T1 sagittal and axial images were obtained following the administration of gadolinium. FINDINGS: Diffuse bony metastasis is identified in the lumbar region and in the visualized sacrum. There is no evidence of high-grade thecal sac compression identified. No epidural mass is seen. At L4-5, there is diffuse disc bulge identified indenting the thecal sac with mild left-sided and moderate right-sided foraminal narrowing. The disc bulging and a small protrusion is in contact with exiting right [**Name (NI) 5774**] nerve root at this level. At L5-S1 level, mild disc bulging identified. IMPRESSION: Diffuse bony metastatic disease. No evidence of epidural mass or high-grade thecal sac compression. Degenerative changes in the lower lumbar region as described above. COMMENT: Compared to the previous MRI of [**2102-7-5**], there appears to be some progression of bony metastatic lesions in the spine. No epidural mass is seen. The degenerative changes in the lumbar region appear stable. . Pertinent Labs: [**2103-12-22**] 05:14AM BLOOD calTIBC-298 VitB12-> [**2094**] Folate-8.4 Ferritn-> [**2094**] TRF-229 [**2103-12-22**] 05:14AM BLOOD Calcium-9.8 Phos-5.9* Mg-1.6 Iron-245* Brief Hospital Course: 40F with metastatic breast CA to bone presenting with facial numbness and leg weakness and urinary incontinence. . # Mental Numbness: The patient presented with left sided facial weakness and bilateral mental numbness. This was thought to be secondary to metastic disease. The patient was given decadron 10mg IV x 1, and then 4mg po q6hrs. The patient underwent a single cranial XRT treatment and subsequently her left sided facial weakness and numbness resolved. Neuro-Onc was consulted and stated "This is most likely localized in the jaw but not in the principal or spinal gnaglia of V." The patient stated her mental numbess was much improved at the time of discharge. . # Left Sided Visual Changes: The patient reported black spots in her vision upon presentation. This was thought to be second to optic nerve compression secondary to tumor. Neuro was consulted and stated "The tumor to the optical canal explains the eyes symptoms." Following dexamthasone and XRT the patients symptoms resolved. . # Leg Weakness and r/o Cord Comprssion: The patient reported 5 to 7 day history of left lower extremity and numbness prior to admission. In addition she had noted urinary incontinence. The initial differential included deficits to cord compression vs a central process. It thought to be unlikely a central process due to sparing her arms. The patient was seen by neurology, neuro-onc and rad-onc. The patient underwent a MRI spine (requiring subsequent intubation and transfer to the unit for extubation, details of which are above), that did not reveal evidence of cord compression. The patient continued to receive PO dexamethasone and subsequently her leg weakness and numbness completely at the time of discharge. . # Anemia of Chronic Disease: The patient presented with a Hct of 26. Iron studies that were sent that were consistent with anemia of chronic disease. The patient's Hct at discharge was 24.5. The patient did not receive transfusions during her hospital course. The patient should have her hematocrit checked this week. Medications on Admission: albuterol prn flexeril 5-10mg po q 6 H prn hctz 25mg po daily lisinopril 30mg po daily Toprol XL 100mg po daily oxycontin 20mg po bid percocet 1-2 tabs po q 4-6 hrs prn zometa q month MVI Discharge Medications: 1. Metoprolol Succinate 100 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO at bedtime. 2. Lisinopril 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 3. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 4. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 9. Flexeril 10 mg Tablet Sig: One (1) Tablet PO four times a day. 10. Dexamethasone 4 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*21 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis - Metstatic Breast CA - Mental Neuropathy - r/o Cord Compression - r/o Left Optic Nerve Compression Discharge Condition: Good. Patients left lower extremity weakness completly resolved. Left lower extremity numbness completely resolved. Left visual changes completely resolved. Left facial numbess resolved with exception to mild numbess on the patients chin. Patient ambulating and at her mental and physical baseline. Discharge Instructions: You were admitted to hosptial with facial numbness, blurred vision in your left eye and left leg weakness and numbness. You were intubated and underwent an MRI. You received one dose of radiation. . Please continue to take all of your medications as listed below. . Please keep all of your appointments. . Please return to hospital if you experience worsening back pain, loss of urine or stool, numbess in your lower extremities, fevers, chills, shortness of breath, worsening visual changes. Please stop smoking. Information was given to you on admission regarding smoking cessation. Followup Instructions: Please follow-up with your PCP [**Name Initial (PRE) 176**] 1-2 weeks of discharge. . Please call Dr. [**First Name4 (NamePattern1) 1356**] [**Last Name (NamePattern1) 5775**] office tomorrow for follow-up. . Radiation Oncology plans to call you on Monday morning to schedule follow-up. [**Name6 (MD) **] [**Name8 (MD) 490**] MD, [**MD Number(3) 491**]

[ "V86.0", "V87.41", "674.54", "300.00", "198.4", "351.8", "368.8", "278.01", "174.8", "196.3", "V15.3", "305.1", "285.22", "788.30", "377.49", "401.9", "300.29", "311", "198.5" ]

icd9cm

[ [ [] ] ]

[ "92.29" ]

icd9pcs

[ [ [] ] ]

9700, 9706

6469, 8512

326, 351

9868, 10169

2850, 2850

10802, 11187

1869, 2016

8751, 9677

9727, 9847

8538, 8728

10193, 10779

2031, 2831

271, 288

379, 1463

2866, 6256

6272, 6446

1485, 1756

1772, 1853

78,559

143,964

40652

Discharge summary

report

Admission Date: [**2126-4-9**] Discharge Date: [**2126-4-17**] Date of Birth: [**2064-8-6**] Sex: M Service: CARDIOTHORACIC Allergies: Propoxyphene / Levofloxacin / Penicillins / Erythromycin Base Attending:[**First Name3 (LF) 1406**] Chief Complaint: s/p fall and NSTEMI Major Surgical or Invasive Procedure: [**2126-4-12**]: Coronary Artery ByPass Grafting x5 (LIMA>LAD, SVG>Diag, SVG>OM, SVG>PDA>PLV) History of Present Illness: Mr. [**Known lastname 43357**] is a 61 year old man with a history of Diabetes Mellitus, End stage renal disease, Hypertension who developed some unsteadiness at his home and fell while in the bathroom, striking his head on Saturday, and subsequently presented to the emergency department at [**Hospital1 487**] with respiratory failure. He says that he fell in the shower because he slipped on some soap, and at that time denied any chest pain or shortness of breath. However, subsequently upon presenting to the emergency room, he started to develop chest pain, which felt similar to the pain he had had a few months ago at LGH. At LGH at that time, apparantly he was told that he might be a candidate for cardiac surgery; he was also evaluated at [**Hospital1 2025**] several years ago for surgery, which ultimately did not materialize. Regardless, he had an CXR at LGH that was interpreted as congestive heart failure, and was dialyzed with the removal of four liters of fluid. He initally was on the step down unit, but was transferred subsequently to the ICU after more respiratory distress. He had cardiac enzymes that were cycled and ruled in for an NSTEMI with elevated tropinin I. Repeat CXR post dialysis showed upper and lower lobe infiltrates consistent with PNA, and had a fever to 103. He was placed on Zosyn and Zithromax for a presumed pneumonia, despite negative cultures. Further cardiac workup included angiogram which revealed multivessel coronary disease. He was transferred to [**Hospital1 18**] for evaluation of surgical revascularization. Past Medical History: +Diabetes, Dyslipidemia,Hypertension, ESRD, Diabetic nephropathy, - Tonsillectomy in [**2119**] - (L)BC AV Fistula in the LUE in [**2123**] Social History: SOCIAL HISTORY: Married -Tobacco history: Nonsmoker -ETOH: Does not drink alcohol -Illicit drugs: Family History: FAMILY HISTORY: Family history of malignancy. Physical Exam: Admission Physical Exam: Weight 66.9 kg VS: T 98.2 BP 177/77 HR 60 RR 20 100% 2L GENERAL: WDWN male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple without JVD CARDIAC: 2/6 systolic ejection murmur appreciated LUNGS: Faints crackles at the bases bilateraly ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: Trace edema bilateraly. Good thrill in the right arm. A femoral bruit is apprecaited on the right. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Pertinent Results: Admission labs: [**2126-4-9**] 09:50PM PT-12.8 PTT-24.6 INR(PT)-1.1 [**2126-4-9**] 09:50PM PLT COUNT-186 [**2126-4-9**] 09:50PM WBC-4.8 RBC-3.19* HGB-10.2* HCT-30.7* MCV-96 MCH-32.1* MCHC-33.3 RDW-16.5* [**2126-4-9**] 09:50PM TOT PROT-6.1* ALBUMIN-3.3* GLOBULIN-2.8 CALCIUM-8.3* PHOSPHATE-4.0 MAGNESIUM-2.2 [**2126-4-9**] 09:50PM CK-MB-3 cTropnT-0.69* [**2126-4-9**] 09:50PM CK(CPK)-131 [**2126-4-9**] 09:50PM GLUCOSE-137* UREA N-40* CREAT-7.1* SODIUM-139 POTASSIUM-5.4* CHLORIDE-103 TOTAL CO2-23 ANION GAP-18 [**2126-4-10**] 04:16AM BLOOD %HbA1c-5.3 eAG-105 Discharge labs: [**2126-4-17**] 06:28AM BLOOD WBC-6.1 RBC-2.71* Hgb-8.6* Hct-25.1* MCV-93 MCH-31.6 MCHC-34.2 RDW-16.0* Plt Ct-205 [**2126-4-17**] 06:28AM BLOOD Plt Ct-205 [**2126-4-17**] 06:28AM BLOOD PT-11.8 PTT-19.0* INR(PT)-1.0 [**2126-4-17**] 06:28AM BLOOD Glucose-95 UreaN-51* Creat-7.6*# Na-131* K-5.1 Cl-90* HCO3-28 AnGap-18 [**2126-4-16**] 10:04AM BLOOD ALT-19 AST-26 LD(LDH)-236 AlkPhos-51 Amylase-84 TotBili-0.2 [**2126-4-17**] 06:28AM BLOOD Albumin-2.9* Calcium-8.4 Phos-9.4*# Mg-2.5 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 55% to 60% >= 55% Findings LEFT ATRIUM: Normal LA size. Good (>20 cm/s) LAA ejection velocity. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Overall normal LVEF (>55%). RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal ascending, transverse and descending thoracic aorta with no atherosclerotic plaque. Normal ascending aorta diameter. Normal aortic arch diameter. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. No AS. No AR. MITRAL VALVE: No MS. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. Pulmonic valve not well seen. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. The patient received antibiotic prophylaxis. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. patient. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-CPB:1. The left atrium is normal in size. 2. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. The ascending, transverse and descending thoracic aorta are normal in diameter and free of atherosclerotic plaque. There are simple atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. There is no aortic valve stenosis. No aortic regurgitation is seen. 6. Mild (1+) mitral regurgitation is seen. Dr. [**Last Name (STitle) **] was notified in person of the results. POST-CPB: On infusion of phenylephrine. AV then A pacing for slow sinus rhythm. Preserved biventricular systolic function post cpb. MR remains 1+. The aortic contour is normal post decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2126-4-12**] 17:27 Radiology Report CHEST (PA & LAT) Study Date of [**2126-4-15**] 9:21 AM Final Report: Anterior mediastinal wires appear intact. A left IJV line tip ends in the mid SVC. A tiny left upper pneumothorax is again noted. There is no pneumothorax on the right. There is no pleural effusion. Interval decrease in small right retrocardiac opacity since prior study [**2126-4-13**]. Subtle opacity in the left base is less conspicuous and likely represents atelectasis. The cardiomediastinal and hilar contours are stable. IMPRESSION: Tiny small left upper pneumothorax. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Brief Hospital Course: 61 year old man with Hx DM, ESRD, HTN who fell at home, was found to have an NSTEMI, and diffuse 3VD on cardiac catheterization. # CORONARIES/NSTEMI: The patient at OSH was notd to have an NSTEMI with elevations in his troponin to a maximum of 2.74. At our hospital, he was noted to have stable tropinins at approximately 0.63. An EKG done from OSH on [**4-2**] shows ?RBBB as well as ST depressions in V5 and V6, as well as elvations in V1 and AvR. A repeat EKG at [**Hospital1 18**] shows similar findings, with less elvation in AvR, V1, and less depressions in V4, V5. Cardiac catheterization from OSH report can be seen in the HPI, but briefly had very diffuse 3VD. Given this finding, the patient's Plavix from OSH was held, and the patient was started on [**Hospital1 **] 325 mg. His Metoprolol was discontinued, and changed to Labetolol 200 mg [**Hospital1 **]. We continued his Atorvastatin 80 mg Daily, and increased his lisinopril to 40 mg Daily (up from 2.5 mg Daily at home). LDLcalc was 27, but in the setting of NSTEMI can be falsely low. HgBA1c is low at 5.3%, indicating good control of his diabetes. The patient left the medical floor on appropriate medical therapy for his CAD with a beta [**Last Name (LF) 7005**], [**First Name3 (LF) **], lisinopril, and high dose statin. # PUMP: Per OSH ECHO, patient has hypokinesis of the mid inferior, the apical inferior, and the basal inferior segments. EF on our echo does not demonstrate any focal hypokinesis, but confirms the EF aroudn 55% percent. Patient is very volume overloaded given his hypertension in the setting of ESRD. He underwent two dialysis sessions prior to his transfer to surgery, and were ultimately able to take off approximately 5 L of fluid. # ESRD: Secondary to longstanding diabetes, OSH Cr was 6.65. Patient recieves dialysis as per HPI three times a week. He underewnt two sessions of dialysis prior to his transfer to surgery. We decreased his insulin glargine regimen from 15 U a day to 10 U a day given his excellent A1c control, and continued his Sevelamer CARBONATE 800 mg PO TID. # DM: Patient HgBA1c indicates excellent control of his home diabetes, and patient has had some issues with partially low BS. Therefore we continued his long acting insulin at 10 U instead of 15 U. # Bone Scan Findings: OSH Bone scan showed mild degenerative changes over the SI joint, moderate focal skeletal lesions anterior left lateral aspect L2, anterior right latrael aspect L3, possibly suggesting focal traumatic changes or focal compression changes. The patient does not appear to have a colonoscopy per LGH records, but the patient's T-protein and Albumin are both low. A PSA screen is negative. As an outpatient, it will be appropriate for the patient to get age appropriate screen. # PNA: Patient has had a fever at OSH to 103, and per CXR report had what looked like a multifocal PNA. During his medicine admission he did nto have any fevers or elevations in his white count, or any cough with productive sputum. LGH records indicate that hte patient was treated for at least 7 days with both azithormycin as well as Zosyn. Given an appropriate treatment for what we believed to be a CAP PNA, we did not continue his antibiotics without any ill effects in terms of symptoms, WBC count, or fevers. Repeat CXR shows possible PNA in the RLL, but we will presume that this is old in the setting of appropriate antibiotic treatment. Urine cultures have been negative. Cardiac Surgery Hospital Course The patient was brought to the operating room on [**2126-4-12**] where the patient underwent CABG x5 (LIMA>LAD, SVG>Diag, SVG>OM, SVG>PDA>PLV). Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 the patient was extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable. Beta [**Date Range 7005**] was initiated. Nephrology continued to follow for hemodialysis. Insulin was titrated to maintain FSBS < 120. The patient transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication per cardiac surgery protocol. The patient worked with the physical therapy service for assistance with strength and mobility. By the time of discharge on POD 5 the patient was ambulating with assistance, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to [**Hospital3 105**]-[**Location (un) 86**] in good condition with appropriate follow up instructions. Medications on Admission: Lasix 40 mg PO Renagel 800 mg PO Simvastatin 80 mg Daily Toprol Xl 30 mg PO Omeprazoel 20 mg PO Lisinopril 20 mg PO Clonazepam 0.5 mg PO Amlodipine 30 mg PO Reglan 10 mg PO Aspirin 81 mg Daily Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. insulin regular human 100 unit/mL Solution Sig: sliding scale Injection QAC&HS. 7. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 8. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for fever, pain. 9. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed for constipation. 10. tramadol 50 mg Tablet Sig: One (1) Tablet PO every 4-6 hours as needed for pain. 11. lisinopril 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: Diabetes Dyslipidemia Hypertension AV Fistula in the LUE in [**2123**] ESRD- stage 5 Chronic Kidney disease (on HD) Diabetic Nephropathy Past Surgical History: s/p Tonsillectomy in [**2119**] Left brachiocephalic AVF for dialysis Discharge Condition: Alert and oriented x3 nonfocal Ambulating, with assistance-very limited effort Sternal pain managed with Ultram Sternal Incision - healing well, no erythema or drainage Edema-none Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for one month or while taking narcotics. Driving will be discussed at follow up appointment with surgeon. No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments: Surgeon Dr.[**Last Name (STitle) **] Phone #:[**Telephone/Fax (1) 170**] Date/Time:[**2126-5-8**] at 1:00 pm Cardiologist Dr.[**Last Name (STitle) **]: on [**5-15**] at 3:45pm Follow up appt in AV Care clinic: call [**Doctor First Name **] @[**Telephone/Fax (1) 3618**] to confirm time of appt Please call to schedule the following: Primary Care Dr. [**Last Name (STitle) 88931**],[**First Name3 (LF) **] in [**2-26**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2126-4-17**]

[ "V45.11", "V15.82", "414.01", "787.91", "585.6", "410.71", "285.9", "276.7", "250.40", "486", "781.3", "272.4", "403.91", "V58.67" ]

icd9cm

[ [ [] ] ]

[ "36.14", "38.93", "39.95", "39.61", "36.15" ]

icd9pcs

[ [ [] ] ]

13406, 13477

7517, 12138

347, 443

13752, 13934

3148, 3148

14685, 15355

2349, 2380

12381, 13383

13498, 13636

12164, 12358

13958, 14662

3737, 5538

13659, 13731

5582, 7494

2420, 3129

287, 309

471, 2037

3164, 3721

2060, 2201

2233, 2317

41,457

142,779

38266

Discharge summary

report

Admission Date: [**2197-7-14**] Discharge Date: [**2197-7-31**] Date of Birth: [**2141-6-5**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 598**] Chief Complaint: MVA Major Surgical or Invasive Procedure: Left thoracostomy tube x3 History of Present Illness: This patient was transferred from an outside hospital following a motor scooter accident where she was driving a motor scooter and was struck by a car; there was positive loss of consciousness; she was taken to [**Hospital **] Hospital where she was evaluated there in the emergency department; she had a CT of her head, chest, abdomen, neck, and was found to have an intracranial hemorrhage, multiple rib fractures on the left, left clavicle fracture, and a small left-sided pneumothorax; no chest tube was placed at the outside hospital due to concern for bleeding; she was given FFP as she is on Coumadin; on arrival here in the emergency department her mental status was normal, her GCS was 15, she was complaining of pain in her chest and left arm; her O2 sat was in the low to mid 90s on [**3-16**] L of nasal cannula at [**Hospital **] Hospital, in the emergency department her O2 sat dropped to the high 70s and needed to be supplemented with nonrebreather facemask which brought her O2 sat up to 100%. Past Medical History: Type 2 diabetes Opiate dependent chronic pain syndrome on methadone maintenance Hepatitis C History of embolic stroke x 2 On coumadin Migraine headaches Social History: - Tobacco Use: positive - Alcohol Use: unkown - Recreational Drug Use: opiates Family History: unkown Physical Exam: Temp:98.6 HR:106 BP:182/90 Resp:16 O(2)Sat:94 Constitutional: Awake alert and oriented HEENT: Multiple abrasions, Pupils equal, round and reactive to light. Extraocular muscles intact Patient is protecting her own airway Chest: Clear to auscultation, tenderness to palpation over the left chest, breath sounds are slightly diminished on the left. Cardiovascular: Regular Rate and Rhythm Abdominal: Soft, Nontender Pelvic: Pelvis is stable to palpation, there is a large hematoma over the left hip Extr/Back: She is moving her lower extremities equally and has normal sensation, capillary refill, and pulses distally Neuro: Speech fluent Pertinent Results: [**2197-7-14**] 02:55PM BLOOD WBC-18.1* RBC-3.97* Hgb-11.0* Hct-33.3* MCV-84 MCH-27.8 MCHC-33.1 RDW-14.0 Plt Ct-308 [**2197-7-15**] 03:52AM BLOOD WBC-13.8* RBC-3.75* Hgb-10.5* Hct-31.9* MCV-85 MCH-27.8 MCHC-32.7 RDW-14.0 Plt Ct-320 [**2197-7-16**] 02:38AM BLOOD WBC-16.2* RBC-3.67* Hgb-10.3* Hct-30.7* MCV-84 MCH-28.0 MCHC-33.4 RDW-14.2 Plt Ct-282 [**2197-7-16**] 06:38PM BLOOD WBC-14.8* RBC-3.75* Hgb-10.3* Hct-31.3* MCV-83 MCH-27.4 MCHC-32.8 RDW-13.9 Plt Ct-250 [**2197-7-17**] 04:55AM BLOOD WBC-12.9* RBC-3.56* Hgb-10.1* Hct-29.6* MCV-83 MCH-28.4 MCHC-34.2 RDW-14.0 Plt Ct-375 [**2197-7-18**] 01:14AM BLOOD WBC-8.2 RBC-3.04* Hgb-8.4* Hct-25.2* MCV-83 MCH-27.5 MCHC-33.2 RDW-14.0 Plt Ct-336 [**2197-7-20**] 12:50PM BLOOD WBC-13.1*# RBC-3.13* Hgb-8.6* Hct-26.6* MCV-85 MCH-27.6 MCHC-32.5 RDW-14.2 Plt Ct-586*# [**2197-7-22**] 09:00AM BLOOD WBC-10.6 RBC-2.93* Hgb-7.9* Hct-25.4* MCV-87 MCH-27.0 MCHC-31.0 RDW-14.6 Plt Ct-578* [**2197-7-27**] 06:20AM BLOOD WBC-11.8* RBC-3.03* Hgb-8.3* Hct-26.9* MCV-89 MCH-27.5 MCHC-31.0 RDW-16.9* Plt Ct-856* [**2197-7-28**] 07:10AM BLOOD WBC-10.4 RBC-2.99* Hgb-8.2* Hct-26.5* MCV-89 MCH-27.4 MCHC-30.9* RDW-17.2* Plt Ct-824* [**2197-7-14**] 02:55PM BLOOD PT-17.3* PTT-24.6 INR(PT)-1.6* [**2197-7-16**] 02:38AM BLOOD PT-12.1 PTT-21.7* INR(PT)-1.0 [**2197-7-27**] 06:20AM BLOOD PT-12.7 PTT-23.1 INR(PT)-1.1 [**2197-7-28**] 07:10AM BLOOD PT-13.8* PTT-24.7 INR(PT)-1.2* [**2197-7-29**] 07:25AM BLOOD PT-16.8* PTT-26.5 INR(PT)-1.5* [**2197-7-14**] 02:55PM BLOOD Glucose-217* UreaN-13 Creat-0.7 Na-137 K-3.6 Cl-100 HCO3-27 AnGap-14 [**2197-7-15**] 03:52AM BLOOD Glucose-223* UreaN-11 Creat-0.6 Na-133 K-3.4 Cl-99 HCO3-23 AnGap-14 [**2197-7-16**] 06:38PM BLOOD Glucose-328* UreaN-15 Creat-0.6 Na-130* K-3.9 Cl-94* HCO3-23 AnGap-17 [**2197-7-18**] 01:14AM BLOOD Glucose-178* UreaN-19 Creat-0.6 Na-132* K-3.9 Cl-97 HCO3-27 AnGap-12 [**2197-7-19**] 06:00AM BLOOD Glucose-60* UreaN-14 Creat-0.5 Na-132* K-3.9 Cl-96 HCO3-29 AnGap-11 [**2197-7-22**] 01:35PM BLOOD Glucose-190* UreaN-14 Creat-0.7 Na-134 K-4.3 Cl-96 HCO3-32 AnGap-10 Ucx [**7-22**] STAPHYLOCOCCUS, COAGULASE NEGATIVE | STAPHYLOCOCCUS, COAGULASE NEGATIVE | | GENTAMICIN------------ <=0.5 S <=0.5 S LEVOFLOXACIN----------<=0.12 S <=0.12 S NITROFURANTOIN-------- <=16 S <=16 S OXACILLIN-------------<=0.25 S <=0.25 S TETRACYCLINE---------- <=1 S <=1 S VANCOMYCIN------------ 1 S 2 S [**2197-7-22**] 10:00 am SPUTUM Source: Expectorated. GRAM STAIN (Final [**2197-7-22**]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. RESPIRATORY CULTURE (Final [**2197-7-24**]): MODERATE GROWTH Commensal Respiratory Flora. LEGIONELLA CULTURE (Final [**2197-7-29**]): NO LEGIONELLA ISOLATED. FUNGAL CULTURE (Preliminary): YEAST. ACID FAST SMEAR (Final [**2197-7-24**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. MRSA screen: Neg Brief Hospital Course: 56 yo F transferred from an outside hospital following a motor scooter accident where she was driving a motor scooter and was struck by a car; there was positive loss of consciousness; she was taken to [**Hospital **] Hospital where she was evaluated there in the emergency department; she had a CT of her head, chest, abdomen, neck, and was found to have an intracranial hemorrhage, multiple rib fractures on the left, left clavicle fracture, and a small left-sided pneumothorax; no chest tube was placed at the outside hospital due to concern for bleeding; she was given FFP as she is on Coumadin Also Recieved Vitamin K and factor 9 in ED here. Injuries: punctate foci hem L ftl, suporb ftl L frontal SDH lt clavicular & scapular fx lt ribs 1-7fx tiny lt PTX (seen on CT only) ->CT placed in TICU IMAGING: [**7-14**] Admitted TSICU. Home methadone use . CT head: mult punctate foci of hemorrhage in L superior frontal lobe. New 4 mm left frontal acute SDH. Bilat occipital old infrcts. New small left IVH. New foci punctate hemorrgae in the supra orbital parts of the frontal lobes. [**7-15**] Reg diet. Nsurg recs rpt CT head unchanged, sign-off, okay for HSQ, f/u Dr. [**First Name (STitle) **] 1 month. NPH 10u qpm, insulin gtt. d/c PCA, percocet. CXR: reexpansion of the left lung. L CT basal. CT head: Tiny punctate hyperdensity in the right temporal lobe just medial to the temporal [**Doctor Last Name 534**] of the right lateral ventricle. Stable appearance of intraparenchymal and intraventricular hemorrhages. Stable appearance of bilateral occipital lobe infarcts. Interval decrease in left frontal subdural hematoma. [**7-16**] [**Name (NI) 85277**] No PTX. LLLatelectasis and RML and RLL opacities unchanged. [**7-17**]: Left Hip Xray:no e/o fracture EVENTS: . [**7-16**] CPS consulted for pain regimen. Started Ocycontin 40 mg ( recs to inc to 60) and oxycodone 10 mg with methadone maintence. OT / PT consult. Hyperglycemic to 400s immediatley before given NPH. [**7-18**]: Neuro consult for hx CVA's. CT waterseal, CXR post no expand PTX, placed back on suction. Records from PCP [**Name Initial (PRE) **]. CPS recs d/c oxycontin, inc methadone to home dose 60 [**Hospital1 **]. Neurologic: Neuro checks Q: 4 hr, L frontal/supraorbital IPH, L frontal SDH stable on repeat CT. F/u with Dr. [**First Name (STitle) **] 1 month. Chornic pain consulted re tranisitional pain regimen. Pain control - methadone 40mg qd, Oxycontin 40mg, Oxycodone 10 prn.Tylenol 1000 q6h.[**Month (only) 116**] increase Oxycontin and add Gabapentin or Tizanidine as adjuncts.No epidural for now per Pain team ASA 325 Started [**7-17**] . Left hip Xray:no e/o fracture Cardiovascular: Goal Maintain SBP < 160. Autoregulating.Lopressor PRN Pulmonary: Multiple rib fractures left side, left clavicle and scapula fracture. - Sling to left arm - cont CT to suction Gastrointestinal / Abdomen: - bowel regimen Nutrition: - regular diet.Not eating much therefore IV Fluids continued Renal: Foley, Adequate UO, No active issues. Hematology: Stable HCT. Endocrine: Type 2 DM. glucose control improved.on NPH and sliding scale Infectious Disease: No active infectious issues. Patient improved, was transferred to the floor. OT and PT started working with her, recommended rehabilitation services at the moment of discharge. Patient was not able to get rehabilitation services due to insurance coverage, Neurology was consulted We were asked to comment on the need for resumption of OAC given her history of recurrent strokes and recent MVA. We obtained records from her PCP in an attempt to clarify her previous work up and the cause(s) of her prior strokes. On neurological examination is mostly noted for a dense right field cut and a milder left field cut. Testing muscle strength in the left arm is limited due to pain. Toes appear upgoing bilaterally. She is in NSR. Her head CT scan shows small scattered ICHs and a small IVH in the left occipital [**Doctor Last Name 534**], a left frontal SDH, and old bilateral occipital lobe infarcts (left > right). It is unclear from the faxed records why she was started on OAC after her first stroke. However, she tolerated it well and had no recurrent strokes until she stopped taking coumadin. Based on the available information , it is likely reasonable to resume OAC in [**8-19**] days. In the meantime, we will attempt to contact her Neurologist to obtain further information and to discuss the issue of resuming OAC with him since he has been primarily involved in her care. Pain service was consulted for management of pain. We continue Methadone, Oxycodone and Tylenol for management of her pain. Chest x ray showed left apical pneumothorax with no interval change in spite left basilar and apical CT in place, on suction. Anterior chest tube was place, apical pneumothorax discharge. CXR [**7-29**] Previously reported left pneumothorax is no longer evident. Multiple contiguous rib fractures are again demonstrated throughout the left hemithorax, some of which are segmental. Adjacent pleural opacity has apparently slightly worsened and could reflect areas of loculated pleural fluid and/or extrapleural hematoma. New subtle interstitial opacities have developed in the mid and lower lungs and may reflect interstitial edema superimposed upon known underlying emphysema. Infectious etiology is also possible in the appropriate clinical setting. CXR 6/20Multiple consecutive rib fractures are again visualized in the left hemithorax as well as left clavicular fracture. Adjacent area of pleural or extrapleural opacity has decreased. Band-like areas of linear atelectasis in the left mid and lower lung are not appreciably changed. No pneumothorax. Physical therapy cleared her to go home due to improvement on ambulation. At the moment of discharge she was alert and oriented , ambulating with out assistant. Coumadin was restarted on HD 10 as recommended for Neurology service. Patient schedule a follow up appointment with PCP the day after discharge for INR check. PCP was informed of Hospitalization details. Medications on Admission: - methadine 60 mg po q 7am, 12 pm - levemir 20 mg sc daily - coumadin 10mg/1mg po daily - asa 325 mg po daily - percocet 5/325 mg 1-2 tabs po q6h - bupropion 150 mg po daily - lisinopril 5 mg po daily - vit D 5000 iu po daily - lovastatin 20 mg po daily - methadone 60 mg po daily - insulin Discharge Medications: 1. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) ML Injection TID (3 times a day). 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Neb Inhalation Q6H (every 6 hours). 4. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Neb Inhalation every six (6) hours. 5. Bupropion HCl 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Calcium 500 mg Tablet Sig: Two (2) Tablet PO three times a day. 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Senna 8.6 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed for constipation. 13. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 15. Methadone 10 mg Tablet Sig: Six (6) Tablet PO BID (2 times a day): On for chronic pain syndrome. 16. Oxycodone 5 mg Tablet Sig: 2-3 Tablets PO Q3H (every 3 hours) as needed for breakthrough pain. 17. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 18. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once): dose coumadin daily until goal range 2-3 reached. 19. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Fifteen (15) Units Subcutaneous Every morning at breakfast. 20. NPH Insulin Human Recomb 100 unit/mL Suspension Sig: Ten (10) Units Subcutaneous at bedtime. 21. Insulin Regular Human 100 unit/mL Solution Sig: One (1) dose Injection four times a day as needed for per sliding scale: see attached scale. Discharge Disposition: Home Discharge Diagnosis: s/p Motorscooter crash vs auto Left frontal subdural hemorrhage Left comminuted left clavicle and scapula fractures Multiple left sided rib fractures [**2-16**] Left pneumothorax 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 SHOULD NOT DRIVE OR OPERATE ANY MOTORIZED VEHICLES PER RECOMMENDATION OF NEUROLOGY. You were hospitalized following a crash on your motorized scooter vs. a car. You sustained multiple injuries including a bleeding injury to your brain; a broken collar bone & shoulder blade; left sided rib fractures [**2-16**] and a collapsed lung. Your collapsed lung required that you have a chest tube that was placed x3. Chest xrays were followed closely and once the collapsed area improved the chest tubes were removed. Followup Instructions: Follow up in [**Hospital 1957**] clinic in 2 weeks with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 85278**] NP; call [**Telephone/Fax (1) 9769**] for an appointment. Follow up in 4 weeks with Dr. [**First Name (STitle) **], Neurosurgery with a repeat non contrast head CT scan; call [**Telephone/Fax (1) 1669**] for an appointment. [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**] Completed by:[**2197-8-7**]

[ "810.02", "V58.61", "V12.54", "807.07", "E812.2", "599.0", "250.00", "070.70", "860.0", "853.02", "811.00", "346.90", "368.46" ]

icd9cm

[ [ [] ] ]

[ "34.04" ]

icd9pcs

[ [ [] ] ]

13964, 13970

5527, 6386

316, 344

14192, 14192

2358, 5293

14913, 15401

1673, 1682

11950, 13941

13991, 14171

11633, 11927

14374, 14890

1697, 2339

5329, 5504

273, 278

372, 1384

6839, 11607

14207, 14350

1406, 1561

1577, 1657

6,001

181,168

26072

Discharge summary

report

Admission Date: [**2183-11-18**] Discharge Date: [**2183-11-23**] Date of Birth: [**2148-9-23**] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Bactrim / Latex Attending:[**First Name3 (LF) 28789**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: 1) placement of central line into right subclavian 2) placement of midline History of Present Illness: Pt is a 35 year old G3P1011 at 21w2d ega who initially developed nausea and vomiting 2 days prior to admission. She developed acute-onset N/V and reports vomiting bilious fluid every 15 mintues. She ws unable to keep down po fluid. Pt presented to an OSH and received antiemetics and fluids and was sent home. On the day of admission the pt developed a fever and chills along with right pleural pain. The pt was seen at an OSH and was found to have a collapsed right middle lobe by CT scan along with infiltrate. Pt wa also found to be hypotensive and was subsequently given IVF (3L) at OSH w/ response. Pt was then transferred to [**Hospital1 18**] for further management. When pt arrived she ws tachycardic and tachypneic. She was kept on 5L NC to keep O2 sat > 94% and she was given a dose of ceftriaxone and azithromycin at the OSH. Pt states that her nausea has improved but states that she is very thirsty. She also states that one of her children recently had fever and URI symptoms. She has a non-prodouctive cough but denies hemoptysis or hematemesis. PNC: 1) Dating - EDC [**2184-3-29**] by first trimester US (per pt report) 2) Labs - O+/ Ab - (other prenatal labs not available given PNR not available) 3) Normal fetal survey per pt report 4) AMA -> normal first trimester screening and normal level 2 ultrasound per pt report 5) Hyperemesis - Treated w/ zofran prn Past Medical History: POBHx: - first trimester SAB - NSVD at term, 7#10, no complications PGYNHx: - hx of HPV, no other STDs PMH: benign PSH: none Social History: Pt works as a chemical engineer at [**Hospital1 10915**]. She denies EtOH, smoking, and drug use. Family History: Noncontributory Physical Exam: Vitals: T 101 HR 116 BP 97/40 RR 35 O2sat 94% 2L NC Gen: sitting up in bed, tachypneic HEENT: PERRLA, EOMI, OP clear, MMM Neck: enlarged thyroid gland on left, supple Lungs: decreased BS at right base Cardiac: tachycardic, RR, S1/S2 no murmurs Abdomen: soft, nontender, gravid Ext: warm, no edema, no rashes Neuro: A&O x 3 FHT 150s via doppler Pertinent Results: [**2183-11-18**] 07:58PM GLUCOSE-80 UREA N-8 CREAT-0.6 SODIUM-139 POTASSIUM-2.8* CHLORIDE-114* TOTAL CO2-13* ANION GAP-15 [**2183-11-18**] 07:58PM ALT(SGPT)-11 AST(SGOT)-16 LD(LDH)-150 ALK PHOS-31* TOT BILI-0.4 [**2183-11-18**] 07:58PM ALBUMIN-2.2* CALCIUM-7.0* PHOSPHATE-1.2* MAGNESIUM-1.5* [**2183-11-18**] 07:58PM TSH-1.2 [**2183-11-18**] 07:58PM FREE T4-0.8* [**2183-11-18**] 07:58PM WBC-6.1 RBC-3.23* HGB-10.7* HCT-29.2* MCV-91 MCH-33.0* MCHC-36.5* RDW-14.9 [**2183-11-18**] 07:58PM NEUTS-70 BANDS-18* LYMPHS-9* MONOS-2 EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 [**2183-11-18**] 07:58PM PLT COUNT-162 [**2183-11-18**] CXR: 1. Right subclavian venous access catheter with tip at the right atrial/SVC junction. The catheter tip location was discussed with the intern caring for the patient at the time of interpretation (8:50 p.m.). 2. Right middle and lower lobe opacity and right pleural effusion. 3. Rightward deviation of the trachea. This may represent enlargement of the left lobe of the thyroid gland. Correlation with any possible history of instrumentation in this region is also recommended. [**2183-11-20**]: TAUS Single live intrauterine gestation with size equals dates. Evaluation of the left ventricular outflow tract is limited due to position of the fetus. [**2183-11-20**]: Thyroid US The right thyroid lobe measures 1.7 x 2.1 cm at the level of the isthmus and no nodules are seen within it. The left lobe is nearly entirely replaced by a solitary nodule measuring 3.8 x 3.6 x 3.4 cm. The nodule has a hypoechoic rim, however also demonstrates increased color flow. IMPRESSION: Dominant nodule in the left lobe as described above. Ultrasound- guided FNA is recommended. Brief Hospital Course: 1) Pneumonia: Given concern for sepsis, the pt was admitted to the [**Hospital Unit Name 153**] upon transfer from the OSH. A central line into the R subclavian was placed. She was continued on ceftriaxone and azithromycin for community pneumonia coverage and was kept on supplemental O2 to keep her O2 sat > 94%. Aggressive chest PT was performed and albuterol nebulizers were administered to help open airways. The pt's hypotension improved w/ aggressive IV hydration and she did not require pressors. On HD#3, the pt had stabilized and was transferred to the floor to the antepartum service. On the evening of HD#3, the pt spiked a fever to 101.4 F and the infectious disease service was consulted to assess antibiotic coverage. Per ID recs, a repeat set of blood cultures were drawn, a sputum gram stain and culture, legionella urine antigen , and mycoplasma serologies were sent. The legionella urinary antigen was negative and gram stain of the sputum showed no organisms. Blood cultures from both [**2183-11-18**] and [**2183-11-20**] are still pending at the time of this dictation but have demonstrated no growth to date. ID also recommended keeping the pt on her current regimen of ceftriaxone and azithromycin. The pt subsequently defervesced. Her central line was removed on HD#4 without difficulty and a midline was placed for continuing antibiotics. On HD#6, the pt's O2 sat was 94-96% on room air. However, her maximum temperature within the past 24 hours was 100.6F. Given the pt's ongoing intermittent low-grade fevers as well as the serious nature of her pneumonia, she was counseled regarding staying in the hospital for another 1-2 days for further monitoring by both Dr. [**Last Name (STitle) **] ([**Doctor Last Name 13675**]) and Dr. [**First Name (STitle) **] (Infectious Disease). However, the pt refused and signed herself out against medical advice. VNA was set up for the pt for line care and antibiotic administration. Prescriptions for ceftriaxone and azithromycin were given to the pt. She was encouraged to make a follow-up appointment with Dr. [**Last Name (STitle) **] in [**12-1**] weeks and with her PCP [**Last Name (NamePattern4) **] 1 week. 2) Fetal well-being: Given the previable gestational age, the fetal heart tones were checked every day but no further interventions were performed. The pt had reassuring fetal heart rate spot checks in the 140s-150s throughout her hospital course. She underwent a full fetal survey on [**2183-11-20**] that demonstrated a single live intrauterine gestation with size equals dates. Evaluation of the left ventricular outflow tract was limited due to position of the fetus. 3) Thyroid nodule: On CT scan at the OSH, the pt was incidentally found to have a thyroid nodule in the left lobe. She underwent a thyroid ultrasound at [**Hospital1 18**] which demonstrated that the left thyroid lobe was nearly entirely replaced by a solitary nodule measuring 3.8 x 3.6 x 3.4 cm. The nodule has a hypoechoic rim, however also demonstrates increased color flow. Given this finding, ultrasound-guided FNA was recommended. TSH was checked and found to be wnl at 1.2, free T4 was slightly low at 0.8. The endocrine service was informally consulted and recommended outpatient follow-up in the thyroid nodule clinic in [**Month (only) 404**] for FNA. The pt was discussed w/ [**Doctor First Name **] [**Doctor Last Name 9835**] (endocrine fellow) who recommended scheduling a follow-up appointment for the pt ([**Telephone/Fax (1) 6468**]) with her upon discharge. Medications on Admission: prenatal vitamins zofran Discharge Medications: 1. azithromax Sig: One (1) 500 mg once a day for 7 days: Take daily for 7 days. Disp:*10 * Refills:*0* 2. Ceftriaxone 1 g Recon Soln Sig: One (1) Intravenous once a day for 4 days. Disp:*4 * Refills:*0* 3. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) **] home therapy Discharge Diagnosis: Right lower lobe pneumonia with sepsis Discharge Condition: Stable Discharge Instructions: Minimal exertion at home. ceftriaxone 1g each day azithromax 250mg each day Followup Instructions: Dr. [**Last Name (STitle) **] in [**12-1**] weeks Primary Care physician [**Name Initial (PRE) 176**] 1 week follow-up laboratory data and chest x-ray with primary care physician

[ "647.83", "648.13", "241.0", "648.23", "995.91", "486", "276.2", "038.9" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

8283, 8347

4252, 7812

312, 388

8430, 8439

2510, 4229

8563, 8745

2093, 2110

7887, 8260

8368, 8409

7838, 7864

8463, 8540

2125, 2491

253, 274

416, 1807

1829, 1961

1977, 2077

56,816

119,068

36225

Discharge summary

report

Admission Date: [**2131-5-23**] Discharge Date: [**2131-6-9**] Date of Birth: [**2072-7-22**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Progressive dyspnea on exertion Major Surgical or Invasive Procedure: Aortic Valve Replacement (#21mm St.[**Male First Name (un) 923**] Mechanical)/Mitral Valve Replacement (#29mm St.[**Male First Name (un) 923**] Mechanical)-[**5-23**] History of Present Illness: 58 year-old gentleman who has had progressive dyspnea on exertion. He also had a prior history of aortic stenosis and underwent cardiac catheterization in [**Month (only) 547**] which showed no significant coronary artery disease with severe aortic stenosis and mitral regurgitation. Echocardiogram performed on [**2131-1-31**] showed posterior mitral valve leaflet prolapse with moderate-to-severe MR, severe aortic stenosis with aortic valve area of 0.6 cm2 (peak gradient of 39 mm and mean gradient of 22 mm), and ejection fraction of 55%.Dr.[**Last Name (STitle) **] was consulted for surgical intervention and valvular replacement. Past Medical History: metabolic syndrome, hypertension, non-insulin-dependent diabetes mellitus, mitral regurgitation, aortic stenosis, aortic insufficiency, obstructive sleep apnea, chronic obstructive pulmonary disease, and pulmonary hypertension. Social History: He works as a contractor. His last dental examination was two months ago. He denies using tobacco currently but has used it occasionally in the past. However, he does have significant alcohol problem as he admits to six to nine beers per day...patient states he was quit drinking ETOH over the last month. Family History: His father had coronary artery bypass surgery in his 50s and died in his early 60s. A strong family history is also present of diabetes. Physical Exam: On exam, his heart rate is 73, respiratory rate 16, and blood pressure of 103/74. He is well developed and well nourished in no apparent distress. Skin was unremarkable and intact. His EOMs were intact. His pupils were equally round and reactive to light and accommodation. Neck was supple with full range of motion and no JVD or carotid bruitswere appreciated. Lungs were clear bilaterally. Heart revealsa regular rate and rhythm with a grade II/VI holosystolic murmur. Abdomen was soft, nontender, and nondistended with positive bowel sounds. Extremities were warm and well perfused without any edema or varicosities. He was alert and oriented x3. He is moving all extremities and had a nonfocal neurologic exam. He had 2+ bilateral femoral DP, PT, and radial pulses. Pertinent Results: [**2131-6-8**] 05:10AM BLOOD PT-24.3* PTT-87.7* INR(PT)-2.3* [**2131-6-7**] 05:30AM BLOOD PT-24.8* PTT-63.7* INR(PT)-2.4* [**2131-6-6**] 06:10AM BLOOD PT-20.4* PTT-64.6* INR(PT)-1.9* [**2131-6-5**] 06:05AM BLOOD PT-19.0* PTT-58.9* INR(PT)-1.7* [**2131-6-4**] 08:55AM BLOOD PT-19.9* PTT-77.4* INR(PT)-1.8* [**2131-5-23**] 05:46PM BLOOD WBC-7.7 RBC-3.02*# Hgb-8.6*# Hct-25.1*# MCV-83 MCH-28.4 MCHC-34.2 RDW-13.6 Plt Ct-120* [**2131-5-23**] 05:46PM BLOOD PT-15.0* PTT-33.2 INR(PT)-1.3* [**2131-5-26**] 02:11AM BLOOD Calcium-8.1* Phos-2.3* Mg-2.2 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT Done [**2131-5-29**] at 2:30:00 PM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. [**Hospital1 18**], Division of Cardiothorac [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2072-7-22**] Age (years): 58 M Hgt (in): 68 BP (mm Hg): 119/81 Wgt (lb): 205 HR (bpm): 75 BSA (m2): 2.07 m2 Indication: H/O cardiac surgery with 21mm [**First Name8 (NamePattern2) **] [**Male First Name (un) 923**] AVR, and [**First Name8 (NamePattern2) 70723**] [**Male First Name (un) 923**] MVR. ICD-9 Codes: V43.3, 424.1, 424.0 Test Information Date/Time: [**2131-5-29**] at 14:30 Interpret MD: [**First Name11 (Name Pattern1) 553**] [**Last Name (NamePattern4) 4133**], MD Test Type: Portable TTE (Complete) Son[**Name (NI) 930**]: [**First Name8 (NamePattern2) 4134**] [**Last Name (NamePattern1) 4135**], RDCS Doppler: Full Doppler and color Doppler Test Location: [**Location 13333**]/[**Hospital Ward Name 121**] 6 Contrast: None Tech Quality: Suboptimal Tape #: 2009W051-0:18 Machine: Vivid [**5-28**] Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: >= 60% >= 55% Aortic Valve - Peak Velocity: *2.8 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: *30 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 15 mm Hg Mitral Valve - Peak Velocity: 1.6 m/sec Mitral Valve - Mean Gradient: 5 mm Hg Mitral Valve - E Wave: 1.6 m/sec Mitral Valve - A Wave: 1.1 m/sec Mitral Valve - E/A ratio: 1.45 Mitral Valve - E Wave deceleration time: 209 ms 140-250 ms TR Gradient (+ RA = PASP): *30 mm Hg <= 25 mm Hg Findings LEFT VENTRICLE: Suboptimal technical quality, a focal LV wall motion abnormality cannot be fully excluded. Low normal LVEF. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. Paradoxic septal motion consistent with prior cardiac surgery. AORTIC VALVE: Bileaflet aortic valve prosthesis (AVR). Normal AVR gradient. No AR. MITRAL VALVE: Bileaflet mitral valve prosthesis (MVR). Normal MVR gradient. Trivial MR. [Due to acoustic shadowing, the severity of MR may be significantly UNDERestimated.] TRICUSPID VALVE: Normal tricuspid valve leaflets. Mild [1+] TR. Mild PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Pulmonic valve not well seen. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor parasternal views. Suboptimal image quality - bandages, defibrillator pads or electrodes. Conclusions Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. A bileaflet aortic valve prosthesis is present and appears well-seated. The transaortic gradient is normal for this prosthesis. No aortic regurgitation is seen. A bileaflet mitral valve prosthesis is present and appears well-seated. The transmitral gradient is normal for this prosthesis. Trivial 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. Electronically signed by [**First Name11 (Name Pattern1) 553**] [**Last Name (NamePattern4) 4133**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2131-5-29**] 17:33 Brief Hospital Course: [**5-23**] Mr.[**Known lastname 82119**] went to the operating room and underwent Aortic Valve Replacement (#21mm St.[**Male First Name (un) 923**] Mechanical)/Mitral Valve Replacement (#29mm St.[**Male First Name (un) 923**] Mechanical).Cross clamp time=126 minutes. Cardiopulmonary Bypass time=148 minutes. Please refer to Dr[**Last Name (STitle) **] operative report for further details. He tolerated the procedure well and was transferred to the CVICU in critical but stable condition, requiring pressors and inotrope to optimize cardiac output. He awoke neurologically intact and was extubated without difficulty. All drips were weaned to off. Beta-blocker was initially held off due to a first degree AV block. Anticoagulation was started with Coumadin, and bridged with a Heparin drip for therapeutic INR with mechanical valves. [**Last Name (un) **] was consulted for glucose control. Low dose Beta-blocker was ultimately started due to his increased heart rate. His rate blocked down, beta-blocker discontinued , and Electrophysiology was consulted. POD#9 PPM was placed secondary to heart block. EP interrogated the PPM and continued to follow. The remainder of his postoperative course was essentially uneventful. Discharge was dependent upon therapeutic INR. On POD# 17/8 Mr.[**Known lastname 82119**] was cleared by Dr.[**Last Name (STitle) **] for discharge to home with VNA. All follow up appointments were advised. Coumadin/INR to be followed by his PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 74648**]. Medications on Admission: Quinaretic 20/25 mg daily, Cartia XT 180 mg daily, Cozaar 100 mg daily, Simvastatin 80 mg daily, TriCor 48 mg daily, Aspirin 325 mg daily, Glucotrol 5 mg daily, Metformin 500 mg q.a.m. and 1000 mg q.p.m., Lasix 40 mg daily, Albuterol Inhalers, and Flovent Inhalers two puffs twice a day. Discharge Medications: 1. Outpatient Lab Work Dr. [**Last Name (STitle) **] will follow INR (confirmed with [**Doctor First Name **] in office) (P) [**Telephone/Fax (1) 82120**], (F) [**Telephone/Fax (1) 81987**]. VNA to fax results to office for titration. 2. Zocor 80 mg Tablet Sig: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*0* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Tablet, Delayed Release (E.C.)(s) 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 8. Fenofibrate Micronized 48 mg Tablet Sig: One (1) Tablet PO daily () as needed for hyperlipidemia. Disp:*30 Tablet(s)* Refills:*0* 9. Glipizide 5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*0* 10. Metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 12. Warfarin 2.5 mg Tablet Sig: as directed Tablet PO once a day: Please take 7.5 mg daily. INR will be checked monday by VNA and your doctor will call you with dose changes as needed. Disp:*90 Tablet(s)* Refills:*0* 13. Warfarin 1 mg Tablet Sig: as directed Tablet PO once a day: Please take 7.5 mg daily. INR will be checked monday by VNA and your doctor will call you with dose changes as needed. Disp:*50 Tablet(s)* Refills:*0* 14. Insulin Glargine 100 unit/mL Solution Sig: 15 units Subcutaneous at bedtime. Disp:*qs qs* Refills:*0* 15. Insulin Lispro 100 unit/mL Solution Sig: as directed Subcutaneous every six (6) hours: see discharge instructions for scale. Disp:*qs qs* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] [**Location (un) 14663**] Discharge Diagnosis: mitral regurgitation aortic stenosis s/p AVR, MVR this admission Discharge Condition: good Discharge Instructions: Please shower daily including washing incisions, no baths or swimming Monitor wounds for infection - redness, drainage, or increased pain Report any fever greater than 101 Report any weight gain of greater than 2 pounds in 24 hours or 5 pounds in a week No creams, lotions, powders, or ointments to incisions No driving for approximately one month No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] H. [**Telephone/Fax (1) 4688**]-in 1 week please call for appointment Dr. [**Last Name (STitle) **] will follow INR, confirmed with [**Hospital1 **] VNA to draw PT/INR Mon. [**2131-6-11**] and call results to Dr. [**Last Name (STitle) **] Wound check appointment [**Hospital Ward Name 121**] 6 as instructed by nurse ([**Telephone/Fax (1) 3071**] Completed by:[**2131-6-9**]

[ "E878.1", "427.69", "428.0", "416.8", "E849.7", "426.0", "396.2", "427.2", "493.20", "250.00", "997.1", "277.7" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.22", "37.72", "37.83", "35.24", "37.26" ]

icd9pcs

[ [ [] ] ]

10806, 10881

6863, 8402

352, 521

10990, 10997

2739, 6840

11509, 12039

1783, 1922

8741, 10783

10902, 10969

8428, 8718

11021, 11486

1937, 2720

281, 314

549, 1188

1210, 1440

1456, 1767

6,097

113,801

45169

Discharge summary

report

Admission Date: [**2111-1-1**] Discharge Date: [**2111-1-10**] Service: TRAUMA [**Last Name (un) **] HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname **] is an 88-year-old man status post a mechanical fall who apparently landed on his face with probable loss of consciousness. He was initially transferred to an outside hospital and, by report, had facial fractures with a severe nasal bleed. The patient subsequently asked to be transported to [**Hospital1 190**] because his primary care doctor is at [**Hospital1 1444**]. Prior to transport a posterior nasal pack was placed for a significant nose bleed. Upon arrival Mr. [**Known lastname **] was hypertensive with a blood pressure systolic of 190-200/palp and a heart rate in the 80's. He was noticeably bleeding from both nares, right greater than left. [**Location (un) 2611**] Coma Scale was 15. The posterior nasal pack was placed. Upon arrival Anesthesia was called to evaluate Mr. [**Known lastname **] because of the high likelihood of needing an airway. A 7.0 endotracheal tube was placed without significant difficulty. After the intubation the Trauma consult team was called to evaluate Mr. [**Known lastname **]. PAST MEDICAL HISTORY: 1. Coronary artery disease. 2. Parkinson's disease. 3. Hypertension. 4. Cerebrovascular accident. 5. Left eye ophthalmoplegia. 6. Echocardiogram in [**2110-7-20**] revealed an ejection fraction greater than 60%. PAST SURGICAL HISTORY: Coronary artery bypass graft. MEDICATIONS ON ADMISSION: 1. Aggrenox 25/200 p.o. b.i.d. 2. Sinemet 100 mg p.o. with one-half tablet t.i.d. 3. Lipitor 10 mg p.o. q. day. 4. Diltiazem XL 180 mg p.o. q. day. ALLERGIES: No known drug allergies. PHYSICAL EXAMINATION ON ADMISSION: Temperature 97.0 degrees, heart rate 78, blood pressure 216/88, respiratory rate 18, pulse oximetry 95% on room air. The physical examination was obtained prior to intubation. In general, in no acute distress sitting up in bed speaking in complete sentences. Neck: C-collar. No tracheal deviation. HEENT: Right eye: Pupil round and reactive with full range of motion. Left eye: Deviated laterally. Bilateral orbital ecchymosis. Mid face is stable. No malocclusion. No hemotympanum. Edema and ecchymoses over the entire mid face. Chest notable for a sternotomy scar. No crepitus. Breath sounds bilateral and equal. Cardiac regular rate and rhythm. Normal S1, S2. Abdomen is soft, non-tender and non-distended. Extremities: No deformities, no step-offs. Moves all extremities. Back: No step-offs, non-tender. Rectal: Normal tone, no mass, guaiac negative, normal prostate. Genitourinary: No blood at the meatus, otherwise normal. Neurologic: [**Location (un) 2611**] Coma Scale 15. Sensory and motor are intact bilaterally in all extremities. LABORATORIES ON ADMISSION: Sodium 139, potassium 4.2, chloride 102, bicarb 26, BUN 34, creatinine 1.3. White blood cell count 15.6, hematocrit 39.8. Platelets 222,000. INR 0.9. PTT 24.0. Lactate 1.3. Fibrinogen 289. Blood gas status post intubation with FiO2 of 100%: 7.46/38/491/28/3. Serum tox screen negative. Urine tox screen negative. Urinalysis negative. RADIOLOGY: Chest x-ray: No fracture, no pneumothorax. Pelvis: No fractures. Cervical spine: Lateral plain films C3, C4 anterolisthesis. Thoracic and lumbar plain films are negative. CT of the head is negative for any intracranial bleeding. CT of the face shows bilateral anterior and medial maxillary sinus fractures, bilateral medial pterygoid fracture. Multiple nasal bone fractures. There are air-fluid levels present within the sphenoid and frontal sinuses and left maxillary sinus. There is suspicion for a right orbital wall fracture but not definitely seen. HOSPITAL COURSE: After being evaluated in the Emergency Department and being intubated by Anesthesia, Mr. [**Known lastname **] was subsequently admitted to the Trauma Intensive Care Unit for further management and stabilization. He was started on Kefzol while the nasal packing was in place. The ORL/ENT consult service was asked to see Mr. [**Known lastname **] for his multiple nasal fractures and for management assistance with his nasal packing. The ORL team recommended continued nasal packing and followed Mr. [**Known lastname **] throughout his hospital stay. The Ophthalmology consult service was also asked to evaluate Mr. [**Known lastname **] given his findings on examination as well as his multiple fractures including possible orbit fracture. They continued to follow Mr. [**Known lastname **] throughout his hospital stay and there was no ophthalmologic intervention needed during Mr. [**Known lastname **] stay except for continuation of his dexamethasone and Cipro ophthalmic drops. They recommended follow up with his ophthalmologist upon discharge. The Plastic Surgery service was also asked to evaluate Mr. [**Known lastname **] given his multiple facial fractures. In addition, the Neurosurgery service was asked to evaluate Mr. [**Known lastname **] given his findings on his lateral C-spine. The Plastic Surgery service recommended an MRI of his spine which showed multiple severe spondylitic changes of the cervical spine with central canal and neural foraminal stenosis. On the [**8-1**] Mr. [**Known lastname **] was extubated without any problem. [**Name (NI) **] was maintained on supplemental oxygen and he did very well. On the [**8-2**] Mr. [**Known lastname **] was transferred to the regular floor where he has been progressing steadily with a decrease in his ecchymosis and edema. The Neurosurgery service signed off on Mr. [**Known lastname **] on [**1-3**] with a final [**Location (un) 1131**] on the MRI as being unremarkable and without any significant ligamentous injury or spinal cord compression. For Mr. [**Known lastname **] multiple facial fractures he was maintained on clindamycin for an antibiotic throughout his hospital stay. Also upon transfer to the floor the physical therapist and occupational therapy team began working with Mr. [**Known lastname **] to make sure that he was able to get out of bed and move towards rehabilitation given his multiple fractures and the confirmation of a LeFort type I fracture on a repeat CT scan, he was maintained on a pureed soft diet. He tolerated this well and there was no evidence of aspiration or other problems. On the [**2111-1-8**] Mr. [**Known lastname **] was taken to the Operating Room for an open reduction internal fixation of his LeFort type I fracture with four plates inserted. Dr. [**Last Name (STitle) 13797**] was the attending plastic surgeon on the case. There was also an excisional biopsy of a left alar lesion performed. Mr. [**Known lastname **] was intubated for this procedure and there were no complications associated with the procedure and he tolerated it very well. He was subsequently transferred back to the Post Anesthesia Care Unit and then the regular floor without any problems postoperatively. [**Name2 (NI) **] has done remarkably well. He has a nasal packing in place that will be removed prior to discharge by the Plastic Surgery team. He has a nasal splint that will be in place until follow up in the Plastic Surgery Clinic and he will not be able to wear his upper dentures for four weeks and he will be maintained on a pureed diet. He will also be continued on clindamycin for five days per the Plastic Surgery team. CONDITION AT DISCHARGE: Good. DISCHARGE STATUS: Acute rehabilitation facility per recommendations of the Physical Therapy team. DIAGNOSES: 1. LeFort type I fracture. 2. Nasal fractures. DISCHARGE MEDICATIONS: 1. Clindamycin 450 mg p.o. t.i.d. times five days. 2. Tylenol with codeine one to two tablets p.o. q. 4-6h. p.r.n. 3. Peridex mouth washes t.i.d. 4. Lipitor 10 mg p.o. q. day. 5. Sinemet 25/100 one-half tab p.o. t.i.d. 6. Dulcolax 10 mg p.o./p.r. q. day p.r.n. 7. Milk of magnesia 30 mL p.o. q. 6h. p.r.n. 8. Colace 100 mg p.o. b.i.d. 9. Diltiazem ER 240 mg p.o. q. day. 10. Dexamethasone ophthalmic solution one drop O.D. b.i.d. 11. Cipro ophthalmic solution one drop O.D. b.i.d. DISCHARGE INSTRUCTIONS: 1. Nasal splint on until seen in the Plastic Surgery Clinic on [**2111-1-16**], at 2:30 p.m. [**Telephone/Fax (1) 274**]. 2. No upper dentures for four weeks. 3. Diet is a cardiac diet with pureed. 4. Physical therapy and occupational therapy to work on strength and endurance. 5. Please follow up with Mr. [**Known lastname **] primary care doctor, Dr. [**First Name8 (NamePattern2) 1312**] [**Last Name (NamePattern1) 6457**], in five to seven days to recheck his physical and psychological condition. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 18153**], M.D. [**MD Number(1) 18154**] Dictated By:[**Last Name (NamePattern1) 9126**] MEDQUIST36 D: [**2111-1-9**] 14:20 T: [**2111-1-9**] 13:29 JOB#: [**Job Number 96545**]

[ "E885.9", "802.4", "723.0", "V45.81", "802.8", "272.0", "401.9", "332.0", "802.0" ]

icd9cm

[ [ [] ] ]

[ "76.78", "76.74" ]

icd9pcs

[ [ [] ] ]

7666, 8157

1525, 1737

3788, 7460

8181, 8971

1468, 1499

7475, 7643

142, 1203

2850, 3770

1225, 1444

20,145

163,989

45833

Discharge summary

report

Admission Date: [**2182-5-20**] Discharge Date: [**2182-6-6**] Date of Birth: [**2118-1-27**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 14964**] Chief Complaint: Transfer for cath s/p abnormal stress Major Surgical or Invasive Procedure: [**2182-5-23**] CABG x 3 (LIMA->LAD, SVG->[**Last Name (LF) **], [**First Name3 (LF) **]) [**2182-6-3**] Doxy Pleuradesis History of Present Illness: 64 year old male who was initially admitted to Good Samariton on [**5-10**] with complaint of left sided chest pain which he states that he had for years and COPD exacerbation. At OSH patient had CTA which was negative for PE but showed RLL, RML, and LLL infiltrates suggestive of PNA. Patient was started on ceftriaxone and levofloxacin which he recieved for 7 days and was stopped because patient had 2 days of diarrhea. At the OSH patient sputum cx came back positive for group B strep. Patient was started on Aspirin, Imdur, Lopressor, and Plavix at the OSH and stated that his CP resolved after 2 days. Cardiac enzymes were sent and patient had flat CK but elevated Troponin that peaked to 2.15 and then trended down. Patient underwent dobutamine stress atthe OSH which showed lateral ischemia. He was transferred to [**Hospital1 18**] for cardiac catherization. Patient currently states that he his breathing at his baseline and is CP free. No orthopnea or PND, however patient unable to climb more than 1 flight of stairs [**1-16**] SOB. . ROS: Patient denies and fever/chills. He denies any cough. Currently denies any diarrhea, BRBPR, melena. No HA, n/v, lightheadedness. Past Medical History: COPD; severe emphysema HTN Intersitial Lung disease Hyperlipidemia GERD Anxiety Depression H/O rotator cuff injury Cardiac Cath in past (approx. 12 years ago) [**1-16**] chronic CP, no dialation or stenting done. Social History: Patient lives with girlfriend, currently divorced. He is a retired truck driver. He has a 100 pack/year history quit 15 years ago. Occasional etoh use. No drug history. Family History: Mother - emphysema; sister died of CAD @ 46; F - died in accident Physical Exam: PE: T:98.3 BP 149/71 HR 65 RR 19 O2Sat 97% RA Gen: Patient lying on stretcher NAD, breathing well on RA; tatoos on arms HEENT: PERRLA, scelra anicteric, MMM, OP clear Neck: No carotid bruit, No JVD, Lungs: Crackles at Left base, no wheezes Cardiac: RRR S1/S2 no murmurs Abd: Soft NTND NABS no HSM Ext: No edema, Pedal pulses +2; no femoral bruits Neuro: AAOx3, no focal defecits Pertinent Results: EKG: NSR @ 62 nl axis; no ST changes or qwaves. TWI in III . Cardiac Cath [**2182-5-20**]: 1. Selective coronary angiography revealed a right dominant system with three vessel coronary artery disease. The LMCA had a 50% ostial lesion. The LAD had a 60% mid vessel lesion with a 90% ostial stenosis at the first diagonal branch. The moderately calcified non-dominant LCX had serioal 80% lesions in the AV groove vessel leading to a 90% proximal stenosis of the OM1. The OM2 and OM3 no angiographically apparent flow limiting lesions. The RCA had a proximal occlusion with left to right collateral. 2. Resting hemodynamics demonstrated normal right sided and left sided pressures with mildly elevated pulmonary pressures (mean PA 26 mmHg) and moderately elevated systemic pressures (central aortic pressure 172/71 mmHg). The cardiac index was mildly depressed (2.1 l/min/m2). 3. Left ventriculography showed no wall motion abnormalities (EF 60%). FINAL DIAGNOSIS: 1. Three vessel coronary artery disease. 2. Normal ventricular function. 3. Mild precapillary pulmonary hypertension . Brief Hospital Course: Selective coronary angiography revealed a right dominant system with three vessel coronary artery disease. The LMCA had a 50% ostial lesion. The LAD had a 60% mid vessel lesion with a 90% ostial stenosis at the first diagonal branch. The moderately calcified non-dominant LCX had serioal 80% lesions in the AV groove vessel leading to a 90% proximal stenosis of the OM1. The OM2 and OM3 no angiographically apparent flow limiting lesions. The RCA had a proximal occlusion with left to right collateral. Left ventriculography showed no wall motion abnormalities with an LVEF of 60%. Based on the above results, cardiac surgery was consulted for coronary revascularization. Further evaluation included pulmonary consultation given his severe COPD. He was maintained on MDI and nebulizers and was cleared to proceed with surgery. A preoperative carotid ultrasound was notable for bilateral mild internal carotid artery stenosis of less than 40%. He otherwise remained stable on medical therapy. On [**5-23**], Dr. [**Last Name (STitle) 70**] performed three vessel coronary artery bypass grafting utilizing the LIMA to LAD, SVG to diagonal and SVG to obtuse marginal. Following the operation, he was brought to the CSRU. Within 24 hours, he was extubated. MDI and nebulizer therapies were resumed. Chest tubes were removed and he transferred to the Step Down Unit on postoperative day two. Later that night, he experienced acute respiratory distress secondary to a right pneumothorax. A chest tube was urgently placed and he returned to the CSRU. His respiratory status gradually improved over several days and he eventually transferred back to the SDU. Despite chest tube placement, serial chest x-rays were notable for persistent right pneumothorax. The thoracic service was consulted and recommended a chest CT scan which confirmed a small right pneumothorax, and pneumomediastinum with small bilateral pleural effusions. It also showed diffuse centrilobular emphysema with no focal lung consolidations. A new chest tube was therefore placed on [**6-1**] and put to suction while the "old" chest tube was eventually removed. Unfortunately, the pneumothorax persisted. On [**6-3**], Doxy pleurodesis was performed. The chest tube remained and serial chest x-rays were performed. The chest tube was eventually removed on [**6-5**]. The chest x-ray prior to removal was notable for no significant residual right pneumothorax. The post pull chest x-ray showed small, stable right apical pneumothorax. From a cardiac standpoint, he maintained stable hemodynamics. He tolerated beta blockade without significant wheezing. He remained in a normal sinus rhythm without ventricular or atrial arrhythmias. Beta blockade was advanced as tolerated. He responded well to diuresis and by discharge, had oxygen saturations of 92% on room air. He was medically cleared for discharge on postoperative day 14. Pt. still with dyspnea on exertion, states it is relieved by supplemental oxygen at 2L/minute prn. Repeat CXR this am showed small right apical ptx (? somewhat smaller than post-pull film of [**6-5**]) Medications on Admission: Levofloxacin 500mg x 7 days Ceftriaxone 1g daily x 7 days Prevacid 30mg [**Hospital1 **] Prozac 20mg daily Zocor 40mg qhs Aspirin 325 daily Singular 10mg qhs Motrin 800mg tid Plavix 75mg qd (started at OSH) Tylenol Xanax 0.25 tid Dilaudid 2mg q4-6 Lopressor 50mg [**Hospital1 **] Imdur 60mg qam Diltiazem 360mg daily Albuterol/Atrovent neb Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). Disp:*30 Capsule(s)* Refills:*2* 5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Fluticasone Propionate 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*1 MDI* Refills:*2* 7. Montelukast Sodium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) MDI Inhalation Q6H (every 6 hours). Disp:*1 MDI* Refills:*2* 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). Disp:*1 1* Refills:*2* 12. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2H (every 2 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*1* Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: CAD Pneumothorax Discharge Condition: Good. Discharge Instructions: Oxygen at Shower daily,wash incisions with mild soap and water,pat dry. No lifting more than 10 pounds. No driving until follow up, or after if taking pain medication. Call with weight gain greater than 2 pounds in one day or five pounds in one week, temperature 101.5 or greater, or redness or drain2L/minute as needed for shortness of breathge from incision. Followup Instructions: Dr. [**Last Name (STitle) 70**] 6 weeks Dr. [**Last Name (STitle) **] 1-2 weeks Dr. [**Last Name (STitle) **] 2-3 weeks Completed by:[**2182-6-6**]

[ "300.4", "515", "492.8", "530.81", "414.01", "787.91", "V15.82", "512.1", "486", "272.4", "518.5", "401.9" ]

icd9cm

[ [ [] ] ]

[ "88.53", "88.72", "36.12", "37.22", "36.15", "39.61", "34.6", "88.56", "97.41", "34.04" ]

icd9pcs

[ [ [] ] ]

8693, 8764

3726, 6827

359, 483

8825, 8832

2614, 3565

9241, 9391

2132, 2199

7218, 8670

8785, 8804

6853, 7195

3582, 3703

8856, 9218

2214, 2595

282, 321

511, 1693

1715, 1930

1946, 2116

29,846

141,052

33244

Discharge summary

report

Admission Date: [**2186-11-20**] Discharge Date: [**2186-11-21**] Date of Birth: [**2125-10-23**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2736**] Chief Complaint: Angina Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: 61 y/o M with hx of DMT2, hyperlipidemia, fam hx of premature CAD presents with dull aching chest pain since [**2186-8-5**], [**7-14**] over precordium, no radiation, worse with exertion (carrying groceries up a flight of stairs will elicit CP), lasting for most of the day and unrelieved by SLNTG. He also reports DOE, walks 100 feet before getting SOB, but no PND, no orthopnea. He saw his cardiologist who referred him for a GI consultation but no gastric etiology was found. On [**2186-9-26**] he was admitted to [**Hospital3 417**] with chest pain, stress echo enremarkable at the time. He also underwent a kidney ultrasound, a chest and abdominal ultrasound and a CT of the chest which revealed coronary artery calcification. He was referred by his cardiologist, Dr. [**Last Name (STitle) 15069**], for a cardiac catheterization to further evaluate his coronary anatomy. Cardiac review of systems is notable for absence of paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. He was admitted to CMI service for elective c. cath. Cath revealed severe 98% RCA disease s/p 1 DES and 1 BM stent, diffuse 50% LAD, LCX diffuse disease, LVEF 45%. Post cath, he developed hypotension 84/53, STAT echo without effusion, CT abd without RP bleed. Atropine 2 mg total given, NS given, foley inserted and drained 800cc urine. Upon insertion of foley, SBP rose back to baseline. Pt was CP free during this. In the CCU, he is currently CP free and feeling without complaints. ROS positive for chronic cough and hx of hemorrhoidal bleeding. He denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains. 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: Diabetes: dx [**2167**] on insulin pump c/b retinopathy and neuropathy Hyperlipidemia RBBB Osteoarthritis Depression H/O Bell??????s palsy in [**2186-5-5**] on the left side Bilateral foot drop S/p umbilical hernia repair in [**1-/2177**] and [**3-/2183**] Erectile dysfunction GERD Hepatitis A in the 70??????s Cardiac Risk Factors: + Diabetes, + Dyslipidemia, + Hypertension Social History: He is married and he does not smoke or drink currently. Quit smoking 40 years ago. Currently on disability. Family History: Father had a CABG at age 50, his mother had DM and died of an MI at age 72, his uncle died of an MI in his 50??????s. Physical Exam: VS: T98.4 , BP 118/62 , HR 94 , RR 13 , 97% on 2LNC Ht: 5 feet 7.5 inches Wt: 227 lbs Gen: WDWN middle aged male in NAD, resp or otherwise. Oriented x3. Mood, affect appropriate. Pleasant. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. NECK: no bruits CV: RR, normal S1, S2. no murmurs Chest: Resp were unlabored, no accessory muscle use. No crackles, wheeze, rhonchi anteriorly and laterally. Abd: Obese, soft, NTND, No HSM or tenderness. Ext: No edema. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; 2+ DP Pertinent Results: EKG demonstrated NSR, 80 bpm, LAD, RBBB, L ant fasc block, TWI III, no ST changes. no prior for comparison. TELEMETRY demonstrated: NSR 2D-ECHOCARDIOGRAM performed on [**11-20**] demonstrated: (prelim) 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. There is no pericardial effusion. There is an anterior space which most likely represents a fat pad. IMPRESSION: No pericardial effusion. Normal biventricular function. Cardiac Cath [**2186-11-20**]: 1. Selective coronary angiography of this right dominant system demonstrates 2 vessel coronary artery disease. The mid LAD at the site of bifurcation with the 1st diagonal artery has diffuse, calcified 50-60% disease. The LCx artery and its branches are without obstructive lesions. The mid-RCA has a discrete 95% stenosis and gives rise to the PDA and RPL arteries. 2. Limited resting hemodynamic measurements demonstrates high normal central aortic pressure of 140/66mmHg. The LVEDP is severely elevated at 26mmHg. There is no gradient between the left ventricle and the aorta. 3. Left ventriculography demonstrates mild systolic dysfunction with a calculated ejection fraction of 45% and inferior posterior hypokinesis. 4. Successful PTCA and stenting of the proximal RCA with overlapping Cypher (3.5x18mm) drug eluting stent (distal) and a Driver (3.5x15mm) bare metal stent. Both stents were postdilated with a 3.5mm balloon. Final angiography demonstrated no angiographically apparent dissection, no residual stenosis and TIMI III flow throughout the vessel (See PTCA Comments). FINAL DIAGNOSIS: 1. Two vessel coronary artery disease. 2. Low- normal systolic ventricular function with moderate to severe diastolic dysfunction. 3. Successful PTCA and stenting of the proximal RCA with an overlapping drug eluting and bare metal stent. . ECHO [**2186-11-21**]: The left atrium is normal in size. The estimated right atrial pressure is 0-5 mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild regional left ventricular systolic dysfunction with mild mid to apical inferolateral wall hypokinesis. Overall left ventricular systolic function is normal (LVEF>55%). Transmitral Doppler and tissue velocity imaging are consistent with normal LV diastolic function. Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. . Compared with the prior study (images reviewed) of [**2186-11-20**], the mild inferolateral wall hypokinesis is better appreciated. Mild symmetric left ventricular hypertrophy with normal overall systolic function and diastolic function. . [**2186-11-20**] 11:16PM GLUCOSE-90 UREA N-27* CREAT-1.2 SODIUM-138 POTASSIUM-4.4 CHLORIDE-103 TOTAL CO2-30 ANION GAP-9 [**2186-11-20**] 11:16PM estGFR-Using this [**2186-11-20**] 11:16PM ALT(SGPT)-27 AST(SGOT)-19 LD(LDH)-130 CK(CPK)-175* ALK PHOS-55 TOT BILI-0.2 [**2186-11-20**] 11:16PM CK-MB-5 cTropnT-<0.01 [**2186-11-20**] 11:16PM CALCIUM-8.6 PHOSPHATE-4.6* MAGNESIUM-2.2 [**2186-11-20**] 11:16PM WBC-8.9 RBC-4.01* HGB-11.5* HCT-34.0* MCV-85 MCH-28.7 MCHC-33.8 RDW-13.7 [**2186-11-20**] 11:16PM PLT COUNT-392 [**2186-11-20**] 07:00PM HCT-34.3* Brief Hospital Course: CAD/Ischemia: S/p c. cath found to have [**1-7**] vessel disease and status post DES and BMS to RCA. Patient was continued on integrillin for 18hours post cath, started on plavix, should continue for at least 12 months post intervention given drug eluting stents. Continue full dose aspirin, zetia, simvastatin and tricor for cholesterol managagement. Continue lisinopril, decreased to 2.5 daily. Patient was started on Toprol XL 25mg daily. He should have these medications titrated to BP and HR as outpatient. Cholesterol studies pending upon discharge. . Hypotension: patient had a transient episode of post cath hypotension with no RP bleed and no echo signs of tamponade. The episode was transient and thought to be due to high vagal tone from urinary retention, his hypotension spontaneously resolved after foley placed and 800cc of urine drained. Foley was removed and patient was voiding spontaneously prior to discharge. DM- type 2. Patient controlled on insulin pump, A1C on this hospitalization was 7.6%. Medications on Admission: Prescriptions filled at [**Company 25795**] at [**Telephone/Fax (1) 77218**] MVI 1 tab daily ASA 81 mg 1 tab daily Gabapentin 100 mg 1 tab 6 times daily Zoloft 100 mg 1 tab daily Omeprazole 20 mg 1 tab daily Zetia 10 mg 1 tab daily Tricor 145 mg 1 tab daily Protonix 40 mg 1 tab daily at hs Flexeril 5 mg 1 tab daily Lisinopril 5mg 1 tab daily Ambien CR 12.5 mg 1 tab q hs Insulin pump [**Doctor First Name **], (Humalog) Zocor 40 mg 1 tab daily Discharge Medications: 1. Hexavitamin Tablet Sig: One (1) Cap PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Toprol XL 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q 12H (Every 12 Hours). 6. Sertraline 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 7. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 8. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Fenofibrate Micronized 145 mg Tablet Sig: One (1) Tablet PO qd (). 10. Cyclobenzaprine 10 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). 11. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): take [**12-6**] tablet per day . 12. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Insulin Lispro 100 unit/mL Cartridge Sig: INSULIN PUMP Subcutaneous four times a day: INSULIN PUMP, USE AS DIRECTED. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Coronary Artery Disease Secondary Diagnosis: Diabetes Mellitus Hyperlipidemia Discharge Condition: Stable, chest pain free. Discharge Instructions: You were admitted to the hospital for an elective cardiac catheterization and were found to have coronary artery disease. You had two stents placed in your Right Coronary artery which was 98% blocked. Your blood pressure dropped for a short period of time and due to this you were transferred to the CCU for closer monitoring. In the CCU you were stable. Please see attached medication list for important medication changes. Please note that you should under no circumstance stop taking "PLAVIX" (clopidogrel) unless your cardiologist specifically says it is okay to stop. This is preventing you from having a heart attack. If you have any chest pain, shortness of breath, nausea/vomiting, lightheadedness, palpitations or other worrisome symptoms please call your doctor or return to the emergency room. Followup Instructions: Please keep the following appointment with your primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **],[**First Name3 (LF) **] M. at [**Hospital 5164**] Medical Associates on [**12-4**] at 8:15 a.m. phone # [**Telephone/Fax (1) 3183**]. Please follow up with Dr. [**Last Name (STitle) 7047**] at [**Street Address(2) 14531**], [**Hospital 5164**] Medical Associates, on Thursday, [**11-23**] at 4:00 p.m. phone [**Telephone/Fax (1) 24523**].

[ "788.20", "796.3", "736.79", "455.8", "356.9", "607.84", "426.4", "401.9", "V17.3", "250.00", "V58.67", "429.9", "414.01", "272.4", "530.81", "070.1", "715.90", "V15.82" ]

icd9cm

[ [ [] ] ]

[ "37.22", "00.66", "00.46", "36.07", "00.40", "88.56", "88.53", "99.20" ]

icd9pcs

[ [ [] ] ]

9920, 9926

7202, 8227

325, 351

10068, 10095

3593, 5318

10953, 11427

2778, 2898

8724, 9897

9947, 9947

8253, 8701

5335, 7179

10119, 10930

2913, 3574

279, 287

379, 2234

10012, 10047

9966, 9991

2256, 2636

2652, 2762

57,599

180,150

38530

Discharge summary

report

Admission Date: [**2108-5-30**] Discharge Date: [**2108-6-26**] Date of Birth: [**2059-8-24**] Sex: F Service: MEDICINE Allergies: Topamax / Percocet / Tizanidine / Lyrica / Tramadol / Methocarbamol / Naproxen / Gabapentin / Sulfa (Sulfonamide Antibiotics) / Cefazolin Attending:[**First Name3 (LF) 1253**] Chief Complaint: airway inflammation/respiratory failure with tracheal/L mainstem bronchus stent removal Major Surgical or Invasive Procedure: tracheal and L mainstem bronchus stent removals flexible bronchoscopy PEG tube placement Percutaneous tracheostomy History of Present Illness: Mrs [**Known lastname **] is a 48yoF with severe tracheobronchomalacia with chronic dyspnea on exertion and bronchitis. She has been treated with steroids and antibiotics repeatedly with recurrence of symptoms including cough with minimal sputum production, wheezing, and shortness of breath. She has had multiple bouts of pneumonia in recent years. She had reported normal walking PFTs 5/10 per notes. Mrs. [**Known lastname **] [**Known lastname **] was found to have severe TBM on bronchoscopy and underwent a bronchoscopy on [**2108-5-7**] with unsuccessful attempt at silicone-Y-stent placement. She returned on [**2108-5-24**] for flexible bronchoscopy with placement of metal stents in the L mainstem bronchus and distal trachea. However, she developed chest pain and increasing sputum production post-stent placement and returned on [**2108-5-31**] for elective removal. During the procedure, there was significant airway inflammation precluding extubation and she was transferred to the ICU on [**5-31**]. Past Medical History: PNA x3 in recent years Osteopenia/osteoarthritis Chronic pain Type II DM Diabetic neuropathy Depression Fibromyalgia Herpes Hiatal hernia Hypertension Hypothyroidism IBS GI bleed nephrolithiasis Irregular heart rhythm NASH PTSD GERD Latent TB - INH course stopped (with ID input) [**1-3**] transaminitis Carpal tunnel S/P appendectomy S/P C-section S/P cholecystectomy S/P hysterectomy S/P R oophorectomy S/P L ovarian cystectomy S/P shoulder surgery x4 S/P L breast ductal excision S/P liver biopsy x2 Social History: Lives in [**State 3914**] with husband of 14 years, has 3 daughters. [**Name (NI) 1403**] as professional care assistant for autistic boy. Used to be [**Doctor Last Name **] parent. Has won [**State 3914**] Governor's award for her work. Former smoker, quit 20 years ago after ~ 18 pack/year history. Smokes Marijuana daily for chronic pain. Denies any ETOH or IVDA. Family History: Severe emphysema in mother and sister. Asthma in daughter. Physical Exam: Physical Exam (upon transfer to the floor): BP: 115/83 P:87 R:18 O2:99% on 50% trach mask General: Alert, oriented, no acute distress, able to communicate by writing or in very short phrases by occluding tracheostomy HEENT: Sclera anicteric, MMM, oropharynx clear, no plaques on tongue Neck: supple, JVP not elevated, no LAD Lungs: Coarse breath sounds throughout, no wheezes, rales, rhonchi, coughing CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly. Painful to palpation around PEG-tube site but no erythema or pus. Mild RUQ tenderness to deep palpation but no rebound or guarding. GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: AAO x3, cranial nerves grossly intact, moves all extremities freely Pertinent Results: CXR [**5-31**]: 1. ET tube 2.5 cm above the carina. 2. Left hemithorax opacification likely representing components of collapse and effusion. CXR [**6-1**]: Previous left lung atelectasis has resolved. Right lung clear. ET tube in standard placement. No pneumothorax or appreciable pleural effusion. Heart size normal. CXR [**6-4**]: The tip of the endotracheal tube now lies approximately 5 cm above the carina. Nasogastric tube and right central catheter remain in place. There is continued bibasilar opacification, most likely representing atelectasis, more prominent on the left. Again, in the appropriate clinical setting, the possibility of pneumonia would have to be considered. CT trach [**6-4**]: 1. The full severity of tracheomalacia is probably not demonstrated by this study because of the indwelling endotracheal tube and suboptimal performance of expiration. Nevertheless collapse of the distal trachea is demonstrated to a clinically significant degree. There is no appreciable tracheal wall thickening. Expiratory collapse, at least as judged by this study is mild in the bronchial tree. 2. Bibasilar atelectasis, moderate on the right, mild on the left. CXR [**6-6**]: 1. ET tube 3.5 cm above the carina; central line tip in the right atrium - would recommend pulling back 2-3 cm if patient experiences tachycardia/arrhythmias. 2. Small left effusion with associated atelectasis and retrocardiac atelectasis. Head CT [**6-11**]: No acute intracranial pathology. Small right maxillary mucus retention cyst. CXR [**6-12**]: Mild interval improvement in degree of left lower lobe atelectasis. Satisfactory position of new tracheostomy tube. CXR [**6-14**]: The region of apparent opacification at the left base has decreased. This is most consistent with atelectasis, though the possibility of a supervening pneumonia cannot be unequivocally excluded. . [**5-31**] MRSA screen negative [**6-2**] UCx negative [**6-3**] BAL: STAPH AUREUS COAG +. >100,000 ORGANISMS/ML. Sensitive to clindamycin, erythromycin, gentamicin, levofloxacin, oxacillin, TMP-SMX. HAEMOPHILUS INFLUENZAE, BETA-LACTAMASE NEGATIVE. >100,000 ORGANISMS/ML. Beta-lactamse negative: presumptively sensitive to ampicillin. Confirmation should be requested in cases of treatment failure in life-threatening infections. [**6-14**] Sputum Cx: GRAM STAIN >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. 1+ (<1 per 1000X FIELD): YEAST(S). 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2108-6-17**]): Commensal Respiratory Flora Absent. STAPH AUREUS COAG +. SPARSE GROWTH. Sensitive to clindamycin, erythromycin, gentamicin, levofloxacin, oxacillin, TMP-SMX. YEAST. SPARSE GROWTH. [**6-14**] Blood Cx x2 no growth to date [**6-14**] UCx negative . [**2108-5-30**] 09:40PM BLOOD WBC-9.4 RBC-4.15* Hgb-12.5 Hct-37.4 MCV-90 MCH-30.2 MCHC-33.5 RDW-12.4 Plt Ct-263 [**2108-5-30**] 09:40PM BLOOD Neuts-55.9 Lymphs-32.8 Monos-4.4 Eos-6.0* Baso-0.8 [**2108-5-31**] 07:15AM BLOOD PT-13.1 INR(PT)-1.1 [**2108-5-30**] 09:40PM BLOOD Glucose-256* UreaN-8 Creat-0.5 Na-136 K-3.6 Cl-97 HCO3-28 AnGap-15 [**2108-5-30**] 09:40PM BLOOD Albumin-4.1 Calcium-9.4 Phos-3.8 Mg-1.7 . [**2108-5-30**] 09:40PM BLOOD ALT-90* AST-94* LD(LDH)-139 AlkPhos-140* TotBili-0.3 [**2108-6-17**] 06:02AM BLOOD ALT-94* AST-72* AlkPhos-148* TotBili-0.2 [**2108-6-18**] 05:25AM BLOOD ALT-229* AST-213* AlkPhos-214* Amylase-61 TotBili-0.2 [**2108-6-19**] 05:34AM BLOOD ALT-152* AST-104* LD(LDH)-216 AlkPhos-197* TotBili-0.2 . [**2108-6-12**] 05:46AM BLOOD Lipase-175* [**2108-6-13**] 05:52AM BLOOD Lipase-218* [**2108-6-18**] 05:25AM BLOOD Lipase-40 . [**2108-6-13**] 05:52AM BLOOD WBC-8.2 RBC-3.84* Hgb-11.3* Hct-33.7* MCV-88 MCH-29.3 MCHC-33.4 RDW-12.9 Plt Ct-313 [**2108-6-13**] 05:52AM BLOOD Ret Aut-2.3 [**2108-6-13**] 05:52AM BLOOD calTIBC-320 Ferritn-321* TRF-246 . [**2108-6-10**] 04:55AM BLOOD Cortsol-36.0* . [**2108-6-19**] 05:34AM BLOOD %HbA1c-8.1* eAG-186* . [**2108-6-15**] 07:16AM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN-PND [**2108-6-15**] 07:16AM BLOOD B-GLUCAN-negative . [**2108-6-12**] 05:46AM BLOOD ALPHA-1-ANTITRYPSIN-229 H Ref: 83-199 mg/dL Brief Hospital Course: 48 y/o F with history of severe TBM s/p tracheal and L mainstem stent removal [**5-31**] with severe airway inflammation and friability requiring ventilation in the ICU, s/p tracheostomy and PEG placement [**6-8**] with transfer to the floor [**6-12**]. . # Tracheobronchomalacia: As per HPI, the patient developed respiratory failure and airway inflammation during stent removal. The patient was initiated on high-dose dexamethasone 4mg IV q6h on [**5-31**] for inflammation and edema and a rapid wean was started on [**6-3**], with discontinuation on [**6-4**]. A bedside bronch on [**6-3**] revealed some improvement of the mucosal inflammation. The patient was weaned on [**6-3**] from AC to CPAP. The patient passed spontaneous breathing trial on [**6-6**] but desaturated to 74% after 10 minutes extubation so was re-intubated. On [**6-7**], pt was put on Lasix drip with good response, since there was concern that volume overload was aggravating her respiratory symptoms. On [**6-8**], IP and thoracics placed a trach and PEG without complications. On [**6-10**], diuresis was stopped, and the patient was able to sat well on trach collar. She was transferred to the floor on [**6-12**]. . The patient was followed closely by IP. She received regular respiratory therapy and speech and swallow evaluations for PMV and diet advancement, but did not yet meet criteria for PMV. She maintained good oxygen saturations on trach mask. She received standing ipratropium and PRN albuterol nebulizers. On [**6-18**] she was reevaluated by IP for possible trach downsizing but it was felt to be too early. She will follow up outpatient with IP and thoracics to evaluate for possible surgical repair of her TBM. . The etiology of the patient's severe tracheobronchomalacia is not clear, but she has a history of frequent upper respiratory infections, chronic cough and medical marijuana use. History of chronic bronchitis, elevated LFTs, elevated pancreatic enzymes, diabetes, osteopenia in a young woman, nephrolithiasis, and severe lung disease in her mother and sister could be consistent with a heterozygous CFTR mutation. Alpha-1-antitrypsin was tested, and she was not deficient. . # VAP: The patient had a respiratory culture on [**6-3**] that was positive for H.flu and MSSA. She was started on IV ceftriaxone on [**6-3**] and vancomycin on [**6-4**] for GPC+ sputum. Once MSSA was confirmed with sensitivities, vancomycin was discontinued. Clinical status improved. Ceftriaxone was d/c'ed after an 8 day course on [**6-11**]. On the floor, the patient did well until [**6-13**], when she started to feel ill, had increasing suction requirement, and complained of congestion, with temperature to max 100.6. She was started on vanc/cefepime on [**6-14**]. When culture grew MSSA, she was switched off vanc/cefepime and onto cefazolin on [**6-17**], but the following morning, she had an increased transaminitis. ID was consulted and recommended resuming the vancomycin to complete a full 2-week course for PNA, with end date [**6-27**]. The patient has clinically improved and is back to her respiratory baseline and afebrile. . # Left Lobe collapse: The patient had a L lobe collapse on [**5-31**]. Bronchoscopy showed severe inflammation and excessive granulation tissue collapsing on itself. Bronchoscopy [**6-1**] and [**6-3**] demonstrated improved inflammation. Treatment was the same as for TBM above. . # DM: She was on metformin at home, but this was held during admission. Her blood sugars were persistently in the 200s during her ICU stay, initially thought to be related to steroid administration. However, once steroids were discontinued and sugars remained elevated, glargine was increased incrementally, up to 60U. She was also on sliding scale insulin. . # Anxiety/Depression: She was continued on fluoxetine and amitryptyline. The patient developed acute anxiety in the ICU, related to her failed stent, failed extubation, and prolonged respiratory failure. She was started on Klonopin 1 mg PO BID on [**6-7**] to help mitigate her acute anxiety. She continued to have fluctuating mental status and intermittently tearful affect s/p trach; in the ICU, she also had episodes of delirium, which had resolved before she came to the floor. On the floor, her Klonopin was increased to 1 mg PO tid on [**6-14**] due to panic attacks/anxiety. Social work followed her and discussed some of the root causes of her anxiety in the hospital, particularly concern about her health and her desire to get back to her family. She became frustrated at her inability to go home to [**State 3914**] and threatened several times to leave AMA. Psych was consulted. She was briefly on a 1:1 sitter for 1 day after a stressful family visit, but this was discontinued. . # Transaminitis/hx of RUQ pain: Patient was admitted with transaminitis (and normal bili) with known h/o NASH, possibly worsened by INH (notes reference AST to 290's in [**5-10**] prior to admission). INH was discontinued inpatient, as above. She reportedly had outside liver biopsies in the past but records were not available. She complained intermittently of mild RUQ pain to deep palpation. On [**6-18**] after starting cefazolin the previous night, her enzymes, which had been down to ALT 94, AST 72, AlkPhos 148 spiked overnight to ALT 229, AST 213, Alk Phos 214, but they came down the following day when cefazolin had been discontinued. Hepatitis serologies were negative, she had no iron overload, and alpha-1-antitrypsin was not low. . # Elevated pancreatic enzymes: The patient had elevated amylase (max 119) and lipase (max 218), with no prior baseline available in records. Though she did complain of abdominal pain, this seemed to be related to the PEG (location deep to PEG, reproduced with movement of the PEG), not any frank pancreatitis. Her illness in the ICU followed by tube feeds could have caused some pancreatic inflammation, but she was tolerated food well on the floor with no nausea or vomiting. It was felt that abdominal imaging would not change management. Her enzymes normalized once tube feeds were discontinued. . # Abdominal Pain: The patient complained of pain deep to her PEG site on the floor. Thoracics examined her site multiple times and felt that her pain was normal post-PEG placement pain with serous, non-purulent drainage. She had an ultrasound of the PEG area on [**2108-6-26**] which showed no fluid collections or abscesses around the site. It was recommended that she wash the area gently with soap and water. Pain was controlled with PRN Tylenol and PRN MSIR 15-30mg q6h started [**6-13**] and resolved with time. . # Deconditioning with fall: The patient had a fall in ICU and was very deconditioned, with atrophic musculature and poor balance. She had several minor falls with no injury or head trauma on the floor when she tried to get out of bed on her own. She received regular PT and her strength, coordination, gait, and balance improved substantially. She was maintained on fall precautions. . # Hypothyroidism: She was continued on home levothyroxine. . # Herpes: The patient is on chronic suppressive therapy, and since stress can induce an outbreak, she was continued on acyclovir. . # Normocytic Anemia Records showed baseline Hct of approximately 37. In house, her Hct fluctuated in the 30-34 range. Her retic index suggested underproduction. Iron studies showed high ferritin c/w illness, with normal TIBC, transferrin, and iron. . # Latent TB: The patient worked in prisons and had a positive PPD in past, so was admitted on INH therapy for latent TB. Given elevated LFTs and RUQ pain, INH discontinued on admission. She will have an appointment with outpatient ID (Dr. [**Last Name (STitle) **] to restart after discharge. . # Chronic Pain: The patient has chronic pain with Xanax and Dilaudid use at home; per report, she was difficult to originally sedate in the OR with both paralytics and propofol. When sedated in the ICU, she was on fentanyl and versed. She did not complain of her chronic pain on the floor, but did get MSIR and Tylenol for belly pain as above. . # HTN: She was stable and normotensive on admission and during stay in ICU. Home hypertensive medications were held as patient was hypo- to normotensive in the unit and normotensive on the floor. . # GERD: She was maintained on a daily PPI, as at home. . # Vaginal yeast infection This was treated with miconazole powder and cream, with resolution of symptoms. . # Osteopenia: She has a history of osteopenia, so was started on Ca/Vit D during admission. . # Nutrition: She initially received tube feeds, advanced to a rate of 60 cc/hr, with PEG tube placed on [**6-8**]. Her diet was slowly advanced by speech and swallow when she was transferred to the floor, first to ground solids/thin liquids, then on [**6-14**] to regular diet (constant carb/diabetic). Tube feeds were weaned from continuous to 12h overnight on [**6-14**], then D/C'ed on [**6-17**]. The patient had good appetite. Medications on Admission: -acyclovir 400mg qhs -amitriptylin 100mg qhs -enalapril 10 daily -fluoxetine 25mg daily -HCTZ 25mg daily -isoniazid 300mg daily -kapidex 60mg daily -levothyroxine 25 mg daily -medical MJ -metformin 500mg [**Hospital1 **] -pyridoxine 50mg daily -xanax 1mg TID -motrin 800mg po TID -dilaudid 4mg TID Discharge Medications: 1. Acyclovir 400 mg Tablet [**Hospital1 **]: One (1) Tablet PO QHS (once a day (at bedtime)). Disp:*30 Tablet(s)* Refills:*2* 2. Levothyroxine 25 mcg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily): Take on an empty stomach 45-60 minutes before food. Disp:*30 Tablet(s)* Refills:*2* 3. Cholecalciferol (Vitamin D3) 400 unit Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 4. Calcium Carbonate 500 mg Tablet, Chewable [**Hospital1 **]: One (1) Tablet, Chewable PO twice a day as needed for low calcium. Disp:*60 Tablet, Chewable(s)* Refills:*2* 5. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) neb Inhalation Q6H (every 6 hours). Disp:*120 nebulizer treatments* Refills:*2* 6. Senna 8.6 mg Tablet [**Hospital1 **]: 1-2 Tablets PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*0* 7. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 8. Miconazole Nitrate 2 % Powder [**Hospital1 **]: One (1) Appl Topical TID (3 times a day) as needed for itching/discomfort. Disp:*1 bottle* Refills:*1* 9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Hospital1 **]: One (1) nebulizer Inhalation Q4H (every 4 hours) as needed for wheezing/sob. Disp:*120 nebulizer treatments* Refills:*0* 10. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: Two (2) doses PO BID (2 times a day) as needed for constipation. Disp:*60 containers* Refills:*0* 11. Vancomycin 500 mg Recon Soln [**Hospital1 **]: 1500 (1500) mg Intravenous Q 12H (Every 12 Hours) for 3 doses: Please give in evening of [**6-26**], in morning of [**6-27**] and in evening of [**6-27**]. Disp:*3 doses* Refills:*0* 12. Clonazepam 1 mg Tablet [**Date Range **]: One (1) Tablet PO TID (3 times a day) as needed for anxiety. Disp:*90 Tablet(s)* Refills:*0* 13. coolmist to trach via compressor (room air) [**Date Range **]: continuous flow continuous. Disp:*1 month supply* Refills:*2* 14. portable suction with supplies, including 14 French suction catheter 15. #8 ported perc trach 16. disposable inner cannulas #[**Numeric Identifier 85703**] 17. nebulizer 18. Insulin Lispro 100 unit/mL Cartridge [**Numeric Identifier **]: per sliding scale units Subcutaneous QACHS. Disp:*10 vials* Refills:*2* 19. Insulin Glargine 100 unit/mL Cartridge [**Numeric Identifier **]: Fifty Five (55) units Subcutaneous at bedtime. Disp:*1 month supply* Refills:*2* 20. Home Oxygen 2-5 Liters per min > 35% continuous 88% Room air sat Dx: tracheobroncheomalacia, s/p trach Length needed: lifetime 21. Amitriptyline 100 mg Tablet [**Numeric Identifier **]: One (1) Tablet PO at bedtime. Disp:*30 Tablet(s)* Refills:*2* 22. Fluoxetine 40 mg Capsule [**Numeric Identifier **]: Two (2) Capsule PO once a day. Disp:*60 Capsule(s)* Refills:*2* 23. ambu bag 24. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). Disp:*30 Tablet,Rapid Dissolve, DR(s)* Refills:*2* 25. Morphine 15 mg Tablet [**Last Name (STitle) **]: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. Disp:*90 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: central [**State **] vna Discharge Diagnosis: tracheobronchomalacia ventilator-associated pneumonia (MSSA, H flu) diabetes mellitus, Type II transaminitis abdominal pain Discharge Condition: Mental status: Alert and oriented x3 Ambulatory status: Ambulatory (mild gait instability) Patient has a trach + PEG Discharge Instructions: You were admitted to the ICU for airway inflammation with your stent removal. In the ICU, you were given steroids to reduce the inflammation and were also treated with antibiotics for pneumonia. You transitioned from a ventilator to a tracheostomy mask on [**6-8**] and also had a PEG tube placed for feeding. You were transferred out of the ICU to the floor on [**6-12**]. On [**6-14**], you were started on a new 2-week course of antibiotics for bronchitis with possible pneumonia. Your diet was slowly advanced to a regular diet. Speech and swallow, physical therapy, and respiratory therapy worked closely with you. 1. Follow-up for you with interventional pulmonology will be arranged. 2. Follow-up for you with thoracic surgery will be arranged. 3. Your lab work showed high liver enzymes and high pancreatic enzymes and anemia. Please follow-up with a primary care provider and have full labs rechecked. 4. Please have your primary care provider follow up on your blood sugars and adjust your insulin doses as needed. Your lab work indicates that your sugars even prior to hospitalization had been poorly controlled. 5. You will need physical therapy and nursing services when you go home, which will be arranged for you. 6. Please discuss with your primary provider whether you should consider genetic testing for a gene called CFTR. 7. Please see the attached sheet for the multiple medication changes that have occurred. You have been given refills of all your medications to ensure that you have enough at home before you see your new doctor. Followup Instructions: It is very important that you follow up with your primary care physician for an initial visit and to have labs including electrolytes, CBC, and LFTs checked. The following appointment has been arranged for you: Dr. [**First Name8 (NamePattern2) 14880**] [**Last Name (NamePattern1) 131**], [**Location (un) **], [**Location (un) **], VT, [**Telephone/Fax (2) 85054**], [**7-3**], 3:15pm. You need a follow-up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Office Phone: ([**Telephone/Fax (1) 17398**] Office Location: [**Street Address(2) 8667**], [**Hospital1 **] 201 Division: Division of Thoracic Surgery. An appointment will be made for you for some time in the next two weeks. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] will be calling you to notify you of the time of this appointment by the end of this week. You also need a follow-up appointment with Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) **]. Office Phone: ([**Telephone/Fax (1) 18313**] Office Location: W/[**Hospital1 **] 201-A1 Division: Pulmonary. An appointment will be made for you for some time in the next two weeks. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] will be calling you to notify you of the time of this appointment by the end of this week. THE PATIENT HAS THE FOLLOWING APPOINTMENTS SET UP: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] called on [**2108-6-27**] the day after discharge to give the patient these times/dates. A visiting nurse answered the phone and took the instructions. She noted this falls on the same day as her new PCP appointment, and the nurse said she would call to reschedule the new PCP appointment for [**Name Initial (PRE) **] different date. [**2108-7-3**] 10:00a [**Doctor Last Name 829**],CDC PROCEDURES DE [**Hospital1 **] BUILDING ([**Hospital Ward Name **] COMPLEX), [**Location (un) **] CDC PROCEDURES [**2108-7-3**] 10:00a CDC ROOM,TWO [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **] COMPLEX), [**Location (un) **] CDC ROOMS/BAYS [**2108-7-3**] 09:30a CDC INTAKE,ONE CDC ROOMS/BAYS [**2108-7-3**] 09:00a [**Doctor Last Name 85704**] CLINIC DE [**Hospital1 **] BUILDING ([**Hospital Ward Name **] COMPLEX), [**Location (un) **] THORACIC SURGERY (SB) [**2108-7-3**] 08:30a [**Doctor Last Name 85705**] CLINIC DE [**Hospital1 **] BUILDING ([**Hospital Ward Name **] COMPLEX), [**Location (un) **] INTERVENTIONAL PULMONARY (SB)

[ "011.90", "511.9", "733.90", "564.1", "E849.7", "790.4", "518.0", "250.02", "573.3", "599.71", "112.1", "300.4", "244.9", "285.29", "338.29", "997.31", "518.81", "E878.2", "041.11", "553.3", "996.59", "293.0", "E930.5", "519.19", "571.40", "458.9", "401.9", "782.1", "V15.88", "564.00", "041.5" ]

icd9cm

[ [ [] ] ]

[ "96.6", "96.72", "38.93", "31.1", "96.04", "43.11", "33.78", "33.22", "96.05", "33.24" ]

icd9pcs

[ [ [] ] ]

20589, 20644

7888, 16920

486, 603

20812, 20812

3545, 7865

22540, 25073

2582, 2643

17268, 20566

20665, 20791

16946, 17245

20955, 22517

2658, 3526

359, 448

631, 1653

20827, 20931

1675, 2180

2196, 2566

682

188,382

22313

Discharge summary

report

Admission Date: [**2118-8-19**] Discharge Date: [**2118-9-3**] Service: [**Hospital Unit Name 196**] Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 9554**] Chief Complaint: Intrascapular back pain at OSH Major Surgical or Invasive Procedure: None History of Present Illness: 81 yo w/ HTN, hypercholesterolemia, hypothyroidism, h/o CVA ([**1-16**]), DM, and [**Hospital **] transferred to [**Hospital1 18**] from an OSH for evaluation and further management of a possible dissection of her descending thoracic aorta (type B) versus an intramural ulcer seen on CT. Pt initially presented to the OSH with intrascapular back pain. In the ED at [**Hospital1 18**] her pain had resolved but she was found to be hypertensive to the 180's and was started on a Nipride drip and given lopressor 2.5 mg IV x1. She received IV vitamin K to reverse an INR of 3.3. She denied chest pain, shortness of breath. Past Medical History: 1. Hypercholesterolemia. 2. HTN 3. hypothyroidism 4, h/o CVA ([**1-16**]) 5. DM by labs 6. CRI (baseline Cr 1.8-2.0) Social History: Lives alone. Has a idential twin sister. Children involved in her health care. Denies tob, EtOH, or drug use. Family History: NC Physical Exam: Done in ED: HR 60, BP L arm 114/58, R arm 122/61 on Nipride 1.7 mcg/kg, RR 14, O2 98% NRB Gen: awake in NAD, A&Ox3 HEENT: PERRLA, EOMI, MMM, clear oropharynx, upper/lower dentures Neck: supple, FROM Lungs: CTAB CV: RRR, No M/R/G, b/l radial, femoral, DP, PT pulses Skin: warm, dry, no bruises or rashes Pertinent Results: [**2118-8-19**] 09:15PM TYPE-ART PO2-163* PCO2-32* PH-7.50* TOTAL CO2-26 BASE XS-2 [**2118-8-19**] 09:15PM GLUCOSE-228* LACTATE-4.6* NA+-137 K+-2.9* CL--103 [**2118-8-19**] 09:15PM freeCa-1.07* [**2118-8-19**] 08:43PM GLUCOSE-237* UREA N-34* CREAT-1.9* SODIUM-138 POTASSIUM-3.4 CHLORIDE-97 TOTAL CO2-24 ANION GAP-20 [**2118-8-19**] 08:43PM CK-MB-1 cTropnT-<0.01 [**2118-8-19**] 08:43PM CALCIUM-9.0 PHOSPHATE-2.6* MAGNESIUM-1.8 [**2118-8-19**] 08:43PM WBC-9.6 RBC-3.26* HGB-10.4* HCT-28.5* MCV-87 MCH-31.8 MCHC-36.4* RDW-13.2 [**2118-8-19**] 08:43PM PLT COUNT-138* [**2118-8-19**] 08:43PM PT-16.4* PTT-32.2 INR(PT)-1.8 [**2118-8-19**] 04:30PM UREA N-33* CREAT-1.7* POTASSIUM-3.6 [**2118-8-19**] 04:30PM PHOSPHATE-3.7 MAGNESIUM-2.0 [**2118-8-19**] 04:30PM PT-16.1* PTT-32.6 INR(PT)-1.7 [**2118-8-19**] 09:01AM GLUCOSE-198* UREA N-33* CREAT-1.8* SODIUM-140 POTASSIUM-3.4 CHLORIDE-100 TOTAL CO2-27 ANION GAP-16 [**2118-8-19**] 09:01AM CK(CPK)-53 [**2118-8-19**] 09:01AM CK-MB-NotDone cTropnT-0.01 [**2118-8-19**] 09:01AM WBC-12.0* RBC-3.83* HGB-11.9* HCT-35.5* MCV-93 MCH-30.9 MCHC-33.4 RDW-12.7 [**2118-8-19**] 09:01AM NEUTS-86.4* BANDS-0 LYMPHS-9.8* MONOS-3.1 EOS-0.4 BASOS-0.2 [**2118-8-19**] 09:01AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2118-8-19**] 09:01AM PLT SMR-NORMAL PLT COUNT-194 [**2118-8-19**] 09:01AM PT-22.2* PTT-33.6 INR(PT)-3.3 Brief Hospital Course: 81 yo w/ DM, HTN, hypercholesterolemia, h/o CVA ([**1-16**]), trasferrred from OSH c/o interscapular back pain. There found to have SBP's in 200's, and a CTA revealing a dissection of her descending thoracic aorta (type B) vs an intramural ulcer, subsequently transferred to vascular surgery service at [**Hospital1 18**] for evaluation/further management. In our ED started on Nipride drip, given lopressor and vitamin K to reverse INR of 3.3. BP down to 130's/60's, HR 55. Course complicated by ARF, CHF, NSTEMI (peak CK 520/MBI 11.3, w/ ECG on [**8-20**] showing sinus @70bpm, Normal axis, TWI in V2-6, I, II, III, AVF) and Delerium. Made DNR/DNI on [**8-22**] at family meeting. Studies: 1. Carotid U/S: mild non significant Plaque, luminal narrowing <40%. 2. CT head ([**8-19**]): chronic small vessel ischemic disease with multiple bilateral small lacunar infarcts. 3. CT of chest (done at [**Hospital **] Hospital [**2118-8-19**]): [**Location (un) **] type b dissection involving a small segment of the descending thoracic aorta, more distal to the dissection is an aneurysm measuring 5.6x 3.9cm. 4. MRI ([**8-30**]): There is no evidence of dissection involved within the aorta. Multifocal penetration ulcers are identified throughout the aorta. There is no evidence however of focal intramural hematoma. The right common carotid artery is significantly tortuous. There is a 4.3-cm aneurysm of the descending thoracic aorta with areas of thickened atherosclerosis. This reaches its maximum dimension above the level of the diaphragmatic hiatus. Bilateral pleural effusions are present. Problems: 1. Question of aortic dissection: Transferred to vascular service here after CTA at outside hospital concerning for aortic dissection. Pt's blood pressure was aggressively controlled with IV labetalol drip. However, a MRI/A done here did not show evidence of aortic dissection but rather multifocal penetration ulcers along her aorta. No intervention was needed and pt's BP was able to be adequately controlled on po B-[**Month/Year (2) 7005**] and ACE-I. 2. A on CRF: Etiology likely multifactorial. Our initial differential included decompensated diastolic CHF(FE Urea found to be 34%), medications (eosinophils found in her urine), vs a progression of her dissection into her renal arteries, however this was ruled out by repeat MRI. She was also found to have b/l renal artery stenosis clinically significant on the right. She refused a diagnostic catheterization with possible stenting. Her Cr returned to 1.6 on the day of discharge. She will need follow up with her PCP to evaluate for diabetic/hypertensive nephropathy. Pt is to have outpt Cr and K checked. Results to be sent to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. 3. DM. Pt was started on a regular insulin sliding scale with good effect. She will need evaluation of her blood glucose by her PCP and possible initiation of oral hypoglycemic medications. 4. Diastolic CHF. Pt became clinically overloaded and was transiently on Natrecor for diuresis as well as prn lasix. Pt required O2 via NRB and NC but was successfully weaned off prior to discharge. An echocardiogram done on [**2118-8-19**] showed an EF of ~60%, E/A ratio 0.91, no wall motion abnorm, and 1+ AR. Pt subsequently suffered a NSTEMI shortly after the echo, therefore a repeat echo was performed on [**2118-9-1**] which showed an EF of 50-55%, [**1-14**]+AR, and 1+MR (no significant change since prior Echo). She was d/c'ed on an ACEI for afterload reduction and given a prescription for lasix to be started if clinically indicated after she sees Dr. [**First Name (STitle) **]. 5. Hypothyroidism. Pt continued on her outpt dose of synthroid. No active issues. 6. NSTEMI. Pt started on a beta [**Last Name (LF) 7005**], [**First Name3 (LF) **], and Lipitor, which she tolerated well. Enzymes peaked at 520. Persantine-MIBI stress test on [**2118-9-2**] showed moderate reversible defect in the inferior wall. However, the pt refused cardiac cath at this time and she was discharged on medical management as above. She will follow up in the cardiology clinic. 8. Resp Acidosis--resolved on its own. Thought to be secondary to episodes of hypoventilation secondary to pain vs. medications (benzo's, barbituates, narcotics). 9. Delirium--resolved. Etiology thought to be multifactorial. Differential included metabolic (increased BUN/uremia?) vs. infection vs. NSTEMI vs. medication in the setting of ARF. LFT's, TSH, amylase/lipase all were within normal limits. Benzo's, bendadryl and narcotics were discontinued. Pt was administered prn zyprexa and haldol at night for increased confusion with good result. 10. UTI diagnosed by UA. Pt was treated with Levofloxacin. Medications on Admission: Levoxyl, Lasix, Atenolol, Lipitor, Coumadin Discharge Medications: 1. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 2. Levothyroxine Sodium 100 mcg Tablet Sig: One (1) Tablet PO QD (once a day). Disp:*30 Tablet(s)* Refills:*2* 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QD (once a day). Disp:*30 Tablet, Chewable(s)* Refills:*2* 4. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 5. Zestril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 6. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 1 days: please take [**9-5**]. Disp:*1 Tablet(s)* Refills:*0* 7. Outpatient Lab Work Crea/K Please send to [**Last Name (LF) **],[**First Name3 (LF) 900**] E. [**Telephone/Fax (1) 10508**] 8. Lasix 40 mg Tablet Sig: One (1) Tablet PO q: m,w,f: PLEASE DO NOT TAKE UNITL YOU SEE DR [**First Name (STitle) **],[**First Name3 (LF) 900**] E. [**Telephone/Fax (1) 10508**]. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Perforated Ulcers of Descending Aorta Non ST segment elevation Myocardial Infarction Delirium UTI Acute on Chronic Renal Failure Discharge Condition: Good Discharge Instructions: Please call your primary care physician or return to the hospital if you have symptoms of shortness of breath, chest pain, or any other promblems arise. [**Last Name (LF) **],[**First Name3 (LF) 900**] E. [**Telephone/Fax (1) 10508**] Followup Instructions: 1. PCP: [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Office to call to make appointment early this week (tues/wed) 2. Please follow-up with cardiologist. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 4450**], M.D. [**Hospital Ward Name **] CENTER CARDIAC SERVICES Phone:[**Telephone/Fax (1) 4451**] Date/Time:[**2118-9-21**] 11:30 [**First Name8 (NamePattern2) 2064**] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2139**]

[ "276.2", "447.2", "599.0", "584.9", "428.30", "403.91", "780.09", "428.0", "410.71" ]

icd9cm

[ [ [] ] ]

[ "00.13", "38.93" ]

icd9pcs

[ [ [] ] ]

8969, 9044

3065, 7821

312, 319

9217, 9223

1595, 3042

9507, 10041

1251, 1255

7915, 8946

9065, 9196

7847, 7892

9247, 9484

1270, 1576

242, 274

347, 968

990, 1108

1124, 1235

31,673

187,471

2444

Discharge summary

report

Admission Date: [**2121-3-14**] Discharge Date: [**2121-3-18**] Date of Birth: [**2047-7-7**] Sex: F Service: CARDIOTHORACIC Allergies: Codeine / Tylenol/Codeine No.3 Attending:[**First Name3 (LF) 1505**] Chief Complaint: coronary artery disease Major Surgical or Invasive Procedure: Coronary Artery Bypass Grafting x 3(LIMA-=LAD,SVG-OM,SVG-PDA)[**2121-3-14**] History of Present Illness: Mrs. [**Known lastname 12549**] is a 73 year old female with multiple cardiac risk factors and known coronary artery disease since [**2118**]. Given worsening shortness of breath and angina, she underwent stress testing which was positive for ischemia. Subsequent cardiac catheterization at [**Hospital6 5016**] revealed severe three vessel coronary artery disease including a 50% left main lesion. LVEF was normal. Given the above, she was referred for surgical revascularization. Past Medical History: Coronary Artery Disease Peripheral Vascular Disease, s/p Right Fem-Tib BPG [**2119**] Non-Insulin Depedent Diabetes Mellitus Hypertension Chronic Renal Insufficiency Tremor Depression/Anxiety Osteoporosis Cystic Pancreatic Mass Partial Colectomy for Malignant Polyp Thyroidectomy for Benign Mass Appendectomy Social History: Denies tobacco history. Denies ETOH. Family History: Mother died in her 50's, possible MI. Father sudden death, unknown age. Physical Exam: Admission: BP 140/63, P 58, R 16, SAT 98% room air Height 61 inches Weight 160 lbs General: Elderly female, very anxious, obvious tremor Skin: Unremarkable HEENT: PERRLA, EOMI, sclera anicteric, oropharynx benign Neck: Supple, no JVD Chest: Clear bilaterally Heart: Regular rate and rhythm, normal s1s2, no murmur or rub Abdomen: soft, NT,ND with normoactive bowel sounds Ext: Warm, 2+ edema on right LE, 1+ edema on left LE Neuro: Severe tremor o/w non-focal Pulses: 1+ distally, no carotid bruits noted. Pertinent Results: [**2121-3-14**] Intraop TEE: Pre-CPB: No spontaneous echo contrast is seen in the left atrial appendage. Overall left ventricular systolic function is low normal (LVEF 50-55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is no pericardial effusion. Post-CPB: Preserved biventricular systolic fxn. No AI. Trace-mild MR. Aorta intact. [**2121-3-18**] 05:30AM BLOOD WBC-4.8 RBC-2.88* Hgb-9.5* Hct-25.6* MCV-89 MCH-33.0* MCHC-37.2* RDW-15.1 Plt Ct-106* [**2121-3-17**] 05:40AM BLOOD Glucose-60* UreaN-22* Creat-1.1 Na-138 K-3.7 Cl-104 HCO3-29 AnGap-9 Brief Hospital Course: Mrs. [**Known lastname 12549**] was admitted and underwent coronary artery bypass grafting surgery by Dr. [**Last Name (STitle) **]. For surgical details, please see dictated operative note. She weaned from bypass on propofol, without the need for pressors. Following the operation, she was brought to the CVICU for invasive monitoring. Within 24 hours, she awoke neurologically intact and was extubated without incident. She maintained stable hemodynamics and transferred to the floor on postoperative two. Chest tubes and pacing wires were removed according to protocol. Beta blockers were resumed and diuresis was begun towards preoperative weight. physical therapy worked with the patient for mobilization and strength/endurance. She desired to go home from the hospital and arrangements were made for home health care. Medications, precautions and restrictions were discussed with the patient prior to leaving. Out patient followup was also discussed. Medications on Admission: K Clor-con 20 meq qd, Primidone 250 [**Hospital1 **], Seraquel 25 qhs, Metoprolol 50 qd, Calcium 500 [**Hospital1 **], Aspirin 81 qd, Simvastatin 10 qd, Clonazepam 0.5 prn, Imdur 30 qd, Metolazone 2.5 every Tues and Friday, Lasix 40 qd, Glyburide 5 [**Hospital1 **], Sertraline 50 qd Discharge Medications: 1. Influen Tr-Split [**2120**] Vac (PF) 45 mcg/0.5 mL Syringe Sig: One (1) ML Intramuscular ASDIR (AS DIRECTED) for 1 doses. 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 2 weeks. Disp:*28 Tablet(s)* Refills:*0* 4. Primidone 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Sertraline 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): twice daily for 7 days then decrease to once a day. Disp:*60 Tablet(s)* Refills:*2* 8. Propoxyphene N-Acetaminophen 100-650 mg Tablet Sig: [**2-7**] Tablets PO Q6H (every 6 hours) as needed for 2 weeks. Disp:*50 Tablet(s)* Refills:*0* 9. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. 10. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours). Disp:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2* 11. Glyburide 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Coronary Artery Disease s/p coronary artery bypass grafts Peripheral Vascular Disease- s/p bypass grafts Non-Isulin Depedent Diabetes Mellitus Hypertension Chronic Renal Insufficiency depression diastolic ventricular dysfunction s/p thyroidectomy Discharge Condition: Good Discharge Instructions: No driving for one month and off all narcotics No lifting more than 10 lbs for 10 weeks from the date of surgery. Do not apply creams, lotions or ointments to surgical incisions. Shower daily and wash surgical incsions daily with soap and water only. Pat dry incisions, no rubbing. No baths or swimming. Report any redness of, or drainage from incisions Report any fever greater than 100.5 Report any weight gain greater than 2 pounds a day or 5 pounds a week Take all medications as directed Followup Instructions: Dr. [**Last Name (STitle) **] in [**5-11**] weeks ([**Telephone/Fax (1) 12550**]) Dr. [**Last Name (STitle) **] in [**3-11**] weeks Dr. [**Last Name (STitle) **] in [**3-11**] weeks ([**Telephone/Fax (1) 12551**]) Please call for appointments Completed by:[**2121-3-18**]

[ "733.00", "585.9", "250.00", "781.0", "428.0", "428.30", "443.9", "414.01", "577.2", "300.4", "403.90" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

5463, 5538

2797, 3760

320, 399

5829, 5836

1927, 2774

6377, 6651

1313, 1386

4094, 5440

5559, 5808

3786, 4071

5860, 6354

1401, 1908

257, 282

427, 910

932, 1243

1259, 1297

15,912

140,531

14235+56517

Discharge summary

report+addendum

Admission Date: [**2131-1-11**] Discharge Date: [**2131-1-18**] Date of Birth: [**2058-9-1**] Sex: M Service: HISTORY OF PRESENT ILLNESS: Patient is a 72-year-old gentleman who had a mechanical fall. Initially awake at the scene, fell on the right side of his head with a laceration to his ear. Was taken to [**Hospital6 5016**] alert and oriented. Had a head CT there which showed a small 4.5 mm left subdural and 2.2 cm left temporal tip contusion. Patient was on Coumadin. His INR was 5.8 for mitral valve repair. He was transferred via Med Flight to [**Hospital1 346**]. PHYSICAL EXAMINATION: Temperature was 96.9, heart rate 65, blood pressure 171/70, respiratory rate 19, and sats 100%. He is awake, alert, aphasic with positive speech output, but word finding difficulties. Difficulty naming and with repetition. Speech was fluent, following some simple commands, slight right sided drift to grasp full bilaterally and moving legs bilaterally. Reflexes are 2+ throughout and symmetric. Toes are upgoing bilaterally. Gaze is conjugate. Face was symmetric. PAST MEDICAL HISTORY: 1. Mitral valve repair three years ago. 2. Status post carotid endarterectomy. 3. Tremor. 4. CABG. 5. Hypertension. 6. CVA. Head CT again shows left temporal lobe contusion and left parietal lobe contusion which developed after the prior head CT. A 1-2 cm left frontal contusion, right temporal tip contusion, subdural hematoma were stable and a traumatic subarachnoid hemorrhage in the left parietal lobe. The contusions did blossom after the initial scan. The patient was seen by Dr. [**Last Name (STitle) 739**], the attending physician, [**Name10 (NameIs) 1023**] recommended repeat head CT in the a.m. and monitoring neuro status closely. No need for surgical intervention at this time. Patient continued to be awake and alert. Pupils are equal, round, and reactive to light. His INR was corrected down to 1.3. He continued to have his blood pressure maintained less than 140. Was given Lasix to maintain negative fluid balance, and was started on Dilantin. On [**1-12**], he closed his eyes at times, inattentive, expressive aphasia, bilateral grips full, tremor in the left arm. Tremors make drift difficult to assess. Difficulty with complex commands. Patient was seen by Cardiology given the fact that his Coumadin was stopped due to the bleed and his mitral valve repair, he feels it is fine for him to be off anticoagulation. They recommended getting an echocardiogram. Echocardiogram has been performed and the Coumadin will be held for at least one month. The patient's neurological status remained stable. He was awake, attentive, localizing the right upper extremity showing slow to localize on the left, tremor, continues with tremors bilateral upper extremities withdrawing his lower extremities. His repeat head CT was stable. Stroke Neurology was consulted as well. Neurology recommended an EEG which showed just diffuse slowing consistent with encephalopathy with no epileptiform features. The patient remained stable and was transferred to the regular floor on [**2131-1-14**]. He is awake, attentive, somewhat confused at times, had a sitter in the room with him. Laboratories were all stable. White count of 9.0, hematocrit 28.4, platelets of 253, 139/3.7, 103/30, 17/0.8 and 108, this was all on [**2131-1-14**]. Dilantin level was 13.9. Continues to have full EOMs. Face with slight facial droop on the left side. Tongue midline. Strength in his extremities is [**6-12**]. He was seen by Physical Therapy and Occupational Therapy and found to acquire acute rehab. He will be discharged to rehab when acute bed available. MEDICATIONS ON DISCHARGE: 1. Miconazole powder 2% topically prn. 2. Dilantin 100 mg p.o. t.i.d. 3. Primidone 50 mg p.o. q.d. 4. Ciprofloxacin 500 mg p.o. q12 for five days for supposed UTI, he had 17 white cells on his urinalysis culture from [**2130-3-16**]. 5. Cyanocobalamin 50 mcg p.o. q.d. 6. Thiamine 100 mg p.o. q.d. 7. Multivitamin one cap p.o. q.d. 8. Paroxetine 20 mg p.o. q.d. 9. Metoprolol 25 mg p.o. b.i.d., hold for systolic blood pressure less than 100, heart rate less than 50. 10. Pantoprazole 40 mg p.o. q.24h. 11. Heparin 5,000 units subQ q12. 12. Amiodarone 200 mg p.o. q.d. 13. Colace 100 mg p.o. b.i.d. 14. Tylenol 650 p.o. q.4h. prn. FOLLOW-UP INSTRUCTIONS: He will follow up with Dr. [**Last Name (STitle) 739**] in one month with a repeat head CT. CONDITION ON DISCHARGE: Stable. [**Name6 (MD) 742**] [**Name8 (MD) **], M.D. [**MD Number(1) 743**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2131-1-18**] 09:40 T: [**2131-1-18**] 09:58 JOB#: [**Job Number 42312**] Name: [**Known lastname 6108**], [**Known firstname **] Unit No: [**Numeric Identifier 7643**] Admission Date: [**2131-1-11**] Discharge Date: [**2131-1-22**] Date of Birth: [**2058-9-1**] Sex: M Service: Discharge date was delayed until [**2131-1-22**] due to lack of rehab bed. CONDITION ON DISCHARGE: Patient's condition was stable at the time of discharge. FOLLOW-UP INSTRUCTIONS: He will follow up with Dr. [**Last Name (STitle) **] in one month's time. [**Name6 (MD) **] [**Name8 (MD) 1041**], M.D. [**MD Number(1) 7644**] Dictated By:[**Last Name (NamePattern1) 366**] MEDQUIST36 D: [**2131-3-13**] 11:19 T: [**2131-3-13**] 11:51 JOB#: [**Job Number 7645**]

[ "E888.9", "427.31", "E849.6", "851.41", "414.00", "401.9", "V45.81", "305.00", "599.0" ]

icd9cm

[ [ [] ] ]

[ "99.04" ]

icd9pcs

[ [ [] ] ]

3721, 4353

625, 1096

159, 602

5176, 5493

1118, 3695

5093, 5151

75,972

148,037

41769

Discharge summary

report

Admission Date: [**2190-8-9**] Discharge Date: [**2190-8-23**] Date of Birth: [**2111-9-16**] Sex: F Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1505**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: [**2190-8-12**] Cardioversion [**2190-8-17**] Coronary artery bypass graft x1 (left internal mammary artery > left anterior descending) Mitral valve repair (28 mm annuloplasty ring) History of Present Illness: 78F presented to OSH last week with c/o chest pain. She ruled in for NSTEMI with troponin peaking at 13ng/mL. Cardiac cath showed severe two vessel coronary artery disease with a 90% lesion in a heavily calcified LAD and total occlusion on the right. The PDA is supplied via collaterals from the LAD, therefore stenting of the LAD was considered high risk. She is transferred for CABG evaluation. She has been taking Plavix. Additionally, she presented to the ED with new onset rapid atrial fibrillation, which was rate controlled with IV Diltiazem, digoxin and Lopressor. Initial hematocrit was 30%, GI was consulted and recommended follow up as an outpatient following resolution of cardiac issues. Past Medical History: Coronary Artery Disease Mitral Valve Prolapse chronic diastolic heart failure Diabetes Mellitus Hypertension Hypothyroidism Social History: Lives with: alone, has 4 children Cigarettes: Smoked no [x] yes Other Tobacco use: none Family History: non contributory Physical Exam: Pulse: 86 Resp: 16 O2 sat: 98%RA B/P Right: 117/61 Left: Height: 65" Weight: 156lb General: NAD, WGWN elderly female Skin: Dry [x] intact [x] HEENT: PERRLA [] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [] Irregular [x] Murmur [] grade ______ Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] Extremities: Warm [x], well-perfused [x] Edema [] trace_ Varicosities: minor Neuro: Grossly intact [x] Pulses: Femoral Right: 2+ Left:2+ DP Right: 1+ Left:1+ PT [**Name (NI) 167**]: 1+ Left:1+ Radial Right: 2+ Left:2+ Carotid Bruit none Pertinent Results: Conclusions PRE-BYPASS: -No spontaneous echo contrast or thrombus is seen in the body of 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. -The coronary sinus is mildly dilated (diameter 1.1cm). No bubbles/saline noted in CS during interrogation for persistent LSVC. -Left ventricular wall thicknesses are normal. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is mildly depressed (LVEF= 40-50 %). -There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. -The aortic valve leaflets (3) are mildly thickened. Mild (1+) aortic regurgitation is seen. -The mitral valve leaflets are severely thickened/deformed. There is severe restriction of the posterior mitral valve leaflet. There is moderate thickening of the mitral valve chordae attached to the anterior mitral leaflet. The mitral regurgitation vena contracta is >=0.7cm. Severe (4+) mitral regurgitation is seen. Due to the eccentric nature of the regurgitant jet, its severity may be significantly underestimated (Coanda effect). -The tricuspid valve leaflets are mildly thickened. -There is mild pulmonary artery systolic hypertension. -There is no pericardial effusion. Dr. [**Last Name (STitle) **] was notified of the results at the time of the study. POSTBYPASS: On phenylephrine, a pacing briefly. Prior to weaning from cpb, there was moderate to severe mitral regurgitation, which reduced to 1+ off bypass. Two small jets of mitral regurgitation were seen. Dr. [**First Name (STitle) 6507**] was able to image the regurgitation using 3-D. LV fuction was normal. The annuloplasty ring was well-seated without rocking and with only a small perivalvular leak. The AI remains 1+ and the aortic contour is normal post decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2190-8-17**] 13:42 [**2190-8-21**] 08:00AM BLOOD WBC-12.0* RBC-3.49* Hgb-10.7* Hct-31.0* MCV-89 MCH-30.7 MCHC-34.6 RDW-14.9 Plt Ct-179 [**2190-8-20**] 06:20AM BLOOD PT-17.2* INR(PT)-1.5* [**2190-8-21**] 08:00AM BLOOD Glucose-166* UreaN-24* Creat-0.8 Na-136 K-4.0 Cl-98 HCO3-31 AnGap-11 [**2190-8-21**] 08:00AM BLOOD Calcium-8.4 Phos-2.3* Mg-2.0 [**2190-8-23**] 06:20AM BLOOD WBC-10.8 RBC-3.17* Hgb-9.6* Hct-27.9* MCV-88 MCH-30.2 MCHC-34.3 RDW-14.4 Plt Ct-234 [**2190-8-23**] 06:20AM BLOOD PT-35.0* INR(PT)-3.5* [**2190-8-22**] 06:40AM BLOOD PT-39.5* INR(PT)-4.0* [**2190-8-21**] 07:11PM BLOOD PT-27.7* PTT-27.2 INR(PT)-2.7* [**2190-8-21**] 02:43PM BLOOD PT-62.2* INR(PT)-6.9* [**2190-8-21**] 01:10AM BLOOD PT-55.4* INR(PT)-6.0* [**2190-8-20**] 06:20AM BLOOD PT-17.2* INR(PT)-1.5* [**2190-8-23**] 06:20AM BLOOD UreaN-23* Creat-1.0 Na-140 K-4.1 Cl-98 [**2190-8-22**] 06:40AM BLOOD Glucose-120* UreaN-24* Creat-0.8 Na-137 K-3.8 Cl-97 HCO3-33* AnGap-11 Brief Hospital Course: Transferred in from outside hospital for surgical evaluation. Her lisinopril was stopped for creatinine elevation of 1.6 up from 1.1 on labs from outside hospital - noted for acute kidney injury on admission. Her creatinine was monitored preoperatively and progressively trended down. Additionally on admission labs, she had urine culture that revealed E coli that was treated with ciprofloxacin. She was continued on heparin for atrial fibrillation, and continued on digoxin and diltiazem for rate management. Then on [**2190-8-12**] she underwent transesophageal echocardiogram to evaluate valve and rule out any clot prior to cardioversion. She underwent cardioversion and converted to sinus rhythm. She was started on amiodarone and digoxin was stopped, and continued on heparin until right groin presented with hematoma. She underwent ultrasound that ruled out pseudo aneurysm and vascular surgery was consulted. She did have drop in hct from admission at 32 down to 24.8 and was transfused with packed red blood cells, and responded appropriately. Her groin remained stable until she was brought to the operating room on [**8-17**] for coronary artery bypass graft and mitral valve repair surgery. See operative report for further details. Post operatively she was transferred to the intensive care unit for management. She had post operative bleeding that was treated with blood products with improvement. She remained intubated overnight on propofol and neosynephrine for blood pressure management. The morning of postoperative day one she was weaned from sedation, awoke neurologically intact and was extubated without complication. She was started on lasix for diuresis but remained on neosynephrine until that afternoon, of which then betablockers were started. She remained in the intensive care unit for monitoring and on post operative day two was restarted on amiodarone for preoperative atrial fibrillation and coumadin. She continued to improve and was ready for transfer to the floor. Physical therapy worked with her on strength and mobility. Chest tubes and pacing wires were removed without complication. She is to be discharged to rehab on telemetry with history of preoperative atrial fibrillation as well as IV lasix with significant post operative residual edema. ***Plavix may be restarted per her cardiologist ( please check with him prior to her discharge from rehab).Target INR for A Fib 2.0-2.5. First INR check day after discharge. Cleared for discharge to [**Hospital3 **] in [**Location (un) 8957**] on POD 6. All f/u appts were advised. Medications on Admission: on admission to OSH: ISMN Lasix Lipitor Atenolol levothyroxine lisinopril metformin aspirin loratadine Discharge Medications: 1. furosemide 10 mg/mL Solution Sig: Four (4) Injection every twenty-four(24) hours for 7 days: 40 mg IV every 24 hours for one week; please monitor creatinine. 2. potassium chloride 20 mEq Tablet, ER Particles/Crystals Sig: One (1) Tablet, ER Particles/Crystals PO once a day for 7 days. 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. 4. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 5. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 6. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain/fever. 7. levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day: through [**8-26**]; then 200 mg daily ongoing. 10. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 11. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. warfarin 1 mg Tablet Sig: daily dosing per rehab provider Tablet PO Once Daily at 4 PM: target INR 2.0-2.5 for A Fib. 13. insulin lispro 100 unit/mL Solution Sig: per insulin flowsheet sliding scale as attached Subcutaneous ASDIR (AS DIRECTED). 14. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 15. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 16. magnesium hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO HS (at bedtime) as needed for constipation. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 8957**] Discharge Diagnosis: Coronary artery disease s/p CABG Mitral valve prolapse s/p MV repair Atrial Fibrillation preoperative Non ST elevation myocardial infarction Acute kidney injury on transfer Cr 1.6 was 1.1 at OSH Urinary tract infection on transfer Right groin hematoma s/p cardiac catheterization OSH Chronic diastolic heart failure Diabetes Mellitus Hypertension Hypothyroidism Discharge Condition: Alert and oriented x3 nonfocal Ambulating with assistance Incisional pain managed with oral analgesics Incisions: Sternal - healing well, no erythema or drainage Edema [**12-6**]+ Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr [**Last Name (STitle) **] Wednesday [**9-22**] @ 1:30 pm [**Hospital Ward Name **] 2A [**Telephone/Fax (1) 170**] Cardiologist: Dr [**Last Name (STitle) 42394**] [**9-2**] @ 2:00 PM Please call to schedule appointments with your Primary Care Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**3-9**] 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 A Fib Goal INR 2.0-2.5 First draw [**2190-8-24**] ***please arrange for coumadin/INR f/u prior to discharge from rehab Completed by:[**2190-8-23**]

[ "244.9", "428.32", "250.00", "041.4", "E878.2", "410.71", "E879.0", "424.0", "401.9", "427.31", "998.12", "518.5", "584.9", "428.0", "414.01", "458.29", "599.0", "285.1", "V70.7", "998.11" ]

icd9cm

[ [ [] ] ]

[ "88.72", "96.71", "39.61", "99.62", "36.15", "35.33" ]

icd9pcs

[ [ [] ] ]

9819, 9893

5375, 7969

321, 506

10299, 10481

2208, 5352

11404, 12156

1512, 1530

8123, 9796

9914, 10278

7995, 8100

10505, 11381

1545, 2189

270, 283

534, 1242

1264, 1390

1406, 1496

17,412

187,840

44772

Discharge summary

report

Admission Date: [**2106-11-18**] Discharge Date: [**2106-11-21**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1185**] Chief Complaint: Anemia Major Surgical or Invasive Procedure: Esophagogastroduodenoscoy (EGD) History of Present Illness: Mr. [**Known lastname 95715**] is an 88 year old man with paroxysmal atrial fibrillation and atrial tachycardia which are now persistent, coronary disease status post inferior MI in [**2092**], status post dual-chamber pacemaker for impaired AV nodal conduction in [**Month (only) 116**] [**2104**], and chronic kidney disease who presents today from [**Hospital3 9475**] Care Center a HCT of 23. HCT in the ED found to be 23*. EKG showed slow atrial fibrillation without P waves, with atypical RBB, leftward axis, and some T wave flattening in the precordium (normally has Twave inversion across precordium). 2 large bore IVs placed. Guaiac positive from below with black stool, assumed to be secondary to the patient ingesting blood. The patient was consented for blood, and a CXR showed a worsening and possibly loculated R pleural effusion. He also received 1 U PRBC in the ED. At rehab, his labs on [**11-19**] in the AM were notable for Cr 1.4, K 5, HCT of 23, INR 4.2 Of note, 3 weeks ago he was admitted to [**Hospital 4199**] Hospital where he was diagnosed with pneumonia. He was discharged to rehab where he has been for several weeks. While at rehab, he developed a bloody nose from his right nares and has undergone packing which needs to remain in place until Friday [**11-20**]. He had been receiving amoxicllin clavulonic acid as part of his regime for packing. In the ED, initial VS: 99.3 95 123/62 18 99% 4L Nasal Cannula. Labs were notable for: K 5.2, BUN 51, Cr 1.5 (baseline 1.6 since [**2102**]), HCT 23.2* (baseline 34), MCV 99*, INR 4.5*. The patient was given 1 g CeftriaXONE and 500 mg Azithromycin for a presumed PNA. He was transfused 1 U PRBC, and sent up with a second unit. Of note, for med changes, his Lasix has been decreased from 40 mg b.i.d. His metoprolol succinate 25 mg once a day is now carvedilol 12.5 mg b.i.d. His lisinopril 2.5 mg was discontinued recently as well. He denies any lightheadedness or chest pain. No shortness of breath. Does have a junky sounding cough. REVIEW OF SYSTEMS: Positive for "chills" at night, a cough for the past several days which has turned from dark red to a tannish color, melena (black stool) for a week. Denies fever, night sweats, headache, vision changes, rhinorrhea, sore throat, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, hematochezia, dysuria, hematuria. Denies dizziness or lightheadedness. Past Medical History: - Dilated cardiomyopathy with an EF of 25% with chronic systolic and diastolic heart failure - Mitral regurgitation status post bioprosthetic MVR, - Persistent atrial fibrillation and atrial tachycardia - Coronary artery disease status post IMI in [**2092**] with a most recent left heart catheterization in [**2100-11-21**] showing no flow-limiting disease - AV conduction disease status post dual-chamber pacemaker in [**2105-3-21**] - Chronic kidney disease stage IV with baseline creatinine of 1.8 - Trigeminal neuralgia status post trigeminal nerve ablation - Gastritis and duodenitis - Orchiectomy for a testicular mass in [**2074**], and diverticulosis Social History: Social and family history were reviewed and remain unchanged. He was living with his family, but is now at a rehab. He is a former probation officer. He has no history of tobacco or drug use and drinks occasional alcohol. Family History: There is no family history of premature coronary artery disease, heart failure, or sudden death. Physical Exam: ADMISSION PHYSICAL EXAM VS - Temp F, BP 115/49 HR 61 RR 28 )2 Sat 100% on 2 L GENERAL - NAD, comfortable, appropriate HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM NECK - supple, no thyromegaly, no JVD appreciated LUNGS - Dullness to percussion on the R, crackles at the L base, mild accessory muscle use HEART - irreigularly irreigular, nl S1/S2 ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, 1+ peripheral edema B, 2+ peripheral pulses (radials, DPs) SKIN - eccymosis on the L hand NEURO - awake, A&Ox3 DISCHARGE PHYSICAL EXAM Pertinent Results: ADMISSION LABS [**2106-11-18**] 05:30PM BLOOD WBC-8.4 RBC-2.34*# Hgb-7.2*# Hct-23.2*# MCV-99* MCH-30.7 MCHC-30.9* RDW-13.2 Plt Ct-193# [**2106-11-18**] 05:30PM BLOOD Neuts-88.6* Lymphs-6.1* Monos-4.0 Eos-1.1 Baso-0.2 [**2106-11-18**] 05:30PM BLOOD PT-45.4* PTT-36.0 INR(PT)-4.5* [**2106-11-17**] 03:54PM BLOOD UreaN-40* Creat-1.4* Na-141 K-5.5* Cl-105 HCO3-27 AnGap-15 [**2106-11-18**] 05:30PM BLOOD CK-MB-9 [**2106-11-18**] 05:30PM BLOOD cTropnT-0.15* [**2106-11-18**] 11:10PM BLOOD CK-MB-8 cTropnT-0.14* [**2106-11-19**] 06:25AM BLOOD CK-MB-8 cTropnT-0.16* [**2106-11-19**] 12:30PM BLOOD CK-MB-7 cTropnT-0.15* [**2106-11-18**] 11:10PM BLOOD CK(CPK)-951* [**2106-11-19**] 06:25AM BLOOD CK(CPK)-1037* [**2106-11-19**] 12:30PM BLOOD CK(CPK)-1019* [**2106-11-19**] 06:25AM BLOOD Calcium-8.1* Phos-3.6 Mg-2.8* DISCHARGE LABS MICROBIOLOGY [**2106-11-18**] BLOOD CULTURES X2: pending [**2106-11-19**] SPUTUM CULTURE GRAM STAIN (Final [**2106-11-19**]): Contamination with upper respiratory secretions. RESPIRATORY CULTURE (Final [**2106-11-19**]): Test cancelled. IMAGING [**2106-11-18**] CHEST (PA & LAT): Increased moderate-to-large right pleural effusion which may be partially loculated, with overlying atelectasis, underlying consolidation cannot be excluded. Brief Hospital Course: ICU Course . 88 year old man with paroxysmal atrial fibrillation and atrial tachycardia which are now persistent, CAD s/p inferior MI in [**2092**], status post dual-chamber pacemaker for impaired AV nodal conduction in [**2105-3-21**], and CKD who p/w a GI bleed in the setting of a supratherapeutic INR. ACTIVE ISSUES # HCT Drop/GI Bleed: Per pt report, has been having melanotic stools over the past week. Also, due history of gastritis and duodenitis, GI was consulted who performed an [**Year (4 digits) 95785**] (EGD) once the patien was transferred to the ICU so that he may receive MAC anesthesia. Pt is now s/p 4 units pRBCs and 2 units FFP. His aspirin and coumadin were held for the duration of his hospitalization. The EGD showed gastritis and doudenitis with duodenal ulcer which was clean based. H. Pylori serology was added and PPI continued. # CAD: Patient denies any CP, but had elevated troponin at 0.14-0.16 x4, with a borderline normal CK-MB, although still slightly elevated from prior. EKG shows some non-specific T wave flatting, and patient denies chest pain, with troponemia concerning for the demand in the setting of a low HCT. 2nd troponin trending down. His home carvedilol and simvastatin were continued, though aspirin was held. # Elevated INR: Likely elevated in the setting of antibiotic useage for Nasal packing as well as antibiotic usage for PNA as treated at [**Hospital 4199**] Hospital 3 weeks ago. Antibiotics were held during the admision, as well as warfarin. # Hypoxemia: In the ED was treated as PNA, and has had PNA in the past, but currently does not have WBC count or fever, but does endorse productive sputum, though adequate sample was unable to be obtained for culture. The Care referral form make a note of an exudative R pleural effusion (possibly infectious, now possibly loculated per report) at his OSH stay, which was also found on chest x-ray here. Nasal packing that patient had placed about 1 week prior to admission due to epistaxis was removed on HD #1. Pt was also administered extra doses of lasix due to the blood products he received so as not to fluid overload him. CHRONIC/INACTIVE ISSUES # CKI: At baseline. No active issues. # Dilated Cardiomyopathy with chronic systolic heart failure: Not currently exhibiting signs of heart failure. Extra doses of lasix given due to blood products he was supplied, as above. His home carvedilol was continued. # Nasal bleeding: Pt's nasal packing was removed on HD #1 prior to transfer to the ICU for EGD. # Hyperkalemia: Pt's lisinopril was held given high K, and came down with administration of lasix. # Atrial fibrillation: Carvedilol was continued for rate control. Coumadin (and ASA) were held given bleeding. # Insomnia: Pt was continued on home Lorazepam 0.5 mg qHS prn insomnia TRANSITIONAL ISSUES -H. Pylori ab needs to be followed Medications on Admission: amoxicillin/clavulanate 875/125 mg twice a day for 7 days (started [**2106-11-11**]) Multivitamin PRN Carvedilol 12.5 mg twice daily Lasix 20 mg daily DuoNeb PRN Lorazepam 0.5 mg at bedtime as needed for insomnia Simvastatin 80 mg daily Coumadin 5 mg as instructed for goal INR 2 to 3 Aspirin 81 mg daily Discharge Medications: 1. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 2. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 5. furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 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. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. Disp:*30 Tablet, Chewable(s)* Refills:*2* 8. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital3 9475**] Care Center - [**Location (un) 3146**] Discharge Diagnosis: Gastrointestinal bleed, likely from a duodenal ulcer. Supratherapeutic INR. Nose bleed. Elevated CPK and liver function tests. Complicated and loculated right pleural effusion. Dilated cardiomyopathy with systolic heart function. Chronic kidney disease. Insomnia Atrial Fibrillation 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 95715**], It was a pleasure taking care of you during your hospital stay at [**Hospital1 18**]. You were admitted due to a low blood count. Your low blood count was likely caused by bleeding from your upper gastrointestinal tract. The gastrointestinal doctors performed [**Name5 (PTitle) **] [**Name5 (PTitle) 95785**] (a scope that looks into your esophagus, stomach, and first part of the intestine) and found that you had an ulcer in your small intestine that might have been the cause of your bleeding. The treatment for this is time, medicine to control the acid in your stomach, and sometimes antibiotics. We took a test to see if you'll need the antibiotics, called an H.pylori test. Your primary care doctors [**Name5 (PTitle) **] monitor the results and let you know the answer. While you were here, your INR was very high. Your coumadin was held during your hospitalization. Upon discharge, you should not take your coumadin for several days. It needs to be restarted in the near future. The doctors at rehab [**Name5 (PTitle) **] tell you when you should start taking the medication again. Also, your nasal packing was removed while you were here. Nothing else needs to be done regarding this problem for now. Because of your chest xray we got a computed tomography (CT) of your chest. This shows that you still have a pleural effusion on the right side of your chest. We talked to the pulmonologists (lung doctors) here about trying to drain the fluid, but we decided that it didn't need to get done right now. Dr.[**Name (NI) 25722**] team was involved with the decision, and we'd like you to make an appointment to see him in his office in two (2) weeks. Additionally, you need to have your blood drawn in one (1) week time to check the level of a blood test called CPK. It is important that you weigh yourself every morning, and call your doctor if your weight goes up more than 3 lbs. Please make the following changes to your medications. Please START taking: ----------> Pantoprazole 40mg, once daily. Please STOP taking: XXXXXXXXXXX Simvastatin 80mg, once daily XXXXXXXXXXX Coumadin 5mg, but this may be restarted in the future. Please continue taking your other home medications as prescribed. Followup Instructions: You will need to call the Pulmonology Clinic on Tuesday [**11-23**] to schedule an appointment to be seen by Dr. [**First Name (STitle) **] at ([**Telephone/Fax (1) 514**] to make an appointment to be seen in two (2) week's time. Additionally, you already have the following appointment to keep: Department: CARDIAC SERVICES When: FRIDAY [**2107-3-11**] at 1 PM With: DEVICE CLINIC [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: CARDIAC SERVICES When: FRIDAY [**2107-3-11**] at 1:40 PM With: [**Name6 (MD) 251**] [**Last Name (NamePattern4) 677**], M.D. [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: ADULT SPECIALTIES When: WEDNESDAY [**2107-4-6**] at 9:50 AM With: [**Doctor First Name **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1142**] Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Parking on Site [**Name6 (MD) **] [**Name8 (MD) **] MD [**Doctor Last Name 1189**] Completed by:[**2106-11-23**]

[ "428.0", "780.52", "790.01", "427.31", "412", "425.4", "426.7", "428.42", "V45.01", "562.10", "585.4", "511.89", "V58.61", "V42.2", "276.7", "784.7", "790.92", "414.01", "532.40" ]

icd9cm

[ [ [] ] ]

[ "21.01", "45.13" ]

icd9pcs

[ [ [] ] ]

9768, 9854

5696, 8560

260, 294

10181, 10181

4408, 5673

12645, 13960

3699, 3798

8915, 9745

9875, 10160

8586, 8892

10357, 12622

3813, 4389

2361, 2760

214, 222

322, 2341

10196, 10333

2782, 3444

3460, 3683

11,146

155,635

23998

Discharge summary

report

Admission Date: [**2150-6-8**] Discharge Date: [**2150-6-25**] Date of Birth: [**2077-11-8**] Sex: F Service: VSU DATE OF TRANSFER TO VASCULAR SERVICE: [**2150-6-22**] CHIEF COMPLAINT: Sternal wound and groin infections. HISTORY OF PRESENT ILLNESS: The patient is well-known to the cardiac service and vascular service, who was recently discharged after a protracted hospital stay for cardiogenic shock, status post coronary artery bypasses x2 with a vein graft to the LAD and a vein graft to obtuse marginal. She was transferred to the emergency room with pain at the surgical site and drainage x24 hours. She denies constitutional symptoms. The patient was initially evaluated in the emergency room by the cardiothoracic service. She was given IV vancomycin and oxycodone for analgesic control. The patient is now admitted for further evaluation and treatment. PAST MEDICAL HISTORY - ALLERGIES: Cephalosporins and penicillin--manifestations unknown. ILLNESSES: Include hypertension, cardiomyopathy, gallbladder disease status post cholecystectomy. Status post cardiac catheterization on [**2150-4-17**] which showed left main trunk disease of 90%, proximal LAD 50%, with 70% midcircumflex lesion, and a totally occluded right coronary artery with 2-3+ mitral regurgitation. Status post intra- aortic balloon pump. Status post coronary artery bypasses with vein to the LAD and obtuse marginal, and a mitral valve repair with a 26 annuloplasty ring. History of bilateral lower extremity ischemia status post thrombectomies. Status post AKA. History of acute renal failure. Recurrent CVVHD. Status post a tracheostomy and PEG placement. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Noncontributory. HOSPITAL COURSE: On [**2150-6-8**], the patient was admitted to the cardiac service after being evaluated in the emergency room. Physical exam demonstrated that neurologically she was grossly intact. Lungs were clear to auscultation bilaterally with diminished breath sounds in the bases. She had had a right subclavian catheter in place. Heart was a regular rate and rhythm. Abdominal exam showed soft with a PEG in place. External left and right groins and an aspect of the thigh with a large amount of purulence and erythema. Sternal wound with open area midincision with large amount of purulent drainage. The patient's white count on admission was 13.6, hematocrit 29.2, BUN 6, creatinine 0.3. Urinalysis showed leukocyte positive, bacteria positive, with 3-5 WBCs. The patient was continued on her transfer medications except for Coumadin which was held. ID was consulted. Wound cultures were obtained. Plastic surgery was consulted on [**2150-6-8**] for recommendations regarding sternal wound infection. Vascular surgery was notified of the patient's admission on [**2150-6-9**]. The AKA stumps looked intact and healing, though the patient had bilateral groin wounds. The patient underwent reversal of her INR and was transfused 2 units of FFP. She underwent on [**2150-6-9**] a sternal wound debridement with a left groin debridement. The patient tolerated the procedure and was transferred to the ICU for continued monitoring and care. ID recommendations included wound cultures on the right thigh which grew 3+ gram-positive cocci pairs and clusters, and external wound grew 3+ gram- positive cocci in pairs. Recommendations were to continue current antibiotic management and adjust according to organism sensitivities. Vancomycin trough was monitored and dosage adjusted accordingly. Groin wounds were continued with normal saline wet-to-dry dressings. The patient underwent on [**2150-6-9**] a pectoral advance and flap closure. She tolerated it well. On [**2150-6-10**], the left groin wound had a VAC dressing placed. The patient continued on vancomycin and levofloxacin. She continued to be followed by infectious disease. Sternal wound cultures came back MRSA. The patient was continued on vancomycin. VAC dressing to the groins was changed q 3-4 days. The patient returned to the OR on [**2150-6-12**] and underwent a repeat debridement with bilateral pectoral major muscle flapping and advancement. She tolerated the procedure well and was transferred to the PACU in stable condition, and actual dressings were removed on postoperative day 1. A PICC line was placed on [**2150-6-13**] with continued IV access and antibiotics. The patient's JP drains removed on [**6-16**], [**6-18**], and last JP drain was removed on [**2150-6-21**]. The patient was followed by nutrition for nutritional needs and recommendations, and continued on her tube feeds cycling. She was evaluated by physical therapy who felt that she would require continued rehab. The wound care nurse followed the patient for her sacral pressure ulcer and her occipital ulcer. The occipital ulcer was mostly healed. The sacral ulcer was small with partial thickness. Recommendations for the occiput ulcer was DuoDerm gel, antifungal powder to posterior gluteal areas, and Allevyn foam changes q. 3 days to the sacral area. The patient was transferred to the vascular service on [**2150-6-22**]. The remainder of the hospital course was unremarkable. The patient was treated for MRSA and Klebsiella and Proteus wound infections. Vancomycin was dosed at 750 mg IV q. 12 h. Recommendations were to continue her vancomycin and keep the trough between 15 and 20. The patient should follow-up in [**Hospital **] Clinic on [**2150-7-7**] at 3:30 p.m. with Dr. [**Last Name (STitle) 61104**]. The patient should have weekly CBCs and differentials done while on continued antibiotics, along with LFTs and renal function. ESRs and CRPs should be done q. 3 week. Levofloxacin and Flagyl will be continued until [**2150-7-9**], and vancomycin until [**2150-7-23**]. The patient will continue with current PICC care. The patient will continue with left VAC to groin with changes q. 3 days. The right groin wound is normal saline wet-to-dry dressings b.i.d. The patient will be discharged to rehab as soon as bed availability. DISCHARGE MEDICATIONS: 1. Heparin porcine 5,000 units t.i.d. 2. Escitalopram oxalate 10 mg daily. 3. Fluconazole propionate actuation in aerosol inhaler puffs 2 b.i.d. 4. Albuterol sulfate 0.083 solution q. 6 h. 5. Ipratropium bromide 0.02% solution inhalation q. 6 h. 6. Oxycodone/acetaminophen 5/325 tablets [**12-28**] q. [**4-1**] h. p.r.n. 7. Levofloxacin 500 mg q. 24 h. to continue until [**2150-7-9**]. 8. Flagyl 500 mg t.i.d. to continue until [**2150-7-9**]. 9. Vancomycin 750 mg q. 12 h. to be continued until [**2150-7-23**]. 10. Metoprolol 12.5 mg b.i.d. 11. Colace 100 mg b.i.d. 12. Acetaminophen 325 mg once daily. 13. Magnesium hydroxide 400 mg in 5 cc suspension 30 cc at bedtime p.r.n. 14. Dulcolax suppository once daily p.r.n. 15. Miconazole nitrate 2% powder to affected areas q.i.d. 16. Lorazepam 0.5 mg tablets q. 4 h. p.r.n. 17. Lansoprazole 30 mg once daily 18. Insulin Humulin 100 units regular and sliding scale q.i.d. a.c. and h.s. WOUND CARE: As described previously. Last VAC dressing was on [**2150-6-25**]. FO[**Last Name (STitle) 996**]P: The patient should follow-up with Dr. [**Last Name (STitle) **] in [**12-28**] weeks and call for an appointment at [**Telephone/Fax (1) 60472**]. She will also follow-up with Dr. [**Last Name (Prefixes) **] in 1 month's time; please call for an appointment. The patient should also follow-up with the plastic service, Dr. [**First Name (STitle) 3228**], in [**1-29**] weeks post discharge, and call for an appointment at [**Telephone/Fax (1) **]. The patient has a follow-up appointment with the infectious disease service on [**2150-7-7**] at 3:30 p.m. with Dr. [**Last Name (STitle) 61104**]. Weekly CBCs with diffs, creatinine and LFTs should be drawn and faxed to [**Hospital **] Clinic at [**Telephone/Fax (1) 1419**]. Also obtain ESR and CRPs 2-3 weeks while patient is on antibiotics. Vancomycin trough level should be done once a week--trough between 15 and 20. DISCHARGE DIAGNOSES: Sternal wound and groin infections bilaterally with Methicillin resistant Staphylococcus aureus, Klebsiella and Proteus. Status post sternal wound and groin debridements. Status post pectoral flap closure. Postoperative blood loss anemia--transfused. Status post peripherally inserted central catheter line placement. History of coronary artery disease and mitral valve disease status post coronary artery bypass graft x2 with mitral valve repair. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(2) 6039**] Dictated By:[**Last Name (NamePattern1) 2382**] MEDQUIST36 D: [**2150-6-25**] 12:45:18 T: [**2150-6-25**] 13:42:59 Job#: [**Job Number 61105**]

[ "V45.81", "414.00", "707.03", "707.09", "285.1", "998.59", "041.11", "V49.76", "V09.0", "790.92" ]

icd9cm

[ [ [] ] ]

[ "86.74", "99.04", "99.07", "86.22", "38.93" ]

icd9pcs

[ [ [] ] ]

1684, 1702

8072, 8798

6066, 7062

1755, 6043

209, 246

7075, 8050

275, 1667

1719, 1737

74,410

196,126

40180

Discharge summary

report

Admission Date: [**2120-6-18**] Discharge Date: [**2120-6-26**] Date of Birth: [**2053-2-25**] Sex: F Service: SURGERY Allergies: Penicillins / Tetracycline Analogues Attending:[**First Name3 (LF) 1481**] Chief Complaint: Ventral hernia Major Surgical or Invasive Procedure: [**2120-6-18**]: Open ventral hernia repair with component separation and mesh History of Present Illness: 66-year-old obese female with HTN, DM who presents with a ventral hernia. Patient is s/p laparoscopic cholecystectomy in [**2112**] c/b incisional hernia at umbilical port site. She underwent herniorrhaphy in [**2112**] and developed a wound dehiscence and infection. She was treated with intravenous antibiotics. This then was opened and it seemed to heal by secondary intention. She has had no drainage, but she has noted increasing abdominal swelling and mass. She denies any chronic cough, constipation, or urinary difficulty. She has had no symptoms of intestinal obstruction. She does have significant obesity. Past Medical History: PMH: obesity, DM2, HTN, ^chol, GERD, depression PSH: Intestinal wall cyst removal ([**2056**]), tonsillectomy ([**2059**]), Removal benign tumor L leg ([**2063**]), tubal ligation ([**2093**]), B/L cataract, ORIF L ankle ([**2100**]), lap ccy ([**2112**]), umbo hernia repair w mesh ([**2112**]), I&D infected umbo hernia site ([**2112**]) [**Last Name (un) 1724**]: Amlodipine 5', Carvedilol 6.25'', Lisinopril 40', Ezetimibe 10, Simvastatin 20, Fenofibrate 134', Metformin 500", Omega 3, Prilosec 20, Ferrex 150, Citalopram 20', Amitriptyline 10 Social History: Tobacco: quit [**2113**]; EtOH: 2 glasses wine/month; Drugs: Denies Family History: Unknown Physical Exam: VS: T: 97.0 P: 90 BP: 136/60 RR: 20 O2sat: 93RA GEN: WD, morbidly obese F in NAD HEENT: NCAT, EOMI, anicteric CV: RRR PULM: decreased BS at bases, minimal crackles at bases B/L, no respiratory distress ABD: soft, minimal peri-incisional tenderness, ND, no mass, no hernia; lower abdominal preperitoneal [**Doctor Last Name **] drains x 3 to bulb suction w serosanguinous output; incision: some necrosis at left midline, unchanged postoperatively EXT: WWP, no CCE NEURO: A&Ox3, no focal neurologic deficits Pertinent Results: LABORATORIES: [**2120-6-19**] 04:45AM BLOOD WBC-17.6*# RBC-3.59* Hgb-10.8* Hct-33.6* MCV-94 MCH-30.2 MCHC-32.2 RDW-13.8 Plt Ct-510* [**2120-6-24**] 06:25AM BLOOD WBC-9.9 RBC-2.68* Hgb-8.1* Hct-24.9* MCV-93 MCH-30.3 MCHC-32.6 RDW-13.8 Plt Ct-471* [**2120-6-19**] 04:45AM BLOOD Glucose-121* UreaN-37* Creat-2.1*# Na-140 K-5.3* Cl-102 HCO3-25 AnGap-18 [**2120-6-24**] 06:25AM BLOOD Glucose-128* UreaN-25* Creat-0.8 Na-142 K-4.3 Cl-106 HCO3-26 AnGap-14 MICROBIOLOGY: None IMAGING: TTE [**6-19**]: The left atrium is mildly dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. CXR [**6-23**]: There is a right IJ central venous line with the distal tip in the mid right atrium. This should be pulled back slightly for more optimal placement. There is again seen linear atelectasis at the lung bases which is stable. There are low lung volumes. No pneumothoraces or pulmonary edema is seen. The heart size is grossly within normal limits. PATHOLOGY: [**6-18**]: I. Mesh, excision (A): Fibrous tissue with scarring, foreign body giant cell reaction, and acute and chronic inflammation. II. Hernia sac, ventral (B): Fibrovascular tissue with mesothelial lining consistent with hernia sac. III. Skin and soft tissue (C): Unremarkable skin and subcutaneous tissue. Brief Hospital Course: The patient was admitted to the [**Location 63928**] general surgery service on [**2120-6-18**] and had an open ventral hernia repair with component separation and mesh. Patient tolerated procedure well but required neosynephrine for intraoperative hypotension. Remained in PACU POD0 to AM POD1 for hypotension/oliguria. Admitted TSICU POD1 for blood pressure support, intensive hemodynamic monitoring. Neuro: Preoperatively, the patient had an epidural placed. Post-operatively, the epidural rate was decreased secondary to hypotension. Hypothesized that epidural placement may have been intra-thecal given hypotension. Epidural was capped and removed AM POD1 and patient started on Dilaudid IV/PCA with good effect and adequate pain control. When tolerating oral intake, the patient was transitioned to oral pain medications. CV: The patient was hypotensive in the operating room requiring neosynephrine for BP support. This was attributed to having taken AM dose ACE inhibitor and subsequently theorized to possibly be related to question of intrathecal placement of epidural catheter. Hypotension persisted postop in PACU though not accompanied by tachycardia. Patient received several boluses of 1L LR in PACU POD0-1 for hypotension/oliguria. TTE POD1 demonstrated hyperdynamic physiology but no structure abnormality. Following removal of epidural on POD1, BP improved and patient was weaned off pressors POD1-2 and this was tolerated well though with continued mild sinus tachycardia (HR 95-105). Home anti-hypertensives were resumed POD5-6. Vital signs were routinely monitored. Pulmonary: Patient had persistent O2 requirement likely secondary to baseline COPD, obesity and fluid overload given to support blood pressure. POD1 patient received multiple doses of lasix to attempt diuresis and assist in pulmonary function. POD2 patient was briefly started on a lasix gtt in setting of respiratory distress. CXR obtained at that time showed pulmonary congestion and atelectasis. Serial CXRs were performed to assess pulmonary status and patient was intermittently diuresed to assist in fluid removal. O2 requirement decreased in subsequent days and SaO2 improved with increased patient activity. Pulmonary toilet including incentive spirometry and early ambulation were encouraged. Vital signs were routinely monitored. At time of discharge, she still had saturations in the mid-80s with exertion, and a baseline of 93RA, 94 on 2L NC. No obvious crackles or wheezing on exam. GI/GU: Post-operatively, the patient was given multiple IVF boluses as outlined above. Her diet was advanced to sips POD1 and regular DM diet POD2, which was tolerated well. She was returned to her normal, baseline bowel pattern which alternates between frequent, loose BMs and constipation. She manages this w diet at baseline and has continued to do so. Patient was oliguric in PACU as mentioned above requiring multiple IVF boluses and neosynephrine to support renal perfusion. Patient was hep locked on POD1 and did not require additional IVF througout stay. Cr checked on POD1 showed increase from 0.9(baseline) to 2.1. FeNa 0.1% c/w prerenal. Cr rose again to 2.4 POD2 but then decreased to baseline over following days. As above lasix given on multiple occasions to support urine output and diurese fluid overload. Foley was removed on POD#5 and patient voided appropriately. Intake and output were closely monitored. ID: Preoperatively, the patient was given vancomycin/levofloxacin and this was continued for one additional postop dose. The patient's temperature was closely watched for signs of infection. Prophylaxis: The patient received subcutaneous heparin during this stay, and was encouraged to get up and ambulate as early as possible. HEME: Patient's hct was checked postop and found to be similar to preop value (38->34). This remained consistent over course of admission with no significant change from baseline. At the time of discharge on POD 8, the patient was doing well, afebrile with stable vital signs, tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. Medications on Admission: Amlodipine 5mg daily, Carvedilol 6.25mg [**Hospital1 **], Lisinopril 40mg daily, Ezetimibe 10mg daily, Simvastatin 20mg daily, Fenofibrate 134mg daily, Metformin 50mg [**Hospital1 **], Omega 3, Prilosec 20mg daily, Ferrex 150mg daily, Citalopram 20mg daily, Amitriptyline 10mg daily Discharge Medications: 1. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain: Do not drive or operate machinery while taking this medication. . Disp:*30 Tablet(s)* Refills:*0* 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*30 Capsule(s)* Refills:*0* 4. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 5. amitriptyline 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. metformin 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Ferrex 150 150 mg Capsule Sig: One (1) Capsule PO once a day. 10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours) as needed for pain. 11. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 12. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. fenofibrate micronized 145 mg Tablet Sig: One (1) Tablet PO daily (). 14. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*30 Tablet(s)* Refills:*0* 15. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) NEB Inhalation Q2H (every 2 hours) as needed for sob/wheezing. INH 17. Oxygen INH 2-4Liters/Hour via Nasal Canula Titrate to SaO2 greater than 94% Discharge Disposition: Extended Care Facility: Life Care Center of [**Location 15289**] Discharge Diagnosis: 1. Ventral hernia 2. Obesity 3. Acute renal insufficiency 4. Postoperative hypoxemia 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 [**Location 63928**] general surgery service for open ventral hernia repair with component separation and mesh. General Discharge Instructions: Please resume all regular home medications, unless specifically advised not to take a particular medication. Please take any new medications as prescribed. Please take the prescribed analgesic medications as needed. You may not drive or heavy machinery while taking narcotic analgesic medications. You may also take acetaminophen (Tylenol) as directed, but do not exceed 4000 mg in one day. Please get plenty of rest, continue to walk several times per day, and drink adequate amounts of fluids. Avoid strenuous physical activity and refrain from heavy lifting greater than 10 lbs., until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Please also follow-up with your primary care physician. Incision Care: *Please call your surgeon or go to the emergency department if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until cleared by your surgeon. *You may shower and wash incisions with a mild soap and warm water. Gently pat the area dry. *If you have staples, they will be removed at your follow-up appointment. *If you have steri-strips, they will fall off on their own. Please remove any remaining strips 7-10 days after surgery. Bulb Suction Drain Care: *Please look at the drain site every day for signs of infection (increased redness or pain, swelling, odor, yellow or bloody discharge, warmth, and fever). *Maintain the bulb on suction. *Record the color, consistency, and amount of fluid in the drain. Call the surgeon, nurse practitioner, or VNA nurse if the amount increases significantly or changes in character. *Empty the drain frequently. *You may shower and wash the drain site gently with warm, soapy water. You may also wash with half strength hydrogen peroxide followed by saline rinse. *Keep the insertion site clean and dry otherwise. Place a drain sponge for cleanliness. *Avoid swimming, baths, and hot tubs. Do not submerge yourself in water. *Attach the drain securely to your body to prevent pulling or dislocation. Followup Instructions: Please follow up with Dr. [**First Name8 (NamePattern2) 333**] [**Last Name (NamePattern1) **] for a follow up appointment in two weeks for evaluation and staple removal. Call ([**Telephone/Fax (1) 1483**] to schedule or with any questions/concerns. Please follow up with your primary care physician, [**Name10 (NameIs) **] [**Name Initial (NameIs) **] [**Name12 (NameIs) **], within two weeks of dishcarge from rehab regarding your hospital course and in particular your breathing and bowel pattern. Contact info below: Location: [**Hospital1 **] HEALTHCARE - [**Location (un) **] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 6698**] Phone: [**Telephone/Fax (1) 6699**] Fax: [**Telephone/Fax (1) 66415**]

[ "E878.8", "311", "276.2", "V85.41", "272.0", "553.21", "276.69", "278.01", "584.9", "518.0", "401.9", "799.02", "458.29", "530.81", "250.00" ]

icd9cm

[ [ [] ] ]

[ "38.91", "03.90", "53.61", "38.93" ]

icd9pcs

[ [ [] ] ]

10442, 10509

4369, 8517

311, 392

10638, 10638

2274, 4346

13080, 13820

1719, 1728

8850, 10419

10530, 10617

8543, 8827

10821, 10959

11753, 13057

1743, 2255

10991, 11738

257, 273

420, 1045

10653, 10797

1067, 1618

1634, 1703

45,566

114,477

9967

Discharge summary

report

Admission Date: [**2194-2-26**] Discharge Date: [**2194-4-8**] Date of Birth: [**2115-9-30**] Sex: M Service: MEDICINE Allergies: Cytarabine Attending:[**First Name3 (LF) 7591**] Chief Complaint: dizziness Major Surgical or Invasive Procedure: none History of Present Illness: 78 yo Cantonese speaking male started noticing dizziness about 5 days ago. He felt a room spinning sensation with both standing up and change in head position. He did not have any tinnitus, hearing loss, ear pain or drainage, headache, visual changes, focal neurological changes. He denies fevers, chills, congestion, cough. He took a chinese herbal tea called "small box tea" day before yesterday and then went to see his PCP [**Name Initial (PRE) 1262**]. His PCP drew some labs and he was found to have neutropenia and anemia and pt was asked to see PCP again today. Over the last 2 days, his dizziness had been improving and currently he does not have any dizziness anymore. Other than the herbal tea, he denies ingesting any other over the counter or herbal medications. He does not get medications from anyone other that his PCP and has been on the same medications for years Other than recent dizziness he has not fallen ill in the last few months, he does not have any sick contacts and has not had any foreign travel. He denies easy bruising or bleeding He denies chest pain, shortness of breath, cough, nausea/vomiting/diarrhea, deneis urinary symptoms ROS: -Constitutional: [x]WNL []Weight loss []Fatigue/Malaise []Fever []Chills/Rigors []Nightweats []Anorexia -Eyes: [x]WNL []Blurry Vision []Diplopia []Loss of Vision []Photophobia -ENT: [x]WNL []Dry Mouth []Oral ulcers []Bleeding gums/nose []Tinnitus []Sinus pain []Sore throat -Cardiac: [x]WNL []Chest pain []Palpitations []LE edema []Orthopnea/PND []DOE -Respiratory: [x]WNL []SOB []Pleuritic pain []Hemoptysis []Cough -Gastrointestinal: [x]WNL []Nausea []Vomiting []Abdominal pain []Abdominal Swelling []Diarrhea []Constipation []Hematemesis []Hematochezia []Melena -Heme/Lymph: [x]WNL []Bleeding []Bruising []Lymphadenopathy -GU: [x]WNL []Incontinence/Retention []Dysuria []Hematuria []DIscharge []Menorrhagia -Skin: [x]WNL []Rash []Pruritus -Endocrine: [x]WNL []Change in skin/hair []Loss of energy []Heat/Cold intolerance -Musculoskeletal: [x]WNL []Myalgias []Arthralgias []Back pain -Neurological: [x] WNL []Numbness of extremities []Weakness of extremities []Parasthesias []Dizziness/Lightheaded []Vertigo []Confusion []Headache -Psychiatric: [x]WNL []Depression []Suicidal Ideation -Allergy/Immunological: [x] WNL []Seasonal Allergies . Past Medical History: 1. Diabetes Mellitus Social History: Lives with wife. Married for 30+ years. Denies smoking, alcohol or drug use history ever. Denies hx of blood transfusion. Does not have intercourse with anyone other than wife. Family History: No one in family has hx of cancer/blood disorders Physical Exam: Physical Exam: Appearance: NAD Vitals: T:98.4 BP:103/64 HR:93 RR: 16 O2:99 % RA Eyes: EOMI, PERRL, conjunctiva clear, anicteric, ENT: Moist Neck: No JVD, no LAD Cardiovascular: RRR, nl S1/S2, no m/r/g Respiratory: CTA bilaterally, comfortable, no wheezing, no ronchi, no rales Gastrointestinal: soft, non-tender, non-distended, normal bowel sounds Musculoskeletal/Extremities: no clubbing, no cyanosis, no joint swelling, no edema in the bilateral extremities Neurological: Alert and oriented x3, fluent speech, no pronator drift, no asterixis, sensation WNL, CNII-XII intact Integument: warm, no rash, no ulcer Psychiatric: appropriate, pleasant Hematological/Lymphatic: No cervical, supraclavicular, axillary, or inguinal lymphadenopathy GU: no CVAT Pertinent Results: [**2194-2-26**] 10:50AM WBC-0.9* RBC-2.78* HGB-9.6* HCT-27.1* MCV-97 MCH-34.7* MCHC-35.6* RDW-15.6* [**2194-2-26**] 10:50AM NEUTS-10* BANDS-0 LYMPHS-80* MONOS-10 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2194-2-26**] 10:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2194-2-25**] 09:33AM UREA N-16 CREAT-0.7 SODIUM-133 POTASSIUM-4.3 CHLORIDE-97 TOTAL CO2-27 ANION GAP-13 [**2194-2-25**] 09:33AM TSH-0.90 Brief Hospital Course: AP: 78 yo Chinese male w PMHx of T2DM presents with 4-5 day hx of dizziness which is now resolved and found to have neutropenia and anemia and AML. #. Leukemia: Patient presented with neutropenia and anemia. Found to have AML. Started on 7+3. Course complicated by stridor and ICU stay (see below). Patient recovered and continued his chemo course without complication. His counts dropped as expected and he developed severe abdominal pain and fevers (discussed below). Eventually his counts recovered and he did well. He was noted to have some atypical cells in his peripheral smear. He never had a day 14 BM biopsy because of his clinical deterioration during that time. He will follow up with Dr. [**Last Name (STitle) 410**] and they can discuss future treatments. . #. T2DM: Holding outpatient oral regemin and treating with lantus at night and sliding scale. Patient had increased inslulin requirements while on steroids. Then he had pretty well controlled diabetes until the week prior to discharge when he started having pretty severe hyperglycemia. [**Last Name (un) **] was consulted and his lantus and sldiding scale were changed. He was not on insulin prior to admission, and so he needed insulin teaching and was hooked into the [**Hospital **] clinic as an outpatient. He and his wife and children were doing well with insulin teaching. . # Febrile neutropenia / Fungemia - while patient was having fevers during his nadir, he had a positive blood cutlure growing [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 563**]. ID was consulted and the patient had an echo and eye exam, both of which were normal. He was started on micafungin and stopped having fevers. Eventually when he had elevated LFTs, we switched his micafungin to anidlofungin per ID recs. During this time, he was having severe abdominal pain, so with worries for hepatosleno candidemia, we did an MRI that did not show any involvement. His abdominal pain improved, but he contined to have elevated LFTs despite switching antifungals. He also was hyperglycemic and tachycardic which would lead more to continued infection. We thought he should have an extended course of the anidlofungin and was discharged home on it with ID follow up prior to the end of his course. . # Elevated LFTs - after having fungemia, he had elevated LFTs which were thought to likely be due to med effect v. hepatospleno candidemia. His MRI was negative, but he continued to have clinical signs of infection (although never spiked another fever once on antifungals). Liver was consulted, and his LFTs started trending down so it was decided that a biopsy was not needed. By time of discharge, they continued to be trending downward. Will follow up as outpatient. . # Abdominal pain - while patient was in his nadir of his counts, he developed severe abdominal pain, which caused him to stop eating. He was placed on TPN because of his poor PO intake. He had two CT scans that did not show any bowel infection or typhlitis. It did show severe constipation. He was treated for his constipation and his symptoms improved. When his counts recovered, he no longer had abdominal pain and was eating very very well by the time of discharge. . # Enterococcus UTI: Diagnosed from urine culture in the ED and treated with cefepime. Patient was spiking fevers after that which were attributed to Leukemia but as he was neutropenic he was continued on a course of Vancomycin and cefepime for neutropenic fevers until his count recovers. He had second fevers while on vanco/cefepime and found to have fungemia (as discussed above). . # Stridor/respiratory distress: The patient was started on chemotherapy on [**3-6**]. He was given cytarabine and idarubicin. After his first dose, he developed acute respiratory distress, with tachypnea and audible stridor. He was presumed to have an anaphylactic reaction to his chemotherapy, and was given solumedrol 125mg IV X1, Benadryl 25mg IV X1, inhaled racemic epinephrine, and epinephrine .3mg IM X1. His respiratory distress did not subside, and he was transferred to the [**Hospital Unit Name 153**] emergently for intubation. Anesthesia intubated the patient without complications, and did not observe swollen or edemetous trachea or vocal cords. His vitals at this time were Temp 103.0, BP 180/100, HR 160. He was transported to the ICU and intubated for airway protection. It could not be determined if he actually had a reaction to the chemo or a transfusion reaction. He was restarted on the chemo while getting IV steroids. He was premedicated for all blood products. His blood was sent for a transfusion reaction but none could be identified. He had no other respiratory symptoms except one day of wheezing which was likely due to fluid overload and disappeared after being diuresed. # Gluteal Hematoma: Patient had a traumatic bone marrow biopsy complicated by a gluteal hematoma. This eventually extended down his thigh and was likely the cause of a hematocrit drop. There was no evidence of compartment syndrome and he was transfused. He improved with supportive care. By time of discharge, the bruising and discoloration was gone and he had no pain. Medications on Admission: 1. Doxazosin 2mg QHS 2. Aspirin 325mg QD 3. Metformin 1000mg [**Hospital1 **] 4. Glipizide 10mg [**Hospital1 **] 5. Lisinopril 10mg QD Discharge Medications: 1. Doxazosin 4 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime). Disp:*15 Tablet(s)* Refills:*2* 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed: take for constipation. 3. 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* 4. Anidulafungin 100 mg Recon Soln Sig: One (1) Recon Soln Intravenous daily () for 11 days. Disp:*11 Recon Soln(s)* Refills:*0* 5. Saline Flush 0.9 % Syringe Sig: One (1) flush Injection twice a day for 30 days. Disp:*60 syringes* Refills:*0* 6. Lamivudine 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Lantus 100 unit/mL Solution Sig: 16 u in AM, 30 u in PM units Subcutaneous qAM and qPM. Disp:*10 ml* Refills:*2* 8. Insulin Syringes (Disposable) 1 mL Syringe Sig: One (1) syringe Miscellaneous twice a day. Disp:*120 syringes* Refills:*2* 9. Ultra Thin Lancets Misc Sig: One (1) lancet Miscellaneous four times a day. Disp:*120 lancets* Refills:*2* 10. Blood Glucose Test Strip Sig: One (1) strip In [**Last Name (un) 5153**] four times a day. Disp:*120 strips* Refills:*2* 11. Insulin Regular Human 100 unit/mL Solution Sig: as directed by sliding scale unit Injection four times a day. Disp:*10 ml* Refills:*2* Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Final Diagnosis: 1. Neutropenia/Anemia 2. AML 3. Diabetes 4. Fungemia 5. Hepatospleno candidasis Discharge Condition: stable, walking around with walker, feeling well Discharge Instructions: You were admited because your primary care doctor found some of your blood levels to be low. You were worked up and found to have leukemia. You started chemotherapy. Right when you started you had a bad reaction to either some blood or the chemo. It required you to go to the intensive care unit and be intubated. You were extubated and restarted your chemotherapy without any issues. You were given medications to prevent another reaction with blood. . While your white count was low, you got an infection with [**Female First Name (un) **] (a type of yeast/fungus). You were very sick and had a lot of abdominal pain during this time, too. We treated you with antibiotics. You will need to continue receiving the anti-fungal at home through your PICC line, with the help of a home nurse. . We also did several CT and MRI scans to look at your abdomen. We think your pain was mostly from constipation. You should continue to make sure you are having bowel movements at home and call or take stool softeners if you have not had one in over 2 days. You also likely had the fungus infection in your liver. We followed your liver function tests in your blood and they have started going towards normal. You will need to continue getting IV antibiotics for the next two weeks. . Please return to the hospital for any fevers, chills, redness or pain around your PICC line, chest pain, shortness of breath, abdominal pain, worsening diarrhea, constipation or any other concerns. Please follow up as listed below. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 410**] on Thursday [**4-10**] at 11:00 am in [**Hospital Ward Name 23**] 7 to discuss the future AML treatment. Please follow up with Dr. [**Last Name (STitle) 724**] in infectious disease next Tues [**4-15**] at 2pm in [**Hospital Ward Name 23**] 7 (where you see Dr. [**Last Name (STitle) 410**] to determine whether or not you will need to continue your antibiotics. Please follow up at [**Last Name (un) **] in the Asian [**Hospital 982**] Clinic with [**First Name8 (NamePattern2) 8463**] [**Last Name (NamePattern1) 13260**] on [**5-13**] at 1:30 pm. [**Last Name (un) **] will be contacting you if there is a cancellation for you to see them earlier. Please make sure to call your opthamologist and make a follow up appointment at some point in the near future. They will help you set up this appointment when you see the diabetes doctor [**First Name8 (NamePattern2) **] [**Last Name (un) 4372**]. Please follow up with your primary care doctor Dr. [**First Name (STitle) **] [**Name (STitle) **] at phone number [**Telephone/Fax (1) 8236**]. Call to make an appointment for sometime in the next month. Completed by:[**2194-4-17**]

[ "458.29", "518.5", "266.2", "E933.1", "362.01", "285.22", "E879.8", "V58.11", "995.0", "288.03", "564.00", "250.80", "787.91", "E849.7", "041.04", "599.0", "576.8", "998.12", "070.30", "250.50", "205.00", "276.52", "117.9", "401.9", "287.5" ]

icd9cm

[ [ [] ] ]

[ "41.31", "38.93", "96.71", "99.15", "97.49", "96.04", "99.25" ]

icd9pcs

[ [ [] ] ]

11045, 11097

4242, 9451

280, 286

11238, 11289

3736, 4219

12857, 14054

2895, 2946

9636, 11022

11118, 11118

9477, 9613

11135, 11217

11313, 12834

2976, 3717

231, 242

314, 2641

2663, 2685

2701, 2879

64,188

132,412

41715

Discharge summary

report

Admission Date: [**2176-10-14**] [**Month/Day/Year **] Date: [**2176-10-29**] Date of Birth: [**2140-9-16**] Sex: M Service: MEDICINE Allergies: Bactrim DS Attending:[**First Name3 (LF) 983**] Chief Complaint: Altered mental status, leg pain Major Surgical or Invasive Procedure: None History of Present Illness: 36yo male w/ h/o depression, substance abuse and diabetes found hypotensive and altered this morning by his family. Yesterday he came home from being out and was "like a zombie" and vomited. He went downstairs to his basement apartment until this morning, when he walked up the stairs and complained of right leg pain, difficulty voiding and difficulty hearing. He had vomit on himself. He has had trouble voiding in the past, but a work-up including cystoscopy was negative. He had difficulty standing, and was found by his cousin to have a pressure of 60/40, so they called EMS. He would not tell them what substance he had taken. He had had a productive cough for the last 2 weeks. He had a voluntary weight loss of 60 lbs over the last several months through dieting and exercise. He had been working out a lot, but they did not know of him taking supplements. He had a history of severe depression and oxycontin abuse, and had recently been very depressed, but had not told his [**First Name3 (LF) **] of plans for suicide. He told them he had a 'tumor' in his groin, but that he had it checked out by a doctor, and it was okay. . Found by EMS confused, pale, cool and sitting in a chair. He was complaining of pain in his right thigh and hearing loss. Found to be bradycardic to the 40s, hypotensive, and hypothermic with a rectal temperature of 95.7. Blood sugar 52. . At [**Hospital3 **], he was initially awake enough to admit to heroin abuse and that he took a bunch of pills yesterday, though altered. Labs were notable for WBC 18.3 with 17% bands, CK [**Numeric Identifier 2686**], Lactate 6.9, AST 2399, ALT 1720, K 7.4, Cr 4.19, Acetamin neg, Salic 7.2 (nml), tox + for cocaine, opiates, benzos and amphetamines. Got narcan, insulin, D50 and bicarb. He had two PIV's and an IO placed. He got IV fluids, ceftriaxone and vancomycin. CXR showed diffuse bilateral opacities. Intubated prior to transfer. . On arrival to our ED, initial vitals were 98.0 rectal, 86, 103/40, 16, 100%. Initial gas 7.18, 45, 235, 18. I/O not working, so it was removed. Hypotensive to 72/48. Patient had a R IJ CVL placed and was started on Levophed. Bedside ultrasound showed poor cardiac squeeze, but no pericardial effusion and a negative FAST. WBC count 14 with 9% bands. Given Zosyn and IV fluids. K+ down to 5.3, lactate 4.6. Serum tox negative, urine tox positive for cocaine and opiates, but negative for benzos and amphetamines. Lipase 165. LFTs trending up, so patient started empirically on NAC. Vital signs prior to transfer were 135/58 (on 0.15 Levophed), 90, sat 100% on vent. . On the floor, intubated and sedated. Unable to give further ROS. Grimaces with palpation of his legs. Past Medical History: - diabetes, diet controlled - GERD - oxycontin abuse, has been to rehab in the past - depression Social History: unemployed, lives in a basement apartment underneath his [**Numeric Identifier **] house. - Tobacco: none - Alcohol: none, per family - Illicits: long history of oxycontin use. For the last [**5-14**] months has been "hanging with the wrong crowd", but his [**Month/Day (3) **] are not sure which drugs he has been using. Family History: family history of diabetes and coronary artery disease. His [**Month/Day (3) **] are healthy, except that his mother has COPD. Physical Exam: ADMISSION PHYSICAL EXAM: General: Intubated, responds to basic commands HEENT: Sclera anicteric, pupils pinpoint but reactive. MMM, NG tube in place. Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation anteriorly. CV: Hyperdynamic, regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Obese, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place. Small skin tag Ext: Grimaces to palpation of lower extremities. Otherwise warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: Moving all extremities, following basic commands. . [**Month/Day (3) 894**] PHYSCIAL EXAM: Vitals: Tmax: 99.5 Tcur: 98.6 BP:141/93 P:86 R:20 O2: 97% on RA General: NAD, interacting appropriately HEENT: Sclera anicteric, EOMI, MMM, pupils reactive bilaterally. Neck: supple, no JVP elevation appreciated, no LAD Lungs: CTAB, good aeration, no accessory muscle use CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: Obese, soft, non-distended, bowel sounds present, nontender, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis. no edema. Skin: clear, no lesions Neuro: CNII-XII intact, A&Ox3, extremity motor strengh [**4-11**], sensation grossly intact. talking & interacting appropriately. Pertinent Results: Admission labs: [**2176-10-14**] 12:40PM WBC-14.0* RBC-4.21* HGB-10.4* HCT-32.8* MCV-78* MCH-24.7* MCHC-31.7 RDW-15.2 [**2176-10-14**] 12:40PM NEUTS-82* BANDS-9* LYMPHS-7* MONOS-1* EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 [**2176-10-14**] 12:40PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-1+ POLYCHROM-NORMAL OVALOCYT-OCCASIONAL ELLIPTOCY-OCCASIONAL [**2176-10-14**] 12:40PM PLT SMR-NORMAL PLT COUNT-412 [**2176-10-14**] 12:40PM PT-17.0* PTT-33.3 INR(PT)-1.5* [**2176-10-14**] 11:54AM TYPE-ART RATES-16/11 TIDAL VOL-550 PEEP-5 O2-100 PO2-235* PCO2-45 PH-7.18* TOTAL CO2-18* BASE XS--11 AADO2-444 REQ O2-75 -ASSIST/CON INTUBATED-INTUBATED [**2176-10-14**] 12:40PM GLUCOSE-144* UREA N-40* CREAT-3.2* SODIUM-139 POTASSIUM-5.3* CHLORIDE-104 TOTAL CO2-17* ANION GAP-23* [**2176-10-14**] 12:40PM ALT(SGPT)-2709* AST(SGOT)-5253* CK(CPK)-[**Numeric Identifier **]* ALK PHOS-118 TOT BILI-0.8 [**2176-10-14**] 12:40PM LIPASE-165* [**2176-10-14**] 12:40PM cTropnT-0.30* [**2176-10-14**] 12:40PM ALBUMIN-3.4* CALCIUM-7.1* MAGNESIUM-2.3 . [**Month/Day/Year **] Labs: [**2176-10-29**] 06:42AM BLOOD WBC-14.9* RBC-4.24* Hgb-10.3* Hct-31.2* MCV-74* MCH-24.2* MCHC-33.0 RDW-17.3* Plt Ct-755* [**2176-10-29**] 06:42AM BLOOD Plt Ct-755* [**2176-10-29**] 06:42AM BLOOD Glucose-95 UreaN-51* Creat-3.6* Na-141 K-5.1 Cl-100 HCO3-28 AnGap-18 [**2176-10-29**] 06:42AM BLOOD Calcium-10.4* Phos-5.0* Mg-2.2 . Electrolytes/Creatinine trend: [**2176-10-14**] 12:40PM BLOOD Glucose-144* UreaN-40* Creat-3.2* Na-139 K-5.3* Cl-104 HCO3-17* AnGap-23* [**2176-10-14**] 05:27PM BLOOD Glucose-107* UreaN-44* Creat-3.6* Na-140 K-5.9* Cl-102 HCO3-19* AnGap-25* [**2176-10-14**] 09:52PM BLOOD Glucose-171* UreaN-45* Creat-3.9* Na-138 K-6.0* Cl-102 HCO3-19* AnGap-23* [**2176-10-15**] 02:01AM BLOOD Glucose-154* UreaN-46* Creat-4.2* Na-139 K-4.8 Cl-100 HCO3-22 AnGap-22* [**2176-10-15**] 06:15AM BLOOD Glucose-169* UreaN-48* Creat-4.5* Na-141 K-4.4 Cl-100 HCO3-24 AnGap-21* [**2176-10-15**] 04:33PM BLOOD Glucose-127* UreaN-52* Creat-5.4* Na-145 K-4.3 Cl-100 HCO3-28 AnGap-21* [**2176-10-16**] 03:10AM BLOOD Glucose-119* UreaN-59* Creat-6.1* Na-145 K-4.3 Cl-100 HCO3-26 AnGap-23 . Echocardiogram: IMPRESSION: Vigorous biventricular systolic function (LVEF >55%). No significant valvular disease seen. Normal estimated intracardiac filling pressures with high cardiac output. . CT head: IMPRESSION: No acute intracranial process. Fluid within the sinuses as above, most likely due to intubation. . Renal ultrasound: IMPRESSION: No evidence of renal obstruction. Brief Hospital Course: 36yo male w/ h/o substance abuse and depression, found altered, hypothermic and hypotensive. After his ICU admission he was transferred to the floor in stable condition although his creatinine continued to rise. After that improved with no intervention other than diuresis, he was discharged in stable condition to a shelter for help with his polysubstance dependency issues. . # Altered mental status: Most likely secondary to an ingestion. Patient later admitted to heroin ingestion. Percocet and Oxycontin bottles found in his room. Urine tox positive for opiates (on a screen that does not detect oxycodone) and cocaine. Other possibilities would be sepsis, post-ictal phase, toxic/metabolic encephalopathy, hepatic or renal encephalopathy. Toxicology was consulted and thought this could be due to tylenol overdose or cocaine in setting of elvated LFTs, although OSH tylenol was negative. Patient started on NAC protocol and completed with resolution of LFTs. Patient mental status cleared by the time patient was tranferred to the floor. Patient states his only ingestion leading up to admission was his home vicodin, heroin (inhaled) and clonipin. Patient MS continued to improve but in setting of worsening renal failure, patient carefully monitered for uremic encephalopathy. On the floor the patients mental status returned to [**Location 213**], labs improved and the patient was discharged with a normal mental status. . # Hypotension/hypothermia: Differential originally included drug overdose, hypovolemia and overwhelming infection. Patient had no source of infection as CXR and lung exam clear, UA negative, no abdominal pain therefore antbiotics were withheld. Per toxicology, differential of ingestion in setting of initial bradycardia includes calcium channel blockers, beta blockers and digoxin. Patient had no change in blood sugars and his digoxin level was negative. Patient was continued on IVF wide open, especially in setting of rhabdo. Patient was eventually weaned from pressors that were started in the MICU. Once patient had stable BP for 24hrs, patient was transferred to the floor. Patient continued to have stable blood pressures for the rest of his admission. . # Transaminitis: Most likely due such as Tylenol vs shock liver. Started on N-Acetylcysteine in ED, received full course. Believe that LFTs could have been elevated with acute tylenol overdose but hypoperfusion is more likely especially as patient has signs of hypoperfusion with his kidneys with evidence of ATN. LFTs continue to downtrend. INR continues to downtrend as well. At time of [**Location **] his LFTs had normalized, his INR was baseline and he did not require further checks of his LFTs. . # Rhabdomyolysis: Appears to be localized primarily to his lower extremities. Could be cocaine, an exercise supplement, or prolonged period down. Patient started on aggressive fluid resuscitation for his first few days in the MICU. Patient continued to have downtrending CK with eventual DC of fluids especially in the setting of worsening renal failure. . # Acute renal failure: Likely a combination of hypovolemia (hypoperfusion) and rhabdomyolysis. Patient aggressively fluid resuscitated as above, with down trending CK. Urinalysis showed evidence of muddy brown casts consistent with ATN, most likely due to hypoperfusion. Renal ultrasound was negative for any other acute process. Patient creatinine continued to trend up, as well as BUN. Patient was hypervolemic on examination and per renal given large dose lasix to try to improve kidney function. Patient was monitered for signs of uremic encephalopathy. Patient also had increasing anion gap most likely due to uremia. Patient was followed by nephrology and did not require any HD as he reached plateau and then began having downtrending creatinine which was siginificantly improved at the time of disposition. Urine output remained excellent . # Elevated lipase: Likely from hypotension, never c/o abdominal pain. Lipase trended down with fluid resuscitation. . # Elevated troponin: Likely from overall hypoperfusion. EKG was reassuring. Enzymes were trended and came down without EKG changes. . # Depression/substance abuse: Patient has hx of severe depression. It was unclear if patient had suicide attempt. Per family, patient's depression has been getting more severe and in turn his drug abuse more frequent. Social work was involved in patient's care early. Once patient's sensorium cleared, patient evaluated by psych who thought the patient was stable from a psychiatric point of view. He will be discharged to a shelter where he can continue his rehabilitation. . Transitional care: 1. CODE: Full 2. Medication changes: No longer on anti-depressants 3. Follow-up: with nephrology, primary care 4. Contact: [**Name (NI) 6961**] 5. Pending studies/labs: None/Chem 7 ordered for outpatient follow-up Medications on Admission: Medications found in patient's room: - omeprazole 20mg daily - citalopram 20mg daily - oxycontin (several bottles) - naproxen 500mg - colchicine 0.6mg - indomethicin 50mg - metoclopramide 10mg [**Name (NI) **] Medications: 1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 2. aluminum hydroxide gel 600 mg/5 mL Suspension Sig: Thirty (30) ML PO Q8H (every 8 hours). Disp:*31 ML(s)* Refills:*2* 3. Outpatient Lab Work Please have your labs checked on [**2176-11-4**] for Chem 7. 4. cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for neck pain: Do not drive or operate heavy machinery while taking this medication. Disp:*15 Tablet(s)* Refills:*0* [**Date Range **] Disposition: Home [**Date Range **] Diagnosis: Primary: 1. Overdose 2. Acute Renal Failure Secondary: 1. Diabetes [**Date Range **] Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. [**Date Range **] Instructions: Dear Mr. [**Known lastname **], It was a pleasure taking care of you. You were in the hospital for evaluation after an overdose. You were originally intubated and in the ICU. You were evaluated by toxicology. You got better and were transferred to the floor. You had liver failure, which slowly improved. You also had severe kidney failure and the kidney team followed you closely. You were evaluated by social work and pyschiatry. Please refrain from using illegal substances in the future, it is bad for your health. Your kidney function slowly improved. You will need to follow-up with the kidney doctors [**First Name (Titles) **] [**Last Name (Titles) **] to ensure improvement in the kidneys. Your white blood cell count was high, but we found no sources of infection and you had no fevers. You should follow-up with your doctors [**First Name (Titles) **] [**Last Name (Titles) 32942**] for improvement in the white blood cell count. The following medications were added to your home regimen: 1. START Aluminum hydroxide, three times a day 2. START Cyclobenzaprine, every 8 hours as needed for neck pain, you should not take this while driving or operating heavy machinery You should continue taking your omeprazole, 20mg a day by mouth. We did not add any additional medications. Your blood sugars were high here and you were on insulin briefly. However, this will not be continued when you leave. Once your renal function improves, we suggest you discuss with your primary care doctor [**First Name (Titles) 51972**] [**Last Name (Titles) 243**] anti-diabetic medications. Followup Instructions: Please follow-up with the following appointments: Name: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 90641**], MD Specialty: Internal Medicine When: Monday [**11-4**] at 11:15am Location: [**Hospital **] MEDICAL & WALK IN CENTER Address: [**Last Name (un) 39144**], [**Hospital1 **],[**Numeric Identifier 66038**] Phone: [**Telephone/Fax (1) 72680**] We are working on a follow up appointment for you to be seen in our nephrology department within the next 8 business days. You will be called at home with the appointment. If you have not heard within 2 business days, please call [**Telephone/Fax (1) 721**] to see when the appointment is. You will also need to have your labs drawn at your appointment with your doctor this coming Monday to assess for improvement in your kidney function. Completed by:[**2176-11-1**]

[ "305.50", "584.5", "E950.0", "965.09", "995.91", "296.90", "785.50", "969.72", "038.9", "276.2", "250.00", "E950.3", "970.81", "790.4", "518.81", "728.88", "E950.4", "965.01", "965.00", "E849.0" ]

icd9cm

[ [ [] ] ]

[ "96.71", "38.97" ]

icd9pcs

[ [ [] ] ]

7648, 8038

316, 323

5061, 5061

15286, 16129

3513, 3641

12548, 13516

3681, 5042

12343, 12522

245, 278

351, 3038

7449, 7625

5077, 7440

13531, 15263

3060, 3158

3174, 3497

53,216

102,395

5626

Discharge summary

report

Admission Date: [**2181-10-18**] Discharge Date: [**2181-10-21**] Date of Birth: [**2123-7-24**] Sex: F Service: MEDICINE Allergies: Ampicillin Attending:[**First Name3 (LF) 2181**] Chief Complaint: Low Hematocrit Major Surgical or Invasive Procedure: None History of Present Illness: 58 yo F with HIV on HAART, (CD4+:266 and VL undetectable [**8-/2181**]), HCV cirrhosis w/o known varices, ESRD on HD ([**3-13**] HIV nephropathy) p/w a Hb of 7 found in HD today. Of note, patient was recently admitted to the medicine service from [**10-13**]- [**10-16**] for melana. Push enteroscopy performed on [**10-16**] did not show any active bleeding but was significant for gastritis. She did not require any blood transfusions and since she remained HDS was discharged home with close followup. Since discharge she continued to have melontic stools x 5 days with associated lightheadedness and fatigue that has been constant. Since 5 days ago Hct: 36.5 ([**10-13**])--> 33 ([**10-16**]) --> 23.2 today. In HD today, 2.7 kg of fluid was taken off. . Of note, she was also admitted [**6-/2181**] with melana, and underwent a capsule study which showed active bleeding in her duodenum. EGD at that time revealed no active bleeding, portal HTN-ive gastropathy, no esophageal varices noted. A colonoscopy also performed showed two sessile adenomatous polyps though examination of mucosa limited by melena which were removed. An enteroscopy had been attempted at this time but was deferred since the patient had eaten. She remained without evidence of melana until this most recent admission [**10-13**]. . In ED VS were 97.5 95 113/68 16 97% RA. (Baseline sbp in the 110s-120s noted in OMR) Received 1 liter NS. Did not receive prbcs. NG lavage pink in first 150 cc and did not clear with another 300 cc -> pink with specs of blood. Given 40 IV pantoprazole. GI consulted and suggested a tagged RBC scan to find active bleeding. Notably, guaiac positive brown stool. Vitals prior to transfer BP: 109/61 87 100% 2L . Upon arrival to the MICU, patient was HDS and felt mildly fatigued. C/O mild abdominal pain. Blood transfusion was started prior to transfer to nuclear medicine for tagged rbc. Past Medical History: 1. ESRD due to HIV nephropathy, on hemodialysis (TuThuSat), right transposed basilic AV fistula 2. HIV, diagnosed [**2165**]; last CD4 143 VL 49 ([**5-/2181**]) 3. Hepatitis C with reported cirrhosis and portal hypertension; diagnosed mid-[**2161**] per pt; not treated with interferon, followed and monitored by Liver Center 4. Zoster [**2177**] 5. Bronchitis (recently diagnosed, pt has not started treatment Social History: Patient on disability. Lives alone, but has 5 adult children. >25 pack-year tobacco history, currently smokes [**2-10**] ppd. History of crack cocaine use and IVDU (per pt, last use 10 yrs ago); stopped since starting dialysis ~[**2171**]. Denies EtOH use. Family aware of HIV diagnosis. Family History: Mother with DM, HTN; died from brain aneurysm. GM with DM, HTN; died from diabetic coma. Older sister died of liver cancer. [**Name (NI) **] sister w/ breast cancer. Physical Exam: VS: 84 127/68 18 100% 2L GA: AOx3, NAD HEENT: PERRLA. MMM. no LAD. no JVD. neck supple. Cards: PMI palpable at 5/6th IC space. No RVH. RRR S1/S2 heard. 2-3/6 SEM heard best at base Pulm: Diffuse crackles and rhonchi heard bilaterally. Moving air Abd: soft, TTP in RUQ and RLQ, +BS. no g/rt. neg HSM. Extremities: wwp, no edema. DPs, PTs 2+. 16G and 18G in left arm. Fistula with palpable thrill in right arm. Skin: no rashes Neuro/Psych: CNs II-XII intact. 5/5 strength in U/L extremities. sensation intact to LT, gait deferred. Pertinent Results: ADMISSION LABS: [**2181-10-18**] 07:20PM BLOOD WBC-3.9* RBC-2.50*# Hgb-7.4* Hct-23.2*# MCV-93 MCH-29.8 MCHC-32.1 RDW-17.6* Plt Ct-83* [**2181-10-18**] 07:20PM BLOOD Neuts-63.5 Lymphs-26.3 Monos-5.3 Eos-4.3* Baso-0.5 [**2181-10-18**] 07:55PM BLOOD PT-15.7* PTT-27.6 INR(PT)-1.4* [**2181-10-18**] 07:20PM BLOOD Glucose-89 UreaN-27* Creat-4.6* Na-140 K-3.6 Cl-98 HCO3-33* AnGap-13 [**2181-10-18**] 07:20PM BLOOD ALT-9 AST-15 AlkPhos-50 TotBili-0.3 [**2181-10-18**] 07:20PM BLOOD Lipase-73* [**2181-10-19**] 02:02AM BLOOD Calcium-7.9* Phos-4.6* Mg-1.6 [**2181-10-18**] 06:15AM BLOOD %HbA1c-5.6 eAG-114 . Pertinent Labs [**2181-10-19**] 06:14AM BLOOD Hct-27.9* [**2181-10-19**] 04:39PM BLOOD Hct-27.8* [**2181-10-20**] 08:10AM BLOOD WBC-4.7 RBC-3.00* Hgb-9.0* Hct-27.7* MCV-92 MCH-29.9 MCHC-32.4 RDW-17.6* Plt Ct-82* [**2181-10-21**] 08:00AM BLOOD WBC-5.0 RBC-3.23* Hgb-9.6* Hct-30.6* MCV-95 MCH-29.6 MCHC-31.3 RDW-17.7* Plt Ct-87* MICROBIOLOGY: none IMAGING: [**2181-10-18**] TAGGED RBC SCAN: Following intravenous injection of autologous red blood cells labeled with Tc-[**Age over 90 **]m, blood flow and dynamic images of the abdomen for 60 minutes were obtained. Blood flow images show normal vascular tracer distribution. Dynamic blood pool images show no evidence of tracer within the gastrointestinal tract. IMPRESSION: No evidence of GI bleeding. ADMISSION CXR: Mild central vascular congestion without overt edema. Stable cardiomegaly. Small Bowel Enteroscopy: [**2181-10-16**] Impression: Erythema in the whole stomach compatible with gastritis Otherwise normal small bowel enteroscopy to jejunum Colonoscopy:[**2181-6-27**] Polyp in the transverse colon (polypectomy, endoclip), Polyp in the sigmoid colon (polypectomy) Grade 1 internal hemorrhoids There was melanotic blood coating along th ecolon mucosa. We were unable to thoroughly examine the mucosa of colon. Otherwise normal colonoscopy to cecum EGD: [**2181-7-3**]: Hiatal hernia noted. Erythema, congestion, petechiae and abnormal vascularity in the whole stomach compatible with portal hypertensive gastropathy. Otherwise normal EGD to third part of the duodenum. No esophageal or gastric varices noted. No source of bleeding visualized on examination to the 3rd portion of the duodenum. Recommend continue PPI. Would recommend enteroscopy for further evaluation. Capsule Study: [**2181-6-28**] Summary: 1. The capsule remained in the stomach for 3h 2. Active bleeding in the duodenum 3. Fresh blood in the small bowel 4. Ileocecal valve could not be identified Brief Hospital Course: 58 year old female with HIV on HAART, (CD4+:266 and VL undetectable [**8-/2181**]), HCV cirrhosis w/o known varices, ESRD on HD ([**3-13**] HIV nephropathy) admitted with melena and significant hematoctrit drop s/p 2 units of PRBCs . 1. GI Bleed: Source likely Upper GI given melana and pink NG lavage. Tagged RBC scan did not show active bleeding. She was given two units of PRBCs overnight. She was started on IV pantoprazole 40 [**Hospital1 **]. Her hematocrit remained stable after red blood cell transfusion. . 2. Abdominal Pain: TTP in RUQ/RLQ of unclear etiology. @ baseline. . 3. ESRD on HD: On T/Th/Sat schedule. Continued on sevelemer, nephrocaps with Epogen in HD . 4. HIV: Last VL undetectable, CD4+ 266 (7/[**2181**]). Patient started on Bactrim in previous admissions, however has not been taking. Reportedly refused Bactrim in previous admission. Continued HAART regimen. Bactrim was held since CD4 is >200, no h/o PCP, [**Name10 (NameIs) **] no history of oral candidiasis which is based on CDC guidelines. She was discharged on Bactrim to be further managed by her primary care/ Infectious disease doctor. . 5. Hepatitis C: c/b reported cirrhosis and portal hypertension (portal hypertensive gastropathy, no esophageal varices). Followed by liver clinic. Last viral load less than one million. Not on interferon. . 6. Murmur: Harsh holosystolic murmur heard throughout the precordium. This should be followed up as an outpatient with an echocardiogram. . Patient left AMA before she was seen by attending and could receive discharge paperwork. She was aware of the risks and benefits of leaving. She was aware of her post discharge follow up appointments tomorrow. Medications on Admission: 1. Lamivudine 50 mg DAILY 2. Etravirine 200 mg [**Hospital1 **] 3. Tenofovir Disoproxil Fumarate 300 mg One QFRI 4. B Complex-Vitamin C-Folic Acid 1 mg DAILY 5. Sevelamer HCl 800 mg PO TID W/MEALS 6. Albuterol Sulfate 90 mcg/Actuation 1-2 Puffs Inhalation Q6H as needed for shortness of breath or wheezing. 7. Sulfamethoxazole-Trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Omeprazole 40 mg Capsule twice a day. Discharge Medications: 1. Lamivudine 100 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 2. Etravirine 100 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 3. Tenofovir Disoproxil Fumarate 300 mg Tablet Sig: One (1) Tablet PO QFRI (every Friday). 4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 5. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 6. Omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. 8. Bactrim 400-80 mg Tablet Sig: One (1) Tablet PO once a day. 9. Outpatient Lab Work CBC tomorrow for Hct check. Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis 1. Melena . Secondary Diagnosis 1. Hepatitis C with cirrhosis 2. End stage renal disease on hemodialysis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted because you were noted to have melena, weakness and significant drop in your blood volume. You were given two units of blood. Upper GI endoscopy and tagged RBC study showed no active bleeding. . NO MEDICATION CHANGES WERE MADE TO YOUR REGIMEN . Patient left AMA before she was seen by attending and could receive discharge paperwork. She was aware of the risks and benefits of leaving. She was aware of her post discharge follow up appointments tomorrow. Followup Instructions: Please make an appointment with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] within the next two days. [**Telephone/Fax (1) 3581**] Department: ADVANCED VASC. CARE CNT When: MONDAY [**2181-10-22**] at 10:00 AM With: [**Name6 (MD) 5536**] [**Name8 (MD) **], MD [**Telephone/Fax (1) 5537**] Building: [**Street Address(2) 7298**] ([**Location (un) 583**], MA) [**Location (un) **] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: LIVER CENTER When: MONDAY [**2181-10-22**] at 11:15 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Unit Name **] [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: DIV. OF GASTROENTEROLOGY When: TUESDAY [**2181-11-6**] at 3:00 PM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 22561**], 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

[ "042", "789.09", "571.5", "V45.11", "578.1", "553.3", "491.9", "070.54", "785.2", "535.50", "287.5", "455.0", "537.89", "585.6" ]

icd9cm

[ [ [] ] ]

[ "45.13", "39.95" ]

icd9pcs

[ [ [] ] ]

9259, 9265

6275, 7971

288, 295

9432, 9432

3715, 3715

10084, 11229

2983, 3150

8458, 9236

9286, 9411

7997, 8435

9583, 10061

3165, 3696

234, 250

323, 2226

3731, 6252

9447, 9559

2248, 2660

2676, 2966

31,883

145,649

32598

Discharge summary

report

Admission Date: [**2149-1-17**] Discharge Date: [**2149-1-24**] Service: NEUROSURGERY Allergies: Aspirin Attending:[**First Name3 (LF) 78**] Chief Complaint: Transfer with subdural hematoma Major Surgical or Invasive Procedure: Right sided craniotomy for subdural removal History of Present Illness: [**Age over 90 **] y.o. M with h/o recent [**Hospital 56102**] transferred from [**Hospital3 2737**] s/p syncope tx, after questionable fall at NH. CT scan at OSH reportedly shows bilat SDH - unable to load here. EMS reports seizure activity vs tremor this morning. Pt is alert and oriented x 3, states that he remembers falling two days ago and hitting his L knee, does not recall head trauma. He has an old right eye ptosis, right lower extremity weakness x 10 years old, and right shoulder/upper extremity weakness/stiffness x four years. Past Medical History: HTN Diastolic CHF EF 40% (echo [**2147-12-8**] at [**Hospital 1474**] Hospital) Admission s/p [**2147**]- treated for dehydration, C. diff infection ,hypokalemia (3.1) Social History: Lives at home in an in-law apartment in house shared by son. Intermittently uses walker at home. Though recently in a nursing home temporarily after a recent hospitalization Family History: Non-contributory. Physical Exam: O: T: 97.5 BP:145/55 HR:80 R 20 O2Sats 95% RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: PERLA bilaterally EOMs full bilaterally Neck: Supple. Extrem: Warm Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [**2-16**] objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: II: Pupils equally round and reactive to light, 5mm to 2 mm bilaterally. III, IV, VI: Extraocular movements intact bilaterally without nystagmus, R eye ptosis, (old) 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 bilateral Strength: Bilateral upper extremities [**4-19**] R trap/deltoid - old injury; otherwise all remaining muscle groups [**5-19**] Bilateral lower extremities [**4-19**] IP bilaterally, otherwise all remaining muscle groups [**5-19**]. Tremors present bilateral upper extremities, R more prominent than L . Minimal R pronator drift, question tremors and long standing h/o RUE weakness Sensation: Intact to light touch, proprioception bilaterally. Reflexes: B T Br Pa Ac Right 1 1 1 1 0 Left 1 1 1 1 0 Toes downgoing bilaterally Coordination: normal on finger-nose-finger. Pertinent Results: [**2149-1-17**] 12:40AM GLUCOSE-109* UREA N-20 CREAT-1.4* SODIUM-131* POTASSIUM-4.8 CHLORIDE-96 TOTAL CO2-24 ANION GAP-16 [**2149-1-17**] 12:40AM CK(CPK)-450* [**2149-1-17**] 12:40AM cTropnT-0.01 [**2149-1-17**] 12:40AM CK-MB-10 MB INDX-2.2 proBNP-3250* [**2149-1-17**] 12:40AM CALCIUM-8.5 PHOSPHATE-2.9 MAGNESIUM-2.4 [**2149-1-17**] 12:40AM PHENYTOIN-4.7* [**2149-1-17**] 12:40AM WBC-9.7 RBC-4.33* HGB-13.9* HCT-40.0 MCV-92 MCH-32.1* MCHC-34.7 RDW-12.8 [**2149-1-17**] 12:40AM NEUTS-75.0* LYMPHS-16.0* MONOS-7.7 EOS-1.1 BASOS-0.2 [**2149-1-17**] 12:40AM PLT COUNT-95* [**2149-1-17**] 12:40AM PT-11.7 PTT-22.2 INR(PT)-1.0 Head CT [**2149-1-16**] IMPRESSION: 1. Interval worsening of the right subdural hematoma as described. New left frontal subdural hematoma has also developed. There is a new 8 mm rigthward subfalcine herniation. No other interval change is visualized. CT HEAD W/O CONTRAST [**2149-1-21**] 10:24 AM IMPRESSION: No interval change in the size of the bilateral subdural hematomas containing heterogeneous densities. No change in mass effect. US EXTREMITY NONVASCULAR LEFT [**2149-1-22**] 8:15 PM IMPRESSION: 1. The palpable mass corresponds to muscle. No hematoma or fluid collection. If further characterization is required, MR may be obtained. Brief Hospital Course: Pt was admitted to the SICU for close neurologic monitoring. He had pre-op work up and was brought to the OR [**2149-1-17**] where under general anesthesia he underwent right craniotomy with evacuation of SDH. He tolerated this procedure well and returned to SICU for close neuro checks. He had drains in and was kept on antibxs for prophylaxsis until they were removed. He had post op hypertension and was maintained on IV medication until under control. His activity and diet were advanced. He transferred to the floor [**2149-1-19**]. Geriatrics evaluated and made medication recommendations which were followed. He was seen by PT and OT and felt to be a good rehab candidate. On day of transfer he is alert and oriented to self, cooperative with exam, has an old R eye ptosis, pupils are perrla bilaterally, eoms are full, no pronator drift, with noted tremor. Range of motion of bilateral upper and lower extremities are limited due to joint pain/arthritis/long-standing. Strength is limited by pain. Pt needs assistance with nutrition, he needs extensive PT/OT to return to baseline. Pt family agrees with plan of care. Medications on Admission: Medications prior to admission: Unsure per pt: Dilantin Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever/pain. 6. Albuterol Sulfate 2.5 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 7. Valsartan 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Insulin Regular Human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED). 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 10 days: take thru [**2149-1-29**]. 12. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. 13. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 14. Oxycodone 5 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed: for severe pain. 15. Olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for severe agitation/danger to self. 16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 17. Celecoxib 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for pain for 7 days: Celebrex started [**2149-1-21**] - [**2149-1-28**]. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Bilateral Subdural Hematoma R>L post op hypertension chronic CHF UTI Discharge Condition: Neurologically stable Discharge Instructions: ?????? Have a family member check your incision daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? You may wash your hair only after sutures and/or staples have been removed ?????? You may shower before this time with assistance and use of a shower cap ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? You have been prescribed an anti-seizure medicine, take it as prescribed. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING: ?????? New onset of tremors or seizures ?????? Any confusion or change in mental status ?????? Any numbness, tingling, weakness in your extremities ?????? Pain or headache that is continually increasing or not relieved by pain medication ?????? Any signs of infection at the wound site: redness, swelling, tenderness, drainage ?????? Fever greater than or equal to 101?????? F Followup Instructions: Follow up with Dr [**First Name (STitle) **] in 4 weeks with head CT call [**Telephone/Fax (1) 1669**] for an appointment Have staples removed at rehab on [**2148-1-28**] Completed by:[**2149-1-24**]

[ "428.32", "401.9", "348.4", "E888.9", "428.0", "715.36", "852.20", "599.0", "293.0" ]

icd9cm

[ [ [] ] ]

[ "01.31" ]

icd9pcs

[ [ [] ] ]

7027, 7124

4122, 5251

249, 295

7237, 7261

2808, 4099

8538, 8740

1268, 1287

5358, 7004

7145, 7216

5277, 5277

7285, 8515

1302, 1467

5309, 5335

178, 211

323, 869

1760, 2789

1482, 1744

891, 1060

1076, 1252

24,807

174,252

9845

Discharge summary

report

Admission Date: [**2145-6-15**] Discharge Date: [**2145-6-18**] Date of Birth: [**2104-11-11**] Sex: F Service: HISTORY OF THE PRESENT ILLNESS: The patient is a 40-year-old female with a history of C3-C4 spinal cord lesion leading to quadriplegia, who was admitted initially for a history of desaturation to 85%, oxygen saturation on room air, and with increased somnolence. Also, of note, the patient has been intubated five times during the past month.; Most recently, the patient has been treated for MRSA in the sputum. The most recent hospital admission prior to this admission was between [**6-5**] and [**6-7**], during which time she was intubated for respiratory distress and hypercarbic respiratory failure. During that admission, the patient's sputum was MRSA positive. She was treated with Vancomycin. Previous admission had been between [**4-7**] to [**2145-4-12**] for which she was intubated for approximately 36 hours for hypercarbic respiratory failure. Previous to that she had been admitted between [**2145-2-28**] to [**2145-3-10**] at the [**Hospital 882**] Hospital for a right lower lobe pneumonia, which had required intubation. The patient was noted to be MRSA positive at that time. She was intubated for approximately seven days and at that time she refused the placement of her tracheostomy or PEG. During this admission, the patient, as noted, has increased shortness of breath and decreased oxygen saturations with saturations in the 80s. She was able to speak in full sentences at this time, but she was noted to have slightly labored breathing. Blood pressure was at her baseline admission value of 90/60. PAST MEDICAL HISTORY: 1. C3-C4 spinal cord lesion in [**2139**], status post motor vehicle accident. 2. Gastroesophageal reflux disease. 3. Depression. 4. Chronic adrenal insufficiency from chronic steroid use. 5. History of anemia. 6. History of heel osteomyelitis. 7. History of decubitus ulcers. 8. History of multiple aspiration pneumonias requiring five intubations during the last nine months. ALLERGIES: The patient is allergic to PENICILLIN AND SULFA. SOCIAL HISTORY: The patient has been a resident at the [**Hospital 33091**] Rehabilitation Service. Her mother is involved in her care. She has a history of smoking in the past. PHYSICAL EXAMINATION: Examination revealed the following on admission: The patient was a female in no acute distress, who was alert and oriented times three. Temperature was 98.5, pulse 64, blood pressure 110/57, saturation 90% on room air. HEENT: Notable for clear oropharynx with positive gag reflex. NECK: Examination was supple. LUNGS: Lungs were notable for diffuse and coarse rhonchi bilaterally. CARDIOVASCULAR: Regular rate and rhythm with no murmurs, rubs, or gallops. ABDOMEN: Benign. EXTREMITIES: 1+ edema. The patient was alert and oriented times three. The patient also had decubitus ulcers. The patient had an ischial wound, stage 2, with granulation approximately 3 cm deep. The patient also had an area on the posterior thoracic region of her skin, which was approximately 4 cm x 4 cm with an eschar. NEUROLOGICAL: Examination was notable for quadriplegia. LABORATORY DATA: Laboratory data on admission revealed the following: White count 9.3, hematocrit 26.3, platelet count 116,000, coagulations and BMP was within normal limits. The bicarbonate was 26. The patient had a urinalysis, which was notable for nitrate positive, large leukocyte Estrace positive, as well as 3 to 5 white blood cells and many bacteria. EKG: Sinus rhythm with no acute ST or T segment changes. Chest x-ray: The patient had a persistent left lower lobe opacity, which was similar to a previous chest x-ray on [**2145-5-28**]. HOSPITAL COURSE: The patient, initially, was admitted to the Intensive Care Unit for observation. During this time, the patient was noted to have good oxygen saturations of 95%, 98% on room air. The patient's blood pressure has been in the range of the 90s to 110 systolic blood pressure, which is near her baseline blood pressure. The patient also completed her 14-day course of Vancomycin during this admission. Regarding the patient's pulmonary status during this admission she also had been given chest PT to help with her secretions. Albuterol and Atrovent were also continued. INFECTIOUS DISEASE: The patient has been completing a course of Vancomycin for MRSA in her sputum for 14 days, which had been completed upon admission. The patient also was noted to have UTI by urinalysis and she was started on a 7-day course of Ciprofloxacin for the UTI. During the admission, the patient spiked a fever to 101.2. The patient has been afebrile for 36 hours and the patient's blood cultures and urine cultures have no growth to date. ENDOCRINE: The patient was admitted with a history of chronic adrenal insufficiency and she was given stress dose steroids of 100 mg hydrocortisone in the emergency room. The patient continued on her pre-admission regimen of Prednisone 5 mg PO q.d. afterwards. GASTROINTESTINAL: The patient has history of reflux, so we continued Protonix for that. The patient also was treated with Reglan and Colace for promotility and stool softening. DECUBITUS ULCERS: The patient was seen by the Plastic Service during this admission and they noted that she had the left ischial wound stage II with approximately 3 cm granulation tissue, as well as the left posterior thoracic area with some skin breakdown with approximately 4 cm x 4 cm. They felt that at this time that these wounds did not need to be debrided. They recommended b.i.d. wet-to-dry dressing changes in the ischial wound. They recommended wet-to-dry changes to the left back wound. They also noted an area of early breakdown on the right ischemic, for which they recommended DuoDerm dressing. In addition, the patient, during this admission, was screened for rehabilitation and currently the plan is to return to Brick Farm and at that time the patient will have further placement and screening from there. DISCHARGE CONDITION: Fair. DISCHARGE STATUS: [**Hospital 33092**] Rehabilitation. FINAL DIAGNOSIS: 1. Urinary tract infection. 2. History of pneumonia. DISCHARGE MEDICATIONS: 1. Tylenol 650 mg PO q.4h. to 6h.p.r.n. 2. Prednisone 5 mg PO q.d. 3. Protonix 40 mg PO q.d. 4. Ditropan 5 mg PO b.i.d. 5. Iron 325 mg PO t.i.d. 6. Multivitamin one PO q.d. 7. Zoloft 50 mg PO q.d. 8. Estraderm patch. 9. Reglan 10 mg PO q.i.d. 10. Neurontin 900 mg PO b.i.d. 11. Baclofen 20 mg PO q.i.d. 12. Colace 100 mg PO b.i.d. 13. Klonopin 0.5 mg b.i.d. 14. Ciprofloxacin 500 mg PO b.i.d. times 5 days. 15. Albuterol and Atrovent nebulizers q.4h.p.r.n. 16. Albuterol inhaler MDI two to four puffs q.4h. to 6h. p.r.n. (DISCHARGE MEDICATIONS CONTINUED ON NEXT PAGE). 17. Atrovent two puffs q.i.d. 18. OxyContin extended 20 mg PO b.i.d. [**Name6 (MD) 251**] [**Name8 (MD) **], M.D. [**MD Number(1) 1197**] Dictated By:[**Doctor Last Name 33093**] MEDQUIST36 D: [**2145-6-18**] 11:29 T: [**2145-6-18**] 11:34 JOB#: [**Job Number 33094**]

[ "519.1", "344.00", "491.20", "599.0", "907.2", "255.4", "E929.0", "707.0", "518.82" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6114, 6178

6274, 7163

3790, 6092

6195, 6251

2348, 3772

1694, 2143

2160, 2325

71,193

118,377

48106

Discharge summary

report

Admission Date: [**2160-1-8**] Discharge Date: [**2160-1-24**] Date of Birth: [**2115-10-23**] Sex: M Service: ORTHOPAEDICS Allergies: Codeine / Celebrex / Ibuprofen Attending:[**First Name3 (LF) 3645**] Chief Complaint: Dysphagia Major Surgical or Invasive Procedure: I&D surgical incision Tracheostomy History of Present Illness: I had the pleasure of seeing Mr. [**Known lastname 19205**] back in followup today. As you know, he is a pleasant 44-year-old gentleman, who underwent C3 with C4 partial corpectomy with fusion by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1352**] on [**2159-12-18**]. He was admitted to the [**Hospital1 771**] after a fall resulted in bilateral upper extremity radiculitis, numbness and tingling bilaterally. MRI showed a large central disc herniation at C3-C4 and he did have progressive neurologic symptoms. At that time, he underwent a surgical procedure. He tolerated the procedure well. He is now approximately three weeks postoperative. He comes in today stating that over the last week, he has experienced symptoms of vomiting. In addition, he has had some thick white drainage from his anterior cervical incision. He states that two or three days ago this broke open and a lot of fluid came out. In addition, he feels hotter than normal, though he does not have objective documented fever. Secondary to all of this, he has also had an increase in his dysphagia. He states that he did have some mild dysphagia during his surgical procedure; however, four days afterwards he was doing well and eating all types of food both solid and liquid. Since that time, approximately day eight he has shown intolerance towards soft and solid foods. Overall, he feels that this is worsening. Temperature measured today in clinic was 98.8. We asked that Mr. [**Known lastname 19205**] go to the emergency department for urgent MRI of his cervical spine. He was admitted from the emergency department Past Medical History: Chronic Pain, HTN Social History: NC Family History: NC Physical Exam: On discharge, Upper extremity strength is [**6-11**] throughout, he is sensory intact to light touch. Incision appears well healed throughout, sutures were removed. Cervical spine is still tender in and around the incision area. He does show some difficulty swallowing and he coughs numerous times during the exam. Trach is in place, he is able to clear trach without difficulty. No evidence of infection. Pertinent Results: [**2160-1-9**] 4:25 pm TISSUE CONTENT CERVICAL SPINE. GRAM STAIN (Final [**2160-1-9**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Final [**2160-1-17**]): REPORTED BY PHONE TO DR.[**First Name (STitle) **] ON [**2160-1-10**] AT 13:45. STAPH AUREUS COAG +. SPARSE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). SPARSE GROWTH. SENSITIVITIES REQUESTED BY DR. [**First Name (STitle) **] #[**Numeric Identifier 95354**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CORYNEBACTERIUM SPECIES (DIPHTHEROIDS) | | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S 4 R GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S PENICILLIN G---------- =>0.5 R 1 S TRIMETHOPRIM/SULFA---- <=0.5 S VANCOMYCIN------------ <=1 S ANAEROBIC CULTURE (Final [**2160-1-13**]): NO ANAEROBES ISOLATED. ACID FAST SMEAR (Final [**2160-1-10**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. FUNGAL CULTURE (Final [**2160-1-22**]): NO FUNGUS ISOLATED. ACID FAST CULTURE (Preliminary): POTASSIUM HYDROXIDE PREPARATION (Final [**2160-1-9**]): NO FUNGAL ELEMENTS SEEN. [**2160-1-9**] 4:18 pm SWAB RETROPHANGNX. GRAM STAIN (Final [**2160-1-9**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2160-1-13**]): Due to mixed bacterial types (>=3) an abbreviated workup is performed; P.aeruginosa, S.aureus and beta strep. are reported if present. Susceptibility will be performed on P.aeruginosa and S.aureus if sparse growth or greater.. STAPH AUREUS COAG +. SPARSE GROWTH. Staphylococcus species may develop resistance during prolonged therapy with quinolones. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. Testing of repeat isolates may be warranted. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | CLINDAMYCIN-----------<=0.25 S ERYTHROMYCIN----------<=0.25 S GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- 0.25 S OXACILLIN------------- 0.5 S PENICILLIN G---------- =>0.5 R TRIMETHOPRIM/SULFA---- <=0.5 S ANAEROBIC CULTURE (Final [**2160-1-13**]): NO ANAEROBES ISOLATED. ACID FAST SMEAR (Final [**2160-1-10**]): NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. A swab is not the optimal specimen for recovery of mycobacteria or filamentous fungi. A negative result should be interpreted with caution. Whenever possible tissue biopsy or aspirated fluid should be submitted. POTASSIUM HYDROXIDE PREPARATION (Final [**2160-1-10**]): TEST CANCELLED, PATIENT CREDITED. Inappropriate specimen collection (swab) for Fungal Smear (KOH). [**2160-1-16**] 1:35 am SPUTUM Site: ENDOTRACHEAL **FINAL REPORT [**2160-1-18**]** GRAM STAIN (Final [**2160-1-16**]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). RESPIRATORY CULTURE (Final [**2160-1-18**]): SPARSE GROWTH OROPHARYNGEAL FLORA. CITROBACTER KOSERI. MODERATE GROWTH. This organism may develop resistance to third generation cephalosporins during prolonged therapy. Therefore, isolates that are initially susceptible may become resistant within three to four days after initiation of therapy. For serious infections, repeat culture and sensitivity testing may therefore be warranted if third generation cephalosporins were used. GRAM NEGATIVE ROD #2. SPARSE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ CITROBACTER KOSERI | CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- 8 R TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S MRI C-Spine [**2160-1-9**] FINDINGS: Since the prior study, a metallic anterior cervical fusion complex, consisting of two pairs of pedicle screws and an anterior connecting plate span the C3-4 interspace. There is substantial prevertebral soft tissue swelling at this level, encroaching upon the oropharynx and proximal hypopharynx. This area has slightly elevated T2 signal, best shown on the STIR images, as well as a diffuse enhancement pattern, moderate in extent. Within the posterior half of the C3-4 interspace is a rectangular-shaped area of enhancement, which causes mild impression upon the ventral cord margin, which is at the level of the stated cord edema. This region could represent granulation tissue, but it is impossible to determine on the basis of the imaging study whether this or the prevertebral soft tissue swelling is either sterile or infected. The spinal cord compression noted preoperatively appears to be unaltered. More over, as was discussed with Dr. [**Last Name (STitle) 1352**] today, there is diffuse spinal stenosis, congenital in origin involving the C3-4 through C6-7 levels, aggravated by small posterior disc protrusions at the C5-6 and C6-7 levels, and to a minimal degree at C4-5. There is no malalignment of the component vertebrae. There is a somewhat heterogeneous signal pattern within slightly prominent posterior-superior nasopharyngeal soft tissues. This finding could represent a complex Tornwaldt cyst, which could be further evaluated by transaxial MR imaging of this region. Finally, it is to be noted that the present axial gradient-echo scans are grossly compromised by patient motion, precluding precise analysis on the basis of these images. CONCLUSION: Interval development of extensive prevertebral soft tissue swelling as well as some impingement upon the spinal cord by enhancing soft tissue posterior to the C3-4 bone cage. On the basis of imaging, it is not possible to determine whether these findings are sterile or infected (phlegmon). CT Scan C-Spine [**2160-1-9**] IMPRESSION: 1. Extensive increased attenuation in the prevertebral and retropharyngeal soft tissues, with possible fluid, with thin linear enhancement anteriorly which can represent inflammation/infection/ phlegmon/ evolving abscess. This is seen extending from above the level of the dens to the upper thoracic region. The fat plane is not clearly visualized in prevertebral soft tissues. No definite focal well- formed thick-walled abscess. However, close followup is necessary. Pl.s ee above details. Multilevel mild degenerative changes in the C-spine are not adequately assessed on the present study. Pl. see the report on MR C spine performed earlier for additional details. Brief Hospital Course: Mr. [**Known lastname 19205**] was directly admitted from the emergency department here at [**Hospital1 18**] after follow up visit in clinic on [**2160-1-8**]. He was approximatly 3 weeks from his anterior cervical decompression and fusion when he noted significant increase in dysphagia. He had no dysphagia after his discarge from his surgical procedure on [**2159-12-18**]. On his MRI from the ED he was noted to have significant interval retropharangeal soft tissue swelling. Mr. [**Known lastname 19205**] was brought to the OR for I&D of his anterior cervical spine. He tolerated the procedure well, but was left intubated and transfered to the SICU to allow for decrease in tissue swelling from his I&D. Once Mr. [**Known lastname 19205**] was taken off sedation, he recieved a tracheostomy and the intubation tube was removed. Cultures were sent. Tissue and swab cultures grew out MSSA and Corynebacterium. Infectious disease was consulted and he was placed on Nafcillin till [**2160-1-23**]. He was also started on TPN for his nutrition requirements. Mr. [**Known lastname 19205**] has tolerated the tracheostomy well. He was brought to the general floor and was re-evaluated by speech and swallow. He was advanced to nectar soft liquids and soft solids. Nutrition was reconsulted for removal of TPN. Medications on Admission: [**Known lastname 101433**] [**Known lastname **] nexium lipitor singulair advair oxycontin lisinopril Discharge Medications: 1. Gabapentin 250 mg/5 mL Solution Sig: [**2-7**] PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (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. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day): contiune untill pt is abulatory. 8. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for wheeze. 9. Docusate Sodium 50 mg/5 mL Liquid Sig: [**2-7**] PO BID (2 times a day). 10. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day) as needed for prn constipation. 11. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a day) as needed. 12. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Diphenhydramine HCl 25 mg Capsule Sig: [**2-7**] Capsules PO TID PRN (). 14. Nortriptyline 10 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 15. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). 17. Diazepam 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 18. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever. 19. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed: please crush and serve with applesauce. 20. Oxycodone 20 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day): please crush and serve with applesauce. 21. Lorazepam 1 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Discharge Disposition: Extended Care Facility: [**Hospital1 **] Sattelite Discharge Diagnosis: Wound Infection Discharge Condition: Stable to rehab Discharge Instructions: Please keep incision clean and dry. You may shower in 48 hours, but please do not soak the incision. Change the dressing daily with clean dry gauze. If you notice drainage or redness around the incision, or if you have a fever greater than 100.5, please call the office at [**Telephone/Fax (1) **]. Please resume all home mediciation as prescribed by your primary care physician. [**Name10 (NameIs) **] have been given additional medication to control pain. Please allow 72 hours for refills of this medication. Please plan accordingly. You can either have this prescription mailed to your home or you may pick this up at the clinic located on [**Hospital Ward Name 23**] 2. We are not allowed to call in prescriptions for narcotics to the pharmacy. If you have questions concerning activity, please refer to the activity sheet. Physical Therapy: Activity as tolerated Treatments Frequency: No staples or sutures to remove. Please monitor for signs of infection. Followup Instructions: Please follow up with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 3648**] PA-C at two weeks from the date of discharge. You will need to call [**Telephone/Fax (1) **] for this appointment. Please follow up with Dr. [**Last Name (STitle) **] for your tracheostomy in [**2-7**] weeks. Please call [**Telephone/Fax (1) **] to make this appointment. Completed by:[**2160-1-24**]

[ "117.9", "250.00", "041.11", "E878.1", "787.20", "478.25", "723.0", "723.4", "564.00", "998.59", "336.9", "401.9" ]

icd9cm

[ [ [] ] ]

[ "86.28", "96.72", "33.21", "31.1", "33.22", "86.09", "38.93" ]

icd9pcs

[ [ [] ] ]

13834, 13887

10446, 11771

305, 342

13947, 13965

2529, 4181

14988, 15386

2080, 2084

11925, 13811

13908, 13926

11797, 11902

13989, 14829

2099, 2510

14847, 14869

14891, 14965

5776, 5776

5812, 10423

256, 267

370, 2002

2024, 2043

2059, 2064

9,576

129,268

8129

Discharge summary

report

Admission Date: [**2115-8-27**] Discharge Date: [**2115-9-3**] Date of Birth: [**2043-3-12**] Sex: F Service: CT Surgery HISTORY OF PRESENT ILLNESS: The patient is a 72 year old female with a history of shortness of breath and malignant pericardial effusion, status post pericardial window on [**2115-7-31**] and was discharged home on [**2115-8-2**]. She noticed increased shortness of breath on her second day home. An echocardiogram was done on [**2115-8-27**] and showed normal left ventricular function with a left ventricular ejection fraction of 60% with a large recurrent frontal pericardial effusion consistent with tamponade. PAST MEDICAL HISTORY: 1. Decreased thyroid hormone status post thyroidectomy. 2. Cervical cancer, status post conization and radiation therapy in [**2106**]. 3. Cesarean section. 4. Small cell lung cancer. 5. Status post right eye surgery. 6. Status post pericardial window on [**2115-7-31**]. HOSPITAL COURSE: The patient was taken to the Operating Room by Dr. [**First Name (STitle) 10102**] on [**2115-8-28**] for a pericardectomy. Postoperatively, the patient did well and. She was extubated and her drips were weaned to off. The patient was transferred to the floor with a chest tube. On the floor, the patient was stable and was able to ambulate. She achieved a rehabilitation status of four to five. The patient's postoperative course was somewhat complicated by continuous output from her chest tube, but the chest tube was discontinued on [**2115-9-3**] after draining less than 200 cc for a 24 hour period. DISCHARGE MEDICATIONS: Lopressor 12.5 mg p.o.b.i.d. Albuterol meter dose inhaler two puffs q.6h.p.r.n. Percocet one to two tablets p.o.q.4-6h.p.r.n. Synthroid 0.125 mcg p.o.q.d. DISCHARGE STATUS: The patient will be sent home with services to monitor her pulmonary status and for postoperative wound care. CONDITION ON DISCHARGE: Stable. Incisions were clean, dry and intact without drainage or pus; sternum stable. The patient had no complaints. FOLLOW-UP: The patient was instructed to follow up with her oncologist, Dr. [**First Name4 (NamePattern1) 402**] [**Last Name (NamePattern1) **], after discharge and to follow up with Dr. [**First Name (STitle) 10102**] in three to four weeks. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 13625**] Dictated By:[**Name8 (MD) 186**] MEDQUIST36 D: [**2115-9-3**] 09:04 T: [**2115-9-3**] 08:53 JOB#: [**Job Number 28971**]

[ "V10.11", "423.9", "198.89" ]

icd9cm

[ [ [] ] ]

[ "37.24", "37.31" ]

icd9pcs

[ [ [] ] ]

1621, 1907

986, 1598

171, 661

684, 968

1932, 2555

22,588

188,912

9121

Discharge summary

report

Admission Date: [**2206-2-11**] Discharge Date: [**2206-2-27**] Date of Birth: [**2143-12-3**] Sex: M Service: MEDICINE Allergies: Vicodin / Roxicet / Sirolimus Attending:[**First Name3 (LF) 4393**] Chief Complaint: Confusion Major Surgical or Invasive Procedure: removal of HD line Intubation Central line placment and removal Picc line placement and removal History of Present Illness: 62 yo male with history of HBV/HCV/EtOH cirrhosis with hepatic failure s/p liver [**First Name3 (LF) **] on immunosuppression, ESRD on HD, seizure disorder, polymyositis on prednisone, recent STEMI ([**2205-12-5**]) on ASA/plavix, with recent large GI bleed [**1-8**] duodenal ulcer s/p clipping and injection, and recent admission for sepsis (d/c [**2206-1-30**]) presents with confusion and elevated WBC count. Patient was found to have elevated WBC at rehab, no fevers, no complaints. Then per EMS became confused en route and was found to have a possible facial droop and weak on R side. . In the ED, initial vitals were 98.2F 139/85 HR 106 RR 22 100% RA. On assessment there a code stroke was called and he was assessed by neurology. . Per neurology: "Patient is reportedly "not too swift" at baseline, but this AM he just seemed more out of it. He hasn't eaten much of anything since he arrived to their facility. He undergoes dialysis on M/W/F and has been getting weekly lab work. WBC was apparently 13 last week and this week was 20. A UA was done, but was negative. He hasn't been running a fever, but with his change in mental status and his leukocytosis, it was requested that he come in for evaluation. Apparently en-route to the ED, the patient had a right facial droop and when he arrived, a code stroke was called." They felt that given apparent bilateral asterixis that he was encephalopathic. On assessment, patient did not have focal neuro deficits but not cooperative with exam. . CT showed no acute process with old ischemic disease. WBC elevated and was afebrile in the ED. LP was attempted x3 but unsuccessful done by ED resident and attending. Makes little urine (on HD) so no UA was done. He was given 2g CTX and 1g Vancomycin. . I was able to get limited history from the patient who did not speak to me throughout the interview other than when I asked him his name at the time of the physical examination. [**First Name8 (NamePattern2) **] [**Last Name (un) 8692**] wife he has been similar to this and not talking over the past 3 weeks and since discharge has been minimally conversant. He will oeby commands and get upa nd sit but not walking and will periodically respond. He would previously watch TV but not showing much interest in this anymore.It seems that the trend has been that he is less attentive to people recently. he had intermittent twicthing while in the ED and wife feels he is more disihibited. Last time she was able to have a conversation with him was in [**2205-11-6**]. His last (and seemingly only) seizure was in [**2200**] but wife was unsure regarding the presentation. He was rubbing his groin on assessment intermittently. . Review of systems: Limited account from patient but did respond by head nodding/shaking to my questions. (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria - but very little urine. Past Medical History: s/p liver [**Year (4 digits) **] [**1-8**] HBV, HCV, and EtOH abuse ([**2194**]) s/p hepatic artery replacement ([**2195**]) ESRD on HD Asymptomatic strokes ([**2195**]: left corona radiata and posterior putaminal infarct, periventricular white matter disease; [**8-12**] MRI with evidence of chronic cerebellar infarcts) Frontal gait disorder of unclear etiology Central and obstructive sleep apnea (sleep study [**2203**])- not on CPAP Polymyositis of unclear etiology though possibly from tacrolimus Seizure disorder Paraproteinemia Cataract removal Retinal detachment Inguinal hernia repair Duodonal ulcer [**2205-12-2**] STEMI with BMS to proximal LAD ([**2205-12-5**]) Social History: Previously lived with wife until [**Name (NI) 1096**] but now in nursing home. Limited mobility - no recent walking and only into chair. Past 3 weeks limited verbalising. He has no children. No current use of tobacco or EtOH. Ex-smoker 40/day for 40 years and quit 7 years ago. Previous heavy drinking history (~30 years) previous 6pack/day at his worst. No EtOH use several years prior to [**Name (NI) **]. H/o IVDU as per previous records. Family History: The patient is adopted. No known family history of stroke or neurological disease. Physical Exam: VS - Temp F, BP 112/85, HR 98, RR 20, O2-sat 100% RA (in ED) GENERAL - lying in bed, attentive but almost mute with very sparse verbalising, minimal movements and playing with his groin intemittently suggesting disinhibition. Difficult to assess but likely some asterixis bilaterally. HEENT - NC/AT, PERRL 3.5+/3.5+, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no JVD LUNGS - Limited exam. Seems clear but very inccoperative and shallow breaths CHEST - HD line in R Chest no erythema or tenderness CVS: HS 1+2+ systolic murmur throughout praecordium and best heard in aortic area without radiation JVP depressed at 1cm above sternal angle ABDOMEN - Sift, patient complains of tenderness in RUQ without guarding or rebound. No masses or organomegaly. BS normal. EXTREMITIES - WWP, no c/c/e, 1+ DP pulses bilat normmal radials. calves SNT no asymmetry SKIN - bruises on hips b/l and arms NEURO - GCS E4 V2-4 M6 [**2110-11-18**]. Awake, alert and intermittently attentive but generally mute. Limited verbalising. Intermittent twitches ? myoclonus. Minimal verbalising and would nod or shake head in response to questions until asked directly regarding his name - oriented to person (knows self and wife), partially to place (knows in [**Location (un) 86**]) and not to time - did not want to respond. CNs II-XII unremarkable save fields where there is no formal field examination but has a likely left-sided gaze preference although will look toward me and is able to follow my fingers on assessment with both eyes. No particular abnormalities seen on comfrontation. Fundoscopy almost immpossible due to patient inccoperation - briefly visualised left disc which did not appear grossly papilledematous but inadequate examination. Power appears [**4-10**] throughout, sensation grossly to light touch intact throughout but on little pressure would yell out as if in pain, brisk reflexes++ throughout more so on right with [**Last Name (un) 1842**] +ve, pronounced clonus in right but due to incooperation not able to assess on left as keeping left ankle rigid. Plantar flexor on left and extensor on right. Coordination (only assessed in left UE seemed normal). . On discharge: All central lines removed, NG tube removed. Pertinent Results: Admission labs: [**2206-2-11**] 12:30PM BLOOD WBC-18.6*# RBC-4.20*# Hgb-13.8*# Hct-43.9# MCV-105* MCH-32.9* MCHC-31.4 RDW-18.2* Plt Ct-140* [**2206-2-11**] 12:30PM BLOOD PT-11.7 PTT-26.5 INR(PT)-1.0 [**2206-2-11**] 12:30PM BLOOD Glucose-219* UreaN-41* Creat-5.3*# Na-143 K-5.5* Cl-98 HCO3-25 AnGap-26* [**2206-2-11**] 12:30PM BLOOD ALT-258* AST-474* LD(LDH)-1519* AlkPhos-71 TotBili-0.5 [**2206-2-11**] 12:30PM BLOOD Lipase-55 [**2206-2-11**] 12:30PM BLOOD Albumin-4.0 [**2206-2-11**] 12:30PM BLOOD Ammonia-19 Other labs: [**2206-2-11**] 12:30PM BLOOD CK(CPK)-116 [**2206-2-11**] 12:30PM BLOOD Lipase-55 [**2206-2-11**] 12:30PM BLOOD Albumin-4.0 [**2206-2-11**] 12:30PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-POSITIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE [**2206-2-12**] 10:35AM BLOOD tacroFK-10.4 [**2206-2-11**] 12:38PM BLOOD Lactate-3.1* K-5.4* [**2206-2-11**] 04:22PM BLOOD Lactate-3.5* K-5.2 [**2206-2-12**] 03:32PM BLOOD Lactate-2.8* Microbiology: - [**2206-2-11**] Blood culture: No growth - [**2206-2-11**] Blood culture: No growth - [**2206-2-11**] HCV viral load: 1,020,000 copies - [**2206-2-11**] HBV viral load: Negative - [**2206-2-12**] CMV viral load: Negative - [**2206-2-12**] HCV viral load: 3,500,000 copies - [**2206-2-12**] MRSA screen: Negative - [**2206-2-12**] Blood culture: No growth - [**2206-2-12**] C. difficile toxin: Negative - [**2206-2-13**] CSF cryptococcal antigen: Negative - [**2206-2-13**] CSF gram stain: No PMNs, no organisms - [**2206-2-13**] CSF cultures (bacterial, viral, fungal, AFB): PENDING - [**2206-2-15**] Blood culture: PENDING - [**2206-2-15**] Blood culture: PENDING - [**2206-2-15**] Blood culture: PENDING - [**2206-2-16**] Blood culture: PENDING - [**2206-2-16**] Blood culture: PENDING - [**2206-2-16**] C. difficile: Negative - [**2206-2-16**] Catheter tip culture: No growth - [**2206-2-18**] Sputum culture: <10 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS AND CHAINS. RESPIRATORY CULTURE (Final [**2206-2-20**]): MODERATE GROWTH Commensal Respiratory Flora. MOLD. RARE GROWTH. 1 COLONY ON 1 PLATE. IMAGING: CT Study Date of [**2206-2-11**] 12:34 PM FINDINGS: There is no evidence of acute intracranial hemorrhage, mass effect, or shift of normally midline structures. There is no cerebral edema or loss of [**Doctor Last Name 352**]-white matter differentiation to suggest an acute ischemic event. Extensive confluent hypodensities in deep white matter and periventricular distribution, most likely represent small vessel ischemic disease. The sulci and ventricles are prominent, likely age-related involutionary changes. Focal hypodensities in bilateral cerebellar hemispheres, likely represent remote infarcts, unchanged. Linear hyperattenuation seen in the left occipital lobe (2:10) most likely represents laminar cortical necrosis in area of prior stroke. The paranasal sinuses and mastoid air cells appear well aerated. Visualized soft tissue and osseous structures are unremarkable. No acute fracture is seen. IMPRESSION: 1. No acute intracranial process. 2. Stable appearance of remote cerebellar infarcts. 3. Extensive small vessel ischemic disease. 4. Prominent sulci and ventricles, likely age-related involutionary changes XR CHEST (PA & LAT) Study Date of [**2206-2-11**] 1:24 PM FINDINGS: A large-bore dual-lumen dialysis catheter from a right internal jugular approach is in stable and standard course and position. The lungs are clear without consolidation or edema. Mild aortic tortuosity is again noted, similar to prior. The cardiac silhouette is within normal limits for size. Lung volumes are slightly diminished. No effusion or pneumothorax is noted. The osseous structures are unremarkable. IMPRESSION: Relatively stable chest x-ray examination with no acute pulmonary process noted. DUPLEX DOPP ABD/PEL Study Date of [**2206-2-12**] 8:33 AM FINDINGS: There is limited visualization of the liver, especially of the left hepatic lobe given the extensive bowel gas. The imaged portion of the liver is unremarkable, without intrahepatic biliary dilatation or focal liver lesions. The common hepatic duct measures 5 mm. The main portal vein, anterior right portal vein, posterior right portal vein and the left portal veins demonstrate normal appropriate directional flow and waveforms. No demonstrable color Doppler or waveforms were obtained in the region of the main or the intrahepatic branches of the hepatic artery, despite extensive scanning. The extrahepatic arteries assessment is limited by the overlying bowel gas. The right, middle and left hepatic veins demonstrate normal flow and waveforms. The abdominal aorta demonstrates moderate atherosclerotic calcification, without aneurysmal dilation. There are no perihepatic or intrahepatic fluid collections. The pancreas is obscured by overlying bowel gas. The spleen is normal in size measuring 8.0 cm. There is no ascites. IMPRESSION: 1. No demonstrable arterial flow within the main hepatic artery and intrahepatic branches of the hepatic artery in this [**Date Range **] liver. No focal hepatic lesions or fluid collections. 2. Patent portal vein and hepatic veins. CTA ABD W&W/O C & RECONS Study Date of [**2206-2-12**] 11:19 AM IMPRESSION: 1. Continued thrombosis of the common hepatic artery as visualized previously on [**2198-4-17**]. 2. Interval enlargement of infrarenal abdominal aortic aneurysm with a mural thrombus. 3. Stenoses at the origin of bilateral renal arteries along with markedly atrophic kidneys bilaterally. 4. Evidence of mild fluid overload. MR HEAD W/O CONTRAST Study Date of [**2206-2-12**] 7:51 PM IMPRESSION: Limited examination due to motion artifacts. Overall, no significant changes are noted since the prior studies, persistent areas of high signal intensity in the subcortical white matter detected on FLAIR, likely reflecting chronic microvascular ischemic disease and global atrophy. Portable TTE (Focused views) Done [**2206-2-13**] at 3:34:27 PM Focused imaging performed. The left ventricular cavity is small. Left ventricular systolic function is hyperdynamic (EF 80%). Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are moderately thickened. There is mild aortic valve stenosis. There is an anterior space which most likely represents a prominent fat pad, although a small pericardial effusion cannot be exzcluded with certainty. Compared with the findings of the prior study (images reviewed) of [**2206-1-30**], no obvious change but the technically suboptimal nature of both studies precludes definitive comparison. Portable TEE (Complete) Done [**2206-2-14**] at 5:46:17 PM No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast at rest. Maneuvers were not performed due to iniability of patient to cooperate. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are calcified and thickened/deformed, with probable mild stenosis. No masses or vegetations are seen on the aortic valve. Moderate to severe (3+) eccentric aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. IMPRESSION: No intracardiac thrombus seen. No ASD or PFO. No abcesses or vegetations. Calcific aortic valve disease with probable mild stenosis and moderate to severe regurgitation. Mild mitral regurgitation. MRA NECK W/O CONTRAST Study Date of [**2206-2-14**] 8:44 PM IMPRESSION: Limited study due to motion. There appears to be a calcified plaque with narrowing of the distal left common carotid artery. Contrast enhanced CTA of the neck would help for better assessment.An ultrasound of the carotids can also help if clinically indicated. CT HEAD W/O CONTRAST Study Date of [**2206-2-15**] 3:14 PM IMPRESSION: 1. No interval change in the left occipital lobe hyperdensity since the earlier study of [**2206-2-11**], which represents a combination of calcification and blood products. 2. No other sites of intracranial hemorrhage detected. CT CHEST ABD & PELVIS W/O CONTRAST Study Date of [**2206-2-16**] 12:32 PM IMPRESSION: 1. Few tiny nonspecific ground-glass and nodular opacities scattered throughout both lungs and both lung bases. While some of this may represent atelectasis, infection and other inflammatory processes are within the differential and clinical correlation is recommended. 2. The superior vena cava markedly decreases in caliber just proximal to its entry into the right atrium and possibly related to chronic atheterization. 3. Small fluid around the proximal endotracheal tube. Small posterior right paratracheal soft tissue of unclear significance. This could possibly be related to chronic endotracheal tube placement. 4. Contrast-filled bladder (presumably from CT from [**2206-2-12**]) with multiple left-sided diverticula. Thickened bladder wall with trabeculations are suggestive of a more chronic process. 5. Stable infrarenal aortic aneurysm. UNILAT UP EXT VEINS US LEFT Study Date of [**2206-2-18**] 11:15 AM IMPRESSION: Overall, examination is limited. DVT with nonocclusive thrombus identified within the left brachial vein. Brief Hospital Course: HOSPITAL SUMMARY: 62 yo male with history of HBV/HCV/EtOH cirrhosis with hepatic failure s/p liver [**Date Range **] on immunosuppression, ESRD on HD, seizure disorder, polymyositis on prednisone, recent STEMI ([**2205-12-5**]) on ASA/clopidogrel, recent large GI bleed [**1-8**] duodenal ulcer s/p clipping and injection, and recent admission for sepsis (d/c [**2206-1-30**]) admitted from rehab facility with altered mental status and elevated WBC count. He was initially admitted to the general medical wards under a hepatology attending but was transferred to the medical ICU following seizure preceded by a run of VT at dialysis on [**2206-2-12**]. Active issues were addressed as below and he was called out of the MICU on [**2206-2-20**]. . ACTIVE ISSUES: # ALTERED MENTAL STATUS/SEIZURE/EMBOLIC STROKE: Mr. [**Known lastname 2809**] had been noted by his wife to be inattentive and speaking in shorter sentences than usual for several weeks with no preciptious decline in mental status (subacute course). She reports that his overall functional status has been deteriorating since early Decemeber [**2204**], which was the last time he was living at home. He had an EEG on his prior admission [**2205-1-28**] which showed non-specific slowing but no epileptiform activity or focal slowing. The initial differential for his altered mental status was broad and included infectious process (given markedly elevated WBC count and immunosupprsion), liver disease (given elevated LFTs), and neurological impairment. He then had an apparent generalised tonic clonic seizure after 45 minutes on dialysis [**2206-2-12**] which was proceeded by a 1 minute episode of VT at 200/min for which he was unresponsive and received 2 chest compressions before waking up. Fingerstick glucose was 130 at the time. He was transferred to the medical ICU following that episode. Of note, he had a prior seizure disorder though no episodes since [**2200**]; he had been on oxcarbazepine as prophylaxis. After he was noted to have seizure during HD on [**2206-2-12**], post-ictal state from unobserved seizure was also in the differential for his altered mental status on initial presentation. Further work up was undertaken and included LP (initially unobtainable at bedside; patient was ultimately intubated for this and other procedures and LP was performed by IR; CSF was notable only for elevated protein to 178; cultures were negative), MRI (which revealed multiple embolic infarcts as per report above); EEG (consistent with encephalopathy, no seizure activity documented); and CT scan to evaluate area of hyperdensity in occipital lobe concerning for progression of old bleed. He was evaluated by the neurology consult service and oxcarbazepine was stopped, Keppra was started (dialysis protocol dosing). Tacrolimus toxicity/PRES was considered as a possible etiology of symptoms, but MRI was not consistent with that diagnosis (instead revealed embolic strokes). Tacrolimus was initially held in this setting but restarted at lower dose on [**2206-2-19**]. Embolic stroke work up included echo with bubble study (negative) and MRI/MRA of neck demonstrating calcified plaque with narrowing of the distal left common carotid artery. He was initially placed on heparin gtt where he was frequently supratherapeutic given his ESRD; this was stopped in the setting of Hct to 27 (from 40 on admission) and concern for expansion of old/subacute bleed in occipital region on imaging. He received 1 unit of pRBCs with appropriate bump in Hct. TTP was considered as a potential etiology of symptoms (as can occasionally cause microvascular disease creating similar picture), and hematology consult was called but their team did not feel this was likely; no further work up for TTP was undertaken. Following extubation the patient was noted to be awake but was not speaking except for rare one-word responses. He was able to move all four extremities but diffusely weak. As the patient was transitioned to CMO care, the decision was made that the patient is allowed to eat for comfort despite having failed speech and swallow evaluation. . # CORONARY ARTERY DISEASE: Following his seizure, the patient developed a troponin leak to a peak of 1.32. He did not have significant EKG changes during this time. Subsequent echocardiogram showed preserved EF with no major new wall motion abnormalities. He was continued on his home aspirin/Plavix and was started on heparin gtt shortly thereafter, though this was cheifly for treatment of his embolic strokes. He did not complain of active chest pain. # HYPOTENSION: On [**2206-2-15**], patient became acutely hypotensive to SBP in 70s. He had no localizing symptoms. Lactate was elevated to 8 and central venous O2 sat was as low as 32%. He was started on broad spectrum antibiotics with vancomycin and Zosyn, pancultured, and started on pressors for pressure support. He was changed from prednisone to stress-dose hydrocortisone for 3 days. A CVL and an A-line were placed for monitoring; due to extreme difficulty with line placement, the A-line was placed by the general surgery team. There were no significant EKG changes. The cardiology fellow was consulted by telephone, but given the normal echocardiogram, absence of EKG changes, and CVP of 6 he felt the overall clinical picture was inconsistent with cardiogenic shock. Septic shock was felt to be the next most likely etiology despite his low CV O2 sat, though no organisms were cultured. The patient's blood pressures stabilized within 24 hours and he was taken off of pressors. # LEUKOCYTOSIS: Patient was noted to have elevated WBC count to 18K on admission which peaked at 21K following seizure. Cultures of blood, sputum, and CSF were unrevealing and C. difficile was negative. The patient was treated with broad spectrum antibiotics (initially including ampicillin and acyclovir for potential meningitis organisms) later narrowed to vancomycin for planned 10 day course. HCV viral load was positive, though HBV and CMV viral loads were negative. Beta-D-glucan and galactomannan were negative. # RESPIRATORY FAILURE: Patient was intubated on [**2206-2-13**] because he was unable to tolerate critical studies including MRI and LP without requiring sedation. However, just prior to his planned extubation, he developed the episode of hypotension as above. He remained intubated until his blood pressures recovered. He then failed SBT for two days as he was unable to be weaned from pressure support. He was successfully extubated on [**2206-2-18**]. # LEFT UPPER EXTREMITY DVT: Patient was noted to have left upper extremity swelling. Ultrasound of the arm was notable for brachial/axillary non-occlusive DVT. He had been anticoagulated for several days on heparin gtt for embolic stroke, but anticoagulation was held over concern for possible enlarging area of bleed in occipital region on head CT. # ELEVATED LFTs, S/P LIVER [**Date Range **]: [**Date Range 1326**] was in [**2194**] and patient has generally done well since that time (initially for HBV, HCV, ETOH cirrhosis). However, LFTs were noted to be elevated on this admission to peak values on the day of admission of ALT 258, AST 474, LDH 1519. TB peaked several days later at 0.8 and INR at 1.4. Differential for these values included reactivation of hepatitis virus (known HBV, HCV+) or graft rejection. In addition, U/S with doppler on [**2-12**] demonstrated hepatic artery occlusion; follow up CTA demonstrated continued thrombosis of the common hepatic artery as visualized previously on [**2198-4-17**]. HCV viral load returned positive at 3,500,000 copies; HBV and CMV viral loads were negative. The patient was initially started on lactulose but this was held when he developed diarrhea (C. difficile negative) as hepatic cause of his encephalopathy was felt less likely given his laboratory profile. Atorvastatin and Effexor were held during this admission. He was followed by the hepatology team during his ICU stay. He was continued on Cellcept and steroids throughout this admission, though tacrolimus was held from [**2206-2-12**] through [**2206-2-19**] given possibility of contribution to his neurologic presentation. It was then restarted at low dose with goal of level [**3-12**]. # VENTRICULAR TACHYCARDIA: Patient was noted by his nurse to have a run of ventricular tachycardia during his dailysis session on [**2206-2-12**] immediately preceding his seizure. Unfortunately, the monitor did not save the rhythm strip and it could not be printed for evaluation. He was monitored on telemetry during his ICU stay with no further events. # POLYMYOSITIS: Unclear etiology. Not active during this admission. Patient was continued on prednisone 25 mg PO daily except for 3 days during which he was placed on stress-dose steroids for hypotension. He was continued on Bactrim prophylaxis. # ESRD: Hemodialysis initiated in [**2205-11-6**]. On M/W/F schedule. Renal failure thought possibly due to tacrolimus toxicity, but tacro was restarted on HD. He was followed by the renal dialysis team while in-house. # HYPERTENSION: Patient was periodically hypertensive during his ICU stay to SBP > 200s. Pressures were controlled to goal of SBP 160 in accordance with neurology recommendations. # DEPRESSION: Of note pt expressed suicidal ideation during early [**Month (only) 404**] admission. His Effexor and Ritalin were held during this admission. # DIABETES MELLITUS: He was treated with a HISS while in house. FS was 130 after seizure on [**2206-2-12**]. # NUTRITION: During intubation, an OGT was placed and the patient was started on tube feeds. NGT was placed prior to extubation to continue medications and tube feeds as the patient was speaking and moving his mouth very little. . # GOALS OF CARE: Code status was initially full. However, at the time of call out from the ICU, discussion with the patient's wife regarding goals of care was undertaken, and the patient was made DNR/DNI. A palliative care consult was called to discuss options. . Following transition from the ICU to the floor, focus was turned to goals of care. After several discussions between the patient's wife and his primary hepatologist, Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**], the decision was made to transition the patient to comfort measures only. Palliative care was instrumental in helping the patient's wife consider what the patient's wishes would be in this situation. After decision was made to transition the patient to CMO, all central lines were removed. NG tube was removed and tube feeds were discontinued. All medications except those geared towards comfort - morphine, zyprexa, tylenol, prochlorperazine - were discontinued. The decision was made to not proceed with dialysis and dialysis catheter was removed. Hospice care came to evaluated the patient and he was discharged to an inpatient hospice facility. Medications on Admission: 1. prednisone 10 mg Tablet Sig: Three (3) Tablet PO EVERY OTHER DAY (Every Other Day). 2. prednisone 10 mg Tablet Sig: Two (2) Tablet PO EVERY OTHER DAY (Every Other Day). 3. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1) Tablet PO QMOWEFR (Monday -Wednesday-Friday). 4. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 5. tacrolimus 1 mg Capsule Sig: One (1) Capsule PO QPM (once a day (in the evening)). 6. tacrolimus 1 mg Capsule Sig: 1.5 Capsules PO QAM (once a day (in the morning)). 7. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. mycophenolate mofetil 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Two (2) Capsule, Ext Release 24 hr PO DAILY (Daily). 10. oxcarbazepine 150 mg Tablet Sig: One (1) Tablet PO QAM, Two (2) Tablets PO QPM 11. methylphenidate 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 12. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 13. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 15. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 16. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. insulin lispro 100 unit/mL Solution Sig: as directed units Subcutaneous QACHS: per scale below Subcutaneous qachs: 150-200: 2 units, 201-250: 4 units, 251-300: 6 units, 301-350: 8 units, 351-400: 10 units. Discharge Medications: 1. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig: Five (5) mg PO every four (4) hours as needed for pain or breathlessness. Disp:*30 ml* Refills:*0* 2. Ativan 1 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for anxiety. Disp:*16 Tablet(s)* Refills:*0* 3. atropine 1 % Drops Sig: Two (2) drops Ophthalmic every four (4) hours as needed for secretions. Disp:*5 ml* Refills:*0* 4. olanzapine 5 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO BID (2 times a day) as needed for agitation. Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*0* 5. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for fever. 6. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. Discharge Disposition: Extended Care Facility: [**Location (un) 31427**] House (Hospice Home) - [**Hospital1 8**] Discharge Diagnosis: Stroke, seizure disorder, Coronary Artery Disease, End Stage Renal Disease on Hemodialysis, Hepatitis B / Hepatitis C / EtOH Cirrhosis status-post Liver [**Hospital1 1326**], Polymyositis Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Lethargic but arousable. Activity Status: Bedbound. Discharge Instructions: Mr. [**Known lastname 2809**] was admitted to the hospital with altered mental status, confusion and low blood pressure. He was also found to have had a seizure during hemodialysis associated with a possible episode of ventricular tachycardia. He was transfered to the medical intensive care unit and intubated for a short period of time. There it was discovered that he had experienced a stroke and also that he had a blood clot in his left upper extremity. We also found persistent clot in his hepatic artery. . After several discussions between Mr. [**Known lastname 31428**] wife and his primary hepatologist as well as with the palliative care team, the decision was made to transition the patient to comfort measures only. NG tube and central access lines were removed. Medications were tailored to improve comfort. Followup Instructions: None [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 4407**]

[ "414.01", "038.9", "250.00", "V49.86", "311", "585.6", "995.92", "285.21", "348.30", "710.4", "307.9", "785.52", "276.8", "V42.7", "444.89", "410.71", "287.5", "453.82", "V45.82", "V45.11", "427.1", "327.23", "403.91", "345.90", "781.94", "434.11", "276.0", "518.81" ]

icd9cm

[ [ [] ] ]

[ "03.31", "39.95", "96.04", "96.6", "96.72", "38.93", "38.97" ]

icd9pcs

[ [ [] ] ]

30153, 30246

16793, 17542

300, 398

30480, 30480

7075, 7075

31466, 31582

4724, 4808

29350, 30130

30267, 30459

27739, 29327

30616, 31443

4823, 6997

7011, 7056

3128, 3549

251, 262

17558, 27713

426, 3109

7091, 7586

30495, 30592

3571, 4248

4264, 4708

7598, 16770

21,826

160,970

19421+57050

Discharge summary

report+addendum

Admission Date: [**2104-12-17**] Discharge Date: [**2104-12-21**] Date of Birth: [**2040-4-10**] Sex: M Service: Medical Intensive Care Unit CHIEF COMPLAINT: Hematochezia HISTORY OF PRESENT ILLNESS: The patient is a 64 year old man with several medical problems listed below. He was in his usual state of health until four to five months ago when he began to experience a significant weight loss (total 30 pounds). He also appreciated the development of relatively painless jaundice. He stated that he lost his appetite completely and is nauseated most of the time. The patient was scheduled for endoscopic retrograde cholangiopancreatitis beyond the date of admission, however, laboratory evaluation prior to the procedure revealed a markedly elevated INR (greater than 18). The procedure was scrapped. The patient received Vitamin K 10 mg subcutaneously and was admitted to the Medical Service pending return of his INR to the normal range. Once admitted to the Medical Floor he passed approximately 200 cc of blood per rectum without pain. He remained awake, comfortable and normal and had normal blood pressures throughout this, however, he was tachycardiac to approximately 100 beats/minute. This rate did not respond to fluid resuscitation. He received a total of 2 liters of normal saline prior to transfer to the Intensive Care Unit. REVIEW OF SYSTEMS: Constitutional loss of weight and depressed appetite as described above. Head, eyes, ears, nose and throat: No visual changes, hearing loss or difficulty swallowing. No rashes, colds or sweating. Cardiac: No angina, dyspnea, orthopnea, diaphoresis or peripheral edema. He has occasional palpitations, owing to his longstanding atrial fibrillation. Pulmonary: No cough, hemoptysis or pleurisy. He has stable shortness of breath attributed to his chronic obstructive pulmonary disease. Gastrointestinal: Nausea as above, no vomiting, diarrhea, constipation or hematemesis, hematochezia as described above. There has not been any episodes of melena. Musculoskeletal: There are no plans to take his exercise tolerances down as described below. ALLERGIES: None reported. MEDICATIONS ON PRESENTATION: 1. Spironolactone 50 mg daily 2. Sustained action Verapamil 240 mg every 12 hours 3. Furosemide 80 mg daily 4. Warfarin 4 mg every Monday, Tuesday, Thursday and Sunday, 6 mg every Wednesday and Saturday 5. Fluticasone 2 puffs b.i.d. 6. Ipratropium 2 puffs b.i.d. 7. Xopenex 125 mcg twice daily, nebulized solution PAST MEDICAL HISTORY: 1. Atrial fibrillation, rate-controlled with calcium channel blockers as described above, he was on Warfarin for stroke prophylaxis; 2. Chronic obstructive pulmonary disease, status post lung resection. His exercise tolerance is approximately one mile, he uses oxygen at home, 2 liters at night as well as bronchodilators and steroids as described above; 3. Presumed pseudomembranous colitis in [**2104-10-11**] during an admission to [**Hospital3 **] for a chronic obstructive pulmonary disease exacerbation. He received Vancomycin per us, however, he stopped this medication owing to nausea and. He continued to take his regular dose of Warfarin during that time. 4. Testicular cancer, status post orchiectomy; 5. Hypertension, treated with calcium channel blockers as described above; 5. Appendicitis, status post appendectomy; 6. Cholecystitis, status post open cholecystectomy. FAMILY HISTORY: Non-contributory. SOCIAL HISTORY: He has remote alcohol use and tobacco exposure as well. He lives with his wife. [**Name (NI) **] owns an insurance agency. PHYSICAL EXAMINATION: Temperature 97.8, heart rate 125 and irregular, blood pressure 115/75, oxygen saturation 94% on 4 liters. General: He is a jaundiced-appearing man, sitting upright in bed, speaking in full sentences. Head, eyes, ears, nose and throat: Normocephalic, atraumatic, anicteric sclerae, normal conjunctiva, pupils equal, round and reactive to light and accommodation from 4 mm to 2 mm with extraocular movements intact without nystagmus. Clear oropharynx. There is subungual icterus. Neck: Supple, full range of motion. Jugulovenous pressure is 4 cm at 45 degrees. There is no carotid bruit. There is no thyromegaly. Nodes: There is no anterior cervical, posterior cervical, supraclavicular or infraclavicular, axillary or inguinal adenopathy. Heart: Point of maximal impulse is in the fifth rib space in the midclavicular line. Rate is irregular, normal S1 and S2, there is no S3, S4, murmurs, rubs or gallops. Lungs: Good effort, normal excursions. Clear to auscultation and percussion bilaterally. Abdomen: Protuberant, normal bowel sounds, soft, nondistended. There is a right upper quadrant 8 cm diameter firm mass that is tender to palpation without rebound or guarding. A McBurney's incision is well-healed as is an open cholecystectomy scar. Back: There is normal curvature of the spine without costovertebral angle tenderness. Vascular: Carotid, radial, femoral, dorsalis pedis pulses are brisk and equal. Extremities: There is no rash, cyanosis, clubbing or edema. There is jaundice over the entire body. Neurological examination: Mental status is alert, oriented to person, place and time. He has normal attention with preserved short and longterm memory. He has euthymic mood and broad affect. He has grossly full visual fields. Writing sample was not obtained. Cranial nerves: I, not tested formally; II, III, IV and VI, normal as described above; V and VII symmetric, intact sensation in all three branches; VIII he could hear the examiner's watch ticking bilaterally; IX, X and XII tongue is midline. There is normal gage. Clear phonation. [**Doctor First Name 81**], normal shoulder shrug. Motor: Normal bulk and tone with preserved strength in all muscle groups of the upper and lower extremities. Sensory examination: Grossly normal, he had normal rapid alternating hand movements, the deep tendon reflexes were brisk and equal bilaterally. LABORATORY DATA: White blood cell count was 10, 500, hemoglobin 14 mg/dl, hematocrit 41.1%, platelets 254,000/mcl. Sodium 137, potassium 2.7, chloride 94, bicarbonate 31, blood urea nitrogen 33, creatinine 0.7, glucose 118, calcium 8.5, phosphate 2.8, magnesium 1.3. ALT 200, AST 148, alkaline phosphatase 244, total bilirubin 10.2, amylase 40, lipase 24, carcinoembryonic antigen was 6.9. CA19-9 was pending at the time of this dictation. Repeat hematocrit was 43.1. The patient underwent abdominal imaging showing a mass in the porta hepatis as well as a calcified mass in the right upper pole of the right kidney. Arrangements were made for him to undergo esophagogastroduodenoscopy, endoscopic retrograde cholangiopancreatography and possibly colonoscopy after the computerized tomography scan was obtained. HOSPITAL COURSE: After admission to the Medical Intensive Care Unit the patient had his INR reversed completely with a total of 4 units of fresh frozen plasma. He also received transfusion of 1 unit of packed red cells. The patient underwent endoscopic retrograde cholangiopancreatography. An incomplete of the lower third of the common bile duct was identified with proximal dilation. Intraductal ultrasound confirmed that the lesion was not a stone. There was bleeding from the site of compression. A stent was placed with passage of clotted blood. Plans for a more detailed esophagogastroduodenoscopy and colonoscopy were scrapped owing to the finding of hemobilia. The patient was returned to the Medical Intensive Care Unit after question of cytologic samples and brushings. At the time of this dictation the results of those pathological examinations are pending. On the day following his endoscopic retrograde cholangiopancreatography he was found to have stable hematocrit, electrolytes had returned to [**Location 213**] as had his INR. However, his amylase and lipase were markedly elevated (amylase was 1,062, lipase was [**Numeric Identifier 52792**]), however, the patient had no pain. His diet was slowly advanced. Hepatobiliary Surgery consultation was obtained. Plans for surgery are pending at the time of this dictation. [**Name6 (MD) **] [**Last Name (NamePattern4) 5837**], M.D. [**MD Number(1) 8285**] Dictated By:[**Name8 (MD) 7102**] MEDQUIST36 D: [**2104-12-20**] 19:59 T: [**2104-12-20**] 20:43 JOB#: [**Job Number 52793**] Name: [**Known lastname 9818**],[**Known firstname 140**] Unit No: [**Unit Number 9819**] Admission Date: [**2104-12-17**] Discharge Date: [**2104-12-27**] Date of Birth: [**2040-4-10**] Sex: M Service: [**Company 112**] ADDENDUM: This addendum covers the admission from [**2104-12-21**] through [**2104-12-27**]. CONTINUATION OF HOSPITAL COURSE: 1. Biliary mass: The patient tolerated the endoscopic retrograde cholangiopancreatography procedure with stent well and liver function tests declined after endoscopic retrograde cholangiopancreatography procedure. His appetite returned. His jaundice was improved. The patient was evaluated by General Surgery for this mass. The 8D cells sampled on endoscopic retrograde cholangiopancreatography were found to be atypical, likely thought to be cholangiocarcinoma versus pancreatic cancer. The patient had extensive discussions with Dr. [**First Name (STitle) **] in General Surgery. At the time of discharge it seemed unlikely that surgery would go ahead given the patient's considerable risks both cardiac, pulmonary and vascular (see below), but the patient is to follow up with Dr. [**First Name (STitle) **] after discharge. 2. Abdominal aortic aneurysm: The patient was evaluated by Vascular Surgery. A CT with aortic protocol was performed. The patient also underwent cardiac catheterization. Aneurysm was characterized as approximately 5 cm. At the time of discharge it was not clear if it was amenable to a stent graft type of procedure or other full surgical procedure would be required to repair it. 3. Right renal mass: This is suspected to be renal cell carcinoma based on the CT urogram findings. Possible resection by urologic surgery in coordination with Dr. [**First Name (STitle) **]. 4. Severe chronic obstructive pulmonary disease status post lung reduction surgery with home O2: The patient is currently relatively well compensated on his meter dose inhalers with occasional nebulizer use. Pulmonary consulted on this patient and felt that he had severe chronic obstructive pulmonary disease and was a significant perioperative pulmonary risk. 5. Cardiovascular: Congestive heart failure, systolic dysfunction, paroxysmal atrial fibrillation, the patient's echocardiogram showed systolic dysfunction with ejection fraction of approximately 30%. A stress test was performed, which showed that the left ventricular cavity enlarged on stress images when compared to resting perfusion images. It also showed a mild perfusion defect of the inferoapical wall with partial reversibility and also global hypokinesis. Cardiac catheterization showed normal pulmonary wedge pressures again and ejection fraction of 30%, overall hypokinetic motion, no focal stenoses though diffuse disease in the right coronary artery and the proximal left anterior descending coronary artery as well as the proximal circumflex. The patient was aggressively diuresed during this portion of his stay and felt to be euvolemic and discharged on a stable regimen of Lasix and Spironolactone. He was in sinus rhythm with regard to his atrial fibrillation after being placed on a beta blocker and having his Verapamil tapered down. He was also started on low dose ace inhibitor upon discharge. His anticoagulation, which had been held at the initial time of his bleed was held on discharge given his risk of bleeding from his biliary tumor. 6. Hypertension: The patient as noted above had his Verapamil decreased and was started on a beta blocker and had a low dose ace begun. He was also continued on Lasix on Spironolactone. DISPOSITION: We arranged follow up for the patient with Dr. [**First Name (STitle) **] in surgery, with Dr. [**Last Name (STitle) **] in vascular surgery, with Dr. [**Last Name (STitle) 9820**] in urology, with Dr. [**Last Name (STitle) **] in cardiology. DISCHARGE DISPOSITION: To home. DISCHARGE INSTRUCTIONS: 1. The patient should call your primary care physician or come to the Emergency Department if he has fevers or chills, nausea, vomiting, bleeding from below or worsening abdominal pain. 2. From now on you should take a dose of Amoxicillin 2 grams if having dental work. You should make your dentist aware that you require prophylaxis and you should call your primary care physician for [**Name Initial (PRE) **] prescription for a dental appointment. 3. You should see your primary care physician next week. 4. You should follow up with Dr. [**First Name (STitle) **] in general surgery [**2105-1-1**]. 5. Given your bleeding from biliary system you should not restart your Coumadin. 6. You will see Dr. [**Last Name (STitle) **] in the Heart Failure Clinic on [**2105-1-1**]. 7. You should follow up with Dr. [**Last Name (STitle) **] of vascular surgery. 8. You should follow up with Dr. [**Last Name (STitle) 9820**] in urologic surgery. MEDICATIONS ON DISCHARGE: 1. Multivitamin once a day. 2. Xopenex 1.25 mg one nebulizer b.i.d. as needed. 3. Flovent four puffs b.i.d. 4. Atrovent four puffs every six hours. 5. Prochlorperazine 10 mg q 6 hours prn. 6. Lasix 80 mg once a day. 7. Spironolactone 50 mg once a day. 8. Verapamil 80 mg q 8 hours. 9. Metoprolol 100 mg SR 24 hour tablet once a day. 10. Captopril 6.25 mg t.i.d. DISCHARGE DIAGNOSES: 1. Biliary mass. 2. Gastrointestinal bleed. 3. Atrial fibrillation. 4. Chronic obstructive pulmonary disease. 5. Coronary artery disease. 6. Abnormal liver function studies. 7. Right renal mass. 8. Abdominal aortic aneurysm. MAJOR PROCEDURES: Blood transfusions, endoscopic retrograde cholangiopancreatography with stent, cardiac catheterization. DISCHARGE CONDITION: Biliary obstruction relieved with stent, hematocrit stable, appetite improved. [**First Name11 (Name Pattern1) 27**] [**Last Name (NamePattern1) 28**], M.D. [**MD Number(1) **] Dictated By:[**Last Name (NamePattern1) 2223**] MEDQUIST36 D: [**2104-12-29**] 09:35 T: [**2104-12-29**] 09:57 JOB#: [**Job Number 9821**]

[ "157.9", "578.1", "577.0", "V58.61", "401.9", "155.1", "496", "427.31", "428.0" ]

icd9cm

[ [ [] ] ]

[ "99.04", "37.23", "88.42", "51.87", "99.07", "88.53", "88.56" ]

icd9pcs

[ [ [] ] ]

12358, 12368

14143, 14499

3456, 3475

13763, 14121

13369, 13742

8830, 12334

12392, 13343

3641, 5431

1397, 2524

180, 194

223, 1377

5448, 6840

2547, 3439

3492, 3618

3,830

168,714

45200

Discharge summary

report

Admission Date: [**2169-8-11**] Discharge Date: [**2169-8-25**] Service: MEDICINE Allergies: Aspirin / Percocet / Codeine Attending:[**First Name3 (LF) 348**] Chief Complaint: Tachypnea. Major Surgical or Invasive Procedure: None. History of Present Illness: 84 yo F with severe COPD, asthma, HTN, steroid induced hyperglycemia, and VRE recently discharged on [**2169-8-1**] for a left lower lobe pneumonia who presented to her pulmonary f/u appointment with increased SOB, and 13 pound weight gain (Lasix dose decreased in hospital given rising creatinine). . Patient reports that since discharge, her breathing has worsened and her legs have swelled up significantly. Additionally, she reports that her breathing has gotten much worse at home (patient on home O2, discharged with O2 for sat of 88% on room air on day of discharge). Finally, patient reports that she has no history of diabetes but began to have sugars to the 500s on steroids during her last hospitalization and she was sent home with SQ insulin during her prednisone taper. . In the [**Name (NI) **], pt was tachypneic with sats at baseline 88-92% on RA. Physical exam showed significant LE edema, elevated JVP, and rhonchorus breath sounds. CXR showed RLL atelectasis. Cr elevated to 1.8. Pt given lasix 40mg IV, neb treatments, and insulin. Past Medical History: # Asthma. History of greater than 5 hospitalization with no history of intubations. She has been on steroids since the beginning of [**Month (only) 216**]. Prior to this, she had been steroid free for the past 2 years. # Hypertension. # Steroid induced hyperglycemia. Discharged on insulin following her [**Hospital1 **] admission. # Peripheral vascular disease, status post left fem-peroneal bypass in [**2162**] Social History: The patient denies any tobacco use. Occasional alcohol use. The patient has a 24 hour home health aide at home. Family History: Asthma in her father Physical Exam: BP 125/61, HR 106-115, RR 30-34, O2 Sat 97% on 3L Gen: older female in NAD HEENT: clear oral pharynx, dry MM CV: RRR 2/6 SM at RUSB Lungs: scattered wheezes and rhonchi especially around right lung fields Abd: soft, NT, +BD, +distended Extrem: +[**11-28**] pitting edema bilat to thigh with skin color changes Skin: right flank area with non blanching erythmatous rash with few blisters in a dermatomal distribution, does not cross midline. Pertinent Results: CXR: 9//14/06 IMPRESSION: Interval volume loss in the right middle lobe that could represent infiltrate, atelectasis, or neoplasia compressing the right middle bronchus. Persistent left lower lobe opacity obscuring the hemidiaphragm and cardiac silhouette. . [**2169-8-14**]: BARIUM ESOPHAGRAM: Barium passes freely through the esophagus. There was an episodes of aspiration into the [**Last Name (un) **] heaa which did not elicit spontaneous cough . No structural abnormalities were detected in the region of the pharynx and cervical esophagus. There are tertiary peristaltic contractions and mild dilatation of the esophagus. There is a small axial hiatal hernia and a small degree of GE reflux was observed. IMPRESSION: 1. Axial hiatal hernia and GE reflux. 2. Nonspecific motor disorder of esophagus 3. Episode of aspiration with no spontaneous cough . ECHO [**2169-8-11**]: Conclusions: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Left ventricular systolic function is hyperdynamic (EF>75%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets are moderately thickened. There is moderate aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). There is a trivial/physiologic pericardial effusion Brief Hospital Course: Brief Hospital Course: 84 y/o F with h/o COPD, asthma, HTN, recent LLL pneumonia, who presents with increased dyspnea. Pt was admitted to the medical ICU with dyspnea SOB. She was initially found to have a RML lung collapse: No fever, leukocytosis to support infectious etiology, and recently completed 2 week course of levofloxacin. Therefore held off on further antibiotics innitially. Suspected collapse secondary to aspiration. Barium swallow confirmed silent aspiration into the airways. Aggressive chest physical therapy, nebulizers, and aspiration precautions undertaken to help prevent further aspiration and recruit atelectatic lung. [**Month (only) 116**] need PEG for nutritional support given her ongoing aspiration, but patient declined. Video swallow study and nutrition consult for further evaluation displayed gross aspiration. An attempt was made to transfer the patient to the floor, upon arrival she became tachypneic and tachycardic with labored breathing and was returned to the MICU. Pt was started on Vancomycin/Zosyn to complete a 14 day course for aspiration pneumonia. She responded well clinically. Pt was discharged NPO and was receiving nutirition via an NG tube. . # Tachycardia: h/o MAT. HR in 100's-120's on admission. Continued on diltiazem. Treating underlying lung disease. . # COPD: On home O2. Continued on prednisone taper. Continued albuterol/atrovent nebs prn. . # Hyperglycemia: Steroid induced hyperglycemia. Covered with glargine + SSI. . # Acute renal failure: Cr 1.8 on admission, up from baseline 1.0-1.1. At time of last discharge, creatinine was 1.5. Likely volume overloaded but intravascularly depleted, with pre-renal physiology. Attempted diuresis with lasix as creatinine tolerates. Held ace-I pending stable renal function. Pt never fully returned to baseline renal fnx. . #UTI: A VRE UTI was treated with oral Cipro in house and the infection resolved. . # Back rash: R back/hip rash in dermatomal distribution along with pain locally at site. Likely zoster. No active vesicles, but treated empirically on acyclovir. Pain persisted and patient was tried on Capsaicin cream. She was d/c on Lidocaine gel for the rash and ultram for pain. # PVD: continued on plavix # Asthma: cont singulair, advair, [**Doctor First Name 130**] # Prophylaxis: bactrim, PPI, hep SC # Code: Full # Access: PIV She was discharged to rehab with PCP [**Last Name (NamePattern4) 702**]. Medications on Admission: 1. Prednisone 30 mg p.o. q. day. 2. Ambien. 3. Atrovent. 4. Fosamax. 5. Allopurinol. 6. Singulair. 7. [**Doctor First Name **]. 8. Lasix 40 mg p.o. q. day. 9. Lisinopril 5 mg p.o. q. day. 10. Norvasc 5 mg p.o. q. day. 11. Plavix 75 mg p.o. q. day. Discharge Medications: 1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 2. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 4. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 8. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 9. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 10. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 11. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Puff Inhalation [**Hospital1 **] (2 times a day). 12. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q48H (every 48 hours). 13. Nitroglycerin 0.6 mg/hr Patch 24HR Sig: One (1) Patch 24HR Transdermal Q24H (every 24 hours). 14. Levalbuterol HCl 0.63 mg/3 mL Solution Sig: 1.26 mg Inhalation q4-6h () as needed for prn wheezing. 15. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 16. Aluminum-Magnesium Hydroxide 225-200 mg/5 mL Suspension Sig: 15-30 MLs PO QID (4 times a day) as needed. 17. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed. 18. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO Q6H (every 6 hours) as needed. 19. Guaifenesin 100 mg/5 mL Syrup Sig: Ten (10) ML PO TID (3 times a day). 20. Verapamil 40 mg Tablet Sig: Three (3) Tablet PO QID (4 times a day). 21. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO DAILY (Daily). 22. Docusate Sodium 150 mg/15 mL Liquid Sig: One Hundred (100) mg PO BID (2 times a day). 23. Capsaicin 0.025 % Cream Sig: One (1) Appl Topical TID (3 times a day). 24. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) for 3 doses: Start [**2169-8-26**]. 25. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 3 doses: Start [**2169-8-29**]. 26. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q12H PRN () as needed for Zoster pain. 27. Lidocaine HCl 2 % Gel Sig: One (1) Appl Urethral QID PRN () as needed for Zoster pain. 28. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: 1000 (1000) mg Intravenous Q48H (every 48 hours) for 3 doses. 29. Piperacillin-Tazobactam 2.25 g Recon Soln Sig: 2.25 g Intravenous Q8H (every 8 hours) for 7 days. 30. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed. 31. Insulin Glargine 100 unit/mL Solution Sig: Seven (7) units Subcutaneous at bedtime. 32. Humalog 100 unit/mL Solution Sig: per SSI Subcutaneous four times a day. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Aspiration Pneumonia Zoster outbreak Discharge Condition: Good Discharge Instructions: You were admitted to the hospital for pneumonia likely due to aspiration. You should call your doctor or return to the ER should you experience any of the following: Difficulty breathing Severe Chest Pain Coughing up Blood Vomiting Blood Bloody Stools Fever > 101 Severe pain to right leg Numbness/Tingling/Paralysis Severe Dizziness Nausea/Vomiting Severe Chest Pain/SOB Any other symptoms that worry you. Followup Instructions: Please follow-up with your primary Care Doctor in [**11-28**] weeks. You should call and schedule an appointment. Completed by:[**2169-8-25**]

[ "518.81", "038.9", "276.1", "782.1", "584.9", "E849.8", "041.04", "424.1", "995.91", "053.9", "507.0", "251.8", "493.22", "E932.0", "284.8", "599.0", "E915", "933.1", "428.0", "401.9" ]

icd9cm

[ [ [] ] ]

[ "99.04", "38.93" ]

icd9pcs

[ [ [] ] ]

9620, 9692

4057, 6463

246, 253

9773, 9780

2419, 4011

10235, 10380

1920, 1942

6762, 9597

9713, 9752

6489, 6739

9804, 10212

1957, 2400

196, 208

281, 1336

1358, 1774

1790, 1904

76,945

168,598

42822

Discharge summary

report

Admission Date: [**2120-1-22**] Discharge Date: [**2120-2-14**] Date of Birth: [**2056-7-26**] Sex: M Service: MEDICINE Allergies: All allergies / adverse drug reactions previously recorded have been deleted Attending:[**First Name3 (LF) 949**] Chief Complaint: Lethargy Major Surgical or Invasive Procedure: Initiation of CVVH and hemodialysis Placement of a 23 cm 14.5 French tunneled hemodialysis line History of Present Illness: years presenting with confusion, lethargy, and bowel and urinary incontinence for 1 week at home. . The patient is unable to give a meaningful history, but was found by his sister to be confused and lethargic, sitting in his stool and urine. He was brought to an OSH where he was found to have BP 86/41, HR 70s, PO2 100%. He was found to be guaiac positive with hct 18, creatinine 6.8, BUN 89, INR 2.1, ammonia 200. He received 3U pRBCs and IVF at the OSH with SBP 140's on arrival to the [**Hospital1 18**] ED. . In the [**Hospital1 18**] ED, initial VS were: 88/40. The patient was found to have BRB on rectal exam and an NGT was placed with dark red, coffe ground, clotted blood which did not clear with 500cc NG lavage. Hepatology was consulted and the patient was started on pantoprazole gtt and octreotide gtt. Hct had increased to 25.7 following transfusion at OSH, and remained stable with SBP stable in the 100's. He was found to have ascites and a paracentesis was performed. Ceftriaxone 1 gm IV was started empirically. The patient was found to be hypothermic at 92 and was placed on a bear hugger. Blood cultures were sent. He was A&0x2. The patient was also found to have extensive erythema in the folds of his skin and diffusely over his lower body, and Surgery was consulted to r/o Fournier's gangrene. Surgery felt there was no concern for Fourniers gangrene. He was admitted to the MICU for further management. . On arrival to the MICU, the patient was unable to provide a meaningful history but denied pain currently. . Review of systems: Unable to obtain. Past Medical History: Chronic alcohol abuse. Social History: Tobacco: Reports smokes [**1-1**] pk/day - Alcohol: Initially denies, now reports unknown alcohol use - Illicits: Denies Family History: Non-contributory Physical Exam: Admission physical exam: 30.6 (87 F) P 86 BP 102/48 R 17 PO2 100% 2L NC General: Alert, oriented x2 (person, place), no acute distress HEENT: Sclera anicteric, MM dry, oropharynx clear, PERRL Neck: Supple Cardiovascular: Soft heart sounds, regular rate and rhythm, normal S1 + S2, GII systolic murmer at RUSB Lungs: Poor respiratory effort but clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: Soft, non-tender, significantly distended with (+) fluid wave and small umbilical hernia, bowel sounds present Extremities: Warm, well perfused, no clubbing, cyanosis, 2+ pitting edema b/l with stasis dermatitis skin changes on LE's b/l Neuro: Moving all extremities, limited [**2-1**] poor cooperation. (+)asterixis Skin: Erythema without induration or warmth over lower abdomen, bilateral groin, scrotum, b/l thighs, lower extremities b/l. [**Location (un) **] erythema b/l. . Discharge physical exam: Vitals: Tc 96.3 BP 106/61 HR 65 RR 18 O2 Sat 98% RA General: Patient lying in bed sleeping in NAD at HD. HEENT: EOMI. PERRL. dryMM. CV: 2/6 systolic murmur at the RUSB. No radiation. No rubs/gallops. LUNGS: Decreased breath sounds at the right lung base anteriorly, otherwise clear to auscultation bilaterally, anteriorly. No crackles or wheezes. ABD: NABS+. Umbilical hernia present. No tenderness to palpation. Soft. Dullness to percussion present. EXT: 3+ pitting edema to the knees bilaterally w/ overlying chrnic venous stasis changes. NEURO: No asterixis present. CN 2-12 grossly intact. [**5-4**] plantar and dorsiflexion of the ankles bilaterally. Oriented to person, place, and time. Pertinent Results: Admission Labs: [**2120-1-22**] 07:20PM BLOOD WBC-15.0* RBC-2.52* Hgb-8.3* Hct-25.7* MCV-102* MCH-33.1* MCHC-32.5 RDW-18.7* Plt Ct-146* [**2120-1-22**] 07:20PM BLOOD Neuts-92.6* Lymphs-4.5* Monos-2.5 Eos-0.2 Baso-0.1 [**2120-1-22**] 07:20PM BLOOD Plt Ct-146* [**2120-1-22**] 08:55PM BLOOD PT-18.6* PTT-54.6* INR(PT)-1.8* [**2120-1-26**] 12:39PM BLOOD Fibrino-305 [**2120-1-23**] 02:28AM BLOOD Ret Man-2.9* [**2120-1-22**] 07:20PM BLOOD Glucose-96 UreaN-90* Creat-6.0* Na-137 K-4.8 Cl-109* HCO3-13* AnGap-20 [**2120-1-22**] 07:20PM BLOOD ALT-17 AST-27 AlkPhos-82 Amylase-81 TotBili-1.8* [**2120-1-22**] 07:20PM BLOOD Albumin-2.3* Calcium-8.4 Phos-6.7* Mg-2.2 [**2120-1-29**] 05:04AM BLOOD calTIBC-120* Ferritn-329 TRF-92* [**2120-1-23**] 02:28AM BLOOD VitB12-1679* Folate-10.2 [**2120-1-22**] 07:20PM BLOOD TSH-5.3* [**2120-1-23**] 02:28AM BLOOD Free T4-0.63* [**2120-1-23**] 02:28AM BLOOD Cortsol-25.6* [**2120-1-23**] 02:28AM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE HBcAb-NEGATIVE [**2120-1-23**] 01:50PM BLOOD Type-ART pO2-115* pCO2-33* pH-7.30* calTCO2-17* Base XS--8 [**2120-1-23**] 01:50PM BLOOD freeCa-1.08* [**2120-1-23**] 02:28AM BLOOD HEPATITIS C - RIBA-Test Name Imaging: CT HEAD W/O CONTRAST FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or infarction. Prominent ventricles and sulci suggest age-related involutional changes. Confluent areas of low attenuation in the periventricular white matter are nonspecific and most likely due to small vessel disease. A 4-mm round calcification in the right operculum is likely a dural calcification or small granuloma. The basal cisterns are patent. No fracture is identified. The visualized paranasal sinuses, mastoid air cells, and middle ear cavities are clear. Mild atherosclerotic mural calcification of the vertebral and internal carotid arteries is noted. IMPRESSION: 1. No acute intracranial process. 2. Evidence of age-related atrophy and small vessel disease. 3. Incidental calcification in the right operculum is likely a dural calcification or a small granuloma. . DUPLEX DOPP ABD/PEL FINDINGS: There is a moderate-sized right pleural effusion. The liver is diffusely echogenic and nodular in contour. No focal liver lesion identified. There is no intra- or extra-hepatic duct dilation. The common duct measures 4 mm. There is normal hepatopetal flow within the portal vein. There is mild gallbladder wall thickening, which is likely due to patient's underlying liver disease. No cholelithiasis. No pericholecystic fluid. The spleen is normal in size measuring 10.4 cm. The pancreas is not visualized due to overlying bowel gas. The left kidney was not visualized. The right kidney is normal in size and echogenicity, measuring 10.9 cm. No evidence of hydronephrosis, renal lesion or stones. The aorta was not well visualized. The visualized portions of the IVC are normal. There is a small amount of intra-abdominal ascites. IMPRESSION: 1. Fatty liver with nodular contour consistent with patient's history of cirrhosis. No focal liver lesion identified. 2. Right pleural effusion. 3. Small amount of intra-abdominal ascites. The remainder of the study is normal. LIVER OR GALLBLADDER US (SINGLE ORGAN) FINDINGS: There is a moderate-sized right pleural effusion. The liver is diffusely echogenic and nodular in contour. No focal liver lesion identified. There is no intra- or extra-hepatic duct dilation. The common duct measures 4 mm. There is normal hepatopetal flow within the portal vein. There is mild gallbladder wall thickening, which is likely due to patient's underlying liver disease. No cholelithiasis. No pericholecystic fluid. The spleen is normal in size measuring 10.4 cm. The pancreas is not visualized due to overlying bowel gas. The left kidney was not visualized. The right kidney is normal in size and echogenicity, measuring 10.9 cm. No evidence of hydronephrosis, renal lesion or stones. The aorta was not well visualized. The visualized portions of the IVC are normal. There is a small amount of intra-abdominal ascites. IMPRESSION: 1. Fatty liver with nodular contour consistent with patient's history of cirrhosis. No focal liver lesion identified. 2. Right pleural effusion. 3. Small amount of intra-abdominal ascites. The remainder of the study is normal. . CXR on admission: FINDINGS: Lung volumes are low. There are no pleural effusions. However, there is moderate cardiomegaly and a noticeable increase in diameters of the pulmonary vessels. Moreover, the right aspects of the mediastinum and the diameter of the azygos vein are enlarged. Overall, this suggests the presence of mild-to-moderate pulmonary edema. There is no evidence of pneumonia. At the time of dictation, 10:04 a.m. on [**2120-1-23**], the referring physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) **], was paged for notification. . ECHO: The left atrium is dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is normal (LVEF>55%). The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic root is mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve is bicuspid. The aortic valve leaflets are mildly thickened (?#). There is mild aortic valve stenosis (valve area 1.2-1.9cm2). No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is no pericardial effusion. No vegetation seen (cannot definitively exclude). . EGD [**2120-1-29**]: Findings: Esophagus: Mucosa: Esophagitis with no bleeding was seen in the mid to lower esophagus, compatible with severe esophagitis. Protruding Lesions 1 cords of grade I varices were seen in the GE junction. The varices were not bleeding. An attempt was made at banding this varix however, patient did not tolerate intubation with the endoscope and the banding apparatus. Procedure was aborted. Stomach: Mucosa: Diffuse erythema and mosaic appearance of the mucosa with no bleeding were noted in the body and fundus. These findings are compatible with portal hypertensive gastropathy. Duodenum: Mucosa: Normal mucosa was noted. Impression: Normal mucosa in the duodenum. Erythema and mosaic appearance in the body and fundus compatible with portal hypertensive gastropathy Varices at the GE junction (ligation). Esophagitis in the mid to lower esophagus compatible with severe esophagitis. Otherwise normal EGD to third part of the duodenum. . UNILAT LOWER EXT VEINS RIGHT FINDINGS: The common femoral veins demonstrate a normal respiratory flow pattern bilaterally. There is normal compressibility, flow, and augmentation of the right common femoral, superficial femoral, and popliteal veins. There is normal compressibility of the right deep peroneal and posterior tibial veins. IMPRESSION: No evidence of deep vein thrombosis. . CT ABDOMEN WITHOUT INTRAVENOUS CONTRAST: Minimal atelectasis and scarring are identified at the lung bases. No focal pulmonary nodule is visualized. There are small bilateral pleural effusions. The imaged cardiac apex demonstrates calcification of the right coronary artery. The remainder of the heart is normal in appearance. The liver continues to demonstrate a shrunken nodular contour, findings consistent with the history of cirrhosis. No clear hepatic lesion is identified on this non-contrast study. Limited non-contraste views of the remainder of the abdominal viscera including the spleen, pancreas, adrenal glands, kidneys, and gallbladder appear within normal limits. There is a moderate amount of free fluid within the abdomen and pelvis, which appears similar compared to prior. No organized fluid collection is visualized to suggest intra-abdominal or pelvic abscess. Tje abdominal aorta demonstrates moderate calcifications, though is non-aneurysmal throughout its course. The stomach and small-bowel loops are well opacified with contrast and demonstrate normal caliber without signs of obstruction or inflammation. There is diffuse haziness of the mesentery and abdominal soft tissues, findings consistent with diffuse anasarca. CT PELVIS WITHOUT INTRAVENOUS CONTRAST: A rectal tube is visualized. The remainder of the rectum and colon appear normal in caliber and configuration without evidence of obstruction or inflammation. The prostate and seminal vesicles are within normal limits. A Foley catheter and a small amount of air are visualized within the bladder, which is otherwise normal. No pathologically enlarged pelvic lymph nodes are identified. However, prominent inguinal lymph nodes are again identified bilaterally, though unchanged from prior. OSSEOUS STRUCTURES: No bone destructive lesion or acute fracture is identified. A bone island within the right femoral neck is stable. IMPRESSION: 1. Stable moderate simple ascites throughout the abdomen and pelvis. No organized fluid collection to suggest intra-abdominal abscess. 2. Nodular cirrhotic appearance of the liver. 3. Stable prominent inguinal adenopathy. 4. Bibasilar atelectasis and small bilateral pleural effusions. . INDICATION: 63-year-old man with renal failure on hemodialysis with temporary hemodialysis will need permanent HD line. Please place new tunneled hemodialysis line. PROCEDURE: Written informed consent was obtained after explaining the risks, benefits and alternatives of procedure. The patient was brought to the angiographic suite and laid supine on the table. The right neck and chest was prepped and draped in a sterile fashion. A preprocedural huddle and timeout were performed per [**Hospital1 18**] protocol. Patent right internal jugular vein was accessed with a micropuncture needle under ultrasound and fluoroscopic guidance. A micropuncture wire was advanced and micropuncture sheath was placed. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 7648**] wire was placed into the IVC. Then attention was directed to the right chest and the tunneling site was selected and anesthetized with 1% lidocaine and 1% lidocaine with epinephrine. A tunnel was made using a tunneling device. The venotomy site was serially dilated using 12 and 14 French dilators. A peel-away sheath was placed into the right atrium. The tunneled catheter was inserted through the peel-away sheath and tip was placed in the right atrium. The venotomy site was closed with 4-0 Vicryl. The catheter was secured to the skin using 0 silk sutures. Sterile dressing was applied. The patient tolerated the procedure well. There were no immediate complications. IMPRESSION: Successful uncomplicated placement of a 23 cm 14.5 French tunneled hemodialysis line through the right IJ with the tip in the right atrium. The line is ready to use. . Flex Sig Findings: Protruding Lesions Small grade 1 internal & external hemorrhoids with skin tags were noted. Excavated Lesions A posterior anal fissure was noted. Multiple diverticula were seen in the sigmoid colon.Diverticulosis appeared to be of mild severity. Other No evidence of active bleeding Impression: Posterior anal fissure. Diverticulosis of the sigmoid colon Grade 1 internal & external hemorrhoids. No evidence of active bleeding Otherwise normal sigmoidoscopy to descending colon Recommendations: 1. Return to the floor 2. Follow up HCT 3. Once discharge from the hospital will need a colonoscopy 4. High fiber diet . Discharge labs: [**2120-2-14**] 06:21AM BLOOD WBC-9.6 RBC-2.44* Hgb-8.2* Hct-24.4* MCV-100* MCH-33.6* MCHC-33.7 RDW-17.6* Plt Ct-143* [**2120-2-13**] 07:20AM BLOOD PT-19.0* INR(PT)-1.8* [**2120-2-14**] 06:21AM BLOOD Glucose-121* UreaN-30* Creat-4.8* Na-135 K-3.6 Cl-96 HCO3-26 AnGap-17 [**2120-2-13**] 07:20AM BLOOD ALT-11 AST-27 TotBili-2.1* [**2120-2-14**] 06:21AM BLOOD Calcium-8.5 Phos-4.3 Mg-1.8 Microbiology: [**2120-1-22**] 9:00 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES PERITONEAL FLUID. **FINAL REPORT [**2120-1-28**]** Fluid Culture in Bottles (Final [**2120-1-28**]): PSEUDOMONAS AERUGINOSA. OF TWO COLONIAL MORPHOLOGIES. FINAL SENSITIVITIES. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 2 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM------------- 0.5 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S Aerobic Bottle Gram Stain (Final [**2120-1-23**]): GRAM NEGATIVE ROD(S). Reported to and read back by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] ([**Numeric Identifier **]) [**2120-1-23**] @1835. . [**2120-1-31**] 4:49 pm PERITONEAL FLUID PERITONEAL FLUID. **FINAL REPORT [**2120-2-6**]** GRAM STAIN (Final [**2120-1-31**]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. This is a concentrated smear made by cytospin method, please refer to hematology for a quantitative white blood cell count.. FLUID CULTURE (Final [**2120-2-3**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2120-2-6**]): NO GROWTH. . [**2120-1-23**] 1:15 pm SWAB FROM PANNUS. **FINAL REPORT [**2120-2-5**]** GRAM STAIN (Final [**2120-1-23**]): 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. WOUND CULTURE (Final [**2120-1-26**]): PSEUDOMONAS AERUGINOSA. SPARSE GROWTH. Piperacillin/Tazobactam sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 2 S CEFTAZIDIME----------- 4 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM------------- 0.5 S PIPERACILLIN/TAZO----- S TOBRAMYCIN------------ <=1 S FUNGAL CULTURE (Final [**2120-2-5**]): NO FUNGUS ISOLATED. A swab is not the optimal specimen for recovery of mycobacteria or filamentous fungi. A negative result should be interpreted with caution. Whenever possible tissue biopsy or aspirated fluid should be submitted. . [**2120-2-8**] 1:27 pm PERITONEAL FLUID PERITONEAL. **FINAL REPORT [**2120-2-14**]** GRAM STAIN (Final [**2120-2-8**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2120-2-11**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2120-2-14**]): NO GROWTH. . [**2120-2-8**] 1:27 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES PERITONEAL. **FINAL REPORT [**2120-2-14**]** Fluid Culture in Bottles (Final [**2120-2-14**]): NO GROWTH. . [**2120-1-31**] 4:49 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES PERITONEAL FLUID. **FINAL REPORT [**2120-2-6**]** Fluid Culture in Bottles (Final [**2120-2-6**]): NO GROWTH. . [**2120-2-6**] 3:30 pm CATHETER TIP-IV Source: R IJ. **FINAL REPORT [**2120-2-8**]** WOUND CULTURE (Final [**2120-2-8**]): No significant growth. . [**2120-2-2**] 2:43 pm IMMUNOLOGY Source: Venipuncture. **FINAL REPORT [**2120-2-5**]** HCV VIRAL LOAD (Final [**2120-2-5**]): HCV-RNA NOT DETECTED. Performed using the Cobas Ampliprep / Cobas Taqman HCV Test. Linear range of quantification: 43 IU/mL - 69 million IU/mL. Limit of detection: 18 IU/mL. Rare instances of underquantification of HCV genotype 4 samples by [**Doctor Last Name **] COBAS Ampliprep/COBAS TaqMan HCV test method used in our laboratory may occur, generally in the range of 10 to 100 fold underquantitation. If your patient has HCV genotype 4 virus and if clinically appropriate, please contact the molecular diagnostics laboratory ([**Telephone/Fax (1) 6182**]) so that results can be confirmed by an alternate methodology. [**2120-2-1**] 3:42 am BLOOD CULTURE Source: Line-right IJ dialysis catheter. **FINAL REPORT [**2120-2-7**]** Blood Culture, Routine (Final [**2120-2-7**]): NO GROWTH times 2 . [**2120-1-31**] 10:12 pm URINE Source: Catheter. **FINAL REPORT [**2120-2-2**]** URINE CULTURE (Final [**2120-2-2**]): NO GROWTH. . [**2120-1-31**] 6:50 am STOOL CONSISTENCY: LOOSE Source: Stool. **FINAL REPORT [**2120-1-31**]** CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2120-1-31**]): Feces negative for C.difficile toxin A & B by EIA. (Reference Range-Negative). . [**2120-1-31**] 1:45 am BLOOD CULTURE Source: Line-vip. **FINAL REPORT [**2120-2-6**]** Blood Culture, Routine (Final [**2120-2-6**]): NO GROWTH time 2. . [**2120-1-31**] 2:14 am URINE Source: Catheter. **FINAL REPORT [**2120-2-1**]** URINE CULTURE (Final [**2120-2-1**]): NO GROWTH. . [**2120-1-23**] 11:47 am URINE Source: Catheter. **FINAL REPORT [**2120-1-25**]** Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Final [**2120-1-25**]): Negative for Chlamydia trachomatis by PCR. NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION (Final [**2120-1-25**]): Negative for Neisseria Gonorrhoeae by PCR. . [**2120-1-23**] 11:47 am SEROLOGY/BLOOD CHEM # 60684M [**1-23**] 11:47AM. **FINAL REPORT [**2120-1-24**]** RAPID PLASMA REAGIN TEST (Final [**2120-1-24**]): NONREACTIVE. Reference Range: Non-Reactive. . [**2120-1-22**] 8:55 pm BLOOD CULTURE **FINAL REPORT [**2120-1-28**]** Blood Culture, Routine (Final [**2120-1-28**]): NO GROWTH time 2. . [**2120-1-23**] 2:28 am URINE Source: Catheter. **FINAL REPORT [**2120-1-23**]** Legionella Urinary Antigen (Final [**2120-1-23**]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. (Reference Range-Negative). Performed by Immunochromogenic assay. A negative result does not rule out infection due to other L. pneumophila serogroups or other Legionella species. Furthermore, in infected patients the excretion of antigen in urine may vary. . [**2120-1-23**] 1:00 am MRSA SCREEN Source: Nasal swab. **FINAL REPORT [**2120-1-24**]** MRSA SCREEN (Final [**2120-1-24**]): POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS. Brief Hospital Course: #. GI bleed: The patient had an initial hematocrit of 18 at OSH with increase of hematocrit to 26 with 3 units pRBC transfused at the outside hospital. He had bright red blood on rectal exam in the [**Hospital1 18**] ED with NG lavage positive for blood that did not clear with 500cc. Hepatology was consulted and since he stabilized with no further bleeding, he was not scoped immediately. He was continued on an octreotide drip for 72 hours and transitioned from pantoprazole drip to IV twice daily dosing. He underwent EGD which showed showed portal hypertensive gastropathy, severe esophagitis and grade 1 varices at the GE junction that could not be banded. He was given a total of 8 units of blood through the admission. He was initiated on naldolol. The patient was also noted to have small blood clots in flexiseal with a slowly down-trending hematocrit. He underwent flex-sig that showed no active signs of bleeding but a posterior anal fissure as well as diverticulosis and grade 1 internal and external hemorrhoids. Hematocrit remained stable through the patient's hospitalization. OUTPATIENT ISSUES: The patient may require repeat endoscopy under MAC for variceal banding. The patient will need a complete colonoscopy upon discharge from rehab. . #. Ascites due to cirrhosis: Patient with chronic alcohol abuse and stigmata of chronic liver disease on exam. RUQ u/s was consistent fatty liver with nodular contour which is consistent with cirrhosis. Likely from EtOH etiology. Hepatitis serologies were negative. OUTPATIENT ISSUES: Follow-up with Hepatology at [**Hospital1 18**]. [**Month (only) 547**] is the first available with any of the Liver doctors [**First Name (Titles) **] [**Last Name (Titles) 18**]; patient was booked for this appointment. The administrative assisstant in Hepatology is going to check with Dr. [**Last Name (STitle) **] to see if this is clinically safe. If it is not, the hepatology department will fit him in sooner and contact his ECF with appointment information. . #. Altered Mental Status: Patient with evidence of encephalopathy on exam, also with chronic alcohol abuse and with renal failure. Improved with lactulose/rifaxamin, treatment of infection, and dialysis. His mental status was at baseline at the time of transfer to the floor was alert and oriented to person, place, and time. OUTPATIENT ISSUES: Continuation of lactulose and rifaxamin, titrating the lactulose to [**3-3**] bowel movements daily. . #. Hypothermia/Leukocytosis: Patient with hypothermia and leukocytosis upon admission in the ED in the setting of an upper GI bleed. Likely felt secondary to sepsis. Improved with treatment of upper GI bleed. . # Spontaneous Bacterial Peritonitis- The patient underwent diagnostic paracentesis with cell count consistent with SBP (WBC 910 51% PMNs). He was started on empiric ceftriaxone. Cultures ultimately grew Pseudomonas, and his antibiotics was broadened to Zosyn and Vancomycin. He completed a 5 day course of antibiotics and was transitioned to prophylactic ciprofloxacin. However, the patient experienced hypotension with systolic BPs in the 70s which did not improve with IVF. He required transfer back to the MICU were antibiotics were broadended to Meropenem and Vancomycin. Diagnostic tap during the patient's second ICU course revealed a Gram stain with 3+ PMNs; however, no organisms were isolated. The patient was continued on Meropenema and Vancomycin through the patient's second ICU course. While on the general medicine floor, the patient was continued on Meropenem and Vancomycin. ID was consulted for management of antibiotics and recommeded a 14 day course of Meropenem and a 7 day course of Vancomycin. The patient completed a course of Vancomycin dosed with hemodialysis. Patient will have another 2 days of Meropenem to complete a total of 14 days for treatment of sponatenous bacterial peritonitis. After completion of Meropenem, the patient should take 250mg ciprofloxacin daily for prophylaxis against spontaneous bacterial peritonitis. OUTPATIENT ISSUES: Continuation of Meropenem for another 2 days to complete a 14 day course. After completion of Meropenem, start 250mg ciprofloxacin daily for prophylaxis against spontaneous bacterial peritonitis. . # Sepsis- Following discontinuation of antibiotics the patient experienced hypotension with blood pressures in the 70s systolic. He was given fluid bolus with little response and subsequently transferred back to the MICU where he required initiation of pressors (levophed). Given patient's known infection and recent discontinuation of antibiotics, the patient's presentation was consistent with sepsis. Antibiotics were broadened to vancomycin and meropenem given sepsis. Through the patient's ICU course, he was weaned from levophed after midodrine and octreotide were started. Upon arrival to the general medicine floor from the patient's second ICU stay, the patient remained afebrile and vital signs were stable. . # Rash: Dermatology consulted and biopsy of skin revealed pseudomonus. The patient was started on topical gentamicin. This medication was discontinued prior to discharge as rash was noted to improve. The patient will follow up with dermatology as an outpatient. OUTPATIENT ISSUES: Patient is scheduled for outpatient follow-up with Dermatology at [**Hospital1 18**]. . #. Acute Renal Failure: Patient with Cr 6.8 at the outside hospital. Initially, this was felt to most likely be secondary to acute tubular necrosis. He required initiation of CVVH in MICU due to hypotension. Blood pressure improved and patient transitioned to hemodialysis upon transferring to regular floor. Hepatitis serologies were negative and PPD was negative. Hemodialysis was continued through the patient's second course in the ICU as well as his stay on the medicine floor prior to discharge. On the medicine floor prior to discharge, patient was on a Monday, Wednesday, Friday schedule. OUTPATIENT ISSUES: Continuation of hemodialysis as an outpatient as well as nephrocaps to be taken daily. Follow-up with renal at [**Hospital1 18**]. . #. Anion gap metabolic acidosis: Metabolic acidosis with gap of 15, felt secondary to uremia. Resolved and improved with dialysis. On day of discharge, patient with bicarbonate or 26. Medications on Admission: None, per patient Discharge Medications: 1. heparin (porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 2. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain: Do NOT exceed greater than 2 grams daily. 4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 5. midodrine 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO every twelve (12) hours. 7. lactulose 10 gram/15 mL Syrup Sig: 15-30 MLs PO Q 8H (Every 8 Hours): Titrate to [**3-3**] bowel movements daily. 8. nadolol 20 mg Tablet Sig: Two (2) Tablet PO QHD (each hemodialysis): HOLD for SBP < 95, after HD . 9. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 10. meropenem 500 mg Recon Soln Sig: One (1) Recon solution Intravenous every twenty-four(24) hours for 2 days: Last dose will be administered [**2120-2-16**]. Discharge Disposition: Extended Care Facility: [**Hospital6 2222**] - [**Location (un) 538**] Discharge Diagnosis: PRIMARY DIAGNOSIS: Cirrhosis secondary to alcoholism SECONDARY DIAGNOSIS: Pseudomonas spontaneous bacterial peritonitis Sepsis, resolved Thrombocyotpenia Upper GI bleed Hepatorenal syndrome Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: Dear Mr. [**Known lastname 17926**], It was a pleasure taking care of you during your hospitalization at [**Hospital1 69**]. You were hospitalized for lethargy and found to have a bleed in your gastrointestinal tract which resulted in a stay in the intensive care unit. You have had a long hospital course complicated by an infection in the fluid surrounding your abdominal organs (known as spontaneous bacterial peritonitis) which led to a second course in the intensive care unit. You are currently on IV antibiotics for treatment of infection of the fluid surrounding your abdominal organs. While at rehab, you will continue antibiotics to complete a full course. During this admission, you were initiated on dialysis because of renal failure. You will continue to have dialysis as an outpatient, on a Monday, Wednesday, Friday schedule. Please take all medications as instructed. Please note the following medication changes. 1. *ADDED* Lactulose 15-30mL every 8 hours 2. *ADDED* Meropenem 500mg IV every 24 hours for another two days, to complete a full course of antibiotics. After completing Meropenem you will be switched to Ciprofloxacin for prophylaxis against infection in the fluid surrounding your abdominal organs. 3. *ADDED* Nephrocaps 4. *Nadolol 40mg by mouth after dialysis 5. *ADDED* Pantoprazole 40mg by mouth twice daily 6. *ADDED* Rifaximin 550mg by mouth twice daily Please keep all follow-up appointments. Your upcoming follow-up appointments are listed above. Followup Instructions: Department: DERMATOLOGY When: MONDAY [**2120-3-11**] at 10:15 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 2762**], MD [**Telephone/Fax (1) 1971**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 551**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: LIVER CENTER When: WEDNESDAY [**2120-4-17**] at 9:00 AM With: [**First Name11 (Name Pattern1) 640**] [**Last Name (NamePattern4) **], MD [**Telephone/Fax (1) 2422**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage [**Month (only) 547**] is the first available with any of the Liver doctors [**First Name (Titles) **] [**Name5 (PTitle) 6787**]; patient was booked for this appointment. The administrative assisstant in Hepatology is going to check with Dr. [**Last Name (STitle) **] to see if this is clinically safe. If it is not, the hepatology department will fit him in sooner and contact his ECF with appointment information.

[ "456.21", "428.30", "456.8", "572.3", "038.43", "286.9", "785.52", "789.59", "276.2", "571.2", "572.4", "995.92", "578.9", "584.9", "572.2", "428.0", "567.23", "530.10" ]

icd9cm

[ [ [] ] ]

[ "48.23", "96.6", "45.13", "39.95", "38.95", "54.91" ]

icd9pcs

[ [ [] ] ]

30589, 30662

23157, 25186

345, 443

30897, 30897

3917, 3917

32589, 33671

2251, 2269

29513, 30566

30683, 30683

29471, 29490

31075, 32566

15421, 23134

2309, 3177

2028, 2048

297, 307

471, 2009

30758, 30876

3933, 8196

30702, 30737

8210, 15405

30912, 31051

2071, 2095

2112, 2235

3202, 3898

20,747

118,901

4081

Discharge summary

report

Admission Date: [**2139-10-10**] Discharge Date: [**2139-10-10**] Date of Birth: [**2086-3-6**] Sex: M Service: MEDICINE Allergies: Erythromycin Base / Protamine / Minoxidil Attending:[**First Name3 (LF) 338**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: CVL placement in ED History of Present Illness: 53 yo M with CAD s/p CABG and PCI (most recently [**8-/2139**]), ischemic cardiomyopathy (EF=15%), DMI, extensive PVD s/p multiple amputations, ESRD on HD presented to the ED after awaking from sleep acutely SOB. Initially with WBC=18, BP=51/19 and HR=90s-130s. After 500cc of IVF, he began complaining of shortness of breath and developed minimal crackles at the bases along with an increasing oxygen requirement, ultimately requiring NRB to maintain sats in the low 90s. Vanco/zosyn was given in the ED and a central line was placed. . On arrival to the floor, pt interviewed with his wife present. [**Name2 (NI) **] was SOB on NRB with O2 sat ranging 85-100% with variable pleth. He denied preceding fevers, chills, diaphoresis. He had noted a dry cough for some days leading up to this, but the onset of SOB was sudden & severe; it awoke him from sleep. Per his wife, his leg ulcers have been healing well. Pt has had recurrent ESBL Klebiella UTIs which continue to be a problem. [**Name (NI) **] also has an infected molar which was scheduled to be removed this week and for which he has been taking penicillin. . He was weaned to 50% FIO2 on arrival with BP 60/34 (systolic confirmed by doppler). CVP was 8 (pt does have 2+ TR and PA HTN). Telemetry/EKGS notable for AFIB with rate ranging 90-[**Street Address(2) 17950**] depressions across the precordium. At that time, pt complaining of lightheadedness and diffuse weakness; denying chest pain. He was given 500cc over 30min with good response in his BP to 70s/40s. He stated that he felt less weak. CVP~12 after the first 500cc given on the floor. After another 250cc, pt became acutely unresonsive & cyanotic for 30 seconds. O2 sat failed to register initially and then returned at 60% with poor pleth--no better on ears, fingers, forehead. He was intubated by anethesia and good pleth obtained on the nose, sat 90s post-intubation. A-line could not be placed for more accurate monitoring during these events as his only palpable artery is the femoral in his left stump & INR=3. . After intubation, pt's non-invasive BP=116/38 with HR~100 (afib) and CVP 14-18. . ROS: Denied fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, sore throat, cough, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, hematuria. Endorsed some mild bladder discomfort, still produces minimal urine daily. Past Medical History: # DM I with diabetic retinopathy, nephropathy, neuropathy # CAD - s/p CABG [**2125**], LIMA-LAD, SVG-PDA, SVG-RI, SVG-OM (occluded) - cath [**2135-1-21**]: pLAD 90% then TO, mLCX 95%, OM1 TO, p-ramus 70%, p-RCA TO, patent LIMA, SVG-PDA, TO SVG-OM # post infarction cardiomyopathy, EF 15%, 3+ MR, PA htn # Paroxysmal Atrial fibrillation # h/o CVA [**2135**] on coumadin # ESRD s/p renal transplant (living related) x 2 (second [**2122**]) now on HD M/W/F(since [**3-5**]) d/t acute tubular nephropathy in [**2131**] # PVD - s/p Right fem-tibial bypass surgery in [**2125**] - s/p R BKA - s/p L AKA # h/o RLE bursitis # h/o Listeria infection in [**2132**] # h/o Shingles in [**2132**] # h/o Squamous cell carcinoma,diagnosed and removed in [**2133**]. # Anemia of chronic disease # Glaucoma # Gastroparesis # Gastritis # Diveriticulosis # h/o GI Bleed of unknown etiology during hospitalization - coffee ground emesis in setting of supratherapeutic INR # recurrent UTIs w/ ? enterovesicular fistula # ESBL Klebsiella colonization in urine # Gout Social History: Lives at home with his wife. Fifteen pack year smoking history per prior documentation quite > 25 yrs ago. No history of alcohol, IVDU. He has been discharged several times within the last year--it is the strong preference of his family that he spend as much time as possible at home. Family History: No h/o early CAD or malignancy. Physical Exam: Vitals - T:98.1 BP:74/36 (automatic), sytolic 70 doppler HR:90-130 RR:26 02 sat: variable 70-99% depending on location of sat probe GENERAL: pale, mild distress, appropriate, conversant, orientedx3, pleasant HEENT: Left IJ in place, JVP not appreciable secondary to body habitus CARDIAC: RRR, III/VI systolic and II/VI diastolic murmurs. Possible S3 gallop LUNG: Limited air movt, crackles at bases, clear apices ABDOMEN: non-distended, soft, bowel sounds present EXT: cold, cyanotic, peripheral pulses not palpable NEURO: alert and oriened x 3. CN2-12 INTACT, moving all ext, but weak to opposition DERM: diffuse venous stasis channges over lower exts . Pertinent Results: [**2139-10-10**] 03:54AM BLOOD WBC-14.6* RBC-3.43* Hgb-11.2* Hct-36.5* MCV-107* MCH-32.7* MCHC-30.7* RDW-18.4* Plt Ct-107* [**2139-10-9**] 11:45PM BLOOD WBC-17.5*# RBC-3.86* Hgb-12.8* Hct-40.2 MCV-104* MCH-33.1* MCHC-31.8 RDW-18.3* Plt Ct-138* [**2139-10-10**] 03:54AM BLOOD Neuts-88.0* Lymphs-7.6* Monos-4.2 Eos-0.1 Baso-0.1 [**2139-10-9**] 11:45PM BLOOD Neuts-85* Bands-0 Lymphs-6* Monos-8 Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0 NRBC-1* [**2139-10-9**] 11:45PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-NORMAL Macrocy-1+ Microcy-NORMAL Polychr-OCCASIONAL Ovalocy-OCCASIONAL Burr-OCCASIONAL Fragmen-OCCASIONAL [**2139-10-10**] 03:54AM BLOOD Plt Ct-107* [**2139-10-10**] 03:54AM BLOOD PT-31.7* PTT-51.5* INR(PT)-3.2* [**2139-10-9**] 11:45PM BLOOD Plt Smr-LOW Plt Ct-138* [**2139-10-10**] 03:54AM BLOOD Glucose-161* UreaN-27* Creat-2.6* Na-138 K-3.5 Cl-99 HCO3-25 AnGap-18 [**2139-10-9**] 11:45PM BLOOD Glucose-95 UreaN-26* Creat-2.5*# Na-133 K-7.0* Cl-94* HCO3-24 AnGap-22* [**2139-10-10**] 03:54AM BLOOD ALT-18 AST-32 CK(CPK)-67 AlkPhos-141* TotBili-0.8 [**2139-10-9**] 11:45PM BLOOD cTropnT-0.66* [**2139-10-10**] 03:54AM BLOOD CK-MB-NotDone cTropnT-1.11* [**2139-10-10**] 06:18AM BLOOD Type-ART pO2-172* pCO2-55* pH-7.43 calTCO2-38* Base XS-10 [**2139-10-10**] 03:54AM BLOOD Calcium-7.2* Phos-3.0 Mg-1.7 [**2139-10-9**] 11:57PM BLOOD Glucose-93 Lactate-5.1* Na-135 K-3.9 Cl-96* calHCO3-23 [**2139-10-10**] 04:32AM BLOOD Lactate-3.5* [**2139-10-10**] 06:18AM BLOOD Glucose-225* Lactate-8.6* Na-145 K-4.0 Cl-91* CXR The endotracheal tube has been pulled back since the previous study and now is 4.5 cm above the carina. The rest of the lines and tubes are within normal limits. There are no pneumothoraces. There is improved aeration at the left base since the previous study. No overt pulmonary edema is seen. There is loculated pleural fluid on the right side. The cardiac silhouette and mediastinum is within normal limits. Brief Hospital Course: 53 yo M presented with SOB hypotension, tachycardia (afib/rvr), and leukocytosis. Although his baseline BPs are low, his initial systolic of 50 was well below his baseline. He received zosyn and fluid in the ED. He received additional fluid on the floor totaling 1L NS with good BP response. He subsequently became hypoxic and unresponsive--it later became clear that peripheral sats did not correlate with arterial blood gases (sat 50% when pO2 120). Pt received meropenem given the sensitivity profile of his ESBL KLEB. Also received a dose of vancomycin. He was intubated follwing this hypoxic episode and amio loaded over 30 minutes. He transiently became bradycardic and converted to sinus, his BP improved. Several minutes later, BP drop acutely and pt lost pulse--monitor showing asystole. CPR was initiated for asystole at 6am. ACLS algorithm was followed. Afib with ventricular rate ~90 returned, and PEA algorithm followed. In total pt received 5 doses of epinephrine, calcium, magnesium, bicarbonate. Pulse and BP regained for 15 minutes. He then lost his pulse again and was shocked for a-fib with RVR and returned in a wide-complex ventricular rhythm with AV dissociation. After a subsequent shock, pt converted to a narrow rhythm at 100bpm with complete av dissociation. Chest compressions given throughout for 50 minutes. Pt pronounced dead at 6:50am. Family notified. Medications on Admission: ALENDRONATE - 70 mg Tablet - 1 Tablet(s) by mouth once a week take 1st thing in AM on empty stomach, take with lots of water, keep upright x 30 min ALLOPURINOL - 100 mg Tablet - 1 Tablet(s) by mouth once a day B COMPLEX-VITAMIN C-FOLIC ACID [RENAL CAPS] - (Prescribed by Other Provider) - 1 mg Capsule - 1 Capsule(s) by mouth daily BD ULTRAFINE 1CC SYRINGES - - USE AS DIRECTED, DX TYPE ONE DIABETES EPOETIN ALFA [EPOGEN] - (Prescribed by Other Provider; three times a week at dialysis) - Dosage uncertain INSULIN GLARGINE [LANTUS] - 100 unit/mL Solution - 18 U every evening at supper INSULIN LISPRO [HUMALOG] - 100 unit/mL Solution - sliding scale as directed four times a day LISINOPRIL - 5 mg Tablet - 1 Tablet(s) by mouth daily METOCLOPRAMIDE [REGLAN] - 5 mg Tablet - one Tablet(s) by mouth twice a day METOPROLOL SUCCINATE - 25 mg Tablet Sustained Release 24 hr - one Tablet(s) by mouth daily at bedtime NITROGLYCERIN - 0.4 mg Tablet, Sublingual - 1 Tablet(s) sublingually every 5 minutes up to 3 as needed for chest pain NITROSTAT - 0.4MG Tablet, Sublingual - AS NEEDED FOR AS DIRECTED OMEPRAZOLE - 20 mg Capsule, Delayed Release(E.C.) - 2 Capsule(s) by mouth once a day OXYCODONE - 5 mg Tablet - [**11-28**] Tablet(s) by mouth three times a day as needed for pain PREDNISONE - 5 mg Tablet - one Tablet(s) by mouth every day PT/INR AS NEEDED - - ICD 434.91 Fax to [**Telephone/Fax (1) 3053**] as needed for INR as needed WARFARIN - 5 mg Tablet - one Tablet(s) by mouth every day WARFARIN - 2.5 mg Tablet - 1 Tablet(s) by mouth daily or as directed by coumadin clinic WARFARIN - 1 mg Tablet - 1 Tablet(s) by mouth daily or as directed by coumadin clinic Medications - OTC ASPIRIN - 81MG Tablet - ONE TABLET PER DAY BLOOD SUGAR DIAGNOSTIC [ONE TOUCH ULTRA TEST] - Strip - Use as directed qid and prn; Dx Type One DM Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: Septic shock Congestive heart failure coronary artery disease Discharge Condition: Deceased Discharge Instructions: Expired Followup Instructions: Expired Completed by:[**2139-10-10**]

[ "427.31", "799.02", "362.01", "522.4", "250.41", "996.81", "E849.8", "038.19", "357.2", "V45.81", "V10.83", "583.81", "250.61", "250.51", "427.89", "997.5", "584.5", "E878.0", "414.00", "995.92", "428.0", "414.8", "785.52" ]

icd9cm

[ [ [] ] ]

[ "99.60", "96.04", "99.61", "38.93" ]

icd9pcs

[ [ [] ] ]

10161, 10170

6855, 8247

322, 344

10276, 10287

4908, 6832

10343, 10383

4185, 4218

10133, 10138

10191, 10255

8274, 10110

10311, 10320

4233, 4889

263, 284

372, 2799

2821, 3867

3883, 4169

81,057

130,992

33796

Discharge summary

report

Admission Date: [**2138-6-13**] Discharge Date: [**2138-6-21**] Date of Birth: [**2059-8-14**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 15237**] Chief Complaint: Chief Complaint: Leaky J-Tube . Reason for MICU transfer: Ventilator Management Major Surgical or Invasive Procedure: none History of Present Illness: 78y/o M with history of bronchoalveolar carcinoma s/p rt upper lobectomy in [**2-/2138**], aspiration pneumonia c/b L sided empyema s/p thoracentesis and chronic respiratory failure s/p tracheostomy transferred from OSH for J tube evaluation. . In [**2-/2138**], patient was diagnosed with bronchoalveolar carcinoma and underwent a lobar resection. This hospitalization was complicated by a prolonged hospitalization, prolonged chest tube, and malnutrition. Given malnutrition and h/o esophageal stricture, a J-tube was placed. Pt also has h/o partial gastrectomy and Bilroth II procedure and thus J tube was considered over G-tube. After this hospitalization, pt was d/c'ed LTAC at [**Hospital1 **]. . LTAC reported that J tube was leaky and patient subsequently underwent 2 revisions on [**5-20**] and [**5-29**] by general surgery at OSH. Per OSH surgeons, cause of leak was [**12-25**] poor wound healing from malnutrition. . Recent health has been complicated by aspiration pneumonia which led to chronic respiratory failure requiring trach, which was completed 3 days ago. This PNA was also complicated by MRSA empyema which was drained by pigtail catheter placed over past weekend. Pigtail catheter fell out yesterday however repeat CT showed interval improvement of pleural effusion. Patient was started on imipenem empirically for aspiration pneumonia was due to finish treatment on [**6-14**]. Additionally, patient was started linezolid, today being day 4. . Patient was significant improving from ventilation stand point and was due to be sent back to rehab however J-tube remained leaky which prompted transfer for further evaluation. . On MICU, Patient was in no acute distress and had no complaints. Patient however did not appear to be inattentive. Past Medical History: - Mild dementia - Spinal stenosis - Esophageal strictures - Bronchoalveolar carcinoma s/p RULobeectomy, c/b pneumothorax requiring month long chest tube - COPD - Pernicious anemia - PUD, s/p Billroth Type II - h/o TIA - states was "age related" and noted on a CT scan and denies any h/o daughter denies any residual deficits - Malnutrition, requiring J-Tube Social History: unable to obtain Family History: unable to obtain Physical Exam: Vitals: 97.8 171/87 80 98% on CPAP 12/5 50% F102 General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission Labs: [**2138-6-13**] 12:51AM BLOOD WBC-4.9 RBC-3.32* Hgb-9.7* Hct-29.0* MCV-87 MCH-29.1 MCHC-33.3 RDW-18.7* Plt Ct-130* [**2138-6-13**] 12:51AM BLOOD Neuts-87.0* Lymphs-9.7* Monos-3.0 Eos-0.2 Baso-0.1 [**2138-6-13**] 12:51AM BLOOD PT-13.2 PTT-33.2 INR(PT)-1.1 [**2138-6-13**] 12:51AM BLOOD Glucose-101* UreaN-23* Creat-0.5 Na-144 K-4.1 Cl-112* HCO3-26 AnGap-10 [**2138-6-13**] 12:51AM BLOOD ALT-35 AST-18 LD(LDH)-255* AlkPhos-92 TotBili-0.6 [**2138-6-13**] 12:51AM BLOOD Albumin-2.3* Calcium-8.1* Phos-2.6* Mg-2.2 Micro: [**2138-6-14**] 5:27 am SPUTUM Source: Endotracheal. **FINAL REPORT [**2138-6-18**]** GRAM STAIN (Final [**2138-6-16**]): THIS IS A CORRECTED REPORT ON [**2138-6-16**]. Reported to and read back by DR. [**Last Name (STitle) 2345**], E ([**Numeric Identifier 18663**]) ON [**2138-6-16**] AT 14:09 PM. >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI. PREVIOUSLY REPORTED ON [**2138-6-14**] AS:. >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI IN PAIRS. 2+ (1-5 per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI. RESPIRATORY CULTURE (Final [**2138-6-18**]): RARE GROWTH Commensal Respiratory Flora. ACINETOBACTER BAUMANNII COMPLEX. MODERATE GROWTH. "Note, for Amp/sulbactam, higher-than-standard dosing needs to be used, since therapeutic efficacy relies on intrinsic activity of the sulbactam component". SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ACINETOBACTER BAUMANNII COMPLEX | AMPICILLIN/SULBACTAM-- =>32 R CEFEPIME-------------- =>64 R CEFTAZIDIME----------- =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S IMIPENEM-------------- =>16 R LEVOFLOXACIN---------- =>8 R TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- 2 S Imaging: CT chest: [**6-13**] FINDINGS: Thyroid is normal in appearance. There is no supraclavicular, mediastinal, hilar or axillary lymphadenopathy. Scattered nonenlarged nodes are seen. The heart and pericardium are unremarkable with physiologic pleural fluid. Atherosclerotic calcification of the coronary vessels and aortic arch are noted. Left-sided PICC line terminates in the mid distal SVC. Aortic and mitral valvular calcifications are also noted. Dense consolidative process is seen involving the basal portion of the right upper lobe as well as the entire right lower lobe in a similar fashion as on the prior with slight improved aeration in the right middle lobe. Patient is status post what appears to be partial right upper and right lower lobectomies. Aspirated secretions are seen in bronchus intermedius and right lower lobe bronchus as well as in the left main stem bronchus concerning for continued aspiration with a bolus of secretion seen immediately superior to the tracheostomy tube (601B:21). Scattered ground-glass and tree-in-[**Male First Name (un) 239**] opacification is seen in the remaining lobes concerning for milder aspiration related changes versus infectious or inflammatory process. In this setting of bronchoalveolar carcinoma, this could also reflect foci of malignant involvement and followup to resolution should be performed. Small left pleural effusion is seen and improved from the prior study with improved aeration of the left lower lobe. Though the indication describes a left-sided empyema what appears to be a loculated air-fluid collection in the prior study in the right pleural space is improved on the current examination resembling a partially loculated right pleural effusion which is small and simple in appearance. Evaluation for empyema is limited by non-contrast technique. Paraseptal and centrilobular emphysema is noted. Though this study is not tailored for subdiaphragmatic evaluation, limited upper abdominal evaluation demonstrates numerous surgical clips compatible with history of gastrectomy and Billroth II reconstruction. Multiple left-sided rib fractures are seen along with diffuse osteopenia. IMPRESSION: 1. Aspiration with secretions within bronchus intermedius, right lower lobe bronchus and left main stem bronchus along with dense opacification in the right lower lobe and basal right upper lobe. Impending aspiration of additional bolus of secretions proximal to the tracheostomy tube. 2. Ground-glass/tree-in-[**Male First Name (un) 239**] opacities in the left upper, right upper and right middle lobes could be additional foci of aspiration versus infectious or inflammatory process. Given the history of bronchoalveolar carcinoma, these pulmonary opacifications should be followed up for resolution. 3. Though the indication describes left-sided empyema, it appears the prior empyema was on the right according to the outside hospital CT and this collection appears to have improved now reflecting a smaller loculated effusion, though determination of empyema is limited by non-contrast technique. 4. Decrease in size of small left effusion with improved left lower lobe aeration. CT abdomen/pelvis [**6-15**]: FINDINGS: The heart is enlarged. The patient is status post surgery in the right lung. Consolidation is observed in the superior segment of the right lower lobe with air bronchogram which is highly suspicious for aspiration pneumonia. Loculated right pleural fluid is observed with enhancement of both the visceral and parietal pleura most probably represent empyema. Moderate amount of left pleural fluid with secondary atelectasis. ABDOMEN: Many artifacts due to retained contrast media from previous fluoroscopic examination and from many surgical clips. The liver is within normal limits regarding size and morphology. The hepatic veins are patent as well as the portal vein. To note, the SMV is not clearly visualized. Status post cholecystectomy. No intra- or extra-biliary dilatation is noted. The pancreas is not well visualized. The spleen, the kidneys and the adrenals are within normal limits. The stomach is not well observed. A jejunostomy tube is seen. No dilatation of the large or of the small bowel. The appendix is detected and is within normal limits. Tubular air filled structures that branch are seen on series 2, image 75, free air cannot be ruled out definitely. Free fluid that is of slightly high density is observed in the abdomen and in the pelvis. No mesenteric or retroperitoneal lymphadenopathy is observed. The aorta is heavily calcified. A Foley catheter is detected within the urinary bladder. fractures of ribs 10, 9, 8, 7 and 6 on the left side some of them with calus and some may be acute. Fractures of right ribs 11 and 10 with no calus formation. IMPRESSION: 1. Consolidation of the superior segment of the right lower lobe with air bronchogram consistent with aspiration pneumonia. 2. Loculated fluid with enhancement of the visceral and parietal pleura, highly suggestive of empyema. 3. Air-filled tubular structure within the right lower quadrant, cannot rule out free air we recommend further clinical follow up or an interval CT examination with oral contrast ( through J tube ). Echo ([**6-17**]) The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is low normal (LVEF 50-55%). The right ventricular cavity is mildly dilated with normal free wall contractility. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**11-24**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is 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 [**2135-2-28**], left ventricular systolic function is now slightly less vigorous. Tricuspid regurgitation is now more prominent and the right ventricle cavity size appears larger. Mitral regurgitation is now more prominent. Estimated pulmonary artery systolic pressure is now higher. [**6-17**]: UENI: FINDINGS: Grayscale and Doppler son[**Name (NI) 1417**] of the right upper extremity performed. The left and right subclavian veins are patent. The right internal jugular vein, right axillary vein, right basilic and right brachial veins are patent and compressible. The right cephalic vein is not visualized. No thrombus identified. There is a PICC line in situ within the right subclavian and right basilic veins. No thrombus identified in relation to the intravenous line. IMPRESSION: No evidence of right upper extremity thrombus. PICC line in situ within the right subclavian and right basilic veins. Brief Hospital Course: 78 y/o M with h/o malnutrition requiring J-tube with recent respiratory failure from aspiration PNA c/b MRSA empyema now s/p tracheostomy transferred with J-tube evaluation found to have profound malnutrition who clinically deteriorated during MICU stay and after multiple family meetings was ultimately made CMO. . # MICU Course: Patient was transferred to the MICU for evaluation of J tube. MICU admission was warranted as patient was recently trached for respiratory failure. Upon evaluation, it was clear that patient was suffering from several malnutrition which was contributing to his overall ability to heal from his multiple J-tube revisions. His J tube site appeared macerated. IR was consulted who performed a J tube study which confirmed placement and patency. Surgery was consulted and upsized the tube however J tube continue to leak. Ultimately the J-tube was removed. TPN was started and family was approached regarding [**Last Name (un) 1372**]-jujenal feedings. After a series of several family meetings, given patients decline and likelihood for requiring a long recovery, family decided to move towards comfort measures. Patient was ultimately called out to general medicine floors with palliative care to aide in this transition. # Floor Course: Mr [**Known lastname 78143**] was continued on his morphine and ativan with transition to IV morphine drip the following morning. On [**2138-6-21**], he expired at 145 PM. Family requested an autopsy given possibility of surgical trauma at outside hospital - the case was submitted to the medical examiner because the suspicion of trauma was raised. Medications on Admission: - Albuterol/Ipratropium Nebs - Linezolid 600mg IV Q12h - started on [**6-10**] - Imipenem/Cilastatin 250mg IV Q6h - Nitropaste 1" Q6h prn SBP > 140 - Nystatin [**Numeric Identifier 78144**] unit PO QID - Fondaparinux 2.5mg SC - Prednisone 20mg daily - Potassium Chloride 40mEq daily - MVI - Fluoxetine 20mg Daily - Amlodipine 10mg daily - Tylenol 650mg Q6h prn - Aspart Flex Pen - Lisinopril 10mg daily - Pantoprazole 40mg daily - Terazosin 5mg daily Discharge Medications: (expired) Discharge Disposition: Expired Discharge Diagnosis: expired secondary to pneumonia, empyema Discharge Condition: expired Discharge Instructions: expired Followup Instructions: expired

[ "510.9", "162.3", "783.7", "294.8", "261", "787.91", "569.62", "V44.0", "790.29", "514", "401.9", "530.3", "V12.71", "507.0", "518.83", "041.85", "788.5", "482.42", "V66.7", "496" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.6", "99.15" ]

icd9pcs

[ [ [] ] ]

14634, 14643

12475, 14098

386, 392

14726, 14735

3186, 3186

14791, 14801

2619, 2637

14600, 14611

14664, 14705

14124, 14577

14759, 14768

2652, 3167

283, 348

420, 2187

3202, 12452

2209, 2569

2585, 2603

8,674

121,938

8431

Discharge summary

report

Admission Date: [**2131-5-2**] Discharge Date: [**2131-5-24**] Date of Birth: [**2077-9-26**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 13256**] Chief Complaint: hypotension, bacteremia Major Surgical or Invasive Procedure: chest tube placement PICC placement dobhoff tube placement History of Present Illness: 53 year old male with history of chronic hepatitis C cirrhosis complicated by variceal bleeding (grade [**1-9**]), ascites, and refractory hepatic hydrothorax s/p TIPS who presented to OSH with volume overload and abdominal pain and was found to be hypotensive with positive blood cultures. He presented to [**State 20192**] Center [**2131-4-30**] with 25lb weight gain despite reported compliance with diet and diuretics (lasix had been discontinued on previous hospital admission due to hypotension). He also reported increasing pain in right upper quadrant, midepigastric, and right chest as well as SOB and abdominal distention. He also reported subjective fevers and chills. Labs were significant for Cr 1.6 that peaked at 1.9; WBC 12.2 that peaked at 17 with 20% bands; Hct 30.8, plts 80, INR 1.4, Tbili 7.7 that peaked at 14.4, AST 144, ALT 61, albumin 1.6. CXR showed opacified right hemithorax. Abdominal ultrasound showed cirrhosis with splenomegaly and ascites and gallstones without evidence of ductal dilatation. He underwent paracentesis on [**2131-4-30**] with removal of 1100mL fluid removed that was negative for SBP (WBC 140, 21% neuts, 60% lymphs, 48% monocytes, 15% mesothelials). Blood cultures from [**2131-4-30**] and [**2131-5-1**] grew 3/4 bottles with GPCs in clusters for which he was started on vancomycin. Pt had recent complicated hospital course from [**Date range (3) 29730**] for hepatic hydrothorax. He initially presented to [**Hospital 28448**] Center where he was given IVFs for acute kidney injury and underwent thoracentesis and paracentesis. He developed progressive SOB despite tx for presumed HCAP and was found to have reaccumulation of hepatic hydrothorax and was transferred to [**Hospital1 18**] for TIPS. At [**Hospital1 18**], repeat paracentesis was performed with 6L removed; repeat thoracentesis was complicated by pneumothorax [**2-8**] trapped lung requiring chest tube placement. TIPS was performed on [**2131-3-15**] complicated by failure to wean off mechanical ventilation immediately following surgery. He was extubated the following day and discharged on home oxygen. He was readmitted [**Date range (3) 29731**] for right sided chest pain and hypotension worse than baseline. He was [**Date range (3) 20003**] out for ACS and referred for outpatient stress testing. Since then, he has had follow up with transplant for work-up of liver transplant candidacy. On arrival to the MICU, pt states that he feels generally well but has RUQ/right chest pain. States that he has had this pain for 8-9months but it has gotten worse recently. ROS also positive for fevers (states he was febrile to 103 at home), mild productive cough, weight gain of 25lbs, headache, lightheadedness, rhinorrhea, diarrhea (4-5BMs daily on lactulose), SOB. He also notes some increasing confusion today. . Review of systems: (+) Per HPI (-) Denies nausea, vomiting, constipation, dysuria Past Medical History: Hep C- chronically on pegylated interferon (trial) Grade I esophageal varices cirrhosis of the liver GERD COPD Social History: Currently denies alcohol, tobacco or IVDU. Previously had heavy alcohol abuse, quit in [**2105**]. Smoked [**3-11**] cigarettes daily x 1 year; quit 4 days ago. Denies recreational drug use. Lives alone. Former postal service worker. States that he has good support; brother and sister live nearby. Family History: Father: lung problems; no family history of liver disease Physical Exam: On admission: VS: 98.2 104/56 85 18 96%1L General: Alert, oriented x 3, no acute distress HEENT: Jaundiced, dry MM, oropharynx clear, EOMI, PERRL Neck: supple, JVP at earlobe, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: decreased breath sounds throughout right side of chest, no wheezes, mildly tachypneic with minimal activity, able to speak in full sentences Abdomen: soft, moderately distended, diffusely tender worse in RUQ, voluntary guarding Ext: warm, well perfused, 2+ pulses, 2+ pitting edema b/l to knees; pain on flexion of right wrist, no swelling or obvious bony deformities Neuro: CNII-[**Doctor First Name 81**] intact, following commands, moving all extremities, no asterixis PHYSICAL EXAMINATION: VS: 98.5 95/56 81 20 100%RA 250ml from chest tube GENERAL: Comfortable. AOx3, pleasant, jaundiced. HEENT: Sclera icteric. PERRL, EOMI. dry oropharynx NECK: Supple with low JVP CARDIAC: RRR, S1 S2 clear, 2/6 systolic murmur heard at left lower sternal border, no rubs or gallops. No S3 or S4 appreciated. LUNGS: Resp were unlabored, no accessory muscle use, decreased breath sounds throughout right side of chest, absent breath sounds at right base, no wheezing, able to speak in full sentences comfortably. ABDOMEN: Mildly distended, NABS, NT. EXTREMITIES: Warm and well perfused, no clubbing or cyanosis. 1+ [**Location (un) **] L>R, right wrist in splint NEURO: CNII-[**Doctor First Name 81**] intact, following commands, moving all extremities, no asterixis Pertinent Results: IMAGING: CHEST (PORTABLE AP) Study Date of [**2131-5-2**] FINDINGS: As compared to the previous radiograph, there is massive progression of the previously extensive right pleural effusion. The effusion now occupies the entire right hemithorax and to displacement of the heart and the mediastinum to the left. No ventilated lung parenchyma is visible in the right hemithorax. On the left, there might be a small area of left perihilar atelectasis. Otherwise, the left lung parenchyma is unremarkable. There is no left pleural effusion. No pulmonary edema or pneumonia is seen. . WRIST(3 + VIEWS) RIGHT PORT Study Date of [**2131-5-2**] FINDINGS: There is mild irregularity of the radial styloid process with well-corticated margins, which likely represents old trauma. Subtle linear lucency in the distal radius extending to the radiocarpal articular surface, seen on 2 views, may represent a nondisplaced fracture. Mineralization is slightly reduced about the wrist. Alignment is anatomic. No significant soft tissue swelling or definite joint effusion. IMPRESSION: Possible nondisplaced distal radial fracture. . CT ABD & PELVIS W/O CONTRAST Study Date of [**2131-5-3**] CT THORAX: There is a massive right pleural effusion causing complete collapse of the right lung and shift of mediastinal structures to the left. The peripheral ground-glass opacity noted on CT on [**2131-3-18**] is no longer visualized. However, there is now a multifocal opacity involving the left upper lobe (2:20). The left lung bronchi are patent to the subsegmental level. There is no supraclavicular, axillary, or mediastinal lymphadenopathy. Evaluation of hilar lymphadenopathy is limited due to large pleural effusion and lack of intravenous contrast. Several coronary artery calcifications are noted (2:31). The heart and great vessels are otherwise unremarkable. Gynecomastia is seen in the soft tissues of the thorax. CT ABDOMEN: The liver is small, nodular, and a TIPS is in place, consistent with known cirrhosis. There is a small amount of ascites. Splenomegaly is unchanged. There is a large gallstone (2:71), unchanged from [**2130-3-11**]. The stomach and small bowel are unremarkable. The pancreas and adrenal glands are normal. There is no evidence of hydronephrosis. There is a 15-mm cyst arising from the lower pole of the left kidney. There is no free air. Diffuse anasarca is seen in the soft tissues of the entire torso. CT PELVIS: The appendix is normal (2:94). There are several sigmoid diverticula without evidence of diverticulitis. A foley catheter terminates in the bladder, which is collapsed. The rectum, seminal vesicles, and prostate are unremarkable. There are tiny fat-containing inguinal hernias. There is no pelvic lymphadenopathy. There are scattered atherosclerotic calcifications in the aortic bifurcation and iliac arteries. OSSEOUS STRUCTURES: There are no lytic or blastic lesions suspicious for malignancy. IMPRESSION: 1. Massive right pleural effusion with complete right lung collapse and mediastinal shift. 2. Left upper lobe pneumonia. 3. Small abdominal ascites and known cirrhosis. 4. Coronary artery disease. 5. Cholelithiasis without evidence of cholecystitis. 6. Diverticulosis without evidence of diverticulitis. . DUPLEX DOPP ABD/PEL Study Date of [**2131-5-3**] FINDINGS: The liver is shrunken and nodular in appearance, consistent with known cirrhosis. No focal liver lesion is identified. No intra- or extra-hepatic biliary duct dilatation is identified. TIPS in situ. The spleen is enlarged measuring 18.3 cm. There is a single large gallstone within the gallbladder. The gallbladder wall is thickened which is likely due to patient's underlying chronic liver disease as the gallbladder is not distended. There is a small volume of ascites within the right upper quadrant. There is a large right pleural effusion. DOPPLER: Flow is reversed within the left portal vein consistent with functioning TIPS. The TIPS is patent with appropriate direction of flow and waveforms within the main portal vein and right portal vein. Velocities within the proximal, mid, and distal TIPS are 134, 163, and 148 cm/sec. There is normal phasicity with respiration IMPRESSION: 1. Large right pleural effusion. 2. Cirrhotic liver with splenomegaly and small volume ascites with TIPS in situ. 3. No focal liver lesions identified. No biliary dilatation. 4. TIPS is patent with appropriate direction and velocity. 5. Cholelithiasis. Thickened gallbladder wall likely due to patient's liver disease. . Portable TTE (Complete) Done [**2131-5-4**] The left atrium is mildly dilated. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: No vegetations or clinically-significant valvular disease seen. Normal global and regional biventricular systolic function. . CT CHEST W/CONTRAST Study Date of [**2131-5-7**] AIRWAYS AND LUNGS: Airways are patent to subsegment bronchi. A pleural pig tail catheter is present in the right lung base. Following right thoracocentesis, previously larger pleural effusion is moderate, right upper lobe has re-expanded while middle-lower lobe collapse persists and contralateral mediastinal shift has almost resolved. Hydropeumothorax and multiple air pockets which are new since [**2131-4-8**] can be simply explained by recent therapeutic intervention. Mild and diffuse interlobular septal thickening is likely from reexpansion edema. Small, nonhemorrhagic, posteriorly layering left pleural effusion, accompanying minimal posterior basal atelectasis is new since [**2131-5-3**]. Since [**2131-5-3**], Preexisting ground-glass opacity in the left upper lobe though unchanged in extent, is more dense, and in addition, there is a new, perihilar, small, ground-glass opacity (2:27-2:29), concerning for evolving pneumonia. MEDIASTINUM: Thyroid gland is normal. There are no pathologically enlarged mediastinal, supraclavicular or axillary lymph nodes. 13 mm lower paratracheal lymph node (2:23) in addition to a few other borderline sized upper and lower paratracheal are most likely reactive and stable. Heart is normal size and there is no pericardial abnormality. ABDOMEN: The study is not designed for assessment of subdiaphragmatic pathology; however, limited views were remarkable for nodular contour of liver which is consistent with cirrhosis, TIPS stent, splenomegaly and 19 x 16 mm gallstone. Moderate ascites has increased since [**2131-5-3**]. BONES: There is no bone lesion concerning for malignancy or infection. IMPRESSION: 1. Following drainage of a previously large right pleural effusion, residual fluid is moderate with evidence of post-procedural hydropneumothorax with pigtail pleural catheter in place. The right upper lobe has reexpanded while right lower and middle lobe remain collapsed. 2. Small left pleural effusion accompanying minimal atelectasis on the left side is new. 3. Evolving left upper lobe pneumonia. 4. Enlarged and borderline sized mediastinal lymph nodes are likely reactive. 5. Cirrhosis with TIPS stent, splenomegaly and cholelethiasis. Moderate ascites, increased since [**2131-5-3**]. Brief Hospital Course: 53 year old male with history of chronic hepatitis C cirrhosis complicated by variceal bleeding (grade [**1-9**]), ascites, and refractory hepatic hydrothorax s/p TIPS who presented to OSH with volume overload and abdominal pain and was found to be hypotensive with MRSA bactermia and MRSA empyema ACTIVE ISSUES # MRSA empyema: Pt has a history of refractory hepatic hydrothorax. His initial thoracentesis during this admission revealed an MRSA empyema. This was thought to be the etiology of his presenting hypoxia. He initially had a pigtail catheter placed, which was upsized on HD 7 with improved drainage. He was treated with vancomycin to high troughs. Cardiothoracic surgery and interventional pulmonology followed throughout the course of his hospitalization. Because of large volume drainage from his chest tube, pt received albumin 6g/L pleural fluid drained every other day until his output decreased to <500cc daily, at which point his aldactone was restarted at a higher dose (50mg daily), which he tolerated well. Infectious Disease was involved who recommended 6 weeks total of IV vancomycin from the start of negative blood cultures ([**5-5**], last day [**6-15**]). He will follow-up with ID as an outpatient in the next few weeks but will likely require oral suppressive antibiotics until his transplant due to the TIPS (foreign body). In addition, he will require his chest tube for 6 weeks from [**2131-5-9**] (last day [**2131-6-20**]) per IP, although he will follow-up with them sooner for repeat evaluation. # MRSA bacteremia: Pt was hypotensive on admission, and etiology of MRSA bacteremia is likely his empyema. His TTE was negative for vegetations. Infectious disease was consulted and felt that TEE was not necessary give that pt will need prolonged antibiotic course as it is for treatment of his empyema. Last positive blood culture [**5-4**]. Course outlined above. # MRSA UTI: secondary to hematogenous spread. Treatment as above. # Anemia: Pt was anemic during this hospitalization with fluctuating hematocrit. He has a positive direct coombs at OSH. However, his repeat Coombs test here was negative and his LDH and haptoglobin were within normal. His peripheral smear was also normal. He received 2 units PRBC during his hospitalization and stabilized. # Hep C Cirrhosis: Pt with worsening liver disease, likely decompensated liver failure, admission MELD 26, current MELD 16. Decompensation at admission likely related to severe disseminated MRSA infection. No evidence of PVT on RUQ US, TIPS patent by RUQ U/S. No SBP on para at OSH, but no culture data available. Transplant evaluation to date - panorex completed, pt will need 2 teeth extracted. Got Hep A vaccine, quantiferon gold negative. Remainder of pre-transplant workup defered to outpatient due to current clinical status: colonoscopy, stress test, PFTs, BMD. Will also require the 2 teeth extracted prior to surgery. Continued on lactulose/rifaximin and nadolol. Dobhoff in-place with tube feeding recommendations by nutrition for nutrition in setting of cirrhosis; ongoing need to be reviewed by outpatient hepatologist. # Distal radius fracture: Pt states that he fell at home onto right wrist the week prior to admission. Has pain on flexion of right wrist. X-ray showed distal radius fracture. Ortho was consulted who recommended no surgical intervention. He was given a wrist brace. Transitional Issues: - f/u specialty appointments: Hepatology, Infectious Disease, Interventional Pulmonology - Hepatology: ongoing workup for liver transplant, requires colonoscopy, stress test, PFTs, BMD. Will also require the 2 teeth extracted prior to surgery. - Infectious Disease: 6 weeks of IV vancomycin, start date [**5-4**]. Will then require re-evaluation for suppressive PO regimen in setting of TIPS. - Interventional Pulmonology: 6 weeks of chest tube to water seal, start date [**2131-5-9**]. Ongoing evaluation for need of chest tube and ?decortication. Medications on Admission: -citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). -spironolactone 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) -multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). -albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed for SOB/wheezing. -nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). -lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). -nadolol 20 mg Tablet Sig: 0.5 Tablet PO once a day. -aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. -oxycodone 10-20mg 14h prn -omeprazole 40mg daily Discharge Medications: 1. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. spironolactone 25 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. nadolol 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 4. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO QID (4 times a day): goal 3-4BM daily. 5. nicotine 14 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). 6. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB or wheeze. 7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. oxycodone 5 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 9. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 10. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. vancomycin 500 mg Recon Soln Sig: Seven [**Age over 90 1230**]y (750) mg Intravenous Q 12H (Every 12 Hours): First day [**5-4**] Continue for 6 weeks (last day [**2131-6-15**]). Discharge Disposition: Extended Care Facility: [**Hospital3 7665**] Hospital [**Location (un) 8117**], NH Discharge Diagnosis: PRIMARY: MRSA empyema MRSA bactermia MRSA UTI Hepatitis C cirrhosis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Mr. [**Known lastname 12536**], It was a pleasure taking care of you at [**Hospital1 827**]. You were transferred here from [**Location (un) 3844**] for an infection in your lungs and in your blood. You had a chest tube placed to drain the infection, and you were started on IV antibiotics. You will need a long course of antibiotics, 6 weeks of IV from [**5-4**] and then you will need to take an oral antibiotic until you have a liver transplant. Please make the following changes to your antibiotics: START Vancomycin 750mg IV twice per day last day [**2131-6-15**] Rifaximin 550mg by mouth twice per day STOP Aspirin - your platelets are too low INCREASE Aldactone from 25mg daily to 50mg daily Otherwise take all medications as prescribed. Dr [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**] of Infectious Disease will determine which oral antibiotic you should be on after you complete the IV. Followup Instructions: Department: TRANSPLANT When: THURSDAY [**2131-5-31**] at 11:00 AM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] [**Location (un) **]: WEST Best Parking: [**Hospital Ward Name **] Garage Department: TRANSPLANT CENTER When: THURSDAY [**2131-5-31**] at 2:00 PM With: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD [**Telephone/Fax (1) 673**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] [**Location (un) **]: WEST Best Parking: [**Hospital Ward Name **] Garage Department: TRANSPLANT CENTER When: THURSDAY [**2131-5-31**] at 3:00 PM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 673**] Building: LM [**Hospital Unit Name **] [**Location (un) **] [**Location (un) **]: WEST Best Parking: [**Hospital Ward Name **] Garage Department: INFECTIOUS DISEASE When: MONDAY [**2131-6-11**] at 3:30PM. With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**Telephone/Fax (1) 28344**] Building: LM [**Hospital Unit Name **] [**Location (un) **] [**Location (un) **]: WEST Best Parking: [**Hospital Ward Name **] Garage Department: INTERVENTIONAL PULMONOLOGY When: [**6-14**] AT 11AM With: DR [**Last Name (STitle) 29732**] [**Name (STitle) **]: EAST

[ "511.9", "496", "813.42", "785.52", "789.59", "599.0", "584.9", "263.9", "995.92", "571.5", "038.12", "070.54", "288.50", "486", "E888.9", "570", "287.5", "510.9", "530.81" ]

icd9cm

[ [ [] ] ]

[ "96.6", "34.91", "34.04", "38.93" ]

icd9pcs

[ [ [] ] ]

18970, 19055

13155, 16556

329, 390

19167, 19167

5452, 13132

20274, 21730

3835, 3895

17872, 18947

19076, 19146

17157, 17849

19318, 20251

3910, 3910

4670, 5433

16577, 17131

3296, 3361

265, 291

418, 3277

3924, 4648

19182, 19294

3383, 3496

3512, 3819

29,426

125,067

34367

Discharge summary

report

Admission Date: [**2125-9-6**] Discharge Date: [**2125-9-13**] Date of Birth: [**2064-1-11**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2279**] Chief Complaint: hypotension, altered mental status Major Surgical or Invasive Procedure: s/p L Nephrostomy Tube Placement Right IJ placement (placed at outside hospital) PICC line Placement History of Present Illness: Mr. [**Known lastname **] is a 61 y/o M with PMH notable for prior CVA, neurogenic bladder with indwelling suprapubic catheter with multiple prior UTIs admitted with altered mental status. He was recently admitted to [**Hospital1 18**] from [**Date range (1) 79060**] for septic shock secondary to aspiration pneumonia which improved rapidly with fluid boluses. There was concern for UTI at that time, but urine culture was negative and his suprapubic catheter was changed on [**8-27**]. He also was diagnosed with gastritis (biopsies negative) and acute renal failure (Cr to 2) which resolved prior to discharge. Per notes from the nursing home, the patient had low grade fevers since discharge of 99-100.8. He completed vancomycin and cefepime on [**8-30**] (prior admission). In the morning of [**9-6**], the patient was noted to have altered mental status (details unclear). His temp at that time was 101.8, P 124, BP 98/78, RR 18, O2 86-88% on RA up to 91-92% on 2L NC. His FS was 304 at that time. He was started on doxycycline 100 mg [**Hospital1 **] (with planned 10 day course). CXR was performed and tylenol was administered. Temp decreased to 98.4, HR 104, BP 108/76, O2 95% on 2L prior to transfer. . He presented to the [**Hospital6 **] ED on [**9-6**] with altered mental status from his nursing facility. In their ED, initial vitals T 96.5, P 96, BP 86/64-->79/57, 100% on [**Month/Day (4) 597**]. He received 3 L NS with improvement of BPs to 100s-130s systolic. A R IJ central venous line was placed. He had evidence of a UTI on UA. Blood cultures were sent X 2. He was treated with vancomycin 1 g IV (given at [**2032**] on [**9-6**]), ceftazadime 1 g IV (given at 1700 on [**9-6**]) and flagyl 500 mg IV (given at 1715 on [**9-6**]). His hyperkalemia was treated with D50/insulin and bicarb. He also received solumedrol 125 mg IV X 1 and morphine 2 mg IV X 1. He made 300 cc of urine in their ICU. On arrival to the MICU, the patient is complaining of bilateral leg pain which is longstanding per his report. He denies cough, vomiting, abdominal pain, and diarrhea. He denies headache, neck pain, and fevers. He denies chest pain. Past Medical History: s/p CVA Neurogenic bladder s/p suprapubic cath Recurrent UTIs with Klebsiella/Pseudomonas Non-hodgkins Marginal Zone Lymphoma of the left orbit Dx in 03 (s/p R-CHOP x 6 cycles) Bells Palsy BPH Hypertension Partial Bowel obstruction s/p colostomy Hepatitis C Cryoglobulinemia SLE with transverse myelitis, anti-dsDNA Ab+ Insulin Dependant Diabetic Fungal Esophagitis Stage IV? Urinary Tract Infections-pseudomonas & enterococcus Social History: Pt has been residing in nursing home since [**3-9**] but speaks to sister regularly and is alert & oriented x 3 at baseline. Family History: non-contributory Physical Exam: VS - Temp 95.9 F, BP 167/107, HR 84, R 14, O2-sat 98% 2L NC GENERAL - somnolent male, responsive to voice & sternal rub, answers questions appropriate (via interpreter), no acute distress HEENT - L facial droop, pupils small but reactive 3-->2 mm bilaterally, EOMI, sclerae anicteric, dry MM NECK - supple, no thyromegaly / LAD / JVD, R IJ cath in place LUNGS - clear bilaterally without crackles or rhonchi, good inspiratory effort HEART - RRR, normal S1 & S2, no murmur appreciated ABDOMEN - normoactive bowel sounds, distended but soft, no appreciable tenderness to palpation, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, no peripheral edema, 1+ DP pulses bilaterally, 2+ bilateral radial pulses NEURO - arousable to voice/sternal rub, moves left arm easily with prompting, able to hold right arm to gravity, hand grip [**5-7**] bilaterally, moves both legs on command, no clonus, toes equivocal bilaterally, + rigidity of hip flexors bilaterally, withdraws both hands to pain Pertinent Results: [**2125-9-6**] 11:30PM ALBUMIN-4.0 CALCIUM-9.0 PHOSPHATE-2.4* MAGNESIUM-2.0 [**2125-9-6**] 11:30PM CK-MB-NotDone cTropnT-0.02* [**2125-9-6**] 11:30PM ALT(SGPT)-15 AST(SGOT)-17 LD(LDH)-164 CK(CPK)-32* ALK PHOS-97 TOT BILI-0.9 [**2125-9-6**] 11:30PM estGFR-Using this [**2125-9-6**] 11:30PM GLUCOSE-405* UREA N-11 CREAT-2.0* SODIUM-135 POTASSIUM-5.8* CHLORIDE-101 TOTAL CO2-29 ANION GAP-11 EKG ([**9-6**]): Sinus rhythm. The P-R interval is prolonged. ST-T wave changes suggestive of early repolarization. Compared to the previous tracing the rate is slower. ([**9-7**]): Sinus rhythm. ST-T wave changes are suggestive of early repolarization. Compared to the previous tracing there is no significant change. HEAD CT WITHOUT IV CONTRAST: ([**9-7**]) There is no evidence of infarction, hemorrhage, edema, mass effect, or shift of normally midline structures. The ventricles and sulci are normal in size and configuration for the patient's age. The left maxillary sinus demonstrates extensive opacification consistent with chronic sinus disease. The visualized soft tissues are unremarkable. IMPRESSION: Left maxillary sinus opacification. Otherwise normal study. RENAL U/S ([**9-7**]): The left kidney measures 13.0 cm. There is a moderate hydronephrosis seen in this kidney. A large obstructing stone is seen in the pelvis of the left kidney measuring about 2.5 cm. A smaller stone is seen in the lower pole of the left kidney measuring 0.6 cm. No solid masses are identified in the left kidney. The right kidney measures 11.8 cm. A non-obstructing stone is seen in the lower pole of the right kidney measuring 2.1 cm. There is no hydronephrosis on the right kidney, and no solid masses are identified. Some cortical thinning is noted in the right kidney. The bladder is not identified on this exam, as the patient has a urinary catheter. IMPRESSION: Moderate hydronephrosis of the left kidney. Large stone seen in the left UPJ. Smaller bilateral renal stones. CXR ([**9-8**]): FINDINGS: There is a right IJ line with tip at the SVC/RA junction. There is ill definition of both hemidiaphragms consistent with volume loss/consolidation in these regions. There is probably bilateral layering effusions. There is pulmonary vascular re-distribution. IMPRESSION: Likely fluid overload, cannot totally exclude small bilateral lower lobe effusion, infiltrates. KUB ([**9-9**]): IMPRESSION: 1. No evidence of obstruction or significant amount of retained colonic stool. 2. Known large right renal stone re-demonstrated. Other known left renal stones not well seen due to overlying bowel gas. 3. A few small metallic densities projecting over the central pelvis could be present in bladder or rectum however may be external to the patient and clinical correlation recommended. Brief Hospital Course: 61 year old man with an indwelling catheter secondary to transverse myelitis secondary to lupus and multiple prior resistent urinary tract infections, including enterococcus and pseudomonas, transferred from [**Hospital6 13753**] for septic shock due to obstructive nephropathy with nephrolithiasis and hydronephrosis. . #. Urinary tract infection: Since the patient had a history of recurrent UTI's and enterococcal and pseudomonal UTI's, he was started empirically on vancomycin and piperacillin-tazobactam. A renal ultrasound was performed and the patient was found to have an obstructing stone in the left renal pelvis, with moderate hydronephrosis of the left kidney. A percutaneous left nephrostomy tube was placed by interventional radiology to drain and decompress the obstruction. On urine cultures from both [**Hospital1 112**] and [**Hospital1 18**] the patient was found to have a pseudomonal UTI, with sensitivities to piperacillin and ceftazidime. The patient was switched from Zosyn to ceftazidime given a lower MIC with ceftazidime. A PICC was placed for IV medication administration. The patient was discharged on a two-week course of ceftazidime, with a plan to follow up with urology following treatment of the patient's UTI. Interventional radiology will plan to change the nephrostomy tube in three months if it is not removed by urology. . #. Altered mental status: The patient was admitted to the hospital for a change in mental status noted at the [**Hospital 228**] nursing home. This presentation was similar to past episodes of altered mental status in the setting of acute infection. Given the patient's history of a prior CVA and his somnolence upon admission, a non-contrast head CT was obtained which did not reveal any acute intracranial event. The patient's mental status improved with treatment of his urinary tract infection and IV fluids. . #. Hypotension: The patient's hypotension was thought to be septic in etiology secondary to a UTI, and the patient's blood pressure improved with IV fluids and treatment of the UTI. On day of discharge the patient's blood pressure was 130/70. . #. Acute renal failure: The patient's creatinine was 2.1 at [**Hospital1 112**] and at [**Hospital1 18**] was 2.0. This elevation in creatinine was likely secondary to hypotension and hypovolemia in the setting of urosepsis. The patient continued to have fair urine output during the hospitalization and his creatinine returned to baseline (1.0) over the course of admission following decompression of the hydronephrosis and with antibiotic treatment and IV fluids. . #. Respiratory distress: The patient was hypoxic prior to transfer to [**Hospital1 112**], but upon admission at [**Hospital1 18**] there was no evidence of respiratory distress. Chest xray did not reveal any acute lung process or pneumonia, and the patient's lund exam was benign. It was noted that the patient had finished a course of vancomycin and cefepime on [**2125-9-1**] for aspiration pneumonia. Supplemental oxygen was started to keep the patient's oxygen saturation above 92%, and was subsequently weaned when patient was transferred to the floor. On the day of discharge the patient's oxygen saturation while breathing room air was 97%. . #. Abdominal distension/C. difficile infection: The patient's abdomen was distended on admission, but no vomiting or abdominal painwas reported by patient. At [**Hospital1 112**] a KUB did not reveal evidence of obstruction and LFTs and lipase were normal. On c.diff assay the patient was found to have c.diff and IV Flagyl was initiated. Pt was transitioned to PO Flagyl upon arrival on the floor when he began to tolerate PO. While on the floor the patient complained of nausea and abdominal pain following oral intake, and a KUB was unrevealing. The patient's pantoprazole was increased to [**Hospital1 **], and the patient was started on simethicone with significant symptomatic improvement. The patient was discharged with instructions that he continue Flagyl for two weeks following the end of the course of ceftazidime. . # Bilateral leg pain: Patient states that lower extremity pain is bilateral and longstanding. Patient was continued on home doses of gabapentin and oxycodone. On discharge the patient complained of intermittent lower extremity pain that he noted in the past had been controlled with his home regimen. . # Stoma protrusion: On discharge, the stoma continued to appear pink. Ostomy output continued to be quite voluminous likely secondary to the patient's known c.diff. . # DM: The patient's elevated finger stick glucose levels were treater with standing Glargina and sliding scale insulin during the hospitalization. On discharge it was anticipated that patient would re-start home insulin regimen upon return to nursing home. . #. FEN/GI: The patient was transitioned to PO and tolerated PO upon discharge. The patient's electrolytes were repleted frequently in the setting of GI losses secondary to c.diff diarrhea. Medications on Admission: MEDS AT TIME OF TRANSFER: folate 1 mg daily citalopram 20 mg daily thiamine 100 mg daily asa 81 mg daily senna 2 tabs three times weekly at bedtime calcium 600 with vitamin D [**Hospital1 **] gabapentin 1200 mg TID ferrous sulfate 325 mg TID oxycodone 10 mg TID kaopectate 30 mL po Q6h prn diarrhea oxycodone 5 mg q6h prn lactulose 30 mL po daily prn constipation dulcolax suppository prn lantus 12 U SC QHS humalog 8 U SC TID and humalog sliding scale doxycycline 100 mg TID X 10 days (start date [**9-6**]) tylenol prn Discharge Medications: 1. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 24 days: Continue until [**2125-10-7**]. 2. Gabapentin 400 mg Capsule Sig: Three (3) Capsule PO TID (3 times a day). 3. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for gas. 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush Temporary Central Access-ICU: Flush with 10mL Normal Saline daily and PRN. 10. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 11. Oxycodone 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for pain. 12. Outpatient Lab Work CBC on [**2125-9-15**] 13. Lantus 100 unit/mL Cartridge Sig: Eighteen (18) units Subcutaneous qam. 14. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for pain. 15. Calcium 600 + D 600-400 mg-unit Tablet Sig: One (1) Tablet PO twice a day. 16. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 17. Ceftazidime 2 gram Recon Soln Sig: One (1) Intravenous every eight (8) hours for 10 days: Continue until [**2125-9-23**]. 18. FSBS Please check finger stick glucose before each meal and at bedtime. 19. Sliding Scale Insulin Please administer regular sliding scale qid achs, see attached sliding scale. 20. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: Two (2) units Subcutaneous ac lunch. Discharge Disposition: Extended Care Facility: [**Hospital **] Healthcare-[**Location (un) 86**] Discharge Diagnosis: Primary Diagnosis: 1. Sepsis secondary to Urinary Tract Infection 2. C. difficile infection 3. Nephrolithiasis 4. Acute renal failure Secondary Diagnosis: 1. Diabetes, uncontrolled Discharge Condition: Stable. Afebrile. Discharge Instructions: You were admitted for a severe infection that was from your kidneys (called urosepsis). You were originally treated in the intensive care unit and then transferred to the general medical floor after improving. You were treated with IV antibiotics for your kidney infection. You were also treated with an antibiotic for c. difficile infection. A nephrostomy tube was placed to help release the pressure in your kidney/ureters. Urologists also helped in your care. Please take all your medications as prescribed, but with the following changes: 1. Please take ceftazadime until [**2125-9-23**]. 2. Please take flagyl until [**2125-10-7**]. 3. Please take Simethicone 80 mg 4 times a day as needed for gas. 4. We have increased your Pantoprazole to 40mg [**Hospital1 **]. 5. We have changed your insulin to 18u glargine every morning, with sliding scale If pt not ambulating in nurshing home, please consider starting heparin SQ 5000 units TID Please keep all your medical appointments. If you have any of the following symptoms, please call your doctor or go to the nearest ER: fever>101, chest pain, shortness of breath, abdominal pain, or any other concerning symptoms. Followup Instructions: Please follow up with your primary care physician [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**Name (STitle) **] at [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **]. [**Telephone/Fax (1) 6019**] We have a arranged for you to follow up at the urology clinc on [**2125-9-26**] 10:30am on the [**Location (un) 10043**] of the [**Hospital Ward Name 23**] Building. You will also follow up with Interventional Radiology so that they can change your nephrostomy tube. They will contact you to arrange a time 3 months after your discharge. If you have questions you can reach them at: [**Telephone/Fax (1) 9387**]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]

[ "276.1", "070.54", "785.52", "323.82", "276.7", "250.02", "799.02", "V44.3", "038.43", "273.2", "600.00", "787.02", "599.0", "V10.79", "438.89", "591", "995.92", "112.0", "710.0", "276.52", "338.29", "592.0", "584.5", "596.54", "V58.67", "V45.89", "008.45", "729.5", "401.9" ]

icd9cm

[ [ [] ] ]

[ "55.03", "00.14", "38.93" ]

icd9pcs

[ [ [] ] ]

14554, 14630

7100, 8473

349, 452

14856, 14877

4291, 7077

16106, 16878

3245, 3263

12663, 14531

14651, 14651

12117, 12640

14901, 16083

3278, 4272

275, 311

480, 2634

14807, 14835

14670, 14786

8488, 12091

2656, 3086

3102, 3229

78,029

119,297

38554

Discharge summary

report

Admission Date: [**2161-3-3**] Discharge Date: [**2161-3-12**] Date of Birth: [**2091-8-11**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3227**] Chief Complaint: Gait distrubance Major Surgical or Invasive Procedure: Thoracentesis [**2161-3-5**] Chest Tube Placement [**2161-3-5**] Right frontal craniotomy [**2161-3-9**] History of Present Illness: This is a 69 year old male with a histpry of small-cell lung CA in [**2160**] (s/p chemo and XRT), who has been experiencing frequent falls and loss of balance for 1 week. States he easily loses his balance, has fallen almost daily, and has had increased difficulty with walking. He has baseline ataxia, but this has become more pronounced. He has hit his head on 2 fall occasions, but no LOC. Was seen at his PCP last evening who ordered a Head CT - this demonstrated a Right frontal rim enhancing lesion with hemorrhagic component and mass effect. He comes from [**Hospital3 85745**] hospital for continued care and further neurosurgical evaluation. He currently has no complaints; specifically, no headache, nauea, double vision, or problems with speech. Past Medical History: 1. Small Cell Lung CA [**2160**], s/p chemo and XRT 2. CVA [**2159**] and ? [**2128**] with subtle left sided weakness 3. HTN Social History: Divorced. Retired engineer. 13 pack year smoking history, quit 7 years ago. No EtOH Family History: Father deceased of Prostate CA, mother deceased on Liver CA Physical Exam: On admission: O: T:98.4 BP: 155/81 HR:80 R:18 O2Sats:100% Gen: WD/WN, comfortable, NAD. HEENT: Normocephalic, Atraumatic. Slight L facial droop. Pupils: PERRLA EOMs intact Neck: Supple. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [**3-18**] 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, 2 to 1 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. Ataxic movements/tremors to all extremities when extended. Hand grasps 5-/5 on the L. Full strength Right upper and lower extremities. L pronator drift Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Toes downgoing bilaterally On Discharge: AOx3, Left tricep [**4-20**] otherwise full motor. Left tremor. No pronator drift. PERRL. Left nasolabial flattening. Wound is C/D/I, sutures are dissolveable. Pertinent Results: Head CT [**3-3**]: 1. A large hemorrhagic mass with vasogenic edema causing 5.4 mm leftward subfalcine herniation in the right frontal lobe measuring up to 3 cm. This finding is concerning for a metastasis. 2. Area of hypoattenuation compatible with vasogenic edema likely from a second metastasis in the left parieto-temporal region. This should be further evaluated with gadolinium-enhanced MRI. Chest X-ray [**3-3**]: 1. Right-sided hydropneumothorax with a small right apical pneumothorax and a moderate right-sided effusion. 2. Severe volume loss in the right lower lobe. 3. Enlarged right hilum either representing the known primary tumor and/or hilar lymphadenopathy. MRI Brain [**3-10**]: IMPRESSION: 1. No definite evidence of persistent nodular enhancement in the resection cavity. 2. Focal area of nodular restricted diffusion along the posterior margin of the resection cavity may be related to surgery. However, clinical correlation and continued attention on followup recommended. 2. Extra-axial fluid layering along the convexities of both hemispheres. Expected postoperative changes in the right frontal region as above. Brief Hospital Course: Mr. [**Known lastname 30984**] was admitted to the [**Hospital1 18**] Neurosurgery service under the care of Dr. [**First Name (STitle) **]. He was on Decadron and Keppra. A chest X-ray showed right pleural effusion/low lung volume and hydropneumothorax. He was stable with 02 sat 95% RA. CT/CXR reports from [**12-24**] did not reveal history of pneurmothorax. Pulmonology was consulted. They recommend that he be on 02. MRI Brain showed a large Right frontal lesion and left temporal parietal edema. Ct torso showed adrenal thickening and lung abnormalities. Subsequent work up revealed that the patient had developed a right pleural effusion. This effusion was tapped by the interventional radiologist. Cytology from the pleural effusion did not reveal evidence of metastasis. The patient was seen by Dr. [**Last Name (STitle) 3929**] on [**3-5**]. He recommended outpatient brain radiation after resection of the tumor. The same recommendation was also made by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**], the neuro-oncologist. He underwent tumor resection on [**2161-3-9**]. There was a cystic portion of the mass that was sent for cytology and the remaining portion was resected without difficulty. The patient was extubated in the OR and was in the ICU overnight for Q 1 hour neuro checks. He remained neurologically stable was transferred back to the neurosurgical floor where he worked with PT. Rehab was recommended and he was discharged to rehab on [**2161-3-12**]. Cytology from thoracentesis showed 2+ POLYMORPHONUCLEAR LEUKOCYTES- Infectious Disease recommended no further intervention as this was seen to be contaminate. Medications on Admission: Lasix 20 mg Tab Oral 1 Tablet(s) Once Daily Diovan -- Unknown Strength 1 Tablet(s) Once Daily Prilosec 20 mg Cap Oral 1 Capsule, Delayed Release(E.C.)(s) Once Daily Zestril 20 mg Tab Oral 1 Tablet(s) Once Daily Bactrim DS 800 mg-160 mg Tab Oral 1 Tablet(s) Twice Daily Compazine -- Unknown Strength 1 Suppository(s) , as needed Percocet -- Unknown Strength 1 Tablet(s) , as needed ASA - 325mg Tab Oral 1 Tablet Once Daily Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain fever. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*90 Tablet(s)* Refills:*0* 4. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 5. Valsartan 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily): While on Dexamethasone. Disp:*30 Capsule, Delayed Release(E.C.)(s)* Refills:*2* 9. Dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Extended Care Facility: [**Month (only) 53281**] Rehabilitation & Nursing Center - [**Location (un) 28318**] Discharge Diagnosis: Right Frontal Brain Tumor Right pleural effusion Right hydropneumothorax 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. ?????? You have been prescribed an anti-seizure medicine, Keppra, take it as prescribed. ?????? Clearance to drive and return to work will be addressed at your post-operative office visit. CALL YOUR SURGEON IMMEDIATELY IF YOU EXPERIENCE ANY OF THE FOLLOWING ?????? New onset of tremors or seizures. ?????? Any confusion or change in mental status. ?????? Any numbness, tingling, weakness in your extremities. ?????? Pain or headache that is continually increasing, or not relieved by pain medication. ?????? Any signs of infection at the wound site: redness, swelling, tenderness, or drainage. ?????? Fever greater than or equal to 101?????? F. ** Keep your incision clean and dry until [**2161-3-16**]. then you may use shampoo/soap. ** You do not need an appointment for suture removal. The stures will dissolve on their own. ** Please continue your Dexamethasone until your follow-up with Dr. [**Last Name (STitle) 724**]. Because this is a steroid, we recommend that you take Omeprazole while on Dexamethasone to protect your stomach. *** You should follow up with your PCP to discuss your tremor. Followup Instructions: Follow-Up Appointment Instructions You have a Brain Tumor Appointment on [**2161-4-6**] with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 724**]. The BTC is located on [**Hospital Ward Name **] [**Location (un) **] [**Hospital Ward Name 23**] Bld. You can call [**Telephone/Fax (1) 1844**] with questions. Completed by:[**2161-3-12**]

[ "511.89", "198.3", "348.5", "781.3", "729.89", "438.89", "162.2", "401.9", "512.8" ]

icd9cm

[ [ [] ] ]

[ "34.04", "01.59", "34.91" ]

icd9pcs

[ [ [] ] ]

7360, 7471

4232, 5905

335, 442

7588, 7588

3065, 4209

9422, 9781

1500, 1562

6386, 7337

7492, 7567

5931, 6363

7768, 9399

1577, 1577

2885, 3046

279, 297

470, 1232

2108, 2871

1591, 1815

7603, 7744

1254, 1382

1398, 1484

54,494

111,053

51576

Discharge summary

report

Admission Date: [**2167-1-5**] Discharge Date: [**2167-1-9**] Date of Birth: [**2116-5-26**] Sex: F Service: MEDICINE Allergies: Pentothal Attending:[**First Name3 (LF) 5134**] Chief Complaint: hypotension, AMS, hypoxia Major Surgical or Invasive Procedure: Central line History of Present Illness: (see MICU [**Location (un) **] note for full details) 50yoF with remote h/o PE, schizophrenia, anxiety, DMII, COPD, and MSSA meningitis who was admitted to the MICU on [**1-5**] after being found hypotensive (SBP 70s), hypoxic (80% on RA) and with AMS at home. The entire story is unclear, but apparently the patient became altered, slid off her chair, and was evidently down for an extended period of time. She does not remember the events. . Initially, the patient was resuscitated with 7L IVF, was found to be in [**Last Name (un) **] and with rhabdomyolysis. CT head was negative. CXR was suspicious for RLL infiltrate and broad-spectrum antibiotics were started empirically. She did not require intubation. In the unit, the patient was on levophed for < 24 hours. Hypoxia and hypotension resolved with supportive care and Cr normalized with IVF. Mental status also improved over the course of the past 2 days. Psychiatry was consulted in the unit given the patient's history of psychiatric problems and concern for medication side effect as the root cause of the patient's presentation. Given the patient's history of PE, she was treated empirically with a heparin drip, however this was stopped yesterday given the resolution of hypoxia, tachycardia, and hypotension. LENIs were negative for DVT bilaterally and TTE showed normal systolic function. . Currently, the patient states that she feels better than her normal self. She does not remember the events that led to her hospitalization. She complains of R foot pain, left shoulder pain (is scheduled for operation), and some worsened SOB over baseline. Current VS are 97.1 91 125/67 18 94% on RA. The patient states that she lives alone at home, ambulates with a cane, and has [**Name Initial (MD) **] home RN and home health aide who assist her each day. She is able to list her medications and doses. Her psychiatrist is [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12262**]. She denies overdosing on medications at home or wanting to hurt herself. Endorses cough with deep inspiration. . ROS: Denies fever, chills, night sweats, headache, vision changes, rhinorrhea, congestion, shortness of breath, chest pain, abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena, hematochezia, dysuria, hematuria. . Past Medical History: Morbid obesity Bipolar disorder Schizophrenia Anxiety Depression PTSD Diabetes x 15 years, complicated by diabetic neuropathy Hyperlipidemia Pulmonary embolism in [**2134**] Endometriosis Glaucoma COPD Hypertension DJD MSSA meningitis Cervical C2 osteomyelitis in [**3-/2166**], completed 7 week course of nafcillin. s/p cholecystectomy s/p C-section s/p hysterectomy Social History: Lives with herself, however according to father has been increasingly disabled and may need [**Hospital3 **]. Is disabled, divorced, unemployed. Son, father, and sisters live in the area and are supportive. Usually smokes 2 ppd - has smoked for 35 years. She very rarely drinks alcohol. Remote h/o cocaine abuse. She completed twelfth grade. She completed twelfth grade. Family History: History of diabetes, Crohn's colitis, cystitis in the family. Mother died at 61 from failure to thrive. Physical Exam: On transfer from the intensive care unit to the floor: VS - 97.1 91 125/67 18 94% on RA GENERAL - morbidly obese woman in NAD, a&ox3, answers questions appropriately HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no thyromegaly, difficult to assess JVP, triple lumen R IJ in place, no carotid bruits LUNGS - end-expiratory wheezing throughout lung fields, no accessory muscle use, no crackles, good bs throughout HEART - RRR, no MRG, nl S1-S2 ABDOMEN - obese abdomen, NABS, soft/NT/ND EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs); complains of R heel pain on the plantar surface NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength [**3-26**] throughout, cerebellar exam intact Pertinent Results: On admission: [**2167-1-5**] 08:10AM BLOOD WBC-12.0*# RBC-4.55 Hgb-13.5 Hct-40.0 MCV-88 MCH-29.7 MCHC-33.8 RDW-14.4 Plt Ct-201 [**2167-1-5**] 08:10AM BLOOD Neuts-74* Bands-13* Lymphs-7* Monos-5 Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0 [**2167-1-5**] 08:10AM BLOOD PT-12.2 PTT-22.5 INR(PT)-1.0 [**2167-1-5**] 08:10AM BLOOD Glucose-291* UreaN-41* Creat-5.3*# Na-130* K-7.1* Cl-94* HCO3-22 AnGap-21* [**2167-1-5**] 08:10AM BLOOD ALT-123* AST-378* CK(CPK)-[**Numeric Identifier 106896**]* AlkPhos-83 TotBili-0.3 [**2167-1-5**] 08:10AM BLOOD Albumin-4.0 Calcium-8.4 Phos-7.9*# Mg-2.6 [**2167-1-5**] 01:38PM BLOOD Type-ART Temp-37.2 pO2-76* pCO2-67* pH-7.15* calTCO2-25 Base XS--6 Intubat-NOT INTUBA Comment-VENTIMASK [**2167-1-5**] 08:19AM BLOOD Lactate-2.2* K-5.4* . Blood and urine cultures: negative . CXR: FINDINGS: A supine portable AP view of the chest was obtained. The left costophrenic angle is excluded from the film. A right internal jugular catheter terminates in the mid SVC. There has been interval worsening of moderate pulmonary vascular congestion. Hazy opacity at the right lung base may represent developing consolidation versus crowding of vessels secondary to low lung volumes. No pleural effusions or pneumothorax are identified. Surgical pins are noted in the left glenoid. . Normal Head CT . Echo: The left atrium is elongated. The estimated right atrial pressure is 0-10mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 70%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. There is a trivial/physiologic pericardial effusion. There are no echocardiographic signs of tamponade. Compared with the findings of the prior study (images reviewed) of [**2166-3-14**], no obvious change but the technically suboptimal nature of both studies precludes definitive comparison. . Renal U/S: Normal study . LENIs: negative for DVT bilaterally . On discharge: [**2167-1-8**] 04:35AM BLOOD WBC-5.3 RBC-3.61* Hgb-11.1* Hct-31.7* MCV-88 MCH-30.9 MCHC-35.1* RDW-14.4 Plt Ct-201 [**2167-1-9**] 05:50AM BLOOD Glucose-216* UreaN-10 Creat-0.7 Na-135 K-4.2 Cl-100 HCO3-24 AnGap-15 [**2167-1-9**] 05:50AM BLOOD CK(CPK)-1466* [**2167-1-9**] 05:50AM BLOOD Calcium-9.1 Phos-4.6* Mg-1.6 Brief Hospital Course: 50 y.o woman with history of PE and MSSA meningitis last year complicated by osteomyelitis who presents today with change in mental status, hypoxia, shock and rhabdomyelysis. . #Shock - Patient presented with hypotension, likely due to a combination of hypovolemia and sepsis secondary to a pneumonia. The patient responded to fluids and was on norepinephrine for blood pressure support. Levophed weaned off and a-line d/c-ed. Resolved. Patient was normotensive after transfer to the floor and anti-hypertensives were slowly restarted. . #Respiratory failure/pneumonia - ABG showed a hypercarbic respiratory failure and acute respiratory acidosis. The patient has a history of COPD and also has a urine tox screen that was positive for opiates. The patient did receive 1mg of narcan in the emergency room, without any improvement. It is possible that the patient has a pneumonia that was exacerbating her COPD. Did not require intubation. Patient was treated with 5-days of ceftriaxone and azithromycin. For the 2 days prior to discharge, oxygen saturations were >95% on RA. . #Change in mental status - Thought to be secondary to hypercarbia, although potential contributing etiology may include narcotic overdose or other medication side effect/accumulation in renal failure. Mental status cleared in the unit. Upon transfer to the floor, the patient was alert, oriented, and able to recount her list of medications and health problems. She was not able to relay the events that led to her hospitalization. [**Month/Day/Year **] was consulted and the patient's home psychiatric medicines were restarted. . #Rhabdomyolysis - Was likely secondary to lying on the ground for several hours. Improved with fluids. Creatinine normalized with IV hydration. Statin was held - to be restarted after discharge. . #Acute renal failure - Thought to be multifactorial - prerenal, rhabdomyolysis, continuing to take Ace-I in renal failure. Cr improved to baseline with IV hydration. . #DM - Patient was on insulin sliding scale and standing lantus during hospitalization. Metformin was restarted on discharge. . #Schizophrenia/anxiety/depression: Home psychiatric medications celexa, risperdal, clonazepam were restarted prior to discharge. . # COPD: Continued fluticasone inhaler and albuterol prn. . # Communication: HCP [**Telephone/Fax (1) 106897**]-FATHER CELL ([**Name2 (NI) **]) # Code: Full (discussed with HCP) . Transitional Issues: -BP medications may need uptitrated -restarting statin Medications on Admission: ALBUTEROL SULFATE - (Prescribed by Other Provider) - 90 mcg HFA Aerosol Inhaler - 2 puffs(s) every 4 to 6 hours as needed for sob PT STATES SHE DOESN'T REALLY USE THIS. AMLODIPINE - (Dose adjustment - no new Rx) - 2.5 mg Tablet - 1 Tablet(s) by mouth once a day CITALOPRAM [CELEXA] - (Prescribed by Other Provider) - 20 mg Tablet - one Tablet(s) by mouth daily. CLONAZEPAM [KLONOPIN] - (Prescribed by Other Provider: [**Name Initial (NameIs) **]) - 1 mg Tablet - 3 Tablet(s) by mouth twice a day CYCLOBENZAPRINE - 10 mg Tablet - 1 Tablet(s) by mouth q8hrs as needed for neck and shoulder pain FLUTICASONE [FLOVENT HFA] - 110 mcg/Actuation Aerosol - 2 puffs(s) inhaled twice a day GABAPENTIN - 800 mg Tablet - 1 Tablet(s) by mouth three times a day INSULIN GLARGINE [LANTUS] - 100 unit/mL Solution - 20 units at bedtime LATANOPROST [XALATAN] - (Prescribed by Other Provider: [**Name Initial (NameIs) **]) - 0.005 % Drops - 1 drp OU at bedtime LISINOPRIL - 40 mg Tablet - 1 Tablet(s) by mouth once a day LOVASTATIN - 40 mg Tablet - 1 Tablet(s) by mouth once a day METFORMIN [GLUCOPHAGE] - 1,000 mg Tablet - One Tablet(s) by mouth twice a day OXYCODONE - 5 mg Tablet - 1 Tablet(s) by mouth twice a day as needed for pain RISPERIDONE [RISPERDAL] - (Prescribed by Other Provider) - 2 mg Tablet - 1 Tablet(s) by mouth twice a day Discharge Medications: 1. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. 2. citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. clonazepam 1 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 4. fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 5. gabapentin 400 mg Capsule Sig: Two (2) Capsule PO Q8H (every 8 hours). 6. Lantus 100 unit/mL Solution Sig: Twenty (20) Units Subcutaneous at bedtime. 7. latanoprost 0.005 % Drops Sig: One (1) Drop(s) each eye Ophthalmic HS (at bedtime). 8. risperidone 1 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 11. metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 12. oxycodone 5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for pain. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary: Sepsis Hypotension Pneumonia Anxiety Depression Rhabdomyolysis Acute kidney injury Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure caring for you at the [**Hospital1 827**]. You were admitted for confusion, low oxygen levels, and low blood pressure. We are not certain what caused the event, but you were extremely sick and required intesive care unit attention - you required medicines to help support your blood pressure as well. You completed a 5-day course of antibiotics to treat pneumonia. . We made the following changes to your medications: We STOPPED cyclobenzaprine (because this can interact with Celexa) We STOPPED lovastatin (because your muscle breakdown levels were high; Dr. [**Last Name (STitle) **] may restart this medication as your blood test normalizes) We HELD amlodipine (because your blood pressure was low on admission; Dr. [**Last Name (STitle) **] may restart this medicine if your blood pressures are high) We CHANGED lisinopril from 40 mg per day to 20 mg per day (Dr. [**Last Name (STitle) **] may increase this medicine if your blood pressures are low) . Your follow-up information is listed below. Followup Instructions: Department: [**Hospital1 18**] [**Location (un) 2352**] - ADULT MED When: FRIDAY [**2167-1-16**] at 11:15 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1143**], MD [**Telephone/Fax (1) 1144**] Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site

[ "518.81", "038.9", "357.2", "365.9", "250.60", "995.92", "295.90", "496", "458.9", "486", "272.4", "305.1", "584.9", "V12.51", "728.88" ]

icd9cm

[ [ [] ] ]

[ "38.97" ]

icd9pcs

[ [ [] ] ]

11610, 11668

6698, 9113

294, 309

11804, 11804

4328, 4328

12997, 13364

3442, 3547

10570, 11587

11689, 11783

9217, 10547

11955, 12362

3562, 4309

6361, 6675

9134, 9191

12391, 12974

229, 256

337, 2645

4342, 6347

11819, 11931

2667, 3036

3052, 3426

8,817

144,854

50324

Discharge summary

report

Admission Date: [**2101-3-26**] Discharge Date: [**2101-4-5**] Date of Birth: [**2047-4-18**] Sex: F Service: MEDICINE HISTORY OF PRESENT ILLNESS: The patient is a 53 year old female with a past medical history significant for splenectomy after a motor vehicle accident twenty years ago, who had acute onset of headache approximately 36 hours prior to presentation. The headache was diffuse, severe and throbbing associated with mild photophobia but no neck rigidity. The day prior she awoke and went to work, still with the complaint of a headache, developed fever to 102.8, despite Tylenol and finally presented to an outside hospital once a rash developed. Petechiae first noted on the face and then spread to bilateral upper extremities and chest, none below the waist. The lesions on the face since coalesced to a violaceous rash over the nose. The patient was initially tachycardia and hypertensive with systolic blood pressure in the 70s, heart rate at 110. She was transferred to the Intensive Care Unit where infectious disease, hematology and cardiology were consulted. Sepsis protocol was initiated and she received five to six liters of intravenous fluids. Concern for meningitis prompted a lumbar puncture followed by empiric Vancomycin, Ceftriaxone, Chloramphenicol and steroids. Swan-Ganz catheter was placed for management of volume status and the patient was transferred to [**Hospital1 346**] on Levophed and Dopamine for further management. PAST MEDICAL HISTORY: 1. Status post splenectomy twenty years ago. 2. Hypertension. ALLERGIES: Penicillin causes a rash. Sulfa causes a rash. Intravenous dye causes a rash. OUTPATIENT MEDICATIONS: 1. Diovan 80 mg. 2. Hydrochlorothiazide 25 mg. 3. A cox2 inhibitor p.r.n. MEDICATIONS ON TRANSFER: 1. Levophed 4 mcg/kg. 2. Dopamine 5 mcg/kg. 3. Ceftriaxone 2 grams. 4. Vancomycin 500 mg. 5. Chloramphenicol one gram. 6. Activated protein C 25 mcg/kg/hour. 7. Protonix. 8. Solu-Medrol 100 mg q8hours. SOCIAL HISTORY: The patient works as a registered nurse. Previously worked at [**Hospital1 69**]. She denied tobacco use. Occasional alcohol. She lives with her partner and two children. FAMILY HISTORY: Positive for coronary artery disease, cerebrovascular accident, no cancer or diabetes mellitus. PHYSICAL EXAMINATION: At admission, temperature was 100.0, pulse 113, blood pressure 110/77, oxygen saturation 100% in room air. The patient appeared critically ill. The heart was tachycardic, S1, split S2, no murmurs. The lungs were clear to auscultation bilaterally. The abdomen was soft, nontender, nondistended, positive bowel sounds. Extremities - no cyanosis, clubbing or edema. Neurologic - No Kernig or Brudzinski signs. Dermatology revealed numerous petechiae in the bilateral upper extremities and some on the chest. Lesions on her face coalesced to form violaceous patches over the nose and maxilla bilaterally. LABORATORY DATA: From the outside hospital, white blood cell count was 12.1, 32% bands, 67% neutrophils, hematocrit 33.1, platelet count 77,000. INR 1.5, partial thromboplastin time 70, fibrinogen low at 164. D-dimer greater than 1.0. Blood urea nitrogen 34, creatinine 3.0. Albumin 3.1, ALT 67, AST 58, amylase 47, AST 440, total bilirubin 135, lipase 106. Cerebrospinal fluid was 186 red cells and [**Pager number **] white cells, 85% polys, glucose 68, protein 320. Crypto antigen negative, gram stain negative. Data from [**Hospital1 69**], white blood cell count 13.9 with 72% neutrophils, 24% bands, hematocrit 34.0, platelet count 81,000. INR 1.6. D-dimer greater than 10,000. Fibrinogen 184. Blood urea nitrogen 22, creatinine 1.0. ALT 70, AST 311, alkaline phosphatase 45, LDH 545, albumin 3.2, amylase 46, total bilirubin 2.0. HOSPITAL COURSE: 1. Infectious disease - The patient was initially admitted to the Medical Intensive Care Unit where she was treated with Neo-Synephrine for blood pressure support and aggressive fluid hydration was continued. She was treated initially with empiric therapy for meningitis with Vancomycin, Ceftriaxone and briefly with Acyclovir as well. The blood cultures from the outside hospital eventually grew out Streptococcal pneumoniae and it was therefore felt that the patient had pneumococcal sepsis and meningitis. The gram stain and culture from the cerebrospinal fluid, however, did not grow any organisms. The patient was also continued briefly on the intravenous steroids but this was weaned off. The patient was quickly able to be weaned off the pressor support and improved nicely on antibiotic therapy. She was eventually transferred to the medical floor where she continued to spike low grade fevers, prompting a further fever workup which included further blood cultures and a CT of the chest which revealed evidence of a resolving pneumonia but no further sources. The sensitivities came back sensitive to Ceftriaxone and Penicillin. As the patient was allergic to Penicillin, the patient was continued on Ceftriaxone to finish a twenty-one day course as directed. At the time of discharge, the patient was afebrile for greater than 24 hours and her white blood cell count had returned to [**Location 213**]. 2. Hematologic - The patient was in DIC at the time of admission. She was treated with activated protein C started at the outside hospital and continued at [**Hospital1 346**]. She had activated protein C for a total of eighty hours and was stopped early as her platelet count dropped to 39,000. There was no evidence of bleeding and subsequent to the discontinuation of the activated protein C, the patient's platelet count rebounded nicely to the high normal range. 3. Gastrointestinal - Near the end of her hospital course, the patient developed abdominal pain and nausea postprandially. An amylase and lipase were checked and showed evidence of pancreatitis. A CT scan was performed although intravenous contrast could not be used because of an allergy. CT scan showed no evidence of a large abscess in the pancreas or other pathology. It was felt the pancreatitis was due to sepsis and resulting inflammation. The patient's enzymes titrated down nicely after one day of NPO and intravenous fluids and her diet was advanced and tolerated well. DISCHARGE STATUS: The patient was discharged home with services. FINAL DIAGNOSES: 1. Pneumococcal meningitis and sepsis. 2. Pancreatitis. 3. Disseminated intravascular coagulopathy. RECOMMENDED FOLLOW-UP: Primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 7389**], as well as Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 977**] of infectious disease. MEDICATIONS ON DISCHARGE: 1. Percocet one to two tablets p.o. q4-6hours p.r.n. pain. 2. Ceftriaxone two grams intravenously q12hours times ten days. The patient was instructed to follow-up with her primary care physician in regard to restarting her blood pressure medications and hormone replacement. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5004**] [**Last Name (NamePattern1) **], M.D. Dictated By:[**Name8 (MD) 13747**] MEDQUIST36 D: [**2101-4-5**] 16:31 T: [**2101-4-5**] 19:41 JOB#: [**Job Number 104932**]

[ "V45.79", "320.1", "785.52", "577.0", "286.6", "401.9", "428.0", "038.2", "995.92" ]

icd9cm

[ [ [] ] ]

[ "38.93", "00.11" ]

icd9pcs

[ [ [] ] ]

2212, 2309

6722, 7275

3808, 6355

6372, 6696

1690, 1768

2332, 3791

165, 1487

1793, 2004

1509, 1666

2021, 2195

17,928

182,341

13755+13756

Discharge summary

report+report

Admission Date: [**2124-6-30**] Discharge Date: [**2124-7-10**] Date of Birth: [**2060-2-11**] Sex: Service: CHIEF COMPLAINT: Left toe gangrene. HISTORY OF PRESENT ILLNESS: This is a 64-year-old male with a history of diabetes, end-stage renal disease on dialysis, coronary artery disease, the patient with a left first toe gangrene, initially the patient was evaluated in the Emergency Room and then admitted to the vascular service for continued care. The patient is known to Dr. [**Last Name (STitle) 1391**] and is scheduled for aorta-bifemoral for [**2124-7-18**]. One month prior to this admission the patient developed discoloration of the left first toe. Two weeks later it did not appear better and was not improved. He was placed on antibiotics, type unknown. He finished a course of antibiotics on [**2124-6-29**]. He was seen by his primary care physician who suggested to have the patient evaluated in the Emergency Room. He denies history of bilateral claudication of calves, thighs or rest pain. Currently the patient denies any constitutional symptoms. PAST MEDICAL HISTORY: No known drug allergies. Illnesses includes coronary artery disease, diabetes mellitus, chronic renal failure on hemodialysis Monday, Wednesday and Friday, Meckel diverticulum. PAST SURGICAL HISTORY: Coronary artery bypass graft in [**2116**], colostomy times two in [**2122**]. MEDICATIONS: 1. Lopressor 50 mg twice a day. 2. Amiodarone 200 mg q day. 3. Nephrocaps q day. 4. Prevacid 15 mg q day. 5. Phos-Lo 667 mg tablets three times a day. 6. Synthroid 100 mcg q day. 7. Entericoated aspirin one q day. 8. Lipitor 40 mg q day. 9. Klonopin 1 twice a day. 10. Diazepam 30 mg q day. 11. Glucotrol 5 mg q day. 12. Neurontin 100 mg q day. The patient denies alcohol or tobacco use. PHYSICAL EXAMINATION: Vital signs 97.7, 72, 125/61. 100% O2 sat on room air. General: Awake, male in no acute distress. Head, eyes, ears, nose and throat exam is unremarkable for jugular venous distention or carotid bruits. Lungs are clear to auscultation bilaterally. Heart is a regular rate and rhythm. Abdomen is unremarkable. Midline incision is well healed. There is a colostomy in the left lower quadrant. Pulse exam shows a palpable 2+ femorals bilaterally with dopplerable popliteals bilaterally, dorsalis pedis and posterior tibial pulses bilaterally. Left first toe is blue with plantar tissue loss, no fracture. There is on erythema or edema but there is diminished hair bilaterally in the lower extremities. LABORATORY: Electrocardiogram showed a left axis deviation, wide QRS unchanged from previous Electrocardiogram. White count 8.7, hematocrit 42.0, PT/INR was normal. BUN 47, creatinine 8.7, K 4.3. HOSPITAL COURSE: The patient was placed in the hospital on bedrest. Wound cultures were obtained. Normal saline wet-to-dry dressings were begun. Vancomycin was initiated at 1 gram and dosed when level less than 15. Levofloxacin and Flagyl were renally dosed. The patient had undergone and arteriogram of the lower left extremity on [**2124-5-23**] which demonstrated renal arteries were diffusely diseased, small in caliber bilaterally, more prominent on the left. There was diffuse irregularity of the infrarenal abdominal aorta without evidence of stenosis or aneurysm. There is focal moderate lesion at the origin of the right internal iliac artery. There was marked diffuse disease of the right external iliac artery. There is a tubular stenosis in the left common iliac artery and diffuse irregularity with more focal moderate stenosis of the left external iliac. There was a 17 mm gradient between the distal abdominal aorta and external left iliac artery. Left leg showed profundus femoris was patent at the common femoral with mildly irregular otherwise unremarkable. The SFA was diffusely diseased with a severe long radial stenosis at the adductor canal. The popliteal artery was mildly irregular with a three vessel run off with spinal stenosis in the proximal anterior tibial and proximal segment of the posterior tibial. Femoral artery is diffusely attenuated. There is diffuse irregularity of the anterior posterior tibial arteries. Dorsalis pedis and plantar arteries are diffusely diseased. A repeat arteriogram was not indicated. Renal service followed the patient and managed his renal and hemodialysis needs. The patient was preop for surgery and underwent on [**2124-7-4**] aortobifemoral with a 16x8 mm graft, he tolerated the procedure well, he required three units of packed red blood cells intraoperatively. He was transferred to the Post Anesthesia Care Unit in stable condition. His immediate postoperative check, he was hemodynamically stable, his postoperative hematocrit was 36, he had DP/PT signals bilaterally. He continued to do well and was transferred to the VICU for continued monitoring and care. Postop day one, he required Nitroglycerin for systolic hypertension and required two units of sodium bicarbonate for metabolic acidosis. His post transfusion crit after three units was 35. His exam remained unchanged, he continued on a PCA for analgesic control, continued NO, the nasogastric tube was discontinued. Dialysis was scheduled on Monday, Wednesday and Friday basis. He remained in the VICU. On postop day one the resident of the Vascular service was called to see the patient because of sinus tachycardia and systolic blood pressure in the 90's. The patient had undergone hemodialysis earlier that day and he felt that the hypotension and tachycardia were secondary to volume extraction and intravascular depletion. The patient was bolused with significant improvement in his systolic blood pressure. The patient was weaned off his Nitroglycerin. Postoperative day two he remained on his triple antibiotics, his hematocrit remained stable at 32, his exam remained unchanged. Lopressor was restarted for heart rate control. He continued to remain NPO. He will continue his antibiotics for a total of 14 days. Physical therapy saw the patient on postop day four, and they thought he would benefit from rehabilitation placement if possible in a facility with dialysis, increase his independence in mobility. From the renal standpoint the patient continued to do well and remained NPO until postoperative day five when his diet was instituted, bowel sounds were noted and ostomy was draining. The remaining hospital course was unremarkable. The patient continued with physical therapy and at the time of discharge he was in stable condition tolerating p.o.'s. DISCHARGE MEDICATIONS: 1. Propofol 50 mg twice a day hold for systolic blood pressure less than 100, heart rate less than 55. 2. Amiodarone 200 mg q day. 3. Nephrocaps one q day. 4. Protonix 40 mg q day. 5. Levothyroxine 100 mcg q day. 6. Aspirin buffered 325 mg q day. 7. Norvostatin 40 mg q day. 8. Zolazepam 1 mg twice a day. 9. Temazepam 30 mg h.s. p.r.n. 10. Gambafentin 100 mg three times per week. The patient should receive this one hour prior to dialysis. 11. Calcium Acetate 2100 mg three times a day with meals. 12. Hydromorphine 2 mg p.o q two hours p.r.n. for pain. 13. Folic Acid 1 mg three times a day. DISCHARGE DIAGNOSIS: 1. Aorta iliac femoral disease, status post aortobifemoral. 2. End-stage renal disease on dialysis with hyperphosphatemia corrected. 3. Hypertension with systolic hypertension perioperatively, treated, resolved. 4. Diabetes mellitus insulin dependent, left arm arteriovenous fistula for hemodialysis. DISCHARGE INSTRUCTIONS: The patient should follow-up with Dr. [**Last Name (STitle) 1391**] in two weeks post discharge. Wounds were clean, dry and intact. He will continue with staples in place until seen in follow-up. Ambulation will be full weight bearing, essential distances only. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**] Dictated By:[**Last Name (NamePattern1) 1479**] MEDQUIST36 D: [**2124-7-10**] 14:13 T: [**2124-7-10**] 15:19 JOB#: [**Job Number 41383**] Admission Date: [**2124-6-30**] Discharge Date: [**2124-7-10**] Date of Birth: [**2060-2-11**] Sex: M Service: VASCULAR ADDENDUM: (to #[**Numeric Identifier 41383**]) The patient was discharged on a regular insulin sliding scale at breakfast, lunch, dinner and at bedtime. Sliding scale glucoses less than 120 no insulin, 121-160 two units, 161-200 four units, 201-240 six units, 241-280 eight units, 281-320 ten units, 321-360 twelve units, greater than 360 fourteen units. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 4417**] Dictated By:[**Last Name (NamePattern1) 1479**] MEDQUIST36 D: [**2124-7-10**] 14:17 T: [**2124-7-10**] 17:47 JOB#: [**Job Number 41384**]

[ "440.24", "585", "414.01", "276.5", "250.40" ]

icd9cm

[ [ [] ] ]

[ "39.95", "39.25" ]

icd9pcs

[ [ [] ] ]

6609, 7215

7236, 7542

2766, 6586

7567, 8885

1325, 1817

1840, 2748

145, 165

194, 1099

1122, 1301