ChanBeDu/relevant_section_length · Datasets at Hugging Face

17,613

109,576

29658

Discharge summary

report

Admission Date: [**2111-10-6**] Discharge Date: [**2111-10-11**] Date of Birth: [**2049-3-13**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Angina Major Surgical or Invasive Procedure: [**2111-10-6**] - CABGX3 (Left internal mammary->Left anterior descending artery, Saphenous vein graft to Obtuse marginal artery and saphenous vein graft to posterior descending artery.) History of Present Illness: 62 year old gentleman with h/o esophageal adenocarcinoma s/p transhiatal esophagectomy in [**2-6**]. He has had recurrent angina which prompted an ETT which was positive. A cardiac cath was performed which showed severe three vessel disease. He was subsequently refered for surgical revascularization. Past Medical History: GERD, hypertension, and orally controlled diabetes, esophageal adenocarcinoma, Renal artery stenosis, neuropathy Social History: He works as an electrician and has a remote 20-pack-year smoking history. He quit drinking one year ago, but drank a 6-pack of beer per week prior to that. Family History: Noncontributory Physical Exam: VS: 98.9, 135/87, 91SR, 18, 96%RA Gen: NAD, [**Male First Name (un) 4746**] Pulm: LCTAB CV: RRR, no murmur or rub abd: NABS, soft, non-tender, non-distended Ext: warm, trace edema Incisions: [**Doctor Last Name **]- c/d/i, no erythema or drainage, sternum stable, EVH- c/d/i, no erythema or drainage Neuro- non-focal Pertinent Results: [**2111-10-10**] 07:45AM BLOOD WBC-6.9 RBC-2.92* Hgb-9.1* Hct-25.1* MCV-86 MCH-31.3 MCHC-36.3* RDW-14.6 Plt Ct-190 [**2111-10-11**] 06:50AM BLOOD Hct-28.5* [**2111-10-10**] 07:45AM BLOOD Glucose-96 UreaN-19 Creat-0.8 Na-135 K-3.4 Cl-103 HCO3-26 AnGap-9 [**2111-10-11**] 06:50AM BLOOD K-4.2 [**2111-10-10**] 07:45AM BLOOD Mg-2.2 CXR [**Known lastname **],[**Known firstname **] E [**Medical Record Number 71079**] M 62 [**2049-3-13**] Radiology Report CHEST (PA & LAT) Study Date of [**2111-10-10**] 8:28 AM [**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2111-10-10**] SCHED CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 71080**] Reason: infiltrate [**Hospital 93**] MEDICAL CONDITION: 62 year old man s/p CABG x3 REASON FOR THIS EXAMINATION: infiltrate Final Report CHEST PA AND LATERAL REASON FOR EXAM: Status post CABG. Since yesterday, bilateral pleural effusions, more marked on the left, slightly increased. Minimal left apical pneumothorax is unchanged. Retrosternal area is unchanged, likely postoperative. Left retrocardiac atelectasis is also unchanged. The cardiomediastinal silhouette and hilar contours are otherwise unchanged. The study and the report were reviewed by the staff radiologist. DR. [**First Name8 (NamePattern2) 4078**] [**Name (STitle) 4079**] DR. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 4392**] Approved: SAT [**2111-10-10**] 12:04 PM Imaging Lab Brief Hospital Course: Mr. [**Known lastname 71037**] was admitted to the [**Hospital1 18**] on [**2111-10-6**] for surgical management of his coronary artery disease. He was taken to the operating room where he underwent coronary artery bypas grafting to three vessels. Please see operative note for details. Postoperatively he was taken to the intensive care unit for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated. On postoperative day one, he was transferred to the step down unit for further recovery. He was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. Chest tubes and pacing wires were discontinued without complication. Hospital course was uneventful. By the time of discharge on POD 5, the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. Medications on Admission: lopressor 200', metformin 500', nifediac 90', protonix 40", simvastatin 10', erythromycin 400"', imdur 30', lisinopril 10' Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. 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* 3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day for 5 days. Disp:*5 Tablet(s)* Refills:*0* 5. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO DAILY (Daily) for 5 days. Disp:*5 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 7. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 8. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*0* 9. Erythromycin 250 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO Q6H (every 6 hours). Disp:*240 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 10. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Disp:*20 Tablet(s)* Refills:*0* 11. Metformin 500 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(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* Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: CAD s/p CABGx3 HTN GERD Esophageal adnocarcinoma and is s/p esophagectomy Diabetes Renal artery stenosis Hyperlipidemia Neuropathy Discharge Condition: Good Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. In the event that you have drainage from your sternal wound, please contact the [**Name2 (NI) 5059**] at ([**Telephone/Fax (1) 1504**]. 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 lotions, creams or powders to incision until it has healed. You may shower and wash incision. Gently pat the wound dry. Please shower daily. No bathing or swimming for 1 month. Use sunscreen on incision if exposed to sun. 5) No lifting greater then 10 pounds for 10 weeks. 6) No driving for 1 month or while taking narcotics for pain. 7) Call with any questions or concerns. Followup Instructions: Dr. [**Last Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment Dr.[**Last Name (STitle) 27945**] in 1 week ([**Telephone/Fax (1) 54195**]) please call for appointment Dr. [**Last Name (STitle) **] [**1-4**] weeks () please call for appointment Completed by:[**2111-10-11**]

[ "411.1", "272.0", "530.81", "492.8", "250.60", "414.01", "V10.03", "440.1", "357.2", "401.9", "V17.3" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

5760, 5843

3023, 3950

329, 518

6018, 6025

1545, 2230

6802, 7114

1176, 1193

4123, 5737

2270, 2298

5864, 5997

3976, 4100

6049, 6779

1208, 1526

283, 291

2330, 3000

546, 849

871, 985

1001, 1160

10,957

155,819

17344

Discharge summary

report

Admission Date: [**2174-8-3**] Discharge Date: [**2174-8-6**] Date of Birth: [**2140-12-29**] Sex: M Service: MEDICINE Allergies: Vancomycin / Norvasc / Iodine; Iodine Containing / Tums Anti-Gas/Antacid / Compazine / Thymoglobulin / Dilaudid / Cefazolin Attending:[**First Name3 (LF) 338**] Chief Complaint: HD initiation Major Surgical or Invasive Procedure: Hemodialysis. History of Present Illness: 33 YO M w DM1 s/p LRRT in [**2168**] and cadaveric pancreatic transplant in [**2169**] now with worsening kidney transplant function and uremia presenting for intiation of HD via permaCath. Patient has had gradual decline in renal function, worsening in the past 2 years. Today he underwent a tunneled catheter placement in his right chest for HD access. He now complains of some pain around the catheter site. Unrelated, patient also notes that his right big toe has had trouble healing after a toe nail falling off. He states he has tried to manage it on his own for the past 1-2 months by keeping it clean and dry. On further questioning, he states that it often smells bad and has pus. Denies any associated erythema or warmth around the site or extending up his right leg. Denies fever or pain. Additionally, reports recent sprain of right wrist, now in plaster cast. Specifically denies any bone fracture to that area. ROS: Per HPI, blind in right eye; Denies N/V/D, fever, SOB, cough, chest pain, headache, rhinorrhea, cough, abdominal pain, abnormal bruising, or feeling light-headed or dizzy. Past Medical History: h/o type I diabetes mellitus s/p pancreas transplant [**2170-5-20**] ESRD s/p living related renal transplant [**2172-7-17**] Recurrent UTIs Blind in left eye d/t toxoplasmosis infection Occlusion of radial/ulnar arteries s/p eye laser surgery Diabetic retinopathy Neuropathy Fistula right arm Social History: Lives with his parents; previously worked in a warehouse. Recently quit smoking, smoked 1 pack per week, no ETOH, no drugs Family History: Noncontributory. No history of diabetes Physical Exam: VS: 98.0 BP 109/67 HR 82 RR 20 O2 100RA Gen: NAD, lying in bed, well groomed, conversant HEENT: Left eye ptosis, EOMI, normal vision R eye, blind in left eye, oropharynx clear. NECK: supple, no lymphadenopathy, no thyromegally. Right IJ tunneled HD catheter with mild tenderness to palpation, dressing c/d/i, no sign of infection CV: RRR, no murmurs, gallops or rubs. S1 and S2 heard. PMI not displaced. Lungs: CTA bilaterally, no wheezes Abd: protuberant, +BS, non-tender, midline incision from previous surgery noted with hernia's detectable towards superior portion of incision. EXT: Left BKA, prosthetic leg in place. Right leg with no cyanosis or edema. Scarring on right leg below the knee present in round 1-2cm lesions. Radial pulses not plapable in upper extremities, previously noted. DP pulse on right leg faint. right forarm in purple cast for wrist. Right large toe with ulcer producing pus and erythema and swelling of entire toe. NEURO: alert, oriented x 3. CN II-XII intact bilaterally except CN II response limited in left eye [**12-27**] hx of retinal detachment. strength 5/5 in bilateral UE and right LE, sensation intact to light touch in bilateral UE, decreased in right LE. No dysdidochokinesis. gait not assessed. Lines, tubes: Tunneled HD catheter in right IJ. Brief Hospital Course: ASSESSMENT AND PLAN: 33 YO M s/p LRRT [**2168**], s/p pancreatic transplant [**2169**] admitted for HD initiation [**12-27**] worsening renal function over past 2 years now on day 2 of HD with right toe ulceration. . # Renal Failure - Patient was admitted for initiation of hemodialysis due to chronic failure of his transplant kidney. On day of admission, patient had Right IG tunneled HD line placed and recieved first HD session. Patient then recieved two more HD sessions, with last session on [**2174-8-5**]. There were no complications with the HD line placement or with any of the HD sessions. Hepatology serology and Chest X-ray were done for outpatient HD placement. Patient scheduled for MWF HD on discharge. . # Syncope - Patient developed significant nausea followed by brief period of loss of consciousness one hour later. There was concern that loss of consciousness was related to receiving IV cefazolin. As 2g infusion was being completed, patient developed red flushing of face and eventual loss of conciousness. Benadryl was ordered prior to LOC, however Code Blue was called. He woke up spontaneously without any intervention with rigors and vomiting. Blood pressure, heart rate and oxygen saturation was normal. Epi pen was administered and benadryl given. He was placed on telemetry and 12-lead EKG done. EKG showed sinus tachycardia. He was transferred to MICU for overnight observation. He received 100mg solumedrol IV. Patient had no further events. With further history, it was felt unlikely to be related to cefazolin. ICU team considered challenging pt with another dose of cefazolin, however given recent dose of solumedrol, felt challenge would be low yield. Therefore pt was discharged home, and should be rechallenged with cephalosporin in a monitored setting at a later date. . # Diabetic Foot Ulcer - Patient noted to have diabetic ulcer on Right large toe that produced pus with erythema and swelling of entire foot. Podiatry was consulted and surgically debrided the ulcer. Deep culture was taken and grew GNR and gram positive cocci in pairs. Patient was given Cefazolin 2g IV prior to planned discharge with plant to continue Cefazolin with HD. Mr. [**Known lastname 48549**] developed syncope receiving cefazolin. Therefore this was discontinued and patient was discharged home on course of levaquin with follow up planned with podiatry. . # S/P LR Renal Transplant - Transplant in [**2168**], on immunosupression. Immunosuppression was continued with prograf, rapamune and prednisone. Daily prograf and rapamune levels were obtained. Due to elevated rapamune levels, dosing was decreased to 1 mg qday. Patient is to follow up with renal transplant physician as outpatient. . # S/p Pancreatic Transplant - Transplant in [**2169**]. Currently on immunosuprression. History of rejection, however pancreatic function now adequate. See above section for discussion of immunosuppressants. . # Hypertension - History of hypertension now with failing renal transplant. Likely multifactorial, but may be strongly related to volume. On admission (after first dialysis session) blood pressure was noted to be 109/67. Hydralazine was discontinued and patient was continued on clonidine out of concern for rebound hypertension and reduced dose of metoprolol 25mg [**Hospital1 **]. On the second day of admission, patient's clonidine was held before dialysis due to relative hypotension, but was then administered afterwards when he came back from HD hypertensive. . # Depression - continued Lexapro Medications on Admission: atorvastatin 40mg daily clonidine 0.2mg [**Hospital1 **] lexapro 10mg daily lasix 40mg daily hydralazine 10mg [**Hospital1 **] toprol XL 200mg [**Hospital1 **] omeprazole 20mg [**Hospital1 **] prednisone 5mg daily sirolimus 2mg daily tacrolimus 1mg [**Hospital1 **] bactrim 400/80 daily ambien 10mg qhs prn aspirin 81mg calcium and vitamin D iron Discharge Medications: 1. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4. Sirolimus 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Tacrolimus 1 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours). 6. Clonidine 0.2 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Escitalopram 10 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 BID (2 times a day). 9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. Ferrous Sulfate 325 mg (65 mg Iron) Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Nephrocaps 1 mg Capsule Sig: One (1) Capsule PO once a day. Disp:*30 Capsule(s)* Refills:*2* 12. Acetaminophen-Codeine 300-30 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain for 2 days. Disp:*10 Tablet(s)* Refills:*0* 13. Os-Cal 500 + D 500 mg(1,250mg) -200 unit Tablet Sig: One (1) Tablet PO twice a day. 14. Ambien 5 mg Tablet Sig: 1-2 Tablets PO at bedtime as needed for insomnia. Disp:*60 Tablet(s)* Refills:*0* 15. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO every other day for 3 doses: Start on [**2174-8-8**]. Disp:*3 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: End Stage Renal Disease Diabetic Foot Ulcer Syncope Secondary: Diabetes Mellitus, type 1 Peripheral Neuropathy Discharge Condition: Good. Hemodynamically stable. Discharge Instructions: You were admitted to the hospital for initiation of hemodialysis. A PermaCath was placed and hemodialysis was started. You are set up to have Monday, Wednesday, Friday Hemodialysis as an outpatient in [**Location (un) 7661**]. You had an episode of nausea and unresponsiveness. It is unclear what caused this event. It may have been due to a medication called Cefazolin. You will need to be evaluated again to see if this is a true allergy. While in the hospital you were also noted to have a great toe ulcer. You were seen by podiatry and the wound was debrided. A swab was growing several types of bacteria which are not yet fully characterized. You were started on an antibiotic called levaquin for your toe. Complete the course of this medication unless podiatry states otherwise. Please follow up with podiatry next week for further evaluation. You decided not to have nursing services come to your home to help manage the ulcer on your toe. Please change the dressings on your right big toe as instructed by the podiatrists. If you have any questions about the instructions, please contact your podiatrists office at [**Telephone/Fax (1) **]. You have a follow-up appointment with Dr. [**Last Name (STitle) **] on [**2174-8-8**] at 3:20 pm. CHANGES TO YOUR MEDICATIONS: STOP hydralazine. DECREASE metoprolol. STOP lasix. Decrease Rapamune to 1 mg daily START NEPHROCAPS. START LEVAQUIN for total of 7 days (including 1 tab while in hospital). Discuss bone health and calcium/vitamin D replacement with your primary nephrologist. Please call your doctor or go to the emergency room if you develop fever, chills, nightsweats, nausea, vomiting, inability to take your medications, abdominal pain, rash, change in urination, diarrhea, or other concerning symptoms. Followup Instructions: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2174-11-2**] 10:00 [**First Name11 (Name Pattern1) 1980**] [**Last Name (NamePattern4) 1981**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2174-9-6**] 11:10 [**First Name11 (Name Pattern1) 5445**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 5446**], DPM Phone:[**Telephone/Fax (1) 543**] Date/Time:[**2174-8-8**] 3:20

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icd9cm

[ [ [] ] ]

[ "38.95", "39.95", "86.22" ]

icd9pcs

[ [ [] ] ]

8832, 8838

3407, 6956

396, 412

9003, 9035

10857, 11329

2028, 2069

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8859, 8982

6982, 7331

9059, 10312

2084, 3384

10341, 10834

343, 358

440, 1552

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6,528

151,761

28990

Discharge summary

report

Admission Date: [**2147-8-11**] Discharge Date: [**2147-8-17**] Date of Birth: [**2072-1-14**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins Attending:[**First Name3 (LF) 922**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [**2147-8-11**] Coronary Artery Bypass Graft x 4 (LIMA to LAD, SVG to OM, SVG to Diag, SVG to PDA) History of Present Illness: 75 y/o male who presented to [**Hospital 1474**] hospital c/o shortness of breath and dizziness. He was ruled in for a myocardial infarction. Transferred to [**Hospital1 18**] for cardiac cath which revealed three vessel disease. Then referred for cardiac surgery. Past Medical History: Hypertension, Hypercholesterolemia, Carotid Stenosis, Chronic Obstructive Pulmonary Disease, Asthma, h/o Asbestos exposure, Peptic Ulcer Disease, s/p Appendectomy, s/p hernia repair, cyst removal from chest, s/p T&A Social History: Retired. Smoked 1ppd x 60 yrs. Denies ETOH. Lives with wife Family History: Father with multiple MI's in 70's. Physical Exam: VS: 66 18 123/56 5'4" 56.7kg General: WD/WN male in NAD HEENT: EOMI, PERRL, OP benign, NCAT Neck: Supple, FROM - JVD Lungs: CTAB -w/r/r Heart: RRR, +S1S2, -c/r/m/g Abd: Soft, NT/ND +BS Ext: Warm, well-perfused, -c/c/e, -varocisities Neuro: A&O x 3, MAE, non-focal Pertinent Results: Echo [**8-11**]: Pre-CPB: The right ventricular cavity is mildly dilated. The descending thoracic aorta is mildly dilated. There are simple atheroma in the descending thoracic aorta. The aortic valve leaflets are moderately thickened. The non-coronary cusp is hypo-mobile.There is mild aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). Post-CPB: Preserved biventricular systolic fxn. No AI, trace MR, aorta intact. CXR [**8-16**]: Persistent small pleural effusions, right greater than left. Basilar interstitial abnormality, likely due to a combination of acute interstitial edema and chronic underlying interstitial fibrosis. Extensive asbestos-related pleural disease. [**2147-8-11**] 04:08PM BLOOD WBC-20.2*# RBC-3.53* Hgb-10.6* Hct-30.7* MCV-87 MCH-29.9 MCHC-34.4 RDW-13.0 Plt Ct-337 [**2147-8-12**] 03:05AM BLOOD WBC-17.2* RBC-3.57* Hgb-10.6* Hct-30.8* MCV-86 MCH-29.8 MCHC-34.5 RDW-13.0 Plt Ct-384 [**2147-8-15**] 06:30AM BLOOD WBC-13.2* RBC-3.62* Hgb-11.6* Hct-32.1* MCV-89 MCH-32.2* MCHC-36.3* RDW-13.3 Plt Ct-441* [**2147-8-11**] 04:08PM BLOOD PT-12.9 PTT-37.9* INR(PT)-1.1 [**2147-8-15**] 06:30AM BLOOD PT-11.3 PTT-27.8 INR(PT)-0.9 [**2147-8-11**] 04:08PM BLOOD UreaN-15 Creat-0.6 Cl-112* HCO3-24 [**2147-8-15**] 06:30AM BLOOD Glucose-109* UreaN-21* Creat-1.0 Na-138 K-4.8 Cl-100 HCO3-31 AnGap-12 [**2147-8-14**] 03:49AM BLOOD Phos-2.8 Mg-2.2 [**2147-8-17**] 06:30AM BLOOD WBC-9.8 RBC-3.19* Hgb-9.8* Hct-28.1* MCV-88 MCH-30.7 MCHC-34.9 RDW-13.2 Plt Ct-549* Brief Hospital Course: Mr. [**Known lastname 3065**] was a same day admit after undergoing all pre-operative work-up as an outpatient. On [**8-11**] he was brought to the operating room where he underwent a coronary artery bypass graft x 4. Please see operative report for surgical details. Following surgery he was transferred to the CSRU for invasive monitoring in stable condition. Later on op day he was weaned off sedation, awoke neurologically intact and extubated. On post-operative day two his chest tubes were removed. He was transfused with pRBC's and received Amiodarone for atrial fibrillation. He continued on Amiodarone throughout his hospital course and anticoagulation was initiated. Beta blockers and diuretics were started and he was diuresed towards his pre-op weight. On post-op day three he was transferred to the cardiac surgery telemetry floor. Epicardial pacing wires were removed on post-op day four. Physical therapy followed patient during post-op course for strength and mobility. He did continue to require aggressive pulmonary toilet with multiple inhalers, diuretics, IS and oxygen via nasal cannula. Otherwise he appeared to be doing well and on post-op day six he was discharged to rehab facility with the appropriate follow-up appointments. On day of discharge his heart rate was 66 SR, BP 122/59 and O2 saturation 97% with 3L NC. Medications on Admission: Aspirin, Imdur, Lisinopril, HCTZ, Plavix, Advair, Simvastatin, Pantoprazole, NTG patch 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:*2* 3. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*1* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 5. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*3 Tablet(s)* Refills:*1* 6. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO BID (2 times a day). Disp:*90 Tablet(s)* Refills:*1* 7. 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* 8. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 9. Lasix 40 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. 10. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7 days. 11. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): For 5 days. Then 400mg qd for 7 days. Then 200mg qd until stopped by cardiologist. 12. Coumadin 3 mg Tablet Sig: One (1) Tablet PO once a day: Titrate for a goal INR of 2 (for Post-op Atrial Fibrillation). Discharge Disposition: Extended Care Facility: [**Location (un) **] at [**Location (un) 701**] Discharge Diagnosis: Coronary Artery Disease s/p Coronary Artery Bypass Graft x 4 Post-operative Atrial Fibrillation PMH: Hypertension, Hypercholesterolemia, Carotid Stenosis, Chronic Obstructive Pulmonary Disease, Asthma, h/o Asbestos exposure, Peptic Ulcer Disease, s/p Appendectomy, s/p hernia repair, cyst removal from chest, s/p T&A Discharge Condition: Good Discharge Instructions: You may take shower. Wash incisions and gently pat dry. Do not take bath. Do not apply lotions, creams, ointments or powders to incisions. Do not drive for 1 month. Do not lift greater than 10 pounds for 2 months. If you develop a fever, notice drainage from incisions, or redness around incisions, please contact office. [**Name2 (NI) **] to make all follow-up appointments. Followup Instructions: Dr. [**Last Name (STitle) 914**] in 4 weeks Dr. [**Last Name (STitle) **] in [**1-16**] weeks Cardiologist in [**2-17**] weeks Completed by:[**2147-8-17**]

[ "272.0", "401.9", "533.90", "501", "414.01", "997.1", "493.20", "410.92", "433.10", "427.31" ]

icd9cm

[ [ [] ] ]

[ "39.61", "36.15", "99.04", "36.13", "88.72" ]

icd9pcs

[ [ [] ] ]

5985, 6059

2969, 4312

297, 397

6419, 6425

1358, 2946

6849, 7006

1023, 1059

4449, 5962

6080, 6398

4338, 4426

6449, 6826

1074, 1339

238, 259

425, 691

713, 930

946, 1007

5,596

199,100

13144

Discharge summary

report

Admission Date: [**2161-5-8**] Discharge Date: [**2161-6-17**] Date of Birth: [**2112-10-13**] Sex: M Service: SURGERY Allergies: Heparin Agents Attending:[**First Name3 (LF) 1481**] Chief Complaint: Chronic mesenteric ischemia with abdominal pain and weight loss of 30lbs over 3 years Major Surgical or Invasive Procedure: [**2161-4-24**]: Aorta and nonselective mesenteric angiography [**2161-5-11**]: Right iliac limb of aortobifemoral graft to superior mesenteric artery bypass with reversed saphenous vein graft. Intraoperative angioscopy and valve lysis. Lysis of adhesions. Resection of small bowel times one and repair of enterotomy times one [**2161-5-21**]: Exploratory laparotomy, drainage of intra-abdominal perforations, near total enterectomy, right colectomy, gastrostomy. [**2161-5-21**]: Re-exploration for hemoperitoneum and thrombosed mesenteric bypass graft [**2161-5-28**]: Exploratory laparotomy, G tube removal [**2161-6-3**]: Flexible bronchoscopy with BAL History of Present Illness: 48 yo male w/ chronic mesenteric ischemia in outside hospital until [**2161-1-28**] noted dull intermittent abdominal pain; admitted w/ occluded SMA/celiac (s/p angiography on [**4-24**]). Please see below in hospital course for more details. Past Medical History: -chronic mesenteric ishcemia -s/p aortobifemoral artery bypass [**2144**] -occluded SMA and celiac arteries -s/p abdminal stents x2 ([**2157**], [**2159**]) -hypercholesterolemia -s/p splenectomy [**12/2159**] -reflux -emphysema Social History: Tobacco smoker - quit; ~60 pack year history; occasional EtOH, no IVDU Physical Exam: Current PE: General: thin appearing, alert and oriented, not in distress Cardiac: RRR, normal S1, S2, no murmurs Lungs: Clear to auscultation bilaterally Abdomen: +bowel sounds, soft, non-tender, non-distended Wounds: Midline incision and leg incision intact with steri-strips, mucous fistula above ostomy site is covered with sterile dressings; ostomy intact and functioning Extremities: no cyanosis, no tenderness, no edema Pertinent Results: [**2161-6-13**] URINE URINE CULTURE-FINAL (Negative) [**2161-6-12**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC BOTTLE-PENDING [**2161-6-12**] CATHETER TIP-IV WOUND CULTURE-FINAL {YEAST, PRESUMPTIVELY NOT C. ALBICANS} [**2161-6-3**] BRONCHOALVEOLAR LAVAGE GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {STAPH AUREUS COAG +}; FUNGAL CULTURE-PRELIMINARY [**2161-6-2**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {STAPH AUREUS COAG +} [**2161-6-2**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE}; ANAEROBIC BOTTLE-FINAL [**2161-6-2**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL (Negative) [**2161-6-1**] MRSA SCREEN MRSA SCREEN-FINAL {STAPH AUREUS COAG +} [**2161-5-31**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-FINAL {STAPH AUREUS COAG +} [**2161-5-29**] CATHETER TIP-IV WOUND CULTURE-FINAL {[**Female First Name (un) **] (TORULOPSIS) GLABRATA, STAPHYLOCOCCUS, COAGULASE NEGATIVE} [**2161-5-28**] URINE URINE CULTURE-FINAL; FUNGAL CULTURE-FINAL {[**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **]} [**2161-5-28**] PERITONEAL FLUID GRAM STAIN-FINAL; FLUID CULTURE-FINAL {STAPH AUREUS COAG +, STAPHYLOCOCCUS, COAGULASE NEGATIVE}; ANAEROBIC CULTURE-FINAL [**2161-5-28**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL CULTURE-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE}; BLOOD/AFB CULTURE-FINAL [**2161-5-28**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {STAPHYLOCOCCUS, COAGULASE NEGATIVE}; ANAEROBIC BOTTLE-FINAL [**2161-5-27**] BLOOD CULTURE AEROBIC BOTTLE-FINAL {[**Female First Name (un) **] (TORULOPSIS) GLABRATA}; ANAEROBIC BOTTLE-FINAL {[**Female First Name (un) **] (TORULOPSIS) GLABRATA} [**2161-5-24**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL {[**Female First Name (un) **] (TORULOPSIS) GLABRATA} [**2161-5-22**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL {[**Female First Name (un) **] (TORULOPSIS) GLABRATA} [**2161-5-28**] 04:30PM ASCITES WBC-[**Numeric Identifier 40125**]* RBC-[**Numeric Identifier 3652**]* Polys-0 Lymphs-0 Monos-0 [**2161-5-28**] 04:30PM ASCITES Amylase-5655 TotBili-3.7 [**2161-6-9**] 06:30AM BLOOD WBC-12.6* RBC-2.93* Hgb-9.0* Hct-27.2* MCV-93 MCH-30.6 MCHC-33.0 RDW-17.0* Plt Ct-479* [**2161-6-8**] 02:36AM BLOOD WBC-11.2* RBC-2.81* Hgb-8.6* Hct-25.8* MCV-92 MCH-30.5 MCHC-33.1 RDW-16.7* Plt Ct-489* [**2161-6-3**] 04:43AM BLOOD WBC-23.6* RBC-2.87* Hgb-8.7* Hct-26.1* MCV-91 MCH-30.3 MCHC-33.3 RDW-15.2 Plt Ct-411 [**2161-6-2**] 09:55PM BLOOD WBC-22.1* RBC-3.11* Hgb-9.7* Hct-28.6* MCV-92 MCH-31.2 MCHC-33.9 RDW-15.0 Plt Ct-401 [**2161-5-23**] 04:17AM BLOOD WBC-18.0* RBC-3.21*# Hgb-9.8*# Hct-28.5*# MCV-89 MCH-30.4 MCHC-34.3 RDW-16.2* Plt Ct-428 [**2161-5-18**] 03:00AM BLOOD WBC-12.8* RBC-2.75* Hgb-8.5* Hct-25.9* MCV-94 MCH-30.8 MCHC-32.7 RDW-15.2 Plt Ct-201 [**2161-5-16**] 03:17AM BLOOD WBC-21.6* RBC-2.91* Hgb-9.0* Hct-26.4* MCV-90 MCH-30.8 MCHC-34.1 RDW-15.1 Plt Ct-164 [**2161-5-15**] 04:08AM BLOOD WBC-26.3* RBC-2.84* Hgb-9.0* Hct-25.4* MCV-89 MCH-31.5 MCHC-35.3* RDW-14.7 Plt Ct-121* [**2161-5-13**] 04:17PM BLOOD WBC-25.2* RBC-3.06* Hgb-9.3* Hct-26.3* MCV-86 MCH-30.4 MCHC-35.4* RDW-14.7 Plt Ct-110* [**2161-5-12**] 05:02AM BLOOD WBC-10.8 RBC-3.29* Hgb-9.9* Hct-28.4* MCV-87 MCH-30.3 MCHC-35.0 RDW-14.8 Plt Ct-82*# [**2161-5-12**] 02:04AM BLOOD WBC-8.9 RBC-3.07* Hgb-9.3* Hct-26.9* MCV-88 MCH-30.2 MCHC-34.5 RDW-14.8 Plt Ct-54* [**2161-5-10**] 01:45AM BLOOD WBC-19.0* RBC-3.47* Hgb-10.6* Hct-31.7* MCV-91 MCH-30.7 MCHC-33.6 RDW-14.3 Plt Ct-573* [**2161-5-9**] 02:57AM BLOOD WBC-19.8* RBC-3.79* Hgb-11.8* Hct-34.6* MCV-91 MCH-31.1 MCHC-34.0 RDW-14.5 Plt Ct-632* [**2161-5-8**] 07:25PM BLOOD WBC-16.9* RBC-3.42* Hgb-10.7* Hct-31.7* MCV-93 MCH-31.3 MCHC-33.8 RDW-14.5 Plt Ct-521* [**2161-5-27**] 08:33AM BLOOD Neuts-89.7* Lymphs-7.2* Monos-2.7 Eos-0.3 Baso-0.1 [**2161-6-8**] 02:36AM BLOOD PT-19.2* PTT-30.0 INR(PT)-1.8* [**2161-5-30**] 04:21AM BLOOD PT-21.2* PTT-33.4 INR(PT)-2.1* [**2161-5-8**] 07:25PM BLOOD PT-13.1 PTT-25.5 INR(PT)-1.1 [**2161-6-7**] 02:45AM BLOOD Fibrino-342 [**2161-5-23**] 01:15AM BLOOD FDP-10-40 [**2161-5-23**] 01:15AM BLOOD D-Dimer-2310* [**2161-6-15**] 01:47PM BLOOD Glucose-102 UreaN-23* Creat-0.4* Na-136 K-4.7 Cl-106 HCO3-24 AnGap-11 [**2161-6-2**] 09:55PM BLOOD Glucose-122* UreaN-18 Creat-0.5 Na-140 K-4.4 Cl-107 HCO3-28 AnGap-9 [**2161-5-28**] 10:07PM BLOOD Glucose-157* UreaN-22* Creat-0.6 Na-141 K-4.0 Cl-107 HCO3-27 AnGap-11 [**2161-5-27**] 03:26AM BLOOD Glucose-103 UreaN-13 Creat-0.3* Na-141 K-3.2* Cl-109* HCO3-26 AnGap-9 [**2161-5-23**] 12:14AM BLOOD Glucose-92 UreaN-22* Creat-0.6 Na-140 K-4.6 Cl-109* HCO3-23 AnGap-13 [**2161-5-8**] 07:25PM BLOOD Glucose-90 UreaN-9 Creat-0.7 Na-139 K-3.8 Cl-103 HCO3-28 AnGap-12 [**2161-5-24**] 02:13AM BLOOD ALT-55* AST-39 AlkPhos-95 TotBili-1.9* DirBili-1.6* IndBili-0.3 [**2161-5-23**] 12:14AM BLOOD ALT-61* AST-40 LD(LDH)-196 AlkPhos-90 Amylase-10 TotBili-2.6* [**2161-5-21**] 09:45AM BLOOD ALT-88* AST-51* LD(LDH)-296* AlkPhos-175* Amylase-37 TotBili-2.8* [**2161-5-8**] 07:25PM BLOOD ALT-10 AST-10 LD(LDH)-102 AlkPhos-107 Amylase-53 TotBili-0.2 [**2161-5-23**] 12:14AM BLOOD Lipase-6 [**2161-5-8**] 07:25PM BLOOD Lipase-12 [**2161-6-3**] 02:07PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2161-5-9**] 02:57AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2161-6-15**] 01:47PM BLOOD Albumin-2.7* Calcium-8.8 Phos-4.2 Mg-2.0 Iron-102 [**2161-6-5**] 01:39AM BLOOD Albumin-2.2* Calcium-7.6* Phos-2.7 Mg-2.0 [**2161-5-31**] 02:42AM BLOOD Albumin-2.4* Calcium-7.8* Phos-2.8 Mg-2.0 [**2161-5-13**] 01:58AM BLOOD Albumin-1.6* Calcium-7.0* Phos-2.6* Mg-1.7 Iron-40* [**2161-5-8**] 07:25PM BLOOD Albumin-3.7 Calcium-8.9 Phos-4.0 Mg-2.0 [**2161-6-15**] 01:47PM BLOOD calTIBC-150* Ferritn-369 TRF-115* [**2161-6-7**] 12:19AM BLOOD Type-ART pO2-50* pCO2-32* pH-7.51* calTCO2-26 Base XS-2 [**2161-6-6**] 05:25AM BLOOD Type-ART pO2-66* pCO2-37 pH-7.49* calTCO2-29 Base XS-4 [**2161-6-6**] 02:32AM BLOOD Type-ART pO2-63* pCO2-37 pH-7.51* calTCO2-31* Base XS-5 [**2161-5-31**] 05:57PM BLOOD Type-ART Rates-25/ Tidal V-550 PEEP-10 FiO2-70 pO2-79* pCO2-42 pH-7.44 calTCO2-29 Base XS-3 -ASSIST/CON Intubat-INTUBATED [**2161-5-31**] 02:42PM BLOOD Type-ART Rates-25/6 Tidal V-500 PEEP-10 FiO2-50 pO2-79* pCO2-42 pH-7.44 calTCO2-29 Base XS-3 -ASSIST/CON Intubat-INTUBATED [**2161-5-30**] 04:22PM BLOOD Type-ART Rates-25/7 Tidal V-450 PEEP-8 FiO2-50 pO2-74* pCO2-43 pH-7.43 calTCO2-29 Base XS-3 -ASSIST/CON Intubat-INTUBATED [**2161-5-30**] 01:59PM BLOOD Type-ART pO2-79* pCO2-31* pH-7.41 calTCO2-20* Base XS--3 Intubat-INTUBATED [**2161-5-28**] 04:00AM BLOOD Type-ART Temp-37.8 FiO2-70 pO2-56* pCO2-45 pH-7.44 calTCO2-32* Base XS-5 Intubat-NOT INTUBA Vent-SPONTANEOU [**2161-5-27**] 12:44PM BLOOD Type-ART Temp-38.9 pO2-67* pCO2-44 pH-7.45 calTCO2-32* Base XS-5 Intubat-NOT INTUBA [**2161-5-22**] 09:37PM BLOOD Type-ART Temp-37.3 FiO2-35 pO2-107* pCO2-37 pH-7.41 calTCO2-24 Base XS-0 Intubat-NOT INTUBA Comment-FACE TENT [**2161-5-21**] 10:00AM BLOOD Type-ART pO2-97 pCO2-37 pH-7.50* calTCO2-30 Base XS-4 [**2161-5-12**] 07:56AM BLOOD Type-ART Temp-37.3 Rates-14/ Tidal V-600 PEEP-5 FiO2-40 pO2-178* pCO2-40 pH-7.31* calTCO2-21 Base XS--5 -ASSIST/CON Intubat-INTUBATED [**2161-5-11**] 10:40AM BLOOD Type-ART FiO2-20 pO2-98 pCO2-42 pH-7.45 calTCO2-30 Base XS-4 Intubat-NOT INTUBA [**2161-6-6**] 05:25AM BLOOD Lactate-0.9 [**2161-5-29**] 04:25AM BLOOD Lactate-2.2* [**2161-5-22**] 09:37PM BLOOD Glucose-77 Lactate-5.8* Na-135 K-4.5 [**2161-5-13**] 03:17AM BLOOD Lactate-1.8 [**2161-5-11**] 08:33PM BLOOD Glucose-164* Lactate-6.4* [**2161-5-11**] 10:40AM BLOOD Glucose-114* Lactate-0.6 Na-137 K-3.7 Cl-105 [**2161-6-13**] 01:00AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.017 [**2161-6-13**] 01:00AM URINE Blood-LG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [**2161-6-13**] 01:00AM URINE RBC-1 WBC-[**2-1**] Bacteri-FEW Yeast-NONE Epi-0 Brief Hospital Course: [**2161-4-24**]: Aorta and nonselective mesenteric angiography 1. Occluded SMA and celiac arteries. 2. No endovascular options Admitted on [**2161-5-8**] [**2161-5-11**]: Right iliac limb of aortobifemoral graft to superior mesenteric artery bypass with reversed saphenous vein graft. Intraoperative angioscopy and valve lysis. Lysis of adhesions. Resection of small bowel times one and repair of enterotomy times one. Then developed hemoperitoneum and thrombosed mesenteric bypass graft, returned to OR for exploratory laparotomy and repair of graft. Went to TICU for observation, then to VICU. Returned to SICU on [**5-15**] due to hypotension and worsening respiratory status, where patient was aggressively diuresed with lasix drip, started on levophed drip and placed on ventilator support. [**2161-5-21**]: CT abd/pelvis with contrast 1. Small, left greater than right pleural effusions. 2. Mild intra and extrahepatic ductal dilatation. 3. Heterogeneous predominantly hypodense large lesion within the inferior aspect of the posterior right lobe of the liver, not characterized. An ultrasound can be performed for further evaluation of this lesion and the ductal dilatation. 4. Probable right adrenal adenoma not definitive. 5. Aneurysmal dilatation of the left femoral artery. [**2161-5-21**]: Exploratory laparotomy, drainage of intra-abdominal perforations, near total enterectomy, right colectomy, gastrostomy. [**2161-5-22**]: Pathology of Small Bowel (Right colon) Ileum, cecum, and right colon, ileocolectomy: Small bowel with acute and chronic changes consistent with ischemia. Mesenteric necrosis and ileal perforation with serosal abscess and fibrous adhesions; Colon with dense fibrous serosal adhesions; Resection margins (bowel and mesenteric) appear viable; Eight lymph nodes, no diagnostic abnormalities recognized Pt was discovered to have fungemia along with MRSA and was eventually started on levofloxacin, flagyl, vancomycin and caspofungin. Pt developed respiratory distress while in VICU and was eventually transferred back to the SICU on [**2161-5-28**]. [**2161-5-28**]: CT abd/pelvis with contrast 1. Interval development of a large amount of intra-abdominal ascites with a large air-fluid level, containing multiple foci of air. This finding is concerning for anastamotic breakdown. 2. Status post near total small bowel resection with left mid abdomen jejunostomy and left colon mucous fistula. 3. Celiac and SMA, and infrarenal aortic stents with left iliac to superior mesenteric arterial graft consistent with the patient's history of chronic mesenteric ischemia with multiple revascularization procedures. 4. Increased size of moderate pleural effusions and associated compressive atelectasis. 5. Heterogeneous hypodense lesion within the inferior aspect of the posterior right lobe of the liver, incompletely characterized, but unchanged in size and appearance from the [**2161-5-21**] scan. 6. Probable right adrenal adenoma; however, this finding is incompletely characterized without a non-contrast CT scan. 7. Interval resolution of the mild biliary ductal dilatation. 8. Aneurysmal dilatation of the left femoral artery, stable. 9. Interval increase in size of moderate pleural effusions with associated compressive atelectasis, left greater than right. [**2161-5-28**]: Abdominal US revealed free fluid and he was taken back to OR for ex-lap washout, repair of perforated stomach, and G tube removal. He returned to SICU post-op and was aggressively fluid resuscitated and placed on levophed. His SICU stay was complicated by multiple episodes of worsening respiratory status that required intubations, increased respiratory secretions and fever. [**2161-6-2**]: Unilateral upper extremity vein US Nonocclusive thrombus in the right internal jugular vein [**2161-6-3**]: Flexible bronchoscopy with BAL, protected brush and therapeutic aspiration of secretions. A small amount of thick secretions in the right bronchus intermedius; protected specimen brushing was performed in the right bronchus intermedius; BAL was performed in the right middle lobe. [**2161-6-4**]: Cardiac echo RIGHT ATRIUM/INTERATRIAL SEPTUM: The IVC is normal in diameter with appropriate phasic respirator variation. LEFT VENTRICLE: Overall normal LVEF (>55%). AORTIC VALVE: ?# aortic valve leaflets. No AS. No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor echo windows. Suboptimal image quality - poor parasternal views. Suboptimal image quality - poor apical views. Conclusions: Overall left ventricular systolic function is normal (LVEF 60%). The number of aortic valve leaflets cannot be determined. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. [**2161-6-12**]: Successful placement of a dual-lumen 45 cm [**First Name8 (NamePattern2) **] [**Last Name (un) **] catheter with the tip terminating in the superior vena cava; to be used for TPN, IVF, antibiotics Throughout the course of his stay, his nutriton was given in the form of tube feeds and TPN, which was closely followed by the Nutrition staff. Physical therapy evaluation demonstrated below baseline function for ambulation and ADLs. They recommend that patient goes to rehabilitation to optimize his physical abilities prior to returning home. Medications on Admission: Plavix 75mg [**Hospital1 **], Lipitor 20mg Daily, Folate 1mg daily, ASA 325mg daily, B complex daily, Omeprazole 20mg daily, sucralfate 2gm [**Hospital1 **] Discharge Medications: Pantoprazole 40 mg IV Q12H Metoprolol 15 mg IV Q6H Fondaparinux *NF* 2.5 mg/0.5 mL Subcutaneous daily HIT+ Caspofungin 50 mg IV Q24H Insulin Sliding Scale Total Parenteral Nutrition Albuterol-Ipratropium [**12-1**] PUFF IH Q6H:PRN Albuterol [**12-1**] PUFF IH Q4H:PRN Ipratropium Bromide Neb 1 NEB IH Q6H wheeze Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN wheeze Lorazepam 0.5-2 mg IV Q4H:PRN Morphine Sulfate 2 mg IV Q4H:PRN Acetaminophen 325-650 mg PO/PR Q4-6H:PRN DiphenhydrAMINE HCl 25 mg IV Q6H:PRN pruritis Potassium Chloride 20 mEq / 50 ml SW IV PRN K < 3.5 Magnesium Sulfate 2 gm / 100 ml NS IV PRN Mg < 2.0 Calcium Gluconate 2 gm / 100 ml D5W IV PRN iCa < 1.10 Discharge Disposition: Extended Care Facility: Rehabilitation Facility Discharge Diagnosis: Chronic mesenteric ischemia Discharge Condition: Good Discharge Instructions: Rehabilitation; Peripherally Inserted Central Catheter (PICC) line in place - use for fluids, appropriate medications and Total Parenteral Nutrition; encourage out of bed, ambulation and physical therapy. Followup Instructions: Please call Dr. [**First Name4 (NamePattern1) 333**] [**Last Name (NamePattern1) **] office at [**Hospital1 18**] for follow-up appointment. Please contact Primary [**Name2 (NI) **] Physician at [**Name (NI) 40126**] community hospital for follow-up appointment.

[ "998.59", "996.74", "568.81", "428.0", "285.9", "518.5", "557.1", "998.2", "486", "492.8", "998.11", "997.3" ]

icd9cm

[ [ [] ] ]

[ "99.15", "45.63", "39.49", "43.19", "54.12", "46.39", "96.72", "45.73", "46.11", "38.93", "45.62", "39.32", "33.24", "39.26" ]

icd9pcs

[ [ [] ] ]

16413, 16463

10006, 15511

360, 1018

16535, 16541

2094, 9983

16794, 17061

15719, 16390

16484, 16514

15537, 15696

16565, 16771

1647, 2075

235, 322

1046, 1291

1313, 1544

1560, 1632

14,038

195,274

6838

Discharge summary

report

Admission Date: [**2137-10-24**] Discharge Date: [**2137-11-2**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3913**] Chief Complaint: shortness of breath/fatigue Major Surgical or Invasive Procedure: pheresis catheter placement thoracentesis leukopheresis History of Present Illness: 81 yo M with T-cell positive CLL (flow cytometry [**2137-5-20**] revealed expanded, abnormal T-cell population consistent with high grade T-cell lymphoproliferation) s/p leukophoresis x3 at [**Hospital6 **] (last [**10-23**]), h/o resected chest wall melenoma, and DM presents with WBC count of 678 requiring emergent leukophoresis and hypoxia (O2 sat 75% on RA). He notes increased fatigue and shortness of breath this am. He reports decreased appetite x2 weeks. He denies fever, chills, cough, chest pain, belly pain, N/V/D, dysuria. Of note he was started on Fludarabine this week; he received a dose on Mon, Tues, and Weds. . Since [**5-5**] pt has had an increased WBC count and bilateral pleural effusions. He was treated in [**Month (only) 205**]-[**Month (only) 216**]-[**Month (only) 359**] with Pentostatin which initially controlled his wbc count, however, recently his WBC count has increased to over 600K requiring 3 sessions of leukophoresis to date. He was started on fludarabine last week. . In the [**Name (NI) **] pt noted to be SOB with RA O2 sat of 75%, improved to 95% on a NRB. He was given combivent and Solumedrol. CT Chest revealed large right-sided pleural effusion with near total collapse of RLL and partial collapse of RML, Smaller left-sided pleural effusion with associated compressive atelectasis. (He was given mucomyst and bicarb prior to the contrast CT). . Pt was evaluated by the BMT service. Plt count noted to be 26K (baseline ~30K recently). He received 2 bags of plts with an increase in his plt count to 55 and vit k x1. He underwent a thoracentesis by Dr. [**Last Name (STitle) **] with 1.5 liters of serosanginous fluid removed. He had a phoresis catheder placed in his right groin by general surgery. Post-procedure CXR revealed improvement in right effusion w/o PTX. His K was noted to be 6.3 without ECG changes; he received kayexalate. Upon arrival to the [**Hospital Unit Name 153**] he was started on leukophoresis by the transfusion service. Past Medical History: - T cell leukemia with flow cytometry compatible with a pro lymphocytic leukemia; morphology and performance looks more like chronic lymphocytic leukemia - h/o left sided chest wall melanoma recently resected w/out apparent metastases (Nodal dissections not carried out; Metastatic work up negative to date) - diabetes - h/o right knee arthritis Social History: Denies current tob or illicit drug use. Quit tob 21 yrs ago; previously smoked 2ppd. EtOH - One drink per week. Married x58 yrs; lives with his wife. Family History: Mother died at 86 of Alzheimer's. Father died at 52 of an accident. Brother died at 67 of lung cancer. Sister age 71, alive and well. Physical Exam: Tc 97.5 BP 124/58 HR 86 RR 14 Sat 97% NRB Gen: pleasant elderly appearing male, NAD HENNT: MMM, anicteric, PERRL, EOMI Neck: no LAD, no JVD CV: RRR, nl S1S2, No M/R/G Lungs: anteriorly - decreased breath sounds right base o/w clear Abd: soft, NT/ND, +BS, + splenomegaly Ext: no edema, strong DP/PT pulses bilaterally, phoresis cath in right groin w/o hematoma Neuro: A&Ox3, moving all extremeties Pertinent Results: REPORTS: [**10-23**] Plural fluid cytology: Monomorphic population of small lymphocytes, consistent with involvement by low grade lymphoma. . [**10-25**] FLOW CYTOMETRY REPORT: INTERPRETATION: Immunophenotypic findings consistent with involvement by: A T-cell lymphoproliferative disorder, CD4 positive, with aberrant loss of pan-T marker CD3. . CT Chest [**2137-10-24**]: 1. No evidence of pulmonary embolism. 2. Large right-sided pleural effusion with near total collapse of the RLL and partial collapse of the RML. Smaller left-sided pleural effusion with associated compressive atelectasis. 3. Mediastinal and axillary lymph nodes as described above. 4. Apparent ascites. 5. Tiny hypodense lesion in the liver is incompletely evaluated. 6. Splenomegaly. . CXR [**2137-10-26**]: Cardiomegaly, Bilateral pleural effusions (R>L) with hazy parenchymal opacity over the right mid lung zone. . CT Abd [**2137-10-21**]: Massive splenomegaly, increased in size compared to prior exam. Development of small amount of ascites seen adjacent to the liver and spleen. Left renal cyst present. Numerous diverticula present in the sigmoid colon, unchanged. There is some fascia plane thickening present surrounding the sigmoid colon. There is no evidence of bowel obstruction present. . CXR (s/p first thoracentesis) [**2137-10-24**]: No PTX, improvement in right pleural fluid . ECG: NSR, rate 98, nl intervals, nl axis, no ST-T changes . [**10-30**] CXR: IMPRESSION: AP chest compared to [**10-28**] and 29. Moderate-sized right pleural effusion is reaccumulating. Small left pleural effusion and left basal atelectasis are stable. Heart size is normal. No pneumothorax. . [**11-1**] CXR (s/p second thoracentesis): IMPRESSION: Decrease in right pleural effusion following thoracentesis with no evidence of pneumothorax. . LABS: [**2137-11-2**] 06:55AM BLOOD WBC-216.6* RBC-2.73* Hgb-8.4* Hct-25.9* MCV-95 MCH-30.9 MCHC-32.5 RDW-22.9* Plt Ct-35* [**2137-11-1**] 07:10AM BLOOD WBC-195.7* RBC-2.86* Hgb-9.0* Hct-26.1* MCV-91 MCH-31.6 MCHC-34.6 RDW-21.4* Plt Ct-50* [**2137-10-31**] 06:57AM BLOOD WBC-204.4* RBC-2.46*# Hgb-8.3*# Hct-23.4* MCV-95 MCH-33.7* MCHC-35.4* RDW-23.1* Plt Ct-41* [**2137-10-30**] 11:21AM BLOOD Hct-21.0* Plt Ct-52* [**2137-10-30**] 01:42AM BLOOD Hct-19.5* [**2137-10-30**] 12:13AM BLOOD WBC-203.6* RBC-1.96* Hgb-6.4* Hct-19.0*# MCV-97 MCH-32.5* MCHC-33.5 RDW-23.5* Plt Ct-26* [**2137-10-29**] 01:05AM BLOOD WBC-237.2* Hct-29.0*# Plt Ct-21* [**2137-10-28**] 01:43PM BLOOD WBC-223.3* Hct-22.0* Plt Ct-21* [**2137-10-28**] 03:52AM BLOOD WBC-209.7* Hct-24.0* Plt Ct-20* [**2137-10-27**] 04:51PM BLOOD WBC-200.7* Hct-24.0* Plt Ct-24* [**2137-10-27**] 03:49PM BLOOD WBC-186.0* [**2137-10-27**] 01:44PM BLOOD WBC-237.0* [**2137-10-27**] 02:30AM BLOOD WBC-288.9* RBC-2.42* Hgb-7.9* Hct-23.8* MCV-98 MCH-32.5* MCHC-33.1 RDW-23.6* Plt Ct-29* [**2137-10-26**] 04:20PM BLOOD WBC-263.1* Hct-23.5* Plt Ct-28* [**2137-10-26**] 11:56AM BLOOD Hct-23.9* [**2137-10-26**] 03:49AM BLOOD WBC-223.0* RBC-2.57* Hgb-8.5* Hct-24.6* MCV-96 MCH-33.1* MCHC-34.6 RDW-23.8* Plt Ct-26* [**2137-10-25**] 09:14PM BLOOD WBC-201.6* RBC-2.11* Hgb-7.2* Hct-21.0* MCV-100* MCH-34.0* MCHC-34.2 RDW-22.2* Plt Ct-30* [**2137-10-25**] 07:28PM BLOOD WBC-242.6* [**2137-10-25**] 05:42PM BLOOD WBC-322.5* [**2137-10-25**] 03:18PM BLOOD WBC-316.0* RBC-2.5* Hgb-8.2* Hct-25.2*# MCV-100* MCH-32.7* MCHC-32.5# RDW-22.6* Plt Ct-46* [**2137-10-25**] 05:07AM BLOOD WBC-375.4* Hct-35.0* Plt Ct-53* [**2137-10-25**] 03:45AM BLOOD WBC-342.0* [**2137-10-25**] 01:49AM BLOOD WBC-422.9* [**2137-10-25**] 12:24AM BLOOD WBC-528.0* Hct-38.0*# Plt Ct-79* [**2137-10-24**] 01:30PM BLOOD WBC-678*# Hct-28* Plt Ct-26*# [**2137-11-1**] 07:10AM BLOOD Neuts-1* Bands-0 Lymphs-88* Monos-0 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 Other-11* [**2137-10-30**] 12:13AM BLOOD Neuts-3* Bands-0 Lymphs-22 Monos-1* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 Other-74* [**2137-10-29**] 01:05AM BLOOD Neuts-3* Bands-0 Lymphs-19 Monos-0 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 Other-78* [**2137-10-28**] 03:52AM BLOOD Neuts-2* Bands-0 Lymphs-17* Monos-0 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 Other-81* [**2137-10-27**] 02:30AM BLOOD Neuts-1* Bands-0 Lymphs-11* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 Other-86* [**2137-10-26**] 04:20PM BLOOD Neuts-3* Bands-0 Lymphs-22 Monos-0 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 Other-75* [**2137-10-26**] 03:49AM BLOOD Neuts-2* Bands-0 Lymphs-16* Monos-1* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 Promyel-81* [**2137-10-25**] 05:07AM BLOOD Neuts-1* Bands-0 Lymphs-23 Monos-0 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 Other-76* [**2137-10-25**] 12:24AM BLOOD Neuts-2* Bands-0 Lymphs-0 Monos-0 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 Other-98* [**2137-11-2**] 06:55AM BLOOD Plt Ct-35* [**2137-11-2**] 06:55AM BLOOD PT-13.2 PTT-23.1 INR(PT)-1.2 [**2137-11-1**] 07:10AM BLOOD Plt Ct-50* [**2137-11-1**] 07:10AM BLOOD PT-12.5 PTT-24.4 INR(PT)-1.0 [**2137-10-31**] 06:57AM BLOOD Plt Ct-41* [**2137-10-31**] 04:49AM BLOOD PT-13.0 PTT-23.8 INR(PT)-1.1 [**2137-10-30**] 11:21AM BLOOD Plt Ct-52* [**2137-10-30**] 05:38AM BLOOD Plt Ct-47*# [**2137-10-30**] 12:13AM BLOOD Plt Ct-26* [**2137-10-30**] 12:13AM BLOOD PT-12.9 PTT-25.9 INR(PT)-1.1 [**2137-10-29**] 01:05AM BLOOD Plt Ct-21* [**2137-10-29**] 01:05AM BLOOD PT-13.1 PTT-28.2 INR(PT)-1.2 [**2137-10-28**] 01:43PM BLOOD Plt Ct-21* [**2137-10-28**] 03:52AM BLOOD Plt Ct-20* [**2137-10-28**] 03:52AM BLOOD PT-13.3 PTT-25.9 INR(PT)-1.2 [**2137-10-27**] 04:51PM BLOOD Plt Ct-24* [**2137-10-27**] 04:51PM BLOOD PT-13.6* PTT-24.5 INR(PT)-1.2 [**2137-10-27**] 02:30AM BLOOD Plt Smr-VERY LOW Plt Ct-29* [**2137-10-27**] 02:30AM BLOOD PT-13.2 PTT-21.7* INR(PT)-1.2 [**2137-10-26**] 04:20PM BLOOD Plt Smr-VERY LOW Plt Ct-28* [**2137-10-26**] 04:20PM BLOOD PT-13.3 PTT-22.1 INR(PT)-1.2 [**2137-10-26**] 03:49AM BLOOD Plt Ct-26* [**2137-10-26**] 03:49AM BLOOD PT-13.5* PTT-21.7* INR(PT)-1.2 [**2137-10-25**] 09:14PM BLOOD Plt Ct-30* [**2137-10-25**] 03:18PM BLOOD Plt Ct-46* [**2137-10-25**] 03:18PM BLOOD PT-13.9* PTT-23.7 INR(PT)-1.3 [**2137-10-25**] 05:07AM BLOOD Plt Ct-53* [**2137-10-25**] 05:07AM BLOOD PT-14.1* PTT-22.8 INR(PT)-1.3 [**2137-10-25**] 12:24AM BLOOD Plt Ct-79* [**2137-10-25**] 12:24AM BLOOD PT-13.8* PTT-21.2* INR(PT)-1.3 [**2137-10-24**] 01:30PM BLOOD Plt Ct-26*# [**2137-10-24**] 01:30PM BLOOD PT-14.2* PTT-26.2 INR(PT)-1.4 [**2137-10-28**] 03:52AM BLOOD FDP-40-80 [**2137-10-28**] 03:52AM BLOOD Fibrino-83* [**2137-10-27**] 04:51PM BLOOD FDP-40-80 [**2137-10-27**] 04:51PM BLOOD Fibrino-93* [**2137-10-27**] 02:30AM BLOOD FDP-80-160* [**2137-10-27**] 02:30AM BLOOD Fibrino-78* D-Dimer-7560* [**2137-10-26**] 04:20PM BLOOD Fibrino-69* [**2137-10-26**] 03:49AM BLOOD FDP-10-40 [**2137-10-26**] 03:49AM BLOOD Fibrino-64* [**2137-10-25**] 03:18PM BLOOD Fibrino-83* [**2137-10-25**] 05:07AM BLOOD FDP-10-40 [**2137-10-25**] 05:07AM BLOOD Fibrino-78* D-Dimer-2398* [**2137-10-25**] 12:24AM BLOOD FDP-10-40 [**2137-10-25**] 12:24AM BLOOD Fibrino-98* D-Dimer-2056* [**2137-11-2**] 06:55AM BLOOD Gran Ct-3130 [**2137-11-1**] 07:10AM BLOOD Gran Ct-3870 [**2137-10-26**] 03:49AM BLOOD Ret Aut-1.9 [**2137-11-2**] 06:55AM BLOOD Glucose-90 UreaN-24* Creat-1.0 Na-141 K-3.8 Cl-106 HCO3-28 AnGap-11 [**2137-11-1**] 07:10AM BLOOD Glucose-94 UreaN-28* Creat-0.9 Na-143 K-3.6 Cl-107 HCO3-30 AnGap-10 [**2137-10-31**] 04:49AM BLOOD Glucose-107* UreaN-35* Creat-1.0 Na-142 K-3.7 Cl-106 HCO3-29 AnGap-11 [**2137-10-30**] 12:13AM BLOOD Glucose-114* UreaN-31* Creat-1.0 Na-141 K-4.0 Cl-105 HCO3-31 AnGap-9 [**2137-10-29**] 01:05AM BLOOD Glucose-187* UreaN-29* Creat-1.0 Na-141 K-3.9 Cl-105 HCO3-31 AnGap-9 [**2137-10-28**] 03:52AM BLOOD Glucose-122* UreaN-28* Creat-1.0 Na-143 K-4.0 Cl-105 HCO3-34* AnGap-8 [**2137-10-27**] 04:51PM BLOOD Glucose-131* K-3.8 [**2137-10-27**] 02:30AM BLOOD Glucose-102 UreaN-31* Creat-1.0 Na-144 K-4.3 Cl-106 HCO3-32 AnGap-10 [**2137-10-26**] 04:15PM BLOOD K-3.9 [**2137-10-26**] 03:49AM BLOOD Glucose-112* UreaN-31* Creat-1.1 Na-145 K-3.5 Cl-104 HCO3-34* AnGap-11 [**2137-10-25**] 03:18PM BLOOD Glucose-156* UreaN-31* Creat-1.3* Na-144 K-3.9 Cl-104 HCO3-32 AnGap-12 [**2137-10-25**] 05:07AM BLOOD Glucose-169* UreaN-27* Creat-1.5* Na-144 K-3.7 Cl-103 HCO3-32 AnGap-13 [**2137-10-25**] 12:24AM BLOOD Glucose-195* UreaN-28* Creat-1.6* Na-143 K-4.2 Cl-103 HCO3-29 AnGap-15 [**2137-10-24**] 02:00PM BLOOD K-4.6 [**2137-10-24**] 01:30PM BLOOD Glucose-135* UreaN-23* Creat-1.7* Na-142 K-5.2* Cl-104 HCO3-28 AnGap-15 [**2137-11-2**] 06:55AM BLOOD ALT-15 AST-33 LD(LDH)-794* AlkPhos-82 TotBili-0.8 [**2137-11-1**] 07:10AM BLOOD ALT-15 AST-26 LD(LDH)-654* AlkPhos-86 TotBili-0.8 [**2137-10-31**] 04:49AM BLOOD ALT-13 AST-26 LD(LDH)-649* AlkPhos-82 TotBili-0.8 [**2137-10-30**] 12:13AM BLOOD ALT-14 AST-24 LD(LDH)-567* AlkPhos-72 TotBili-0.4 [**2137-10-29**] 01:05AM BLOOD ALT-15 AST-23 LD(LDH)-551* AlkPhos-73 TotBili-0.4 [**2137-10-28**] 03:52AM BLOOD LD(LDH)-626* [**2137-10-27**] 04:51PM BLOOD LD(LDH)-635* [**2137-10-26**] 03:49AM BLOOD LD(LDH)-605* TotBili-0.8 DirBili-0.3 IndBili-0.5 [**2137-10-25**] 05:07AM BLOOD LD(LDH)-800* TotBili-0.5 [**2137-10-25**] 12:24AM BLOOD ALT-23 AST-39 LD(LDH)-952* AlkPhos-97 TotBili-0.6 [**2137-11-2**] 06:55AM BLOOD Albumin-3.0* Calcium-7.5* Phos-2.9 Mg-2.0 UricAcd-2.6* [**2137-11-1**] 07:10AM BLOOD Albumin-3.3* Calcium-7.4* Phos-3.3 Mg-2.1 UricAcd-2.7* [**2137-10-31**] 04:49AM BLOOD Albumin-2.9* Calcium-7.2* Phos-4.0 Mg-2.1 UricAcd-2.4* [**2137-10-30**] 12:13AM BLOOD Albumin-2.6* Calcium-6.8* Phos-4.0 Mg-2.2 UricAcd-2.1* [**2137-10-29**] 01:05AM BLOOD Albumin-2.9* Calcium-7.0* Phos-3.6 Mg-2.0 UricAcd-2.1* [**2137-10-28**] 03:52AM BLOOD Calcium-7.5* Phos-3.8 Mg-2.1 [**2137-10-27**] 04:51PM BLOOD Calcium-7.7* Phos-3.8 Mg-1.9 UricAcd-2.1* [**2137-10-27**] 02:30AM BLOOD Calcium-7.3* Phos-4.4 Mg-2.0 [**2137-10-26**] 03:49AM BLOOD Calcium-7.6* Phos-5.2* Mg-1.9 UricAcd-2.8* [**2137-10-25**] 03:18PM BLOOD Calcium-7.5* Phos-5.1* Mg-2.0 [**2137-10-25**] 05:07AM BLOOD Calcium-8.3* Phos-5.7* Mg-2.1 UricAcd-3.1* [**2137-10-25**] 12:24AM BLOOD TotProt-5.9* Albumin-3.6 Globuln-2.3 Calcium-8.0* Phos-5.6*# Mg-2.1 UricAcd-3.2* [**2137-10-30**] 12:13AM BLOOD Hapto-54 [**2137-10-26**] 03:49AM BLOOD Hapto-44 [**2137-10-25**] 05:30PM BLOOD Type-[**Last Name (un) **] pH-7.42 [**2137-10-24**] 02:14PM BLOOD Lactate-1.5 K-6.3* [**2137-10-25**] 05:30PM BLOOD freeCa-1.00* . MICRO: . [**2137-10-24**] 1:30 pm BLOOD CULTURE VENIPUNCTURE #1. **FINAL REPORT [**2137-10-30**]** AEROBIC BOTTLE (Final [**2137-10-30**]): NO GROWTH. ANAEROBIC BOTTLE (Final [**2137-10-30**]): NO GROWTH. . [**2137-10-24**] 11:00 pm PLEURAL FLUID GRAM STAIN (Final [**2137-10-25**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2137-10-28**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2137-10-31**]): NO GROWTH. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. ACID FAST SMEAR (Final [**2137-10-25**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Pending): Brief Hospital Course: 81 yo M with T-cell positive CLL s/p leukophoresis x3 at NEBH, h/o melenoma, and DM who presented with WBC count of 678 requiring emergent leukophoresis, and hypoxia secondary to pleural effusions. . #) Leukocytosis (600K) secondary to T-cell positive CLL: Pt had a leukophoresis catheter placed in his right groin by surgery. He then underwent emergent leukophoresis, with good response, and was admitted to the ICU. He was leukophoresed a total of 3 times during the admission. He also underwent chemo with cytoxan and fludarabine, and tolerated this well. His WBC count decreased to 216.6 on the day of discharge, and he did not have any signs of tumor lysis syndrome. Pt's pleural fluid was negative for infection, fluid WBC count was elevated, and cytology was c/w low grade lymphoma. Pt was continued on allopurinol, although at a lower dose given elevated creatinine on admission. The day before discharge, the pt's leukophoresis catheter was removed by surgery, with adequate hemostasis. Pt was instructed to follow up with his oncologist immediatley after discharge to discuss the possible administration of neupogen or nulasta. . #) Hypoxia: Pt was satting in 70's upon arrival to the ED, likely secondary to large right sided pleural effusion and leukostasis. Pt underwent a diagnostic/therapeutic thoracentesis in the ED (fluid non-infectious, but malignant), and then had reaccumulation of the R sided fluid seen on CXR over the next several days. He then had a second therapeutic thoracentesis, and 1700 cc of serosanguinous fluid was removed from his R lung. On the day of discharge, the pt was satting well on room air. CXR the day before d/c did not show a pneumothorax s/p thoracentesis. . #) Acute Renal Failure, Cr 1.7 on admission (baseline Creat 0.9): Was likely secondary to leukostasis. - pt was given bicarb and mucomyst prior to chest CT - pt was hyrdated gently and Cr decreased to 1.0 on day of discharge . #) DM: Pt's metformin was held during the admisssion and on discharge. His blood sugars were controlled with sliding scale insulin. . #) Anemia/Thrombocytopenia related to CLL and chemo: Pt has received procrit with Pentostatin in the past. He was supported during this admission with blood and platelet transfusions (total 4 U PRBC's, 5 U platelets), with goal platelets >50 before procedures and goal hct>25. Pt bumped appropriately s/p blood and platelet transfusions. Medications on Admission: -Metformin 500 mg p.o. daily -Allopurinol 300 mg p.o. daily -Cozaar 50 mg p.o. daily -s/p Pentostatin 2-4 per meter squared q1-2 wks x2-3 mos with procrit -s/p Cytoxan 500 mg per meter squared Discharge Medications: 1. Losartan 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Discharge Disposition: Home Discharge Diagnosis: CLL pleural effusions Discharge Condition: Stable. Satting in mid 90's on RA. Ambulating. Discharge Instructions: Please seek medical attention immediately if you experience fatigue, chest pain, shortness of breath, nausea, vomiting, fevers, or chills. Please take all medications as prescribed. Please do not take your metformin until you see Dr. [**Last Name (STitle) **] on Monday. Please attend all follow-up appointments. You should call your oncologist, Dr. [**Last Name (STitle) **], as soon as you get home to make a follow-up appointment for this Monday morning. You had chemotherapy with cytoxan and fludarabine during the admission, and you might need a shot of Neupogen or Neulasta on Monday. You should discuss this with Dr. [**Last Name (STitle) **]. You should also follow up with the lung doctors to discuss [**Name5 (PTitle) **] to manage the fluid in your lungs. Followup Instructions: Please call your oncologist, Dr. [**Last Name (STitle) **], as soon as you get home to make a follow-up appointment for monday. Please follow-up with the lung doctors (clinic phone # [**Telephone/Fax (1) 612**]) to further discuss the treatment for the fluid in your lungs. Please call your PCP on [**Name9 (PRE) 766**] to make a follow-up appointment. Completed by:[**2137-11-6**]

[ "276.7", "584.9", "202.80", "204.10", "518.82", "518.0", "288.8", "998.12", "511.8", "V10.82", "287.5", "250.00", "401.9" ]

icd9cm

[ [ [] ] ]

[ "34.91", "38.93", "99.25", "99.28", "99.05", "99.04", "99.72" ]

icd9pcs

[ [ [] ] ]

17433, 17439

14609, 17034

292, 349

17505, 17554

3535, 14403

18374, 18760

2944, 3082

17278, 17410

17460, 17484

17060, 17255

17578, 18351

3097, 3516

14436, 14555

14586, 14586

224, 254

377, 2388

2410, 2758

2774, 2928

19,155

194,765

53426

Discharge summary

report

Admission Date: [**2173-8-2**] Discharge Date: [**2173-8-6**] Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Cephalosporins Attending:[**First Name3 (LF) 317**] Chief Complaint: syncopal episode at rehab center Major Surgical or Invasive Procedure: none History of Present Illness: 88 yo M with a history of CABG ([**2153**]) and perioperative MI ([**2171**]) brought to ED after syncopal event at rehab. Pt reports that after having a bowel movement this morning, he became dizzy and lightheaded, relieved with a few minutes of rest. He is unable to provide further details of the event, but aides at [**Hospital 100**] Rehab indicated that he seemed to fall toward the right, although they were there to hold him up and he did not actually fall. There was no loss of bowel or bladder control and no shaking movements. . In the ED, he was noted to have frequent ventricular ectopy. . On review of symptoms, he has had a history of a small stroke in [**2147**]. Also he had PE in [**2153**]. All of the other review of systems were negative. Cardiac review of systems is notable for absence paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: Cardiac: CABG 4 vessel [**2153**] in [**State 760**], complicated by PE CVA [**2147**], no residual weakness, decreased memory Hypertension Hyperlipidemia CHF EF 30-35% Aortic stenosis (valve area ~0.9-1.2) Mitral and tricuspid regurgitation Pulmonary htn Generalized anxiety disorder Osteoarthritis Chronic right heel ulcer COPD DM2 Depression History of SBO S/P appy S/P cholecystectomy [**2167**] BPH TURP [**2151**] History of Esophagitis Hemorrhoids [**2171**] Hip fracture [**11/2172**], repair Dementia . Cardiac Risk Factors: (+)Diabetes, +Dyslipidemia, +Hypertension . Cardiac History: CABG, in [**2153**] anatomy unknown . Percutaneous coronary intervention: none known Social History: Social history is significant for the history of tobacco use (approx 50 pack year). There is no history of alcohol abuse. Family History: He reports that his sister had an MI at age 88. Physical Exam: VS: T 98.4, BP 104/78, HR 88, RR20 , O297 % on 2L Gen: Elderly male in NAD, resp or otherwise. A+Ox3 with prompting. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. Neck: Supple with JVP of 10cm. CV: PMI located in 5th intercostal space, midclavicular line. Occ irreg beats with 2/6 high pitched systolic murmur at the apex and [**1-12**] harsh murmur at RUSB. No S4, no S3. Chest: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Faint basilar crackles, rhonchi on the L lower field Abd: Obese, soft, NTND, No HSM or tenderness. No abdominial bruits. Ext: No c/c/e. Skin: Right heel with large (2cm) circular area with black scab. No surronding erythema, no signficant tenderness surronding Pulses: Right: Carotid 2+ without bruit; 1+ DP 1+ PT [**Name (NI) 2325**]: Carotid 2+ without bruit; 1+ DP 1+ PT Pertinent Results: [**2173-8-2**] 11:16AM WBC-10.1 RBC-4.11* HGB-13.3* HCT-39.5* MCV-96 MCH-32.4* MCHC-33.8 RDW-15.1 [**2173-8-2**] 11:16AM NEUTS-79.2* BANDS-0 LYMPHS-14.7* MONOS-4.8 EOS-0.7 BASOS-0.5 [**2173-8-2**] 11:16AM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2173-8-2**] 11:16AM PLT SMR-NORMAL PLT COUNT-374 [**2173-8-2**] 11:16AM PT-14.4* PTT-31.5 INR(PT)-1.3* [**2173-8-2**] 11:16AM GLUCOSE-171* UREA N-20 CREAT-1.1 SODIUM-138 POTASSIUM-4.8 CHLORIDE-100 TOTAL CO2-27 ANION GAP-16 [**2173-8-2**] 11:16AM CK-MB-NotDone cTropnT-0.03* [**2173-8-2**] 11:16AM CK(CPK)-54 [**2173-8-2**] 05:45PM CK-MB-NotDone [**2173-8-2**] 05:45PM cTropnT-0.09* [**2173-8-2**] 05:45PM CK(CPK)-33* [**2173-8-3**] 07:15AM BLOOD CK(CPK)-29* [**2173-8-3**] 07:15AM BLOOD CK-MB-NotDone cTropnT-0.06* Admission CXR: AP and lateral views of the chest are obtained. Midline sternotomy wires and mediastinal clips are noted, likely related to prior CABG. There has been interval resolution of previously noted airspace opacity in the right lower lung. There is, however, persistent blunting of the CP angles, which may reflect small bilateral pleural effusions. The heart is enlarged. The mediastinal contour is stable. Calcification noted along the aortic knob. There is no pneumothorax. The previously noted PICC line has been removed. IMPRESSION: 1. Cardiomegaly, small bilateral pleural effusions. 2. Interval resolution of right lower airspace opacity. Brief Hospital Course: 88 yo M with severe AS, CAD s/p CABG (88) and COPD who presents with syncopal episode . # Respiratory distress: On hospital day 4, after eating supper, patient became dyspneic with audible wheezing and rhonchi and crackles throughout bilateral lung fields. Patient was transferred to the coronary care unit for closer monitoring. Lasix was given to treat possible pulmonary edema. Chest xray was concerning for aspiration, and antibiotics were started. However, patient became progressively more hypercarbic and developed recurrent ventricular tachycardia, thus suffering simultaneous cardiac and respiratory arrest. . #)Cardiac: a)CAD: on ASA, plavix, beta blocker. b)Valves: Aortic stenosis: valve area 0.9-1.2. Also has mitral regurgitation, tricuspid regurgitation. Not a candidate for valve surgery because of low EF. c) Pump: history of systolic heart failure with EF 35%. Continued lasix daily with lasix boluses prn. d) Rhythm: SR with ventricular ectopy: likely that run of NSVT or SVT, superimposed on his severe AS, lead to his syncope. On telemetry here, had frequent ventricular premature complexes, couplets, triplets, and runs of ventricular tachycardia. Potassium and magnesium were repleted, beta blockade was maintained as blood pressure tolerated, and amiodarone was started. On HD#2, patient had 15 minutes of sustained ventricular tachycardia, hemodynamically stable, so amiodarone infusion was begun, with control of the VT. Over the next 24 hours, ventricular ectopy decreased in frequency but did persist. Electrophysiology consult advised against EP study, which would be high risk in a patient with aortic stenosis and would not be consistent with patient's wishes to be DNR/DNI and avoid invasive procedures, which the EP consultants discussed with the [**Hospital 228**] healthcare proxy. On HD#4, immediately after an apparent aspiration event described above, patient again developed sustained VT and subsequently expired. . #) Hypertension/hyperlipidemia: currently not hypertensive, will give metoprolol. Hold ACE as pt likely to get more benefit from BB. Continue statin . #) Right heel ulcer: Recent arterial studies showed poor flow in right lower extremity arteries. Has severe ulceration of right heel and is getting aggressive wound care at rehab per daughter. [**Name (NI) 109876**] [**Name2 (NI) **] and wound care as recommended by wound nurse. . #) Diabetes: with elevated fasting glucose. - continued insulin sliding scale. - diabetic diet . #) COPD: continue inhalers - alb/ipratropium prn . #) Aspiration risk: S & S last admission recommended modified diet of nectar thick liquids with the chin tuck and ground consistency solids with the knowledge that he may intermittently aspirate. . # FEN: Euvolemic, lytes pending, nutrition with cardiac diet. # PPX: heparin sc, ppi # DNR/I (discussed with daughter) # dispo: pending improvement in symptoms. # Comm: with health care proxy, his daughter [**Name (NI) 1494**] [**Name (NI) **] [**Telephone/Fax (1) 109875**] Medications on Admission: Acetaminophen 650 TID Aspirin 81 mg damily Calcium carbonate 650 mg tab [**Hospital1 **] Vit D 1000U Qday pantoprazole 40mg [**Hospital1 **] Citalopram 40 mg daily Furosemide 40 mg daily simvastatin 80 mg captopril 6.25 [**Hospital1 **] metoprolol 12.5 [**Hospital1 **] and 6.25 at 2pm Nitroglycerin 0.4 mg prn Oxycodone prn Fluticasone/salmeterol 250/50 [**Hospital1 **] Albuterol/ipratropium neb Tiotropium 18mcg daily Discharge Medications: n/a Discharge Disposition: Expired Discharge Diagnosis: coronary artery disease aortic stenosis congestive heart failure ventricular tachycardia hypertension hyperlipidemia Discharge Condition: deceased Discharge Instructions: n/a Followup Instructions: n/a

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8106, 8115

4593, 7606

275, 281

8276, 8286

3069, 4570

8338, 8344

2071, 2120

8078, 8083

8136, 8255

7632, 8055

8310, 8315

2135, 3050

203, 237

309, 1211

1233, 1916

1932, 2055

54,716

122,152

38798

Discharge summary

report

Admission Date: [**2155-3-16**] Discharge Date: [**2155-3-16**] Date of Birth: [**2089-11-25**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 618**] Chief Complaint: Unresponsiveness Major Surgical or Invasive Procedure: None History of Present Illness: HPI: The pt is a 65 year-old right-handed male, w/ hx of hypertension, dyslipidemia, DM, who presents with an acute episode of altered mental status earlier this morning. According to his wife, pt woke up at 6:30am and began to complain of eye pain and became very pale, then began vomiting multiple times. He appeared to have fallen asleep and later became unresponsive & unarousable. EMS found the patient unresponsive. He was brought to OSH where he was rapidly intubated and sedated. He was transferred to [**Hospital1 18**] after he had a HCT that was notable for intraventricular hemorrhage in all 4 ventricles and a cerebellar bleed. Following his arrival at [**Hospital1 18**] he was given verced and fentanyl. No active seizures noted. Neurosurger was consulted and determined no further management. Neurology was being consulted for further evaluation. His wife denies any recent illness, trauma, fall or c/o headache, N/V, bowel or bladder changes. He went to bed last night with no complaints or difficulty. Past Medical History: - Colonic CA (dx [**2146**]) underwent chemotheraphy. Later dx with liver CA ([**2150**]). Considered treated. - HTN, dyslipidemia, DM Social History: - lives with wife and 2 sons Family History: - non contributory Physical Exam: Vitals: T:112/65 P:50 R: BP: SaO2: General: Intubated, sedated. 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: Sedated, intubated, no response to verbal, tactile or noxious stimuli. - Cranial Nerves: Olfaction not tested. Pupils 2mm fixed,non-reactive. Conjugated gaze, (-) VOR, (-) corneal reflex, (-) gag reflex. No facial droop. - Motor: Normal bulk, increase tone throughout. No spontaneous movements. - Sensory: No response to deep pressure or noxious stimuli throughout. - Reflex: 2 UE bilateral; 1+ LE bilateral Plantar response was extensor bilaterally. - Coordination & Gait:unable to assess Pertinent Results: Admission Labs: 137 | 106 | 14 ---------------< 176 4.2 | 20 | 0.8 13.4 7.6 >------< 181 39.0 Ca: 7.5 Mg: 1.3 PO4: 2.5 Imaging: Head CT FINDINGS: There is marked intraventricular hemorrhage involving the entire ventricular system. There is moderate-to-severe hydrocephalus. There is no shift of normally midline structures, although there is transtentorial herniation into the foramen magnum, stable. There is no definite intraparenchymal hemorrhage or extra-axial fluid collection. There appears to be mild diffuse cerebral edema. The sulci are effaced at the level of the lateral ventricles. There is no evidence of acute fracture. Patchy opacity in the bilateral ethmoid air cells are noted. IMPRESSION: Severe intraventricular hemorrhage with hydrocephalus and transtentorial herniation as described above. This is not significantly changed when compared to prior exam. CXR FINDINGS: A single AP portable upright view of the chest was obtained. Endotracheal tube terminates approximately 3.5 cm above the carina. The cardiomediastinal silhouette is normal in appearance. There is evidence of volume loss in the right hemithorax with an elevated right hemidiaphragm and a sharply defined opacity in the right upper lobe consistent with right upper lobe collapse. The left lung is clear. A PICC line terminates at the cavoatrial junction. No acute osseous abnormalities are identified. Multiple foreign bodies, possibly surgical clips, project over the right upper quadrant, and are apparently new compared to the prior study. IMPRESSION: 1. Endotracheal tube terminating 3.5 cm above the carina. 2. Right upper lobe collapse, new compared to prior study dated [**2155-3-16**] at 8:20 a.m. from an outside hospital. Brief Hospital Course: 65 year-old right-handed male, w/ hx of hypertension, dyslipidemia, DM, who presents with an acute episode of altered mental status in the setting of intraventricular hemorrhage and hydrocephalus. Neurologic exam on admission was notable for absent brainstem functions. He was evaluated by Neurosurgery, who did not recommend further intervention. Given his significantly depressed level of consciousness, he was initially intubated for airway protection. The team had extensive conversation with the family regarding the patient's poor prognosis. He was initially admitted to the ICU on the ventilator, however the decision was made to electively extubate him and make him CMO. He expired shortly following extubation. Medications on Admission: - metformin 850mg tid - ASA 81mg qd - lovastatin 20mg qd - metoprolol ER 75mg qd Discharge Medications: None - expired Discharge Disposition: Expired Discharge Diagnosis: Hemorrhagic stroke with intraventricular extension Discharge Condition: Expired Discharge Instructions: None Followup Instructions: None [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**]

[ "348.4", "272.4", "431", "401.9", "197.7", "331.4", "153.8", "250.00" ]

icd9cm

[ [ [] ] ]

[ "96.71" ]

icd9pcs

[ [ [] ] ]

5327, 5336

4429, 5156

333, 339

5430, 5439

2663, 2663

5492, 5591

1612, 1633

5288, 5304

5357, 5409

5182, 5265

5463, 5469

1648, 2137

277, 295

367, 1390

2241, 2644

2680, 4406

2152, 2225

1412, 1549

1565, 1596

3,516

117,040

22789

Discharge summary

report

Admission Date: [**2145-8-17**] Discharge Date: [**2145-8-21**] Date of Birth: [**2070-1-19**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 613**] Chief Complaint: abd pain, hypotension Major Surgical or Invasive Procedure: Central line placement, R subclavian History of Present Illness: 75 y/o M w/ ILD, AVR who presented to the ED [**2145-8-17**] c/o abd pain. He was in his USOH until he was driving home from his Cardiology appointment and developed BLQ abd pain. He reported eating raw clams earlier in the day. He became nauseous and vomited 3 times (non-bloody) and had one episode of diarrhea. Also noted SOB but denied any cough or chest pain. Also had chills, no fevers. . In ED, he was initially tachycardic at 131, temp 99.5, bp 105/59, RR 20, 97% 2L. He spiked to 101.2 and was given levoflox 500 mg IV. His BP drifted down to 85/41, 78/palp-->66 at which point he was confused. Lactate level was 2.8. CXR revealed a LLL infiltrate. At this point a code sepsis was initiated and he was begun on levophed. He was given vancomycin 1g and 6L NS. R SC CVL was placed. Initial CVP 8-10, mixed venous 71. He was admitted to the MICU on the sepsis protocol. . MICU Course: Patient was off pressors since arrival to the MICU. He remained hemodynamically stable and afebrile on levofloxacin. He has been auto diuresing. . Patient was transferred to medicine service on [**8-20**] and was feeling well. He complained of abdominal pain with palpation. He is tolerating PO diet and has not had episodes of emesis or diarrhea since admission. He is guiaic positive with Hct 32 but stable. Cardiac enzymes were noted for slightly elevated tropI 0.03 on [**8-19**], normal CK-MB. He was afebrile with normal WBC count. He had mild SOB while laying flat. Denied fevers, chills, chest pain, weakness, headache, dysuria, hematuria. Past Medical History: Interstitial lung disase Glaucoma GERD CHF Cataracts GI Bleed Fistula repair surgery Social History: Retired. Lives with wife in [**Location (un) 538**], MA. Quit smoking 30 years ago after a 35 pack year hsitory. Drinks a [**1-18**] glass of wine daily. Denies any past or current recreational drug use. Family History: Noncontributory Physical Exam: T: Tm 98.4 (oral) Tc 98.4 (ax) P 93 BP 122.62 R 20 O2 98 on 2L Gen: alert and oriented pleasant male in NAD HEENT: anicteric, OP clear Neck: supple, no LAD, no JVD Lungs: dry crackles throughout, L>R at bases CV: RRR, II/VI SEM at LSB Abd: soft, mildly distended, tender over BLQ, no rebound no guarding Rectal - prior rectal fistula, GUIAC + per NF Ext: no edema, warm/dry Pertinent Results: [**2145-8-20**] 12:50PM BLOOD Hct-35.0* [**2145-8-20**] 06:15AM BLOOD WBC-5.0 RBC-3.08* Hgb-10.4* Hct-30.9* MCV-101* MCH-33.9* MCHC-33.7 RDW-15.2 Plt Ct-144* [**2145-8-18**] 04:16AM BLOOD Neuts-76.6* Bands-0 Lymphs-17.6* Monos-4.0 Eos-1.0 Baso-0.7 [**2145-8-17**] 05:30PM BLOOD Neuts-84* Bands-1 Lymphs-6* Monos-9 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2145-8-18**] 04:16AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL Macrocy-2+ Microcy-NORMAL Polychr-OCCASIONAL [**2145-8-20**] 06:15AM BLOOD Plt Ct-144* [**2145-8-17**] 05:30PM BLOOD PT-12.2 PTT-18.1* INR(PT)-1.0 [**2145-8-20**] 06:15AM BLOOD Glucose-94 UreaN-8 Creat-0.7 Na-142 K-3.9 Cl-107 HCO3-31 AnGap-8 [**2145-8-19**] 03:34AM BLOOD Glucose-121* UreaN-7 Creat-0.8 Na-142 K-3.3 Cl-104 HCO3-29 AnGap-12 [**2145-8-20**] 06:15AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2145-8-19**] 10:12AM BLOOD CK-MB-3 cTropnT-0.03* [**2145-8-17**] 05:30PM BLOOD cTropnT-<0.01 [**2145-8-18**] 04:16AM BLOOD Calcium-7.0* Phos-3.0 Mg-1.6 [**2145-8-17**] 07:10PM BLOOD Comment-GREEN TOP [**2145-8-18**] 01:00AM BLOOD Lactate-1.3 [**2145-8-17**] 11:32PM BLOOD Lactate-1.5 [**2145-8-17**] 07:10PM BLOOD Lactate-2.8* [**2145-8-17**] 10:15PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.014 [**2145-8-17**] 10:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2145-8-17**] 10:15PM URINE RBC-0 WBC-0 Bacteri-RARE Yeast-NONE Epi-0 CHEST PORT. LINE PLACEMENT [**2145-8-17**] IMPRESSION: Properly positioned new right CV line. Bilateral loculated pleural effusions that are stable. Bilateral atelectasis and worsening pulmonary edema. CHEST (PORTABLE AP) [**2145-8-17**] 5:57 PM IMPRESSION: 1) Interval improvement in pulmonary edema compared to [**2144-2-27**] with persistent bilateral interstitial opacities. These are present on the preoperative study performed on [**2144-2-19**], suggesting that they represent chronic changes. 2) There is loss of the definition of the left hemidiaphragm suggestive of a left lower lobe process. 3) Density at the left lateral hemithorax with a sharp linear border is unchanged compared to the preoperative studies dated [**2144-2-19**]. Possibly representing loculated pleural fluid or pleural thickening. EKG [**2145-8-17**] Sinus tachycardia. Compared to the previous tracing of [**2144-2-24**] the rate is now faster. CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST [**2145-8-20**] CT OF THE ABDOMEN WITH IV CONTRAST: There are diffuse interstitial opacities in both lower lobes with a peripheral predominance with areas of subpleural honeycombing. Calcified pleural plaques are seen in the right lung base posteriorly. Extensive pleural fat deposition is present. There are no pleural or pericardial effusions. There is a vague area of decreased density within the left medial lobe of the liver inferiorly (segment IVB), which is located anteriorly just to the right of the gallbladder which measures 15 x 18 mm, and is incompletely assessed. Several tiny calcifications are seen in the periphery of the spleen. The gallbladder, adrenal glands, pancreas, stomach, and small bowel loops are unremarkable. There is no ascites or pathological mesenteric or retroperitoneal lymph node enlargement. Both kidneys enhance symmetrically and homogeneously without evidence of focal mass or obstruction. No intra-abdominal collection is identified. CT OF THE PELVIS WITH IV CONTRAST: There is diffuse diverticulosis but no evidence of acute diverticulitis. Distal ureters and bladder are unremarkable. There is no free fluid in the pelvis or pathological inguinal or pelvic lymph node enlargement. Note is made of bilateral fat containing inguinal hernias, left greater than right. There is diffuse demineralization and degenerative changes in the spine. No suspicious lytic or sclerotic osseous lesions are identified. IMPRESSION: 1. Vague round low density lesion in segment IVB of liver, incompletely assessed. Further evaluation with ultrasound is reccommended. 2. No other evidence of intraabdominal infection. 3. Multiple hepatic granulomas. 4. Diffuse interstitial lung disease in both lung bases with calcified pleural plaques and extensive fat deposition in the subpleural space. Differential diagnosis includes pulmonary fibrosis and asbestosis. 5. Diverticulosis without evidence of acute diverticulitis. . CHEST (PA & LAT) [**2145-8-20**] 5:20 PM PA AND LATERAL CHEST X-RAY: Patient is status post median sternotomy with the prosthetic aortic valve in stable position. The cardiac silhouette, mediastinal, and hilar contours are stable. There is decreased pulmonary edema compared with prior exam. Stable interstitial opacities are seen diffusely and bilaterally. There is circumferential pleural thickening bilaterally, with nodularity at the right lung apex. Increased opacity in the left lower lung is likely related is to the surrounding pleural thickening. The surrounding soft tissue and osseous structures are stable. . There has been interval removal of a right subclavian central venous catheter. No pneumothorax is seen. . IMPRESSION: Interval decrease in pulmonary edema. Brief Hospital Course: 75 y/o M w/interstitial lung disease on chronic steroids who presents with fever, hypotension, and tachycardia. . # SIRS w/sepsis: Patient's clinical status improved quickly with antibiotics and fluids. It is possible that the patient may have had a viral/bacterial gastroenteritis resulting in sepsis. This can happen in immunosuppressed patients. Patient's WBC count was normal since he is on azothioprine preventing from mounting an immune response to infection. Lung exam noted for bibasilar crackles [**2-18**] to interstitial lung disease. CXR in ICU was negative for pneumonia which may not have been intially detected given low volume status. However, a pneumonia could have also resulted in patient's sepsis. A repeat CXR on [**8-20**] to eval pneumonia/infiltrate showed interval decrease in pulmonary edema. Patient was on levofloxacin and flagyl for enteric and anaerobic bacterial coverage. He remained afebrile and hemodynamically stable after transfer from ICU to floor. . #Abdominal pain: Differential includes infectious causes resulting in sepsis either bacterial or viral gastroenteritis; diverticulosis or diverticulitis also likely given guiaic + stool; low probability of ischemic bowel due to improved abdominal exam and lack of board-like rigidity. CT abdomen with/without contrast revealed diffuse diverticulosis, multiple granulomas in liver, and vague round low density lesion in segment IVB of liver, incompletely assessed. Hematocrit had increased and initial drop was most likely dilutional effect from aggressive IVF resucitation. He was advised include fiber in his diet and stay well hydrated. . #. Demand Ischemia: Patient is diabetic and presented SOB. He had a mild increase in cardiac tropT due to strain on pump in setting of sudden hypotension and lack of oxygen being delivered to myocardium. However, his last set of enzymes were within normal and initial ST depressions in V4-V6 had resolved on repeat EKG. . #. HTN Patient's BP was stable in ICU and on medicine floor. His metoprolo was restarted prior to discharge, however patient may benefit from ACE more given diabetes. . #. ILD: On home O2 (2L NC), currently sats great on stable O2 requirement. He was resumed on prednisone, azathioprine; His oxygen requirement was at his home O2 of 2L. . #. Type 2 DM: FS QID, insulin sliding scale. Blood sugars remained stable while inpatient. . #. Dispo: Patient will be discharged with followup by outpatient cardiologist for caridiac stress test and echocardiogram for further evaluation. PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 58938**] updated on inpatient status and progress. Medications on Admission: Metoprolol 25 mg [**Hospital1 **] Protonix 40 mg daily Lasix 20 mg daily Aspirin 81 mg daily Prednisone 5 mg [**Hospital1 **] Colace 1 drop Timolol left eye daily Azathioprine 50 mg daily Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Prednisone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Azathioprine 50 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Timolol Maleate 0.25 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). Disp:*1 * Refills:*2* 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 7. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 6 days. Disp:*6 Tablet(s)* Refills:*0* 8. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 6 days. Disp:*18 Tablet(s)* Refills:*0* 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Sepsis [**2-18**] viral gastroenteritis Possible pneumonia Secondary diagnoses: Interstitial lung disease with moderate restrictive PFTs [**1-21**] Porcine AVR for severe AS [**2-21**] DM type II HTN GERD Glaucoma Discharge Condition: Stable Discharge Instructions: Please take all medications. Avoid eating raw clams. Continue antibiotic course of levofloxacin and flagyl for 5 days. Followup Instructions: Please see PCP at [**Hospital6 2910**] for further management. Recommend cardiac stress test and echocardiogram outpatient given slightly elevated cardiac enzymes during hospital course. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**]

[ "530.81", "250.00", "515", "V42.2", "486", "428.0", "008.8", "995.91", "V58.65", "038.9" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

11794, 11800

7880, 10520

336, 374

12058, 12066

2714, 7857

12233, 12544

2288, 2305

10758, 11771

11821, 11881

10546, 10735

12090, 12210

2320, 2695

11902, 12037

275, 298

402, 1942

1964, 2050

2066, 2272

59,198

130,393

40922

Discharge summary

report

Admission Date: [**2194-10-14**] Discharge Date: [**2194-10-17**] Date of Birth: [**2135-12-13**] Sex: M Service: MEDICINE Allergies: Tetanus Attending:[**Last Name (un) 11974**] Chief Complaint: hypotension post EP atrial tachycardia ablation Major Surgical or Invasive Procedure: EP atrial tachycardia ablation History of Present Illness: Mr. [**Known lastname 20756**] is a 58 y/o male who was admitted electively to the PACU earlier today for EP ablation of Atrial Tachycardia and is transfered post procedure to the CCU for ongoing hypotenension and pressor dependence. . [**Hospital **] medical history is notable for COPD on intermittent home O2, non-ischemic CMP s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] procedure([**2178**]) for congenital bicuspid aortic valve, aortic aneurysm s/p arch replacement with reimplantation of RCA and closure of PFO ([**2188**]), s/p CRT-D ([**2192**], EF 25 -> 45-53% with CRT), AF s/p PVI [**2194-3-25**], s/p DCCV [**2194-3-29**] repeated DCCV [**5-/2194**] and currently NYHA class II-III heart failure in setting of persistent Atrial-Tachycardias. Patient has had ongoing atrial tachycardias with worsening exercise tolerance and lightheadesness and presented today for a planned ablation under general anesthesia. . Procedure was prolonged (~10h), bil femoral veins were accessed, no arteries, 3 foci were identified and ablated (one focus floor of LA, second under left pulmonary vein, and 3rd which induced a mitral anular flutter). Patient was subsequently in sinus rythm. Patient became hypotensive immediately following anasthesia induction for intubation and remained on neosynephrin throughout the procedure. His home SBP's are lowish in the 80's-90's. During the procedure patient was sedated with versed + fentanyl and required neosynephrin throughout for hypotension. He recieved 6L of NS and had UOP of 4L. Intracardiac echo post procedure no effusion. And post procedure Hct was stable. He underwent extubation in the PACU and was started on Dopamin which was uptitrated from 5 to 7.5 and allowed down titration of neo from 1.3 to 1. He also recieved toradol 30mg for back pain. He also recieved Ca 2g, Cefazolin 2gX2. Post procedure Hct was stable. . . Currently patient feels comfortable, complains of fatigue and ongoing mild back pain, otherwise no complaints. . REVIEW OF SYSTEMS On review of systems denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, black stools or red stools. Denies recent fevers, chills or rigors. Denies exertional buttock or calf pain. . Cardiac review of systems: + DOE at 50 paces, palpitations, no PND or orthopnea - notable for absence of chest pain, PND, Orthopnea Past Medical History: 1. COPD on intermittent home O2 2. non-ischemic CMP, s/p CRT-D ([**2192**], EF 25 -> 45-53% with CRT), more recently NYHA class II-III heart failure in setting of AF. 3. s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] procedure([**2178**]) for congenital bicuspid aortic valve 4. s/p arch replacement for aortic aneurysm with reimplantation of RCA and closure of PFO ([**2188**]) 5. AF with ? of tachy mediated CMP s/p PVI [**2194-3-25**], s/p DCCV [**2194-3-29**] repeated DCCV [**5-/2194**] 6. Hypothyroidism 7. Chronic neck and back pain 8. kidney stones 9. depression 10. s/p R/L hernia repair 11. L shoulder surgery x3 [**94**]. L knee arthroscopy 13. Remote hx of Multiple abdominal surgeries for perforated bowel Social History: Single, one child age 19. Lives alone, in contact with his 2 parents which are alive and well and also with 2 nieces. disabled Stopped smoking '[**90**]. Prior ETOH abuse > 27 years. Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: Admission Exam: GENERAL: lying in bed, alert+oriented X3, tachypneic to 22 but no sings of dyspnea. HEENT: no pallor, Jaundice or cyanosis NECK: Supple, difficult to assess JVP given body habitus. CARDIAC: S1, S2, [**2-17**] holosystolic murmur heard at LSB w/o radiation (TR?). No thrills, lifts. No S3 or S4. LUNGS: minimal [**Hospital1 **]-basilar crackles, no wheezes or rhonchi. ABDOMEN: multiple abdominal surgival scars, obese, Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. Small hematomas in bil groins (2cm-3cm) no induration. right radial a-line, PIVX2 RUE. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: DP, TP doplerable bilaterally. Exam on Discharge: afebrile, normotensive, not tachycardic, not tachypnic General: found sitting up in bed in NAD, AAO x 3. HEENT: supple, no LAD, JVD to about 8 cm. Cardiac: RRR, S1 and S2 audible, 2/6 systolic murmur heard at left sternal boder. Lungs: CTAB, normal effort of breathing, no accessory muscle use. Abd: obese, soft, NTND, +BS, multiple abdominal scars Ext: no c/c, trace to 1+ edema 1/2 up shins. No femoral bruits. Pulses: DP, TP doplerable bilaterally Pertinent Results: Pre-procedure labs: Preprocedure Labs [**2194-10-14**]: WBC 7.7, HCT 48.6, PLT 227, INR 2.6, NA 141, K , BUN 12, CRET 1.0. Labs on admission to CCU: [**2194-10-14**] 07:00PM BLOOD WBC-7.6 RBC-4.22* Hgb-14.7 Hct-43.8 MCV-104* MCH-34.9* MCHC-33.6 RDW-13.9 Plt Ct-220 [**2194-10-14**] 07:00PM BLOOD PT-28.2* PTT-44.9* INR(PT)-2.7* [**2194-10-14**] 07:00PM BLOOD Glucose-108* UreaN-9 Creat-1.0 Na-146* K-4.0 Cl-110* HCO3-28 AnGap-12 CXR [**2194-10-15**]: AP chest reviewed in the absence of prior chest radiographs: Heart is moderately enlarged, lungs are clear and there is no edema. Minimal left pleural effusion or pleural thickening is present. No pneumothorax or mediastinal widening. Transvenous right atrial pacer and right ventricular pacer defibrillator lead follow their expected courses. The intended left ventricular lead cannot be localized on frontal view but appears to have several sharp turns. Conventional radiography recommended when feasible. Labs on Discharge: [**2194-10-17**] 06:13AM BLOOD WBC-6.5 RBC-3.56* Hgb-12.4* Hct-36.1* MCV-102* MCH-34.9* MCHC-34.4 RDW-13.3 Plt Ct-142* [**2194-10-17**] 06:13AM BLOOD PT-23.5* PTT-39.1* INR(PT)-2.2* [**2194-10-17**] 06:13AM BLOOD Glucose-95 UreaN-12 Creat-0.8 Na-142 K-3.4 Cl-101 HCO3-33* AnGap-11 [**2194-10-17**] 06:13AM BLOOD Calcium-8.0* Phos-2.2* Mg-2.0 Brief Hospital Course: 58 y/o with PMH of COPD, non-ischemic CMP s/p procedures for cong bicuspid AV([**2178**]), thoracic aortic aneurysm + PFO([**2188**]), CRT-D ([**2192**], EF 25 -> 45-53% with CRT), AF s/p PVI 312 and multiple subsequent DCCV's, more recently with worsening functional level from worsening heart failure attributed to persistent atrial tachycardia who was admitted electively for EP ablation of three atrial tachycardia foci and was subsequently admitted to CCU for persistent hypotension and pressor requirement. # s/p atrial tachycardia foci ablation X3: The patient was taken for elective EP ablation of atrial tachycardia. Three atrial tachycardic foci were susccessfully ablated. Post-procedure course complicated but diffucult to extubate [**2-13**] COPD. He was extubated in PACU sucessfully. He also required pressors post-procedure. On arrival to CCU he was in sinus rythm. Pressors were weaned within 24 hrs. His ASA was incresed to 325mg daily for one month. He was monitored on telemetry and remained in sinus rhythm. Warfarrin dose held on HOD 2 secondary to supratherapeutic INR. He was restarted on warfarrin at a dose of 2.5 mg daily on day of discharge and instructed to follow up in a few days to have INR rechecked. # Hypotension: patient has baseline low SBP's in the 80's-90's, became hypotensive after anasthesia induction. No evidence of tamponade, bleeding, sepsis post procedure. Recieved fluids and is urinating well. Initially on neo and dopamine and were weaned off in 24 hours. . # Systolic Heart Failure: worsening functional class in the setting of Afib and Atrial tachycardias. Initially ACE-I, metoprolol, lasix, and metolazone held in setting of hypotension. Prior to discharge patient was restarted on home medications without changes. He remained without symptoms of acute heart failure throughout admission. . # Respiratory: patient with signifiant COPD, stable respiratory status post extubation. He was continued on home tiotropim and symbicort with albuterol prn. Supplemental O2 at night was continued per home regimen. Transitional Issues: -Will need INR checked on [**2194-10-21**] and warfarrin adjusted accordingly. Message left for Dr. [**First Name (STitle) 3646**] who follows patient's INR as an outpatient. Medications on Admission: Preadmission medications listed are correct and complete. Information was obtained from Patient. 1. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB, wheeze 2. Symbicort *NF* (budesonide-formoterol) 80-4.5 mcg/actuation Inhalation [**Hospital1 **] 2 INH [**Hospital1 **] 3. Digoxin 0.125 mg PO DAILY 4. Furosemide 40 mg PO DAILY 5. Gabapentin 300 mg PO TID:PRN pain 6. Lisinopril 5 mg PO DAILY 7. Metolazone 2.5 mg PO 2X/WEEK (MO,TH) on Mondays and thursdays 8. Metoprolol Succinate XL 25 mg PO DAILY 9. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours Hold for K > 4 10. Simvastatin 20 mg PO QHS 11. Tiotropium Bromide 1 CAP IH DAILY 12. Warfarin 2.5 mg PO 2X/WEEK (MO,TH) 13. Aspirin 81 mg PO DAILY 14. Cyanocobalamin 1000 mcg PO DAILY 15. Docusate Sodium 200 mg PO BID 16. FoLIC Acid 400 mcg PO DAILY 17. Magnesium Oxide 400 mg PO BID 18. Warfarin 5 mg PO 5X/WEEK ([**Doctor First Name **],TU,WE,FR,SA) Discharge Medications: 1. Albuterol Inhaler 1 PUFF IH Q6H:PRN SOB, wheeze 2. Aspirin 81 mg PO DAILY 3. Cyanocobalamin 1000 mcg PO DAILY 4. Docusate Sodium 200 mg PO BID 5. FoLIC Acid 400 mcg PO DAILY 6. Lisinopril 5 mg PO DAILY 7. Furosemide 160 mg PO DAILY 8. Magnesium Oxide 400 mg PO BID 9. Metolazone 2.5 mg PO 2X/WEEK (MO,TH) on Mondays and thursdays 10. Potassium Chloride 20 mEq PO DAILY Duration: 24 Hours Hold for K > 4 11. Simvastatin 20 mg PO QHS 12. Symbicort *NF* (budesonide-formoterol) 80-4.5 mcg/actuation Inhalation [**Hospital1 **] 2 INH [**Hospital1 **] 13. Tiotropium Bromide 1 CAP IH DAILY 14. Warfarin 2.5 mg PO DAILY16 15. Metoprolol Succinate XL 25 mg PO DAILY 16. Digoxin 0.125 mg PO DAILY 17. Gabapentin 300 mg PO TID:PRN pain 18. Outpatient Lab Work Diagnosis Atrial Fibrilation Please check INR [**2194-10-20**] Fax results to Dr. [**First Name (STitle) **] at [**Telephone/Fax (1) 89338**] Discharge Disposition: Home Discharge Diagnosis: Atrial Tachycardia s/p ablation Chronic systolic heart failure Non-Ischemic cardiomyopathy Atrial Fibriilation COPD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname 20756**], You were admitted to the hospital to have a procedure done to ablate an abnormal rhythm of his heart called atrial ablation. After the proceudre you had a low blood pressure and required some medications through your vein to keep your blood pressure up. We were able to get you off of these and then restarted your home blood pressure medications and lasix. Once we restarted your lasix you required potassium replacement. When you go home you will continue taking your potassium replacement as you were before coming in to the hospital. It is important for you to weigh yourself every morning, and call your cardiologist if weight goes up more than 3 lbs. Additionally it is very important that you eat a low salt diet and that you limit your fluid intake to 1.2L per day. It was a pleasure caring for you, Your [**Hospital1 **] doctors Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] G. Address: [**Street Address(2) **], STE#403, [**Hospital1 **],[**Numeric Identifier 66038**] Phone: [**Telephone/Fax (1) 69547**] Appt: Monday, [**10-27**] at 11:30am Department: CARDIAC SERVICES When: TUESDAY [**2194-11-4**] at 11:00 AM With: ICD CALL TRANSMISSIONS [**Telephone/Fax (1) 59**] Building: None None Campus: AT HOME SERVICE Best Parking: None Department: CARDIAC SERVICES When: FRIDAY [**2194-11-14**] at 10:40 AM With: [**Name6 (MD) **] [**Name8 (MD) 163**], MD [**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 [**2194-11-14**] at 11:30 AM With: DEVICE CLINIC [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 11975**] Completed by:[**2194-10-18**]

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Discharge summary

report+addendum

Admission Date: [**2168-2-23**] Discharge Date: [**2168-5-17**] Date of Birth: [**2113-2-2**] Sex: M Service: MEDICINE Allergies: Ipratropium And Derivatives / Peanut Containing Products / Acyclovir Attending:[**Last Name (NamePattern1) 4377**] Chief Complaint: Febrile neutropenia Major Surgical or Invasive Procedure: Central line placement bronchoscopy History of Present Illness: Mr. [**Known lastname **] is a 54-year-old man with a history of plasma cell leukemia/myeloma with IgG paraprotein complicated in the past by DVT/PE, who is day 11 s/p DPACE. The patient presented to clinic today with fever to 100.8 and a WBC count of 0.1 (ANC pending). He was admitted for DPACE on [**2168-2-12**] due to rapid progression of disease (markedly elevated IgG level) s/p Cytoxan on [**2-1**]. He tolerated DPACE well, only experiencing some fatigue and water retention, and was discharged to home with 10days of neupogen injections. He experienced progressive fatigue upon discharge home, however had no fevers or localizing signs at home. He has had no appetite since discharge. He has a rash on his scalp and face consistent with folliculitis which has been present since discharge. Accompanying the above weakness, he has been experiencing some associated shortness of breath. He was getting dressed to come in to clinic and felt as though he could not catch his breath. This was alleviated with rest. He has also developed some oral lesions. He denied any nasal congestion, sore throat, headache, chest pain, dysuria, hesitancy or urinary frequency. He does report decreased bowel movements which he attributes to decreased PO intake. He does report some mild epigastric "pressure" which is relieved with belching. . He presented to clinic and on arrival noted a non-productive cough and fever. He had no cough prior to this afternoon. . Review of systems: No chest pain, palpitations. No nausea, vomiting, diarrhea or constipation, or back pain. No numbness or tingling of his extremities. No headaches, dizziness, blurred vision. He denies any bleeding or increased bruising, hematuria, hematochezia, epistaxis or gum bleeding. All other systems reviewed in detail and negative except for what has been mentioned above. Past Medical History: Past Oncologic History: 1. Diagnosed on [**12/2164**] with plasma cell leukemia/myeloma when he presented with sepsis. 2. Status post hyper-CVAD x2 cycles in [**1-/2165**] and 01/[**2165**]. 3. Status post Cytoxan 750 mg/m2 for 2 days with Decadron pulses followed by thalidomide at 200 mg daily in 2/[**2165**]. This treatment was complicated by a left leg DVT for which he was started on coumadin. 4. Status post autologous stem cell transplant in 05/[**2165**]. 5. Noted for recurrent disease and treated on the Revlimid/Velcade study, number 04-130 with excellent response to treatment from [**7-/2166**] until [**1-/2167**], however discontinued on protocol due to pulmonary embolism in 01/[**2167**]. 6. Started maintenance Velcade in [**8-/2167**] with three and half cycles of therapy given his first cycle was given without Decadron, Decadron added for the subsequent cycles. 7. Initiated treatment with Revlimid alone on [**2167-12-16**] with increasing doses for 21-day cycle with therapeutic Lovenox to 100 mg b.i.d. due to history of PE. 8. Given cytoxan therapy on [**2-1**], tolerated well. 9. Treated with DPACE on [**2171-2-12**], tolerated well. . Other Past Medical History: 1. Hx of DVT [**2165**], hx of PE [**2-/2167**] 2. Renal insufficiency 3. Hx of Zoster Social History: Denies any current smoking, quit smoking 15 years ago, denies any alcohol use or history of alcohol abuse, denies any IVDU. Currently lives in [**Hospital1 1474**] with his wife and child. Works as a computer programmer. Has one child, currently alive and well. Family History: He has a maternal uncle with lung cancer and a paternal uncle with [**Name2 (NI) 500**] cancer. He has 1 brother, 1 sister and 1 half brother. His sister has MS, and his half brother died from diabetes. His mother died from a stroke, and his father is still alive and well. Physical Exam: VS: T:100.8 HR: BP: RR: Sat: %RA Gen: Fatigued appearing male, in no distress, sitting up on hospital bed. HEENT: NCAT, PERRL, sclera anicteric, oropharynx with some aphthous ulcers on buccal mucosa, tongue, throat erythematous, no exudates, no thrush LN: no cervical, axillary lymphadenopathy CV: RRR, normal S1/S2, no m/r/g, no tenderness to palpation of precordium Lungs: Clear to auscultation bilaterally, No w/r/rh Abdomen: Soft, nondistended, normoactive bowel sounds, no hepatosplenomegaly. Mild tenderness to deep palpation of epigastric region. Ext: Trace edema bilaterally. No clubbing, cyanosis, or calf pain, DP pulses are 2+ bilaterally Neuro: A + O x 3, CN II-XII grossly intact, Motor [**6-11**] both upper and lower extremities, Sensation grossly intact to light touch Skin: pink, warm, rash noted at hair follicle over scalp, nose, chest. POC - dressed, clean, dry, intact. Pertinent Results: Admission Labs: [**2168-2-23**] 02:40PM BLOOD WBC-.1* RBC-3.07* Hgb-11.2* Hct-30.1* MCV-98 MCH-36.6* MCHC-37.3* RDW-14.5 Plt Ct-41* [**2168-2-23**] 02:40PM BLOOD Plt Smr-VERY LOW Plt Ct-41* [**2168-2-23**] 02:40PM BLOOD Gran Ct-20* [**2168-2-24**] 12:15AM BLOOD SerVisc-2.0* [**2168-2-23**] 02:40PM BLOOD Glucose-165* UreaN-22* Creat-1.6* Na-129* K-4.5 Cl-100 HCO3-24 AnGap-10 [**2168-2-23**] 02:40PM BLOOD ALT-32 AST-25 LD(LDH)-117 AlkPhos-56 TotBili-0.7 [**2168-2-23**] 02:40PM BLOOD TotProt-12.1* Albumin-3.0* Globuln-9.1* Calcium-9.7 Phos-4.8* Mg-1.5* [**2168-2-23**] 02:40PM BLOOD PEP-ABNORMAL B IgG-8079* IgA-8* IgM-8* Discharge Labs: Reports: [**2-23**] CXR: IMPRESSION: No acute pulmonary process. As noted previously, the 3 mm nodule seen on CT is not evident on the radiographs. . [**2-24**] Skin biopsy: Skin, right face (A): Skin with central dilated follicle and mild perifollicular chronic inflammation. Note: No leukemic infiltrate is seen in the sections examined and inflammation is minimal (there is a focal mild perifollicular lymphohistiocytic infiltrate). While there is a central dilated follicle, no Demodex is seen within the follicle. The findings are non-specific and clinical correlation is needed. Dr. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 54131**] is notified of the diagnosis on [**2168-2-25**]. . [**3-1**] ECHO: MPRESSION: Very small, mobile echodensity as described above on the aortic valve annulus/sinus. The location is very atypical for a vegetation and no aortic regurgitation is seen. Compared with the prior study of [**2168-2-12**], the findings are similar (the mobile echodensity is less well defined, but suggested on clip #[**Clip Number (Radiology) **]). If clinically indicated, a TEE might be better able to define the aortic annular echodensity. [**3-27**] Abd MRI 1. Right lower lobe airspace disease, which may be infection or atelectasis. 2. Evidence of hemosiderosis. 3. L3 compression fracture deformity appears chronic. 4. Gallbladder wall thickening. 5. No abnormal lesions within the liver or spleen, however, evaluation for hepatosplenic candidiasis is limited due to the lack of post-contrast imaging. If clinically warranted, patient should return for post-contrast images. [**4-2**] CXR 1. Support lines in place. 2. Right basilar atelectasis and small left-sided pleural effusion. ECHO: Conclusions: The left ventricular cavity size is normal. LV systolic function appears depressed. There is probably inferior hypokinesis but views are technically suboptimal. LV ejection fraction difficult to estimated (?45%). Right ventricular chamber size is normal. Right ventricular systolic function is normal. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2168-4-20**], left ventricular function now appears similar in suboptimal views. Heart rate is now slightly lower. ... CT Chest: IMPRESSION: 1. Rapidly enlarging right hilar mass, obstructing the right middle lobe bronchi and markedly narrowing bronchus intermedius and right lower lobe bronchi. Findings are most consistent with a neoplastic process, and bronchoscopy would have a high yield for diagnosis. In an immune-suppressed patient, granulomatous infection may sometimes mimic a neoplastic process. 2. New small right pleural effusion. 3. Diffuse skeletal lucencies consistent with myeloma. .... Discharge labs Brief Hospital Course: Mr. [**Known lastname **] is a 54-year-old man w/ history of plasma cell leukemia/multiple myeloma who has hx of PE during treatment with Revlimid, s/p recent DPACE treatment here with febrile neutropenia. . # Plasma cell leukemia/myeloma: The patient recently received DPACE and was persistently neutropenic. Originally presented with non-productive cough since this afternoon, oral lesions and papular rash noted on scalp and face. He was originally started on Cefepime monotherapy for febrile neutropenia and Bactrim and Valacyclovir were continued for PCP and HSV prophylaxis respectively. Blood and urine cultures were taken in clinic. CXR was done which was negative for an infiltrate. His counts on presentation were low and he was continued on daily neupogen injections. On [**2-24**], Cefepime was switched to [**Last Name (un) **]/Vanco as his blood cultures grew out Coagulase negative staph and strep viridans. In addition, on [**2-24**], as his IgG came back at 8000, he was instructed to start to take his own Revlimid (15mg daily). Given his slow to respond white count, the revlimid was tapered to 5mg daily and stopped temporarily. The revlimid was restarted with decadron on [**3-1**] for four days. He received 4 days of decadron, completed on [**3-4**]. He continued to take the Revlimid at 15mg. He was also started on lovenox for DVT prophylaxis given his history of PE while on Revlimid. While on lovenox, his platelets were checked twice daily and kept >50. Bm Bx done on [**3-9**] showed 50% plasma cells. Patient was started on pentostatin/TBI mini-allo SCT. Revlimid and lovenox were stopped prior to transplant. Patient was given pentostatin and TBI with Day 0 was [**4-5**] he tolerated the transplant well but had muscle pain. He then received received MTX day +1, +3, +5. His counts were slow to recover but now ANC >[**2161**]. Antibiotics have been slowly taken off and the patient remains AF. However, there were signs that disease is worsening (IgG increased to ?9000). As well the right middle low mass that was thought to be a plasmacytoma showed increasing size on repeat CT. Therefore he was started thalidomide [**4-28**] for treatment of myeloma as his disease was previously responsive to this. Given that he previously had a DVT/PE on this regimen, he was started on heparin gtt with a goal of 50-70 and give platelets with goal of >50 . # Dyspnea: Respiratory distress several times week of [**4-18**] and eventually needed [**Hospital Unit Name 153**] stay with 1 night of BiPAP after bronchoscopy thought to be due to pulmonary edema but with only mild improvement with lasix. Also with concern for engraftment syndrome or DAH, but with little improvement with steroids or evidence on bronchoscopy. Sputum cultures show aspergillus. Will continue posaconazole at treatment dosage. No signs of fluid overload and improvement without diuresis making aspergillus infection likely. . # Muscle pain- Likely secondary to marrow edema or fungal infx. Gradually improving. Initially required a fentanyl PCA that was converted to a fentanyl patch that was removed o n [**4-29**]. . # Hypertension/tachycardia- Occurred after transplant. Was started on metoprolol and eventually achieved control at metoprolol 75 mg. . # Bacteremia: On cultures drawn on admission, he grew 2 bottles of coagulase negative staph and 1 bottle of strep viridans. The suspected sources of the bacteremia were the rash of the scalp as a source of the coagulase negative staph and his aphthous ulcers as the source of his strep viridans. He was initially placed on Cefepime and Vancomycin, however after his cultures grew out he was changed to Meropenem and Vancomycin. His fever curve trended back to normal. Because of the culture positive for Strep viridans and question of possible endocarditis, an echocardiogram was done which showed a small fluttering echodensity on the aortic annulus which was stable from an echocardiogram three weeks earlier. Multiple blood cultures were negative and cefepime and vancomycin were stopped after he was afebrile for 2 weeks. As patient began to spike fevers again with no clear source these were restarted 1 wk prior to transplant. . # ? Transfusion reaction: A blood transfusion was stopped on [**2-24**], as the patient was febrile during the transfusion. An investigation was done and the conclusion was that the fever was likely due to the patient's bacteremia and was unrelated to the transfusion. He went on to receive blood transfusions for the remainder of the hospitalization. . # Rash: The patient presented with a papular rash on scalp, face. He was seen by dermatology who did a biopsy on [**2-24**]. The results showed no leukemic infiltrate in the sections examined and inflammation is minimal (there is a focal mild perifollicular lymphohistiocytic infiltrate). While there is a central dilated follicle, no Demodex was seen within the follicle. He developed a second rash on [**2-25**] which seemed related in timing to the initiation of Meropenem and Vancomycin. As this was deemed the most appropriate antibiotic regimen, he was started on atarax 4x/day with good response in the rash. The rash resolved within 2 days and the atarax was stopped without recurrence of symptoms. . # Renal insufficiency: The patient presented with creatinine of 1.6. Per OMR, creatinine is often elevated with worsening of disease. His creatinine continued to improve with hydration but again worsened when being diuresed for concern of volume overload. Remains persistently high despite no diuresis. Urine studies show likely secondary to myeloma. . # Transaminitis- patient has underlying fatty liver seen on RUQ US and MRI and then voriconazole was started which caused a rise in his LFTs. Vorinconazole was stopped after 2 days and LFTs continued to rise for days and then trended down. He was treated with ursodiol as well. LFTs remained normal after transplant and stayed normal while being treated on posaconazole. Medications on Admission: Valtrex 1000 mg daily Bactrim DS 1 tab [**Hospital1 **] MWF Neupogen SC daily Discharge Medications: NA Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: Plasma Cell Leukemia Multiple Myeloma Discharge Condition: NA Discharge Instructions: NA Followup Instructions: NA Completed by:[**2168-6-22**] Name: [**Known lastname **],[**Known firstname **] A Unit No: [**Numeric Identifier 10059**] Admission Date: [**2168-2-23**] Discharge Date: [**2168-5-17**] Date of Birth: [**2113-2-2**] Sex: M Service: MEDICINE Allergies: Ipratropium And Derivatives / Peanut Containing Products / Acyclovir Attending:[**Last Name (NamePattern1) 2211**] Addendum: Please use Hospital course summary in addendum Brief Hospital Course: Mr. [**Known lastname **] is a 54-year-old man w/ history of plasma cell leukemia/multiple myeloma who has hx of PE during treatment with Revlimid, s/p recent DPACE treatment here with febrile neutropenia. . # Plasma cell leukemia/myeloma: The was admitted on Day +11 post DPACE and was persistently neutropenic. He was started on Cefepime monotherapy for febrile neutropenia and Bactrim and Valacyclovir were continued for PCP and HSV prophylaxis respectively. Blood and urine cultures were taken in clinic. CXR was done which was negative for an infiltrate. His counts on presentation were low and he was continued on daily neupogen injections. On [**2-24**], Cefepime was switched to [**Last Name (un) **]/Vanco as his blood cultures grew out Coagulase negative staph and strep viridans. In addition, on [**2-24**], as his IgG came back at 8000, he was instructed to start to take his own Revlimid (15mg daily). Given his slow to respond white count, the revlimid was tapered to 5mg daily and stopped temporarily. The revlimid was restarted with decadron on [**3-1**] for four days. He received 4 days of decadron, completed on [**3-4**]. He continued to take the Revlimid at 15mg. He was also started on lovenox for DVT prophylaxis given his history of PE while on Revlimid. While on lovenox, his platelets were checked twice daily and kept >50. Bm Bx done on [**3-9**] showed 50% plasma cells. Patient was started on pentostatin/TBI mini-allo SCT. Revlimid and lovenox were stopped prior to transplant. Patient was given pentostatin and TBI. The match unrelated donor transplant was peformed on [**4-5**] (Day 0). He tolerated the transplant well but had muscle pain. He then received received MTX day +1, +3, +5. His counts were slow to recover but now ANC >[**2161**]. The patient remained AF post transplant, but had signs of worsening disease: (IgG increased to ?9000 and right middle lobe mass thought possibly to be a plasmacytoma showed increasing size on repeat CT. Due to concern for recurrent disease, he was started thalidomide [**4-28**] for treatment of myeloma as his disease was previously responsive to this. Given that he previously had a DVT/PE on this regimen, he was started on heparin gtt with a goal of 50-70 and give platelets with goal of >50. . # Disemminated aspergillosis: The patient developed respiratory distress several times week of [**4-18**]. On [**4-20**] he had an episode of atrial flutter resulting in volume overload and required diuresis. A pulmonary consult was called and a bronchoscopy performed on [**4-22**] which showed no endobronchial lesions and friable mucosa generally throughout the right middle and lower lobes. Biopsy was performed which resulted in bleeding but hemostasis was obtained. Following the bronch the patient became hypoxic and had increased O2 requirement leading to a transfer to the ICU. In the ICU he was diuresed and his bronchoscopy results demonstrated ASPERGILLUS SP. NOT FUMIGATUS, FLAVUS OR [**Country 10060**]. He was started on posaconazole therapy at that time. He required BiPAP at one point during his ICU stay but otherwise improved and his O2 requirement decreased with diuresis. He was transferred back to the floor. On [**5-3**] he developed a new rash (distinct from previous ones) whcih was biopsied. The biopsy demonstrated Dense dermal neutrophilic infiltrate containing fungal organisms (branched, septate), best see on PAS-reacted sections. (The sample eventually was identified as ASPERGILLUS USTUS, but results were not available until more than a week). On [**5-3**] the patient was deemed to have disseminated aspergillosis and was started on voriconazole and caspofungin. Ambisome was not started at this time because the patient was in acute renal failure from other causes. On [**5-10**], due to progression of his renal failure the patient was started on dialysis and at this point ambisome was started in addition to continued voriconazole. CXR on [**5-14**] showed worsening of his pulmonary findings. . # Renal insufficiency: The patient initially presented with some mild renal failure, which quickly resolved. After a long course in the hospital, on [**4-20**] his creatinine started to rise from a baseline of 1.2 and by [**5-3**] had progressed to 3.0. His renal failure was thought secondary to cyclosporin toxicity. There were likely other contributing factors, including his underlying disease. His cyclosporin was discontinued and he was started on cellcept and steroids. His creatinine continued to rise and on [**5-10**] he began dialysis. . # Intracranial hemorrhage: On the night of [**4-21**], the patient had an acute change in his mental status and became unresponsive. A head CT w/ and w/out contrast was performed which showed "large intraparenchymal hemorrhage in the right parietal-occipital lobe region, with extension into the right lateral and fourth ventricles, effacement of the basal cisterns, right hippocampal and subfalcine herniation. Right parietal- occipital subarachnoid hemorrhage." Possible etiologies for the bleed included disseminated aspergillosis. The patient was not a candidate for aggressive surgical management and remained unresponsive. He was made comfort measures only and expired at 1:32 on [**5-17**]. Intracranial hemorrhage was the immediate cause of death. . # GVHD: The was initially on IV cyclosporin for his transplant and his dose was titrated according to daily levels. Cyclosporin was discontinued and cellcept/steroids started due to renal failure as described above. The patient developed a new skin rash on [**5-10**] which was Day +34 post transplant that was thought consistent with GVHD. His cellcept and solumedrol doses were adjusted in the days afterward to manage this problem. On [**5-15**] he developed increasing bilirubin, the differential of which included GVHD and antifungals therapy. . # Hypertension/tachycardia- Occurred after transplant. Was started on metoprolol and eventually achieved control at metoprolol 75 mg. . # Bacteremia: On cultures drawn on admission, he grew 2 bottles of coagulase negative staph and 1 bottle of strep viridans. The suspected sources of the bacteremia were the rash of the scalp as a source of the coagulase negative staph and his aphthous ulcers as the source of his strep viridans. He was initially placed on Cefepime and Vancomycin, however after his cultures grew out he was changed to Meropenem and Vancomycin. His fever curve trended back to normal. Because of the culture positive for Strep viridans and question of possible endocarditis, an echocardiogram was done which showed a small fluttering echodensity on the aortic annulus which was stable from an echocardiogram three weeks earlier. Multiple blood cultures were negative and cefepime and vancomycin were stopped after he was afebrile for 2 weeks. As patient began to spike fevers again with no clear source these were restarted 1 wk prior to transplant. . # ? Transfusion reaction: A blood transfusion was stopped on [**2-24**], as the patient was febrile during the transfusion. An investigation was done and the conclusion was that the fever was likely due to the patient's bacteremia and was unrelated to the transfusion. He went on to receive blood transfusions for the remainder of the hospitalization. . # Rash: The patient presented with a papular rash on scalp, face. He was seen by dermatology who did a biopsy on [**2-24**]. The results showed no leukemic infiltrate in the sections examined and inflammation is minimal (there is a focal mild perifollicular lymphohistiocytic infiltrate). While there is a central dilated follicle, no Demodex was seen within the follicle. He developed a second rash on [**2-25**] which seemed related in timing to the initiation of Meropenem and Vancomycin. As this was deemed the most appropriate antibiotic regimen, he was started on atarax 4x/day with good response in the rash. The rash resolved within 2 days and the atarax was stopped without recurrence of symptoms. He developed other rashes on [**5-3**] and [**5-10**] which are covered in more detail under the "disseminated aspergillosis" and GVHD sections above. . # Transaminitis- patient has underlying fatty liver seen on RUQ US and MRI and then voriconazole was started which caused a rise in his LFTs. Vorinconazole was stopped after 2 days and LFTs continued to rise for days and then trended down. He was treated with ursodiol as well. Discharge Disposition: Home With Service Facility: Critical Care Systems Discharge Diagnosis: asperigillosis Cerebral vascular acident myeloma pulmonary embolism plasma cell leukemia Discharge Condition: deceased. Discharge Instructions: na [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 2212**] Completed by:[**2168-6-24**]

[ "117.3", "704.8", "E878.0", "203.00", "428.0", "E930.1", "790.7", "996.85", "782.1", "431", "203.10", "403.91", "484.6", "253.6", "V12.51", "V42.82", "584.5", "786.3", "573.3", "427.31", "518.82" ]

icd9cm

[ [ [] ] ]

[ "99.15", "33.24", "41.31", "86.11", "39.95", "99.05", "99.04", "93.90", "38.95", "99.07", "92.29", "41.05" ]

icd9pcs

[ [ [] ] ]

23826, 23878

15346, 23803

356, 394

24010, 24021

5067, 5067

14838, 15323

3865, 4140

14622, 14626

23899, 23989

14519, 14599

24045, 24234

5710, 8477

4155, 5048

1898, 2265

297, 318

422, 1879

5083, 5693

3481, 3570

3586, 3849

29,414

194,253

32690

Discharge summary

report

Admission Date: [**2128-10-30**] Discharge Date: [**2128-11-16**] Date of Birth: [**2087-2-2**] Sex: M Service: SURGERY Allergies: Valproic Acid And Derivatives Attending:[**First Name3 (LF) 4691**] Chief Complaint: unresponsive Major Surgical or Invasive Procedure: none History of Present Illness: Mr. [**Known lastname 14164**] is a 41 yo M who was found down by roommate in a pool of blood after a fall vs. assault. The patient was brought to [**Hospital1 18**] ED for further evaluation and treatment. Past Medical History: ETOH Abuse (1 gallon whiskey/day) Depression anxiety PTSD-sexual abuse from parents as a child thrombocytopenia cirrhosis with esophageal varices - two recent bleeding episodes Social History: Denies Smoking 1 gallon of etoh a day Family History: noncontributory Physical Exam: On discharge: Afebrile, VSS Gen: NAD, lying in bed HEENT: small unrepaired granulating laceration on chin CV; RRR NL s1s2 Pulm: CTA b/l no w/c/r Abd: soft, NT/ND Ext: no c/c/e Pertinent Results: [**2128-10-30**] 03:15AM ASA-NEG ETHANOL-381* ACETMNPHN-NEG bnzodzpn-POS barbitrt-NEG tricyclic-NEG [**2128-10-30**] 03:15AM WBC-13.3* RBC-4.06* HGB-9.9* HCT-31.6* MCV-78* MCH-24.4* MCHC-31.3 RDW-22.4* [**2128-10-30**] 03:15AM ALT(SGPT)-169* AST(SGOT)-305* CK(CPK)-2081* ALK PHOS-396* AMYLASE-71 TOT BILI-1.5 [**2128-10-30**] 11:48AM WBC-4.4 RBC-3.07* HGB-7.6* HCT-24.1* MCV-79* MCH-24.8* MCHC-31.6 RDW-21.6* [**2128-11-12**] 07:45PM BLOOD WBC-6.7 RBC-3.85* Hgb-10.1* Hct-32.2* MCV-84 MCH-26.3* MCHC-31.4 RDW-21.1* Plt Ct-559* [**2128-10-30**] 11:48AM BLOOD WBC-4.4 RBC-3.07* Hgb-7.6* Hct-24.1* MCV-79* MCH-24.8* MCHC-31.6 RDW-21.6* Plt Ct-278 [**10-30**]: CT OF THE FACIAL BONES: There is moderate left periorbital soft tissue swelling. No retrobulbar hematoma. The globes are intact. The orbits demonstrate no fractures. The frontal sinuses, maxillary sinuses and ethmoid air cells are clear. There are comminuted fractures of the nasal bones bilaterally. There is rightward nasal septal deviation and a 7-mm area of high density adjacent to the distal portion of the nasal septum, raising the possibility of a nasal septal hematoma. There is no significant blood or fluid within the nasal cavity. [**10-30**]: CT- 1. Acute L3 vertebral body compression fracture with small paravertebral hematoma, 7 mm in diameter. No retropulsed bony fragments or gross evidence of epidural hematoma. If there is suspicion for acute cord injury, MRI can better delineate the ligamentous structures and the central canal. 2. Multiple chronic and subacute rib fractures. 3. Fatty liver. [**11-2**]: CTA-1. Patchy scattered ground-glass opacities in both lungs are likely infectious or inflammatory, and may represent a combination of aspiration with superimposed infection. 2. No pulmonary embolism or aortic dissection. 3. Diffuse fatty infiltration of the liver with multiple contour abnormalities on the surface of the liver suggestive of early cirrhosis. Brief Hospital Course: The patient was brought to the [**Hospital1 18**] ER intoxicated, tachycardic, and tremulous. He was found to have a nasal septal fracture, L3 compression fracture, and possible GI bleeding. The patient was not hemodynamically stable, he was intoxicated but appeared tremulous and to be in acute delerium tremens despite a blood alcohol above 350 mg/dL. He was intubated to protect his airwayand admitted to the Trauma service in the trauma ICU. The patient was evaluated by GI for the GI bleed who recommended blood transfusions as needed, volume repletion, a PPI, Levaquin for cirrhosis and portal hypertension to reduce infectious risk and mortality, thiamine, folate, and an MVI, and evaluation of hepatitis profile, albumin, and an ultrasound to evaluate portal/hepatic flow. Hepatology was also consulted who followed during his stay. The patient was transfused as needed throughout his hospital stay for anemia and hemodynamic instability when appropriate. His hematocrit was monitored frequently, and at the time of discharge had been stable for one week with no transfusions. The patient was given instructions to follow up with his PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] at [**Hospital1 2025**] to arrange for an outpatient colonoscopy when appropriate. Initially, the patient remained intubated to protect his airway during alcohol withdrawal. The vent was weaned as tolerated, but the patient developed fevers on [**11-1**] for which he was started empirically on vanc and zosyn for presumed VAP. The patient was bronched, and BAL Cultures were followed for sensitivities (they grew coag + staph aureus--MRSA). Despite these febrile episodes, the patient did not develop leukocytosis. The patient was also tested for clostridium difficil, and was found to be positive; his antibiotics were changed to flagyl and vanco. The patient was persistently febrile, however, for which his lines were changed On [**11-4**], extubation was attempted, but the patient developed respiratory distress requiring re-intubation. On [**11-11**], the patient was succesfully extubated, From a nutrition standpoint, the patient was started on tube feeds while intubated,which were titrated up when appropriate to goal. Once extubated, the patient was started on a diet when appropriate. His diet was advanced, and the patient received anti-emetics when necessary for nausea. The [**Hospital 228**] hospital course was also complicated by decreasing platelet count, for which HIT was tested, and found to be negative. The patient received benzodiazepines throughout his hospital course, which were weaned slowly as indicated. The patient's hemodynamic instability improved with transfusions and aggressive volume repletion. The patient was also felt to have rhabdomyolysis for which aggressive hydration and serial CKs and urine myoglobin were monitored; the myoglobinuria resolved with treatmetn. The patient became briefly hypervolemic during his stay for which he was diuresed when appropriate. The patient was evaluated by ortho-spine who had the patient fitted for a TLSO brace which he was instructed to wear when out of bed. The patient received physical therapy treatment and evaluation throughout his stay. Mr. [**Known lastname 14164**] was put on GI prophylaxis and had SCDs and SQH for DVT prophylaxis. He was transferred to the floor from the ICU when the patient was stable and a bed was available. The patient did well on the floor with no complications. His diet was tolerated, the patient was urinating without a foley catheter, he ambulated multiple times throughout the day with the aid of physical therapy, and he continued on benzodiazepines for DT prophylaxis, and flagyl for c.diff. At the time of discharge, the patient was afebrile and doing well; both he and the team felt the patient was ready for discharge. The patient was seen by social work and case menagement, and was sent home with the appropriate follow up information for discharge. The patient was instructed to continue all home medications, and was given a prescription for flagyl, as well as a Valium taper. The team also spoke with his sister, Dr. [**First Name (STitle) **] and his girlfriend concerning his disposition and follow up. Medications on Admission: Prozac, trazadone, neurontin Discharge Medications: 1. Fluoxetine 40 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 2. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 3 days. Disp:*9 Tablet(s)* Refills:*0* 3. Valium 2 mg Tablet Sig: One (1) Tablet PO every six (6) hours for 5 days. Disp:*20 Tablet(s)* Refills:*0* 4. Valium 2 mg Tablet Sig: 0.5 Tablet PO every six (6) hours for 5 days: Take 1 mg([**12-30**] tab) every 6 hours for 5 days, then as needed only for agitation, trembling or anxiety. Disp:*10 Tablet(s)* Refills:*1* 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 6. Gabapentin 600 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 7. traZODONE 100 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed. Tablet(s) Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Alcohol withdrawal gastro-intestinal bleed MRSA pneumonia Clostridium difficil Discharge Condition: stable Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. Followup Instructions: Please follow up with orthopedics-spine at 1:10pm on Wed [**12-1**]; the clinic number is [**Telephone/Fax (1) 9769**]. Please have an appointment with Dr. [**Last Name (STitle) **] on Tues [**11-30**] at 1:45pm; the phone number is [**Telephone/Fax (1) 6429**]. You have an appointment with Dr. [**Last Name (STitle) 76175**] at 10 am on [**2128-11-26**]; their phone number is [**Telephone/Fax (1) 23525**]. Please follow up with your PCP [**Last Name (NamePattern4) **] [**12-30**] weeks, Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 76174**]; we have called your physician but were unable to make an appointment for you. you will need to have a colonoscopy in the future as your were found to have a GI bleed while in the hospital.

[ "999.9", "008.45", "309.81", "728.88", "V09.0", "805.4", "303.01", "873.44", "802.0", "482.41", "285.1", "578.9", "571.2", "291.0", "873.42", "311", "807.09", "300.00", "E988.9", "287.5" ]

icd9cm

[ [ [] ] ]

[ "33.24", "96.6", "96.72", "38.91", "96.04", "86.59", "99.04", "38.93" ]

icd9pcs

[ [ [] ] ]

8252, 8310

3028, 7302

303, 309

8433, 8442

1047, 3005

9532, 10285

818, 835

7381, 8229

8331, 8412

7328, 7358

8466, 9509

850, 850

864, 1028

251, 265

337, 546

568, 746

762, 802

31,664

160,571

12741

Discharge summary

report

Admission Date: [**2187-6-19**] Discharge Date: [**2187-6-26**] Service: MEDICINE Allergies: Wellbutrin / Kaopectate Attending:[**First Name3 (LF) 358**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Diagnostic thoracentesis [**6-21**] PICC line placement [**6-23**], left arm, single lumen 51cm History of Present Illness: 85yo woman w recent dx PE, refractory HTN, DM, CKD (bl Cr 1.4-1.6), anemia who presents from NH with increasing SOB. Per NH records, she became febrile to 103 w HR 79, BP 180, O2 sat 89% RA. Per patient, she noted increasing DOE over the last 24h. She has had increasing fatigue and has been less mobile for [**12-13**] days. Per d/w her son, he noticed she was more dyspneic yesterday while walking. He also noted increased fluid retention of her legs. . In the ED: initial VS 102.1 79 193/63 40 97% 4L. SBP ranged from 159-202 and not treated. RR 30, 97% 3L, HR 70s. Rectal temp was 103.4 then improved to 101.1 w tylenol 500mg. Initially noted to have bibasilar crackles. Lactate 1.5, WBC elevated to 17.1. CXR read as "possible PNA" so given ceftriaxone/levaquin. ? wheezes so given nebulizer. Also had positive UA. . Currently she feels quite well. She denies any recent CP, HA, photophobia, abd pain, diarrhea, change in urinary frequency. . Of note, recently at [**Hospital1 18**] in [**Month (only) 547**] for bilateral PE with RV strain. Now on coumadin Past Medical History: -Bilat PE in [**2187-3-13**] with RV strain. On coumadin -diastolic dysfunction: weight recorded at NH up 4 pounds over last week. Echo in [**Month (only) 547**] with high E/e' and symmetric LVH -Bipolar d/o -Mild dementia -Refractory HTN -DM type II -Hypothyroidism -Chronic Kidney Disease - new baseline Cr 1.6 -Bilateral hearing loss -Arthritis -Bilateral carotid stenosis -hx Cdiff infection, now on suppressive therapy Social History: Lives at [**Location 583**] House Nursig Home since [**2186-12-12**]. Son, [**Name (NI) **], is the HCP at [**Telephone/Fax (1) 39303**]. [**Name2 (NI) **]ant smoking history (50 pack years), distant social EtOH. Family History: per OMR: mother w psych dz Physical Exam: per Dr. [**First Name (STitle) **] VS 101.4 74 139/38 64 25 91% Gen: AAO to person, place, situation, time. pleasant, NAD Neuro: cn ii-xii intact. Motor: 4+/5 bilat upper extensors, [**4-16**] bilat lower. [**Last Name (un) 36**] to light touch intact. toes down bilat HEENT: MMM, JVP 16cm. no nuchal rig or photophobia Cards: RRR iii/vi systolic m at base. no heave Lungs: decreased BS left base. Rales 1/2 up bilat. Abd: BS+ NT ND soft no masses Rectal: OB neg in ED Ext: 3+ edema bilat legs Discharge Exam: =============== VS: T 98.1 BP 166/77 HR 78 RR 22 96%RA General: Elderly woman sitting in chair, NAD. Neuro: Alert and oriented x 3. Pleasant, cooperative with care. Follows commands. Muscle strentgh [**4-16**] bilaterally. HEENT: Dry MM. CV: RRR, II/VI SEM. Chest: Lung sounds with crackles at right base, left base diminished with crackles. No wheezes. Fair air exchange. Abd: + BS. soft, nontender, nondistended. BM [**6-25**] loose x 4. Ext: 1+ DP pulses. No peripheral edema. Left arm PICC. Pertinent Results: Admission tests: =============== EKG: NSR, LAFB, RBBB, TWI V1-V3 which are old admit CXR: appears to have bilateral cephalization with bilat pleural effusions L>R. Possible LLL opacity . Lactate:1.5 141 106 26 --------------< 127 3.8 24 1.6 Ca: 8.2 Mg: 1.8 P: 3.4 . WBC: 17.1 - diff 88% PMNs HCT: 28.3 - at baseline PLT: 408 . PT: 16.1 PTT: 25.5 INR: 1.4 . [**2187-3-15**] CTA: Pulmonary embolism involving the bifurcation of both the right and left main pulmonary arteries with extension into all bilateral lobar branches. . [**3-20**] Echo: LA normal, mild symmetric LVH. Hyperdynamic EF. High E/e' ratio with increased LV filling pressure. Mild MR. [**First Name (Titles) **] [**Last Name (Titles) 39304**]n Troponin [**2187-6-19**]: 0.03 Troponin [**2187-6-20**]: 0.02 [**2187-6-19**] Urine Cx: E.coli AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFTRIAXONE----------- =>64 R CEFUROXIME------------ =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 4 S NITROFURANTOIN-------- 128 R PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- =>16 R [**2187-6-19**] Blood Cx: E.coli AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- =>32 R CEFAZOLIN------------- =>64 R CEFEPIME-------------- R CEFTAZIDIME----------- R CEFTRIAXONE----------- R CEFUROXIME------------ =>64 R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 4 S MEROPENEM-------------<=0.25 S PIPERACILLIN---------- R PIPERACILLIN/TAZO----- 8 S TOBRAMYCIN------------ =>16 R TRIMETHOPRIM/SULFA---- =>16 R [**2187-6-21**] Pleural Fluid Gram Stain: No PMNs; No microorganisms Culture: (Prelim) No growth Pleural fluid analysis: WBC RBC Hct,Fl Polys Lymphs Monos Macro 565* 1830* <1 44* 20* 22* 14* TotProt Glucose LD(LDH) Albumin Cholest pH 1.2 99 73 <1 10 7.55 Anemia workup: calTIBC VitB12 Folate Ferritn TRF 316 276 10.6 56 243 BNP [**2187-6-19**]: 8145 Legionella Urinary Antigen (Final [**2187-6-22**]): NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN CT CHEST W/O CONTRAST Study Date of [**2187-6-25**] 11:32 AM HRCT OF THE CHEST: New non-hemorrhagic bilateral pleural effusions, small to moderate on the left and small on the right, have resulted in near-complete collapse of the left lower lobe and less extensive atelectasis in the right lower lobe. Two nodular opacities in the lingula may be atelectasis or a small regions of infection. A more wedge-shaped consolidative opacity at the right lung apex could be infection or infarction. Diffuse moderate ground- glass opacities and interlobular septal thickening reflect volume overload. There is no evidence of fibrosis. Heart size is top normal. There is no pericardial effusion. Atherosclerotic calcification is extensive--in the coronary arteries, aortic root, and aorta and extending into the carotid and subclavian arteries. Dystrophic calcification of the mitral valve annulus could be hemodynamically signficiant since the left atrium is dilated. Pulmonary arterial size is also top normal. Left PICC tip in the right atrium, is 3.5 cm below the SVC- right atrial junction. A precarinal node is 10 mm wide (2:32); no other nodes are pathologically enlarged. This exam is not tailored for subdiaphragmatic assessment. The imaged portion of the unenhanced upper abdomen is normal. There are no concerning osseous lesions. IMPRESSION: 1. New moderate cardiac decompensation manifested in bilateral pleural effusions and interstitial and alveolar edema. 2. Small areas of right apical and lingular infection or infarction. 3. No pulmonary fibrosis CHEST PORT. LINE PLACEMENT Study Date of [**2187-6-23**] 11:55 AM FINDINGS: Comparison is made to previous study from [**2187-6-22**]. There is a left-sided PICC line with distal lead tip in the cavoatrial junction. No pneumothoraces are seen. There is a persistent left-sided retrocardiac opacity and left-sided pleural effusion, stable. Discharge labs: ============== [**2187-6-26**] 05:27AM BLOOD WBC-11.8* RBC-3.40* Hgb-9.6* Hct-29.8* MCV-88 MCH-28.2 MCHC-32.1 RDW-15.6* Plt Ct-284 [**2187-6-25**] 05:41AM BLOOD PT-24.1* PTT-32.3 INR(PT)-2.3* [**2187-6-26**] 05:27AM BLOOD Glucose-115* UreaN-18 Creat-1.2* Na-145 K-3.7 Cl-106 HCO3-33* AnGap-10 [**2187-6-26**] 05:27AM BLOOD Calcium-8.1* Phos-3.4 Mg-1.9 [**2187-6-23**] 07:36AM BLOOD TSH-2.4 [**2187-6-20**] 04:48AM BLOOD Lithium-0.7 Brief Hospital Course: 85yo woman with hx of recent bilat PE, refractory HTN, DM, CKD here with worsening DOE. Was admitted to the ICU [**Date range (1) 23465**], transferred to floor [**6-23**]: # fever/ e.coli bacteremia/ UTI: Had positive U/A, grew E.coli sensitive only to meropenem in blood and urine cultures. Initially on broad spectrum antibiotics, but switched to meropenem on [**6-21**] and had improvement in fever curve and mental status. Meropenum course complete [**7-4**]. . # Hypoxia: Initially felt to be pna given fever. Began treatment for possible PNA with levaquin, ceftriaxone (double cover strep and also cover atypical, GNR) and vancomycin (since NH resident). Final read on cxr was pulm edema, no infiltrate. Also with moderate left pleural effusion and small right.(see below) She was treated for diastolic dysfunction with better BP control and fluid status. She received several doses of IV lasix in ICU with good response and was restarted on po lasix on [**6-23**]. She continued to have O2 requirement, so CT chest was obtained to rule out interstitial process. Please see full report above, including evidence of pulmonary edema, bilateral pleural effusions and apical parynchymal consolidation consistent with infarction from known pulmonary embolus. Thoracentesis was performed and consistent with transudative process. She sucessfully weaned off with further diureseis. She will be discharged on lasix 40mg [**Hospital1 **] (home dose 20mg daily) and volume status as well as electrolytes should be followed closely. . # acute of chronic diastolic CHF: Recent echo with documented increased filling pressures. This may have been in setting of her PE. However, has longstanding hypertension and symmetric LVH. Appeared overloaded on admission exam. BNP ([**2187-6-19**]): 8145. Effusion seen on cxr. Diagnosic thoracentesis performed on [**2187-6-21**] - 10 cc straw-colored fluid; transudate by light's criteria (ph 7.55, gluc 99, GS, cx negative). Given IV lasix for diuresis in ICU and restarte PO lasix [**6-23**]. Foley d/c'd [**6-24**]. Chest CT indicates bilateral pleural effusions and interstitial and alveolar edema. - Rate controled with BB and afterload reduced with captopril. - Slowly increase to home dose of metoprolol 150mg TID, she is now on 50mg TID. - Home dose of norcasc started [**6-26**]. . # Anemia: she had fluctuating hct from 22-27. Iron studies suggest [**Doctor First Name **]. Fluid shifts likely accounted for changes in hct. Given 2u pRBCs while in unit (with lasix) and pt responded well. Hct remained stable and all stools guiaic negative. Discharged on home dose of ferrous sulfate. . # CAD: no clear new ischemic pattern on EKG. CE at baseline. Continued BB, statin. Unclear why not on aspirin, but may be [**1-13**] high risk for bleed with coumadin. . # Cards rhythm: reportedly with hx of [**Month/Day (2) **]. - BB and amio . # hx PE: subtherapeutic on INR. Possible that hypoxia is related to persistent/recurrent PE. treated w heparin gtt and continued coumadin. - Follow INR. . # HTN: difficult to control per recent d/c summaries. We started low on BP meds and uptitrated slowly. Need to continue uptitration of beta blocker at rehab to previous home dose. . # CKD: at baseline renal dysfunction. Monitor meds and fluid status. - Meropenum renally dosed. - Follow renal function with diuresis. . # DMII: She had several low blood sugars in ICU while not eating well. Her lantus was held and maintained on humalog insulin sliding scale. Rare coverage needed in the hospital, 2-6 units of sliding scale per day. Glucose levels [**6-25**] were 143, 148, 162, 184. - On discharge ordered for lantus 4 units daily, home dose is 8 units. Titrate up as oral intake improves. . # h/o c.diff -- continued previous dose of oral vanco, end date [**6-27**]. . # history of [**Month/Year (2) **] - continued on home amiodarone . # Hypothyroidism - continued on levothyroxine . # Depression/Bipolar - continued on celexa, risperdal, lithium . # history of constipation - intially constipated and given several laxatives. BM x 4 [**6-25**], meds held [**6-26**]. To resume home regimen at discharge. . # Comm: HCP is son, [**Name (NI) **] [**Name (NI) **] at [**Telephone/Fax (1) 39303**]. [**Location (un) 583**] NH [**Telephone/Fax (1) 39305**] Medications on Admission: Medications per NH: vanco 125 PO QOD as of [**6-19**] Lantus 8 qam vitamin C daily metop 150 [**Hospital1 **] Prilosec 20 [**Hospital1 **] lasix 20 daily iron 325 daily amio 200 daily amlodipine 5 daily captopril 100 tid citalopram 40 daily clonidine 0.1 [**Hospital1 **] levothyroxine 175 colace qhs senna sucralfate 1 tid warfarin 2.5 qhs MVI lipitor 10 daily lithium 150 qhs remeron 7.5 qhs risperdal 0.25 qhs tylenol prn bisacodyl prn fleets prn mom Discharge Medications: 1. Prilosec 20 mg Capsule, Delayed Release(E.C.) [**Hospital1 **]: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 2. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day): Hold for SBP<100 HR <55. 3. Vancomycin 125 mg Capsule [**Hospital1 **]: One (1) Capsule PO once a day for 1 days: Please give on [**6-27**]. This is the last dose of every other day. 4. Lasix 40 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO twice a day: Give at 0800 and 1200. 5. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). 6. Amiodarone 200 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). 7. Amlodipine 5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). 8. Captopril 100 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO three times a day: Hold for SBP <110. 9. Celexa 40 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO once a day. 10. Clonidine 0.1 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO BID (2 times a day). 11. Docusate Sodium 100 mg Capsule [**Month/Year (2) **]: One (1) Capsule PO at bedtime. 12. Senna 8.6 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO HS (at bedtime). 13. Sucralfate 1 gram Tablet [**Month/Year (2) **]: One (1) Tablet PO three times a day: one hour before meals. 14. Warfarin 2.5 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO Once Daily at 4 PM. 15. Acetaminophen 325 mg Tablet [**Month/Year (2) **]: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain. 16. Multivitamin Tablet [**Month/Year (2) **]: One (1) Cap PO DAILY (Daily). 17. Levothyroxine 175 mcg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily): give at 6:30am. 18. Atorvastatin 10 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). 19. Lithium Carbonate 150 mg Capsule [**Month/Year (2) **]: One (1) Capsule PO QHS (once a day (at bedtime)). 20. Remeron 15 mg Tablet [**Month/Year (2) **]: 7.5mg Tablets PO at bedtime. 21. Risperidone 0.25 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO HS (at bedtime) as needed for anxiety. 22. Lantus 100 unit/mL Solution [**Month/Year (2) **]: Four (4) units Subcutaneous once a day. 23. Meropenem 500 mg Recon Soln [**Month/Year (2) **]: One (1) Recon Soln Intravenous Q12H (every 12 hours) for 8 days: last dose [**2187-7-4**]. 24. Heparin, Porcine (PF) 10 unit/mL Syringe [**Month/Day/Year **]: Two (2) ML Intravenous three times a day as needed for line flush: Flush with 10mL sormal saline followed by heparin. Daily and after use of PICC. Discharge Disposition: Extended Care Facility: [**Location (un) 583**] House Nursing & Rehab center Discharge Diagnosis: Primary: ESBL e.coli bacteremia/UTI, refractory HTN, recent bilateral PEs, UTI Secondary: CKD, anemia, DMt2, hypothyroidism, mild dementia, hx of C.diff Discharge Condition: Good. Room air, ambilating with assist. Able to participate in ADLs with supervision. Discharge Instructions: You were admitted to ICU with fever, shortness of breath, and elevated white blood cell count suggestive of pneumonia. Your lab work indicated that you had a urinary tract infection as well as bacteria in your blood. Your chest x-ray and lung exam showed fluid on your lungs. We treated your infections with antibiotics. Your fever resolved and your breathing improved. Followup Instructions: Please follow up with your primary care provider [**Name Initial (PRE) 176**] 2 weeks of discharge from the hospital. Name: [**Doctor Last Name **],LAURAINE E. MD Location: [**Hospital1 **] Address: 26 CITY [**Doctor Last Name **] MALL, [**Location (un) **],[**Numeric Identifier 11562**] Phone: [**Telephone/Fax (1) 39306**] Fax: [**Telephone/Fax (1) 39307**] Recommend: repeat chest CT to evalutate LLL re-expansion in [**12-14**] months.

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

15102, 15181

7715, 12023

250, 348

15378, 15468

3213, 7242

15891, 16338

2136, 2164

12528, 15079

15202, 15357

12049, 12505

15492, 15868

7258, 7692

2179, 2674

2690, 3194

191, 212

376, 1441

1463, 1889

1905, 2120

45,347

121,878

34884

Discharge summary

report

Admission Date: [**2140-9-25**] Discharge Date: [**2140-10-7**] Service: MEDICINE Allergies: Morphine Attending:[**First Name3 (LF) 4365**] Chief Complaint: Acute pancreatitis Major Surgical or Invasive Procedure: RIJ CVL R arterial line Endotracheal intubation ERCP History of Present Illness: [**Age over 90 **] year old W with PMH of CAD s/p MI, CVA, atrial fib on coumadin, AAA (4.5cm) admitted to OSH with RLQ and LLQ pain radiating to her back, Tm 100, leukocytosis of 18, amylase 1167, lipase 3123, found to have a 5mm stone in the ampulla with a dilated CBD of 7mm on CT abd and pancreas with associated edema. Pain became progressively more severe. Therefore patient underwent CTA Torso which was negative for PE or ruptured aortic aneurysm. Of note, patient was also found to have a supratherapeutic INR to 3.5. Patient was persistently hypotensive. She received 500 ml bolus x 2 and was started on levophed peripherally. She was covered with ceftriaxone 2g and flagyl and received 10mg SC vitamin k for coagulopathy. She was then transferred to [**Hospital1 18**] for further management. Upon transfer to [**Hospital Unit Name 153**], she continued to require peripheral pressors. PIV had infiltrated. Access was attempted but patient aspirated as she was lying flat requiring CODE BLUE and urgent intubation for airway protection. A line was placed with subsequent central line placement. Past Medical History: Hx of CVA x 2 without residual deficits CAD s/p MI Afib on coumadin GERD s/p colon resection s/p vaginal prolapse Social History: Lives with son and daughter-in-law; Has own private apartment; Cooks her own meals Family History: nc Physical Exam: VS: BP 90/60 HR 106 97% on AC GEN: Elderly, lethargic HEENT: EOMI, PERRL, anicteric NECK: Supple, No [**Doctor First Name **] CHEST: CTABL, no w/r/r CV: Irregular, no m/r/g ABD: Soft/NT/ND, +BS EXT: No cyanosis or edema, 2+ DP SKIN: No rashes NEURO: Responding appropriately to questions; strength and sensation grossly intact Pertinent Results: Labs on admission: [**2140-9-25**] 10:32PM BLOOD WBC-32.4* RBC-3.20* Hgb-9.8* Hct-29.3* MCV-92 MCH-30.6 MCHC-33.4 RDW-13.6 Plt Ct-146* [**2140-9-25**] 10:32PM BLOOD PT-55.4* PTT-53.6* INR(PT)-6.5* [**2140-9-25**] 11:33PM BLOOD Fibrino-169 D-Dimer-5051* [**2140-9-25**] 10:32PM BLOOD Glucose-76 UreaN-22* Creat-1.3* Na-141 K-4.0 Cl-113* HCO3-13* AnGap-19 [**2140-9-25**] 10:32PM BLOOD ALT-26 AST-71* LD(LDH)-408* CK(CPK)-131 AlkPhos-88 TotBili-0.5 [**2140-9-25**] 10:32PM BLOOD Lipase-345* [**2140-9-25**] 10:32PM BLOOD Albumin-2.6* Calcium-6.1* Phos-3.6 Mg-0.7* [**2140-9-26**] 03:50AM BLOOD Type-ART Temp-36.2 pO2-73* pCO2-37 pH-7.18* calTCO2-15* Base XS--13 Intubat-INTUBATED [**2140-9-26**] 03:50AM BLOOD Lactate-3.5* . Labs on discharge: [**2140-10-7**] 05:27AM BLOOD WBC-6.4 RBC-3.02* Hgb-9.3* Hct-26.8* MCV-89 MCH-30.8 MCHC-34.7 RDW-16.5* Plt Ct-224 [**2140-10-6**] 04:47AM BLOOD PT-15.2* PTT-70.1* INR(PT)-1.3* [**2140-10-7**] 05:27AM BLOOD Glucose-102 UreaN-12 Creat-0.8 Na-140 K-3.6 Cl-100 HCO3-33* AnGap-11 [**2140-10-7**] 05:27AM BLOOD Calcium-7.9* Phos-3.4 Mg-1.5* . Microbiology: Outside hospital blood cultures - positive for e coli Blood cultures 10/13, [**9-28**], [**9-30**] - negative Stool c diff [**10-3**], [**10-6**] - negative . Imaging: [**2140-9-26**] ERCP: IMPRESSION: Dilated common bile duct suggestive of papillary stenosis or sphincter dysfunction and subsequent plastic stent placement. A stone was extracted per ERCP report. . [**2140-10-4**] CXR: FINDINGS: In comparison with the study of [**10-2**], there is continued enlargement of the cardiac silhouette with elevated pulmonary venous pressure and bilateral pleural effusions, which now appears more prominent on the right. . [**2140-10-5**] ECHO: The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF 60%). The right ventricular free wall is hypertrophied. The right ventricular cavity is dilated with normal free wall contractility. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The aortic regurgitation jet is eccentric, directed toward the anterior mitral leaflet. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. The supporting structures of the tricuspid valve are thickened/fibrotic. Moderate [2+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Brief Hospital Course: Mrs. [**Known lastname **] is a [**Age over 90 **] year old female with a PMH significant for afib on coumadin with gall stone pancreatitis, biliary sepsis, e coli bacteremia, respiratory failure, and Atrial fibrillation with rapid ventricular response. 1. Sepsis/e coli bacteremia: Patient presented with biliary sepsis and outside hospital cultures speciated as pan-sensitive E.coli. She was hypotensive on admission requiring IV fluid rescusitation and levophed pressor, which was weaned off. She was treated with zosyn which was converted to ampicillin/sulbactam which was coverted to PO augmentin upon extubation to complete 14 day course on [**10-10**]. 2. Respiratory Failure: Patient aspirated in setting of central venous line insertion and was subsequently intubated. Her extubation was difficult due to volume overload which was attributed to the volume rescusitation she had received. An echocardiogram and cardiac enzymes ruled out acute myocardial infarction/congestive heart failure as etiology of the volume overload. She was succesfully extubated and transferred to the regular medical floor, where she was diuresed with IV lasix and weaned down on her oxygen requirement. Because of her aspiration, she was evaluated by speech and swallow and was cleared for thick liquids and soft solids. She was discharged on PO lasix, to be weaned and discontinued as able with her oxygen requirement. 3. Pancreatitis: Patient presented with gallstone pancreatitis and underwent successful ERCP with normalization of her LFTs and lipase. She will need to return for repeat ERCP and stent removal in 4 weeks after discharge. 4. Coagulopathy: Patient was anticoagulated with coumadin for her atrial fibrillation on presentation. She received FFP and vitamin K, and her coags normalized during her hospital course. 5. Atrial fibrillation with rapid ventricular response: Patient developed tachycardia in setting of diuresis with furosemide after volume overload. This was treated successfully with diltiazem, transitioned to metoprolol 12.5 mg po bid. Re-initiation of coumadin was started on discharge, and INR will need to be monitered as outpatient. 6. Anemia: Patient was transfused 2u PRBC during her hospital stay, which stabilized hematocrit. 7. CAD: ASA and lisinopril and metoprolol were restarted after stabilized from sepsis. Medications on Admission: Lovastatin Elavil (amitryptiline) 10 PO qHS PRN Zestril Omeprazole 20mg Coumadin Aspirin 81mg Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: Ten (10) mL PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever/pain. 4. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours): Please continue through [**10-10**], then may discontinue. 6. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) nebulizer Inhalation Q6H (every 6 hours) as needed. 8. Coumadin 2 mg Tablet Sig: 2.5 Tablets PO once a day: Please adjust as needed to maintain INR [**1-17**]. 9. Lasix 20 mg Tablet Sig: One (1) Tablet PO twice a day: Please titrate down as patient is able to wean off of oxygen. Discharge Disposition: Extended Care Facility: Life Care Center of the [**Hospital3 **] - [**Location (un) 3493**] Discharge Diagnosis: Primary: Gallstone pancreatitis E coli bacteremia Sepsis Respiratory failure Aspiration pneumonia Volume overload Discharge Condition: Good. Patient with improved oxygenation, tolerating PO soft diet. Ambulating with heavy assistance. Discharge Instructions: You were admitted to the hospital with gallstone pancreatitis, and subsequently developed e coli bacteremia/sepsis, aspiration pneumonia, volume overload, respiratory failure requiring intubation. Please follow up with appointments as directed. Please take medications as directed. Please contact physician if develop shortness of breath, chest pain/pressure, abdominal pain, any other questions or concerns. Followup Instructions: Please follow up with your primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 54392**]... Please follow up with ERCP, they will contact you for follow up appointment in 4 weeks. Please call Dr.[**Name (NI) 12202**] office at ([**Telephone/Fax (1) 2306**] if you have not heard from them by [**10-27**].

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icd9cm

[ [ [] ] ]

[ "96.72", "38.91", "99.04", "51.88", "38.93", "99.07", "96.6", "51.87" ]

icd9pcs

[ [ [] ] ]

8166, 8260

4729, 7084

235, 289

8418, 8522

2046, 2051

8982, 9318

1679, 1683

7228, 8143

8281, 8397

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8546, 8959

1698, 2027

177, 197

2788, 4706

317, 1425

2065, 2769

1447, 1563

1579, 1663

70,156

174,073

55096

Discharge summary

report

Admission Date: [**2138-7-23**] Discharge Date: [**2138-8-3**] Date of Birth: [**2107-9-13**] Sex: M Service: MEDICINE Allergies: Gadavist / lisinopril Attending:[**First Name3 (LF) 3913**] Chief Complaint: hypotension, tachycardia Major Surgical or Invasive Procedure: Left IJ central line placement History of Present Illness: This is a 30 year-old Male with a PMH significant for non-alcoholic steatohepatitis (NASH), impaired glucose tolerance, presumed non-ischemic cardiomyopathy (LVEF 45% with mild global left ventricular hypokinesis), subclinical hypothyroidism with recently diagnosed [**Location (un) 5622**] chromosome negative (cytogenetics hypodiploid) pre-B cell acute lymphoblastic leukemia who is day 13 s/p hyperCVAD part B admitted for rectal pain and low grade temperatures in the setting of neutropenia. . The patient was initially started on chemotherapy in the ALL consortium trial but subsequently developed a dural venous sinus thrombosis on the right side on MRA/MRV imaging. Neuro-Oncology was consulted and recommended heparinization and he was removed from the study at that point. He was transitioned to Lovenox 80 mg SC Q12H on [**2138-7-10**]. On serial imaging, the sinus thrombosis in the right sigmoid and sagittal sinuses appeared stable and the patient started hyperCVAD part A on [**2138-6-16**]. During therapy, neutropenic fever was treated with empiric Cefepime, Vancomycin changed to Daptomycin, Micafungin and Metronidazole. Culture data and imaging at that time was reassuring, however, there was some concern for a line infection and his central catheter was removed and the tip culture was negative. He completed hyperCVAD part A on [**2138-7-11**] and was discharged home at that time. He was re-admitted for hyperCVAD part B on [**2138-7-14**] and was discharged on [**2138-7-19**]; his only complication that admission was an episode of atrial fibrillation with rapid ventricular reponse to the 130s, responsive to beta-blockers and without clear source. He had spontaneous conversion to sinus rhythm. He received IT cytarabine on [**7-21**] without issues, CSF fluid was unremarkable. . The patient was re-admitted on [**2138-7-23**] with febrile neutropenia and recurrent peri-rectal pain. The patient was assessed in clinic and was found to have low grade temperatures to the 99.5F range and tenderness in the peri-rectal area with radiation to the right groin in the setting of neutropenia (WBC 0.14, ANC 0 - 7% neutrophils and no bands) and he received IV Zosyn in clinic before admission. On [**2138-7-24**], he reported some dizziness, nausea and constipation for 24-hours. He had ongoing rectal pain with some mild streaking on the toilet paper with bowel movements and pain with defecation that resolved following these BMs. Past Medical History: 1. Non-alcoholic steatohepatitis (diagnosed in [**Country 2784**] in [**2133**]-[**2134**] via liver biopsy. LFTs resolved within one year of addressing metabolic concerns and with cod-liver oil supplementation) 2. Impaired glucose tolerance 3. History of chronic bronchitis (last pneumonia in [**2135**], resolved with antibiotics) 4. Folliculitis (recently required Doxycycline) 5. Subclinical hypothyroidism (diagnosed in the setting of depression, fatigue with elevated TSH, normal thyroxine) . Social History: The patient was born in [**Country 11150**] and moved to [**State 622**] for educational purposes at age 21 years and stayed there for 7-years. He moved to [**Country 2784**] for 2 years following that and has been in [**Location (un) 86**] for the last 10-11 months for post-doc work at the [**University/College **]-Smithsonian Institute. He is a doctor of philosophy in astronomy. He denies ever smoking and consumed alcohol [**1-27**] times weekly (social use only). He is sexually active with women only and had recent negative STI testing. Family History: Paternal grandmother died in her mid 50s of PVD and CAD. Mother with type 2 diabetes mellitus and HTN. Mother with thyroid disorder (hypothyroidism). Physical Exam: Admission Exam: VS: 99.0, 120/80, 92, 20, 100RA GEN: AAOx3, NAD, lying in bed flat, uncomfortable appearing HEENT: PERRLA, EOMI, MMM, no thrush,or visible lesions NECK: supple, no LAD, no JVD CVS: RRR, split S2, no MRG appreciated LUNGS: CTAB ABD: soft, NT, ND, NABS ext: 2+ pulses, no c/c/e External Rectal exam- patient has no visible external lesions or ulcerations in his perirectal area. No rectal exam was performed as he is neutorpenic Skin: no rashes Back- no visible lesions or rashes. No tenderness to palpation of the posterior vertebral column neuro: CN 2-12 intact, strength 5/5 in UE and LE bilat. Discharge Exam: VSS, afebrile Gen: A+Ox3 HEENT: PEERLA, EOMI, MMM, no thrush or visible lesions CV: RRR, no MRG Lungs: CTAB Abd: Soft, nt nd Extremities: 2+DP puses bilateraly, warm and well perfused, no edema Skin: dry, no visible rashes Pertinent Results: ADMISSION LABS [**2138-7-23**] 03:35PM PLT COUNT-85*# [**2138-7-23**] 10:45AM UREA N-9 CREAT-0.8 SODIUM-142 POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-28 ANION GAP-13 [**2138-7-23**] 10:45AM estGFR-Using this [**2138-7-23**] 10:45AM ALT(SGPT)-151* AST(SGOT)-37 LD(LDH)-180 ALK PHOS-72 TOT BILI-1.1 [**2138-7-23**] 10:45AM WBC-0.14*# RBC-2.97* HGB-8.9* HCT-26.8* MCV-90 MCH-29.9 MCHC-33.1 RDW-16.4* [**2138-7-23**] 10:45AM NEUTS-7* BANDS-0 LYMPHS-86* MONOS-0 EOS-7* BASOS-0 ATYPS-0 METAS-0 MYELOS-0 [**2138-7-23**] 10:45AM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2138-7-23**] 10:45AM PLT SMR-VERY LOW PLT COUNT-47*# MICU Course labs Hct [**7-25**]: 19.4, (2 units PRBC transfusion given), [**7-26**]: 25.1, [**7-27**]: 23.2 Plt [**7-25**]: 23, (2 units FFP given) [**7-26**]: 35, 7/1:49\ WBC [**7-25**]: 0.1, [**7-27**]: 2.2 (42% neutrophils) Creatinine [**7-25**]: 3.7 --> [**7-26**]: 3.2 --> [**7-27**]: 1.8 Micro: [**2138-7-24**]: B GLucan <31- NEGATIVE [**2138-7-24**]: Aspergillus Galactomannan Antigen 0.1- NEGATIVE Blood culture [**7-23**], [**7-25**], [**7-26**]- NEGATIVE Urine culture [**7-24**]- NEGATIVE Discharge Labs: [**2138-8-3**] 12:00AM BLOOD WBC-2.9* RBC-2.83* Hgb-8.8* Hct-24.4* MCV-86 MCH-31.1 MCHC-36.0* RDW-15.1 Plt Ct-477* [**2138-8-3**] 12:00AM BLOOD Neuts-83.2* Lymphs-11.7* Monos-4.8 Eos-0.2 Baso-0 [**2138-8-3**] 12:00AM BLOOD PT-10.6 PTT-31.1 INR(PT)-1.0 [**2138-8-3**] 12:00AM BLOOD Glucose-97 UreaN-20 Creat-0.8 Na-141 K-4.2 Cl-108 HCO3-25 AnGap-12 [**2138-8-3**] 12:00AM BLOOD ALT-73* AST-33 AlkPhos-65 TotBili-0.5 [**2138-8-3**] 12:00AM BLOOD Calcium-8.8 Phos-3.1 Mg-2.2 Imaging: CXR [**2138-7-23**]: Cardiomediastinal contours are normal. The lungs are clear. There is no evidence of pneumonia or pleural effusion. Brief Hospital Course: Mr. [**Known lastname 112418**] is a 30yo M w/ PMH of Ph- pre B Cell ALL, nonischemic cardiomyopathy, who presented with febrile neutropenia leading to severe sepsis and acute renal failure requiring ICU stay which resolved upon blood counts improving and underwent his next round of HyperCVAD part A with IT treatments without complication. #ALL- patient has recent diagnosis of ALL and has undergone multiple cycles of treatment with hypercvad. He was at his nadir at the time of admission despite being on neupogen and was febrile without source. After his counts returned, he underwent his next round of HyperCVAD part A with IT treatment without complications. -He will follow-up with Dr. [**Last Name (STitle) **] and requires Vincritstine treamtent on day 11 -Pt to restart neupogen on discharge #Neutropenic fever: Patient was admitted with febrile neutropenia and rectal symptoms. He was started on broad spectrum antibiotics however he continued to be febrile and rigor. He developed hypotension in the setting of this despite being on maintenance IV fluids and went into renal failure with oliguira and was transferred to the ICU where he was given large boluses of fluids and did not require pressors with return of his kidney function. A fter his counts improved he was no longer febrile. He completed a 7 day course of Meropenem and was switched to ciprofloxacin for prophylaxis at the time of discharge given his severe infection during his last neutropenic period. -Ciprofloxacin was started #Acute renal failure- patient went into acute renal failure at the beginning of his hosptialization and his Cr bumped to 3.7. Renal was consulted and felt that it was due to hypoperfusion from hypotension. This resolved with fluids and his Cr returned to baseline after a couple of days. #Dural sinus thrombosis- patient has known dural sinus thrombosis. He was on lovenox at home and was being transufsed with platelts while his counts were low in order to continue anticoagulation. He complained of postLP like headache on admission and repeat MRI of his head showed improved recanulization of the thrombus. He was continued on his lovenox during his stay and his headahce improved. -continuing lovenox Pending labs/studies: None Medications started: -ciprofloxacin- antibiotic to try to prevent infections -atovaquone- antibiotic to prevent lung infection -senna- as needed for constipation Medications changed: None Medications stopped: None Follow-up needed for: 1. Follow-up with Dr. [**Last Name (STitle) **] as per below 2. You will need to follow-up with ophthalmology as an outpatient to discuss your blind spots Medications on Admission: 1. Enoxaparin Sodium 90 mg SC Q12H 2. Acyclovir 400 mg PO Q8H 3. Carvedilol 3.125 mg PO BID 4. Calcium carbonate 500 mg calcium (1,250 mg) PO daily 5. Multivitamins 1 tab PO daily 6. Pantoprazole 40 mg PO Q24H 7. Simethicone 80 mg PO QID PRN gas/bloating 8. Docusate sodium 100 mg PO BID 9. Polyethylene Glycol 17 g PO daily PRN constipation 10. Zolpidem Tartrate 5 mg PO HS PRN insomnia 11. Filgrastim 300 mcg SC Q24H 12. Oxycodone 5 mg PO Q4H PRN pain 13. Ondansetron 4 mg ([**1-27**] pills) PO every 6-8 hours as needed for nausea Discharge Medications: 1. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) injection Subcutaneous Q12H (every 12 hours). Disp:*10 syringes* Refills:*0* 2. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). 3. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day. 5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for gas/bloating. 8. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 10. polyethylene glycol 3350 17 gram Powder in Packet Sig: One (1) Powder in Packet PO DAILY (Daily) as needed for constipation. 11. zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 12. filgrastim 300 mcg/0.5 mL Syringe Sig: One (1) injection Injection once a day. 13. ondansetron 4 mg Tablet, Rapid Dissolve Sig: [**1-27**] Tablet, Rapid Dissolves PO every 6-8 hours as needed for nausea. 14. atovaquone 750 mg/5 mL Suspension Sig: Two (2) doses PO once a day. Disp:*60 doses* Refills:*0* 15. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*60 Tablet(s)* Refills:*0* 16. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. Disp:*60 Tablet(s)* Refills:*0* 17. fluconazole 200 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Acute lymphocytic Leukemia Dural sinus thrombosis Severe sepsis Acute 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 112418**] [**Last Name (Titles) **] were admitted to the hosptial because you had fevers while your blood counts were very low (neutropenic fever). You were treated with IV antibiotics and for a time the infection had caused your blood pressure to be low which temporarily injured your kidneys so you were transferred to the ICU, and this has all since resolved after your counts returned to [**Location 213**]. It is still not known what the source of your infection was. Because you were so sick with your infection you will need to be on prophylactic (preventative) antibiotics after you leave (see below). After your counts improved and you were looking well it was decided to start another round of your chemotherapy which you underwent and tolerated without problem. [**Name (NI) **] complained of some worsening of the blind spots in your eyes. Unfortunately we were not able to get ophthalmology to see you while you were here and you should make a follow-up appointment with them as an outpatient. For your internal hemmoroid it will be important to make sure you do not get constipated. We have added an additional stool softener to your list of as needed medications. Transtional Issues: Pending labs/studies: None Medications started: -ciprofloxacin- antibiotic to try to prevent infections -atovaquone- antibiotic to prevent lung infection -senna- as needed for constipation Medications changed: None Medications stopped: None Follow-up needed for: 1. Follow-up with Dr. [**Last Name (STitle) **] as per below 2. You will need to follow-up with ophthalmology as an outpatient to discuss your blind spots #If you develop a fever you need to call the office## Followup Instructions: Department: HEMATOLOGY/BMT When: [**Last Name (STitle) **] [**2138-8-4**] at 1 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7779**], 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/BMT When: [**Hospital Ward Name **] [**2138-8-4**] at 1 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9574**], NP [**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/BMT When: FRIDAY [**2138-8-8**] at 1 PM With: [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], RN [**Telephone/Fax (1) 3241**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

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Discharge summary

report

Admission Date: [**2134-5-16**] Discharge Date: [**2134-6-1**] Date of Birth: [**2068-12-28**] Sex: M Service: MEDICINE Allergies: Penicillins / Shellfish Attending:[**First Name3 (LF) 594**] Chief Complaint: leg swelling, DOE Major Surgical or Invasive Procedure: Esophagogastroduodenoscopy Colonoscopy Tracheostomy PICC line placement Arterial line placement Trauma line placement History of Present Illness: 65yo M with a PMH of afib on coumadin, diabetes, HIV, HTN and CHF BIBA after calling 911 for several months of increasing LE edema x2months and concerns that he was not doing well at home w/ lightheadness, DOEx4days, disorientation. Upon further questioning he does note DOE x4days and several weeks of dark malodorous loose stool with intermittent BRBPR in the toilet bowl. Does recall some mild abdominal pain 4 days ago that has resolved. States he has had a colonoscopy and EGD previously at [**Hospital1 2025**], does not know why, states he does not remember being told anything was wrong. Denies ETOH use, occasional Aleve use. Of note, he states his VNA stopped checking his blood levels about 1 month ago. He continued to take his coumadin as previously instructed (1.5pills/day, unknown dose). Denies F/C/CP/SOB at rest/N/V/hematemesis, diaphoresis. Noted LE edema has worsened over the last 2 days. In the ED, initial VS were Temp 98 HR 148 BP 98/58 RR 15 sat 100% 3LNC. He was noted to be pale appearing and tachycardic with guaiac positive black stool on rectal exam. Labs were significant for a hct of 12.8 (last noted to be 37.4 in [**2121**]), hgb 3.6, INR 14.2, plts 216, Cr 2.7 (last noted to be 1.2 in [**2121**]) with a BUN of 73, Bicarb 20, glucose 216, trop 0.07, lactate 1.3, LFTs normal, Alb 3.6. Repeat Hct 1.5hrs later was stable at 12.4 prior to PRBC transfusions. Blood cultures were sent. ECG showed afib with RVR (HR120s) and poor baseline. CXR showed mild cardiomegaly, clear lungs without acute process. Patient received 1 liter NS with improvement in his SBP from 80s to 100s and HR from 140s to 120s. Patient was ordered for 4PRBCs ad 3 units FFP, however only the first unit of FFP had been completed prior to transfer. Patient was receiving the second unit of FFP on arrival and had not received any PRBCs. He received pantoprazole 40mg IV and vitamin K 10mg IV. GI was consulted and plans to do EGD and colonoscopy early this week, when hct is >25 and INR is therapeutic. Admitted with a presumed diagnosis of subacute lower GI bleed. VS on transfer HR 120-130 BP94/60 rr16 100% RA. On arrival to the MICU, he is comfortable lying in bed without chest pain, SOB, lightheadedness. C/o trembling. Past Medical History: afib on coumadin (CHADS 3, denies h/o strokes) diabetes on oral hypoglycemics HTN HL CHF CAD s/p MI 15yrs ago (denies PCI or CABG) CKD (unknown baseline) HIV, pt reports undetectable viral load s/p right hernia repair Social History: Retired, lives in [**Location 669**]. States an old girlfriend gave him HIV many yrs ago. - Tobacco: 1/2ppdx10yrs, quit 20yrs ago - Alcohol: none, quit 30yrs ago (used to drink on the weekends) - Illicits: denies Family History: Mother w/ HTN. Father w/ HTN and h/o MI. Denies DM, CVA, cancers including stomach and colon cancer. Physical Exam: Admission Exam: Vitals: T: 98.4 BP: 117/66 P: 133 R: 18 O2: 100%2LNC General: Alert, oriented, no acute distress, pleasant and interactive HEENT: Sclera anicteric, MMM, oropharynx clear w/ dentures, EOMI, PERRL Neck: supple, JVP could not be assessed [**12-24**] large neck, no LAD, trauma line in right JVP with moderate hematoma posteriorly CV: rapid irreg irreg, normal S1 + S2, no murmurs, rubs, gallops appreciated Lungs: Clear to auscultation bilaterally with mild rales at the bases bilaterally, no wheezes, rhonchi Abdomen: Obese, soft, non-tender, mildly distended, bowel sounds present- normoactive, unable to assess for organomegaly. healed scar to the right of the umbilicus GU: no foley Ext: [**11-23**]+ symmetric edema to knees bilaterally, warm, well perfused, 1+ pulses, no clubbing, cyanosis, verucous lesions on anterior shins bilaterally Neuro: A&Ox3, CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred Discharge Exam: General: Awake, sitting in chair, interactive, following commands. HEENT: PERRL, anicteric sclera. CV: S1S2 RRR w/o m/r/g??????s. Lungs: CTA bilaterally w/o crackles or wheezing. Ab: Positive BS??????s, NT/ND, no HSM. Ext: Brawny LE skin changes. Neuro: Alert and interactive. Moving all extremities. No focal motor deficits noted. Pertinent Results: Admission Labs: [**2134-5-15**] 11:10PM BLOOD WBC-6.2# RBC-1.33*# Hgb-3.6*# Hct-12.8*# MCV-97 MCH-27.3# MCHC-28.3*# RDW-17.4* Plt Ct-216 [**2134-5-15**] 11:10PM BLOOD Neuts-75.1* Lymphs-18.3 Monos-6.1 Eos-0.3 Baso-0.2 [**2134-5-15**] 11:10PM BLOOD PT-136.7* PTT-45.9* INR(PT)-14.2* [**2134-5-16**] 03:06AM BLOOD Fibrino-217 [**2134-5-15**] 11:10PM BLOOD Glucose-216* UreaN-73* Creat-2.7*# Na-143 K-4.5 Cl-114* HCO3-20* AnGap-14 [**2134-5-15**] 11:10PM BLOOD ALT-11 AST-8 AlkPhos-114 TotBili-0.1 [**2134-5-15**] 11:10PM BLOOD cTropnT-0.07* [**2134-5-16**] 03:06AM BLOOD Calcium-7.6* Phos-3.5 Mg-2.2 [**2134-5-15**] 11:10PM BLOOD Albumin-3.6 [**2134-5-16**] 03:17AM BLOOD Type-[**Last Name (un) **] pH-7.30* [**2134-5-15**] 11:25PM BLOOD Lactate-1.3 [**2134-5-15**] 11:25PM BLOOD Hgb-3.9* calcHCT-12 [**2134-5-16**] 03:17AM BLOOD freeCa-1.02* [**2134-5-16**] 05:59AM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.009 [**2134-5-16**] 05:59AM URINE Blood-SM Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-SM [**2134-5-16**] 05:59AM URINE RBC-2 WBC-6* Bacteri-NONE Yeast-NONE Epi-<1 [**2134-5-16**] 05:59AM URINE Hours-RANDOM UreaN-616 Creat-84 Na-43 K-27 Cl-33 [**2134-5-31**] 03:51AM BLOOD WBC-8.0 RBC-2.80* Hgb-7.9* Hct-25.0* MCV-89 MCH-28.1 MCHC-31.5 RDW-16.4* Plt Ct-369 [**2134-6-1**] 05:39AM BLOOD WBC-7.8 RBC-2.75* Hgb-7.9* Hct-24.5* MCV-89 MCH-28.7 MCHC-32.1 RDW-16.6* Plt Ct-366 [**2134-5-27**] 03:15AM BLOOD PT-12.0 PTT-24.4* INR(PT)-1.1 [**2134-5-29**] 12:58AM BLOOD PT-13.6* PTT-26.7 INR(PT)-1.3* [**2134-5-30**] 04:01AM BLOOD PT-16.5* PTT-25.0 INR(PT)-1.6* [**2134-5-31**] 03:51AM BLOOD PT-19.9* PTT-29.2 INR(PT)-1.9* [**2134-5-29**] 12:58AM BLOOD Glucose-153* UreaN-36* Creat-1.8* Na-150* K-3.0* Cl-112* HCO3-28 AnGap-13 [**2134-5-29**] 12:00PM BLOOD Na-149* K-3.5 Cl-114* [**2134-5-29**] 11:13PM BLOOD Glucose-180* UreaN-31* Creat-1.7* Na-145 K-3.4 Cl-110* HCO3-25 AnGap-13 [**2134-5-30**] 04:01AM BLOOD Glucose-139* UreaN-29* Creat-1.6* Na-145 K-3.7 Cl-111* HCO3-27 AnGap-11 [**2134-5-31**] 03:51AM BLOOD Glucose-112* UreaN-25* Creat-1.5* Na-146* K-3.8 Cl-110* HCO3-26 AnGap-14 [**2134-5-31**] 10:04PM BLOOD Glucose-120* UreaN-18 Creat-1.5* Na-147* K-3.6 Cl-112* HCO3-24 AnGap-15 [**2134-6-1**] 05:39AM BLOOD Glucose-90 UreaN-17 Creat-1.5* Na-147* K-4.0 Cl-112* HCO3-27 AnGap-12 [**2134-6-1**] 05:39AM BLOOD Calcium-8.4 Phos-2.4* Mg-2.0 [**2134-6-1**] 05:35AM BLOOD HERPES SIMPLEX (HSV) 1, IGG-PND [**2134-6-1**] 05:35AM BLOOD HERPES SIMPLEX (HSV) 2, IGG-PND [**2134-5-28**] 03:56PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.012 [**2134-5-28**] 03:56PM URINE Blood-SM Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD [**2134-5-28**] 03:56PM URINE RBC-1 WBC-12* Bacteri-NONE Yeast-NONE Epi-0 [**2134-5-28**] 3:56 pm URINE Site: NOT SPECIFIED Source: Line-PICC line. URINE CULTURE (Preliminary): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. Cefazolin interpretative criteria are based on a dosage regimen of 2g every 8h. Piperacillin/tazobactam sensitivity testing available on request. STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [**2134-5-25**] 4:00 pm STOOL CONSISTENCY: NOT APPLICABLE Source: Stool. **FINAL REPORT [**2134-5-26**]** C. difficile DNA amplification assay (Final [**2134-5-26**]): Negative for toxigenic C. difficile by the Illumigene DNA amplification assay. (Reference Range-Negative). ECG Study Date of [**2134-5-15**] 11:12:34 PM Atrial fibrillation with rapid ventricular response rate of 126 beats per minute. Multifocal premature ventricular complexes. Delayed R wave transition. Non-specific ST segment changes in the lateral and high lateral leads. No previous tracing available for comparison. CT ABD & PELVIS W/O CONTRAST Study Date of [**2134-5-17**] 10:29 AM FINDINGS: CT OF THE ABDOMEN WITHOUT CONTRAST: Although this study is not tailored for the evaluation of supradiaphragmatic contents, the visualized lung bases show bilateral consolidations/collapse on the right greater than the left with air bronchograms and trace bilateral pleural effusions on the right greater than the left. Diffuse ground-glass opacification in the aerated portions of the lung bases is also noted. No pulmonary nodules are seen. Limited imaging of the heart shows moderately enlarged size without pericardial effusion. The visualized portion of the descending thoracic aorta is slightly tortuous in its course. The esophagus contains an enteric tube and otherwise appears unremarkable. Evaluation of the solid organs is limited without intravenous contrast. Within these limitations, no gross abnormality is detected within the liver. There is trace perihepatic fluid. No intrahepatic or extrahepatic biliary ductal dilatation is seen. The gallbladder contains several calcified gallstones in the dependent portion measuring up to 6 mm in size. No gallbladder wall thickening, edema, or pericholecystic fluid is seen. The pancreas is unremarkable. The spleen contains a 2.1-cm hypodensity with internal fluid density of 19 Hounsfield units, likely representing a splenic cyst. The spleen is otherwise unremarkable. The bilateral adrenal glands and kidneys are within normal limits. The stomach contains an enteric tube in the distal body. The intra-abdominal loops of small and large bowel are unremarkable without evidence of wall thickening or obstruction. The appendix is normal in appearance. Minimal fluid is noted tracking along the left paracolic gutter. There is no large volume abdominal ascites or retroperitoneal fluid collection. No free air is present. No mesenteric or retroperitoneal lymphadenopathy is noted, although there are scattered small retroperitoneal and iliac lymph nodes which do not meet CT size criteria for lymphadenopathy. The abdominal aorta is normal in caliber throughout. CT OF THE PELVIS WITHOUT CONTRAST: The urinary bladder is decompressed by Foley catheter in appropriate position. The prostate and seminal vesicles are unremarkable. A small amount of simple free fluid is noted superior to the urinary bladder, within the superior pelvis. The rectum and sigmoid colon are unremarkable. Several prominent pelvic side wall and inguinal lymph nodes are noted measuring up to 12 mm in short axis. OSSEOUS STRUCTURES AND SOFT TISSUES: There is a compression fracture deformity at the L5 vertebral body which is indeterminate in age. No suspicious lytic or sclerotic lesions are detected in the bone. There is mild generalized anasarca. No focal fluid collections are noted within the soft tissue to suggest hematoma. IMPRESSION: 1. No evidence of retroperitoneal or subcutaneous fluid collection to suggest hematoma. Mild generalized anasarca and minimal perihepatic and pelvic ascites is noted. 2. Bibasilar consolidation/collapse of the lungs, on the right greater than the left, with trace pleural effusions. 3. Cholelithiasis. 4. Nonspecific prominent pelvic side wall and inguinal lymph nodes. TTE (Complete) Done [**2134-5-24**] at 10:56:45 AM FINAL The left atrium is moderately dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and regional/global systolic function (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([**11-23**]+) mitral regurgitation is seen. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild-moderate mitral regurgitation. Pulmonary artery hypertension. PORTABLE ABDOMEN Study Date of [**2134-5-31**] 11:51 AM *** UNAPPROVED (PRELIMINARY) REPORT *** !! WET READ !! Preliminary report has not yet been released for viewing. CHEST (PORTABLE AP) Study Date of [**2134-5-28**] 2:50 PM NG tube tip is in the stomach. Tracheostomy tube is in the standard position. Left PICC tip is in the mid-to-lower SVC. Moderate cardiomegaly is stable. There is mild vascular congestion. Bibasilar opacities, larger on the left side are unchanged, could be due to atelectasis and/or pneumonia. There are no new lung abnormalities. EGD [**2134-5-17**] 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 General anesthesia. A physical exam was performed prior to administering anesthesia. Supplemental oxygen was used. 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 vocal cords were visualized. The procedure was not difficult. The patient tolerated the procedure well. There were no complications. Findings: Esophagus: Mucosa: Esophagitis with no bleeding was seen in the GE junctoin, compatible with mild esophagitis. Stomach: Mucosa: Erythema of the mucosa with no bleeding was noted in the antrum. These findings are compatible with mild gastritis. Other linear erosion on the greater curvature of the stomach consistent with NG tube trauma Duodenum: Mucosa: Normal mucosa was noted. Impression: Esophagitis in the GE junctoin compatible with mild esophagitis Linear erosion on the greater curvature of the stomach consistent with NG tube trauma Erythema in the antrum compatible with mild gastritis Normal mucosa in the duodenum Otherwise normal EGD to third part of the duodenum Recommendations: No clear explanation for the patient's GI bleed from this EGD. Will need colonoscopy when more stable Additional notes: The attending was present for the entire procedure. The patient's home medication list is appended to this report. FINAL DIAGNOSIS are listed in the impression section above. Estimated blood loss = zero. No specimens were taken for pathology. Bronchoscopy [**2134-5-26**] Procedure: The procedure, indications, preparation and potential complications were explained to the patient, who indicated his understanding and signed the corresponding consent forms. A standard time out was performed as per protocol. The procedure was performed for diagnostic and therapeutic purposes at the operating room. A physical exam was performed. The bronchoscope was introduced through an endotracheal tube and advanced under direct visualization until the tracheobronchial tree was reached.The procedure was not difficult. The quality of the preparation was good. The patient tolerated the procedure well. There were no complications. Recommendations: Admit to ICU Additional notes: Patient medication list was reconciled. Attending was present for the entire procedure. FINAL DIAGNOSES are listed in the impression section above. Estimated blood loss = 25 ml. No specimens were taken for pathology. Colonoscopy [**2134-5-31**] Procedure: The procedure, indications, preparation and potential complications were explained to the patient, who indicated his understanding and signed the corresponding consent forms. The efficiency of a colonoscopy in detecting lesions was discussed with the patient and it was pointed out that a small percentage of polyps and other lesions can be missed with the test. A physical exam was performed. The patient was administered moderate sedation. The physical exam was performed prior to administering anesthesia. Supplemental oxygen was used. The patient was placed in the left lateral decubitus position.The digital exam was normal. The colonoscope was introduced through the rectum and advanced under direct visualization until the cecum was reached. The appendiceal orifice and ileo-cecal valve were identified. Careful visualization of the colon was performed as the colonoscope was withdrawn. The colonoscope was retroflexed within the rectum. The procedure was not difficult. The quality of the preparation was fair. The patient tolerated the procedure well. There were no complications. Findings: Protruding Lesions Three sessile non-bleeding polyps of benign appearance and ranging in size from 5 mm to 6 mm were found in the ascending, descending, sigmoid. Excavated Lesions A single circular ulcer was found in the rectum. A single linear ulcer was found in the rectum. Impression: Polyps in the ascending, descending, sigmoid Ulcer in the rectum Ulcer in the rectum Otherwise normal colonoscopy to cecum Recommendations: Colonoscopy in 6 mos. Additional notes: The procedure was performed by the fellow and the attending. The attending was present for the entire procedure. Degree of difficulty 1 (5 most difficult) FINAL DIAGNOSES are listed in the impression section above. Estimated blood loss = zero. No specimens were taken for pathology Brief Hospital Course: 65yo M with a PMH of afib on coumadin, diabetes, HIV, HTN, and CHF admitted to the ICU with likely subacute GIB, with hct 12.8 in the context of supratherapeutic INR at 14.2. Originally he was hypotensive secondary to significant blood loss. Patient was noted to have SBPs in the 80s on admission, was responsive to IVF bolus. He then receivied 6 units PRBCs and FFP with a massive transfusion protocol with SBPs in the 100s with a trauma line that was placed. All his at home antihypertensives were held clonidine, monixidil, isosorbide dinitrate. His atrial fibrillation normally treated with coumadin and diltiazem at home became Afib with RVR likely 2ndary to anemia (rates in the 120s to 140s). Patient then became agitiated and went into flash pulmonary edema. he was intubated and then was stablaized. He failed 3 extubation attmepts, 1 planned and 2 self attmepts. He then got a tracheosomty placed. He improved afterwards and was able to breath off of the ventilator without hemodynamic compromise. # Anemia [**12-24**] gastrointestinal bleeding: Patient reports a history of weeks of dark stools and was noted to have dark guaiac positive stool on rectal exam. He does not carry a diagnosis of liver disease or known GI pathology, however he has also not seen a GI physician and has not had an EGD or colonoscopy previously. LFTs are normal, MCV normal. Hcts stabilized, then dropped again and he was transfused another 2 more units. His EGD showed esophagitis in the GE junctoin compatible with mild esophagitis, linear erosion on the greater curvature of the stomach consistent with NG tube trauma, erythema in the antrum compatible with mild gastritis. He had a colonoscopy that showed several rectal ulcers and polyps in the ascending, descending, and sigmoid colon. No clear explanation of the GI bleed was discovered and a colonscopy was recommened in 6 months. # Supratherapeutic INR: patient is on coumadin for atrial fibrillation. It is currently unclear how or for how long his INR has been supratherapeutic. He was given vitamin K 10mg IV and multiple units of FFP. Patient is a poor historian and may have inadvertantly taken more than recommended. He was continued without anticoagulation due to the GIB. At the end of the hospitalization his coumadin was restarted at his home dose and will be continued to be montiored and managed as an outpatient. #A. fib. with RVR on multiple occasion led to flashing during the extubation attempts. He was managed as above for coumadin and rate controlled with diltiazem and metoprolol. #CHF Pt required large doses of iv lasix and lasix drips to treat vol overload and lost over 19 kilograms during the hospitalization likely due to a fluid overloaded state and LE edema that resolved by the time of discharge. #Hypertension: History of htn he was treated before with clonidine, Isosorbide Dinitrate, Lisinopril, Diltiazem ER, Metoprolol, and Minoxidil. He was treated with clonidine, diltiazem, metoprolol mainly, but several medicines were used on a prn basis including hydralazine and a nitroglycerin drip. We discharged him with lisinopril, metoprolol, clonidine, and isosorbide dinitrate. # [**Last Name (un) **]/CKD: It is unknown whether the patient carries a diagnosis of CKD, however he does related that he has been told his kidneys do not work well. States he does not urinate a lot as well. Admission Cr is 2.7. Last known Cr is 1.2 from [**2121**]. [**Last Name (un) **] could be due to renal hypoperfusion [**12-24**] acute/subacute blood loss. Final Cr during hospitalization 1.5. # Elevated troponin: Likely due to demand ischemia [**12-24**] tachycardia and significant anemia. Following trops flat. Outpatient management should be continued. # Diabetes: Blood glucose 216 on admission. Patient managed on oral hypoglycemics as an outpatient. Managed with 10 units of glargine and a sliding scale, may be continued as an outpatient or transitioned to oral medications. # HIV: patient reports an undetectable viral load. Inactive issue during this hospitalization. -continued home meds and needs to continue outpt followup Hypernatremia -Pt required free water flushes to resolve his hypernatremia. This issue resolved in the hospitalization. UTI- He was found to have a E.Coli UTI and we decided to treat for 7 days with ceftriaxone staring on [**2134-6-1**]. End dat [**2134-6-8**]. Transitional issues: Colonoscopy with GI within 6 months Gi says the flexiseal- would be best to avoid, but can continue for patient comfort/ skin issues. [**Month (only) 116**] start glipizide when taking PO, now discharging on insulin per regimen in the hospital Diet per Page 1: pureed and nectar thick with cuff deflated, no PMV Discharged on subq heparin for dvt prophylaxis will read address the issue of anticoagulation as an outpatient Pt was send out on 7 days on ceftriaxone for a UTI end on [**2134-6-8**]. PICC line Hypertension medications may need uptitration Holding lasix as patient diuresed during hospitalization over 20 pounds and was borderline hypernatremic at time of discharge, during cardiology appointment, reconsideration of restarting lasix. Blood cultures pending Emergency contact [**Name (NI) **] [**Telephone/Fax (1) 28767**] Sister [**Name (NI) **] [**Name (NI) 28768**] [**Telephone/Fax (3) 28769**], not official emergency contact. Full code during this admission Medications on Admission: Unable to obtain information regarding preadmission medication at this time. Information was obtained from dc list from [**Hospital1 2025**] in [**3-4**]. 1. Abacavir Sulfate 600 mg PO HS 2. Efavirenz 600 mg PO HS 3. LaMIVudine 150 mg PO HS 4. Azithromycin 250 mg PO Q24H 5. Diltiazem Extended-Release 240 mg PO DAILY 6. Metoprolol Succinate XL 100 mg PO DAILY 7. Lisinopril 40 mg PO DAILY 8. Isosorbide Dinitrate 20 mg PO TID 9. Minoxidil 5 mg PO BID 10. CloniDINE 0.4 mg PO BID 11. Furosemide 40 mg PO DAILY 12. Furosemide 20 mg PO PRN lower extremity edema 13. Pravastatin 40 mg PO DAILY 14. Aspirin 81 mg PO DAILY 15. Warfarin 5 mg PO DAILY16 16. GlipiZIDE 5 mg PO DAILY take 30 minutes before a meal 17. traZODONE 25 mg PO HS 18. Calcitriol 0.25 mcg PO MWF 19. Cyanocobalamin 1000 mcg PO DAILY 20. Doxazosin 8 mg PO HS 21. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN pain 22. Omeprazole 40 mg PO DAILY 23. Docusate Sodium 100 mg PO BID 24. Polyethylene Glycol 17 g PO DAILY:PRN constipation 25. Lactulose 15 mL PO Q8H:PRN constipation 26. Senna 1 TAB PO BID:PRN constipation Discharge Medications: 1. Abacavir Sulfate 600 mg PO HS 2. CloniDINE 0.4 mg PO BID 3. Efavirenz 600 mg PO HS 4. Isosorbide Dinitrate 40 mg PO TID HOLD for SBP<100 5. LaMIVudine 150 mg PO HS 6. Senna 1 TAB PO BID:PRN constipation 7. Warfarin 5 mg PO DAILY16 8. Diltiazem Extended-Release 240 mg PO DAILY 9. Docusate Sodium 100 mg PO BID 10. Heparin 5000 UNIT SC TID 11. Lisinopril 20 mg PO DAILY 12. Glargine 10 Units Dinner Insulin SC Sliding Scale using REG Insulin 13. Omeprazole 40 mg PO DAILY 14. Metoprolol Tartrate 100 mg PO TID hold for SBP < 100, HR < 60 15. Aspirin 81 mg PO DAILY 16. Calcitriol 0.25 mcg PO MWF 17. Cyanocobalamin 1000 mcg PO DAILY 18. Lactulose 15 mL PO Q8H:PRN constipation 19. Polyethylene Glycol 17 g PO DAILY:PRN constipation 20. Pravastatin 40 mg PO DAILY 21. traZODONE 25 mg PO HS:PRN Sleep aide 22. Quetiapine Fumarate 50 mg PO Q12H:PRN agitation 23. CeftriaXONE 1 gm IV Q24H Duration: 7 Days Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Lower gastrointestinal bleed Congestive heart failure 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 **], It was our pleasure to care for you at [**Hospital1 18**]. You were treated in the hospital for low blood pressures likely from a gastrointestinal bleed in the setting of a high INR, which is a measure of the thinness of your blood on coumadin. You received several blood transfusions. You were also seen by the gastroenterology doctors who recommended a colonoscopy that showed rectal ulcers, which may be where the bleed was coming from. You should have another colonoscopy in 6 months. Because you stopped bleeding your coumadin was restarted on discharge. Because you were critically ill, you were treated in the intensive care unit and were intubated for several days due to fluid in your lungs. Since you had the breathing tube in for several days and it had been replaced several times, we changed your tube to a tracheostomy, which is the breathing tube that was placed in your neck. As you improve this may be able to be removed in the future. Since you cannot eat safely right now, you have a feeding tube in as well which can be removed when you can safely swallow. Changes to your medications: STOP taking minoxidil STOP taking doxazosin. STOP taking glipizide STOP taking azithromycin STOP taking Lasix CHANGE dose of lisinopril to 20 mg daily CHANGE dose of isosorbide dinitrate to 40 mg three times a day CHANGE metoprolol to three times daily START taking heparin shots three times a day. This can help prevent blood clots. START taking lantus insulin 10 units at night and insulin sliding scale with meals. START taking seroquel 50 mg twice a day as needed START taking ceftriaxone 1 g daily x 7 days, starting [**2134-6-1**], given in the ICU. Followup Instructions: Department: DIV. OF GASTROENTEROLOGY When: WEDNESDAY [**2134-6-16**] at 1 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 463**] Building: Ra [**Hospital Unit Name 1825**] ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) **] Campus: EAST Best Parking: Main Garage Department: CARDIAC SERVICES When: THURSDAY [**2134-6-24**] at 8:40 AM With: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: WEST PROCEDURAL CENTER When: THURSDAY [**2134-8-5**] at 1:30 PM With: WPC ROOM THREE [**Telephone/Fax (1) 5072**] Building: [**Hospital Ward Name 121**] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage

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Discharge summary

report

Admission Date: [**2127-7-2**] Discharge Date: [**2127-7-9**] Date of Birth: [**2102-7-10**] Sex: F Service: [**Last Name (un) **] BRIEF CLINICAL HISTORY: The patient is a 24-year-old, African American woman who presented through the GYN Emergency Department on postoperative day 4 following a laparotomy, reduction of right ovarian torsion, suspension of right ovary at the uterus with acute onset of sharp lower left quadrant pain. By the patient's report, she states that she had been at home doing quite well when she had a fall in the bathroom. She reports acute onset of [**10-26**] sharp pain radiating along her left side to her back. She took several Percocet on the morning of admission without any relief of pain. She describes the pain as sharp and burning, worse with movement, and slightly improved with lying still. She had 1 episode of vomiting and persistent nausea. She reports having had normal bowel movements following her surgery. On presentation to the Emergency Department, she had a fever of 102.3 degrees. PRIOR MEDICAL HISTORY: Ovarian torsion. Asthma. PRIOR SURGICAL HISTORY: Laparoscopic repair of ovarian torsion. ALLERGIES: PENICILLIN. MEDICATIONS: 1. Tylenol number 3. 2. Motrin. SOCIAL HISTORY: The patient denies tobacco and alcohol. Her home situation is complicated. She cares for 2 children, lives in Section 8 Housing. Her mother has had persistent problems with drug addiction and this has contributed to problems with this patient, caring for her children. LABORATORY DATA: On admission, white blood cell count was 8.5, hematocrit 28.8. Sodium 138, potassium 3.7, chloride 102, CO2 27, BUN 5, creatinine 0.6, glucose 92. AST 53, ALT 55, alkaline phosphatase 64, total bilirubin 0.7, amylase 32, lipase 13. PHYSICAL EXAMINATION: Upon examination in the Emergency Department, the patient's T-max, T-current was found to be 102.2 degrees, pulse 104, blood pressure 110/54, respirations 18, saturating 100 percent on room air. The patient is described as a moderately obese, African American female, in moderate discomfort. Her HEENT examination is normocephalic, atraumatic. Pupils are equal and reactive to light. Cranial nerves II through XII are grossly intact. Lungs: Clear to auscultation bilaterally. Cardiac examination: Regular rate and rhythm. Abdomen: Noted to be distended, diffusely tender. There is positive guarding, positive bowel sounds. Her laparoscopic incision ports are clean, dry, and intact. On deep palpation, the abdomen is diffusely tender without localization to the left lower quadrant. Rectal examination shows stool in the vault and is heme positive. RADIOGRAPHIC STUDIES: CT scan performed in the Emergency Department with p.o. and IV contrast showed a large ventral hernia without evidence of bowel obstruction. There is also a large fluid collection and subcutaneous soft tissue in the region of the patient's laparotomy incision with intermediate density thought to be reflecting infected fluid. There is also subcutaneous gas noted. CLINICAL COURSE: Based on the patient's presentation and CT findings, a decision was made to admit the patient to the General Surgery Service. On [**2127-7-2**], the patient was taken to the Operating Room for an exploratory laparotomy, abscess drainage, and a hernia repair. The procedure is said to have gone without complication. The patient was transferred to the surgical intensive care unit, still intubated. Plan was to keep the patient intubated and paralyzed through at least her first dressing change. In the intensive care unit, she was started on broad-spectrum antibiotics and her vital signs remained stable. On postoperative day number 1, the patient had her first dressing change. This showed her fascia to still be intact. She was given 2 units of packed red blood cells for hematocrit of 22.9. At that time, her antibiotic coverage was expanded to include vancomycin, levofloxacin, and Flagyl. Later that same day, she was extubated without any complications. On the morning of postoperative day 2, the patient was transferred to the normal surgical floor, doing well. At that time, a wound VAC was placed. By postoperative day 5, the patient was doing very well. Her diet was gradually advanced through sips and clears and ultimately to a regular diet. At that time, all intraoperative cultures had come back negative for MRSA. A final wound VAC change was performed, which the patient tolerated very well. On postoperative day 6, planning began for possible discharge. A final dressing change at that time showed the wound to have closed sufficiently for the dressing to be changed from a wound VAC to a wet-to-dry. This final dressing change was performed with only oral analgesia to ensure that the patient could tolerate dressing changes at home. Premedication with 2 Percocet tablets and 1 mg of Ativan p.o. was sufficient to allow changing of the patient's dressing. After discussing the importance of twice a day wound dressing changes and the need to continue her antibiotics, the patient was evaluated one final time by Dr. [**Last Name (STitle) **] and the rest of the surgical team. She was deemed to be an appropriate candidate for discharge. DISCHARGE DISPOSITION: The patient is discharged to home in stable condition. DISCHARGE MEDICATIONS: 1. The patient is given a prescription for Percocet, 2 tablets to be taken 1 hour prior to dressing changes b.i.d. 2. Ativan 1 mg tablets, 1 tablet is to be taken 1 hour prior to dressing changes b.i.d. 3. Levofloxacin 500 mg 1 tablet to be taken p.o. q.d. x2 weeks. 4. Augmentin 500 mg tablets, 1 tablet to be taken b.i.d. for 2 weeks. FOLLOW UP: The patient has been set up for twice a day VNA services. She will have dressing changes with wet-to-dry gauze. She will follow up with Dr. [**Last Name (STitle) **] in his clinic in 1 to 2 weeks, at which time the wound can be assessed. She is instructed to contact the on-call surgery resident immediately should she have any episodes of fever or chills, the output from her wound changes significantly, or if she has any changes in her pain level. DISCHARGE DIAGNOSES: Ovarian torsion. Asthma. Subcutaneous abscess. Hernia, status post exploratory laparotomy and repair of hernia. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) **], [**MD Number(1) 13037**] Dictated By:[**Last Name (NamePattern1) 9178**] MEDQUIST36 D: [**2127-7-12**] 20:24:19 T: [**2127-7-12**] 22:49:45 Job#: [**Job Number 16241**]

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48070

Discharge summary

report

Admission Date: [**2178-11-18**] Discharge Date: [**2178-12-16**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 348**] Chief Complaint: s/p fall with femur fracture Major Surgical or Invasive Procedure: Retrograde nailing of right periprosthetic femur fracture. PEG tube placement History of Present Illness: Pt is a [**Age over 90 **] yo F who presents after fall at home. On the ground for unknown length of time and taken immediately to [**Hospital1 18**]. . In the ED found to have rib fracture and right femur fracture. Given ASA and morphine for pain. Seen by ortho who did reduction with plan for surgery on Friday. Pt remained nonresponsive/noncooperative. Only Morphine was administered for pain. . Hospital course complicated by continued blood loss [**1-14**] fracture requiring 6 units PRBC. Initial difficulty with worsening mental status secondary to narcotics which cleared overtime with changes in pain regimen minimizing opoid analgesics. Workup included a negative CT and EEG with possible evidence of anoxic injury. Additional concerns for aspiration PNA for which she is completing a standard course of Levo/Flagyl. . Pt underwent surgical repair of this femoral fracture [**11-25**], and post-operatively developed hypotension to 75/30. She was given 2L of LR, 1U of PRBC, and was transiently on peripheral neosynephrine. Her EBL was 400cc. Of concern, her urine output decreased, with a total of 75cc UOP for which she was transferred to [**Hospital Unit Name 153**] for closer monitoring. Pt since which has done well; hemodynamically stable without significant change. Continues to be sedated and minimally responsive. Past Medical History: chronic lower extremity edema, osteoarthritis, status post lumbar laminectomy, h/o CVA Social History: Lives with son. [**Name (NI) **] home care providor for activities of daily living. No ETOH. No Tobacco. Family History: NC Physical Exam: 96.8 100/60 78 20 98% RA GEN: Pt asleep but arousable. Not responsive or cooperative. HEENT: Pupils pinpoint, MM dry NECK: No C-spine tenderness LUNGS: Clear anteriorly CV: RRR, S1, S2, 3/6 SEM @ LUSB ABD: Soft, NABS, ND, cannot assess tenderness EXT: LLE swelling/ Left leg bruises and scrapes, RLE bandaged from foot to hip. NEURO: Asleep but barely arousable. Pertinent Results: [**2178-11-18**] 10:45PM GLUCOSE-106* UREA N-49* CREAT-1.7* SODIUM-141 POTASSIUM-5.6* CHLORIDE-109* TOTAL CO2-21* ANION GAP-17 [**2178-11-18**] 10:45PM CK(CPK)-1195* [**2178-11-18**] 10:45PM CK-MB-40* MB INDX-3.3 cTropnT-0.05* [**2178-11-18**] 10:45PM CALCIUM-8.9 PHOSPHATE-4.8* MAGNESIUM-1.8 [**2178-11-18**] 10:45PM WBC-9.3 RBC-3.35* HGB-11.2* HCT-31.1* MCV-93 MCH-33.3* MCHC-35.9* RDW-13.2 [**2178-11-18**] 10:45PM NEUTS-88.9* BANDS-0 LYMPHS-7.2* MONOS-3.6 EOS-0.1 BASOS-0.1 [**2178-11-18**] 10:45PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2178-11-18**] 10:45PM PLT SMR-LOW PLT COUNT-148* [**2178-11-18**] 08:08PM GLUCOSE-109* UREA N-47* CREAT-1.6* SODIUM-143 POTASSIUM-5.7* CHLORIDE-109* TOTAL CO2-20* ANION GAP-20 [**2178-11-18**] 08:08PM CK(CPK)-947* [**2178-11-18**] 08:08PM CK-MB-33* MB INDX-3.5 [**2178-11-18**] 08:08PM cTropnT-0.04* [**2178-11-18**] 04:24PM GLUCOSE-150* UREA N-49* CREAT-1.8* SODIUM-139 POTASSIUM-6.7* CHLORIDE-104 TOTAL CO2-22 ANION GAP-20 [**2178-11-18**] 04:24PM CK(CPK)-486* [**2178-11-18**] 04:24PM CK-MB-22* MB INDX-4.5 cTropnT-0.04* [**2178-11-18**] 04:24PM WBC-10.2# RBC-3.88* HGB-13.0 HCT-36.1 MCV-93 MCH-33.6* MCHC-36.1* RDW-13.4 [**2178-11-18**] 04:24PM PLT COUNT-164 . [**11-18**] Femur/Pelvis Xray IMPRESSION: AP VIEW OF THE PELVIS, TWO VIEWS OF THE RIGHT FEMUR, AND ONE VIEW OF THE LEFT FEMUR: There is an oblique fracture of the distal third of the right femur. The fracture fragments overlap, and there is posterior displacement of the distal fracture fragment with respect to the proximal. A right knee replacement is in place, without evidence of hardware loosening. A dynamic hip screw is present within the left proximal femur, unchanged from the prior study. There is no evidence of hardware loosening there as well. The bones are demineralized. IMPRESSION: Oblique fracture of the right distal femur. . [**11-18**] CT C-SPINE: Study is limited secondary to motion. No definite fractures are identified. There is degenerative change at multiple levels. Additionally, there is lordosis related to degenerative change. There is grade 1 retrolisthesis of C2 on C3. IMPRESSION: No definite fracture identified. Degenerative change at multiple levels. . [**11-20**] Echocardiogram Conclusions: 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. There is a mild mid cavity gradient (peak ~20-26 mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are moderately thickened/deformed with mild to moderate aortic stenosis. Trace aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The left ventricular inflow pattern suggests impaired relaxation. There is moderate pulmonary artery systolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the report of the prior study (tape unavailable for review) of [**2176-10-14**], the aortic valve gradient is now higher and the estimated pulmonary artery systolic pressure is now higher. . [**11-20**] CXR IMPRESSION: New right upper and lower lobe consolidation, which may be due to aspiration or evolving infectious pneumonia. . [**11-20**] CT head IMPRESSION: No intracranial hemorrhage or significant change in the head CT. . [**11-20**] EEG IMPERSSION: This is an abnormal EEG due to the presence of a slow and disorganized background rhythm with burst of generalized delta slowing and bust of suppression. This finding suggest deep subcortical dysfunction and is consistend with an anoxic encephalophathy. No lateralizing or epileptiform abnormality were seen. . [**11-30**] EEG IMPRESSION: This is an abnormal EEG due to the presence of PLEDS and [**Hospital1 **]-PLEDS as well as bursts of generalized mixed frequency slowing. The PLEDS were more frequent on the right than left. Periodic epileptiform discharges such as these can be seen with the presence of the deep underlying brain lesion. It is possible that this patient may have an underlying structural brain lesion on the right to account for this finding. . [**11-30**] MR [**First Name (Titles) 430**] [**Last Name (Titles) **]: This exam is limited by gross patient motion. The brain appears structurally normal, with prominent ventricles and sulci consistent with atrophy. There are FLAIR signal hyperintensities in the periventricular white matter areas bilaterally, likely residua of prior small vessel infarction. There are no enhancing masses following gadolinium administration. No abnormal susceptibility artifact is noted to suggest the presence of hemorrhage. No abnormal diffusion signal is seen to suggest the presence of an acute infarction. Incidentally noted is fluid within the mastoid air cells bilaterally as well as mucosal thickening involving the ethmoid and left maxillary sinus, likely inflammatory in origin. IMPRESSION: 1. Limited examination due to gross patient motion, but no enhancing abnormalities or evidence of acute infarction. 2. Fluid within the mastoid air cells and sinus mucosal disease as described, likely inflammatory in origin. . Brief Hospital Course: Assessment [**Age over 90 **] yo F found down for unknown period found to have MS changes with rib fracture with right femur fracture repair on [**11-20**] with subsequent MS [**First Name (Titles) 4245**] [**Last Name (Titles) 101377**] since her fall. . # MS changes- The circumstances of her fall were unclear. She had new ECG changes with RBBB on admission but no elevation in CE. Her MS changes were presumed to be from pain/medication induced delerium or some intracranial pathology. CT head was unremarkable on both [**11-18**] and [**11-20**] for bleed or mass. She had surgery on [**11-20**] and recovered well with Ortho following (see below). Post-operatively developed hypotension to 75/30 and she was transferred to the ICU. She was given 2L of LR, 1U of PRBC, and was transiently on peripheral neosynephrine. Her EBL was 400cc. Of concern, her urine output decreased, with a total of 75cc UO. Per report her CXR was thought to have CHF, but sats remained stable. Additionally, she may have had acute on chronic renal failure, and her urine sediment was significant for multiple muddy brown casts. Hypotension, resolved with minimal IVF's and she was transferred back to the floor from the ICU. MS changes, however, did not resolve. EEG revealed possible anoxic brain encephalophathy on [**11-20**]. She did not improve clinically and an NG tube was placed for feeding. She remained somnolent and arousable but only grunted to pain and loud commands. All potentiating medications were held, including pain medications for several days without any signs of wither increased pain orthat can be seen with the presence of the deep underlying brain lesion with the possibility of an underlying structural brain lesion. MRI on [**12-2**] yielded no enhancing abnormalities or evidence of acute infarction. On [**12-3**], after several weeks without improvement, palliative care spoke at length with [**Doctor Last Name **], the patient's son about goals of care. At that point, the patient was showing slight signs of increased alertness. She pulled out her own NG tube and discussion was about feeding options vs. hospice care. The patient remained on the floor for over a week, while the son decided on whether she would want a PEG tube and placement in rehab, or home with hospice. During this time, her mental status improved somewhat, although she was never able to follow commands fully but was more alert. The son eventually decided upon PEG placement with rehab. Palliative care was involved throughout this decision-making process, and the son was open to the idea that her course may get worse and hospice care may be a possibility in the future. . # Femur fracture- Per X-rays on admission, she had an oblique fracture of the right distal femur that was fixed surgically by Ortho on [**11-20**]. Pain control was with Morphine but due to MS changes, it was quite difficult to assess pain well. PT and Ortho followed and the patient was reportedly healing well at the time of discharge. She had continued pain with turning, and based on the conversation with her son (see above) on [**12-2**], a decision was made to minimize rolling and other painful interventions. Per Ortho, plan to remove staples on [**12-8**] (Tues), 14 days post operative. She was discharged on lovenox to follow up with orthopedics as an outpatient, continue rehab for hip surgery. . # ARF- Baseline cr 1.1-1.2. 1.8 on admission. This was presumed to be most likely prerenal as she was clinically dehydrated on admission. Her creatinine steadily improved to baseline throughout the admission with continued IVFs as needed. She was edematous after her surgery so we carefully balanced fluids with diuresis of excess fluid. Her creatinine trended down throughout. On discharge, her labs had been stable. . # Hyperkalemia- Elevated on admission and resolved with fluids . # UTI - She had UTI per Urine cultures on [**11-24**] with E. coli res only to levoquin. She was treated with - Off antibiotics, U/A yest showed no evidence of persistent UTI. - Resolved. HTN: Continued on metoprolol Wound care: Changed daily. Continued on zinc/vit C/collagenase. Medications on Admission: Calcium Colace Lasix 20mg Daily Ultram 50mg daily Dyazide 23-37.5 Discharge Disposition: Extended Care Facility: [**Location (un) 582**] of [**Location (un) 583**] Discharge Diagnosis: Primary diagnosis: R femur fracture Anoxic brain injury . Secondary diagnosis: HTN osteoarthritis h/o CVA depression/anxiety Discharge Condition: Stable. Discharge Instructions: Please give all medications as prescribed. Continue wound care. Continue rehab. Followup Instructions: Please follow up with your PCP [**Last Name (NamePattern4) **] [**12-14**] weeks.

[ "276.7", "458.29", "348.1", "821.20", "599.0", "285.1", "996.44", "V43.65", "507.0", "807.02", "403.91", "276.0", "584.5", "707.03", "E888.9" ]

icd9cm

[ [ [] ] ]

[ "99.04", "43.11", "96.6", "99.15", "79.05", "79.35" ]

icd9pcs

[ [ [] ] ]

12125, 12202

7835, 11941

292, 371

12371, 12381

2389, 7812

12509, 12594

1986, 1990

12223, 12223

12034, 12102

12405, 12486

2005, 2370

224, 254

11953, 12008

399, 1735

12302, 12350

12242, 12281

1757, 1846

1862, 1970

17,921

152,535

44371+44372

Discharge summary

report+report

Admission Date: [**2152-11-14**] Discharge Date: [**2152-11-19**] Date of Birth: [**2087-6-24**] Sex: F Service: [**Company 191**] MED Date of Transfer to Surgery: [**2152-11-19**] HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 11386**] is a 65-year-old female with a history of chronic low back pain, status post laminectomy, spinal cord stimulator placement, and intrathecal catheter placement with subsequent relief of pain, who was admitted to the chronic pain service on [**2152-11-8**] for removal of both her spinal cord stimulator and intrathecal catheter, and replacement of intrathecal catheter. After the surgery, it was noted on [**11-10**] that she was febrile to 102.8 F, and hypoxic. At this point, she was originally seen by the Medicine consult team, who recommended ceftriaxone for coverage of pneumonia, given the evidence of a left lower lobe infiltrate on chest x-ray. It was also recommended that this would cover meningitis and possibly a urinary tract infection. There was also initially some concern for CHF, and she was diuresed with Lasix with some resolution of symptoms. Her ceftriaxone was subsequently changed to levofloxacin, however, she persistently was spiking fevers and was with negative blood cultures and urine cultures. On [**2152-11-14**], she spiked to 101.3 F, the Medicine consult team recommended transfer of the patient from the Pain service to the Medicine team for further management. At the time of transfer, she was denying cough, was complaining of incisional pain at the sites of her incisions in her abdomen. She denied any pleuritic chest pain. She reported that her shortness of breath had been stable since Friday, and that she was not requiring oxygen prior to that point, yet now she was on 4 liters. She denied any dysuria, rashes, photophobia, neck stiffness, headache, abdominal pain, oral ulcers, runny nose, or sputum production. She did report that she had been having night sweats, chills, and loose stools, which was chronic from her multiple GI surgeries in the past, yet increased in amount. PAST MEDICAL HISTORY: 1. Chronic low back pain with details in HPI. 2. Gastroesophageal reflux disease. 3. Status post Billroth II secondary to mesenteric ischemia. 4. Status post hemicolectomy. 5. Laminectomy. 6. Status post spinal cord stimulator implant in [**2148**]. 7. Status post intrathecal pump placement in [**2150-8-9**]. SOCIAL HISTORY: Ms. [**Known lastname 11386**] was present in the hospital with her partner of 30 years. They are unmarried. She is a smoker. He used to smoke one to two packs per day for 40 years, but quit in [**2144**]. She denies any alcohol or other drug use. FAMILY HISTORY: Noncontributory. ALLERGIES: She has no known drug allergies. MEDICATIONS ON TRANSFER: 1. Cefazolin 1 g IV q 8 hours. 2. Levofloxacin 500 mg p.o. q.d. 3. Lasix 40 mg p.o. b.i.d. 4. Subcu heparin. 5. Morphine sulfate IR 90 mg q. 3 hours. 6. Tylenol p.r.n. 7. Neurontin 1,200 mg q. AM, 800 mg at lunch, and 1,600 mg q. h.s. 8. Methadone 10 mg p.o. q 4 hours p.r.n. PHYSICAL EXAM: Vitals revealed blood pressure of 132/70, pulse of 88, respirations at 16, temperature of 101.3 F, and oxygen saturation of 95% on 4 liters. In general, Ms. [**Known lastname 11386**] was resting comfortably, in no acute distress. She was alert and oriented times three and appearing her stated age. She was obviously diaphoretic, and was speaking in choppy sentences. HEENT exam revealed pupils are equally round and reactive to light, and her extraocular muscles were intact. She had some lid lag, and no icterus. Her oropharynx is moist, and there were no lesions or exudates. Her neck was supple, without lymphadenopathy or thyromegaly. She had no JVD at 90 degrees, and she had no meningismus. Her heart was regular, and there were no murmurs, rubs, or gallops. Her lungs revealed fine, bibasilar crackles, greater on the left than the right. She had no audible wheezes. Abdomen was soft, obese, and she had good bowel sounds. Abdominal binder was in place, and her incision looks clean, dry and intact. Her abdomen was nontender and nondistended. Her extremities were without cyanosis, clubbing or edema. She had 2+ pulses, no palpable cords. Varicosities were noted on her extremities peripherally. LABORATORIES ON TRANSFER: CBC revealed a white count of 8.8, hematocrit of 32.3, with MCV of 99, and platelets of 170. Her chemistries were normal. Chest x-ray revealed left lower lobe infiltrate on the chest x-ray from [**2152-11-12**]. She had an EKG which revealed a sinus rate of 100, normal axis, Q wave in lead III, and 0.[**Street Address(2) 1755**] depressions in leads V5-V6. She had a blood culture with no growth to date, and urine culture that was negative as the final report. HOSPITAL COURSE: 1. Infectious disease: As mentioned above in the HPI, Ms. [**Known lastname 11386**] was having persistent postop fevers despite antibiotics. On [**11-14**], she was transferred to the Medicine service for further work up and evaluation. She was then switched to vancomycin 1 g IV b.i.d., and Zosyn 4.5 mg IV q. 6 hours. She had some issues with IV access, and several doses were held while she was awaiting PICC line placement. A PIC line was subsequently placed and despite multiple doses of both the antibiotics, she was persistently spiking fevers and hypoxic as well. She had a CTA of the chest done, which revealed no evidence of pulmonary embolism, and was actually noted to not have a left lower lobe pneumonia on chest CT Scan. At this point, an abdominal CT Scan was obtained due to her persistent fevers and concern for a possible intra-abdominal process given her multiple past GI surgeries. This CT Scan revealed multiple fluid-filled collections inferior to the liver and extending to the cecum, at least one was an air fluid level. There was also a questionable fluid-filled collection in the head of the pancreas. At this point, she was continued on antibiotics. However, Surgery was consulted and after much discussion felt that an ultrasound guided needle aspiration of the largest fluid collection was appropriate, and then transfer to Surgery pending results of the aspiration for likely surgery. She was transferred to Surgery on [**2152-11-19**], and was still febrile at this time. 2. Cardiovascular: When the Medicine consult team originally saw Ms. [**Known lastname 11386**], there was some concern for CHF given some vascular prominence on her chest x-ray. She was given extra doses of Lasix and diuresed with some resolution of symptoms, however, she was persistently on 4 liters of oxygen. She had an echo while admitted, which showed normal ejection fraction and no evidence of any ventricular wall motion defects. It was also noted when seen by the Medicine consult team that she had some ST depressions in leads V5-V6, and CK MB and troponin were checked and she had a small troponin leak, but no evidence of acute ischemia. 3. Pulmonary: As mentioned above, Ms. [**Known lastname 11386**] was hypoxic throughout her course of the Medicine team. It was originally felt that this was secondary to her left lower lobe pneumonia, however, after fur analyzation of the chest x-ray and a chest CT Scan with no evidence of left lower lobe pneumonia, it was unclear of the etiology of her hypoxia. She had a CTA, which was negative for a pulmonary embolism. At the time of transfer to Surgery, she is still hypoxic and sating 96% on 4 liters. At this point, there is no evidence of congestive heart failure. 4. Gastrointestinal: As mentioned above, eventually intra-abdominal fluid-filled collections were found on abdominal CT Scan. Prior to this, Ms. [**Known lastname 11386**] had minimal right upper quadrant tenderness to palpation on exam, and LFTs were checked for possible hepatitis or possible biliary tract disease contributing to fever. Her LFTs were all within normal limits. 5. Hematologic: Ms. [**Known lastname 11386**] had a normocytic anemia with a crit of 32.3, and MCV of 99. She had iron studies checked, which revealed a low iron, borderline high ferritin, and borderline low TIBC. It was felt that these labs were most consistent with developing anemia of chronic disease. Her hematocrit was continually checked, and she required no blood transfusions. 6. Musculoskeletal: As mentioned above, Ms. [**Known lastname 11386**] has multiple issues with chronic pain, and was originally admitted to the Chronic Pain service. Her pain control throughout her admission was dictated by the Pain service, with the above regimen. She was frequently noted to be in pain and very persistent about getting her pain medicines on schedule. There were no changes in her regimen, other than the addition the day prior to discharge of [**3-14**] mg of IV morphine q. 4-6 hours p.r.n. It was felt by the pain team that this is appropriate in the setting of her acute infection. DISCHARGE CONDITION: Ms. [**Known lastname 11386**] was transferred to Surgery on [**2152-11-19**] and at that time she was still hypoxic with oxygen saturations of 96% on 4 liters. She was also continually febrile with temperatures ranging from 99 F to 102.0 F. She had no worsening of abdominal pain or any chest pain at this time. DISCHARGE STATUS: She was transferred to the General Surgery service on [**2152-11-19**] and the remainder of her course will be dictated upon her discharge from Surgery. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4446**] Dictated By:[**Last Name (NamePattern1) 14268**] MEDQUIST36 D: [**2152-11-19**] 20:26 T: [**2152-11-20**] 12:08 JOB#: [**Job Number 95132**] Admission Date: [**2152-11-8**] Discharge Date: [**2152-11-28**] Date of Birth: [**2087-6-24**] Sex: Service: HISTORY OF PRESENT ILLNESS Mrs. [**Known lastname 11386**] is a 65-year-old woman with chronic lower back pain secondary to radiculopathy. She was admitted to the hospital on [**2152-11-8**] for removal of the spinal cord stimulator. A new intrathecal pump was placed. PAST MEDICAL HISTORY: 1. Seizure disorder since [**2144**]. 2. Peptic ulcer disease. 3. Status post [**First Name8 (NamePattern2) 892**] [**Last Name (NamePattern1) **] II. 4. Osteoporosis. 5. Lower back pain, status post spinal cord stimulator and intrathecal pump. HOME MEDICATIONS: 1. Intrathecal pump (Baclofen, Bupivacaine, Dilaudid). 2. Neurontin 200 mg three times a day. 3. Lasix 40 mg twice a day. 4. Fosamax 70 mg q day. 5. Methadone. ALLERGIES: No known drug allergies. SOCIAL HISTORY: Mrs. [**Known lastname 11386**] lives at home with her partner. She had a two pack per day history of smoking for 35 years but quit sometime ago. She is an occasional social alcohol drinker. HOSPITAL COURSE: Mrs. [**Known lastname 11386**] was admitted on [**2152-11-8**] for removal of intravenous spinal cord stimulator and intrathecal pump. She had those placed four years prior for management of her chronic lower back pain. She tolerated procedure well and was placed on Cefazolin postoperatively. Postoperatively she did well and was transferred to the floor. Initially she was placed on PCA and then switched to p.o. pain medications. She developed some urinary incontinence subsequently a urology consultation was obtained. On [**2152-11-10**] she spiked a temperature of 102.8 and an episode of desaturation down to 89% on two liters nasal prongs. A medical consult was then obtained. A fever workup was largely negative at the time. Her white count was 7.4, her urinalysis was negative. Her cardiac enzymes were negative. A chest x-ray showed slight prominence of pulmonary arteries bilaterally, no evidence of pneumonia. She continued to spike fevers up to 102 degrees Farenheit. Follow-up on blood and urine cultures were negative and she was changed to Levaquin for antibiotic coverage. Mrs. [**Known lastname 11386**] continued to have fevers and was subsequently switched to Vancomycin and Zosyn for broader coverage. A follow-up chest x-ray suggested evidence of a left lower lobe pneumonia. She was continued on Zosyn and Vancomycin. The patient continued to have a fever and elevated white count up to 19.5. An abdominal CT was obtained on [**2152-11-17**] which showed multiple collections underneath the liver. A general surgery consult was then obtained. She was found to have two loculated abscesses in the right subhepatic and a lower right quadrant. The patient was sent on [**2152-11-19**] for percutaneous drainage of the subhepatic abscesses. She tolerated the procedure well without complications. The abscess originally drained 100 cc's of purulent fluid and a drain was left in place. The patient continued to have fevers and an elevated white count. A repeat CT suggested that the inferior abscess might be amenable to drainage. On [**2152-11-20**] Mrs. [**Known lastname 11386**] was brought back to Interventional Radiology for drainage of the inferior collection. She tolerated the procedure well and the drain was left in place. The superior drain was replaced with a new one and 100 cc's of purulent fluid was extracted. She tolerated procedure well without complications. Subsequently, her temperature came down to 100.5 with occasional spikes. She continued to defervesced over the next several days. Her diet was advanced and she was taken off TPN. Cultures of the fluid collections showed enterococcus, lactobacilli and fungal growth. Intravenous Fluconazole was added to her antibiotics. She is currently ambulating well independently. She has been tolerating p.o. intake with no nausea or vomiting. She has had regular bowel movements and has been passing flatus. She has been switched to oral antibiotics and has been afebrile. She will require follow-up CT. She is currently stable for discharge and will require follow-up with Dr. [**First Name (STitle) 2819**]. Discharge Diagnoses: 1. Chronic Pain and Spinal Degeneration 2. Peritonitis with abscess for loculated perforated viscous 3. Hypovolemia requiring fluid rescusitation 4. Seizure disorder 5. Malnutrition requiring parenteral nutrition 6. Osteroporosis and Osteoarthritis [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] m.d [**MD Number(1) 38191**] Dictated By:[**First Name3 (LF) 95133**] MEDQUIST36 D: [**2152-11-27**] 21:00 T: [**2152-11-27**] 22:09 JOB#: [**Job Number 95134**]

[ "572.0", "998.89", "428.0", "486", "780.39", "998.51", "996.2", "780.6", "996.63" ]

icd9cm

[ [ [] ] ]

[ "54.91", "99.15", "86.06", "03.94", "38.93", "86.05", "03.90" ]

icd9pcs

[ [ [] ] ]

9015, 10151

2723, 2787

14030, 14549

10874, 14008

3113, 4830

10442, 10646

229, 2095

2812, 3097

10173, 10424

10663, 10856

16,055

177,220

20086+57112

Discharge summary

report+addendum

Admission Date: [**2152-12-21**] Discharge Date: [**2153-1-25**] Service: General surgery -- Blue service. NOTE: This is an interim summary. CHIEF COMPLAINT: Malaise and low grade fevers and abdominal pain. HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname **] is an 83 year old female with past medical history significant for gastroesophageal reflux disease, colon cancer, noninsulin dependent diabetes mellitus, who is well known to the general surgery blue service, as she underwent an antrectomy/vagotomy with Bilroth II reconstruction as well as splenectomy and partial pancreatectomy for a large bleeding duodenal ulcer on [**2152-11-25**]. She recovered well from this previous surgery and she was discharged to acute care rehabilitation on [**2152-12-8**] with both a duodenostomy tube in the afferent limb of her gastrojejunostomy and a feeding jejunostomy tube placed. She was sent to the Emergency Department on [**2152-12-21**] with report of fevers, abdominal pain and general malaise, as well as a report of some purulent drainage from her former right upper quadrant [**Location (un) 1661**]-[**Location (un) 1662**] drain site. PAST MEDICAL HISTORY: Significant for gastroesophageal reflux disease; colon cancer; ventral hernia; chronic obstructive pulmonary disease; asthma; noninsulin dependent diabetes mellitus; cataracts; arthritis; bleeding duodenal ulcer. PAST SURGICAL HISTORY: Right colectomy. Cataract surgery. Ventral herniorrhaphy. Bilateral hip replacements. Antrectomy/vagotomy with Bilroth II repair. Splenectomy. Distal pancreatectomy. MEDICATIONS AT HOME: 1. Lasix 40 mg q. a.m. and 20 q. p.m. 2. Atrovent. 3. NPH 10 units q. a.m. 4. Ambien 5 mg q h.s. 5. Lopressor 25 mg p.o. twice a day. 6. Zinc 20 mg p.o. q. day. 7. Flovent two puffs twice a day. 8. Paxil 20 mg p.o. q. day. 9. Protonic 40 mg p.o. twice a day. 10. Reglan 10 mg p.o. q.o.d. 11. Aldactone 25 mg p.o. twice a day. PHYSICAL EXAMINATION: She is afebrile at 98.6; pulse 80; blood pressure 125/55; respiratory rate 18; oxygen saturation 96% on three liters. She is sleepy, oriented, in no apparent distress. She does have some scleral icterus. Lungs: She has decreased breath sounds bilaterally. Heart: Regular rate and rhythm with a normal S1 and S2. Her abdominal examination is significant for softness and obese. There is a 5 by 5 cm area that is tender, indurated and erythematous surrounding the former right [**Location (un) 1661**]-[**Location (un) 1662**] drain site with purulent drainage from the site. Some fluctuance inferior to it. There is a duodenostomy tube with some serous drainage from around the skin site and a feeding jejunostomy in good position. The prior surgical incision is well healed with no erythema or drainage. Rectal examination: No masses, nontender. She is guaiac positive. Extremities: She has 1+ peripheral edema. LABORATORY DATA: On admission, white count was 21.3 with a left shift with 86% neutrophils; hematocrit of 40.5; platelets of 355. Sodium of 149; potassium of 3.8; chloride of 103; bicarbonate of 36; BUN 49; creatinine 1.4; sugar of 252. Her urinalysis shows positive nitrates and trace leukocyte esterase. Her PT was 12.6; PTT was 23.2; INR was 1.1. A CAT scan of the abdomen showed a large subcutaneous collection of air and soft tissue. This collection did not seem to involve the fascia. There were also signs of a dilated afferent limb as well as some stranding in the area around the end of the duodenostomy stump, indicating possibility of a duodenal stump leak. In addition, the radiologist noted the expected changes following a Bilroth II reconstruction as well as a distal pancreatectomy and splenectomy. She had follow-up contrast studies, during which gastrografin was injected into both the jejunostomy and duodenostomy tubes. The J tube contrast study showed that the J tube was in good position and there was no evident leak. However, the duodenostomy contrast study showed a small amount of contrast exiting from the duodenal stump, indicating a slight leak from the duodenal stump. It was determined that Ms. [**Known lastname **] had an angry abdominal wall abscess which required emergent surgery. Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **], after consulting with Dr. [**Last Name (STitle) 957**], proceeded to consent Ms. [**Known lastname **] to surgery and the patient was taken to the operating room for treatment. Please refer to the previously dictated operative note by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] for the specifics of this surgery. However, in brief, the surgery had the following findings: 1.) A large subcutaneous abscess was found almost immediately after opening the skin overlying the abdomen, with about 400 to 500 ml of purulent debris draining almost immediately. This purulent material was washed out with high pressure saline and further inspection revealed that there was a small fascial dehiscence of the inferior aspect of Ms. [**Known lastname **] prior surgical wound. Otherwise, Ms. [**Known lastname **] abdominal fascia was intact and once this was repaired, two Penrose drains were placed to assist with the drainage of the subcutaneous layer. Intraoperatively, Ms. [**Known lastname **] had several episodes of hypotension which required the administration of pressure support. This, combined with the fact that the duodenal leak appeared to be relatively minimal and would be unlikely to be repaired by adjusting the duodenostomy tube precluded additional intervention. It was decided that she would be transferred to the Intensive Care Unit and managed conservatively. In addition, the abdominal wound was packed with Betadine soaked Kerlix and the Penrose drains assisted with the drainage. Once this was completed, Ms. [**Known lastname **] was transferred to the Intensive Care Unit, intubated and in good condition. Wound cultures taken during this procedure eventually grew out Vancomycin sensitive enterococcus, pseudomonas, [**Female First Name (un) **] albicans, the anaerobe Prevotella, for which Ms. [**Known lastname **] was put on intravenous antibiotics. Ms. [**Known lastname **] Intensive Care Unit course was relatively uncomplicated. She underwent hemodynamic monitoring with an arterial line and Swan-Ganz catheter. She continued to have twice daily dressing changes with wet to dry gauze of her abdominal wound in the subcutaneous layer. TPN and tube feeds were started on postoperative day number three and Mrs. [**Known lastname **] actually began taking p.o. on postoperative day number five. While in the Intensive Care Unit, Mrs. [**Known lastname **] also received several red blood cell transfusions. On postoperative day number six, Ms. [**Known lastname **] was transferred to the floor, as she was doing very well. However, she bounced right back to the Intensive Care Unit after she suffered an episode of confusion, low grade fever and tachycardia. Blood cultures were sent. Ms. [**Known lastname **] central venous access line was changed; however. Electrocardiogram, chest x-ray and arterial blood gases were all obtained; however, one of these tests resulted in a diagnosis. This episode was attributed to a reaction to the intravenous Dilaudid that Ms. [**Known lastname **] was receiving for her dressing changes. This is in agreement with the prior allergy to Percocet, noted from her prior admission. The second Intensive Care Unit stay was also uncomplicated and on [**12-31**], which was postoperative day number nine, Ms. [**Known lastname **] was transferred back to the floor. The rest of her floor stay can be described in an organ system base fashion. Neurologic: Ms. [**Known lastname **] was started on very small doses of Demerol to assist with her dressing changes. By [**1-2**], Ms. [**Known lastname **] was actually able to tolerate the dressing changes without any narcotics. In addition, Ms. [**Known lastname **] was soon started on her home dose of Paxil which she [**Known lastname 8337**] well. Her pain, for the rest of her hospital stay of note was easily controlled with Tylenol. Cardiovascular: Ms. [**Known lastname **] was on her home dose of Lopressor, 25 mg twice a day for the rest of her hospital stay. Respiratory: Ms. [**Known lastname **] did have some wheezing difficulties, for which she continued on her Flovent. She also received nebulizer treatments q. six and was oxygen saturation requiring because of oxygen saturations down into the mid 80's; however, her oxygen saturation would quickly climb back up with administration of oxygen via a shovel mask. Gastrointestinal: During this time on the floor, Ms. [**Known lastname **] has been sustained with a combination of parenteral and enteral nutrition. Towards the beginning of the month, a nitrogen balance was calculated and Ms. [**Known lastname **] was found to have a nitrogen balance of -7.5, clearly catabolic. Ms. [**Known lastname **] TPN was changed over. The protein was changed over to HepatAmine, in the hopes that this would assist with closing of her colocutaneous fistula. She was able to increase the amount of protein in her TPN. In addition, Ms. [**Known lastname **] also received tube feeds via her jejunostomy tube. She received 1/2 strength Impact tube feeds plus fiber at 70%. In an attempt to increase her protein intake, when she was noted to be subcatabolic, these tube feeds were supplemented with 30 grams of ProMod every day. She [**Known lastname 8337**] this increase in protein very well and her subsequent nitrogen balance was noted to be +2. Hematology: There were no issues. Ms. [**Known lastname **] did not require any more transfusions. Infectious disease: After being treated for several days with intravenous antimicrobials, Ms. [**Known lastname **] was noted to have some low grade fevers on [**12-27**]. She was cultured and a urine culture on that day ended up growing out [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 563**]. Ms. [**Known lastname **] was started on Voriconazole for this but she subsequently had a dramatic increase in her creatinine. She was switched back to Diflucan for several days; however, by [**1-16**], Ms. [**Known lastname **] did not clear the [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 563**] from her urine and she was treated with Amphotericin B bladder irrigation. On [**1-23**], urine culture, after her five day course of bladder washings revealed that her urine had been cleared of the fungus. Gradually, of note, no blood cultures have come back positive and she has been discontinued from all her intravenous and oral antibiotics as of [**1-25**]. Renal: As mentioned before, Ms. [**Known lastname **] had a poor reaction to Voriconazole with rising creatinine. She [**Known lastname 53183**] well to hydration and discontinuance of the Voriconazole. Throughout the month of [**Month (only) 404**], she was actively diuresed with Lasix, anywhere from 5 to 20 mg of intravenous Lasix a day. She remained relatively stable with her weight. Baseline weight was 72.7 kilograms. On [**1-23**], she was 80.4 kg, still 8 kg over her baseline weight. Finally with renal, her Foley was discontinued on [**1-25**]. Ms. [**Known lastname **] [**Last Name (Titles) 8337**] this well. Musculoskeletal: Ms. [**Known lastname **] did injure her left wrist in the middle of [**Month (only) 404**], on [**1-9**]. Ms. [**Known lastname **] had a wrist x-ray obtained which did not show any fractures or any pathology. A wrist splint was placed and Ms. [**Known lastname **] [**Last Name (Titles) 53183**] well to Celebrex. Skin care: It was noted on [**1-6**] or so, that Ms. [**Known lastname **] had a small ulcer or area of induration on her sacrum. An ostomy nurse [**First Name (Titles) **] [**Last Name (Titles) 4221**] and the patient received Duoderm intermittently to help prevent development of a worse decubitus ulcer. Wound: Ms. [**Known lastname **] surgical wound has been packed on a twice daily regimen, early morning on rounds and in the evening after rounds by the surgical house officer. This is packed with wet to dry Kerlix, covered over with four by fours and abdominal pads and held together with [**Location (un) **] straps with rubber bands holding them together. Her duodenostomy tubes were also covered with ABD's. Her drainage has significantly decreased from the beginning of her hospital stay. She still does put out a small amount of greenish feculent material. The current abdominal wound has a midline 2 by 3 cm defect at its superior aspect. At the superior aspect of the defect, one can see the prosthetic mesh from her prior umbilical hernia repair. It is likely that this mesh is impeding the ability of this wound to definitively heal. To the patient's right, there is also another wound at approximately 10 o'clock. There is a subcutaneous tunnel connecting these two which is also packed with the Kerlix. At 8 o'clock, there is a Penrose drain. This is also connected to the subcutaneous cavity. To the patient's left of the midline wound is a small connection to another subcutaneous cavity. At the deep layer of this cavity is a enterocutaneous fistula from which the feculent material drains. It drains at approximately 5 to 10 cc per day. At the inferior aspect of this left sided cavity, there is another Penrose drain which is sutured in place as well. Above this cavity, Ms. [**Known lastname **] also has her jejunostomy and duodenostomy tubes in place. Discharge medications and discharge instructions will be added at the end of Ms. [**Known lastname **] hospital stay. Her current medication list includes: 1. Metoprolol 25 mg p.o. twice a day. 2. Protonic 40 mg p.o. q. day. 3. Sliding scale of insulin. 4. Glycerin suppositories prn. 5. Flovent 2 puffs twice a day. 6. Nebulizer treatments q. six hours. 7. Paxil 20 mg p.o. q. day. 8. Tylenol q. day. 9. Aldactone 25 mg p.o. twice a day. 10. Kaopectate 30 cc twice a day. 11. Imodium 2 mg p.o. twice a day. 12. Celebrex 200 mg p.o. q. day. 13. Lasix 10 mg intravenous twice a day. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 4007**] Dictated By:[**Last Name (NamePattern1) 1179**] MEDQUIST36 D: [**2153-1-25**] 04:26 T: [**2153-1-25**] 04:36 JOB#: [**Job Number 54061**] Name: [**Known lastname 5160**], [**Known firstname **] M Unit No: [**Numeric Identifier 10041**] Admission Date: [**2152-12-21**] Discharge Date: [**2153-2-21**] Date of Birth: [**2069-6-16**] Sex: F Service: SURGERY ADDENDUM: Hospital course starting on [**1-28**], through [**2153-2-21**]. On [**1-28**], the status of the patient was that the patient was afebrile with stable vital signs on two liters of oxygen saturating at 94%. The patient's nutrition included tube feeds, TPN, and an NPO diet status. The patient was being diuresed at this time. On [**1-30**], the patient went to the Operating Room for debridement of abdominal wound, removal of Marlex mesh, J-tube change under local anesthesia. The patient got perioperative Vancomycin and Gentamicin and tolerated the procedure well. On [**1-31**], the patient was weaned off TPN and tube feeds were cycled. The patient was started on a diabetic diet with Boost supplementations and calorie counts were started. In the PM, senior resident was called regarding questionable changes in mental status. No neurologic deficits were found and a cardiac evaluation was negative for a cardiac event. The patient was found to be hypoxic, saturating into the mid 80%. A chest x-ray was obtained which showed large left pleural effusion, moderate right pleural effusion. The patient's arterial blood gas at this time was 7.36/63/97/37. The patient was given Lasix for diuresis, a Foley catheter was placed and the patient was transferred to the Intensive Care Unit. On [**2-1**], a repeat chest x-ray was obtained which showed worsening left pleural effusions. Thoracic surgery was consulted and a bronchoscopy was performed. The patient was intubated at this time. In addition, a left chest tube was placed and a thoracentesis was performed. During this time, the patient was being aggressively diuresed with Lasix with improvement in chest x-ray. On [**2-4**], the patient was extubated without problems. On [**2-4**], the patient spiked a temperature to 104.0 F.; the patient was pan cultured and a repeat chest x-ray was obtained. The patient was started on Vancomycin and Zosyn for Gram positive cocci and Pseudomonas which grew out of the BAL obtained from the bronchoscopy. Cultures came back at this time from [**2-2**] which grew out [**First Name5 (NamePattern1) 1441**] [**Last Name (NamePattern1) 2619**]. At this time, AmBisome was started. The patient's central lines were changed as a part of the fever work-up; the catheter tip was found to be negative. Cultures at this time were positive blood cultures from [**2-2**] two out of two [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 2619**]. Repeat blood cultures from [**2-4**] were two out of two [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 2619**] in addition to two out of two fungal blood cultures growing [**First Name5 (NamePattern1) 1441**] [**Last Name (NamePattern1) 2619**]. As mentioned, the catheter tip from [**2-6**] was negative. Sputum cultures from [**2-3**], grew out Pseudomonas aeruginosum and Staphylococcus aureus, coagulation positive. Urine cultures from [**2-3**] grew out E. coli and Pseudomonas aeruginosum. As mentioned, cultures from the bronchoalveolar lavage on [**2-1**] grew out Pseudomonas and Staphylococcus aureus coagulase positive. Pleural fluid obtained from the thoracentesis on [**2-1**] grew out alpha Streptococcus, carinii bacterium, diphtheroids. After a few days on these anti-microbials, the patient's temperature resolved. On [**2-6**], the patient's chest tube was discontinued and a follow-up chest x-ray showed improvement. On [**2-7**], the patient's TPN was discontinued and the patient's tube feeds were cycled. At this time, surveillance blood cultures were negative. The patient was being diuresed aggressively with Lasix to obtain her dry preoperative weight. Calorie counts were being obtained and Physical Therapy was working with the patient at this time. The patient was to finish fourteen days of these anti-microbials. On [**2-16**], the patient's central venous line was discontinued and a peripheral line was obtained. At this time, Vancomycin and Zosyn were discontinued for a course of 14 days. On [**2-18**], the patient's course of AmBisome reached 14 days and the patient remained afebrile. On [**2-19**], the patient's G-tube was discontinued with peri-procedure Gentamicin and ampicillin. Also at this time, routine electrolytes were obtained and the patient's creatinine was found to be 1.8 which is increased from previous. On [**2-1**], the patient's BUN and creatinine have improved at 41/1.6 respectively. Upon discharge, the patient was afebrile and with a temperature of 97.2 F.; heart rate of 80; blood pressure of 124/46; saturation at 94% on room air. The patient had adequate urine output with fingersticks ranging from 130 to 191. The patient's physical examination was remarkable for lungs clear to auscultation bilaterally. Abdominal dressings revealed two abdominal wounds, 1.5 by 1.5 cm, granulating well with dressings in place. A jejunostomy tube is also in place. Upon discharge, the patient is at goal k-cals at about 1200 per day, including her tube feeds of half strength ProMod with fiber running at 70 cc an hour from 7 p.m. until 7 a.m. CONDITION AT DISCHARGE: Stable. SURGICAL procedures IN [**Month (only) **] TO INCLUDE: 1. Status post debridement of an abdominal wall wound, removal of Marlex mesh, J-tube change on [**1-30**]. 2. Status post bronchoscopy on [**2-1**]. 3. Status post left chest tube placement on [**2-1**]. 4. Status post thoracentesis on [**2-1**]. 5. Status post central venous access times three and arterial catheter placement times two. DISCHARGE MEDICATIONS: 1. Lasix 5 mg p.o. q. day. 2. Lopressor 25 mg p.o. twice a day. 3. Protonix 40 mg p.o. q. day. 4. Regular insulin sliding scale with fingerstick twice a day. 5. Loperamide 2 mg p.o. twice a day. 6. Subcutaneously heparin 5000 units per ml, one injection q. 12 hours. 7. Acetaminophen 325 mg, one to two tablets p.o. q. four to six hours p.r.n. pain, fever. 8. Celebrex 200 mg p.o. q. day p.r.n. arthritis. 9. Zinc sulfate 220 mg p.o. q. day. 10. Benadryl 25 mg p.o. q. h.s. p.r.n. insomnia. 11. Kaopectate 5.85/0.13 grams per 30 ml suspension, 30 ml p.o. twice a day. 12. Acetylcysteine 20% (200 mg per ml) solution, 1 ml q. four to six hours nebulizer q. four to six hours p.r.n. 12. Ipratropium 0.02% solution, one inhalation q. six hours p.r.n. 13. Albuterol 0.083% solution, one inhalation q. four hours p.r.n. 14. Sodium chloride aerosol spray, one to two sprays, nasal four times a day p.r.n. 15. Fluticasone propionate 110 micrograms / activation aerosol two puffs inhalation twice a day p.r.n. DISCHARGE INSTRUCTIONS: 1. Diabetic diet, cycled tube feeds, Boost three times a day. 2. Out of bed with Physical Therapy three times a day to assist with mobility, strength, endurance. 3. Abdominal wound dressings changes times two with half strength Dakin's solution and miconazole powder twice a day. 4. The patient is instructed to return immediately to [**Hospital1 1294**] if J-tube is dislodged or loosened. The patient should arrive immediately via ambulance and General Surgery Blue Team should be contact[**Name (NI) **]. 5. The patient's O2 saturations should be kept over 92% with oxygen p.r.n. 6. The patient should be treated with chest Physical Therapy, nebulizer treatment, and inhalers. 7. Weight should be obtained q. day. DISCHARGE DIAGNOSES: As mentioned above, multiple diagnoses. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 486**] Dictated By:[**Last Name (NamePattern1) 7275**] MEDQUIST36 D: [**2153-2-21**] 15:53 T: [**2153-2-21**] 16:25 JOB#: [**Job Number 10042**]

[ "584.9", "292.81", "998.31", "493.20", "511.9", "790.7", "707.0", "997.4", "998.59" ]

icd9cm

[ [ [] ] ]

[ "96.71", "34.91", "38.91", "89.64", "38.93", "34.04", "33.24", "99.04", "96.6", "96.04", "99.15", "86.22", "54.12" ]

icd9pcs

[ [ [] ] ]

22080, 22363

20296, 21308

21332, 22058

1615, 1951

1425, 1594

1974, 19847

19863, 20273

172, 222

251, 1164

1187, 1401

18,312

166,594

22591

Discharge summary

report

Admission Date: [**2101-4-15**] Discharge Date: [**2101-5-10**] Date of Birth: [**2019-7-28**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Sulfa (Sulfonamides) / Codeine / Tagamet / Prilosec / Shellfish Attending:[**First Name3 (LF) 165**] Chief Complaint: Chest Pain with positive stress test, cath revealed CAD. Transferred to [**Hospital1 18**] for ?CABG. Pt also bleeding from R groin, unstable BP, needed emergent CABG Major Surgical or Invasive Procedure: [**2101-4-16**] CABG x 3 LIMA to LAD, SVG to OM, SVG to RCA; R femoral artery repair. Complicated with difficult access/SVC perforation with line placement, & cardiac tamponade, chest re-opened/blood evacuated. [**2101-4-25**] Tracheostomy (Portex Per-fit 7mmm-6mm inner cannula) and PEG done in OR. No complications. [**2101-5-6**]: down sized trach to #6mm History of Present Illness: Present to outside hospital for worsening chest pain with positive stress test, cath revealed CAD. Transferred to [**Hospital1 18**] for possible CABG. Pt bleeding from R groin, BP unstable, treated to OR for emergent CABG/ repair SFA-pseudoaneurysm Past Medical History: 1. hypertension 2. angina 3. hyperlipidemia 4. hypothyroidism 5. chronic renal failure-HD rt arm AV fistula 6. s/p CVA 3 years ago-no residual 7. depression Social History: Pt lives at home with a relative. Family History: History of heart disease. Her brother had one kidney removed for a reason not known to her. Physical Exam: Admission VS T98 HR 91SR BP 111/58 RR 20 O2Sat Neuro: Awake, A&O Neck: [**2-27**] bruit on left CV RRR, S1-S2, 2/6 SEM Pulm CTA-bilat Abdm: soft NT/ND Ext large rt groin hematoma, legs warm Discharge: VS: T97.5, HR80, BP160/44, RR24, O2Sat100% NEURO: Alert, awake, follows commands approp, Pt on Passy-Muir valve and tolerating, able to communicates needs verbally, denies any pain, PERRLA, gag impaired/cough intact, R arm/leg moves on bed/no movement noted on L side RESP: Tolerating trach collar on 40%, Sats 99%, lung sounds clear, Pt expectorates tan/thick secretions, may need suctioning every 1-2 hours, tolerates her Passy-Muir valve but Pt prefers to not wear it at this time. CV: NSR with HR 70-80s, SBP in 150-160 (goal is 130-150s), pedal pulses palpable, L arm has AV fistula for dialysis (positive for thrill/bruit), afebrile, WBC down to 15. R PICC in place. GI: Pt continues on Nutren Renal at goal 35cc/hr, abd soft, nontender, BS present, small BM today, holding Colace for loose stools the past two days GU: Straight cath every other day (last done [**5-1**] for 500cc urine), Pt has hx of chronic renal disease, renal service following, Pt continues on hemodialysis three times per week (Pt next scheduled on [**5-3**]), last creatinite was 2.6 ENDO: Continues on sliding scale of Humalog SC & morning dose of Lantus SKIN: Areas of ecchymosis noted on R arm, L upper shoulder; Sternal incision clean/dry/intact with DSD; mediastinal (old chest tube sites) clean/dry/intact with DSD; PEG with DSD; coccyx is pink/unbroken skin, applied heavy skin cream, Right groin incision staples removed [**5-10**] [**1-25**] area open with W-D drsg [**Name5 (PTitle) **] [**Hospital1 **] [**Name5 (PTitle) 31186**] pink and healing Pertinent Results: [**2101-5-9**] 03:51AM BLOOD WBC-10.8 RBC-3.29* Hgb-10.2* Hct-29.8* MCV-90 MCH-30.9 MCHC-34.2 RDW-16.5* Plt Ct-421 [**2101-4-15**] 10:12PM BLOOD WBC-12.6*# RBC-3.85* Hgb-11.4* Hct-34.6* MCV-90 MCH-29.6 MCHC-33.0 RDW-16.2* Plt Ct-191 [**2101-5-10**] 03:51AM BLOOD Plt Ct-432 [**2101-5-10**] 03:51AM BLOOD PT-12.4 PTT-47.7* INR(PT)-1.1 [**2101-4-15**] 10:12PM BLOOD Plt Ct-191 [**2101-4-15**] 10:12PM BLOOD PT-12.5 PTT-47.0* INR(PT)-1.1 [**2101-4-16**] 11:52PM BLOOD Fibrino-129*# [**2101-5-10**] 03:51AM BLOOD Glucose-118* UreaN-138* Creat-3.2* Na-135 K-3.8 Cl-100 HCO3-28 AnGap-11 [**2101-4-15**] 10:12PM BLOOD Glucose-161* UreaN-26* Creat-2.2*# Na-142 K-4.2 Cl-103 HCO3-26 AnGap-17 [**2101-4-18**] 03:21AM BLOOD ALT-31 AST-57* LD(LDH)-374* AlkPhos-55 TotBili-0.8 [**2101-4-16**] 11:43AM BLOOD CK(CPK)-37 [**2101-5-10**] 03:51AM BLOOD Calcium-8.2* Phos-3.6 Mg-2.4 [**2101-4-25**] 06:50PM BLOOD Type-ART Temp-36.1 Rates-12/ Tidal V-400 PEEP-5 FiO2-40 pO2-128* pCO2-44 pH-7.40 calTCO2-28 Base XS-2 Intubat-INTUBATED Vent-IMV CXR RADIOLOGY Final Report CHEST (PORTABLE AP) [**2101-5-2**] 7:39 AM CHEST (PORTABLE AP) Reason: 7:30am please. [**Hospital 93**] MEDICAL CONDITION: 81 year old woman with CAD s/p Emergent CABG s/p trach/PEG REASON FOR THIS EXAMINATION: 7:30am please. HISTORY: Emergent cardiac bypass, recent endoscopic gastrostomy tube placement. FINDINGS: Compared to the study three days earlier, there has been resolution of the free air. PEG is seen in the region of the gastric body. There has been interval increase in the right-sided pleural effusion, that on the left remains unchanged as well as the left basilar volume loss/consolidation. There is associated right basilar passive atelectasis and mild congestion. IMPRESSION: Resolved free air. New right effusion and associated volume loss and mild congestive failure. DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 6888**] Approved: TUE [**2101-5-3**] 7:45 AM UNILAT UP EXT VEINS US LEFT [**2101-4-29**] 10:28 AM UNILAT UP EXT VEINS US LEFT Reason: r/o dvt - edema [**Hospital 93**] MEDICAL CONDITION: 81 year old woman with s/p cabg x3 REASON FOR THIS EXAMINATION: r/o dvt - edema INDICATION: Status post CABG x 3 with left upper extremity edema, rule out DVT. No prior examinations. LEFT UPPER EXTREMITY DEEP VENOUS ULTRASOUND: [**Doctor Last Name **] scale and Doppler examination of the left internal jugular, axillary, brachial, and cephalic veins was performed. These demonstrate normal compressibility, contour variation and flow. Of note, the patient has an arteriovenous fistula with the left brachiocephalic vein leading to a somewhat erratic waveform. No intraluminal thrombus is identified. IMPRESSION: No evidence of deep venous thrombosis in the left upper extremity. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 18394**] [**Name (STitle) 18395**] DR. [**First Name11 (Name Pattern1) 177**] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Approved: FRI [**2101-4-29**] 1:47 PM RADIOLOGY Final Report CT HEAD W/O CONTRAST [**2101-4-18**] 5:41 PM CT HEAD W/O CONTRAST Reason: r/o cva [**Hospital 93**] MEDICAL CONDITION: 81 year old woman s/p CABG, left sided weakness REASON FOR THIS EXAMINATION: r/o cva CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Status post CABG one week ago with extended intubation. Now with left-sided weakness, rule out CVA. No prior examinations. TECHNIQUE: MDCT acquired axial images of the head were performed without IV contrast. FINDINGS: There is a large (6.5 x 4.1 cm) hypoattenuating confluent region of likely sub-acute infarction in the right MCA distribution. There are additional areas of hypodensity involving the [**Doctor Last Name 352**] and white matter of both occipital lobes and cerebellar hemispheres, suggesting relatively acute embolic phenomena from a central source. No gross hemorrhagic transformation is evident, though the large right MCA lesion has several punctate areas of hyperdensity suggesting early petecchial hemorrhage. There is no shift of normally midline structures, hydrocephalus, or herniation. No areas suspicious for infarct in the brainstem. Osseous structures and paranasal sinuses are unremarkable. IMPRESSION: Large right MCA infarct, likely subacute, with additional foci of infarction in both occipital lobes and cerebellar hemispheres. The distribution suggests embolic phenomena from a central source (cardiac or aortic). No overt hemorrhagic conversion and no midline shift or herniation. COMMENT: Results were discussed with Dr. [**Last Name (STitle) **] at 9:35 p.m. on [**2101-4-18**]. The study and the report were reviewed by the staff radiologist. DR. [**First Name (STitle) 18394**] [**Name (STitle) 18395**] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7593**] Approved: WED [**2101-4-20**] 12:07 PM RENAL U.S. (PORTABLE) [**2101-4-18**] 7:07 AM RENAL U.S. (PORTABLE) Reason: Assess kidneys [**Hospital 93**] MEDICAL CONDITION: 81 year old woman with ATN REASON FOR THIS EXAMINATION: Assess kidneys INDICATION: 81-year-old with ATN, assess kidneys. COMPARISONS: None. RENAL ULTRASOUND: The right and left kidneys measure 9.0 and 7.5 cm respectively. Both kidneys demonstrate thinned and echogenic cortices. There is no hydronephrosis nor focal solid renal lesions identified. IMPRESSION: Small, echogenic kidneys consistent with chronic renal parenchymal disease. No hydronephrosis. The study and the report were reviewed by the staff radiologist. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 7832**] Approved: MON [**2101-4-18**] 9:21 PM CAROTID SERIES COMPLETE [**2101-4-18**] 2:18 PM CAROTID SERIES COMPLETE Reason: S/P CABG, SLOW TO WAKE [**Hospital 93**] MEDICAL CONDITION: 81 year old woman with carotid bruit, s/p cabg slow to wake REASON FOR THIS EXAMINATION: assess for stenosis DUPLEX CAROTID ULTRASOUND INDICATION: Carotid bruit. Slow to wake status post CABG. Evaluate for stenosis. FINDINGS: There was a modest amount of atherosclerotic plaque at the origins of the ICAs and ECAs bilaterally. On the right, peak systolic velocities measured 99, 65, and 82 cm/sec respectively in the right ICA, CCA, and ECA. The right ICA/ECA ratio measured 1.52. On the left, the peak systolic velocities measured 93, 70, and 88 cm/sec respectively in the left ICA, CCA, and ECA. Left ICA/CCA ratio was 1.32. The peak systolic velocity in the left vertebral artery was 81 cm/sec with normal arterial waveforms. However, the peak velocity in the right vertebral artery was 17, and to and fro flow was noted with tardus parvus. There is also decreased triphasic flow in the right brachial artery. These are suggestive of a right subclavian steal. IMPRESSION: Less than 40% stenosis in both carotids. Right subclavian steal. DR. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Approved: MON [**2101-4-18**] 11:19 PM PATIENT/TEST INFORMATION: Indication: Abnormal ECG. Chest pain. Hypertension. Mitral valve disease. Status: Inpatient Date/Time: [**2101-4-16**] at 14:25 Test: TEE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2007AW2-: Test Location: Anesthesia West OR cardiac Technical Quality: Adequate REFERRING DOCTOR: DR. [**First Name (STitle) **] [**Name (STitle) **] MEASUREMENTS: Left Ventricle - Ejection Fraction: 35% to 40% (nl >=55%) INTERPRETATION: Findings: LEFT ATRIUM: Normal LA size. No spontaneous echo contrast in the body of the LA. No thrombus in the LAA. RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. PFO is present. Left-to-right shunt across the interatrial septum at rest. LEFT VENTRICLE: Mild symmetric LVH with normal cavity size. Mild symmetric LVH. Normal LV cavity size. LV WALL MOTION: basal anterior - normal; mid anterior - normal; basal anteroseptal - normal; mid anteroseptal - normal; basal inferoseptal - normal; mid inferoseptal - normal; basal inferior - normal; mid inferior - normal; basal inferolateral - normal; mid inferolateral - normal; basal anterolateral - normal; mid anterolateral - normal; anterior apex - normal; septal apex - normal; inferior apex - normal; lateral apex - normal; apex - normal; RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Simple atheroma in ascending aorta. Complex (>4mm) atheroma in the aortic arch. Complex (>4mm) atheroma in the descending thoracic aorta. Complex (mobile) atheroma in the descending aorta. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets (3). No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. No MS. Mild (1+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient received antibiotic prophylaxis. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. The patient was under general anesthesia throughout the procedure. Conclusions: PRE-CPB:1. The left atrium is normal in size. No spontaneous echo contrast is seen in the body of the left atrium. No thrombus is seen in the left atrial appendage. 2. A patent foramen ovale is present. A left-to-right shunt across the interatrial septum is seen at rest. 3. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. 4. Right ventricular chamber size and free wall motion are normal. 5. There are simple atheroma in the ascending aorta. There are complex (>4mm) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. There are complex (mobile) atheroma in the descending aorta. 6. There are three aortic valve leaflets. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. 7. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 8. After an episode of acute ST depression, the anterior wall of the the LV showed profound hypokinesis. POST-CPB: On infusion of phenylephrine. Improved global lv systolic function from ischemic episode prebypass. LVEF now 40%. Anterior basal and apical hypokinesis. Trace MR. ASD remains mild. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD on [**2101-4-16**] 16:21. [**Location (un) **] PHYSICIAN: Brief Hospital Course: Admitted with chest pain on [**2101-4-15**] and underwent cardiac catherization that revealed coronary artery disease. Emergently went to OR for coronary artery bypass graft due to worsening chest pain, see operative report for further details. Complicated with SVC perforation during central line placement, chest re-opened for cardiac tamponade. Blood evacuated and hemodynamic stabilized. POD 2 neurology was consulted due to no movement left side, underwent stroke work up which revealed Right MCA infarct. Due to inability to protect airway she had a tracheostomy and PEG placement on [**4-27**]. She continues with hemodialysis via left arm AV fistula. Physiocal therapy, occupational therapy, and speech therapy consulted please see notes for further details. She was ready for transfer to rehab on post op day 26 Medications on Admission: Lopressor 25" Aspirin 81' Levothyroxine 75' Lasix 20 Q3rd day Simvastatin Doxazosin 4" Protonix 40' Isordil Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable [**Month/Day (4) **]: One (1) Tablet, Chewable PO DAILY (Daily). 2. Docusate Sodium 50 mg/5 mL Liquid [**Month/Day (4) **]: Ten (10) cc's PO BID (2 times a day). 3. Atorvastatin 20 mg Tablet [**Month/Day (4) **]: One (1) Tablet PO DAILY (Daily). 4. Levothyroxine 75 mcg Tablet [**Month/Day (4) **]: One (1) Tablet PO DAILY (Daily). 5. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (4) **]: 5000 (5000) units Injection [**Hospital1 **] (2 times a day). 6. Amlodipine 5 mg Tablet [**Hospital1 **]: Two (2) Tablet PO DAILY (Daily). 7. Amiodarone 200 mg Tablet [**Hospital1 **]: One (1) Tablet PO once a day. 8. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 9. Metoprolol Tartrate 25 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 10. Insulin Glargine 100 unit/mL Solution [**Hospital1 **]: Twenty (20) units Subcutaneous once a day. 11. Lansoprazole 30 mg Susp,Delayed Release for Recon [**Hospital1 **]: Thirty (30) mg PO once a day. 12. Nystatin 100,000 unit/mL Suspension [**Hospital1 **]: Five (5) ML PO QID (4 times a day). 13. Epoetin Alfa 10,000 unit/mL Solution [**Hospital1 **]: One (1) Injection ASDIR (AS DIRECTED): with HD . 14. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 15. insulin sliding scale please see sliding scale Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: s/p CABGx3 (LIMA-LAD, SVG-OM, SVG-RCA)[**4-16**] CRF(HD), left Forearm AV fistula HTN ^chol Hypothyroid s/p CVA Rt renal artery stenosis Discharge Condition: good Discharge Instructions: keep wound clean and dry. Wet to dry dressing right groin Take all medications as prescribed Call for any fever, redness or drainage from wounds Followup Instructions: Dr [**Last Name (STitle) 7772**] in 4 weeks Dr [**Last Name (STitle) 17025**] after discharge from rehabilitation [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2101-5-10**]

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icd9cm

[ [ [] ] ]

[ "36.15", "39.61", "99.04", "96.6", "39.52", "38.93", "36.12", "34.03", "99.07", "88.72", "99.06", "34.04", "99.05", "96.72", "43.11", "31.1" ]

icd9pcs

[ [ [] ] ]

16697, 16769

14248, 15076

510, 873

16950, 16957

3281, 4427

17150, 17386

1402, 1496

15234, 16674

9314, 9374

16790, 16929

15102, 15211

16981, 17127

10530, 14188

1511, 3262

304, 472

9403, 10504

901, 1154

14225, 14225

1176, 1335

1351, 1386

29,365

193,193

9765

Discharge summary

report

Admission Date: [**2124-8-6**] Discharge Date: [**2124-8-11**] Date of Birth: [**2076-8-4**] Sex: F Service: CARDIOTHORACIC Allergies: Morphine Attending:[**First Name3 (LF) 3948**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: [**8-6**] Thoracentesis - pulled 300mL [**8-7**] Thoracentesis - pulled 1600mL, placed pleurex for further pleural drainage. History of Present Illness: 48 F w/ metastatic Ca breast p/w SOB. Has complete L lung collapse and left pleural effusion. went to OSH w/ SOB. was xferred here as all her care has been here. woke up this am w/ SOB. also pain on L ant chest wall w/ coughing. has been having cough since last few months. not bringing up anything. no F/C. no N/V/D/abd pain . in the ED VS .CTA showed no PE but showed rightward cardiomediastinal shift secondary to increasing left pleural effusion and complete L lung collapse. L sided [**Female First Name (un) 576**] yielded only 300 cc of fluid. WBC 27 and lactate 4.1. pt was given 4L NS. also given vanc/levo/CTX. Past Medical History: [**5-/2116**] intraductal carcinoma of the breast with multiple recurrences S/p resections and flap reconstructions. The last surgery involved the latissimus flap in 6/[**2120**]. Social History: She is married, has 2 children. She works as a retired manager. She does not smoke. She only drinks occasionally. Family History: Father died at age 68 of emphysema, mother is alive and well, her brother is 46 alive and well, and her first cousin died of melanoma. Physical Exam: 96 100 104/70 25 97/4L gen: SOB Chest: no BS on L side, basilar crackles on R Heart: RRR, no M/R/G, nl S1 S2 Abd: soft, NT, ND, no HSM Extr: no edema Pertinent Results: [**2124-8-6**] 05:00PM WBC-27.0*# RBC-3.50* HGB-9.2* HCT-31.6* MCV-90 MCH-26.3* MCHC-29.1* RDW-16.1* [**2124-8-6**] 05:00PM HYPOCHROM-OCCASIONAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2124-8-6**] 05:00PM PLT SMR-HIGH PLT COUNT-463* Brief Hospital Course: A/P: 48 F w/ massive metastatic breast CA obliterating the left lung, causing a pulmonary effusion, which had become infected and caused the patient to have increasing dyspnea. . Mrs. [**Known lastname 14893**] arrived at an OSH with dyspnea on [**8-6**] and was transferred to [**Hospital1 18**], as all of her care ans been here. In the ED, chest CT showed mediastinal shift due to pts rapidly growing L lung mass and effusion. Effusion was tapped - 300mL was taken off. She also was shown to have a high white count and lactate of 4.1. She was started on vanc and cefepime. . In the MICU, interventional pulmonology performed a second thoracentesis, this time taking 1600cc's off. A pleurex device was placed to allow for further drainage. As the effusion grew GPCs, vanc and cefepine were d/c'd in favor of Unasyn. The patient became dyspnic and wheezy after the thoracentesis and was started on albuterol and atrovent, as well as Advair. On the morning of [**8-8**], the pt had a procedure to unclot the pleurex with tPa. She became dyspnic after the procedure as well as tachycardic to the 130s. Her albuterol was initially held, then changed to Xopenex. IP came and withdrew the fluid they had infused, leading to improved sx's. The patient becomes hypotensive after fluid drainage, the malignant pleural effusion is rapidly accumulating and leads to decreased intravascular volume. The plurax catheter is being drained Q6H to gravity foley bag with one way valve. There is suspiciton of post-obstructive PNA that is being treated with a `seven day course of unasyn b/c of GPCs on pleural fluid gram stain. Patient was transfused 1 unit of PRBC on 7.15. Echo showed minimal pericard effusion and PHTN. Responsive to fluid. Being transferred to Ct surgery in stable condition. The pt stayed overnight on the floor in stable condition and was discharged to hospice on [**8-10**]. Medications on Admission: ACETAMINOPHEN-CODEINE [TYLENOL-CODEINE #3] - 300 mg-30 mg Tablet - [**1-26**] Tablet(s) by mouth q6-8h BENZONATATE [TESSALON PERLES] - 100 mg Capsule - 200 mg Capsule(s) by mouth three times a day COMPAZINE - 10MG Tablet - TAKE ONE TABLET EVERY 6 HOURS AS NEEDED FOR NAUSEA CYCLOBENZAPRINE [FLEXERIL] - 5 mg Tablet - 1 Tablet(s) by mouth three times a day/prn GABAPENTIN - 300 mg Capsule - 1 Capsule(s) by mouth three times a day LORAZEPAM [ATIVAN] - 1 mg Tablet - 1 Tablet(s) by mouth q6h prn ONDANSETRON HCL [ZOFRAN] - 4 mg Tablet - [**1-26**] Tablet(s) by mouth [**Hospital1 **] post chemo PANTOPRAZOLE [PROTONIX] - 40 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth once a day ROBITUSSIN W/ CODEINE - - [**1-26**] teaspoons po q 4-6 h as needed for cough SCOPOLAMINE BASE - 1.5 mg/72 hour Patch 72 hr - apply behind ear 2-4 hours prior to surgery daily SERTRALINE [ZOLOFT] - 50 mg Tablet - 1 Tablet(s) by mouth at bedtime Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: metastatic breast cancer w/ left effusion Discharge Condition: fair Completed by:[**2124-8-23**]

[ "785.0", "197.0", "799.02", "198.7", "486", "458.9", "V10.3" ]

icd9cm

[ [ [] ] ]

[ "34.91", "34.04", "99.04" ]

icd9pcs

[ [ [] ] ]

4933, 4982

2053, 3940

293, 420

5068, 5104

1745, 2030

1422, 1559

5003, 5047

3967, 4910

1574, 1726

234, 255

448, 1071

1093, 1274

1290, 1406

15,691

198,180

22754

Discharge summary

report

Admission Date: [**2153-2-23**] Discharge Date: [**2153-2-28**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 11495**] Chief Complaint: DOE Major Surgical or Invasive Procedure: Cardiac cath s/p stent s/p Intubation History of Present Illness: 84yo F with h/o interstitial lung disease, COPD, and CAD, with known abnl stress test [**10-29**], who has noted 6 mo of increasing DOE. No CP, palps, LE edema, orthop, PND, or med changes. For the past two days, has c/o worsening of her usual non-productive cough and fatigue. No fever, sick contacts. Went to pulmonologist 2 days PTA to OSH, who started pt on 60mg po prednisone for COPD flare, no abx. 2 days ([**2-17**]) later saw no improvement, and pt presented to OSH after increased SOB; EMS found pt with O2 sat of 86%RA with decreased mentation. In ER pt had JVD 8cm, EKG NSR with old LBBB, WBC 12.5, CK 116, Trop .2. Given lasix, MSO4, lovenox, BB, aspirin, for NSTEMI and CHF. Pt had adenosine myoview showing large, severe reversible anterior wall defect. Transferred to [**Hospital1 18**] for cath. In holding area, had respiratory failure and was intubated. In cath, had stent of 90% diag and 80% RCA. Given 80 IV lasix. On floor on night of admission, noted to be tachycardic with low BP's (80-100's). Hct noted to have dropped from 43 on admission to 35 at noon, to 28 at 1am. Emergent CT abdomen showed moderate sized bilateral pleural effusions (blood or pus by attenuation), and suggestion of pericardial effusion. CK's noted to be positive and increasing. Past Medical History: COPD ILD [**2-28**] occupational exposure to sandblasting HTN Hyperchol S/p CCY Cervical disease s/p surgery Breast CA s/p lumpectomy and XRT Social History: Lives with son Pertinent Results: [**2153-2-28**] 06:20AM BLOOD WBC-13.5* RBC-4.00* Hgb-12.3 Hct-36.9 MCV-92 MCH-30.7 MCHC-33.2 RDW-13.4 Plt Ct-287 [**2153-2-28**] 06:20AM BLOOD Plt Ct-287 [**2153-2-28**] 06:20AM BLOOD Glucose-78 UreaN-27* Creat-0.7 Na-140 K-4.9 Cl-98 HCO3-35* AnGap-12 [**2153-2-28**] 06:20AM BLOOD Calcium-9.2 Phos-2.2* Mg-2.1 [**2153-2-24**] 10:15PM BLOOD Type-ART Temp-37.4 pO2-112* pCO2-54* pH-7.36 calHCO3-32* Base XS-3 Cath: FINAL DIAGNOSIS: 1. Three vessel coronary artery disease complicated by acute pulmonary edema and cardiogenic shock. 2. Severe congestive heart failure. 3. Moderate pulmonary hypertension. 4. Bilateral renal artery stenosis. 5. Successful PCI of the LAD/D1. 6. Successful PCI of the RCA. Echo: Conclusions: The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. There is severe regional left ventricular systolic dysfunction with near akinesis of the inferior wall and the inferior and anterior septum. The distal half of the anterior wall and apex are also hypokinetic. No left ventricularaneurysm or thrombus is seen. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be quantified. There is a prominent anterior space which most likely represents a fat pad. IMPRESSION: Normal left ventricular cavity size with extensive regional systolic dysfunction c/w multivessel CAD. Mild mitral regurgitation. No significant pericardial effusion. Based on [**2145**] AHA endocarditis prophylaxis recommendations, the echo findings indicate a moderate risk (prophylaxis recommended). Clinical decisions regarding the need for prophylaxis should be based on clinical and echocardiographic data. CXR: 1. Interval improvement in previously evident multifocal airspace and interstitial opacities. 2. Interval decrease in size of bilateral pleural effusions. 3. Persistent asymmetric right apical pleural thickening. EKG: Sinus tachycardia Possible left atrial abnormality Left bundle branch block with repolarization changes Since previous tracing, heart rate has slowed and ST changes are less pronounced Brief Hospital Course: Ms. [**Known lastname 58884**] is an 84 y.o. female with CAD, COPD, ILD, who p/w NSTEMI and CHF, hypercarbic respiratory failure in holding area awaiting cath requiring intubation, now s/p PTCA with stents to LAD/diag and RCA. 1. CAD: Pt presents with NSTEMI with cath showing three vessel disease s/p stents to LAD/Diag and RCA. CK peaked post-cath around 400 and trended down. PCP to set up with outpt cardiologist. 2. Pump: CHF, EF 35-40%. Diuresed post cath and ultimately extubated and weaned to 2L NC. 3. Pleural effusions: Discovered on CT scan done on day after admission for evaluation of dropping hct. Unclear etiology. Effusions with hounsfield units consistent with blood. Repeat CXR improving on [**2-26**]. 4. Ventilator: Pt. with h/o ILD secondary to radiation, COPD, therefore likely CO2 retention. Extubated s/p 2 days on vent, doing well. O2 weaned to 2L. Pt seen by physical therapy who determined pt has need for home O2 (~85% on RA). 5. GIB with Hct drop: Guiaic positive non-melanotic stool, likely promoted by [**Last Name (LF) **], [**First Name3 (LF) **]. Hct stable after 1 U PRBCs. Outpt GI workup. Will see PCP on [**Name9 (PRE) 2974**] [**3-2**]. 6. Renal artery stenosis: Not that significant given BP peaks around 160 and renal function is normal (Cr = 0.7). [**Month (only) 116**] need cath in future for renal aa if worsens. 7. FEN - low Na/heart healthy diet Code - Full. Medications on Admission: verapamil, metop, isosorbide, lisinopril, prednisone, aspirin, singulair, lasix, lipitor, prednisone, levoquin Discharge Medications: 1. Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Atorvastatin Calcium 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 3. Prednisone 10 mg Tablet Sig: AS DIRECTED Tablet PO once a day for 3 days: 3 pills by mouth [**3-1**], 2 pills by mouth [**3-2**], 1 pill by mouth [**3-3**], then stop. Disp:*6 Tablet(s)* Refills:*0* 4. 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* 5. Metoprolol Succinate 100 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours). 9. Home Oxygen Please use 2L of Oxygen by nasal canula continuously. Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Primary: 1. NSTEMI s/p stent to LAD/diag and RCA 2. Congestive heart failure 3. Bilateral pleural effusions and pericardial effusion 4. GI bleed 5. Bilateral renal artery stenosis Secondary: 1. Hypertension 2. Hypercholesterolemia 3. CAD 4. COPD 5. ILD d/t occupational exposure to sandblasting Discharge Condition: Pt was in good condition, with >92% O2 sats on 2L, ambulating, mentating well, VSS. Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1500ml Please call your doctor if you experience increasing shortness of breath, chest pain, increased swelling in your ankles, weakness, pale skin, dark black or tarry stool, bright red blood in your stool. Continue to take your medications as prescribed. Followup Instructions: Call Dr.[**Name (NI) 58885**] office [**Telephone/Fax (1) 26330**] to confirm your appointment with his partner, Dr. [**Last Name (STitle) 58886**], for Friday at 12:45pm. He will recheck your blood count and arrange for a GI and cardiology workup.

[ "440.1", "511.9", "515", "428.0", "423.9", "578.9", "518.81", "V10.3", "250.00", "414.01", "401.9", "410.71" ]

icd9cm

[ [ [] ] ]

[ "99.04", "99.20", "37.23", "96.04", "88.56", "99.19", "96.71", "36.06", "88.45", "36.05", "36.07" ]

icd9pcs

[ [ [] ] ]

6951, 7022

4215, 5643

268, 308

7361, 7446

1832, 2248

7872, 8123

5804, 6928

7043, 7340

5669, 5781

2265, 4192

7470, 7849

224, 229

336, 1616

1638, 1781

1797, 1813

32,498

147,173

34461

Discharge summary

report

Admission Date: [**2142-9-19**] Discharge Date: [**2142-9-21**] Date of Birth: [**2088-4-4**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 99**] Chief Complaint: Abdominal pain and CT at OSH reportedly air in biliary tree Major Surgical or Invasive Procedure: None History of Present Illness: Mr. [**Known lastname 79206**] is a 54 year old Greek-speaking man with a history of mental retardation who initially presented to [**Hospital **] Hospital on the morning of [**2142-9-19**] with approximately 2-3 days of nausea, vomitting, and questionable diarrhea. He was reportedly in his usual state of health up until about three days before admission. He was complaining of nausea with vomitting, and had decreased PO intake as a result. There was also a report of him having diarrhea, though this is not entirely clear. He reportedly has not had fevers or abdominal pain. He presented to [**Hospital **] Hospital on hte morning of [**2142-9-19**] where he had normal laboratories and was presumed to have a viral gastroenteritis. Of note, his SBP was reportedly in the 80s-90s persistently even with fluids. On CT imaging of his abdomen, however, he was reported to have "specks" of air within his portal venous system, as well as emphysematous gastritis and inflammation of his sigmoid and descending colon. Due to these findings, he was started on empiric levofloxacin/metronidazole. They planned for an EGD to evaluate possible emphysematous gsatritis, though they felt he was too hypotensive (SBP still in the 80s) to tolerate this, and he is now transferred to [**Hospital1 18**] for further evaluation. . . ROS: Unable to obtain. Past Medical History: (obtained from sister by phone) - prior hernia repair over a decade ago - s/p cataract surgery Social History: Lives in a group home. Speaks Greek. Otherwise unable to obtain. Family History: Unable to obtain. Physical Exam: T 96.4 BP 88/44 HR 61 RR 18 Sat 100% on room air General: well-appearing, maneuvering around bed without difficulty HEENT: no scleral icterus, moist mucous membranes Neck: supple, JVP 6cm Chest: clear to auscultation throughout, though poor cooperation with exam; no wheezes/rales/ronchi CV: regular rate/rhythm, normal s1s2, II/VI systolic murmur loudest at apex Abd: soft, nontender, nondistended, normal bowel sounds, no HSM; well-healed vertical midline scar, and well-healed scar along right costal margin Extr: no edema, warm, 2+ PT pulses Neuro: alert, intermittently cooperative with exam, CN 2-12 intact Skin: no rashes or jaundice Pertinent Results: From [**Hospital **] Hospital: WBC 4.5 (81% PMN, 11% L, 8% Mono), Hgb 15.3, Hct 43.5, MCV 96.9, Plts 105 Na 138, K 3.7, Cl 108, HCO3 21, BUN 14, Cr 1.0, Gluc 90, Ca 7.3 AST 31, ALT 33, TBili 0.6, DBili 0.2, Alk Phos 66, amylase 55, lipase 24, albumin 4.2, TProt 7.9 CK 54, TnI <0.02 PT 13.7, INR 1.32, PTT 28.1 Urinalysis: negative . . Studies: CT Abdomen ([**9-19**] at [**Hospital **] Hospital): Dependent changes in the lung bases. The visualized portions of the heart and mediastinum are unremarkable. Specks of portal venous air. There is a long segment of colon with wall thickening, involving the sigmoid colon (and questionably other portions of the distal colon extending from the splenic flexure to the rectum). Must consider ischemia in the presence of portal venous air. Other diagnostic considerations include inflammatory bowel disease, infectious colitis and pseudomembranous colitis (under appropriate clinical setting). Underlying lesion not excluded; consider follow up evaluation if clinically indicated. No discrete abscess. There appears to be a broad area in the stomach that shows lucency subjacent to the apparent stomach wall. Must consider the possibility of emphysematous gastritis. If this one finding is to be confirmed without delaying overall treatment of the patient, further evaluation can be made with additional CT imaging with optimal intraluminal contrast opacification in the stomach, taken in supine (and prone) position. The enhanced gallbladder, spleen, pancreas, adrenal glands, kidneys, urinary bladder and the vascular structures are unremarkable for acute disease. . ECG: Sinus rhythm at 61 bpm, left axis deviation, RBBB and LAFB, TWIs in V3. . CT Abdomen at [**Hospital1 18**] [**2142-9-20**]: Intralobar air trapping consistent with possible airways disease and/or CHF. Recommend clinical correlation and CT chest if concern. No pneumobilium or dilation of the ducts. Mild colitis. Left inguinal mass likely a cryptorchid testicle. . [**2142-9-20**] 12:18AM BLOOD WBC-3.2* RBC-4.53* Hgb-15.2 Hct-43.5 MCV-96 MCH-33.5* MCHC-34.9 RDW-13.8 Plt Ct-108* [**2142-9-20**] 12:18AM BLOOD Neuts-53.9 Lymphs-34.3 Monos-9.0 Eos-2.2 Baso-0.6 [**2142-9-20**] 12:18AM BLOOD PT-16.0* PTT-31.9 INR(PT)-1.4* [**2142-9-20**] 12:18AM BLOOD Glucose-90 UreaN-12 Creat-1.0 Na-139 K-3.9 Cl-109* HCO3-23 AnGap-11 [**2142-9-20**] 12:18AM BLOOD ALT-29 AST-34 LD(LDH)-146 AlkPhos-50 Amylase-54 TotBili-0.7 [**2142-9-20**] 12:18AM BLOOD Lipase-30 [**2142-9-20**] 12:18AM BLOOD Albumin-3.3* Calcium-7.9* Phos-1.7* Mg-1.8 [**2142-9-20**] 01:19AM BLOOD Lactate-1.0 Brief Hospital Course: ## Emphysematous gastritis/portal venous air: On admission was highly concerning for intra-abdominal catastrophe and CT CDs were not available. Empiric vancomycin, levofloxacin, metronidazole were started and ppi [**Hospital1 **] was continued. Surgery was consulted and felt abdominal exam and labs were un-concerning for serious abdominal pathology but repeat CT was ordered to ensure no free air, etc. The repeat CT was essentially normal with mild colitis likely [**3-3**] gastroenteritis. . ## Colitis: ?infectious (bacterial vs viral) vs inflammatory vs ischemic. stool culture, C Diff toxin, O&P, Giardia were sent. Given empiric antibiotics until results of CT came back and then were d/c'd. . ## Hypotension: was initially concerning for ominous abdominal process, though he is tolerated this quite well and it may be his baseline. After a 500mL bolus of NS he had good uop. . ## Nausea: was treated with PRN odansetron . ## Mental retardation: definite diagnosis unclear. home benzodiazepines were continued. . ## Stress ulcer prophylaxis: ppi ## DVT prophylaxis: SC heparin ## FEN: Initally NPO then tolerated his regular diet. ## Access: PIVs ## Communication: sister [**Name (NI) 79207**] [**Name (NI) 79206**] Medications on Admission: Home Meds: - aspirin 81 mg daily - clonazepam 0.5 mg qam - MVI once daily - diazepam 5 mg daily - acetaminopehn 500 mg q6h prn [**Hospital **] Hospital Transfer Meds: - clonazepam 0.5 mg daily - diazepam 5 mg daily - levofloxacin 500 mg IV daily ([**9-19**] - ) - metronidazole 500 mg IV q8h ([**9-19**] - ) - pantoprazole 40 mg IV q12h - acetaminophen 650 mg q6h prn - multivitamin once daily Discharge Medications: 1. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Diazepam 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Discharge Disposition: Home Discharge Diagnosis: Mild gastroenteritis Discharge Condition: Stable. No nausea or vomiting. Discharge Instructions: You have been diagnosed with a mild infection of your colon. This caused nausea and vomiting but no serious complications in your gastrointesinal tract. You should call your primary care physcian or return to the ED if you have lightheadedness, dizziness, shortness of breath, chest pain, nausea, vomiting, fevers, bloody or black stools, or abdominal pain. Followup Instructions: Follow-up with PCP [**Last Name (NamePattern4) **] [**1-31**] weeks Follow-up with urology for undescended testicle.

[ "319", "458.9", "787.02", "558.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7343, 7349

5285, 6512

372, 378

7414, 7447

2677, 5262

7853, 7974

1977, 1996

6957, 7320

7370, 7393

6538, 6934

7471, 7830

2011, 2658

273, 334

406, 1759

1781, 1878

1894, 1961

22,938

126,079

49983

Discharge summary

report

Admission Date: [**2170-5-12**] Discharge Date: [**2170-5-19**] Service: NEUROLOGY Allergies: Penicillins Attending:[**First Name3 (LF) 5018**] Chief Complaint: expressive aphasia Major Surgical or Invasive Procedure: IR placement of PEG-J tube History of Present Illness: [**Age over 90 **] yo woman presents after acute onset of inability to speak at ~6:00 pm today. History is obtained from daughter who was with her at onset. She was eating dinner and was last seen well at ~5:50 pm. Her daughter went into the other room and upon returning found her mother unable to speak and with a ? right facial assymetry. She called EMS who arrived soon after and took a blood glucose at 143. She arrived at [**Hospital1 18**] at 6:17 pm. Code Stroke was called at 6:18 pm and I arrived at 6:20 pm, with Neurology Resident already at the bedside. NIHSS was ~22 (2 for not alert, 2 incorrect month/age, 2 incorrect commands, 2 forced deviation to the left, 2 complete hemianopia, 2 partial facial paralysis, 4 no movement right arm, 2 right leg some effort against gravity, 3 mute, 1 inattention). Labs were drawn and she was taken to CT scan at 6:28 pm, CT sone at 6:30 pm and read at 6:31 pm with no bleed, no sign of early infarct and ? slight left dense MCA sign. She returned to ER and floey was placed, 2nd IV was placed and t- PA was mixed. After lengthy discussion with daughter about risks and benefits (including bleeding risk) she agreed to treat with t-PA. tPA bolus given at 6:55 pm. Past Medical History: - Biliary adenocarcinoma - Pancreatitis, ?ischemic. - CAD status post MI in [**2167**] and again [**2169-3-14**], medically managed. - CHF with an EF of 35 to 40 percent with apical left ventricular aneurysm and wall motion abnormality. - Pulmonary hypertension. - Type 2 diabetes. - Alzheimer disease. - Hypothyroidism. - Hypertension. - Recurrent UTIs. - Symptomatic bradycardia, she is now status post DDD pacemaker placement. - Colon cancer status post resection. - Previous stroke - Hysterectomy. Social History: Lives with daughter. [**Name (NI) **] history of tobacco, alcohol or drug use. She is DNR/DNI. Family History: non-contributory Physical Exam: Vitals BP 170/76 P 70 R 18 General: Well nourished, sleeping in bed Neck: supple Lungs: Clear to auscultation CV: Regular rate and rhythm Neurologic Examination: Please see above for NIHSS Mental Status: No spontaneous verbal output, no command following Cranial Nerves: Gaze deviation to the left, + oculocephalic and corneals, pupils equal and minimally reactive, decreased blink to threat from the right, right facial paresis (partial) Motor: Normal bulk and tone decreased on the right No tremor. No spontaneous movement on the right arm or with deep pain Right leg with some movement with deep pain, not triple flexion and some slight movement against gravity Sensation was difficult to assess but she did withdraw on the right LE to pain Reflexes: symmetric/decreased Grasp reflex absent Toes were upgoing on right, down on left Coordination and gait could not be assessed Pertinent Results: [**2170-5-12**] 06:30PM BLOOD WBC-5.5 RBC-3.87* Hgb-11.7* Hct-35.5* MCV-92 MCH-30.4 MCHC-33.0 RDW-14.3 Plt Ct-309# [**2170-5-14**] 11:45AM BLOOD WBC-8.1 RBC-3.87* Hgb-11.8* Hct-35.6* MCV-92 MCH-30.5 MCHC-33.2 RDW-14.2 Plt Ct-286 [**2170-5-17**] 07:20AM BLOOD WBC-9.4 RBC-3.57* Hgb-11.1* Hct-32.6* MCV-91 MCH-31.1 MCHC-34.0 RDW-14.2 Plt Ct-262 [**2170-5-12**] 06:30PM BLOOD Neuts-64.1 Lymphs-26.5 Monos-3.8 Eos-5.0* Baso-0.6 [**2170-5-17**] 07:20AM BLOOD Plt Ct-262 [**2170-5-14**] 03:10PM BLOOD PT-13.1 PTT-24.0 INR(PT)-1.1 [**2170-5-12**] 06:30PM BLOOD PT-11.9 PTT-24.0 INR(PT)-0.9 [**2170-5-12**] 06:30PM BLOOD Plt Ct-309# [**2170-5-17**] 07:20AM BLOOD Glucose-161* UreaN-18 Creat-0.9 Na-140 K-3.9 Cl-107 HCO3-24 AnGap-13 [**2170-5-14**] 11:45AM BLOOD Glucose-115* UreaN-19 Creat-0.9 Na-143 K-4.6 Cl-110* HCO3-20* AnGap-18 [**2170-5-12**] 06:30PM BLOOD Glucose-190* UreaN-30* Creat-1.0 Na-140 K-4.1 Cl-105 HCO3-26 AnGap-13 [**2170-5-15**] 07:50AM BLOOD ALT-6 AST-16 AlkPhos-95 TotBili-0.5 [**2170-5-12**] 06:30PM BLOOD cTropnT-0.05* [**2170-5-17**] 07:20AM BLOOD Calcium-10.4* Phos-2.4* Mg-2.2 [**2170-5-14**] 03:10PM BLOOD Calcium-10.2 Phos-2.7 Mg-2.3 [**2170-5-13**] 06:13AM BLOOD Phos-3.1 [**2170-5-15**] 07:50AM BLOOD Triglyc-116 HDL-35 CHOL/HD-4.8 LDLcalc-109 [**5-12**] CT head Chronic infarct in left parietal region and moderate changes of small vessel disease. No acute hemorrhage or mass effect. MR [**First Name (Titles) 151**] [**Last Name (Titles) 3631**] weighted images may help to exclude acute infarct,if clinically indicated. [**5-12**] CTA head- 1) Large left middle cerebral artery territory infarct, with occlusion of the left internal carotid artery from just above the carotid bifurcation to and throughout the left middle cerebral artery. 2) No evidence of dissection, aneurysm, or occlusion within the right carotid artery, right and left vertebral arteries, and the remainder of the vessels of the Circle of [**Location (un) 431**]. [**5-15**] ECHO: The left atrium is normal in size. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is an apical left ventricular aneurysm. There is moderate regional left ventricular systolic dysfunction (estimated ejection fraction ?35-40%). No apical thrombus is seen (however the apical aneurysm is a potential cause of thromboembolism). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. Brief Hospital Course: [**Age over 90 **] Year old woman presents with global aphasia, left eye deviation and right hemiparesis and NIHSS ~22 treated with tPA. Neuro-She was admitted to the Neuro SICU with standard post tPA orders. Repeat CT scan on [**5-13**] showed evolving left MCA infarct, small vessel disease and chronic left parietoccipital infarct. CTA revealed a distal left ICA thrombus that extended in the M1 segment of the left MCA. Her exam did not improve after tPA and she remained unresponsive with with flacid right hemiparesis. Initial plan was for Aggrenox but this was held since the daughter did not want an [**Name (NI) 104370**] placed and preferred PEG placement. Per daughter the patient had been on coumadin in the past and repeat TTE revealed an apical aneurysm with telemetry no revealing any atrial fibrillation. Coumadin was initially held for placement of PEG on [**5-15**] but plan was made for NO anticoagulation due to the patient's poor prognosis and risk of bleeding. She was restarted on ASA on [**5-16**]. Tube feedings were initiate per nutrition recs. Given poor prognosis for functional recovery, episodes of apnea, and hypoperfusion of extremities, her daughter decided to transfer the patient to hospice for comfort care. Hypothyroidism-While NPO she was converted to 40mcg of IV levothyroxine but converted back to PO 88mcg after PEG-J tube placement. HTN-All antihypertensives were initially held due to stable SBP's in the 110-150 range. Outpatient lisinopril 5mg was restarted on [**5-16**] and lasix was held until the patient was established on an appropriate tube feeding regimen. Px-She was maintained on PPI and SC heparin was started after PEG placement Medications on Admission: 1.Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2.Clopidogrel Bisulfate 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3.Donepezil Hydrochloride 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 4.Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5.Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6.Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 7.Levothyroxine Sodium 88 mcg Tablet Sig: One (1) Tablet PO once a day. 8.Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule, Delayed Release(E.C.) Sig: Two (2) Cap PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 9.Quetiapine Fumarate 25 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 10.Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11.Insulin Insulin NPH 23 units in AM, 18 units qpm Continue home sliding scale 12.Lisinopril 5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 13.Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO once a day for 4 days. Disp:*4 Tablet(s)* Refills:*0* Discharge Medications: 1. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed. 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Docusate Sodium 150 mg/15 mL Liquid Sig: One (1) PO BID (2 times a day). 4. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 5. SL Morphine 20mg/ml 0.5ml q 1h PRN discomfort Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - Acute Rehab Discharge Diagnosis: Left MCA stroke Billiary cancer Chronic pancreatitis Discharge Condition: Guarded-unresponsive, right hemiparesis, periods of apnea, hypoperfusion of extremities Discharge Instructions: Transfer to hospice for comfort care. Followup Instructions: [**Name6 (MD) **] [**Name8 (MD) **], M.D. Where: [**Hospital6 29**] [**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2170-6-21**] 3:00 [**Name6 (MD) 4267**] [**Last Name (NamePattern4) 4268**] MD, [**MD Number(3) 5023**]

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icd9cm

[ [ [] ] ]

[ "43.11", "99.10", "96.6" ]

icd9pcs

[ [ [] ] ]

9223, 9296

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239, 267

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181, 201

295, 1521

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2374, 2401

1543, 2047

2063, 2160

48,032

108,394

2606

Discharge summary

report

Admission Date: [**2155-3-29**] Discharge Date: [**2155-4-7**] Service: MEDICINE Allergies: Motrin / Sulfa (Sulfonamide Antibiotics) / Lisinopril Attending:[**First Name3 (LF) 2698**] Chief Complaint: SOB Major Surgical or Invasive Procedure: intubation History of Present Illness: 89 y/o female with MMP including severe AS s/p bioprosthetic AVR ([**2155-2-13**]), dCHF (EF>55%), afib (on coumadin), CRI (baseline Cr 1.3-1.6), HTN, HLD, and history of pulmonary edema after surgery, who was re-hospitalized for CHF exacerbation after her AVR, and was discharged from rehab to home on [**2155-3-26**]. She now presents with worsening dyspnea and lower extremity edema. She was noted to have gained 5 lbs at rehab, and her outpatient lasix regimen (40 mg daily) was increased to 80 mg daily yesterday. She was noted to be 87% RA this AM by VNA. She was asked to come to [**Hospital1 **] for evaluation. Of note, at rehab, she had VRE UTI that has not been treated (she was on cipro, then amox -> resistant to both). . In the ED, initial VS - 97.5, 84, 110/81, 20, 92% 4L NC. She denied CP. PTA patient received 1 ntg spray. Exam notable for somnolence, decreased BS at right base. Labs notable for INR 2.6, Hct 31.1, Cr 1.3, lactate 1.6. Bcx and Ucx pending. CXR showing worsening right sided pleural effusion and pulmonary congestion. EKG showing atrial fibrillation, LAD, LBBB (old), ?ST depressions I, aVL. CT head without focal process. She was given 600 mg IV linezolid for UTI noted at rehab. She also was given 750 mg IV levaquin for ?pneumonia. Bipap was attempted, but her ABG was 7.41/60/108. The ABG, combined with her somnolence, led to intubation with versed and fentanyl. She dropped her pressures to SBP 60-70, and a CVL was placed in the ED. She is admitted for CHF exacerbation and SIRS. . Access - 2 piv, CVL . ROS: as per HPI. Per daughter, patient's speech has been garbled in past (required neuro c/s last admission). She is also "loopy" with torsemide, and is therefore on lasix. No recent chest pain, cough, sputum, dysuria, abdominal pain, fevers, chills, nausea, vomitting, neurologic symptoms such as focal weakness, black outs, or recent seizures. Denies sick contacts or recent travel. Past Medical History: Hypertension Atrial fibrillation on Coumadin Chronic diastolic CHF Severe aortic stenosis (AV area 0.6 cm?????? on [**10/2154**] OSH echo) Compression fracture s/p kyphoplasty Hypothyroidism Osteoarthritis Osteoporosis Chronic renal insufficiency (baseline Cr 1.3) Probable Alzheimer's dementia (mild) T10 compression fracture s/p vertebroplasty in [**10/2154**] S/p appendectomy S/p hysterectomy S/p hernia repair S/p bilateral cataract surgery Social History: Recently discharged from rehab but usually lives with husband who is also healthcare proxy, four adult children. Retired clerk in admitting dept at [**Hospital 13128**]. # Tobacco: Denies # Alcohol: Denies # Drugs: Denies Family History: Daughter s/p valve replacement due to rheumatic fever. Sister with breast cancer, brother with skin cancers, another sister died at age 47 of stomach cancer (and her daughter died of pancreatic cancer). Physical Exam: GEN: intubated, heavily sedated HEENT: PERRL, anicteric, MMM, JVP 8 cm, no carotid bruits, no thyromegaly or thyroid nodules RESP: crackles R > L base, decreased BS at R base, dullness to percussion at R base CV: irregular, S1 and S2 wnl, grade III HSM heard best at LSB ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: 1+ BLE pitting edema SKIN: no rashes/no jaundice/no splinters NEURO: intubated, sedated, PERLL Pertinent Results: Admission Labs: [**2155-3-29**] 12:30PM BLOOD WBC-6.8 RBC-2.93* Hgb-10.0* Hct-31.1* MCV-106* MCH-34.0* MCHC-32.0 RDW-17.6* Plt Ct-230 [**2155-3-29**] 12:30PM BLOOD Neuts-65.9 Lymphs-18.9 Monos-12.4* Eos-1.6 Baso-1.1 [**2155-3-29**] 12:30PM BLOOD PT-27.0* PTT-32.1 INR(PT)-2.6* [**2155-3-29**] 12:30PM BLOOD Glucose-104* UreaN-22* Creat-1.3* Na-144 K-3.7 Cl-99 HCO3-38* AnGap-11 [**2155-3-29**] 12:30PM BLOOD Calcium-9.3 Phos-4.1 Mg-2.1 Discharge Labs: [**2155-4-7**] 06:20AM BLOOD WBC-5.7 RBC-2.96* Hgb-9.8* Hct-30.4* MCV-103* MCH-33.3* MCHC-32.4 RDW-16.1* Plt Ct-383 [**2155-4-7**] 06:20AM BLOOD PT-19.7* PTT-33.4 INR(PT)-1.8* [**2155-4-7**] 06:20AM BLOOD Glucose-83 UreaN-26* Creat-1.3* Na-141 K-3.3 Cl-97 HCO3-34* AnGap-13 [**2155-4-7**] 06:20AM BLOOD Calcium-8.8 Phos-3.5 Mg-1.9 STUDIES: CHEST (PORTABLE AP) Study Date of [**2155-3-29**] IMPRESSION: 1. Worsening right-sided pleural effusion. Stable left-sided pleural effusion with retrocardiac opacity which may represent combindation of effusion and atelectasis, underlying consolidation can not be excluded. Mild pulmonary edema. 2. Stable cardiomegaly and widened mediastinum, status post surgery. CT HEAD W/O CONTRAST Study Date of [**2155-3-29**] IMPRESSION: No acute intracranial process. Chronic involutional changes. Portable TTE (Complete) Done [**2155-3-31**] Conclusions The left atrium is mildly dilated. The right atrium is moderately dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. The right ventricular cavity is mildly dilated with normal free wall contractility. The ascending aorta is mildly dilated. A bioprosthetic aortic valve prosthesis is present. The aortic valve prosthesis appears well seated, with normal leaflet/disc motion and transvalvular gradients. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate to severe (3+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. [In the setting of at least moderate to severe tricuspid regurgitation, the estimated pulmonary artery systolic pressure may be underestimated due to a very high right atrial pressure.] There is no pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [**2155-3-11**], no change. Brief Hospital Course: # Respiratory Distress: Patient intubated in the ED due to somnolence and respiratory distress. The patient was easily extubated after arrival to the MICU and BIPAP used for 1 day. Given her diastolic CHF, history of pulmonary edema, lower extremity edema, weight gain, and interstitial fluid on CXR, most likely etiology was felt to be volume overload, pulmonary edema. There was an unclear precipitant, we considered worsening valvular disease, ECHO showed moderate to severe (3+) mitral regurgitation and moderate to severe [3+] tricuspid regurgitation. ACS was felt to be less likely given radiographic findings and lack of chest pain with negative biomarkers. In addition, she had a recent cardiac cath ([**2155-2-11**]) with normal coronaries. PE also felt to be less likely given lack of pleuritic chest pain, lack of tachycardia, and alternate explanation on radiograph. Pneumonia also seemed unlikely lack of fevers, cough, sputum, sick contacts, and focal infiltrate on CXR. Patient was placed on a lasix drip and diuresed net -4L over two days and then lasix drip was transitioned to 40 IV BID of lasix and the patient continued to have good urine output and was able to wean down to 3L 02. Cardiology was consulted and agreed with aggressive diuresis. She was transitioned to the floor and diuresis was continued with IV Lasix boluses initially with good effect. She was transitioned to 80mg PO Lasix daily for 4 days prior to discharge. PT [**Hospital 13131**] rehab placement, however the family refused as she had bounced back twice from rehab for CHF exacerbations. She was ultimately discharged home with VNA and telemonitoring on 80mg of Lasix daily. She was on room air at time of discharge with minimal pedal edema. # Hypercarbia: The patient had serial VBGs in the ICU with PCO2 in the 60s but normal pH. Although prior to her valve surgery her C02 was in the high 40s, it may be that her chronic metabolic alkalosis (due to increasing amounts of diuretics) has caused a chronic respiratory compensation. She was aklalemic with pc02 in the 40s on the floor and had a normal pH with c02 in the 60s. Her mental status did not appear any different with a c02 of 40 and a c02 of 60. # Atrial fibrillation: Patient continued on coreg and her HR was well controlled. INR at goal on admission but coumadin held in the ICU due to concern that the patient would require more procedures. She was bridged with heparin gtt. On the floor her coumadin was uptitrated and her INR was uptrending at the time of discharge. # CAD: recent cardiac cath ([**2155-2-11**]) is with normal coronaries. Patient continued on aspirin, statin, coreg. # HTN: Patient's blood pressure well controlled on coreg and with diuresis. # HLD: Continued statin. # CKD: Cr 1.3, baseline Cr 1.3-1.6. Despite aggressive diuresis the patient's creatinine remained stable at 1.3. # UTI: rehab notes documenting VRE resistant to cipro, pcn, vanc, and levaquin. Sensitive to tetracycline. Unclear if true pathogen or contaminant as patient was without fever, leukocytosis or urinary symptoms. Empiric antibiotics were not given and U/A was repeated and the culture was negative. # Delirium/somnolence: per prior chart review and prior admissions, patient has been noted to be somnolent most pronounced in the late afternoons. She is alert in the mornings. Most likely she has an element of sundowning that manifests as lethargy in the PM. # Osteoporosis: Continued calcium, vitamin D and alendronate regimen qTues # Hypothyroidism: TSH was checked and was slightly elevated at 8.0 and free t4 was low normal at 4.4 so her levothyroxine dose was not changed - check TSH and free t4 as an outpatient. # Fe deficiency anemia: Continued home iron. Medications on Admission: 1. aspirin 81 mg 2. simvastatin 20 mg 3. levothyroxine 50 mcg 4. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 5. albuterol sulfate 0.63 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation once a day. 6. warfarin 1 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 7. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 8. multivitamin, stress formula Oral 9. alendronate 70 mg Tablet Sig: One (1) Tablet PO QTUES (every Tuesday). 10. cholecalciferol (vitamin D3) 400 unit DAILY (Daily). 11. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 12. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. lasix 80 mg daily Discharge Medications: 1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. alendronate 70 mg Tablet Sig: One (1) Tablet PO QTUES (every Tuesday). 4. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 5. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 6. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:*30 Tablet(s)* Refills:*2* 7. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a day. 8. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) patch Topical once a day. 9. multivitamin Tablet Sig: One (1) Tablet PO once a day. Tablet(s) 10. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*1* 12. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. furosemide 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 14. simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital1 3894**] Health VNA Discharge Diagnosis: Primary: acute on chronic diastolic heart failure hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [**Known lastname 13130**], It was a pleasure taking part in your care. You were admitted to [**Hospital1 18**] because of a heart failure exacerbation- excess fluid on your lungs and body. You required intubation (a breathing tube and breathing machine) and a stay in the Medical Intensive Care Unit to help you breath while they removed fluid from your body. You responded well to the medication (lasix) and you were quickly able to have the breathing tube removed. Over the course of a few days, you were able to breath on your own without oxygen. We continued to use Lasix to remove excess fluid from your body. At the time of discharge you were greatly improved and stable on 80mg of Lasix, by mouth daily. You will continue this dose at home. You will continue to need monitoring and physical therapy at home to help keep you strong and avoid hospitalizations. We made the following changes to your medications: - INCREASE lasix to 80mg by mouth daily - DECREASE carvedilol to 3.125 mg by mouth twice a day - INCREASE warfarin (coumadin) to 2.5 mg by mouth daily at 4pm The following medications were not changed in dose. 1. aspirin 81 mg 2. simvastatin 20 mg 3. levothyroxine 50 mcg 4. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 5. albuterol sulfate 0.63 mg/3 mL Solution for Nebulization Sig: One (1) Inhalation once a day. 6. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 7. multivitamin, stress formula Oral 8. alendronate 70 mg Tablet Sig: One (1) Tablet PO QTUES (every Tuesday). 9. cholecalciferol (vitamin D3) 400 unit DAILY (Daily). 10. calcium carbonate 200 mg (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 11. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight goes up more than 3 lbs. You have very close follow-up with your primary care doctor scheduled for tomorrow morning. You have follow-up in the heart failure clinic in one week with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. If you have concerns prior to your appointment on [**4-15**], please call [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**MD Number(3) 13132**] Failure, at [**Telephone/Fax (1) 13133**]. Followup Instructions: Please follow-up with your doctors at the [**Name5 (PTitle) 4314**] below: Department: INTERNAL MEDICINE When: TUESDAY [**2155-4-8**] at 10:15 AM With: [**First Name8 (NamePattern2) 1141**] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 4775**] Building: [**Location (un) 2790**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: CARDIOLOGY When: TUESDAY [**2155-4-15**] at 3:00 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**MD Number(3) 13132**] Failure, [**Telephone/Fax (2) 13133**] Building: [**Location (un) 830**], [**Hospital Ward Name 23**] 7, [**Location (un) 86**] [**Numeric Identifier 718**] Campus: [**Hospital Ward Name **] Department: ADULT SPECIALTIES When: TUESDAY [**2155-4-22**] at 5:00 PM With: [**First Name11 (Name Pattern1) 2053**] [**Last Name (NamePattern4) 2761**], MD [**Telephone/Fax (1) 8645**] Building: [**Location (un) 2790**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site Department: ADULT SPECIALTIES When: MONDAY [**2155-4-28**] at 3:00 PM With: [**Name6 (MD) **] [**Name8 (MD) **], MD, PHD [**Telephone/Fax (1) 8645**] Building: [**Location (un) 2790**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site Completed by:[**2155-4-14**]

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icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

12441, 12503

6382, 10125

264, 276

12610, 12610

3631, 3631

15172, 16583

2962, 3167

11066, 12418

12524, 12589

10151, 11043

12761, 13658

4084, 6359

3182, 3612

13687, 15149

221, 226

304, 2237

3647, 4068

12625, 12737

2259, 2706

2722, 2946

21,553

176,297

49855

Discharge summary

report

Admission Date: [**2183-2-5**] Discharge Date: [**2183-2-10**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5827**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: 88yo F resident of [**Hospital3 2558**] with CAD s/p CABG (last known EF 40%), CHF, DM who presents with progressive sob for one week. As per the daughter, the pt has been having progressive LE edema and orthopnea as well. The pt was treated for presumed pneumonia for the last 1 week at [**Hospital3 2558**]. Per records and daughter, pt never had fever but had light colored sputum production. She was treated with levofloxacin but did not improve. After few days without improvement in dyspnea, pt was given lasix diuresis. Ultimately renal function declined and she was given IVF. On the day of admission, she became increasingly dyspneic and lethargic and was subsequently transfered to the ED. EMS found the pt pale diaphoretic and tachypneic to 30s with SaO2 of 80% on 2L -> 100% on NRB. The pt was also found to have BP of 170/65, with HR of 80 on arrival to the ED. On exam, she was found to have elevated JVP, with [**Month (only) **] BS at bases and crackles up halfway, he was also having abdominal breathing and was minimally responsive (although primarily Russian speaking). ABG at the time was 7.34/67/229. A foley catheter was placed and the pt was given lasix 40mg IV x1. A nitro gtt was started and the pt was placed on BiPAP. Due to difficult access, a right fem line was placed. Placed on BiPAP without improvement in CO2 or mental status. The pt eventually put out several hundred ml of urine and her respiratory status improved. Her nitro gtt was discontinued and she was eventually converted to NC. ABG improved to 7.41/61/89. BNP returned at [**Numeric Identifier 104170**]. She was also given ceftriaxone 1g IV x1 and transferred to the [**Hospital Unit Name 153**]. Past Medical History: 1. CAD s/p CABG in [**2172**]. TTE in [**2175**] demonstrated EF 40% with inferolateral hypokinesis. 2. Hypertension 3. Hypercholesterolemia 4. Diabetes Mellitus 5. Colorectal Cancer, s/p resetion in [**2177**] with positive nodes. Chose to be followed conservatively without chemotherapy. 6. s/p left hemispheric CVA. Pt had left internal capsule and left occipital infarcts. 7. Gait instability. Patient has had frequent falls due to instability secondary to knee and hip pain, DJD of spine and old CVA's (above) 8. s/p L ORIF ([**6-14**]) 9. GERD 10. Vitamin B12 deficiency. Patient receives monthly injections. Social History: The patient lives at [**Hospital3 2558**]. No history of tobacco or alcohol use ever. [**Name (NI) **] grandson, [**Name (NI) **], can be reached at [**0-0-**]. Patient's daughter, [**Name (NI) 440**], can be reached at [**Telephone/Fax (1) 104171**]. Family History: CAD. Physical Exam: VS in ED: T: 98.3, HR: 76, BP; 170/65, RR: 35, SaO2: 100% on NRB VS in [**Hospital Unit Name 153**]: HR: 66, BP: 111/33, RR: 12, SaO2: 100% on 2L NC GEN: Elderly female in NAD wearing NC, comfortably asleep. arousable with significant physical stimulus, no accessory muscle use. HEENT: EOMI, anicteric, mmm, op clear Neck: thick big neck, difficult to appreciate JVP Chest: [**Month (only) **]. BS with crackles anteriorly and laterally CV: RRR, S1, S2, no m/r/g Abd: soft, NT, ND, BS+ Ext: 2+ bilateral pitting edema Pertinent Results: STUDIES: ECG [**2183-2-5**]: NSR at 80, nml-left [**Hospital1 **] axis, wide QRS, Q in III, TWI in I and L, V4-v6. CXR [**2183-2-5**]: bilateral pleural effusions and pulmonary vascular congestion consistent with CHF. Evaluation of the underlying lung parenchyma is difficult with likely superimposed bibasilar compressive atelectasis or consolidation. The lung apices are better visualized on the current study and appear clear. The osseous structures are grossly unremarkable. . TTE [**2-6**]: The left atrium is mildly dilated. There is asymmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF 70%). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The number of aortic valve leaflets cannot be determined. The aortic valve is not well seen. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate to severe (3+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Impression: moderate-to-severe mitral regurgitation; asymmetric septal hypertrophy . [**2183-2-5**] 05:00PM BLOOD WBC-10.0 RBC-3.15* Hgb-9.4* Hct-28.4* MCV-90 MCH-29.8 MCHC-33.1 RDW-17.8* Plt Ct-288 [**2183-2-7**] 07:15AM BLOOD WBC-8.7 RBC-3.08* Hgb-8.8* Hct-27.4* MCV-89 MCH-28.8 MCHC-32.3 RDW-17.0* Plt Ct-242 [**2183-2-5**] 05:00PM BLOOD Neuts-92.0* Bands-0 Lymphs-6.6* Monos-1.3* Eos-0 Baso-0.1 [**2183-2-5**] 05:00PM BLOOD PT-13.0 PTT-23.6 INR(PT)-1.1 [**2183-2-6**] 04:01AM BLOOD PT-12.6 PTT-22.3 INR(PT)-1.1 [**2183-2-5**] 05:00PM BLOOD Glucose-306* UreaN-44* Creat-1.6* Na-140 K-4.5 Cl-97 HCO3-33* AnGap-15 [**2183-2-7**] 07:15AM BLOOD Glucose-138* UreaN-51* Creat-1.6* Na-142 K-3.8 Cl-93* HCO3-39* AnGap-14 [**2183-2-5**] 05:00PM BLOOD ALT-10 AST-18 CK(CPK)-26 AlkPhos-89 Amylase-56 [**2183-2-5**] 05:00PM BLOOD Lipase-19 [**2183-2-5**] 05:00PM BLOOD cTropnT-<0.01 proBNP-[**Numeric Identifier 104170**]* [**2183-2-6**] 10:11AM BLOOD CK-MB-2 cTropnT-<0.01 [**2183-2-5**] 05:00PM BLOOD Albumin-3.6 Calcium-10.8* Phos-3.5 Mg-2.0 [**2183-2-7**] 07:15AM BLOOD Calcium-9.7 Phos-3.3 Mg-1.7 [**2183-2-6**] 04:01AM BLOOD calTIBC-329 VitB12->[**2177**] Folate-GREATER TH Ferritn-85 TRF-253 [**2183-2-7**] 07:15AM BLOOD Hapto-301* [**2183-2-6**] 04:01AM BLOOD Triglyc-147 HDL-36 CHOL/HD-4.2 LDLcalc-86 [**2183-2-6**] 04:01AM BLOOD TSH-0.45 [**2183-2-5**] 05:08PM BLOOD Type-ART pO2-229* pCO2-67* pH-7.34* calHCO3-38* Base XS-7 [**2183-2-5**] 06:29PM BLOOD Type-ART pO2-58* pCO2-60* pH-7.38 calHCO3-37* Base XS-7 [**2183-2-5**] 06:53PM BLOOD Type-ART pO2-89 pCO2-61* pH-7.41 calHCO3-40* Base XS-10 [**2183-2-6**] 12:07AM BLOOD Type-ART pO2-89 pCO2-58* pH-7.43 calHCO3-40* Base XS-11 [**2183-2-6**] 12:24AM BLOOD Type-ART pO2-57* pCO2-53* pH-7.46* calHCO3-39* Base XS-11 [**2183-2-5**] 05:08PM BLOOD Glucose-323* Lactate-1.8 K-4.7 [**2183-2-5**] 06:29PM BLOOD Glucose-313* Lactate-1.8 K-4.7 [**2183-2-5**] 06:53PM BLOOD O2 Sat-96 COHgb-1 MetHgb-0 Brief Hospital Course: 88yo F with CAD s/p CABG, CHF with EF of 40% and DM presents with one week of progressive SOB. . Heart Failure: Mrs. [**Known lastname **] was admitted for progressive shortness of breath and was thoroughly evaluated from a cardiopulmonary and hematologic standpoint. Her hematocrit was near baseline. A myocardial infarction was excluded with an ECG and three sets of cardiac enzymes. Her CXR had the distinctive appearance of CHF without evidence of pneumonia; a BNP level supported this diagnosis, as did both her history and physical. She was initially and briefly admitted to the MICU and treated with BiPAP; she responded well there to diurese and was soon transferred to the medical floor where diuresis continued without difficulty. Given renal insufficiency, her captopril was held and she was started on hydralazine and isosorbide mononitrate, as an ace-inhibitor equivalent. She was negative by ins/outs and her oxygen requirement improved to mid-90's on room air by the time of discharge. Her Echo showed and ef of 70% but mod-severe MR. She was put on a brief prednisone taper for a concern of exacerbation of an underlying reactive airways disease. . DM: For her DM, Mrs. [**Known lastname **] was continued on NPH and regular insulin. Her Avandia was stopped given its propensity to increase fluid rentenion. Her blood sugars were well controlled on the insulin-only regimen. . UTI: The pt had UA suggestive of infection at time of admission. As the pt was recently on fluoroquinolones (levofloxacin until day of admission) and the culture came back for FQ-resistant E. coli and P. mirabilis, she was started on cefpodoxime, to which the bacteria was sensitive, for a three day course. She should have a repeat urinalysis/culture sent next week. She has had no symptoms, abdominal tenderness, fever, or leukocytosis while an inpatient. . Knee pain: Per the notes and family, this is a chronic problem for the patient. She was continued on her lidoderm knee patches and put on scheduled acetaminophen for pain relief. She should have PT as an outpatient. . Renal failure -- The patient came in above her baseline, with a creatinine of 1.6, up from her previous value of 1.0. This was felt to be due to CHF and improved slightly with diuresis. With further diuresis, her Cr increased to 1.8, likely from over-diuresis, so her furosemide dosing was scaled back to 40mg by mouth daily. It was felt that the overall picture was consistent with worsening renal function due to diabetes and hypertension, with an acute exacerbation in the setting of shifting renal function. Medications on Admission: 1. Lasix 20mg once daily 2. Aspirin 325mg once daily 3. Atenolol 50mg once daily 4. Gemfibrozil 600mg [**Hospital1 **] 5. NPH 14units QAM and 4units QPM 6. Regular 4units QAM with NPH 7. Avandia 2mg [**Hospital1 **] 8. Levoxyl 25mcg HS 9. Prednisone taper - currently on 50mg once daily 10. Duoneb PRN 11. Prozac 20mg once ddaily 12. Acetominophen PRN 13. Cyanocobalamin 1000mcg sub Q monthly (given [**2183-2-3**]) 14. Nortriptyline 10mg QHS 15. Lidoderm patch 5% to knees 16. Lactulose 30cc daily 17. Senna 18. Docusate 19. Bisacodyl 10mg suppository 20. Os-Cal TID 21. MOM PRN Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Fourteen (14) u Subcutaneous q AM. 4. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Four (4) u Subcutaneous q PM. 5. Insulin Regular Human 300 unit/3 mL Insulin Pen Sig: Four (4) u Subcutaneous q AM w/ NPH. 6. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical QD (). 7. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 8. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 9. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 10. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 13. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q24HOURS PRN (). 14. Heparin (Porcine) 5,000 unit/mL Solution Sig: 5000 (5000) units Injection TID (3 times a day). 15. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 16. Hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 17. Isosorbide Mononitrate 30 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). 18. Prednisone 10 mg Tablet Sig: Per below taper Tablet PO daily (): 30mg (3tabs) x 2 days, then 20mg (2tabs) x 2 days, then 10mg (1tab) x 2 days. 19. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 20. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 21. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO once a day for 3 days. 22. Levothyroxine 25 mcg Tablet Sig: One (1) Tablet PO once a day. 23. Nortriptyline 10 mg Capsule Sig: One (1) Capsule PO at bedtime. 24. Prozac 20 mg Capsule Sig: One (1) Capsule PO once a day. 25. Vitamin D 400 unit Tablet Sig: One (1) Tablet PO once a day. 26. Calcium 500 mg Tablet Sig: One (1) Tablet PO twice a day. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: congestive heart failure urinary tract infection Secondary: 1. CAD s/p CABG in [**2172**]. TTE in [**2175**] demonstrated EF 40% with inferolateral hypokinesis. 2. Hypertension 3. Hypercholesterolemia 4. Diabetes Mellitus 5. Colorectal Cancer, s/p resetion in [**2177**] with positive nodes. Chose to be followed conservatively without chemotherapy. 6. s/p left hemispheric CVA. Pt had left internal capsule and left occipital infarcts. 7. Gait instability. Patient has had frequent falls due to instability secondary to knee and hip pain, DJD of spine and old CVA's (above) 8. s/p L ORIF ([**6-14**]) 9. GERD 10. Vitamin B12 deficiency. Patient receives monthly injections. Discharge Condition: improved w/ good O2 saturation Discharge Instructions: Please return for further care if you have fever, chills, shortness of breath, chest pain, increased swelling in your legs, acute confusion, blood in your urine, difficulty with urination or any other symptoms that are concerning to you. . Weigh yourself everyday; if your weight increases by more than 2 pounds, please call you primary care doctor. . Please rigidly adhere to a two gram sodium diet. Followup Instructions: Please follow up with your primary care provider in the next week; call [**Telephone/Fax (1) 608**] to make an appointment.

[ "428.0", "V45.81", "599.0", "530.81", "584.9", "250.00", "414.01", "401.9", "272.0", "V10.06" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12160, 12230

6701, 9301

269, 276

12950, 12983

3487, 6678

13432, 13559

2926, 2932

9932, 12137

12251, 12929

9327, 9909

13007, 13409

2947, 3468

222, 231

304, 2000

2022, 2640

2656, 2910

82,249

196,986

49054

Discharge summary

report

Admission Date: [**2133-5-24**] Discharge Date: [**2133-5-28**] Date of Birth: [**2070-9-8**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 1973**] Chief Complaint: Respiratory distress Major Surgical or Invasive Procedure: CPAP History of Present Illness: 62 yo M with metastatic renal cell carcinoma to lung and spine with recent XRT to thoracid spine, hemochromatosis, HTN, admitted for respiratory distress. Limited history is available from the patient given his respiratory distress. . Patient reported acute onsert SOB that woke him up at 4am. EMS was called and he had a sat of 79% which increased to 94% on a NRB. He was initially going to the VA but looked too clinically unstable so came to [**Hospital1 **]. . In the ED, initial VS: 97 165/86 109 22 94% on combivent neb with NRB. He was placed on CPAP and did well. EKG with STD v4-v6. Cards reviewed and advised ASA and statin. He was stridorous and received racemic epi without significant effect. He was noted to have chronic venous stasis changes and his BNP was ~1200, so he was given lasix 20mg as thought was pulmonary edema. CTA was discussed with patient by attending given CKD (Cr 1.5 which is baseline) and patient declined CT as he is also s/p nephrectomy. He was also teated with iv methyl pred and nebs. He initially was able to be weaned to 4L nc, but after CT was worsening and was put back on non-invasive ventilation. The MICU fellow evaluated the patient and had a code discussion. The patient stated he did not want heroic measures and did not want to be intubated. . On arrival to the floor, he is acute distress and only able to answer yes/no questions. He denies chest pain but endorses chest tightness and significant difficulty breathing. Past Medical History: Metatstatic RCC to lung and thoracic spine HTN EtOH abuse Hemochromatosis Pseudogout Social History: Not working, no tobacco or drugs. Drinks 8 beers/day recently cut down from 15 beers/day. He used to work as a bartender, has been without work for a few months. + tobacco, with 60 pack-year smoking history. + EtOH abuse, drinks about [**3-10**] cans of beer daily or every other day, limited by money recently. No history of IVDU, no illicit drug use. Family History: Father with history of CVA in his 60s. 2 brothers with CADs in their 40s-50s, both s/p CABG. No history of sudden death or death in unusual circumstances. Physical Exam: Physical Exam on admission: GEN: pleasant, comfortable, NAD HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules CV: RR, S1 and S2 wnl, no m/r/g RESP: CTA b/l with good air movement throughout 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 [**2133-5-24**] 11:00AM WBC-9.7# RBC-3.82* HGB-12.2* HCT-36.9* MCV-97 MCH-32.0 MCHC-33.1 RDW-16.7* [**2133-5-24**] 11:00AM NEUTS-80* BANDS-6* LYMPHS-7* MONOS-6 EOS-0 BASOS-1 ATYPS-0 METAS-0 MYELOS-0 [**2133-5-24**] 11:00AM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-NORMAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL [**2133-5-24**] 11:00AM PT-12.6 PTT-23.9 INR(PT)-1.1 [**2133-5-24**] 11:00AM cTropnT-0.05* [**2133-5-24**] 11:00AM CK-MB-6 proBNP-1288* [**2133-5-24**] 11:00AM CK(CPK)-107 [**2133-5-24**] 11:00AM GLUCOSE-221* UREA N-20 CREAT-1.5* SODIUM-134 POTASSIUM-4.4 CHLORIDE-95* TOTAL CO2-20* ANION GAP-23* [**2133-5-24**] 11:04AM GLUCOSE-201* LACTATE-5.8* K+-4.1 [**2133-5-24**] 03:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2133-5-24**] 03:00PM URINE RBC-1 WBC-4 BACTERIA-NONE YEAST-NONE EPI-<1 . Discharge labs: Cr 1.5 . CXR ([**5-24**]): 1. Bibasilar opacities and blunting of the right costophrenic angle correspond to pleural effusions, overlying atelectasis, and possible pulmonary edema and metastatic disease on subsequent chest CT. 2. Nodular opacity in the left mid lung corresponds to pulmonary nodule on subsequent CT consistent with metastasis. . CT Head ([**5-24**]): No evidence of metastatic disease in this non-contrast CT head. An MRI is more sensitive for more sensitive for metastatic disease . CT Chest ([**5-24**]): 1. Extensive bilateral pulmonary metastatic disease. Bibasilar consolidations, may represent a combination of metastatic disease or atelectasis. Superimposed infection is not excluded. Small bilateral pleural effusions. 2. Extensive osseous metastatic disease of the thoracic spine and bilateral ribs. . CT Neck ([**5-24**]): Extensive osseous metastatic lesions in the lower cervical spine and upper thoracic spine as described in detail above, also involving the ribs, correlation with MRI of the cervical and thoracic spine is recommended for characterization of the thecal sac and rule out spinal cord involvement. Mild multilevel degenerative changes at C5/C6. Atherosclerotic calcifications are visualized at the cervical carotid bifurcations. The airway appears patent. Multiple pulmonary nodules in both lungs with bibasilar consolidations and interstitial thickening also suggesting metastatic disease, please refer to the report of the dedicated CT of the chest performed concurrently. . TTE ([**5-25**]): The left atrium is mildly dilated. 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 mildly dilated at the sinus level. The ascending aorta is mildly dilated. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mitral regurgitation is seen. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Suboptimal image quality. Normal global biventricular systolic function. Technically suboptimal to exclude focal wall motion abnormality . CXR ([**5-25**]): In comparison with the study of [**5-24**], there is increase in the bilateral pulmonary opacifications, most likely consistent with pulmonary edema and underlying metastatic disease (seen on prior CT scan). In the appropriate clinical setting, the possibility of supervening pneumonia would have to also be considered. . CXR ([**5-26**]): In comparison with the study of [**5-25**], there is little overall change. Diffuse bilateral pulmonary opacifications again are most likely reflective of pulmonary edema and underlying metastatic disease that was seen on the previous CT scan. In the appropriate clinical setting, the possibility of supervening pneumonia would have to be considered. Brief Hospital Course: 62 year diagnosed with RCC 1 year ago with mets to lungs and spine s/p XRT and dexamethasone taper who was admitted to the MICU for respiratory distress resolving well with diuresis. . #. Hypoxic Respiratory distress: Patient with hypoxia in the setting of flash pulmonary edema, chest xray at admission showed right sided opacity and bilateral infiltrates consistent with edema and pneumonia. The patient was diuresed with Lasix IV and had a net loss of near 9 liters in the medical ICU with very good improvement of respiratory status. He also had purulent sputum concerning for pneumonia. He was given broad spectrum antibiotics in the ED, and covered with Levofloxacin/Ceftriaxone which was subsequently narrowed to levofloxacin in the medical ICU. Sputum cultures were sent and showed only commensal respiratory flora. Echocardiogram showed normal global biventricular systolic function and there was no significant pathology seen at the valves. He was transferred out of the ICU to the general medical floor where he was given one dose of 40mg Lasix by mouth. He continued to lose fluid and his respiratory status continued to improve. He was eventualy completely weaned off of oxygen. He was seen by physical therapy and cleared to go home without services. He is off diuretics on discharge. . # Elevated Troponin: At presentation, the patient did not have chest pain, but did show non-specific EKG changes with ST changes in leads V4-6. He had mildly elevated troponin which downtrended, and CK-MB and MBI which downtrended on 2nd set of cardiac enzymes. CK peak was 250's, and MB peaked at 14 and subsequently down-trended within 24 hours. Troponin peak was 0.20 and down trended. As above, TTE was with normal systolic function without wall motion abnormalities, and this was felt to not be consistent with ACS. Patient was tachycardic to 130's so most likely demand ischemia rather than acute coronary syndrome from coronary disease. Repeat EKG did not show acute ischemic changes, and the patient was started on ASA 325mg daily and high dose statin after LFTs returned normal. It is recommended he have cardiology follow up. He will resume his home dose statin and aspirin on discharge. . #. Metastatic Renal Cell Carcinoma: The patient's oncologist was called and per discussion, his lung metastases were considered unlikely to be cause of his acute respiratory distress. The patient was given 4mg dexamethasone in the medical ICU, given that he was on this while getting radiation therapy while and there was concern for abrupt steroid withdrawal. While on the general medical floor, he was weaned off steroids. He is off steroids on discharge. . #. Chronic kidney disease: The patients chronic kidney disease was believed to be secondary to being status post nephrectomy. His lisinopril and indomethacin were held while in the hospital with plan to resume on outpatient basis after follow of his kidney status by his primary care physician. [**Name10 (NameIs) **] was 1.5 on discharge. . # ETOH use: Given the patients report of drinking 8 beers per day, he was initially put on the CIWA protocol. He had no signs of withdrawal during the first 72 hours of his hospital stay and so the protocol was taken off. . # Wound care: Patient was seen by our wound care team with the following plan: WOUND CARE FOR ULCER ABOVE RIGHT ANKLE Commercial wound cleanser to irrigate/cleanse all open wounds. Be very generous spaying the ulcer. Pat the ulcer dry with dry gauze. Apply moisture barrier ointment to the peri wound tissue with each DRG change. Apply hydrogel. Cover with single layer of adaptic. Secure with Kerlix. Change dressing daily . Apply Spiral Ace Wraps to both feet from just below toes to just below knees. Snug but not tight. Before you get out of bed or after elevating LE's for 30 minutes. Remove ace Wraps when in bed. . Overall, on discharge, we recommend continuing previous wound care plan with VA. . # Transitional Issues Patient is having an appointment with his PCP at the VA the day after discharge [**2133-5-29**]. Please check Mr. [**Known lastname **] electrolytes and kidney status, and resume lisinopril and indomethacin per PCP [**Name Initial (PRE) 8469**]. It is also recommended that Mr. [**Known lastname **] have follow up with a cardiologist given his mildly elevated cardiac enzymes at admission. Mr. [**Known lastname **] will also follow up with his primary oncologist at the VA regarding his renal cell carcinoma. Medications on Admission: Simvastatin 20mg daily Oxycodone HCl 5mg Q6 Pentoxifylline 400mg TID [**Doctor Last Name 1819**] Aspirin 325mg daily Indomethacin 25mg 6 tabs per day Lidocain/Nystatin/Mag 2 teaspoons before meal Discharge Medications: 1. simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 3. pentoxifylline 400 mg Tablet Extended Release Sig: One (1) Tablet Extended Release PO TID (3 times a day). 4. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. hydralazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). Disp:*30 Tablet(s)* Refills:*0* 6. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 days. Disp:*1 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: PRIMARY: 1. pulmonary edema 2. metastatic renal cell carcinoma . SECONDARY: 1. Hypertension 2. Chronic kidney disease Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital for shortness of breath, which was likely from excess fluid in your lungs (pulmonary edema), COPD, and possibly pneumonia. You were treated with water pills (diuretics) to help remove this extra fluid, nebulizers, steroids, and antibiotics. You improved with the above, and can be discharged with the medication changes below. You were also seen by wound care for your ulcer at your lower right leg. Please continue to take care of this ulcer as you were before with help at the VA. You also had an echocardiogram of your heart which was showed normal function and valves. . MEDICATION CHANGES: - START levofloxacin (ending [**5-29**]) - START hydralazine for blood pressure as prescribed - HOLD lisinopril until discussed with PCP [**Name Initial (PRE) **] [**Name10 (NameIs) **] [**Name11 (NameIs) 102943**] until discussed with PCP . Hydralazine (a blood pressure medication) was started while you were in the ICU and medical floor. Please continue this on discharge, but discuss with your PCP if he would like to change this to another blood pressure medication. . Please seek medical attention for any worsening shortness of breath, chest pain, cough, or any other concerning symptoms. . Because your kidney function was somewhat decreased while you were in the hospital, your lisinopril and indomethacin were not given to you. Please discuss restarting these medications with your PCP at your [**2133-5-29**] VA primary care visit. Followup Instructions: - Follow up appointment with PCP at VA on [**2133-5-29**]. Please check electrolytes as Mr. [**Known lastname **] creatinine has been elevated. - Evaluation for angioplasty for right lower extremity as outpatient at Veteran Affairs. Completed by:[**2133-5-28**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12414, 12420

7127, 10364

324, 330

12582, 12582

3110, 4017

14229, 14492

2333, 2489

11848, 12391

12441, 12561

11628, 11825

12733, 13342

4033, 7104

2504, 2518

13362, 14206

264, 286

10376, 11602

358, 1838

2532, 3091

12597, 12709

1860, 1946

1962, 2317

13,546

151,627

30074

Discharge summary

report

Admission Date: [**2142-1-13**] Discharge Date: [**2142-1-26**] Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 18141**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: Intubation Colonoscopy EGD History of Present Illness: This is a 84 y/o with h/o AVR, CHF, pAF, h/o LGIB, who complains of progressive SOB x 1 mo. Presently, she is SOB even at rest. No CP, N/V associated with this SOB. She has also been very fatigued for about one year. She endorses orthopnea, PND and occ LE edema. She has been having black stools recently and reports diarrhea after eating since her last intestinal operation (unclear date). She reports a 20 lb weight loss in the last five months. She has had decreased appetite over this time period. She has not been ambulating over the last few days [**12-29**] fatigue but normaly walks independently and can climb stairs. . Of note, one mo ago the pt was hospitalized at [**Hospital1 2025**] for virus and periph edema and then was sent to [**First Name4 (NamePattern1) 1785**] [**Last Name (NamePattern1) **] from there. . In the ED, noted to have: AF, BP 122/59 HR 75 RR 16, sats 91-98 RA, 100 on 4 L NC. CXR consistent with effusion/collapse/consolidation wet read per radiology. HCT 23, unknown baseline. ED called up to floor that pt. was guaiac negative, but it is not documented anywhere in ED paperwork. On arrival to the floor, found to be guaiac positive with brown stool. Called [**Hospital3 1186**], no baseline hct info. Called PCP, [**Name10 (NameIs) **] [**Name Initial (NameIs) **]/c MD Dr. [**Last Name (STitle) **], who called [**Hospital1 2025**] and reported back that her hct [**2141-11-2**] was 33.9. Past Medical History: --CAD --CHF --AVR --Paroxysmal A fib --Hypothyroidism --Hx. LGIB --Anemia --PVD Social History: Lives at [**Hospital3 1186**]. No tob, etoh, drugs. Family History: NC Physical Exam: Tm/c 97.9, BP 103/67 SBP 82-103, P 90 (90-100) R 23, Sa02 100% RA Gen - Alert, spanish speaking, cachectic female, breathing with mod effort HEENT - PERRL, extraocular motions intact, anicteric, MMM, pale conjunctiva Neck - JVD to earlobes, no cervical lymphadenopathy CV - harsh, mechanical $/6 SEM with click, PMI displaced laterally Pulm- Diminished BS RLL with occ crackles, + exp wheeze in LLL Abd - Soft, nontender, nondistended, with normoactive bowel sounds Back - No costovertebral angle tendernes Extr - No clubbing, cyanosis, 1+ edema. trace DP pulses bilaterally Neuro - Alert and oriented x 3, Skin - No rash, chronic venous stasis changes in LE. Pertinent Results: [**2142-1-13**] 05:50PM BLOOD WBC-7.5 RBC-2.50* Hgb-7.5* Hct-23.3* MCV-93 MCH-29.9 MCHC-32.1 RDW-20.2* Plt Ct-240 [**2142-1-14**] 08:25AM BLOOD WBC-7.9 RBC-3.08* Hgb-9.5*# Hct-27.6* MCV-90 MCH-30.8 MCHC-34.4 RDW-19.9* Plt Ct-177 [**2142-1-14**] 10:05AM BLOOD Hct-29.0* [**2142-1-15**] 06:00AM BLOOD WBC-10.2 RBC-3.15* Hgb-9.6* Hct-28.6* MCV-91 MCH-30.6 MCHC-33.7 RDW-19.7* Plt Ct-180 [**2142-1-17**] 05:40AM BLOOD WBC-5.3 RBC-2.97* Hgb-9.2* Hct-26.8* MCV-90 MCH-30.9 MCHC-34.2 RDW-19.5* Plt Ct-150 [**2142-1-20**] 01:24AM BLOOD WBC-10.2# RBC-3.29* Hgb-10.1* Hct-30.0* MCV-91 MCH-30.8 MCHC-33.8 RDW-18.9* Plt Ct-140* [**2142-1-24**] 05:30AM BLOOD WBC-4.3 RBC-3.08* Hgb-9.3* Hct-28.1* MCV-91 MCH-30.0 MCHC-32.9 RDW-18.4* Plt Ct-107* [**2142-1-26**] 05:20AM BLOOD WBC-4.5 RBC-2.99* Hgb-8.8* Hct-27.0* MCV-90 MCH-29.4 MCHC-32.5 RDW-18.0* Plt Ct-105* [**2142-1-13**] 05:50PM BLOOD PT-31.6* PTT-37.7* INR(PT)-3.4* [**2142-1-18**] 06:30AM BLOOD PT-22.1* PTT-78.0* INR(PT)-2.2* [**2142-1-24**] 05:30AM BLOOD PT-16.9* PTT-62.8* INR(PT)-1.6* [**2142-1-13**] 05:50PM BLOOD Glucose-110* UreaN-18 Creat-0.8 Na-130* K-3.7 Cl-97 HCO3-29 AnGap-8 [**2142-1-20**] 01:24AM BLOOD Glucose-80 UreaN-24* Creat-1.0 Na-133 K-3.4 Cl-100 HCO3-21* AnGap-15 [**2142-1-26**] 05:20AM BLOOD Glucose-93 UreaN-9 Creat-0.8 Na-134 K-3.3 Cl-101 HCO3-27 AnGap-9 [**2142-1-14**] 08:25AM BLOOD ALT-18 AST-34 CK(CPK)-37 AlkPhos-70 TotBili-2.5* CXR ([**1-13**]): 1. Cardiomegaly, with slight upper zone redistribution, but no overt CHF. 2. Prosthetic ball and cage type valve noted. 3. Opacification at right base consistent with right lower lobe collapse and/or consolidation and effusion. Echo ([**1-17**]): The left atrium is elongated. The right atrium is markedly dilated. No atrial septal defect or patent foramen ovale is seen by 2D, color Doppler or saline contrast. The estimated right atrial pressure is 11-15mmHg. There is mild symmetric left ventricular hypertrophy with normal cavity size. The right ventricular cavity is markedly dilated. There is mild global right ventricular free wall hypokinesis. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic root is mildly dilated at the sinus level. The ascending aorta is moderately dilated. A "ball-and-cage" type aortic valve prosthesis is present. The prosthetic aortic leaflets appear normal.The transaortic gradient is top normal for this prosthesis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are moderately thickened. The mitral valve shows characteristic rheumatic deformity. There is no mitral valve prolapse. There is moderate thickening of the mitral valve chordae. There is moderate mitral stenosis (area 1.0-1.5cm2). Moderate to severe (3+) mitral regurgitation is seen. The mitral regurgitation jet is eccentric. The tricuspid valve leaflets are moderately thickened. Severe [4+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. The main pulmonary artery is dilated. There is no pericardial effusion. CXR ([**1-18**]): There has been interval increase in moderate right pleural effusion with increase in right lower and right middle lobe atelectasis. Left lower lobe retrocardiac opacity consistent with atelectasis is new. There is no overt CHF. ETT tip is 3.9 cm above the carina. Unchanged calcified granuloma is in the left upper lobe. There is no pneumothorax. The patient is post median sternotomy and valve replacement. There is no overt CHF. CT Chest ([**1-18**]): 1. Right lower lobe atelectasis surrounded by moderate sized simple right pleural effusion. Ground glass opacities within the lingula are likely related to pulmonary edema. 2. Mild interstitial pulmonary edema, cardiomegaly with biatrial enlargement and RV failure, and 5cm ascending aorta dilatation. Mild dilatation to main pulmonary artery suggestive of underlying pulmonary hypertension. 3. Unchanged appearance to appropriately positioned endotracheal tube and malpositioned left-sided PICC catheter with tip in unclear location and possibly extravascular. CXR ([**1-20**]): Bilateral pleural effusions, worse on the right than the left and unchanged. CHF, unchanged. Brief Hospital Course: 84 y/o with hx of AVR, CHF, pAF, h/o LGIB, who complains of progressive SOB x 1 mo, found to have possible RLL PNA and GIB with an INR of 3.4 on warfarin and a greater than 10 point hematocrit drop from baseline. # GIB: On admission the patient was found to have a GIB with guaiac + brown stool and a Hct 23 from a baseline of about 30 per [**Hospital1 2025**] records. She received a total of three units PRBC from [**Date range (1) 71723**] with a Hct stable between 27-29. She was started on protonix IV BID and her Hct was checked Q4 hrs. She continued to have melena with one episode of BRBPR. GI was following the patient and recommended letting her INR drift down from 3.4 on admission. They advised a heparin bridge once her INR was <1.5. The plan was to scope her when her INR<1.5. She completed 4L golytely without worsening of her black tarry stool. She received 2u FFP on the morning of [**5-18**]. After the first unit had infused, the patient became tachypneic and hypoxic with Sa02 in the low 70s and had rigors and diffuse wheezes/crackles on lung exam. She was given IV methylprednisolone and diphenhydramine for presumed transfusion rxn, furosemide for volume overload and was intubated. She was then transferred to the MICU. A transfusion reaction workup wa performed, and it was preliminarily c/w TRALI. In terms of her GI bleed, her Hct remained stable, she was extubated and transferred back to the floor. After her INR drifted down on a heparin drip, a colonoscopy and EGD were performed without any evidence of a source for her GIB. Heparin was continued, and she was discharged with a stable Hct. # PNA: On admission CXR, the pt was found to have a RLL infiltrate/effusion/collapse per radiology read and she was treated with a 7-day course of vancomycin and levofloxacin without any change in her CXR. # Hyponatremia: Most likely etiology is secondary to heart failure. Stable throughout admission. # CHF: She was discharged on her home dose of furosemide 40 # Hypothyroidism: continued synthroid 75 mcg. She should have her TSH ckecked again as an outpt as PPIs can affect the absorption of levothyroxine. # CAD: no sx. Pt ruled out with two sets on admission. Continued digoxin. Her aspirin was held in light of her GIB, and she was discharged only on warfarin and the heparin drip. Her aspirin can be restarted as an outpatient when she is off the heparin drip. # AVR: heparin bridging while INR subtherapeutic. Medications on Admission: coumadin iron 325 mg daily synthroid 150 mcg daily digoxin 0.25 mg daily alprazolam 0.25 mg QHS prn lasix 40 mg every other day triamt/hctz 37.5 mg/25mg eery other day mvi bowel meds Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Tablet(s) 2. Levothyroxine 75 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 4. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB, wheeze. 5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Heparin (Porcine) in D5W 100 unit/mL Parenteral Solution Sig: One (1) Intravenous ASDIR (AS DIRECTED). Discharge Disposition: Extended Care Facility: [**Hospital3 **] Center Discharge Diagnosis: Primary: GI bleed Pneumonia Transfusion reaction Respiratory failure Secondary: CAD CHF S/P AVR Paroxysmal A fib PVD Hypothyroidism Hx. LGIB Anemia Gout/Pseudogout h/o SBO s/p bowel resection Discharge Condition: Stable Discharge Instructions: You were admitted with bleeding. No source was found. You should call your PCP or return to the hospital if you experience bleeding, chest pain, shortness of breath or have any other concerns. Please take all of your medications as prescribed. Please keep all of your follow-up appointments. Followup Instructions: Please call your primary care doctor to make a follow-up appointment.

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icd9cm

[ [ [] ] ]

[ "99.07", "38.93", "33.24", "99.04", "45.23", "45.13", "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

10544, 10594

6973, 9422

240, 269

10831, 10840

2616, 6950

11182, 11255

1916, 1920

9656, 10521

10615, 10810

9448, 9633

10864, 11159

1935, 2597

181, 202

297, 1727

1749, 1831

1847, 1900

12,643

112,571

23122

Discharge summary

report

Admission Date: [**2184-12-17**] Discharge Date: [**2184-12-31**] Service: MEDICINE Allergies: Percodan Attending:[**First Name3 (LF) 425**] Chief Complaint: Not well Major Surgical or Invasive Procedure: Placement of temporary pacer Placement of [**Hospital1 **]-ventricular pacer. History of Present Illness: The patient is an 81 year old male with h/o CAD s/p CABG x 3 in [**2179**], h/o htn, CVA, PVD who presented to the ED in third degree heart block. He was found by his neighbor earlier this evening not looking well who called EMS. EMS records indicate that the patient was found in bed, pale, incontinent of feces, lethargic and complaining of chest pain. The patient was unable to give any history upon arrival to the emergency room. VS in the field BP = 140/38, HR = 24, RR = 18, SaO2 = 90%. Pacer pads were placed in the filed and he was transported to [**Hospital1 18**] and placed on non-rebreather mask. Patient was then admitted to CCU. Past Medical History: Peripheral Vascular Disease-s/p right axillo [**Hospital1 **]-femoral bypass [**11/2180**](indicated for complete occlusion of infrarenal abdominal aorta) Coronary Artery Disease-s/p NSTEMI -[**10/2180**] s/p CABG x 3 [**11/2180**] Hyperlipidemia S/p Coronary artery bypass graftx 3 [**11/2180**]- LIMA-LAD, SVG-OM, SVG-RAMUS Carotid Stenosis s/p bilateral carotid endarterectomy CVA-with residual right arm hemiparesis H/o bladder cancer H/o hepatitis A s/p inguinal hernia repair H/o presumed pulmonary embolism diagnosed by intermediate probability V/Q scan-[**2180-12-12**] Social History: Widower, lives alone, has a daughter [**Name (NI) **] who is actively involved in his care-([**Telephone/Fax (1) 59528**] Physical Exam: T=95.7, BP = 95/P, P =20s, RR? Gen: confused agitated HEENT: Dry mucous membranes, PERRL Neck: JVP-flat, supple Chest: Anteriorly clear without crackles. CV: Extremely bradycardic, no m/r/g Abd: nabs, steel tubing appreciated in stomach-bipass, nt Pertinent Results: [**2184-12-17**] 11:39PM TYPE-ART PO2-259* PCO2-47* PH-7.21* TOTAL CO2-20* BASE XS--9 INTUBATED-INTUBATED [**2184-12-17**] 11:39PM LACTATE-4.6* K+-5.2 [**2184-12-17**] 11:39PM O2 SAT-98 [**2184-12-17**] 10:49PM URINE COLOR-LtAmb APPEAR-SlCldy SP [**Last Name (un) 155**]-1.030 [**2184-12-17**] 10:49PM URINE BLOOD-TR NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-SM UROBILNGN-NEG PH-5.0 LEUK-NEG [**2184-12-17**] 10:49PM URINE RBC-9* WBC-3 BACTERIA-NONE YEAST-NONE EPI-0 [**2184-12-17**] 10:35PM TYPE-ART PO2-36* PCO2-64* PH-7.19* TOTAL CO2-26 BASE XS--5 [**2184-12-17**] 10:35PM LACTATE-6.4* [**2184-12-17**] 10:23PM GLUCOSE-106* UREA N-62* CREAT-4.7* SODIUM-144 POTASSIUM-6.8* CHLORIDE-105 TOTAL CO2-20* ANION GAP-26* [**2184-12-17**] 10:23PM ALT(SGPT)-24 AST(SGOT)-50* LD(LDH)-379* CK(CPK)-259* ALK PHOS-80 TOT BILI-0.4 [**2184-12-17**] 10:23PM CK-MB-4 cTropnT-0.15* [**2184-12-17**] 10:23PM CALCIUM-8.3* PHOSPHATE-6.1* MAGNESIUM-2.3 [**2184-12-17**] 10:23PM TSH-2.8 [**2184-12-17**] 10:23PM WBC-11.0 RBC-3.54* HGB-10.7* HCT-33.2* MCV-94 MCH-30.3 MCHC-32.3 RDW-14.6 [**2184-12-17**] 10:23PM PLT COUNT-187 [**2184-12-17**] 10:23PM PT-18.6* PTT-29.8 INR(PT)-2.2 [**2184-12-17**] 10:23PM PT-18.6* PTT-29.8 INR(PT)-2.2 [**2184-12-17**] 09:03PM GLUCOSE-96 LACTATE-3.7* NA+-142 K+-5.6* CL--107 TCO2-21 [**2184-12-17**] 09:03PM HGB-12.5* calcHCT-38 O2 SAT-31 CARBOXYHB-0.8 MET HGB-0.9 [**2184-12-17**] 09:03PM freeCa-1.08* [**2184-12-17**] 08:50PM GLUCOSE-95 UREA N-58* CREAT-4.7* SODIUM-144 POTASSIUM-5.6* CHLORIDE-107 TOTAL CO2-22 ANION GAP-21* [**2184-12-17**] 08:50PM AMYLASE-57 [**2184-12-17**] 08:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2184-12-17**] 08:50PM WBC-13.0* RBC-3.86* HGB-11.8* HCT-36.0* MCV-94 MCH-30.5 MCHC-32.7 RDW-14.7 [**2184-12-17**] 08:50PM PLT COUNT-234 [**2184-12-17**] 08:50PM PT-19.9* PTT-32.6 INR(PT)-2.5 [**2184-12-17**] 08:50PM FIBRINOGE-460* ECG: [**Hospital1 112**] report [**2184-1-3**] - no image sent: NSR with ? LA enlargement RBB- Echo: post CABG- [**2180-11-29**]- EF = 55-60%, Mild concentric LVH Brief Hospital Course: Plan: 1. CVS: CHB: Etiology of complete heart block remains unclear. The differential diagnosis included medications, ischemia, fibrosis and sclerosis, along with hyperkalemia. The pateint's troponin was elevated at 0.15 upon admission but this was difficult to interpret in light of his acute renal insufficiency. He was also on a small dose of beta blocker and this was thought to be too small to lead to complete heart block. We thought that that it was highly likely that the patient had a diseased conduction system at baseline as evidenced by his baseline right bundle branch which may have pre-disposed him to have complete heart block in the face of a secondary insult such as small electrolyte imbalance or brewing infection. A temporary pacer wire was placed which was removed two days later secondary to concerns of a potential infection. See ID. He resumed normal sinus rhthym without incident and once his infection was adequately treated with antibiotics a permanent [**Hospital1 **]-ventricular pacer was placed. . Coronary Artery Disease: His complete heart block was concerning for potential ischemia. We trended his cardiac enzymes which peaked at a troponin of 0.3 with a CKMBI of 7. WE thought that his cardiac ischemia was secondary to his poor cardaic output in light of his severe bradycardia and not acute coronary syndrome. His cardiac ischemia was managed by improving his cardiac output by placing a temporary pacer. His enzymes trended down and he was continued on atorvastatin and aspirin. . Htn: His beta-blocker was held until his pacer was placed and then he was re-started on his home regimen. . 2. CVA: -During his hospital course the patient was found with left lower extremity hemiparesis and a head MRI demonstrated new R embolic strokes. The patient was continued on heparin and his SBP was maintained >140 for one week. He recovered use of his left leg and left arm but he continued to have a waxing and [**Doctor Last Name 688**] exam which was most notable for left sided neglect. . 3. UTI: During the course of his hospitalization the patient began spiking temperatures. He was fond to have a levaquin resistant E. Coli UTI along with pulmonary infiltrates concerning for possible aspiration pneumonia. He was started on zosyn and completed a 7 day course. . 4. H/o CVA, PE and fem-[**Doctor Last Name **] graft: His coumadin was held and he was continued on a IV heparin while in hospital. His coumadin was restarted upon discharge with lovenox as a bridge. . 5.Acute renal insufficiency: We thought this is elevated creatinine was secondary pre-renal in etiology as demonstrated by its decrease with fludis to 2.0 upon discharge. . 6.Ventilation: The patient was intubated electively for agitation,confusion and out of concern for airway protection. He was successfully extubated and weaned off his O2 with lasix and antibiotics until upon the day of discharge he was sating well on room air. 6. COPD/Shortness of Breath: The patient experienced episodes of SOB with exertion while in hospital which resolved with nebulizers and serial chest X rays and ECGs were unchanged. He was thus started on a rapid prednisone taper with good effect. . 7. Guaic positive stools: The patient was found to have guaic positive stool during this admission. His hematocrit remained stable and thus we suggest an outpatient GI work up. . 8.Pocket Hematoma: The patient developed a pocket hematoma after his pacer was placed. He was started on kelfext complete a 7 day course to prevent an infection. 9.FEN: He was continued on a low Na, renal diet. 10. Hyperkalemia: During the last two days of his hospital stay the patient was found to have elevated potassium. Serial EKGs were checked and the patient remained asymptomatic. We then realized that the patient has a penchant for bananas. In light of his elevated creatinine we suggest that he be conitinued on renal cardiac diet. 11. In light of his continued improvement he was discharged to stroke rehab to recuperate from his hospital stay. Medications on Admission: Coumadin 2.5 mg qd Gemfibrozil 600 mg po bid Terazosin 2 mg qs Metoprolol 25 mg qd Folate 1 mg qd Lasix 20 mg M/W/F Lipitor 20 mg qhs Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Primary: Complete heart block Pneumonia Urinary Tract Infection Secondary: Peripheral Vascular Disease Coronary Artery Disease-s/p NSTEMI -[**10/2180**] Hyperlipidemia S/p Coronary artery bypass graft x 3 Carotid Stenosis s/p bilateral carotid endarterectomy CVA-with residual right arm hemiparesis H/o bladder cancer H/o hepatitis A s/p inguinal hernia repair H/o presumed pulmonary embolism Discharge Condition: Good. Still requiring oxygen, which he uses at home at his baseline - he has been on [**1-21**] L via NC. Has COPD, therefore keeping sats 91-94%. Alert, conversant. Discharge Instructions: Please return to the emergency room if you experience shortness of breath, sudden weakness, slurred speech, light headedness, chest pain, black stools or bright red blood per rectum. Please cut back on your banana intake!! They cause your potassium levels in your blood to be too high. Please take all medications as prescribed. You have been re-started on your home regimen of medications. Followup Instructions: Provider: [**Name10 (NameIs) 676**] CLINIC Where: [**Hospital6 29**] CARDIAC SERVICES Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2185-1-5**] 11:30 Please call your PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 24943**] at [**Telephone/Fax (1) 8506**] for follow up within one week. He will need frequent INR checks (every other day) until INR is stable between 2 and 3, as we have just restarted his coumadin.

[ "584.9", "426.0", "438.30", "507.0", "599.0", "443.9", "998.12", "792.1", "434.11", "V58.61", "041.4" ]

icd9cm

[ [ [] ] ]

[ "96.04", "00.17", "37.78", "37.72", "99.07", "96.71", "37.83" ]

icd9pcs

[ [ [] ] ]

8395, 8467

4168, 8210

226, 305

8904, 9072

2007, 4145

9514, 9986

8488, 8883

8236, 8372

9096, 9491

1738, 1988

178, 188

333, 983

1005, 1584

1600, 1723

21,507

122,271

12577

Discharge summary

report

Admission Date: [**2187-3-21**] Discharge Date: [**2187-4-6**] Date of Birth: [**2118-10-20**] Sex: F Service: HISTORY OF PRESENT ILLNESS: The patient is a 68 year old white female with a history of asthma and coronary artery disease with exertional angina, who was recently admitted to St. [**Hospital **] Hospital with shortness of breath and chest pain. She was found to be in congestive heart failure with lateral ST depressions on EKG, positive troponin to 5.6. The patient was transferred to [**Hospital1 18**] for a cardiac catheterization. PAST MEDICAL HISTORY: 1. Asthma with frequent steroid tapers; one endotracheal intubation in the past. 2. Chronic obstructive pulmonary disease. 3. Gastroesophageal reflux disease. 4. Transient ischemic attacks. 5. Lacunar stroke in [**2178**]. 6. Coronary artery disease with exertional angina. 7. Diabetes mellitus on insulin. 8. Hypertension. 9. Anaphylactic reaction to aspirin. 10. Anaphylaxis to ACE inhibitors. 11. Total hip replacement in [**2182**]. MEDICATIONS: 1. Dilantin 100 mg p.o. three times a day. 2. Bumex 6 mg p.o. q. a.m., 2 mg p.o. q. p.m. 3. Procardia XL 120 mg p.o. q. day. 4. Reglan 10 mg p.o. q. day. 5. Insulin 75/25, 16 mg p.o. q. a.m.; 60 mg p.o. q. p.m. 6. Prevacid 30 mg p.o. twice a day. 7. Hydralazine 25 mg p.o. three times a day. 8. Plavix 75 mg p.o. q. day. 9. Accolade 200 mg p.o. twice a day. 10. Nitro-Dur 0.6 mg patch. 11. Levaquin 500 mg p.o. q. day. 12. Neurontin. 13. Catapres 0.3 mg transdermal q. week. LABORATORY: Cardiac catheterization demonstrated three-vessel disease, left MCA 80 to 90% calcified osteo, left anterior descending 70% proximal and diffuse disease, left circumflex 90% OM2 and right coronary totally occluded proximally, left greater than right. PHYSICAL EXAMINATION: On physical examination, elderly pleasant woman in moderate respiratory distress with audible wheeze. Neck: Supple, obese, unable to use jugular venous distention. Lungs: Wheezing bilaterally. Cardiovascular: S1 and S2 normal but heart sounds were muffled. Abdomen obese, nontender, nondistended. Extremities: Doppler-able pulses bilaterally. HOSPITAL COURSE: The patient was admitted to the [**Hospital Unit Name 196**] Service and underwent carotid study on [**2187-3-22**], which showed narrowing of 40 to 59% bilaterally of the internal carotid arteries and right subclavian steal. A Vascular Surgery consultation was called regarding the subclavian steal and no vascular intervention was recommended at that time. Initially, the patient was refusing surgery. On [**2187-3-25**], a Cardiac Surgery consultation was called as the patient seemed to change her mind regarding the intervention. Although the patient was high-risk for coronary artery bypass graft it seemed to be the best option for the patient. This was explained to her. A consent was signed on [**2187-3-25**]. The patient was taken to the Operating Room on [**2187-3-26**], for a coronary artery bypass graft times three with left internal mammary artery to the left anterior descending, reverse saphenous vein graft to right coronary artery and to obtuse marginal. The morning of postoperative day number one, the patient was re-intubated for poor oxygenation and mental status changes. A Pulmonary consultation was obtained and they suggested aggressive diuresis with a wedge pressure of 10 to 15 as goal. The patient received two units of packed red blood cells for a hematocrit of 23.5 on postoperative day number one. A ventilator wean was started on postoperative day number three and the patient was extubated. The patient continued to require chest PT and suctioning for good pulmonary toilet, but the patient did not require re-intubation. On postoperative day number five, the patient had an episode of atrial fibrillation. The patient was given Amiodarone p.o. and spontaneously converted to sinus. The patient continued to improve and by postoperative day number nine was off all drips. The patient was transferred to the floor on postoperative day nine. On postoperative day number ten, the patient's wires and Foley catheter were removed. Physical Therapy worked with the patient on postoperative day number ten and recommended rehabilitation facility. On postoperative day number eleven, the patient was discharged to rehabilitation in stable condition. DISCHARGE DIAGNOSES: 1. Status post coronary artery bypass graft times three with left internal mammary artery to the left anterior descending, and reverse saphenous vein graft to right coronary artery and obtuse marginal. DISCHARGE MEDICATIONS: 1. Prednisone 5 mg p.o. q. day. 2. Accolade 20 mg p.o. twice a day. 3. Dilantin 100 mg p.o. three times a day. 4. Levaquin 500 mg p.o. q. day times two more days. 5. Protonix 40 mg p.o. q. day. 6. Combivent Metered-Dose Inhaler four puffs q. four hours p.r.n. 7. Nystatin Powder to groin p.r.n. 8. Percocet one to two tablets p.o. q. four to six hours p.r.n. 9. Amiodarone 400 mg p.o. q. day. 10. Heparin 5000 units subcutaneously three times a day. 11. [**First Name5 (NamePattern1) 233**] [**Last Name (NamePattern1) 1002**] 20 mEq p.o. twice a day. 12. Colace 100 mg p.o. twice a day. 13. Plavix 75 mg p.o. q. day. 14. Imdur 90 mg p.o. q. day. 15. Digoxin 0.25 mg p.o. q. day. 16. Aldactone 75 mg p.o. twice a day. DISCHARGE INSTRUCTIONS: 1. The patient was to follow-up in four weeks with Dr. [**Last Name (STitle) **]. 2. The patient was to follow-up in one week after rehabilitation with her primary care physician, [**Last Name (NamePattern4) **]. [**First Name (STitle) 3924**] Reback. CONDITION AT DISCHARGE: The patient was discharged in stable condition. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Last Name (NamePattern1) 6067**] MEDQUIST36 D: [**2187-4-6**] 09:25 T: [**2187-4-6**] 09:33 JOB#: [**Job Number 38920**]

[ "414.01", "458.2", "250.01", "518.5", "427.31", "440.21", "428.0", "410.71", "491.21" ]

icd9cm

[ [ [] ] ]

[ "88.56", "96.6", "96.04", "39.61", "36.15", "96.71", "37.23", "36.12" ]

icd9pcs

[ [ [] ] ]

4414, 4618

4641, 5369

2195, 4393

5393, 5658

1826, 2177

5674, 5998

160, 571

593, 1803

82,482

113,214

6593

Discharge summary

report

Admission Date: [**2194-12-12**] Discharge Date: [**2194-12-20**] Date of Birth: [**2114-1-24**] Sex: M Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3227**] Chief Complaint: Subdural Hematoma Major Surgical or Invasive Procedure: None History of Present Illness: Pt is a 80 yo male w/ PMHx sig for CABGx4, pacemaker,recent hospitalization and rehab for R MRSA ankle infection who present after falling at home, found to have a R SDH. The patient has been at home for 1 week after a 5 week rehab stay. He was on his porch walking into the house and tripped on a step an fell backwards. Unclear if he hit his head. No LOC. The patient was brought to an OSH where CT head showed a R frontal SDH along falx. He was transferred to [**Hospital1 18**] for further management. In [**Name (NI) **], pt was noted to have left facial droop. He was given 2 units of FFP. Repeat INR 1.8. Past Medical History: CABG x 4, L knee repair, MRSA infection of R ankle, pacemaker. Social History: Lives at home with wife. Family History: Non-contributory Physical Exam: Physical Exam: Vitals: T 99.2; BP 127/81; P 70; RR 16; O2 sat 100% General: lying in bed NAD HEENT:dry mucous membranes Extremities: no c/c/e. Neurological Exam: Mental status: Awake & alert, year [**2174**] corrects to [**2194**], month - [**Month (only) **], Fluent speech with no paraphasic errors. Adequate comprehension. Cranial Nerves: II: PERRL, 4-->2mm with light. III, IV, VI: EOMI. no nystagmus. V, VII: facial sensation intact, L facial droop [**Doctor First Name 81**]: SCM [**5-13**] XII: Tongue midline without fasciculations. Motor: Normal bulk. Normal tone. No pronator drift. Delt Tri [**Hospital1 **] WE WF FE FF IP QD Ham C5 C7 C6 C8 L2 L3 L4-S1 RT: 5 5 5 5 5 5 5 4 5 4 LEFT: 5 5 5 5 5 4 5 4 5 4 Sensation: intact to light touch Reflexes: Bic T Br Pa Ac Right 2 2 2 1 - Left 2 2 2 1 - Upon Discharge: right facial droop alert and oriented x3 (year only) limited ROM left shoulder due to chronic injury. Pertinent Results: CT Head [**2194-12-12**]: IMPRESSION: 1. New right frontoparietal subdural hematoma measuring 4 mm. 2. Interval enlargement of the right parafalcine subdural hematoma layering along the right tentorium as well as enlargement of the left frontal intraparenchymal hemorrhage as described above. Areas of hypodensity within the right parafalcine subdural hematoma are concerning for hyperacute bleeding. 3. No shift of normally midline structures. CT Head [**2194-12-13**]: IMPRESSION: Stable appearance of parafalcine and right tentorial subdural hematoma, and left periventricular hemorrhage, with no new bleeding and no herniation. CT Head [**2194-12-14**]: IMPRESSION: Unchanged right convexity, parafalcine and tentorial hematoma. Unchanged left periventricular hemorrhage. CT Head [**2194-12-15**]: unchanged Brief Hospital Course: [**Known firstname **] [**Known lastname 9996**] was admitted to [**Hospital1 18**] Neurosurgery on [**2194-12-12**] who is s/p fall and found to have a right subdural hematoma and left frontal subcortical IPH. He was admitted to the ICU for close observation. On [**12-13**] he was note to be more confused and it was unknown if this was due to sundowning vs. worsening bleed and a Head CT was repeated revealed no significant interval change. On [**12-14**], he had left arm and leg jerking x3, self resolved, no Ativan was required. He was on Keppra 500mg [**Hospital1 **] and it was increased to 1000mg [**Hospital1 **] and he also received a 250mg IV bolus. A STAT Head CT which revealed no evidence of interval hematoma progression. He was kept in the ICU overnight and Neurology consulted for seizure management. Neurology agreed with the Keppra increase and recommended an EEG which was done on [**2194-12-15**]. Pt was neurologically stable and transferred to the Step Down Unit on [**2194-12-15**]. A repeat head CT showed stable intracranial findings. On [**12-17**], He had some intermittent right hemiparesis. Neurology was again consulted. No stroke was identified on imaging. CTA did not reveal any significant hemadynamic lesions. Work up was notable only for a UTI for which the patient received a course of Ciprofloxicin. He was started on ASA and closely followed by neurology for these intermittent symptoms which persisted through the remainder of his hospitalization. Ultimately, the patient was cleared for discharge by the neurology consult. The patient was transferred to a [**Hospital1 1501**] on [**2194-12-20**] Medications on Admission: Prilosec 20 mg q day, Cordarone 200 mg q day, ASA 81 mg q day, Lopressor 50 mg [**Hospital1 **], Vit C 500 mg [**Hospital1 **], Zocor 80 mg qhs, Xalatan OS qhs, HCTZ 25 qod, Coumadin 2 mg q day, Digoxin 125mcg q day, Lasix 80 mg q day, MVI, KCl 20 meq q day, Vit D 800 units q day, Vit E 200 units q day, Colace 100 mg q day. Discharge Medications: 1. Simvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Vitamin E 100 unit Capsule Sig: Two (2) Capsule PO DAILY (Daily). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Insulin Regular Human 100 unit/mL Solution Sig: RISS Injection ASDIR (AS DIRECTED). 8. Silver Sulfadiazine 1 % Cream Sig: One (1) Appl Topical DAILY (Daily). 9. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Hold SBP<110 HR<60. 11. Levetiracetam 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 12. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for Pain. 13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 14. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 16. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 10 days. 19. Tobramycin Sulfate 0.3 % Ointment Sig: One (1) Appl Ophthalmic [**Hospital1 **] (2 times a day) for 5 days. 20. Ondansetron 4 mg IV Q8H:PRN nausea 21. Ondansetron HCl (PF) 4 mg/2 mL Solution Sig: One (1) Injection Q8H (every 8 hours) as needed for n/emesis. Discharge Disposition: Extended Care Facility: Aberjona Nursing Center - [**Hospital1 2436**] Discharge Diagnosis: Right Subdural Hematoma and Left frontal subcortical IPH Urinary Tract Infection Discharge Condition: neurologically stable Discharge Instructions: General Instructions ??????Take your pain medicine as prescribed. ??????Exercise should be limited to walking; no lifting, straining, or excessive bending. ??????Increase your intake of fluids and fiber, as narcotic pain medicine can cause constipation. We generally recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. ??????Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, Aspirin, Advil, or Ibuprofen etc. ??????If you were on a medication such as Coumadin (Warfarin), or Plavix (clopidogrel), or Aspirin prior to your injury, please refrain from taking until you are seen by Dr. [**First Name (STitle) **] in follow-up ??????You have been given Keppra to take. Please continue with this medication until you are seen in follow-up with Dr. [**First Name (STitle) **] ??????No Driving. You had multiple seizures while in hospital. Followup Instructions: You will need to follow-up with Dr. [**First Name (STitle) **] in 4 weeks with a Head CT w/o contrast. Please call [**Location (un) 3230**] for this appointment at [**Telephone/Fax (1) 3231**] Please call [**Telephone/Fax (1) 3231**] with any questions or concerns. Completed by:[**2194-12-20**]

[ "728.87", "781.94", "599.0", "853.01", "V12.04", "V45.81", "852.21", "E885.9", "V45.01", "348.39", "780.39" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6770, 6843

3029, 4675

339, 345

6968, 6991

2189, 3006

7982, 8280

1141, 1160

5052, 6747

6864, 6947

4701, 5029

7015, 7959

1191, 1321

1340, 1340

282, 301

2067, 2170

373, 995

1522, 2051

1355, 1506

1017, 1082

1098, 1125

53,286

182,055

33092

Discharge summary

report

Admission Date: [**2122-4-11**] Discharge Date: [**2122-4-17**] Service: MEDICINE Allergies: Benzodiazepines / Nsaids Attending:[**First Name3 (LF) 905**] Chief Complaint: lethargy Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname 72502**] is a [**Age over 90 **] yo F/ w/ h/o GERD, venous insufficiency, HTN, DM and recurrent UTIs who presents from [**Hospital1 1501**] with 2 days of weakness and lethargy. Patient was also noted to have bradycardia to upper 40-50s, and there was concern for pacemaker dysfunction. Of note, the pt had a recent admission from [**2122-3-15**] to [**2122-3-18**] for fever and AMS and was treated for a UTI. . At patient's [**Hospital1 1501**], noted to have R sided crackles, 88% RA, baseline 93% or greater, pulse- 48-50. The NP had thought pt had lower limit of pacer of 60 (leading her to question if the pacer was fuctioning poorly) but pt has had pulses in 50s consistently in past here. concerned about pacemaker function. Last telephonic interrogation was reportedly normal on [**2122-3-25**]. NP also confirmed pt's son and HCP wanted the pt full code . In our ED, the pt was oriented x2, pleasant but poor historian. RA sat 88%. EKG was paced and c/w prior EKGs also paced at 50s. The pt had a CXR with pleural effusions. CT abdomen was performed for abd tenderness which showed ?appendicitis. Surgery was consulted in the ED and thought the pt's suprapubic tenderness was c/w UTI. Pt also had a pericardial effusion on CT abd and cards was called but was not impressed. TTE [**4-11**] showed small pericardial effusion. She was given levofloxacin given inability to rule out pneumonia hidden by pleural effusions. Pt was also noted to have a UTI. In the [**Name (NI) **], pt was noted to have poor UOP from foley while getting 75 D5NS/hr. The pt's HCP was not contact[**Name (NI) **] while the pt was in the [**Name (NI) **]. On transfer from the ED, vitals were: T 98.1 P 50 paced BP 129/52 R 17 O2 sat 98% on 2l NC. 2 peripheral IVs were placed in the ED. . In the ICU, patient was monitored overnight. Patient was very stable, remained bradycardic, recent interogation of pacer showed it was working normally. Patient's abx was changed to ceftriaxone based on prior sensitivities, urine sensitivities pending. Patient's course was uneventful and was called out to the floor. . Review of systems: (+) Per HPI (-) Denies fever, chills, headache, cough, shortness of breath, chest pain, nausea, vomiting, diarrhea, constipation. . Past Medical History: Past Medical History: Dizziness GERD Venous insufficiency h/o skin cancer h/o colon cancer dyspepsia HTN DM Osteoarthritis Depression Hyperlipidemia Chronic recurrent UTIs Social History: Social History: Lives at nursing home Nonweight bearing Incontinent of urine and stool Family History: Family History: Unknown Physical Exam: VS:99.2, 108/60, 70, 27, 99%2LNC General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Bilateral rales CV: Regular rate and rhythm, normal S1 + S2 Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: +2 BLE edema Pertinent Results: Labs on Admission: [**2122-4-10**] 11:55PM BLOOD WBC-14.2* RBC-4.01* Hgb-10.2* Hct-33.5* MCV-83 MCH-25.5* MCHC-30.5* RDW-14.4 Plt Ct-463* [**2122-4-10**] 11:55PM BLOOD Neuts-73.1* Lymphs-21.8 Monos-3.7 Eos-1.0 Baso-0.4 [**2122-4-10**] 11:55PM BLOOD PT-26.9* PTT-36.5* INR(PT)-2.6* [**2122-4-10**] 11:55PM BLOOD Plt Ct-463* [**2122-4-10**] 11:55PM BLOOD Glucose-151* UreaN-16 Creat-0.8 Na-140 K-4.0 Cl-97 HCO3-36* AnGap-11 [**2122-4-10**] 11:55PM BLOOD proBNP-382 [**2122-4-10**] 11:55PM BLOOD cTropnT-0.01 [**2122-4-11**] 12:13AM BLOOD Lactate-1.3 Urine Studies on Admission: [**2122-4-11**] 01:03AM URINE Color-Yellow Appear-Hazy Sp [**Last Name (un) **]-1.026 [**2122-4-11**] 01:03AM URINE Blood-MOD Nitrite-NEG Protein-75 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-MOD [**2122-4-11**] 01:03AM URINE RBC-[**1-30**]* WBC->50 Bacteri-FEW Yeast-NONE Epi-1 Labs on Transfer to Floor: [**2122-4-12**] 05:16AM BLOOD WBC-9.4 RBC-3.95* Hgb-10.1* Hct-32.8* MCV-83 MCH-25.5* MCHC-30.8* RDW-14.4 Plt Ct-460* [**2122-4-12**] 05:16AM BLOOD Plt Ct-460* [**2122-4-12**] 05:16AM BLOOD PT-30.9* PTT-38.8* INR(PT)-3.1* [**2122-4-12**] 05:16AM BLOOD Glucose-138* UreaN-13 Creat-0.7 Na-141 K-3.7 Cl-98 HCO3-37* AnGap-10 [**2122-4-12**] 05:16AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.8 Labs on Discharge: [**2122-4-17**] 08:40AM BLOOD WBC-10.7 RBC-3.96* Hgb-10.0* Hct-32.8* MCV-83 MCH-25.2* MCHC-30.5* RDW-14.5 Plt Ct-603* [**2122-4-17**] 08:40AM BLOOD PT-25.1* PTT-33.5 INR(PT)-2.4* [**2122-4-17**] 08:40AM BLOOD Glucose-191* UreaN-17 Creat-0.7 Na-140 K-3.9 Cl-96 HCO3-38* AnGap-10 [**2122-4-17**] 08:40AM BLOOD Calcium-8.8 Phos-2.3* Mg-2.0 [**2122-4-13**] 06:20AM BLOOD calTIBC-267 VitB12-326 Folate-12.0 Ferritn-107 TRF-205 Iron 16 MICRO: URINE CULTURE (Final [**2122-4-13**]): ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in M _________________________________________________________ ESCHERICHIA COLI | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R IMAGING: CT ABDOMEN W/CONTRAST Study Date of [**2122-4-11**] 2:32 AM IMPRESSION: 1. No evidence of appendicitis. 2. Small pericardial effusion with enhancing pericardium suggesting a potential serosanguineous/exudative nature of the effusion. Clinical correlation is recommended. 3. Bilateral renal cysts. CT CHEST [**2122-4-13**] IMPRESSION: No evidence of pneumonia. No pulmonary masses. Bilateral pleural and pericardial effusion. Extensive coronary and aortic calcifications. Partly calcified thyroid nodules. Bilateral renal cysts. TTE: The left atrium and right atrium are normal in cavity size. Left ventricular wall thickness, cavity size, and global systolic function are normal (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is moderate estimated pulmonary artery systolic hypertension. There is a small circumferential pericardial effusion without evidence of hemodynamic compromise. IMPRESSION: Suboptimal image quality. Small circumferential pericardial effusion. Normal biventricular cavity sizes with preserved global biventricular systolic function. Brief Hospital Course: # UTI: Pt grew 10-100,000 ecoli from urine and had suprapubic pain. She was treated c 7d course of ceftriaxone. Blood cultures from [**4-10**] were negative. Pt was started on suppressive abx with bactrim ss daily as her family feels that her frequent UTIs are interfering with her happiness. BLOOD CULTURES FROM [**4-13**] WERE PENDING AT THE TIME OF DISCHARGE, BUT NO GROWTH TO DATE. . # pleural effusions/O2 req: Felt to be most likely [**12-30**] CHF, though diastolic dysfunction is relatively mild. Pt could have PE which can cause pleural effusions, however, that seems less likely in setting of therapeutic INR. Pt did have chest CT to r/o which large tumor or pneumonia, which was negative for both. Thoracentesis was discussed with family and the risks and benefits shared with them. Both family ([**Doctor First Name **]) and MDs agreed that risks outweighed the benefits in this elderly lady in whom the most likely dx remains CHF. Pt was diuresed with lasix and 4doses of acetazolamide and was breathing comfortable on room air on discharge. . # pericardial effusion: noted incidentally on CT. Further evaluated with TTE which showed only a small effusion. . # Acute on Chronic diastolic heart failure: Patient felt to be mildly volume overloaded on admission and throughout her stay. She was diuresed with lasix 60IV [**Hospital1 **] and acetozolamide added as her bicarbonate approached 40. Pt was able to breathe comfortably on RA though she did still have occasional crackles at the bases of her lungs as well as LE edema on discharge. Her home lasix regimen was increased from 40BID to 60BID (PO). HER VOLUME STATUS WILL NEED TO BE MONITORED CAREFULLY ON DISCHARGE IN SETTING OF HIGHER LASIX DOSE. . # low grade fevers/mild leukocytosis: pt had several fevers in the 100-100.5 range throughout admission, even after initiation of ceftriaxone for UTI. Pt had BCx, chest xray, chest CT and abd CT as well as repeat UA/UCx, none of which showed a source of infection. Pt had been afebrile x48h at the time of discharge and WBC count was 10. C diff toxin was not sent as pt did not have diarrhea and WBC count improved without intervention. If pt develops loose stool at rehab, would consider check diff toxin. . # abd pain- Pt had abd pain on admission felt to be most c/w UTI. She did have CT in ED which did not show e/o diverticulitis or other acute process. This pain resolved by HD2 c treatment of UTI. . # Bradycardia on admission: EKG showed paced rhythm, recent PPM interrogation was normal in [**Hospital1 18**] records. HR increased to 60s-70s throughout most of her admission. . # [**Name (NI) 1568**] Initially pt's home glipizide and metformin held and pt maintained on HISS. Glipizide and metformin restarted on discharge. . # Dementia: Continued aricept . # h/o PE- continued coumadin. . # thyroid nodule: noted incidentally on ct chest, partially calcified. Could consider further w/u if seems c/w overall clinical picture. Medications on Admission: - Glipizide ER 10mg daily - Fluticasone nasal spray 50mcg each nostril [**Hospital1 **] - Metformin ER 500mg daily - Metoprolol 12.5mg [**Hospital1 **] - Zocor 40mg daily - Prozac 20mg QHS - Acetaminophen 1gm [**Hospital1 **] - Aspirin 81mg daily - Coumadin 5mg 5 days/wk then 2mg 2 days/wk - Aricept 5mg daily - Lasix 40mg [**Hospital1 **] - Multivitamin with minerals daily - Senna QHS Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain. 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Donepezil 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 6. Fluoxetine 20 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 7. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Tablet(s) 8. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal [**Hospital1 **] (2 times a day). 9. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 10. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 11. Glipizide 10 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. 12. Lasix 40 mg Tablet Sig: 1.5 Tablets PO twice a day. 13. Metformin 500 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 14. Coumadin 5 mg Tablet Sig: One (1) Tablet PO 5 days per week. 15. Coumadin 2 mg Tablet Sig: One (1) Tablet PO the other 2 days per week. 16. 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. 17. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 18. Sulfamethoxazole-Trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): for suppression, continue indefinitely. Discharge Disposition: Extended Care Facility: [**Hospital **] [**Hospital **] Nursing Home - [**Location (un) **] Discharge Diagnosis: PRIMARY: diastolic dysfunction c acute exacerbation, UTI Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: It was a pleasure taking care of you during your admission at [**Hospital1 69**]. You were admitted for a urinary tract infection. You were treated with antibiotics. You also had some extra fluid in your lungs for which you got some extra lasix. Initially you needed oxygen but you were able to breathe ok without the oxygen by the time you were discharged. We have changed some of your medications during your admission and we will communicate these to your nursing home. In brief, we have increased your lasix dose and we have started you on an antibiotic to take every day to try to prevent urinary tract infections. Followup Instructions: You have the following appointment that we arranged for you for the lesion on your face: Department: DERMATOLOGY When: MONDAY [**2122-6-22**] at 2:15 PM With: [**Name6 (MD) 6821**] [**Name8 (MD) **], 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 [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**] Completed by:[**2122-4-21**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12186, 12280

7144, 9586

240, 246

12381, 12381

3284, 3289

13201, 13702

2875, 2885

10543, 12163

12301, 12360

10130, 10520

12556, 13178

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274, 2390

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2587, 2738

2770, 2843

19,568

131,173

28621

Discharge summary

report

Admission Date: [**2124-3-13**] Discharge Date: [**2124-3-16**] Date of Birth: [**2066-11-6**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 20640**] Chief Complaint: Atrial flutter Major Surgical or Invasive Procedure: None History of Present Illness: 57M with PMH Metastatic renal cell ca, currently on phase II of XL880 protocol (small molecule inhibitor), presents with atrial flutter with RVR in the setting of admission for routine chemo administration. He apparently was in his USOH, was reporting to OMED for his scheduled chemo, when he was noted to be in rapid atrial flutter with RVR to 150s. He denied any CP, SOB, LH, palpitations, N/V, weakness, fatigue, or any other symptoms during the episode. As mentioned, prior to this event, he denies any F/C/NS, change in his chronic clear mucous cough, HA, nasal congestion, D/C, abd pain, dysuria, or LE edema. Of note, he was found to have DVT and PE on a prior hospitalization, and was started on lovenox as well as IVC filter placed. However, the lovenox had to be d/c'd as he was found to have hemorrhage into his L kidney causing L sided swelling. Since d/c of this (a week of two ago), he has been without symptoms. During the PE, he had no symptoms of SOB, CP, and only experienced some L leg dyscomfort, which has not returned. Past Medical History: ONC HX: Recently diagnosed with metastatic renal cell cancer after he developed a lingering cough and dyspnea and was found to have loss of lung volume in the left lung in [**7-14**]. CT scan showed an obstructing lesion in his left main stem bronchus with atelectasis of his entire left lung. CT scan of his torso as well as PET scanning showed lesions in his left kidney, left main stem bronchus, periaortic lymph node, and his thyroid. On flexible bronchoscopy, performed on [**2123-9-1**] by Dr. [**First Name (STitle) **] [**Name (STitle) **], he underwent debulking of the endobronchial lesion and had resultant hemoptysis. He has subsequently received a course of radiation treatment which he completed on [**9-29**]. He had a successful tumor excision, tumor destruction of the left mainstem obstruction and placement of a 12 mm x 40 mm covered Ultraflex stent to achieve left lower lobe patency. Since that time, and has decided to enroll in phase 2 XL 880 treatment and begin stage 2 XL880 research protocol 06-132 on [**2123-11-22**]. . PMH: # metastatic papillary RCC # GERD # s/p appendectomy Social History: He lives alone, is divorced, and has a 16-year-old daughter. [**Name (NI) **] works as a heavy equipment mechanic and supervisor. He is currently not working, though he remains employed. He has never smoked. He drinks approximately one to two drinks per day; however, he has not drunk since his initial diaagnosis. Family History: CAD and DM in father. Mother died in 40s from liver disease( ?EtOH). Physical Exam: * T 96.0 HR 156 RR 24 136/68 94RA GEN:NAD HEENT: Clear OP, MMM Neck: Supple, Mild to mod JVD, several palpable LN with largest in L lower neck, no carotid bruits Lungs: CTA, BS BL, No W/R/C Cardiac: RRR NL S1S2. No murmurs Abd: Soft, NT, ND. NL BS. No HSM. Ext: No edema. Neuro: A&Ox3. Appropriate. CN 2-12 intact. Full strength and sensation in all extremities with no appreciable defects. Pertinent Results: [**2124-3-13**] 08:45PM D-DIMER-1383* [**2124-3-13**] 10:45AM GLUCOSE-127* UREA N-14 CREAT-0.7 SODIUM-139 POTASSIUM-4.2 CHLORIDE-102 TOTAL CO2-25 ANION GAP-16 [**2124-3-13**] 10:45AM ALT(SGPT)-24 AST(SGOT)-21 LD(LDH)-311* CK(CPK)-40 ALK PHOS-111 AMYLASE-65 TOT BILI-0.3 [**2124-3-13**] 10:45AM LIPASE-42 GGT-44 [**2124-3-13**] 10:45AM CK-MB-2 cTropnT-<0.01 [**2124-3-13**] 10:45AM TOT PROT-6.2* ALBUMIN-3.5 GLOBULIN-2.7 CALCIUM-9.0 PHOSPHATE-4.0 MAGNESIUM-2.1 [**2124-3-13**] 10:45AM TSH-4.7* [**2124-3-13**] 10:45AM FREE T4-1.5 [**2124-3-13**] 10:45AM CORTISOL-12.4 [**2124-3-13**] 10:45AM WBC-18.2*# RBC-5.20 HGB-13.3* HCT-41.4 MCV-80* MCH-25.7* MCHC-32.2 RDW-17.4* [**2124-3-13**] 10:45AM PLT SMR-NORMAL PLT COUNT-396# Brief Hospital Course: The patient was briefly admitted to the medical oncology service. He was treated with diltiazem 10mg IV push x 4, and IV lopressor 10mg x 1. His systolic BP fell to 80; he was bolused 1L NS, and placed in trendelenberg with improvement in SBP 100s. He was asymptomatic throughout. He was transferred to the [**Hospital Unit Name 153**] for closer monitoring. In [**Hospital Unit Name 153**], he was given IV digoxin and IV esmolol without effect. The following morning he spontaneously converted to sinus rhythm. Later that day he developed SVT, likely AVNRT, given adenosine which converted to sinus rhythm. Later, he went back into SVT, and again broke with vagal. EP was consulted. They suggested metoprolol and verapamil, did not recommend EP study or ablation. CTA was perfomed and showed no new PE. . The patient was started on PO verapamil and metoprolol. He was monitored overnight and remained in sinus rhythm, therefore was discharged home on this regimen. Medications on Admission: Vit C QD Multivitamin 1 tablet QD Tylenol OTC PRN for pain/discomfort Percocet [**1-11**] every 6 hrs for pain** [**2123-12-31**] Celexa 20mg po Daily XL per protocol Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Verapamil 80 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours). Tablet(s) 3. Verapamil 240 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO once a day. [**Month/Day/Year **]:*30 Tablet Sustained Release(s)* Refills:*2* 4. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. [**Month/Day/Year **]:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Atrial Flutter. Metastatic Papillary Renal Cell Ca Discharge Condition: Hemodynamically stable, normal sinus rhythm, symptom free Discharge Instructions: During this admission you were treated for atrial flutter. Two new medications were started. Please continue to take all medications as prescribed. Please seek immediate medical care if you develop chest pain, palpatations, rapid heart rate, or any other concerning symptoms. Followup Instructions: Follow up with your oncologist, Dr [**First Name (STitle) **], on [**2124-3-27**]. Please call for an appointment.

[ "198.89", "197.0", "196.2", "189.0", "427.32", "530.81" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

5882, 5888

4165, 5138

331, 338

5983, 6043

3397, 4142

6370, 6489

2899, 2970

5356, 5859

5909, 5962

5164, 5333

6067, 6347

2985, 3378

277, 293

366, 1409

1431, 2544

2560, 2883

25,217

126,868

5746

Discharge summary

report

Admission Date: [**2169-9-21**] Discharge Date: [**2169-10-6**] Date of Birth: [**2117-3-1**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 949**] Chief Complaint: dislodged G-tube, fever/malaise, now tx'd back from unit after resolution of oversedation s/p ativan Major Surgical or Invasive Procedure: none History of Present Illness: 52 yo M with EtOH induced cirrhosis and chronic Hepatitis C s/p liver transplant x 2 (first on [**2169-2-25**], then repeated [**2169-5-28**] after graft failure from rejection/ Hep C activation), complicated by hepatic artery stenosis who was admitted [**2169-9-21**] with fever, abdominal pain, malaise and nausea X 1 week. The pt states that he has been having worsening malaise with fevers to 101 X 1 week. Has had acute on chronic abd pain, diffuse with RUQ focus, w/worsening nausea. No vomiting/diarrhea. No stool changes. No dysuria. No headache. Denies CP, +mild SOB, no cough. . In [**Name (NI) **] pt febrile to 101, VS o/w stable. Pt received Ceftriaxone 2 gm X1. CT abd/pelvis demonstrated mild intrahepatic biliary dilatation; patency of major vessels; bilbasilar opacities, atelectasis vs infection; ascites, anasarca. U/S demonstrated small amount of ascites, not enough to tap. Tx surgery re-advanced G-tube and secured. . It was felt that the interferon was causing his fever, malaise and nausea. He was diagnosed with pneumonia on CXR so started on levofloxacin. He continued to have nausea so was given several antiemetics and a large dose of ativan 2 mg IV on [**9-23**] and was transferred to the unit for decreased responsiveness and was monitored overnight. He did well after the ativan wore off and is stable to return to floors. Currently, he complains of diffuse abdominal pain worst in the periumbilical region only slightly worse than baseline. He reports that it is worse w/eating. He has noticed that his stool has been lighter than usual and that his urine is darker than usual. Also endorses that he looks more jaundiced than baseline. He does report that he is passing flatus and having stools. Denies melena/BRBPR, dysuria/frequency/urgency. Denies CP/SOB. Past Medical History: - Chronic Hepatitis C - EtOH cirrhosis - s/p 2 liver transplants, the first performed on [**2169-2-25**], and the second performed on [**2169-5-28**], likely because of graft loss secondary to hepatitis C - hepatic artery stenosis, s/p stenting on [**7-18**] (placed on ASA and Plavix) - h/o varices in [**2162**] - h/o ascites and encephalopathy - depression - Diabetes mellitus, Type 2 - chronic pain, controlled with methadone - J tube in place - gets tube feeds for supplemental nutrition (promote with fiber) Social History: Per prior d/c summary, patient is separated, lives with his sister. [**Name (NI) **] has 3 grown children. Smoked until 1 year ago about 20-pack year history. Patient has a history of alcohol abuse, drank heavily until 9 years ago when he quit. Reports one slip ~1.5 years ago, no EtOH since then, goes to AA. There is a history of IV drug in his 20s. +Tattoos. Family History: Father died of HCC [**1-26**] alcoholic cirrhosis Physical Exam: VS T 97.5 BP 98/66 HR 102 R 20 O2sat 93%RA wt 78.3kg GENERAL: A&Ox3, NAD, jaundiced HEENT: NCAT, icteric, + conjuncival pallor, EOMI NECK: no LAD, no JVD HEART: RR, nS1 s2, no m/r/g LUNGS: fine crackles to halfway up BL and decreased BS at bases ABDOMEN: well-healed chevron scar, mild diffuse tenderness worse in periumbilical region, +rebound tenderness, no rigidity/guarding. EXTREMETIES: 2+ pitting edema to knees b/l, 1+ DP pulses bilaterally SKIN: Jaundiced NEURO: No asterixis, moving all extremities . Pertinent Results: ABdominal x-ray [**2169-10-3**]: Minimal opcification of a mid abdominal loop of small bowel, consistent with intraluminal position of J-tube.. . CT abdomen 10/6/06:1. Stable appearance of post-transplant liver compared to previous study. No focal collections of fluid are seen within the liver. 2. Increased amount of ascites, anasarca, as well as an increase in the left-sided pleural effusion. . [**2169-9-20**] 05:15PM PT-17.0* PTT-31.0 INR(PT)-1.6* [**2169-9-20**] 05:15PM HYPOCHROM-1+ ANISOCYT-3+ POIKILOCY-3+ MACROCYT-2+ MICROCYT-1+ POLYCHROM-OCCASIONAL SPHEROCYT-OCCASIONAL OVALOCYT-2+ TARGET-OCCASIONAL SCHISTOCY-1+ BURR-1+ PENCIL-OCCASIONAL TEARDROP-2+ BITE-OCCASIONAL [**2169-9-20**] 05:15PM NEUTS-59 BANDS-6* LYMPHS-22 MONOS-11 EOS-1 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 [**2169-9-20**] 05:15PM WBC-3.6* RBC-3.42* HGB-11.0* HCT-33.4* MCV-98 MCH-32.1* MCHC-32.9 RDW-23.3* [**2169-9-20**] 05:15PM TOT PROT-4.2* ALBUMIN-2.7* GLOBULIN-1.5* CALCIUM-7.8* PHOSPHATE-3.0 MAGNESIUM-2.1 [**2169-9-20**] 05:15PM LIPASE-24 [**2169-9-20**] 05:15PM ALT(SGPT)-52* AST(SGOT)-191* LD(LDH)-722* ALK PHOS-594* AMYLASE-12 TOT BILI-24.3* [**2169-9-20**] 05:15PM GLUCOSE-152* UREA N-13 CREAT-0.4* SODIUM-131* POTASSIUM-5.5* CHLORIDE-101 TOTAL CO2-20* ANION GAP-16 [**2169-9-20**] 05:29PM LACTATE-2.6* [**2169-9-21**] 06:05AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-LG UROBILNGN-8* PH-7.0 LEUK-TR [**2169-9-21**] 06:05AM PT-19.2* PTT-36.1* INR(PT)-1.8* [**2169-9-21**] 06:05AM HYPOCHROM-3+ ANISOCYT-3+ POIKILOCY-3+ MACROCYT-3+ MICROCYT-1+ POLYCHROM-OCCASIONAL SPHEROCYT-OCCASIONAL OVALOCYT-2+ SCHISTOCY-2+ BURR-OCCASIONAL TEARDROP-2+ BITE-OCCASIONAL [**2169-9-21**] 06:05AM NEUTS-81* BANDS-4 LYMPHS-6* MONOS-8 EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 [**2169-9-21**] 06:05AM ALBUMIN-2.3* CALCIUM-7.7* PHOSPHATE-3.2 MAGNESIUM-2.0 [**2169-9-21**] 06:05AM WBC-3.9* RBC-3.39* HGB-11.0* HCT-34.0* MCV-100* MCH-32.4* MCHC-32.3 RDW-23.3* [**2169-9-21**] 06:05AM ALT(SGPT)-47* AST(SGOT)-142* LD(LDH)-298* ALK PHOS-552* AMYLASE-11 TOT BILI-22.4* [**2169-9-21**] 06:05AM GLUCOSE-78 UREA N-10 CREAT-0.7 SODIUM-133 POTASSIUM-4.1 CHLORIDE-102 TOTAL CO2-22 ANION GAP-13 [**2169-9-21**] 05:10PM FK506-7.8 Brief Hospital Course: A/P: 52 yo M h/o hepatitis C, ETOH cirrhosis, s/p liver tx X2 p/w G-tube dislodged, now replaced, and fever/malaise, s/p transient decreased responsiveness secondary to ativan, stable upon return to floor, now with FTT. . # Interferon therapy: probable cause of low grade fever/malaise/abdominal pain/failure to thrive- ## Fever: most likely drug fever, but ?infiltrate on admission CXR; continued presumptive tx as CAP with levofloxacin, course complete, but continued ABx therapy for SBP prophylaxis. ## abdominal pain- probable [**1-26**] baseline hepatic failure, increased distention and discomfort w/tube feeds, LFT's stable/improved through hospital course. Day prior to d/c home, d/w nutrition- decreased rate and extended length of time for tube feeds which pt tolerated much better. Continued supportive care including Simethicone/antiemetics, started lasix for ascites, held on aldactone for now b/c pt on Prograf. . # elevated LFTs, s/p transplant: initially rising bilirubin/alt/ast, peaked HD4, then trended down for the rest of his hospital course. Pt was not encephalopathic during this admission; CMV [**2169-9-26**] negative; continued Mycophenolate 250 [**Hospital1 **], tacrolimus(goal [**5-3**])-last trough [**2169-10-6**] low at 3.8- pt's dose of Tacrolimus was increased to 0.5mg [**Hospital1 **] from once daily; lactulose, ursodiol, ribavirin, and interferon continue throughout hospital course. . # hep C: viral load([**2169-9-26**]) 1.96mil Iu/mL decreased since starting interferon/ribavirin therapy; maintained on ribavirin and IFN throughout hospital course. # pancytopenia: Leukocytopenia secondary to interferon/marrow suppression in the context of chronic disease and possible splenic sequestration in the context of liver disease. Thrombocytopenia likely secondary to interferon, liver disease. Anemia in the context of chronic disease, liver disease with splenomegaly and spur hemolysis. B12 and folate normal on last admission. All cell lines appear to be at baseline; continued filgastrim, Epo throughout hospitalization. . # s/p hepatic artery stent: continues to be patent, maintained on ASA, plavix. . # DM: Continued home dose regimen glargine with aspart sliding scale. . # Chronic pain: continued methadone, hydromorphone PRN. . # G tube- foley placed b/c of repeated loss of J tube placement, fluoro showed good placement; continued to successfully cycle tube feeds. pt will continue to use the foley as feeding tube on oupatient basis. # G tube- foley placed, fluoro showed good placement; continue to cycle tube feeds . # ppx: hep sc, pneumoboots, PPI, bowel regimen . # Full code Medications on Admission: meds: Ribavirin 400 mg QAM 200 mg QPM Epoetin Alfa 40,000 U qweek Ursodiol 300 mg Capsule TID Bactrim DS 80-400 mg qd Pantoprazole 40 mg Tablet qd Lactulose 30ml Q8H PRN stools [**1-27**]/day Clopidogrel 75 mg qd Aspirin 81 mg qd Docusate Sodium 100 mg [**Hospital1 **] Methadone 20 mg Tablet [**Hospital1 **] Insulin sliding scale Hydromorphone 2 mg PO Q4-6H PRN. Glargine 15U qhs Prochlorperazine 10 mg Q6H PRN Tacrolimus 0.5 mg Capsule [**Hospital1 **] Filgrastim 480 mcg QWEEK Bismuth Subg-Balsam-ZnOx-Resor Suppository QD PRN hemorrhoids. Interferon alfacon-1: 9 mcg qday Discharge Medications: 1. Wheelchair with elevated leg rests DX: End stage liver disease 2. 3 in 1 commode Dx: End stage liver disease 3. Ribavirin 200 mg Capsule Sig: Two (2) Capsule PO QAM (once a day (in the morning)). 4. Ribavirin 200 mg Capsule Sig: One (1) Capsule PO QPM (once a day (in the evening)). 5. Epoetin Alfa 10,000 unit/mL Solution Sig: One (1) Injection QMOWEFR (Monday -Wednesday-Friday). 6. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 7. Trimethoprim-Sulfamethoxazole 80-400 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 9. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day) as needed for encephalopathy. 10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. Filgrastim 480 mcg/1.6 mL Solution Sig: One (1) Injection QWEEK (). 14. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:*30 Tablet(s)* Refills:*2* 15. Interferon alfacon-1 30 mcg/mL Injectable Sig: One (1) Subcutaneous DAILY (Daily). 16. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 17. Mycophenolate Mofetil 250 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 18. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2H (every 2 hours) as needed. Disp:*10 Tablet(s)* Refills:*0* 19. Promethazine 25 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:*15 Tablet(s)* Refills:*0* 20. Simethicone 80 mg Tablet, Chewable Sig: 1.5 Tablet, Chewables PO QID (4 times a day) as needed for gas. Disp:*60 Tablet, Chewable(s)* Refills:*2* 21. Methadone 10 mg Tablet Sig: One (1) Tablet PO QPM (once a day (in the evening)). 22. Methadone 10 mg Tablet Sig: One (1) Tablet PO QAM (once a day (in the morning)). 23. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 24. Tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: failure to thrive s/p liver transplant recurrent HCV Discharge Condition: stable Discharge Instructions: Please weigh yourself every day, if you have increased weight, please call your primary care provider. [**Name10 (NameIs) 357**] call your primary care provider or present to the hospital if you have shortness of breath, increasing abdominal pain, chest pain, worsening fever/chills. Please take all of your medications as directed and follow up with your appointments. Followup Instructions: You have the following appointments: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2169-10-9**] 11:40 Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2169-10-18**] 8:20

[ "284.8", "V55.4", "250.00", "E933.1", "486", "996.82", "780.6", "070.54", "E878.0" ]

icd9cm

[ [ [] ] ]

[ "99.04", "96.6" ]

icd9pcs

[ [ [] ] ]

11533, 11582

6050, 8679

415, 421

11679, 11688

3779, 6027

12106, 12388

3181, 3232

9306, 11510

11603, 11658

8705, 9283

11712, 12083

3247, 3760

274, 377

449, 2243

2265, 2781

2797, 3165

24,671

191,460

9800

Discharge summary

report

Admission Date: [**2122-12-12**] Discharge Date: [**2122-12-17**] Date of Birth: [**2048-5-12**] Sex: F Service: MEDICINE Allergies: Codeine / Morphine / Lidocaine Attending:[**First Name3 (LF) 2698**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: s/p diagnostic cath s/p PCI with stenting of SVG graft to RCA History of Present Illness: 73 yo female with PMH CAD (s/p CABG '[**02**]) and PCI x 3 ([**2116**], [**2117**]) with stenting of SVG to LCx presents from OSH with substernal chest pain since [**2122-12-6**]. Pt had chest/epigastric discomfort on Sunday which seemed worse with food. Pain did not resolve. No radiation, SOB, nausea. . Pt seen in clinic on Thursday with persistent CP and found to have anterior ST depressions in V1-2 along with stable ST elevations inferiorly. Pt admitted to [**Location (un) **] [**Hospital **] hospital where chest pain was relieved with nitro drip, has been chest pain free since. . At [**Name (NI) 7145**], pt found to have positive troponin and negative CK, which coupled with EKG changes led to the diagnosis of NSTEMI. Sent to CCU here at [**Hospital1 18**] for potential cath. . Pt is currently without complaints: denies CP, SOB, DOE, PND . ROS negative for fever, chills, nausea, vomiting, diarrhea, abdominal pain. Past Medical History: Significant for CAD (s/p CABG '[**02**]; s/p PCIx3 '[**16**],'[**17**]) angina hypertension anxiety depression history of TIAs carotid endarterectomy bilateral spinal stenosis Social History: Denies tobacco, ETOH, drugs Family History: non-contributory Physical Exam: VS: afebrile, p67, 112/55, rr20, 98%2Lnc HEENT: PERRL, EOMI, MMM Neck: JVP~7cm Heart: RRR, nl s1 s2, 2/6 SEM Lungs: CTAB Abd: soft, NT, ND, +BS Groin: no bruits bilaterally Ext: no edema bilaterally, 2+ DP Neuro: CN2-12 intact, [**6-17**] upper and lower extremity strength Pertinent Results: [**2122-12-12**] 12:53PM WBC-5.1 RBC-3.37* HGB-10.0* HCT-29.0* MCV-86 MCH-29.7 MCHC-34.5 RDW-12.7 [**2122-12-12**] 12:53PM PLT COUNT-192 [**2122-12-12**] 12:53PM PT-13.6 PTT-53.9* INR(PT)-1.2 . [**2122-12-12**] 12:53PM GLUCOSE-135* UREA N-14 CREAT-1.0 SODIUM-138 POTASSIUM-3.8 CHLORIDE-101 TOTAL CO2-25 ANION GAP-16 [**2122-12-12**] 12:53PM CALCIUM-9.1 PHOSPHATE-3.9 MAGNESIUM-2.1 . [**2122-12-12**] 12:53PM CK(CPK)-40 [**2122-12-12**] 12:53PM CALCIUM-9.1 PHOSPHATE-3.9 MAGNESIUM-2.1 [**2122-12-12**] 10:48PM CK(CPK)-33 [**2122-12-12**] 10:48PM CK-MB-NotDone cTropnT-0.87* [**2122-12-13**] 02:56AM BLOOD CK(CPK)-30 [**2122-12-13**] 02:56AM BLOOD CK-MB-NotDone cTropnT-0.83* [**2122-12-13**] 04:25PM BLOOD CK(CPK)-22* [**2122-12-13**] 04:25PM BLOOD CK-MB-NotDone cTropnT-0.83* [**2122-12-14**] 06:30AM BLOOD CK(CPK)-21* [**2122-12-14**] 09:54PM BLOOD CK(CPK)-44 [**2122-12-15**] 04:50AM BLOOD CK(CPK)-67 [**2122-12-15**] 03:22PM BLOOD CK(CPK)-58 . [**12-12**]: EKG sinus brady with new ST depressions in V1-2 and old 1mm ST elevation in inferior leads. inferior q waves. anterior TW flattening. . Brief Hospital Course: 1. CAD: Pt admitted s/p NSTEMI with positive Tn and negative CK with new anterior ST depressions and old inferior ST elevations. On admission, pt was chest pain free. She was continued with medical management on ASA, heparin drip, integrillin drip, nitro drip, ezetimibe (lipid lowering [**Doctor Last Name 360**]), beta blocker, and ACEI. On the night of admission, pt developed 3 episodes of chest pain, each associated with hypertension. Each time the pt was given IV lopressor to lower blood pressure, sublingual nitro, and increase in nitro drip with resolution of chest pain. The second episode of chest pain was associated with ST depressions in anterolateral leads. Cardiology fellow was consulted and emergent cardiac cath was considered. After the third episode of chest pain, pt had slowly resolving chest pain on maximal dose of nitro drip. Pt was taken to emergent cath and found to have fully occluded native vessels and SVG grafts. The only vessel that was patent was her LIMA graft to LAD, which was stenosed 70% beyond the anastomosis. Left ventriculography found LVEF of 40% with inferior akinesis. CT surgery was consulted for potential CABG, however they felt that she was not a good surgical candidate given the high risk of the surgery with only one patent major artery. Pt was taken back to cardiac cath during which a cypher drug-eluding stent was placed in the SVG graft to the RCA. Pt had no post-procedure complications. Her medical management was optimized. Pt remained hemodynamically stable and chest pain free throughout the rest of the hospitalization. . 2. Pump: Pt was euvolemic on admission. Left ventriculography during cardiac cath found LVEF of 40% with inferior akinesis. . 3. Rhythm: No arrythmias were noted on telemetry. . 4. Hypertension: Pt's blood pressure was managed with beta blocker and ACE. She was given IV lopressor for transient episodes of hypertension associated with chest pain. . 5. Anemia: On admission, hct was 29. Hct decreased to 23 after the first cardiac cath. Pt was transfused 1 unit with hct bump to 29. Prior to discharge, pt was transfused for hct of 28, with hct bump to 31. . 6. Hx CVA/TIA: Stable with non-focal neuro exam on admission. Pt was continued on ASA. . 7. Hx depression and anxiety: Pt remained stable without any psych medications. . 8. Prophylaxis: Pt was given PPI and initially on heparin drip. Medications on Admission: lopressor 25 [**Hospital1 **] colace 100 [**Hospital1 **] iron 325 [**Hospital1 **] MVI Maalox 30cc q4-6h Zetia 10mg qd Zebeta 10mg qd Ativan prn Norvasc 2.5 qd Nitrostat Imdur 50 [**Hospital1 **] Dyazide 1 tab qd Zoloft 25 qd Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: NSTEMI Discharge Condition: Stable Discharge Instructions: If you develop chest pain or difficulty breathing, call your PCP or return to the emergency immediately Followup Instructions: follow-up with your primary care doctor (Dr. [**Last Name (STitle) 11679**], [**Telephone/Fax (1) 2394**]) follow-up with your cardiologist.

[ "996.72", "414.01", "V45.81", "401.9", "410.71", "428.0", "285.9" ]

icd9cm

[ [ [] ] ]

[ "36.07", "99.20", "37.22", "36.01", "88.53", "99.04", "88.55" ]

icd9pcs

[ [ [] ] ]

5717, 5796

3056, 5440

304, 367

5847, 5855

1916, 3033

6007, 6152

1589, 1607

5817, 5826

5466, 5694

5879, 5984

1622, 1897

254, 266

395, 1327

1349, 1528

1544, 1573

17,782

124,483

54494+54495

Discharge summary

report+report

Admission Date: [**2114-1-8**] Discharge Date: [**2114-1-12**] Date of Birth: [**2056-10-30**] Sex: F Service: O-MED HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old female with a history of morbid obesity, inflammatory breast cancer, status post chemotherapy, and cardiomyopathy with systolic and diastolic dysfunction who was sent to the Emergency Department from her primary care physician's office secondary to fevers and shortness of breath times two days. The patient states she awoke on the night prior to admission feeling very short of breath with fevers and chills. There was no chest pain or palpitations. No diaphoresis. She denies a cough. She is also complaining of pain in her left knee which is chronic and unchanged. In the Emergency Department, the patient was noted to have a temperature of 100.8 degrees Fahrenheit and was saturating 94% on 4 liters. She was treated with meter-dosed inhaler and nebulizers in addition to levofloxacin for a questionable left retrocardiac opacity on chest x-ray. Her subsequent temperature was 103.7 degrees Fahrenheit. Her blood pressure decreased from 159/86 on admission to Emergency Department to 99/69 when a Medical Intensive Care Unit evaluation was called. At that time, the patient was 100% nonrebreather. PAST MEDICAL HISTORY: 1. Morbid obesity. 2. Obstructive sleep apnea (on [**Hospital1 **]-level positive airway pressure). 3. Hypoventilation (on home oxygen). 4. Cardiomyopathy (with an ejection fraction of 30% and global right ventricular hypokinesis with a right ventricular ejection fraction of 32% on a Mobitz scan obtained in [**2113-11-15**]). 5. Inflammatory breast cancer diagnosed in [**2113-6-15**]. ERP negative. Bone scan in [**2113-6-15**] was negative. On Taxol and Herceptin. 6. History of abnormal Papanicolaou smear. 7. Hypertension. 8. Gastroesophageal reflux disease. 9. Depression. 10. Anemia. ALLERGIES: PENICILLIN (causes hives). MEDICATIONS ON ADMISSION: SOCIAL HISTORY: The patient is a rehabilitation resident. She quit tobacco 23 years ago. The patient denies alcohol or intravenous drug use. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination per Intensive Care Unit note on admission the patient's temperature was 97.4 degrees Fahrenheit, her blood pressure was 85/52, her heart rate was 92, her respiratory rate was 25, and her oxygen saturation was 98% on 4 liters. In general, the patient was morbidly obese. She spoke in short sentences. Head, eyes, ears, nose, and throat examination revealed the head was normocephalic and atraumatic. The pupils were equal, round, and reactive to light and accommodation. The oropharynx was clear. The mucous membranes were moist. The neck was supple. Chest revealed distant breath sounds. There were no wheezes. Cardiovascular examination revealed tachycardia. No murmurs, rubs, or gallops. There were distant heart sounds. The abdomen was obese, soft, nontender, and nondistended. There were positive bowel sounds. Extremity examination revealed 2+ pitting edema to the knees bilaterally. No palpable cords. Skin examination revealed left breast with erythema. No rashes were noted. PERTINENT LABORATORY VALUES ON PRESENTATION: Admission white blood cell count was 5.6 and her hematocrit was 32.7 (with 18% bands). D-dimer was greater than 10,000. Blood culture revealed no growth. Urine culture revealed no growth. Legionella antigen was negative. Alanine-aminotransferase was 15, aspartate aminotransferase was 15, alkaline phosphatase was 28, and her total bilirubin was 0.9. PERTINENT RADIOLOGY/IMAGING: Lower extremity noninvasive studies done on [**2114-1-10**] were negative for deep venous thrombosis bilaterally. A V/Q scan on [**1-10**] revealed perfusion only, no defect noted; however, limited secondary to body habitus. Admission chest x-ray revealed a left lower lobe consolidation; question congestive heart failure. An electrocardiogram revealed sinus tachycardia at a rate of 100. Normal axis. First-degree atrioventricular block. Left atrial enlargement. No ischemic changes. BRIEF SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The patient is a 57-year-old female with a history of inflammatory breast cancer admitted with shortness of breath, fever, and hypotension. The patient was initially admitted to the Medical Intensive Care Unit for probable sepsis; likely secondary to right upper lobe consolidation concerning for pneumonia. Negative workup for a pulmonary embolism; although suboptimal secondary to the patient's body habitus. 1. PNEUMONIA ISSUES: The patient was noted to have a left lower lobe consolidation on admission chest x-ray and received levofloxacin in the Emergency Department. The patient was continued on this antibiotic with a plan for a total of 10 days. The patient's white blood cell count decreased, and she remained afebrile on this regimen. 2. OBSTRUCTIVE SLEEP APNEA ISSUES: The patient was maintained on her home [**Hospital1 **]-level positive airway pressure with 3 liters oxygen. 3. HYPOTENSION ISSUES: The patient with an episode of hypotension while in the Emergency Department prompting a Medical Intensive Care Unit evaluation. The patient was thought to be possibly septic secondary to a presumed pneumonia. The patient was continued on levofloxacin and received intravenous fluids to support her blood pressure. Her blood pressure stabilized on this regimen, and the patient was able to be transferred out of the Medical Intensive Care Unit to the floor. 4. KNEE PAIN ISSUES: The patient was complaining of left knee pain with a history of past imaging in [**2113-6-15**] which revealed severe joint space narrowing and osteophyte formation consistent with degenerative changes, but no evidence of acute fracture. The patient's pain was managed with ibuprofen, and no further imaging was obtained during this admission. 5. BREAST CANCER ISSUES: The patient was receiving weekly Taxol and Herceptin. No treatment was administered during her admission. The patient's staging was limited secondary to her body habitus. Thus, it is unclear whether or not surgery will follow her medication treatment. DISCHARGE DIAGNOSES: Community-acquired pneumonia. CONDITION AT DISCHARGE: Condition on discharge was good. The patient was saturating well on room air. Knee pain controlled with scheduled ibuprofen. DISCHARGE STATUS: The patient was to be discharged to an extended care facility. MEDICATIONS ON DISCHARGE: 1. Fluoxetine 20 mg by mouth once per day. 2. Flovent 110-mcg inhaler 2 puffs inhaled twice per day. 3. Aspirin 325 mg by mouth once per day. 4. Albuterol inhaler 1 to 2 puffs inhaled q.6h. as needed. 5. Levofloxacin 500 mg by mouth once per day (times five days). 6. Ibuprofen 800 mg by mouth q.8h. (times five days). 7. Lactulose 30 mL by mouth q.8h. as needed (for constipation). 8. Colace 100 mg by mouth twice per day. 9. Senna one tablet by mouth twice per day as needed (for constipation). 10. Protonix 40 mg by mouth once per day. 11. Lisinopril 40 mg by mouth once per day. DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was instructed to follow up with Dr. [**First Name (STitle) **] for her next dose of chemotherapy on [**2114-1-19**]. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 16520**] Dictated By:[**Name8 (MD) 14337**] MEDQUIST36 D: [**2114-4-17**] 20:50 T: [**2114-4-19**] 20:22 JOB#: [**Job Number 111515**] Admission Date: [**2114-1-8**] Discharge Date: [**2114-1-12**] Date of Birth: [**2056-10-30**] Sex: F Service: O-MED HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old female with a history of morbid obesity, inflammatory breast cancer, status post chemotherapy, and cardiomyopathy with systolic and diastolic dysfunction who was sent to the Emergency Department from her primary care physician's office secondary to fevers and shortness of breath times two days. The patient states she awoke on the night prior to admission feeling very short of breath with fevers and chills. There was no chest pain or palpitations. No diaphoresis. She denies a cough. She is also complaining of pain in her left knee which is chronic and unchanged. In the Emergency Department, the patient was noted to have a temperature of 100.8 degrees Fahrenheit and was saturating 94% on 4 liters. She was treated with meter-dosed inhaler and nebulizers in addition to levofloxacin for a questionable left retrocardiac opacity on chest x-ray. Her subsequent temperature was 103.7 degrees Fahrenheit. Her blood pressure decreased from 159/86 on admission to Emergency Department to 99/69 when a Medical Intensive Care Unit evaluation was called. At that time, the patient was 100% nonrebreather. PAST MEDICAL HISTORY: 1. Morbid obesity. 2. Obstructive sleep apnea (on [**Hospital1 **]-level positive airway pressure). 3. Hypoventilation (on home oxygen). 4. Cardiomyopathy (with an ejection fraction of 30% and global right ventricular hypokinesis with a right ventricular ejection fraction of 32% on a Mobitz scan obtained in [**2113-11-15**]). 5. Inflammatory breast cancer diagnosed in [**2113-6-15**]. ERP negative. Bone scan in [**2113-6-15**] was negative. On Taxol and Herceptin. 6. History of abnormal Papanicolaou smear. 7. Hypertension. 8. Gastroesophageal reflux disease. 9. Depression. 10. Anemia. ALLERGIES: PENICILLIN (causes hives). MEDICATIONS ON ADMISSION: SOCIAL HISTORY: The patient is a rehabilitation resident. She quit tobacco 23 years ago. The patient denies alcohol or intravenous drug use. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination per Intensive Care Unit note on admission the patient's temperature was 97.4 degrees Fahrenheit, her blood pressure was 85/52, her heart rate was 92, her respiratory rate was 25, and her oxygen saturation was 98% on 4 liters. In general, the patient was morbidly obese. She spoke in short sentences. Head, eyes, ears, nose, and throat examination revealed the head was normocephalic and atraumatic. The pupils were equal, round, and reactive to light and accommodation. The oropharynx was clear. The mucous membranes were moist. The neck was supple. Chest revealed distant breath sounds. There were no wheezes. Cardiovascular examination revealed tachycardia. No murmurs, rubs, or gallops. There were distant heart sounds. The abdomen was obese, soft, nontender, and nondistended. There were positive bowel sounds. Extremity examination revealed 2+ pitting edema to the knees bilaterally. No palpable cords. Skin examination revealed left breast with erythema. No rashes were noted. PERTINENT LABORATORY VALUES ON PRESENTATION: Admission white blood cell count was 5.6 and her hematocrit was 32.7 (with 18% bands). D-dimer was greater than 10,000. Blood culture revealed no growth. Urine culture revealed no growth. Legionella antigen was negative. Alanine-aminotransferase was 15, aspartate aminotransferase was 15, alkaline phosphatase was 28, and her total bilirubin was 0.9. PERTINENT RADIOLOGY/IMAGING: Lower extremity noninvasive studies done on [**2114-1-10**] were negative for deep venous thrombosis bilaterally. A V/Q scan on [**1-10**] revealed perfusion only, no defect noted; however, limited secondary to body habitus. Admission chest x-ray revealed a left lower lobe consolidation; question congestive heart failure. An electrocardiogram revealed sinus tachycardia at a rate of 100. Normal axis. First-degree atrioventricular block. Left atrial enlargement. No ischemic changes. BRIEF SUMMARY OF HOSPITAL COURSE BY ISSUE/SYSTEM: The patient is a 57-year-old female with a history of inflammatory breast cancer admitted with shortness of breath, fever, and hypotension. The patient was initially admitted to the Medical Intensive Care Unit for probable sepsis; likely secondary to right upper lobe consolidation concerning for pneumonia. Negative workup for a pulmonary embolism; although suboptimal secondary to the patient's body habitus. 1. PNEUMONIA ISSUES: The patient was noted to have a left lower lobe consolidation on admission chest x-ray and received levofloxacin in the Emergency Department. The patient was continued on this antibiotic with a plan for a total of 10 days. The patient's white blood cell count decreased, and she remained afebrile on this regimen. 2. OBSTRUCTIVE SLEEP APNEA ISSUES: The patient was maintained on her home [**Hospital1 **]-level positive airway pressure with 3 liters oxygen. 3. HYPOTENSION ISSUES: The patient with an episode of hypotension while in the Emergency Department prompting a Medical Intensive Care Unit evaluation. The patient was thought to be possibly septic secondary to a presumed pneumonia. The patient was continued on levofloxacin and received intravenous fluids to support her blood pressure. Her blood pressure stabilized on this regimen, and the patient was able to be transferred out of the Medical Intensive Care Unit to the floor. 4. KNEE PAIN ISSUES: The patient was complaining of left knee pain with a history of past imaging in [**2113-6-15**] which revealed severe joint space narrowing and osteophyte formation consistent with degenerative changes, but no evidence of acute fracture. The patient's pain was managed with ibuprofen, and no further imaging was obtained during this admission. 5. BREAST CANCER ISSUES: The patient was receiving weekly Taxol and Herceptin. No treatment was administered during her admission. The patient's staging was limited secondary to her body habitus. Thus, it is unclear whether or not surgery will follow her medication treatment. DISCHARGE DIAGNOSES: Community-acquired pneumonia. CONDITION AT DISCHARGE: Condition on discharge was good. The patient was saturating well on room air. Knee pain controlled with scheduled ibuprofen. DISCHARGE STATUS: The patient was to be discharged to an extended care facility. MEDICATIONS ON DISCHARGE: 1. Fluoxetine 20 mg by mouth once per day. 2. Flovent 110-mcg inhaler 2 puffs inhaled twice per day. 3. Aspirin 325 mg by mouth once per day. 4. Albuterol inhaler 1 to 2 puffs inhaled q.6h. as needed. 5. Levofloxacin 500 mg by mouth once per day (times five days). 6. Ibuprofen 800 mg by mouth q.8h. (times five days). 7. Lactulose 30 mL by mouth q.8h. as needed (for constipation). 8. Colace 100 mg by mouth twice per day. 9. Senna one tablet by mouth twice per day as needed (for constipation). 10. Protonix 40 mg by mouth once per day. 11. Lisinopril 40 mg by mouth once per day. DISCHARGE INSTRUCTIONS/FOLLOWUP: The patient was instructed to follow up with Dr. [**First Name (STitle) **] for her next dose of chemotherapy on [**2114-1-19**]. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(1) 16520**] Dictated By:[**Name8 (MD) 14337**] MEDQUIST36 D: [**2114-4-17**] 20:50 T: [**2114-4-19**] 20:22 JOB#: [**Job Number 111516**]

[ "311", "401.9", "486", "425.4", "285.9", "493.90", "278.01", "174.9" ]

icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

13795, 13836

14088, 14691

9553, 9553

14726, 15089

11734, 13773

13851, 14061

7708, 8850

8873, 9526

9570, 11699

2,550

152,273

9388

Discharge summary

report

Admission Date: [**2158-12-23**] Discharge Date: [**2158-12-27**] Service: [**Last Name (un) **] ICU HISTORY OF PRESENT ILLNESS: Patient is an 86-year-old male with a history of coronary artery disease status post coronary artery bypass graft and a redo CABG in [**2143**] and then in [**2151**] with the left internal mammary artery graft to the left anterior descending, SUG to posterior descending artery and SUG to obtuse marginal along with multiple PCIs and a stent NCM and CCX times three with instant restenosis treated with brachy therapy. Patient stopped his aspirin and Plavix in [**7-/2158**] following stomach cancer and a partial gastrectomy. Patient reports he was in his usual state of health until the morning of admission when he developed bilateral upper extremity pain and substernal chest pain. No diaphoresis. No shortness of breath. No dyspnea on exertion. Patient went to the outside hospital where first set of enzymes showed CK of 257, MB 37, index 13.9, troponin I 8.19. EKG showed intermittently paced with native beats showing normal axis, [**Street Address(2) 4793**] elevations in 1, 2, and an inverted T in inferior leads. Patient was transferred to [**Hospital3 **] for catheterization. In the Catheterization Lab selected coronary angiography demonstrated a right dominant system with three-vessel coronary artery disease. The left main stent was patent. The left anterior descending was occluded distally. The left circumflex stents in the obtuse marginal 1 were patent. The distal left circumflex had a 70% lesion. The right coronary artery was noted to be occluded and was not injected. Left to right collaterals supplied the right posterior descending artery. The saphenous vein graft to the obtuse marginal was patent. Saphenous vein graft to the right posterior descending artery was occluded proximally with extensive thrombus. The left internal mammary artery graft to the left anterior descending was known to be patent on [**4-/2158**] and was not injected. Left ventriculography was not performed. The thrombotic occlusion in the proximal SVG to the right posterior descending artery was successfully treated by rheolytic thrombectomy, angioplasty and stenting. The mid SVG was stented using a Hepacoat stent as is the distal SVG. Final angiography revealed no residual stenosis within the stent. Patient was admitted to the Cardiac Intensive Care Unit. PAST MEDICAL HISTORY: 1. Hypercholesterolemia. 2. Hypertension. 3. Coronary artery bypass graft times two. 4. Status post pacemaker. 5. Chronic renal insufficiency with a baseline creatinine of 1.8 status post nephrectomy. 6. Peripheral vascular disease of the left iliac stent. 7. Carotid endarterectomy bilaterally. 8. History of cerebrovascular accident. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: Patient is a retired policeman. He is married. He quit smoking in [**2118**]. Denies any alcohol or additional drug use. HOME MEDICATIONS: 1. Zestril. 2. Toprol. 3. Temazepam. 4. Sucralfate. 5. Aciphex. 6. Compazine. 7. Reglan. PHYSICAL EXAMINATION ON ADMISSION: Heart rate 67 and paced, blood pressure 130/58, respiratory rate 16, 100% on room air. In general, patient is in no acute distress. Mucous membranes are moist. Gums, palate, mucosa are within normal limits. No jugular venous distention. No thyroid is palpated. Respiratory: Clear to auscultation; multiple surgical wounds are noted. Cardiovascular exam: Rhythm is regular; normal S1, S2; no S3, no S4; there is a holosystolic III/VI murmur. Abdominal exam: Soft, nontender, nondistended. Extremities: No edema as noted. Patient has 2+ posterior tibial pulses. Skin: No rashes present. LABORATORY DATA: EKG on admission: LVH with strain, normal axis, interim immediately paced, 1 to [**Street Address(2) 1766**] elevations in II and III, Q waves in II, III, and aVF, ST depressions in V2 through V6 with T-wave inversion. An echocardiogram from [**1-/2158**] shows an ejection fraction greater than 50%, mild pulmonary hypertension, TR gradient 29, moderate atrial regurgitation, mild mitral regurgitation, mild tricuspid regurgitation. Cardiac catheterization [**2157-12-23**]: As previously discussed. ASSESSMENT AND PLAN: This is an 86-year-old male with extensive history of coronary artery disease, including CABG and redo and multiple PCIs and stent placement presented from the outside hospital with acute, inferior, posterior ST elevation myocardial infarction. Catheterization Lab revealed thrombus and saphenous vein graft to the posterior descending artery with collaterals to the left circumflex. Patient was stented times two. Patient had TIMI 3 flow post stent placement. 1. Cardiovascular/coronary artery disease: Patient had two stents placed in the SVG to the posterior descending artery. He was placed on Aggrastat times 72 hours as well as Plavix, expected course of nine months. Patient was maintained on an aspirin, a statin, beta blocker. Liver function tests were checked. Cholesterol was 108, triglycerides 75, HDL 36, LDL 57. Patient was sent home on a statin. LFTs were within normal limits. Patient was followed with daily EKGs. He was started on a low-dose ACE inhibitor, and his beta blocker was changed to q.d. dosing prior to discharge. 2. Pump: Patient had a post myocardial infarction echo which demonstrated moderately dilated left atrium; left ventricular cavity size normal; moderate global left ventricular hypokinesis. Overall, left ventricular systolic function is moderately depressed, aortic root is mildly dilated; 1+ atrial regurgitation, 1+ mitral regurgitation. Ejection fraction of 40%. This was done on [**2158-11-24**]. Patient had a beta blocker tolerated and switched to q.d. dosing prior to discharge. Patient was started on an ACE inhibitor on [**2158-12-26**]. Although he had only one kidney, great care was taken to evaluate this effect on patient's renal function. Patient's creatinines will be discussed increased on first-day ACE inhibitor. Patient will be followed in outpatient for further management on ACE inhibitor. 3. Rhythm: Patient is AV paced, maintained on a beta blocker. On the evening of [**2158-12-25**] patient had 10 to 13 beats of NSVT, asymptomatic multiple times. Electrophysiology was consulted and recommended Holter monitoring in a few weeks as well as a follow-up echo with further follow up by Electrophysiology should these still show ectopy or cause for concern. 4. Renal: Patient is status post nephrectomy. Patient was maintained on two doses of Mucomyst following his cardiac catheterization. His creatinine and electrolytes were followed as described above. Patient was started on an ACE inhibitor with caution as he has a single kidney. Patient's creatinine increased from 1.4 to 1.6 following one day on ACE inhibitor therapy. Patient will be discharged and followed as an outpatient in two days and the monitoring of his electrolytes and creatinine for further management of ACE inhibitor use. 5. Heme: Patient had stable hematuria, thrombocytopenia secondary to his known mild dysplastic syndrome. Patient was transfused on [**2158-12-24**] one unit with a hematocrit of 28. Hematocrit responded appropriately and was 34, trended down to 33 prior to patient's discharge. 6. FENGI: Patient was maintained on a proton pump inhibitor and had nutrition counseling for a cardiac diet. DISPOSITION: Discharged home. Patient worked with Physical Therapy and was ambulating well prior to his discharge home. FINAL DIAGNOSES: 1. Acute myocardial infarction. 2. Coronary artery disease status post coronary artery bypass graft times two. 3. Chronic renal insufficiency. 4. Hypertension. 5. Hyperlipidemia. 6. Status post nephrectomy. 7. Status post partial gastrectomy. 8. Congestive heart failure with ejection fraction of 40%. 9. Cardiac catheterization with stenting of the saphenous vein graft to the posterior descending artery with two stents on [**2158-12-23**]. DISCHARGE INSTRUCTIONS: 1. Patient will follow with Dr. [**Last Name (STitle) 11493**] [**2159-1-2**], 9:30 a.m. He will get a referral for the Holter monitor and echo study at that time. 2. Patient will follow at Dr.[**Name (NI) 27809**] office for lab monitoring two to three days post discharge. 3. The patient has an appointment [**2159-1-10**] at the Holter Lab for Holter placement. 4. Patient is given the number to arrange a cardiac echo in four weeks. DISCHARGE CONDITION: Patient is walking well, working with Physical Therapy, taking POs, instructed on a cardiac diet, started on ACE inhibitor. DISCHARGE MEDICATIONS: 1. Aspirin 325. 2. Plavix 75 q.d. times nine months. 3. Acetaminophen. 4. Docusate 100 b.i.d. 5. Protonix 40 q.d. 6. Senna p.r.n. 7. Sucralfate, one tablet, p.o. q.i.d. 8. Lisinopril 5, take half tablet p.o. q.d. 9. Metoprolol 100 q.d. 10. Atorvastatin 10 q.d. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7169**] Dictated By:[**Last Name (NamePattern1) 5713**] MEDQUIST36 D: [**2158-12-28**] 14:06 T: [**2158-12-28**] 18:04 JOB#: [**Job Number 32063**]

[ "401.9", "V45.01", "414.02", "287.5", "V45.81", "272.0", "410.31", "593.9", "414.01" ]

icd9cm

[ [ [] ] ]

[ "88.56", "36.01", "36.06", "99.04", "37.22" ]

icd9pcs

[ [ [] ] ]

8541, 8666

2815, 2833

8689, 9254

8077, 8519

2993, 3111

7600, 8053

140, 2431

3764, 7583

2453, 2798

2850, 2975

30,089

136,556

17384

Discharge summary

report

Admission Date: [**2114-3-24**] Discharge Date: [**2114-3-26**] Service: MEDICINE Allergies: Glipizide Attending:[**First Name3 (LF) 2751**] Chief Complaint: Agitation Major Surgical or Invasive Procedure: None History of Present Illness: [**Age over 90 **] year old male from [**Hospital 100**] Rehab, dementia at baseline, transferred for worsening agitation. Patient has progressive dementia and has been declining rapidly in the past several weeks. PCP drew labs yesterday. Found to have WBC 16, and Cr 1.7 (baseline 0.8). Initial ED VS 98.2, 124, 145/77, 24 and 97/RA. Ultimately in ED was febrile 101.2, HR 125. Abdominal exam notable for TTP, unable to relay more historical details (baseline). Given 2L NS with improved HR control, now in the 90s. Also with recent poor glucose control, recently in 400s at NH. Given 10U Regular, 12U Humalog. No anion gap and no ketones in urine. CT abdomen preliminarily negative for acute process. Given for Vanc 1g/Zosyn 4.5gm for ?GI source (pre-CT). Also given Tylenol 1gm PR, UA notable for bacteria, pyuria. CXR negative, blood and urine cx pending. 20g IV x2. Past Medical History: 1. CAD s/p CABG, 2. Type 2 DM 3. Alzheimer-type dementia 4. Macular degeneration 5. S/p prostatectomy 6. S/p hernia repair Social History: Resident of [**Hospital 100**] Rehab. Originally from [**State 531**]. Rabbi with law degree. Family History: Not contributory. Physical Exam: VS: T 98.7, BP 126/72, HR 74, RR 19, O2 98%4L Gen: Elderly man lying in bed. Alert, oriented to person only. Says he doesnt know where he is. HEENT: PERRL, EOMI, dry mucus membranes, poor dentition Neck: Supple with JVP of 8 cm. CV: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. No S4, no S3. Chest: CTAB, no crackles Abd: No abdominal pain. NABS Ext: No c/c/e. No femoral bruits. Skin: No stasis dermatitis, ulcers, scars, or xanthomas. Pulses: Right: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Left: Carotid 2+ without bruit; Femoral 2+ without bruit; 2+ DP Pertinent Results: [**2114-3-24**] 04:25PM PLT SMR-NORMAL PLT COUNT-344 [**2114-3-24**] 04:25PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2114-3-24**] 04:25PM NEUTS-83* BANDS-2 LYMPHS-9* MONOS-4 EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-1* [**2114-3-24**] 04:25PM WBC-14.5*# RBC-4.81# HGB-13.8*# HCT-44.6# MCV-93 MCH-28.8 MCHC-31.0 RDW-13.5 [**2114-3-24**] 04:25PM CALCIUM-10.4* [**2114-3-24**] 04:25PM CK-MB-3 cTropnT-0.04* [**2114-3-24**] 04:25PM LIPASE-44 [**2114-3-24**] 04:25PM ALT(SGPT)-82* AST(SGOT)-162* CK(CPK)-208 ALK PHOS-99 TOT BILI-0.4 [**2114-3-24**] 04:25PM estGFR-Using this [**2114-3-24**] 04:25PM GLUCOSE-520* UREA N-71* CREAT-2.5*# SODIUM-144 POTASSIUM-9.5* CHLORIDE-108 TOTAL CO2-23 ANION GAP-23* [**2114-3-24**] 04:28PM GLUCOSE-463* LACTATE-5.0* K+-5.6* [**2114-3-24**] 04:55PM URINE RBC->50 WBC->50 BACTERIA-OCC YEAST-NONE EPI-[**4-6**] [**2114-3-24**] 04:55PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-75 GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-MOD [**2114-3-24**] 04:55PM URINE COLOR-Yellow APPEAR-Cloudy SP [**Last Name (un) 155**]-1.024 [**2114-3-24**] 06:50PM GLUCOSE-426* LACTATE-3.7* K+-5.0 [**2114-3-26**] 01:30AM BLOOD WBC-11.8* RBC-3.85* Hgb-11.4* Hct-35.6* MCV-93 MCH-29.7 MCHC-32.1 RDW-13.3 Plt Ct-257 [**2114-3-26**] 10:00AM BLOOD Na-141 K-3.7 Cl-108 [**2114-3-26**] 01:30AM BLOOD Glucose-116* UreaN-25* Creat-0.9 Na-146* K-3.7 Cl-113* HCO3-24 AnGap-13 [**2114-3-24**] 4:55 pm URINE Site: CATHETER **FINAL REPORT [**2114-3-26**]** URINE CULTURE (Final [**2114-3-26**]): PROTEUS MIRABILIS. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PROTEUS MIRABILIS | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 4 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ 2 S TRIMETHOPRIM/SULFA---- =>16 R Brief Hospital Course: [**Age over 90 **] yo M with CAD, DMII, dementia presents from nursing home with acute renal failure, leukocytosis, and hypoactive dementia, febrile in ED and with UA c/w UTI. . # Acute Renal Failure: Consistent w/ prerenal azotemia secondary to decreased PO intake. Resolved with ivfs. . # UTI: Patient presented w/ leukocytosis and fevers. CT abdomen/pelvis w/o abcess, but air in bladder likely secondary to UTI. Patient started on cipro for treatment of Proteus mirabilis UTI, but sensitivities showed resistance so changed to Cefpodoxime which was sensitive to. . # Delerium: Secondary to infection (see above). Improved with treatment . # Hyperglycemia / Diabetes: Likely [**3-6**] infectious process. No evidence of DKA or HONK. Patient maintained on lantus, moved to 20units from 26U, and a sliding scale. . # ST depressions on ECG: Demand ischemia in the setting of infection with troponin leak. CE trended and did not rise. Have noted for [**Hospital 100**] rehab to see about putting on beta blockade, aceihibitor, statin if these have not otherwise been intentionally omitted. . # CHF: Patient monitored clinically while receiving ivfs. Not on ACE, though may have been omitted intentionally by rehab. HAve asked daughter to corroborate with them, and [**Hospital 48630**] rehab to corroborate with daaughter to determine need to go back on these. If no other known contraindications, should be on low dose beta blocker, ace inhibitor, and a statin as tolerated. . # Hypoactive Dementia/Agitation Per report, not oriented at baseline, now even less responsive over last two weeks. Was on seroquel and ativan. Seroquel d/c'd at NH. Ativan held. . # GERD --cont home pepcid Patient DNR/DNI HCP = daughter [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 48631**] Medications on Admission: pepcid 20 daily ativan 0.125 hs prn aspirin 325 daily tylenolol 325 prn NGL prn lantus 26 hs Discharge Medications: 1. Insulin Glargine 100 unit/mL Cartridge Sig: Twenty (20) Units Subcutaneous at bedtime. 2. Insulin Regular Human 100 unit/mL Cartridge Sig: sliding scale Injection every six (6) hours: for FS ____ give ___ units Humalog: 151-200; 2U 201-250; 4U 251-300; 6U 301-350; 8U 351-400; 10U >400 [**Name8 (MD) 138**] MD on call <70 [**Name8 (MD) 138**] MD on call. 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 5. Nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Sublingual q 5min x 3 as needed for chest pain. 6. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO twice a day as needed for pain. 7. Clotrimazole 1 % Cream Sig: One (1) application Topical twice a day. 8. Cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 12 days. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - LTC Discharge Diagnosis: Urinart Tract Infection - + Proteus Delerium Acute Renal Failure Hypernatremia Discharge Condition: Mental Status:Confused - always Level of Consciousness:Alert and interactive Activity Status:Out of Bed with assistance to chair or wheelchair Discharge Instructions: You were admitted with agitation/delerium secondary to UTI. You were treated with IV and then oral antibiotics for Proteus mirabilis UTI. You had acute renal failure and high sodium, which improved with IV fluids and antibiotics. Followup Instructions: [**Hospital 100**] Rehab doctor to see on admission to [**Hospital **] rehab. Please see additional orders on Page 1 referral about medication reconcilitation with daughter (HCP). She could not answer why pt not on cardiac regimen.

[ "041.6", "428.22", "599.0", "V45.81", "428.0", "293.0", "584.9", "331.0", "276.0", "294.10", "414.00", "250.00", "530.81" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

7171, 7236

4390, 6178

227, 233

7359, 7359

2072, 4367

7782, 8019

1411, 1430

6321, 7148

7257, 7338

6204, 6298

7528, 7759

1445, 2053

178, 189

261, 1134

7373, 7504

1156, 1281

1297, 1395

26,412

112,187

10342

Discharge summary

report

Admission Date: [**2116-2-19**] Discharge Date: [**2116-2-27**] Date of Birth: [**2055-5-29**] Sex: F Service: MEDICINE ICU HISTORY OF PRESENT ILLNESS: This is a 60 year old woman with a history of end stage renal disease secondary to polycystic kidney disease on hemodialysis, also with chronic obstructive pulmonary disease, coronary artery disease, pneumonia, congestive heart failure, atrial fibrillation, and recurrent line sepsis, who was transferred from [**Hospital3 10377**] Hospital to [**Hospital1 69**] for percutaneous endoscopic gastrostomy tube placement. On arrival to the surgery floor, she was found to have a blood pressure of around 60 to 80 over 30 to 50 with an altered mental status. She was then transferred to the Medical Intensive Care Unit for further monitoring and treatment. The patient was initially admitted to [**Hospital3 10377**] Hospital on [**2116-1-24**], from [**Hospital3 **] [**Hospital **] Hospital with suspicion of line sepsis. She had been febrile and had her permacath removed that same day. The catheter was placed in her right groin and then her left groin temporarily. She then had a permacath placed in her left subclavian on [**2116-2-7**]. Culture data showed coagulase negative Staphylococcus in blood cultures from [**2116-1-11**], gram positive cocci in clusters from [**2116-1-21**], in a blood culture, and Serratia marcescens sensitive to Amikacin, Imipenem, Bactrim, and Levofloxacin from a right femoral line on [**2116-2-1**], and finally coagulase negative Staphylococcus on blood cultures from [**2116-2-6**]. She was treated with Amikacin and Linezolid between [**2116-2-2**], and [**2116-2-16**]. She was also seen by neurology for an altered mental status. It was believed that her altered mental status was due to a metabolic encephalopathy. This was determined by an electroencephalogram on [**2116-12-19**], and [**2116-1-24**], as well as a magnetic resonance scan which was reportedly negative. Because she was somnolent and had difficulty eating, it was believed that she may be at serious risk for aspiration. Gastroenterology consultation was obtained for percutaneous endoscopic gastrostomy tube placement as her nutritional status was poor as evidenced by an albumin of 1.8. The outside records document that she is DNI. After being transferred to the [**Hospital1 188**] Medial Intensive Care Unit, a left femoral arterial line and right femoral central venous catheter were placed. She was given approximately three liters of normal saline which did not improve her hypotension or mental status. She was then started on Levophed, which subsequently improved the above. An arterial blood gas was obtained while on ten liters face mask and that revealed the following values: 7.26/56/109. Because she was DNI, a trial of BiPAP was performed and she was not intubated. However, this was discontinued because she could not tolerate BiPAP secondary to discomfort while wearing the mask. PAST MEDICAL HISTORY: 1. End stage renal disease on hemodialysis three times a week secondary to polycystic kidney disease. 2. Chronic obstructive pulmonary disease. 3. Cerebrovascular accident. 4. Pneumonia. 5. Intractable diarrhea history. 6. Status post cholecystectomy. 7. Status post appendectomy. 8. Hypertension. 9. Recurrent sepsis secondary to line infections. 10. Compression fracture of the lumbar spine. 11. Atrial fibrillation with rapid ventricular rate, on Coumadin. 12. Congestive heart failure. 13. Oxacillin resistant Staphylococcus aureus. 14. Coronary artery disease. 15. Anemia. ALLERGIES: 1. Vancomycin causes redman syndrome. 2. Hycodone, unknown allergy. 3. Levofloxacin, unknown allergy. 4. Penicillin causes anaphylaxis. 5. Quinidine, unknown reaction. 6. Sulfa drugs cause anaphylactic reaction. 7. Opiates, unknown reaction. MEDICATIONS AT OUTSIDE HOSPITAL: 1. Digoxin 0.125 mg q.Monday, Wednesday and Friday. 2. Advair Discus 250/50 one puff twice a day. 3. Prevacid. 4. Lactulose. 5. Linezolid. 6. Nephrocaps. 7. Pericolace. 8. Digoxin. 9. Dicacodyl. 10. Epoetin. 11. Amikacin. 12. Coumadin. FAMILY HISTORY: Not obtained. SOCIAL HISTORY: The patient is married and lives with her husband and two daughters. She also has another daughter. She has no alcohol history. She smoked thirty-five plus years but stopped smoking three years ago. PHYSICAL EXAMINATION: Vital signs revealed a temperature 97.0, pulse 89, blood pressure 82/42, oxygen saturation 96% on ten liters cool nebulizer. In general, the patient is oriented times two in moderate respiratory distress. Head, eyes, ears, nose and throat examination - Mucous membranes are dry. No jugular venous distention. Cardiovascular is regular rate and rhythm, no murmurs, rubs or gallops. Distant heart sounds. Respiratory - Decreased breath sounds throughout, crackles at the left lung base greater than right, scattered wheezes. Abdomen reveals mild epigastric tenderness and no rebound, positive bowel sounds. Extremities - no cyanosis, clubbing or edema. LABORATORY DATA AND DIAGNOSTICS: On admission, electrocardiogram showed an atrial fibrillation at a rate of 66 beats per minute and normal axis, Q wave in V1, diffuse T wave flattening and inversions in V4 and V5, but no change compared to that done at outside hospital. Chest x-ray revealed a right lower lobe opacity and a retrocardiac density. White blood cell count was 7.5, hematocrit 29.7, platelet count 162,000. INR 1.6, partial thromboplastin time 36.4. Normal chemistries with the exception of a potassium of 3.5, blood urea nitrogen 8 and creatinine of 3.0. Normal liver function tests. Cardiac enzymes revealed a CPK of 19, CK MB of 3.0 and a troponin of 0.5. The patient's magnesium level was low at 1.5. Her calcium was 7.9, phosphate was 3.5. The patient's blood gases on 100% nonrebreather mask were 7.29/57/113. ASSESSMENT AND PLAN: This is a 60 year old female with a history of end stage renal disease on hemodialysis, also with chronic obstructive pulmonary disease, and recurrent line infections, admitted to the outside hospital for treatment of permacath line infection. She was transferred to [**Hospital1 346**] for percutaneous endoscopic gastrostomy tube. On arrival, the patient was found to be hypertensive along with an arterial blood gas consistent with hypercarbic respiratory failure. She was admitted to the Medical Intensive Care Unit for aggressive treatment of her hypotension with pressor support, management of possible pulmonary edema, management of overwhelming sepsis, and monitoring of her electrolytes and mental status. HOSPITAL COURSE: The following is a summary of the [**Hospital 228**] hospital course by systems: 1. Respiratory - The patient was diagnosed with acute hypercarbic respiratory failure likely triggered by pneumonia, all this on top of a setting of chronic obstructive pulmonary disease. BiPAP was attempted at the time of hospitalization, however, the patient could not tolerate the mask. The patient was maintained on ten liters face mask during which her saturation was satisfactory. The patient remained tachypneic throughout her hospital stay. Serial chest x-rays continued to reveal bilateral pleural effusions and congestive heart failure. The patient continued to receive nebulizer treatments throughout her hospital stay for her chronic obstructive pulmonary disease. She was continued on her face mask for noninvasive ventilation, and towards the end of her hospital stay, she was switched to BiPAP which she, unlike during the beginning of her hospital stay, began to tolerate. She was treated for possible pneumonia, the treatment of which is further delineated under the infectious disease section. She received respiratory therapy in the form of nebulizer treatments and chest physical therapy and suctioning throughout her hospital stay. The patient's wish to remain DNI was honored throughout her hospital stay. When the patient was made comfort measures only, she was taken off her BiPAP and once again placed on a comfortable Venturi mask. Respiratory cultures were obtained in the form of sputum samples and these ended up growing 4+ gram negative rods, which lead to a change in her antibiotic regimen as described in the infectious disease section. 2. Infectious disease - The patient was diagnosed with presumed sepsis, the most likely cause being one of her lines, although a chest x-ray suggesting pneumonia could also point to a culprit. The patient underwent a sepsis workup which included CT and magnetic resonance scan of the lumbar spine to rule out osteomyelitis, CT of the brain to rule out an abscess, serial chest x-rays which showed continued pulmonary processes which may be suggestive of pneumonia, multiple blood cultures including blood cultures positive for gram positive cocci later identified as coagulase negative Staphylococcus, CT of the abdomen to rule out abdominal abscess or colitis. The patient's antibiotic regimen was carefully chosen in light of the patient's multiple drug allergies. At first, she was started on broad spectrum antibiotics consisting of Linezolid, Imipenem, and Flagyl. This was then changed to Amikacin, Vancomycin, and Flagyl. When no gram negative culture data had been obtained after a few days, her Amikacin and Flagyl were discontinued and she was continued on Vancomycin. She had levels of Vancomycin that were therapeutic throughout her hospital stay. When gram negative rods were discovered in her sputum culture towards the end of her hospital stay, the Amikacin was restarted. When the patient was made comfort measures only, the patient was taken off all antibiotics. 3. Cardiovascular - The patient had hypotension for which she required pressor support consisting of Vasopressin and Levophed throughout her hospital stay. With these, we were able to maintain her MAP greater than 70 throughout her hospital stay. The patient was initially started on Digoxin, but this medication was discontinued after an echocardiogram was performed which showed no signs of heart failure. She did, however, have multiple x-rays which revealed pulmonary edema. The patient's Coumadin was held in light of possible need for percutaneous endoscopic gastrostomy in the near future, and she was prophylaxed for deep vein thrombosis with pneumatic boots. However, given concern for her atrial fibrillation and the need for anticoagulation, she was eventually restarted on a Heparin drip in addition to having had subcutaneous Heparin before that. The patient underwent another echocardiogram towards the end of her hospital stay to rule out pulmonary embolism after her tachypnea did not resolve. This echocardiogram did not reveal any new right heart disease, but, as on earlier studies, did indicate that there was mild pulmonary hypertension and right ventricular volume and pressure overload. 4. Renal - The patient had end stage renal disease secondary to polycystic kidney disease. She was continued on her dialysis regimen of three times a week. In addition, the patient required extra dialysis during her hospital stay to either remove volume or provide ultrafiltration. The patient's dialysis catheter which had been placed on [**2116-2-7**], did grow positive blood cultures, but given her poor access issues, this catheter was left in place. An attempt was made to provide the patient with another source of access, but ultrasound of the right neck area revealed a clotted superior vena cava which would preclude any chance for a right IJ or permacath site. The patient was continued on her Nephrocaps. Her electrolyte balance was maintained within normal limits throughout her hospital stay. She remained anuric throughout her hospital stay. 5. Neurology - The patient was admitted with altered mental status most likely secondary to toxic metabolic changes and hypotension. She did improve with respect to her mental status when her pressures were increased by pressors, but her mental status remained subpar throughout her hospital stay. She had had a negative magnetic resonance scan at the outside hospital, and she had a negative CT scan for acute processes such as bleeds or abscesses at this hospital. Her TSH, folate and B12 levels were normal. Towards the end of her hospital stay, the patient developed new mental status changes that were more profound and her neurologic examination revealed left sided weakness and decreased reflexes as well as left sided hemineglect. It was thought that the patient would require new brain imaging, but, given her persisting tachypnea, she was deemed unstable to leave the Medical Intensive Care Unit. When she was made comfort measures only, the patient's mental status worsened to the point that she was no longer responsive. 6. Endocrine - The patient ruled in for adrenal insufficiency with an ACTH stimulation test. It was thought that this could be a potential contributing factors to her hypotension. She was started on Dexamethasone empirically before this test was positive, and afterwards was started on Florinef and Hydrocortisone. However, her pressures did not increase substantially with these alone, and she continued to need pressors. Her TSH was negative which ruled out any potential hypothyroidism. She was placed on a regular insulin sliding scale throughout her hospital stay for coverage since the patient was on steroids. 7. FEN, gastrointestinal - The patient was diagnosed with functional dysphagia secondary to either her mental status changes or a real neuromuscular defect at the outside hospital. A speech and swallow consultation was requested for the purpose of evaluating dysfunctional dysphagia, but give the patient's poor mental status, a video swallowing study was never performed. The patient was made NPO throughout her hospital stay, and a nasogastric tube was placed so that the patient could receive nutrition in the form of tube feeds. The patient tolerated these tube feeds, except for the fact that towards the middle of her hospital stay, she was found to have blood in her residual. As a result, nasogastric tube feeds were discontinued and the tube was used only for medication delivery. The patient then received TPN for the rest of her hospital stay, which she tolerated without any problem. The patient was maintained on aspiration precautions during her hospital stay. She received no extra fluids given chest x-rays revealing pulmonary edema and her end stage renal disease status. It was thought that dialysis would help her volume status, but her hypotension and pulmonary edema persisted regardless. The patient's electrolyte levels were maintained within normal limits throughout her hospital stay. 8. Pain - The patient was admitted with a complaint of pain secondary to compression fractures in her lumbar spine. She was continued on Tylenol PR which she was on at the outside hospital. Given her renal failure, there was concern about giving narcotics, and more so, the patient had a history of opioid allergies as well as hypotension. The decision was made not to treat the patient with narcotics. Instead, the patient was treated at first with Toradol, and then with Tramadol. Her pain was maintained under control throughout her hospital stay. 9. Access - The patient received a femoral arterial line on her left leg, a femoral venous line on her right leg and a nasogastric tube. Arterial lines were attempted in her upper extremities, but these attempts were not successful throughout her hospital stay. The femoral arterial line was discontinued after it grew positive blood cultures. The patient had a permacath on her left upper thorax throughout her hospital stay, but this was not discontinued despite gram positive blood cultures as dialysis access was desperately needed. 10. Prophylaxis - The patient was placed on a H2 blocker at the time of admission and that was later changed to a PPI after blood was found in her residual. The patient was also started on Heparin subcutaneous on her admission. When the blood was found, this was taken off and she was placed on pneumatic boots. When she developed neurological deficit, she was started on a Heparin drip. 11. Code Status - The patient came into the hospital with a DNI status. This status was honored throughout her hospital stay. Towards the end of her hospital stay, numerous family meetings were held, including with the help of the palliative care team and Dr. [**Last Name (STitle) 22926**] [**Name (STitle) **], and the decision was made to change the patient's status to comfort measures only. Previous to this, the family had decided to make her DNR/DNI. When she was made comfort measures only, the patient was discontinued of all her medications. Her nasogastric tube was pulled. She was discontinued of all her medications and she was started on a Morphine drip. She passed away on [**2116-2-27**], at 10:22 a.m. when her breathing stopped. Permission was obtained from the family for an autopsy. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 7585**] Dictated By:[**Last Name (NamePattern1) 1595**] MEDQUIST36 D: [**2116-2-27**] 13:48 T: [**2116-3-1**] 12:07 JOB#: [**Job Number 4719**]

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icd9cm

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icd9pcs

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52714

Discharge summary

report

Admission Date: [**2146-7-4**] Discharge Date: [**2146-7-21**] Date of Birth: [**2071-10-28**] Sex: F Service: MEDICINE Allergies: Enalapril Attending:[**First Name3 (LF) 1666**] Chief Complaint: lethargy, melena, hematemesis Major Surgical or Invasive Procedure: Transfusion 2u pRBC History of Present Illness: 74 yo F with h/o atrial fibrillation on coumadin, s/p MVR, HTN, PUD, and diverticulosis who presents with lethargy, melena, blood oozing from her mouth and ? hematemesis. Per pt, has had epigastric pain for several days and vomited up "small" amount of dark colored blood for past 3 days. She later denies this and states that she only vomited up dark blood on one occasion on the day PTA. Per daughter, noted dried, dark blood around pt's lips on Saturday. Denies hematochezia, BRBPR but does report one episode of melena the night PTA. Per husband, he noted that pt was much more fatigued and tired yesterday and was unable to climb up a flight of stairs. He also noted "dark colored spots" over her legs and arms and dark blood oozing from her mouth after removing her dental plates. No coughing or vomiting up of blood per husband. This morning, she was found to be very hard to arouse from bed and again noticed dark, dried blood around her mouth and clothes. Upon EMS arrival, FS reportedly wnl, BP 60/palp. She was given IVFs during transport to ED. . In the ED, initial BP 80/palp [**Name6 (MD) **] [**Name8 (MD) **] RN. Given 500 cc bolus and BPs improved to 103/56. She continued to be fluid resuscitated with a total of 4L NS. NGL lavage performed with return of dark, coffee-grounds. Labs significant for Hct 29.8 (baseline mid 30's), INR 21.2, venous lactate 10.7, Cr 3.6 (baseline 1.4 - 1.9), troponin 0.02, CK 81. The pt was given 2 units pRBC, 2 units FFP, panoprazole 40 mg IV X 1, and vit K 10 mg IV X 1. Given elevated venous lactate, a CTA abd/pelvis was performed that showed no signs of mesenteric ischemia, bibasilar lung opacities, non-specific bilateral perinephric stranding possibly related to renal failure, and ascites, pericholecystic fluid, and RV enlargement suggestive of R sided heart failure. She was seen by GI consult and admitted to the MICU for further care. Past Medical History: Type II diabetes mellitus Hypertension s/p mechanical mitral valve replacement [**2140**] Atrial fibrillation on coumadin Hypothyroidism Hyperlipidema Depression Peptic ulcer disease - dx'd by EGD in [**2118**]'s, H.pylori + in [**2128**]'s Diverticulosis on colonoscopy in [**2145**] L vitreous hemorrhage - followed by Dr. [**Last Name (STitle) **], plan for vitrectomy on [**2146-7-26**] R retinal detachment Social History: Lives with her husband. Originally from [**Country **] H/o 20 pack-yrs tobacco; quit 6yrs ago. No EtOH or other drugs. Family History: sister with breast ca. another sister with ca of unknown etiology. No h/o GI disease, IBD. Physical Exam: T 98.0 BP 103/65 HR 112 RR 20 O2 sat 98% on 50% shovel mask Gen - NAD, speaking in full sentences without SOB HEENT - NCAT, L eye with grossly appreciated conjunctival hemorrhage, R eye slighly injected, no scleral icterus, dried dark blood over lips, tongue, no active oozing of blood noted from oral cavity, JVP approximately 10 cm above sternal notch but difficult to fully appreciate CV - irregularly irregular, tachycardic, mechanical click, no m/r/g appreciated Lungs - limited by anterior exam, slight expiratory wheezing at bases b/l, no rales or rhonchi Abd - Soft, obese, non-tender to palpation throughout, no palpable masses or HSM, guaiac positive, grossly red colored stool in ED Ext - trace pitting LE edema b/l, warm, cap refill < 2 sec Neuro - AAO X 3 (although not entirely sure which hospital she is in but knows she is in a hospital in [**Location (un) 86**]), moves all 4 extremities purposefully Pertinent Results: [**2146-7-4**] 09:00AM BLOOD WBC-11.4* RBC-3.03* Hgb-8.3* Hct-27.2* MCV-90 MCH-27.3 MCHC-30.4* RDW-15.5 Plt Ct-197 [**2146-7-6**] 04:35AM BLOOD WBC-8.2 RBC-3.15* Hgb-9.3* Hct-27.2* MCV-86 MCH-29.4 MCHC-34.0 RDW-16.1* Plt Ct-141* [**2146-7-9**] 07:30AM BLOOD WBC-7.1 RBC-3.72* Hgb-10.5* Hct-32.7* MCV-88 MCH-28.2 MCHC-32.1 RDW-17.6* Plt Ct-193 [**2146-7-15**] 07:00AM BLOOD WBC-6.8 RBC-3.64* Hgb-10.4* Hct-32.8* MCV-90 MCH-28.5 MCHC-31.6 RDW-17.5* Plt Ct-268 [**2146-7-4**] 09:17AM BLOOD Neuts-84.0* Bands-0 Lymphs-11.0* Monos-4.5 Eos-0.2 Baso-0.3 . [**2146-7-4**] 09:17AM BLOOD PT-146.7* PTT-79.6* INR(PT)-21.2* [**2146-7-4**] 02:47PM BLOOD PT-19.2* PTT-32.9 INR(PT)-1.8* [**2146-7-6**] 12:18AM BLOOD PT-15.1* PTT-150* INR(PT)-1.3* [**2146-7-10**] 06:25AM BLOOD PT-14.8* PTT-36.8* INR(PT)-1.3* [**2146-7-14**] 06:35AM BLOOD PT-13.6* PTT-56.7* INR(PT)-1.2* [**2146-7-14**] 09:19PM BLOOD PT-14.7* PTT-74.6* INR(PT)-1.3* . [**2146-7-4**] 09:05AM BLOOD Glucose-112* UreaN-47* Creat-3.8*# Na-142 K-5.7* Cl-103 HCO3-12* AnGap-33* [**2146-7-6**] 05:40PM BLOOD Glucose-211* UreaN-34* Creat-1.5* Na-140 K-3.2* Cl-98 HCO3-31 AnGap-14 [**2146-7-13**] 07:25AM BLOOD Glucose-112* UreaN-24* Creat-1.7* Na-143 K-3.8 Cl-101 HCO3-32 AnGap-14 [**2146-7-15**] 07:00AM BLOOD Glucose-110* UreaN-29* Creat-1.5* Na-142 K-3.9 Cl-103 HCO3-30 AnGap-13 [**2146-7-4**] 09:05AM BLOOD Albumin-3.4 Calcium-8.1* Phos-7.7*# Mg-2.4 [**2146-7-8**] 06:40AM BLOOD Calcium-9.1 Phos-2.6* Mg-1.9 [**2146-7-11**] 07:28PM BLOOD Mg-2.0 [**2146-7-15**] 07:00AM BLOOD Calcium-8.9 Phos-4.0 Mg-2.1 . [**2146-7-4**] 09:05AM BLOOD ALT-16 AST-38 CK(CPK)-81 AlkPhos-46 Amylase-195* TotBili-1.1 . [**2146-7-4**] 09:05AM BLOOD CK-MB-NotDone cTropnT-0.02* [**2146-7-4**] 06:57PM BLOOD CK-MB-4 cTropnT-0.04* [**2146-7-5**] 04:26AM BLOOD CK-MB-5 cTropnT-0.01 . [**2146-7-4**] 09:17AM BLOOD TSH-0.67 [**2146-7-5**] 04:26AM BLOOD T3-52* Free T4-1.2 [**2146-7-4**] 09:05AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2146-7-4**] 09:02AM BLOOD Glucose-111* Lactate-10.7* Na-140 K-5.3 Cl-105 calHCO3-17* . [**2146-7-4**] 09:45AM URINE Blood-TR Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [**2146-7-7**] 02:08PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-7.5 Leuks-SM [**2146-7-4**] 09:45AM URINE RBC-[**3-30**]* WBC-[**3-30**] Bacteri-OCC Yeast-NONE Epi-0-2 TransE-0-2 [**2146-7-7**] 02:08PM URINE RBC-182* WBC-8* Bacteri-NONE Yeast-NONE Epi-<1 . UCx neg C diff neg . [**7-4**] CXR SINGLE PORTABLE VIEW OF THE CHEST: There has been previous sternotomy, with midline sternal wires and prosthetic mitral valve again identified. Marked cardiomegaly is again noted with bilateral peripheral interstitial opacities. Findings may be related to chronic interstitial lung disease though superimposed mild congestion is also probable. There is no pleural effusion. The bony thorax is unremarkable. IMPRESSION: 1. Cardiomegaly with probable mild congestion. . [**7-4**] CT abd/pelvis IMPRESSION: 1. No evidence of mesenteric ischemia. 2. New bilateral perinephric stranding, a nonspecific finding. This may be related to medical renal disease. 3. Reticulonodular opacities at the lung bases likely reflect edema superimposed on chronic interstitial lung disease. 4. Cardiomegaly with right heart failure. 5. Small volume ascites. . [**7-4**] CT head IMPRESSION: 1. No evidence of infarction or hemorrhage, allowing for the presence of intravenous contrast from the preceding abdominal/pelvic CT. . [**7-7**] CT head IMPRESSION: No evidence of acute hemorrhage or acute large vascular territory infarcts. Prominence of the ventricles slightly out of proportion to prominence of the sulci is unchanged compared to [**2146-7-4**]. Periventricular hypodensities may represent chronic small vessel ischemic disease, transependymal migration of CSF, or a combination of the two; comparison with earlier prior imaging, if available, may be helpful in assessing change over time. . [**7-8**] CXR The heart is enlarged. Mitral valve replacement is present. The interstitial failure present on the prior chest x-ray of [**7-7**] appears less marked but this could be due to technical differences and I suspect that some interstitial failure is still present. Atelectasis is again present. IMPRESSION: Persistent cardiomegaly, interstitial failure possibly better. Brief Hospital Course: Hospital course was as follows: In the ED, initial BP 80/palp [**Name6 (MD) **] [**Name8 (MD) **] RN. Given 500 cc bolus and BPs improved to 103/56. She continued to be fluid resuscitated with a total of 4L NS. NGL lavage performed with return of dark, coffee-grounds. Labs significant for Hct 29.8 (baseline mid 30's), INR 21.2, venous lactate 10.7, Cr 3.6 (baseline 1.4 - 1.9), troponin 0.02, CK 81. The patient was given 2 units pRBC, 2 units FFP, panoprazole 40 mg IV X 1, and vit K 10 mg IV X 1. Given elevated venous lactate, a CTA abd/pelvis was performed that showed no signs of mesenteric ischemia, bibasilar lung opacities, non-specific bilateral perinephric stranding possibly related to renal failure, and ascites, pericholecystic fluid, and RV enlargement suggestive of R sided heart failure. She was seen by GI consult and admitted to the MICU for further care. . In the MICU, GI performed EGD and noted esophagitis/gastritis and to have large clot in stomach but no active bleeding. Hematocrit nadir was 27, transfused 2 units w/ appropriate increase. Reversed anticoagulation w/ vitamin K, now on heparin gtt as INR<2 w/o new bleeding. Also patient noted to have a history of interstitial lung disease (f/b Dr. [**Last Name (STitle) 11528**] and does not have home O2 but currently w/ O2 requirement s/p IVF resuscitation on arrival given hypovolemic hypotension in setting of bleed. Her O2 requirement has been lessening w/ diuresis. The morning of transfer, the patient was noticed to be slightly confused and does have a h/o sundowing. A head CT was negative for bleed and then found +U/A so started ciprofloxacin which was changed to ceftriaxone for concerns of deleriogenesis. . Please see the following problem list for the pt's course once called out to the medical floor: . *) Increasing O2 requirement: Likely [**2-26**] volume overload from diastolic heart failure in combination with known interstitial lung disease. s/p echo [**7-5**] with EF 60-70%. Pt received IV lasix to a goal of -1.5L for approx 5 days and was transitioned to PO lasix when no longer exhibited signs of fluid overload. She continued to have a fluctuating O2 requirement and NC was titrated to >93%. On discharge, patient was satting well on 2L off of lasix. . *) Upper GI bleed: In setting of supratherapeutic INR. s/p 2u pRBC. Resolved and Hct stable s/p transfusion and Vit K. EGD with esophagitis, gastritis, clot but no acute bleeding. Continued [**Hospital1 **] protonix. Daily hcts were stable and increased throughout stay. . *) Anti-Coagulation/MVR - Patient on IV heparin with goal 50-70 for anticogagulation for MVR. Initially on coumadin 2mg QD, which was eventually increased to her home regimen of 10mg Mon-Sat and 15mg Sun. On discharge, INR was 3.1 and heparin gtt discontinued. Patient to have close follow up with [**Hospital **] Clinic. . *) Confusion/dementia: Pt with occasional severe agitation. Last episode [**7-10**] AM (pulled out IVs, refusing PO meds and O2NC). Likely secondary to underlying dementia/sundowning. Pt received zyprexa and haldol prn. Per daughter, this is her baseline. . *) Acute on chronic renal failure: Prerenal, baseline Cr 1.4-1.6. Followed Cr daily. On discharge, creatinine was 1.5. . *) Cardiac - EF 60-70%. Continued metoprolol and transitioned to XL. Lisinopril was decreased as BPs were low normal. Continued statin. . *) UTI: Pt received cipro x 3d. Cx negative. . *) s/p MVR - Mechanical valve. Heparin as above. . *) Hypothryoidism - Continued synthroid at home doses. TSH 0.68, free T4 normal. . *) DM II - Continue ISS while in house, but pt with little requirement. D/C'd on HD#12. Restarted metformin 1 day prior to discharge. Medications on Admission: Coumadin 2.5 mg take as directed Lasix 40 mg daily Lisinopril 20 mg daily Toprol 100 mg daily Metformin 1000 mg daily Flonase 1 spray daily Levothyroxine 112 mcg daily Simvastatin 20 mg qhs Discharge Medications: 1. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 2. Levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal DAILY (Daily). Disp:*1 INH* Refills:*2* 4. Metformin 1,000 mg Tab,Sust Rel Osmotic Push 24hr Sig: One (1) Tab,Sust Rel Osmotic Push 24hr PO once a day. Disp:*30 Tab,Sust Rel Osmotic Push 24hr(s)* Refills:*2* 5. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. Disp:*30 Tablet Sustained Release 24 hr(s)* Refills:*2* 6. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 7. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Warfarin 5 mg Tablet Sig: Two (2) Tablet PO Once Daily at 4 PM: Titrate to INR 2.5-3.5. Disp:*60 Tablet(s)* Refills:*2* 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 10. Outpatient Lab Work Standing INR to be faxed to Dr. [**Last Name (STitle) 8499**] at [**Telephone/Fax (1) 13238**]; Goal INR 2.5-3.5 Discharge Disposition: Home With Service Facility: [**Hospital **] Home Health Care Discharge Diagnosis: Primary: -Upper GI bleed -Interstitial lung disease -Acute on chronic diastlic heart failure -Mechanical mitral valve Secondary: -Type II diabetes mellitus -Hypertension -s/p mechanical mitral valve replacement [**2140**] -Atrial fibrillation on coumadin -Hypothyroidism -Hyperlipidema -Depression -Peptic ulcer disease - dx'd by EGD in [**2118**]'s, H.pylori + in [**2128**]'s -Diverticulosis on colonoscopy in [**2145**] -L vitreous hemorrhage - followed by Dr. [**Last Name (STitle) **], plan for vitrectomy on [**2146-7-26**] -R retinal detachment Discharge Condition: Stable. Unstable on ambulation with walker. We are recommending rehabilitation but the patient has refused and is deemed competent to do so. Discharge Instructions: You were admitted to the hospital for an upper gastrointestinal bleed because your coumadin made your blood too thin. Studies demonstrated no further bleeding and after receiving fluids and a blood transfusion, your hematocrit was stable throughout your hospital admission. . While in the ICU, you required more oxygen than at baseline and continued to have an increased requirement on the floor. You received medication to help excrete fluid that collected in your lungs. . You were restarted on your coumadin and stayed in the hospital until your labs showed that your blood was thin enough for your mechanical heart valve. Followup Instructions: Provider: [**Last Name (NamePattern4) **]/EYE LIST OR EYE SURGERY Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2146-7-26**] 11:30 Provider: [**First Name11 (Name Pattern1) 354**] [**Last Name (NamePattern4) 3013**], M.D. Phone:[**Telephone/Fax (1) 253**] Date/Time:[**2146-7-27**] 8:30 Provider: [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **], MD. Phone [**Telephone/Fax (1) 7976**] Date/Time:[**2146-7-27**] 03:30pm [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**] Completed by:[**2146-7-21**]

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icd9cm

[ [ [] ] ]

[ "99.04", "99.07", "45.13", "88.72", "96.34" ]

icd9pcs

[ [ [] ] ]

13561, 13624

8314, 12007

300, 321

14219, 14363

3880, 8291

15037, 15638

2835, 2927

12248, 13538

13645, 14198

12033, 12225

14387, 15014

2942, 3861

231, 262

349, 2248

2270, 2683

2699, 2819

42,525

142,743

4883

Discharge summary

report

Admission Date: [**2125-2-1**] Discharge Date: [**2125-2-13**] Date of Birth: [**2048-4-24**] Sex: F Service: MEDICINE Allergies: Disopyramide Attending:[**First Name3 (LF) 443**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: None History of Present Illness: 76-year-old woman with h/o DM2, HTN, HL, CVA on warfarin with residual L sided weakness presented to Dr.[**Name (NI) 19421**] office on [**2125-2-1**] and was found to be in afib with RVR with HR 150s. Patient denied any symptom at that time. She did report some dyspnea with exertion in [**Month (only) 956**]. Of note, patient was recently found to have a breast nodule on mammogram which is being worked up. She has been having significant anxiety over this. On presentation to the ED, afeb, HR 140, BP 181/124, 97%RA. Her exam was unremarkable. CE neg x 1. ECG showed afib with rate in the 140s, without any ischemic changes. INR 3.7. She received metoprolol 10 mg IV x 2, 5 mg IV x 4, labetolol 10 mg IV x 1, metoprolol 25 mg PO x 1. Her HR decreased to 105-115, and BP 135/87. Was admitted to [**Hospital1 1516**] for further management. On arrival to floor, patient was asymptomatic. On review of systems, she denies any prior history of deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: DM2 dyslipidemia hypertension CVA, residual L-sided weakness, on warfarin hypothyroidism CARDIAC RISK FACTORS: Diabetes(+), Dyslipidemia(+), Hypertension(+) CARDIAC HISTORY: -CABG: none -PERCUTANEOUS CORONARY INTERVENTIONS: none -PACING/ICD: none Social History: Married. Family History: No family history of early MI, otherwise non-contributory. Physical Exam: VS: afeb, 121/96, 120, 98%RA GENERAL: Elderly woman in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of 8 cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. 2/6 systolic murmur at LLSB. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. Some crackles at both bases. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ Pertinent Results: [**2125-2-1**] 08:00PM CK(CPK)-81 [**2125-2-1**] 08:00PM cTropnT-<0.01 [**2125-2-1**] 08:00PM CK-MB-NotDone [**2125-2-1**] 08:00PM TSH-1.4 [**2125-2-1**] 03:10PM PT-35.1* PTT-26.8 INR(PT)-3.7* [**2125-2-1**] 02:00PM GLUCOSE-126* UREA N-27* CREAT-1.5* SODIUM-140 POTASSIUM-3.7 CHLORIDE-103 TOTAL CO2-25 ANION GAP-16 [**2125-2-1**] 02:00PM estGFR-Using this [**2125-2-1**] 02:00PM CK(CPK)-47 [**2125-2-1**] 02:00PM cTropnT-<0.01 [**2125-2-1**] 02:00PM CK-MB-NotDone [**2125-2-1**] 02:00PM WBC-10.1# RBC-4.83 HGB-13.5 HCT-40.9 MCV-85 MCH-27.9 MCHC-33.0 RDW-15.2 [**2125-2-1**] 02:00PM NEUTS-83.3* LYMPHS-12.7* MONOS-3.2 EOS-0.1 BASOS-0.6 [**2125-2-1**] 02:00PM PLT COUNT-389 Discharge Labs [**2125-2-13**] 05:50AM BLOOD WBC-9.1 RBC-4.04* Hgb-11.1* Hct-34.4* MCV-85 MCH-27.5 MCHC-32.2 RDW-14.7 Plt Ct-318 [**2125-2-13**] 05:50AM BLOOD PT-16.2* PTT-31.3 INR(PT)-1.5* [**2125-2-13**] 05:50AM BLOOD Glucose-122* UreaN-15 Creat-0.9 Na-138 K-4.3 Cl-104 HCO3-23 AnGap-15 [**2125-2-13**] 05:50AM BLOOD Calcium-8.8 Phos-3.2 Mg-1.9 [**2125-2-6**] 07:09AM BLOOD %HbA1c-7.0* [**2125-2-1**] 08:00PM BLOOD TSH-1.4 [**2125-2-12**] 05:30AM BLOOD Digoxin-0.7* Reports/Imaging [**2125-2-2**] TTE The left atrium is markedly 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 moderately dilated with mild global free wall hypokinesis. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. There is mild valvular mitral stenosis (area 1.5-2.0cm2). An eccentric, anteriorly-directed jet of severe (4+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a small pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Mild mitral stenosis. Severe eccentric mitral regurgitation. Moderate to severe tricuspid regurgitation. Moderate pulmonary hypertension. [**2125-2-5**] Carotid Series Complete:Impression: Right ICA no stenosis . Left ICA no stenosis . Rib films: There is bibasilar atelectasis, and there are bilateral pleural effusions, small to moderate. The heart is enlarged. In addition, there are multiple non-displaced rib fractures in the lower right. No definite displaced rib fractures are seen on the left. This could be better assessed with CT if this is a clinical concern. CXR [**2125-2-1**] IMPRESSION: Mild heart failure with bilateral pleural effusions. Likely atelectasis at the lung bases, although repeat radiography following appropriate diuresis recommended to assess for underlying infection. CXR [**2125-2-7**] IMPRESSION:Retrocardiac atelectasis. Worsening bilateral pleural effusions. [**2125-2-10**] Rib Xray: here is bibasilar atelectasis, and there are bilateral pleural effusions, small to moderate. The heart is enlarged. In addition, there are multiple non-displaced rib fractures in the lower right. No definite displaced rib fractures are seen on the left. This could be better assessed with CT if this is a clinical concern. [**2125-2-12**] Cardiac Cath: report not yet available Brief Hospital Course: BRIEF HOSPITAL COURSE BY PROBLEM # Atrial fibrillation: Afib likely [**12-25**] atrial enlargement from valvular disease. She does have a history of hypothyroidism, on replacement, TSH normal in [**2124-10-23**]. No excessive alcohol or caffeine. Initially she did not respond to beta blockers and so was rate-controlled with diltiazem. She then converted to SR spontaneously and was maintained in SR with disopyramide. Her QTc was prolonged at ~500 after starting the long-acting form of the drug. Patient was transferred to the CCU for better monitoring while the disopyramide washed out. She then developed torsades and cardiac arrest as below. After torsades resolved, her medications were subsequently adjusted so she was on diltiazem for rate control, amiodarone 200mg PO BID x 2 weeks (then 200mg daily) for rhythm and rate control and digoxin 0.125 daily. For anticoagulation her coumadin was held for breast biopsy and cath. She was placed on a hep gtt for ppx while awaiting procedures. She was discharged on lovenox [**Hospital1 **] with bridge to coumadin. She was [**First Name9 (NamePattern2) 20387**] [**Male First Name (un) **] lower dose of coumadin given interaction with amiodarone and will need close monitoring of INR. For her outpatient dental procedure (prior to cardiac surgery), she will hold the warfarin without a lovenox bridge. She was discharged with [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] of Hearts monitor. # Torsades de pointes/Cardiac arrest: Pt was transferred to CCU on [**2125-2-6**] for management of torsades de pointes. She was given 4mg Mg IV and started on standing Mg repletion. Disopyramide was discontinued since she was felt to have long QT and torsades secondary to disopyramide. She was noted to have increasing ectopy on telemetry [**2125-2-6**] in pm and again went into VT with loss of consciousness and pulse. Code blue was called. She received external shocks x 2 and was intubated for airway protection. She received epi and atropine and lidocaine bolus. She was started on isoproterenol and subsequently levophed for hypotension. Femoral line placed under sterile conditions during code. After this episode, she had occasional runs of NSVT but no further sustained VT. On [**2125-2-8**], she was weaned off levophed and groin line was d/c'd. Around noon, she developed SVT with HRs 160s trending down to 120s which appeared to be afib. Isoproterenol was discontinued. She was started on metoprolol 12.5 [**Hospital1 **] which was uptitrated as tolerated then changed to diltiazem with improved heart rate control. She was subsequently extubated. She had residual chest wall pain after CPR and rib films revealed non displaced rib fractures. Pain was was controlled on tylenol. # Mild volume overload: Initially patient had left-sided failure with evidence of pulmonary edema and pleural effusions on imaging and minimal basilar crackles on exam, likely secondary to the atrial fibrillation. No evidence of right-sided failure. No history of CHF. On TTE had severe valvular disease (see below) that was most likely the cause of her CHF. Diuretics were held in light of acute kidney injury and after patient converted to NSR symptoms of CHF resolved. # Severe MR [**First Name (Titles) **] [**Last Name (Titles) **]: On TTE done to work up a murmur on exam and atrial fibrillation patient had severe MR [**First Name (Titles) **] [**Last Name (Titles) **]. Cardiac surgery was consulted and felt a MVR and TVR were required. The patient underwent some pre-op studies including a cath that showed clean coronaries. She will follow up with Dr. [**Last Name (STitle) 914**] in 2 weeks to schedule her surgery. # [**Last Name (un) **]: Cr 1.5 from baseline of 1.1. Likely to poor forward secondary to afib with RVR. Initially losartan and triamterene/HCTZ were held. Creatinine trended down. Patient was given lasix for diuresis given evidence of CHF on exam as above. With lasix had creatinine bump so further diuresis was held, however, patient converted to sinus rhythm and had self-diuresis thereafter with lessening of her CHF symptoms. She was restarted on losartan at 25mg daily (home dose 100mg daily) before discharge. # H/o CVA: On warfarin at home. Was on heparin gtt while inpatient for procedures and then lovenox bridge to warfarin on discharge due to high risk (CHADS2 score 6). # Abnl mammogram: Patient recently had BIRADS 4 abnormality on mammogram and was scheduled for breast biopsy. Was bridged from coumadin onto hep gtt and underwent biopsy as inpatient on [**2125-2-7**]. Preliminary results were negative for malignancy, and final results will be forwarded to her PCP for further management. # DM2: Was maintained on ISS while hospitalized but will continue oral hypoglycemics as outpatient. # HTN: Slightly hypertensive initially in admission. Controlled with losartan and coreg which were subsequently held while diltiazem was uptitrated. Losartan resumed before discharge as above. # Code: Full Medications on Admission: losartan 100 mg qday triamterene-HCTZ 37.5-25 mg 3x/week warfarin 2 mg qday atorvastatin 20 mg qday glyburide 5 mg qday levothyroxine 50 mcg qday metformin 500 mg qday calcium carbonate-Vit D 1 tab [**Hospital1 **] Discharge Medications: 1. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Glyburide 5 mg Tablet Sig: One (1) Tablet PO once a day. 4. Metformin 500 mg Tablet Sig: One (1) Tablet PO once a day: Do not start taking until [**2-15**] evening dose. 5. Calcium 500 + D 500 (1,250)-200 mg-unit Tablet Sig: Two (2) Tablet PO twice a day. 6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 8. Diltiazem HCl 240 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO BID (2 times a day). Disp:*60 Capsule, Sustained Release(s)* Refills:*2* 9. Outpatient Lab Work Please check INR, digoxin level on Friday [**2-16**] and call results to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**] at [**Telephone/Fax (1) 10492**] 10. Lovenox 60 mg/0.6 mL Syringe Sig: One (1) Subcutaneous twice a day for 10 days: or until INR is > 2.0. Disp:*10 qs* Refills:*2* 11. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 12. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO every eight (8) hours. 13. Cozaar 25 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Primary Diagnosis: Atrial Fibrillation Severe Mitral Regurgitation Acute Renal failure Torsades de Pointes Secondary: Chronic Renal failure HTN DM2 Discharge Condition: The patient was afebrile and hemodynamically stable prior to discharge. Discharge Instructions: You were admitted to the hospital with difficulty breathing and an abnormal heart rhythm. You were started on medications to control your heart rate. Unfortunately, a side affect of one of your medications caused a complicated rhythm that required CPR and intubation. Luckily, you recovered from both but did have some rib fractures as a result of the CPR. . While you were here you had an ultrasound of your heart that showed a leaky valve. The cardiologists and cardiac surgeons think they you will need this repaired. In preparation for your valve repair you had a cardiac catheterization. This showed no blockages in your coronary arteries. You had a breast biopsy as well and the final results were still pending at the time of discharge. Please follow up with Dr. [**Last Name (STitle) 1007**] for the final results. . Dr. [**Last Name (STitle) 1007**] will also follow your rib fractures. You can take tylenol and Tramadol for control of the pain but no other intervention was needed at this time. . You still need surgical clearance from your dentist. Your dentist can fax the clearance to the cardiac surgery office at ([**Telephone/Fax (1) 15187**] (ATTN Dr. [**Last Name (STitle) 914**]. . Your INR (coumadin level) was high while you were here. We held your coumadin so that you could have your cardiac cath and your breast biopsy. You will start taking your couamdin again at a lower dose. Please check your INR on Friday [**2-16**]. You should continue taking the lovenox shots twice daily until your INR is greater than 2.0. Dr. [**Last Name (STitle) 1007**] will monitor your INR and let you know when you can stop taking the Lovenox. . Medication changes: START: Lovenox 60 mg injected twice a day START: Digoxin 0.125mg daily START: Diltiazem SR 240 mg twice a day START: Amiodarone 200 mg twice a day START: Tramadol 50 mg twice daily STOP taking Diazide and decrease the Cozaar to 25 mg daily STOP taking Metformin, you can restart on [**2-15**] at your evening dose Decrease your coumadin dose to 1 mg daily. . Please come back to the emergency room or call your doctor if you have fainting, light-headedness, dizziness, palpitations, chest pain, shortness of breath, abdominal pain, nausea, vomiting, weight gain more than 3 lbs in one day, leg swelling, or other concerning symptoms. Followup Instructions: Psychiatry: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7449**], MD Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2125-4-5**] 10:30 . Primary Care: Please follow up with your primary care doctor, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 1007**], ([**Telephone/Fax (1) 10492**]) on Wednesday [**2-28**] at 1:45pm. . Cardiac Surgery: Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 914**] Phone: [**Telephone/Fax (1) 170**] Date/Time: [**3-6**] at 1:00pm . Cardiology: Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2125-4-4**] 11:20

[ "394.2", "585.9", "E849.7", "438.89", "584.9", "427.1", "E942.0", "250.00", "V58.61", "E878.8", "403.90", "416.8", "E879.8", "272.4", "794.31", "728.89", "397.0", "427.5", "398.91", "244.9", "998.12", "807.09", "427.31", "793.81" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04", "88.56", "37.23", "38.93", "99.60", "85.11" ]

icd9pcs

[ [ [] ] ]

12939, 12997

6280, 11288

291, 297

13190, 13264

2946, 6257

15620, 16304

2055, 2115

11554, 12916

13018, 13018

11314, 11531

13288, 14942

2130, 2927

14962, 15597

232, 253

325, 1737

13037, 13169

1759, 2013

2029, 2039

57,255

197,778

41428

Discharge summary

report

Admission Date: [**2172-4-25**] Discharge Date: [**2172-5-21**] Date of Birth: [**2105-3-24**] Sex: F Service: SURGERY Allergies: No Known Drug Allergies Attending:[**First Name3 (LF) 1384**] Chief Complaint: BRBPR Major Surgical or Invasive Procedure: Colonoscopy [**2172-5-1**] Liver [**Month/Day/Year **] [**2172-5-12**] ERCP, sphincterotomy, stent placement History of Present Illness: 67 yo female with autoimmune hepatitis and cirrhosis p/w staph bacteremia and right hand cellulitis now with 600cc BRBPR. She had an episode of BRBPR on Sat night with guaiac positive brown stools since. She went down for an ultrasound today then had 500 cc of bright red blood from below while on the toilet. She had an EGD a few days ago which showed only grade 1 varices. Reportedly with colonic varices on an OSH colonoscopy, but we do not have any record of this. Plan to scope today in ICU. T&C; ordered for 2 units (Hct 28 <-- 35) and 1 unit platelets (41); INR 2.8; vitamin K + 4 units FFP. Has right 18g and tenuous 22g left antecub. Not febrile, surveillance blood cultures pending. Past Medical History: HLD Autoimmune hepatitis/cirrhosis, diagnoed 14 yrs ago with bx in [**Male First Name (un) 1056**], complicated by varices RA DM2 with neuropathy HTN, incl hypertensive nephropathy B12 deficiency Vitamin D Deficiency Chronic pain syndrome - "colonic pain" per pt records Colon polyps (hyperplastic and tubular adenoma) Diverticulitis Depression PAD s/p chole s/p appy s/p TAH/USO Bladder prolapse repair [**2172-5-1**] Liver [**Month/Day/Year **] [**2172-5-12**] ERCP, sphincterotomy, stent placement Social History: originally from [**Male First Name (un) 1056**]; has lived her with family for last 3 years; has her care done at [**Hospital3 934**]. No etoh, illicits or tobacoo. Family History: non-contributory Physical Exam: Vitals: T: BP: 103/36 P: 67 R: 20 O2: 96% RA General: Alert, oriented, no acute distress, mild asterixis HEENT: Sclera icteric, 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, holosystolic murmur at LUSB Abdomen: soft, obese, non-tender, mildly-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley in place Rectum: small external hemorrhoids not actively bleeding. Ext: warm, well perfused, 2+ pulses, no edema in legs Skin: R dorsal hand with erythema, indistinct border, warm to touch with mild edema, extending to lower forearm; L antecubital erythema warm to touch, no drainage or breaks in skin Pertinent Results: [**2172-5-16**] 06:00AM BLOOD WBC-7.9 RBC-2.89* Hgb-9.3* Hct-29.0* MCV-100* MCH-32.1* MCHC-32.0 RDW-19.1* Plt Ct-105* [**2172-5-21**] 05:30AM BLOOD WBC-5.1 RBC-2.88* Hgb-9.3* Hct-29.4* MCV-102* MCH-32.4* MCHC-31.7 RDW-21.4* Plt Ct-69* [**2172-5-16**] 06:00AM BLOOD PT-13.4 PTT-24.6 INR(PT)-1.1 [**2172-5-6**] 03:26PM BLOOD Fibrino-191 [**2172-5-18**] 05:32AM BLOOD Glucose-36* UreaN-75* Creat-1.9* Na-145 K-4.6 Cl-114* HCO3-21* AnGap-15 [**2172-5-21**] 05:30AM BLOOD Glucose-68* UreaN-49* Creat-1.6* Na-143 K-5.0 Cl-115* HCO3-20* AnGap-13 [**2172-5-19**] 05:03AM BLOOD ALT-10 AST-33 AlkPhos-584* TotBili-2.2* [**2172-5-20**] 05:28AM BLOOD ALT-7 AST-31 AlkPhos-590* TotBili-1.9* [**2172-5-21**] 05:30AM BLOOD ALT-6 AST-28 AlkPhos-577* TotBili-1.9* [**2172-5-21**] 05:30AM BLOOD Calcium-8.6 Phos-3.7 Mg-1.8 [**2172-5-21**] 05:30AM BLOOD tacroFK-9.7 [**4-25**] BCx: 2/2 bottles MSSA [**4-26**] joint fluid: 1+PMNs, no growth [**4-27**] BCx: no growth [**4-27**] stool cultures: no OVA/ PARASITES/ SALMONELLA/ SHIGELLA/ CAMPYLOBACTER [**4-27**] MRSA swab: neg [**4-28**] toxoplasma: equivocal [**4-28**] BCx: NG [**4-30**] BCx: NG [**5-1**] UCx: <10k ORGS [**5-1**] BCx: NG [**5-1**] VRE swab: VRE positive [**5-1**] MRSA swab: neg [**5-2**] sputum: yeast, rare growth TWO COLONIAL MORPHOLOGIES [**5-2**] PICC tip: no significant growth [**5-2**] UCx: no growth [**5-2**] BCx: neg [**5-3**] RIJ tip: no sig growth [**5-4**] UCx: NG [**5-4**] BCx: neg [**5-4**] MRSA: neg IMAGING: [**2172-4-16**] Echo: ormal global and regional biventricular systolic function. No pulmonary hypertension or clinically-significant valvular disease seen. EF 70%. [**2172-4-16**] PMibi: Normal cardiac perfusion. EF >70% 5/8 US: A 1.3 x 1.1 x 2 cm cyst is seen in the pancreas, suggestive of IPMN [**4-27**] Colonoscopy: Grade 1 external hemorrhoids, Rectal varices were seen. They were not actively bleeding. There was a blood clot on the varix that was washed away. No hemocystic spots were seen. No therapy was done. Otherwise normal colonoscopy to cecum [**4-28**] MRI Hand/Wrist: c/w cellulitis throughout hand & fingers, w/ diffuse soft tissue edema & skin thickening. No definite e/o osteomyelitis. [**4-30**] TEE: No discrete valvular veg seen; complex desc aortic plaque (25cm from incisors) w/highly mobile element ?part of the cholesterol plaque, intravascular infection or thrombus Brief Hospital Course: 67 yo F w/ autoimmune hepatitis, cirrhosis who p/w staph aureus bacteremia and BRBPR. Hepatology was consulted and started her on azathioprine and prednisone. Sigmoidoscopy showed rectal varices and grade 1 external hemorrhoids with no active bleeding and no therapy was done. The patient was transfused and continued on PPI/sucralfate. Creatinine increased and it was presumed that she was developing hepatorenal syndrome. Nephrology was consulted and followed. [**Month/Year (2) 1326**] surgery was consulted and [**Month/Year (2) **] workup was expedited. She was listed for liver [**Month/Year (2) **]. MSSA bacteremia source was felt to be from L arm thrombophlebitis from site of prior IV and R wrist, U/S had no e/o DVT in LUE. Surveillance cultures were done. PICC line was placed for extended course of antibiotic therapy. TTE then TEE was done to look for vegetations on the heart valves. No vegetations were seen. ID was consulted, vancomycin continued until speciation and sensitivities isolated MSSA. Vanco was changed to nafcillin. Ortho was consulted to evaluate right hand cellulitis. MRI was done with findings consistent with cellulitis throughout the hands and fingers, with diffuse soft tissue edema, and skin thickening. No definite evidence of osteomyelitis. Degenerative changes at the distal radius, base of the thumb, and MTP joints were noted (h/o RA). ID recommended switching Nafcillin to Cefazolin for a 6 week course. Cefazolin started on [**4-27**] and was to continue until [**6-7**]. On [**5-11**], a double lumen PICC line was placed via the left basilic venous approach. Final internal length is 47 cm, with the tip positioned in SVC. The line was ready for use. On [**2172-5-1**], a liver donor became available. Donor offer was accepted and patient underwent liver [**Date Range **]. Surgeon was Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 816**] assisted by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Please refer to operative note for details. Two JP drains were placed. JP outputs were sanguinous (non-bilious. She was transferred to the SICU immediately postop for management. Initially she was extubated, but required immediate reintubation for agitation/tachypnea/severe hypertension. Scheduled clonidine was started along with several other antihypertensives. Agitation persisted and Zyprexa was added with resolution of agitation. However, she continued to be delirious. She was successfully extubated. LFTs initially increased. Liver duplex on postop day 0 demonstrated resistive indices in the hepatic arteries are on the high side secondary to slightly low diastolic flow. LFTs trended down. Diet was on hold due to mental status. A post pyloric feeding tube was started and feedings were given. Around postop day 6, LFTs continued to trend down with the exception of the alk phos which started to trend up. Alk phos increased to 600 from 300. On [**6-12**], an ERCP was done showing biliary anastomosis stricture. A sphincterotomy was performed and a stent placed. Alk phos then trended down to 45. Alk phos started to rise slowly around postop day 14 ([**5-15**]). Repeat hepatic duplex demonstrated patent vasculature. There were no dilated biliary ducts. A liver biopsy was then done ([**5-15**]) to evaluate. This was negative for rejection. There were prominent bile ductular proliferation with associated neutrophils and focally prominent eosinophils and rare plasma cells. She remained on immunosuppression consisting of steroid taper to po prednisone, CellCept and Prograf per trough levels (goal of 10). A post pyloric feeding tube was placed and tube feedings continued until feeding tube was removed for ERCP on [**5-12**]. Replacement was attempted but tube was found in stomach. Post pyloric placement was unsuccessful under fluoro on [**5-19**]. A speech and swallow evaluation was done with recommendations to allow patient soft solids and thin liquids with chin tuck and supervision. The decision to leave feeding tube out was made and patient reported that she would try to eat. Mental status improved, but she continued to be confused at times. However, she remained cooperative. Renal function improved. Foley was removed on [**5-21**] at midnight and she voided (amount not quantitated as she was incontinent. Abdominal JP drains were removed by [**5-19**]. Incision remained intact with staples, but had developed a large bruised/necrotic area. This was debrided on [**5-16**] and [**5-20**] then a wound VAC was applied. Wound culture gram stain and potassium hydroxide prep were negative. Fungal and AFB cultures of wound were pending. Physical therapy worked with her and got her out of bed using the Freespan to lift her out of bed. She was severely debilitated/deconditioned. Vital signs were notable for SBP that had improved on Lopressor, hydralazine, clonidine, and amlodipine. On [**5-21**], clonidine taper was started, decreasing from 0.2mg tid to 0.1mg tid. Hydralazine was decreased from 10mg q6 to 5mg q6. Medications on Admission: 1. omeprazole 20 mg daily 2. nadolol 40 mg daily 3. sucralfate 1 gram QID 4. prednisone 60 mg daily 5. azathioprine 200 mg daily 6. Vitamin D 50,000 unit monthly 7. Lantus 100 unit/mL Solution Sig: 40 untis SQ at bedtime Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml Injection Q 8H (Every 8 Hours). 3. sulfamethoxazole-trimethoprim 400-80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 5. Dextrose 50% 12.5 gm IV PRN hypoglycemia protocol 6. tacrolimus 0.5 mg Capsule Sig: One (1) Capsule PO Q12H (every 12 hours): trough level every Monday & Thursday. 7. prednisone 5 mg Tablet Sig: 3.5 Tablets PO DAILY (Daily): see printed taper schedule. 8. mycophenolate mofetil 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 9. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 10. cefazolin 10 gram Recon Soln Sig: Two (2) gram Injection Q12H (every 12 hours): started [**4-27**]. continue until [**6-7**] for MSSA bacteremia. . 11. valganciclovir 450 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day): cmv prophylaxis. 12. amlodipine 5 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily): hold for sbp <110 or HR <60. 13. hydralazine 10 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours): hold for sbp <110. 14. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): hold for sbp<100 or hr<60 . 15. clonidine 0.2 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 16. hydromorphone 2 mg Tablet Sig: 0.5-1 Tablet PO every four (4) hours as needed for pain. 17. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 18. ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 19. olanzapine 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 20. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 21. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 22. insulin glargine 100 unit/mL Solution Sig: Nine (9) units Subcutaneous at bedtime. 23. insulin lispro 100 unit/mL Solution Sig: see printed sliding scale Subcutaneous four times a day. 24. Labs Work Every Monday and Thursday stat cbc, chem 10, ast, alt, alk phos, t.bili, albumin, UA and trough prograf fax results to [**Telephone/Fax (1) 697**] 25. Meds Do not adjust medications without discussing with [**Hospital1 18**] [**Hospital1 1326**] Office [**Telephone/Fax (1) 673**] Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: autoimmune hepatitis/cirrhosis s/p liver [**Location (un) **] biliary anastomosis stricture MSSA bactereima right hand cellulitis DM II Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You will transfer to [**Hospital1 **] Rehab in [**Location (un) 701**] [**Hospital1 18**] [**Hospital1 1326**] [**Telephone/Fax (1) 673**] should be called if any fever (101 or greater), chills, nausea, vomiting, inability to eat/drink or take medications, increased abdominal pain or distension, incision or abdominal wound redness/bleeding/drainage Labs need to be drawn every Monday and Thursday and sent to [**Hospital1 18**] for Stat processing. Followup Instructions: Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2172-5-28**] 9:50 Provider: [**Name10 (NameIs) **] SOCIAL WORKER Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2172-5-28**] 10:40 Provider: [**First Name11 (Name Pattern1) 819**] [**Last Name (NamePattern4) 820**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2172-6-4**] 9:50 Completed by:[**2172-5-21**]

[ "455.3", "293.0", "571.42", "571.5", "996.82", "357.2", "682.4", "578.9", "585.6", "338.4", "790.4", "250.60", "V58.65", "714.0", "790.7", "266.2", "041.11", "572.2", "456.8", "E878.0", "E849.7", "576.2", "456.21", "403.91", "584.5", "041.19" ]

icd9cm

[ [ [] ] ]

[ "96.04", "88.72", "50.11", "45.23", "38.97", "51.85", "38.93", "50.59", "96.71", "96.6", "00.93", "51.87" ]

icd9pcs

[ [ [] ] ]

12917, 12989

5065, 10121

289, 400

13169, 13169

2668, 5042

13823, 14272

1847, 1865

10393, 12894

13010, 13148

10147, 10370

13347, 13800

1880, 2649

244, 251

428, 1123

13184, 13323

1145, 1648

1664, 1831

66,768

176,145

42153

Discharge summary

report

Admission Date: [**2150-9-9**] Discharge Date: [**2150-9-15**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 5129**] Chief Complaint: Jaundice, Dilated CBD Major Surgical or Invasive Procedure: ERCP - [**9-10**] PICC placement by IR -- [**9-11**] History of Present Illness: 89 y/o F with DM, HTN and gout who initially presented to [**Location (un) 21541**] Hospital with painless jaundice that she says developed over the past day. She denied any associated abdominal pain, n/v/d, constipation, or blood in her stool. She does admit to drinking one small drink with vodka per day, but denies ever being told that she liver problems in the past. At [**Hospital3 **] Hospital her labs were notable for a white count of 10.6, alk phos of 394, total bilirubin of 31.2, direct bilirubin of 28.7, Albumin of 2, AST of 102, ALT of 51, Cr of 2.95, bicarb of 14 and an INR of 7.0. An ultrasound of her abdomen showed a heterogenous liver with nodular edge suspicious for cirrhosis, patent portal vein, thickened gall bladder wall, CBD dilated to 20mm and medium amount of ascites. Given the concern for biliary obstruction she was transferred to [**Hospital1 18**] for ERCP, hepatology and surgery evaluations. She was also given 5mg of vitamin K and 1 pack of FFP before transfer. . In the ED, initial VS were: 98.7, 90, 126/57, 18, 100% RA. Labs here showed a t-bili of 36.6, d-bili of 29.1, AP of 379, Cr of 3.3, bicarb of 14, WBC of 12.6 (2 metas, 2 myelos) and an INR of 7.0. A repeat RUQ U/S again showed a likely cirrhotic liver with CBD dilatation to 1.5cm and moderate ascites. She was seen by surgery and discussed with hepatology and ERCP, the decision was made to attempt to reverse her coagulopathy and get an ERCP. She was given zosyn and vancomycin for possible cholangitis, although she has been afebrile. She was also given another 10mg of IV vitamin K. She also was found to be a difficult stick and developed a large hematoma on her right hand post an attempt at IV placement. . On arrival to the ICU initial VS were: 97.6, 92, 125/61, 16, 99% on RA. She currently is complaining of right hand pain at the site of her hematoma, and will also admit to about one week of easy bruising and ankle edema prior to admission. She denies any n/v/d, constipation, abdominal pain or fever/chills. Past Medical History: Atrial fibrillation on coumadin Diabetes on insulin Hypertension Gout GERD CKD (stage III, baseline 2.6 [**3-6**]) Social History: Married, lives in [**Location 23723**] on [**Hospital3 **] with her Husband. [**Name (NI) **] to do ADL, has hired help for IADL. Husband with poor mobility. Son is involved in care. Handles her own meds. - Tobacco: never - Alcohol: 1oz vodka with soda nightly - Illicits: Denies Family History: No FH autoimmune disease, liver disease, or GI disease, including IBD/UC. Mother with diabetes. Physical Exam: Admission Physical Exam: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema . Discharge Physical Exam: Pertinent Results: Admission Labs: [**2150-9-9**] 06:50PM WBC-12.6* RBC-4.00* HGB-12.6 HCT-37.4 MCV-94 MCH-31.5 MCHC-33.7 RDW-17.8* [**2150-9-9**] 06:50PM NEUTS-74* BANDS-0 LYMPHS-11* MONOS-8 EOS-3 BASOS-0 ATYPS-0 METAS-2* MYELOS-2* [**2150-9-9**] 06:50PM HYPOCHROM-1+ ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-1+ POLYCHROM-NORMAL SPHEROCYT-1+ TARGET-1+ [**2150-9-9**] 06:50PM PLT SMR-NORMAL PLT COUNT-322 [**2150-9-9**] 06:50PM PT-64.3* PTT-53.7* INR(PT)-7.1* [**2150-9-9**] 06:50PM GLUCOSE-60* UREA N-48* CREAT-3.3* SODIUM-137 POTASSIUM-3.7 CHLORIDE-106 TOTAL CO2-14* ANION GAP-21* [**2150-9-9**] 06:50PM ALT(SGPT)-50* AST(SGOT)-93* ALK PHOS-379* TOT BILI-36.6* DIR BILI-29.1* INDIR BIL-7.5 [**2150-9-9**] 06:50PM LIPASE-7 [**2150-9-9**] 06:50PM ALBUMIN-2.7* CALCIUM-8.4 PHOSPHATE-4.5 MAGNESIUM-2.4 [**2150-9-9**] 06:50PM HBsAg-NEGATIVE HBc Ab-NEGATIVE HAV Ab-NEGATIVE [**2150-9-9**] 06:50PM HCV Ab-NEGATIVE [**2150-9-9**] 06:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2150-9-9**] 07:21PM GLUCOSE-55* LACTATE-2.4* K+-3.6 . Microbiology: [**2150-9-9**] URINE CULTURE (Final [**2150-9-11**]): ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 16 I CEFAZOLIN------------- <=4 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- <=16 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- =>16 R . blood culture ([**9-9**]): pending . Imaging: RUQ ultrasound ([**9-9**]): 1. No evidence of cholecystitis. Large amount of gallbladder sludge identified without evidence of stones. 2. The common bile duct demonstrates increasing dilatation towards the level of the pancreatic head, suggestive of obstruction. No common bile duct stone or pancreatic head mass definitely identified. Recommend ERCP for further evaluation. 3. Coarse echogenic liver texture suggestive of cirrhosis. 4. Moderate amount of ascites. 5. Low amplitude portal venous flow, could suggest impending reversal of flow. . XR hand ([**9-9**]): 1. Massive soft tissue swelling at dorsum of hand, tracking proximally. 2. Query erosive changes at dorsum of radius - is osteomyelitis a clinical concern. 3. No discrete fracture. 4. Chondrocalcinosis. 5. Degenerative changes of the wrist and hand as described above. 6. Possible CPPD involving the ulnocarpal joint. . TTE ([**9-11**]): The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 0-5 mmHg. 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. There is no ventricular septal defect. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. The left ventricular inflow pattern suggests impaired relaxation. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. . ERCP ([**9-10**]): - Moderate diffuse biliary dilation . Likely common bile duct stricture. - Possible extravasation of contrast at level of tumor. Given possible extravasation of contrast and presentation with cholangitis, detailed cholangiogram was not obtained. - Likely distal pancreatic duct stricture - Sphincterotomy was performed - Cytology samples were obtained for histology using a brush. - Successful placement of a 7cm by 10 FR biliary stent - Successful placement of a 5cm by 5FR pancreatic stent - Otherwise normal ercp to third part of the duodenum Recommendations: - Follow for response and complications. If any abdominal pain, fever, jaundice, gastrointestinal bleeding please call ERCP fellow on call - Consider CT abd to further evaluate pancreas once renal function improves. - Repeat ERCP in 2 months. . Renal ultrasound ([**9-12**]): pending IMPRESSION: Normal kidneys bilaterally, without obstruction COMMON BILE DUCT BRUSHINGS Procedure Date of [**2150-9-10**] Distal common bile duct brushing: POSITIVE FOR MALIGNANT CELLS, consistent with adenocarcinoma. Brief Hospital Course: 89 y/o F with a h/o HTN and DM who initially presented to [**Location (un) 21541**] Hospital complaining of one day of jaundice, found to have an obstructive pattern of jaundice on LFT's and imaging, likely a more chronic process given the degree of CBD dilatation seen on abdominal ultrasound. . #) Hyperbilirubinemia: On presentation the patient had a high bilirubin level (36.6) and was obviously jaundiced. She was treated with Zosyn for empiric coverage of cholangitis. ERCP was performed on [**9-10**] revealing obstruction at the distal main pancreatic duct. Brushing was performed for cytologic study, which revealed cancer cells. . . #) Acute Kidney Injury: On presentation the patient was found to have a Cr of 3.3. The patient denies any history of CKD, but her baseline Cr is unknown. Hydration did not improve her renal function, and she continued to have low urine output and her creatinine continued to rise. She was seen by Nephrology and dialysis was not felt to extend life and, on discussion with the patient with family was not pursued. She does not wish to have dialysis even when she develops symptoms of uremia. She is making no urine to speak and we are aware of this. # Communication:Son, [**Name (NI) **] [**Name (NI) **] ([**Telephone/Fax (1) 91423**]) # Code: DNR/DNI/CMO per discussion with the patient on [**9-14**] and [**9-15**]. Family is in agreement. # Disposition: Hospice at [**Hospital1 1501**]. Given the pancreatic/billiary cancer, endstage liver and kidney disease, her age, and poor prognosis, the patient wished to move forward with comfort measures only and hospice care. Family meetings were held which included her son [**Name (NI) **], and everyone is in agreement. Medications on Admission: - Colchicine 0.6 mg daily PRN - Atenolol 50 mg [**Hospital1 **] - Allopurinol 200mg daily - Omeprazole 20mg daily - Novolin 70/30 20u QAM - Novolin 70/30 6u QPM - Simvastatin 10 - Cardizem 240 mg Discharge Medications: 1. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical TID (3 times a day) as needed for rash. 2. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 3. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 4. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig: Five (5) mg PO Q2H (every 2 hours) as needed for pain. Discharge Disposition: Extended Care Facility: Eagle [**Hospital **] Rehabilitation Center - [**Location 23723**] Discharge Diagnosis: Pancreatic cancer Renal failure Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were diagnosed with inoperable cancer of the bile ducts/pancreas. Your kidney function worsened and your kidneys shut down. You are no longer making urine, which can happen when the liver fails from bile duct/pancreatic cancer. You chose to not have continued aggressive care, and your treating team at the [**Hospital1 **] as well as your family agreed that this is the best course of action given the poor prognosis associated with the kidney failure and the cancer. You decided on hospice care and comfort measures only. Followup Instructions: You will be followed by the physician at the skilled nusing facility where you will be receiving your hospice care.

[ "599.0", "578.9", "041.4", "585.3", "250.00", "V58.67", "274.9", "427.31", "276.2", "584.9", "576.1", "V58.61", "157.8", "576.2", "571.5", "280.0", "403.90" ]

icd9cm

[ [ [] ] ]

[ "38.93", "51.14", "51.87", "52.93", "51.85" ]

icd9pcs

[ [ [] ] ]

10487, 10580

8124, 9847

273, 327

10656, 10656

3500, 3500

11384, 11503

2849, 2947

10094, 10464

10601, 10635

9873, 10071

10832, 11361

2987, 3454

211, 235

355, 2396

3516, 8101

10671, 10808

2418, 2535

2551, 2833

3481, 3481

22,792

148,623

46467

Discharge summary

report

Admission Date: [**2175-6-18**] Discharge Date: [**2175-6-29**] Date of Birth: [**2096-5-21**] Sex: M Service: MEDICINE Allergies: Penicillins / Percocet / Sulfa (Sulfonamides) / Niacin / Shellfish Derived / Iodine; Iodine Containing / Fruit Flavor Attending:[**First Name3 (LF) 7651**] Chief Complaint: Heart Failure Exacerbation Major Surgical or Invasive Procedure: Right heart catheterization History of Present Illness: The patient is a 79 year old male with a complicated past medical history, including bioprosthetic mitral valve ([**2170**]), coronary artery disease (s/p LAD CABG [**2170**]), congestive heart failure with preserved LV function, severe pulmonary artery hypertension, permanent atrial fibrillation, chronic right diaphragm paralysis, s/p left pleural effusion and peel with VATS decortication [**2173**] who presents with decompensated heart failure. . The patient was hospitalized at the [**Hospital1 18**] from [**2175-4-25**] through [**2175-4-30**] with shortness of breath. This is felt to be secondary to his pulmonary hypertension as well as decompensated diastolic heart failure. The patient is followed by Dr. [**Last Name (STitle) 575**], and pulmonary was consulted during that hospitalization. He was continued on his home sildenafil, with the hope that adequate diuresis and attention optimizing renal function and keeping his Sat's at or over mid 90's he can get to and remain at his basseline functional level. The patient was aggressively diuresed in the hospital. The patient does have atrial fibrillation for which he has been treated with Coumadin and digoxin. The digoxin was discontinued as he was digoxin toxic. The patient was having diarrhea during his hospitalization and found to be positive for Clostridium difficile, and was treated with a 14d course of flagyl. In subsequent follow up, the patient had improved dyspnea, but still remained modestly fluid overloaded. His diuretic regimen has underone continued titration. . It is interesting to note that 3 weeks prior to presentation, he was started by his pulmonology provider in [**Name9 (PRE) 108**] on ambrisentan. Over the last 2 weeks, he has noted increasing lower extremity edema. His weight continued to rise on his home scale, with a dry weight of around 157 lbs now up to 167. It seems metolazone had been added to his diurectic regimen, but he continued to have worsening edema. He also reports mild increase in fatigue and dyspnea. He has stable orthopnea. He denies any fevers, chest pain, palipitations, and only stable lightheadedness when rising to a standing position. With these symptoms, the patient decided to return early from [**State 108**] for medical evaluation. . . On arrival to the [**Hospital1 18**] ED, inital vitals were 97.4, 140/70, 80, 24, 96% on 2L. He remained hemodynamically stable throughout his ED course. He was admitted to the [**Hospital Unit Name 196**] service for further manegment. . On review of systems, he denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. He denies recent fevers, chills or rigors. He denies exertional buttock or calf pain. All of the other review of systems were negative. *** Cardiac review of systems is notable for absence of chest pain, palpitations, syncope or presyncope. Past Medical History: 1. Temporal lobe epilepsy - The patient is followed by Dr. [**Last Name (STitle) **] in [**Hospital 878**] Clinic. 2. Hypothyroidism 3. Atrial fibrillation - The patient's anticoagulation is followed by Dr. [**Last Name (STitle) 696**]. 4. Right phrenic nerve paralysis 5. CAD status post CABG - [**2170**] 6. Hypertension 7. Hypercholesterolemia 8. Nephrolithiasis 9. Severe Pulmonary hypertension 10. Epistaxis 11. Lower extremity edema 12. Weight loss 13. Cervical myelopathy - The patient denies any discomfort at this time. 14. Left fibrothorax and hemothorax status post decortication 15. Restrictive lung disease - PFTs [**8-16**] with FEV1 36% predicted 16. OSA . PAST SURGICAL HISTORY: 1. Status post left video-assisted thorascopic surgery decortication and flexible bronchoscopy for left thorax plus clotted hemothorax - [**2173-10-20**] 2. Status post CABG - [**2170**] 3. Status post mitral valve replacement - [**2170**] Social History: Spends half his time in [**State 108**] and half his time in [**Location (un) 86**]. Lives with his wife. [**Name (NI) **] [**Name2 (NI) 5927**] in home. Walks independently and was very funcional prior to admission. -Tobacco history: 30 pack year smoking history, quit 40 years ago -ETOH: occasional -Illicit drugs: none Family History: No family history of early MI, arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: VS: 131/82 97.4 101 20 97% on 3L; 76.1kg Gen: Sleeping in an erectly seated position. NAD, but using accessory muscles to breath. Tan dry skin. HEENT: MMM, prominent JVD with pulsation at the mandible CV: Tachycardic and irregular. PMI 5th ICS, MCL. S1, S2, without murmurs, gallops, or rubs. Pulm: Decreased breath sounds at the left base, b/l basilar crackles. Abd: Soft, NTND Ext: Woody LE edema with chronic venous stasis changes, but softer 2+ edema extending from 2/3 up ship to groin and scrotom. Pertinent Results: Admission labs: [**2175-6-18**] 07:10PM WBC-6.4 RBC-3.78* HGB-12.4* HCT-36.7*# MCV-97 MCH-32.7* MCHC-33.7 RDW-15.7* [**2175-6-18**] 07:10PM NEUTS-75.8* LYMPHS-16.7* MONOS-6.3 EOS-0.9 BASOS-0.3 [**2175-6-18**] 07:10PM PLT COUNT-123* [**2175-6-18**] 07:10PM GLUCOSE-108* UREA N-112* CREAT-2.8*# SODIUM-127* POTASSIUM-3.6 CHLORIDE-80* TOTAL CO2-29 ANION GAP-22* [**2175-6-18**] 07:10PM ALT(SGPT)-24 AST(SGOT)-34 CK(CPK)-104 ALK PHOS-153* TOT BILI-1.5 [**2175-6-18**] 07:10PM CK-MB-5 proBNP-3147* [**2175-6-18**] 07:10PM cTropnT-0.08* [**2175-6-18**] 07:10PM PT-23.2* PTT-33.2 INR(PT)-2.2* . Imaging: ECG Study Date of [**2175-6-18**] Atrial fibrillation. Incomplete right bundle-branch block. Prior anterolateral myocardial infarction. Consider also possible right ventricular overload or possible left posterior fascicular block. Modest inferior lead T wave changes are non-specific. Clinical correlation is suggested. Since the previous tracing of [**2175-4-26**] ventricular rate is faster. Otherwise, there is probably no significant change. Intervals Axes Rate PR QRS QT/QTc P QRS T 96 0 108 394/457 0 108 -6 . CHEST (PA & LAT) Study Date of [**2175-6-18**] 1. Mild volume overload. 2. Confluent left lower lobe consolidation could reflect a combination of atelectasis, edema and effusion; however, superimposed pneumonia is not excluded. . TTE (Complete) Done [**2175-6-19**] The left and right atria are markedly dilated. No left atrial mass/thrombus seen (best excluded by transesophageal echocardiography). No atrial septal defect is seen by 2D or color Doppler. The estimated right atrial pressure is 10-20mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). The right ventricular cavity is moderately dilated with moderate global free wall hypokinesis. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic arch and descending thoracic aorta are mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. A well seated bioprosthetic mitral valve prosthesis is present with mobile leaflets and normal gradient. No mitral regurgitation Moderate [2] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2175-4-26**], the estimated pulmonary artery systolic pressure is slightly lower. The other findings are similar. . RENAL U.S. Study Date of [**2175-6-20**] CONCLUSION: No hydronephrosis. Bilateral simple renal cysts. . CT HEAD W/O CONTRAST Study Date of [**2175-6-20**] IMPRESSION: Limited study due to patient motion. No large intracranial hemorrhage or parenchymal edema. . Cardiac Cath Study Date of [**2175-6-23**] *** Not Signed Out *** COMMENTS: 1. Limited resting hemodynamics demonstrated elevated left sided filling pressures. PCW mean was 20 mmHg. Right sided filling pressures were mildly elevated with RVEDP of 10 mmHg and RA mean of 13 mmHg. There was severe pulmonary hypertension with PA pressure of 55/18 mmHg, mean of 35 mmHg. Of note, large V waves present on PCW tracing. The cardiac output, calculated using an assumed oxygen consumption, was 6.3 l/min. Pulmonary vascular resistance was calculated at 191 dynes-sec/cm5. FINAL DIAGNOSIS: 1. Elevated left sided and right sided filling pressures. 2. Severe pulmonary hypertension. . labs at discharge: Brief Hospital Course: The patient is a 79 year old man with severe pHTN, congestive heart failure, CAD s/p CABG, AF on coumadin, and restrictive lung disease on 2L home O2 who was admitted with decompensated heart failure, is now s/p R heart cath on [**2175-6-23**], whose post cath course has been complicated by admission to CCU for R groin hematoma, 10 point Hct drop, hypotension. . # Acute on chronic congestive heart failure, right-sided: The patient presented significantly fluid overloaded on exam with JVP elevated to his mandible (although has moderate TR,) worsening LE edema, pulmonary edema on CXR, and weight up by 10lbs in the last month. He has normal LV function on last TTE, with R-sided HF mostly due to moderate to severe pulmonary hypertension with dilated and mildly hypokinetic right ventricle. Ambrisentan, a new medication for him, may be worsening his LE edema. He had a repeat TTE that showed slightly lower estimated pulmonary artery systolic pressure of 32 to 38 mm Hg (although the degree of tricuspid regurgitation likely means that this is UNDERestimated. He had a right-sided cardiac cath (see below). He was diuresed well on a Lasix gtt, which was briefly held in the setting of the acute bleed (see below), however was restarted on his home diuretic regimen of Toresemide 40 mg daily and Metalazone 2.5 mg daily. His discharge weight was 68 kg His metoprolol was also titrated up to a total of 25 mg TID for improved rate control. Please change to toprol XL if pt tolerates this increased dose. . # Pulmonary HTN: As above, patient has severe pHTN, followed by Dr. [**Last Name (STitle) 575**]. Has been on Sildenafil, with good response, although had persisently elevated PA pressures on TTE in the 50-70 range. He had recently been started on Ambrisentan, with improvement of PA pressures per OSH records. His right-heart cath showed elevated left sided filling pressures with PCW mean of 20 mmHg. It was felt that his pulmonary HTN was due to diastolic, L-sided congestive heart failure. His sildenafil and ambrisentan were discontinued. Pulmonary service was consulted and agreed. With diuresis in the hospital, his right ventricular size became smaller and the left ventricle slightly larger. He should avoid volume loading either orally or with intravenous fluids in the future as this could exacerbate right ventricular dilatation and consequent compression of the left ventricle. . # R groin hematoma: The pt was briefly transferred to CCU after he triggered on the floor for a 10 pt Hct drop, hypotension, and tachycardia and he was found to have a large R groin hematoma. He was transfused 2u PRBC's and 1u FFP through his CCU course and he hemodynamically stabilized. A R groin ultrasound showed a hyperechoic region consistent with the hematoma with no pseudoaneurysm and no flow obstructions, other than some displacement of the common femoral vein. His right thigh is swollen and stiff as the ecchymosis tracks down the leg. He has mild discomfort and impaired ability to walk because of this. . # Coronary Artery Disease: He has a history of prior CABG but had no complaints of chest pain. He was continued on his home cardiac medications. . # Atrial fibrillation: The patient has a history of permanent AF. His metoprolol was titrated up to a total of 75 mg daily for improved rate control. He was maintained on coumadin with goal of [**3-15**]. Please check INR on [**7-1**]. . # Acute on Chronic Renal Failure: Patient has a baseline creatinine of 1.6, but was up to 2.8 on presentation. This is most likely due to poor forward flow as his creatinine improved with diuresis. He had a renal ultrasound that did not show hydronephrosis. His creatinine on [**6-29**] was 1.6. . # Mitral valve replacement, bioprosthetic: He was continued on warfarin for INR goal of [**3-15**]. . # Hypercholesterolemia: His LDL is within target, and he was continued on simvastatin. . # Hypothyroidism: He was continued on Synthroid. He should have his TSH checked as an outpatient as last value in our system in [**Month (only) 958**] revealed a TSH of 21. . # GERD: HE was continued on his home PPI. . Code: Full Code Medications on Admission: Astepro nasal spray, once spray daily Availnex 750mg [**Hospital1 **] CARBAMAZEPINE [TEGRETOL XR] - 200 mg [**Hospital1 **] DORZOLAMIDE [TRUSOPT] - (Prescribed by Other Provider) - 2 % Drops - 1 (One) drop in each eye twice a day LEVOTHYROXINE [SYNTHROID] - 125 mcg DAILY METOPROLOL TARTRATE - 25 mg [**Hospital1 **] OMEPRAZOLE - 20 mg DAILY SILDENAFIL [REVATIO] - 20 mg TID SIMVASTATIN - 20 mg DAILY TESTOSTERONE CYPIONATE 300mg injected intramuscularly every 3 weeks TORSEMIDE - 40 mg [**Hospital1 **] WARFARIN 3MG EVERY Mon-Wed-[**Hospital1 **]-Sun 2MG Tue and Sat FERROUS SULFATE 325 mg daily LETAIRIS 5MG QOD MVI METMOLAZONE 2.5mg daily Discharge Medications: 1. Carbamazepine 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 2. Dorzolamide 2 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 3. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 5. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. Ferrous Sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Metolazone 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Torsemide 20 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 10. Warfarin 2 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. 11. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 2 days: HOLD SBP <100, HR < 55. 12. Toprol XL 50 mg Tablet Sustained Release 24 hr Sig: 1.5 Tablet Sustained Release 24 hrs PO once a day: Please START only if pt tolerates Metoprolol 25 mg TID, then D/C Metoprolol Tartrate. Hold HR < 55, SBP < 100. 13. Outpatient Lab Work Please check Chem 7 and INR on Saturday [**7-1**] Discharge Disposition: Extended Care Facility: Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**] Discharge Diagnosis: Primary: Acute on chronic diastolic heart failure Secondary: Coronary artery disease Atrial fibrillation Pulmonary hypertension Temporal lobe epilepsy Hypothyroidism Hypertension Hypercholesterolemia Discharge Condition: Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Mental Status: Clear and coherent. Discharge Instructions: You were admitted for shortness of breath. This was from too much fluid in your lungs as well as your legs. You were started on IV diuretics to help get rid of the fluid. With this, we also saw an improvement in your kidney function. While you were here, we performed a right-sided heart cardiac catheterization. We found that your pulmonary hypertension (or elevated blood pressure in your lungs) was due to heart failure and NOT due to lung disease. Thus, we have stopped your sildenafil (Revatio) and ambrisenten. To make sure you don't reaccumulate fluid anymore, please weigh yourself every morning. If your weight goes up by more than 3 lbs in 1 day or 6 pounds in 3 days, please call Dr. [**First Name (STitle) 437**] or [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] to have your torsemide dose adjusted. The following changes were made to your medications: 1. Your sildenafil (Revatio) has been STOPPED. 2. Your ambrisenten (Letairis) has been STOPPED. 3. Your testosterone has been STOPPED, please talk to Dr. [**Last Name (STitle) **] about restarting 4. Your Astepro has been STOPPED 5. Your metoprolol was increased to 25 mg three times a day. You will be changed to Toprol (a long acting Metoprolol) in a few days if your heart rate is OK on the increased dose. 6. Your coumadin was decreased to 2 mg daily. Your goal INR is 2.0-3.0. The rest of your medications have not changed. Please continue to take them as originally prescribed. Followup Instructions: Heart Failure Clinic: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] with Dr. [**First Name8 (NamePattern2) 401**] [**Last Name (NamePattern1) 437**] Phone: [**Telephone/Fax (1) 62**] Date/time: Tuesday [**7-4**] at 12:30pm. [**Hospital Ward Name 23**] [**Location (un) 436**]. Your other previously scheduled appointments are: Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 719**] Date/Time:[**2175-7-7**] 8:30 Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2175-7-11**] 9:30 Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2175-7-11**] 9:30

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icd9cm

[ [ [] ] ]

[ "89.68" ]

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33754

Discharge summary

report

Admission Date: [**2103-4-2**] Discharge Date: [**2103-4-11**] Date of Birth: [**2029-10-22**] Sex: M Service: CARDIOTHORACIC Allergies: Penicillins / Sulfa (Sulfonamides) / Zinc/Petrolatum,White Attending:[**First Name3 (LF) 1283**] Chief Complaint: Occasional chest tightness Major Surgical or Invasive Procedure: [**2103-4-3**] Replacment of Ascending Aorta and Hemiarch(34mm Gelweave Graft) and Single Vessel Coronary Artery Bypass Grafting utilizing the left internal mammary artery to left anterior descending artery. History of Present Illness: Dr. [**Known lastname **] is a 73 year old male who underwent nasal surgery in [**2102-9-30**] which was complicated by atrial fibrillation, bradycardia and hypotension. Cardiac evaluation at that time revealed single vessel coronary artery disease and ascending aortic aneurysm measuring 6.4 centimeters. Echocardiogram showed only mild aortic insufficiency and an LVEF of 65%. Based upon the above, he was referred for cardiac surgical intervention. Past Medical History: Ascending Aortic Aneurysm Coronary Artery Disease History of Atrial Fibrillation Elevated Cholesterol Obesity Benign Prostatic Hypertropy Peripheral Neuropathy Cholelithiasis Nasal Surgery Tonsillectomy Umbilical Hernia Repair Prior ORIF Right Radial Fracture Social History: He is a physician. [**Name10 (NameIs) 78079**], live with his wife. Quit [**Name2 (NI) 78080**] in [**2058**]. Quit pipe [**2085**]. Admits to one ETOH drink/day. Family History: Denies premature coronary artery disease. Physical Exam: ADMISSION EXAM: Vitals: 150/84, 84, 18, 98% RA General: WDWN elderly male in no acute distress HEENT: Oropharynx benign, EOMI, slight bilateral ptosis Neck: Supple, no JVD, no carotid bruits Lungs: CTA bilaterally Heart: Regular rate and rhythm, faint systolic ejection murmur Abdomen: Soft, nontender with normoactive bowel sounds. Obese. Ext: Warm, no edema Pulses: decreased distally Neuro: Alert and oriented, CN 2- 12 grossly intact, no focal deficits noted Pertinent Results: [**2103-4-10**] 05:35AM BLOOD WBC-9.8 RBC-3.49* Hgb-10.8* Hct-32.6* MCV-93 MCH-30.9 MCHC-33.1 RDW-15.8* Plt Ct-412 [**2103-4-11**] 05:30AM BLOOD PT-18.4* INR(PT)-1.7* [**2103-4-10**] 05:35AM BLOOD PT-17.6* INR(PT)-1.6* [**2103-4-9**] 05:45AM BLOOD PT-14.8* INR(PT)-1.3* [**2103-4-8**] 07:25AM BLOOD PT-13.6* PTT-30.5 INR(PT)-1.2* [**2103-4-10**] 05:35AM BLOOD Glucose-89 UreaN-16 Creat-0.9 Na-140 K-4.2 Cl-101 HCO3-30 AnGap-13 [**2103-4-3**] Intraop TEE: Pre Bypass: There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. The ascending aorta is markedly dilated, (6.9 cm in proximal ascending, 5.6 cm at the distal ascending just prior to the aortic arch. The aortic arch is moderately dilated. There are complex (>4mm) atheroma in the aortic arch. The descending thoracic aorta is moderately dilated and tortuous. There are complex (>4mm) atheroma in the descending thoracic aorta. There are three aortic valve leaflets. The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The aortic regurgitation jet is eccentric, directed toward the anterior mitral leaflet. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. Post Bypass: Patient is a-paced on phenylepherine infusion. Preserved biventricular function LVEF >55%. Aortic Insufficiency is now trace to mild. A tube graft is partially visualized above the sinotubular junction extending into the ascending aorta. Flow appears laminar in the proximal graft. Remaining aortic contours intact. Remaining exam is unchanged. All findings discussed with surgeons at the time of the exam. [**2103-4-9**] Chest x-ray: A small right apical pneumothorax is slightly decreased in size with chest tube remaining in place in the lower right hemithorax. Cardiomediastinal contours are stable in the postoperative period. Small left pleural effusion is again demonstrated. A small amount of subcutaneous emphysema is present in the right chest wall adjacent to the chest tube insertion site. CHEST (PA & LAT) [**2103-4-10**] 9:14 AM CHEST (PA & LAT) Reason: r/o ptx [**Hospital 93**] MEDICAL CONDITION: 73 year old man with REASON FOR THIS EXAMINATION: r/o ptx HISTORY: 73-year-old man status post coronary artery bypass and ascending aortic replacement. COMPARISON: [**2103-4-9**]. CHEST PA AND LATERAL: The post-operative appearance of the cardiac, mediastinal and hilar contours are unchanged. Pulmonary vasculature is unremarkable. The lungs are clear. The small right apical pneumothorax is unchanged. Small bilateral pleural effusions are stable. Right-sided chest tube is again noted. IMPRESSION: Unchanged small right pneumothorax. [**2103-4-10**] 05:35AM BLOOD WBC-9.8 RBC-3.49* Hgb-10.8* Hct-32.6* MCV-93 MCH-30.9 MCHC-33.1 RDW-15.8* Plt Ct-412 [**2103-4-11**] 05:30AM BLOOD PT-18.4* INR(PT)-1.7* Brief Hospital Course: Dr. [**Known lastname **] was admitted on [**4-2**]. Preoperative evaluation was unremarkable and he was cleared for surgery. On [**4-3**], Dr. [**Last Name (STitle) 1290**] performed replacement of ascending aorta and hemiarch along with coronary artery bypass grafting surgery. For surgical details, please see seperate dictated operative note. Following the operation, he was brought to the CVICU for invasive monitoring. Within 24 hours, he awoke neurologically intact and was extubated without incident. Low dose beta blockade was resumed and diuretics were initiated. He maintained stable hemodynamics and transferred to the SDU on postoperative day two. He experienced atrial fibrillation on postoperative day three and was started on Amiodarone. He successfully converted back to normal sinus rhythm. Amiodarone was titrated accordingly and beta blockade was advanced as tolerated. Given his history atrial fibrillation, he was started on Warfarin. Dr. [**Known lastname **] also required replacement of a right sided chest tube for a residual pneumothorax. He was followed closely by serial chest x-rays and by discharge, his pneumothorax had significantly improved and his chest tube was discontinued. Prior to discharge, Dr. [**Last Name (STitle) 1683**] was contact[**Name (NI) **] who agreed to monitor his PT/INR as an outpatient. Warfarin should be dosed for a goal INR between 2.0 - 2.5. First blood draw is scheduled for Friday [**4-13**]. He was eventually cleared for discharge to home on postoperative day #8. Medications on Admission: Metoprolol 25 [**Hospital1 **], Finasteride 5 qd, Lipitor 10 qd, MVI Discharge Medications: 1. 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* 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) for 1 months. Disp:*60 Capsule(s)* Refills:*2* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 4. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 5. Finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed. Disp:*50 Tablet(s)* Refills:*0* 7. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed: Take with food. Disp:*40 Tablet(s)* Refills:*0* 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 9. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 11. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 2 days: Take 5 mg today [**4-11**] and 5 mg [**4-12**];then take as directed by Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] for INR goal of [**3-3**].5. Disp:*30 Tablet(s)* Refills:*0* 12. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months. Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) **] Country Home Care and Hospice Discharge Diagnosis: Ascending Aortic Aneurysm Coronary Artery Disease Postoperative Atrial Fibrillation(History of AF preop) Elevated Cholesterol Obesity Discharge Condition: Good Discharge Instructions: 1)Please shower daily. No baths. Pat dry incisions, do not rub. 2)Avoid creams and lotions to surgical incisions. 3)Call cardiac surgeon if there is concern for wound infection. 4)No lifting more than 10 lbs for at least 10 weeks from surgical date. 5)No driving for at least one month. 6)Monitor PT/INR every Monday, Wed and Friday. Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1683**] will manage Wafarin as an outpatient. INR should be dosed for goal INR between 2.0 - 3.0. Please call results to Dr.[**Last Name (STitle) 1683**] [**Telephone/Fax (1) 78081**].First blood draw Friday [**4-13**]. Followup Instructions: Dr. [**Last Name (STitle) 1290**] in [**5-5**] weeks, call for appt Dr. [**Last Name (STitle) 1683**] in [**3-4**] weeks, call for appt Dr. [**Last Name (STitle) **] in [**3-4**] weeks, call for appt Completed by:[**2103-4-11**]

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icd9cm

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icd9pcs

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1065, 1326

1342, 1506

53,463

183,511

31832

Discharge summary

report

Admission Date: [**2178-8-7**] Discharge Date: [**2178-8-15**] Date of Birth: [**2114-6-9**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 2297**] Chief Complaint: Lethargy Major Surgical or Invasive Procedure: Intubation/ventilation twice History of Present Illness: Mrs [**Known lastname 74676**] is a 64F discharged to rehab 2d prior for admission after mechanical fall and bilateral wrist fx p/w lethargy, now presenting with lethargy and respiratory distress. Per patient's husband, she had been doing well after recent discharge, however he had visited her in rehab earlier today and noted that she was more lethargic than usual. Later on this evening in rehab pt was noted to be more somnolent, without increased SOB or difficulty breathing, and therefore EMS was called. On arrival to the nursing facility, EMS noted a L facial droop. According to her family, pt had no other complaints leading up to this event. . In the ED, initial vitals were 78% on RA RR 20-30, HR 80-100, BPs 150-180 systolic. Pt was initially interacting with family but became confused and unable to answer questions, was SOB with hypoxia to the 70s on 3 L NC. She was given oxycodone and nebs. Given her desaturations to the 70s with tachycardic hypertension and hypercarbia, pt was intubated. CXR showed severe emphysema, head CT was negative. Rectal exam was performed given severe crit drop and was negative. Pt was also seen by neuro out of concern for stroke, however this was thought to be unlikely. .. ROS: (+) Per HPI (-) Denies fever, chills, night sweats, recent weight loss or gain. Denies headache, sinus tenderness, rhinorrhea or congestion. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: COPD/severe emphysema on 3-5L home O2 and FEV1=13% predicted, baseline sat 80-85% HTN anxiety Social History: Independent with ambulation. H/o smoking [**2-1**] ppd for 25 years. Denies alcohol or drugs. Family History: Non-contributory. Physical Exam: On Admission: VS: Temp:98.6 BP: 124/49 HR:102 RR:20 O2sat 98% GEN: intubated, sedated HEENT: PERRL, EOMI, anicteric, MMM, ETT in place, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules CV: RR, S1 and S2 wnl, no m/r/g RESP: CTA b/l, prolongued expiratory phase, no W/r/r ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e SKIN: no rashes/no jaundice/no splinters NEURO: opens eyes to voice, follows commands On discharge: GEN: NAD, sitting up in bed, alert HEENT: Right eye with surrounding ecchymoses, PERRL, EOMI, oral mucosa moist NECK: Supple, no JVD PULM: Minimal air movement on exam without audible wheezing or crackles CARD: RR, nl S1, nl S2, no M/R/G ABD: Soft, BS+, NT, ND EXT: No cyanosis or edema NEURO: Oriented to place, day of week, clinical situation, month and year, not oriented to date (16th) Pertinent Results: ADMISSION LABS: [**2178-8-7**] 09:05PM BLOOD WBC-8.4 RBC-2.92* Hgb-9.2* Hct-28.3* MCV-97 MCH-31.6 MCHC-32.5 RDW-12.2 Plt Ct-382 [**2178-8-7**] 09:05PM BLOOD PT-11.8 PTT-19.1* INR(PT)-1.0 [**2178-8-7**] 09:05PM BLOOD Glucose-113* UreaN-18 Creat-0.5 Na-143 K-4.4 Cl-93* HCO3-44* AnGap-10 [**2178-8-7**] 09:05PM BLOOD ALT-13 AST-24 AlkPhos-45 TotBili-0.4 [**2178-8-7**] 09:05PM BLOOD Calcium-9.4 Phos-4.1 Mg-2.0 [**2178-8-8**] 05:14AM BLOOD calTIBC-226* VitB12-309 Folate-19.3 Ferritn-113 TRF-174* [**2178-8-8**] 02:00AM BLOOD Rates-/25 pO2-56* pCO2-95* pH-7.31* calTCO2-50* [**2178-8-8**] 06:02PM BLOOD Lactate-0.7 DISCHARGE LABS: [**2178-8-15**] 03:12AM BLOOD WBC-10.8 RBC-2.55* Hgb-8.0* Hct-25.3* MCV-99* MCH-31.3 MCHC-31.6 RDW-13.4 Plt Ct-384 [**2178-8-15**] 03:12AM BLOOD Plt Ct-384 [**2178-8-15**] 03:12AM BLOOD Glucose-152* UreaN-18 Creat-0.4 Na-144 K-4.6 Cl-94* HCO3-45* AnGap-10 [**2178-8-15**] 03:12AM BLOOD Calcium-8.8 Phos-4.0 Mg-1.7 ANEMIA W/U: [**2178-8-8**] 05:14AM BLOOD calTIBC-226* VitB12-309 Folate-19.3 Ferritn-113 TRF-174* most recent VBG: [**2178-8-14**] 04:51AM BLOOD Type-[**Last Name (un) **] Temp-37.2 pO2-47* pCO2-93* pH-7.35 calTCO2-54* Base XS-20 Intubat-NOT INTUBA MICRO: [**2178-8-8**] 1:30 am URINE Site: NOT SPECIFIED **FINAL REPORT [**2178-8-9**]** URINE CULTURE (Final [**2178-8-9**]): NO GROWTH. [**2178-8-12**] 10:21 am SPUTUM Source: Endotracheal. GRAM STAIN (Final [**2178-8-12**]): [**11-24**] PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Final [**2178-8-14**]): SPARSE GROWTH Commensal Respiratory Flora. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED. Blood cultures 7/13, [**8-13**]: pending STUDIES: CXR [**2178-8-7**]: IMPRESSION: COPD. No acute cardiopulmonary process. CXR [**2178-8-8**]: The lungs are hyperinflated and the diaphragms are flattened, consistent with COPD. There is probable mild cardiomegaly. There is upper zone redistribution, without other definite evidence of CHF. There is slight prominence of markings at both lung bases, new compared with [**2178-8-7**]. These could represent small pneumonic infiltrates or areas aspiration. The differential includes an atypical distribution of CHF, in the setting of considerable parenchymal scarring, but this is considered less likely. Focal density in the right lung apex appears to represent overlap of vascular and osseous shadows. Attention to this area on followup films is recommended. CT HEAD W/O: IMPRESSION: No acute intracranial process. CXR [**2178-8-8**]: ET tube is in standard position. The tip is 5.7 cm above the carina. NG tube tip is out of view below the diaphragm. Cardiomediastinal contours are normal. There is no pneumothorax or pleural effusion. The lungs are hyperinflated consistent with emphysema. Atelectases in the left base are minimal. CTA CHEST [**2178-8-11**]: IMPRESSION: No CT evidence of central or segmental pulmonary emboli. Panlobular emphysema. Atelectatis in the right lower lobe, right middle lobe and lingula. Stable calcified right adrenal nodule which is likely a sequela to previous adrenal hemorrhage. CXR [**2178-8-14**]: Cardiomediastinal contours are normal. The lungs are hyperinflated consistent with emphysema. There are no lung consolidations or evidence of pulmonary edema, pneumothorax or pleural effusion. Brief Hospital Course: 64 yo woman with history of COPD, presenting from rehab with AMS and lethargy most likely secondary to opioid use, found to be in respiratory distress with hypercarbia and hypoxia. Pt was intubated and transferred to the MICU. # Lethargy/AMS: Initial AMS most likely secondary to medication effect. Patient presented with AMS and lethargy, however was responsive and interactive. O2 requirements and somnolence worsened after a dose of oxycodone while in the ED. MS [**First Name (Titles) 1095**] [**Last Name (Titles) 41963**]d by hypercarbia/hypoxia. Low concern for infectious process initially given no fever, leukocytosis or localizing symptoms prior on admission, nl UA. Cultures revealed no growth to date including blood, sputum, urine, and stool. Her mental status cleared as her hypercarbia improved. # Hypoxia, hypercarbic respiratory distress: Likely due to COPD/severe emphysema on 3-5L home O2 and FEV1=13% predicted. Given recent surgery and sudden onset of sympoms, also considered PE given hypoxia out of proportion to lung disease and ruled out with CTA. No signs of PNA or COPD flare and the inciting insult causing her respiratory failure was thought to be oversedation in someone who is very sensitive given her very poor lung function. Pt was extubated on HOD#1; however, pt again had hypercarbia, and dyspnea requiring re-intubation. She was started on IV steroids and Azithromycin for COPD exacerbation for optimization. She was able to be weaned off the ventilator on [**2178-8-12**] with transition directly to facemask and continued to improve for the next two hospital days. She was discharged on a prednisone taper. She will have continued BiPAP as needed at LTAC. She will continue to follow with Dr. [**Last Name (STitle) 575**] and [**Hospital1 **] as an outpatient for lung transplant evaluation. # L distal radius fx: s/p closure and reduction with improved alignment on post-reduction plain films. Receiving antibiotics to prevent infection and oxycodone and tylenol for pain prior to admission. Completed Keflex 500 mg Capsule QID for 10 days (day 1 was [**2178-8-1**], last day [**2178-8-10**]), Tylenol for pain. Ortho was consulted while an inpatient and repeated x-rays that were unremarkable. Casts were changed on [**2178-8-14**]. She should follow up in ortho clinic after discharge. # HTN: Normotensive on admission, continued lisinopril 20 mg daily, but increased to 30mg daily due to persistent hypertension. # Anxiety: Held clonazepam (prn medication) initially in the MICU given presentation of lethargy as discussed above. Post-extubation, she was given small doses of Ativan for anxiety. Restarted on home Clonazepam prn on discharge, with holding parameters for sedation, or low respiratory rate. # Anemia: Mildly decreased from recent baseline. Pt had no active bleeding and was guaiac negative. Iron studies c/w possible ACD or mixed picture. Vitamin B12 level 309, could consider workup with MMA vs. empiric treatment with Vitamin B12. Could consider outpatient colonoscopy with her PCP, [**Name10 (NameIs) **] would be challenging given sedation issues as above. # Left facial droop: Concern for stroke initially; however, evaluated by neuro who was not concerned for acute stroke. There was no further focal neurologic findings during her MICU course. TRANSITIONAL CARE: 1. CODE: FULL 2. CONTACT: HUSBAND 3. RISKS TO RE-HOSPITALIZATION: severe COPD, requiring intubation 4. MEDICAL MANAGEMENT: steroid taper, start spiriva, continue symbicort, pulmonary rehab at LTAC; try to avoid oversedation with benzos or pain medications Medications on Admission: Medications at home (per last DC summary [**2178-8-2**]): acetaminophen 325 mg Q6H docusate sodium 100 mg [**Hospital1 **] Symbicort 160-4.5 mcg/Actuation [**2-1**] Inh [**Hospital1 **] lisinopril 20 mg DAILY clonazepam 0.5 mg [**Hospital1 **]:PRN oxycodone 5 mg [**2-1**] tab Q3H:PRN ipratropium bromide 17 mcg/Actuation HFA Aerosol 3 puffs TID Keflex 500 mg Capsule QID for 10 days (day 1 was [**2178-8-5**]) Discharge Medications: 1. bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 2. Senna Laxative 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 3. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8 PRN () as needed for pain. 5. insulin regular human 100 unit/mL Solution Sig: One (1) Injection ASDIR (AS DIRECTED): Sliding scale. 6. glucagon (human recombinant) 1 mg Recon Soln Sig: One (1) Recon Soln Injection Q15MIN () as needed for hypoglycemia protocol. 7. quetiapine 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 8. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day. 9. cholecalciferol (vitamin D3) 400 unit Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: 1-2 Puffs Inhalation Q4H (every 4 hours) as needed for sob, wheezing. 11. prednisone 5 mg Tablet Sig: 1-6 Tablets PO once a day: -40mg by mouth daily x 4 days ([**Date range (1) 74677**]) -then 30mg by mouth daily x 4 days ([**Date range (1) 18858**]) -then 20mg by mouth daily x 4 days ([**Date range (1) 57841**]) -then 10mg by mouth x 4 days ([**Date range (1) 74678**]) -then 5mg by mouth x 4 days ([**Date range (1) 74679**]) . 12. dextrose 50% in water (D50W) Syringe Sig: One (1) Intravenous PRN (as needed) as needed for hypoglycemia protocol. 13. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 14. lisinopril 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. docusate sodium 100 mg Tablet Sig: One (1) Tablet PO twice a day. 16. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO twice a day as needed for anxiety: hold for sedation, RR<12. 17. Symbicort 160-4.5 mcg/Actuation HFA Aerosol Inhaler Sig: [**2-1**] puffs Inhalation twice a day. 18. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation once a day. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] TCU - [**Location (un) 701**] Discharge Diagnosis: 1) Severe chronic obstructive pulmonary disease 2) Hypercarbic respiratory failure 3) Hypoxia 4) Bilateral wrist fractures 5) Anxiety 6) Delerium 7) Anemia 8) Hypertension 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 Ms. [**Known lastname 74676**], It was a pleasure taking care of you here at [**Hospital1 18**]. You were admitted for respiratory failure, secondary to sedating pain medications. You intubated twice, and extubated twice, and were slow to recover your breathing function due to your severe lung disease. As you know, continuing to quit smoking, frequent inhaler use as prescribed, and pulmonary physical therapy are the keys to your recovery. In the long term, you should continue to follow with Dr. [**Last Name (STitle) 575**], and [**Hospital6 1708**] for lung transplant evaluation. You were also seen by the orthopedic doctors [**Name5 (PTitle) 1028**] [**Name5 (PTitle) **] were here, and your casts were replaced. We have made the following changes to your medications: 1) START taking prednisone taper starting with -40mg by mouth daily x 4 days ([**Date range (1) 74677**]) -then 30mg by mouth daily x 4 days ([**Date range (1) 18858**]) -then 20mg by mouth daily x 4 days ([**Date range (1) 57841**]) -then 10mg by mouth x 4 days ([**Date range (1) 74678**]) -then 5mg by mouth x 4 days ([**Date range (1) 74679**]) -then stop 2) CONTINUE taking symbicort inhaler twice daily 3) START taking albuterol inhalers every 4 hours 4) START taking spiriva inhaler daily 5) START doing chest physical therapy daily 6) START Seroquel 12.5mg twice daily 7) INCREASE dose of Lisinopril to 30mg daily 8) START Insulin sliding scale as needed for hyperglycemia 9) START Calcium & Vitamin D for bone health Followup Instructions: Please follow up in ortho trauma clinic in [**8-9**] days with [**Doctor Last Name **] [**Name8 (MD) **], NP. Please call [**Telephone/Fax (1) 1228**] to make an appointment. Department: PULMONARY FUNCTION LAB When: TUESDAY [**2178-10-13**] at 9:00 AM With: PULMONARY FUNCTION LAB [**Telephone/Fax (1) 609**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: PFT When: TUESDAY [**2178-10-13**] at 9:00 AM Department: MEDICAL SPECIALTIES When: TUESDAY [**2178-10-13**] at 9:30 AM With: [**First Name11 (Name Pattern1) 1569**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], M.D. [**Telephone/Fax (1) 612**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Completed by:[**2178-8-15**]

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icd9cm

[ [ [] ] ]

[ "97.11", "96.04", "38.97", "96.71", "96.6" ]

icd9pcs

[ [ [] ] ]

12885, 12961

6681, 10276

312, 343

13177, 13177

3182, 3182

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2235, 2254

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81,850

161,970

54024

Discharge summary

report

Admission Date: [**2192-2-22**] Discharge Date: [**2192-2-26**] Date of Birth: [**2152-5-1**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1556**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: [**2192-2-23**] 1. Exploratory laparotomy. 2. Lysis of adhesions with freeing of small bowel obstruction. 3. Liver biopsy (Tru-Cut needle). History of Present Illness: Pt is a 39F who developed central abdominal pain ~18 hours ago. It is accompanied with nausea and dry heaves. She is not really able to vomit. Pain does not radiate. She denies sick contacts. [**Name (NI) **] previous episodes. No recent travel or unusual food. Nl BM this am. + flatus. Past Medical History: 1. s/p open RNY gastric bypass ~9 years ago @ [**Hospital1 2177**], lost 200 lbs 2. s/p open cholecystectomy 3. s/p tummy tuck 4. alcoholism Social History: Very heavy alcohol use. Has 8 children. Family History: Non-contributory Physical Exam: PE: 98.9 92 160/107 10 96RA NAD, looks uncomfortable. Dry heaving No Jaundice or icterus CTA B/L RRR Abd: obese. well-healed midline, RUQ, and low transverse incisions. No hernias. TTP centrall only. No rebound or guarding. no tap or shake tenderness No LE edema Pertinent Results: [**2192-2-22**] 12:55AM WBC-3.1* RBC-4.22 HGB-9.7* HCT-31.6* MCV-75* MCH-23.1* MCHC-30.9* RDW-19.4* [**2192-2-22**] 12:55AM NEUTS-71.0* LYMPHS-21.4 MONOS-6.9 EOS-0.4 BASOS-0.4 [**2192-2-22**] 12:55AM PLT COUNT-91*# [**2192-2-22**] 12:55AM LIPASE-50 [**2192-2-22**] 12:55AM ALT(SGPT)-39 AST(SGOT)-104* ALK PHOS-61 TOT BILI-0.9 [**2192-2-22**] 01:35AM URINE RBC-0 WBC-0-2 BACTERIA-NONE YEAST-NONE EPI-0-2 [**2192-2-22**] 01:35AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-15 BILIRUBIN-SM UROBILNGN-8* PH-8.0 LEUK-NEG [**2192-2-22**] CT Abdomen: 1. Distension of distal portion of efferent limb of Roux-en-Y gastric bypass, just proximal to an area of narrowing. Passage of oral contrast through this narrowing is consistent with efferent limb partial obstruction. 2. Fatty liver. Brief Hospital Course: The patient was admitted to the bariatric surgery service and underwent and exploratory lysis of adhesions and liver biopsy on [**2192-2-22**], which she tolerated well. Post-operatively, she remained intubated in the ICU overnight due to a concern that she would develop significant alcohol withdrawal symptoms given her extremely heavy alcohol use. She was extubated successfully on POD1 without incident. She remained in the ICU and was initially on a benzodiazapine drip per the CIWA scale. On POD2, she required only intermittent administration of benzodiazapines and she was transferred to the floor. She recovered normally from her exploratory laparotomy. On POD3, she was tolerating liquids. On POD4, she was advanced to regular diet and was ready for discharge. The patient expressed an interest in speaking to a social worker; however, she was discharged on a weekend when social work was unavailable. She was discharged to home in good condition with plans to follow up with her attending surgeon in clinic in 2 weeks and with an outpatient social work appointment to be scheduled. Medications on Admission: Omeprazole 20mg daily, Oxybutynin ER 10mg daily, Ambien 10mg qhs, Celexa 20mg qAM, Trazodone 50-100mg qHs Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: [**12-16**] PO BID (2 times a day). 2. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Psyllium Packet Sig: One (1) Packet PO TID (3 times a day) as needed. 7. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 8. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 9. Oxybutynin Chloride 5 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 10. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4H (every 4 hours) as needed. Disp:*100 ML(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Small bowel obstruction Discharge Condition: Good Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. . * Take all new meds as ordered. * Do not drive or operate heavy machinery while taking any narcotic pain medication. You may have constipation when taking narcotic pain medications (oxycodone, percocet, vicodin, hydrocodone, dilaudid, etc.); you should continue drinking fluids, you may take stool softeners, and should eat foods that are high in fiber. * Continue to increase activity daily * No heavy lifting (>[**9-27**] lbs) for 6 weeks. * You may shower and wash. No tub baths or swimming. * Monitor your incision for signs of infections Followup Instructions: Call Dr.[**Name (NI) **] office at ([**Telephone/Fax (1) 2047**] to schedule a follow up appointment in 2 weeks. Dr.[**Name (NI) **] office will coordinate a social work appointment with you. If you have questions, call ([**Telephone/Fax (1) 110739**] during normal business hours and ask to speak to a member of his team.

[ "571.0", "V45.86", "291.81", "303.91", "560.81", "287.5" ]

icd9cm

[ [ [] ] ]

[ "54.59", "50.11" ]

icd9pcs

[ [ [] ] ]

4233, 4239

2184, 3278

328, 474

4307, 4314

1353, 2161

5822, 6148

1035, 1053

3434, 4210

4260, 4286

3304, 3411

4338, 5799

1068, 1334

274, 290

502, 798

820, 962

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58,242

139,697

507

Discharge summary

report

Admission Date: [**2203-10-4**] Discharge Date: [**2203-10-26**] Date of Birth: [**2143-10-4**] Sex: M Service: NEUROSURGERY Allergies: Codeine / Streptokinase / Iodine / Bee Pollens / Narcan Attending:[**First Name3 (LF) 78**] Chief Complaint: "worst headache of life" Major Surgical or Invasive Procedure: [**10-4**] Cerebral Angiogram [**10-4**] Right EVD placement [**10-6**] Right EVD catheter replacement [**10-19**] IVC filter placement [**10-21**] Ventriculoperitoneal Shunt History of Present Illness: This is a 59 year old man on Aspirin and Coumadin for Atrial Fibrillation/CVA who was medflighted from [**Hospital3 3583**] today following worst headache of life 24 hours ago with a INR of 4 and head CT consistent with extensive Subarachnoid Hemorhage. The patient was given Vitamin K 10 mg and Factor 7 to reverse his INR. Upon arrival the patient and his daughter stated that he has over the past day developed a left facial droop, slurred speech and a droopy left eye. He has had some weakness in his bilateral upper extremities that he has had since his care accident approximately 3 weeks ago and his very bad fall three days ago. His right arm is in a cast. Past Medical History: Type II Diabetes on oral agents Systemic Lupus Erythematosus Coronary Artery Disease s/p MI in [**2186**] Hepatitis C COPD with emphysema and asthmatic component (FEV1 60% predicted [**1-7**]) Diastolic Congestive Heart Failure EF 55% in [**3-/2198**] Seizure disorder TIA 199 Colon Cancer s/p resection in [**2194**] without chemotherapy s/p abdominal trauma with subsequent splenectomy and amputation of digits of his left hand Hyperlipidemia Hypertension h/o cocaine abuse Neuropathy and chronic pain on methadone Chronic Atrial Fibrillation on Coumadin Obstructive Sleep Apnea on home CPAP Left Total Knee Replacement [**2201**] Social History: On disability, former mechanic. Quit smoking [**2181**]. Denies EtOH, h/o cocain abuse, none since [**2181**]. Family History: Adopted - Unknown birth family hx Physical Exam: Admission Exam: *************** T: 96.3, BP: 142/78, HR: 98, R: 22, O2Sats:98% on 4 liters Gen: comfortable, slurred speech HEENT:left facial droop and left ptosis, atraumatic Pupils: %mm EOMs5 mm bilaterally non reactive Neck: Supple. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert to person and place only Orientation: Oriented to person, place, and NOT date. Recall: unable to perform Language: Speech is slow and slurred Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light,5 mm NON REACTIVE bilaterally. III, IV, VI: Extraocular movements intact on right, 3rd/4th/6th nerve palsy on LEFT, disconjugate gaze V, VII: Facial strength LEFT facial droop VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength- antigravity x 4. Pronator drift- unable to perform- right arm cast and residual bilateral arm weakness from fall/car accident- antigravity Sensation: Intact to light touch bilaterally. Reflexes: Toes downgoing bilaterally Coordination: Unable to perform Discharge Exam: *************** Gen: Trach/PEG placed, NAD HEENT: Left facial droop with left ptosis Neck: Supple. Extrem: Warm and well-perfused. Neuro: Mental status: Awake and alert to person and place only Orientation: Oriented to person, place, and NOT date. Recall: unable to perform Language: Speech is slow and slurred Cranial Nerves: I: Not tested II: Pupils 4mm -> 3mm on right, EOMs 5 mm bilaterally non reactive, rotated externally III, IV, VI: Extraocular movements intact on right, 3rd/4th/6th nerve palsy on LEFT, disconjugate gaze V, VII: Facial strength LEFT facial droop VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength - in right arm and leg. Pronator drift - unable to perform- right arm cast and residual bilateral arm weakness from fall/car accident- antigravity Sensation: Intact to light touch bilaterally. Reflexes: Toes downgoing on right, equivocal on left Coordination: Could not perform Pertinent Results: [**2203-10-4**] ANGIOGRAM: 1. Tiny 1-2 mm questionable infundibulum versus questionable broad-based focal ectasia versus tiny aneurysms noted at the level of the anterior communicating artery and right middle cerebral artery bifurcation. 2. Evaluation of the right external carotid artery, left internal carotid artery, left external carotid artery, right vertebral artery, and left vertebral artery demonstrates no definite evidence of aneurysms or vascular malformations. [**2203-10-4**] CT HEAD W/O CONTRAST: Status post ventriculostomy catheter placement from a right frontal approach with tip in the third ventricle; stable-to-slight increase in extent of subarachnoid hemorrhage with layering intraventricular hemorrhage within the occipital horns of the lateral ventricles [**2203-10-5**] ECHOCARDIOGRAM: The left atrium is moderately dilated and elongated. The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is mildly depressed (LVEF= 45-50 %) secondary to hypokinesis of the basal-mid inferior wall, and inferior/anterior septum. The LV apex and distal anterior wall appeared normokinetic, although their function may be overestimated given significantly foreshortened apical views. The right ventricle is mildly dilated with borderline normal free wall function. The aortic root is mildly dilated at the sinus level. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. [**2203-10-5**] CXR FINDINGS: As compared to the previous radiograph, the nasogastric tube has been advanced. The tip of the tube now projects over the gastroesophageal junction. To ensure correct position in the stomach, the tube must be advanced by another 10 cm. Unchanged position of the endotracheal tube. Unchanged moderate cardiomegaly with mild fluid overload. The extent and severity of the pre-existing right lower lung parenchymal opacity is unchanged. [**2203-10-6**] CT HEAD W/O CONTRAST (9:27 AM) CONCLUSION: 1. Interval increase of the hemorrhage at the mid brain compared to the previous study, concerning for hemorrhage within the mid brain versus expanding hemorrhage at the interpeduncular cistern. 2. Interval increase in the size of the ventricles as described above,concerning for hydrocephalus. [**2203-10-6**] CT UP EXT W/O Study Date (9:27 AM) IMPRESSION: 1. Comminuted and impacted right medial clavicle fracture. 2. Severe emphysema. 3. Multinodular thyroid can be further evaluated by ultrasound, if clinically indicated. [**2203-10-6**] CT HEAD W/O CONTRAST Study Date of (2:05 PM) CONCLUSION: 1. The hemorrhage at the midbrain has seems to have increased in size compared to the study from earlier this morning. 2. There is an increased amount of intraparenchymal hemorrhage around the catheter site. 3. The size of the ventricles is unchanged compared to the study performed earlier this morning. [**2203-10-7**] PORTABLE HEAD CT W/O CONTRAST (7:45 AM) CONCLUSION: 1. Subarachnoid and intraventricular hemorrhage, unchanged compared to the previous study. 2. No new evidence of hemorrhage, mass effect, or acute infarction. 3. Intraparenchymal hemorrhage around the catheter site is stable compared to the previous study. 4. Size of the ventricles is unchanged compared to the previous study. [**2203-10-7**] CHEST (PORTABLE AP) (10:22 AM) IMPRESSION: AP chest compared to [**10-2**] through 5: Relatively symmetric infiltrative abnormality in the lower lungs is probably pulmonary edema. Previous right lower lobe pneumonia is improving. Pleural effusions are small if any. Moderate-to-severe cardiomegaly is longstanding. ET tube in standard placement. Nasogastric drainage tube passes into the stomach and out of view. No pneumothorax. [**2203-10-8**] EKG Atrial fibrillation with controlled ventricular response. Poor R wave progression. Non-specific ST-T wave changes in the inferior and anterolateral leads. Compared to the previous tracing of [**2203-10-7**] the ventricular response is slower. Intervals Axes Rate PR QRS QT/QTc P QRS T 88 0 96 [**Telephone/Fax (2) 4214**]6 [**2203-10-8**] CT HEAD W/O CONTRAST (4:42 PM) IMPRESSION: No significant change since the prior study. No evidence of new hemorrhage, mass effect, or infarction. [**2203-10-8**] CHEST (PORTABLE AP) (5:20 PM) FINDINGS: In comparison with the study of [**9-6**], there is again substantial enlargement of the cardiac silhouette with only mild elevation of pulmonary venous pressure. This suggests cardiomyopathy or pericardial effusion. Endotracheal and nasogastric tubes remain in good position. The hemidiaphragms are more sharply seen, consistent with clearing of the previous pulmonary edema. Mild atelectatic changes may be present. [**2203-10-9**] Neurophysiology Report EEG IMPRESSION: This is an abnormal continuous ICU monitoring study due to generalized slowing of the background activity with 3-5 theta and superimposed 1-1.5 Hz delta. There are frequent bursts of generalized sharp waves with maximal amplitude over the frontal regions often with shifting laterality in terms of maximal amplitude. These findings are suggestive of moderate to severe encephalopathy with potential underlying epileptogenic cortex. Compared to the previous day's study, the generalized sharp waves are slightly less frequent and now they are more blunted in their appearance [**2203-10-10**] Neurophysiology Report EEG IMPRESSION: This is an abnormal continuous ICU EEG monitoring study due to a slow background of [**5-5**] theta with superimposed [**1-31**] Hz delta. Frontally maximal, generalized sharp waves are frequently seen. The background activity becomes discontinuous after 16:00 to 00:45 with alternating pattern of one to two second severe EEG suppression and two to three seconds of diffuse 5 Hz theta predominantly over frontal-central areas, superimposed with 2-3 Hz delta. These finds are suggestive of severe encephalopathy with potential underlying epileptogenic cortex. [**2203-10-10**] CTA HEAD W&W/O C & RECONS (10:33 AM) IMPRESSION: 1. Improvement/stable subarachnoid and intraventricular hemorrhage as described above. 2. Patent Circle of [**Location (un) 431**]. Patent carotid and vertebral arteries and their major branches with no evidence of stenosis. 3. Again seen is the small 1- to 2-mm aneurysm at the level of the ACA and right MCA bifurcation, as seen previously on the cerebral angiography from [**2203-10-4**]. No evidence of vasospasm. [**2203-10-10**] BILAT LOWER EXT VEINS PORT (2:24 PM) IMPRESSION: No son[**Name (NI) 493**] evidence for lower extremity deep vein thrombosis. [**2203-10-10**] CHEST PORT. LINE PLACEMENT (5:55 PM) FINDINGS: In comparison with the study of earlier in this date, there has been placement of a left subclavian catheter that extends to the upper-to-mid portion of the SVC. No evidence of pneumothorax. The left basilar opacification is slightly less prominent. Other monitoring and support devices remain in place. [**2203-10-11**] CHEST (PORTABLE AP) (4:08 AM) FINDINGS: In comparison with the study of [**10-10**], there is continued prominence of the cardiac silhouette without definite pulmonary vascular congestion. There is now increasing opacification at the right base with poor definition of the hemidiaphragm. This suggests pleural effusion and atelectasis. Less prominent opacification is seen at the left base. No evidence of pneumothorax. [**2203-10-12**] CHEST (PORTABLE AP) (4:39 AM) IMPRESSION: AP chest compared to [**10-11**] - Right lower lobe consolidation has improved. There is no pulmonary edema. Moderate cardiomegaly has improved since [**10-7**]. Pleural effusions are small on the right, if any. Configuration of the diaphragm suggests COPD. ET tube in standard placement. Left subclavian line ends at the junction of brachiocephalic veins and an enteric tube ends in the upper stomach. [**2203-10-12**] CXR: FINDINGS: As compared to the previous radiograph, there is constant appearance of the heart and the lung parenchyma. No interval appearance of new parenchymal opacities. Unchanged moderate cardiomegaly without overt pulmonary edema. The monitoring and support devices are constant. [**2203-10-13**] CXR: FINDINGS: As compared to the previous radiograph, there is no relevant change. Unchanged monitoring and support devices. Unchanged appearance of the lung parenchyma. Unchanged appearance of the cardiac silhouette. No pneumothorax, no pleural effusions. [**2203-10-14**] CXR: IMPRESSION: Status post tracheostomy and PEG placement, both of which appear in appropriate position. Apparent increase in right pleural effusion is likely due to patient rotation with respect to the film. [**2203-10-16**] CXR: FINDING: Pulmonary vascular congestion with associated peribronchial cuffing appears unchanged. When compared to a similarly positioned radiograph of [**2203-10-14**] at 4:50 a.m., there has been apparent increase in confluent opacity in the right infrahilar region. This area is difficult to compare to the more recent radiograph of 12:50 p.m. on the same date, but may be improved since that time. Differential diagnosis includes asymmetrical pulmonary edema, aspiration, and less likely a focal infection. [**2203-10-18**] CXR: IMPRESSION: Right-sided pleural effusion, small to moderate in size. Otherwise, unchanged examination of the chest. [**2203-10-18**] BILATERAL LOWER VEIN: IMPRESSION: Nonocclusive thrombus within the left common femoral vein. The remainder of the veins of both legs are normal. [**2203-10-21**] CT HEAD W/O CONTRAST IMPRESSION: 1. Ventriculoperitoneal shunt terminating in the frontal [**Doctor Last Name 534**] of the right lateral ventricle, as compared to within the third ventricle on prior examination. 2. New small foci of air within the right frontal [**Doctor Last Name 534**] of the lateral ventricle, likely due to recent instrumentation. 3. Overall, decreased amount and density of previously seen subarachnoid and intraventricular hemorrhage. No mass effect or evidence of herniation. Stable ventricular size. 4. Increased opacification of the right mastoid air cells [**2203-10-22**] CT HEAD W/O CONTRAST IMPRESSION: Stable examination (since [**10-21**] study) [**2203-10-23**] CXR - The ET tube tip is approximately 7 cm above the carina. The gastrostomy projecting over the stomach consistent with feeding tube. Heart size and mediastinum are unchanged. Left lower lobe opacity is unchanged, associated with small amount of pleural effusion concerning for infectious process. No new abnormalities demonstrated. [**2203-10-24**] CXR - IMPRESSION: 1. Left lower lung improved. 2. Mild pulmonary edema which is more evenly distributed on the study, but overall unchanged. [**2203-10-25**] CXR FINDINGS: In comparison with study of [**10-24**], the left hemidiaphragm is not as sharply seen, raising the possibility of atelectasis or even developing consolidation at the left base. Remainder of the study is essentially within normal limits and the monitoring and support devices are unchanged. Brief Hospital Course: 60 y/o M on aspirin and coumadin for Afib presents s/p worst headache of his life with SAH found on head CT. His INR was elevated to 4 and was actievely reversed with factor 7 and vitamin K. He was intubated and an EVD was placed in the ED at the bedside. He was then admitted to neurosurgery and went for an angiogram for evaluation of aneurysm. Angiogram was negative for any aneurysm. Post angiogram, the patient on exam withdrew all four extremities to noxious stimuli. His INR was stable at 1.0. On [**10-5**], patient opened his eyes to voice, but had CN 3, 4 and 6th nerve palsy. He followed simple commands in bilateral hands and feet. His EVD was elevated to 20cmH2O. The EVD stopped functioning twice overnight but this was quickly resolved when flushed. On [**10-6**] the EVD again stopped working, but the patient remained neurologically stable. A Head CT revealed a new hemorrhage along the catheter tract. It was decided to replace the EVD, which was performed without complication. Post placement CT revealed good catheter positioning. His dilantin level was subtherapeutic so he was re-bolused.fluid volume balance - 2 liters negative. The serum sodium was uptrending so ICU increased intravenous fluids. The patient stopped moving Left upper and left lower extremity. On [**10-7**], The patient was febrile to 103 with tachycardia to 150s in Atrial flutter. Femoral Alcius was placed. A diltiazem continuous IV drip was initiated. The patient was pan cultured. The External Ventricular Drain was clamped at 5 pm and later unclamped due to elevated intercranial pressures. The patient's EVD was left open at 10 above tragus. On [**10-8**], The external ventricular drain was open at 10 abouve tragus. The serum sodium was 155 and the serum BUN was 30. The patient's intravenous fluid was increased to NS at 100cc/hr. The dilantin level was checked and repleted. Per the epilepsy attending the EEG much improved from teh day prior and there were no seizures noted. Recomendations were made to maintain the Dilantin level higher at 20.On exam, the patient was able to eye open to voice. The pupils were 5mm and non reactive. Left ptosis, dysconjugate gaze continued. The patients left upper extremity exhibited no movement. The left lower extremity withdrew to noxious stimulus. The right upper extremity the patient moves fingers to commands, localizes and moves his right lower extremity on the bed On [**10-9**], The EEG without seizures. On [**10-10**], The EEG showed no seizures and was stable consistent with severe encephalopathy. The CTA Head showed no vasospasm.( premedicated with 100 hydrocort/50 bendryl) for decreased exam. Free water 300 q 6 hours for elevated serum sodium of 152. The goal goal serum sodium wa 138-145. The external ventricular drain was clamped at 0830 in teh morning and the patient failed the clamping trial in afternoon when he had a fever. The dilantin level was 13.1. The patientw as febrile to 101.3. Blood cultures were sent and venous femoral alcius cooling catheter removed. On [**10-11**], The patient was febrile overnight and CSF was again sent which was consistent with ***. On exam, the patient was slightly improved . He was wiggling his toes to command. He was able to flicker move his right hand fingers to command. The EVD open at 20. The Transcranial Doppler study was limited due to EEG leads placement but there was no vasospasm of opthalmic/vertebral or extracranial carotid arteries. The serum sodium was elevated at 151 and at 1730 the serum sodium was up to 153. The free water flushes were increased to 360 cc q 6 hours.Late morning the patient's fever was 102.8 and a Chest XRY was consistent with a new right sided consolidation. A Bronchcoscopy was performed and a BAL was sent. IV abts vancomycin and cefipime was initiated for pneumonia. A EEG showed no seizures but consistent severe encephalopathy. Per the epilepsy service as there had been no seizures noted on EEG the EEG was discontinued. On exam ,the patient opened eyes to voice. The right pupil was 5-4.5mm reactive and the left pupil 5mm NR. The Right Upper Extremity exhibited flicker finger movement to command and was casted. The patient moved toes bilaterally to command/briskly. There was no movement in the left upper extremity which was stable. On [**10-12**], patient was seen to have a stable examination, he was following simple commands on his RLE, w/d RUE, spontaneous on the LLE and no movement on his LUE. He was febrile throughout the day and was cooled with a cooling blanket. His Na increased from 151 to 153, free water was increased. His vancomycin was also increased to 1250mg QD. He was placed on a dilt gtt for a-fib and was being converted to PO. He was recultured for his fevers. U/A was negative. On [**10-13**] he was again febrile. Sputum Cultures from the 11th including a BAL were positive for staph and yeast. WBC cont to increase to 24.3. Na was stable at 150 and dilantin was corrected to 10.8. An MRI/MRA were ordered to evaluate for vascular malformation and prognostication. A family meeting was scheduled for [**10-14**] but Dr [**First Name (STitle) **] met with the patient's daughter in advance and Dr [**Name (NI) **] spoke to the patient's wife on the phone. Everyone was in agreement that they would like to proceed with a trach and peg. This was scheduled for [**10-14**]. Overnight he was febrile and was suddenly hypotensive to the 60s. He required Neo for a short while but this was then weaned off. CSF was sent for culture. In the AM [**10-14**] he was neurologically stable. His trach and peg were placed at the bedside. On [**10-19**] patient developed fevers again and his scheduled VPS procedure was posponed. VPS placement was accomplished on [**10-21**]. The patient was seen [**10-22**]: restarted FW bolus, thick secretions-febilre 103 right after PICC, central line removed, blood/sputum sent, sputum resulted in GPC in clusters with sensitivities pending. Over the course of the [**Date range (1) 4215**], the patient spiked fevers on a nightly basis for which Vancomycin was restarted, and tailored for supratheraputic value. Hypernatremia was noted to improve over this time on Free Water flush (149-146-141 over the course of [**4-3**] days). Lovenox was also restarted for DVT with a coumadin bridge both for DVT and AFib history. A VPS tap resulted in the findings of a leukocytosis in the CSF (100 WBC with 89 neutro) without any organisms seen, and normal protein/glucose. ID was consulted regarding the patients continued fevers, with recommendation to continue Vanco for total course of [**11-13**] days given previous Cx of GPC x2 from sputum. Over [**2117-10-23**] evening patient remained afebrile with decreasing serum leukocytosis. Spoke with Orthopedics regarding right cast, which had been placed in [**2203-8-31**] s/p an ORIF procedure for MVA-related fracture. Plan to remove the cast on [**11-4**] with repeat XRays. Patient remained afebrile and stable from a respiratory and neurological standpoint. He was discharged to rehab on [**2203-10-26**]. Medications on Admission: 1. Acetaminophen 650 mg PO Q6H 2. Albuterol Inhaler [**1-31**] PUFF IH Q4H:PRN wheeze 3. Aspirin 325 mg PO DAILY 4. Captopril 100 mg PO TID 5. CloniDINE 0.1 mg PO BID 6. Docusate Sodium 100 mg PO BID 7. Fluoxetine 60 mg PO DAILY 8. Gabapentin 600 mg PO QID 9. HydrALAzine 25 mg PO Q6H 10. HYDROmorphone (Dilaudid) 4-8 mg PO Q3H:PRN severe pain Please wean off medication as tolerated, you can take tylenol alone to help wean off. All future prescriptions from outpatient chronic care provider. [**Name10 (NameIs) **] not take medication other than prescribed 11. Hydroxychloroquine Sulfate 200 mg PO BID 12. Methadone 10 mg PO BID (10mg at 8am, 10mg at noon) 13. Methadone 20 mg PO BID (20mg at 6pm, 20mg at 10pm) 14. Metoprolol Tartrate 50 mg PO BID 15. Omeprazole 20 mg PO BID 16. Pravastatin 40 mg PO DAILY 17. Prochlorperazine 10 mg PO Q6H:PRN nausea 18. Senna 1 TAB PO BID:PRN constipation 19. Spironolactone 25 mg PO DAILY 20. Tizanidine 4 mg PO QHS 21. Torsemide 50 mg PO 12PM 22. Warfarin 2.5 mg PO QHS redose per coumadin clinic Discharge Medications: 1. Acetaminophen (Liquid) 650 mg PO Q6H:PRN headache/pain 2. Albuterol Inhaler [**5-6**] PUFF IH Q4H:PRN wheezing 3. Docusate Sodium 100 mg PO BID 4. HYDROmorphone (Dilaudid) 0.125-1 mg IV Q4H:PRN headache for breakthru pain; hold rr < 12 Only give this medication if the patient has not already been dosed PO Dilaudid to avoid over-administration of narcotics. wean off medication as tolerated, you can take tylenol alone to help wean off. All future prescriptions from outpatient chronic care provider. 5. Gabapentin 600 mg PO TID home medication 6. Fluoxetine 60 mg PO DAILY 7. Metoprolol Tartrate 100 mg PO BID Hold for HR < 60bpm 8. Pravastatin 40 mg PO DAILY 9. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL [**Hospital1 **] 10. Fluticasone Propionate 110mcg 2 PUFF IH [**Hospital1 **] 11. Nystatin Oral Suspension 5 mL PO QID:PRN thrush 12. Senna 1 TAB PO HS 13. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY 14. Artificial Tear Ointment 1 Appl BOTH EYES QID dry eyes 15. Tizanidine 4 mg PO HS 16. Bisacodyl 10 mg PO/PR DAILY 17. Diltiazem 60 mg PO QID Hold HR < 60 and SBP < 100. 18. Enoxaparin Sodium 60 mg SC Q12H 19. HYDROmorphone (Dilaudid) 2-4 mg PO Q6H:PRN headache hold for lethargy and rr < 12 20. Ibuprofen Suspension 400-800 mg PO Q8H:PRN fever please alternate with tylenol 21. Glargine 45 Units Q24H Insulin SC Sliding Scale using REG Insulin 22. Sodium Chloride 0.9% Flush 10 mL IV PRN line flush PICC, non-heparin dependent: Flush with 10 mL Normal Saline daily and PRN per lumen. 23. Vancomycin 750 mg IV Q 12H 24. Warfarin 7.5 mg PO DAILY16 Duration: 1 Doses INR goal [**3-4**] Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Subarachnoid Hemorrhage Hydrocephalus Non-occlusive L common femoral artert DVT Hypernatremia PNA Respiratory failure Dysphagia Discharge Condition: Mental Status: Confused - always. Level of Consciousness: Alert and interactive. Activity Status: Bedbound. Discharge Instructions: ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort. What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs. ?????? Keep your incision dry until staple removal. ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal). What to report to office: ?????? Changes in vision (loss of vision, blurring, double vision, half vision) ?????? Slurring of speech or difficulty finding correct words to use ?????? Severe headache or worsening headache not controlled by pain medication ?????? A sudden change in the ability to move or use your arm or leg or the ability to feel your arm or leg ?????? Trouble swallowing, breathing, or talking ?????? Numbness, coldness or pain in lower extremities ?????? Temperature greater than 101.5F for 24 hours ?????? New or increased drainage from incision or white, yellow or green drainage from incisions ?????? Bleeding from groin puncture site *SUDDEN, SEVERE BLEEDING OR SWELLING (Groin puncture site) Lie down, keep leg straight and have someone apply firm pressure to area for 10 minutes. If bleeding stops, call our office. If bleeding does not stop, call 911 for transfer to closest Emergency Room! - Lovenox bridge to Coumadin, INR goal [**3-4**] - Vancomycin thru [**2203-11-1**] - Cast follow-up due for [**11-4**] with Ortho Followup Instructions: Please follow up with Dr. [**First Name (STitle) **] in 4 weeks with a non contrast head CT. This appointment can be scheduled by calling the neurosurgery office at [**Telephone/Fax (1) 1669**]. cast for [**2203-11-4**]. Please call [**Telephone/Fax (1) 1228**]. Completed by:[**2203-10-26**]

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Discharge summary

report

Admission Date: [**2119-9-22**] Discharge Date: [**2119-10-1**] Date of Birth: [**2055-4-28**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2969**] Chief Complaint: Readmitt for fever and chills Major Surgical or Invasive Procedure: Diagnostic thoracentesis. Intubation History of Present Illness: Mr. [**Known lastname 72100**] presents with fever and respiratory failure with undiagnosed right-sided pleural effusion. Past Medical History: Esophageal Cancer s/p Transthoracic esophagectomy Hypertension Hypercholesterolemia Myocardial Infarction [**2109**] Chronic Right Shoulder Pain Social History: He is married. He has four children in their 20s. He lives in [**Location 5110**] with his wife. [**Name (NI) **] is retired from the meat cutting industry. He does not smoke cigarettes nor has he in the past. He drinks alcohol rarely about a six-pack per summer. Family History: His mother is alive at age 88 with breathing difficulties and memory loss and heart problems. His father is alive at age [**Age over 90 **] and was just recently diagnosed with gastric cancer. He has a sister who died at age 61 of pancreatic cancer and a sister who is alive at age 54. There is no other family history of breast, ovarian, uterine, or colon cancer. Physical Exam: General: 64 y.o. male in no added distress HEENT: normocephalic, mucusmembranes moist Neck: supple no lymphadenopathy Card: RRR, normal S1,S2 no mumur/gallop or rub Resp: decreased breath sounds with faint crackles GI: bowel sounds positive, abdomen soft non-tender/non-distended Extr: warm no edema Skin: neck incision well healed, mid-abdominal incision well healed J-tube site clean, no dishcarge, mild skin thickening around J-tube site Neuro: non-focal Pertinent Results: [**2119-9-23**]: Pleural fluid (right): Mesothelial cells, histiocytes and mixed inflammatory cells. [**2119-9-26**] Esophogram: 1. Collection of contrast at approximate level of the anastomosis may represent a folded loop versus contained anastomotic leak. Correlation with the type of anastomosis performed is suggested. 2. No evidence of stricture. [**2120-9-25**] Echocardiogram: 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 ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are structurally normal. No mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is a small circumferential pericardial effusion without echocardiographic signs of tamponade. IMPRESSION: Preserved biventricular systolic function. Small pericardial effusion without echocardiographic signs of tamponade. Mild aortic regurgitation. [**2119-9-25**] Chest CT: 1. No evidence of pulmonary embolism. 2. Subcutaneous soft tissue air anterior to the trachea, of uncertain clinical significance. In consultation with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], this air along the anterior neck is secondary to a recent procedure in this region. 3. Loculated pleural effusions and atelectasis. 4. Small pericardial effusion. 5. Cholelithiasis without evidence of cholecystitis. Brief Hospital Course: Patient was admitted for fever of unknown origin. He was admitted for further work-up. All blood cultures and urine cultures were negative. However, he developed respiratory distress and was intubated for a question of aspiration. He was taken to the ICU. A CT scan showed no frank evidence of leak at the anastamosis site and pleural effusions. However, he had thoracentesis which drained 400 cc of serous fluid which did not grow anything on subsequent culture. His BAL while in the ICU likewise showed no growth. He was extubated and transferred to the floor in stable condition. Tube feeds were restarted and a barium swallow was performed which showed no leak. After this, the patient was started on a soft mechanical diet and tolerated it without difficulty. He worked with physical therapy and they believed that he would be able to go home with [**Last Name (NamePattern1) 269**] and continued PT. He was discharged afebrile and in stable condition. Medications on Admission: Lipitor 20', Metoprolol XL 50', Lisinopril 10' Discharge Medications: 1. Megestrol 40 mg/mL Suspension [**Last Name (NamePattern1) **]: One (1) PO DAILY (Daily). Disp:*30 * Refills:*2* 2. Metoprolol Succinate 50 mg Tablet Sustained Release 24 hr [**Last Name (NamePattern1) **]: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 3. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 4. Heparin Lock Flush (Porcine) 10 unit/mL Solution [**Last Name (STitle) **]: One (1) ML Intravenous DAILY (Daily) as needed. 5. Roxicet 5-325 mg/5 mL Solution [**Last Name (STitle) **]: One (1) PO every six (6) hours as needed for pain for 7 days. Disp:*30 5ml* Refills:*0* 6. Lipitor 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. 7. Lisinopril 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: Partners [**Name (NI) 269**] Discharge Diagnosis: Esophageal Cancer s/p Transthoracic esophagectomy Hypertension Hypercholestolemia Myocardial Infarction [**2109**] Chronic Right Shoulder Pain Discharge Condition: Deconditioned Discharge Instructions: Call Dr.[**Last Name (STitle) 28484**] office [**Telephone/Fax (1) 170**] if experience: -Fever > 101 -Increased shortness of breath, cough or sputum production -Chest pain Tube feeds site: keep clean and dry. Flush every 8 hrs with water Should it become clogged instill warm water or coke If your feeding tube sutures become loose or break, please tape securely and call the office [**Telephone/Fax (1) 170**]. Should the feeding tube fall out, call the office immediately it will need to be replaced in a timely manner so the tract will not close. Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **]. Please call [**Telephone/Fax (1) 170**] for an appointment at the [**Hospital Ward Name 517**] [**Hospital Ward Name 23**] Clinical Center, [**Location (un) 8939**] Report to the [**Location (un) **] radiology department for a chest x-ray 45 minutes before your appointment Follow-up with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 7047**] [**Telephone/Fax (1) 3183**]

[ "719.41", "518.82", "401.9", "511.9", "V16.0", "423.9", "574.20", "272.0", "V10.03", "424.1", "412" ]

icd9cm

[ [ [] ] ]

[ "34.91", "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

5523, 5582

3571, 4542

351, 390

5769, 5785

1872, 3548

6385, 6826

1012, 1379

4639, 5500

5603, 5748

4568, 4616

5809, 6362

1394, 1853

282, 313

418, 542

564, 710

726, 996

13,960

171,286

5819

Discharge summary

report

Admission Date: [**2150-4-9**] Discharge Date: [**2150-4-29**] Date of Birth: [**2104-4-9**] Sex: F Service: MEDICINE Allergies: Compazine Attending:[**First Name3 (LF) 1850**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: tracheostomy and PEG tube placement central line placement PICC line placement History of Present Illness: 45 yo woman with severe Asthma and COPD with FEV1 of 0.24 being evaluated for possible lung transplant comes in after 2 days of fevers to 102, cough, congestion, unable to bring up sputum and shortness of breath. She tried increasing frequency of her home nebs, spoke with her PCP and was started on erythromycin and mucinex. As she was still short of breath, she came in to the ED for evaluation via EMS. She denies any sick contacts and has been compliant with med regimen. she denies any other symptoms. . In ED started on continuous nebs with heliox and improvement in respiratory distress, but still tachypnic and working to breathe. Received solumedrol, 125mg IV, levoquin 500mg once, Magnesium 2gm and continuous neb as above. Past Medical History: 1. COPD, PFTs in [**1-17**] with FEV1 0.24(10%), FVC 1.25(41%) and FVC/FEV1 28%- on Home O2 at 2L NC, on chronic steroids, hx of prolonged intubation requiring trach for resp failure in [**1-15**], last flare [**11-16**] 2. Hypertension 3. Anxiety 4. Leukocytosis of unknown etiology with negative BMBx. 5. Osteoporosis- on fosamax 6. Shoulder pain 7. History of positive PPD s/p 6mos of isoniazid 8. Mitral valve prolapse Social History: +smoker, has young son and involved mother Family History: NC Physical Exam: VS:101.2 axillary, 144 123/79 28 97%2LNC GEN aao, tachypneic in mod resp distress, able to answer in short word phrases with increased work of breathing HEENT PERRL, dryMM, + trach scar CHEST diffuse wheezes bilaterally, no crackles CV RRR, tachycardic Abd soft, NT/ND, +BS EXT no edema Pertinent Results: [**2150-4-9**] 10:43AM TYPE-ART RATES-/24 PO2-264* PCO2-50* PH-7.35 TOTAL CO2-29 BASE XS-1 INTUBATED-NOT INTUBA [**2150-4-9**] 07:43AM GLUCOSE-183* LACTATE-2.0 NA+-130* K+-3.8 CL--94* [**2150-4-9**] 07:43AM HGB-13.1 calcHCT-39 [**2150-4-9**] 07:43AM freeCa-1.23 [**2150-4-9**] 07:30AM GLUCOSE-155* UREA N-11 CREAT-0.7 SODIUM-132* POTASSIUM-3.9 CHLORIDE-94* TOTAL CO2-32* ANION GAP-10 [**2150-4-9**] 07:30AM CALCIUM-9.8 PHOSPHATE-3.0 MAGNESIUM-3.3* [**2150-4-9**] 07:30AM TSH-0.46 [**2150-4-9**] 07:30AM WBC-14.0* RBC-4.33 HGB-13.5 HCT-38.6 MCV-89 MCH-31.1 MCHC-34.9 RDW-13.0 * CT Sinus: Pansinus opacification with air-fluid levels. * CTA: 1. No evidence of PE. 2. Severe emphysematous changes of the lungs and interstitial changes in the periphery of the bases. 3. New tree-in-[**Male First Name (un) 239**] opacities in the lower lobes could represent an acute infectious process in the bases versus aspiration * MRI C-spine: ) No evidence of epidural abscess. 2) T5 vertebral body compression fracture. * Brief Hospital Course: A/P: 45 yo with end stage pulmonary disease secondary to emphysema and asthma here with COPD exacerbation and prolonged respiratory failure. * 1) Respiratory Failure: secondary to COPD exacerbation with poor FEV1(0.23) at baseline from PFTs [**1-17**] and was on transplant list but taken off for continued smoking. Unclear trigger of exacerbating event, but on arrival was febrile to 101. Started on and completed 7 day course of levoquin for suspected pneumonia/bronchitis. Her DFA for influenza was negative and sputum was minimal with sputum cultures growing only oropharyngeal flora. She was intubated [**2150-4-10**] for increased respiratory distress and remained on ventilator with slow wean despite steroids and bronchodilators. Initially was difficult to ventilate without excessive sedating meds, of note on last prolonged respiratory failure last year- she had required paralytics. CTA [**4-13**] (-) for PE. Given prolonged ventilator wean, patient had trach and PEG placed by CT surgery [**2150-4-17**]. Current respiratory status improving and tolerating pressure support. . 2) Steroid myopathy: after weaning of sedation, patient initially noted to be weak. She had C-spine imaged and neurology consult. Her C-spine was negative for epidural abscess, but noted to have a T-5 fracture- that is assymptomatic and will just be followed. Neurology was consulted and the patient had an EMG [**4-27**] that was consistent with axonal polyneuropathy. Given brisk LE reflexes, she underwent a thoraic and lumbar MRI [**2150-4-28**], results pending at time of dictation. . 3) Sinusitis: after 2weeks into her stay after intubation, patient developed fevers and had a positive head CT for sinusitis and was treated empirically with 10 days of Vancomycin and ceftaz; she will complete her course on [**2150-5-2**]. At time of discharge, she remained afebrile with wbc 12.5 (trending down). * 4) Fluid overload: Following admission, the patient was aggressively hydrated given low urine output with good response. Over the course of her stay, however, she was noted to have a positive fluid balance with increased lower extremity edema. She was treated with IV furosemide with good results and was transitioned over to PO lasix for a goal I/O (-) 500 cc/day. Her volume state (including daily weights) will need to be monitored following discharge and her furosemide dose adjusted as needed for clinical euvolemia. * 5) Esophageal candidiasis: During PEG placement on [**2150-4-17**], she was noted to have evidence of esophageal candidiasis and was treated with a 7 day course of fluconazole. * 6) Cephalic vein clot: On [**2150-4-15**], the patient was noted to have increased right upper extremeity edema. A right upper extremity ultrasound confirmed an occlusive thrombus in the right cephalic vein. She completed a 7 day course of heparin for a superficial clot. * 7) HTN: The patient blood pressure was initially elevated, however it improved with appropriate pain/anxiety management. She was discharged on her home dose of captopril. * 8) Anxiety: The patient's chronic anxiety was a major management issue during this hospitalization. Following intubation, she was initially sedated with propofol, however was transitioned to Fenanyl/Versed with better results. She was continued on home doses of Seroquel, and neurontin. Klonopin was added to her regimen along with prn Ativan. She had multiple episodes of severe anxiety with associated tachypnea (respiratory rate in the 30s) and tachycardia (HR 120s-140s) requiring IV ativan/haldol. Effexor was restarted on [**2150-4-27**] once she was able to take oral medications (using Passy Muir valve). * 9) Ileus: secondary to excessive narcotics regemin and resolved with aggressive bowel regemin. * 10) FEN: Passed swallow evaluation on [**4-27**] who recommended advancing pt to PO diet as tolerated (thin liquids and soft solids) with PMV in place. Medications whole with water as tolerated (or via PEG). At time of discharge, the patient's oral intake is limited by tachypnea. She continues to receive tube feeds via PEG tube and is only receiving Effexor by mouth. Medications on Admission: Albuterol/Atrovent nebs Flovent Serevent Singulair Tiotropium Captoril Fosomax Efffexor Neurontin Seroqul Protonix Oxybutinin Klonopin Discharge Disposition: Extended Care Facility: [**Hospital6 85**] - [**Location (un) 86**] Discharge Diagnosis: COPD exacerbation Discharge Condition: Fair Discharge Instructions: Please follow-up with primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] ([**Telephone/Fax (1) 250**]) within 1 week following discharge from rehab facility. Followup Instructions: Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Where: [**Hospital6 29**] [**Hospital3 249**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2150-6-3**] 1:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1882**], MD Where: [**Hospital6 29**] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2150-6-23**] 2:10 [**First Name8 (NamePattern2) 1176**] [**Name8 (MD) 1177**] MD [**MD Number(2) 5799**] Completed by:[**2150-4-29**]

[ "276.3", "493.22", "305.1", "112.84", "518.81", "285.9", "E887", "785.0", "276.2", "E937.9", "805.2", "424.0", "276.5", "453.8", "359.4", "795.5", "E932.0", "300.00", "473.9", "564.00", "276.6", "560.1", "401.9", "295.70" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.72", "38.91", "99.04", "31.1", "43.11", "96.04" ]

icd9pcs

[ [ [] ] ]

7366, 7436

3043, 7181

288, 369

7498, 7504

1993, 3020

7741, 8255

1667, 1671

7457, 7477

7207, 7343

7528, 7718

1686, 1974

229, 250

397, 1137

1159, 1591

1607, 1651

24,298

135,639

26316

Discharge summary

report

Admission Date: [**2152-1-27**] Discharge Date: [**2152-2-4**] Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Admitted for elective PCI Major Surgical or Invasive Procedure: [**2152-1-27**] Urgent Two Vessel Coronary Artery Bypass Grafting(vein graft to obtuse marginal, vein graft to posterior descending artery) on IABP [**2152-1-27**] Cardiac Catheterization History of Present Illness: This is an 81 year old male s/p elective cath at [**Hospital 1474**] Hospital on [**2152-1-20**]. This was done to assess symptoms of progressive dyspnea in the setting of a known dilated CMP (EF 15-20%) and positive nuclear ETT. The preliminary findings revealed 85% prox LAD, 80-90% mid RCA stenosis and mild LCx disease with 60% OM1 lesion. He was transferred to [**Hospital1 18**] and underwent PCI of LAD with cypher stent x2 on [**1-20**]. He returned today for planned RCA PCI. His cardiac history dates back to [**2151-2-23**] when he presented with pneumonia. After completing antibiotics, he had persistent dyspnea and required an additional admission in [**2151-4-25**]. He was found to be in CHF. Echo at that time revealed EF 15-20%, LV cavity dilation, moderate MR. [**Name13 (STitle) **] has been followed by Dr [**Last Name (STitle) **] and Dr [**Last Name (STitle) **] [**Last Name (STitle) **] medical management of heart failure. A follow up nuclear stress test done [**10-29**] revealed mild global hypokinesis with an EF 33- 40%. Imaging showed moderate inferior wall infarct with small territory of peri-infarct ischemia. Clinically, he reports feeling mildly short at breath at both times during exertion and rest. He is able to complete most daily activities, but overall feels his energy level has dropped significantly since having pneumonia in [**Month (only) 958**]. Past Medical History: Coronary Artery Disease - s/p LAD stenting, Congestive Heart Failure, Dilated Cardiomyopathy, Mitral Regurgitation, Hypertension, Hyperlipidemia, s/p Cataract Surgery Social History: Lives independently. Denies tobacco and ETOH Family History: Denies premature CAD Physical Exam: Vitals: BP 100/50, HR 86, RR 23, SAT 99% General: elderly male in no acute distress HEENT: oropharynx benign Neck: supple, no JVD Heart: regular rate, normal s1s2, soft systolic murmur Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, no edema, no varicosities Pulses: 2+ distally Neuro: nonfocal Pertinent Results: [**2152-1-27**] 11:30AM GLUCOSE-123* NA+-138 K+-4.2 [**2152-1-27**] 02:20PM WBC-11.2* RBC-2.65* HGB-8.3* HCT-24.0*# MCV-91 MCH-31.4 MCHC-34.7 RDW-12.7 [**2152-2-3**] CXR 1. Improved congestive heart failure. 2. Stable small bilateral pleural effusions, left greater than right. [**2152-1-31**] ECHO Poor echo windows. The left atrium is mildly dilated. The right atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. Overall left ventricular systolic function is moderately depressed - clear regional assessment could not be performed due to sub-optimal images. No masses or thrombi are seen in the left ventricle. Right ventricular chamber size and free wall motion are normal. The aortic root is mildly dilated. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are mildly thickened. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**12-27**]+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. [**2152-1-30**] EKG Sinus rhythm with frequent atrial ectopy. Left axis deviation with left anterior fascicular block. Intraventricular conduction defect. Non-specific ST-T wave changes. Compared to the previous tracing of [**2152-1-29**] no significant diagnostic abnormality. [**2152-1-27**] Cardiac Catheterization COMMENTS: 1. The proximal LAD stent is widely open with no angiographic changes noted since his last angiogram. 2. The RCA lesion was predilated using 2.0 X 20mm Voyager and 2.5 X 15mm Voyager balloons, but we were unable to deliver any stent due to poor guide support. The procedure was complicated by a mid vessel dissection and the patient was referred for urgent CABG. (see PTCA comments) 3. A 30 CC IABP was positioned with satisfactory diastolic augmentation. FINAL DIAGNOSIS: 1. Patent LAD stent 2. RCA lesion PCI was complicated by vessel dissection - referred for urgent CABG. Brief Hospital Course: Mr. [**Known lastname 65138**] was admitted for an elective PCI of his RCA on [**2152-1-27**]. Coronary angiography showed a right dominant system with a widely patent LAD stent, 70% ostial lesion in the obtuse marginal and severe, diffuse disease of the RCA. Unsuccessful attempt to open the RCA was made with resultant dissection and no flow to the distal vessel. No stent was placed in the RCA. He complained of increasing chest pain but remained hemodynamically stable. An IABP was placed and he was emergently brought to the operating room for coronary revascularization. Dr. [**Last Name (STitle) **] performed two vessel coronary artery bypass grafting. The operation was complicated by bleeding which required multiple blood products as well as re-exploration. For further details, see operative note. Following the operation, he was brought to the CSRU. Over several days, the IABP was weaned and removed without complication. He was extubated without difficulty and slowly weaned from inotropic support. Amiodarone was started for episodes of paroxysmal atrial fibrillation. Additional units of PRBCs were transfused to maintain his hematocrit near 30%. Plavix was resumed for his previous left anterior descending artery stent. He otherwise maintained stable hemodynamics. Aspirin, beta blockade and a statin were resumed. All chest tubes and pacing wire were removed and he transferred to the SDU on postoperative day five. He was gently diuresed towards his preoperative weight. The physical therapy service was consulted for assistance with his postoperative strength and mobility. Ciprofloxacin was started for some mild drainage and erythema of his leg incisions. Mr. [**Known lastname 65138**] continued to make steady progress and was discharged home on postoperative day eight. He will follow-up with Dr. [**Last Name (STitle) **], his cardiologist and his primary care physician as an outpatient. Medications on Admission: Aspirin 325 mg qd Plavix 75 mg qd Coreg 6.25 mg qd Lisinopril 2.5 mg qd Lasix 20 mg qd Lipitor 20 mg qd SL NTG prn Discharge Medications: 1. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 5. Carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Disp:*45 Tablet(s)* Refills:*2* 7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 months. Disp:*30 Tablet(s)* Refills:*0* 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 9. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO Q12H (every 12 hours) for 7 days. Disp:*28 Capsule, Sustained Release(s)* Refills:*0* 10. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 11. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*45 Tablet(s)* Refills:*0* 12. Albuterol Sulfate 90 mcg/Actuation Aerosol Sig: Two (2) puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. Disp:*1 MDI* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital1 **] VNA, [**Hospital1 1559**] Discharge Diagnosis: Coronary Artery Disease, Congestive Heart Failure, Cardiomyopathy, Hypertension, Hyperlipidemia, s/p Cataract Surgery, Postoperative Atrial Fibrillation Discharge Condition: Good Discharge Instructions: Patient may shower, no baths. No creams, lotions or ointments to incisions. No driving for at least one month. No lifting more than 10 lbs for at least 10 weeks from the date of surgery. Monitor wounds for signs of infection. Please call with any concerns or questions. Followup Instructions: Cardiac surgeon, Dr. [**Last Name (STitle) **] in [**3-29**] weeks. Local PCP [**Last Name (NamePattern4) **] [**1-28**] weeks. Local cardiologist in [**1-28**] weeks. Completed by:[**2152-2-4**]

[ "997.1", "427.31", "401.9", "425.4", "272.4", "424.0", "998.11", "414.01", "785.51", "428.0", "V45.82", "998.2", "413.9" ]

icd9cm

[ [ [] ] ]

[ "00.40", "88.56", "99.07", "97.44", "36.12", "00.66", "99.05", "37.61", "89.60", "99.20", "99.04", "39.61" ]

icd9pcs

[ [ [] ] ]

8250, 8323

4659, 6577

293, 483

8520, 8527

2571, 4514

8846, 9044

2179, 2201

6743, 8227

8344, 8499

6603, 6720

4531, 4636

8551, 8823

2216, 2552

228, 255

511, 1909

1931, 2100

2116, 2163

80,658

117,314

27455

Discharge summary

report

Admission Date: [**2111-4-12**] Discharge Date: [**2111-5-1**] Date of Birth: [**2053-12-24**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1253**] Chief Complaint: hypoxia Major Surgical or Invasive Procedure: intubation History of Present Illness: 57M with ILD (?NSIP) on prednisone 20 mg daily, Afib s/p recent ablation, CAD, OSA; transfer from OSH after admission [**2111-4-10**] for dyspnea, hypoxia, and hemoptysis. Recent admit to OSH from [**2111-4-7**] to [**2111-4-9**] for TEE and Afib catheter ablation. Discharged on coumadin and lovenox until INR >2. Prior to discharge, had small volume hemoptysis x few episodes, attributed to intubation for procedure. On the day following discharge, patient presented to [**Location (un) 11248**] in [**Location (un) 3844**] with c/o dyspnea and more episodes of small volume hemoptysis. CTA was performed and was negative for PE. Transferred to [**Hospital **] hospital (had ablation there). CT reviewed and thought to have diffuse ground glass opacities. Admitted to the medicine floor, continued on O2 by simple FM with gradual increase up to 10 L/min. Continued having hemoptysis. Given several doses of lasix. On [**4-12**] steroids increased from home 20 mg PO pred to solumedrol 80 mg IV Q8H. ABG today 7.41/37/73 on 10 L FM. Transferred to [**Hospital1 18**] given that his pulmonologist ([**Doctor Last Name 2168**]) located here. . Currently continues to have both hemoptysis and dyspnea. Thinks hemoptysis may be slightly improved, but dyspnea overall worsening. Other ROS: + epistaxis on day of OSH admission, + chills. Negative for fever, HA, vision changes, CP, abdominal pain, diarrhea, constipation, vomiting/nausea, dysuria, bleeding from other sites, weight gain, change in baseline LE edema. Past Medical History: - CAD s/p BMS to LAD in [**2101**], subsequent caths without significant obstructive disease - ILD (early IPF vs. NSIP) - Afib s/p ablation/PVI x 2, first [**10/2110**] and second [**2111-4-7**]. Previously dofetilide (not tolerated due to side effects); currently on sotalol. - Mild pulmonary hypertension (PAP 38/19 seen on past RHC; no PA HTN on CPET [**3-/2110**]) - Obesity - OSH note of "PFO with shunting" - Sleep apnea (intolerant of CPAP) - Type II DM - NAFLD - Dyslipidemia - HTN - Bilateral torn rotator cuffs - BPH - GERD c/b Barrett's esophagus - Anxiety - severe spinal stenosis - s/p CCY - s/p multiple back surgeries (for disc herniation) - s/p hernia repair Social History: Social history is significant for the absence of current tobacco use. 50 pk year history of smoking. Prior h/o ETOH abuse - 7 years ago cut down significantly now occasional ETOH use. Last drink was 2 weeks ago. Married w/ 2 children, on disability due to back problems. Ambulates with crutches at baseline Family History: Father w/ MI in 50s or 60s, had a CABG. Mother: Type [**Name (NI) **] Diabetes and hypertension. Physical Exam: On transfer from the ICU to the medicine service: . t:96.0 HR: 75 BP: 96/47 02: 96% on 5L and 90% on 5L while getting up to bathroom. GEN: Obese male, NAD HEENT: PERRL, EOMI NECK: Full Lungs: Decreased breath sounds in lower [**3-4**] of lungs L>R, mild rhonchi. ABD: soft, non-tender, obese EXT: No edema, DP pulses 2+ Pertinent Results: Admission labs: [**2111-4-13**] 01:30AM BLOOD WBC-6.8 RBC-2.97*# Hgb-10.0*# Hct-28.8*# MCV-97 MCH-33.7* MCHC-34.7 RDW-15.6* Plt Ct-237 [**2111-4-13**] 01:30AM BLOOD PT-20.6* PTT-38.4* INR(PT)-1.9* [**2111-4-13**] 01:30AM BLOOD Glucose-202* UreaN-23* Creat-0.9 Na-135 K-4.4 Cl-100 HCO3-21* AnGap-18 [**4-13**] CXR: There is probably a region of consolidation in the right suprahilar lung, new since prior study. Conventional radiographs would be more definitive. Heart size is mildly enlarged, augmented substantially by mediastinal fat, also responsible in part for widening of the mediastinum in the right paratracheal region and at the thoracic inlet. Pleural effusion, if any, is minimal. The upper esophagus is mildly distended with air. [**4-14**] CT Chest: Newly developed areas of ground-glass opacities in addition to areas of chronic subpleural minimal interstitial chronic changes. The chronic interstitial abnormalities are most likely consistent with NSIP. The rapid development in last two weeks of the diffuse homogeneous ground glass opacities in combination with severe hypoxia and radiological appearance of the findings are highly concerning for several possibilities: acute exacerbation of interstitial lung disease, infection (for example opportunistic infection), acute interstitial pneumonia, hypersensitivity reaction to a new drug/[**Doctor Last Name 360**] and less likely hemorrhage. [**4-15**] BAL: Rare atypical group of squamous cells. Background pulmonary macrophages, neutrophils, and red blood cells. Brief Hospital Course: 57M with ILD on prednisone, Afib s/p recent ablation, CAD; transfer from OSH with dyspnea, hypoxia, and hemoptysis with high O2 requirements. . # Dyspnea/hypoxia: This patient had multiple potential causes of dyspnea including ILD/NSIP, potential cardiac causes (CHF, CAD, Afib s/p recent ablation - potential for pulmonary vein stenosis, ?history of PFO - potential for shunt), and pulmonary artery hypertension. He was also thought to have component of chronic dyspnea unrelated to ILD, with a significant hyperventilatory response to exercise. Pulmonary vein stenosis was considered in light of recent ablation, but thought by cardiology to be unlikely after imaging pre and post ablation was reviewed with radiology. Instead, they felt that pulmonary contusion as sequelae of ablation was possible explanation. . On [**4-15**], he began having tachypnea in the evening once BiPAP mask applied, which progressed to tachypnea to the 50s with oxygen desats. He underwent urgent intubation after discussion with him and his wife. [**Name (NI) **] then required high level of sedation and airway pressure release ventilation (APRV) mode prior to getting oxygen sats from mid-80s post intubation back to 90. He was subsequently very agitated, requiring extra sedation. He underwent bronchoscopy showing diffuse alveolar hemorrhage. Infectious workup from BAL was negative for PCP, [**Name10 (NameIs) 3019**], AFB, legionella. Vasculitis was a potential cause, and he was started on solumedrol 1g q24h. He was extubated successfully shortly thereafter. An attempt was made to diurese him, but this was limited by blood pressure. On [**4-24**], due to low-grade fever and persistent copious thick secretions was started on on empiric Vanc and Zosyn. Mini-BAL culturs were negative. He continued to desaturate with movement to and from chair, but was otherwise with O2 Sats low 90s on 5-6L NC. Given negative blood and sputum cultures, antibiotics were stopped. He was called out of the ICU to the general medicine wards. He transitioned from IV steroids to an oral prednisone taper. (60 mg x 10 days followed by 40 mg for a total of 7 days, to be followed as an outpatient by 20 mg daily for 7 days, and then 15 mg ongoing.) Also, cyclophosphamide therapy was initiated (250 mg daily for 7 days followed by 150 mg ongoing). There, he continued to desaturate with exertion and intermittently at night. Bipap was placed, but the patient found it uncomfortable and didn't wear it. . Liver function tests were trended while on cyclophosphamide. Prior to discharge, transaminases were mildly but stably elevated, and TBili rose to 1.7. These should be trended every 3 days, and the dose of cyclophosphamide reduced if needed. . Prior to discharge, the patient was requiring 50% venti mask to maintain O2 Sat ~94%, with a respiratory rate in the mid 20s. He would desaturate with exertion to the low 80s, with respiratory rate increasing to ~35. The patient and his family understand that this will continue to improve as his alveolar hemorrhage resolves and the steroids and cyclophosphamide exert their effect on his underlying lung disease. He will follow up with his pulmonologist in 2 weeks. . # Hemoptysis: On coumadin for Afib with recent ablation. Differential for bleeding initially included bronchitis, airway trauma from intubation, pneumonia (including bacterial, PCP, [**Name10 (NameIs) **], or other atypical), neoplasm, bronchiectasis, ?pneumonitis exacerbation. Bronchoscopy demonstrated diffuse alveolar hemorrhage. All anticoagulation was held. . # Atrial fibrillation: He was s/p recent ablation and now in sinus rhythm. On anticoagulation at admission, which was stopped when alveolar hemorrhage found. Sotalol was continued. Atenolol was stopped because of borderline blood pressures. . # CAD: He was ruled out for MI by enzymes on admission. ASA, statin, beta blocker, and ACE were continued. . # HTN: Continue home regimen. . # DM: FSBG were elevated in the setting of high-dose steroids. He was initially covered with sliding scale insulin. Given persistently high [**Location (un) 1131**], long-acting insulin was added. After transitioning to oral steroids and being called out to the floor, the long-acting insulin was stopped and metformin restarted. His fingersticks were ~150 on this regimen. . The patient remained full code throughout this admission. . Medications on Admission: MEDS on Transfer: Lisinopril 5 mg PO DAILY Acetaminophen 325-650 mg PO Q6H:PRN Multiple Vitamins Liq. 5 ml PO DAILY Atorvastatin 80 mg PO DAILY Nystatin Oral Suspension 5 mL PO QID:PRN thrush Bisacodyl 10 mg PO/PR DAILY:PRN constipation Ondansetron 4 mg IV Q8H:PRN nausea Calcium Carbonate 1000 mg PO DAILY Paroxetine 40 mg PO DAILY Colchicine 0.6 mg PO DAILY Piperacillin-Tazobactam Na 4.5 g IV Q8H Cyanocobalamin 1000 mcg PO DAILY PredniSONE 60 mg PO DAILY Order date: [**4-19**] @ 1009 Cyclophosphamide 250 mg PO DAILY Ropinirole 0.25 mg PO HS Docusate Sodium (Liquid) 100 mg PO BID Senna 2 TAB PO BID Haloperidol 2 mg PO TID:PRN agitation Heparin 7500 UNIT SC TID Sotalol 160 mg PO BID Ibuprofen 400-800 mg PO Q8H:PRN Sulfameth/Trimethoprim DS 1 TAB PO 3X/WEEK (MO,WE,FR) Insulin SC (per Insulin Flowsheet) Vancomycin 1000 mg IV Q 12H Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY Vitamin D 800 UNIT PO DAILY Lactulose 30 mL PO Q8H:PRN constipation . MEDICATIONS AT HOME: ATENOLOL 50 mg Tablet DAILY ATORVASTATIN 80 mg DAILY CELECOXIB 200 mg once a day COLCHICINE 0.6 mg Tablet daily FEXOFENADINE 180 mg daily LISINOPRIL 5 mg Tablet - DAILY METFORMIN 1000 mg QAM, 500 mg QPM OMEPRAZOLE 20 mg twice a day PAROXETINE HCL 50 mg daily PREDNISONE 20 mg Tablet daily (recently decreased from 30 mg daily) PROPOXYPHENE N-ACETAMINOPHEN 100 mg-650 mg Q4H prn pain ROPINIROLE 0.25 mg at night SOTALOL 160 mg [**Hospital1 **] TAMSULOSIN 0.4 mg daily TRIMETHOPRIM-SULFAMETHOXAZOLE - 800 mg-160 mg three times a week WARFARIN LOVENOX 140 [**Hospital1 **] ASPIRIN 81 mg DAILY CALCIUM 500 + D CYANOCOBALAMIN 1,000 mcg daily MULTIVITAMIN daily Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: primary: diffuse alveolar hemorrhage, interstitial lung disease secondary: type 2 diabetes mellitus, coronary artery disease, anemia Discharge Condition: stable, on 50% venti mask with O2 Sats in the mid 90s falling to mid 80s with exertion Discharge Instructions: You were transferred to [**Hospital1 18**] because of trouble breathing. This was due to bleeding in your lungs. You were intubated in the intensive care unit, but after that your oxygen saturation improved and you came to the regular hospital floor where you had physical therapy and monitoriing. The following medications were changed: cyclophosphamide was added prednisone was changed atenolol was stopped celecoxib was stopped fexofenadine was stopped warfarin was stopped lovenox was stopped Please call your doctor or return to the emergency department for worsening shortness of breath, chest pain, fevers and chills, or other symptoms that are concerning to you. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 2171**] as below: Provider: [**Name10 (NameIs) 1571**] FUNCTION LAB Phone:[**Telephone/Fax (1) 609**] Date/Time:[**2111-5-11**] 9:30 Provider: [**Name10 (NameIs) 1570**],INTERPRET W/LAB NO CHECK-IN [**Name10 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2111-5-11**] 9:30 Provider: [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2111-5-11**] 10:00 Completed by:[**2111-5-1**]

[ "530.85", "300.00", "724.00", "427.31", "E932.0", "417.8", "414.01", "112.0", "518.81", "600.00", "250.00", "285.1", "786.3", "V15.82", "571.8", "515", "244.9", "458.29", "272.4", "276.6", "V58.61", "V45.82", "327.23" ]

icd9cm

[ [ [] ] ]

[ "93.90", "33.24", "88.72", "31.42", "96.04", "38.93", "96.72", "38.91" ]

icd9pcs

[ [ [] ] ]

11029, 11108

4933, 9339

323, 335

11287, 11376

3372, 3372

12098, 12630

2918, 3016

11129, 11266

9365, 9365

11400, 12075

10347, 11006

3031, 3353

276, 285

363, 1877

3388, 4910

1899, 2576

2592, 2902

9383, 10326

60,925

197,668

50144

Discharge summary

report

Admission Date: [**2173-7-20**] Discharge Date: [**2173-8-11**] Date of Birth: [**2115-6-15**] Sex: F Service: SURGERY Allergies: Danazol Attending:[**First Name3 (LF) 371**] Chief Complaint: RUQ Pain Major Surgical or Invasive Procedure: ERCP [**7-20**]: CBD could not be cannulated due to angulation [**8-4**]: Attempt at laparoscopic cholecystectomy, converted to open cholecystostomy History of Present Illness: 58 years-old woman with h/o of paroxysmal Afib, s/p gastric bypass in [**2167**] who presented with non radiating RUQ abdominal pain, nausea and vomiting (non-bloody, nonbilious), fevers to 103 at home and jaundice. Patient initially presented to [**Hospital 1474**] Hospital. There, a CT scan revealed a distended gallbladder, pericholecystic inflammatory changes c/w acute cholecystitis as well as a diffusely fatty liver. Patient received IV Unasyn. ERCP was also attempted; however, given patient's prior gastric bypass surgery, the CBD could not be cannnulated. Patient was transferred to the [**Hospital1 18**] for further management. Past Medical History: Paroxysmal Afib Hypertension hypercholesterolemia ETOH withdrawal after L-foot surgery in [**2172**] Proximal phalangeal and metacarpal fracture of left 4th digit h/o GI bleed h/o gastric ulcers h/o Gout h/o depression s/p corrective surgery of left forefoot - [**2172**] s/p Roux en Y Gastric Bypass - [**2167**] s/p TAH/BSO for endometriosis c/b pelvic abscess- [**2162**] s/p laparoscopy with LOA - [**2158**] s/p tubal ligation - [**2155**] s/p Lumpectomy of breast Social History: Patient lives with her husband; No children Her support system includes her husband, father, and two sisters. ETOH use- According to husband, pt drinks up to 3L of whiskey/day (last drink was on [**2173-7-18**]) Denies Tobacco or illicit drugs Family History: NC Physical Exam: VS: Temp: 98 HR: 120 afib BP: 126/92 RR: 12 O2 Sat: 98% on 2L Pain: [**3-2**] Gen: NAD HEENT: NCAT. Sclera anicteric. PERRL, EOMI. OP clear, no exudates or ulceration. Neck: Supple, JVP not elevated. CV: irregular irregular; No m/r/g. Chest: CTAB; No rales, wheezes or rhonchi Abd: Obese, Soft, ND, tender to palpation in RUQ. No rebound, positive guarding Ext: Warm and well perfused. No c/c/edema Skin: Jaundice otherwise no stasis, ulcers, or scars Pertinent Results: [**2173-7-20**] 02:40AM URINE RBC-[**3-25**]* WBC-0-2 BACTERIA-OCC YEAST-NONE EPI-0-2 [**2173-7-20**] 02:40AM URINE BLOOD-SM NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-TR BILIRUBIN-MOD UROBILNGN-12* PH-6.5 LEUK-NEG [**2173-7-20**] 02:40AM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.019 [**2173-7-20**] 02:40AM PLT COUNT-149*# [**2173-7-20**] 02:40AM WBC-8.6 RBC-4.02* HGB-13.7# HCT-40.1 MCV-100* MCH-34.0* MCHC-34.1 RDW-13.7 [**2173-7-20**] 02:40AM NEUTS-96.1* LYMPHS-1.9* MONOS-1.4* EOS-0.5 BASOS-0.1 [**2173-7-20**] 02:40AM ALBUMIN-3.4 [**2173-7-20**] 02:40AM LIPASE-18 [**2173-7-20**] 02:40AM ALT(SGPT)-259* AST(SGOT)-451* ALK PHOS-168* TOT BILI-11.8* [**2173-7-20**] 02:40AM GLUCOSE-119* UREA N-14 CREAT-0.7 SODIUM-133 POTASSIUM-3.6 CHLORIDE-100 TOTAL CO2-21* ANION GAP-16 [**2173-7-20**] 04:38AM PT-15.3* PTT-33.6 INR(PT)-1.3* [**2173-7-20**] 04:38AM PLT COUNT-160 [**2173-7-20**] 04:38AM WBC-10.2 RBC-3.84* HGB-13.1 HCT-38.3 MCV-100* MCH-34.1* MCHC-34.1 RDW-13.7 [**2173-7-20**] 04:38AM CALCIUM-8.5 PHOSPHATE-2.9 MAGNESIUM-1.9 [**2173-7-20**] 04:38AM ALT(SGPT)-257* AST(SGOT)-419* ALK PHOS-164* TOT BILI-12.0* [**2173-7-20**] 04:38AM GLUCOSE-98 UREA N-15 CREAT-0.8 SODIUM-135 POTASSIUM-3.4 CHLORIDE-100 TOTAL CO2-21* ANION GAP-17 [**2173-7-21**] 07:10AM BLOOD TSH-1.3 [**2173-8-8**] 11:43PM BLOOD WBC-7.9 RBC-2.99* Hgb-10.2* Hct-31.8* MCV-106* MCH-34.3* MCHC-32.3 RDW-14.0 Plt Ct-510* [**2173-8-8**] 11:43PM BLOOD Plt Ct-510* [**2173-8-11**] 05:47AM BLOOD ALT-34 AST-54* AlkPhos-487* TotBili-5.1* DirBili-3.2* IndBili-1.9 [**2173-7-24**] 02:28AM BLOOD Lipase-138* [**2173-8-10**] 04:55AM BLOOD Calcium-8.7 Phos-4.1 Mg-1.7 [**2173-8-8**] 11:43PM BLOOD calTIBC-174* Ferritn-333* TRF-134* [**2173-8-8**] 11:43PM BLOOD Digoxin-1.0 ------------- URINE CULTURE (Final [**2173-7-30**]): YEAST Blood Culture, Routine (Final [**2173-8-4**]): NO GROWTH. CLOSTRIDIUM DIFFICILE TOXIN A & B TEST (Final [**2173-7-29**]): CLOSTRIDIUM DIFFICILE Brief Hospital Course: Patient presented with RUQ pain, nausea, vomiting, fevers, jaundice (total bilirubin on admission was 11.8). On hospital day 1 ([**2173-7-20**]), An U/S showed a non distended but abnormal appearing gallbladder with moderate wall thickening, and trace pericholecystic fluid. There was no definite gallstones, but possible small amount of GB sludge. No biliary ductal dilatation was seen. Furthermore, the liver was noted to have markedly diffuse fatty infiltrate. An ERCP performed by GI endoscopy reported a CBD that could not be cannulated due to angulation. On HD2 ([**2173-7-21**]), patient continued to be jaundice with a total bilirubin of 12, which was concerning for CBD obstruction. An MRCP was obtained to assess intra and extra hepatic ducts. MRCP confirmed acute cholecystitis but also showed diffuse peribiliary edema and enhancement consistent with acute cholangitis. The distal CBD although not dilated, contained sludge. Later that day, ([**7-21**]), Interventional Radiology performed a percutaneous transhepatic cholangiogram with successful placement of a biliary catheter. Under direct fluoroscopic guidance. The ductal sludge/stones were also pushed into the bowel via insufflation of [**Last Name (un) **] balloon. Follow up cholangiogram did not reveal retained stones. Post IR procedure, while in the PACU, patient became increasingly agitated, confused, and tachycardic to the 170s. Per husband, patient drinks approximately 3L of whiskey/day and had a similar episode of ETOH withdrawal in [**2173-2-21**] after left bunionectomy. A total of 4mg Lorazepam was given in the PACU and patient was placed on CIWA protocol. Patient was transferred to ICU for Delerium Tremens. Social work was consulted regarding ETOH abuse and to provide emotional support to patient around her hospitalization. On [**7-22**], the cathter was re evaluated by IR and was upsized. Patient was intubated for airway protection prior to procedure. Although the plan was extubated the next morning, patient's mental status was not adequate for extubation. Patient was gradually weaned off ventilator and safely extubated on the [**7-25**]. Blood and urine cultures were negative were negative on [**7-23**]. Bile from percutaneous drain were sent for culture and showed sparse yeast and 3+ GNR enterobacter cloacae. Patient started on Meropenem. On HD4, ([**2173-7-23**]), a Dobbhoff feeding tube was place. Of note, on HD9 ([**2173-7-28**]) C.DIFFICILE TOXIN A & B TEST on patient's stool sample was positive and patient was treated with Metronidazole. Given patient's continued elevation of total bilirubin, a followup MRCP was performed on HD11 [**2173-7-30**] to assess for obstruction in the biliary system and biliary abscesses. There was no evidence of continued cholecystitis or cholangitis. Gallbladder sludge was again noted with mildly enlarged lymph nodes in the porta hepatis. On [**2173-8-3**], the PTC Drain was still putting out >1000cc/day and patient still jaundiced/hyperbilirubinemic. on [**2173-8-4**] a cholecystectomy tube was placed. A tube cholangiogram was performed on [**8-7**] and also repeated on [**8-9**]. Both studies showed a narrowed lower CBD; there was no evidence of obstruction. Patient [**Name (NI) 3539**] trended down. On [**8-9**] [**Month/Year (2) 3539**] was 5.1 compared to admission Tbilli of 12.0*. Pt was transferred to floor but had ongoing episodes of Afib with RVR to 160s (with stable BP (90-110 baseline). EKGs showing some ST depressions though pt remained asymptomatic (no CP or SOB) and cardiac enzymes negative x 3. Per Medicine recommendations, Atenolol was discontinued and patient was started on Metoprolol 37.5mg TID. Digoxin was continued and the levels checked. For breakthrough of RVR, Metoprolol 5mg IV push was given was well as an additional Metoprolol 12.5-25mg po. Cardiology was also agreed with recs since and recommended increasing lopressor patient was started on Aspirin 325mg. On the day of discharge, the patient had finished her CIWA taper. She was taking PO, she was out of bed and ambulating witout difficulties. she was taking all her medications PO including home digoxin and Lopressor. Medications on Admission: Atenolol 25mg [**Hospital1 **] Protonix 40mg Digoxin 0.125mg daily Simvastatin 40 mg daily Multivitamin 1 tablet/day Calcium Carbonate 1 tablet/day Discharge Medications: 1. Ursodiol 250 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheeze / dyspnea. 3. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Fluconazole 200 mg Tablet Sig: Two (2) Tablet PO Q24H (every 24 hours). Disp:*20 Tablet(s)* Refills:*0* 7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours for 7 days. Disp:*14 Tablet(s)* Refills:*0* 8. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Atenolol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO once a day for 7 days. Disp:*7 Tablet(s)* Refills:*0* 11. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO every four (4) hours as needed for pain for 10 days. Disp:*40 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital1 1474**] VNA Discharge Diagnosis: cholecystitis and cholangitis Discharge Condition: stable Discharge Instructions: Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. *Avoid lifting objects > 5lbs until your follow-up appointment with the surgeon. *Avoid driving or operating heavy machinery while taking pain medications. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. * Continue to ambulate several times per day. Incision Care: -Your staples will be removed in clinic. -You may shower, and wash surgical incisions. -Avoid swimming and baths until your follow-up appointment. -Please call the doctor if you have increased pain, swelling, redness, or drainage from the incision sites. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] within the next week. Please call [**Telephone/Fax (1) 1864**] to make appointment. Please follow-up with your cardiologist (Dr. [**Last Name (STitle) 19**] within a week to discuss episodes of increased heart rate and atrial fibrillation. Please see Dr. [**First Name8 (NamePattern2) 6339**] [**Last Name (NamePattern1) 19420**] ([**Telephone/Fax (1) 40118**] to remove drain next week. Call to make appointment. Completed by:[**2173-8-11**]

[ "274.9", "V64.41", "008.45", "276.1", "291.81", "272.0", "287.5", "276.3", "576.1", "574.61", "518.81", "112.2", "427.31", "401.9", "V45.86" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.6", "51.03", "51.10", "51.98", "87.51", "38.93", "96.04", "87.54" ]

icd9pcs

[ [ [] ] ]

9852, 9907

4374, 8558

275, 426

9981, 9990

2365, 4351

11477, 11977

1873, 1877

8756, 9829

9928, 9960

8584, 8733

10038, 11182

11197, 11454

1892, 2346

227, 237

454, 1098

1120, 1593

1609, 1857

81,233

161,589

37984

Discharge summary

report

Admission Date: [**2145-11-21**] Discharge Date: [**2145-11-24**] Date of Birth: [**2078-12-12**] Sex: F Service: SURGERY Allergies: Codeine / Dilaudid (PF) Attending:[**First Name3 (LF) 598**] Chief Complaint: Nausea, vomiting, epigastric pain Major Surgical or Invasive Procedure: [**2145-11-21**] ERCP History of Present Illness: HPI: 66F s/p lap chole ~1 year ago who presents with epigastric pain after a fatty meal. She presents here with substantial epigastric pain, and LFT abnormalities indicative of an obstructed biliary system without jaundice. Findings are concerning for retained gallstone pancreatitis. The patient had fluctuates of blood pressure and heart rate as well as tachypnea, prompting the ED to suddenly obtain a CTA Torso to rule out PE while still evaluating the abdomen. CTA Chest was negative, but the abdomen scan demonstrated dilated extra- and intra- hepatic ducts, keeping with the presumed diagnosis. Past Medical History: Little medical care in several years. Presentation to [**Hospital3 **] where had stress test (full results not available) LBBB ([**2141**]) PE at age 21 while on OCPs DM type II Hyperlipidemia Gallstones GERD Anxiety, panic attacks Hemorrhoids H/o toxin-induced hepatitis from overdose of OTC medication Anemia "Congenital [**Last Name **] problem in which blood was flowing the wrong way" Social History: Takes care of an elderly woman for work. Walks up and down stairs during work, sometimes feels shortness of breath. Notes that she has been anxious related to a disagreement with her boss lately. No EtOH or drug use ever. Smoked up until age 30. Not sexually active. Family History: No blood clots or liver disease. Brother with hypertension and heart disease of some type. Physical Exam: Upon presentation to [**Hospital1 18**]: 97.6 74 194/104 18 99% RA GENERAL: NAD, concerned and anxious about her pain control and what is causing her pain CV: s1 s2 no murmur Lungs: CTA - some mild diminishing of sounds at the bases Abdomen: mild RUQ tenderness, epigastric tenderness elicited but otherwise soft and mildly distended Vitals thirty minutes later HR 123 BP 224/100 Pertinent Results: [**2145-11-21**] 02:49AM GLUCOSE-199* UREA N-17 CREAT-0.8 SODIUM-142 POTASSIUM-3.5 CHLORIDE-110* TOTAL CO2-20* ANION GAP-16 [**2145-11-21**] 02:49AM ALT(SGPT)-623* AST(SGOT)-409* ALK PHOS-524* AMYLASE-[**2156**]* TOT BILI-2.7* [**2145-11-21**] 02:49AM LIPASE-6095* [**2145-11-21**] 02:49AM ALBUMIN-3.6 CALCIUM-8.9 PHOSPHATE-3.7 MAGNESIUM-1.5* [**2145-11-21**] 02:49AM WBC-14.6*# RBC-4.64 HGB-12.0 HCT-36.8 MCV-79* MCH-25.9* MCHC-32.7 RDW-15.1 [**2145-11-21**] 02:49AM NEUTS-86* BANDS-4 LYMPHS-5* MONOS-5 EOS-0 BASOS-0 ATYPS-0 METAS-0 MYELOS-0 CT Chest/ABD: CT CHEST WITH AND WITHOUT CONTRAST: The IV bolus timing is slightly suboptimal, but there is no filling defect in the central, lobar or segmental pulmonary arteries. Of note, there is a right aberrant subclavian artery. The remaining mediastinal vessels are unremarkable. Patchy bibasilar opacities are nonspecific, but could represent atelectasis, but cannot rule out aspiration or pneumonia. There is no pleural effusion. Evaluation of small pulmonary nodule is limited in the presence of patchy opacity, but there is no large lung pulmonary lesion. The heart is normal in size without pericardial effusion. Aortic valvular calcifications are noted. Small mediastinal and hilar lymph nodes are not pathologically enlarged. There is no axillary lymphadenopathy. CT ABDOMEN WITH IV CONTRAST: The liver is normal without focal lesion. The patient has undergone interval cholecystectomy. Mild intrahepatic and extrahepatic biliary ductal dilatation is new from prior, with the common bile duct measuring up to 8-9 mm. There is enlargement of the pancreatic head and neck with minimal adjacent peripancreatic fat stranding. The pancreas enhances normally without peripancreatic fluid collections. There is no calcified stone in the biliary tract. The spleen is within normal limits. A hyperdense exophytic cyst arising from the lower pole of the left kidney is unchanged. The stomach, duodenum and loops of small bowel are normal. There is no free air, lymphadenopathy, or fluid. Abdominal aorta is normal in caliber. BONE WINDOW: There are no lytic or sclerotic lesions. Multilevel degenerative changes are mild-to-moderate. IMPRESSION: 1. Limited evaluation of the subsegmental pulmonary arteries. No pulmonary embolism within the main, lobar, or segmental branches. 2. Interval increased prominence of pancreatic head and neck, with mild peripancreatic fat stranding, compatible with pancreatitis. 3. Interval cholecystectomy with new, mild intra-hepatic and extrahepatic biliary ductal dilatation. While no calcified intraluminal biliary stone is identified, CT is insensitive for choledocholithiasis. Consider MRCP for further evaluation. 4. Bilateral patchy opacities in the lung bases. Differential considerations include pneumonia, aspiration, or atelectasis. Brief Hospital Course: She was admitted to the ACS service and underwent ERCP with sphincterotomy where a 10 mm stone and drained pus were removed. She was started on Cipro and Flagyl IV early on. On the day following her ERCP she was noted with tachypnea and low oxygen saturations. CXR showed pulmonary edema, she was given IV Lasix with resolution of her symptoms. As her GI symptoms resolved her diet was upgraded to regular for which she was able to tolerate. Her home medications were restarted as well. She was discharged to home on oral Cipro and Flagyl and will follow up in [**Hospital 2536**] clinic in [**1-20**] weeks. Medications on Admission: VitD-2 400U', calcium carbonate 600'', ASA 81', lisinopril 20', simvastatin 20', omeprazole 20', metformin 1000' Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 2. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 3. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 5. metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 7 days. Disp:*21 Tablet(s)* Refills:*0* 6. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO every 4-6 hours as needed for pain. Discharge Disposition: Home Discharge Diagnosis: Cholangitis/Gallstone pancreatitis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were hospitalized with inlammation of your biliary system and underwent and ERCP procedure where some of the excess contents that were contributing to this inflammation were removed. You are being being discharged on antibitoics, please complete the course as prescribed. You may resume your heome medications as prescribed. If taking narcotics for pain be sure to take a laxative and stool softener to prevent constipation. Followup Instructions: Follow up in [**1-20**] weeks in [**Hospital 2536**] clinic, call [**Telephone/Fax (1) 600**] for an appointment. Follow up with your PCP [**Last Name (NamePattern4) **] [**1-20**] weeks for a general physical, you will need to call for an appointment. [**First Name8 (NamePattern2) **] [**Name8 (MD) **] MD [**MD Number(2) 601**] Completed by:[**2145-12-1**]

[ "574.51", "995.91", "250.00", "V45.79", "285.9", "300.00", "577.0", "576.1", "V15.82", "038.9", "530.81", "V12.51", "300.01", "288.60", "272.4" ]

icd9cm

[ [ [] ] ]

[ "51.88", "51.85" ]

icd9pcs

[ [ [] ] ]

6461, 6467

5074, 5688

320, 343

6545, 6545

2202, 5051

7151, 7542

1693, 1785

5851, 6438

6488, 6524

5714, 5828

6695, 7128

1800, 2183

246, 282

371, 979

6560, 6671

1001, 1392

1408, 1677

80,287

150,457

42070

Discharge summary

report

Admission Date: [**2173-10-18**] Discharge Date: [**2173-10-29**] Date of Birth: [**2132-11-24**] Sex: F Service: MEDICINE Allergies: Penicillins / Compazine / Benadryl Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: T-tube placement Major Surgical or Invasive Procedure: T-tube placement History of Present Illness: 40 y.o woman with history of mixed central and obstructive sleep apnea, multiple sclerosis, recurrent cellulitis s/p recent admission who presents to the hospital for a t-tube placement by interventional radiology. The patient had previously had a tracheostomy tube but had airway collapse above the tracheostomy, causing significant apneas at night when the tracheostomy was plugged. She therefore was admitted today for a t-tube placement that stents upen her upper trachea, and is now postoperative. Currently, she denies any symptoms save for significant throat pain. Past Medical History: respiratory failure s/p tracheostomy mixed central/obstructive sleep apnea diabetes mellitus morbid obesity cellulitis hypothyroidism hypocalcemia spastic bladder multiple sclerosis diagnosed in [**2165**], wheelchair bound and completely dependent on ADL's iron deficiency anemia anxiety s/p CCY/appy/tonsillectomy Social History: Tobacco: denies Alcohol: denies Lives at [**Hospital 91298**] Rehab Facility, [**State 1727**]. Has 1 son Occupation: prior to MS diagnosis worked in retail Family History: No lung cancer or congenital lung diseases DM, Hypothyroidism Physical Exam: GEN: No acute distress. HEENT: Mucous membranes moist, no lesions noted. Sclerae anicteric. No conjunctival pallor noted. NECK: JVP could not be appreciated. No lympadenopathy. T-tube in place, clean, dry, intact. CV: Regular rate and rhythm, no murmurs, rubs or [**Last Name (un) 549**] PULM: Clear to auscultation bilaterally, no wheezes, rales or rhonchi. ABD: Soft, obese, non-tender, non distended, bowel sounds present. No hepatosplenomegaly EXTR: No edema, 2+ Dorsalis pedis and radial pulses bilaterally. NEURO: Alert and oriented x3. Grossly non-focal. DISCHARGE PHYSICAL EXAM: GEN: No acute distress. HEENT: Mucous membranes moist, no lesions noted. Sclerae anicteric. No conjunctival pallor noted. NECK: JVP could not be appreciated. No lympadenopathy. Trach-tube in place, clean, dry, intact. CV: Regular rate and rhythm, no murmurs, rubs or [**Last Name (un) 549**] PULM: Clear to auscultation bilaterally, no wheezes, rales or rhonchi. ABD: Soft, obese, non-tender, non distended, bowel sounds present. No hepatosplenomegaly EXTR: No edema, 2+ Dorsalis pedis and radial pulses bilaterally. NEURO: Alert and oriented x3. Grossly non-focal. SKIN: Multiple excoriative lesions, with venous stasis ulcers on lower extremities in varios stages of healing. Pertinent Results: Amdmission labs: [**2173-10-19**] 04:31AM BLOOD WBC-9.7 RBC-3.61* Hgb-9.6* Hct-28.9* MCV-80* MCH-26.7* MCHC-33.4 RDW-18.3* Plt Ct-294 [**2173-10-19**] 04:31AM BLOOD Plt Ct-294 [**2173-10-19**] 04:31AM BLOOD Glucose-201* UreaN-15 Creat-1.1 Na-145 K-4.0 Cl-103 HCO3-31 AnGap-15 [**2173-10-20**] 04:10AM BLOOD ALT-9 AST-11 AlkPhos-90 TotBili-0.4 [**2173-10-20**] 04:10AM BLOOD Albumin-4.1 Calcium-9.5 Phos-3.7 Mg-1.3* EKG: sinus tach at 115bpm, NA/NI, poor R wave progression. Imaging: [**10-20**] CT head: IMPRESSION: No acute intracranial pathology [**10-21**] EEG: IMPRESSION: This EEG telemetry did not capture any pushbutton events for seizures. It was a 3.5 hour extended routine study. There was present two relatively short duration periods of what appeared to be perhaps slow wave sleep activity. It could not be determined based upon patient's clinical state since she appeared to lie relatively motionless throughout the entire record. The impression essentially is that this is a normal awake and breakthrough sleep study. No clear epileptic activity was identified. [**10-22**] AP CXR: The nasogastric tube ends in the mid stomach. Moderate cardiomegaly is stable. Previous pulmonary edema has largely cleared. Greater opacification at the right lung base could be atelectasis or pneumonia. Right internal jugular infusion port ends in the right atrium. No pneumothorax. Pleural effusion is minimal if any. [**2173-10-25**] 03:32AM BLOOD WBC-11.9* RBC-3.34* Hgb-8.7* Hct-26.8* MCV-80* MCH-25.9* MCHC-32.3 RDW-17.5* Plt Ct-332 [**2173-10-25**] 11:10AM BLOOD WBC-9.8 RBC-3.27* Hgb-8.6* Hct-26.2* MCV-80* MCH-26.2* MCHC-32.7 RDW-17.5* Plt Ct-267 [**2173-10-25**] 11:32PM BLOOD WBC-7.8 RBC-3.39* Hgb-8.7* Hct-26.9* MCV-79* MCH-25.8* MCHC-32.5 RDW-17.3* Plt Ct-273 [**2173-10-27**] 05:48AM BLOOD WBC-8.3 RBC-3.55* Hgb-9.2* Hct-28.2* MCV-79* MCH-26.0* MCHC-32.8 RDW-17.7* Plt Ct-296 [**2173-10-28**] 03:31AM BLOOD WBC-7.4 RBC-3.71* Hgb-9.8* Hct-29.6* MCV-80* MCH-26.3* MCHC-33.0 RDW-17.8* Plt Ct-283 [**2173-10-25**] 11:10AM BLOOD Glucose-204* UreaN-22* Creat-1.0 Na-143 K-3.7 Cl-100 HCO3-34* AnGap-13 [**2173-10-25**] 11:32PM BLOOD Glucose-252* UreaN-22* Creat-0.8 Na-141 K-4.0 Cl-98 HCO3-38* AnGap-9 [**2173-10-27**] 05:48AM BLOOD Glucose-143* UreaN-22* Creat-0.9 Na-143 K-3.3 Cl-100 HCO3-40* AnGap-6* [**2173-10-28**] 03:31AM BLOOD Glucose-170* UreaN-18 Creat-0.9 Na-141 K-3.2* Cl-99 HCO3-38* AnGap-7* [**2173-10-28**] 03:31AM BLOOD Calcium-9.4 Phos-3.4 Mg-1.5* [**2173-10-20**] 04:15AM BLOOD Type-ART pO2-119* pCO2-60* pH-7.35 calTCO2-35* Base XS-5 Intubat-NOT INTUBA [**2173-10-20**] 01:47AM BLOOD Type-ART pO2-324* pCO2-71* pH-7.29* calTCO2-36* Base XS-5 Comment-NON-REBREA Brief Hospital Course: 40 y.o woman with history of multiple sclerosis, central and obstructive sleep apnea who is now post-op s/p T-tube placement. . #Trach-tube placement - the patient underwent placement of a Hebeler T-tube for evidence of tracheal collapse above her previous tracheostomy tube. The procedure was without complication, and the patient was kept overnight for observation. Care for the tube should include [**Hospital1 **] saline flushing with 5mL and suctioning. Cap during the day and uncap during the night with humidified trach mask. The patient was also started on mucinex for mucous control. [**10-22**] the patient had a rigid bronchoscopy by IP that showed severe inflammation. During the procedure the patient had mucous plugging resulting in severe hypoxia. Afterwards she was treated with 4 days of Solumedrol 40mg Q4hrs and 5 days of Vanc/Zosyn to try to reduce the swelling. She was kept in the ICU in case of repeat plugging episode. On [**10-26**] her T-tube was replaced with #7 uncuffed. Patient tolerated procedure well. She was restarted on regular diet after the procedure. # Unresponsiveness episodes: Early AM of [**10-20**], the patient became unresponsive during an albuterol nebulizer treatment. Code blue was called, however she was never pulseless or apneic. Her vital signs were stable and she did not get chest compressions. ABG showed hypercarbia with pCO2 70, however this was not high enough to explain her symptoms, given her baseline in the 50s and 60s. Head CT negative. EEG showed no seizure activity. Her mental status exam slowly improved over the next two to three days to the point the patient was at baseline. Initially she complained of being unable to move her body except for blinking, followed by inability to move the left side of her body. Neurology was consult, who felt that that her neurology exam was inconsistent, and this was likely caused by a conversion disorder. Psychiatry was consulted, who felt the patient was at a high risk for a psychiatric event, but that this was a diagnosis of exclusion. She had one further even the night of [**10-22**] lasting about 10 minutes, that resolved spontaneously. She had no further episodes. We held her abilify given self-reported dizziness, in concert with psychiatry consult. She will need follow up with psychiatry as outpatient. . #. Nutrition: after the bronch [**10-22**] the patient had trouble swallowing solids. The patient had to be NPO for several days, so an NG tube was placed and tube feeds were started. She was seen by speech and swallow after replacement of her tube , who recommended regular diet. . #Diabetes - continued glargine. While on Tube feeds the patient was covered with regular insulin Q6hrs. . #Depression - continued paroxetine, aripiprazole. . #Hypothyroidism - continued levothyroxine at 200mcg/day. . #[**Last Name (un) **] - creatinine trending down from prior admission. This normalized to 0.9 prior to discharge. TRANSITIONAL ISSUES: - Patient will need psychiatry follow up as outpatient. We held her aripiprazole given episodes of unresponsiveness and self reported dizziness. - Patient will need her baclofen [**Last Name (un) 4581**] refilled with Dr. [**First Name (STitle) **] Medications on Admission: Levothyroxine Sodium 200 mcg PO/NG DAILY Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN dypsnea/wheezing/cough Acetaminophen 650 mg PO/NG Q6H:PRN pain Mucinex *NF* (guaiFENesin) 1,200 mg Oral [**Hospital1 **] Aripiprazole 5 mg PO/NG DAILY Montelukast Sodium 10 mg PO/NG DAILY Clonazepam 0.5 mg PO/NG QHS:PRN insomnia Miconazole Powder 2% 1 Appl TP [**Hospital1 **] Order Docusate Sodium 100 mg PO BID Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **] Ferrous Sulfate 300 mg PO/NG DAILY Pantoprazole 40 mg PO Q12H Gabapentin 300 mg PO/NG [**Hospital1 **] Paroxetine 60 mg PO/NG DAILY Senna 1 TAB PO/NG QHS:PRN constipation Insulin SC SS and glargine 20 qhs Simvastatin 40 mg PO/NG DAILY modafinil *NF* 100 mg Oral daily Discharge Medications: 1. levothyroxine 200 mcg Tablet Sig: One (1) Tablet PO once a day. 2. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for dypsnea/wheezing/cough. 3. acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 4. montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS:PRN as needed for insomnia. 6. miconazole nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 7. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 8. pantoprazole 40 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q12H (every 12 hours). 9. ferrous sulfate 300 mg (60 mg iron)/5 mL Liquid Sig: One (1) PO DAILY (Daily). 10. gabapentin 300 mg Capsule Sig: One (1) Capsule PO twice a day. 11. senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 12. insulin glargine 100 unit/mL Solution Sig: One (1) 20 Subcutaneous QHS: with insulin Humalog sliding scale during the day. 13. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 14. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. modafinil 100 mg Tablet Sig: One (1) Tablet PO daily (). 16. Sarna Anti-Itch 0.5-0.5 % Lotion Sig: One (1) Topical once a day: apply to affected areas. 17. paroxetine HCl 30 mg Tablet Sig: Two (2) Tablet PO once a day. Tablet(s) 18. Bactrim DS 800-160 mg Tablet Sig: Two (2) Tablet PO every eight (8) hours for 7 days. Discharge Disposition: Extended Care Facility: [**Hospital 32458**] Rehab Discharge Diagnosis: Central and obstructive sleep apnea 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 Mrs. [**Known lastname **], You underwent a procedure to replace your tracheostomy tube that should help with your problems with sleep apnea in the future. The inner cannula of your trach needs to be cleaned daily. The following changes were made to your medications: STOP Aripiprazole START Bactrim - for 7 days It is very important that you follow up with your psychiatrist, as well as with the pulmonologist regarding your new trach tube. Followup Instructions: [**Known lastname **] will need to be refilled. Dr. [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 1356**] [**Last Name (NamePattern1) **] is your outpatient MD [**First Name (Titles) **] [**Last Name (Titles) 4581**] , alarm date per Dr. [**First Name (STitle) **] is [**2173-11-9**] Please follow up with your psychiatrist once you are discharged. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "459.81", "041.3", "327.27", "300.4", "250.00", "486", "280.9", "340", "584.9", "327.23", "244.9", "478.6", "599.0", "041.49", "V46.3" ]

icd9cm

[ [ [] ] ]

[ "33.21", "97.23", "96.72" ]

icd9pcs

[ [ [] ] ]

11211, 11264

5560, 8508

322, 340

11344, 11344

2847, 3344

11995, 12503

1474, 1538

9563, 11188

11285, 11323

8806, 9540

11520, 11972

1553, 2120

8529, 8780

266, 284

368, 944

3353, 5537

11359, 11496

966, 1283

1299, 1458

2145, 2828

75,668

163,819

21801

Discharge summary

report

Admission Date: [**2124-10-23**] Discharge Date: [**2124-10-24**] Date of Birth: [**2075-1-31**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2817**] Chief Complaint: hyperkalemia Major Surgical or Invasive Procedure: none History of Present Illness: The pt is a 49 yo Spanish Speaking only male with h/o CAD s/p CABG, DM, ESRD secondary to DM on HD (MWF), HTN, HL, cardiomyopathy EF 25% from Chagas, and h/o pancreatitis who presented to HD today with hypotension and bradycardia. Per the patient and wife he was in his normal state of health until today at HD. He did report 3 episodes of liquid diarrhea today after lunch. He was reportly hypotensive to the SBP 65/13 and HR in the 50's. He was brought to the ED. . In the ED 95.7 65/13 55 16 99%RA. He then became bradycardic to the 20's with ECG showing idioventricular rhythm. He was given atropine 0.5mg. His labs showed a potassium of 8.6. He was given calcium gluconate 2 amps, 10U insulin, 1 amp of bicarb and was started on peripheral dopamine. A right femoral line was placed. His heart rate improved to the 50's and he was weaned off the dopamine gtt. he was given vancomycin/zosyn and BCx were sent. He was evaluated by Renal and was transferred to the MICU for emergent HD. . The patient and wife report that he was doing well. He denied any fevers, chills, CP or SOB. He states that he has missed some doses of his medications, unclear which ones. He also reported some neck weakness, but no rigidity, stiffness, photophobia or headache. Past Medical History: -ESRD on hemodialysis, on transplant list, s/p L brachiocephalic AV fistula, left brachiocephalic AV fistula [**12-17**], s/p angioplasty in [**5-16**], s/p thrombectomy in [**8-16**], left upper extremity graft placed [**11-15**] -CABG x4 [**2123-3-9**]: Left internal mammary artery grafted to the left anterior descending, reverse saphenous vein graft to the diagonal branch, third marginal branch, and acute marginal branch. -Diabetes c/b neuropathy -Dyslipidemia -Hypertension -Cardiomyopathy secondary to Chagas -Gastritis, GERD -History of pancreatitis -Obstructive Sleep Apnea -Depression -Hyperuricemia Social History: Patient is married with five children. Patient with disability due to poor vision from diabetic retinopathy. Wife works at [**Hospital1 4601**]. Denies tobacco, no EtoH use and no h/o abuse, no illicits. Family History: Mother and father with diabetes. Denies family history of CAD. Physical Exam: GEN: Well-appearing, well-nourished, no acute distress HEENT: EOMI, PERRL, sclera anicteric, no epistaxis or rhinorrhea, MMM, OP Clear NECK: No JVD, carotid pulses brisk, no bruits, no cervical lymphadenopathy, trachea midline, neck stiffness, nuchal rigidity COR: RRR, no M/G/R, normal S1 S2, radial pulses +2 PULM: Lungs CTAB, no W/R/R ABD: Soft, NT, ND, +BS, no HSM, no masses EXT: No C/C/E. LUE AV graft with + thrill NEURO: alert, oriented to person, place, and time. CN II ?????? XII grossly intact. Moves all 4 extremities. Pertinent Results: [**2124-10-24**] 06:15AM BLOOD WBC-4.3 RBC-3.21* Hgb-10.2* Hct-31.1* MCV-97 MCH-31.9 MCHC-32.8 RDW-13.8 Plt Ct-151 [**2124-10-24**] 02:08AM BLOOD WBC-3.9* RBC-3.10* Hgb-10.1* Hct-30.3* MCV-98 MCH-32.6* MCHC-33.4 RDW-13.9 Plt Ct-147* [**2124-10-23**] 04:30PM BLOOD WBC-5.3 RBC-3.78*# Hgb-12.4*# Hct-37.9*# MCV-100* MCH-32.9* MCHC-32.8 RDW-13.8 Plt Ct-162 [**2124-10-24**] 02:08AM BLOOD Neuts-63.8 Lymphs-30.4 Monos-4.2 Eos-1.2 Baso-0.4 [**2124-10-23**] 04:30PM BLOOD Neuts-61.0 Lymphs-33.5 Monos-3.6 Eos-1.1 Baso-0.8 [**2124-10-24**] 06:15AM BLOOD Plt Ct-151 [**2124-10-24**] 06:15AM BLOOD PT-14.5* PTT-30.3 INR(PT)-1.3* [**2124-10-24**] 02:08AM BLOOD Plt Ct-147* [**2124-10-24**] 02:08AM BLOOD PT-14.4* PTT-29.0 INR(PT)-1.2* [**2124-10-23**] 04:30PM BLOOD Plt Ct-162 [**2124-10-23**] 04:30PM BLOOD PT-14.7* PTT-29.0 INR(PT)-1.3* [**2124-10-24**] 06:15AM BLOOD Glucose-135* UreaN-25* Creat-5.1* Na-138 K-4.0 Cl-97 HCO3-33* AnGap-12 [**2124-10-24**] 02:08AM BLOOD Glucose-280* UreaN-22* Creat-4.6*# Na-137 K-3.8 Cl-97 HCO3-32 AnGap-12 [**2124-10-23**] 04:30PM BLOOD Glucose-305* UreaN-65* Creat-9.5*# Na-132* K-9.0* Cl-97 HCO3-24 AnGap-20 [**2124-10-24**] 06:15AM BLOOD CK(CPK)-28* [**2124-10-24**] 02:08AM BLOOD CK(CPK)-29* [**2124-10-23**] 04:30PM BLOOD CK(CPK)-71 [**2124-10-24**] 06:15AM BLOOD CK-MB-2 cTropnT-0.12* [**2124-10-24**] 02:08AM BLOOD CK-MB-2 cTropnT-0.10* [**2124-10-23**] 04:30PM BLOOD CK-MB-3 cTropnT-0.10* [**2124-10-24**] 06:15AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.2 [**2124-10-24**] 02:08AM BLOOD Calcium-8.2* Phos-3.2# Mg-2.1 [**2124-10-23**] 04:30PM BLOOD Calcium-8.9 Phos-4.9* Mg-2.9* [**2124-10-23**] 06:04PM BLOOD Lactate-1.1 K-7.5* [**2124-10-23**] 04:35PM BLOOD Glucose-277* Lactate-2.7* Na-140 K-8.6* Cl-98* calHCO3-25 [**2124-10-23**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2124-10-23**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT Brief Hospital Course: 49 yo male with ESRD on HD (MWF), CAD s/p CABG, CHF last EF 30% secondary to Chagas, who presents with bradycardia and hypotension found to have significant hyperkalemia. # Hyperkalemia: Pt presented with potassium of 8.6 from his HD session. Unclear etiology of the hyperkalemia though one possibility was he left his HD session prior to completion. He reports being compliant with his diet with out any deviation. He has been on lisinopril, although he has been on it since [**5-18**]. Potassium returned to [**Location 213**] level after dialysis. His cardiac meds were restarted but his lisinopril was reduced to 40mg daily. # Bradycardia/Hypotension: Unclear etiology and improved after treatment for hyperkalemia in the ED with calcium. He did require atropine and dopamine gtt in the ED. ECG showed idioventricular rhythm with slow response. Possible etiologies include electrolyte abnormalities. No evidence of infection on CXR and no fever or leukocytosis and therefore unlikely sepsis. He did report some mild diarrhea. The patient has mildly elevated trop in the setting of renal failure. No chest pain. Continued on aspirin. Home blood pressure meds initially held and then restarted once blood pressures stabilized. Blood cultures drawn and were pending at the time of discharge. # ESRD: On M/W/F HD. Last dialysis was on Friday. See above for hyperkalemia. Renal consulted. Continued on calcium acetate and cinacalcet as well as nephrocaps. Discharged with plans for HD on day after discharge. # DM: Briefly hypoglycemic after 10U insulin in the ED but normalized after 1 amp of D50. Continued on Q6H FS and an insulin sliding scale. His lantus was held at first and then restarted prior to discharge. Medications on Admission: Sensipar 30mg daily fenofibrate 160mg daily Carvedilol 25mg [**Hospital1 **] Lisinopril 40mg daily Omeprazole 20mg daily Pravastatin 20mg daily Calcium acetate 1334 w/ meals Nephrocaps daily Doxazosin 4mg [**Hospital1 **] Super Complex B daily Lantus 13U daily ASA 81mg daily Discharge Medications: 1. carvedilol 12.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 2. isosorbide mononitrate 60 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 3. torsemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 5. fenofibrate micronized 145 mg Tablet Sig: One (1) Tablet PO daily (). 6. insulin lispro 100 unit/mL Solution Sig: ASDIR Subcutaneous ASDIR (AS DIRECTED). 7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 9. cinacalcet 30 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. calcium acetate 667 mg Capsule Sig: Two (2) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 12. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 13. insulin glargine 100 unit/mL Cartridge Sig: ASDIR Subcutaneous ASDIR: Use as previously directed. 14. aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: PRIMARY hyperkalemia ESRD CHF Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted for high potassium. We dialyzed you and your potassium came down. It is important for you to go to your entire dialysis sessions regularly. Please weigh yourself every morning and call your physician if your weight goes up more than 3 lbs. We have reduced your lisinopril dose to 40mg daily. We have not made any other changes to your medications. You are scheduled for dialysis tomorrow. Followup Instructions: Hemodialysis session tomorrow Provider: [**Name10 (NameIs) **] Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2124-12-12**] 2:00 Provider: [**First Name8 (NamePattern2) 1903**] [**Last Name (NamePattern1) 1904**], [**MD Number(3) 1240**]:[**Telephone/Fax (1) 62**] Date/Time:[**2124-12-12**] 3:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 62**] Date/Time:[**2125-4-18**] 9:40

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icd9cm

[ [ [] ] ]

[ "38.97" ]

icd9pcs

[ [ [] ] ]

8315, 8321

5039, 6761

330, 337

8395, 8395

3125, 5016

8980, 9426

2494, 2558

7088, 8292

8342, 8374

6787, 7065

8546, 8957

2573, 3106

278, 292

365, 1620

8410, 8522

1642, 2256

2272, 2478

29,168

183,597

11724

Discharge summary

report

Admission Date: [**2115-9-12**] Discharge Date: [**2115-9-16**] Service: MEDICINE Allergies: Risperidone / Rofecoxib / Ciprofloxacin Attending:[**First Name3 (LF) 1666**] Chief Complaint: Coffee-ground emesis Major Surgical or Invasive Procedure: EGD History of Present Illness: 93-year old female from NH (DNR/I) with history of stroke, dementia, dvt on coumading, schizophrenia, DM, presents with coffee-ground emesis. . Pt developed coffee-ground emesis one day PTA at [**Hospital1 100**]-Rehab. No previous h/o GIB. SBP was in the 100s but dropped to 80s, responsive to IVFs. Pt was sent to the ED. VS were HR 108, BP 106/67, then 86/45 which came back up to 136/64 after 1L NS. Pt was guaiac positive. NG lavage was attempted several times, including by GI but was unsuccessful. 2 large-bore IVs were placed. Hct was 18 from baseline of 30 to 34 (on Aranesp). Patient also on coumadin for h/o DVT. INR was 2.3 and pt received Vitamin K 5mg sc x1. FFP was ordered in the ED but not yet administered. One unit of pRBC were started prior to transfer to ICU. . ROS could not be obtained given her dementia. HPI was obtained from daughter who is HCP. Confirmed DNR/I. No central lines. Past Medical History: dementia with paranoid psychosis depression/anxiety DM Type II CRI, Cr baseline 1.3 CVA in [**2099**] per family, only speech impairment that resolved OP with compression fx (T11,12, L4) diverticulitits BCC of nose Breast Ca: excision/XRT '[**00**] esophagitis OA anemia Hct baseline 30, has been on aranesp hypernatremia constipation LLE DVT [**2115-4-22**], on coumadin R hip fracture [**4-/2115**] Social History: No ETOH. No tobacco. Lives at [**Hospital6 459**]. Family History: non-contributory Physical Exam: VS: Temp: 96.7 BP: 138/55 HR: 107 RR: 27 O2sat 100%RA GEN: demented, comfortably lying in bed, NAD HEENT: PERRL, EOMI, anicteric, dry MM, op without lesions NECK: no cervical lymphadenopathy, no jvd, no carotid bruits RESP: CTA b/l, no wheezes, rhales or rhonchi CV: RR, S1 and S2 wnl, [**4-9**] decrescendo murmur at USB w/o radiation ABD: nd, +b/s, soft, nt, no masses EXT: no c/c/e, warm, good pulses SKIN: no rashes/no jaundice NEURO: demented, moving all extremities, responds to simple commands Pertinent Results: Labs in the ED: 128 92 70 ===========380 4.9 24 1.3 . Ca: 8.5 Mg: 2.7 P: 3.3 . WBC 9.2, Hct 18.3, Plt 373 . [**2115-9-13**] 12:41a Urine Chemistry: UreaN:1115 Creat:59 Na:<10 Osmolal:604 Source: Catheter Color Yellow Appear Clear SpecGr 1.018 pH 5.0 Urobil Neg Bili Neg Leuk Mod Bld Lge Nitr Neg Prot Tr Glu 250 Ket Neg RBC 57 WBC 143 Bact Many Yeast None Epi 1 . Imaging: CXR [**2115-9-12**]: IMPRESSION: No definite volume overload. No consolidation seen. Marked low lung volumes with baseline cardiomegaly. . [**2115-9-13**] EGD: unable to scope past pharynx secondary to pt's mental status and intolerability; further EGD deferred as pt is hemodynamically stable with medical management . [**2115-9-13**] TTE: IMPRESSION: Mild aortic valve stenosis. Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. Left ventricular diastolic dysfunction with elevated LVEDP. Mild aortic regurgitation. . Brief Hospital Course: A/P: This 93-year old female from NH (DNR/I) with history of stroke, dementia, schizophrenia, DM, presents coffee-ground emesis. # Upper GI bleed: The patient presented with coffee-ground emesis and mild tachycardia and hypotension to the ED. Patient was on coumadin with therapeutic INR upon presentation. Given her age and comorbities at high risk for bleeding, it was felt that coffee-ground emesis was consistent with upper GIB. Sources were most likely felt to be gastritis/PUD but also esophagitis possible given prior history. The patient was kept NPO (including po meds) and given IVFs through large bore peripheral IVs. She was started on an IV PPI [**Hospital1 **]. Hct increased from 18 to 20 to 22.6 to 26.9 with 3 units PRBC. GI evaluated her in the ED with plan to scope on HD2 since she remained hemodynamically stable overnight. The patient was also given 2u FFP(see below) prior to attempted scope. EGD by GI was not successfull after several attempts given the patient's anatomy and intolerability due to mental status. After discussion with the patient's daughter, it was decided that further EGD attempts would be deferred as the patient was hemodynamically stable. -the patient was evaluated in the ICU, remained hemodynamically stable without evidence of further bleed and was transferred to a general medical floor. -her po medicines were restarted, her hematocrit remained stable (31) for >48 hours after tranfer from the ICU. # DVT -placed on coumadin [**4-10**] for lower extremity DVT per records. coumadin therapeutic at time of admission, though patient admitted with life-threatening gi bleed. She has completed nearly 6 months of therapy, and in the setting of a life-threatening GI bleed that was unamenable to endoscopy (barring intubation which is against her DNR/I order) due to her dementia, I would favor discontinuing coumadin at this time as the benefit of preventing recurrent DVT seems to be outweighed by recent risk of life-threatening bleed. I discussed this with her daughter (HCP) and she was in agreement with withholding coumadin at this time, realizing she may be at risk for recurrent dvt or pulmonary embolism. # Elevated INR: Patient was on coumadin for h/o DVT. Coumadin was held upon presentation. The patient received Vitamin K and 2 units of FFP in the setting of active GI bleed and planned endoscopy. # UTI: the patient was started on Bactrim on [**9-13**] for evidence of UTI on admission UA; urine cultures returned pan-sensitive e.coli. plan for 7 day course of treatment. # Arotic Stenosis -noted on physical exam, likely accentuated by volume depletion. Echo revealed mild AS and preserved systolic function. # Chronic anemia: Likely due to diabetic nephropathy. Baseline around 30-34 on Aranesp. On iron supplementation. No iron studies in our system, but not pursued during this hospitalization. . # Hyponatremia: Hypovolemic Hyponatremia in the setting of GI bleed. resolved with volume resusitation . # DM II controlled with complications: Insulin sliding scale while hospitalzed. may resume actos outpatient regimen upon transfer back to [**Hospital **] rehab. Medications on Admission: (per NH sheet): Morphine 4mg q4h prn Ativan 0.25mg q6h prn Tylenol 650mg q6h prn Iron 325 mg daily Zyprexa 5mg daily Compazine 25mg q12h prn Warfarin (per schedule - not included) Trazodone 50mg qHS Senna Erythromycin ointment Pioglitazone 30mg daily Lidoderm patch Protonix 40mg [**Hospital1 **] Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - LTC Discharge Diagnosis: upper gastrointestinal bleed Discharge Condition: stable Discharge Instructions: complete antibiotics as prescribed we are not restarting coumadin all other orders as prior to admit, or per facility Followup Instructions: as per facility [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1672**] MD, [**MD Number(3) 1673**] Completed by:[**2115-11-13**]

[ "041.4", "V58.61", "285.1", "250.40", "578.9", "733.90", "599.0", "295.90", "V64.3", "715.90", "294.8", "276.1", "585.9", "285.21", "V58.67", "424.1" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

6764, 6829

3277, 6417

268, 273

6902, 6911

2273, 3254

7077, 7254

1717, 1735

6850, 6881

6443, 6741

6935, 7054

1750, 2254

208, 230

301, 1209

1231, 1633

1649, 1701

5,396

185,461

9132

Discharge summary

report

Admission Date: [**2139-7-13**] Discharge Date: [**2139-7-16**] Date of Birth: [**2086-11-15**] Sex: F Service: SURGERY Allergies: Penicillins / Sulfur Attending:[**First Name3 (LF) 3223**] Chief Complaint: s/p fall off bicycle Major Surgical or Invasive Procedure: none History of Present Illness: 52 yo female, helemeted rider of bicycle who fell off bike onto train tracks, hitting her head. +LOC at scene. Transferred to [**Hospital1 18**] via Lifeflight from referring hospital where patient was intubated secondary to decreased mental status; required Dopamine for blood pressure support. Past Medical History: Breast CA, s/p right mastectomy Depression Social History: Divorced Lives alone Family History: Noncontributory Physical Exam: VS on admission to Trauma bay: BP 110/60 HR 78 RR intubated on vent O2 Sat 100% T 99.6 rectal HEENT - 1 cm laceration above right eye with ecchymosis Neck - cervical collar in place Back/SPine - no stepoffs Chest - bilateral breath sounds Cor - RRR S1 S2 Abdomen - softRectum - normal tone, guaiac negative Extr - bilat knees ecchymotic Pertinent Results: [**2139-7-13**] 08:37PM GLUCOSE-90 UREA N-11 CREAT-0.7 SODIUM-136 POTASSIUM-3.8 CHLORIDE-103 TOTAL CO2-23 ANION GAP-14 [**2139-7-13**] 08:37PM WBC-8.4 RBC-3.44* HGB-11.2* HCT-30.9* MCV-90 MCH-32.6* MCHC-36.3* RDW-12.8 [**2139-7-13**] 08:37PM PLT COUNT-224 [**2139-7-13**] 08:37PM PT-12.6 PTT-23.5 INR(PT)-1.1 [**2139-7-13**] 05:38PM GLUCOSE-106* LACTATE-1.7 NA+-140 K+-4.0 CL--101 TCO2-26 [**2139-7-13**] 05:20PM AMYLASE-103* [**2139-7-13**] 05:20PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2139-7-13**] 05:20PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG cocaine-NEG amphetmn-NEG mthdone-NEGCT [**2139-7-15**] HEAD W/O CONTRAST Reason: interval change in SAH [**Hospital 93**] MEDICAL CONDITION: 52 year old woman s/p bicycle fall, small parapontine SAH, increasing headache since this AM REASON FOR THIS EXAMINATION: interval change in SAH CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: 52-year-old woman status post bicycle fall, subarachnoid hemorrhage. TECHNIQUE: Non-contrast CT of the head. COMPARISON: Head CT dated [**2139-7-14**]. FINDINGS: Again, note is made of small amount of subarachnoid blood within the right ambient cistern, slightly decreased in size compared to the prior study. No new hemorrhage is seen. No shift of normally midline structure is noted. Note is made of right frontal scalp hematoma, decreased in size. IMPRESSION: 1. Small amount of subarachnoid hemorrhage in the right ambient cistern, decreased in size compared to the prior study. 2. Decreased right frontal scalp hematoma. [**2139-7-13**] CT CHEST W/CONTRAST [**2139-7-13**] 5:30 PM CT ABDOMEN W/CONTRAST; CT PELVIS W/CONTRAST Reason: r/o bleed, intraabdominal process Contrast: OPTIRAY [**Hospital 93**] MEDICAL CONDITION: 52 year old woman with fall from bicycle, neg fast REASON FOR THIS EXAMINATION: r/o bleed, intraabdominal process CONTRAINDICATIONS for IV CONTRAST: None. INDICATION: Status post fall from bicycle, trauma, intracranial hemorrhage. TECHNIQUE: A trauma torso protocol was used. Axial MDCT images were obtained from the lung bases through the symphysis pubis after the administration of 150 cc of non-ionic Optiray contrast. Coronal and sagittal reconstructions were also obtained. CT OF THE CHEST WITH IV CONTRAST: There is no evidence of pneumothorax. The heart and great vessels are unremarkable. An NG tube terminates within the distal esophagus. The ET tube terminates within the trachea above the carina. There is dependent, bibasilar atelectasis. Within the right lung, there are multiple noncalcified nodules, some of which are pleurally based. The largest is within the right lower lobe and measures 1.5 x 0.9 mm. There is a right- sided breast prosthesis in place. There is a small pericardial effusion. There are no pleural effusions. The aorta is of normal caliber throughout the chest. There is no significant thoracic lymphadenopathy. CT OF THE ABDOMEN WITH IV CONTRAST: The spleen, kidneys, and adrenal glands are unremarkable. There are two, tiny hypoattenuating areas within the tail of the pancreas and one within the body, which may represent pseudocysts, although not definitively characterized in this study. Within the left lobe of the liver, there is a 1.4 x 1.4 cm hypoattenuating lesion not completely characterized. There is no free air, fluid, or significant lymphadenopathy within the abdomen. CT OF THE PELVIS WITH IV CONTRAST: A Foley catheter is within the bladder. There is no free air, fluid, or significant lymphadenopathy within the pelvis. BONE WINDOWS: There are no suspicious lytic or sclerotic osseous lesions. CT RECONSTRUCTIONS: There is no evidence of fracture within the thoracic or lumbar spines. There is an S-shaped scoliosis to the thoracolumbar spine with a mild amount of degenerative change. IMPRESSION: 1. No evidence of traumatic injury within the chest, abdomen, or pelvis. 2. Right-sided breast prosthesis with multiple right-sided pulmonary nodules. This is suggestive of metastatic breast cancer. 3. Hypoattenuating lesions within the right lobe of the liver and the pancreas which are not definitively characterized on this study. Brief Hospital Course: Patient admitted to the Trauma Service; she was transferred from the emergency department to the Trauma ICU. Neurosurgery was immediately consulted for her SAH; felt non surgical; recommended close neurological monitoring and follow up head CT scans. She was extubated on [**2139-7-14**] and was transferred to the floor later that night. Her home meds were restarted on [**2139-7-14**]. Physical and Occupational therapy both consulted and evaluated patient on [**2139-7-15**]. On [**2139-7-15**] patient also complained of frontal headache, neurosurgery re-consulted and recommended repeat head CT scan which showed a decrease in size of SAH; their recommendations at this time were for follow up with Neurosurgery after discharge as needed and Percocet for headaches. Of note Chest CT scan performed on [**2139-7-13**] revealed multiple noncalcified pulmonary nodules in right lung; largest in right lower lobe measuring 1.5 x 0.9 mm. Patient with known history of breast CA on right, s/p mastectomy. Patient's primary care provider, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 5450**] of [**Hospital3 **] Hospital in [**Hospital1 1559**] was informed of these findings after patient's discharge from hospital and will follow up with patient on this. Patient was discharged to home on [**2139-7-16**] with PT and OT home services, and instructions to follow up with neurosurgery as needed per recommendations and her primary doctor within [**12-7**] weeks. Medications on Admission: Paxil 40 mg qhs Neurontin 800 mg qid Discharge Medications: 1. Fluoxetine 20 mg Capsule Sig: Two (2) Capsule PO QHS (once a day (at bedtime)). Disp:*60 Capsule(s)* Refills:*2* 2. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO QID (4 times a day). Disp:*240 Capsule(s)* Refills:*2* 3. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) **] Nursing Services Discharge Diagnosis: s/p Fall off Bicycle Small SAH right cistern Discharge Condition: stable Discharge Instructions: Follow up with your Primary Care Doctor after your discharge from the hospital. Follow up with Neurosurgery as needed. Take your medications as prescribed. Seek medical attention should your headaches worsen. Followup Instructions: Call your PCP for an appointment in next 1-2 weeks If needed, call to schedule followup appointment with Neurosurgery [**Telephone/Fax (1) 1669**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 520**] MD, [**MD Number(3) 3226**] Completed by:[**2139-7-23**]

[ "V10.3", "197.0", "E826.1", "311", "852.06" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

7303, 7371

5350, 6825

302, 309

7460, 7469

1146, 1860

7726, 8032

754, 771

6912, 7280

2932, 2983

7392, 7439

6851, 6889

7493, 7703

786, 1127

242, 264

3012, 5327

337, 634

656, 700

716, 738

28,616

199,981

14010

Discharge summary

report

Admission Date: [**2110-9-24**] Discharge Date: [**2110-9-27**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2901**] Chief Complaint: Transfer for cardiac catheterization Major Surgical or Invasive Procedure: Cardiac Catheterization History of Present Illness: [**Age over 90 **] year old man with known CAD, s/p BMS to LAD in [**2104**] and s/p BMS to RCA in [**2-/2110**] presents for cardiac catheterization. Per report, pt had 2 "NSTEMI"s in the last 6 months, but has refused cardiac caths until now. Most recently, he was admitted to [**Location (un) **] with a RLL pneumonia on [**2110-9-6**] and was found to have leak troponins in this setting. He refused a cath at that time and was discharged to [**Hospital 41830**]Rehab on [**2110-9-15**]. He has recently become agreeable to cath and was transferred to [**Hospital1 18**] today for cardiac catheterization. . Patient reports that he has had worsening shortness of breath over the last 2-3 months. His dyspnea was initially mainly on exertion, but more recently he has been dyspneic even at rest. He now has limited ambulation due to his dyspnea. He reports that he sleeps on 2 pillows at baseline, but denies orthopnea, denies PND. He has recently noticed bilateral LE edema. He denies chest pain, palpitations. He does note that he has had productive cough of clear to yellow tinged sputum for the last 1 month. He denies fevers, dysuria, neck stiffness. . He reports that his worsening dyspnea is the main reason that he has changed his mind about having further cardiac interventions. . Given lasix 10 IV x 2 in the cath lab. Past Medical History: Cardiac Risk Factors: + Dyslipidemia, + Hypertension . Significant Past Medical History: 1) Coronary artery disease, s/p BMS to LAD [**2104**] and MI and BMS to ostial RCA [**2110-2-20**] - NSTEMI [**2-26**] - Diabetes mellitus, type 2 - Chronic obstructive pulmonary disease - Hypothyroidism - Hypertension - Hypercholesterolemia - s/p carpal tunnel surgery - s/p cataract surgery - s/p transurethral resection of prostate Social History: Lives alone, children live locally and are involved in care. Former smoker. There is no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death. Reports FHx of CVA. Physical Exam: VS: T 95.6, BP 129/59, HR 84, RR 21, SpO2 100% on 2L NC Gen: elderly [**Male First Name (un) 4746**], supine in bed, NAD HEENT: MM dry, PERRLA, EOMI Neck: No JVD, supple Resp: +Scattered crackles anteriorly CV: RRR nl s1 s2 [**1-28**] HSM best heard at apex Abd: +BS Soft, NT/ND Ext: Trace pitting edema b/l R>L . Pulses: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 1+ PT 1+ Pertinent Results: ETT performed on [**2110-8-21**] demonstrated : inferoposterolateral reversible defect. Dilated LV cavity. LVEF 42%. CARDIAC CATH performed on [**2110-3-17**] demonstrated: 1. Selective coronary angiography in this right dominant system revealed three vessel coronary artery disease. The LMCA had a 40% distal stenosis. The LAD had a widely patent stent with diffuse calcific disease to 40%. The LCx had a 100% stenosis in the first OM with left to left collaterals. The RCA had a 90% stenosis at the ostium. 2. Left venticulography was deferred. 3. Limited hemodynamics demonstrated an elevated central aortic pressure of 140/58 mmHg. FINAL DIAGNOSIS: Three vessel coronary artery disease. . Cardiac Cath on [**9-24**]: LAD: Origin and proximal disease with 80% distal lesion in proximal vessel LCx: Occulsion of OM1, 70% lesion of ramus RCA: Severe in-stent restenosis 90% lesion s/p RCA intervention . Echo [**9-6**] LVEF of 25% with modeate MR, moderate to severe TR and pulmonary hypertension. Brief Hospital Course: CAD: Multiple cardiac risk factors (DM, hyperlipid, tobacco use, HTN) and with evidence of diffuse disease on cardiac catheterization. He had a prolonged cath with high dye load and PCI to the RCA and was admitted to the CCU for hydration and observation. He was hydrated post cath with D5 and bicarb for a total of ~1.5 L. he was managed with ASA, plavix, and statin. On admission, he was mildly hypotensive to SBP 90s and his beta blocker was held. On day 2 of admission, he was restarted on his beta blocker, metoprolol 12.5 [**Hospital1 **]. He would likely benefit from an ACEi given his CAD and HF with a low EF, however an ACEi was not started on this admission due to ARF. . CHF: He had an echocardiogram on this admission which showed severe systolic dysfunction with EF 25%. He was given lasix 10 IV x 3 for high filling pressures (PCWP 29). On day 3 of admission he was near euvolemic and was continued on a PO regimen of lasix 20. . Anemia: His hct remained stable throughout admission. His iron studies revealed iron deficiency anemia and he was started on iron. He will benefit from an outpatient colonoscopy to evaluate the etiology of his iron deficiency anemia. . COPD: He was admitted on prednisone 15 for a COPD exacerbation from his previous hospitalization. His prednisone was tapered on this admission with a schedule of 5 mg every 4 days. His chest x-ray revealed a RLL infiltrate, was thought to be a resolving pnuemonia from his previous hospitalization ([**Date range (1) 41831**]) which was treated with levofloxacin. He remained afebrile and clinically without evidence of a new infection. . CRI: His Cr trended up from 1.2 to 1.4. His acute renal failure is likely secondary to contrast nephropathy. He received post-cath hydration. He was discharged with instructions for follow up chem panel. He should be started on an ACEi when his creatnine returns to baseline. . UTI: He was also found to have an asymptomatic urinary tract infection. He was discharged with a 7 day course of bactrim. He was afebrile on discharge. . BRBPR: He was noted to have an episode of bright red blood per rectum. On exam he had external hemorrhoids which is likely the cause of his bleed. His hct remained stable and he had no further episodes. He will benefit from a screening colonoscopy. Medications on Admission: 1. Advair 100/50 1 puff q12h 2. Prilosec 20 mg daily 3. Spiriva 18 mcg 1 puff daily 4. Mucinex 600 [**Hospital1 **] 5. Prednisone 15 Daily 6. Xopenex 1.25 neb q8 hours 7. Lantus 5 units Daily at 5 pm 8. Lipitor 10 mg daily 9. Plavix 75 daily 10. ASA 325 11. Toprol 12.5 [**Hospital1 **] ? 12. Ambien 5 qhs 13. Celexa 20 daily 14. Senekot 2 tabs daily 15. Colace 100 [**Hospital1 **] 16. Lasix 10 [**Hospital1 **] 17. Prilosec 20 daily Discharge Medications: 1. Aspirin 325 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO bid prn as needed. 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 8. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 9. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation once a day. 10. Mucinex 600 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO twice a day. 11. Xopenex 1.25 mg/0.5 mL Solution for Nebulization Sig: One (1) Inhalation every eight (8) hours. 12. Lantus 100 unit/mL Solution Sig: 5 units Subcutaneous at 5 pm. 13. Fluticasone-Salmeterol 100-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 14. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. 15. Celexa 20 mg Tablet Sig: One (1) Tablet PO once a day. 16. Prednisone 5 mg Tablet Sig: See taper Tablet PO see below for 7 days: Taper as follows: 10 mg (2 tablets) from [**9-27**] to [**9-28**], then 5 mg (1 tablet) from [**9-29**] to [**10-2**], then 2.5 mg ([**12-24**] tab) from [**10-2**] to [**10-5**]. Then dicontinue prednisone completely. . 17. Other Insulin sliding scale: 0-60 mg/dL Juice 4 oz. 61-150 mg/dL 0 Units. 151-200 mg/dL 2 Units. 201-250 mg/dL 4 Units. 251-300 mg/dL 6 Units. 301-350 mg/dL 8 Units. 351-400 mg/dL 10 Units. >400 mg/dL Notify MD 18. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 6 days. Discharge Disposition: Extended Care Facility: [**Hospital6 25759**] & Rehab Center - [**Location (un) **] Discharge Diagnosis: Primary Coronary Artery Disease Congestive heart failure . Secondary Hypertension Chronic renal insufficiency COPD Type II Diabetes Mellitus Iron deficiency Anemia Discharge Condition: Stable, O2 requirement of 2L unchanged from prior to admission Discharge Instructions: You were admitted for a cardiac catheterization. You were found to have coronary artery disease and were treated with two stents to one of your coronary arteries. You were also found to have congestive heart failure (back up of fluid to your lungs) and you were treated with diuretics. . The following of your medications were adjusted during your hospital course. 1) Your lasix was increased to 20 daily. 2) You were also found to have iron deficiency and were started on an iron supplement. You should have a colonoscopy done to further evaluate the cause of your iron deficiency anemia. 3) You should taper off of the prednisone as instructed in your discharge paperwork. . If you have any of the following symptoms you should return to the ED or see your PCP: [**Name10 (NameIs) **] pain, difficulty breathing, fever, chills, worsening lower extremity swelling or any other serious concerns. . You should not discontinue taking Plavix until you are instructed to do so by your cardiologist. Stopping this medication without your doctor's recommendation may be life threatening. Followup Instructions: We have made a follow-up appointment for you with Dr. [**Last Name (STitle) 11493**] ([**Telephone/Fax (1) 11650**]). Your appointment is on [**10-13**], at 11 am. . You should also schedule a follow up appointment with your PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] [**Telephone/Fax (1) 31592**] for further evaluation of your anemia and a future colonoscopy. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2908**] MD, [**MD Number(3) 2909**] Completed by:[**2110-9-30**]

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icd9cm

[ [ [] ] ]

[ "00.46", "36.07", "88.56", "00.40", "99.20", "00.66", "88.52", "37.23" ]

icd9pcs

[ [ [] ] ]

8632, 8718

3881, 6208

299, 325

8926, 8991

2854, 3493

10125, 10669

2285, 2389

6694, 8609

8739, 8905

6234, 6671

3510, 3858

9015, 10102

2404, 2835

223, 261

353, 1688

1799, 2136

2152, 2269

68,962

131,337

48065

Discharge summary

report

Admission Date: [**2126-12-9**] Discharge Date: [**2126-12-16**] Date of Birth: [**2075-12-30**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamide Antibiotics) / dapsone / simvastatin / efavirenz Attending:[**First Name3 (LF) 5810**] Chief Complaint: SOB, cough Major Surgical or Invasive Procedure: Left internal jugular central line placement on [**2126-12-9**] Bronchoscopy (scope of your lung) on [**2126-12-13**] History of Present Illness: 50yo female w/ HIV, HCV, depression here with 6 months of malaise, weight loss (~15-20 lbs), 3-4 weeks of cough and worsening SOB. Cough is persistent and productive of scant white sputum. She has had SOB on exertion and fevers with shaking chills for 2 weeks. No N/V/D or change in color of her BMs. No chest pain, edema or dysuria. No recent Abx and no sick contacts, has not been hospitalized for quite some time. Has had a 15-20lb weight loss and decreased energy over the last 6 months. Today she saw her PCP, [**Name10 (NameIs) 1023**] ordered a c-xray showing a RUL 6cm mass. In the ED, initial vitals were 102.2 120 107/68 18 100% 3L RA. Scant wheezes throughout, dullness to percussion at RLL. Initially looked well. Pressures dropped from 107/68 to a MAP of 50 even after 2L fluid. Lactate 1.3. Given Vanc, Levaquin, cefepime. No pericardial effusion on bedside echo. Placed L IJ after failed R IJ. Hct 25. Sent SV02. MAP 72 prior to transfer. Satting well on 2L. On the floor, patient resting comfortably. She endorses fatigue and generally feeling depressed. She was born in [**Location (un) 86**] and has lived here most of her life. She has travelled with her partner several times to [**Name (NI) 101361**], [**Country 21363**]. No other sick contacts. She has been post-menopausal for one year. All other ROS negative. Past Medical History: - HIV not on antiretrovirals, CD4 count in [**2124**] was 163 - during hospitalization in [**12/2126**], CD4 count 124 and HIV viral load 574K/mL - chronic hepatitis C - depression - leiomyoma of the uterus - condyloma acuminatum - oral HSV Social History: Has a partner [**Name (NI) **], who is also her HCP. [**Name (NI) **] travelled several times to Medillin, [**Country 21363**] in the past several years, last in [**2124**]. Works as a personal trainer at a gym. - Tobacco: Has smoked on and off since age 14, currently trying to quit. - Alcohol: minimal EtOH - Illicits: none since [**2103**] Family History: No h/o lung disease except a grandfather w/ emphysema Physical Exam: ADMISSION EXAM: Vitals: T 96.2 HR 87 BP 112/74 RR 18 O2sat: 100%RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, LUL cold sore Neck: supple, JVP not elevated, no LAD, L IJ c/d/i Lungs: Focal rhochi at R base, w/ surrounding crackles and dullness to percussion. CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: aaox3, CNs [**3-16**] intact, strength and sensation grossly nl. DISCHARGE EXAM: 97.9 120/88 99 20 97% RA Thin woman, breathing comfortably. Tired appearing but appropriate and pleasant. Lungs clear to auscultation with good air movement, no crackles or wheezes. Pertinent Results: ADMISSION LABS: [**2126-12-9**] 04:52PM BLOOD WBC-9.3 RBC-2.96* Hgb-8.7* Hct-25.2* MCV-85 MCH-29.4 MCHC-34.6 RDW-13.9 Plt Ct-205 [**2126-12-9**] 04:52PM BLOOD Neuts-71.3* Lymphs-21.5 Monos-6.4 Eos-0.6 Baso-0.3 [**2126-12-9**] 04:52PM BLOOD WBC-9.3 Lymph-22 Abs [**Last Name (un) **]-2046 CD3%-88 Abs CD3-1793 CD4%-6 Abs CD4-124* CD8%-80 Abs CD8-1640* CD4/CD8-0.1* [**2126-12-9**] 04:52PM BLOOD Ret Aut-1.1* [**2126-12-9**] 04:52PM BLOOD Glucose-117* UreaN-20 Creat-1.4* Na-130* K-4.8 Cl-99 HCO3-23 AnGap-13 [**2126-12-10**] 04:25AM BLOOD ALT-20 AST-34 AlkPhos-52 TotBili-0.2 [**2126-12-9**] 04:52PM BLOOD Iron-14* [**2126-12-9**] 04:52PM BLOOD calTIBC-157* Ferritn-883* TRF-121* [**2126-12-9**] 10:03PM BLOOD Type-[**Last Name (un) **] pO2-63* pCO2-33* pH-7.39 calTCO2-21 Base XS--3 Comment-GREEN TOP [**2126-12-9**] 05:08PM BLOOD Lactate-1.3 K-4.7 [**2126-12-9**] 10:03PM BLOOD O2 Sat-88 [**2126-12-9**] 10:03PM BLOOD freeCa-0.96* URINE: [**2126-12-9**] 08:00PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.010 [**2126-12-9**] 08:00PM URINE Blood-NEG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG [**2126-12-9**] 08:00PM URINE RBC-2 WBC-0 Bacteri-FEW Yeast-NONE Epi-0 OTHER PERTINENT LABS: Beta-glucan: 280 pg/mL Cryptococcal Ag: negative Galactomannan: pending Histoplasma Ag: pending Coccidio Ab: pending MICROBIOLOGY: [**2126-12-9**] BCx: no growth x2 [**2126-12-10**] BCx: no growth x2 [**2126-12-12**] BCx: pending, NGTD [**2126-12-13**] BCx: pending, NGTD [**2126-12-13**] fungal BCx: pending, preliminary no fungal growth [**2126-12-9**] UCx: no growth [**2126-12-9**] MRSA screen: negative [**2126-12-9**] Legionella Ag: NEGATIVE [**2126-12-10**] Sputum cx: MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. [**2126-12-10**] Sputum cx: GRAM STAIN: <10 PMNs and <10 epithelial cells/100X field. MULTIPLE ORGANISMS CONSISTENT WITH OROPHARYNGEAL FLORA. QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE: SPARSE GROWTH Commensal Respiratory Flora. ACID FAST SMEAR: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): pending [**2126-12-11**] Sputum cx: LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. ACID FAST SMEAR: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): pending [**2126-12-12**] Sputum cx: ACID FAST SMEAR: NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR. ACID FAST CULTURE (Preliminary): pending Immunoflourescent test for Pneumocystis jirovecii (carinii): NEGATIVE for Pneumocystis jirovecii (carinii). [**2126-12-13**] BAL x2: 1. Left upper lobe -> GRAM STAIN: 1+ PMNs, NO MICROORGANISMS SEEN. RESPIRATORY CULTURE: NO GROWTH, <1000 CFU/ml. ACID FAST SMEAR (Preliminary): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): pending FUNGAL CULTURE (Preliminary): pending Immunoflourescent test for Pneumocystis jirovecii (carinii): NEGATIVE for Pneumocystis jirovecii (carinii). 2. Right upper lobe -> Immunoflourescent test for Pneumocystis jirovecii (carinii): NEGATIVE for Pneumocystis jirovecii (carinii) [**2126-12-13**] Right upper lobe mass: GRAM STAIN: NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. TISSUE (Final [**2126-12-16**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. ACID FAST SMEAR (Preliminary): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): pending FUNGAL CULTURE (Preliminary): pending POTASSIUM HYDROXIDE PREPARATION (Preliminary): Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [**2126-12-15**]): NEGATIVE for Pneumocystis jirovecii (carinii). [**2126-12-13**] EBUS TBNA LEVEL 7 (biopsy): GRAM STAIN: 1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. TISSUE (Preliminary): GRAM POSITIVE BACTERIA. RARE GROWTH. ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED. ACID FAST SMEAR (Preliminary): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): pending FUNGAL CULTURE (Preliminary): pending POTASSIUM HYDROXIDE PREPARATION (Preliminary): pending Immunoflourescent test for Pneumocystis jirovecii (carinii) (Final [**2126-12-15**]): NEGATIVE for Pneumocystis jirovecii (carinii). STUDIES: [**2126-12-9**] CXR: Single AP upright portable view of the chest was obtained. The left internal jugular central venous catheter is seen, terminating at the lateral aspect of where the mid SVC would be expected to be located. No pneumothorax is seen. Right upper lung consolidation is worrisome for pneumonia. There may also be subtle patchy left base opacity. No pleural effusion is seen. Cardiac and mediastinal silhouettes are unremarkable. [**2126-12-10**] CT chest: 1. Geographic ground-glass opacities with upper lobe predominance, left greater than right with relative peripheral sparing. In this patient with HIV and CD4 count below 200, this is concerning for PCP [**Name Initial (PRE) 1064**]. 2. Superimposed mass-like consolidation in the right upper lobe would be highly atypical for PCP. [**Name10 (NameIs) **] could thus be explained by a second infectious process, including community acquired bacterial pneumonia. Though the imaging findings do not specifically suggest fungal infection or tuburculosis, these should be considered in this immunocompromised patient until ruled out. Alternatively, this RUL consolidation could also represent malignancy, such as lymphoma. The presence of enlarged mediastinal, axillary, and cervical lymph nodes support consideration of this latter diagnosis. 3. Small pleural effusions with diffuse interlobular septal and bronchial wall thickening, suggesting volume overload. This could account for a degree of the ground-glass opacity as well. [**2126-12-11**] CT abd/pelvis: 1. Extensive periportal, retrocrural, paraaortic, and aortocaval adenopathy. Differential would include lymphoma, TB, or infection. 2. Bibasal pleural effusions with bibasal atelectasis. 3. Bilateral renal cortical scarring. 4. Small amount of air within the bladder. Suggest correlation with history of any foley catheter insertion or instrumentation. [**2126-12-13**] Echocardiogram: The left atrium and right atrium are normal in cavity size. The estimated right atrial pressure is 0-5 mmHg. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no mitral valve prolapse. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. No clinically-significant valvular disease seen. DISCHARGE LABS: Brief Hospital Course: Ms. [**Known lastname 100653**] is a 50 year old woman w/ AIDS (CD4 124), HCV, and depression, who was admitted with 3 weeks of worsening cough and fevers, found to have RUL opacity and ground glass opacity in CT chest that is concerning for PCP. [**Name10 (NameIs) **] was treated with azithromycin and ceftriaxone x7 days for community acquired pneumonia, and had bronchoscopy and BAL done on [**2126-12-13**]. Patient was started on empiric treatment for PCP. [**Name10 (NameIs) **] respiratory status remained stable in the hospital. # Community acquired pneumonia: Given patient's immunocompromised status, broad differential was maintained initially for her cough and fevers and she was covered broadly in the ED with vancomycin, cefepime and levofloxacin. However, given that patient has not been near healthcare facilities, her antibiotics were narrowed to ceftriaxone and azithromycin and she remained clinically stable on that regimen. Patient was ruled out for tuberculosis with 3 negative acid fast bacilli smears (given her history of travel to [**Country 21363**]). Her beta D-glucan was found to be elevated, with increased suspicion for fungal process (PCP, [**Name10 (NameIs) **] or coccidio). She was initially started on empiric PCP treatment with clindamycin and primaquine after her bronchoscopy was done, but when her PCP DFA from BAL and tissue biopsy came back negative, they were discontinued. Her PCP DFA from both sputum and BAL have been all negative. Histoplasma antigen and coccidio antibodies are pending at the time of discharge. Her legionalla urine antigen and sputum culture are negative. # Right upper lobe lung mass and lymphadenopathy: possibly related to her infection, but concerning for malignancy given her history of night sweats and weight loss. Biopsy of lymph node was done during bronchoscopy and the results from the biopsy are pending. # HIV/AIDS: Patient has been on HAART in the past, but discontinued them for various reasons, including side effects. She has been out of contact with physicians for some time now. CD4 count during this hospitalization was 124, down from 163 in [**2124**]. HIV VL was 574,000 copies/mL. ID was consulted and recommended testing for cryptococcus, histoplasma, cocciodiomycosis, aspergillosis (galactomannan) and ruling out PCP and TB with sputum studies. Patient reported interest in restarting HAART with her primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **]. Given her CD4 count during this hospitalization, patient was discharged on dapsone as PCP [**Name Initial (PRE) 1102**] (adverse reaction to dapsone listed as headache, but patient does not recall the reaction and is willing to try it). # Anemia: After fluid resuscitation, patient's hct was found to be 21.7, with unclear baseline. Iron studies were done and it was suggestive of anemia of chronic inflammation. She had no evidence of acute blood loss. Patient spiked a fever prior to transfusion, so it was held off. Repeat HCT was found to be 23 and it remained stable afterwards, so she was never transfused. # Elevated BNP: Given ground glass opacity and negative PCP [**Name9 (PRE) 97174**], BNP was checked for possibility of pulmonary edema from heart failure and was found to be elevated. Echocardiogram was done and did not show any systolic or diastolic dysfunction. Possibly related to rapid fluid resuscitation patient received in the emergency room. # Acute renal failure: Cr 1.4 on admission, up from baseline 1.0. Resolved with fluids. # Hyponatremia: Na 130 on admission - likely hypovolemic, improved with IVF. # Cold sore: Started on PO Acyclovir and completed 7 day course. Transitional Issues: [ ] appointment with Dr. [**Last Name (STitle) **] made for [**12-18**]. Patient will need to discuss with her PCP about restarting [**Name9 (PRE) 2775**]. [ ] pending labs: [**Name9 (PRE) **], coccidio, galactomannan [ ] pending results from BAL/biopsy: fungal cultures/AFB cultures [ ] pathology pending from bronchoscopy biopsy Medications on Admission: None. Discharge Medications: 1. multivitamin Tablet Sig: One (1) Tablet PO once a day. 2. dapsone 100 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis: Community acquired pneumonia Acquired immune deficiency syndrome Secondary Diagnosis: Human immunodeficiency virus Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 100653**], It was a pleasure to take care of you at [**Hospital1 827**]. You were admitted because of your shortness of breath, cough and weight loss. Because of your low blood pressure, you were given IV fluid and initially admitted to the ICU for monitoring. You were given antibiotics for community-acquired pneumonia and several studies were sent out to test for various infectious causes. You had a bronchoscopy to get samples from different parts of your lung and the results from that are still pending. These NEW medications were started for you: - Dapsone 100 mg tablet: one tablet by mouth daily for prophylaxis of PCP. [**Name10 (NameIs) **] you experience any side effects from this medication, please contact Dr. [**Last Name (STitle) **] before discontinuing it on your own. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] J. Location: [**Hospital1 641**] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 2260**] Phone: [**Telephone/Fax (1) 3530**] When: Wednesday, [**2126-12-18**]:20 AM *Please discuss the possibility of seeing a Pulmonary Specialist with Dr. [**Last Name (STitle) **].

[ "458.9", "070.54", "276.1", "486", "285.29", "042", "054.9", "786.6", "584.9" ]

icd9cm

[ [ [] ] ]

[ "38.93", "33.27", "33.24" ]

icd9pcs

[ [ [] ] ]

14654, 14660

10383, 14066

341, 461

14839, 14839

3404, 3404

15831, 16178

2469, 2524

14475, 14631

14681, 14681

14445, 14452

14990, 15808

10360, 10360

2539, 3186

7405, 7413

3202, 3385

7443, 10342

14087, 14419

291, 303

489, 1828

14787, 14818

3420, 4631

14700, 14766

4653, 5499

7275, 7372

14854, 14966

1850, 2093

2109, 2453

81,810

198,406

42987

Discharge summary

report

Admission Date: [**2146-1-31**] Discharge Date: [**2146-2-2**] Service: MEDICINE Allergies: Nitroglycerin / Aspirin / Penicillins / Levaquin / Hydrochlorothiazide Attending:[**First Name3 (LF) 4765**] Chief Complaint: s/p fall Major Surgical or Invasive Procedure: none History of Present Illness: This is a [**Age over 90 **] y.o. female with past medical history of CAD, critical AS, hypertension, and radiation proctitis who presented to the emergency department after sustaining an unwitnessed fall this morning. The patient was moving from a commode to the bed when she sustained a fall. The exact circumstances of this fall are unclear. She does not remember experiencing any chest pain, shortness of breath. The patient's son, who lives with her, heard her fall and found her on the ground lying on her left side. She was oriented and appropriate but complaining of severe left arm pain. In the ED initial vitals T 96.8, HR 72, BP 141/88, RR 16, O2 Sat 91% on RA. She went for radiographs, which revealed a left femoral neck fracture, and then became hypotensive to 70s after returning from radiology. She had some sensation of dizziness and appeared pale but denied any localizing pain symptoms or shortness of breath. She vomited once. After receving 3 L of IVF her SBP's improved to the 90's but then drifted back down to the 70's. Serial ECG with baseline LVH but transient STE in V2. 1st set of cardiac enzymes was negative. The patient endorsed mild abdominal pain but denies chest pain, dyspnea, or presyncope. She has had normal BM's. Vitals at time of signout T 96.5, AF 100-117, BP 80/45, RR 16, O2 97% on 2L. Currently, she reports [**10-30**] left shoulder pain but denies any chest pain, dyspnea, or other acute symptoms at this time. Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. REVIEW OF SYSTEMS: On review of systems, she endorses chronic minimally productive cough as well as mild abdominal pain and loose stools related to her radiation proctitis. She denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. She denies recent fevers, chills or rigors. She denies exertional buttock or calf pain. All of the other review of systems were negative. Past Medical History: 1. CARDIAC RISK FACTORS: - Diabetes, - Dyslipidemia, + Hypertension (recent SBP's around 100 per son) 2. CARDIAC HISTORY: -CABG: None. -PERCUTANEOUS CORONARY INTERVENTIONS: None. -PACING/ICD: None. 3. OTHER PAST MEDICAL HISTORY: - Coronary artery disease, s/p MI x 2 - Hypertrophic cardiomyopathy - Critical AS ([**Location (un) 109**] = 0.7 cm2 in [**1-/2144**]); mild (1+) AR - Moderate (2+) MR - Atrial fibrillation on ASA - Graves' disease, s/p treatment with radioactive iodine - Osteoporosis with known vertebral fractures - Chronic obstructive pulmonary disease - Melanoma of the foot - Cervical cancer status post radiation therapy and radium implant c/b radiation proctitis and chronic diarrhea - History of hyponatremia and SIADH - Posterior gastric polypoid lesion noted in [**1-/2145**] on CT - Cystic pancreatic head lesion - Anemia Social History: Previously manager of clothing stop. Remote 30 pack year history of smoking (>40 years ago). No alcohol. Lives with her son. Family History: Her father and sister died of lung cancer. Her brother had multiple myeloma. Physical Exam: VITAL SIGNS: T 94.6, P 92, BP 79/51, RR 17, O2 Sat 95% on 4L by NC GENERAL: Thin, elderly female appearing uncomfortable but in NAD HEENT: Normocephalic, atraumatic, PERRL, EOMI, sclerae anicteric, mucous membranes dry appearing but no lesions on oropharynx. NECK: supple, no JVD, no masses LUNGS: Exam limited by positioning and sling but clear anteriorly, no wheezes, rhonchi, or rales CV: Tachycardic, irregular, 2/6 Systolic ejection murmur heard best at base, no S3 or S4; Palpable pulses at carotids, radials, and DP's bilaterally ABDOMEN: Soft, mildly tender to palpation diffusely, no organomegaly or masses appreciated, no rebound/guarding. EXTREMITIES: W&WP, No C/C/E SKIN: no rashes or lesions, no stasis dermatitis, ulcers, or scars NEURO: A and O*3, sensation intact in all extremities Pertinent Results: ADMISSION LABS: [**2146-1-31**] 09:00AM BLOOD WBC-6.3 RBC-4.67 Hgb-14.3 Hct-43.6 MCV-94 MCH-30.6 MCHC-32.8 RDW-13.7 [**2146-1-31**] 09:00AM BLOOD Neuts-61 Bands-0 Lymphs-27 Monos-8 Eos-4 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2146-1-31**] 09:00AM BLOOD PT-12.0 PTT-27.6 INR(PT)-1.0 [**2146-1-31**] 09:00AM BLOOD Glucose-107* UreaN-31* Creat-0.9 Na-143 K-3.8 Cl-100 HCO3-35* AnGap-12 [**2146-1-31**] 09:00AM BLOOD ALT-16 AST-25 LD(LDH)-216 CK(CPK)-37 AlkPhos-63 TotBili-0.6 [**2146-2-1**] 04:38AM BLOOD Calcium-8.1* Phos-6.2*# Mg-1.6 [**2146-1-31**] 12:31PM BLOOD Lactate-2.3* ---------------- CARIDAC ENZYMES: [**2146-1-31**] 05:37PM BLOOD CK(CPK)-73 [**2146-2-1**] 04:38AM BLOOD CK(CPK)-278* [**2146-2-1**] 12:59PM BLOOD CK(CPK)-494* [**2146-2-2**] 04:02AM BLOOD ALT-42* AST-65* LD(LDH)-263* CK(CPK)-863* AlkPhos-47 TotBili-0.3 [**2146-1-31**] 09:00AM BLOOD CK-MB-NotDone cTropnT-LESS THAN [**2146-1-31**] 05:37PM BLOOD CK-MB-NotDone cTropnT-0.04* [**2146-2-1**] 04:38AM BLOOD CK-MB-18* MB Indx-6.5* cTropnT-0.30* [**2146-2-1**] 12:59PM BLOOD CK-MB-21* MB Indx-4.3 cTropnT-0.37* [**2146-2-2**] 04:02AM BLOOD CK-MB-21* MB Indx-2.4 cTropnT-0.47* ---------------- DISCHARGE LABS: [**2146-2-2**] 04:02AM BLOOD WBC-18.6* RBC-3.00* Hgb-9.6* Hct-29.4* MCV-98 MCH-32.1* MCHC-32.8 RDW-14.3 Plt Ct-195 [**2146-2-2**] 04:02AM BLOOD PT-17.9* PTT-83.6* INR(PT)-1.6* [**2146-2-2**] 04:02AM BLOOD Glucose-170* UreaN-49* Creat-2.9* Na-140 K-5.4* Cl-106 HCO3-21* AnGap-18 [**2146-2-2**] 04:02AM BLOOD ALT-42* AST-65* LD(LDH)-263* CK(CPK)-863* AlkPhos-47 TotBili-0.3 [**2146-2-2**] 04:02AM BLOOD Calcium-8.0* Phos-6.6* Mg-1.6 ---------------- STUDIES: SHOULDER (AP, NEUTRAL & AXILLARY) TRAUMA LEFT Study Date of [**2146-1-31**] 10:06 AM FINDINGS: Total of two views of the left shoulder were obtained. There is an acute fracture involving the left humeral neck with impaction and slight medial displacement of the distal fracture fragment. No additional fractures are seen. IMPRESSION: Left humeral neck fracture. . CHEST (SINGLE VIEW) Study Date of [**2146-1-31**] 10:06 AM FINDINGS: AP upright view of the chest is obtained. There is an acute fracture involving the left humeral neck with a slightly impacted appearance and medial displacement of the distal fragment. Patient is rotated to left with a marked scoliotic deformity, which limits evaluation through the chest, though there is no definite evidence of lung consolidation, effusion, or pneumothorax. Cardiomediastinal silhouette appears grossly stable. Bones are demineralized. IMPRESSION: Left humeral neck fracture. Otherwise, no acute findings. . TTE (Complete) Done [**2146-2-1**] at 9:42:07 AM The left atrium is moderately dilated. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity is unusually small. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is normal (LVEF>55%). The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Trace aortic regurgitation is seen. [Due to acoustic shadowing, the severity of aortic regurgitation may be significantly UNDERestimated.] 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 moderate pulmonary artery systolic hypertension. The pulmonic valve leaflets are thickened. There is no pericardial effusion. IMPRESSION: Critical aortic stenosis. Moderate symmetric left ventricular hypertrophy with vigorous left ventricular systolic function. Moderate mitral regurgitation. Moderate to severe tricuspid regurgitation. Moderate pulmonary hypertension. Compared with the prior study (images reviewed) of [**2144-2-13**], the calculated aortic valve area is smaller. The severity of tricuspid regurgitation has increased. The previously seen small secundum ASD is not well-visualized. . CHEST (PORTABLE AP) Study Date of [**2146-2-2**] 7:47 AM FINDINGS: In comparison with the study of [**2-1**], there is little interval change on this somewhat limited study. Enlargement of the cardiac silhouette persists with bibasilar atelectatic change. There is suggestion of gas within a hiatal hernia. No evidence of acute focal pneumonia. Brief Hospital Course: [**Age over 90 **] year old female with past medical history significant for CAD, critical AS, and radiation proctitis presenting after a fall with a humeral fracture and hypotension following opiates. . # Hypotension: Patient was found to be hypotensive in the ED after coming back from radiology study. The etiologies for her hypotension were thought to be related to pain-medications and critical AS. Patient was given gental IV fluid boluses after being admitted to CCU. Patient's blood pressure continued to be low, systolics in the 60s and 70s, during the rest of her hospital stay. Pressors were avoided given her severe AS. Because of hypotension, she developed acute renal failure rapidly (creatinine bumped from 0.9 to 2.9 in 2 days). Patient declined hemodialysis, also denied AVR or valvuloplasty, so after extensive discussions with patient's HCP (her son, [**Name (NI) **] [**Name (NI) 10166**]), decision was made to make patient comfort measures only. She expired on day 3 of her hospital stay from acute renal failure and electrolyte abnormalities. . # Critical AS: The patient had a previous valve area of 0.7cm2. She underwent a repeat TTE which showed critical aortic valve stenosis (valve area <0.8cm2). She declined AVR or valvuloplasty. She expired on [**2146-2-2**] in the setting of critical AS, hypotension and acute renal failure. . # Acute Renal Failure: Baseline Cr difficult to assess from labs but appeared to be around 0.6-0.7. Patient's creatinine was 0.9 on admission, likely prerenal in the context of appearing dry. No recent antibiotics or other nephrotoxins, and no symptoms of UTI with benign UA. Patient was hypotensive during her hospital stay. As a result, her kidney function deteriorated rapidly. Her creatinine bumped to 2.9 on day 3. Patient declined hemodialysis, so she was made comfort measures only after all medical options to keep her alive failed. On the morning of her expiration, her K was 5.4, and she was not producing urine. She passed at 1900 that day. It is therefore very likely that she died of hyperkalemia. On telemetry, she went into brief VT followed by asystole minutes before her demise. . # Fall: Etiology of fall was unclear. The most concerning possibility was that patient's AS led to syncope due to hypoperfusion. Unfortunately, as the fall was unwitnessed and the patient did not remember what happened this was impossible to prove. Patient underwent a repeat TTE which showed critical aortic valve stenosis (valve area <0.8cm2). Therefore, it was certainly very likely that AS played a role in the fall. . # Humeral Fracture: Patient was seen by Orthopedics in the ED. Ortho decided to manage conservatively with sling and analgesia. Pain control was achieved with tylenol around the clock, lidocaine patch, and low dose dilaudid with a goal to minimize effect on blood pressure. Patient's pain was well-controlled on the above regimen. . # Rhythm: Patient was in atrial fibrillation, and not anticoagulated. She was not on aspirin or coumadin because of a previous GI bleed. Metoprolol was held given her hypotension. Patient was observed on telemetry during her hospital stay in CCU. She went into VT followed by asystole minutes before she expired, likely secondary to hyperkalemia in the setting of acute renal failure. . # Leukocytosis: Unclear etiology, though rapid increase and lack of fevers, chills, or other acute changes suggested possibly leukemoid reaction in the context of fracture and injury. Cultures were negative, including blood cx, urine cx and c.diff. Patient was not started on antibiotics since she had no sign of infection. . # Anemia: Patient had history of normocytic anemia, baseline around 29-20. Her hct was 43.6 on admission, likely hemoconcentrated. Hct decreased to her baseline of 29 during the next two days. She had no signs of active bleeding. . # CAD: Patient reported history of CAD, but with minimal details and there are no caths in our system. Patient was not on ASA or statin (lipids normal). Patient had some cardiac enzyme leaks during her hospital stay, likely in the setting of hypotension and decreased blood supply to coronaries. . # PPx: Patient was given subcutaneous heparin for DVT prophylaxis. . # FEN: Patient was given cardiac healthy diet during this hospital stay. . # CODE: DNR/DNI (discussed with patient and son-HCP) . # Contact: [**Name (NI) **] [**Telephone/Fax (1) 92787**](H), [**Telephone/Fax (1) 92788**](C) Medications on Admission: 1. Metoprolol Tartrate 25 mg PO TID 2. Levothyroxine 100 mcg PO once a day. 3. Calcium Carbonate 500 mg PO TID 4. Ergocalciferol 50,000 unit weekly 5. Risedronate 35 mg PO once a week. 6. Cyanocobalamin 1,000 mcg/mL Injection once a month 7. Lorazepam 0.25 QAM, O.25 QPM, 0.5 mg QHS 8 Capsaicin 0.025 % Cream Topical TID 9. Acetaminophen 1000 mg PO Q6H 10. Mirtazapine 15 mg PO QHS Discharge Medications: Deceased Discharge Disposition: Expired Discharge Diagnosis: Chief cause of death: critical AS Immediate cause of death: acute renal failure Discharge Condition: Deceased Discharge Instructions: Deceased Followup Instructions: Deceased

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

13693, 13702

8751, 13227

286, 292

13825, 13835

4408, 4408

13892, 13903

3495, 3573

13660, 13670

13723, 13804

13253, 13637

13859, 13869

5582, 8728

3588, 4389

2611, 2687

1980, 2467

238, 248

320, 1961

4424, 5566

2718, 3337

2489, 2591

3353, 3479

25,049

192,017

10609+10610

Discharge summary

report+report

Admission Date: [**2140-4-22**] Discharge Date: [**2140-4-29**] Date of Birth: [**2078-1-6**] Sex: M Service: MED CHIEF COMPLAINT: Persistent shortness of breath. HISTORY OF PRESENT ILLNESS: The patient returned to the hospital 12 hours after discharge on [**2140-4-21**]. He states that he felt short of breath upon returning home and had to increase his oxygen delivery by nasal cannula without improvement, and called 911 to return to the Emergency Department. He stated that the right-sided chest pain was unchanged; however, he felt more tired and has slept throughout his Emergency Department stay. REVIEW OF SYSTEMS: Please see the discharge summary dated [**2140-4-21**] for a detailed review of systems that is unchanged. PAST MEDICAL HISTORY: Cholecystitis, status post laparoscopic cholecystectomy with persisting bile leak as described in the previous discharge summary. Restrictive lung disease, as described in the previous discharge summary. PFT's were not repeated upon this admission. Type 2 diabetes complicated by neuropathy. Note: The patient is being transitioned from oral hypoglycemic agents to subcutaneous insulin administration. Benign prostatic hyperplasia. Appendicitis, status post appendectomy. Coronary artery disease, status post non-ST segment elevation myocardial infarction, [**2140-3-3**]. Glaucoma. ALLERGIES: Vicodin causes hallucinations. MEDICATIONS ON PRESENTATION: 1. Levofloxacin 500 mg q 24 h. The patient had taken 1 dose since discharge and was to complete a 10-day course. 2. Aspirin 235 mg qd. 3. Albuterol/ipratropium inhaler 2 puffs q 6 h. 4. Metoprolol 50 mg [**Hospital1 **]. 5. Oxycodone/acetaminophen 5 mg tablets [**12-4**] q 4-6 h prn. 6. Transdermal fentanyl 25 mcg q h. 7. Dorzolamide/timolol drops prn. 8. Fosamax 0.4 mg capsules [**Hospital1 **]. 9. Ranitidine 150 mg [**Hospital1 **]. 10.Ibuprofen 400 mg po q 8 h. 11.Pioglitazone 30 mg po qd. 12.Glucotrol 10 mg po bid. FAMILY HISTORY: There is no interval change. SOCIAL HISTORY: No change since his previous admission. PHYSICAL EXAMINATION: Temperature 97.6, heart rate 78, blood pressure 127/57, oxygen saturation 100 percent on 3 liters and 99 percent and 1 liter. Generally, he was a tired appearing, pleasant, articulate man who is sitting comfortably in a chair. HEENT: Normocephalic, atraumatic, anicteric sclerae, pale conjunctivae. Pupils equal, round and reactive to light and accommodation. Extraocular movements are intact without nystagmus. The oropharynx is clear. NECK: The jugulovenous pressure is inestimable. The trachea is midline. There is no carotid bruit. The thyroid gland is not palpable. HEART: Regular, normal S1 and S2. There is no S3, S4, murmur, rubs, or gallops. LUNGS: There is a decreased excursion bilaterally and crackles at the right base that are unchanged from his previous evaluation. ABDOMEN: Scaphoid, soft, not tender or distended. There are normal bowel sounds present. EXTREMITIES: There is no rash, clubbing, cyanosis, or edema. LABORATORY EVALUATION: White blood cell count 8,200, hematocrit 31.6 percent, platelets 170,000, sodium 142, potassium 5.5, chloride 106, bicarbonate 29, blood urea nitrogen 33, creatinine 1.4, glucose 194. Serial assessment of CK, CK-MB, troponin-T did not show evidence of myocardial infarction. CHEST X-RAY: Showed slight cephalization of the pulmonary vasculature and a persisting right lower lobe opacity and small bilateral pleural effusions. There were unchanged from his previous evaluation. HOSPITAL COURSE BY SYSTEMS: 1. PULMONARY: The patient's sputum culture dated [**2140-4-20**] grew 2 organisms, specifically Methicillin resistant Staphylococcus aureus was identified, along with Pseudomonas aeruginosa. Due to his previous ciprofloxacin resistant islet of Pseudomonas, levofloxacin was discontinued. Cefepime 1 gm q 8 h was substituted. Also, vancomycin 1 gm q 12 h was added to the patient's regimen. Of note, the patient has been afebrile despite the presence of right lower lobe pneumonia and has had normal white blood cell count throughout. The patient expressed concern that he experienced anxiety and acute shortness of breath upon exerting himself, and asked to have his oxygen delivery increased to 4 L/min. Given his previous hospital stays marked by delirium in the setting of hypercarbia, he was instructed not to increase his oxygen requirement above that recommended by the treating physicians. The patient was evaluated by the physical therapy service and found to have a desaturation of his pulse oxygen to approximately 85 percent on room air while ambulating, with prompt restoration of the normal pulse oxygen saturation on 1 liter of oxygen supplemented by nasal cannula. 1. GASTROINTESTINAL: The patient had his percutaneous gastrostomy tube removed on this admission. He was slated to have it removed by Dr. [**First Name (STitle) 679**] as described previously on the medical record. 1. CORONARY ARTERY DISEASE AND HYPERTENSION: No changes were made to the patient's regimen of aspirin and beta blocker. His blood pressure at a low-normal range, and an ACE inhibitor was not added, although this would be an excellent medication for this patient in the future. The patient required 1 dose of intravenous furosemide on admission with prompt diuresis. 1. TYPE 2 DIABETES: The patient was placed on a regimen of insulin NPH [**Hospital1 **] along with regular insulin sliding scale. The patient had excellent glycemic control for the duration of his hospital stay. 1. BENIGN PROSTATIC HYPERPLASIA: No changes were made to his alpha blocker. 1. DEPRESSION AND ANXIETY: The patient and his wife met with a social worker while in the hospital. Outpatient arrangements for psychiatric evaluation were made. His antidepressant which was started on the previous discharge was restarted here. Specifically, the patient received 20 mg of escitalopram qd. DISCHARGE DIAGNOSES: Complicated hospital acquired pneumonia. Restrictive lung disease. Cholecystitis, status post laparoscopic cholecystectomy with persisting bile leak as described in the previous discharge summary. Type 2 diabetes complicated by neuropathy. Note: The patient is being transitioned from oral hypoglycemic agents to subcutaneous insulin administration. Benign prostatic hyperplasia. Appendicitis, status post appendectomy. Coronary artery disease, status post non-ST segment elevation myocardial infarction, [**2140-3-3**]. Glaucoma. DISCHARGE MEDICATIONS: 1. Ceftazidime 1 gm q 8 h x 14 days (Note: This medication was started on [**2140-4-26**].). 2. Vancomycin 1 gm q 12 h, started on [**2140-4-26**]. The patient should have a trough level checked on [**2140-5-3**]. 3. Heparin 5,000 U q 12 h subcutaneously. 4. Aspirin 325 mg qd. 5. Metoprolol 50 mg [**Hospital1 **]. 6. Albuterol/ipratropium inhaler 1-2 puffs q 6 h prn. 7. Ambien 5-10 mg at night immediately. 8. Flomax 0.4 mg [**Hospital1 **]. 9. Ranitidine 150 mg [**Hospital1 **]. 10.Transdermal fentanyl 25 mcg, change q 72 h. 11.Dorzolamide/timolol 1 drop OU [**Hospital1 **]. 12.Insulin NPH 6 U in the morning and 2 U in the evening with a regular insulin sliding scale as attached separately. 13.Senna 1 tablet [**Hospital1 **]. 14.Colace 10 mg PO or PR prn. 15.Escitalopram 20 mg qd. DISCHARGE CONDITION: Stable. DISPOSITION: The patient was sent to acute rehabilitation for further pulmonary rehabilitation. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-AAE Dictated By:[**Doctor Last Name 34877**] MEDQUIST36 D: [**2140-4-29**] 09:13:46 T: [**2140-4-29**] 09:55:19 Job#: [**Job Number 34879**] Admission Date: [**2140-4-22**] Discharge Date: [**2140-5-4**] Date of Birth: [**2078-1-6**] Sex: M Service: MED ADDENDUM: HOSPITAL COURSE: On the anticipated date of discharge the patient had persisting somnolence. Arterial blood gas performed to document hypercarbia: The pH was 7.21, pCO2 87, pO2 80 on one liter by nasal cannula confirming an acute on chronic respiratory acidosis. The patient's narcotics were discontinued; specifically, the transdermal fentanyl patch was removed and the oxycodone/acetaminophen tablet frequency was decreased. Six hours following the documentation described above, a repeat arterial blood gas was performed showing slight improvement; specifically, the pH was 7.32, pCO2 68, pO2 54. On all gases the SaO2 was above 95 percent. In the face of the patient's transient hypercarbia and acute on chronic respiratory acidosis, he was transfer to the Medical Intensive Care Unit for initiation of biphasic positive airway pressure ventilation without oxygen supplementation. On the first night in the Medical Intensive Care Unit the patient required four hours of BiPAP although by the morning he was breathing comfortably on his own. A repeat blood gas showed stable chronic respiratory acidosis with pH of 7.39, pCO2 58 and pO2 was 79 on the day of discharge from the Medical Intensive Care Unit. Of note, he spent two days in the Intensive Care Unit, the second night he did not require biphasic positive airway pressure. After returning to the Medical [**Hospital1 **], assessment of his vancomycin trough was found to be elevated at nearly 30 mcg/mL. This medication was held for a day and a half until the random level decreased below 15. It was restarted at one gram every 36 hours intravenously. The duration of the treatment is unchanged from the previous discharge summary; specifically, this medication should continue for 14 days starting from [**2140-4-26**], along with ceftazidime one gram every eight hours. Regarding the patient's depression, given that he had a protracted stay, inpatient psychiatric evaluation was obtained and stimulating anti-depressant, specifically bupropion, was added to his regimen. The patient shall establish psychiatric care at [**Hospital6 733**] upon discharge from the rehabilitation hospital. DISCHARGE MEDICATIONS: 1. Vancomycin 1 gram intravenously q. 36h. to complete a 14 day course started on [**2140-4-26**]. 2. Ceftazidime 1 gram q. 8h. to complete a 14 day course started on [**2140-4-26**]. 3. Oxycodone/acetaminophen one to two tablets by mouth every four to six hours as needed. 4. Prochlorperazine 10 mg IV every six hours as needed. 5. Bupropion 100 mg p.o. q. a.m. 6. Furosemide 20 mg daily. 7. Heparin 5000 units subcutaneously every eight hours. 8. Acetaminophen 650 mg by mouth every four to six hours as needed. 9. Albuterol two puffs inhaled every four hours. 10. Ipratropium two puffs inhaled q.i.d. 11. Senna one tablet p.o. b.i.d. 12. Bisacodyl 10 mg p.o. p.r. q. day p.r.n. 13. Regular insulin sliding scale as listed separately (Note: The patient was on oral hypoglycemics prior to discharge from the hospital; however, he has had excellent glycemic control with minimal need for subcutaneous insulin while here. Anticipate restarting his oral hypoglycemics upon discharge and advancement of his diet.) 14. Dorzolamide 2 percent/timolol 0.5 percent ophthalmic solution one drop OU b.i.d. 15. Ranitidine 150 mg p.o. b.i.d. 16. Tamsulosin 0.4 mg p.o. b.i.d. 17. Aspirin 325 mg p.o. daily. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD [**MD Number(2) 34876**] Dictated By:[**Doctor Last Name 34877**] MEDQUIST36 D: [**2140-5-4**] 09:15:18 T: [**2140-5-4**] 09:44:49 Job#: [**Job Number 34880**]

[ "357.2", "365.9", "401.9", "493.90", "276.2", "V09.0", "250.60", "482.41", "482.1" ]

icd9cm

[ [ [] ] ]

[ "97.51", "99.15", "38.93", "96.72", "45.13", "96.04" ]

icd9pcs

[ [ [] ] ]

7457, 7934

1997, 2027

6069, 6611

10127, 11658

7952, 10104

3587, 6047

2108, 3559

652, 760

153, 186

215, 632

783, 1980

2044, 2085

14,176

130,792

6854

Discharge summary

report

Admission Date: [**2137-10-13**] Discharge Date: [**2137-11-12**] Date of Birth: [**2084-9-19**] Sex: M Service: SURGERY Allergies: Plasma Expander Classifier Attending:[**First Name3 (LF) 301**] Chief Complaint: Small bowel obstruction Sepsis Major Surgical or Invasive Procedure: - Exploratory Laparotomy - small bowel resection - insertion of central venous catheter - abdominal closure with alloderm History of Present Illness: The patient is a 53-year-old gentleman who presents to the emergency room complaining of 1 day of "gas" associated with nausea and emesis x3. He had a normal bowel movement yesterday and has had previous episodes of flares from his Crohn disease. He also has a history of a small bowel obstruction with cholecystectomy, a left AKA, a right BKA, antiphospholipid antibody, antithrombin III deficiency and B12 deficiency. The patient is currently on prednisone and Pentasa. The patient was seen in the emergency room with placement of an NG tube after given contrast by the ER for evaluation by CAT scan. At this time, the patient's vital signs were stable. A KUB showed no free air and CT scan later showed a possible transition point. The patient had an INR of 8.0 and received 4 units of FFP and vitamin K. The hematology service was consulted regarding more aggressive correction of coagulopathy which the hematology service cautioned against. The patient became acutely septic and was brought urgently to the operating room with an INR of 2.6. Past Medical History: 1. Crohn??????s disease: diagnosed at age 21, followed by Dr. [**Last Name (STitle) 1940**]. Has involvement of his mouth, proximal small bowel, ampulla of Vater and biliary system. Had small bowel resection and cholecystectomy at same surgery in past. Treated with Remicade in late [**2133**], though course was stopped due to burning pain in his legs and joint pains. Has also had 6-MP therapy (as above) and did not respond to budesonide (Entocort). Currently treated with pentasa and intermittent prednisone. Most recent steroid course completed 1 month ago. 2. Antiphospholipid antibody syndrome: Diagnosed with hypercoagulable state at age 29. In the past has been told that he also had antithrombin III deficiency. Per Dr. [**Last Name (STitle) 410**]??????s notes, he did not have antithrombin III deficiency in [**2125**], but had high levels of anticardiolipin IgG antibody (normal IgM) and positive lupus anticoagulant at that time. Repeat tests in [**2130**] revealed very high levels of both IgG and IgM anticardiolipin antibody. On chronic anticoagulation with coumadin, INR goal 2.9-3.5. 3. [**Doctor Last Name **]??????s syndrome: known to have mild case per Dr. [**Last Name (STitle) 1940**]??????s notes. 4. Pulmonary embolism: History of at least 2 PE??????s in distant past, had IVC filter placed. 5. L AKA and RBA: Status post multiple bilateral amputations secondary to clotting, status post right below-knee amputation in [**5-/2114**], status post revision in 09/84, status post left above-knee amputation in 05/95, status post revision in 05/[**2132**]. 6. Small bowel resection and cholecystectomy: as above. 7. Reversible pancytopenia of unclear etiology. 8. Iron deficiency anemia. 9. Lactose intolerance. 10. Cataract scheduled for surgery on [**2-25**]. 11. Osteoarthritis. Past Surgical History: 12. Status post vascular bypass surgery of his right groin. Social History: The patient does not smoke or drink alcohol. He was using recreational drugs including marijuana in the 60s but not recently. He denies ever using intravenous drugs. He is single and has no children. He has been on disability since [**2108**]. Lives in subsidized housing and has SSD. His insurance is Medicare. Family History: Negative for osteoporosis. His mother had hypercoagulability and was on Coumadin as well. She also had lung cancer. His father was an alcoholic, he had [**Name (NI) 4522**] disease, and he died secondary to cirrhosis. Physical Exam: T: 97.8 P: 72 BP: 118/72 R: 18 O2sat: 97% ra WD, WN, NAD NCAT, PERRL&A, EOMI, neck supple, no lad CTAB, no w/c/r RRR, no m/r/g abd soft, slightly and appropriately tender near open wound, dressing in place, wound with beefy granulation tissue, non-distended, adequate bowel sounds no c/c/e of upper extremities; bilateral lower extremities no swelling, no skin breakdown Pertinent Results: [**2137-11-12**] 05:45AM BLOOD WBC-7.1 RBC-4.09* Hgb-11.1* Hct-33.0* MCV-81* MCH-27.2 MCHC-33.7 RDW-15.7* Plt Ct-167 [**2137-11-6**] 11:53AM BLOOD Neuts-88.6* Lymphs-5.7* Monos-5.7 [**2137-11-12**] 05:45AM BLOOD Plt Ct-167 [**2137-11-12**] 05:45AM BLOOD Glucose-82 UreaN-16 Creat-0.6 Na-134 K-4.6 Cl-96 HCO3-32 AnGap-11 [**2137-10-17**] 03:00AM BLOOD ALT-16 AST-12 LD(LDH)-197 AlkPhos-69 TotBili-1.5 [**2137-11-12**] 05:45AM BLOOD Calcium-8.5 Phos-4.4 Mg-2.0 [**2137-11-12**] 05:45AM BLOOD PT-17.9* PTT-56.1* INR(PT)-1.7* CT ABDOMEN W/CONTRAST [**2137-10-13**] 10:34 AM IMPRESSION: 1. Scattered areas of free air and fluid seen within the mesentery, consitent with perforation. Questionable areas of pneumatosis suggesting ischemic versus inflammatory cause. 2. Dilated loops of small bowel, without definite evidence of decompressed distal bowel, which could represent early versus partial small-bowel obstruction. No definite transition point identified. 3. Areas of bowel narrowing suggesting stricture, consistent with history of Crohns. 4. Pneumobilia again seen. 5. Dependent changes seen at the lung bases, with likely consolidation at the left base. US EXTREMITY NONVASCULAR LEFT [**2137-11-7**] 8:59 PM Reason: Left upper extremity- has numbness and swelling INDICATION: Left upper extremity numbness and swelling. History of previous central venous catheter on the left side. LEFT UPPER EXTREMITY ULTRASOUND: There is echogenic material within the left internal jugular vein with expansion of the lumen of the IJ vein proximally consistent with acute thrombus. More distally, higher in the neck, color flow is demonstrated within the left internal jugular vein. The left subclavian vein demonstrates wall-to-wall color flow, however it demonstrates a monophasic spectral waveform. There is no evidence of thrombus in the left axial vein or brachial veins. Analysis of the contralateral left internal jugular vein could not be performed due to catheter that was in place at the time of the examination. IMPRESSION: Thrombus within the proximal left internal jugular vein. Notably, the left subclavian vein (which appears patent) demonstrates a monophasic spectral Doppler waveform that could suggest more proximal venous occlusion within the chest. Cardiology Report ECHO Study Date of [**2137-10-15**] Conclusions: 1. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. 2. The right ventricular cavity is mildly dilated. Right ventricular systolic function appears depressed. 3. The aortic root is mildly dilated. The ascending aorta is mildly dilated. 4. The aortic valve leaflets (3) are mildly thickened. No aortic regurgitation is seen. 5. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 6.There is mild pulmonary artery systolic hypertension. [**2137-10-14**] 01:57AM BLOOD Hct-32.0* [**2137-10-14**] 04:07AM BLOOD WBC-3.2* RBC-3.67* Hgb-11.2* Hct-31.3* MCV-86 MCH-30.7 MCHC-35.9* RDW-16.0* Plt Ct-137* [**2137-10-14**] 06:28AM BLOOD Hct-25.7* [**2137-10-14**] 09:15AM BLOOD Hct-27.7* [**2137-10-14**] 03:45PM BLOOD Hct-28.2* [**2137-10-14**] 07:39PM BLOOD Hct-25.5* Plt Ct-54*# [**2137-10-15**] 01:49AM BLOOD WBC-5.1# RBC-3.19* Hgb-9.6* Hct-26.7* MCV-84 MCH-29.9 MCHC-35.8* RDW-16.4* Plt Ct-58* [**2137-10-15**] 01:20PM BLOOD Hct-24.3* [**2137-10-16**] 03:05AM BLOOD WBC-6.0 RBC-3.38* Hgb-10.2* Hct-28.7* MCV-85 MCH-30.3 MCHC-35.6* RDW-16.0* Plt Ct-46* [**2137-10-16**] 02:39PM BLOOD WBC-4.3 RBC-3.84* Hgb-11.6* Hct-32.5* MCV-85 MCH-30.2 MCHC-35.6* RDW-15.7* Plt Ct-39* [**2137-10-17**] 01:25AM BLOOD Hct-31.1* [**2137-10-17**] 03:00AM BLOOD WBC-4.0 RBC-3.48* Hgb-10.5* Hct-29.6* MCV-85 MCH-30.2 MCHC-35.6* RDW-15.7* Plt Ct-26* [**2137-10-19**] 03:14AM BLOOD WBC-2.6* RBC-2.99* Hgb-9.1* Hct-25.7* MCV-86 MCH-30.4 MCHC-35.4* RDW-15.3 Plt Ct-56* [**2137-10-20**] 02:37AM BLOOD WBC-3.4* RBC-3.05* Hgb-9.2* Hct-26.1* MCV-86 MCH-30.1 MCHC-35.1* RDW-15.2 Plt Ct-58* [**2137-10-21**] 02:51AM BLOOD WBC-6.0# RBC-3.26* Hgb-9.7* Hct-27.8* MCV-85 MCH-29.6 MCHC-34.8 RDW-15.1 Plt Ct-102*# [**2137-10-22**] 02:36AM BLOOD WBC-7.0 RBC-3.05* Hgb-9.2* Hct-26.1* MCV-85 MCH-30.1 MCHC-35.2* RDW-15.2 Plt Ct-182# [**2137-10-23**] 03:12AM BLOOD WBC-6.6 RBC-3.08* Hgb-8.8* Hct-26.8* MCV-87 MCH-28.5 MCHC-32.7 RDW-15.3 Plt Ct-229 [**2137-10-25**] 09:01AM BLOOD WBC-6.4 RBC-2.93* Hgb-8.5* Hct-25.0* MCV-85 MCH-29.1 MCHC-34.2 RDW-15.5 Plt Ct-289 [**2137-10-28**] 04:32AM BLOOD WBC-5.7 RBC-2.90* Hgb-8.4* Hct-24.4* MCV-84 MCH-29.1 MCHC-34.6 RDW-15.5 Plt Ct-272 [**2137-10-23**] 03:12AM BLOOD WBC-6.6 RBC-3.08* Hgb-8.8* Hct-26.8* MCV-87 MCH-28.5 MCHC-32.7 RDW-15.3 Plt Ct-229 [**2137-10-24**] 02:35AM BLOOD WBC-6.6 RBC-3.01* Hgb-8.9* Hct-25.7* MCV-85 MCH-29.5 MCHC-34.6 RDW-15.1 Plt Ct-284 [**2137-10-25**] 09:01AM BLOOD WBC-6.4 RBC-2.93* Hgb-8.5* Hct-25.0* MCV-85 MCH-29.1 MCHC-34.2 RDW-15.5 Plt Ct-289 [**2137-10-28**] 04:32AM BLOOD WBC-5.7 RBC-2.90* Hgb-8.4* Hct-24.4* MCV-84 MCH-29.1 MCHC-34.6 RDW-15.5 Plt Ct-272 [**2137-10-30**] 05:45AM BLOOD WBC-5.3 RBC-3.03* Hgb-8.4* Hct-25.5* MCV-84 MCH-27.7 MCHC-32.9 RDW-15.7* Plt Ct-262 [**2137-11-2**] 05:00AM BLOOD WBC-5.7 RBC-3.08* Hgb-8.7* Hct-25.2* MCV-82 MCH-28.2 MCHC-34.5 RDW-15.5 Plt Ct-232 [**2137-11-4**] 07:33AM BLOOD Hct-20.8* [**2137-11-4**] 02:59PM BLOOD Hct-24.4* [**2137-11-4**] 11:00PM BLOOD Hct-31.5*# [**2137-11-5**] 03:44AM BLOOD WBC-7.7# RBC-3.99*# Hgb-10.8*# Hct-31.6* MCV-79* MCH-27.1 MCHC-34.3 RDW-15.5 Plt Ct-277 [**2137-11-5**] 03:23PM BLOOD Hct-29.9* [**2137-11-6**] 06:44AM BLOOD WBC-6.4 RBC-3.58* Hgb-9.9* Hct-28.6* MCV-80* MCH-27.7 MCHC-34.6 RDW-15.8* Plt Ct-222 [**2137-11-7**] 06:33AM BLOOD WBC-5.8 RBC-3.46* Hgb-9.5* Hct-27.8* MCV-81* MCH-27.4 MCHC-34.1 RDW-15.5 Plt Ct-212 [**2137-11-8**] 05:41AM BLOOD WBC-5.4 RBC-3.32* Hgb-9.2* Hct-26.2* MCV-79* MCH-27.7 MCHC-35.1* RDW-15.2 Plt Ct-181 [**2137-11-9**] 04:47AM BLOOD WBC-5.6 RBC-3.57* Hgb-9.7* Hct-29.0* MCV-81* MCH-27.2 MCHC-33.5 RDW-15.3 Plt Ct-214 [**2137-11-9**] 04:47AM BLOOD WBC-5.6 RBC-3.57* Hgb-9.7* Hct-29.0* MCV-81* MCH-27.2 MCHC-33.5 RDW-15.3 Plt Ct-214 [**2137-11-10**] 05:00AM BLOOD WBC-6.9 RBC-3.49* Hgb-9.7* Hct-28.2* MCV-81* MCH-27.9 MCHC-34.4 RDW-15.3 Plt Ct-210 [**2137-11-11**] 05:28AM BLOOD WBC-7.3 RBC-3.75* Hgb-10.2* Hct-30.2* MCV-81* MCH-27.3 MCHC-33.8 RDW-15.5 Plt Ct-208 [**2137-11-12**] 05:45AM BLOOD WBC-7.1 RBC-4.09* Hgb-11.1* Hct-33.0* MCV-81* MCH-27.2 MCHC-33.7 RDW-15.7* Plt Ct-167 [**2137-10-13**] 10:03PM BLOOD Fibrino-285 [**2137-10-15**] 10:31AM BLOOD Fibrino-758*# [**2137-10-15**] 10:31AM BLOOD FDP-0-10 [**2137-10-13**] 12:30PM BLOOD Gran Ct-540* [**2137-10-24**] 10:17AM BLOOD AT III-67* [**2137-10-14**] 02:23AM BLOOD K-3.8 [**2137-10-15**] 01:49AM BLOOD Glucose-125* UreaN-9 Creat-0.6 Na-138 K-3.4 Cl-103 HCO3-27 AnGap-11 [**2137-10-16**] 03:05AM BLOOD Glucose-84 UreaN-10 Creat-0.6 Na-136 K-3.9 Cl-101 HCO3-32 AnGap-7* [**2137-10-18**] 03:24AM BLOOD Glucose-108* UreaN-9 Creat-0.6 Na-134 K-3.6 Cl-99 HCO3-31 AnGap-8 [**2137-10-18**] 06:38PM BLOOD Glucose-130* UreaN-8 Creat-0.5 Na-135 K-3.6 Cl-99 HCO3-29 AnGap-11 [**2137-10-19**] 03:14AM BLOOD Glucose-125* UreaN-8 Creat-0.5 Na-138 K-3.6 Cl-101 HCO3-29 AnGap-12 [**2137-10-20**] 02:37AM BLOOD Glucose-119* UreaN-11 Creat-0.5 Na-136 K-3.7 Cl-100 HCO3-28 AnGap-12 [**2137-10-21**] 12:26AM BLOOD K-3.8 [**2137-10-21**] 02:51AM BLOOD Glucose-107* UreaN-13 Creat-0.5 Na-143 K-3.9 Cl-104 HCO3-28 AnGap-15 [**2137-10-21**] 03:38PM BLOOD Glucose-133* UreaN-13 Creat-0.5 Na-137 K-4.0 Cl-103 HCO3-27 AnGap-11 [**2137-10-22**] 02:36AM BLOOD Glucose-111* UreaN-16 Creat-0.5 Na-140 K-3.8 Cl-104 HCO3-27 AnGap-13 [**2137-10-23**] 03:12AM BLOOD Glucose-124* UreaN-18 Creat-0.5 Na-140 K-3.5 Cl-107 HCO3-24 AnGap-13 [**2137-10-24**] 02:35AM BLOOD Glucose-95 UreaN-20 Creat-0.5 Na-141 K-3.4 Cl-108 HCO3-24 AnGap-12 [**2137-10-25**] 09:01AM BLOOD Glucose-89 UreaN-19 Creat-0.5 Na-137 K-4.1 Cl-107 HCO3-21* AnGap-13 [**2137-10-26**] 05:30AM BLOOD Glucose-93 UreaN-17 Creat-0.4* Na-137 K-4.1 Cl-106 HCO3-21* AnGap-14 [**2137-10-28**] 04:32AM BLOOD Glucose-98 UreaN-18 Creat-0.5 Na-136 K-4.2 Cl-105 HCO3-22 AnGap-13 [**2137-10-29**] 05:20AM BLOOD Glucose-88 UreaN-18 Creat-0.6 Na-135 K-4.2 Cl-105 HCO3-22 AnGap-12 [**2137-10-30**] 05:45AM BLOOD Glucose-102 UreaN-18 Creat-0.6 Na-135 K-4.4 Cl-105 HCO3-22 AnGap-12 [**2137-10-31**] 06:15AM BLOOD Glucose-98 UreaN-21* Creat-0.6 Na-134 K-4.5 Cl-103 HCO3-21* AnGap-15 [**2137-11-2**] 05:00AM BLOOD Glucose-98 UreaN-22* Creat-0.7 Na-134 K-4.7 Cl-103 HCO3-21* AnGap-15 [**2137-11-5**] 03:44AM BLOOD Glucose-142* UreaN-19 Creat-0.6 Na-138 K-3.9 Cl-104 HCO3-23 AnGap-15 [**2137-11-6**] 06:44AM BLOOD Glucose-157* UreaN-19 Creat-0.6 Na-136 K-3.5 Cl-104 HCO3-23 AnGap-13 [**2137-11-7**] 06:33AM BLOOD Glucose-134* UreaN-16 Creat-0.5 Na-136 K-3.3 Cl-105 HCO3-23 AnGap-11 [**2137-11-9**] 04:47AM BLOOD Glucose-107* UreaN-13 Creat-0.5 Na-140 K-3.9 Cl-108 HCO3-23 AnGap-13 [**2137-11-10**] 05:00AM BLOOD Glucose-108* UreaN-15 Creat-0.5 Na-139 K-4.3 Cl-106 HCO3-24 AnGap-13 [**2137-11-11**] 05:28AM BLOOD Glucose-97 UreaN-15 Creat-0.6 Na-138 K-4.6 Cl-102 HCO3-29 AnGap-12 [**2137-11-12**] 05:45AM BLOOD Glucose-82 UreaN-16 Creat-0.6 Na-134 K-4.6 Cl-96 HCO3-32 AnGap-11 [**2137-10-15**] 10:31AM BLOOD CK(CPK)-78 [**2137-10-15**] 08:11PM BLOOD CK(CPK)-88 [**2137-10-16**] 03:57AM BLOOD CK(CPK)-67 [**2137-10-17**] 03:00AM BLOOD ALT-16 AST-12 LD(LDH)-197 AlkPhos-69 TotBili-1.5 [**2137-10-15**] 10:31AM BLOOD CK-MB-NotDone cTropnT-0.03* [**2137-10-15**] 08:11PM BLOOD CK-MB-NotDone cTropnT-0.02* [**2137-10-16**] 03:57AM BLOOD CK-MB-NotDone cTropnT-0.01 [**2137-10-14**] 02:23AM BLOOD Mg-1.9 [**2137-10-14**] 04:07AM BLOOD Calcium-7.9* Phos-4.2 Mg-1.8 [**2137-10-16**] 02:39PM BLOOD Calcium-7.9* Phos-3.7 Mg-1.9 [**2137-10-17**] 03:00AM BLOOD Albumin-1.8* Calcium-7.5* Phos-3.1 Mg-1.7 [**2137-10-18**] 03:24AM BLOOD Calcium-7.4* Phos-4.1 Mg-1.9 [**2137-10-18**] 06:38PM BLOOD Calcium-7.9* Phos-3.7 Mg-1.8 [**2137-10-19**] 03:14AM BLOOD Albumin-2.0* Calcium-7.7* Phos-3.2 Mg-2.2 Iron-10* [**2137-10-20**] 02:37AM BLOOD Calcium-8.1* Phos-3.7 Mg-1.6 [**2137-10-21**] 02:51AM BLOOD Calcium-8.3* Phos-4.5 Mg-1.7 [**2137-10-21**] 03:38PM BLOOD Calcium-8.0* Phos-2.4*# Mg-1.9 [**2137-10-22**] 02:36AM BLOOD Calcium-7.9* Phos-2.8 Mg-2.3 [**2137-10-23**] 03:12AM BLOOD Calcium-8.0* Phos-2.0* Mg-1.7 [**2137-10-25**] 09:01AM BLOOD Calcium-7.7* Phos-3.3 Mg-2.0 [**2137-10-26**] 05:30AM BLOOD Calcium-7.9* Phos-3.5 Mg-1.9 [**2137-10-28**] 04:32AM BLOOD Calcium-8.1* Phos-4.1 Mg-2.1 [**2137-10-29**] 05:20AM BLOOD Calcium-8.2* Phos-4.3 Mg-2.0 [**2137-10-30**] 05:45AM BLOOD Calcium-8.4 Phos-5.1* Mg-2.1 [**2137-10-31**] 06:15AM BLOOD Calcium-8.6 Phos-4.3 Mg-2.0 [**2137-11-2**] 05:00AM BLOOD Calcium-8.7 Phos-5.3* Mg-1.7 [**2137-11-4**] 05:00AM BLOOD Calcium-8.3* Phos-4.0 Mg-1.8 [**2137-11-5**] 03:44AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.0 [**2137-11-6**] 06:44AM BLOOD Calcium-8.3* Phos-3.7 Mg-1.9 [**2137-11-7**] 06:33AM BLOOD Calcium-8.1* Phos-3.7 Mg-1.9 [**2137-11-8**] 05:41AM BLOOD Calcium-8.2* Phos-3.3 Mg-2.1 [**2137-11-9**] 04:47AM BLOOD Calcium-8.6 Phos-3.7 Mg-1.8 [**2137-11-10**] 05:00AM BLOOD Calcium-8.4 Phos-3.7 Mg-1.8 [**2137-11-11**] 05:28AM BLOOD Calcium-8.7 Phos-3.9 Mg-1.8 [**2137-11-12**] 05:45AM BLOOD Calcium-8.5 Phos-4.4 Mg-2.0 Brief Hospital Course: The patient is a 53-year-old gentleman who presents to the emergency room complaining of 1 day of "gas" associated with nausea and emesis x3. He had a normal bowel movement yesterday and has had previous episodes of flares from his Crohn disease. He also has a history of a small bowel obstruction with cholecystectomy, a left AKA, a right BKA, antiphospholipid antibody, antithrombin III deficiency and B12 deficiency. The patient is currently on prednisone and Pentasa. The patient was seen in the emergency room with placement of an NG tube after given contrast by the ER for evaluation by CAT scan. At this time, the patient's vital signs were stable. A KUB showed no free air and CT scan later showed a possible transition point. The patient had an INR of 8.0 and received 4 units of FFP and vitamin K. The hematology service was consulted regarding more aggressive correction of coagulopathy which the hematology service cautioned against. The patient became acutely septic and was brought urgently to the operating room with an INR of 2.6. Surgical findings were: Extensive adhesions especially to the upper abdomen, bleeding at root of mesentery with no obvious vessel. This was packed. It was controlled by vascular surgery service. No obvious transition point. However, the mesenteric defect was noted and 6 partial strictures secondary to Crohn's. The procedures performed were: 1. Exploratory laparotomy. 2. Adhesiolysis, 2 hours. 3. Repair of perforated jejunum. 4. Closure of internal hernia mesenteric defects. 5. [**Location (un) 5701**] bag abdominal wall closure. At the end of the case the condition was; Stable at closure of case. However, the patient had hemodynamic instability intraoperatively and was transferred postoperatively to the ICU. He remained intubated. On [**10-16**] the patient was taken back to the OR. The procedures performed at that time were: 1. Oversew mesenteric bleeding and application of hemostatic agents. 2. Full-thickness skin graft to abdominal wall. The patient remained intubated and was transferred back to the ICU. He was weaned off pressors but maintained on antibiotics for spiking temps since admission. The patient was extubated and transferred to the floor. He ahd [**Hospital1 **]- weekly Vac changes per the plastic surgery service. He was placed on a Heparin drip with a PTT goal of 40-60 and placed on TPN for nutrition. His coumadin was started. He was maintained NPO and with a NGT. His VAC was discontinued and WTD dressing changes were started. On [**2137-11-4**], the patient had heme postive stools and a falling hematocrit. He was transferred to the ICU and given blood. His hematocrit responded appropriatly. He was transferred to the floor in stable condition. His diet was advanced to soft foods and his TPN was cut in half. He continued to have frequent bowel movements. GI increased his steroid dose and started him on Pentasa. His c diff was negative and his number of bowel movements decreased. Neurology also was consulted for hand numbness and tingling. They recomended a splint which OT placed on his Left hand. He was discharged in stable condition, tolerating a diet to an extended care facility. During his stay- plastic surgery followed the patient for his abdominal wound, GI followed the patient for his Crohn's disease, ID was consulted for his spiking temps, Neurology followed the patient for his hand numbness and tingling, Hematology followed the patient for his coagulopathy and Vascular followed the patient for his previous vascular history. Medications on Admission: prednisone pentasa coumadin Fe FA plaquenil fosamax Discharge Medications: 1. Albuterol Sulfate 0.083 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed for SOB. 2. Ipratropium Bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours) as needed. 3. Insulin Regular Human 100 unit/mL Solution Sig: 1-20 units Injection ASDIR (AS DIRECTED): see sliding scale order. 4. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed. 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 7. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 8. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: 2.5 Tablet, Delayed Release (E.C.)s PO QID (4 times a day). 9. Prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Heparin Flush CVL (100 units/ml) 1 ml IV DAILY:PRN 10ml NS followed by 1ml of 100 units/ml heparin (100 units heparin) each lumen QD and PRN. Inspect site every shift 11. Dolasetron Mesylate 12.5 mg IV Q8H:PRN nausea 12. Warfarin 1 mg Tablet Sig: 3-5 Tablets PO DAILY (Daily): while in the hospital pt. has alternated between 5mg and 3mg daily to maintain an INR of 2.0-2.5. Pt. will need an INR checked daily to appropriately dose this medication . 13. Outpatient [**Name (NI) **] Work - Pt. will need daily INR checked for coumadin dosing - goal INR of 2.0-2.5 - will need daily Chem 10 while on TPN 14. TPN see additional TPN order Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Crohn's disease Perfed jejunum - with small bowel resection Sepsis Closure of abdomen with alloderm and vac Discharge Condition: stable Discharge Instructions: - You will be discharged to an extended care facility - Please take all medications as prescribed - You will be given TPN for a couple of more days until you are taking enough calories by mouth. Once the TPN has been stopped the special IV you are getting it through needs to be taken out. - Your abdominal wound will have dressing changes everyday. - [**Name8 (MD) 138**] MD or return to ED if T>101.5, chills, nausea, vomiting, chest pain, shortness of breath, severe abdominal pain, redness or smelly drainage from your wound, or any other concern. Followup Instructions: **You need to follow up with the following physicians. Please call to make an appointment** - Dr [**First Name (STitle) 3228**] in the plastic surgery clinic next week ([**Telephone/Fax (1) 25891**] - Dr [**Last Name (STitle) 2305**] next week ([**Telephone/Fax (1) 2306**] - Dr [**Last Name (STitle) 25892**] next week ([**Telephone/Fax (1) 3378**] - Dr [**Last Name (STitle) **] in one month ([**Telephone/Fax (1) 21213**] - Dr [**Last Name (STitle) **] next week ([**Telephone/Fax (1) 25893**] Completed by:[**2137-11-12**]

[ "560.81", "569.83", "277.4", "V12.51", "567.29", "998.11", "V49.76", "038.9", "289.81", "795.79", "555.2", "287.5", "V49.75", "552.8", "V58.65", "354.3", "453.8" ]

icd9cm

[ [ [] ] ]

[ "96.72", "99.05", "99.15", "46.73", "38.93", "54.75", "39.98", "99.07", "99.04", "54.59", "86.67", "89.64", "96.08" ]

icd9pcs

[ [ [] ] ]

20947, 21026

15747, 19298

318, 442

21178, 21187

4424, 15724

21788, 22318

3794, 4014

19400, 20924

21047, 21157

19324, 19377

21211, 21765

3385, 3447

4029, 4405

248, 280

470, 1519

1541, 3362

3463, 3778

7,260

164,742

6356+6357+55747

Discharge summary

report+report+addendum

Admission Date: [**2194-2-18**] Discharge Date: [**2194-3-10**] Date of Birth: [**2124-8-28**] Sex: F Service: INTERNAL MEDICINE [**Location (un) 259**] HISTORY OF PRESENT ILLNESS: Mrs. [**Known lastname **] is a 69 year-old female with a past medical history significant for cirrhosis (secondary to ETOH abuse), asthma, thrombocytopenia, class 1 esophageal varices and gout, who presents with lethargy times two days, back pain times two days and paracervical tenderness times one day along with emesis times two post meals and white blood cell count of [**Numeric Identifier 24587**]. Two days prior to admission the patient describes the onset of back pain in the lower back around the area of T12. It was symmetric bilaterally and was not located directly over the vertebra. She reported that the pain just came on and developed and that has been constant since this onset. The following morning Monday [**2-17**], she developed pain in her neck and she noticed that it was painful to move it. When she ate dinner that night she vomited as soon as she finished. She tried to eat breakfast the following morning and vomited again and was taken to the Emergency Department. She denies any hematemesis, coffee ground vomitus or abdominal pain. She reports no change in bowel habits. She denies headaches, fever, sweats, chills, confusion or photophobia. She admits to being lethargic. REVIEW OF SYSTEMS: Constitutional, the patient denies fevers, sweats, chills, change in appetite, confusion. Pulmonary, no shortness of breath. Cardiovascular, no edema, swelling or chest pain. GI, positive vomiting two times status post meals. Musculoskeletal, neck stiffness and back pain. Neurological no photophobia, no headache. PHYSICAL EXAMINATION ON ADMISSION: Vital signs temperature 97.8. Pulse 60. Respirations 20. Blood pressure 90/50. General, elderly appearing female in no acute distress resting with head in neutral position. Marked icterus. HEENT normocephalic, atraumatic. Pupils are equal, round and reactive to light. Trachea midline. Sclera icterus is marked. Neck, 5 cm JVD, extremely tender and stiff. Pain on passive motion, tenderness in paravertebral muscles especially on the right. Cor regular rate and rhythm, normal S1 S2. No murmurs, rubs or gallops. Pulmonary, scattered rhonchi, otherwise clear to auscultation and percussion. Abdomen, positive bowel sounds, nontender, nondistended. Extremities, no clubbing, cyanosis or edema. No palmar erythema. Dupuytren's contracture in the left hand. Derm, large number of cherry red spots on arms, abdomen, back and chest. Markedly icteric skin, numerous lentigines all over body. Neuro, alert and oriented times three. Thought content was within normal limits. Thought process is tangential, but at times linear. Repetition is intact. The patient has no asterixes. Motor exam, normal bulk and tone. Strength is on the biceps [**5-24**] bilaterally. Triceps [**5-24**] bilaterally. Iliopsoas [**5-24**] bilaterally. Gastrocnemius [**5-24**] bilaterally, tibialis anterior [**5-24**] bilaterally, extensor hallucis [**5-24**] bilaterally. Reflex, triceps 2+ bilaterally, biceps 2+ bilaterally, brachial radialis 2+ bilaterally. Knee 2+ bilaterally, ankles 2+ bilaterally, Babinski was no response. Sensation was grossly intact. Cranial nerves II pupils are equal, round and reactive to light 4 mm 2 mm, III, IV and VI showed extraocular muscles are full. V facial sensation was intact. VII facial movements were symmetrical. VIII within normal limits. IX and X palette elevates in the midline. [**Doctor First Name 81**] not tested secondary to tenderness and stiffness in the neck. XII tongue was midline. Back exam tender at approximately T12 bilaterally. No spinous tenderness. LABORATORIES ON ADMISSION: White count 19.2, differential was 83 neutrophils, 14 bands, 2 lymphocytes, 1 basophil. The hematocrit was 35.4, platelets 77, MCV was 100. PT 19, PTT 40.4, INR 2.4. Sodium 136, potassium 4.9, chloride 105, bicarb 19, BUN 49, creatinine 3.3, glucose was 134, calcium 9.8, phosphorus 5.2, magnesium 1.7, albumin 2.9, ALT 25, AST 36, alkaline phosphatase 144, amylase 22, total bili 3.4. Urinalysis showed yellow urine with specific gravity of 1.018, moderate amount of blood, trace protein, trace ketones, pH equals 5.0, 16 red blood cells per high powered field, 24 white blood cells per high powered field. Occasional bacteria and 2 epithelial cells per high powered field. Chest x-ray on admission looked improved from the comparison film of [**2194-1-20**]. Blood cultures grew out 4/4 bottles of gram positive coxae in pairs and chains by the following morning. IMPRESSION: Mrs. [**Known lastname **] is a 69 year-old female with a past medical history significant for cirrhosis secondary to alcohol abuse, asthma, thrombocytopenia, class 1 esophageal varices, and gout who presents with lethargy times two days, back and neck pain times two and one day respectively and emesis times two post meals. Given the patient's exam, which demonstrated neck and back pain that appeared to be laterally located and more muscular, her lack of photophobia, her equivocal Brudzinski and Kernig signs, it was felt the patient did not have meningitis at the time of admission. However, given the patient's white blood cell count it was clear that she did have a significant infection, therefore the patient was started on Ceftriaxone 1 gram IV q.d. to provide broad coverage against multiple bacteria, and Levofloxacin 500 mg IV q d as well. The patient was started on IV Levo as opposed to po Levo, because she was vomiting and it was felt that she would not be able to tolerate the po medication. It was felt that this combination of antibiotics would adequately cover urinary tract infection and spontaneous bacterial peritonitis until the clinical picture became more clear. Given the patient's low blood pressure of 90/50, which was significantly lower then normal for her, the patient's Propanolol was held until her blood pressure improved. MEDICATIONS ON ADMISSION: Spironolactone 25 mg b.i.d., folate 1 mg po q.d., multi vitamin one tablet po q day, Lactulose 30 cc po t.i.d., Lactulose enema 300 cc per pr q.d. prn, vitamin B-1 100 mg q.d., Celebrex 100 mg b.i.d., Prilosec 20 mg q.d., Propanolol 20 mg b.i.d. PAST MEDICAL HISTORY: 1. ETOH abuse. 2. Cirrhosis. 3. Gout. 4. Asthma. 5. Thrombocytopenia. 6. Class 1 esophageal varices. ALLERGIES: Penicillin, Compazine and sulfa. HABITS: Alcohol half bottle of wine per day times thirty years. She smokes one pack of cigarettes per day. FAMILY HISTORY: Father, sister and cousin with alcoholism. SOCIAL HISTORY: Mrs. [**Known lastname **] lives alone. She was admitted directly from rehab where she had been since her last discharge, which was on [**2194-1-24**]. HOSPITAL COURSE: 1. Group B streptococci infection: The patient grew out 4/4 bottles of group B beta hemolytic streptococci 8 to 10 hours post blood draw. This was concerning for endocarditis or abscess. The patient was scheduled for an MRI after admission. The MRI showed increase signal in T2 and narrowing of the disc spaces at T12 to L1 and L1 to L2 suggesting inflammatory process. There was no evidence of dural abscess at the time. It also showed degenerative changes more prominent in the lower cervical spine. It was felt by neurology that changes in the disc spaces were consistent with discitis and given the patient's neck tenderness a lumbar puncture was done. Given the patient's high grade bacteremia, the patient was started on Vancomycin, but only received one dose, as sensitivities showed that bacteria was susceptible to the other antibiotics the patient was taking. Levofloxacin was decreased to 250 mg po q.o.d. on the second hospital day and then was discontinued later that afternoon. Lumbar puncture that was performed showed the following, tube number one had 115 white blood cells, 64 red blood cells, 72 polys, 1 lymph, 26 monocytes, 1 eosinophils. Tube number four showed 119 white blood cells, 6 red blood cells, 80 polys, 1 lymph, 18 monocytes, 1 eosinophils. The patient was started on Ceftriaxone 2 grams q 12. During the next several days, the patient began to improve gradually. Over the weekend of [**2-22**] and 4th, the patient temporarily cleared mentally and appeared to be improving significantly. However, over the course of the next several days the patient became more confused and her mental status appeared to be decreasing. This was worrisome for possible worsening infection. As a result another LP was attempted to assess whether or not the patient meningitis/parameningeal infection was worsening. However, due to the patient's inability to cooperative fully with the procedure, we were unable to sample anymore spinal fluid. During this time another spinal MRI was attempted at the request of Dr. [**Last Name (STitle) 1338**] who had been consulted from neurosurgery. The patient was unable to cooperative fully with the MRI and could not stay still while in the scanner. We attempted to sedate the patient with Ativan 1 mg prior to the study without success. Attempts to obtain an MRI were temporarily abandoned, because the patient could not cooperate. However, the patient's worsening mental status and lumbar puncture under fluoroscopic guidance was attempted. This was concerning for a protein of 2800. However, the number of white blood cells in the patient's cerebral spinal fluid had decreased markedly to 64. This made the team suspicious that either one, a small walled off pocket of cerebral spinal fluid had been sampled, or two more likely given the fact that it was done under guidance, the patient had a blockage of cerebral spinal fluid flow above the site of the LP. These results were discussed with the patient's daughter, who agreed to temporarily reverse the patient's DNI orders so that we could intubate the patient and achieve an adequate MRI scan. The MRI scan was performed and revealed an epidural abscess in the cervical vertebra around C6 C7 and another one lower down in the lumbar vertebra at around L1 L2. Dr. [**Last Name (STitle) 1338**] from neurosurgery discussed the results with the patient's daughter who felt that she wanted to first try to treat Mrs. [**Known lastname **] with antibiotics since she felt that her mother would not want to have very invasive surgery and it was felt by the medical team and Dr. [**Last Name (STitle) 1338**] that the patient was a poor surgical candidate given her other comorbidities. As a result the patient's Ceftriaxone dose, which had been decreased to 1 gram q 12 by the ID team was raised to 2 grams q 12. The patient began to improve the following week on this dose. Over the course of the next several days the patient's white blood cell count returned to the normal range. The patient remained afebrile and the patient's mental status began to improve. 2. Altered mental status: The patient had multiple reasons for having altered mental status including hepatic encephalopathy and sedating medications, which were given for MRI scans. The patient was treated with Lactulose 30 cc po q.i.d. This dose was titrated to assure that the patient had two to three bowel movements minimum per day. The patient seemed to do best having three bowel movements a day and when the dose was decreased and the patient had fewer then three bowel movements a day her mental status declined. The medical team briefly talked about starting the patient on Neomycin or Flagyl, because we were worried that the patient was not responding to Lactulose, but the patient's mental status began to improve and there was no need to start these other medications. 3. Atrial fibrillation: Four days after admission the patient developed a bout of atrial fibrillation. The patient's daughter was present when this picked up by the medical team and nursing staff. The daughter denied any prior bouts of atrial fibrillation. As a result the patient's Propanolol was restarted 20 mg po b.i.d. the patient was transferred to the PCU and placed on telemetry. The patient returned to [**Location 213**] sinus rhythm spontaneously approximately four hours later. The patient was kept on telemetry for the next two days and then returned to Far 7 where she had previously been. 4. Esophageal varices: The patient was noted to have grade 1 esophageal varices on her last admission. These were treated with 20 mg of Propanolol b.i.d. Although this dose was held initially, because the patient's blood pressure would not tolerate it, the dose was restarted several days into the admission. The patient was continued on this dose throughout the rest of her hospital stay. 5. Renal: On admission the patient's creatinine was elevated to 3.3 from a baseline of 1.0. It was felt that the patient was most likely suffering from prerenal failure as a result of her septicemia and dehydration. The patient was treated aggressively with IV hydration. The patient's creatinine soon returned to [**Location 213**]. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: The patient is currently being evaluated for multiple rehabilitation facilities, and will be discharged to whichever facility accepts her early this week. [**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D. [**MD Number(1) 4521**] Dictated By:[**Name8 (MD) 24588**] MEDQUIST36 D: [**2194-3-10**] 07:22 T: [**2194-3-10**] 07:49 JOB#: [**Job Number 24589**] Admission Date: [**2194-1-20**] Discharge Date: Date of Birth: [**2124-8-28**] Sex: F Service: ADDENDUM: DISCHARGE MEDICATIONS: 1. Multivitamin one tablet by mouth once daily 2. Propranolol 20 mg by mouth three times a day 3. Ceftriaxone 2 grams intravenously every 12 hours 4. Prilosec 20 mg by mouth once daily 5. Potassium chloride 20 mEq by mouth once daily 6. Lactulose 30 cc by mouth four times a day 7. Folate 1 mg by mouth once daily 8. Spironolactone 25 mg by mouth twice a day 9. Magnesium oxide 800 mg by mouth twice a day 10. Neutra-Phos one packet by mouth three times a day with meals 11. Miconazole powder applied to groin twice a day to three times a day as needed [**First Name11 (Name Pattern1) 2515**] [**Last Name (NamePattern4) 4517**], M.D. [**MD Number(1) 4521**] Dictated By:[**Name8 (MD) 24588**] MEDQUIST36 D: [**2194-3-11**] 01:52 T: [**2194-3-11**] 01:57 JOB#: [**Job Number 24590**] Name: [**Known lastname 4175**], [**Known firstname 4176**] Unit No: [**Numeric Identifier 4177**] Admission Date: [**2194-2-18**] Discharge Date: [**2194-3-14**] Date of Birth: [**2124-8-28**] Sex: F Service: [**Location (un) 571**] ADDENDUM: The patient's course was unchanged. Discharge medications are unchanged, with the exception of above for the following reason: the patient had a low grade fever one night and was cultured. A urinalysis and urine culture revealed a urinary tract infection with Enterococcus. patient was initiated on a course of Linezolid 600 mg po bid for a total of a seven day course. The patient was defervesced after starting antibiotics and remained hemodynamically stable and afebrile two days into her course. The course of Linezolid 600 mg po bid should be continued for a total of seven days or until [**3-19**]. No the discharge plan were made. The patient is stable and doing well. [**First Name11 (Name Pattern1) 520**] [**Last Name (NamePattern4) 521**], M.D. [**MD Number(1) 522**] Dictated By:[**Name8 (MD) 4178**] MEDQUIST36 D: [**2194-3-13**] 13:58 T: [**2194-3-13**] 14:39 JOB#: [**Job Number 4179**]

[ "324.9", "286.9", "572.2", "584.5", "456.1", "305.00", "276.5", "571.2", "790.7" ]

icd9cm

[ [ [] ] ]

[ "03.31", "96.71", "38.93" ]

icd9pcs

[ [ [] ] ]

6674, 6718

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6119, 6366

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1433, 1774

199, 1413

3840, 6092

11041, 13151

6389, 6657

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25,668

132,367

7287

Discharge summary

report

Admission Date: [**2192-7-7**] Discharge Date: [**2192-7-12**] Date of Birth: [**2114-4-29**] Sex: F Service: Neurosurgery HISTORY OF PRESENT ILLNESS: Patient is a 78-year-old woman, who was readmitted to [**Hospital1 69**] on the [**7-6**] with mental status changes. The patient was initially admitted on [**6-26**] with a right subdural hematoma and left arm fracture after a fall. The patient was taken to the operating room for evacuation of the hematoma and mental status improved greatly. The patient was transferred to rehab on [**7-4**], and was admitted to an outside hospital, and then transferred here with mental status changes and increased confusion. Head CT scan on admission shows decrease in the subdural hematoma. She was awake, alert, and oriented times three, moving all extremities to command. Her pupils were 2 to 3 mm and equally reactive. Her head incision was clean, dry, and intact, and her left arm was in a cast with good CSM. Her neurological status was stable. She was monitored here at the hospital for three or four days with a stable mental status. She was seen by the Renal service for her renal failure and her hemodialysis which she got every other day during her hospital stay. She remained neurologically and hemodynamically stable during her hospital stay. She did spike a temperature. Blood cultures were sent which were pending. Chest x-ray shows no consolidation, and her temperature did come back to normal. She had no further episodes of mental status changes during her hospital stay. She remained neurologically intact her entire hospital stay. She was discharged to rehab with followup with Dr. [**Last Name (STitle) 1132**] in one month with a repeat head CT scan. DISCHARGE MEDICATIONS: 1. Epogen 20,000 units subQ once a week. 2. Metoprolol 25 mg po bid, hold for systolic less than 110, heart rate less than 55. 3. Percocet 1-2 tablets po q4-6h prn. 4. Folic acid 1 mg po q day. 5. Colace 100 mg po bid. 6. Sorbitol 30 cc po q hs. 7. Senna two tablets po q hs. 8. Insulin-sliding scale. 9. Pantoprazole 40 mg po q24h. 10. Calcium acetate 1334 mg po tid with meals. 11. Nephrocaps one po q day. 12. Lisinopril 20 po q day. CONDITION ON DISCHARGE: Stable. [**Name6 (MD) **] [**Last Name (NamePattern4) **], M.D. [**MD Number(1) 1133**] Dictated By:[**Last Name (NamePattern1) 344**] MEDQUIST36 D: [**2192-7-11**] 13:23 T: [**2192-7-11**] 13:27 JOB#: [**Job Number 26949**]

[ "430", "780.6", "458.9", "585", "250.40", "780.09" ]

icd9cm

[ [ [] ] ]

[ "39.95" ]

icd9pcs

[ [ [] ] ]

1775, 2213

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2238, 2502

25,865

155,944

46623

Discharge summary

report

Admission Date: [**2166-7-14**] Discharge Date: [**2166-7-31**] Date of Birth: [**2098-10-31**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 25876**] Chief Complaint: IL-2 treatment for metastatic Renal cell carcinoma Major Surgical or Invasive Procedure: Chemotherapy Thoracentesis Arterial Line Central Line History of Present Illness: [**Hospital Unit Name 153**] admission: 67yo M w/ metastatic renal cell carcinoma, s/p cycle 1 week 1 of high dose IL-2. Received 8 doses of 9 total, but was stopped due to hypotension. Required dopamine gtt on [**7-16**] and [**7-17**] due to hypotension. Dopamine gtt stopped on [**7-16**] due to afib w/ RVR + hypotension that developed with its use. Given 0.5mg x2 of digoxin and converted. Received dopamine again on [**7-17**] for hypotension, but again went into afib w/ RVR. Switched to neosynephrine and pt required use of pressor for most of the day on [**7-17**]. Also received digoxin on [**7-17**]. Was able to be weaned off neo by [**7-18**], but had frequent runs of NSVT. Troponin leak was felt to be myocarditis by attending, and low dose lopressor was initiated for HR control. At 5am on [**7-20**], pt was noted to go back into SVT at rate of 200s with drop in BP to 80s/40s. Pt was given 250cc NS bolus x1 w/o improvement in BP. Neosynephrine was started with slight improvement in BP (SBP in 90s). Attempted to push 5mg IV lopressor x1 to bring HR down, with improvement in HR to 130s-140s. However, BP still low and pt was anuric. Foley catheter was placed. EKG revealed afib at rate of 140s-150s, so he was transferred to the [**Hospital Unit Name 153**] for further monitoring. Past Medical History: # Metastatic renal cell carcinoma - dx [**12-28**] - underwent R nephrectomy -> [**Last Name (un) 19076**] grade II RCC, clear cell type - XRT to L spine (for L4 met) in [**7-28**] - lung nodules noted -> started phase 1 Avastin/sarafamib trial - taken off study in [**10-28**] due to disease progression - underwent cyberknife to the spine - now starting HD IL-2 due to progression of lung mets - underwent [**Doctor First Name **] [**1-27**] and [**2-27**] for spine stabilization - newly diagnosed L sided pleural effusion -> 2L drained on [**2166-7-14**] # Hypercholesterolemia # Chronic leg edema # DVT w/o sx noted after spine surgery - LENI [**2166-1-29**] showed bilateral popliteal DVT - anticoagulated w/ lovenox - LENI [**2166-6-2**] showed no evidence of DVT Social History: He is an executive at a nonprofit power company. He is married, with two children. He has a ten to 15-pack year smoking history that he quit 25 years ago and drinks a few scotches per week. Family History: Significant for father with liver cancer who died at age 67. Physical Exam: Gen: WDWN obese middle aged M in mod distress. HEENT: NCAT. Cheeks originally pink, well perfused. PERRL 3->2mm, sclera anicteric. EOMI. OP clear, no exudates or erythema. Neck supple, no LAD. Could not assess JVP due to body habitus. CV: Irreg irreg, tachy, normal S1, S2. No murmurs appreciated. Lungs: Audible wheezing, but no wheezing in lung fields anteriorly, ? rhonchi. Unable to sit patient up due to hypotension, but reaching around back heard decreased BS on L, no crackles. Abd: Distended, exquisitely tender in RUQ. ? mild rebound and guarding. Tympanic, quiet BS. Could not assess for HSM due to body habitus. Ext: 2+ PT and radial pulses bilaterally, no c/c/e. Originally were warm, well perfused, with brisk capillary refill. Now cool, clammy, with decreased capillary refill. Neuro: AAOx2. Neurotoxic per 7S, but appropriate, moving all 4 extremities. Strength appears grossly intact in UE and LE bilaterally, grip strong symmetric. Pertinent Results: [**2166-7-14**] 12:07PM OTHER BODY FLUID PH-7.51 [**2166-7-14**] 01:33PM PLEURAL WBC-260* RBC-[**Numeric Identifier **]* POLYS-2* LYMPHS-35* MONOS-0 MESOTHELI-8* MACROPHAG-54* OTHER-1* [**2166-7-14**] 01:33PM PLEURAL TOT PROT-4.4 GLUCOSE-143 LD(LDH)-114 ALBUMIN-2.9 CHOLEST-72 [**2166-7-14**] 01:45PM PT-12.2 PTT-31.1 INR(PT)-1.0 [**2166-7-14**] 01:45PM PLT COUNT-233 [**2166-7-14**] 01:45PM WBC-7.1 RBC-4.11* HGB-11.2* HCT-34.7* MCV-84 MCH-27.2 MCHC-32.2 RDW-15.6* [**2166-7-14**] 01:45PM ALBUMIN-4.0 CALCIUM-9.2 PHOSPHATE-3.6 MAGNESIUM-2.5 [**2166-7-14**] 01:45PM ALT(SGPT)-12 AST(SGOT)-14 CK(CPK)-128 ALK PHOS-83 TOT BILI-0.3 [**2166-7-14**] 01:45PM GLUCOSE-102 UREA N-22* CREAT-1.5* SODIUM-138 POTASSIUM-4.6 CHLORIDE-104 TOTAL CO2-24 ANION GAP-15 [**2166-7-31**] 12:00AM BLOOD WBC-17.6* RBC-3.44* Hgb-9.4* Hct-29.3* MCV-85 MCH-27.2 MCHC-32.0 RDW-17.5* Plt Ct-361 [**2166-7-23**] 03:24AM BLOOD Neuts-70 Bands-2 Lymphs-15* Monos-4 Eos-0 Baso-0 Atyps-0 Metas-6* Myelos-3* NRBC-1* [**2166-7-31**] 12:00AM BLOOD Plt Ct-361 [**2166-7-31**] 12:00AM BLOOD Glucose-121* UreaN-19 Creat-1.5* Na-142 K-3.8 Cl-115* HCO3-16* AnGap-15 [**2166-7-31**] 12:00AM BLOOD Albumin-2.1* Calcium-7.0* Phos-2.9 Mg-1.8 ..................... RLE doppler: No evidence of right lower extremity deep venous thrombosis. Pleural Fluid: NEGATIVE FOR MALIGNANT CELLS. [**7-20**]: CT torso: IMPRESSION: 1. Dilated jejunal and ileal branches without clear transition point. Mild mesenteric stranding and trace mesenteric fluid in the right mid abdomen. Although these findings are nonspecific (lack of IV contrast limits exam), they are not incompatible with small bowel ischemia. Close observation may be warranted ......................... PLEURAL ANALYSIS WBC RBC Polys Lymphs Monos Eos Meso Macro Other [**2166-7-25**] 03:57PM 667* [**Numeric Identifier 98998**]* 20* 75* 1 4* 1 * 1 FEW PLASMACYTOEID LYMPHS SEEN [**2166-7-14**] 01:33PM260* 1 [**Numeric Identifier **]* 2 35* 0 8* 54* 1* PLEURAL CHEMISTRY TotProt Glucose LD(LDH) Albumin Cholest [**2166-7-25**] 03:57PM 1.6 140 155 1.0 [**2166-7-14**] 01:33PM 4.4 143 114 2.9 72 OTHER BODY FLUID OTHER BODY FLUID pH [**2166-7-25**] 04:49PM 7.44 [**2166-7-14**] 12:07PM 7.511 1 PLEURAL FLUID Brief Hospital Course: Mr. [**Known lastname **] is a 67 yo male initially admitted for IL-2 therapy for metastatic renal cell carcinoma. His hospital course was complicated by hypotension and possible GI infection necessitating a short stay in the ICU, but pt recovered and was discharged in stable condition. . Pt was admitted on [**7-14**] for high dose IL-2 therapy. However, pt became hypotensive requiring dopamine with initial episode of A fib on [**7-17**] and occ V tach. However, the patient continued to have hypotensive episodes as well as tachycardia and was eventually transferred to [**Hospital Unit Name 153**] on [**7-20**]. . ICU course: While in ICU cardiology was consulted and recommended Amniodarone 150 bolus followed by 400 mg PO TID for 3 days then 400 po BID x 1 week, with a 1 month course. Additionally, surgery was consulted on [**7-20**] for abdominal pain with concern for ischemic bowel given hypotension and elevated lactate, but surgical intervention was indicated at that time. Finally, Nephrology was consulted for the management of his hypernatremia and renal failure. Renal failure thought to be due to IL-2 coupled with ATN and hypernatremia due to volume depletion. MICU course was also complicated by pleural effusion (tapped) and coagulopathy ( INR increased to 3) thought to be due to IL-2 therapy. TPN was started on [**7-22**] for poor oral intake and rapid weight loss. . 1. GI infection: pt had concern of an abdominal infection given elevated lactat, abdominal pain and leucocytosis. Therefore pt was treated with a 10 day course of levofloxacin and flagyl. For concern of sepsis, pt received decadron while in ICU, but it was rapidly tapered once out of ICU and then discontinued without side effect. Pt's symptoms of abdominal pain resolved and pt was able to eat regular diet and was afebrile. . 2. Acute renal failure- Pt had significant elevation of creatinine while hospitalized (max of 7.1) that was thought to be due to IL-2 therapy with potential element of ATN. Additionally pt had hypernatremia that was managed with free water boluses and encouraging PO water intake. Sodium normalized prior to discharge. Creatinine also normalized to baseline (1.5) . 3. AFIB WITH RVR: Pt initially found to have A fib on [**7-17**] that spontaneously converted. Pt was evaluated by cardiology that recommended loading with amnoidarone IV and continuing on PO which was done. The patient remained in sinus rhythm after transfer to oncology floor and telemetry was discontinued. Pt did not have episodes of tachycardia. Pt was continued on atenolol. Pt will follow up with cardiology. . 4. PLEURAL EFFUSION: Pt initially had pleural effusion on [**7-14**]. Pt again had thoracocentesis once on oncology floor as pt was short of breath and it was done for symptomatic relief. Pt was able to be weaned to room air without hypoxia on discharge. Exam continued to be suggestive for pleural effusion on discharge, but given that the patient was asymptomatic no repeat thoracocentesis was done. The repeat tap appeared to be exudative likely malignant given multiple pulmonary masses. However, cytology was negative both times as was gram stain and culture. . Pt will follow up with Dr. [**Last Name (STitle) 1729**] for further management of his renal cell carcinoma. Medications on Admission: Lasix 40mg PO QD Lovenox 100mg [**Hospital1 **] Flomax Atenolol 25mg PO QD (tapered over weekend prior to admit) Lipitor Miralax Oxycontin 10mg PO BID Percocet prn for breakthrough Discharge Medications: 1. Prochlorperazine 10 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for nausea. Disp:*60 Tablet(s)* Refills:*0* 2. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 3. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 4. Loperamide 2 mg Capsule Sig: One (1) Capsule PO QID (4 times a day) as needed for diarrhea. 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Qam. Disp:*30 Tablet(s)* Refills:*2* 7. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 8. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for nausea or anxiety. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Renal cell cancer treated with IL-2 therapy Secondary: Hypertension Discharge Condition: Stable Discharge Instructions: You were admitted for your treatment of your renal cell cancer with IL-2 therapy. While you were here, you were cared for in the ICU for low blood pressure and kidney failure. Please call your physician or go to the ER if you have: * Fever or chills * Severe nausea or vomiting * Shortness of breath * Chest pain * Any other concerning symptom Followup Instructions: You should see Dr. [**Last Name (STitle) 1729**] on [**8-12**] for follow up appointment at 5:00 PM. You should follow up [**9-9**] at 9 AM, [**Location (un) 436**] cardiology [**Hospital Ward Name 23**] Building Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1013**], M.D. Phone:[**Telephone/Fax (1) 127**] Date/Time:[**2166-9-9**] 9:00 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] HEMATOLOGY/ONCOLOGY-CC9 Date/Time:[**2166-8-12**] 5:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5387**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2166-8-12**] 5:00

[ "V10.52", "997.1", "038.9", "427.1", "197.0", "198.5", "427.31", "V58.12", "429.0", "272.0", "276.0", "401.9", "584.9", "995.92", "511.9", "518.5", "785.52" ]

icd9cm

[ [ [] ] ]

[ "00.15", "38.93", "38.91", "34.91", "99.15" ]

icd9pcs

[ [ [] ] ]

10657, 10706

6147, 9443

368, 424

10818, 10826

3827, 6124

11219, 11848

2778, 2841

9675, 10634

10727, 10797

9469, 9652

10850, 11196

2857, 3808

278, 330

452, 1756

1778, 2552

2568, 2762

74,835

113,119

4522

Discharge summary

report

Admission Date: [**2201-10-14**] Discharge Date: [**2201-10-21**] Date of Birth: [**2164-5-10**] Sex: M Service: SURGERY Allergies: Shellfish / Topamax / Augmentin Attending:[**First Name3 (LF) 2836**] Chief Complaint: Nausea and vomiting Major [**First Name3 (LF) 2947**] or Invasive Procedure: PICC History of Present Illness: 37 yo M with recent admission for acute on chronic pancreatitis caused by prior alcohol binge. He had a complicated course, which included ARDS, emergent tracheostomy, E. coli bacteremia, and MRSA pneumonia. He was discharge to [**Hospital3 **] on [**10-8**]. He was doing reasonably well there, where he was [**Month/Day (2) 19284**] a PMV during the day, tube feeds were weaned off, and was he advanced to a regular diet. He returns today after complaining of nausea and repeated vomiting, with an estimated volume of 2300cc throughout the day. He also had a temperature of 100.7. His WBC was down to 11K. He was on Meropenem at the time of discharge, which was stopped on [**10-8**] to complete a 2 week course for treatment of his GN bacteremia. [**Location (un) **] through his progress notes from Rehab, it appears he has had a significant amount of reflux, despite being on Prilosec. A CT scan was obtained at the OSH, which raised concern of a peripancreatic fluid collection with some compression of the stomach and duodenum. He has a known pseudocyst, as noted on a CT done here on [**10-3**], measuring 9.4 (TRV) x 7.8 (AP) x 12.1 (CC)cm, as well as a separate small fluid collection anterior to the stomach. The images from the CT done at the OSH were not sent with him. He has been nauseated all day. He has had some abdominal pain, mostly in the epigastrum, which is slightly more than baseline. He has felt feverish and has had some chills. He continues to complain of heart burn. His trach has been continually causing him discomfort. He has a productive cough. He has been moving his bowels regularly. Past Medical History: PMH/PSH: - Tracheostomy [**2201-9-14**] (emergent) - Multiple episodes of alcoholic pancreatitis; history of ARDS requiring intubation in the setting of severe pancreatitis in [**2194**], recent admission as above - Splenic hematoma s/p splenectomy. Tail of pancreas was densely adherent to spleen hilum, had distal pancreatectomy - GERD - HTN - Sleep apnea tried on CPAP, biPAP but hasn't tolerated - Hypercholesterolemia - Chronic pain (L abdomen & shoulder) on methadone - Alcoholism/Alcohol withdrawal; several admissions for DTs and intubations - Right upper quadrant abscess, status post percutaneous catheter drainage in [**2192-5-5**]. - Fatty liver and hepatomegaly on US [**2191**] - Hypertriglyceridemia - Migraine HA/cluster HAs - Asthma - Depression - multiple suicide attempts - False positive RPR Social History: SocHx: Tobacco: quit smoking over a year ago, used to smoke 1 ppd EtOH: started drinking 7th grade, drank 30 beers a night plus few shots of alcohol in his 20's, abstinent since [**2194**], attended AA but found it boring. Drugs: remote hx MJ, cocaine. Denies IVDA. Denies recent drug use. Living: Previously lived with mother. Currently at rehab. On disability for chronic pain. Family History: Father CAD (1st MI in 40's), EtOH. Mother type 2 DM, 3 sisters: 1 with seizure d/o, 1 with migraines, + family hx alcoholism (father, 2 sisters) Physical Exam: PE: 100.0 114 150/100 20 96%4L NAD. Awake and alert. Slightly diaphoretic. Anicteric. Tacky mucosal membranes. Trach in place, c/d/i. Regular and tachycardic. Coarse BS bilaterally. Protuberant, possibly midly distended. +BS. Tender to palpation in the epigastrum. No guarding or rebound. Pertinent Results: [**2201-10-15**] 03:18AM BLOOD WBC-18.7* RBC-2.63* Hgb-7.7* Hct-24.2* MCV-92 MCH-29.3 MCHC-31.9 RDW-14.1 Plt Ct-986* [**2201-10-19**] 06:45AM BLOOD WBC-13.5* RBC-2.75* Hgb-8.0* Hct-25.1* MCV-91 MCH-29.0 MCHC-31.8 RDW-14.2 Plt Ct-831* [**2201-10-19**] 06:45AM BLOOD Glucose-148* UreaN-10 Creat-0.6 Na-138 K-4.3 Cl-101 HCO3-31 AnGap-10 [**2201-10-15**] 03:18AM BLOOD ALT-161* AST-38 AlkPhos-930* Amylase-79 TotBili-0.5 [**2201-10-14**] 03:49AM BLOOD ALT-275* AST-95* AlkPhos-1419* Amylase-78 TotBili-0.8 [**2201-10-19**] 06:45AM BLOOD Calcium-9.3 Phos-3.9 Mg-1.9 [**2201-10-19**] 09:16AM BLOOD Triglyc-142 . Radiology Report CT PELVIS W/CONTRAST Study Date of [**2201-10-14**] 6:59 AM IMPRESSION: 1. Large fluid-filled pancreatic pseudocyst which is unchanged in appearance compared to previous examination. 2. Slight interval increase in left anterior abdominal wall fluid collections compared to prior examination. 3. Patient is status post distal pancreatectomy and splenectomy. 4. No sign for bowel obstruction. . Radiology Report CHEST (PORTABLE AP) Study Date of [**2201-10-17**] 8:45 PM Final Report REASON FOR EXAMINATION: Evaluation of NG tube placement in a patient with ethanol pancreatitis. Portable AP chest radiograph was compared to the prior study. The NG tube was inserted in the meantime interval with its tip coiling in the proximal stomach. The cardiomediastinal silhouette is stable. No change in bibasilar linear opacities consistent with atelectasis is present. The tracheostomy is at the midline, with the tip approximately 4.3 cm above the carina. The upper lungs are unremarkable and the cardiomediastinal silhouette is stable. Brief Hospital Course: This is a 37 yo M well known to General Surgery and Dr. [**First Name (STitle) **] following recent admission for acute on chronic pancreatitis caused by EtOH binge complicated by respiratory failure, ARDS, need for emergent trach, E. Coli bacteremia, and MRSA pneumonia. Now presenting with nausea and vomiting for the last 24 hours, suspicious for enlarging pseudocyst with outlet obstruction. Lipase is normal, so recurrent pancreatitis seems unlikely. Low grade fevers and leukocytosis suspicious for infectious process. He may have early sepsis. He was Pan Cx: [**10-14**] BCx: GPC clusters; staph coag neg (1 set only) [**10-14**] UA: [**6-16**] WBC, few bact, small Leuk, trace Protein He was started on Vanc/Meropenem given recent MRSA PNA & E.coli bacteremia He was NPO/IVF's with LR 150cc/hr. He had a NGT/Foley. A CT ABD was performed and unchanged pancreatic pseudocyts and fluid collections. He likely had duodenal obstruction [**2-7**] pseudocyst. . A PICC was placed and he was started on TPN. He required bowel rest due to the pseudocyst and nausea. His abdomen was soft and nontender with no peritoneal signs. The NGT was removed on HD5. His TPN was ramped up and he was discharged to rehab with TPN and ordered for sips of fluid. He reported +flatus and +BM prior to discharge. His antibiotics were stopped once the culture data came back negative. He will have a repeat CT on [**11-2**] and plan for OR pseduocystgastrostomy on [**11-3**]. Resp: He was stable with trach in place. He was suctioned as needed. Medications on Admission: Meds at Rehab: Zofran 4mg IV q4h prn, Methadone 60mg q8h, Lopressor 25'', Tizanidine 4'', Colace 100'', Omeprazole 40', Mucomyst nebs q6h prn, Pancrease 4500u qid, Senokot 8.6mg [**Hospital1 **] prn, Reglan 20mg w/ meals, Clonidine 0.3mg TD qweek, Buproprion 100''', Tizanidine 12mg [**Hospital1 **], Quetiapine 100mg [**Last Name (LF) **], [**First Name3 (LF) **] 81', Desenex 2% powder prn, SQH 5000''', Regular ISS, Loperamide 2mg qid prn, Albuterol q6h prn Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. 2. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 4. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 5. Tizanidine 2 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 6. Tizanidine 2 mg Tablet Sig: Six (6) Tablet PO [**First Name3 (LF) **] (once a day (at bedtime)). 7. Methadone 40 mg Tablet, Soluble Sig: 1.5 Tablet, Solubles PO TID (3 times a day). 8. Acetylcysteine 20 % (200 mg/mL) Solution Sig: 1-10 MLs Miscellaneous Q6H (every 6 hours) as needed. 9. Amylase-Lipase-Protease 20,000-4,500- 25,000 unit Capsule, Delayed Release(E.C.) Sig: Two (2) Cap PO QIDWMHS (4 times a day (with meals and at bedtime)). 10. Clonidine 0.2 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QWED (every Wednesday). 11. Bupropion 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 12. Quetiapine 100 mg Tablet Sig: One (1) Tablet PO [**First Name3 (LF) **] (once a day (at bedtime)). 13. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 14. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 16. Metoclopramide 10 mg Tablet Sig: Two (2) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 17. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 18. Polyethylene Glycol 3350 100 % Powder Sig: One (1) PO DAILY (Daily). 19. PICC PICC care per protocol. TPN Daily Discharge Disposition: Extended Care Facility: [**Hospital1 **] Discharge Diagnosis: Nausea and vomiting Pancreatic Pseudocyst Discharge Condition: Good Discharge Instructions: Please call your doctor or return to the ER for any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. * Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * Your skin, or the whites of your eyes become yellow. * Your pain is not improving within 8-12 hours or not gone within 24 hours. Call or return immediately if your pain is getting worse or is changing location or moving to your chest or back. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. . * Please take all new meds as ordered. * No heavy lifting (>10lbs) for 6 weeks. * Continue to increase activity daily * Continue with TPN Followup Instructions: Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2201-11-2**] 10:15. Please call Dr. [**First Name (STitle) **] at ([**Telephone/Fax (1) 6347**] with questions or concerns. You are tentatively scheduled to be admitted on [**2201-11-2**] with possible OR on [**2201-11-3**]. Dr.[**Name (NI) 5067**] office will help arrange this. Completed by:[**2201-10-21**]

[ "493.90", "311", "719.41", "346.90", "530.81", "V15.82", "789.00", "401.9", "537.3", "272.1", "303.93", "338.29", "V44.0", "577.2", "571.8", "780.57" ]

icd9cm

[ [ [] ] ]

[ "38.93", "99.15" ]

icd9pcs

[ [ [] ] ]

9237, 9280

5401, 6938

9366, 9373

3723, 5378

10477, 10875

3243, 3390

7449, 9214

9301, 9345

6964, 7426

9397, 10454

3405, 3704

254, 340

368, 1992

2014, 2827

2843, 3227

51,859

134,064

35500+58014

Discharge summary

report+addendum

Admission Date: [**2114-5-11**] Discharge Date: [**2114-5-17**] Date of Birth: [**2056-11-6**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 552**] Chief Complaint: Sepsis Major Surgical or Invasive Procedure: Central line placement x2 (femoral and R subclavian) PICC placment and repositioning History of Present Illness: 57 yo M recent discharge from [**Hospital1 18**] to rehab, now returns with tachycardia, hypotension and increasing lethargy/malaise and increasing WBC. Pt is positive for C diff, on PO Flagyl. En route to [**Hospital1 18**], BP dropped to 70s so diverted to [**Hospital1 **], where better access was obtained and an a-line was placed. He received 3500cc crystalloid with improvement in his BP and he was transferred to [**Hospital1 18**]. Recent admission [**4-27**] to this hospital with fever, leukocytosis and hypotension, eventually dx'd with C diff and placed on PO VAnco. Urine cx returned yesterday with pseudomonas resistant to Cipro. In the ED here, VS: 97.9, 100/44, 76, 16, 100% A femoral CVL was placed. Levophed was started. He received Vanco, Zosyn, and Flagyl after cx obtained. On arrival to the MICU pt indicates that he feels better. Past Medical History: ++ Pneumonia - [**2114-1-15**] - respiratory failure, intubation, tracheostomy ++ Acalculous cholecystitis - percutaneous cholecystostomy tube [**2114-2-21**] - percutaneous tube dislodgement --> fever leukocytosis [**2114-3-12**] - fever leukocytosis --> ERCP ([**First Name4 (NamePattern1) 3075**] [**Last Name (NamePattern1) 3549**]) w/ stent [**2114-4-9**] - open cholecystectomy @ [**Hospital1 18**] [**2114-4-17**] ++ Diabetes mellitus, insulin dependent ++ Atrial fibrillation ++ Congestive heart failure ++ Chronic renal insufficiency ++ MRSA ++ CDiff ++ hx ESBL-Klebs Past Surgery History - trach/EG - cholecystostomy tube on [**2-21**], Tube replaced on [**3-12**] Social History: Rehab since admission in [**Month (only) 1096**]. Used to live with his children, Taxi driver, Divorced, 2 children. Family History: Mother healthy; father with MI. Physical Exam: ADMISSION PHYSICAL EXAM VS: 96.7 81 136/61 18 100% on AC Gen: Chronically ill appearing [**Month (only) 4459**]: PERRL Neck: trach in place Heart: s1s2 RRR Pulm: Coarse BS bilaterally Abd: +BS, soft, mild TTP diffusely, Ext: trace edema Back: + sacral decubiti, packed Rectal: Guaiac negative brown stool Neuro: alert, awake, follows commands, MAE Pertinent Results: ADMISSION LABS: [**2114-5-10**] 11:00PM WBC-21.1* RBC-2.89* HGB-8.5* HCT-26.5* MCV-92 MCH-29.4 MCHC-32.1 RDW-15.0 [**2114-5-10**] 11:00PM NEUTS-89.7* LYMPHS-5.1* MONOS-1.6* EOS-3.3 BASOS-0.3 [**2114-5-10**] 11:00PM GLUCOSE-261* UREA N-26* CREAT-1.2 SODIUM-135 POTASSIUM-4.7 CHLORIDE-98 TOTAL CO2-27 ANION GAP-15 [**2114-5-10**] 11:35PM GLUCOSE-245* LACTATE-2.2* NA+-134* K+-4.7 CL--98* TCO2-28 [**2114-5-10**] 11:00PM ALT(SGPT)-24 AST(SGOT)-46* CK(CPK)-24* ALK PHOS-391* TOT BILI-0.3 [**2114-5-10**] 11:00PM LIPASE-8 [**2114-5-10**] 11:00PM TOT PROT-5.6* CALCIUM-7.9* PHOSPHATE-3.8 MAGNESIUM-1.7 [**2114-5-10**] 11:00PM PT-15.7* PTT-40.6* INR(PT)-1.4* WBC trend: [**2114-5-11**] 03:36AM BLOOD WBC-27.1* RBC-2.74* Hgb-7.9* Hct-25.1* MCV-92 MCH-28.9 MCHC-31.6 RDW-14.7 Plt Ct-245 [**2114-5-12**] 04:22AM BLOOD WBC-14.5* RBC-2.88* Hgb-8.2* Hct-25.7* MCV-89 MCH-28.5 MCHC-32.0 RDW-15.5 Plt Ct-195 [**2114-5-13**] 05:48AM BLOOD WBC-10.2 RBC-2.79* Hgb-8.2* Hct-24.9* MCV-90 MCH-29.3 MCHC-32.7 RDW-15.7* Plt Ct-182 [**2114-5-14**] 06:40AM BLOOD WBC-12.5* RBC-3.13* Hgb-9.3* Hct-27.8* MCV-89 MCH-29.7 MCHC-33.4 RDW-15.4 Plt Ct-193 [**2114-5-15**] 05:50AM BLOOD WBC-12.0* RBC-3.42* Hgb-9.8* Hct-30.9* MCV-91 MCH-28.7 MCHC-31.7 RDW-15.2 Plt Ct-208 Discharge labs: Hematology COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW PltCt [**2114-5-17**] 07:46AM 9.6 3.07* 9.3* 27.1* 88 30.2 34.3 15.8* 196 [**2114-5-17**] 07:46AM PT, PTT, INR, Plt Ct: 14.5*, 39.4*, 1.3*, 196 Chemistry RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap [**2114-5-17**] 09:41AM 136* 11 0.4* 138 3.3 107 25 9 Micro: [**2114-5-12**] 5:44 pm SPUTUM Source: Endotracheal. **FINAL REPORT [**2114-5-14**]** GRAM STAIN (Final [**2114-5-12**]): <10 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. QUALITY OF SPECIMEN CANNOT BE ASSESSED. RESPIRATORY CULTURE (Final [**2114-5-14**]): OROPHARYNGEAL FLORA ABSENT. YEAST. RARE GROWTH. . [**2114-5-10**] 11:00 pm BLOOD CULTURE Site: ARM **FINAL REPORT [**2114-5-16**]** Blood Culture, Routine (Final [**2114-5-16**]): NO GROWTH. . [**2114-5-10**] 11:45 pm BLOOD CULTURE Site: CENTRAL LINE CENTRAL LINE-X2. Blood Culture, Routine (Pending): . [**2114-5-11**] 12:45 am URINE Site: CATHETER **FINAL REPORT [**2114-5-12**]** URINE CULTURE (Final [**2114-5-12**]): NO GROWTH. . Radiographic studies: . [**5-11**] CT chest/abd/pelvis: IMPRESSION: 1. No cause for the patient's sepsis identified. No intra-abdominal or intrapelvic abscess. No evidence of pneumonia. 2. Small bilateral pleural effusions and bibasilar atelectasis. 3. Sacral decubitus ulcer with slightly increased gas in the subcutaneous tissues to the right of the coccyx. It is unclear if this increased gas is related to progressive infection or manipulation/debridement. Clinical correlation is recommended. . PORTABLE CHEST, [**2114-5-12**] COMPARISON: Comparison study of one day earlier. INDICATION: Possible pneumonia. FINDINGS: Indwelling devices are in standard position, and cardiomediastinal contours are unchanged. Lower lung volumes result in crowding of bronchovascular structures, limiting assessment of volume status of the patient. Increasing patchy opacities at both bases may be due to atelectasis, but attention to these areas on repeat radiograph with improved inspiratory level may be helpful. Left-sided loculated fluid versus pleural thickening is unchanged. . HISTORY: 57-year-old man, now status post placement of new PICC line, assess for placement. COMPARISON: [**2114-5-12**]. AP PORTABLE CHEST RADIOGRAPH: The left-sided PICC line is seen curled around in the axillory region. The right subclavian central venous line is in unchanged position with the tip at the mid SVC. The patient is status post tracheostomy, but the apparatus is seen without apparent complications. There is persistent low lung volume, with appearance of crowding of bronchovascular structures. The previously noted left side opacity is unchanged and also suggestion of left- sided fluid vs. pleural thickening. LEFT UPPER EXTREMITY DUPLEX ULTRASOUND DATED [**2114-5-16**]: IMPRESSION: Thrombosis of the cephalic vein in the region of the existing PICC line. No deep venous thrombosis. Brief Hospital Course: 57M with MMP returning from rehab with rising WBC and hypoTN, concerning for sepsis. # Hypotension: Most likely cause in setting of leukocytosis and recent infections is recurrence of sepsis (most likely urine, but other possible sources include c diff, pneumonia, sacral decubiti). No evidence of cardiogenic shock [**3-19**] cardiac ischemia based on 12-lead; no indication of hemorrhage (guaiac neg). In the ED had right femoral line placed, was volume resuscitated and started on Levophed. Upon arrival in the ICU, he was continued on volume resuscitation and he pressors were ulimately weaned the day of admission. Given his history of Cipro resistent Pseudomonas and ESBL Klebsiella, he was empirically started on Meropenum / Vancomycin with Flagyl given history of C.diff. On [**5-11**], a right subclavian line was placed and a CT Torso was obtained to evaluate for potential source but was unrevealing. Once hemodynamically stable, he was transferred to the floor for continued care. Patient remained stable on the floor. Sputum culture showed yeast, all other cultures negative. Plastic surgery examined sacral wound and felt was healing well, unlikely source of infection. IV Vanco was d/c. IV flagyl also d/c after pt had decreased BM and WBC remained around 12 and patient remained afebrile with stable vital signs. # CDiff: CDiff pos x3 during last admission. Pt started on IV flagyl upon admission in setting of sepsis, which was D/C on [**5-15**]. At time of d/c the patient is not having any diarrhea. Pt remains on PO vanco and should do so until 2 weeks after d/c meropenem. If diarrhea continues at this point, repeat CDiff studies and additional stool studies may be warrented. # Urinary Tract Infection: Prior culture from last hospitalization revealed Pseudomonas, resistant to Cipro, which is what the patient had been sent to rehab on. New urine culture was sent and he was changed to Meropenem which should be continued to complete a 14 day course. His foley was d/c on anticipation of d/c because patient AAOx3 and states able to use urinal. # Respiratory Failure: Upon admisison, was placed on AC ventilation in ED, but patient stated he is not vent-dependent. He was quickly transitioned to pressure support settings and then back to his home trach mask. Upon transfer from MICU, pt had a Speech and Swallow evaluation for both diet modifications and pass??????-muir valve evaluation. Patient tolerated PMV and his diet was advanced as per SS recommendations. He developed a productive cough while on the floor and was started on chest PT and guaiffenesin syrup, along with his albuterol nebs and ipratroprium MDI. Pt has been 97-100% on TM for several days before d/c. # Atrial Fibrillation: Upon admission was in sinus and on Sotalol. Sotolol was initially held given hypotension, but was restarted [**5-12**]. Records obtained from initial hospitalization in [**1-22**] at [**Hospital 498**] hospital indicated that patient had a single isolated episode of afib w/RVR in the setting of complicated pneumonia w/demand ischemia which resolved on Carizem drip. Pt had been on Warfarin on d/c from [**Hospital1 498**] but was taken off at some point between his d/c on [**3-2**] and his admission to [**Hospital1 18**] in early [**Month (only) 958**], likely for surgical interventions for his cholecystitis. After speaking with the family, it appeared that the patient actually had had several periods of atrial fibrillation including after cardioversion. With this additional history, we made the decision to start the patient on Coumadin at 5mg per day with a Lovenox bridge, which was started at 100 Q12h. He will need his INR checked and his coumadin level adjusted accordingly. The patient should have cardiology f/u at some point to further address this issue as well as consider an outpatient stress test when clinically improved (based on echo during prior admission which showed mild LV dysfunction). # Sacral decubiti: Currently receiving dressing changes TID at rehab. Underwent debridement in early [**Month (only) 958**]. Per prior Plastics recommendations, patient was continued on wound care TID and placed on a KinAir bed. Patient was evaluated by the PRS service after transfer to the floor who recommended [**Hospital1 **] wet to dry dressing changes, nutritional optimizaiton, frequent turning, and f/u at PRS resident clinic in 2 months for re-evaluation. They did not feel that his ulcer was a source of infection and felt that it appeared to be healing well. # Diabetes Mellitus: On Lantus and ISS as an outpatient. Lantus held on admission while holding tubefeeds. Started on insulin gtt for glucose control, which was then discontinued once his condition improved. On [**5-12**], his Glargine was restarted. It was increased from 20U QHS to 25U QHS on [**5-15**] after several high BS (mostly low to mid 200's) requiring ISS coverage. # FEN: the patient was started on TF until evaluated by S&S on [**5-14**] who recommended a modified diet and instructions regarding feeding including: 1:1 observation, sitting upright while eating, single cup sips only Consistency: Pureed (dysphagia); Nectar prethickened liquids, Pills via PEG. PMV in place for all POs. When he is taking adequate POs the patient's TF may be d/c. # IV access: the patient initially had a femoral line placed in the ED which was switched for a R subclavian in the MICU which was switched for a L PICC line on the floor on [**5-15**]. An US was performed for concern for DVT in the LUE which was positive for thrombosis in the cephalic vein (in which the catheter was placed). The L sided PICC was pulled and a R sided PICC was placed. At this point his R subclavian line was pulled by IR. The decision was made not to anticoagulate the patient for the cephalic vein thrombosis as it is not considered a DVT, however, the patient was placed on therapeutic Lovenox as a bridge to anticoagulation with Coumadin for his Atrial fibrillation. # Code - FULL CODE Medications on Admission: - Vanco 125 Po q 6 - Heparin 500 TID - Famotidine 20 [**Hospital1 **] - albuterol neb prn - humalog SS - Sotalol AF 80 [**2-16**] tab [**Hospital1 **] - MVI - Citalopram 20 2 tabs qd - zinc 220 po qd - vit c 500 SR [**Hospital1 **] - tylenol 325 q 4-6 prn - glargine 20 units qhs - alprazolam 1mg [**Hospital1 **] prn - oxycodone 5mg q 4-6 prn - cipro 1 tab po BID Discharge Medications: 1. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: One (1) ML Mucous membrane [**Hospital1 **] (2 times a day). 2. Vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours): please continue for 2 weeks after patient completes course of meropenem. 3. 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. 4. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation QID (4 times a day) as needed for shortness of breath or wheezing. 5. Ascorbic Acid 90 mg/mL Drops Sig: One (1) PO BID (2 times a day). 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 7. Sotalol 80 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). 8. Fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 9. Guaifenesin 100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. 10. Insulin Glargine 100 unit/mL Solution Sig: Twenty Five (25) units Subcutaneous at bedtime. 11. Sodium Chloride 0.9 % 0.9 % Parenteral Solution Sig: Five (5) ML Intravenous PRN (as needed) as needed for line flush. 12. Meropenem 500 mg Recon Soln Sig: Five Hundred (500) mg Intravenous Q6H (every 6 hours) for 9 days: needs 8 more days to complete 14 day course. 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 14. Warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. Enoxaparin 100 mg/mL Syringe Sig: One (1) ml Subcutaneous Q12H (every 12 hours): Lovenox as bridge for anticoagulation with Coumadin - can d/c once therapeutic on Coumadin. ml 16. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 1294**] Discharge Diagnosis: Sepsis Discharge Condition: stable Discharge Instructions: Please continue your Meropenem for 9 more days to complete a 14 day course for your urinary tract infection. Continue taking your oral vancomycin for 2 weeks after the Meropenem is finished. If you continue to have diarrhea, your providers should re-check a CDiff test and my want to consider sending additional stool studies. We have started you on aspirin to reduce your risk of stroke and heart attack. Please take this as directed. After reviewing your records and speaking with your family we have decided to start you on a blood thinning medication to prevent a stroke from your atrial fibrillation. You will need to have your INR (blood test) checked frequently while you are at your rehabilitation facility. Please continue wet to dry dressings twice daily for your wound. Stay off your back as much as possible to help this wound to heal. Please continue to follow the dietary restrictions recommended by speech and swallow: 1. PO intake of nectar thick liquids and puree. 2. Pills crushed with puree or via PEG tube. 3. 1:1 supervision with all POs. 4. PMV in place for ALL POs. 5. a) Strict 1:1 supervision b) Sit fully upright for all POs. c) No consecutive sips of liquid - single sips via CUP only. No straws. e) Alternate between each bite and sip 6. Q6 oral care. 7. Patient awaiting d/c to rehab and recommend continued monitoring and dysphagia therapy. Suggest an instrumental evaluation (MBS) prior to upgrading patient's diet, [**3-19**] h/o silent aspiration of thin liquids. Please continue to work with a social worker once at [**Name (NI) **] to help you cope through this difficult time. Please take your medications as prescribed. Please return to the ED if you develop fevers, chills, are vomiting and unable to tolerate POs, chest pain, shortness of breath, or any other concerns. Followup Instructions: Please call the plastic surgery clinic at [**Telephone/Fax (1) 4652**] to schedule a follow up appointment in resident clinic in 2 months. We have scheduled an appointment for your with your surgeon, Dr [**Last Name (STitle) 468**] because you missed your appointment during this visit. Your new appointment is for [**Last Name (LF) 766**], [**5-28**] at 11:45. You can call [**Telephone/Fax (1) 2835**] if you need to reschedule this appointment. Please also keep your appoinment with Dr [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] On [**2114-6-8**] ay 10:00. Please call [**Telephone/Fax (1) 22**] if you need to reschedule this appointment. Name: [**Known lastname 12990**],[**Known firstname **] Unit No: [**Numeric Identifier 12991**] Admission Date: [**2114-5-11**] Discharge Date: [**2114-5-17**] Date of Birth: [**2056-11-6**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5420**] Addendum: Upon d/c it was recognized that a foley had been re-placed by the night team after the d/c summary was written that the catheter had been d/c. I called [**Hospital3 **] and spoke with RN [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 12992**] regarding this issue and recommended that in light of the recent severe UTI the patient should not have an indwelling catheter. She said she would pass this on to the physician. Discharge Disposition: Extended Care Facility: [**Hospital6 2876**] - [**Location (un) 3542**] [**Name6 (MD) **] [**Last Name (NamePattern4) 5421**] MD [**MD Number(2) 5422**] Completed by:[**2114-5-17**]

[ "038.9", "V58.67", "453.8", "785.52", "707.24", "599.0", "707.05", "V13.02", "427.31", "518.83", "250.00", "428.0", "707.03", "V45.79", "995.92", "V44.1", "327.23", "996.74", "V44.0", "585.9", "V12.04", "285.9", "041.7", "008.45", "E878.1" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

18793, 19006

7018, 13024

321, 407

15350, 15359

2577, 2577

17237, 18770

2149, 2182

13439, 15202

15320, 15329

13050, 13416

15383, 17214

3851, 4901

2197, 2558

4935, 6995

275, 283

435, 1292

2594, 3834

1314, 1997

2013, 2133

14,690

155,459

29043

Discharge summary

report

Admission Date: [**2182-9-29**] Discharge Date: [**2182-10-7**] Date of Birth: [**2119-1-22**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: [**2182-9-30**] Two Vessel Coronary Artery Bypass Grafting(left internal mammary to left anterior descending, vein graft to diagonal), Aortic Valve Replacement(23mm Mosaic Porcine), Mitral Valve Replacement(29mm Mosaic Porcine), and Maze Procedure [**2182-9-30**] Re-exploration for Bleeding History of Present Illness: Mr. [**Known lastname **] is a 63 year old male with new onset dyspnea on exertion and fatigue. Also admits to decreased exercise tolerance and paroxsymal nocturnal dyspnea. An echocardiogram showed mild to moderate aortic insufficiency with moderate to severe mitral regurgitation. His LVEF was estimated at 60-65%. He subsequently underwent cardiac catheterization which showed obstructive coronary artery disease(no official report). Based on the above results, he was referred for cardiac surgical intervention. Past Medical History: Rheumatic Heart Disease with history of Rheumatic Fever, Atrial Fibrillation, History of PVCs and PACs, History of First Degree AV Block and Mobitz I Second Degree AV Block, Hypertension, Prostatism, Menieres Disease, ?Sleep Apnea, Strabismus Repair as a Child Social History: No history of tobacco. Admits to drinking a few beers per week. He is a retired financial manager. He is married and lives with his wife. Family History: Denies premature coronary artery disease. Physical Exam: Vitals: BP 94-100/60, HR 54, RR 18, SAT 98 on room air General: healthy appearing male in no acute distress HEENT: oropharynx benign, Neck: supple, no JVD, transmitted murmur bilaterally Heart: regular rate, normal s1s2, [**2-28**] holosystolic 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: [**2182-9-29**] 04:58PM BLOOD WBC-7.3 RBC-4.36* Hgb-14.1 Hct-39.7* MCV-91 MCH-32.2* MCHC-35.4* RDW-13.8 Plt Ct-179 [**2182-9-29**] 04:58PM BLOOD PT-15.0* PTT-27.2 INR(PT)-1.3* [**2182-9-29**] 04:58PM BLOOD Glucose-83 UreaN-24* Creat-1.1 Na-139 K-4.4 Cl-102 HCO3-26 AnGap-15 [**2182-9-29**] 04:58PM BLOOD ALT-42* AST-32 LD(LDH)-267* AlkPhos-74 Amylase-86 TotBili-0.5 Brief Hospital Course: Mr. [**Known lastname **] was admitted the day prior to surgery for heparinization and preoperative workup. On [**9-30**], he underwent coronary artery bypass grafting, aortic and mitral valve replacements, and a Maze procedure by Dr. [**Last Name (STitle) 1290**]. For further surgical details, please see seperate dictated operative note. After the operation, he was brought to the CSRU for invasive monitoring. He was noted to have persistent postoperative bleeding which required re-exploration that same day. He returned to the CSRU in stable condition. On postoperative day one, he awoke neurologically intact and was extubated without incident. He went on to develop hypotension in the setting of atrial fibrillation/flutter with slow ventricular rhythm. He was started on Neosynephrine and required VVI pacing to maintain hemodynamics. The cardiology service was consulted and initially recommended to initially hold all nodal agents. There was no indication for temporary pacing wire at that time. Over several days, heart rate and hemodynamics improved. Neosynephrine was weaned without difficulty and VVI pacing was no longer required. Pacing wires were removed on POD3 and patient then transferred to the SDU for further care and recovery. He remained mostly in a atrial fibrillation/flutter with a slow ventricular rate in the 50's. Prothrombin times were followed daily and Warfarin was dosed for a goal INR between 2.0 - 3.0. A course of antibiotics were given for possible thrombophlebitis. He continued to make clinical improvements with diuresis and was eventually cleared for discharge on POD7. Medications on Admission: Toprol XL 12.5 qd, Aspirin 81 qd, Lipitor 10 qd, Lisinopril 2.5 qd, Folate, Glucosamine, Lasix 20 qd, Vitamin C, MVI, Fish Oil, Saw [**Location (un) **], Warfarin - last dose [**2182-9-25**] 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. 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* 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. 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* 7. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 8. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 6 days. Disp:*24 Capsule(s)* Refills:*0* 9. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 10. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily): Check INR [**10-9**]. Disp:*90 Tablet(s)* Refills:*0* 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Company 1519**] Discharge Diagnosis: Congestive Heart Failure, Coronary Artery Disease, Aortic Insufficiency, Mitral Regurgitation, Atrial Fibrillation - s/p AVR, MVR, CABG & Maze procedure, Postoperative Bleeding, Postop Thrombophlebitis PMH: Rheumatic Heart Disease, History of First Degree AV Block and Mobitz I Second Degree AV Block, History of PVCs and PACs, Hypertension, Menieres Disease 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. Please have PT/INR drawn within 48-72 hours of discharge. Results should be faxed to Dr. [**Last Name (STitle) 20764**] who will manage Warfarin as outpatient. Warfarin should be dosed for goal between 2.0 - 3.0. Followup Instructions: Dr. [**Last Name (STitle) 1290**] in [**2-27**] weeks, call for appt Dr. [**Last Name (STitle) 1655**] in [**12-28**] weeks, call for appt Dr. [**Last Name (STitle) 20764**] in [**12-28**] weeks, call for appt Completed by:[**2182-10-7**]

[ "386.00", "398.91", "396.3", "401.9", "427.31", "998.12", "458.29", "414.01" ]

icd9cm

[ [ [] ] ]

[ "39.61", "35.23", "36.15", "37.33", "35.21", "36.11", "34.03" ]

icd9pcs

[ [ [] ] ]

5741, 5790

2526, 4141

341, 635

6194, 6201

2135, 2503

6733, 6974

1635, 1678

4382, 5718

5811, 6173

4167, 4359

6225, 6710

1693, 2116

282, 303

663, 1180

1202, 1464

1480, 1619

29,474

105,098

31082

Discharge summary

report

Admission Date: [**2178-7-8**] Discharge Date: [**2178-7-11**] Date of Birth: [**2101-10-25**] Sex: M Service: MEDICINE Allergies: Codeine Attending:[**First Name3 (LF) 1973**] Chief Complaint: Abdominal pain, fever, chills Major Surgical or Invasive Procedure: ERCP Right Internal Jugular Venous Central Line History of Present Illness: Mr. [**Known lastname 69523**] is a 76 year-old male with recent diagnosis of pancreatic mass presumed to be cancer s/p biliary obstruction with stent placement and sphincterotomy presented to the who presented to the emergency department on [**2178-7-8**] with epigastric pain, fever, chills and s/p fall. He denied nausea, vomiting, diarrhea, chest pain. On the morning of presentation, he had lost his balance while using the toilet and hit the back on the toilet. He did not hit his head. He denied dizziness but reported some shaking chills and nausea. He went to an appointment with Dr. [**Last Name (STitle) **], his oncologist, and was found to have a 101.3 fever in clinic and was sent to the emergency department. Mr [**Known lastname 69523**] was diagnosed in [**Month (only) 205**], when he started to notice jaundice and have pruritus. He went to his PCP and [**Name Initial (PRE) **]/S was performed the next day showing biliary obstruction. ERCP was performed twice ([**6-8**] and [**6-25**]) and on [**6-25**] and obstruction was relieved with a metal stent and pruritus resolved. He has had a few biopsies but the samples have been inadequate. Thus, he currently does not have a tissue diagnosis. He had been seen by the surgeon, Dr. [**First Name (STitle) **] [**Name (STitle) **] and deemed not operatable because his pancreatic head mass causing near complete encasement and narrowing of the superior mesenteric vein and abutting both the portal venous confluence, as well as the duodenum. . Past Medical History: Coronary atery disease s/p CABG Porcine AVR Bilateral carotid endarterectomies Cataracts Pancreatitis in [**2175**] GERD HTN "Irregular heartbeat" Social History: Lives at home with his wife. [**Name (NI) **] six children that live locally. Retired employee for GE. Prior smoker (100 pack year history) but quit 5 years prior. Previously drank [**2-1**] beers/night but has not drunk over the past month. Family History: Mother had jaundice and possibly cancer in her 70s Physical Exam: Physical Exam Documented On Admission: Vital Signs: 99.3 76 136/48 17 100% on 2L NC Weight: 144 Lbs, Height: 66 Inches, BMI: 23.2 kg/m2, general: pleasant elderly male with mild jaundice in NAD Head: Non-traumatic, no lesion HEENT: PERRLA, EOMI, MMM, no thrush. Conjuctiva pale and with mild jaundice Neck: Supple, FROM LN: no cervical, submandibular, supraclavicular LAD Lungs: clear bilaterally, no wheezes or rubs Cardiac: RRR, nl S1/S2, no m/r/g. Abd: soft, NT, ND, no hepatosplenomegaly, nl BS, no ascites CNS: CN nl, A&O x3, no asterixis Ext: no edema, no rash, no [**Location (un) **] erythema Skin: mild jaundice down to mid abdomen Pertinent Results: [**2178-7-8**] 11:32PM GLUCOSE-153* UREA N-7 CREAT-0.6 SODIUM-141 POTASSIUM-4.3 CHLORIDE-108 TOTAL CO2-23 ANION GAP-14 [**2178-7-8**] 10:09PM COMMENTS-GREEN TOP [**2178-7-8**] 10:09PM LACTATE-1.3 [**2178-7-8**] 10:09PM HGB-11.9* calcHCT-36 O2 SAT-92 [**2178-7-8**] 09:10PM COMMENTS-GREEN TOP [**2178-7-8**] 09:10PM LACTATE-1.3 [**2178-7-8**] 09:10PM O2 SAT-93 [**2178-7-8**] 08:13PM COMMENTS-GREEN TOP [**2178-7-8**] 08:13PM LACTATE-1.2 [**2178-7-8**] 07:51PM PT-14.1* PTT-24.7 INR(PT)-1.2* [**2178-7-8**] 07:35PM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.003 [**2178-7-8**] 07:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG [**2178-7-8**] 05:55PM GLUCOSE-104 UREA N-8 CREAT-0.8 SODIUM-132* POTASSIUM-4.2 CHLORIDE-94* TOTAL CO2-27 ANION GAP-15 [**2178-7-8**] 05:55PM estGFR-Using this [**2178-7-8**] 05:55PM ALT(SGPT)-50* AST(SGOT)-84* LD(LDH)-279* ALK PHOS-367* AMYLASE-68 TOT BILI-2.3* [**2178-7-8**] 05:55PM LIPASE-192* [**2178-7-8**] 05:55PM ALBUMIN-2.9* CALCIUM-8.8 PHOSPHATE-3.0 MAGNESIUM-1.8 [**2178-7-8**] 05:55PM CORTISOL-41.8* [**2178-7-8**] 05:55PM CRP-14.0* [**2178-7-8**] 05:55PM WBC-21.2* RBC-4.37* HGB-13.7* HCT-37.8* MCV-87 MCH-31.4 MCHC-36.3* RDW-16.7* [**2178-7-8**] 05:55PM NEUTS-82.6* LYMPHS-12.6* MONOS-4.5 EOS-0.1 BASOS-0.2 [**2178-7-8**] 05:55PM PLT COUNT-306 [**2178-7-8**] 05:52PM COMMENTS-GREEN TOP [**2178-7-8**] 05:52PM LACTATE-2.3* Sinus rhythm with ventricular premature depolarizations. Compared to previous tracing ventricular ectopic activity is now evident. Otherwise, no major change. Sinus bradycardia. Compared to previous tracing cardiac rhythm is now sinus mechanism. Intervals Axes Rate PR QRS QT/QTc P QRS T 68 [**Telephone/Fax (3) 73398**]/462.85 91 -46 -34 TRACING #2 Read by: [**Last Name (LF) **],[**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 975**] Brief Hospital Course: Mr. [**Known lastname 69523**] is a 76 year-old man with new pancreatic mass seen int he emergency department for fever, epigastric pain, nausea and chills. . 1) Sepsis/ Cholangitis: In the emergency department, he was hypotensive to the 70s systolic despite 4L IVF and his WBCs were found to be 21. Lactate was initially 2.3. Sepsis code was called, and he was given levophed. A central line was placed for administration of fluids after which time his blood pressure improved to 127/4. He was started empirically on Flagyl and Levoquin for cholangitis and he was subsequently transferred to the Medical Intensive Care Unit. After his transfer, he was afebrile and his blood pressure remained stable with a systolic blood pressure on the low 100s. He was started on ampicillin to cover for enterococcus. An ERCP was performed which revealed a previously placed biliary metal stent whic was blocked with debris and sludge. Cannulation of the metal stent in biliary duct was performed and the sludge and debris were extracted successfully using a 8.5 mm balloon. A 10 cm by 10 Fr plastic biliary stent was placed successfully into the metal stent. Bile flow was seen. The gastroenterology clinic will call Mr. [**Known lastname 69523**] to schedule a follow-up ERCP for stent removal. He was transferred to the floor on [**2178-7-10**] and he continued to remain afebrile and normotensive. He was switched to oral antibiotics and discharged with a two week course. . 2) Pancreatic Mass- No tissue diagnosis has been obtained at this point. Previous FNA biopsies have been unrevealing and current metal stent preclues a biopsy with subsequent ERCP. Mr. [**Known lastname 69523**] is followed by Dr. [**Last Name (STitle) **]. He has been seen by surgeon Dr. [**First Name (STitle) **] [**Name (STitle) **] who deemed the mass unresectable on the basis of CT findings of a pancreatic head mass causing near complete encasement and narrowing of the superior mesenteric vein and abutting both the portal venous confluence, as well as the duodenum. Mr. [**Known lastname 69523**] has an appointment with radiation oncology to determine if cyberknife is possible to be used in conjunction with chemotherapy with a curative intent. He will subsequently follow-up in oncology clinic with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] to determine chemotherapy options. . 3) Atrial Fibrillation- Mr. [**Known lastname 69523**] has intermittent atrial fibrillation during this hospitalization. His metoprolol was initially witheld due to hypotension but was restarted upon transfer to the floor. He did have episodes tachycardia to 120s prior to starting metoprolol. He was continued on his home digoxin and a level was found to be 0.4mg. He was discharged on his previous home regimen on metoprolol and digoxin. Also, given his paroxysmal atrial fibrillation during this admission and his presumed hypercoagulability due to pancreatic cancer, Mr. [**Known lastname 69523**] was started on Lovenox to be continued after discharge. Lovenox was chosen in favor of Coumadin given that it may be more easily discontinued prior to diagnostic procedures. He was advised to follow-up with Dr. [**Last Name (STitle) **] for further management of anticoagulation. . 4) Hyperglycemia - Fingersticks have ranged during his admission between 122-211. [**Month (only) 116**] be due to pancreatic mass. He was advised to follow-up with his primary care provider [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] to further evaluate hyperglycemia. . 5) s/p Fall- This fall was thought to be due to weakness in the setting of his sepsis. Medications on Admission: Lisinopril 10mg PO qday Toprol 25 mg PO qday, Digoxin 0.25 mg PO qday Meclizine 25mg PO QID. Discharge Medications: 1. Meclizine 12.5 mg Tablet Sig: Two (2) Tablet PO QID (4 times a day). 2. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO DAILY (Daily). 4. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 weeks: Continue taking until [**2178-7-22**]. [**Month/Day/Year **]:*28 Tablet(s)* Refills:*0* 5. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 2 weeks: Continue taking until [**2178-7-22**]. [**Month/Day/Year **]:*90 Tablet(s)* Refills:*2* 6. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. [**Month/Day/Year **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 8. Ampicillin 250 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 2 weeks: Continue taking until [**2178-7-22**]. [**Month/Day/Year **]:*112 Capsule(s)* Refills:*0* 9. Enoxaparin 80 mg/0.8 mL Syringe Sig: 0.7 ml Subcutaneous [**Hospital1 **] (2 times a day): Please continue this medication until otherwise directed by your doctor. [**Last Name (Titles) **]:*60 syringes* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital6 486**] Discharge Diagnosis: Sepsis Cholangitis Pancreatic Mass Elevated Blood Sugar Paroxysmal Atrial Fibrillation Discharge Condition: Stable Discharge Instructions: You were admitted for fever, abdominal pain, near loss of consciousness, and nausea and were found to have very low blood pressure. You were thought to have sepsis (Systemic infection) from an infection in your bile ducts. You were admitted to the intensive care unit and started on medications to control your blood pressure. You were given antibiotics. You had an ERCP which showed blockage in the stent in your bile duct. This blockage was drained and a smaller plastic stent was placed. Gastroenterology will call to you to schedule a follow-up appointment for possible removal of this stent. You should continue taking antibiotics to complete a 2 week course on [**2178-7-22**]. Also, you were noted to have elevated blood sugar (up to 180-200) during your admission. You should follow-up with Dr. [**Last Name (STitle) **] about this because this could be a sign that you are developing diabetes. The following medications were started: Ciprofloxacin 500mg by mouth twice a day, Metronidazole 500mg by mouth 3 times a day, ampicillin 250mg by mouth every 6 hours. These are anitbiotics that should be taken until [**2178-7-22**]. You were also started on the blood thinner Lovenox 70mg injection twice a day. You should take this medication until otherwise directed by your doctors. You should call your doctor or go the emergency room if you have fever, chills, nausea, vomiting, abdominal pain, diarrhea, dizziness, lightheadedness, loss of consciousness or any other symptoms that concern you. Followup Instructions: You should attend your appointment on [**2178-7-22**] with Radiation Oncology at 10:00 AM. ([**Telephone/Fax (1) 8082**] You should attend your appointment with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) **] on [**2178-7-29**] at 2:00pm Phone:[**Telephone/Fax (1) 22**] You should follow-up with Dr. [**Last Name (STitle) **] as soon as possible. Please call to make an appointment.

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icd9cm

[ [ [] ] ]

[ "97.05", "51.10", "38.93" ]

icd9pcs

[ [ [] ] ]

10144, 10194

5053, 8720

298, 348

10325, 10334

3080, 5030

11900, 12305

2350, 2402

8864, 10121

10215, 10304

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10358, 11877

2417, 2442

229, 260

379, 1902

2457, 3061

1924, 2072

2088, 2334

16,526

180,230

22807

Discharge summary

report

Admission Date: [**2106-12-2**] Discharge Date: [**2106-12-10**] Date of Birth: [**2034-7-13**] Sex: M Service: CSU HISTORY OF PRESENT ILLNESS: Mr. [**Known lastname 26442**] is a 72-year-old man who presented to [**Hospital6 5016**] 2 days prior to admission to [**Hospital1 18**] complaining of angina. The patient has a history of CAD, status post MI in [**2089**]. Over the last 2 months, he has had recurring chest pain, rarely at rest. The patient has had more pronounced substernal chest pain. On the [**11-30**], awoke from sleep and went to the Emergency Room. He was treated with aspirin, nitroglycerin, Plavix heparin and oxygen. He then underwent a Persantine thallium that showed inferior ischemia that was reversible with a fixed apical inferior defect, and an EF of 40 percent. He had no ST changes at that time. His troponin was 2.04 with a CK of 71, MB of 15.4. Echo showed normal valve function and an EF of 60 percent with inferior posterior hypokinesis. PAST MEDICAL HISTORY: Hypertension. Polycythemia [**Doctor First Name **]. GERD. Gout. Peripheral neuropathy. Left kidney stones. Bilateral cataract surgery. Appendectomy. ALLERGIES: He states no known drug allergies. MEDS ON ADMISSION: 1. Verapamil 240 once daily. 2. Lasix 40 once daily. 3. Hydroxyurea 1,000 five times a week and 1,500 q Monday and Thursday. 4. Allopurinol 100 once daily. 5. Nexium 1 q at bedtime. 6. Neurontin 600 in the a.m. and 300 in the pm. SOCIAL HISTORY: Remote tobacco history. No alcohol use. Widowed. Lives with his granddaughter. [**Name (NI) **] is a retired photographer. PHYSICAL EXAM: GENERAL: No acute distress. HEENT: Anicteric, no lymphadenopathy, no JVD. CARDIOVASCULAR: Regular rate and rhythm. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Soft, nontender, nondistended. EXTREMITIES: No clubbing, cyanosis or edema, and no varicosities. He has [**11-28**] plus pulses throughout his distal extremities. By report, his cath showed 100 percent RCA, 95 percent LAD, 90 percent OM, and an EF of 48 percent. HOSPITAL COURSE: The morning following admission, the patient was brought to the operating room where he underwent coronary artery bypass grafting. Please see the OR report for full details. In summary, the patient had a CABG x 3 with a LIMA to the LAD, saphenous vein graft to the OM, saphenous vein graft to the PDA. His bypass time was 86 minutes with a crossclamp time of 68 minutes. He tolerated the operation well and was transferred from the operating room to the Cardiothoracic Intensive Care Unit. At the time of transfer, the patient was A-paced at 90 beats per minute with a mean arterial pressure of 70 and a CVP of 15. He had Levophed at 0.01 mcg/kg/min, milrinone at 0.25 mcg/kg/min, and propofol at 20 mcg/kg/min. The patient did well in the immediate postoperative period, remaining hemodynamically stable. However, after several attempts to wean the patient from the ventilator were unsuccessful, it was decided to keep the patient on pressure support ventilation throughout the night of his surgery. On postoperative day number 1, he was weaned from his milrinone drip and successfully weaned from the ventilator and extubated. He remained hemodynamically stable throughout this period. On postoperative day 2, the patient was weaned from his Levophed infusion, and diuresis was begun. Additionally, his chest tubes were removed at that time. On postoperative day 3, the patient remained hemodynamically stable, and he was transferred to the floor for continuing postoperative care and cardiac rehabilitation. Over the next several days, the patient had an uneventful postoperative course. His temporary pacing wires were removed on postoperative day 4. His activity level was increased with the assistance of the nursing staff and physical therapy. However, he continued to be dyspneic with activity requiring additional IV Lasix to adequately diurese. On postoperative day 5, the patient was noted to have an acute episode of agitation following administration of some Percocet. At that time, he was, for a short period of time, disoriented and somewhat combative. A psychiatric consult was called. The patient's narcotics were discontinued, and the confusion resolved. On postoperative day 6, it was decided that the patient would be stable ready and for transfer to rehabilitation. On the following day, at the time of this dictation, the patient's physical exam is as follows: Temperature 100, pulse 81/sinus rhythm, blood pressure 140/70, respiratory rate 20, O2 sat 95 percent on 2 liters, weight preoperatively 104 kg, at transfer 112.5 kg. LAB DATA: White count 13, hematocrit 27.2, sodium 139, potassium 5.0, chloride 103, CO2 28, BUN 31, creatinine 1.0, glucose 109. PHYSICAL EXAM: NEURO: Alert and oriented x 3, moves all extremities, follows commands, nonfocal exam. PULMONARY: Diminished at the bases, otherwise clear to auscultation. CARDIAC: Regular rate and rhythm, S1 and S2. Sternum is stable. Incision with Steri-Strips, without drainage, or erythema. Abdomen is soft, nontender, nondistended with normoactive bowel sounds. EXTREMITIES: Warm and well- perfused with 2 plus edema. Bilateral leg incisions with Steri-Strips, right thigh with large ecchymotic area, tender to touch especially at the medial aspect of the knee. The patient was begun on Keflex following this finding on postoperative day 5. CONDITION ON TRANSFER: Stable. He is to be transferred to an extended care facility. DISCHARGE DIAGNOSES: Coronary artery disease, status post coronary artery bypass grafting x 3 with a left internal mammary artery to the left anterior descending, saphenous vein graft to obtuse marginal, and saphenous vein graft to posterior descending artery. Hypertension. Polycythemia [**Doctor First Name **]. Gastroesophageal reflux disease. Gout. Nephrolithiasis. Bilateral cataracts. Status post appendectomy. FOLLOW UP: The patient is to have follow-up with Dr. [**Last Name (STitle) 5017**] in [**12-30**] weeks. Follow-up with Dr. [**Last Name (STitle) **] in [**12-30**] weeks. Follow-up with Dr. [**Last Name (STitle) **] in 4 weeks. DISCHARGE MEDICATIONS: 1. Colace 100 mg [**Hospital1 **]. 2. Zantac 150 mg [**Hospital1 **]. 3. Aspirin 81 mg, enteric-coated, once daily. 4. Allopurinol 150 mg once daily. 5. Neurontin 600 mg once daily and 300 mg q at bedtime. 6. Plavix 75 mg once daily. 7. Combivent 1-2 puffs q 4 h prn. 8. Hydroxyurea 1,000 mg five times a week, Sunday, Tuesday, Wednesday, Friday, Saturday, and Hydroxyurea 1,500 mg two times per week, Monday and Thursday. 9. Keflex 500 mg q 6 h x 7 days 10.Metoprolol 25 mg [**Hospital1 **]. 11.Amiodarone 400 mg [**Hospital1 **] x 1 week, then 400 mg once daily x 1 week, then 200 mg once daily x 1 month. 12.Lasix 40 mg [**Hospital1 **] until back at preoperative weight. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 5897**] Dictated By:[**Last Name (NamePattern4) 1718**] MEDQUIST36 D: [**2106-12-9**] 16:46:09 T: [**2106-12-10**] 10:02:40 Job#: [**Job Number 58974**]

[ "238.4", "414.01", "274.9", "292.81", "E935.2", "411.1", "427.31", "530.81", "356.9", "412" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

5581, 5986

6242, 7165

2108, 4813

4829, 5559

5998, 6219

166, 1006

1254, 1489

1029, 1240

1506, 1634

19,731

100,754

7659

Discharge summary

report

Admission Date: [**2144-9-9**] Discharge Date: [**2144-9-16**] Date of Birth: [**2089-9-20**] Sex: M Service: CCU HISTORY OF PRESENT ILLNESS: The patient is a 54-year-old male with known coronary artery disease who was admitted to [**Hospital6 2910**] on [**2144-9-9**], for elective cardiac catheterization. Past medical history is significant for coronary artery disease status post percutaneous transluminal coronary angioplasty with stent of the left anterior descending coronary artery in [**2138**]. Upon arrival to the [**Hospital6 2910**], the patient reported constant four out of ten chest pain with radiation to his jaw since the previous evening, [**2144-9-8**]. He received morphine prior to catheterization. Catheterization demonstrated a tight LAD lesion, 70% proximal, 90% mid LAD, resulting in an inability to see his previous LAD stent. The patient continued to have chest pain status post catheterization with no electrocardiogram changes evident. Left ventriculogram during catheterization showed normal size and good contraction of all wall segments. He was started on a nitroglycerin intravenous drip at 80 mcg/minute, Aggrastat and heparin. This resulted in a decrease in his chest pain to one to two out of ten in severity. Labs drawn at [**Hospital6 14475**] showed a hematocrit of 39.0, creatinine kinase of 126, troponin 0.06. The patient was transferred to [**Hospital1 69**] for therapeutic catheterization. Upon arrival vital signs were 97.8, blood pressure 140 to 160 over 90 to 100, heart rate in the 60's with normal sinus rhythm, oxygen saturation 98 to 100% on two liters nasal cannula oxygen. Prior to catheterization at [**Hospital1 69**], patient received fentanyl 25 mcg for his discomfort and Versed. Therapeutic catheterization at [**Hospital1 190**] showed left main coronary artery disease with mid ostial disease, left anterior descending with 60% ostial lesion, moderate 50% mid disease prior to stent, 95% tight focal lesion in old stent prior to first major diagonal branch. A Cypher stent was deployed in the proximal/middle LAD. Status post catheterization, the patient had serosanguinous blood discharge and ooze from around sheaths upon arrival to the floor. Tunnel sheaths were pulled with systolic blood pressures in the range of 140's to 150's. Cardiac fellow applied pressure. The patient complained of recurrent pain so additional doses of morphine were given. At this time then his right groin developed a large hematoma. Subsequently, nitroglycerin and Aggrastat were discontinued. Intravenous fluids were started with aggressive fluid hydration. Stat hematocrit value was drawn with a value of 34.9. The patient's hematoma continued to expand and he continued to complain of pain. As the hematoma and groin continued to ooze bloody discharge, a vascular groin C-clamp was applied. The patient was transferred to the Coronary Care Unit for further hemodynamic monitoring. Upon arrival to the CCU, he complained of severe pain, greater than ten out of ten in severity. Upon arrival he then received another 10 mg of morphine, 1 mg of Versed, 50 mcg of fentanyl and Phenergan 25 mg IV. PAST MEDICAL HISTORY: 1. Coronary artery disease status post percutaneous transluminal coronary angioplasty and stent to left anterior descending artery in [**2138**]. 2. Hypothyroidism. 3. Hypertension. 4. Chronic back pain status post multiple surgeries (times eight). 5. Non-Hodgkin's lymphoma status post chemotherapy and radiation therapy. 6. Prostate cancer status post radical prostatectomy. 7. Status post cholecystectomy. 8. Nephrolithiasis. 9. Status post right salivary gland removal. ALLERGIES: Patient with no known drug allergies. MEDICATIONS PRIOR TO ADMISSION: 1. Protonix 40 mg p.o. q. day. 2. Levoxyl 25 mcg p.o. q. day. 3. Catapres patch q. week. 4. Accupril 40 mg p.o. q. day. 5. Lasix 80 mg p.o. b.i.d. 6. Plavix 75 mg p.o. q. day. 7. Wellbutrin SR 150 mg p.o. b.i.d. 8. Zoloft 150 mg p.o. q. day. 9. Potassium chloride 20 mEq p.o. q. day. 10. Nitroglycerin sublingual 0.4 mg p.r.n. chest pain. 11. Ditropan XL 10 mg p.o. q. day. 12. Salagen 5 mg p.o. t.i.d. 13. DDAVP 2 mcg p.o. q. day. 14. Lipitor 10 mg p.o. q. day. 15. Neurontin 300 mg p.o. q.i.d. 16. Folic acid 400 mcg p.o. q. day. PHYSICAL EXAMINATION ON ADMISSION: Temperature 96.0, blood pressure 106/60, respiratory rate 15, heart rate 77, oxygen saturation 99% on three liters nasal cannula. General appearance: Well-developed, obese male, lying flat, lethargic, no apparent distress. HEENT: Normocephalic, atraumatic. Neck: Supple, no masses or lymphadenopathy. No jugular venous distention. Lungs: Clear to auscultation bilaterally. No rhonchi, rales, wheezes. Cardiovascular: Regular rate and rhythm. S1, S2 heart sounds auscultated. No murmurs, rubs or gallops. Abdomen: Soft, mildly tender diffusely, non-distended. Decreased bowel sounds. Groin: Right femoral area with large tense hematoma, markedly expanding, very tender to palpation. Extremities: Cool, 2+ dorsalis pedis pulses bilaterally, 1+ posterior tibial pulses bilaterally. No clubbing, cyanosis or edema. PERTINENT LABORATORIES, X-RAYS AND OTHER STUDIES: Laboratories drawn on the morning of [**2144-9-9**] at [**Hospital6 11896**] showed sodium 132, potassium 3.1, chloride 96, bicarbonate 26, BUN 14, creatinine 0.9, glucose 114, calcium 7.7, magnesium 2.0, creatinine kinase 126, troponin 0.06. The latest coagulation profile from [**2144-9-2**] showed PT 9.9, PTT 26, INR 1.0. The latest hematocrit value from [**2144-8-12**] was 39.0. ELECTROCARDIOGRAM: Dipyridamole EKG ([**2144-8-25**]): Normal sinus rhythm, left atrial enlargement, incomplete right bundle branch block, left anterior hemiblock but inconclusive dipyridamole exercise EKG. No chest pain or diagnostic ST segment changes to heart rate of 101. CARDIOLITE STRESS TEST ([**2144-8-25**]): Normal left ventricular size and function. Ejection fraction 58%. Anterior wall thinning consistent with prior non-transmural myocardial infarction. Inferior basal wall ischemia. ELECTROCARDIOGRAM [**2144-9-9**] AT [**Hospital6 **]: Showed normal sinus rhythm at 60 beats per minute. Left axis deviation. Borderline PR interval. Right bundle branch block. Left anterior fascicular block. Poor R-wave progression. Poor voltage in limb leads. CORONARY CATHETERIZATION ([**2144-9-9**]): Demonstrated selective left-sided coronary angiography in this left dominant circulation demonstrated one vessel coronary artery disease. The left main coronary artery had a 30% ostial lesion. The left anterior descending had serial lesions, with a tubular 60% proximal, 50% mid prior to the old stent, mild in-stent re-stenosis leading into a 95% lesion at the distal end of the stent. The left circumflex had mild luminal irregularity and gave off an OM1 with moderate diffuse disease. The right coronary artery was not engaged. Successful stenting of the main left anterior descending was performed with a 3.5 x 18 mm Cypher (drug alluding stent). ECHOCARDIOGRAM ([**2144-9-10**]): Left ventricular ejection fraction 60%. The left atrium is normal in size. Left ventricular cavity size and systolic function are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (three) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve leaflets are structurally normal. No mitral regurgitation is seen. The estimated pulmonary artery systolic pressure is normal. There is a small pericardial effusion. There is no 2-D echocardiographic findings of tamponade, but a complete Doppler assessment was not possible. ARTERIAL DOPPLERS OF THE RIGHT LOWER EXTREMITY ([**2144-9-10**]). Duplex evaluation performed of the right lower extremity arterial and venous systems with concentration on the inguinal region. Impression was that of a large right groin hematoma. There was no evidence of obvious pseudo-aneurysm or arteriovenous fistula. REPEAT RIGHT VASCULAR ULTRASOUND OF THE LOWER EXTREMITY ([**2144-9-4**]): Again, there was a large right femoral hematoma which demonstrates heterogeneous echotexture. The right common femoral artery and vein are patent demonstrating normal vascular flow. There is no evidence of pseudo-aneurysm or arteriovenous fistula formation. BRIEF SUMMARY OF HOSPITAL COURSE: 1. Coronary artery disease: Patient with known history of coronary artery disease status post coronary catheterization times two on [**2144-9-9**], status post stent placement in the proximal/mid left anterior descending artery. Plan was made to continue aspirin, Plavix, Lipitor and folate. It was unclear originally why the patient was not on a beta blocker. Therefore, once his blood pressure was able to tolerate additional antihypertensives, a low dose beta blocker was added to his medication regimen. We started him on metoprolol, titrating up the dose to desired effect. Initially many of the patient's antihypertensive medications including Catapres and Accupril were held secondary to the questionable hemodynamic instability resulting from his right groin hematoma and blood loss anemia. After stabilization of his intravascular volume status post multiple transfusions, and several days of monitoring, the patient was restarted on metoprolol and captopril. After several days of monitoring, the patient continued to be hypertensive with blood pressures ranging 160 to 180 over 90's to 100. Therefore the doses of the captopril and metoprolol were titrated up. The captopril was switched to longer acting lisinopril. At the time of discharge the patient's blood pressure was controlled on metoprolol 100 b.i.d., lisinopril 40 q. day and hydrochlorothiazide 25 q. day. The patient continued to be monitored on telemetry with no evidence of acute conduction abnormalities. After the complaint of chest pain on the first day of admission with no demonstrable electrocardiographic changes, the patient remained chest pain free for the remainder of this admission. 2. Right groin hematoma resulting in blood loss anemia: Vascular Surgery consultation was obtained status post coronary catheterization and development of large right groin hematoma. Vascular Surgery recommended a lower extremity ultrasound with results as above, namely, ultrasound demonstrated a large right groin hematoma, no evidence of pseudo-aneurysm or arteriovenous fistula formation. In the Coronary Care Unit, serial hematocrits were obtained, patient's blood pressure and hemodynamics were checked serially and peripheral pulse checks were done q. one hour. Due to anemia secondary to blood loss, the patient required multiple blood transfusions for stabilization of his blood volume and maintenance of hematocrit greater than 30. All told he received five units of blood. Initially also he was kept on bed rest with Foley catheter in place and his right leg immobilized. His pain was treated with morphine, fentanyl and Versed initially. After several days it was switched over to Vicodin as the patient uses Vicodin at home for control of his lower back pain. Repeat ultrasound was obtained on [**2144-9-4**], with no evidence of hematoma expansion, no evidence of pseudo-aneurysm or arteriovenous fistula formation. Upon discharge, the patient's hematoma size was stabilized. Serial hematocrits had been stable above 33 to 36 for several days. As the patient's hematoma resolved within a prolonged period of immobilization, it was felt that discharge to a rehabilitation facility where he could work on functional mobility and increasing gait and balance was warranted. CONDITION AT DISCHARGE: Fair. Right groin hematoma size stable. Hematocrit stabilized. Unable to demonstrate full pre-hospital functionality, so discharge to rehab. DISCHARGE STATUS: Patient discharge to extended care facility, rehab program. DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Blood loss anemia. 3. Status post cardiac catheterization with stent. 4. Right groin hematoma. 5. Unstable angina. 6. Hypothyroidism. DISCHARGE MEDICATIONS: 1. Aspirin 325 mg p.o. q. day. 2. Plavix 75 mg p.o. q. day. 3. Folic acid 400 mcg p.o. q. day. 4. Lipitor 10 mg p.o. q. day. 5. Levoxyl 25 mcg p.o. q. day. 6. Sertraline 50 mg three tablets p.o. q. day. 7. Pantoprazole 40 mg p.o. q. day. 8. Salagen 5 mg one tablet p.o. t.i.d. 9. Oxybutynin 10 mg p.o. q. day. 10. Colace 100 mg p.o. b.i.d. 11. Senna one tablet p.o. b.i.d. as needed for constipation. 12. Dulcolax 5 mg two tablets p.o. q. day as needed for constipation. 13. Zolpidem 5 mg one to two tablets p.o. q. hs. p.r.n. insomnia. 14. Neurontin 300 mg one p.o. q.i.d. 15. Tramadol 50 mg one tablet p.o. q. 4-6h. as needed for pain. 16. Hydrocodone/acetaminophen 5/500 mg one to two tablets p.o. q. 4h. as needed for pain, not to exceed eight tablets daily. 17. Milk of magnesia 30 cc q. 6h. as needed for dyspepsia. 18. Metoprolol 100 mg one p.o. b.i.d. 19. Wellbutrin 150 mg two tablets p.o. q. a.m. 20. Lisinopril 20 mg two tablets p.o. q. day. 21. Hydrochlorothiazide 25 mg one p.o. q. day. 22. Augmentin 500/125 mg one tablet p.o. b.i.d., continue for nine days for a total of a ten day course. 23. Potassium chloride 20 mEq one tablet p.o. q. day. FOLLOW-UP PLANS: Patient is being discharged to a rehabilitation program for gait, stair, transfer training with goal of increased functional mobility. He is instructed to please follow up with Dr. [**Last Name (STitle) 2912**] one to two weeks after discharge from the rehabilitation program. He can call [**Telephone/Fax (1) 25832**] for an appointment and was given this information. Additionally, he was told to call Dr.[**Name (NI) 5452**] for a follow-up appointment at [**Telephone/Fax (1) 2394**] within the following two to three weeks. The patient was instructed that we have changed several of his pre-hospital medications, particularly those controlling his blood pressure. He was instructed to discard his Catapres patch, Lasix and Accupril prescriptions. He was instructed that we have added metoprolol, lisinopril and hydrochlorothiazide to his blood pressure regimen. He is instructed to take them as directed. Additionally, he was instructed that he must take daily aspirin and Plavix for the next nine months. He was instructed that if he misses any doses, the risk of his coronary stents occluding dramatically increases. [**Name6 (MD) **] [**Name8 (MD) **], MD [**MD Number(1) 21980**] Dictated By:[**Last Name (NamePattern1) 257**] MEDQUIST36 D: [**2144-9-15**] 20:42 T: [**2144-9-15**] 20:39 JOB#: [**Job Number 27867**] cc:[**Last Name (NamePattern4) 27868**]

[ "E878.8", "996.72", "414.01", "998.12", "411.1", "285.1", "V10.46", "202.80", "244.9" ]

icd9cm

[ [ [] ] ]

[ "88.53", "36.07", "37.22", "36.01", "88.55" ]

icd9pcs

[ [ [] ] ]

11975, 12147

12170, 13339

8424, 11714

3776, 4339

11729, 11954

13357, 14771

164, 3187

4354, 8396

3209, 3744

11,013

148,766

8575+8576

Discharge summary

report+report

Admission Date: [**2132-11-10**] Discharge Date: [**2132-11-21**] Date of Birth: [**2055-11-19**] Sex: F Service: HISTORY OF PRESENT ILLNESS: This is a 76 year old, white female with known coronary artery disease, recently increased in symptoms. The patient underwent a stress test which was positive and was admitted to [**Hospital1 188**] after having a cardiac catheterization at [**Hospital3 1280**]. Cardiac catheterization showed 90% left main and three vessel coronary artery disease. Ejection fraction was found to be 63%. She was transferred to [**Hospital1 188**] from [**Hospital3 1280**] for coronary artery bypass grafting. PAST MEDICAL HISTORY: 1.) Coronary artery disease. 2.) Questionable transient ischemic attack. 3.) Hypercholesterolemia. 4.) Gastroesophageal reflux disease. 5.) History of endocarditis at age 40. 6.) Status post upper gastrointestinal bleed, due to aspirin. 7.) History of diverticulosis. 8.) Status post colon polypectomy. 9.) Chronic back pain. 10.) Status post bilateral cataract extraction. 11.) Status post negative breast biopsy. 12.) Status post tonsillectomy. PREOPERATIVE MEDICATIONS: Enteric coated aspirin 325 mg p.o. q. day. Atenolol 25 mg p.o. q. day. Zantac 50 mg intravenous twice a day. Prevacid 30 mg p.o. q. day. Lipitor 10 mg p.o. q. day. Colace 100 mg p.o. twice a day. Integrilin. Heparin. ALLERGIES: Prednisone which gives her a rash. Vioxx, Robaxin, Celebrex and Amlodipine which don't agree with her. Th[**Last Name (STitle) 1050**] was admitted to the cardiology service, where she remained in the Intensive Care Unit overnight. On the morning of [**2132-11-11**], the patient had carotid ultrasound which showed no significant stenosis in either carotid and the patient was taken to the operating room with Dr. [**Last Name (Prefixes) **] on [**11-11**]. The patient was brought to the operating room and general anesthesia was induced. As the assistants were placing the lines, the patient became hypotensive with ischemic electrocardiogram changes. The patient became profoundly hypotensive, requiring chest compression and intravenous epinephrine. Dr. [**Last Name (Prefixes) **] was called immediately to the operating room and the patient was placed emergently on bypass. In the operating room, the patient had a coronary artery bypass graft times three with saphenous vein graft to left anterior descending, saphenous vein graft to obtuse marginal one and saphenous vein graft to posterior descending artery. At the end of the case, an intra-aortic balloon pump was placed and the patient was started on epinephrine, Levophed, Vasopressin as well as Lidocaine and Amiodarone for ventricular ectopy. Please see operative note for further details. The patient was transferred to the Intensive Care Unit where she had several episodes of hypotension requiring volume resuscitation. The patient underwent a transesophageal echocardiogram at the bedside in the Intensive Care Unit for low cardiac index and profound hypotension. This showed a dilated and severely hypokinetic right ventricle with an ejection fraction of 40% and global hypokinesis, mild central mitral regurgitation, trace tricuspid regurgitation, an intact thoracic aorta and a balloon pump that was in good placement. The patient was started on Milrinone for her right ventricular dysfunction with the Milrinone and volume resuscitation. The patient eventually stabilized. The patient was started on a Midazolam infusion for sedation, as it was felt that the Propofol was contributing to hypotension. On postoperative day number one, the patient remained on vasopressors as well as inotropic support and continued with the intra-aortic balloon pump at 1:1. It was decided that the patient would require several days of gentle weaning of the pressors to allow the myocardial function to return. The patient continued to have good cardiac output. The patient continued to have varying requirements for vasopressors, continuing to require Epinephrine, Levophed and Vasopressin to maintain adequate blood pressure. On postoperative day number three, the patient was noted to be hyponatremic. The patient's sodium in the morning was down to 126. By the evening, it was down to 121. Renal consult was obtained. It was felt that the Vasopressin was contributing to Syndrome of inappropriate diuretic hormone. Their recommendations were to stop the Vasopressin. The patient also required a small amount of hypertonic saline replacement which, by postoperative day number four, corrected her sodium back up to 130. The patient was weaning off of her pressors. The patient was weaned and extubated from mechanical ventilation on postoperative day number four. The intra-aortic balloon pump was removed later in the day on postoperative day number four. The patient had an episode of atrial fibrillation which she tolerated well with continued good blood pressure and cardiac index. On postoperative day number five, the patient again had an episode of atrial fibrillation which resulted in oliguria. The patient was given fluid boluses without any improvement. The patient converted to sinus rhythm spontaneously and oliguria resolved. The patient's Milrinone was weaned off on postoperative day number five. The patient was continued on epinephrine and Levophed. By postoperative day number seven, all inotropes and pressors were weaned off with continued good hemodynamics and cardiac index of 2.5 and SV02 of 64. The PA catheter was removed and the patient was transferred from the Intensive Care Unit to the floor. It was noted on postoperative day number seven that the superior aspect of the vein harvest site on the patient's thigh had dehisced. It was open down to fascia, draining serous fluid, no erythema, a small amount of clot at the base. The wound was packed wet to dry. The patient was also draining moderate amounts of serous fluid from the knee and distal portion of the vein harvest site. The patient's pacing wires were removed without incident. On postoperative day number nine, the superior thigh wound looked clean and a VAC dressing was placed. It was felt that the patient was appropriate for transfer to rehabilitation facility. CONDITION AT DISCHARGE: T max 99.3; pulse 73 and sinus rhythm; blood pressure 132/78; respiratory rate 18; room air oxygen saturation of 93%. Chest x-ray on [**11-20**] showed small bilateral effusions, no pneumothorax, no consolidations. Laboratory data from [**11-19**] showed white blood cell count of 7.6; hematocrit of 34.8; platelet count of 169; potassium of 4.1; BUN 19; creatinine 0.9. Neurologically, the patient is awake, alert and oriented times three, nonfocal. Heart is regular rate and rhythm without murmur. Lungs are clear bilaterally. Abdomen was soft, nontender, nondistended, positive bowel sounds. Sternal incision is clean, dry and intact. Staples are intact. There is no erythema. There is no drainage. The right lower extremity and upper thigh wound is dehisced about six to seven cm, about three to four cm deep, with good granulation tissue at the edges. There is no surrounding erythema. There is some surrounding ecchymosis. The knee and ankle portions of the incision are closed, draining serous fluid. DISCHARGE MEDICATIONS: Protonic 40 mg p.o. q. day. Enteric coated aspirin 325 mg p.o. q. day. Amiodarone 400 mg p.o. q. day. Lasix 20 mg p.o. twice a day times ten days. Potassium chloride 20 meq p.o. twice a day times ten days. Lipitor 10 mg p.o. q. day. The patient is refusing to take this medication because she feels that it is making her stomach upset and she wishes to talk to her cardiologist, Dr. [**Last Name (STitle) 1295**], about this. At this point, the Lipitor is being held. Lopressor 12.5 mg p.o. twice a day. Tylenol with codeine #3, one to two p.o. every four hours prn. The patient is to be discharged to rehabilitation in good condition. DISCHARGE DIAGNOSES: Coronary artery disease. Status post coronary artery bypass graft times three. Right thigh wound dehiscence. FOLLOW-UP: The patient is to follow-up with Dr. [**Last Name (STitle) 1295**] in one to two weeks. The patient is to follow-up with Dr. [**Last Name (STitle) 30107**] in one to two weeks. The patient is to follow-up with Dr. [**Last Name (STitle) **] in three to four weeks. Staples should be removed three weeks after the date of the surgery, which should be approximately [**2132-12-2**]. [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 30108**] MEDQUIST36 D: [**2132-11-20**] 07:08 T: [**2132-11-21**] 04:01 JOB#: [**Job Number 30109**] Admission Date: [**2132-11-20**] Discharge Date: [**2132-11-24**] Date of Birth: [**2055-11-19**] Sex: F Service: Cardiothoracic Surgery Service ADDENDUM: Please refer to the previously dictated Discharge Summary from [**2132-11-21**] by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Basically, Ms. [**Known lastname 11907**] has had three major issues since the previous Discharge Summary. First off, the patient stayed through the weekend and her discharge date was [**11-24**] instead of [**11-21**]. Her first complaint was that of some loose stools. The loose stools have been treated empirically with Flagyl, and two Clostridium difficile cultures have come back as negative. In addition, the patient has had two medications held at this time. Her Lipitor, which she reports at home, is associated with some increased diarrhea as well as her Colace being held. Currently, at the time of discharge, her diarrhea had improved relative to earlier this weekend. Secondly, her sternal wound had its staples were removed on the day of discharge prior to discharge. The wound was clean, dry, and intact. Her leg wound still had a vacuum-assisted closure device still in place. There is no leak about that site, and it continues to drain small amounts of serosanguineous fluid. In addition, she also had some continued drainage around her right ankle and calf where her saphenous vein was harvested. She is on day four of levofloxacin for these wounds, and she was to continue this for 10 days at her rehabilitation facility. DISCHARGE DISPOSITION: It is [**2132-11-24**]; and the patient was to be discharged to the [**Hospital3 1280**] Tertiary Care Unit rehabilitation facility. CONDITION AT DISCHARGE: Condition on discharge was good. Her physical examination was unchanged. DISCHARGE DIAGNOSES: Her discharge diagnoses are the same. MEDICATIONS ON DISCHARGE: (Discharge medications were as follows) 1. Metoprolol 12.5 mg by mouth twice per day. 2. Enteric-coated aspirin 325 mg by mouth every day. 3. Amiodarone 400 mg by mouth once per day for one week and then 200 mg by mouth once per day after that. 4. Lipitor 10 mg by mouth every other day. 5. Levofloxacin 500 mg by mouth once per day (for 10 days). 6. Flagyl 500 mg by mouth three times per day (for 10 days). 7. Lasix 40 mg by mouth twice per day. 8. Potassium chloride 20 mEq by mouth twice per day. 9. Tylenol No. 3 by mouth q.4-6h. as needed (for pain). 10. Protonix 40 mg by mouth twice per day. 11. Tylenol 650 mg by mouth q.6h. as needed (for pain or fever). [**Doctor Last Name 412**] [**Last Name (Prefixes) 413**], M.D. [**MD Number(1) 414**] Dictated By:[**Last Name (NamePattern1) 1179**] MEDQUIST36 D: [**2132-11-24**] 11:11 T: [**2132-11-24**] 11:40 JOB#: [**Job Number 30110**]

[ "414.01", "458.29", "427.5", "428.0", "998.11", "427.31", "998.32", "411.1", "424.0" ]

icd9cm

[ [ [] ] ]

[ "99.04", "89.68", "93.59", "36.13", "37.61", "39.61", "37.91" ]

icd9pcs

[ [ [] ] ]

10351, 10495

10606, 10645

7315, 7954

10672, 11625

1168, 6259

10510, 10584

163, 661

684, 1142

14,458

107,873

7085+7086

Discharge summary

report+report

Admission Date: [**2114-9-12**] Discharge Date: [**2114-10-4**] Date of Birth: [**2050-8-10**] Sex: F Service: GENERAL MEDICINE ADMISSION DIAGNOSIS: Profound acidosis and mental status changes. HISTORY OF PRESENT ILLNESS: This is a 64 year-old African American female with a complicated medical history, which renal disease on hemodialysis. The patient was transferred to the [**Hospital1 18**] from the [**Hospital3 417**] Hospital where she was admitted on [**2114-9-9**] for evaluation of abdominal pain. By report the abdominal pain began the Sunday prior with no associated nausea, vomiting, melena or hematochezia. Reportedly the patient had some complaints of urinary retention the day before, but no frank dysuria. Of note, the hemodialysis. At the [**Hospital3 417**] Hospital her workup was essentially negative and only notable for a urinary tract infection, for which she was treated with Levaquin. There was a question of pelvic ramus fracture, which was thought to be possibly old by orthopedics and constipation, which was successfully treated with enemas at the [**Hospital3 417**] Hospital. The patient was sent to the [**Hospital1 18**] for further workup of her questionable pelvic ramus fracture. On arrival she was found to be febrile, but responsive, although with questionable clarity of mind. Over the preceding hours the patient became increasingly unresponsive and hypotensive. The MICU team was called and examination at the time revealed a temperature of 101, heart rate 115, blood pressure 74/palp. An arterial blood gases done at the time showed a pH of 7.14, PCO2 20, and PO2 144 on 4 liters of supplemented oxygen. PAST MEDICAL HISTORY: From the record, 1. Status post open reduction and internal fixation of the right hip fracture complicated by right femoral fracture in [**2113-10-6**], status post total hip replacement in [**2106**] and [**2109**] due to osteoarthritis with infected hardware, which was removed in [**2113-5-6**]. 2. Type 2 diabetes mellitus with retinopathy and nephropathy. 3. Hypertension. 4. End stage renal disease on hemodialysis secondary to diabetes and hypertension. 5. History of hypertensive episode in [**2114-1-5**]. 6. Anemia. 7. Status post Methacillin resistance staphylococcus aureus bacteremia [**2113-11-5**]. 8. History of deep venous thrombosis [**2113-11-5**]. 9. Coronary artery disease. 10. Gastrotomy tube placement in [**2113-11-5**]. 11. Congestive heart failure, but with a preserved EF of 55%, mild mitral regurgitation and delayed relaxation. 12. Status post respiratory failure and tracheostomy in [**2113-11-5**]. 13. History of aspiration pneumonia. 14. History of Pseudomonas pneumonia. 15. History of previous stroke. 16. History of C-diff colitis. 17. History of bipolar disorder with paranoid hallucinations for about twenty years with a question of schizophrenia. 18. Status post total abdominal hysterectomy and bilateral salpingo-oophorectomy. 19. Osteoporosis. 20. Recurrent chronic atrial fibrillation/atrial flutter. 21. History of myoclonic jerking. ALLERGIES: No known drug allergies, but allergic to strawberries. MEDICATIONS: 1. NPH insulin 14 units q.a.m. and 12 units q.p.m., regular insulin sliding scale. 2. Folate 1 mg po q.d. 3. Nephrocaps one tablet po q.d. 4. Vitamin C 500 mg po b.i.d. 5. Clonazepam 0.25 mg po q.d. 6. Zantac 150 mg po q.d. 7. Coumadin 4 mg po q.d. 8. Lopressor 50 mg po b.i.d. 9. Cardizem 180 mg po q.i.d. 10. Tylenol as needed. 11. Lomotil as needed. 12. Colace 100 mg po b.i.d. 13. Vicodin ES 7.5/750 q 6 hours prn. 14. Dulcolax 10 mg po pr prn. 15. Ativan 1 mg intravenous q.h.s. prn. 16. Klonopin 0.125 q.h.s. 17. Premarin 0.625 q.d. 18. Pravachol 10 mg po q.d. 19. Renagel 800 mg b.i.d. 20. Bromfed two tablets b.i.d. SOCIAL HISTORY: The patient lives at home with daughter. She has lived in nursing homes in the past. No history of alcohol use or cigarette use. She has been retired for seven years before which she was a school teacher. FAMILY HISTORY: No history of epilepsy, schizophrenia, dementia or bipolar disease. PHYSICAL EXAMINATION: Vital signs, temperature 101. Heart rate 115. Blood pressure 74/palp. In general, this was an unresponsive African American woman who is not intubated. Head and neck, myoclonic facial jerks. Pupils are equal, round and reactive to light minimally. Anicteric. No JVD. Pulmonary, clear to auscultation bilaterally. No wheezes. Cardiovascular, irregularly irregular with a rapid rate, but no murmurs, rubs or gallops. Abdomen, nontender, nondistended. No hepatosplenomegaly. No rebound or guarding. Extremities no edema and no clubbing. Neurological, could not assess. LABORATORY: Hematocrit 41.7, white count 8.7, platelet 299, INR 9.4, PT 37.8, PTT 59.3. Repeat blood gas pH 7.15, CO2 54, PO2 405 on 100% oxygen. Large acetone. Cerebral spinal fluid analysis, 1 white cell, 0 red cells, 80 polys and 20 lymphocytes, 53 proteins, 226 glucose, LDH 22. HOSPITAL COURSE: The patient had a complicated hospital course. The initial treatment in the MICU included Levophed, bicarbonate, Vancomycin, Gentamycin and cardiopulmonary support was continued. The patient was subsequently found to be in diabetic ketoacidosis and treated with an insulin drip and responded well. Cardiovascularly, the patient has a history of chronic atrial fibrillation and in the ICU had a heart rate of 100 to 130 with no ectopy noted. She had cardiac enzymes consistent with an acute myocardial infarction. This is likely secondary to rate. Given the patient's unstable condition she was not a candidate for a catheterization while in the Intensive Care Unit. From an infectious disease stand point she had a T max of 102.4 and received one dose of Vancomycin and Gentamycin as previously mentioned. She also received one dose of Ceftriaxone and was started on Flagyl. Urinalysis was consistent with a urinary tract infection. The patient was put on contact precautions secondary to history of C-diff and MRSA. Respiratory wise, the patient improved while in the Intensive Care Unit and weaned down to 3 liters of nasal cannula oxygen with an arterial blood gas of 7.34 pH, 45 CO2. The patient continued to improve over the next couple of days in the unit and was transferred to the floor under the service of Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**]. Hospital history while on the medical service is as follows: 1. Endocrine. The patient has a history of type 2 diabetes complicated by diabetic ketoacidosis. During her stay in the hospital NPH insulin was adjusted to keep blood sugars under 200 with supplemental insulin sliding scale. At the time of discharge the patient had adequate glucose control with NPH insulin 8 units q.a.m. and 7 units q.p.m. The last hemoglobin A1C done at this admission was 6.8. 2. Infectious disease. The patient was found to have a urinary tract infection, which was treated initially with Ceftriaxone, but later found to be Klebsiella species, which expended spectrum beta lactamase resistance. The ID Service was consulted and Zosyn was begun. However, the patient continued to spike fevers for several days despite being on Zosyn and ID was reconsulted and the patient was started on renally dosed Meropenem. Despite our best efforts she continued to spike fevers on Meropenem. All blood cultures from peripheral and central lines had been negative to date. Of note, the patient's clinical picture continued to improve with improving mental status despite elevated temperatures primarily at night. Given the patient's clinical improvement, the issue of bacteremia was readdressed and infectious disease was reconsulted. The patient was discontinued on Meropenem as it was felt Meropenem may be causing a drug fever. The patient became afebrile off Meropenem for four days and at the time of discharge was afebrile. 3. Renal. The patient continued to have hemodialysis during her hospital stay without issue. 4. Fluid and electrolytes. The patient initially had poor po intake and a swallow study was performed. It was not significantly different from the one in [**2113-6-5**], which showed no aspiration, but an increase risk for aspiration secondary to residual. The patient continued to increase her po intake during the hospital course as her mental status improved. She was tolerating loose and a soft diet with assistance. The concern remains that she will not take in enough po to sustain her nutritional needs, however, given her continued improvement, the decision was made to hold off on enteral feedings. 5. Cardiovascular. Her cardiac status was complicated by one episode of cardiac arrest while on the floor. The patient was sitting up in her bed after dialysis and the nurse noted that she became increasingly unresponsive. Assessment revealed that she was in cardiac arrest for about one minute and a code was called and the patient successfully resuscitated. The etiology of this event remains unclear. However, this is likely secondary to a mucous plug leading to decreased respirations and bradycardia secondary to decreased oxygenation. Otherwise the patient's cardiovascular status has been improving. Her beta blocker was increased to better rate control. At the time of discharge her heart rate was in the 60s to 70s and in sinus rhythm. The patient continues to be on Coumadin for anticoagulation with a history of paroxysmal atrial fibrillation. 6. Pulmonary. The patient's pulmonary status has improved markedly since her admission and currently is breathing room air with SPO2s in the high 90s. 7. Rheumatology and rehabilitation. The patient has had a history of hip replacement in the past with osteoporosis and osteoarthritis. She was started on scheduled Ultram with good response. Physical therapy has been working with the patient for increased mobility and ambulation. The patient has received her leg brace fitting to help her with ambulation. Radiologic studies indicate no evidence of acute pubic ramus fracture, but there did reveal extensive heterotopic bone formation surrounding the right total hip replacement. 8. Neurologic. The patient has a history of myoclonic jerking, which was seen by neurology and started on Dilantin. The patient had an abnormal electroencephalogram with background slowing with bursts of generalized slowing. This pattern is suggestive of deep subcortical bilateral dysfunction or may be seen in the setting of moderate to severe encephalopathy of toxic metabolic or anoxic etiology. The [**Hospital 228**] hospital course showed a steady improvement. Multiple laboratory and radiologic studies were performed during the hospitalization to further characterize the problems indicated above. Head CT during this admission revealed extensive chronic microvascular infarctions. A video swallow test was done to evaluate swallowing as indicted above with diffuse pharyngeal residue without evidence of aspiration. A CT of the pelvis and abdomen was done to help localize a source of fevers. There was no evidence of intra-abdominal or intrapelvic abscess. There was a small area of hypodensity on CT consistent with a small left adrenal adenoma. The patient had a small left pleural effusion with some basal atelectasis and consolidation. This was felt to be adequately treated by the ID staff with her multiple courses of antibiotics, which include Vancomycin, Gentamycin, Ceftriaxone, Zosyn and Meropenem. At the time of discharge the patient was medically stable. Of note, the patient is highly sensitive to morphine and becomes disoriented when even low doses of morphine are used. We would recommend that the patient be given .5 mg of Ativan if she becomes agitated at night, but would caution the use of narcotics. DISCHARGE STATUS: Discharged to rehab facility. CONDITION AT DISCHARGE: Improved. DISCHARGE DIAGNOSES: As in past medical history indicated above and: 1. Diabetic ketoacidosis. 2. Status post cardiac arrest. 3. Klebsiella UTI DISCHARGE MEDICATIONS: 1. Dilantin 100 mg po t.i.d. 2. Diovan 80 mg po q.d. 3. Pravachol 10 mg po q.d. 4. Lopressor 125 mg po b.i.d. 5. Nephrocaps one capsule po t.i.d. 6. Klonopin 0.25 mg po q.h.s. 7. Enteric coated aspirin 325 mg po q.d. 8. Colace 100 mg po b.i.d. 9. Renagel two capsules po t.i.d. with meals. 10. Coumadin 2 mg po q.d. 11. NPH insulin 8 units subcutaneous q.a.m. and 7 units subcutaneous q.p.m. 12. Ultram 50 mg po t.i.d. 13. Protonix 40 mg po b.i.d. 14. Motrin 400 mg as needed. 15. Dulcolax 10 mg po pr q.d. prn. 16. Boost vanilla one can po t.i.d. [**Name6 (MD) 7853**] [**Last Name (NamePattern4) 7854**], M.D. [**MD Number(1) 7855**] Dictated By:[**Last Name (NamePattern4) 26426**] MEDQUIST36 D: [**2114-10-4**] 10:01 T: [**2114-10-4**] 11:07 JOB#: [**Job Number 26427**] Admission Date: [**2114-9-12**] Discharge Date: [**2114-10-4**] Date of Birth: [**2050-8-10**] Sex: F Service: GENERAL MEDICINE ADMISSION DIAGNOSIS: Profound acidosis and mental status changes. HISTORY OF PRESENT ILLNESS: This is a 64 year-old African American female with a complicated medical history, which includes type 2 diabetes, hypertension leading to end stage renal disease on hemodialysis. The patient was transferred to the [**Hospital1 18**] from the [**Hospital3 417**] Hospital where she was admitted on [**2114-9-9**] for evaluation of abdominal pain. By report the abdominal pain began the Sunday prior with no associated nausea, vomiting, melena or hematochezia. Reportedly the patient had some complaints of urinary retention the day before, but no frank dysuria. Of note, the patient makes some urine daily at this point being on hemodialysis. At the [**Hospital3 417**] Hospital her workup was essentially negative and only notable for a urinary tract infection, for which she was treated with Levaquin. There was a question of pelvic ramus fracture, which was thought to be possibly old by orthopedics and constipation, which was successfully treated with enemas at the [**Hospital3 417**] Hospital. The patient was sent to the [**Hospital1 18**] for further workup of her questionable pelvic ramus fracture. On arrival she was found to be febrile, but responsive, although with questionable clarity of mind. Over the preceding hours the patient became increasingly unresponsive and hypotensive. The MICU team was called and examination at the time revealed a temperature of 101, heart rate 115, blood pressure 74/palp. An arterial blood gases done at the time showed a pH of 7.14, PCO2 20, and PO2 144 on 4 liters of supplemented oxygen. PAST MEDICAL HISTORY: From the record, 1. Status post open reduction and internal fixation of the right hip fracture complicated by right femoral fracture in [**2113-10-6**], status post total hip replacement in [**2106**] and [**2109**] due to osteoarthritis with infected hardware, which was removed in [**2113-5-6**]. 2. Type 2 diabetes mellitus with retinopathy and nephropathy. 3. Hypertension. 4. End stage renal disease on hemodialysis secondary to diabetes and hypertension. 5. History of hypertensive episode in [**2114-1-5**]. 6. Anemia. 7. Status post Methacillin resistance staphylococcus aureus bacteremia [**2113-11-5**]. 8. History of deep venous thrombosis [**2113-11-5**]. 9. Coronary artery disease. 10. Gastrotomy tube placement in [**2113-11-5**]. 11. Congestive heart failure, but with a preserved EF of 55%, mild mitral regurgitation and delayed relaxation. 12. Status post respiratory failure and tracheostomy in [**2113-11-5**]. 13. History of aspiration pneumonia. 14. History of Pseudomonas pneumonia. 15. History of previous stroke. 16. History of C-diff colitis. 17. History of bipolar disorder with paranoid hallucinations for about twenty years with a question of schizophrenia. 18. Status post total abdominal hysterectomy and bilateral salpingo-oophorectomy. 19. Osteoporosis. 20. Recurrent chronic atrial fibrillation/atrial flutter. 21. History of myoclonic jerking. ALLERGIES: No known drug allergies, but allergic to strawberries. MEDICATIONS: 1. NPH insulin 14 units q.a.m. and 12 units q.p.m., regular insulin sliding scale. 2. Folate 1 mg po q.d. 3. Nephrocaps one tablet po q.d. 4. Vitamin C 500 mg po b.i.d. 5. Clonazepam 0.25 mg po q.d. 6. Zantac 150 mg po q.d. 7. Coumadin 4 mg po q.d. 8. Lopressor 50 mg po b.i.d. 9. Cardizem 180 mg po q.i.d. 10. Tylenol as needed. 11. Lomotil as needed. 12. Colace 100 mg po b.i.d. 13. Vicodin ES 7.5/750 q 6 hours prn. 14. Dulcolax 10 mg po pr prn. 15. Ativan 1 mg intravenous q.h.s. prn. 16. Klonopin 0.125 q.h.s. 17. Premarin 0.625 q.d. 18. Pravachol 10 mg po q.d. 19. Renagel 800 mg b.i.d. 20. Bromfed two tablets b.i.d. SOCIAL HISTORY: The patient lives at home with daughter. She has lived in nursing homes in the past. No history of alcohol use or cigarette use. She has been retired for seven years before which she was a school teacher. FAMILY HISTORY: No history of epilepsy, schizophrenia, dementia or bipolar disease. PHYSICAL EXAMINATION: Vital signs, temperature 101. Heart rate 115. Blood pressure 74/palp. In general, this was an unresponsive African American woman who is not intubated. Head and neck, myoclonic facial jerks. Pupils are equal, round and reactive to light minimally. Anicteric. No JVD. Pulmonary, clear to auscultation bilaterally. No wheezes. Cardiovascular, irregularly irregular with a rapid rate, but no murmurs, rubs or gallops. Abdomen, nontender, nondistended. No hepatosplenomegaly. No rebound or guarding. Extremities no edema and no clubbing. Neurological, could not assess. LABORATORY: Hematocrit 41.7, white count 8.7, platelet 299, INR 9.4, PT 37.8, PTT 59.3. Repeat blood gas pH 7.15, CO2 54, PO2 405 on 100% oxygen. Large acetone. Cerebral spinal fluid analysis, 1 white cell, 0 red cells, 80 polys and 20 lymphocytes, 53 proteins, 226 glucose, LDH 22. HOSPITAL COURSE: The patient had a complicated hospital course. The initial treatment in the MICU included Levophed, bicarbonate, Vancomycin, Gentamycin and cardiopulmonary support was continued. The patient was subsequently found to be in diabetic ketoacidosis and treated with an insulin drip and responded well. Cardiovascularly, the patient has a history of chronic atrial fibrillation and in the ICU had a heart rate of 100 to 130 with no ectopy noted. She had cardiac enzymes consistent with an acute myocardial infarction. This is likely secondary to rate. Given the patient's unstable condition she was not a candidate for a catheterization while in the Intensive Care Unit. From an infectious disease stand point she had a T max of 102.4 and received one dose of Vancomycin and Gentamycin as previously mentioned. She also received one dose of Ceftriaxone and was started on Flagyl. Urinalysis was consistent with a urinary tract infection. The patient was put on contact precautions secondary to history of C-diff and MRSA. Respiratory wise, the patient improved while in the Intensive Care Unit and weaned down to 3 liters of nasal cannula oxygen with an arterial blood gas of 7.34 pH, 45 CO2. The patient continued to improve over the next couple of days in the unit and was transferred to the floor under the service of Dr. [**First Name8 (NamePattern2) **] [**Name (STitle) 805**]. Hospital history while on the medical service is as follows: 1. Endocrine. The patient has a history of type 2 diabetes complicated by diabetic ketoacidosis. During her stay in the hospital NPH insulin was adjusted to keep blood sugars under 200 with supplemental insulin sliding scale. At the time of discharge the patient had adequate glucose control with NPH insulin 8 units q.a.m. and 7 units q.p.m. The last hemoglobin A1C done at this admission was 6.8. 2. Infectious disease. The patient was found to have a urinary tract infection, which was treated initially with Ceftriaxone, but later found to be Klebsiella species, which expended spectrum beta lactamase resistance. The ID Service was consulted and Zosyn was begun. However, the patient continued to spike fevers for several days despite being on Zosyn and ID was reconsulted and the patient was started on renally dosed Meropenem. Despite our best efforts she continued to spike fevers on Meropenem. All blood cultures from peripheral and central lines had been negative to date. Of note, the patient's clinical picture continued to improve with improving mental status despite elevated temperatures primarily at night. Given the patient's clinical improvement, the issue of bacteremia was readdressed and infectious disease was reconsulted. The patient was discontinued on Meropenem as it was felt Meropenem may be causing a drug fever. The patient became afebrile off Meropenem for four days and at the time of discharge was afebrile. 3. Renal. The patient continued to have hemodialysis during her hospital stay without issue. 4. Fluid and electrolytes. The patient initially had poor po intake and a swallow study was performed. It was not significantly different from the one in [**2113-6-5**], which showed no aspiration, but an increase risk for aspiration secondary to residual. The patient continued to increase her po intake during the hospital course as her mental status improved. She was tolerating loose and a soft diet with assistance. The concern remains that she will not take in enough po to sustain her nutritional needs, however, given her continued improvement, the decision was made to hold off on enteral feedings. 5. Cardiovascular. Her cardiac status was complicated by one episode of cardiac arrest while on the floor. The patient was sitting up in her bed after dialysis and the nurse noted that she became increasingly unresponsive. Assessment revealed that she was in cardiac arrest for about one minute and a code was called and the patient successfully resuscitated. The etiology of this event remains unclear. However, this is likely secondary to a mucous plug leading to decreased respirations and bradycardia secondary to decreased oxygenation. Otherwise the patient's cardiovascular status has been improving. Her beta blocker was increased to better rate control. At the time of discharge her heart rate was in the 60s to 70s and in sinus rhythm. The patient continues to be on Coumadin for anticoagulation with a history of paroxysmal atrial fibrillation. 6. Pulmonary. The patient's pulmonary status has improved markedly since her admission and currently is breathing room air with SPO2s in the high 90s. 7. Rheumatology and rehabilitation. The patient has had a history of hip replacement in the past with osteoporosis and osteoarthritis. She was started on scheduled Ultram with good response. Physical therapy has been working with the patient for increased mobility and ambulation. The patient has received her leg brace fitting to help her with ambulation. Radiologic studies indicate no evidence of acute pubic ramus fracture, but there did reveal extensive heterotopic bone formation surrounding the right total hip replacement. 8. Neurologic. The patient has a history of myoclonic jerking, which was seen by neurology and started on Dilantin. The patient had an abnormal electroencephalogram with background slowing with bursts of generalized slowing. This pattern is suggestive of deep subcortical bilateral dysfunction or may be seen in the setting of moderate to severe encephalopathy of toxic metabolic or anoxic etiology. The [**Hospital 228**] hospital course showed a steady improvement. Multiple laboratory and radiologic studies were performed during the hospitalization to further characterize the problems indicated above. Head CT during this admission revealed extensive chronic microvascular infarctions. A video swallow test was done to evaluate swallowing as indicted above with diffuse pharyngeal residue without evidence of aspiration. A CT of the pelvis and abdomen was done to help localize a source of fevers. There was no evidence of intra-abdominal or intrapelvic abscess. There was a small area of hypodensity on CT consistent with a small left adrenal adenoma. The patient had a small left pleural effusion with some basal atelectasis and consolidation. This was felt to be adequately treated by the ID staff with her multiple courses of antibiotics, which include Vancomycin, Gentamycin, Ceftriaxone, Zosyn and Meropenem. At the time of discharge the patient was medically stable. Of note, the patient is highly sensitive to morphine and becomes disoriented when even low doses of morphine are used. We would recommend that the patient be given .5 mg of Ativan if she becomes agitated at night, but would caution the use of narcotics. DISCHARGE STATUS: Discharged to rehab facility. CONDITION AT DISCHARGE: Improved. DISCHARGE DIAGNOSES: As in past medical history indicated above and: 1. Diabetic ketoacidosis. 2. Status post cardiac arrest. DISCHARGE MEDICATIONS: 1. Dilantin 100 mg po t.i.d. 2. Diovan 80 mg po q.d. 3. Pravachol 10 mg po q.d. 4. Lopressor 125 mg po b.i.d. 5. Nephrocaps one capsule po t.i.d. 6. Klonopin 0.25 mg po q.h.s. 7. Enteric coated aspirin 325 mg po q.d. 8. Colace 100 mg po b.i.d. 9. Renagel two capsules po t.i.d. with meals. 10. Coumadin 2 mg po q.d. 11. NPH insulin 8 units subcutaneous q.a.m. and 7 units subcutaneous q.p.m. 12. Ultram 50 mg po t.i.d. 13. Protonix 40 mg po b.i.d. 14. Motrin 400 mg as needed. 15. Dulcolax 10 mg po pr q.d. prn. 16. Boost vanilla one can po t.i.d. [**Name6 (MD) 7853**] [**Last Name (NamePattern4) 7854**], M.D. [**MD Number(1) 7855**] Dictated By:[**Last Name (NamePattern4) 26426**] MEDQUIST36 D: [**2114-10-4**] 10:01 T: [**2114-10-4**] 11:07 JOB#: [**Job Number 26427**]

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icd9cm

[ [ [] ] ]

[ "87.61", "39.95" ]

icd9pcs

[ [ [] ] ]

17219, 17288

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25258, 26099

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50534

Discharge summary

report

Admission Date: [**2167-8-27**] Discharge Date: [**2167-8-29**] Date of Birth: [**2116-11-15**] Sex: F Service: MEDICINE Allergies: Clonidine Attending:[**First Name3 (LF) 2736**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: Cardiac Catherization History of Present Illness: Ms. [**Known lastname **] is 50 y/o F with Hx of CAD s/p MIx2 (most recently in [**2159**] in NC where she underwent cath but had no intervention with cath or CABG), hypertensive nephrosclerosis with ESRD on HD (T-Th-F) via left permacath and has a failed right radiocephalic AVF, HLD who presented to [**Hospital3 3583**] on [**8-24**] with c/o being more fatigue over the previous weekend. Then on the day of presentation she had a hot flash follwed by [**10-7**] midsternal, non-radiating chest pain at rest. She denied lightheadedness, nausea, vomiting or diaphoresis. She called EMS and was taken to [**Hospital3 3583**]. Vitals were 98.2, BP 224/130, HR 80, RR 18, 95%RA. She was given nitroglycerin 0.4SL and aspirin which reduced her CP to 0/10. Her initial EKG showed NSR with non-specific TWI in lead III and lateral precordial leads. Troponin 0.14 which peaked at 1.14 and CK-MB 1.1. She was loaded with Plavix 600mg and started on Heparin drip with bolus. She went to the Cath lab at OSH and was found to have 90% mid RCA stenosis, 60% OM3 stenosis and minimal LAD disease. During the procedure she recieved Fentanyl 100mcg and Versed 2mg due to agitation. Labs and imaging significant for peak trop 0.19, WBC 5.3, Hbg 10/32, Plt 249, IRN 0.88, Na 140, K 4.3, BUN 70, Cr 7.78. CXR at OSH was clear. She was then transferred to [**Hospital1 18**] cath lab for further management, where bare metal stents were implanted to the mid and distal RCA, and residual distal wire dissection distal to stent in PDA. Due to agitation the patient was given a total of Fentanyl 150mcg and Versed 3mg. Following the procedure the patient was nauseous and vomited and was given Zofran 8mg IV. Due to the amount of sedation that was required for cath she was brought to the CCU post-cath for closer monitoring. She also had some oozing from her femoral sheath post cath and has a femstop in place. On admission to the CCU, vital signs were 98.4 105/64 73 100%RA. The patient was quite sleepy and we had to rely on the medical record for most of the history. REVIEW OF SYSTEMS On review of systems, she endorses a 30lb wt loss, she denies any prior history of stroke, TIA, deep venous thrombosis, pulmonary embolism, bleeding at the time of surgery, myalgias, joint pains, cough, hemoptysis, black stools or red stools. S/he denies recent fevers, chills or rigors. S/he denies exertional buttock or calf pain. All of the other review of systems were negative. . Cardiac review of systems is notable for absence of chest pain, dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, ankle edema, palpitations, syncope or presyncope. Past Medical History: 1. CARDIAC RISK FACTORS: Dyslipidemia, Hypertension 2. CARDIAC HISTORY: -CABG: No -PERCUTANEOUS CORONARY INTERVENTIONS: No -PACING/ICD: No 3. OTHER PAST MEDICAL HISTORY: GERD Chronic back pain Partial Thyroidectomy C-section x 2 Social History: Lives in Onset, MA Smoked [**12-29**] pack per day since a teenager. No alcohol use. Family History: Mom with [**Name2 (NI) **] disease, Father with hx of cardiac disease Physical Exam: Admission Physical Exam: VS: T=98.4 BP=82/64 HR=73 RR=12 O2 sat=100% RA GENERAL: WDWN woman in NAD. Oriented x 0. Sleepy, minimaly responsive. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of [**5-3**] cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. 2/6 systolic ejection murmur of LSB. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right femoral with femoral cap after cath. Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Discharge Physical Exam: VS: T=98.4 BP=130/71 HR=76 RR=16 O2 sat=100% RA GENERAL: WDWN woman in NAD. Oriented x 3. Very flat affect. HEENT: Poor dentition. NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with JVP of [**5-3**] cm. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. 2/6 systolic ejection murmur of LSB. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. CTAB, no crackles, wheezes or rhonchi. ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: No c/c/e. No femoral bruits. Right lateral thigh swelling. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right femoral groin c/d/i. No femoral bruits auscultated. Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Pertinent Results: [**2167-8-27**] 07:24PM PT-14.0* PTT-49.1* INR(PT)-1.3* [**2167-8-27**] 07:24PM PLT COUNT-209 [**2167-8-27**] 07:24PM NEUTS-80.3* LYMPHS-16.1* MONOS-1.6* EOS-1.7 BASOS-0.2 [**2167-8-27**] 07:24PM WBC-5.2 RBC-2.83* HGB-8.8* HCT-27.6* MCV-97 MCH-31.1 MCHC-31.9 RDW-16.1* [**2167-8-27**] 07:24PM %HbA1c-5.3 eAG-105 [**2167-8-27**] 07:24PM CALCIUM-7.9* PHOSPHATE-5.1* MAGNESIUM-2.5 [**2167-8-27**] 07:24PM CK-MB-2 [**2167-8-27**] 07:24PM ALT(SGPT)-10 AST(SGOT)-15 LD(LDH)-149 CK(CPK)-49 ALK PHOS-85 TOT BILI-0.1 [**2167-8-27**] 07:24PM estGFR-Using this [**2167-8-27**] 07:24PM GLUCOSE-102* UREA N-34* CREAT-8.2*# SODIUM-127* POTASSIUM-4.9 CHLORIDE-93* TOTAL CO2-23 ANION GAP-16 . 2D-ECHOCARDIOGRAM (TTE): from OSH Mild concentric LVH, diastolic dysfunction, LVEF 55%. Small, insignificant pericardial effusion. 1+MR/1+TR. [**8-27**]: LHC The indications for the procedure were angina and 90% stenoses in the mid RCA and distal RCA s/p successful bare metal stent implantation to the mid and distal RCA. Residual distal wire dissection distal to stent in PDA. Brief Hospital Course: 50 y/o F with hx of CAD s/p MI x 2, HLD, ESRD on HD (T-Th-Sat) admitted to CCU post-cath for NSTEMI found to have 90% RCA occlusion s/p [**Month/Year (2) **]. . # NSTEMI: OSH transfer for management of NSTEMI in setting of very torturous coronaries, now s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **] 2 to RCA. In addition, there was a residual dissection of the distal PDA. She was loaded with Plavix 600mg IV and then continued on 75mg daily. It was recommended that she be on abciximab for 18hrs following the catheterization. However, the only IV access that the patient had was her Permacath. She refused insertion of a central line, therefore, abciximab was not given. We restarted her metoprolol at the home dose of 50 PO BID and captopril 25mg PO TID, which was switched to Lisinopril 20 mg PO daily prior to discharge. In addition, we continued simvastatin 40mg PO daily and Aspirin 81mg PO daily. She had some oozing from her right femoral groin after the cath and a femstop was placed and removed after hemostasis was achieved. On the day of discharge, she had a fluid collection over the right lateral thigh. An ultrasound was obtained which showed a superficial fluid collection more consistent with edema than with hematoma. In addition, there was no evidence of pseudo aneurysm formation around the femoral artery. Her HCT decreased from 26.7 to 24.9, however, the patient refused a blood transfusion prior to discharge. She was advised to have her HCT checked at her dialysis session on Tuesday. # HTN We restarted her metoprolol at the home dose of 50 PO BID and captopril 25mg PO TID. Her blood pressure was elevated to 170s systolic on day 1 following cath, but improved to 130s following dialysis. She was discharged home on her home dose of Metoprolol 50 PO BID and Lisinopril 20mg PO daily. #ESRD She presented to OSH on day of dialysis and subsequently missed dialysis on Thursday. However, while inpatient she received HD on Friday [**8-28**] and Saturday [**8-29**] prior to discharge. She will resume her normal dialysis on Tuesday [**9-1**] at [**Last Name (un) **] in [**Hospital1 1474**]. # GERD Her home dose continue omeprazole 20mg twice daily was continued while she was hospitalized. Discharge Issues: - patient needs follow-up with [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **], her NP at [**Hospital 38937**] Medical Group in [**Hospital1 1474**] (in the office of Dr. [**First Name4 (NamePattern1) 916**] [**Last Name (NamePattern1) 20478**]) - she also needs a follow-up appointment with Cardiology. Medications on Admission: Tylenol PRN Aspirin 81mg Tums Lisinopril 20mg daily Metoprolol 50mg PO BID Zocor 40mg daily Protonix 40mg daily Discharge Medications: 1. Aspirin EC 325 mg PO DAILY RX *aspirin 325 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 2. Clopidogrel 75 mg PO DAILY for the recommended duration RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 3. Lisinopril 20 mg PO DAILY Hold for SBP<100 RX *lisinopril 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 4. Metoprolol Succinate XL 100 mg PO DAILY hold for SBP <100, HR <60 RX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*0 5. Outpatient Lab Work Please have your Hemoglobin and Hematocrit levels checked on Tuesday during Dialysis. Discharge Disposition: Home Discharge Diagnosis: Final Diagnosis: Heart Attack (Non-ST Elevation Myocardial Infarction) Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert, but avoidant. Activity Status: Ambulatory - Independent. Discharge Instructions: Ms. [**Known lastname **] you were admitted to [**Hospital1 1170**] ([**Hospital1 18**]) after being transferred from [**Hospital3 3583**] where you were taken by ambulance after having chest pain at home. Upon arrival to [**Hospital1 18**] you were taken for a heart cathetherization where a catheter was passed through your groin and into your heart to investigate whether your chest pain was due to a heart blockage. The heart doctors (Cardiologists) found a blockage in an artery and was able to open it with 2 metal wire stents. These stents will help to keep your arteries open. However, in order to keep them from closing again it is very important that you take a medication that we started while you were in the hospital called Plavix. This medication needs to be take daily. You should follow-up with your primary care physician in one week. You should also follow-up with your cardiologist Dr. [**Last Name (STitle) 105236**] at [**Hospital3 417**] within one month. Followup Instructions: We would like you to follow up with your primary [**Doctor First Name 4540**] physician ([**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **]) in one week following discharge from the hospital. In addition, you should see a cardiologist in one month for followup of your recent chest pain symptoms. Since we are discharging you on a Saturday, we are unable to make appointments for you. However, we will make appointments for you on Tuesday and call you to give you these appointment times. Please make sure to resume your normal dialysis schedule (T-Th-Sat) next week.

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icd9cm

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icd9pcs

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Discharge summary

report

Admission Date: [**2161-5-1**] Discharge Date: [**2161-6-13**] Date of Birth: [**2099-9-5**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 495**] Chief Complaint: Shoulder pain Major Surgical or Invasive Procedure: Bronchoscopy Intubation Tracheostomy placement PEG Tube placement PICC placement History of Present Illness: History reviewed with nightfloat and confirmed with patient. . HPI: [**Known firstname **] [**Known lastname 9355**] is a 61 year old with ER+ breast cancer metastatic to bone and liver, most recently treated [**2161-4-14**] with 3rd cycle single-[**Doctor Last Name 360**] Doxil, currently on steroid taper after spine radiation, s/p fall at home last week, and referred to [**Hospital1 18**] ED by home care nurse with right shoulder pain, generalized weakness, and tachycardia. She is also being treated at home with iv antibiotics for GPC bacteremia. Patient reports falling and hearing a snap in her shoulder. She also reports hearing a snap in her shoulder 6 weeks ago after bowling as well. . She was referred to [**Hospital1 18**] ED yesterday by home care nurse [**First Name (Titles) **] [**Last Name (Titles) 9356**]a (HR 120s regular), right shoulder pain, and weakness. Shoulder was imaged on [**2161-4-30**] and showed fracture in distal and mid-clavicle. She also spiked fever 100.7 on [**2161-4-28**] and was started on antibiotics at home. Blood cultures from [**2161-4-30**] grew GPC in [**1-17**] bottles, urine cultures also positive for coag+ S. aureus. She also reports constipation with no bowel movement for four days and abdominal pain. She denies having headache, chest pain, cough, dysuria, skin rash. . On the evening on [**5-2**], she spiked fever to 102 through vanc and cefepime and her blood pressure trended down to 100s/60s, along with increased work of breathing. Transferred to ICU, where she was unarousable. ABG 7.42/43/83; received narcan 0.4mg, after which pt became verbal but delirious and moved all four extremities but then began salivating, with tachycardia and gooseflesh. Because of tachypnea with accessory muscle use and retractions, pt was intubated. Family did report that the evening prior to [**Hospital Unit Name 153**] transfer, pt complained of new low back pain. . ROS: denies fevers, chills, sweats, nausea, vomiting, diarrhea, difficulty urinating, denies shortness of breath, coughing Past Medical History: Onc Hx: Metastatic breast cancer involving the axial skeleton, right and left hip region, as well as sacrum, and bilateral ribs. She is currently off chemotherapy and has completed radiation treatment to the left hip and thoracic spine. - [**12/2156**]: Right-sided breast CA dxed on mammography at [**Hospital1 18**] in [**Location (un) **]. An ill-defined 2 cm x 2.5-cm mass was identified in the upper outer quadrant of the right breast. - [**1-/2157**]: Ultrasound-guided biopsy demonstrated infiltrating ductal carcinoma. - [**1-19**]: wide excision surgery with sentinel lymph node sampling pathology demonstrating 2-cm grade II infiltrating ductal carcinoma of the right breast with clean surgical margins and lymphatic vascular invasion noted. One sentinel lymph node showed no evidence of metastatic cancer. Tumor was noted to be ER/PR positive, HER-2/neu negative. -Status post 4 cycles of AC combined with radiotherapy. - [**8-/2157**], she was maintained on Arimidex until [**6-/2159**] when she developed right hip pain; imaging with plain films and bone scan confirmed metastatic disease involving her right acetabulum, left fourth and fifth ribs. - [**6-/2159**]: patient initiated on tamoxifen & monthly Zometa. - [**6-21**]: Palliative XRT to R hip. - [**1-22**] Xeloda, [**Date range (1) 9357**]: Taxol/Avastin, [**Date range (1) 9358**] 3 cycles Gemzar. - [**1-23**]: Palliative XRT to Thoracic spine for back pain and L hip. - [**2161-2-17**]: C1 Doxil . - Hyperlipidemia - hypertension - hiatus hernia - diverticulosis with several episodes of diverticulitis. - [**2159**] Cellulitis involving abdominal pannus s/p multiple antibiotic courses. Social History: Patient denies smoking, drinking, IV drug use. She used to work for [**Hospital1 **] in [**Location (un) **] but is currently on short term disability. She lives in [**Location 1468**] with her husband. She has two children who live close by. Family History: Father had [**Name2 (NI) 499**] CA. Grandfather prostate CA. Uncle [**Name (NI) **] CA Physical Exam: On Admission: PE VS T 98.0 98.4 116/88 109 20 96%2L gen awake, alert, pain [**2-23**] neck no bruits cv nl s1s2 tachycardic pulm: crackles bilaterally gi +bs abd soft ext swelling over right shoulder, trace edema skin warm, dry neuro equal grip r/l, [**4-20**] le motor strength . Exam in ICU prior to discharge: General: Well nourished, anxious HEENT: tracheomstomy in place s/p suture removal, PERRL, EOMI, anicteric CV: Regular rhythm, nl s1 s2, no m/r/g Lungs: Clear anteriorly Abd: soft, PEG in place, healing well. NT, ND. +BS Ext: trace edema bilaterally. LE warm Pertinent Results: RESPIRATORY CULTURE (Final [**2161-6-10**]): SPARSE GROWTH OROPHARYNGEAL FLORA. ACINETOBACTER BAUMANNII COMPLEX. SPARSE GROWTH. Sensitive to Ceftriaxone. CMV Viral Load (Final [**2161-6-12**]): 2,050 copies/ml. Performed by PCR. Detection Range: 600 - 100,000 copies [**6-7**] Blood and fungal cultures: No growth to date. [**2161-4-30**] 04:50PM BLOOD WBC-1.5*# RBC-4.28 Hgb-11.1* Hct-34.8* MCV-81* MCH-26.0* MCHC-32.0 RDW-23.6* Plt Ct-105*# [**2161-5-2**] 08:35AM BLOOD WBC-1.6* RBC-3.69* Hgb-9.9* Hct-30.4* MCV-83 MCH-27.0 MCHC-32.7 RDW-25.5* Plt Ct-126* [**2161-5-3**] 06:38AM BLOOD WBC-1.3* RBC-2.94* Hgb-7.9* Hct-24.2* MCV-82 MCH-26.8* MCHC-32.5 RDW-24.2* Plt Ct-130* [**2161-5-12**] 04:14AM BLOOD WBC-3.1* RBC-2.52* Hgb-7.2* Hct-21.1* MCV-84 MCH-28.5 MCHC-34.0 RDW-23.3* Plt Ct-120* Imaging: [**6-11**] CXR: Diffuse airspace disease, unchanged from prior exam. . [**5-21**] RUE US: o evidence of DVT in the right upper extremity. . [**2161-5-7**] CTA Chest TECHNIQUE: CT of the chest was performed without intravenous contrast followed by CT of the chest post-administration of intravenous contrast, reconstructions were performed in the axial, sagittal and coronal planes. COMPARISON: With CT of [**2160-5-20**]. FINDINGS: There is dense consolidation and multifocal ground-glass opacities present throughout both lungs. This development dramatic since the last examination, and involves right lung more than the left. There are several enlarged mediastinal lymph nodes with the largest measuring 15 x 9 mm in a pretracheal location. There are small bibasal effusions. There is no pericardial effusion. There is no central or segmental pulmonary embolism; however, given the extensive consolidation and atelectasis at the lung bases, it is technically difficult to exclude subsegmental distal pulmonary emboli. The NG tube is in the stomach. The endotracheal tube is 2 cm from the carina. The cuff of the endotracheal tube may be overinflated. MUSCULOSKELETAL: There are multiple bilateral rib fractures. There are multilevel degenerative changes present in the spine along with multiple lucent sclerotic lesions suggestive of diffuse metastatic disease. There is also a fracture through the right clavicle. CONCLUSION: 1. Diffuse patchy opacities as well as scattered ground-glass opacities suggestive of infective change in both lungs. There may be an element of superimposed pulmonary edema. 2. The cuff of the ET tube is slightly over-inflated and the tip of the ET tube is 2 cm from the carina. 3. Interval progression of the metastatic disease as suggested by bilateral rib fractures, fracture of the right clavicle and lytic sclerotic lesions in the axial and appendicular skeleton. [**2161-5-5**] TTE: Conclusions The left atrium is normal in size. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%) Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. No masses or vegetations are seen on the aortic valve. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. No masses or vegetations are seen on the mitral valve, but cannot be fully excluded due to suboptimal image quality. Mild (1+) mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2160-10-14**], the images are suboptimal. The severity of mitral regurgitation has increased slightly. No vegetations identified. If clinically suggested, the absence of a vegetation by 2D echocardiography does not exclude endocarditis. RADIOLOGY Final Report [**5-4**] MR [**Name13 (STitle) 6452**] W & W/O CONTRAST Reason: rule out epidural abscess MRI OF THE LUMBAR SPINE WITHOUT AND WITH GADOLINIUM. HISTORY: Known metastatic breast CA with Staph aureus bacteremia and new low back pain, rule out osteomyelitis or epidural abscess. Re-demonstrated is extensive osseous metastasis throughout the lumbar spine and sacrum with compression deformities of L5, T12, T11 and T10. There is mild epidural disease at T12 which is slightly increased compared to the prior study. No cord compression is identified. Small amount of stable epidural disease is also suggested at L4-L5 particularly in the lateral recesses which is unchanged, with extension to the foramina. There is no loss of discs height to suggest discitis. There is no evidence for epidural abscess. IMPRESSION: Stable diffuse osseous metastatic disease with compression fractures at multiple levels. No evidence for osteomyelitis or epidural abscess [**5-4**] MR HEAD W & W/O CONTRAST MR HEAD: Multiple calvarial metastatic lesions are redemonstrated. However, no evidence of dural or brain metastasis is seen. There is no evidence of acute intracranial hemorrhage, edema, mass, mass effect, or acute infarction. A small amount of mucosal thickening is noted in the right sphenoid sinus; otherwise the visualized paranasal sinuses and the mastoid air cells appear clear. Normal vascular flow voids are identified. The orbits appear unremarkable. Diffuse heterogeneous appearance of the upper cervical spine and the clivus is likely due to metastatic disease also. IMPRESSION: 1. Multiple calvarial metastases. Likely also involvement of the upper cervical spine and clivus. No evidence of brain or dural metastasis. 2. Mucosal thickening in the right sphenoid sinus may be related to chronic sinus disease. [**4-30**] CTA CHEST W&W/O C&RECONS CTA CHEST: Again noted is widespread skeletal metastatic disease with multiple compression fractures through the spine and multiple rib fractures bilaterally at various stages of healing, with resultant deformity of the chest wall. Note is also made of a new right midshaft clavicular fracture. The current study is limited by patient respiratory motion; however, no central or large segmental pulmonary embolus is seen. The central airways are patent. Lung volumes are decreased and there is likely mild fluid overload, without overt pulmonary edema or pleural effusion. Regions of atelectasis/scarring are again noted. Atherosclerotic calcifications are noted along the aortic arch and in the coronary arteries. The heart size remains in the upper limits of normal. There is no evidence of mediastinal, hilar or axillary lymphadenopathy. A 1.8 x 1.1 cm soft tissue density in the right breast is spiculated in appearance and presumably relates to known breast cancer; the left breast is excluded on the current exam. While the current exam is not designed for a subdiaphragmatic diagnosis, note is again made of hypodensities in the liver, which would be consistent with metastatic disease. IMPRESSION: 1. No evidence of central or large segmental pulmonary embolism; study limited by respiratory motion. 2. Low lung volumes, atelectasis/scarring, and probable mild fluid overload. 3. Widespread metastatic disease to skeleton and to liver as previously seen. Suspicious soft tissue lesion in the right breast also noted and presumably related to known breast cancer. 4. New right clavicular fracture. Multiple compression fractures in the spine and multiple rib fractures again noted. [**4-30**] HUMERUS (AP & LAT) RIGHT SIX VIEWS OF THE RIGHT SHOULDER: There is an acute fracture of the mid clavicle with the distal fragment overriding superiorly approximately 1 cm. An old distal clavicle fracture contains moderate surrounding callus. No additional fractures are visualized. Multiple variable aged right rib fractures are noted. IMPRESSION: 1. New mid right clavicle fracture. 2. Old distal right clavicle fracture. Labs on day of discharge: WBC 5.4, Hct 21.3, Plt 152. Neutrophils 81%, 0 bands. Na 144, K 2.5, Cl 101, HCO3 37, BUN 15, Cr 0.2, glucose 111 Brief Hospital Course: Patient was admitted to the ICU for management of altered mental status/respiratory distress: . #Respiratory: Patient was intubated on arrival to the icu for airway protection. In that setting, however, over the next several days she became increasinly hypoxic and spiked low grade fevers. Sputum cultures at that time grew PCP and patient was started on IV bactrim. She was initially continued on her home dose of dexamethasone [**3-18**] as well. In this setting her respiratory status progressed to frank ARDS. Her steroid dose was increased to solumedrol 20mg every 8 hours. She continued to spike fevers and was covered with vancomycin/ceftazadime for possible VAP. Broncheoalveolar lavage was performed when patient developed bloody airway secretions given concern for possible DAH, but showed only a tracheal erosion thought [**1-17**] to her endotracheal tube. CT scan of the chest for persistent tachycardia and respiratory distress showed no evidence of PE, but demonstrated diffuse ground glass opacities consistent with PCP. [**Name10 (NameIs) **] PCP was thought to be unresponsive to therapy due to a concomitant CMV viremia found several days into her hospitalization. The patient was initially started on gancicylovir for CMV therapy though she developed profound marrow suppression requiring change in therapy to foscarnet. Due to electrolyte wasting associated with foscarnet, the patient required large potassium, phosphate and magnesium repletion daily. Her CMV viral load trended downward and her PCP pneumonia is thought to have responded to therapy. Fungal studies on the sputum were negative. Patient was persistently vent dependent with high FIO2 and PEEP requirements. Therefore, she went for tracheostomy. Attempts were made to diurese the patient to treat a possible component of volume overload though this was limited due to relative hypotension. The patient has signs of persistent diffuse patchy infiltrates on CXR concerning also for fibroproliferative ARDS. The patient completed therapy for PCP and continues on foscarnet therapy for CMV viremia. When the CMV viral load reaches zero, the foscarnet dosing can be reduced to 3000mg for a total of 21 days. . # Altered Mental Status: Thought [**1-17**] to opiate intoxication as improved with narcan. CT/MRI of the brain showed no evidence of metastases other than to the calvarium. Her mental status improved and she remained alert, following commands, and lucid for most of the remainder of her ICU stay. Patient did subsequently several days later complain of visual hallucinations attributed to an ICU delerium due to prolonged hospitalization, high dose steroids, low grade fevers, and opiate/benzo use. These symptoms improved. At times she has difficulty following commands. However, the patient is fairly alert upon imminent discharge from ICU, responding to commands. #CMV viremia: Patient found to have unexplained fevers early in course, so was started on Gancyclovir for a presumed CMV infection. Despite this treatment, patient was found to have over 100,000 copies/ml of CMV in blood on [**5-17**]. She developed marrow suppression thought due to gancyclovir. She was switched to Foscarnet therapy. With this treatment CMV viral load steadily dropped - last check was 2050 copies/ml. CMV later found to be sensitive to Gancyclovir, suggesting initial CMV blood test insensitive to effect of Gancyclovir on count (due to presumably very high initial CMV copies in blood). She also received Cytogam per ID recommendations. Foscarnet causes significant electrolyte wasting in this patient and she has very high daily electrolyte repletion requirements. The patient will complete 21 days of additional foscarnet therapy at a reduced dose of 3000mg (reduced from 6000mg) when CMV viral load is zero. . #MSSA Bacteremia: Patient had blood cultures + for MSSA. TTE demonstrated no evidence of valvular lesions. She had no indwelling lines, and imaging of her lumbosacral spine showed no evidence of underlying osteomyelitis. A TEE was attempted but due to significant kyphosis the probe could not be advance beyond the proximal esophagus. The decision was made to treat the patient empirically with a course of IV nafcillin for her MSSA. PICC line was placed. Patient continued to spike through nafcillin. Therefore her coverage was switched to vancomycin. PICC line was removed, and after over 3 weeks on vancomycin and 48 hours without spiking, patient was removed from Vanc. . # Fever: Patient developed a fever on [**6-7**] with unclear source. Originally question whether it was related to Cytogam infusion, however later felt more likely due to infection. Sources included possible PICC vs PNA (no change in CXR) vs UTI. PICC was pulled and patient was started on Cefepime for empiric coverage. She defervesced and culture data was only notable for sputum culture positive for Acinetobacter Baumannii sensitive to Cefepime. Decision was to treat with Cefepime for 14 day course. After 48hrs of no blood culture growth, PICC was replaced. . # Pain: [**1-17**] to bony metastases and clavicular fracture. Patient was continued on fentanyl patch, fentanyl gtt, and PRN bolus fentanyl while intubated. . # Tachycardia: Patient tachycardic during her ICU stay. CTA negative for PE. Thought [**1-17**] to pain, fever, agitation. Patient's tachycardia improved over her ICU course to a range of HR 80-90s. . # Breast Cancer: Followed by Dr. [**First Name8 (NamePattern2) 553**] [**Last Name (NamePattern1) **] as an outpatient. . # Clavicular Fracture: Orthopedics recommended sling and pain control PRN. Pain was controlled as above with addition of lidocaine patch to her clavicle with some relief. . # Nutrition: The patient had a PEG tube placed during hospitalization. Tube feeds detailed in the discharge planning. . # Sacral Wound: Initially with several small open sacral lesions approximatley 1-2 cm in diamteter at greatest with one expressing a small amount of pus. Patient was covered with IV antibiotics as above to treat MSSA bacteremia, VAP, and PCP. [**Name10 (NameIs) 9359**] of the lumbosarcal spine showed no evidence of osteomyelitis. . # Code status. Code status was adressed with the patient and her husband. She is DNR, currently ventilated. Medications on Admission: fentanyl patch, lidocaine patch, gabapentin 100am 300 hs, senna one tab [**Hospital1 **] c olace 100 mg [**Hospital1 **], ativan 0.5-1 mg hs, decadron 2mg am 2 mg hs [**2072-4-29**], 2 mg am [**2076-5-3**], discontinue [**5-9**] asa 81 , oxygen 1 liter hs dilaudid 2 mg 1-2 tabs q3-4. robitussin Discharge Medications: 1. Lidocaine HCl 5 % Ointment Sig: One (1) Appl Topical DAILY (Daily). 2. Guaifenesin 100 mg/5 mL Syrup Sig: Five (5) ML PO Q4H (every 4 hours) as needed for cough. 3. Fentanyl 75 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 4. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day) as needed for constipation. 5. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 7. CefePIME 1 g IV Q12H Day 1: [**2161-6-7**]. To complete 14 day course. 8. Foscarnet 24 mg/mL Solution Sig: 6000 (6000) mg Intravenous Q12H (every 12 hours). 9. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 11. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-17**] Drops Ophthalmic PRN (as needed). 12. Enoxaparin 30 mg/0.3 mL Syringe Sig: One (1) inj Subcutaneous Q12H (every 12 hours). 13. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever/pain. 14. Docusate Sodium 50 mg/5 mL Liquid Sig: Five (5) mL PO BID (2 times a day). 15. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb neb Inhalation Q6H (every 6 hours) as needed. 16. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). 17. Oxycodone 5 mg/5 mL Solution Sig: Five (5) mL PO Q4H (every 4 hours) as needed. 18. Chlorhexidine Gluconate 0.12 % Mouthwash Sig: Fifteen (15) ML Mucous membrane [**Hospital1 **] (2 times a day). 19. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a day). 20. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 21. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 22. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q6H (every 6 hours) as needed. 23. Albuterol 90 mcg/Actuation Aerosol Sig: Four (4) Puff Inhalation Q4H (every 4 hours) as needed. 24. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical Q24 (). 25. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Four (4) Tablet Sustained Release PO three times a day: Please re-evaluate potassium repletion requirements with any change in foscarnet dosing. Monitor daily potassium levels. 26. Neutra-Phos [**Telephone/Fax (3) 4228**] mg Powder in Packet Sig: One (1) PO three times a day. 27. Magnesium Sulfate 4 % Solution Sig: As necessary Injection PRN (as needed): As necessary according to daily magnesium levels. 28. Fentanyl Citrate (PF) 50 mcg/mL Solution Sig: 25-50 mcg Injection Q1H (every hour) as needed. 29. Insulin Regular Human 100 unit/mL Solution Sig: Per sliding scale. Injection ASDIR (AS DIRECTED). 30. PICC line flush Discharge Disposition: Extended Care Facility: [**Hospital1 **] Discharge Diagnosis: Primary Diagnosis: Respiratory failure Secondary Diagnoses - Breast cancer with metastases - Chronic pain secondary to bony mets - CMV viremia - Anemia - Hypokalemia - Hypophosphatemia - Hypernatremia - Anxiety/depression Discharge Condition: Hemodynamically stable. Tracheostomy with chronic mechanical ventilation. Discharge Instructions: Chronic respiratory failure - Mrs. [**Known lastname 9355**] has a tracheostomy and is on chronic ventilatory support. Her vent settings are assist control Vt 500, RR 20, PEEP 8, FiO2 50%. She has had occasional events of respiratory distress while on these vent settings that are likely due to anxiety, somewhat improved with increased sedation. PEG tube - Has PEG for tube feedings. Has been receiving Beneprotein at 30 ml/hour. Check residuals Q4H, holding for >100ml and flushing with 300 ml Q4H. Infectious Disease - Currently on cefepime 1 gram q12 hours (Start day [**2161-6-7**]). Stop date is [**2161-6-21**] to complete course of 14 days. Also on foscarnet 6000 mg IV Q12H with 100cc infusion of D5NS infusion prior to administration. Will need to check CMV viral load on [**2161-6-18**] and serially every 7 days if not at zero. Once CMV viral load is 0, reduce foscarnet to 3000 mg for 21 days. Electrolytes - Mrs. [**Known lastname 9355**] has required daily electrolyte replacement secondary to electrolyte wasting with foscarnet. Please check electrolytes daily. She will need potassium 40 meq po three times daily, neutra-phos 1 packet three times daily, free water flushes for hypernatremia, and magnesium sulfate repletion as necessary. PLEASE NOTE, once foscarnet is reduced, her electrolyte repletion will need to be changed (ie requirements may lessen), please consult with MD. Hypotension - Patient has been intermitently hypotensive at night. Her BP can be as low as 70-80's/40's. It is unclear what causes this though the patient appears asymptomatic with intact mentation and preserved urine output. When awakened her blood pressure typically returns to a baseline of systolic 90s-100s. She should not return to the hospital for hypotension at night unless there are significant associated complications that raise concern for an unstable process. Followup Instructions: Follow up as determined by rehab facility.

[ "401.9", "995.92", "327.23", "562.10", "599.0", "V10.3", "198.5", "V58.65", "279.00", "V15.3", "338.3", "288.04", "733.13", "276.9", "733.19", "733.90", "136.3", "518.81", "078.5", "197.7", "038.11" ]

icd9cm

[ [ [] ] ]

[ "43.11", "33.24", "96.6", "38.93", "31.1", "99.14", "96.04", "96.72" ]

icd9pcs

[ [ [] ] ]

22667, 22710

13124, 15337

334, 417

22977, 23054

5157, 13101

24990, 25036

4458, 4547

19763, 22644

22731, 22731

19442, 19740

23078, 24967

4562, 4562

281, 296

445, 2491

22750, 22956

4576, 5138

15352, 19416

2513, 4181

4197, 4442

76,853

116,498

4771

Discharge summary

report

Admission Date: [**2112-11-14**] Discharge Date: [**2112-11-23**] Date of Birth: [**2062-6-15**] Sex: M Service: CARDIOTHORACIC Allergies: Ibuprofen Attending:[**First Name3 (LF) 165**] Chief Complaint: Angina Major Surgical or Invasive Procedure: [**2112-11-17**] Left heart catheterization, coronary angiogram [**2112-11-18**] Off-pump coronary artery bypass graft x 2(LIMA-LAD,SVG-DG) History of Present Illness: 50 yo man 2 weeks s/p BMS stent placement to OM2 on [**2112-10-28**] for NSTEMI at [**Hospital1 2025**] (admitted [**Date range (3) 20020**]) now here with left chest pain radiating to left jaw, left eye, with associated with sweatiness and SOB.H as been taking his plavix and all his meds. Positive stress at [**Hospital1 18**] on [**2112-11-15**]. Cardiac enzymes negative, no EKG changes per report. CP free with morphine. Per report patient refused CABG at [**Hospital1 2025**] choosing medical management. Patient now amendable to surgical revascularization. Past Medical History: Coronary artery disease s/p coronary stent (BMS to OM2 [**2112-10-28**]) Hypertension Diabetes Mellitus Type 2 (insulin 72/25) poor control due to non compliance Polysubstance abuse Myocardial Infartcion [**10-24**] Hypercholesterolemia Multiple hospital admissions for ileus Gastroesophageal Reflux Disease Rt shoulder SLAP tear s/p steroid injection Rib fracture pancreatitis secondary to ETOH abuse MRSA bacteremia/PNA C4/5 fusion rotator cuff surgery Social History: Reports that he lives in [**Hospital1 8**] in a shelter. Is single and has no children. Smokes 0.5-1ppd X 40+ yrs. Denies current alcohol use - reports he has not had anything to drink in 5 months, admits to crack use 5 months ago. Denies IVDU. Of note, patient uses different names in hospitals around [**Location (un) 86**] and has a history of leaving AMA. Family History: non-contributory Physical Exam: Pulse:74 reg Resp: 18 O2 sat:96% RA B/P: 98.3 Height: Weight:195lbs General: comfortable Skin: Dry [x] intact [x] HEENT: PERRLA [] EOMI [x] Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur - Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [] Extremities: Warm [x], well-perfused [x] Edema Varicosities: None [x] Neuro: Grossly intact. R handed, moves 4 ext. follows commands Pulses: Femoral Right:palp Left:palp DP Right:palp Left:palp PT [**Name (NI) 167**]: Left: Radial Right:palp Left:palp Carotid Bruit Right: - Left: - Pertinent Results: [**2112-11-17**] Cardiac Cath: 1. Selective coronary angiography of this right-dominant system revealed two-vessel coronary artery disease. The LMCA had no significant stenoses. The LAD had a 50-70% stenosis after D1, which itself had a 70% mid-vessel stenosis. The distal LAD tapers and had an 80% stenosis. The LCX had a widely patent prior stent in a large OM2. The RCA had severe diffuse proximal and mid-vessel disease up to its bifurcation. The RPL and RPDA branches were small and without significant stenoses, with distal filling via LAD collaterals. 2. Limited resting hemodynamics demonstrated normal central aortic pressures. [**2112-11-18**] Echo: Off Pump CABG:1. The left atrium is mildly dilated. The left atrial appendage emptying velocity is depressed (<0.2m/s). No thrombus is seen in the left atrial appendage. 2. No atrial septal defect is seen by 2D or color Doppler. 3. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. 4. Right ventricular chamber size is normal. 5. There are simple atheroma in the descending thoracic aorta. 6. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened (?#). There is no aortic valve stenosis. No aortic regurgitation is seen. 7. The mitral valve appears structurally normal with trivial mitral regurgitation. 8. There is no pericardial effusion. The LV systolic function was preserved at the end of the case. [**2112-11-14**] 11:00AM BLOOD WBC-6.1 RBC-3.67* Hgb-11.1* Hct-34.9* MCV-95 MCH-30.3 MCHC-31.8 RDW-15.5 Plt Ct-428 [**2112-11-17**] 05:10PM BLOOD WBC-6.0 RBC-2.96* Hgb-9.6* Hct-28.3* MCV-96 MCH-32.3* MCHC-33.8 RDW-15.3 Plt Ct-293 [**2112-11-23**] 05:00AM BLOOD WBC-6.3 RBC-2.68* Hgb-8.4* Hct-25.6* MCV-95 MCH-31.3 MCHC-32.8 RDW-15.5 Plt Ct-271 [**2112-11-14**] 11:00AM BLOOD PT-12.1 PTT-25.8 INR(PT)-1.0 [**2112-11-18**] 11:46AM BLOOD PT-13.0 PTT-34.3 INR(PT)-1.1 [**2112-11-14**] 11:00AM BLOOD Glucose-95 UreaN-28* Creat-2.0* Na-140 K-5.8* Cl-105 HCO3-27 AnGap-14 [**2112-11-17**] 07:15AM BLOOD Glucose-198* UreaN-18 Creat-1.3* Na-140 K-5.1 Cl-105 HCO3-27 AnGap-13 [**2112-11-21**] 06:40AM BLOOD Glucose-190* UreaN-27* Creat-1.6* Na-141 K-4.6 Cl-105 HCO3-25 AnGap-16 [**2112-11-20**] 01:00PM BLOOD ALT-13 AST-27 LD(LDH)-277* AlkPhos-78 Amylase-20 TotBili-0.4 [**2112-11-15**] 07:20AM BLOOD Calcium-8.7 Phos-4.2 Mg-2.0 Brief Hospital Course: Following admission he ruled out for acute infarction. Cardiac cath on [**11-17**] showed severe left anterior descending coronary disease. Having previously refused surgical intervention elsewhere, he now consented to surgery. On [**11-18**] he went to the operating Room where an off pump bypass was performed. See operative note for details. He tolerated the procedure well and was transferred to the CVICU for invasive monitoring in stable condition. Plavix was administered as he was done off pump. Within 24 hours he was weaned from sedation, awoke neurologically intact and extubated. On post-op day one he was transferred to the telemetry floor. He was admonished to the necessity of taking medications as prescribed, smoking cessation and compliance with glucose control. Beta blockade was resumed and diuresis begun. Chest tubes were removed on the first day after surgery. Physical Therapy was consulted for mobility and strength. Insulin was begun, both fixed dose and sliding scale, as this had previously been his regimen when compliant. He was evaluated by the pain service regarding his pain medication regimen due to his history polysubstance abuse. The remainder of his post-op course was uneventful and on post-op day four he appeared suitable for discharge to rehab with the appropriate medications and follow-up appointments. Medications on Admission: Outside: Plavix 75mg daily Medications in hospital: as of [**2112-11-15**] Metoprolol XL 100mg in am 50mg HS Ranolazine 500mg [**Hospital1 **] Insulin SSR Gabapentin 300mg three times a day Tramadol 50mg po q6hr ; prn NTG 0.3mg SL PRN Ranitidine 150mg po BID aimtriptyline 100mg po at night ASA 325mg po daily Plavix 75 mg daily Discharge Medications: 1. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. 3. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 4. Outpatient Lab Work Please go to lab to have labs drawn on Friday [**2112-11-18**] (Chem 7). Results should be faxed to your primary care physician, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1887**] at [**Telephone/Fax (1) 6309**]. 5. Amitriptyline 50 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). Disp:*60 Tablet(s)* Refills:*2* 6. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). Disp:*240 Tablet(s)* Refills:*2* 7. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*120 Tablet(s)* Refills:*1* 9. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). Disp:*90 Capsule(s)* Refills:*2* 10. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 11. humalog insulin 75/25 18 units every morning subcutaneously 20 units every evening subcutaneously Dispense 2 vials and 2 refills 12. humalog insulin dose according to sliding scale finger sticks dispense 2 vials with 2 refills 13. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:*15 Patch 24 hr(s)* Refills:*2* 14. Oxycodone 5 mg Tablet Sig: 2-4 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*90 Tablet(s)* Refills:*0* 15. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 16. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). Discharge Disposition: Extended Care Facility: [**Hospital6 2222**] - [**Location (un) 538**] Discharge Diagnosis: Coronary artery disease s/p off pump coronary artery bypass x 2 Past medical history s/p coronary stent (BMS to OM2 [**2112-10-28**]) Hypertension Diabetes Mellitus Type 2 (insulin 72/25) poor control due to non compliance Polysubstance abuse Myocardial Infartcion [**10-24**] Hypercholesterolemia Multiple hospital admissions for ileus Gastroesophageal Reflux Disease Rt shoulder SLAP tear s/p steroid injection Rib fracture pancreatitis secondary to ETOH abuse MRSA bacteremia/PNA C4/5 fusion rotator cuff surgery Discharge Condition: Ambulatory, normal mental staus. Wounds healing well. Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month until follow up with surgeon No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] Followup Instructions: Dr. [**First Name (STitle) **] in 4 weeks ([**Telephone/Fax (1) 170**]) [**Hospital Ward Name 121**] 6 wound clinic ([**Telephone/Fax (1) 20021**] [**First Name (Titles) **] [**Last Name (Titles) **] Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 13959**] in [**12-18**] weeks ([**Telephone/Fax (1) 250**]) Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]- [**Company 191**] Post [**Hospital **] Clinic Date/ Time: [**2112-11-29**] 1:10pm Location: [**Location (un) 830**] [**Hospital Ward Name 23**] Building [**Location (un) 895**] Central Suite, [**Location (un) 86**] Phone number: [**Telephone/Fax (1) 250**] [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2112-11-23**]

[ "V45.82", "584.5", "V45.4", "V58.67", "250.60", "V15.81", "491.20", "530.81", "571.2", "357.2", "411.1", "250.80", "305.03", "305.63", "305.90", "414.01", "276.7", "285.9", "338.29", "410.72" ]

icd9cm

[ [ [] ] ]

[ "37.22", "88.56", "36.15", "39.63", "36.11", "88.72", "39.64" ]

icd9pcs

[ [ [] ] ]

8606, 8679

4986, 6339

284, 425

9238, 9293

2598, 4963

9833, 10611

1891, 1909

6719, 8583

8700, 9217

6365, 6696

9317, 9810

1924, 2579

238, 246

453, 1020

1042, 1498

1514, 1875

28,827

147,825

22001

Discharge summary

report

Admission Date: [**2164-9-30**] Discharge Date: [**2164-10-9**] Date of Birth: [**2105-10-10**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 15249**] Chief Complaint: Black emesis, melena, and lethargy Major Surgical or Invasive Procedure: Upper endoscopy with biopsy History of Present Illness: This is a 58 y/o M with AIDS and Hep C who presented with black vomitus, melena, and lethargy, was found to have hemorrhagic shock from suspected upper GI bleed, and was intubated for airway protection. Currenlty he denies fevers, chills, SOB, chest pain, headache, dysuria. He is having a non productive cough, some black stools, and some mild abdominal pain in addition to his chronic back pain. His appetite is good but has early satiety. He reports a 40 lb weight loss. Past Medical History: Hep C HIV HTN Substance abuse (IVDU, EtOH, cocaine/heroin) Diverticulitis s/p resection '[**50**] and temporary colostomy reversed in '[**51**]. Hypoplastic Kidney Social History: Former IV heroin/cocaine user in remote hx. + Tobacco, denies alcohol abuse. Lives with partner Family History: Unknown Physical Exam: PE AVSS NAD, sitting upright, speaking in complete sentences HEENT: significant wasting. Cor: RRR, nl s1, s2, heart sounds distant lung: CTAB, no wheezes, rales, rhonchi abdomen: S/NT/ND ext: No C/C/E Pertinent Results: [**2164-9-30**] 08:18PM URINE HOURS-RANDOM UREA N-304 CREAT-162 SODIUM-10 [**2164-9-30**] 08:18PM URINE COLOR-Amber APPEAR-Clear SP [**Last Name (un) 155**]-1.030 [**2164-9-30**] 08:18PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR GLUCOSE-NEG KETONE-NEG BILIRUBIN-MOD UROBILNGN-NEG PH-6.5 LEUK-TR [**2164-9-30**] 08:18PM URINE RBC-0-2 WBC-[**3-19**] BACTERIA-MOD YEAST-NONE EPI-0-2 [**2164-9-30**] 08:18PM URINE HYALINE-0-2 [**2164-9-30**] 08:18PM URINE AMORPH-FEW [**2164-9-30**] 08:18PM URINE EOS-NEGATIVE [**2164-9-30**] 08:17PM GLUCOSE-155* UREA N-46* CREAT-2.3* SODIUM-138 POTASSIUM-4.6 CHLORIDE-97 TOTAL CO2-31 ANION GAP-15 [**2164-9-30**] 08:17PM ALT(SGPT)-20 AST(SGOT)-33 LD(LDH)-327* ALK PHOS-111 TOT BILI-0.8 [**2164-9-30**] 08:17PM CALCIUM-7.9* PHOSPHATE-4.8* MAGNESIUM-2.0 [**2164-9-30**] 08:17PM CORTISOL-33.5* [**2164-9-30**] 08:17PM WBC-24.3* RBC-4.42*# HGB-13.1*# HCT-39.0*# MCV-88 MCH-29.6 MCHC-33.6 RDW-15.5 [**2164-9-30**] 08:17PM NEUTS-86.4* LYMPHS-11.0* MONOS-2.4 EOS-0.1 BASOS-0.1 [**2164-9-30**] 08:17PM PLT COUNT-365 [**2164-9-30**] 08:17PM PT-15.7* PTT-31.8 INR(PT)-1.4* [**2164-9-30**] 08:17PM FIBRINOGE-351 [**2164-9-30**] 03:52PM K+-5.2 [**2164-9-30**] 03:52PM HGB-8.0* calcHCT-24 [**2164-9-30**] 03:35PM GLUCOSE-144* UREA N-48* CREAT-2.5*# SODIUM-135 POTASSIUM-5.6* CHLORIDE-91* TOTAL CO2-31 ANION GAP-19 [**2164-9-30**] 03:35PM estGFR-Using this [**2164-9-30**] 03:35PM ALT(SGPT)-20 AST(SGOT)-40 LD(LDH)-410* CK(CPK)-318* ALK PHOS-125* AMYLASE-39 TOT BILI-0.4 [**2164-9-30**] 03:35PM LIPASE-41 [**2164-9-30**] 03:35PM cTropnT-0.04* [**2164-9-30**] 03:35PM CK-MB-14* MB INDX-4.4 [**2164-9-30**] 03:35PM ALBUMIN-2.3* CALCIUM-8.9 PHOSPHATE-5.0*# MAGNESIUM-2.2 [**2164-9-30**] 03:35PM ACETONE-NEGATIVE [**2164-9-30**] 03:35PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2164-9-30**] 03:35PM WBC-37.0*# RBC-2.81* HGB-7.8* HCT-25.4* MCV-90 MCH-27.6 MCHC-30.6* RDW-16.6* [**2164-9-30**] 03:35PM NEUTS-89* BANDS-0 LYMPHS-6* MONOS-4 EOS-0 BASOS-0 ATYPS-0 METAS-1* MYELOS-0 [**2164-9-30**] 03:35PM HYPOCHROM-2+ ANISOCYT-1+ POIKILOCY-OCCASIONAL MACROCYT-1+ MICROCYT-1+ POLYCHROM-2+ OVALOCYT-OCCASIONAL SCHISTOCY-OCCASIONAL [**2164-9-30**] 03:35PM PLT SMR-VERY HIGH PLT COUNT-724*# [**2164-9-30**] 03:35PM PT-20.7* PTT-26.0 INR(PT)-2.0* Brief Hospital Course: 1. Esophagitis by EGD, s/p UGIB: 58 yo m admitted on [**2164-9-30**] with shock, GI bleed, and respiratory failure likely due to aspiration of coffee ground emesis. He was intubated upon admission [**2164-10-1**] for airway protection, and extubated [**2164-10-2**] at noon. Crit stabilized after transfusion of 7 units of PRBC's and pt admitted to unit for further management. Pt stabilized in unit with IVF/abx/blood, and was transferred to the floor in stable condition. On [**2164-10-5**] pt underwent EGD demostrating exudative esophagitis. Biopsies were taken looking for CMV/HSV, but empiric treatment was not undertaken, pending biopsy result. Pt continued to eat food without pain, was afebrile, and did not have additional episodes of upper gi bleeding. Pt to continue outpatient protonix for one month. . 2. E.coli PNA: Remains afebrile and without leukocytosis. Patient denies cough, SOB, with good O2 sat on RA. BCx No growth. . 3. C. diff colitis: Patient notes normal bowel movements, no diarrhea -Pt discharged on remainder of course of vancomycin . 4. AIDS: - Continue bactrim for PCP prophylaxis [**Name Initial (PRE) **] Restarted AIDS meds. To follow up with ID for further evaluation and managment of disease.0 . 5. Elevated serum amylase/lipase: Unlikely to be pancreatitis, patient has been eating without pain. Patient s/p recent cholecystectomy in [**Month (only) 216**]. TBili normal. All LFTs and amylase/lipase have been trending downwards . 6. History of Bilateral UE DVT: Holding coumadin for at least one week (possibly restarting on [**2164-10-12**]). Advised by GI not to restart coumadin as patient at increased upper GI bleed risk from esophageal erosions. . 7. Hepatitis C: Recent biopsy without evidence of fibrosis and patient not currently on treatment. No current evidence of portal hypertension. . 8. Anxiety: continue Klonopin 1 mg PO TID and nicotine patch. Smoking cessation modalities discussed with patient. . FEN: Regular diet with supplements Proph: PPI PO BID, Bactrim for PCP [**Name Initial (PRE) 1102**] Medications on Admission: unknown Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours) for 30 days. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 30 days. Disp:*30 Tablet(s)* Refills:*0* 3. Emtricitabine-Tenofovir 200-300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 30 days. Disp:*30 Tablet(s)* Refills:*0* 4. Ritonavir 100 mg Capsule Sig: One (1) Capsule PO DAILY (Daily) for 30 days. Disp:*30 Capsule(s)* Refills:*0* 5. Atazanavir 150 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily) for 30 days. Disp:*60 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: E. Coli PNA Upper GI bleed Discharge Condition: stable and improved Discharge Instructions: Return to the hospital with fevers, chills, nausea, vomiting, diarrhea, chest pain, or shortness of breath. Watch your stool carefully for blood, for darker than normal stools, for tarry stool. If you are feeling weaker than normal, this may be from blood loss you cannot see. Thus, please return to the doctor as soon as possible for further evaluation and treatment. Followup Instructions: Please follow up with [**Hospital **] clinic ([**Telephone/Fax (1) 2233**]. You have an appointment on [**10-17**] at 1:00, [**Hospital Unit Name 1825**] [**Location (un) 448**]. They will need to make recommendations regarding your biopsy results. Please follow up with Dr. [**Last Name (STitle) 2148**] from Infectious Disease on Monday [**10-15**] at 1:30 Call [**Telephone/Fax (1) 457**] if you need to switch your time. They will need to make sure that your lung exam is improved. They will also need to check your esophageal biopsy results to assess the need for treatment. Please follow up with your primary care doctor, [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. Dr. [**Last Name (STitle) **] will need to coordinate restarting your coumadin. This will be safely undertaken, at the earliest, on [**10-12**]. Please wait, though, until your meeting with Dr. [**Last Name (STitle) **]. Dr. [**Last Name (STitle) **] appointment: Tuesday 10:00 ([**Telephone/Fax (1) 34383**], [**State 57589**]. Dr. [**Last Name (STitle) **] will need to check your PT/INR at that time. You can wait until your meeting with Dr. [**Last Name (STitle) **] before resuming your anticoagulation.

[ "507.0", "288.60", "753.0", "305.1", "070.54", "578.1", "401.9", "238.71", "V12.51", "785.59", "496", "584.9", "042", "578.0", "518.81", "482.82", "300.00" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71", "38.91", "45.16", "99.04" ]

icd9pcs

[ [ [] ] ]

6638, 6644

3815, 5879

352, 382

6715, 6737

1451, 3792

7158, 8375

1205, 1214

5937, 6615

6665, 6694

5905, 5914

6761, 7135

1229, 1432

278, 314

410, 887

909, 1074

1090, 1189

60,476

106,006

6817

Discharge summary

report

Admission Date: [**2198-6-12**] Discharge Date: [**2198-6-29**] Date of Birth: [**2121-7-24**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Sulfur Attending:[**First Name3 (LF) 5790**] Chief Complaint: Dehydration, left recurrent chylothorax Major Surgical or Invasive Procedure: [**2198-5-30**] and [**2198-6-8**]: Ultrasound-guided therapeutic thoracentesis (outpt) [**2198-6-13**]: Left video-assisted thoracoscopy exploration and fibrin glue application. Right video-assisted thoracoscopy thoracic duct ligation and fibrin glue. [**2198-6-22**]: Interventional Radiology - lymphangiography with embolism of upper abdominal lymphatics up to the level of cisterna chyli with microcoils and gelfoam slurry [**2198-6-25**] Right pigtail placement for large pleural effusion removed [**2198-6-28**] History of Present Illness: Ms. [**Known lastname 6955**] is a pleasant 76 year old female who underwent video-assisted thoracoscopic surgery left upper lobe wedge resection and left lower lobectomy on [**2198-5-18**]. Pathology revealed a well differentiated adenocarcinoma from the LUL wedge resection (with 1 cm of free margin). The lower lobectomy revealed a 6-cm poorly differentiated mixed acinar and solid adenocarcinoma (with clean margins). Post-operatively, she developed a slow-rate chylous effusion which was conservatively monitored until chest tube removal on [**2198-5-23**]. She was discharged on [**2198-5-24**]. Upon return to clinic it was noted that she had been doing well on oxygen therapy, but her pre-visit CXR revealed evidence of left pleural effusion recurrence. IP was consulted and Dr. [**Last Name (STitle) **] performed an ultrasound-guided thoracentesis on [**2198-5-30**]. This removed 1500 mL of chylous fluid (pleural triglycerides > 400). On [**2198-6-5**] she again returned to clinic with recollection of the chylous effusion and had a second thoracentesis performed. It was felt, at that time, that duct ligation may be warranted, but that her bronchial stump needed adequate healing time. IP performed thoracentesis on [**2198-6-5**] removing 1800 mL of chylous fluid. She was seen in clinic on [**2198-6-12**] with dyspnea, cough symptoms and dehydration and was admitted directly for surgical intervention with thoracic duct ligation for her persistent chylous leak. She had surgery on [**6-13**], but still with a chyle leak. On [**2198-6-22**], she underwent lymphangiography with embolization of the leaking area as well as far distal and proximal to the area. Past Medical History: PMH: Hypertension, Dyslipidemia, Osteoporosis PSH: Status post right oophorectomy, appendectomy, cataract surgery bilaterally. s/p VATS left upper lobe wedge resection and left lower lobectomy Social History: She is a widowed just recently after a 53-year marriage, has two daughters, does not work but used to be an office manager. 15-20 pack year history of smoking. Quit 30 years ago. Furniture stripper and decorator used toxic dye. Family History: Mother died 95 unknown causes Father died 79 of colon cancer sister had myocarditis and died at age 41 Sister 79 stroke Offspring: two healthy daughters Physical Exam: VS: T 97.3, HR 84 reg, BP 106/54, RR 16, O2 sats 97% 2.5 LNC Physical Exam: Gen: pleasant in NAD, Alert and oriented x 4 Lungs: decreased breath sounds on the left, clear on right. Right and Left VATS incisions healing with clean, dry intact dressing on bilateral old chest tube sites. Heart: RRR, S1, S2, no MRG Abd: soft, non tender, non-distended Ext: warm, no edema Pertinent Results: [**2198-6-29**] 08:20AM BLOOD WBC-19.8* RBC-3.36* Hgb-9.8* Hct-30.7* MCV-91 MCH-29.1 MCHC-31.9 RDW-15.5 Plt Ct-539* [**2198-6-28**] 04:10PM BLOOD WBC-25.7* RBC-3.68* Hgb-10.8* Hct-33.3* MCV-91 MCH-29.4 MCHC-32.5 RDW-15.5 Plt Ct-591* [**2198-6-27**] 07:35AM BLOOD WBC-22.8* RBC-3.22* Hgb-9.5* Hct-29.0* MCV-90 MCH-29.3 MCHC-32.6 RDW-15.3 Plt Ct-470* [**2198-6-24**] 08:34PM BLOOD Neuts-86* Bands-0 Lymphs-1* Monos-3 Eos-6* Baso-0 Atyps-0 Metas-0 Myelos-4* [**2198-6-29**] 08:20AM BLOOD Glucose-90 UreaN-20 Creat-0.4 Na-140 K-4.6 Cl-103 HCO3-33* AnGap-9 [**2198-6-29**] 08:20AM BLOOD Albumin-3.1* Calcium-9.0 Phos-3.3 Mg-2.3 [**2198-6-28**] 04:10PM BLOOD Calcium-9.0 Phos-2.8 Mg-2.3 [**2198-6-15**] 07:50AM BLOOD calTIBC-199* Ferritn-238* TRF-153* MRSA on nasal swab [**2198-6-25**] Bedside swallow evaluation [**2198-6-28**]: no evidence of aspiration CTA [**2198-6-25**] IMPRESSION: 1. Left lower lobe pulmonary thrombus in the setting of lower lobectomy. 2. Moderate-to-large right pleural effusion with right basilar collapse. 3. 6.0 cm x 5.1-cm fluid collection within the left pleural space compatible with loculated hydropneumothorax. Continued followup to this area is recommended. 4. Diffuse intralobular septal thickening, findings suggestive of volume overload. 5. Scattered punctate areas of hyperintensity seen in both hemithoraces, likely related to previous embolization procedure. CXR [**2198-6-28**] FINDINGS: PA and lateral chest views have been obtained with patient in upright position. Comparison is made with the next preceding AP single view chest examination of [**2198-6-26**]. During the interval, the right-sided pigtail ending pleural drainage tube has been removed. No evidence of increased pleural effusion in this area and no pneumothorax in the right apical area. Diffuse left lower thorax density obliterating the diaphragmatic contour entirely remains rather unchanged. The same holds for evidence of contrast-dense linear structures, apparently remnants from a thoracic duct examination, remain in unchanged position. There is, however, now evidence of a small 3 cm wide air-fluid level overlying the left hilar area, a finding which was not present on the previous portable examination. It is unclear whether this finding may relate to changes in patient's position which is now upright. It most likely represents a localized hydrothorax in this area considering that the patient has recently undergone a left lower lobectomy. [**2198-6-21**] urine URINE CULTURE (Final [**2198-6-24**]): KLEBSIELLA OXYTOCA. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA OXYTOCA | AMPICILLIN/SULBACTAM-- 8 S CEFAZOLIN------------- 8 S CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S NITROFURANTOIN-------- 32 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S [**2198-6-25**] Urine culture: no growth Brief Hospital Course: Mrs. [**Known lastname 6955**] was admitted to the Thoracic surgery service on [**2198-6-12**] directly from clinic due to recurrent left sided chylothorax, despite two thoracentesis and low fat diet. On [**2198-6-13**] she underwent bilateral VATS with thoracic duct ligation and fibrin glue. Her chylothorax persisted, therefore on [**2198-6-22**] she underwent IR guided embolization of thoracic duct and upper abdominal lymphatics, which was successful. Her left [**Doctor Last Name **] drain revealed small serous output, therefore the drain was removed on [**2198-6-25**]. CXR was stable. The patient however was short of breath with hypoxemia on ABG. The patient underwent CTA of chest that revealed increased right sided pleural effusion and thromus to the [**MD Number(3) 25805**] that was previously resected. Dr. [**Last Name (STitle) 25806**] was not concerned about PE and anticoagulation with this finding; but a normal variant given her LLL lung resection. The patient was transfered to the ICU and underwent emergent pig tail pleural catheter placement which initially drained 1200ml, then 300-400ml every 4 hours, with about 2L over the evening. The patient had marked improvement in her pulmonary status, breathing comfortable, oxygenating well on less oxygen, improved mentation, and less anxiety. She was transferred back to the floor where she recovered, tolerating a regular diet, ambulated with PT and rested. Her chest tube was removed without right pneumothorax on CXR on [**2198-6-28**]. A bedside swallow evaluation was performed which showed normal swallow without evidence of aspiration. The patient however was more comfortable with softer foods and crushed pills. Of note she was afebrile but had leukocytosis to 28,800. Initially she presented on [**2198-6-21**] with klebsiella UTI treated with 5 day course of cipro which was found to be cured on repeat urine culture. She had a PICC with TPN which was removed but all cultures were negative to date. She did however on routine culture test positive for MRSA in the nares. The patient is ambulating with physical therapy, oxygenating well on 2.5 Liter Nasal cannula, eating a low fat diet, with stable electrolytes and vital signs. She is deemed safe for discharge today to her former rehab as discussed with Dr. [**Last Name (STitle) **] and the patient and her daughter [**Name (NI) 2270**]. She will need nutritional optimization and continue vitamin supplements as ordered. We will see her back in one weeks time for followup. Medications on Admission: HYDROMORPHONE - (Prescribed by Other Provider) - 2 mg Tablet - 1 (One) Tablet(s) by mouth every four (4) hours as needed for pain METOPROLOL SUCCINATE [TOPROL XL] - (Prescribed by Other Provider) - 25 mg Tablet Sustained Release 24 hr - 1 (One) Tablet(s) by mouth once a day SIMVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet - 1 (One) Tablet(s) by mouth at bedtime TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - (Prescribed by Other Provider) - 18 mcg Capsule, w/Inhalation Device Discharge Medications: 1. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). 2. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO twice a day. 3. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: One (1) Tablet Sustained Release 24 hr PO once a day. 4. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Oxycodone 5 mg Tablet Sig: half to one Tablet PO Q6H (every 6 hours) as needed for pain. 6. Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Vitamin A 10,000 unit Capsule Sig: Two (2) Capsule PO DAILY (Daily): x 8 more days. 8. Ergocalciferol (Vitamin D2) 50,000 unit Capsule Sig: One (1) Capsule PO 1X/WEEK (SA): saturdays x 8 more weeks. 9. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY (Daily). Capsule(s) 10. Miralax 17 gram/dose Powder Sig: One (1) packet PO once a day. 11. Tylenol Extra Strength 500 mg Tablet Sig: One (1) Tablet PO every eight (8) hours. Discharge Disposition: Extended Care Facility: Newbridge on the [**Doctor Last Name **] - [**Location (un) 1411**] Discharge Diagnosis: Left chylothorax Right pleural effusion Resolving leukocytosis Resolved klebsiella UTI sensitive to ciprofloxacin 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: Call Dr.[**Name (NI) 2347**] office [**Telephone/Fax (1) 2348**] if you experience: -Fevers > 101 or chills or shakes -Increased shortness of breath, cough or sputum production -Chest pain -Keep chest tube site covered with a bandaid until healed. -You may shower no tub bathing or swimming until incision healed Eat high protein foods, with supplemental protein shakes through the day. Dietician consultation and management during rehab stay. Ambulate three times a day with physical therapy Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] on [**2198-7-5**] on [**Hospital1 18**] [**Hospital Ward Name **] at 3:30 pm and get a chest xray at 3pm on [**Location (un) **] radiology before appointment. Completed by:[**2198-6-29**]

[ "276.51", "272.4", "457.8", "733.00", "401.9", "041.3", "997.99", "496", "599.0", "E878.6" ]

icd9cm

[ [ [] ] ]

[ "88.04", "34.6", "40.64", "38.93", "99.15", "39.79", "96.6", "34.21" ]

icd9pcs

[ [ [] ] ]

10880, 10974

6830, 9348

327, 847

11132, 11132

3600, 6807

11835, 12070

3038, 3193

9894, 10857

10995, 11111

9374, 9871

11315, 11812

3285, 3581

248, 289

875, 2558

11147, 11291

2580, 2776

2792, 3022

5,542

118,344

29807

Discharge summary

report

Admission Date: [**2106-3-17**] Discharge Date: [**2106-3-18**] Date of Birth: [**2063-3-10**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 281**] Chief Complaint: shortness of breath Major Surgical or Invasive Procedure: Placement of tracheal stent [**2106-3-17**] History of Present Illness: Pt. is a 43 yr. old female with extensive cardiac history with tracheal stenosis thought to be caused by long-term intubation, and a tracheal mass. Past Medical History: - CAD: h/o MI; s/p cath w/ stents x [**Hospital3 71312**] - CHF - DM type 2 - HTN - hyperlipidemia - asthma - tracheal stenosis Social History: lives w/ daughter; smoked but quit in [**4-16**]; no alcohol, cocaine, or IVDU. Family History: NC Physical Exam: V/S: T96.9 P109 BP102/54 R18 sat100%NRB Gen - morbidly obese female in R lateral decubitus position, moderate distress CV - RRR without audible m/g/r Lungs - limited air movement, CTA bilat. [**Last Name (un) **] - +BS, soft, NT, ND Ext - warm feet, no edema, no clubbing/cyanosis Brief Hospital Course: Pt. presented in the ED after being transferred from an outside hospital for shortness of breath. She underwent uncomplicated placement of tracheal stent on [**2106-3-17**]. Later that evening, she began complaining of angina. A cardiology consult was obtained given her extensive cardiac history. Several ECGs were obtained, including a lateral and posterior ECG, and all were negative for acute ST changes/signs of new ischemia/infarct. She was given ASA, clopidogrel, nitroglycerin, metoprolol, and morphine. She felt better thereafter. She is to see her cardiologist within 1 week after discharge. She is to follow up with Dr. [**Last Name (STitle) **] on [**2106-4-2**]. Medications on Admission: ASA 81mg QD carvedilol 6.25mg [**Hospital1 **] furosemide 40mg [**Hospital1 **] spironolactone 25mg QD metolazone 2.5mg [**Hospital1 **] digoxin 0.125mg QD atorvastatin 40mg QD glargine 40u QHS captopril 12.5mg TID Combivent nebs Discharge Medications: 1. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 3. Spironolactone 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Metolazone 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 5. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Captopril 12.5 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Disp:*45 Tablet(s)* Refills:*2* 8. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for chf. Disp:*30 Tablet(s)* Refills:*0* 9. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 10. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed. Disp:*100 ML(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Tracheal mass, tracheal stenosis, angina Discharge Condition: Stable Discharge Instructions: You may resume your pre-hospital medications. Call Dr. [**Last Name (STitle) **] or come to the emergency room if you have: * fever above 100.5 * nausea, vomiting or diarrhea that doesn't stop * chest pain, shortness of breath, or dizziness See your cardiologist in ONE WEEK. Followup Instructions: Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2106-4-2**] 2:00 Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], M.D. Phone:[**Telephone/Fax (1) 3020**] Date/Time:[**2106-4-2**] 3:00 Provider: [**Name10 (NameIs) **],ROOM FOUR IP ROOMS Date/Time:[**2106-4-2**] 3:00 [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 286**] Completed by:[**2106-3-18**]

[ "519.19", "250.00", "414.01", "V45.82", "493.90", "428.0", "272.4", "413.9", "401.9" ]

icd9cm

[ [ [] ] ]

[ "31.99", "96.05", "31.5", "38.91" ]

icd9pcs

[ [ [] ] ]

3211, 3217

1152, 1833

340, 385

3301, 3309

3633, 4061

828, 832

2113, 3188

3238, 3280

1859, 2090

3333, 3610

847, 1129

281, 302

413, 562

584, 714

730, 812

24,061

147,563

19058

Discharge summary

report

Admission Date: [**2135-11-28**] Discharge Date: [**2135-12-3**] Date of Birth: [**2075-1-18**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: Chest Pain Major Surgical or Invasive Procedure: [**11-28**] Redo Coronary Artery Bypass Graft (saphenous vein graft -> posterior descending artery, saphaneous vein graft -> obtuse marginal) History of Present Illness: 60 year old male with two month history of angina triggered by exertion that has not increased in frequency. Denies dizziness, dyspnea, and palpitations. Underwent stress test that was positive and referred for cadriac catherization that revealed restenosis of saphenous vein grafts. Past Medical History: Coronary Artery Disease s/p CABG [**2124**] Dyslipidemia Hypertension Peripheral Vascular Disease Sleep Apnea Cervical Spine Stenosis Arthritis Chronic Obstructive Pulmonary Disease Left Carotid endarectomy [**2123**] [**Doctor Last Name 52031**] neuroma foot Social History: Works as an alcohol and drug counselor. Lives with spouse. Denies ETOH, used to smoke 3ppd but quit in [**2123**]. Family History: Father had myocardial infarction in early 50's Physical Exam: Preop Vitals HR 80, B/P 94/60, RR 20 Wt 165 lbs Skin intact Neck supple, full ROM Chest clear to ausculation bilaterally Heart RRR Abdomen soft, nontender, nondistended, +bowel sounds Extremeties: warm, well perfused, no edema +2 pulses Neuro: grossly intact Discharge Neuro: alert and oriented x3 MAE R=L strength Chest: clear to ausculation bilaterally Heart: RRR no murmur/rub/gallop Abdomen: soft, nontender, nondistended + bowel sounds Extremeties warm +1 edema LE, pulses +2 Incision: sternal midline healing no drainage, erythema sternum stable Left left endovascular harvest with steristrips, ecchymosis posterior knee no erythema, no drainage Pertinent Results: [**2135-12-2**] 06:20AM BLOOD WBC-8.2 RBC-2.93* Hgb-8.8* Hct-25.5* MCV-87 MCH-30.1 MCHC-34.6 RDW-13.2 Plt Ct-215# [**2135-11-28**] 03:42PM BLOOD WBC-10.1# RBC-3.15*# Hgb-9.7*# Hct-26.8*# MCV-85 MCH-31.0 MCHC-36.4* RDW-13.2 Plt Ct-105*# [**2135-12-2**] 06:20AM BLOOD Plt Ct-215# [**2135-11-29**] 01:59AM BLOOD PT-12.8 PTT-32.4 INR(PT)-1.1 [**2135-11-28**] 03:42PM BLOOD Plt Ct-105*# [**2135-11-28**] 03:42PM BLOOD PT-17.0* PTT-45.4* INR(PT)-1.6* [**2135-12-2**] 06:20AM BLOOD Glucose-105 UreaN-20 Creat-0.8 Na-137 K-4.2 Cl-100 HCO3-30 AnGap-11 [**2135-11-28**] 04:42PM BLOOD UreaN-17 Creat-0.7 Cl-113* HCO3-23 [**2135-12-2**] 06:20AM BLOOD Mg-2.5 GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. No TEE related complications. The patient appears to be in sinus rhythm. Results were Conclusions: Prebypass 1. No atrial septal defect is seen by 2D or color Doppler. 2.There is mild to moderate regional left ventricular systolic dysfunction. Overall left ventricular systolic function is mildly depressed. Resting regional wall motion abnormalities include mildly hypokinetic mid portions of the inferolateral, inferior, anterior and anteroseptal walls. The apical inferior and anterior walls are also hypokinetic. 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the ascending aorta. There are simple atheroma in the descending thoracic aorta. 5.The aortic valve leaflets (3) are mildly thickened. There is no aortic valve stenosis. Trace aortic regurgitation is seen. 6.The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. 7.The tricuspid valve leaflets are mildly thickened. 8.There is no pericardial effusion. Post Bypass Patient is receiving an infusion of phenylephrine and epinephrine. 1. Biventricular systolic function is unchanged. 2. Mild mitral regurgitation persists. 3. Aorta intact post decannulation. Electronically signed by [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD on [**2135-11-28**] 17:20. [**Location (un) **] PHYSICIAN: Brief Hospital Course: Admitted [**2135-11-28**] and went to the operating room for redo coronary artery bypass graft surgery. Please see operative report for further details. He was then transferred to the cardiac surgery recovery unit. In the first 24 hours he woke up neurologically intact and was extubated without difficulty. He was weaned from all vasoactive medications and was transferred to [**Hospital Ward Name **] 2 on post operative day 1. He continued to progress. His left pleural tube remained due to pneumothorax and was removed post operative day 4. He had a persistant small left apical pneumothorax, without oxygen requirement nor shortness of breath. It has remained unchanged for 3 days on chest x-ray. His hematocrit dropped to 22.8 on the day of discharge(from 25 the previous day). He remained hemodynamically stable, and asymptomatic. He was discharged on iron and Vitamin C. He continued to progress with activity and was ready for discharge home with services on postoperative day 5. Medications on Admission: Atenolol 50mg daily lipitor 20mg daily ASA 325mg daily Plavix 75mg daily Zetia 10mg daily Lisinopril 2.5mg daily Multivitamin daily Clonazepam 0.5mg daily Imdur 30mg daily 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. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 4. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 5. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 6. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)). Disp:*30 Tablet(s)* Refills:*0* 8. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 9. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3-4H (Every 3 to 4 Hours) as needed. Disp:*50 Tablet(s)* Refills:*0* 10. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 11. Furosemide 20 mg Tablet Sig: One (1) Tablet PO twice a day for 7 days. Disp:*14 Tablet(s)* Refills:*0* 12. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO twice a day for 7 days. Disp:*28 Capsule, Sustained Release(s)* Refills:*0* 13. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Coronary Artery Disease s/p CABG Dyslipidemia Hypertension Peripheral Vascular Disease Sleep Apnea Cervical Spine Stenosis Arthritis Chronic Obstructive Pulmonary Disease Discharge Condition: Good Discharge Instructions: [**Month (only) 116**] shower, 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 Followup Instructions: Dr [**Name (NI) **] in 4 weeks ([**Telephone/Fax (1) 170**]) please call for appointment Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in 1 week ([**Telephone/Fax (1) 2393**]) please call for appointment Dr [**Last Name (STitle) 1295**] in [**2-11**] weeks please call for appointment Wound check appointment [**Hospital Ward Name 121**] 2 as instructed by nurse ([**Telephone/Fax (1) 3633**]) Completed by:[**2135-12-3**]

[ "496", "414.02", "723.0", "401.9", "512.1", "780.57", "272.4", "443.9" ]

icd9cm

[ [ [] ] ]

[ "36.12", "39.61" ]

icd9pcs

[ [ [] ] ]

6882, 6941

4116, 5113

333, 477

7156, 7163

1962, 4057

7629, 8077

1225, 1273

5336, 6859

6962, 7135

5139, 5313

7187, 7606

1288, 1943

283, 295

505, 792

4093, 4093

814, 1076

1092, 1209

12,435

142,481

1345

Discharge summary

report

Admission Date: [**2136-12-11**] Discharge Date: [**2136-12-25**] Date of Birth: [**2076-9-11**] Sex: M Service: Medicine with a history of type 2 diabetes mellitus, end-stage renal disease, on hemodialysis, and history of guaiac positive stool with a falling hematocrit. mucosa in the stomach and normal duodenum. The patient presents episodes of hematemesis. Of note, he is on Coumadin for a history of recurrent deep vein thromboses and pulmonary emboli. On the day of admission, the patient was at hemodialysis, felt a chill and then threw up dark blood. He had one prior episode of hematemesis a few weeks prior to admission. On the day of admission, he vomited approximately three times, one to two drowsiness and lightheadedness. He also denied chest pain. The patient does not take any aspirin and he has no history of jaundice or liver disease. However, he does take Advil and ibuprofen frequently for pain, along with Percocet and Oxycontin. His last episode of hematemesis was in the Emergency Room. Attempts to pass a nasogastric tube for lavage were unsuccessful. PAST MEDICAL HISTORY: 1. Type 2 diabetes mellitus. 2. End- stage renal disease, on hemodialysis. 3. Peripheral vascular disease, status post left below the knee amputation, status post right transmetatarsal amputation. 4. Deep vein thrombosis/pulmonary embolus, status post [**Location (un) 260**] filter, on Coumadin. 5. Abdominal tuberculosis. 6. Methicillin resistant Staphylococcus aureus cellulitis. 7. Hypertension. 8. Chronic obstructive pulmonary disease. 9. Gastroparesis. 10. Blindness in left eye. 11. Upper gastrointestinal bleed in the past. 12. Trigeminal neuralgia. MEDICATIONS ON ADMISSION: Coumadin, Reglan, Tegretol, calcium carbonate, Nephrocaps, desipramine, Oxycontin, Percocet, Renagel, nifedipine and hydralazine. ALLERGIES: Propulsid (nausea and vomiting) and gentamicin (nausea, vomiting and vertigo). FAMILY HISTORY: Not obtained. SOCIAL HISTORY: The patient is married. He admits to tobacco use. PHYSICAL EXAMINATION: Physical examination on admission was notable for a temperature of 99.7, maximum temperature 100.6, heart rate 119 and blood pressure 108/77. General; Alert, sitting in bed, in no acute distress. Head, eyes, ears, nose and throat: Pupils equal, round, and reactive to light and accommodation, extraocular movements intact, moist mucous membranes, trace dried blood around lips, no carotid bruits. Chest: End expiratory wheezes anteriorly on right, decreased breath sounds posteriorly. Cardiovascular: Tachycardiac, no jugular venous distention, S1 and S2 normal, regular rhythm. Abdomen: Soft, nontender, nondistended, positive bowel sounds, normal liver span, no stigmata of liver disease. Extremities: Left below the knee amputation, right transmetatarsal amputation. Neurologic examination: Alert, speech regular, pupils equal and reactive, tongue midline, moving all four extremities. LABORATORY DATA: Admission potassium was 5.3, BUN 62, creatinine 5.7, white blood cell count 11.7, hematocrit 38, prothrombin time 22.2, INR 3.4 and partial thromboplastin time 60.1. HOSPITAL COURSE: The patient was admitted with a low grade temperature and tachycardia but in no acute distress. His coagulopathy was corrected with vitamin K 5 mg and fresh frozen plasma. He received an esophagogastroduodenoscopy on [**2136-12-12**], which revealed evidence of gastritis and duodenitis. The patient was started on intravenous Protonix and his hematocrit remained relatively stable in the low 30s. Two out of two blood cultures were positive for gram negative rods and he was given one dose of ciprofloxacin and one dose of ceftazidime. At that point, he was called out to the general medical service. He was switched from intravenous to oral Protonix. There were no beds on the floor that day, therefore, two days later, he was called out again to the floor. At this point, the patient had also grown out coagulase negative Staphylococcus in his blood cultures. Because of this, he was given vancomycin in addition to ceftazidime and ciprofloxacin. His antibiotics were dosed at hemodialysis and he severe access problems throughout his hospital course. The patient's left external jugular line and his right Perm-A- Cath appeared to be infected and his left external jugular line was removed upon arrival to the floor per infectious disease recommendations. He was also being followed by the renal team and interventional radiology for possible placement of a Perm-A- Cath. The patient's right Perm-A-Cath was then removed just after hemodialysis and he continued to receive antibiotics with dialysis. Two days later, when his blood cultures had been negative for greater than 48 hours, with no lines in place, interventional radiology placed a new Perm-A-Cath in his left subclavian. His last positive blood culture was from [**2136-12-17**], which grew out Stenotrophomonas maltophilia in one out of two blood culture bottles from the right Port-A-Cath just before it was removed. Based on the sensitivities, the patient was switched to Bactrim in addition to the vancomycin and, since that date, he has been treated with vancomycin and Bactrim, dosed with hemodialysis. The patient's course was also complicated by mental status changes which appeared to be secondary to a combination of his narcotics and Neurontin, which had been given for his trigeminal neuralgia and chronic pain. The Neurontin was stopped and he received hemodialysis on consecutive days. His narcotics and Tegretol were also stopped as they were thought to possibly be contributing to his mental status change. The patient had a negative head CT scan and a negative magnetic resonance imaging scan. A lumbar puncture was not done because he was not febrile and there were no meningeal signs, as well as the fact that his mental status improved with the withdrawal of those medications and hemodialysis removed the Neurontin. The patient was evaluated by physical therapy and deemed not ready to go home. The plan was to transfer to a short term rehabilitation facility for continued antibiotics and physical therapy for eventual transfer to home. FINAL DIAGNOSES: 1. Upper gastrointestinal bleed secondary to gastritis from non-steroidal anti-inflammatory drug use, resolved. 2. Mental status changes believed secondary to Neurontin and narcotics, resolved. 3. Coagulase negative Staphylococcus and Stenotrophomonas bacteremia. DISCHARGE MEDICATIONS: Protonix 40 mg p.o.b.i.d. Nephrocaps one p.o.q.d. Renagel 800 mg two p.o.t.i.d. with meals. Nicoderm patch 14 mg q.d. Reglan 10 mg p.o.t.i.d. Nifedipine XR 60 mg p.o.b.i.d. Colace 100 mg p.o.b.i.d. Desipramine 10 mg p.o.q.h.s. Lovenox 90 mg s.c.b.i.d. until therapeutic INR. Boost supplementation t.i.d. Bactrim 600 mg i.v.q.h.d. given with hemodialysis until [**2137-1-4**], to complete a 14 day course. Vancomycin 1 gm i.v. when the vancomycin level is less than 15, given with hemodialysis until [**2136-12-31**], to complete a 14 day course. Albuterol meter dose inhaler two puffs q.4h.p.r.n. Atrovent meter dose inhaler two puffs q.4h.p.r.n. Dulcolax 10 mg p.o.q.d.p.r.n. Coumadin 5 mg p.o.q.h.s., to be adjusted with INR. DIET: Cardiac [**Doctor First Name **]. DISCHARGE INSTRUCTIONS: The patient should receive physical therapy. CONDITION ON DISCHARGE: The patient is stable for discharge to a short term rehabilitation facility. Addendum: The patient refused rehab stay, and left AMA on [**2136-12-25**] to the care of his wife. [**Name (NI) **] will continue to receive antibiotics at dialysis, and will follow-up in clinic with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] in [**Company 191**]. [**Name6 (MD) **] [**Name8 (MD) **], M.D. [**MD Number(2) 4814**] Dictated By:[**Name8 (MD) 6069**] MEDQUIST36 D: [**2136-12-25**] 11:43 T: [**2136-12-25**] 11:59 JOB#: [**Job Number 8223**]

[ "403.91", "535.41", "038.10", "996.62", "440.20", "E935.9", "496", "250.40" ]

icd9cm

[ [ [] ] ]

[ "45.13", "39.95" ]

icd9pcs

[ [ [] ] ]

1975, 1990

6540, 7311

1735, 1958

3186, 6232

7336, 7382

6249, 6517

2082, 2862

2887, 3168

1130, 1708

2007, 2059

7407, 8008

6,543

164,087

25843

Discharge summary

report

Admission Date: [**2171-8-14**] Discharge Date: [**2171-8-21**] Date of Birth: [**2109-12-29**] Sex: M Service: MEDICINE Allergies: Beta-Adrenergic Blocking Agents Attending:[**First Name3 (LF) 4052**] Chief Complaint: tachycardia, fever, tachypnea Major Surgical or Invasive Procedure: none History of Present Illness: 61M with extensive CAD, hypoxic brain injury s/p trach/G presented from [**Hospital1 **] after tachycardia, tachypnea and fevers . EKG at [**Hospital1 **] Place initially concerning for STE in V1-3, but in ED here on review looked more like Jpoint elevation / demand ischemia in setting of tachycardia. Troponin T initial 0.20 but trending down to 0.19 in setting of Crea of 2.8 (baseline? 2.2). Tachycardia resolved quickly down to 80's with IV fluids in ED. VS in ED were 110/59, 87, 99.5, 100% O2 Sat on [**5-4**] PS. Labs notable for WBC 19K, ESR 132, lactate 1.9, Crea 2.8. U/A had [**6-9**] WBC and occ Bact (in setting of chronic foley). CXR showed no acute cardiopulmonary process. BCx and UCx were sent and patient was started on Vanco/Ceftaz. Cardiology was consulted, felt no need for cardiac intervention at this time. Treat underlying etiology for demand ischemia. . Patient has anoxic brain injury s/o "code blue" in [**2171-5-31**] after femur fracture surgery with baseline nodding and movement of extremities. He has a chronic trach in setting of brain injury and and foley in setting of demyelinating polyneuropathy. As a consequence he has frequent UTIs. Last UCx from [**2171-6-21**] with Pseudomonas resistant to ceftaz/zosyn, but sensitive to cefepime Past Medical History: 1. 3 vessel coronary artery disease "inoperable" per records 2. Severe ischemic cardiomyopathy (EF 20%) 3. Sensorimotor demyelinating polyneuropathy, confirmed by EMG per the pt's brother. Pt. has resultant paraparesis 4. chronic renal insufficiency, known horseshoe kidney 6. chronic sacral and ischial decubitus ulcers (hx MRSA osteo in past) and with chronic indwelling foley and subsequent frequent UTIs 7. atrial fibrillation, on coumadin as an outpatient 8. hyperlipidemia 9. history of AAA 10. history of schizophrenia, "not active since [**83**]'s" per record 11. s/p cardiac arrest in [**2168**] in setting of urosepsis followed by unresponsiveness and "gaze deviation to the left" - c/w severe encephalopathy, and EEG negative for seizure activity 12. old strokes seen on head CTs 13. diabetes, on insulin x ?2 yrs 14. mild cognitive impairment/dementia per PCP notes in chart 15. left femur fracture s/p fixation [**2171-6-19**] followed by Dr [**Last Name (STitle) **]; c/b 15 minutes of asystole on POD#2 Social History: The pt. is a resident of a skilled nursing facility. There is no history of alcohol use. The pt. quit smoking tobacco 2 years ago after approximately 20 years of use. He is a former electrical engineer. Family History: NC Physical Exam: VS:T 98.2, HR 90, BP 106/57, O2 Sat100% on trach FiO2 0.5,PEEP 5,PS 10, RR18 Gen: NAD, AOx3 HEENT: MMM, anicteric, PERRLA, EOMI Neck: no JVD CV: RRR, S1 S2 normal, no r/m/g Chest: rhonchi on anterior exam, trach tube in place Abd: S, NT, ND, +BS, PEG in place Ext: edema, decubitus sacral 7x5 cm w/ 2x2 cm to the bone , 2x2 cm decubitus, R groin hematoma Neuro: alert, blinks eyes to questions, squeezes hand, moves toes R>L Pertinent Results: [**2171-8-14**] 10:05AM BLOOD WBC-19.5*# RBC-3.37* Hgb-10.8* Hct-31.4* MCV-93 MCH-32.1* MCHC-34.5 RDW-16.6* Plt Ct-135*# [**2171-8-15**] 02:57AM BLOOD WBC-13.0* RBC-2.79* Hgb-8.8* Hct-26.2* MCV-94 MCH-31.3 MCHC-33.4 RDW-16.5* Plt Ct-108* [**2171-8-20**] 04:36AM BLOOD WBC-10.0 RBC-2.78* Hgb-8.7* Hct-26.7* MCV-96 MCH-31.4 MCHC-32.8 RDW-16.9* Plt Ct-294 [**2171-8-14**] 10:05AM BLOOD Neuts-91* Bands-2 Lymphs-3* Monos-2 Eos-1 Baso-0 Atyps-1* Metas-0 Myelos-0 [**2171-8-14**] 10:05AM BLOOD PT-15.3* PTT-27.3 INR(PT)-1.4* [**2171-8-14**] 10:05AM BLOOD Fibrino-826*# [**2171-8-14**] 10:05AM BLOOD ESR-132* [**2171-8-14**] 10:05AM BLOOD Glucose-218* UreaN-81* Creat-2.8*# Na-146* K-5.5* Cl-115* HCO3-20* AnGap-17 [**2171-8-20**] 04:36AM BLOOD Glucose-109* UreaN-31* Creat-1.8* Na-141 K-4.6 Cl-113* HCO3-20* AnGap-13 [**2171-8-14**] 05:19PM BLOOD ALT-67* AST-60* LD(LDH)-247 CK(CPK)-70 AlkPhos-282* TotBili-0.3 [**2171-8-14**] 10:05AM BLOOD cTropnT-0.26* [**2171-8-14**] 05:19PM BLOOD cTropnT-0.19* [**2171-8-15**] 02:57AM BLOOD CK-MB-NotDone cTropnT-0.21* [**2171-8-17**] 03:26AM BLOOD CK-MB-NotDone cTropnT-0.11* [**2171-8-14**] 10:05AM BLOOD Albumin-2.9* Calcium-7.8* Phos-2.4* Mg-2.8* [**2171-8-14**] 10:05AM BLOOD CRP-183.8* [**2171-8-14**] 11:42AM BLOOD Type-ART Temp-38.9 FiO2-50 pO2-195* pCO2-35 pH-7.37 calTCO2-21 Base XS--3 Intubat-INTUBATED Vent-SPONTANEOU . CXR 1. Significant improvement aeration of the right lung, with no pleural effusion. No acute cardiopulmonary process. 2. Interval placement of left subclavian venous catheter, with no pneumothorax. . MR [**Name13 (STitle) **]: 1. Decubitus ulcer extending to the sacrum, with no signal changes to suggest infection within the spinal canal, although the evaluation is limited due to the lack of gadolinium. 2. Apparent thickening of cauda equina may represent changes of arachnoiditis. 3. Mild canal and foraminal stenoses at L5-S1 level. . MR Hip: 1. The left ischial decubitus ulcer extends to the left ischial tuberosity, with edema of the adjacent bone marrow. This finding is suspicious for osteomyelitis, although contrast could not be administered due to low GFR. 2. Sacral decubitus ulcer, extending to the coccyx, with mild marrow edema of the coccyx. This finding raises concern for osteomyelitis at this locale as well. 3. Large fluid collection of the left medial thigh proximally, which likely represents a hematoma, stable. 4. Intramedullary rod of the left femur, with edema of the surrounding adjacent muscles. This edema is likely related to post-operative atrophy or change. 5. The lower most portion of the known abdominal aortic aneurysm is visualized. 6. Evidence of fecal impaction. . ECG: Sinus tachycardia. Left axis deviation. Left anterior fascicular block. Extensive anterolateral myocardial infarction. Compared to previous tracing of [**2171-6-30**] the heart rate has increased. Otherwise, multiple abnormalities as noted persist without major change. . ECG: Sinus rhythm Ventricular premature complex Left anterior fascicular block Left ventricular hypertrophy Anterior myocardial infarct, age indeterminate Diffuse ST-T wave abnormalities with prolonged Q-Tc interval - may be due in part to left ventricular hypertrophy and/or ischemia Clinical correlation is suggested Since previous tracing of [**2171-8-15**], ventricular ectopy present Brief Hospital Course: #) Fever with decubitus ulcers and MR evidence of osteomyelitis: fever resolved in the ICU with empiric broad spectrum antibiotics with vancomycin, cefepime, and flagyl. A biopsy was considered for determination of osteomyelitis pathogen, but the risks were felt to outweigh the benefits and given swab culture results he should be treated with vancomycin for 6 weeks. He was seen by plastic surgery and [**Date Range **] care who recommended conservative management with wet to dry dressing, airbed, and frequent turning. . Although sputum cx grew pseudomonas, CXR did not show evidence of pneumonia thus this is most likely chronic colonization. U/A shows evidence of UTI and yeast grew in cultures, so foley changed on day of discharge. . # Tachycardia, ST elevations, CAD. EKG felt to be J-point elevation, cardiac enzymes were trending down. Cardiology consulted and felt patient may have demand ischaemia. As patient has a reported allergy to beta-blockers, he was maintained on aspirin and a statin for his coronary artery disease. . #) Tachypnea: resolved without intervention. no sign of pneumonia on CXR, no evidence of PE and patient is on prophylaxis at [**Hospital1 **]. He was initially on pressure support ventilation and then maintained on the floor with trach mask with 40% FiO2. He was given a scopolamine patch and albuterol nebulizer. He required hourly suctioning which should be continued at rehab, started on acetylcysteine on the day before discharge. . #) CRI: horseshoe kidneys; baseline around 2.8 (per brother) but creatinine at discharge 1.8. . #) DM: Good glycemic control on regular insulin SS. Medications on Admission: Acetaminophen (Liquid) 650 mg PO Q6H:PRN Zinc Sulfate 220 mg NG DAILY Simvastatin 10 mg PO DAILY Scopolamine Patch 1 PTCH TP Q72HRS Senna 1 TAB NG [**Hospital1 **]:PRN Lactulose 30 ml PO DAILY Glycerin Supps 1 SUPP PR PRN Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN Insulin SC (per Insulin Flowsheet) Ascorbic Acid (Liquid) 500 mg PO BID Ranitidine (Liquid) 150 mg PO BID Miconazole Powder 2% 1 Appl TP [**Hospital1 **] Metoclopramide 5 mg NG TID Heparin 5000 UNIT SC Q8H Docusate Sodium 100 mg PO BID Bisacodyl 10 mg PO/PR DAILY:PRN constipation ZOSYN Ceftaz Discharge Medications: 1. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) inj Injection Q8H (every 8 hours). 4. Metoclopramide 5 mg/5 mL Solution Sig: One (1) PO TID (3 times a day). 5. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 6. Ranitidine HCl 15 mg/mL Syrup Sig: One (1) PO BID (2 times a day). 7. Ascorbic Acid 90 mg/mL Drops Sig: One (1) PO BID (2 times a day). 8. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q2H (every 2 hours) as needed. 9. Glycerin (Adult) 3 g Suppository Sig: One (1) Suppository Rectal PRN (as needed). 10. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO DAILY (Daily). 11. Senna 8.8 mg/5 mL Syrup Sig: One (1) Tablet PO BID (2 times a day) as needed. 12. Scopolamine Base 1.5 mg Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72HRS (). 13. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Zinc Sulfate 220 (50) mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 15. Acetaminophen 160 mg/5 mL Solution Sig: One (1) PO Q6H (every 6 hours) as needed. 16. Therapeutic Multivitamin Liquid Sig: Five (5) ML PO DAILY (Daily). 17. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 18. Acetylcysteine 10 % (100 mg/mL) Solution Sig: 1-10 MLs Miscellaneous Q2H (every 2 hours) as needed for secretions. 19. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram Intravenous Q48H (every 48 hours) for 6 weeks. 20. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: Primary: Osteomyelitis Decubitus Ulcers Anoxic Brain Injury Coronary Artery Disease . Secondary: Diabetes Mellitus Discharge Condition: Stable. minimally interactive (waves hand, squeezes on command). on tracheostomy mask with 100% O2 saturation on 40% FiO2. Discharge Instructions: You were admitted for fevers and fast heart rate. These were most likley due to an infection of the bones in your back and hip, the source of which is sores on your back. This infection will be treated with IV vancomycin for 6 weeks. . Please return to the hospital if you experience persistant fevers, worsening ulcers, or any other new or concerning signs or symptoms. Followup Instructions: Provider: [**Name10 (NameIs) **] XRAY (SCC 2) Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2171-9-19**] 9:40 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1984**], MD Phone:[**Telephone/Fax (1) 1228**] Date/Time:[**2171-9-19**] 10:00 [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 4055**]

[ "112.2", "V44.0", "414.01", "730.28", "250.60", "295.90", "482.1", "995.91", "707.05", "276.52", "357.2", "V58.67", "427.31", "585.9", "V58.61", "730.25", "038.9", "357.82", "V44.1", "414.8", "707.03", "348.1" ]

icd9cm

[ [ [] ] ]

[ "96.6", "96.71" ]

icd9pcs

[ [ [] ] ]

10816, 10895

6745, 8379

323, 330

11054, 11180

3383, 6722

11600, 11990

2918, 2922

8989, 10793

10916, 11033

8405, 8966

11204, 11577

2937, 3364

254, 285

358, 1634

1656, 2680

2696, 2902

12,001

173,927

3270+3271

Discharge summary

report+report

Admission Date: [**2100-6-14**] Discharge Date: [**2100-6-23**] Date of Birth: [**2028-10-27**] Sex: F Service: Neurology HISTORY OF PRESENT ILLNESS: Ms. [**Known lastname 15273**] is a 71-year-old woman with a past medical history of hypertension, high cholesterol, thoracic abdominal aortic repair times two, polymyalgia rheumatica, and giant-cell arteritis. At baseline, the patient has been unable to do her activities of daily living due to generalized weakness that started suddenly at the time of her second thoracic aneurysm repair. Today she was in her usual state of health and was noted by her family that while sleeping in a chair, she slumped to the right at 6 p.m. They tried to wake her up a couple of hours later. She mumbled a few words a went back to sleep. At 10 p.m. they again tried to arouse her and had difficulty. She could answer a few simple sentences but she could not open her eyes. They noticed that she had a left facial droop and her left side was weak, but she was able to grip their hands with her hand. She was brought to [**Hospital 882**] Hospital by ambulance where a head computed tomography revealed a right thalamic hemorrhage. She was agitated and received 1 mg of Ativan; after which she became much worse and more lethargic. Her blood pressure was erratic; ranging from 83/54 to 183/141. She was transferred to [**Hospital1 69**] for further management. The patient has baseline dementia with Alzheimer's disease and was admitted to the Intensive Care Unit for blood pressure control and found to have a urinary tract infection; for which she was treated times three days. The patient was on beta blocker, 75 mg of metoprolol p.o. three times per day for control of her blood pressure. An ACE inhibitor was considered, but blood pressure then normalized, and the patient was transferred from the Intensive Care Unit to the floor for further management and disposition. PHYSICAL EXAMINATION ON PRESENTATION: The patient's blood pressure four to five days prior to discharge averaged 130/80 with a heart rate between 80 and 90. The patient was afebrile. On physical examination, the patient was awake and alert. She spoke sporadically with sparse output. On neurologic examination, the patient had a right gaze deviation with a dense left hemiparesis of the arm greater than the leg. The patient was not following tracking past midline. She was able to withdrawal to pain on the left leg; with slight grimacing. She did not withdraw or grimace with pain in the left arm. The patient also had a facial droop on the left side. On motor examination, the patient had increased tone in the left greater than right bilaterally. She also had a 4+/5 right hand grasp and biceps. On the left side, she had [**1-6**] grasp with a positive drift. It was difficult to assess motor in the lower extremities as the patient could not hold up her legs bilaterally. On sensory examination, the patient had normal light touch. Gait was not tested. Coordination was slow on the left side. HOSPITAL COURSE BY ISSUE/SYSTEM: The patient was then evaluated on the Neurology floor. The patient was able to tolerate a diet with assistance after video evaluation and swallow studies which the patient passed. However, it was felt that she may not be able to feed herself in adequate amounts. Therefore, the placement of a percutaneous endoscopic gastrostomy tube was discussed with the family, however, they declined. The patient was then referred to a rehabilitation facility for long-term placement and was approved prior to discharge. The patient was on heparin 5000 units subcutaneously twice per day for deep venous thrombosis prophylaxis with urine cultures being negative since [**2100-6-14**]. The patient was also started on atorvastatin for cardiovascular and stroke prevention. Cholesterol was 196, high-density lipoprotein was 31, and low-density lipoprotein was 94 which were drawn on [**2100-6-15**]. Physical Therapy and Occupational Therapy assessed the patient prior to discharge. The patient was to be discharged on all inpatient medications on discharge. CONDITION AT DISCHARGE: Condition on discharge was stable. DISCHARGE DIAGNOSIS: Right thalamic hemorrhagic stroke. MEDICATIONS ON DISCHARGE: (Discharge medications were as follows) 1. Senna one tablet p.o. twice per day. 2. Dulcolax 100 mg p.o. twice per day. 3. Ibuprofen 600 mg p.o. once per day. 4. Atorvastatin 20 mg p.o. once per day. 5. Metoprolol 75 mg p.o. three times per day. 6. Prevacid 30 mg p.o. every day. 7. Prednisone 5 mg p.o. once per day. 8. Regular insulin sliding-scale. 9. Heparin 5000 units subcutaneously q.12h. DISCHARGE DISPOSITION: The patient was to be discharged to a [**Hospital 4820**] rehabilitation facility (perhaps [**Hospital1 **]). DR.[**Last Name (STitle) 726**],[**First Name3 (LF) 725**] 13-268 Dictated By:[**Name8 (MD) 15274**] MEDQUIST36 D: [**2100-6-22**] 14:13 T: [**2100-6-22**] 14:31 JOB#: [**Job Number 15275**] Admission Date: [**2100-6-14**] Discharge Date: [**2100-6-26**] Date of Birth: Sex: Service: HISTORY OF PRESENT ILLNESS: The patient is a 71 year old, woman with hypertension, high cholesterol, thoracic abdominal aortic repair times two. The patient has also been unable to do her activities of daily living, due to generalized weakness that started suddenly at the time of her second thoracic aneurysm repair. On [**6-14**], she was in her usual state of health when she was noted by her family to be asleep in her chair and slumped to the right at 6 p.m. They tried to wake her a couple of hours later. She mumbled a few words and went back to sleep. Then at 10 p.m., they again tried to arouse her and had difficulty. She could not answer a few simple questions after much prodding and could not open her eyes. They noticed that she had a left facial droop and her left side was weak but she was able to grip her hands on either side. She was brought to [**Hospital 882**] hospital via ambulance with a head CT revealed a right thalamic hemorrhage. She was agitated and received 1 mg of Ativan, after which she became much more lethargic. Her blood pressure was erratic, ranging from 83 to 54 to 183/141. She was transferred to [**Hospital1 346**] for further treatment. The patient was then transferred to Neurologic Intensive Care Unit for further management of her hypertensive hemorrhagic stroke. Magnetic resonance scan of the head revealed right thalamic hemorrhage confirmed by CT, measuring 1.2 by 1.3 by 1.5 cms. Imaging studies showed midline shift or ventricular extension. The patient's blood pressure was vigorously controlled in the neurologic Intensive Care Unit with Labetalol and betablockers. The patient had labile blood pressures in the neurologic Intensive Care Unit for a two to three day course but systolic pressures were maintained between 120 and 140. The patient was also treated with Levofloxacin for urinary tract infection on urinalysis. The patient stabilized in neurologic Intensive Care Unit and was transferred to the floor for further blood pressure management and disposition. The patient's blood pressure was controlled on medication of Labetalol. An ace inhibitor was not added to the pharmacologic regimen. The patient was then stabilized on beta-blocker and had appropriate physical therapy, speech therapy and occupational therapy screens. The patient was deemed not to be able to swallow autonomously and had percutaneous endoscopic gastrostomy tube placed one day prior to discharge. The patient finished course of antibiotics for urinary tract infection with repeat head CT later on admission showing unchanging right thalamic hemorrhage. On physical examination the patient had blood pressure of 98/60 to 190/120 on admission, which was very labile, but then stabilized throughout admission. Pulse was between 70 and 90. Respiratory rate of 13. The patient was afebrile on admission. Throughout admission, the patient was somnolent on general examination with decreased arousability. The patient had a supple neck with normal S1 and S2, 2/6 systolic murmur. Lungs were clear to auscultation bilaterally. Abdomen was soft and extremities had no edema with distal pulses intact with no rashes. On neurologic examination, the patient was only arousable to noxious stimuli on left side and right side on admission, with improvement in alertness and arousability prior to discharge. The patient was able to follow simple commands on the right side, with severe left neglect. The patient was dysarthric with sparse output. She will say name and simple phrases in response to questioning. The patient's ability to follow commands improved and she was able to perform simple commands prior to discharge. The patient also had a right gaze deviation and a dense left hemiparesis on neurologic examination, with arm greater than leg. The patient was unable to tract extraocular movements past the midline and unable to withdraw from painful stimulus on the left arm. On motor examination, the patient had increased tone on the left with 4+/5 right hand grasp, triceps with the left [**1-6**] grasp; positive pronator drift on the left with difficulty assessing lower extremities as the patient could not cooperate with the examination. On cranial nerve examination, the patient had left facial droop with, as mentioned, a right gaze deviation and difficulty crossing midline. The patient was unable to cooperative with coordination examination or gait examination. LABORATORY DATA: The patient had a video swallow study on [**6-21**] which showed no evidence of aspiration or penetration of vocal cords, with a delay in volitional swallow, with trouble initiating. Due to trouble initiating, the patient had gastric tube placed on [**2100-6-25**] to augment nutrition with successful G tube passage of food and liquid. On [**6-20**], the patient also had CT of the head without contrast for follow-up which showed no mass effect or shift of normal midline structures. There was note made of moderate vascular ectasia and neural calcifications, likely related to atherosclerosis with unchanged right thalamic hemorrhage size. The patient also had electrolytes and CBC monitored very closely during admission for supplementation and supportive care. The patient did spike white blood cell count during urinary tract infection which was diagnosed early in admission but white count subsided prior to discharge. The patient was also afebrile prior to discharge. HOSPITAL COURSE: As mentioned, the patient was transferred to neuro-medicine where gastrointestinal consult inserted a gastric tube for p.o. augmentation nutrition. Decision to place G tube was discussed with the patient's family who desired the patient to have supplemental nutrition until the patient could successfully eat on her own and initiate swallowing as an outpatient. The patient will now be transfer to the rehabilitation facility for strengthening of left sided hemiparesis and rehabilitation of dysarthria and swallowing. According to the patient's primary medical doctor, the patient has a baseline functional status of decreased arousability and decreased cognition at baseline. These finding are suggestive of a neurodegenerative process such as dementia of Alzheimer's type. DISCHARGE STATUS: Stable. DISCHARGE DIAGNOSES: -1 Right thalamic, hemorrhagic stroke. -2 Possible dementia of Alzheimer's type DISCHARGE MEDICATIONS: Prednisone 5 mg p.o. q. day. Metoprolol 75 mg p.o. three times a day. Atorvistatin one tablet p.o. q. day. Docusate sodium, one capsule oral twice a day. Senna one capsule oral twice a day. Acetaminophen 650 mg q. eight hours prn fever/headache. Protonic 15 mg capsule p.o. q. day. DISCHARGE INSTRUCTIONS: The patient will follow-up with primary care physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 15276**], at phone number [**Telephone/Fax (1) 6803**]. Dr. [**Last Name (STitle) 15276**] has been in contact regarding this admission prior to discharge. The patient will be going to rehabilitation facility. [**Name6 (MD) 725**] [**Name8 (MD) 726**], M.D. [**MD Number(1) 727**] Dictated By:[**Name8 (MD) 15277**] D: [**2100-6-25**] 04:32 T: [**2100-6-25**] 15:46 JOB#: [**Job Number 15278**]

[ "599.0", "725", "401.9", "707.0", "331.0", "294.10", "272.0", "431" ]

icd9cm

[ [ [] ] ]

[ "96.6", "45.13", "43.11" ]

icd9pcs

[ [ [] ] ]

4725, 5183

11471, 11553

11576, 11859

4233, 4269

4296, 4701

10642, 11449

11884, 12428

3098, 4160

4175, 4211

5212, 10624

20,837

121,625

23663+23664

Discharge summary

report+report

Admission Date: [**2167-2-19**] Discharge Date: [**2167-3-1**] Date of Birth: [**2103-7-3**] Sex: M Service: CSU CHIEF COMPLAINT: Dyspnea on exertion. HISTORY OF PRESENT ILLNESS: The patient is a 63-year-old male with a history of hypertension and hyperlipidemia who is Cantonese speaking and presented to the emergency room at the [**Hospital1 69**] with 2 to 3 months of worsening dyspnea on exertion. During the evaluation it appeared that his stress test was positive, and he under a cardiac catheterization which demonstrated 3-vessel coronary artery disease. He was medically optimized, and the cardiac surgery service was consulted. REVIEW OF SYSTEMS: His history was negative for chest pain, no paroxysmal nocturnal dyspnea, and an otherwise unremarkable review of systems. PAST MEDICAL HISTORY: Significant for hypertension, hyperlipidemia, and hemorrhoids. PAST SURGICAL HISTORY: Significant for an appendectomy. MEDICATIONS ON ADMISSION: Unknown; there are 2 medications for blood pressure. ALLERGIES: No known drug allergies. FAMILY HISTORY: Noncontributory. PHYSICAL EXAMINATION ON ADMISSION: The patient's heart rate is 78, his blood pressure is 142/74, respiratory rate is 18, 98% on room air. He is in no acute distress. The lungs are clear to auscultation bilaterally. The heart is regular with no murmurs. The abdomen is soft. Distal pulses are 2+ bilaterally. No edema. LABORATORY DATA ON ADMISSION: His white count was 5.2, hematocrit was 35, platelets were 149. INR was 1.6. BUN and creatinine were 14 and 0.8. RADIOLOGIC STUDIES: Cardiac catheterization on [**2167-2-19**] shows an ejection fraction of 65%. Normal wall motion. A mid RCA stenosis of 90%, a proximal LAD of 70%, a mid LAD of 80%, mid circumflex of 40%, OM1 of 90%. An echocardiogram done on [**2167-2-23**] does show an EF of 60% and normal wall motion. A chest x-ray was clear with no consolidation or infiltrate or congestion. SUMMARY OF HOSPITAL COURSE: The patient was medically managed, and on hospital day 6 (on [**2167-2-24**]) went to the operating room and underwent a CABG x 4 with SVG to PDA, SVG to OM and diagonal, and a LIMA to LAD. He tolerated the procedure well. Postoperatively, he was transferred to the cardiac intensive care unit where he was extubated. He remained hemodynamically normal. On postoperative day 1 was started on beta blocker and was diuresed, all meter lines were removed, and he was transferred to the floor. On the floor, he passed a level 5 physical therapy evaluation. He demonstrated a postoperative blood loss anemia which has been observed since he has been asymptomatic, and he was started on ferrous sulfate and vitamin C. He was maintained on diuretics and beta blockade, and his rhythm was regular. He is currently stable and ready for discharge to home. His wound is clean, dry, and intact. He will be sent home with VNA and will follow up as directed. DISCHARGE DIAGNOSES: 1. Coronary artery disease; status post coronary artery bypass grafting x 4. 2. Hypertension. 3. Hyperlipidemia. 4. Hemorrhoids. SURGICAL PROCEDURES: Coronary artery bypass grafting x 4. DISCHARGE FOLLOWUP: 1. He should follow up with Dr. [**Last Name (STitle) 70**] in 6 weeks from discharge (call [**Telephone/Fax (1) 12550**]). 2. He should follow up with Dr. [**First Name (STitle) **] J. [**Doctor Last Name **], his primary care physician, [**Last Name (NamePattern4) **] 2 weeks ([**Telephone/Fax (1) 51633**]). 3. He can follow up with Dr. [**Last Name (STitle) **], the cardiologist, in 2 weeks ([**Telephone/Fax (1) 6197**]). DISCHARGE INSTRUCTIONS: 1. VNA to check the wound and check the medications. 2. The patient to follow up as instructed. MEDICATIONS ON DISCHARGE: 1. Lasix 20 mg p.o. b.i.d. (x 7 days). 2. Potassium chloride 20 mEq p.o. daily (x 7 days). 3. Colace 100 mg p.o. b.i.d. 4. Aspirin 81 mg p.o. daily. 5. Zantac 150 mg p.o. b.i.d. 6. Lipitor 10 mg p.o. daily. 7. Lopressor 25 mg p.o. b.i.d. 8. Percocet 5/325 1 to 2 p.o. q.4h. p.r.n. 9. Ferrous gluconate 300 mg p.o. daily. 10. Vitamin C 500 mg p.o. b.i.d. CONDITION ON DISCHARGE: Good. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 5662**], [**MD Number(1) 5663**] Dictated By:[**Last Name (NamePattern1) 8958**] MEDQUIST36 D: [**2167-2-28**] 23:01:40 T: [**2167-3-1**] 12:13:14 Job#: [**Job Number 60508**] Admission Date: [**2167-2-19**] Discharge Date: [**2167-3-2**] Date of Birth: [**2103-7-3**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 14964**] Chief Complaint: Dyspnea on exertion for 2-3 months with abnormal stress test that has 3VD on cardiac cath. Major Surgical or Invasive Procedure: CABG x4 [**2167-2-25**] History of Present Illness: 63 YO male cantonese/mandarin speaking only that per family has had DOE x 2-3months. Pt was evaluated by outpatient Stress test showing: ST depressions inferolaterally, chest burning and decrease in SBP. Nuclear imaging- tracer infiltrated and since had abnormal exercise portion not repeated and sent for cardiac cath on day of admission. Pt denies any chest pain, chest tightness, no dyspnea, no abdominal or back pain. Cardiac Cath showed: LMCA- normal LAD- diffuse prox 70%, diffuse mid disease 80% LCX- large OM1 with long prox 90% RCA- long mid/distal disease to 90% with collateral filling from RCA. Past Medical History: HTN Hyperlipidemia hemorrhoids appendectomy Social History: Mandarin/cantonese only speaking. Remote tobacco, no etOH, no recreational drugs. Family History: Not available. Physical Exam: 98.5, 135/70, 66, 18, 95%RA NAD, AAOx3 but only speaks mandarin/cantonese- MMM, OP- poor dentition No JVD RR with II/VI SEM CTA-B Soft, NT/ND +BS Wwp, no LE edema Pertinent Results: [**2167-2-19**] 05:29PM ALT(SGPT)-13 AST(SGOT)-18 ALK PHOS-57 AMYLASE-48 TOT BILI-0.5 [**2167-2-19**] 05:29PM WBC-5.2 RBC-4.03* HGB-12.4* HCT-35.8* MCV-89 MCH-30.8 MCHC-34.7 RDW-12.5 [**2167-2-19**] 05:29PM PLT COUNT-149* [**2167-2-19**] 04:27PM GLUCOSE-109* UREA N-14 CREAT-0.8 SODIUM-141 POTASSIUM-3.8 CHLORIDE-105 TOTAL CO2-31* ANION GAP-9 Brief Hospital Course: Mr. [**Known lastname **] was admitted for cardiac cath [**2167-2-19**] showing 3 VD and was referred for CABG. On [**2167-2-24**] he proceeded to the OR for CABG x 4 with SVG to the PDA, SVG to the LAD, SVG to the OM to the Diag. Please see op note for full details. He was successfully weened and extubtaed on his operative evening. On POD 1 he was transferred to the inpatient telemetry floor for ongoing management and monitoring. PODs 2,3, and 4 were signifcant only for titration of beta blockade, physical therapy advancement, and ongoing recovery. On POD 5, he was unable to achieve an activity level of five (which is considered safe for home) and was kept in house for one extra day. On POD five it was felt that he is safe to be discharged home. Medications on Admission: Unknown. (2 BP meds and 1 cholesterol med) Discharge Medications: 1. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 2. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO once a day for 7 days. Disp:*7 Capsule, Sustained Release(s)* Refills:*0* 3. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 1 months. Disp:*60 Tablet(s)* Refills:*0* 6. Atorvastatin Calcium 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 7. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*30 Tablet(s)* Refills:*0* 9. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*2* 10. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 11. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital6 1952**], [**Location (un) 86**] Discharge Diagnosis: 1. Three vessel coronary artery disease 2. hypertension 3. hyperlipidemia 4. hemorrhoids Discharge Condition: Stable Discharge Instructions: 1. You may continue activity as instructed by physical therapy. 2. Do not lift any objects >10lbs. 3. Keep the sternal wound dry. If there is increasing drainage or redness of the site call the office. 4. Shower daily and wash incisions with soap and water. Rinse well. Do not apply any creams, lotions, powders, or ointments. 5. Continue the medications as directed. Followup Instructions: 1. Follow up with Dr. [**Last Name (STitle) 70**] in 6 weeks from discharge. Call [**Telephone/Fax (1) 170**]. 2. Follow up with [**Doctor First Name **] [**Doctor Last Name **] in 2 weeks. Call [**Telephone/Fax (1) 51633**]. 3. Follow up with Dr. [**Last Name (STitle) **] in 2 weeks. [**Telephone/Fax (1) 6197**]. Completed by:[**2167-3-2**]

[ "413.9", "285.1", "780.6", "401.9", "287.5", "414.01" ]

icd9cm

[ [ [] ] ]

[ "88.53", "88.56", "39.61", "37.78", "37.22", "36.15", "36.13" ]

icd9pcs

[ [ [] ] ]

8519, 8594

6275, 7035

4837, 4863

8727, 8735

5900, 6252

9153, 9499

5685, 5701

2959, 3153

7128, 8496

8615, 8706

3761, 4122

7061, 7105

8759, 9130

920, 954

5716, 5881

1991, 2938

685, 809

4706, 4799

3173, 3613

4891, 5503

1459, 1962

5525, 5570

5586, 5669

4147, 4689

27,374

153,717

45105

Discharge summary

report

Admission Date: [**2108-7-31**] Discharge Date: [**2108-8-10**] Date of Birth: [**2042-6-25**] Sex: F Service: MEDICINE Allergies: Mevacor / Bactrim / Dilantin Kapseal / Naprosyn / Clindamycin / Percocet / Quinine / Levofloxacin / Penicillins / Vicodin / latex gloves / Morphine / optiflux Attending:[**First Name3 (LF) 1973**] Chief Complaint: melena Major Surgical or Invasive Procedure: 1. Tunnelled Cath Placement 2. Upper GI endoscopy 3. Bone Scan 4. Skin biopsy History of Present Illness: Mrs [**Known lastname 1968**] is a 66 yo woman with ESRD on HD, c/b calciphylaxis, afib on [**Known lastname **], who c/o generalized weakness x2-3 wks now presents with tarry stools and hypotension. Pt states that she had a large, black, tarry BM this morning, then went to [**Known lastname 2286**] today and was feeling weaker than usual, requiring help with ambulating. She was hypotensive and INR was found to be elevated to 19, therefore she was referred to the ED for further evaluation. Pt [**Known lastname **] other symptoms including fever, however does state that she has had watery diarrhea 4x/day for the last several days, also c/o decreased appetite. She has also been feeling lightheaded. She [**Known lastname **] changes in her diet recently and does not think that she could have accidentally overdosed on her [**Known lastname **]. . In the ED, initial vitals were: 97.5 104 80/23 18 100% 4L (baseline 3L), however sbps range from 70-90s at baseline and the pt was mentating well. Exam was notable for melanotic, guiac + stool, gastric lavage showed no evidence of bleeding. Labs were notable for a crit of 20.2, INR was 19.2. She was given pantoprazole, dilaudid, 2U PRBCs, 2 U FFP, 2 U fluids. 2 18 gauge periph IVs were placed. Chest xray was without effusion or consolidation, L-sided [**Known lastname 2286**] line in place. She was seen by renal and GI in the ED who will continue to follow on the floor. . On the floor, pt is alert, oriented, c/o pain in legs, otherwise asmptomatic. . ROS: (+) Per HPI, also c/o chest congestion, worse DOE for the last [**3-1**] wks, pt only able to ambulate a few feet before becoming SOB. She had one epidode of vomiting after taking meds last night. (-) [**Month/Day (3) 4273**] fever, chills, night sweats, recent weight loss or gain. [**Month/Day (3) 4273**] headache, sinus tenderness, rhinorrhea. Denied cough, shortness of breath. Denied chest pain or tightness, palpitations. Denied nausea, vomiting, diarrhea, constipation or abdominal pain. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: Cardiac: 1. CAD s/p Taxus stent to mid RCA in [**2101**], 2 Cypher stents to mid LAD and proximal RCA in [**2102**]; 2 Taxus stents to mid and distal LAD (99% in-stent restenosis of mid LAD stent); NSTEMI in [**7-31**] 2. CHF, EF 50-55% on echo in [**7-/2105**] Systolic and diastolic heart failure with mild mitral regurgitation and tricuspid regurgitation. 3. PVD s/p bilateral fem-[**Doctor Last Name **] in [**2093**] (right), [**2100**] (left) 4. Hypertension 5. Atrial fibrillation noted on admission in [**9-1**] 6. Dyslipidemia 7. Syncope/Presyncopal episodes - This was evaluated as an inpaitent in [**9-1**] and as an opt with a KOH. No etiology has been found as of yet. One thought was that these episodes are her falling asleep since she has a h/o of OSA. She has had no tele changes in the past when she has had these episodes. Pulm: 1. Severe Pulmonary Disease 2. Asthma 3. Severe COPD on home O2 3L 4. OSA- CPAP at home 14 cm of water and 4 liters of oxygen 5. Restrictive lung disease Other: 1. Morbid obesity (BMI 54) 2. Type 2 DM on insulin 3. ESRD on HD since [**2107-2-28**] - 4x weekly [**Year (4 digits) 2286**] Tues/Thurs/Fri/Sat 9R 2 lumen tunnelled line 4. Crohn's disease - not currently treated, not active dx [**2093**] 5. Depression 6. Gout 7. Hypothyroidism 8. GERD 9. Chronic Anemia 10. Restless Leg Syndrome 11. Back pain/leg pain from degenerative disk disease of lower L spine, trochanteric bursitis, sciatica Social History: Lives on the [**Location (un) 448**] of a 3 family house with [**Age over 90 **] year old aunt and multiple cousins in Mission [**Doctor Last Name **]. Walks with walker. Quit smoking in [**2102**], smoked 2.5ppd x 40 years (100py history). Infrequent EtOH use (1drink/6 months), [**Year (4 digits) **] other drug use. Retired from electronics plant. Family History: Per discharge summary: Sister: CAD s/p cath with 4 stents MI, DM, Brother: CAD s/p CABG x 4, MI, DM, ther: died at age 79 of an MI, multiple prior, DM, Father: [**Name (NI) 96395**] MI at 60. She also has several family members with PVD. Physical Exam: On Admission: VS: Temp:97 BP: 109/45 HR:99 RR:12 O2sat 100% on RA GEN: pleasant, comfortable, NAD HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, JVP not visualized CV: tachycardic, irregular, S1 and S2 wnl, no m/r/g RESP: End expiratory wheezes throughout, otherwise CTA BREASTS: large, nodules underlying errythematous patches, ttp ABD: obese, nd, +b/s, soft, nt, no masses or hepatosplenomegaly. Surgical scar on right side. EXT: 1+ edema bilaterally. Incision on R leg with stiches in place, mild surrounding errythema, ttp around lesion and in LE bilaterally, [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) **] throughout to light touch. SKIN: as above NEURO: AAOx3. Cn II-XII intact. Moves all extremities freely On Discharge: VS: 98.9, 96.8, 98-122/48-71, 84-110, 18-22, 93-99% 3L GEN: aox3. somnolant but arousable. CV: irregularly irregular, no m/r/g BREASTS: On left breast: tender indurated nodules underlying errythematous patches; On right breast: covered with dressing. ABD: obese, nd, +b/s, soft, nt, no masses or hepatosplenomegaly. Surgical scar on right side. EXT: no edema/cyanosis. Large black eschar overlying an erythematous base over right thigh; NEW INDURATED ERYTHEMA c/w EARLY LESION on LEFT THIGH SKIN: as above NEURO: AOx3. CN II-XII intact. Moves all extremities freely Pertinent Results: ADMISSION LABS: CBC with Diff: [**2108-7-31**] 04:25PM BLOOD WBC-11.4* RBC-2.26*# Hgb-6.6*# Hct-20.2*# MCV-89 MCH-29.3 MCHC-32.8 RDW-18.0* Plt Ct-495* Neuts-91.7* Lymphs-5.5* Monos-2.5 Eos-0.2 Baso-0.2 CHEM: [**2108-7-31**] 04:25PM BLOOD Glucose-172* UreaN-44* Creat-3.2*# Na-135 K-3.6 Cl-94* HCO3-25 AnGap-20 Calcium-8.9 Phos-2.7# Mg-1.7 COAG: [**2108-7-31**] 12:48PM BLOOD PT-150* INR(PT)->19.2 . DISCHARGE LABS: CBC: [**2108-8-9**] 07:47AM BLOOD WBC-10.7 RBC-3.19* Hgb-9.3* Hct-28.5* MCV-89 MCH-29.1 MCHC-32.6 RDW-16.9* Plt Ct-475* CHEM: [**2108-8-9**] 07:47AM BLOOD Glucose-91 UreaN-35* Creat-6.4* Na-137 K-5.4* Cl-87* HCO3-24 AnGap-31* Calcium-9.6 Phos-4.7* Mg-2.3 COAG: [**2108-8-9**] 05:15AM BLOOD PT-15.2* PTT-36.8* INR(PT)-1.3* . Other: [**2108-8-4**] 06:28AM BLOOD PTH-397* [**2108-8-5**] 10:40AM BLOOD [**Doctor First Name **]-NEGATIVE [**2108-8-7**] 01:20PM BLOOD AT-115 ProtCFn-129* ProtSFn-34* ProtSAg-PND . MICRO: BLOOD CX [**7-31**], [**8-1**]: PENDING . STUDIES: CXR [**2108-7-31**]: FINDINGS: Hilar prominence and interstitial opacities likely reflect a degree of volume overload in the setting of renal dysfunction. Double-lumen left-sided central venous catheter is seen with tips at the cavoatrial junction and well within the right atrium. Cardiac size is top normal with normal cardiomediastinal silhouette. Unchanged right lung granuloma again seen. IMPRESSION: Mild volume overload . EGD [**2108-8-2**]: Procedure: The procedure, indications, preparation and potential complications were explained to the patient, who indicated her understanding and signed the corresponding consent forms. A physical exam was performed. A physical exam was performed prior to administering anesthesia. Supplemental oxygen was used. 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 second part of the duodenum was reached. Careful visualization of the upper GI tract was performed. The vocal cords were visualized. The Z-line was noted at 39 centimeters.The diaphragmatic hiatus was noted at 40 centimeters.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. . Bone Scan ([**2108-8-6**]) IMPRESSION: 1. Possible calciphylaxis vs. poor radionuclide washout in the bilateral distal lower extremities. 2. No evidence of calciphylaxis in the breasts. 3. Moderate increased uptake in the lesser trochanter of the left femur of uncertain etiology. 4. Stable heterogenous uptake in the thoracolumbar spine also consistent with degenerative changes. . Microbiology: Blood Cultures x2: Negative Brief Hospital Course: History: 66 yo woman with hx ESRD on HD, afib, presenting with weakness, hypotension and melena concerning for GIB. INR at admission found to be >19. Pt was admitted to the ICU s/p 6U transfusion. Bleeding resolved with IV PPI. UGI endoscopy normal. Hct stable for 10days. Hospital course c/b with calciphylaxis (lower extremity) on sodium thiosulphate and [**Month/Day/Year **] (breast). Pain management has been challenging. She has been on IV dilaudid PCA, fentanyl patch and standing tylenol. D/ced to rehab on Lovenox for anticoagulation, sodium thiosulfate for calciphlaxis, po dilaudid, fentanyl patch and acetaminophen for pain. #. Calciphylaxis and [**Month/Day/Year 197**] Necrosis: Breast lesions biopy c/w [**Month/Day/Year **] necrosis. Lower extremity lesions c/w with calciphylaxis based on previus biopsy and bone scan. [**Month/Day/Year 197**] stopped upon admission. Calciphylaxis managed on sodium thiosulfate. This may need to be continued for another 6 weeks or more. *Please order this medication ahead of time as there is a national shortage( #. Chronic pain: Pain management had been challenging throughout hospital course. Pt continues to have pain despite 0.25-0.36mg dilaudid PCA q6mins, with 12.5-100mcg/hr fentanyl patch, and standing 1000mg tylenol q8hr/prn. Pain service and palliative care both involved in her care. We will continue her on gabapentin, tylenol 1000mg q8hr/prn, fentanyl patch 25mcg/hr q3days, and po dilaudid 2-4mg q3hrs upon discharge to rehab. She had been monitor for mental status and respiratory depression closely with medication adjustment. Please hold dilaudid if repiratory rate <10 or changes in mentation, or somnolance. . #. Afib, coagulopathy: Held [**Month/Day/Year **] on admission given GIB and supratherapeutic INR, which was reversed. [**Month/Day/Year 197**] was not restarted given [**Month/Day/Year **] necrosis on the breasts. Additionally, she reportedly had an adverse reaction to Plavix in the past. After much discussion with patient, family, pharmacy and renal, we decided to start her on Lovenox. The pharmacokinetics of this medication are unclear in [**Month/Day/Year 2286**] (and obesity). Accordingly, she will be dosed 80mg q48hr with trough anti10a monitoring prior to each dose. Goal anti10a level between 0.2-0.4. If there are problems running this test, please send test to [**Hospital1 18**]. #. Acute Blood Loss anemia due to GI bleeding: Pt Hct drop of 15 points below most recent baseline. NGL in ED was negative. However, pt had reported melena, concerning for upper source. Elevated INR likely a contributing factor as supratherapeutic to 19 on admission. Her INR was reversed with FFP and vitamin K. She was transfused 2 units of units PRBC's in the ED and an additional 4 units while in the ICU. She was also started on IV PPI. GI was consulted, and EGD showed no active bleeding, presumed due to PPI therapy. She was started on Omeprazole 20mg [**Hospital1 **] and. Her Hct stabilized without any repeat bleeding throughout the rest of her course. #ESRD Hemodialysis was continued with consultation by Dr. [**First Name (STitle) 805**], her nephrologist. Medications were renally dosed. #Constipation She was markedly constipated during her admission, finally having multiple BM's with large doses of PEG as well as colace, senna. This was due to the high-dose opiates she was receiving. TRANSFER OF CARE 1. Continue sodium thiosulfate 3x a week 25mg IV over 30mins with Zofran after HD for treatment of calciphylaxis. 2. Continue wound care the skin lesions to prevent superinfection. Pt is at high risk for bacteremia and sepsis. 3. AVOID caustic [**Doctor Last Name 360**] and aggressive debridement of skin lesions given risk of bleeding from underlying arterial source. 4. Continue to follow pain and titrate pain medication. 5. CLOSE MONITORING for mental status changes and respiratory depression closely with pain medication adjustment. 6. Continue to monitor for rebleeding from GI tract while on Lovenox. 7. Continue PO omeprazole and transition to daily upon discharge from rehab or at next PCP [**Name Initial (PRE) 648**]. 8. Please hold dilaudid if repiratory rate <10 or changes in mentation, and somnolance. Medications on Admission: HYDROmorphone (Dilaudid) 4 mg PO/NG Q6H:PRN pain Ipratropium Bromide Neb 1 NEB IH Q6H Albuterol 0.083% Neb Soln 1 NEB IH Q6H Allopurinol 100 mg PO/NG DAILY Insulin SC (per Insulin Flowsheet) Levothyroxine Sodium 175 mcg PO/NG DAILY Acetaminophen 1000 mg PO/NG Q8H Metoprolol Tartrate 12.5 mg PO/NG [**Hospital1 **] Calcitriol 0.25 mcg PO DAILY Neomycin-Polymyxin-Bacitracin 1 Appl TP Doxercalciferol 7 mcg IV ONCE Duration: 1 Doses Order date: [**8-3**] Nephrocaps 1 CAP PO DAILY Omeprazole 20 mg PO BID Paroxetine 40 mg PO/NG DAILY Fluticasone Propionate NASAL 2 SPRY NU Polyethylene Glycol 17 g PO/NG DAILY:PRN Gabapentin 300 mg PO/NG QAM Gabapentin 600 mg PO/NG HS Simvastatin 40 mg PO/NG DAILY Sodium Chloride Nasal [**1-29**] SPRY NU TID:PRN dryness TraMADOL (Ultram) 50 mg PO Q4H:PRN pain sevelamer CARBONATE 800 mg PO TID W/MEALS Order date: [**8-3**] @ 0013 Discharge Medications: 1. [**Doctor First Name **] bra One [**Doctor First Name **] Bra. [**Hospital **] Medical Products 1-[**Numeric Identifier 96397**], the bra is latex free ,XX large order # H84107051. 2. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 4. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY (Daily). 5. gabapentin 300 mg Capsule Sig: One (1) Capsule PO QAM (once a day (in the morning)). 6. levothyroxine 175 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. fluticasone 50 mcg/Actuation Spray, Suspension Sig: [**1-29**] spray Nasal once a day as needed. 8. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 9. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. paroxetine HCl 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every 8 hours). 12. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a day). 13. sodium chloride 0.65 % Aerosol, Spray Sig: [**1-29**] Sprays Nasal TID (3 times a day) as needed for dryness. 14. gabapentin 300 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 15. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 16. metoprolol tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). 17. senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for constipation. 18. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 19. fentanyl 25 mcg/hr Patch 72 hr Sig: One (1) Patch 72 hr Transdermal Q72H (every 72 hours): Up or down titrate as needed based on total dose of opiates. 20. Ondansetron 4 mg IV Q8H:PRN nausea 21. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) injection Subcutaneous q48: Check anti-factor 10a levels prior to dose. Send to [**Hospital1 18**] if your lab does not run this value. 22. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 23. Lantus 100 unit/mL Solution Sig: Eighteen (18) UNITS Subcutaneous at bedtime: . 24. Humalog 100 unit/mL Solution Sig: Sliding scale Subcutaneous breakfast, lunch, dinner, bedtime as needed for FS level. 25. Sodium Thiosulfate 25mg Sig: One (1) 25mg Intravenous every other day: 3x a week at end of HD. 26. Please AVOID chemical debridement of skin lesions. [**Month (only) 116**] cause severe bleeding. Avoid tight dressing as it causes signicant pain. Sig: [**1-29**] once a day. 27. Please titrate pain medicaiton dosage per patient need. Monitor for mental status changes with frequent MS checks. Monitor for respiratory rate and oxygenation. Sig: Three (3) once a day. 28. Dilaudid 2 mg Tablet Sig: 1-2 Tablets PO q3 hours as needed for pain: patient may decline if pain controlled This medicine is scheduled so as to avoid pain crisis. Hold if sedated or if patient declines. Start with 2mg dose. Please titrate dose and frequency to effect . 29. fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 30. Sarna Anti-Itch 0.5-0.5 % Lotion Sig: One (1) application Topical four times a day as needed for itching. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - MACU Discharge Diagnosis: Primary Diagnosis: 1. Upper GI bleed 2. Calciphylaxis Secondary Diagnosis: 1. End-stage Renal Disease 2. Type 2 Diabetes Mellitus 3. Obstructive Sleep Apnea on CPAP 4. Atiral fibrillation 5. Hypothyroidism 6. Gout 7. Rhinitis 8. Hyperlipidemia 9. depression Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 1968**], It was a pleasure taking care of you when you were admitted to [**Hospital1 18**] for gastrointestinal bleeding. At admission, we found that your INR was elevated at >19 and that your labs indicated that you had significant blood loss. We stopped your Warfarin (coudmadin), gave you blood, and treated you with intravenous proton pump inhibitor for a suspected gastric ulcer. An endoscopy was performed to assess the upper portion of your intestinal tract, but did not find any source of bleeding. You did not show any signs of further blood loss during your hospital course, and your labs showed a stable hematocrit for the past 10days. The second issue during your hospital course was your skin lesions on your Right breast and thigh. You had a biopsy of the lower extremity lesions from [**Month (only) **], which showed calciphylaxis. We also did a bone scan which was consistent with this diagnosis. Dermatology team biopsied your right breast lesion and found that it was consistent with [**Month (only) **] necrosis. There had been extensive discussion on which anticoagulation regimen we will send you home with. Since you are no longer able tolerate [**Month (only) **] and have a history of adverse reactions to plavix, we will discharge you on Lovenox for your anticoagulation. We treated you with sodium thiosulfate for your calciphylaxis, and you will continue on this as an outpatient. Pain management and palliative care were both involved for the management of your pain. We will send you to rehab with a pain management plan below, which may be adjusted and titrated according to your pain. The medication we stopped upon your admission was: 1. Warfarin ([**Month (only) **]): we stopped this medication due to a elevated INR, as well as your skin lesions that were consistent with Warfarin necrosis. Upon discharge the new medication you will be continued on are: 1. Lovenox 80mg every other day: this is a medication for anticoagulation. You will have your blood draw before getting the next dose to ensure that anti-10a level is within 0.2-0.4. 2. Sodium Thiosulfate: you will get 25mg of this medication after hemodialysis over a 30mins infusion period. You will receive Zofran during this infusion. This medication may cause hypotension, and you blood pressure should be monitored during this infusion. 3. Fentanyl patch: you will go to rehab on 25mcg/hr of fentanyl patch that should be changed every 3 days. Please stop the patch if you feel lethargic, confused, or if your feel that you are not breathing well. This may be changed at rehab. 4. Hydromorphone 2-4mg every 3 hrs: Please stop using it if you feel sleepy, woozy, lethargic or confused. You respiration and oxygenation needs to be monitored while on this medication. This may be changed at rehab. This dose may be readjusted at rehab. 5. Senna, colace, miralax: these three medications are to help you move your bowel while on the pain medications. 6. Sarna lotion and fexofenadine to help control your itching. Other medication changes: 1. Gapapentin: we decreased this medication for 300mg qday. They may decided to restart you on your outpatient night-time dose. Followup Instructions: Please schedule a follow up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **]e from rehab Department: DERMATOLOGY When: MONDAY [**2108-8-20**] at 3:00 PM With: [**Doctor First Name **]-[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 8476**], MD, PHD [**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: RADIOLOGY When: [**Hospital Ward Name **] [**2108-9-14**] at 9:05 AM With: RADIOLOGY [**Telephone/Fax (1) 327**] Building: [**Hospital6 29**] [**Location (un) 861**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital Ward Name **] SURGERY When: [**Hospital Ward Name **] [**2108-9-21**] at 10:00 AM With: [**Year (4 digits) **] LMOB (NHB) [**Telephone/Fax (1) 1237**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Completed by:[**2108-8-10**]

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Discharge summary

report+report+addendum

Admission Date: [**2115-9-11**] Discharge Date: [**2115-9-21**] Date of Birth: [**2037-10-7**] Sex: F Service: MEDICINE [**Company 191**] HISTORY OF THE PRESENT ILLNESS: Ms. [**Known lastname 96864**] is a 77-year-old female with a history of diabetes, hypertension, gastroesophageal reflux disease, and peripheral neuropathy recently admitted to the [**Hospital3 4527**] and found to have massive ascites and abdominal carcinomatosis on abdominal [**Hospital **] transferred to [**Hospital1 18**] for gynecologic/oncology evaluation and possible surgical staging and debulking who was then subsequently transferred to the Medicine Service for a right deep venous thrombosis and management of this due to her allergy to heparin. At the outside hospital, as mentioned before, she had massive ascites and abdominal carcinomatosis with diffuse omental studding and a CA125 of 1,200. On transfer to the Medicine Service, she was denying any complaints including shortness of breath, chest pain, fever, chills, nausea, vomiting, saying that her left leg was less full than it had been in the several days prior. She reports an allergy to heparin, although she is not sure of the specifics of the allergy, but has been told in the past not to be given heparin. After talking with the family, they state that she has denied seeing a doctor for many months but has been complaining of abdominal swelling and right-sided abdominal pain for months. They also say that she points to the region of her liver as a source of pain. While at [**Hospital3 4527**], she vomited blood and had three transfusions while admitted for maintenance of her hematocrit. Her family is also adamant that she is full code, and they reported that she had a TAH/BSO done many years ago in [**Country 10363**] and the specifics of that they are not sure of. PAST MEDICAL HISTORY: 1. Diabetes. 2. Hypertension. 3. COPD. 4. Gastroesophageal reflux disease. 5. Depression. 6. Osteomyelitis. 7. Peripheral neuropathy. 8. Questionable history of CVA in the past with right-sided weakness. 9. Pneumonia two months ago. 10. History of anemia with Guaiac positive stools at [**Hospital3 4527**] with an EGD and colonoscopy which were negative. She received three blood transfusions at this time. 11. TAH/BSO done in [**Country 10363**] many years ago with unclear specifics. SOCIAL HISTORY: Ms. [**Known lastname 96864**] lives at the [**Hospital 1036**] Nursing Home in [**Location (un) 620**]. She denied any tobacco, alcohol, or other drug use. Per her family, her code status is full. FAMILY HISTORY: She has one daughter who had breast cancer diagnosed at age 45. She denied any family history of ovarian or cervical cancer. ALLERGIES: She has an allergy to aspirin which causes rash and hives. She also has an allergy to heparin with unknown effects. ADMISSION MEDICATIONS: 1. Megace. 2. Nitroglycerin patch 0.1 grams q. 12 hours. 3. Zoloft 50 mg q.d. 4. Lasix 40 mg q.d. 5. Vitamin E. 6. Actos 30 mg q.d. 7. Glyburide 5 mg b.i.d. 8. Captopril 50 mg t.i.d. 9. Iron sulfate 325 mg t.i.d. 10. Ultram 50 mg t.i.d. 11. Atenolol 12.5 mg b.i.d. 12. Protonix 40 mg b.i.d. 13. Klonopin 0.5 mg t.i.d. 14. Zyprexa 2.5 mg q.h.s. 15. Lipitor 40 mg q.h.s. 16. Neurontin 300 mg q.h.s. 17. Trazodone 100 mg q.h.s. 18. Regular sliding scale with insulin. PHYSICAL EXAMINATION ON ADMISSION: Vital signs: Temperature 98.6, blood pressure 142-176/60s-80s, pulse 80, respirations 20, oxygen saturation of 98% on room air. General: The patient was a very pleasant elderly female, appearing her stated age, lying in bed. HEENT: The pupils were equally round and reactive to light and her extraocular muscles were intact. There was no evidence of scleral icterus. Heart: There was a II/VI systolic ejection murmur heard throughout the precordium with radiation to the carotids. Pulmonary: She had decreased breath sounds on the left, no audible wheezes or rhonchi. Abdomen: Distended, tense. She had decreased bowel sounds. She had increased venous distribution in the periumbilical region. She had no rebound or guarding. Abdomen: Nontender to palpation. Extremities: The right lower extremity was noted to be more swollen than the left. She had no palpable cords. She had 2+ dorsalis pedis pulses bilaterally, and there was no erythema or evidence of venostasis changes. LABORATORY/RADIOLOGIC DATA: On admission, the CBC revealed a white count of 11.7 with a differential showing 76.4% neutrophils, 11% lymphocytes, and 8.8 monocytes. Her hematocrit was 32.7 with an MCV of 89, platelets 366,000. Coagulations revealed a PT of 13.8, PTT 22.9, and INR of 1.3. She had normal serum chemistries. She had an ALT of 13, AST of 16, LD 306, alkaline phosphatase 57, amylase 80, T bilirubin 0.3, lipase 36, albumin 3.4. On admission to the [**Hospital1 18**], Doppler ultrasound of her right lower extremity showed a nonocclusive thrombus in the right common femoral vein and occlusive thrombus in the superficial femoral vein. The thrombus also appeared to extend into the greater saphenous vein. She had an EKG as well which showed sinus tachycardia with a right bundle branch block, and Q waves in the lateral limb leads. All of this was unchanged from previous EKG compared to [**Hospital3 4527**]. HOSPITAL COURSE: 1. HEMATOLOGIC: It was presumed and was felt most likely by Gynecology/Oncology as well as Hematology/Oncology that the mass in the patient's abdomen correlated with an elevated CA-125 of 1,200 were probably most consistent with ovarian carcinoma. This was conveyed to her and her family and she was offered surgical debulking and surgical staging by Gynecology/Oncology. It was felt necessary to medically manage her medical issues including her deep venous thrombosis by the Medicine Team with further discussion later in her admission with her family regarding possibility for surgery. Once she was medically managed and further discussions were begun, her family was very inconsistent and indecisive for plans and wishes for their mother. They became angry at one point and dissatisfied with the medical team for talking to the patient without the family present. It was explained to them, however, that Mrs. [**Known lastname 96864**] has the capacity to make decisions on her own, and her health care needs to be discussed with her as well. She was inconsistent as well throughout admission as to whether or not she wanted to undergo surgery or possible paracentesis with analysis of fluid for cytology and possible follow-up chemotherapy. At the beginning of her hospitalization, it seemed as she did wish to undergo surgery, but later throughout her admission it was clear that she was very scared of surgery and did not feel that this was the best option, and preferred paracentesis. Since no conclusion could be made or decision made by her family, it was conveyed to them that it was inappropriate for her to have an extended hospital course or hospital stay while they waited to make this decision and this decision could be made as an outpatient. Hematology/Oncology was consulted and recommended three treatment options; the first being surgical debulking and staging by Gynecology/Oncology with possible follow-up chemotherapy; the second, being abdominal paracentesis with analysis of fluid for cytology and pending the results palliative chemotherapy; the third being hospice care for Mrs. [**Known lastname 96864**]. All of these options were relayed to her family in a family meeting on [**2115-9-18**], and at this point they still felt unable to make a decision. This information was also conveyed to her primary care physician. [**Name10 (NameIs) **] of [**2115-9-23**], the patient has decided to proceed with laparotomy for staging and debulking purposes. She also was noted on admission to have a right deep venous thrombosis, and has an allergy to heparin. Therefore, she was started on lepirudin and maintained on a lepirudin drip for a goal PTT of 60-80. She received one dose of Coumadin prior to consideration of surgery, and resulted in an elevated INR to 5.6, which subsequently came down to the 2.5 range. It was unclear why her INR was persistently elevated, possibly due to malnutrition. She had LFTs checked, all of which were normal. Since she had a therapeutic INR, she was started on Coumadin with no need for overlap with the Lepirudin. HIT antibody was not checked at this time. Mrs. [**Known lastname 96864**] also has a history of anemia with iron studies consistent with anemia of chronic disease. She had been receiving iron supplementation when admitted; however, she was not discharged on iron supplementation due to inability of iron supplementation to help with anemia of chronic disease. Her hematocrit was monitored very closely. She received 1 unit of packed red blood cells on [**2115-9-18**] for a hematocrit of 25. Her hematocrit was stable after that point. 2. CARDIOVASCULAR: Mrs. [**Known lastname 96864**] has a history of hypertension and had good blood pressure control while admitted on her Captopril 50 mg t.i.d., and she was originally kept on her Atenolol 12.5 mg b.i.d., which was subsequently increased to 25 mg b.i.d. with better control of her blood pressure. There was a questionable history of coronary artery disease on admission given the Q waves in the lateral limb leads, and right bundle branch block. She underwent cardiac preoperative evaluation while admission in case of possible surgical debulking and also to better convey risks and benefits to her family. She underwent an echocardiogram which showed a mildly dilated left atrium, a normal left ventricular cavity, a normal ejection fraction, moderate pulmonary hypertension, and mild aortic stenosis. She also had a Persantine MIBI stress test which revealed no EKG changes, normal ejection fraction, and no reversible defect. It was felt that her cardiac postoperative risk for death was 10-15%. Mrs. [**Known lastname 96864**] also suffered from fluid overload and congestive heart failure while admitted. She had some oxygen desaturations and was maintained on 3 liters of oxygen by nasal cannula. She was aggressively diuresed with IV Lasix 80 mg b.i.d. for two days, with resolution of symptoms. She was diuresed until her creatinine bumped to 1.3 and then diuresis was held, and then restarted the next day at the dose of 40 mg p.o. b.i.d. Her creatinine subsequently fell to 1.0. 3. PULMONARY: Mrs. [**Known lastname 96864**] has a history of COPD, and was originally started on Albuterol nebulizer p.r.n., which were subsequently increased to a standing dose in addition to standing Atrovent nebulizers. She was also given Albuterol MDI p.r.n. She had audible wheezing and evidence of hypoxia, but improvement with her nebulizer treatments. She will be discharged with Albuterol MDI p.r.n. and strongly recommended that she have respiratory treatments with nebulizer treatments p.r.n. at the nursing home. She also had evidence of increased sputum production several days after admission and a poor quality chest x-ray. At this point, it was attempted to get sputum from induction; however, no sample was ever obtained. She remained afebrile without any clinical evidence of pneumonia. 4. ENDOCRINE: Mrs. [**Known lastname 96864**] has a history of type 2 diabetes and is maintained on Actos and Glyburide as an outpatient. While admitted, she had decreased p.o. intake, and her Actos and Glyburide were held and she was covered with a sliding scale of regular insulin. At the time of discharge, she will be restarted on her Actos and Glyburide. It was recommended that she have close follow-up at the nursing home as an outpatient for hypoglycemia given her likely decreased p.o. intake from her malignancy. 5. INFECTIOUS DISEASE: Several days into admission, it was noted that Mrs. [**Known lastname 96864**] was somnolent and it was felt that she was possibly developing an infection, and had been on Tylenol; therefore, a fever spike could not be detected. She had urine cultures, blood cultures, and an attempt at sputum culture which was never obtained. A U/A revealed signs of a urinary tract infection; however, urine culture times two came back as fecal contamination. There was a question of whether or not she might have a possible fistula between her rectum and bladder from her malignancy. She was, however, started on levofloxacin, and was discharged on five days to complete a total of a seven day course. Initial blood cultures grew one out of four bottles positive for gram-positive cocci in chains from her PICC line site. This was followed the second day with surveillance cultures which at the time of discharge had never grown anything and it was felt that this was probably secondary to contamination. 6. PSYCHIATRY: Mrs. [**Known lastname 96864**] has a history of depression and has been maintained at the nursing home on Zoloft, Zyprexa 2.5 mg q.h.s., and Klonopin 0.5 mg t.i.d. as an outpatient. These were continued while she was admitted, and several of her Klonopin doses were held for concern of excessive sedation. She was withdrawn. She also was very interactive at other periods. It was felt that she was very worried, anxious, and fearful of her diagnosis, as to be expected. DISPOSITION: Not yet determined. DISCHARGE DIAGNOSIS: 1. Presumed ovarian cancer. 2. Ascites. 3. Hypertension. 4. Diabetes. 5. Chronic obstructive pulmonary disease. 6. Depression. 7. Deep venous thrombosis. 8. Congestive heart failure. 9. Urinary tract infection. DR.[**Last Name (STitle) 2511**],[**Doctor Last Name **] 12-AHZ Dictated By:[**Last Name (NamePattern1) 14268**] MEDQUIST36 D: [**2115-9-20**] 04:52 T: [**2115-9-20**] 21:06 JOB#: [**Job Number 96865**] Admission Date: [**2115-9-11**] Discharge Date: [**2115-9-27**] Date of Birth: [**2037-10-7**] Sex: F Service: ADDENDUM: Ms. [**Known lastname 96864**] was actually not discharged from the hospital on [**2115-9-21**], but rather was kept on the Medicine Service and transferred to Gynecology/Oncology on [**2115-9-27**] which was the date of exploratory laparotomy with surgical debulking and staging of presumed ovarian cancer. From the time of the last dictation until her transfer, she was continually treated for her DVT with a PTT of 60-80. She also received an IVC filter on [**2115-9-24**] without complications, and her Coumadin was restarted after this procedure. She completed a seven day course of levofloxacin for questionable UTI versus fecal contamination. She was afebrile throughout her stay with little rise in her white blood cell count. From the time of the last dictation, she was continually kept on [**12-20**] liters of oxygen via nasal cannula, and kept on Albuterol and Atrovent nebulizer treatments around the clock for her COPD, in addition to diuresis with IV Lasix for likely pulmonary edema. Her creatinine bumped to 1.3 on [**2115-9-26**], and her Lasix was held. Her hypertension was under good control throughout admission with Atenolol 25 mg b.i.d. and Captopril 50 mg t.i.d. Her diabetes was continually controlled with sliding scale insulin with holding of her home oral hypoglycemics due to decreased p.o. intake while admitted. She had no episodes of hypoglycemia. Hematologically, she was anemic with iron studies consistent with anemia of chronic disease, and she was transfused a total of 3 units between the time of the last dictation and the time of transfer to Surgery. She was transfused 2 of these units on the day before surgery in preparation for possible surgical bleeding. MEDICATIONS ON TRANSFER: 1. ? 7 mg IV per hour. 2. GoLYTELY prep. 3. Dulcolax suppository p.r.n. 4. Pyridium 100 mg t.i.d. 5. Magnesium oxide 800 mg q.d. 6. Ambien p.r.n. 7. Miconazole powder. 8. Klonopin 0.5 mg t.i.d. 9. Albuterol nebulizer treatments q. four hours. 10. Ultram 50 mg p.o. q. four to six hours p.r.n. 11. Albuterol MDI. 12. Protonix 40 b.i.d. 13. Sarna lotion. 14. Colace 100 mg b.i.d. 15. Senna one tablet p.o. b.i.d. 16. Captopril 50 mg t.i.d. 17. Atenolol 25 mg b.i.d. 18. Atrovent nebulizer treatment q. six hours. 19. Compazine p.r.n. 20. Tylenol p.r.n. 21. Sliding scale insulin. 22. Neurontin 300 mg p.o. q.h.s. 23. Lipitor 40 mg p.o. q.h.s. 24. Zyprexa 2.5 mg q.h.s. 25. Nitroglycerin patch 0.1 mg per hour q.d. 26. Vitamin E. 27. Zoloft 50 mg q.d. TRANSFER STATUS: The patient will be transferred to the Gynecology/Oncology Service following her surgery. At the time of transfer, she was felt to be medically stable and only acutely being treated for her DVT. She was extremely anxious and nervous about her surgery, but appropriately so. She was reporting some shortness of breath, however, and changed from the week prior. DR.[**First Name (STitle) **],[**First Name3 (LF) **] 12-981 Dictated By:[**Last Name (NamePattern1) 14268**] MEDQUIST36 D: [**2115-9-26**] 02:07 T: [**2115-9-28**] 18:46 JOB#: [**Job Number 96866**] Name: [**Known lastname 15405**],[**Known firstname 15406**] Unit No: [**Numeric Identifier 15407**] Admission Date: [**2115-9-11**] Discharge Date: [**2115-10-23**] Date of Birth: [**2037-10-7**] Sex: F Service: Patient was taken to the OR for exploratory laparotomy on [**2115-9-30**]. The exploratory laparotomy revealed the omentum to be cemented into the anterior abdominal wall, small bowel and large bowel. She also had bloody ascites and diaphragmatic studding and unresectable disease. Frozen section showed poorly differentiated carcinoma. Postoperative attempts to extubate patient were unsuccessful. Therefore, the patient was transferred to the SICU. Patient's respiratory distress was attributed to multiple reasons including CHF, pneumonia, and also large pleural effusion. Patient had a chest tube placed on [**2115-10-5**], which exudative pleural effusion was drained. Patient had no improvement in pulmonary status. Patient was found to have a non-Q-wave myocardial infarction. An echocardiogram near that time showed a reduced EF of 25%. Patient was continued on broad-spectrum antibiotics because of possible pneumonia. She was also continued on lepirudin for her DVT. During the hospital course, her hematocrit trended down requiring multiple transfusions. On [**2115-10-7**], patient developed increasing fevers, hypotension. She was presumed to be septic from possible intraabdominal source. The patient was switched to Zosyn. Patient had worsening edema with increasing anasarca from repetitive fluid boluses. Patient was made DNR on [**10-8**]. Attempts to wean patient continued to be unsuccessful. Attempts to diurese were also unsuccessful with Lasix and Zaroxolyn. Team had several family meetings and on [**2115-10-21**], family decided that patient would not want further transfusions, antibiotics, or blood draws. Pressors were discontinued. Patient's blood pressure gradually trended down. Patient expired on [**2115-10-23**]. Family did not want an autopsy. [**Name6 (MD) 3354**] [**Last Name (NamePattern4) 5357**], M.D. Dictated By:[**Name8 (MD) 3399**] MEDQUIST36 D: [**2116-3-10**] 14:00 T: [**2116-3-10**] 14:28 JOB#: [**Job Number 15408**]

[ "599.0", "453.8", "197.6", "496", "183.0", "410.71", "518.81", "785.52", "428.0" ]

icd9cm

[ [ [] ] ]

[ "54.11", "54.59", "54.23", "38.7" ]

icd9pcs

[ [ [] ] ]

2609, 2866

13417, 15725

5345, 13396

2889, 3385

3400, 5327

15750, 19399

1876, 2374

2391, 2592

4,749

151,395

53126+59498

Discharge summary

report+addendum

Admission Date: [**2103-6-12**] Discharge Date: [**2103-6-15**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: Fever Major Surgical or Invasive Procedure: none History of Present Illness: [**Age over 90 **]F [**Hospital3 **] resident with Afib, SSS s/p PM, h/o cervical CA s/p [**Hospital 16859**] transferred from rehab today for fever, lethargy and hypoxia. Pt had recent [**Hospital Unit Name 153**] admission from [**Date range (1) 109440**] for LLL PNA after she presented with hypoxia, fevers, and hypotension. During that stay, pt received dopamine gtt through peripheral IV (pt's family refused central line after numerous failed attempts in ED)and was treated for LLL PNA with ceftriaxone +azithro +flagyl for empiric coverage for PNA and C diff (h/o recent C diff). Other events during her recent hospital course included worsening renal insufficiency thought to be secondary to ATN, and CHF with episode of flash pulmonary edema in ICU requiring diuretics. She was weaned off pressors, had good UOP, and was satting 95% RA per last d/c summary and was discharged with PICC line for completion of Abx. On that admission, pt's code status was also changed from full code to DNR/DNI after discussion with pt's family (confirmed with living will [**2096**]). Today, at rehab, pt was reported to have increased lethargy, fevers to 102.7, hypoxic. Currently, alert and oriented, mentating well with no c/o sob, no chest pain or abd pain, no dysuria, no fevers/chills. In ED, BP initially 100/50 but subsequent values as low as 80/20, unresponsive to 2L IVF. Given ceftazidime and vancomycin and started on dopamine gtt and transferred to [**Hospital Unit Name 153**] Past Medical History: - PNA/sepsis: intubated x1 day in [**3-20**] - SSS s/p PM - Afib, not on coumadin due to falls risk - NSTEMI [**3-20**] in setting of sepsis & PNA - chronic anemia - Cervical CA s/p XRT - radiation colitis s/p partial colectomy, reversed Social History: Lives in [**Location **] crossing [**Hospital3 **] facility -[**First Name8 (NamePattern2) 4115**] [**Last Name (NamePattern1) 109441**] = daughter [**Telephone/Fax (3) 109442**] -Pt at baseline is alert, communicative Physical Exam: Physical Exam: -VS: T 101.1 BP 88/28 P 70 R 16 Sat 99% 3L -Gen: elderly F asleep, alert, sleeping comfortably -Skin: LLQ colostomy bag, venous stasis changes in bilat shins -HEENT: OP dry, PERRLA, EOMI, -Neck: no JVD -Heart: S1S2 RRR, no M apprec -Lungs: poor air movement throughout with decreased BS at bases L>R -Abdom: colostomy; NT, ND, NABS -Extrem: 2+ pitting edema bilat LEs; moving all extrem equally -Neuro/Psych: A&O to person & place, follows simple commands Pertinent Results: -C diff from [**6-8**] positive from last hospitalization (not noted on d/c summary) -CXR: continued LLL retrocardiac opacity c/w PNA with slight increase in L pleural effusion [**2103-6-12**] Blood Culture AEROBIC BOTTLE (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE SET ONLY. ANAEROBIC BOTTLE (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE SET ONLY. Brief Hospital Course: [**Age over 90 **]F [**Hospital3 **] resident with Afib, SSS s/p PM, h/o cervical CA s/p [**Hospital 16859**] transferred from rehab on [**2103-6-12**] for fevers, lethargy and hypoxia. Pt had recent [**Hospital Unit Name 153**] admission from [**Date range (1) 109440**] for LLL PNA after she presented with hypoxia, fevers, and hypotension. During that stay, pt received dopamine drip through peripheral IV (pt's family refused central line after numerous failed attempts in ED)and was treated for LLL PNA with ceftriaxone +azithro +flagyl for empiric coverage for PNA and C diff (h/o recent C diff). Other events during her recent hospital course included worsening renal insufficiency thought to be secondary to ATN, and CHF with episode of flash pulmonary edema in ICU requiring diuretics. She was weaned off pressors, had good UOP, and was satting 95% RA per last d/c summary and was discharged with PICC line for completion of Abx. On that admission, pt's code status was also changed from full code to DNR/DNI after discussion with pt's family (confirmed with living will [**2096**]). On [**2103-6-12**] (day of admission), at rehab, pt was reported to have increased lethargy, fevers to 102.7, hypoxic. But was alert and oriented, mentating well with no c/o sob, no chest pain or abd pain, no dysuria, no fevers/chills in the ED. In ED, BP initially 100/50 but subsequent values as low as 80/20, unresponsive to 2 L IVF. Given ceftazidime and vancomycin and started on dopamine drip and transferred to [**Hospital Unit Name 153**]. 1. G+ sepsis - admitted with hypotension: Given fevers at rehab and hypotension, thought to be likely an infectious source although lactate not elevated and wbc was normal. Initially fevers thought to be due to inadequently treated LLL PNA and now with worsening left effusion. U/A was negative for UTI. Patient was still having diarrhea with h/o C. diff and [**6-8**] stool sample positive for C diff. On admission the patient was showing good signs of perfusion with good UOP and improved mental status from previous admission. Blood cultures from admission ([**6-12**]) came back positive for G+ cocci. Likely MRSA based on patients history. Awaiting sensitivites. Source likely Right PICC. The right PICC line was removed and the tip was sent for culture. The results were still pending upon discharge. The patient was weaned off of the DA drip within 12 hours of arriving in the ICU. Her pressures have remained in the 80's to 90's. Patients UOP and mentation were good and it seems to be patients baseline BP. We were cautious with using IV fluids to bolus low pressures due to the patients CHF. The patient was treated with Ceftazidime and vancomycin for empiric coverage; Yesterday preliminary cultures ([**1-17**]) came back as gram + cocci in clusters and chains. Will await final culture results and sensitivities. - if still febrile and hypoxic, will need to consider tap of effusion r/o parapneumonic effusion - random cortisol 23.7; no adrenal insufficency - F/u sputum, blood, urine cxs - EKG unchanged 2. PNA: LLL pneumonia still evident on CXR from previous admission, but unlikely the cause of fevers and hypotension on this admission. Patient started on Ceftaz on previous admission to treat the pneumonia. Now on day #7 of that treatment (started on [**6-7**]). Will finish a 14 day course. 3. CHF: pt w/2+ pitting edema, CXR c/w pulm edema, but satting well on 2L O2. We were vary cautious with IVF hydration to avoid fluid overload, especially as patient is DNI. Had echo on last admission with likely diastolic dysfunction with EF >55%. A CXR on [**6-13**] showed increased prominence of upper lung zone pulm. Vasculature consistent with mild CHF 4. C diff positive: Had recent C diff in [**Month (only) 116**] and now [**6-8**] sample positive for C diff, also still with diarrhea. Will treat this 1st recurrance with PO Flagyl for now as this is first treatment failure. If patient has 2nd recurrence should consider treating with PO vancomycin. A stool culture is pending from [**6-13**]. 5. Anemia: Because of cardiac issues, should have low threshold for transfusing at Hct <28. On [**6-14**] patient had hct of 26.9 and was transfused 1 unit of PRBC. Hct rose to 31.9. 5. CAD: h/o NSTEMI in [**3-20**], which was likely demand during sepsis. Continue with ASA. Previous beta blockers on hold from previous admission given hypotension. 6. Afib: stable & rate-controlled currently; only on ASA due to falls risk. 7. Renal insufficiency - h/o ATN on previous admission, creatatine now at baseline, patient has good UOP but could still post-ATN diuresis. Continue to monitor creatine given hypotension on admission. 8. Access: R PICC removed and tip sent for culture, PIV. Will need to wait a few days before a new line can be placed. 11. Code: DNR/DNI re-discussed with pt who still agrees but would like pressors Medications on Admission: Meds@Home: 1. ASA 325 daily 2. Hep SC TID 3. Tylenol prn 4. Atovent neb q6h 5. Albuterol neb q6hr prn 6. Trazodone 25 mg QHS prn 7. Simethicone 80 mg qid prn 8. Lidocaine 2% gel prn 9. Protonix 40 mg daily 10. Flaygl 500 mg TID - to be continued until C diff cxs negative x 3 or 7 days after end of other Abx 11. Ceftriaxone 1 gm IV q24, day #5 12. Azithromycin 500 QD, day #5 Discharge Medications: 1. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 11 days. 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. Albuterol 90 mcg/Actuation Aerosol Sig: [**12-17**] puff Inhalation every 4-6 hours as needed for shortness of breath or wheezing. 5. Ceftriaxone Sodium in D5W 20 mg/mL Piggyback Sig: One (1) gram Intravenous Q24H (every 24 hours) for 6 days. 6. Ipratropium Bromide 18 mcg/Actuation Aerosol Sig: Two (2) puff Inhalation four times a day. 7. Phytonadione 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 2 days. 8. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram Intravenous Q48H (every 48 hours) for 11 days. Discharge Disposition: Extended Care Facility: [**Location (un) 1036**] - [**Location (un) 620**] Discharge Diagnosis: bacteremia, likely from line infection bacterial pneumonia clostridium difficile relapse anemia, chronic Discharge Condition: Stable; baseline systolic blood pressure 80-100s. Discharge Instructions: contact MD if you develop fever/chills, shortness of breath, abdominal pain, or other concerning symptoms Followup Instructions: follow-up with Dr. [**Last Name (STitle) 58**] within 2-4 weeks. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Name: [**Known lastname 299**],[**Known firstname **] Unit No: [**Numeric Identifier 17935**] Admission Date: [**2103-6-12**] Discharge Date: [**2103-6-15**] Date of Birth: [**2007-12-27**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern4) 3776**] Addendum: Blood cultures grew coagulase negative Staphylococcus, likely Stap epi, not MRSA. Final sensitivities still pending on discharge. Discharge Disposition: Extended Care Facility: [**Location (un) 1132**] - [**Location (un) 407**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 593**] [**Name8 (MD) 304**] MD [**MD Number(1) 594**] Completed by:[**2103-6-15**]

[ "996.62", "593.9", "038.19", "V45.01", "412", "041.83", "427.31", "486", "428.0", "281.9", "785.52", "995.91" ]

icd9cm

[ [ [] ] ]

[ "00.17", "99.04" ]

icd9pcs

[ [ [] ] ]

10583, 10831

3223, 8130

275, 281

9621, 9672

2799, 3200

9826, 10560

8557, 9372

9493, 9600

8156, 8534

9696, 9803

2322, 2780

230, 237

309, 1795

1817, 2056

2072, 2292

27,278

120,848

10073

Discharge summary

report

Admission Date: [**2139-10-19**] Discharge Date: [**2139-11-5**] Date of Birth: [**2061-9-19**] Sex: M Service: MEDICINE Allergies: Haldol Attending:[**First Name3 (LF) 2387**] Chief Complaint: Fall from 2 stairs. Major Surgical or Invasive Procedure: None. History of Present Illness: Mr. [**Known lastname 33656**] is a 78 year-old man who presented to the [**Hospital **] Hospital on the night of admission after a fall at home. Apperently he is prone to falls per the ED team and the patient simply fell. The patient was brought to the [**Hospital1 **] by his family. A head CT at the [**Hospital1 **] revealed a left frontal subarachnoid hemorrhage. . Per the patient's wife [**Name (NI) 33657**], the patient was coming down the stairs and fell as he has in the past. He lost consiousness for 3-4 minutes and then was better. At baseline the patient has difficulty dressing and bathing himself. Per the patient's wife his mental status fluctuates. He can be very confused regarding people he should know and the MS exam documented below is not entirely different from how he is on his bad days. Past Medical History: [**Last Name (un) 309**] Body Disease CAD s/p CABG HTN hypothyroidism BPH s/p TURP Social History: Married. No ETOH, Drugs, or Smoking. Family History: Noncontributory. Physical Exam: Admission Physical Exam: VS: T: 98.9 BP: 156/87 HR: 87 RR: 18 O2: 98% RA Gen: not alert and oriented, masked facies, responds appropriately sometimes HEENT: pt is blind; OP - no exudate, no erythema. No LAD Chest: CTAB, but poor exam as pt not cooperative. Cardiac: RRR, nl S1, S2, no m/r/g ABD: NDNT, soft, NABS Ext: no c/c/e, pneumoboots in place bilaterally, 1+ DP bilaterally, 1+ PT bilaterally; [**2-8**] inch purple ecchymosis on left shoulder, left arm/shouder in sling Neuro: A&O x 1 (place: school, did not know month, knows name - [**Known firstname **]) . Discharge Physical Exam: General: elderly male, no acute distress HEENT: PERRL, oropharynx clear Neck: No lymphadenopathy, JVP not elevated CV: RRR, S1 + S2, no murmurs, rubs, gallops Resp: clear to auscultation bilaterally GI: soft, non-tender, non-distended, +BS, PEG tube in place, site without erythema or drainage GU: no foley Ext: WWP, 2+ pulses, no clubbing, cyanosis or edema. Left shoulder with persistent ecchymosis. Mental Status: Alert and oriented to person only. Responds inappropriately to questions. Intermittently agitated. Neurologic: PERRL, EOMI, moves all extremities to pain equally, 1+ reflexes throughout. Pertinent Results: ADMISSION LABS: ================ 13.6 16.3 >------< 239 37.7 . MCV 86 . Neuts 89.2 Bands 0 Lymphs 7.2 Monos 3.3 Eos 0.2 Basos 0.1 . 138 103 18 -----|-----|-----< 114 4.8 22 1.2 . ALT 18 AST 31 Alk Phos 48 Amylase 37 Lipase 22 Total bili 0.9 Albumin 4.5 Phos 3.2 Mg 2.1 . CK 120 MB 4 Trop<0.01 . Lactate 1.7 . UA RBC->50 WBC-0-2 BACTERIA-FEW . PERTINENT LABS DURING HOSPITALIZATION: ====================================== WBC trend: 16.3 - 14.9 - 11.7 - 10.6 - 9.9 - 8.2 - 8.6 - 10.4 - 12.7 TSH: 10 T4: 5.5 T3: 46 Phenytoin: 9.8 - 10.9 - 13 - 13.7 - 13.7 . DISCHARGE LABORATORIES: ====================================== 12.7 10.5 >------< 655 37.6 . 141 104 18 -----|-----|-----< 107 4.9 24 1.2 . Ca: 10.0 Mg: 2.5 Phos: 3.3 . STUDIES: ========== [**2139-10-19**] EKG Supraventricular tachycardia. Probable sinus tachycardia. Marked vertical axis which is more than minus 90 degrees. RSR' pattern in lead V1. Consider inferior ST segment elevation. Clinical correlation is suggested. No previous tracing available for comparison. TRACING #1 . CT C-SPINE W/O CONTRAST [**2139-10-20**] IMPRESSION: No definite evidence for acute traumatic injury to the cervical spine. Please note that evaluation of the spinal canal is limited on CT and that MRI would be more sensitive for detection of soft tissue and ligamentous injury. Multilevel cervical spondylosis. . CT HEAD W/O CONTRAST [**2139-10-20**] IMPRESSION: Relatively stable subarachnoid, intraventricular hemorrhage and hydrocephalus. . CLAVICLE LEFT [**2139-10-20**] IMPRESSION: Grade III AC joint separation with distal clavicle fracture on the left. . CHEST (PORTABLE AP) [**2139-10-20**] IMPRESSION: Allowing for the limitations of the study, no evidence of pneumonia or CHF. . CT HEAD W/O CONTRAST [**2139-10-21**] IMPRESSION: 1. Relatively stable appearance of the previously described subarachnoid and intraventricular hemorrhage. 2. Ventricular dilation, more than expected for patient's age, suggestive of hydrocephalus. . EKG [**2139-10-21**] Regular tachycardia mechanism uncertain - probably atrial tachycardia Modest right ventricular conduction delay pattern Left anterior fascicular block Since previous tracing of [**2139-10-20**], tachyarrhythmia now present and right ventricular conduction delay pattern more prominent . CT HEAD W/O CONTRAST [**2139-10-24**] IMPRESSION: 1. Slightly decreased extent of subarachnoid hemorrhage with similar intraventricular hemorrhage. 2. Stable ventricular dilatation, most consistent with hydrocephalus. . EKG [**2139-10-25**] Supraventricular tachycardia. Baseline artifact makes P waves difficult to interpret. Left axis deviation. Consider left anterior fascicular block. Compared to tracing #1 on [**2139-10-24**] the ventricular rate is faster and the T wave flattening is less pronounced. TRACING #2 . CHEST (PORTABLE AP) [**2139-10-27**] IMPRESSION: No evidence of acute cardiopulmonary process; specifically no evidence of pneumonia. Brief Hospital Course: Mr. [**Known lastname 33656**] is a 78 y.o. M with [**Last Name (un) 309**] Body Dementia, CAD, and HTN admitted s/p fall and found to have left subarachnoid hemorrhage. . # Subarachnoid Hemorrhage: The patient was evaluated by trauma and neurosurgery. The patient's left SAH was continually evaluated by frequent neuro checks and a repeat head CT after the day of fall that did not show any enlargement in the hemorrhage. He was placed on dilantin for seizure prophylaxis and is to remain on this until his appointment with neurosurgery in [**3-13**] weeks. The patient had no further complications or changes in mental status during his hospitalization. He will be followed by neurosurgery and trauma surgery. His aspirin was restarted on [**2139-11-4**] which was 14 days after his stable head CT. . # Supraventricular tachycardia: During the hospital course, the pt had runs of Supraventricular tachycardia. The patient's volume status was monitored as well as his hematocrit with no changes. Cardiology was consulted for further evaluation and treatment, and a diltiazem drip was eventually used to control the patient's heart rate in addition to metoprolol. Upon transfer to the cardiovascular service, patient continued to have runs of supraventricular tachycardia despite maximal doses of metoprolol. He was thus loaded with digoxin and started on digoxin 0.125 mg daily. He tolerated this medication well with good control of his heart rate. . # [**Last Name (un) 309**] Body Disease and Delirium: As the patient has baseline dementia, geriatrics was consulted for evaluation and treatment during his hospital stay. Their service recommended Zyprexa, Lorazepam for agitation, standing acetaminophen and oxycodone for pain. They also reported that the patient has [**Last Name (un) 309**] Body Dementia instead of Alzheimer's disease, which was the diagnosis he previously carried. Upon transfer to the cardiovascular service he continued to have significant periods of delirium. He was started on standing doses of Zyprexa 2.5 mg TID with PRN doses as needed. His delirium persisted with some lucid periods with ability to respond to his name only; however, it was communicated to his wife that this would be a terminal delirium. . # Traumatic Foley Catheter Placement: Urology was consulted after difficulty placing a Foley catheter with obvious trauma. Foley catheter insertion was performed with flexible cystoscopy. Urology recommended keeping the Foley in place for 7 days to allow for healing. The catheter was pulled, and he successfully completed his voiding trial. A catheter was not replaced. Per urology, he does not need follow-up. . # Left Clavicle Fracture: The clavicle was fractured distally s/p fall. This was evaluated by orthopedics, who recommended only a sling and swath for the fracture. Pain medications were prescribed as need. Upon transfer to the cardiovascular team, his pain regimen was simplified, and he received Tylenol around the clock with oxycodone for breakthrough pain. He is to follow up with orthopedics in a few weeks. PT and OT followed the patient during this admission. . # Fever and Leukocytosis: The patient initially had leukocytosis on admission that was treated with levofloxacin x 3 days with resolution. On [**2139-10-27**], his WBC was 12.7 in the setting of a 100.4 axillary temperature. Blood cultures were drawn. UA was equivocal and urine culture grew coagulase negative staph aureus. CXR did not show any obvious infiltrate. C. diff was negative x 1. WBC peaked at 16.2 (90% neutrophils) on [**2139-10-29**] with worsening of his mental status. Although there was no obvious fever source there was continued concern for a urinary source given his recent traumatic foley insertion. He was treated with a 7 day course of levofloxacin for a complicated urinary tract infection. His WBC count improved as did his mental status. On discharge his leukocytosis had resolved and his mental status continued to wax and wane. . # Hypertension: While on the cardiology service, the patient's blood pressures ranged from the 100s to 130s systolic on metoprolol 100 mg [**Hospital1 **] and amlodipine 5 mg PO daily. He was discharged on this regimen and can follow up with his primary cardiologist for this issue. . # Low PO Intake: During the patient's admission, his nutritional status remained poor. Nutrition consult was obtained for calorie counts. Additionally, speech and swallow evaluation was obtained. The patient initially was recommended to be kept NPO given his inability to follow commands but on repeat examination it was recommended that he could take thinned, pureed liquids on days when his mental status was improved. Despite trying to maintain his PO intake with assistance he continued to have poor calorie counts. He also was requiring continuous IV fluids to maintain his blood pressure secondary to dehydration. Extensive discussions took place with the family and they opted for PEG tube placement. On discharge he was tolerating full dose tube feeds with free water boluses. The plan is that he will be fed by mouth on his good days and supplemented with the PEG tube on bad days. The PEG tube can also be used for his medications. . # Coronary Artery Disease s/p CABG: Stable during this admission. His statin, beta blocker and amlodipine were continued. His aspirin was held until [**2139-11-4**] per neurosurgery and restarted. He will follow up with his primary cardiologist. . # Hypothyroidism: His thyroid function tests on this admission were significant for a TSH of 10, T3 of 43 and T4 of 5.5. He was continued on levothyroxine 50 mcg daily. His thyroid function tests should be repeated as an outpatient when he is no longer acutely ill. . # Anemia: On admission the patient was noted to have a hematocrit of 37.7. This slowly trended down to the high 20s on two occasions requiring transfusion given his poor cardiac status. The etiology of his anemia is unclear. [**Name2 (NI) **] was continued on his outpatient folic acid and B12 supplements. He will follow up with his primary care physician for this issue. . # Prophylaxis: He received subcutaneous heparin for DVT prophylaxis during this hospitalization. . # Contact: [**Name (NI) 33657**] (wife) [**Telephone/Fax (1) 33658**] or [**Telephone/Fax (1) 33659**] . # Code: DNR/DNI Medications on Admission: Metoprolol 25mg qday Levothyroxine 25 mcg daily ASA 81mg po daily Lipitor 10mg qhs Vitamin B12 1 tab daily Vitamin B1 1 tab daily Folic acid 1mg po daily Discharge Medications: 1. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. Phenytoin 100 mg/4 mL Suspension Sig: One (1) tablet PO TID (3 times a day). 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 4. Levothyroxine 50 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime). 7. Amlodipine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day): no more than 4 grams acetaminophen in 24 hour period. 9. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 10. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO TID (3 times a day). 11. Olanzapine 5 mg Tablet, Rapid Dissolve Sig: one half Tablet, Rapid Dissolve PO every six (6) hours as needed for delirium, agitation. 12. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 13. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 14. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 15. Cyanocobalamin 250 mcg Tablet Sig: One (1) Tablet PO once a day. 16. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) Discharge Disposition: Extended Care Facility: [**Hospital1 599**] of [**Location (un) 55**] Discharge Diagnosis: Primary Diagnosis: 1. Left frontal subarachnoid hemorrhage 2. L clavicular fracture 3. [**Last Name (un) 309**] Body Disease 4. Suprventricular Tachycardia 5. Traumatic Foley Catheter Placement 6. PEG tube placement. . Secondary Diagnosis: 1. Coronary artery disease s/p CABG 2. Hypertension 3. BPH Discharge Condition: Stable. Baseline dementia secondary to [**Last Name (un) 309**] Body, resolved delirium. Discharge Instructions: You were admitted after a fall and found to have a left frontal subarachnoid hemorrhage and left clavicular fracture. You were evaluated by orthopedics, trauma surgery, and neurosurgery. You had repeat CT scans of your head that showed stablization of your bleed, and no surgical intervention was needed. Your clavicular fracture was treated with immobilization and a sling. Physical therapy and occupational therapy also worked with you. During your hospitalization, you were found to have a very fast heart beat called supraventricular tachycardia, which was controlled with medications. Also, urology helped place a foley catheter. You successfully completed a voiding trial after removal of the foley. You had a low grade fever. Your CXR was negative. You did have a urinary tract infection and were treated with with antibiotics. Lastly, speech and swallow evaluated you as well as nutrition. You developed delirium while in the hospital and were treated with medications. Because of your waxing/[**Doctor Last Name 688**] mental status, a feeding tube was placed in your stomach so that you would consistently get nutrition and your medications. There is no decreased risk of aspiration with this feeding tube. . Please take all your medications as prescribed below. A number of changes have been made to your medication regimen. . Please keep all your follow up appointments as described below. . If you have any of the following symptoms, please call your doctor or go to the ER: fever>101, chest pain, shortness of breath, abdominal pain, bright red blood per rectum, spontaneous bleeding, black stools or any other concerning symptoms. Followup Instructions: 1. Primary care: Dr. [**Last Name (STitle) 11679**] [**Telephone/Fax (1) 26860**]; Tuesday, [**11-10**] at 2:30 PM. . 2. Orthopedics: Dr. [**Last Name (STitle) **] (for clavicle fracture) [**Telephone/Fax (1) 1228**], [**11-12**] at 8:00 AM, [**Hospital Ward Name 23**], [**Location (un) **]. Please arrive on time, you will be getting X-rays prior to seeing Dr. [**Last Name (STitle) **]. . 3. Trauma surgery: Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 600**]; Thursday, [**11-19**] at 1 PM. [**Hospital Unit Name **], [**Hospital Unit Name 14956**] . 4. Neurosurgery: Dr. [**Last Name (STitle) **] ([**Telephone/Fax (1) 1669**]) on [**11-24**] at 1:15 PM for your subarachnoid hemorrhage ([**Last Name (NamePattern1) **], [**Location (un) **], [**Hospital Unit Name 12193**]). You will get a CT of the head before this appointment, on [**11-24**] at 11:45--[**Location (un) 470**] [**Hospital Ward Name 517**] Clinical Center Radiology. 5. Behavioral Neurology: Dr. [**First Name (STitle) 6817**], [**2139-11-16**] at 11:00 am. [**Hospital1 18**] [**Hospital Ward Name 516**] [**Hospital Ward Name 860**] Buildling [**Telephone/Fax (1) 33660**].

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Discharge summary

report

Admission Date: [**2179-3-4**] Discharge Date: [**2179-3-17**] Date of Birth: [**2158-5-11**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2145**] Chief Complaint: Scrotal swelling Major Surgical or Invasive Procedure: Foley catheter repositioning in the OR PICC line placement Bronchoscopy History of Present Illness: This is a 20 year-old paraplegic male with a chronic indwelling foley who was transfered from an outside hospital for new scrotal swelling and fevers. A CT scan demonstrated that the balloon was inflated in the prostatic urethra with extravasation of fluid in the soft tissue. He was intubated in the emergenyc department for respiratory distress. He was taken to the OR for repositioning of the foley catheter. He was started on broad spectrum antibiotics for presumed urosepsis. Past Medical History: 1. Paraplegia status post being a pedestrian struck by a drunk driver. He sustained a C1 fracure. Also, had a splenectomy. 2. History of DVT and PE and is on coumadin. 3. History of MRSA bacteremia 4. History of Pseudomonal, klebsiella, and MRSA pneumonia 5. History of illicit drud use. Social History: He lives with his father. [**Name (NI) **] has been smoking for the past 4 years. He also smokes crystal meth. He denies alcohol or other drug use. Family History: Noncontributory. Physical Exam: Vitals: Temperature:99.6 Pulse:111 Blood Pressure:118/67 Respiratory Rate:18 General: Lying in bed, intubated. HEENT: Pupils equal and reactive, extraoccular movements intact, moist mucous membranes. Neck: Supple. No cervical, submadibular, supraclavicular lymphadenopathy. Cardiac: Regular rate and rhythm, s1, s2 without murmurs, rubs, gallops Pulmonary: Decreased breath sounds at right base about halfway up with occasional end-expiratory wheezes Abdomen: Normoactive bowel sounds, soft, nontender, nondistended, large midline surgical scar. Extremities: Warm and well perfused with pneumoboots and multipodis boots intact. Neuro: Cranial nerves grossly intact, decreased strength in upper extremities, paraplegic in lower extremities, impaired lower extremity sensation. Genitial: Erythematous, firm, enlarged scrotum (about [**6-24**] inches in diameter), foley intact. Pertinent Results: Hematolgy: [**2179-3-17**] 06:30AM BLOOD WBC-13.1* RBC-4.41* Hgb-11.7* Hct-35.7* MCV-81* MCH-26.6* MCHC-32.9 RDW-16.9* Plt Ct-1189* . Chemistries: SODIUM-135 POTASSIUM-4.7 CHLORIDE-100 TOTAL CO2-24 UREA N-23 CREAT-1.0 GLUCOSE-127 LACTATE-2.4 [**2179-3-17**] 06:30AM BLOOD Glucose-82 UreaN-3* Creat-0.5 Na-138 K-4.2 Cl-102 HCO3-28 AnGap-12 . Liver Function Tests: ALT(SGPT)-58 AST(SGOT)-38 CK(CPK)-241 ALK PHOS-95 AMYLASE-19 TOT BILI-1.0 LIPASE-11 . Coagulation: PT-23.4 PTT-30.1 INR(PT)-2.3 Imaging: 1. Chest x-ray: Right lower lobe atelectasis verse pneumonia. Right main stem intubation. 2. CT torso: Large amount of low attenuation fluid and stranding in the scrotum and associated inflammatory stranding of the suprapubic soft tissues. A Foley catheter balloon is seen expanded within the mid penile urethra, and lack of visualization of the right lateral wall of the urethra at this level may represent disruption. These findings likely represent urethral trauma with extravasation of urine to the scrotum. Alternatively, the fluid and stranding could be related to an infectious process. Left gluteal ulcer extending to the ischial tuberosity without associated fluid collection. Developing sinus tract in the right posterior subcutaneous tissues at the L3 level. No PE. Right lower lobe collapse and left lower lobe subsegmental atelectasis. Fatty liver. . [**2179-3-11**]: Repeat CT Scan: Again seen are opacities in the right lower lobe consistent with aspiration, slightly improved compared to prior study. There is also evidence of linear atelectasis in the left lower lobe. Small pericardial effusion is noted. There again appears to be fatty infiltration of the liver. No focal masses are identified within the liver. The gallbladder, pancreas, and adrenal glands appear unremarkable. Multiple small dense foci are seen within the right kidney, possibly representing tiny stones or vascular calcifications. No evidence of hydronephrosis. The patient is status post splenectomy. The large and small bowel appear within normal limits. No pathologically enlarged mesenteric or retroperitoneal lymphadenopathy is identified. There is no evidence of free fluid or free air within the abdomen. CT OF THE PELVIS WITHOUT IV CONTRAST: The rectum and sigmoid colon appear unremarkable. Air is seen within the bladder, likely secondary to repositioned Foley catheterization. Again seen is marked suprapubic cutaneous stranding. Peri- penile, urethral, and scrotal stranding appears slightly improved from prior study. Again seen are large inguinal lymph nodes bilaterally. No pathologically enlarged pelvic lymphadenopathy is identified. There is no evidence of free fluid within the pelvis. Again seen is evidence of a sinus tract in the right posterior subcutaneous tissue. The scrotum is not completely imaged on today's study. BONE WINDOWS: No suspicious lytic or blastic lesions are identified. Again seen is right transverse process fracture of L1. IMPRESSION: 1. Slight decrease in peri- penile, urethral, and scrotal stranding. 2. Suprapubic cutaneous stranding, relatively unchanged from prior study. 3. Air is seen within the bladder, likely secondary to repositioned foley catheter within the bladder. 4. Partial clearing of right lower lobe opacities consistent with aspiration. 5. Unchanged appearing sinus tract in right posterior subcutaneous tissue. 6. Fatty liver. . Brief Hospital Course: This is a 20 year-old paraplegic admitted for presumed urosepsis secondary to malpositioned foley catheter. . 1. Scrotal swelling: He presented with marked scrotal swelling and was found to have the balloon of his foley inflated within the prostatic urethra with extravasation of fluid into the surrounding tissues. The urology team took him to the OR for repositioning of the foley. His scrotum was cellulitic without evidence of an abscess. He was initially maintained on borad spectrum antibiotics with vancomycin, levofloxacin, and zosyn. Urine cultures from the outside hospital grew out greater than 100,000 each of providencia rettgeri, pseudomonas, serratia marcescens, enteroccoccus faecalis. Based on antibiotice sensitivities, his antibiotic coveraged was changed to zosyn and levofloxacin. A repeat CT scan demonstrated decreased stranding. With treatment, his urine bacterial cultures cleared, but then grew out yeast. His catheter has been changed again. He continued to spike fevers and had a persistent leukocytosis and eosinophilia while on zosyn and levo. We suspected possible drug allergy to zosyn, and his antibiotic regimen was changed to his current regimen of levofloxacin, metronidazole,and vancomycin with resolution of fever and improved WBC count. He did have a significant reactive thrombocytosis which has stabilized. He was followed very closely by the infectious disease team throughout his hospitalization, as well as wound care and urology. His scrotal edema is improving, though he still has areas of necrotic tissue with active drainage of yellow pus, in particular the inferior portion of his scrotum. He is to continue on antibiotics for an additional 4 weeks (from start date of his current regimen [**3-13**]) and follow-up with ID and urology in 3 weeks. The team gave him and his family explicit instructions to return for medical attention sooner if he develops any worsening edema, pain, discharge, fever, chills. Additionally, we have emphasized the importance of staying away from illicit drugs. We spent extensive time speaking to both his mother and father regarding his discharge instructions, as Mr. [**Known lastname 45670**] has seemed emotionally unable at times to act in his own best interests (threatening to leave AMA on multiple occasions despite his life-threatening infections, including immediately post-extubation; crying when we advised that he needed additional hospitalization for close monitoring of his severe scrotal infection; shouting that his parents would take him home AMA if he asked them, which was not in fact true). . He was discahrged to home with outpatient urology follow-up. Once his infection clears, he plans to have a suprapubic catheter placed. ID requested follow up MRI of scrotal area to assess for continued infection. The MRI was ordered and the PCP was called: Dr. [**Last Name (STitle) 50167**] will complete the pre-certification necessary to have the MRI and make sure the study is done. . 2. Fevers: Initially his fevers were attributed to urosepsis. No other sources of fever were identified. He continued to spike temperatures despite broad spectrum antibiotic treatments. A repeat CT scan and scrotal ultrasound did not demonstrate any abscess. His fevers were thought to be secondary to drug fevers, especially since he had an eosinophilia as mentioned above and his antibiotic regmien was altered. ALl of his blood cultures showed no growth and he was afebrile by discharge. . 3. Hypoxia: He was intubated for respiratory distress in the emergency department and was extubated successfully on hospital day 2. His chest x-ray demonstrated right lower lobe collapse thought to be from mucous plugging. After extubation, he required 6L nasal canula to maintain his oxygenation. A repeat x-ray demonstrated complete white out of the right lung. He underwent a bronchoscopy for clearing of mucous plugs with subsequent aeration of his right lung. He was successfully weaned from supplemental oxygen. . 4. Reactive thrombocytosis: During previous admissions, he developed a reactive thrombocytosis that resolved with treatment of his infections. During this admission, he had a similar thrombocytosis which stabilized by discharge. . 5. History of PE/DVT: He became supratherapeutic on coumadin so his dose was decreased and eventually held for a few days. His dose was adjusted to maintain an INR between [**2-19**]. He will continue to have close follow up of his INR given the changes made in the hospital. . 6. Paraplegia: He was maintained on his outpatient baclofen and neurontin. . 7. History of substance abuse: He has a history of substance abuse. Since it was not feasible to discharge him on an oral antibiotic regimen, he was discharged with a PICC line. His family is taking responsibility for the line. 8. Prophylaxis: Coumadin, bowel regimen. . 9. Code: He remained full code throughout his admission. Medications on Admission: Medications on Transfer: Levofloxacin 500 mg IV Q24H Piperacillin-Tazobactam Na 4.5 gm IV Q8H Vancomycin HCl 1000 mg IV Q 12H Oxycodone 15 mg PO Q6H:PRN Pantoprazole 40 mg PO Q24H Acetaminophen 325-650 mg PO Q4-6H:PRN Baclofen 20 mg PO TID Docusate Sodium 100 mg PO BID Senna 1 TAB PO BID:PRN Gabapentin 800 mg PO BID Lorazepam 1-2 mg PO Q4-6H:PRN Warfarin 2 mg PO DAILY Zolpidem Tartrate 5 mg PO HS traZODONE HCl 100 mg PO HS:PRN Medications on Admission: Macrobid 100 QD Senna tiweek Dulcolax tiweek Lexapro 10 mg po qd Alprazolam 2 mg po bid Ambien 10 mg po QOD (per OSH records) Diazepam 10 mg po qod Neurontin [**Age over 90 **] m gpo [**Hospital1 **] Baclofen 20 mg po tid Protonix 40 mg po qd Ditropan 10 mg po qd Clonidine 0.1 po BID Discharge Medications: 1. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 2. Baclofen 10 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). 3. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 6. Senna 8.6 mg Tablet Sig: Three (3) Tablet PO HS (at bedtime) as needed. 7. Glycerin (Adult) 3 g Suppository Sig: One (1) Suppository Rectal DAILY (Daily) as needed. 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 9. Paroxetine HCl 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Nystatin 100,000 unit/g Ointment Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). Disp:*qs 1* Refills:*2* 11. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 23 days. Disp:*23 Tablet(s)* Refills:*0* 12. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 23 days. Disp:*69 Tablet(s)* Refills:*0* 13. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) gram Intravenous Q 12H (Every 12 Hours) for 9 days. Disp:*45 gram* Refills:*0* 14. Trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. 15. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 16. Warfarin 2 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 17. Oxycodone 15 mg Tablet Sig: Three (3) Tablet PO every six (6) hours as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 18. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 19. Outpatient [**Hospital1 **] Work CBC, vancomycin level, BUN, creatinine weekly starting [**2179-3-23**]. Please Fax results to Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 1419**] 20. Outpatient [**Name (NI) **] Work PT, INR first draw [**2179-3-19**]. Susequent draws per Primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 50167**] Please fax results to Dr. [**Last Name (STitle) 50167**]. 21. PICC line care Please provide PICC line care per protocol 22. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: Personal Touch in londondery home care Discharge Diagnosis: Urinary tract infection Scrotal cellulitis Right lung collapse Paraplegia Discharge Condition: Afebrile > 24 hours, stable respiratory status, hemodynamically stable. Discharge Instructions: Please take all medications as prescribed. . Seek medical attention for worsening fevers, chills, nausea, vomiting, shortness of breath, chest pain, increased scrotal swelling or drainage from your scrotal wounds, or anything else that you find worrisome. Please be sure to keep all of your follow up appointments. Followup Instructions: Please keep your urology appointment on [**4-8**] at 3:40pm with Dr. [**Last Name (STitle) 770**] [**Telephone/Fax (1) 277**]. [**Hospital Ward Name 23**] Building, [**Location (un) 470**]. If you have any problems keeping this appointment plase call to reschedule. You have a follow up appointment with Dr. [**Last Name (STitle) 50167**] on [**3-24**] at 2:20 PM. If you have any difficulty keeping this appointment please call Dr. [**Last Name (STitle) **],[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 50168**] as you need to follow up with him in the next 1-2 weeks. You will need to have your INR checked in 2 days. Since you are on antibiotics that affect your coumadin dosing you may need alteration in your dosing. These results will be follow by your primary doctor. You need to have an MRI to evaluate for any infection remaining in your scrotum. Your primary care physician will arrange this study. This appointment should be kept as the results will need to be reviewed by Dr. [**Last Name (STitle) **] prior to you appointment with her on [**2179-4-9**]. You have the following appointment with the infectious disease clinic: Provider: [**Last Name (NamePattern4) **]. [**First Name (STitle) **] [**First Name (STitle) **] Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2179-4-9**] 11:30. It is essential that you follow up with them as they need to assess your wounds and to be sure that your infection is improving. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2158**]

[ "564.00", "596.54", "788.8", "518.81", "518.0", "995.92", "608.4", "996.64", "707.05", "112.2", "934.1", "V12.51", "038.9", "493.90", "458.9", "344.1", "599.84", "E929.0", "907.2" ]

icd9cm

[ [ [] ] ]

[ "33.22", "38.93", "57.95", "96.04", "96.71" ]

icd9pcs

[ [ [] ] ]

13851, 13920

5766, 10708

331, 405

14038, 14112

2345, 5743

14476, 16048

1416, 1434

11502, 13828

13941, 14017

11192, 11479

14136, 14453

1449, 2326

275, 293

433, 919

10759, 11166

941, 1232

1248, 1400

7,225

104,973

8324

Discharge summary

report

Admission Date: [**2142-10-24**] Discharge Date: [**2142-11-9**] Date of Birth: [**2074-2-21**] Sex: M Service: Cardiac Surgery HISTORY OF PRESENT ILLNESS: This is a 68 year old gentleman who is status post coronary artery bypass graft times three in [**2121**] with a five year history of exertional chest and throat discomfort. The patient underwent cardiac catheterization in [**2137**] which revealed patent bypass graft. The patient underwent a follow up stress test in [**2142-5-22**] which showed ischemic ST changes. The patient had a cardiac catheterization in [**2142-6-22**] which showed occluded vein grafts of the right coronary artery with native three vessel coronary artery disease and an ejection fraction of 33%. The patient was referred to Dr. [**Last Name (STitle) **] for operative treatment. PAST MEDICAL HISTORY: 1. Status post coronary artery bypass graft times three in [**2121**]; 2. Hypercholesterolemia; 3. Noninsulin dependent diabetes mellitus; 4. Arthritis; 5. Depression; 6. Hypertension; 7. Hard of hearing; 8. Gastroesophageal reflux disease; 9. Enlarged prostate; 10. Anxiety; 11. Status post left rotator cuff repair in [**2134**]; 12. Status post left parotidectomy in [**2140**]. MEDICATIONS: 1. Atenolol 25 mg p.o. q. day 2. Glucotrol 5 mg p.o. q.d. 3. Lipitor 20 mg p.o. q.d. 4. Celebrex 100 mg p.o. b.i.d. 5. Enteric coated Aspirin 325 mg p.o. q.d. 6. Vitamin E 7. Vitamin B 8. Multivitamin 9. Norvasc 5 mg p.o. q.d. 10. Cardura 2 mg p.o. q.d. 11. Zoloft 100 mg p.o. q.d. 12. Folate 13. Vitamin B12 14. Fish oil ALLERGIES: No known drug allergies. HOSPITAL COURSE: The patient was admitted to [**Hospital6 1760**] on [**2142-10-24**] and was taken to the Operating Room with Dr. [**Last Name (STitle) **] for a redo sternotomy and redo coronary artery bypass graft times three, left internal mammary artery to left anterior descending, saphenous vein graft to obtuse marginal and saphenous vein graft to posterior descending artery. The patient tolerated the procedure well and was transferred to the Intensive Care Unit in stable condition. Please see the operative note for further details. The patient initially required Levophed drip for maintenance of the blood pressure. In the Intensive Care Unit the patient had several short runs of nonsustained ventricular tachycardia for which he was started on Amiodarone infusion. She was weaned and extubated from mechanical ventilation on the first postoperative evening and postoperative day #1 the patient was transferred from the Intensive Care Unit to the floor. On the evening of postoperative day #1 into postoperative day #2 the patient became progressively hypoxic without improvement with diuretics, pain control or nebulizer treatment. The morning of postoperative day #2 the patient was transferred from the floor back to the Intensive Care Unit for hypoxia. Prior to transfer the patient was found to be hypotensive and significantly hypoxic and was electively intubated prior to transfer. Intubation was without complications. Upon arrival to the Intensive Care Unit the patient underwent a bronchoscopy which showed normal mucosa, copious thin secretions and a small plug in the left lower lobe. A sputum sample was sent from the bronchoscopy. Chest x-ray after intubation showed diffuse interspace disease, right greater than left. The patient was empirically started on antibiotics, Levofloxacin, Vancomycin and Flagyl. The patient remained significantly hypoxic, requiring paralytics and sedation and pressure control ventilation. The patient underwent a transesophageal echocardiogram which showed severely depressed left ventricular systolic function with ejection fraction of 20 to 25% with inferior akinesis, lateral hypokinesis, moderately depressed right ventricular systolic function, moderate mitral regurgitation and mild tricuspid regurgitation. Paralytics were discontinued on postoperative day #3. On postoperative day #4 pulmonary medicine consult was obtained due to the patient's continued respiratory failure, fevers of unknown origin and diffuse patchy infiltrates on chest x-ray, the Pulmonary Medicine Team's feelings were that the respiratory failure was either due to aspiration pneumonia or Amiodarone toxicity or atypical pneumonia. The Pulmonary Team recommended again using steroids, recommended discontinuing Amiodarone. Considering the present management, the patient was pancultured for his continued fever spikes of 102. All of the cultures from that time were negative with the exception of a sputum sample done during bronchoscopy which was positive for Methicillin-sensitive Coagulase positive Staphylococcus which was minimal growth. All subsequent sputum, blood and urine cultures were negative. On postoperative day #4 the patient had a pulmonary artery catheter placed to rule out cardiogenic pulmonary edema that showed a cardiac output of 7.2 and a cardiac index of 3.17, SVR of 715. The pulmonary artery catheter was removed as it was felt that the patient had adequate cardiac output. On postoperative day #4, the patient was switched from pressure control ventilation to conventional ventilation with assist control and subsequent to SIMV. The patient's sedation was slowly weaned down. The patient continued to have improving oxygenation over the next several days. The patient's positive end-expiratory pressure and sedation were weaned. The patient's fever curve continued to defervesce. The patient had no further atrial or ventricular ectopy. It was thought that the patient did not require any anti-arrhythmic therapy. On postoperative day #6 the patient again spiked a fever to 102.9. Blood cultures were sent which were negative. The patient's central line was removed. The patient continued on triple antibiotic therapy. The patient's white count during this time remained steady in the 13 to 15 range. By postoperative day #8 the patient continued to have fevers. The patient was weaning on the ventilator and had been weaned down to CPAP with pressure support, required Diamox for metabolic alkalosis. Sedation had been weaned off, however, the patient was agitated and not following commands, restless in the bed. A neurological consult was obtained which neurology felt that the majority of his problem was probably due to metabolic and infectious causes, however, felt that it could be due to a stroke and recommended an magnetic resonance imaging scan at a future date to further delineate this. However, by postoperative day #9, the patient's mental status had improved. The patient began to follow commands and move all extremities to command, and their recommendations were changed to consider the magnetic resonance imaging scan if the patient did not continue to progress. The patient continued to progress from a neurologic standpoint. By postoperative day #9, the patient was weaned and extubated from mechanical ventilation and continued to improve from a pulmonary standpoint, was able to tolerate nasal cannula by the morning of postoperative day #10 and required some pulmonary toilet, encouragement with coughing and deep breathing. It was noted about this time that the patient had an area of skin abrasion on his lower coccyx and gluteal cleft. Duoderm was applied and subsequent skin care specialist evaluated the patient and felt that it was a Stage 2 ulcer and recommended continuing Duoderm. The patient continued to improve, neurologically. He was quickly weaned off of oxygen to room air by postoperative day #11. Fever curve decreased by postoperative day #11, temperature maximum was 98. The patient continued to have episodes of confusion and delirium, however, he was following commands and moving all extremities equally. The patient's delirium continued to improve. The patient's antibiotics were weaned. The Vancomycin and the Flagyl were discontinued as the patient had no positive culture, was continued on the Levofloxacin. The patient was tolerating a regular diet without signs or symptoms of aspiration. The patient began walking with physical therapy, ambulating in the Intensive Care Unit. By postoperative day #13, the patient was transferred from the Intensive Care Unit to the regular floor. He remained hemodynamically stable and was able to ambulate with assistance, on room air and by postoperative day #15 the patient was deemed stable for discharge to a rehabilitation facility. The patient will be discharged on postoperative day #16. CONDITION ON DISCHARGE: Temperature maximum 96.5, pulse 78 in sinus rhythm, blood pressure 95/60, respiratory rate 18, room air oxygen saturation 95%, patient's weight on [**11-8**] was 90.1 kg. Preoperatively the patient weighed 100 kg. The patient was awake, alert and oriented times three, moving all extremities equally. Heart regular rate and rhythm without rub or murmur. Respiratory breath sounds are clear bilaterally. Abdomen, positive bowel sounds, soft, nontender, nondistended, tolerating regular diet. Extremities were warm and well perfused, no edema. The pressure ulcer over the gluteal cleft is covered with Duoderm. There is some mild erythema. There is no fluctuance. The sternal incision is clean and dry. The sternum is stable. Staples are intact. Left leg, vein harvest incision is clean and dry. Steri-Strips are intact. LABORATORY DATA: Laboratory data revealed white blood cell count 13.1, sodium 136, potassium 5.0, chloride 98, bicarbonate 29, BUN 27, creatinine 1.1, glucose 104. The patient has a chest x-ray pending for [**11-8**]. DISCHARGE MEDICATIONS: 1. Lopressor 25 mg p.o. b.i.d. 2. Colace 100 mg p.o. b.i.d. 3. Enteric coated Aspirin 325 mg p.o. q. day 4. Plavix 75 mg p.o. q. day 5. Percocet 5/325 one to two p.o. q. 4 hours prn 6. Lipitor 20 mg p.o. q. day 7. Prevacid 30 mg p.o. q. day 8. Zoloft 100 mg p.o. q. day 9. Lasix 20 mg p.o. q. day times seven days 10. Glipizide 5 mg p.o. q. day 11. Regular insulin sliding scale for blood sugar 120 to 150, give 1 unit subcutaneously, for blood sugar 150 to 200 give 3 units subcutaneously, for blood sugar 201 to 250 give 5 units subcutaneously, for blood sugar of 251 to 300 give 7 units subcutaneously, for blood sugar of 301 to 350 give 9 units, subcutaneous, for blood sugar greater than 350 give 11 units subcutaneously. DISCHARGE DIAGNOSIS: 1. Coronary artery disease 2. Status post redo coronary artery bypass graft times three 3. Postoperative respiratory failure due to Amiodarone toxicity versus aspiration pneumonia 4. Postoperative atrial fibrillation 5. Postoperative Stage 2 pressure ulcer on gluteal fold CONDITION ON DISCHARGE: The patient is to be discharged to rehabilitation in stable condition. FOLLOW UP: The patient should follow up with the Dr. [**Last Name (STitle) 29480**] in one to two weeks, the patient should follow up with Dr. [**First Name (STitle) **] in one to two weeks. The patient should follow up with Dr. [**Last Name (STitle) **] in one month. The patient should have the staples removed from the sternal incision on postoperative day #21 which is [**11-14**]. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Last Name (NamePattern1) 1541**] MEDQUIST36 D: [**2142-11-8**] 17:13 T: [**2142-11-8**] 20:48 JOB#: [**Job Number 29481**]

[ "276.3", "276.7", "518.5", "997.3", "707.0", "427.31", "507.0", "414.02", "414.01" ]

icd9cm

[ [ [] ] ]

[ "33.24", "36.12", "96.72", "96.6", "88.72", "36.15", "38.91", "96.04", "39.61", "89.68" ]

icd9pcs

[ [ [] ] ]

9648, 10385

10406, 10685

1656, 8547

10794, 11450

178, 840

863, 1638

10710, 10782

66,560

103,901

16950

Discharge summary

report

Admission Date: [**2168-1-3**] Discharge Date: [**2168-1-15**] Date of Birth: [**2115-7-19**] Sex: F Service: SURGERY Allergies: Ibuprofen / Aspirin Attending:[**First Name3 (LF) 301**] Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: [**2168-1-6**] Exploratory laparotomy and Revision of jejunojejunostomy History of Present Illness: Ms. [**Known lastname 47700**] is a 52 yo F s/p laparoscopic RNY gastric bypass in [**2158**] with Dr. [**Last Name (STitle) **] who is transferred from OSH for SBO. She began to have epigastric abdominal pain on Wednesday, described as constant ache with breakthrough sharp pains, that was persistent. She continued to tolerate PO and had flatus, until yesterday, when she presented to the OSH ED after 1 episode of emesis. Her meals have included vegetable [**Location (un) 6002**], broth, hamburger in the past few days, which she has all tolerated before. Of note, she has had back pain for the past 2 weeks. She complains of persistent nausea. At the OSH ED, NGT was placed, labs were reportedly normal and she was hemodynamically stable. She was given morphine IV and transferred to [**Hospital1 18**] for further care. Past Medical History: HTN - no longer takes medications; HLD - resolved, formerly on crestor Past Surgical History: cholecystectomy [**2140**], lap RNY gastric bypass [**2158**] Social History: Lives at home with her husband. [**Name (NI) **] EtOH or smoking. Family History: Noncontributory, patient is adopted Physical Exam: On Admission: Vitals 98.7 176/108 97 16 96% RA FS 210 General: mild distress, uncomfortable, A&Ox3 CV: RRR, nl s1 s2 Pulm: CTAB, no rhonchi/rales Abd: soft, focal epigastric tenderness to light palpation, no peritoneal signs, nondistended Ext: WWP, no edema On Dishcarge: VS: T 98.9 HR 85 BP 119/78 RR 18 O2 100% RA FS 103 Constitutional: NAD Neuro: Alert and oriented x 3 Cardiac: RRR, NL S1,S2 Lungs: CTA B/l, no respiratory distress. Abdomen: Soft, mildly tender to palpation, no rebound tenderness/ guarding Wound: Abd midline incision c/d/i without steri-strips and with some inferior border erythema that is improving Ext: mild edema, no c/c. MAE. Pertinent Results: [**2168-1-3**] CT Abdomen: Findings: A large amount of stool is present within the ascending and transverse colon. The ascending colon is distended with bowel loops measuring up to approximately 9.5 cm in diameter. Additionally, a few mildly distended loops of small bowel are present in the left mid abdomen near surgical chain sutures. The small bowel measures up to about 4.3 cm in diameter. No free intraperitoneal air is identified. Nasogastric tube is present within the body of the stomach. Within the chest, lungs are clear except for minimal linear atelectasis at the bases. IMPRESSION: Findings which may be related to partial small-bowel obstruction as reported on review of recent outside hospital CT by Dr. [**Last Name (STitle) **]. Recommend short-term followup radiographs or CT. [**2168-1-5**] CT ABD & PELVIS WITH CONTRAST: IMPRESSION: 1. High-grade small bowel obstruction with oral contrast failing to pass the proximal portion the efferent loop. Along with mesenteric tortuosity engorgement and swirl; these findings are concerning for an internal hernia. 2. New abdominal and pelvic free fluid. No evidence of perforation. [**2168-1-5**] ECG: Sinus rhythm. Consider inferior myocardial infarction. T wave abnormalities. No previous tracing available for comparison. [**2168-1-5**] CHEST (PORTABLE AP): IMPRESSION: 1. Proper position of the endotracheal tube and nasogastric tube. 2. Right internal jugular catheter ends in the right atrium approximately 1 cm from the superior atriocaval junction. [**2168-1-8**] CHEST (PORTABLE AP): FINDINGS: In comparison with the study of [**1-7**], there are continued low lung volumes. The right IJ catheter has been removed and the nasogastric tube again extends to the upper stomach. There is opacification at the bases most likely reflecting small right effusion and bilateral atelectasis. In the appropriate clinical setting, superimposed pneumonia would have to be considered. [**2168-1-8**] CHEST PORT. LINE PLACEM: IMPRESSION: 1. PICC wire ends at the atriocaval junction. If the catheter extends beyond the wire, would consider pulling back 2-3 cm. 2. Stable small bilateral pleural effusions and mild bibasilar atelectasis. [**2168-1-15**] 05:20AM BLOOD WBC-14.1* RBC-3.26* Hgb-9.6* Hct-28.6* MCV-88 MCH-29.3 MCHC-33.5 RDW-14.8 Plt Ct-635* [**2168-1-14**] 04:50PM BLOOD WBC-16.2* RBC-2.71* Hgb-7.8* Hct-23.8* MCV-88 MCH-28.9 MCHC-32.9 RDW-15.4 Plt Ct-597* [**2168-1-14**] 04:34AM BLOOD WBC-14.1* RBC-2.52* Hgb-7.4* Hct-22.5* MCV-89 MCH-29.3 MCHC-32.9 RDW-15.2 Plt Ct-549* [**2168-1-13**] 08:15AM BLOOD WBC-14.6*# RBC-2.79*# Hgb-8.1*# Hct-24.3*# MCV-87 MCH-29.2 MCHC-33.5 RDW-15.6* Plt Ct-522*# [**2168-1-9**] 09:09AM BLOOD WBC-5.2 RBC-4.54 Hgb-13.8 Hct-40.6 MCV-90 MCH-30.3 MCHC-33.9 RDW-15.0 Plt Ct-223 [**2168-1-8**] 02:26PM BLOOD WBC-7.9 RBC-4.24# Hgb-12.4# Hct-37.7# MCV-89 MCH-29.2 MCHC-32.9 RDW-15.4 Plt Ct-194 [**2168-1-8**] 03:47AM BLOOD WBC-12.2* RBC-2.81* Hgb-8.3* Hct-25.0* MCV-89 MCH-29.5 MCHC-33.1 RDW-15.4 Plt Ct-243 [**2168-1-7**] 02:03AM BLOOD WBC-9.9 RBC-2.82* Hgb-8.3* Hct-25.1* MCV-89 MCH-29.2 MCHC-32.9 RDW-15.1 Plt Ct-220 [**2168-1-6**] 02:47AM BLOOD WBC-14.0* RBC-3.19* Hgb-9.5* Hct-27.4* MCV-86 MCH-29.6 MCHC-34.5 RDW-15.2 Plt Ct-343 [**2168-1-5**] 07:50PM BLOOD WBC-13.1* RBC-4.02* Hgb-12.0 Hct-34.8* MCV-86 MCH-29.9 MCHC-34.6 RDW-14.5 Plt Ct-424 [**2168-1-5**] 07:10AM BLOOD WBC-16.0* RBC-4.58 Hgb-13.4 Hct-39.3 MCV-86 MCH-29.3 MCHC-34.1 RDW-14.8 Plt Ct-393 [**2168-1-4**] 07:16AM BLOOD WBC-17.1* RBC-4.70 Hgb-13.7 Hct-40.9 MCV-87 MCH-29.1 MCHC-33.4 RDW-14.4 Plt Ct-353 [**2168-1-3**] 08:40PM BLOOD WBC-20.0*# RBC-4.65 Hgb-13.8 Hct-40.7 MCV-88 MCH-29.7# MCHC-33.9# RDW-14.6 Plt Ct-337 [**2168-1-7**] 02:03AM BLOOD Neuts-86.2* Lymphs-8.2* Monos-3.8 Eos-1.5 Baso-0.3 [**2168-1-6**] 02:47AM BLOOD Neuts-85* Bands-8* Lymphs-4* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2168-1-5**] 07:50PM BLOOD Neuts-56 Bands-29* Lymphs-8* Monos-7 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2168-1-7**] 02:03AM BLOOD PT-18.9* PTT-42.5* INR(PT)-1.8* [**2168-1-5**] 07:50PM BLOOD PT-12.7* PTT-24.2* INR(PT)-1.2* [**2168-1-5**] 08:40AM BLOOD PT-11.5 PTT-24.6* INR(PT)-1.1 [**2168-1-15**] 05:20AM BLOOD Glucose-96 UreaN-14 Creat-0.5 Na-131* K-4.9 Cl-99 HCO3-24 AnGap-13 [**2168-1-13**] 08:15AM BLOOD Glucose-91 UreaN-8 Creat-0.5 Na-133 K-4.5 Cl-100 HCO3-23 AnGap-15 [**2168-1-11**] 07:18AM BLOOD Glucose-114* UreaN-7 Creat-0.4 Na-137 K-3.8 Cl-102 HCO3-25 AnGap-14 [**2168-1-9**] 09:09AM BLOOD Glucose-126* UreaN-6 Creat-0.4 Na-136 K-3.5 Cl-99 HCO3-29 AnGap-12 [**2168-1-6**] 04:22PM BLOOD Glucose-90 UreaN-11 Creat-0.6 Na-137 K-3.4 Cl-105 HCO3-24 AnGap-11 [**2168-1-5**] 07:50PM BLOOD Glucose-126* UreaN-13 Creat-0.7 Na-137 K-3.5 Cl-104 HCO3-21* AnGap-16 [**2168-1-5**] 07:10AM BLOOD Glucose-127* UreaN-8 Creat-0.6 Na-134 K-3.4 Cl-97 HCO3-26 AnGap-14 [**2168-1-4**] 07:16AM BLOOD Glucose-138* UreaN-7 Creat-0.6 Na-137 K-4.0 Cl-102 HCO3-22 AnGap-17 [**2168-1-3**] 08:40PM BLOOD Glucose-174* UreaN-6 Creat-0.6 Na-137 K-3.5 Cl-105 HCO3-21* AnGap-15 [**2168-1-7**] 02:03AM BLOOD ALT-79* AST-82* LD(LDH)-280* AlkPhos-51 TotBili-0.6 [**2168-1-6**] 02:47AM BLOOD ALT-140* AST-119* AlkPhos-55 TotBili-0.9 [**2168-1-5**] 07:10AM BLOOD ALT-62* AST-37 LD(LDH)-238 AlkPhos-55 Amylase-70 TotBili-0.6 [**2168-1-4**] 07:16AM BLOOD ALT-90* AST-75* LD(LDH)-284* AlkPhos-56 Amylase-372* TotBili-0.5 [**2168-1-3**] 08:40PM BLOOD ALT-64* AST-105* AlkPhos-56 Amylase-616* TotBili-0.9 [**2168-1-5**] 07:10AM BLOOD Lipase-59 [**2168-1-4**] 07:16AM BLOOD Lipase-615* [**2168-1-3**] 08:40PM BLOOD Lipase-2094* [**2168-1-15**] 05:20AM BLOOD Calcium-8.3* Phos-4.1 Mg-2.1 [**2168-1-13**] 08:15AM BLOOD Albumin-3.0* Calcium-8.2* Phos-4.0 Mg-1.8 [**2168-1-14**] 04:34AM BLOOD Calcium-8.2* Phos-4.1 Mg-2.1 Iron-12* [**2168-1-6**] 02:47AM BLOOD Albumin-3.4* Calcium-8.1* Phos-2.5* Mg-2.1 [**2168-1-4**] 07:16AM BLOOD Calcium-9.2 Phos-3.2 Mg-1.7 Cholest-200* [**2168-1-3**] 08:40PM BLOOD Albumin-4.5 Calcium-9.3 Phos-3.2 Mg-1.7 Iron-170* [**2168-1-14**] 04:34AM BLOOD calTIBC-220* VitB12-682 Ferritn-167* TRF-169* [**2168-1-3**] 08:40PM BLOOD VitB12-816 Folate-GREATER TH [**2168-1-4**] 07:16AM BLOOD Triglyc-105 HDL-36 CHOL/HD-5.6 LDLcalc-143* [**2168-1-6**] 11:39AM BLOOD Lactate-1.8 [**2168-1-6**] 03:07AM BLOOD Lactate-2.3* [**2168-1-5**] 07:58PM BLOOD Lactate-2.9* [**2168-1-5**] 05:09PM BLOOD Glucose-134* Lactate-2.3* Na-132* K-4.0 Cl-105 [**2168-1-5**] 04:00PM BLOOD Glucose-133* Lactate-1.9 K-3.3 Cl-104 [**2168-1-5**] 07:12AM BLOOD Lactate-2.2* [**2168-1-4**] 07:32AM BLOOD Lactate-2.0 [**2168-1-3**] 10:43PM BLOOD Lactate-1.5 [**2168-1-6**] 03:07AM BLOOD freeCa-1.12 [**2168-1-5**] 04:00PM BLOOD freeCa-1.04* [**2168-1-9**] 09:09AM BLOOD VITAMIN B1-Test Brief Hospital Course: The patient was transferred from an OSH on [**2168-1-3**] for concern of small bowel obstruction s/p laparoscopic RNY gastric bypass by Dr. [**Last Name (STitle) **] in [**2158**]. On admission, abdomen was noted to be soft and without peritoneal signs. Admission labs noted elevated pancreatic enzymes, a leukocytolysis to 20K, and a mild tansaminitis. Radiologists at [**Hospital1 18**] reviewed the outside films which were read as an obstruction at the jejunal anastomosis with fluid in the abdomen, and question of internal hernia. Discussed CT with [**Hospital1 18**] radiologist who believed the scan was consistent with partial obstruction, without evidence of internal hernia, and with stool going all the way to the rectum. The patient was made NPO, with IVF, and a foley for urine output monitoring. The patient received IV morphine o/n and was transitioned to a morphine PCA on HD1. On HD3, the patient experienced worsening abdominal pain prompting a repeat Abd/ Pelvic CT scan, which suggested high-grade small bowel with 'mesenteric tortuosity engorgement and swirl' concern for internal hernia. Given these findings, the patient was brought to the operating room emergently where she underwent an exploratory laparotomy with revision of jejunojejunostomy (reader referred to operative note for complete detail). The patient required pressors intraoperatively and was kept intubated overnight due to concern for possible lactic acidosis and worsening cardiopulmonary function which never presented itself. Patient was able to be weaned off pressors over the next 24 hours and was extubated on POD 1 without incident. Neuro: Pre-operatively pain was managed with IV morphine while NPO to good effect and a morphine PCA was started on HD 1. Post-op, the patient experienced intermittent delirium while on a dilauid PCA in the intensive care unit, which resolved by POD 2 after being transferred to morphine PCA with IV tylenol; When tolerating a diet, patient was transitioned to PO pain medications on POD 6 - initially roxicet, then transitioned to liquid tylenol and liquid oxycodone. CV: The patient was noted to be hypertensive upon admissions with SBP 150-170s. Patient has a history of hypertension but no longer takes medications for this. Blood pressure improved with IV lopressor and better pain control, however, it remained in the 150s. Intraoperatively the patient required pressors which were continued until POD 1. Additionally, she was tachycardic until POD1 which improved with aggressive fluid resuscitation, however, she remained intermittently tachycardic throughout the remainder of her hospitalization requiring transition to oral metoprolol. She was hemodynamically stable by POD 3 and transferred tot he floor. At time of discharge, her hypertension and tachycardia were resolving and she was instructed to follow up with her PCP about her cardiovascular physiology and need for continuation of this medication. Pulmonary: The patient remained intubated post-operatively. She was gradually weaned from the ventilator and extubated on POD1. Once extubated, she was weaned from to room air over the next 2 days and remained stable from a pulmonary standpoint. Good pulmonary toilet, ambulation and incentive spirometry were encouraged throughout hospitalization. GI/GU/FEN: Patient was made NPO with IVF and an NGT upon admission, with a foley catheter for UOP monitoring. On HD3, the patient experienced worsening abdominal pain prompting a repeat Abd/ Pelvic CT scan, which suggested high-grade small bowel with 'mesenteric tortuosity engorgement and swirl' concern for internal hernia. Given these findings, the patient was brought to the operating room emergently where she underwent an exploratory laparotomy with revision of jejunojejunostomy (as described above). Post-operatively, the patient was transferred to the intensive care unit for further management. She was kept NPO with NGT and IVF postoperatively - requiring aggressive fluid resuscitation until POD2. A PICC line was placed on POD3 and TPN started. As bowel function returned NGT was discontinued and her diet was advance on POD 6 which was well tolerated. On POD 7 she was advanced to a bariatric stage 4 diet which resulted in increased nausea and bloating and she was told to restrict her diet and reduced to Stage 3 and subsequently had poor PO intake. TPN was subsequently restarted on POD 8. Her urine output was only about 20/hr overnight on POD 0 but after resuscitation patient started making 40/hr by the afternoon of POD 1 and maintained good UOP thereafter. Patient complained of burning upon urination near the end of her hospital stay but urinalysis failed to demonstrate a UTI and patient was not any treatment for this complaint. Patient's intake and output were closely monitored. ID: Patient presented with a white count of 20,000 which was downtrending by HD1. She received intraoperative Kefzol and Flagyl which were continued for 24 hours. The patient's fever curves were closely watched for signs of infection, of which there were none. However, on POD 9 the patient's midline incision began to demonstrate erythema on the inferior border and in light of a bump in her WBC she was started on IV ancef until discharge at which time she was transition to keflex x 1 week. Her white count was down trending at time of discharge. Prophylaxis: The patient received subcutaneous heparin and [**Last Name (un) **] dyne boots were used during this stay; she also received protonix for GI prophylaxis while NGT was in place. She was encouraged to get up and ambulate throughout her stay. At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a regular diet, ambulating, voiding without assistance, and pain was well controlled. The patient received discharge teaching and follow-up instructions including: 1 week intake of oral antibiotic, follow up with PCP regarding overall condition and hospital course, addition of new medications including metoprolol and discussion with PCP about discontinuation, diet information, follow up appointments, need to return to [**Hospital1 18**] for further care, warning signs, and activities all of which she stated she understood and was in agreement with the discharge plan. Medications on Admission: Iron, MTV 1 tab daily, glucosamine, Vitamin D, colace Discharge Medications: 1. TPN Volume: 1450mL. Amino Acid: 95g Dextrose 170 Fat 35 Electrolytes: NaCl 155 NaAc 0 NaPO4 20 KCl 25 KAc 0 KPO4 15 MgS04 12 CaGlu 10. Cycle: 12 hours. Add standard multivitamin Quantity 30 bags. 2. Outpatient Lab Work ALT, AST, Albumin, Chem 10, Triglycerides 3. PICC Care Weekly PICC care including prn dressing and cap change 4. acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every [**3-25**] hours as needed for pain: Crush. Disp:*60 Tablet(s)* Refills:*2* 5. oxycodone 5 mg/5 mL Solution Sig: [**4-28**] ml PO Q3H (every 3 hours) as needed for pain. Disp:*500 ml* Refills:*0* 6. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Crush. Disp:*60 Tablet(s)* Refills:*0* 7. ferrous sulfate 325 mg (65 mg iron) Tablet Sig: One (1) Tablet PO once a day. 8. calcium citrate-vitamin D3 500 mg calcium -400 unit Tablet, Chewable Sig: Two (2) Tablet, Chewable PO once a day. 9. eszopiclone 2 mg Tablet Sig: One (1) Tablet PO once a day as needed for insomnia. 10. docusate sodium 50 mg/5 mL Liquid Sig: Ten (10) ml PO twice a day as needed for constipation. Disp:*250 ml* Refills:*2* 11. ranitidine HCl 15 mg/mL Syrup Sig: Ten (10) mL PO twice a day. Disp:*600 mL* Refills:*0* 12. Keflex 500 mg Capsule Sig: One (1) Capsule PO every six (6) hours for 1 weeks. Disp:*28 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Last Name (un) 6438**] Discharge Diagnosis: High Grade Small Bowel Obstruction with Internal Hernia s/p Exploratory laparotomy and revision of jejunojejunostomy Acute Pancreatitis Constipation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: You were admitted to the hospital with severe abdominal pain related to a small bowel obstruction. This became progressively worse during your hospitalization requiring an urgent operation. You have recovered in the hospital and are now preparing for discharge to home on nocturnal intravenous nutrition with follow-up scheduled on [**2168-1-27**] with Dr. [**Last Name (STitle) **] and [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RD. Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. *Please present to [**Hospital1 18**] if possible for any future complications. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**4-28**] lbs until you follow-up with your surgeon. Avoid driving or operating heavy machinery while taking pain medications. Continue to get up and walk several times a day as tolerated. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower, and wash surgical incisions with a mild soap and warm water. Gently pat the area dry. PICC Line: *Please monitor the site regularly, and [**Name6 (MD) 138**] your MD, nurse practitioner, or [**Name6 (MD) 269**] Nurse if you notice redness, swelling, tenderness or pain, drainage or bleeding at the insertion site. * [**Name6 (MD) **] your MD [**First Name (Titles) **] [**Last Name (Titles) 10836**] to the Emergency Room immediately if the PICC Line tubing becomes damaged or punctured, or if the line is pulled out partially or completely. DO NOT USE THE PICC LINE IN THESE CIRCUMSTANCES. Please keep the dressing clean and dry. Contact your [**Name2 (NI) 269**] Nurse if the dressing comes undone or is significantly soiled for further instructions. Followup Instructions: Please contact your primary care provider to schedule [**Name Initial (PRE) **] follow-up appointment within 1-2 weeks. Department: BARIATRIC SURGERY When: WEDNESDAY [**2168-1-27**] at 3:00 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], RD [**Telephone/Fax (1) 305**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: BARIATRIC SURGERY When: WEDNESDAY [**2168-1-27**] at 3:30 PM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 304**], MD [**Telephone/Fax (1) 305**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Pleae contact your PCP to schedule an appointment within the next 2 weeks. Update him on your hospital course and current medication regimen including addition of lopressor and have him make adjustments as needed.

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Discharge summary

report

Admission Date: [**2145-12-6**] Discharge Date: [**2145-12-23**] Date of Birth: [**2078-11-23**] Sex: M Service: SURGERY Allergies: Ephedrine / Adhesive Tape / Oxycodone / Augmentin / Bactrim Ds Attending:[**First Name3 (LF) 695**] Chief Complaint: GI Bleed Major Surgical or Invasive Procedure: [**2145-12-17**]: Angiogram with coiling History of Present Illness: 67M with history of metastatic renal cell cancer presented to an outside hospital [**2145-11-28**] with BRBPR. He was anticoagulated with coumadin for a mechanical valve and his INR was 3.9, his hematocrit on admission was 24. He was transfused roughly 2 units pRBC, 4U FFP and given vitamin K. He underwent an upper endoscopy [**2145-11-30**] which demonstrated gastritis, duodenitis and an actively bleeding duodenal ulcer which was clipped. He was discharged home on [**2145-12-2**] and returned on the same day with abdominal pain and bright red blood per rectum. He underwent another EGD [**12-3**] which did not show evidence of bleeding, but he did undergo a colonoscopy which demonstrated a splenic flexure mass which is hypervascular, consistent with a hypernephroma. His hematocrit on discharge to [**Hospital1 18**] is 27.4. He is transferred to [**Hospital1 18**] for further management. Past Medical History: RCC [**2140**]; MI [**2136**]; DM- diet controlled PSH: CABGx5 and AVR [**2136**]; Nephrectomy [**2140**]; ERCP x 3 with multiple stent placements [**2144-2-11**]: CBD excision with cholecystectomy, Roux-en-Y and segment III, IV, V, VI and VII mass resections [**2144-9-18**]: Wound revision and closure of incisional hernia with Prolene mesh Supratherapeutic INR Bacteremia, VRE/E.coli [**2145-12-17**] Coil and Gelfoam embolization of the 3rd to 4th order inferior branch off the replaced right hepatic artery Social History: N/[**Doctor First Name **] has no history of alcohol use. He has a smoking history but quit eight years ago. He has no history of IV drug use, marijuana use, tattoos, hepatitis, or piercing. He did have blood transfusions in [**2136**] and [**2140**]. He has one year of college. He has been married for 36 years. Family History: N/C Physical Exam: Vitals: Temp 97.9, HR 92, BP 140/70, RR 16, 92% RA Gen: alert and oriented, somewhat somnolent CVS: RRR, systolic murmur present Pulm: CTA b/l Abd: soft / non distended / min tenderness epigastrium Rectal: giuiac positive, no obvious masses Pertinent Results: On Admission: [**2145-12-7**] WBC-4.0 RBC-3.01*# Hgb-8.2*# Hct-24.9*# MCV-83 MCH-27.2 MCHC-32.9 RDW-17.7* Plt Ct-117* PT-15.0* PTT-30.3 INR(PT)-1.3* Glucose-93 UreaN-12 Creat-0.8 Na-139 K-3.6 Cl-102 HCO3-29 AnGap-12 ALT-15 AST-25 AlkPhos-147* TotBili-1.0 Calcium-8.7 Phos-2.8 Mg-1.7 Albumin-3.0* On Discharge: [**2145-12-23**] WBC-3.6* RBC-3.67* Hgb-10.7* Hct-31.2* MCV-85 MCH-29.2 MCHC-34.4 RDW-18.1* Plt Ct-79* PT-20.2* INR(PT)-1.9* Glucose-104 UreaN-12 Creat-1.1 Na-135 K-4.2 Cl-98 HCO3-32 AnGap-9 ***HEPARIN DEPENDENT ANTIBODIES-PND Brief Hospital Course: 67 y/o male admitted from OSH with recent GI bleeding. Outpatient scope and reports were reviewed and an abdominal CT was showing: - Invasion into the hepatic flexure colonic wall by a tumor closely associated with and possibly arising from the large segment V-VI hepatic mass. Colonic wall thickening from the cecum to the proximal transverse colon, proximal and distal to this mass. - Increase in size of multiple perihepatic masses adjacent to the inferior aspect of the liver in comparison to the prior study. Due to concern for thrombus risk in his prosthetic aortic heart valve, heparin was started and then bridged back to coumadin when it appeared he was not having large amounts of bleeding. He was receiving blood transfusions almost daily to maintain his hematocrit 26-30% Sutent 50 mg was started on [**12-11**], which was the dosage recommended by his Oncologist Dr [**Last Name (STitle) 76148**]. His records had been reviewed by oncology at this institution and it was determined that this was the most appropriate medication given the type of tumor although there was a risk for bleeding. On [**12-16**] he was ordered for bowel prep to attempt a colonoscopy on [**12-17**] and on the morning of [**12-17**] he had multiple large volume bowel movements that were very bloody. He was transfused 4 units pRBCs on [**12-17**] units on [**12-18**], FFP and platelets x 1. His Hct was as low as 9.4% and was restabilized at 30%. On the evening of [**12-17**] an arteriogram was performed. Please see the report for details. He had Coil and Gelfoam embolization of the 3rd to 4th order inferior branch off the replaced right hepatic artery resulting in occlusion of one of the arteries supplying hepatic/hepatic flexure mass. Following the procedure his hematocrit has remained 28-33%. He received an additional 2 units on [**12-22**]. Bowel movements since the time of the procedure have been brown with no evidence of bleeding. His coumadin was only held on the 11th and he has otherwise received 8 mg daily with goal INR 1.5-2 (has aortic valve). Platelet count trended down over the past few days since [**12-17**] when he was 196. Platelet count decreased to 69-79 range. He was started on methadone for pain management as he was requiring frequent dosing of dilaudid. Dilaudid usage has decreased. All other home medications were maintained. He is going home today on coumadin 8mg daily and sutent 50mg daily. He will get daily cbc and inr with results called to Dr. [**Last Name (STitle) 76149**] office [**Telephone/Fax (1) 19102**] (fax [**Telephone/Fax (1) 76150**]). At time of discharge, vital signs were stable. He was ambulatory and tolerating a regular diet. Medications on Admission: Prilosec 20", lasix 40", duoneb QID, advair diskus 250/50 [**Hospital1 **], lactulose, amitriptyline, coumadin 12', colace 100", dilaudid 2 q 4 prn, vicodin 1 tab q 4 prn, zenate 5 qday, iron 325 [**Hospital1 **] Discharge Medications: 1. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): Hold for > 2 stools daily. 3. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Warfarin 5 mg Tablet Sig: One (1) Tablet PO once a day. 5. Warfarin 1 mg Tablet Sig: Three (3) Tablet PO once a day. 6. Methadone 5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): Prescribed for pain relief. Disp:*30 Tablet(s)* Refills:*2* 7. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2 times a day): Hold for > 2 BMs daily. 8. Prilosec 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 9. Hydromorphone 4 mg Tablet Sig: [**1-8**] Tablet PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 10. Sutent 50 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 11. Outpatient Lab Work Daily stat cbc, inr with results called first to Dr.[**Last Name (STitle) 76151**] office [**Telephone/Fax (1) 19102**] and fax'd to Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 697**] 12. Amitriptyline 50 mg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Disposition: Home Discharge Diagnosis: Renal Cell carcinoma with liver metastases now with colonic mass Lower GI bleeding Discharge Condition: Stable, Hct 31.2 upon discharge Ambulatory Alert and Oriented. Caution use of too many narcotics Discharge Instructions: Please call Dr[**Name (NI) 1369**] office at [**Telephone/Fax (1) 673**] for fever, chills, nausea, vomiting, bleeding from rectum, weakness, dizziness, increased abdominal pain. Contact [**Name2 (NI) 76152**] office at [**Telephone/Fax (1) 19102**] for further medication adjustments and continued plan for oncology daily labs for INR and CBC with results called to Dr.[**Last Name (STitle) 76153**] office and fax'd to Dr.[**Name (NI) 1369**] office [**Telephone/Fax (1) 697**] Followup Instructions: CAT SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2146-2-22**] 1:00 Please schedule follow up with Dr. [**Last Name (STitle) **]. [**First Name4 (NamePattern1) 698**] [**Last Name (NamePattern1) 699**] will call you with date/time [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 707**] MD, [**MD Number(3) 709**] Completed by:[**2145-12-23**]

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icd9cm

[ [ [] ] ]

[ "99.04", "88.47", "99.05", "38.93", "39.79", "99.07" ]

icd9pcs

[ [ [] ] ]

7258, 7264

3041, 5730

332, 375

7391, 7490

2479, 2479

8019, 8415

2197, 2202

5994, 7235

7285, 7370

5756, 5971

7514, 7996

2217, 2460

2790, 3018

284, 294

403, 1310

2493, 2776

1332, 1846

1862, 2181

31,021

117,284

26721

Discharge summary

report

Admission Date: [**2102-12-18**] Discharge Date: [**2103-1-5**] Date of Birth: [**2035-6-27**] Sex: M Service: NEUROSURGERY Allergies: Penicillins / Permax / Lisinopril / Lovastatin / Mavik / Erythromycin Attending:[**First Name3 (LF) 1271**] Chief Complaint: Increasing large, chronic left subdural hematoma, associated with functional deterioration Major Surgical or Invasive Procedure: [**2102-12-18**]: Craniotomy for left SDH [**2102-12-26**]: Trach placement [**2103-1-4**]: Percutaneous gastrostomy tube placement History of Present Illness: Mr. [**Known lastname **] is a 67M with Parkinson's disease diagnosed a few years ago. He was referred to Dr. [**Last Name (STitle) 59664**] on [**2102-10-26**] for evaluation of mental status changes including gait and balance, which had been getting progressively worse over the last six months. He also noted diplopia for nearly a year without any ophthalmological etiology. He brought multiple studies (MRI/CT) for evaluation, and it was determined that evacuation of the SDH would provide the best chance at possibly allieviating symptoms given the enlarging size of the hematoma. Past Medical History: Parkinson's disease, with nighttime hallucinations L subdural hemorrhage Hyperlipidemia Social History: married, lives at home Family History: not obtained Physical Exam: [**2103-1-5**] Vitals: 97.5, BP 146/78, HR 73, RR 22, OT Sat 92%, FS 128, I:2290(24h) O:4050(24h) General: NAD Wounds: C/D/I Neuro Exam: -eyes open to voice -PERRLA (2mm-1mm) -Motor: Upper extremities localize bilaterally to painful stimuli Lower extremities withdraw bilaterally to painful stimuli Facial grimmace with painful stimuli Pertinent Results: [**2103-1-5**] 06:00AM BLOOD WBC-10.8 RBC-3.39* Hgb-10.1* Hct-29.6* MCV-87 MCH-29.9 MCHC-34.2 RDW-12.2 Plt Ct-524* [**2103-1-5**] 06:00AM BLOOD Plt Ct-524* [**2103-1-5**] 06:00AM BLOOD PT-13.7* PTT-26.4 INR(PT)-1.2* [**2103-1-5**] 06:00AM BLOOD Glucose-129* UreaN-24* Creat-1.1 Na-137 K-4.9 Cl-102 HCO3-28 AnGap-12 [**2102-12-24**] 03:38AM BLOOD ALT-83* AST-147* LD(LDH)-185 AlkPhos-94 TotBili-0.2 [**2103-1-5**] 06:00AM BLOOD Calcium-8.5 Phos-3.8 Mg-2.3 Brief Hospital Course: Patient electively admitted on [**2102-12-18**] for evacuation of chronic left subdural hematoma complicated by subarachnoid hemmorhage. [**2102-12-20**]: EEG performed: IMPRESSION: Markedly abnormal portable EEG due to the slow and disorganized background rhythm and due to the prominent focal sharp waves in the left fronto-temporal region and, less frequently, in the right frontal area. A slow background indicates a widespread encephalopathy. Medications, metabolic disturbances, and infection are among the most common causes. This should not come from a subdural hematoma alone in most cases. There were very frequent sharp waves, mostly in the left anterior quadrant (and occasionally right frontally), but there were no repetitive discharges to indicate ongoing seizures at the time. Finally, there was no prominent voltage asymmetry [**2102-12-21**]: IV antibiotics started secondary to gram negative rods in the sputum. [**2102-12-22**]: CT performed: IMPRESSION: Compared to the prior study dated [**2102-12-19**], there has been interval improvement of the pneumocephalus. There is a persistent left-sided subdural collection causing mass effect upon the left cerebral hemisphere and 6 mm midline shift, which is unchanged. Persistent widespread subarachnoid hemorrhage. Stable focal intraparenchymal hemorrhage in the left frontal region. Left subclavian line placed for continued antibiotic treatment. [**2102-12-25**]: Portable chest x-ray to follow up temp spike to 102: IMPRESSION: 1. Pulmonary edema with superimposed right middle lobe/right lower lobe infection and/or aspiration. 2. Left retrocardiac atelectasis, however, pneumonia cannot be excluded. 3. Lines, tubes and catheters are in satisfactory location. [**2102-12-26**]: Trach placed in OR, PEG postponed due to fevers. [**2102-12-30**]: IMPRESSION: 1. Compared to the prior CT, there is slight increased size of the left-sided subdural CSF intensity collection with midline shift which has slightly increased with subfalcine herniation. The right temporal [**Doctor Last Name 534**] is more dilated compared to the previous study. Extensive subarachnoid hemorrhage and hemorrhagic contusions are again identified without new hemorrhage. 2. No definite aneurysm is identified but the vascular structures are less distinctly visualized which could be due to mild non-occlusive spasm. Proximal basilar artery demonstrates narrowing which could be due to stenosis as described previously. [**2102-12-31**]: Staples removed from cranial wound. [**2103-1-1**]: Patient received 2U PRBC's for black tarry stool(guiac negative) [**2103-1-4**]: Percutaneous Gastrostomy Tube placed. [**2103-1-5**]: Tube feeds begun without incident. Medications on Admission: ASA 81mg daily Lipitor 40mg every other day Stalevo 100mg six times a day Mirapex 0.25mg TID Seroquel 12.5mg QHS Vesicare 10mg daily Flomax 0.4mg [**Hospital1 **] Discharge Medications: 1. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: to be given via g-tube. 2. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day): to be given via g-tube. 3. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily): to be given via g-tube. 4. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO QOD (): to be given via g-tube. 5. Pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): to be given via g-tube. 6. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO HS (at bedtime): to be given via g-tube. 7. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)): to be given via g-tube. 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): to be given via g-tube. 9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): to be given via g-tube. 10. Entacapone 200 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours): to be given by g-tube. 11. Carbidopa-Levodopa 25-100 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours): to be given via g-tube. 12. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed for wheeze. 13. Ipratropium Bromide 17 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for wheeze. 14. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 15. Metoprolol Tartrate 50 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day): to be given via g-tube. 16. Captopril 12.5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day): to be given via g-tube. 17. Ferrous Sulfate 300 mg/5 mL Liquid Sig: One (1) PO DAILY (Daily): to be given by g-tube. 18. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): to be given via g-tube. 19. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day): To be given via g-tube. 20. Hydromorphone 2 mg/mL Solution Sig: [**11-22**] Injection Q4H (every 4 hours) as needed for pain: to be given via g-tube. 21. Levetiracetam 100 mg/mL Solution Sig: Ten (10) PO BID (2 times a day): Please give via g-tube. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Left subdural hematoma and subarachnoid hemorrhage Discharge Condition: stable Discharge Instructions: ?????? Have a family member check your incision daily for signs of infection (increasing reddness or drainage) ?????? 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 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 anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered ?????? 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: You have sutures that will need to be removed in days 10 days. This may be done at the Rehab facility. You have an appointment with DR. [**Last Name (STitle) 739**] on [**2103-1-31**] at 3pm (immediately following CT). You have a CAT SCAN of the brain (without contrast) scheduled before this appointment at 2:15pm on the [**Hospital Ward Name 517**]. Please call [**Telephone/Fax (1) 1669**] with any questions. [**Name6 (MD) 742**] [**Name8 (MD) **] MD [**MD Number(2) 1273**] Completed by:[**2103-1-5**]

[ "E849.7", "272.4", "285.9", "486", "348.0", "345.90", "518.81", "332.0", "790.29", "348.30", "E878.8", "997.02", "518.0", "348.8", "430", "276.3" ]

icd9cm

[ [ [] ] ]

[ "43.11", "01.31", "96.07", "96.72", "31.1", "38.91", "99.04" ]

icd9pcs

[ [ [] ] ]

7404, 7476

2226, 4934

425, 559

7571, 7580

1746, 2203

8927, 9469

1344, 1358

5147, 7381

7497, 7550

4960, 5124

7604, 8904

1373, 1727

295, 387

587, 1175

1197, 1287

1303, 1328

75,714

156,754

40509

Discharge summary

report

Admission Date: [**2145-5-3**] Discharge Date: [**2145-5-13**] Date of Birth: [**2064-4-8**] Sex: M Service: MEDICINE Allergies: Ketamine Attending:[**First Name3 (LF) 5810**] Chief Complaint: Abdominal Pain Major Surgical or Invasive Procedure: 1) Endoscopic Retrograde Cholangiopancreatography (two times) including sphincterotomy and biliary stent placement 2) Percutaneous transhepatic cholangiogram and drain placement - biliary drain placement, now removed History of Present Illness: 81 yo M with CAD s/p cholecystectomy 1 year ago at [**Hospital 1562**] Hospital presented to OSH ED with one week of intermittent RUQ pain, which became constant and associated with nausea for the preceding 2 days. Of note, he denies fevers or chills at home. He has had a 50 lb weight loss since having the CCY last year that his son attributes to improved diet. He presented one week ago to the hospital with this same pain and was thought to have an ulcer; he was planned for EGD this week. Today, he presented to the [**Hospital1 1562**] ED with constant pain. A CT abdomen was performed showing CBD dilation 0.8-1.2 cm with possibility of obstructing stone. WBC, AP, BILI, and transaminases elevated--he was not given antibiotics, but did receive 4 mg Morphine and by report received a total of 1 L IVF. He was transferred to the [**Hospital1 18**] ED where initial vitals were 97.9, 100, 183/67, 18, 100%3LNC. He was given 4mg IV morphine, 6 mg IV Dilaudid, 4.5g zosyn, and 1L NS. After this, he appeared over sedated and received narcan. ERCP was contact[**Name (NI) **] with plan for biliary stent +/- sphincterotomy in the AM--primary cause for delay being INR 4.3. Family states that he is on coumadin for afib. VS on transfer: HR 110, BP 118/47, 15, 98% 2Lnc. Labs notable for WBC 13.4, Lipase 3500, ALT 283, AP 743, BILI 4.1, Cr 2.0, INR 4.3. EKG sinus tachycardia with no prior for comparison. However, on transfer from ED to ICU, devleped Afib with RVR to 150s. Was given 2.5 Metoprolol X1 with rates to 110s. Indication for [**Hospital Unit Name 153**] admission reportedly toxic appearance and oversedation in setting of excess narcotics. Past Medical History: CAD s/p CABG [**45**] years ago s/p Chole (1 yr ago) Atrial Fibrillation DM, currently not on medications Social History: Lives alone, son and daughter involved. Hx of EtOH use stopped 5 years ago. Occasional marijuana. Family History: NC Physical Exam: ADMISSION EXAM: Vitals: T 99.6 118 114/71 81 29 97% RA General: Alert, oriented x3, fidgeting with mild pain HEENT: Pinpoint pupils Sclera mildly icteric, MMM Neck: JVP not elevated Lungs: Crackles in bases bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, tender, most prominent in epigastric region and RUQ but throughout. No guarding. Ext: warm, well perfused, 2+ pulses, no edema Nuro: No focal abnormalities. Pertinent Results: ADMISSION LABS: [**2145-5-3**] 04:30PM WBC-13.4* RBC-3.14* HGB-11.0* HCT-32.2* MCV-102* MCH-35.0* MCHC-34.2 RDW-14.9 [**2145-5-3**] 04:30PM NEUTS-91.6* LYMPHS-6.8* MONOS-0.6* EOS-0.9 BASOS-0.2 [**2145-5-3**] 04:30PM PLT COUNT-151 [**2145-5-3**] 04:30PM GLUCOSE-162* UREA N-33* CREAT-2.0* SODIUM-140 POTASSIUM-4.6 CHLORIDE-103 TOTAL CO2-24 ANION GAP-18 [**2145-5-3**] 04:30PM ALBUMIN-4.2 CALCIUM-9.2 PHOSPHATE-3.1 MAGNESIUM-1.2* [**2145-5-3**] 04:30PM LIPASE-3530* [**2145-5-3**] 04:30PM ALT(SGPT)-283* AST(SGOT)-253* LD(LDH)-247 ALK PHOS-743* TOT BILI-4.1* DIR BILI-3.5* INDIR BIL-0.6 [**2145-5-3**] 11:30PM TRIGLYCER-84 [**2145-5-3**] 04:30PM PT-41.7* PTT-31.7 INR(PT)-4.3* IMAGING: Micro: [**2145-5-3**] 4:30 pm BLOOD CULTURE Blood Culture, Routine (Preliminary): KLEBSIELLA OXYTOCA. FINAL SENSITIVITIES. Piperacillin/Tazobactam sensitivity testing confirmed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. ENTEROCOCCUS SP.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA OXYTOCA | AMPICILLIN/SULBACTAM-- 4 S CEFAZOLIN------------- 16 I CEFEPIME-------------- <=1 S CEFTAZIDIME----------- <=1 S CEFTRIAXONE----------- <=1 S CIPROFLOXACIN---------<=0.25 S GENTAMICIN------------ <=1 S MEROPENEM-------------<=0.25 S PIPERACILLIN/TAZO----- <=4 S TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Enterococcus: AMPICILLIN------------ 1 S PENICILLIN G---------- 2 S TETRACYCLINE---------- 2 S VANCOMYCIN------------ <=1 S Aerobic Bottle Gram Stain (Final [**2145-5-4**]): Reported to and read back by [**Last Name (un) 88710**] [**Last Name (un) **] [**2145-5-4**] 8:35AM. GRAM NEGATIVE ROD(S). GRAM POSITIVE COCCI IN CHAINS. Anaerobic Bottle Gram Stain (Final [**2145-5-4**]): GRAM NEGATIVE ROD(S). GRAM POSITIVE COCCI IN CHAINS. Pathology: [**5-10**] brushings: NEGATIVE FOR MALIGNANT CELLS. Benign-appearing glandular cells with reactive features. [**5-10**] biopsy Ampulla, biopsy: Small fragment of cauterized fibrovascular tissue with acute inflammation and fibrinopurulent exudate. Scant benign appearing glandular epithelium present. Images: CHEST (PORTABLE AP) Study Date of [**2145-5-3**] IMPRESSION: Increased basal linear markings may reflect scarring or atelectasis. Comparison with old chest radiograph would be helpful. Superimposed patchy opacity in the left base may reflect some minimal consolidation. Followup chest x-ray is advised. TTE (Complete) Done [**2145-5-5**] Conclusions The left atrium is elongated. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function cannot be reliably assessed. The left ventricular ejection fraction appears somewhat reduced. This may be in part or in whole due to atrial fibrillation with a relatively fast ventricular rate. There is considerable beat-to-beat variability of the left ventricular ejection fraction due to an irregular rhythm. The right ventricle appears grossly normal in size, with borderline normal free wall function. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened. The aortic valve is not well seen. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**1-17**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. ERCP [**2145-5-4**] Findings: Esophagus: Limited exam of the esophagus was normal Stomach: Limited exam of the stomach was normal Duodenum: Limited exam of the duodenum was normal Major Papilla: Edematous, lacerated papilla with possible small stone fragment on entry into the duodenum. Cannulation: Cannulation of the pancreatic duct was performed with a sphincterotome after a guidewire was placed. Contrast medium was injected resulting in complete opacification. A 4cm by 5FR Zimmon pancreatic stent was placed successfully. It was placed to help reduce the risk of worsening pancreatitis and to help facilitate cannulation of the bile duct. Procedures: Multiple attempts were made to cannulate the CBD after placement of a pancreatic duct stent. The wire would not pass into the CBD. Further attempts were made with the 5-4-3 catheter which were not successful. Impression: Normal pancreatogram Successful PD stent placement to help with cannulation and reduce risk of worsening pancreatitis. Unsuccessful CBD cannulation that may be attributed to an edematous and lacerated papilla Otherwise normal ercp to third part of the duodenum [**2145-5-8**] Abd CT with contrast IMPRESSION: 1. Dislodged pancreatic duct stent appears in distal small bowel.. Appropriately positioned PTC drain with decompressed right biliary ducts. Minimal left intrahepatic biliary ductal dilatation. 2. Hemorrhagic fluid in the low pelvis, however no site of vascular injury is identified. The fluid within the pelvis may have resulted from the recent instrumentation by interventional radiology or gastroenterology. No active extravisation or free air is present. 3. Moderate to severe sigmoid diverticulosis without diverticulitis. Repeat ERCP [**2145-5-10**] Findings: Esophagus: Limited exam of the esophagus was normal Stomach: Limited exam of the stomach was normal Duodenum: Limited exam of the duodenum was normal Major Papilla: The major papilla had a bulging appearance. A plastic stent placed in the biliary duct was found in the major papilla. The radiology team then accessed the percutaneous drain and advanced a wire through the percutaneous site and into the biliary drain. The biliary drain was then pulled back into a straight position with the tip several cm out of the ampulla, to facilitate biliary cannulation. Cannulation: Cannulation of the biliary duct was successful and deep with a sphincterotome using a free-hand technique. Contrast medium was injected resulting in complete opacification. Biliary Tree: A mild dilation was seen at the biliary tree. Several small filling defects were noted, suggestive of air bubbles. The cholangiogram quality was limited by presence of PTBD drain within the bile duct. No obvious strictures or stones were noted. Procedures: A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. A balloon sweep was performed, and no sludge or stones was noted. Cytology samples were obtained for histology using a brush in the lower bile duct/ampulla. Cold forceps biopsies were performed for histology at the ampulla. A 7cm by 10FR biliary stent was placed successfully in the bile duct. Impression: The ampulla was bulging. A combined procedure with interventional radiology was performed to access bile duct. Cholangiogram revealed mild biliary dilation- several small filling defects were noted, suggestive of air bubbles. The cholangiogram quality was limited by presence of PTBD drain within the bile duct. No obvious strictures or stones were noted. Successful biliary sphincterotomy. Following sphincterotomy, the intra-ampullary segment appeared fleshy/bulging and was concerning for a malignancy. There was no obvious flow of bile after the sphincterotomy. Cytology brushing and cold forceps biopsies were obtained. Balloon sweep was performed- no stones or sludge was noted Successful placement of a 7cm x 10Fr plastic biliary stent with brisk flow of bile Otherwise normal ERCP to 3rd portion of duodenum. CT abdomen: [**5-13**] Preliminary Report Decrease in quantity of dense fluid in the pelvis compatible with resorption of previously described hemorrhagic fluid. Brief Hospital Course: Patient is a 81 yo M with CAD s/p cholecystectomy 1 year ago presented to OSH ED with one week of intermittent RUQ pain, nausea, dilated biliary duct and found to have cholangitis, GNR bacteremia, and pancreatitis # CHOLANGITIS/BACTEREMIA/PANCREATITIS: The patient does not have a recent history of alcohol use, nl triglycerides. Clinical presentation consistent with cholangitis, gallstone pancreatitis, given abdominal pain, elevated TBil/AlkPhos and dilated common bile duct on CT scan at OSH as well as bacteremia (Klebsiella and Enterococcus) He was treated with broad antimicrobials zosyn initially which was changed to unasyn/vanco when blood cultures returned with klebsiella and enterococcus, however, this was eventually changed to cipro/vanco because he developed possible drug rash on his trunk. Unclear if this rash was due to allergy to bleach in the sheets or medications, but it resolved with changing sheets and antibiotic change. He received IV vancomycin until [**5-11**] (though had a therapeutic level through [**5-13**], giving him over 7 days of IV treatment for the enterococcus. He will need to continue a 10 day course for the klebsiella ( he has 3 days remaining at the time of discharge) He had ERCP performed on [**5-4**], but CBD/biliary tree could not be accessed due to edema of the major papilla; a temporary pancreatic duct stent was placed. Interventional radiology thus placed a temporary percut biliary drain [**5-6**]. On [**5-8**] dark red blood was noted in biliary drain possibly secondary to old blood from the IR procedure, it subsequently self resolved. He received a repeat ERCP [**5-10**] which showed no sign of stones but +fullness/fleshy ampulla, sphincterotomy performed, brushings sent for cytology, biopsy. These were negative for malignancy. He is doing very well clinically with resolution of pain, nausea, bacteremia. He is taking po's well and without abdominal pain at the time of dischage. # Anemia his hct trended down from 30 to 22 over the course of his stay. He initally had an abdominal CT which showed some pelvic fluid(likely related to his percutaneous drains), this was repeated in the setting of dropping hct and he had no evidence of intra-abdominal bleeding. He had normal haptoglobin, LDH and bilirubin, making hemolysis unlikely. Iron studies, folate and B12 were pending at the time of discharge. # ATRIAL FIBRILLATION with RVR: After volume resuscitation in the ICU, his home dose of metoprolol was restarted and titrated up as needed. He had several asymptomatic episodes of RVR on the floor which required titration of metoprolol to now 50 mg po tid, decreased to [**Hospital1 **] at the time of discharge given mild bradycardia. He was in sinus rhythym at the time of discharge. His coumadin was stopped for his procedures, restarted initially at 1mg given his ciproflxacin, when he goes home he may resume we will hold his coumadin as he will be having a repeat ercp in the enar future and has been anemic during his stay. # OVERSEDATION: Patient reportedly somnolent in the ED possibly from large doses of narcotics and received narcan; he was alert and oriented upon arrival to the ICU, though with pinpoint pupils. This was not a recurrent issue subsequently in his hospital stay and he had normal orientation, good comprehension of his hospital course. # Acute renal failure and CHRONIC KIDNEY DISEASE: In the setting of antibioitcs (vancomycin), dehydration (poor po intake), CKD at baseline and IV contrast, his creatinine increased and peaked at 3.4 despite hydration and mucomyst after contrast. His creatinine improved with fluids and was 2.7 and trending downwards at the time of discharge. His lisinopril was stopped for now, this may be resumed as an outpatient if creatinine cont to improve. # HTN: metoprolol increased as noted above, lisinopril held # Gout: He was continued on allopurinol. # CAD: Pravastatin was held given transaminitis. This can be restarted at discharge. Of note, patient not currently on ASA, but should discuss with his PCP. # BPH: Terazosin was restarted as BP tolerated. Medications on Admission: Allopurinol 100 mg qd Hydroxyzine 50 mg qhs Lisinopril 40 mg qd Metoprolol Tartrate 25 mg [**Hospital1 **] Pravastatin 80 mg qd Terazosin 2 mg qam Trazodone 100 mg qhs Warfarin 2 mg qd Fish Oil MVI Calcium Azeo-Pangen CoQ-10 Discharge Medications: 1. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO twice a day for 8 days. Disp:*16 Tablet(s)* Refills:*0* 2. pravastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. 3. terazosin 2 mg Capsule Sig: One (1) Capsule PO once a day. 4. trazodone 100 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 3 days. Disp:*3 Tablet(s)* Refills:*0* 7. omega-3 fatty acids Capsule Sig: One (1) Capsule PO BID (2 times a day). 8. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 9. allopurinol 100 mg Tablet Sig: One (1) Tablet PO once a day. 10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for pain, fever. 11. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 12. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Discharge Disposition: Home Discharge Diagnosis: Acute cholangitis Gram negative bacteremia (Klebsiella and Enterococcus) Acute pancreatitis Anemia Secondary: Atrial fibrillation Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Ambulatory status: independent Discharge Instructions: Dear Mr. [**Known lastname 4300**], You were admitted with cholangitis (an infection in your biliary tract) which also caused a bloodstream infection with bacteria. You were treated with antibiotics for these infections and improved. You should continue to take 3 more days of ciprofloxacin after release. You had a drain placed in your gallbladder this admission which has now been removed. You also had a procedure called an ERCP to evaluate your biliary system, and were found to have some thickening of the ampulla, which is where the biliary tract opens/drains into the intestine. Some samples were taken of this area which were negative. You received a sphincterotomy procedure to open up this thickened area. The biliary doctors also placed a temporary stent to keep the duct open. The biliary doctors would [**Name5 (PTitle) **] [**Name5 (PTitle) **] to return in approximately one month for a repeat ERCP procedure for removal of the biliary stent. You should be off coumadin (warfarin) in advance of this appointment, so we will stop it now and you may resume it as per the ERCP doctors Other issues that came up during your hospitalization were that your kidney function declined, this was likely from a combination of factors, including dehydration, IV contrast for your CT scan and generallly being ill, this was steadily improving at the time of discharge. Your were also anemic which is probably related to several different things, including being ill and not eating while ill. You were not found to have active bleeding on your CT scan and there was no evidence of breaking up your red blood cells (no hemolysis). Your iron studies were pending at the time of discharge. The following changes were made to your medications: 1. Your metoprolol was increased to 50 mg TWO times a day to better control your heart rate. 2. Ciprofloxacin 500mg by mouth daily for 3 days 3. Your lisinopril was stopped for now, it may be restarted by your pcp once your kidney function recovers. 4. Please hold your coumadin for now and do not restart until you have had your stent removed Most patients with coronary artery disease are on aspirin at home. It appears that you have not been on this medicine. Please discuss with your PCP whether you should take aspirin. There are several factors that go into this decision including whether your doctor has any concerns about bleeding while taking coumadin (or whether he feels this is safe) and whether you are having any further upcoming procedures. Followup Instructions: Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 88711**], [**Location (un) 9101**] [**Last Name (LF) **], [**5-21**] at 3pm, [**Telephone/Fax (1) 88712**] Department: DIGESTIVE DISEASE CENTER When: THURSDAY [**2145-6-10**] at 10:00 AM With: [**Name6 (MD) 1948**] [**Last Name (NamePattern4) 1949**], MD [**Telephone/Fax (1) 463**] Building: [**First Name8 (NamePattern2) **] [**Hospital Ward Name 1950**] Building ([**Hospital Ward Name 1826**]/[**Hospital Ward Name 1827**] Complex) [**Location (un) 1951**] Campus: EAST Best Parking: Main Garage (please check with the clinic as they may want to move this to an earlier date)

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Discharge summary

report

Admission Date: [**2116-10-12**] Discharge Date: [**2116-10-20**] Service: MEDICINE Allergies: Penicillins / Plavix Attending:[**First Name3 (LF) 12**] Chief Complaint: Chest Pain & Dyspnea Major Surgical or Invasive Procedure: none History of Present Illness: The patient is an 86 year old male with a history of myocardial infarction, CHF, and ICD placed for NSVT, and recently diagnosed metastatic small cell lung cancer presented with weakness, chest pain and dyspnea. He was discharged from the hospital yesterday for chest pain that was believed to be due to metastatic disease to his chest wall. PE was also considered but CT-A could not be completed secondary to renal failure and V/Q was not completed due to underlying disease secondary to his malignancy. He was not anticoagulated secondary to risk for brain metastases. He was seen by his VNA today who noticed hypotension with BP 80s/P. EMS was called and reported O2 sat 70's this am along with hemoptysis seen in his home. Patient feels he was discharged premature. DNR/DNI. Vitals in ED: 96.7 121 91/50 24 86% 4L NC. CXR showed ? LLL pneumonia and also could not rule out pneumobili. Left lateral decubitus final read pending. He was given Vancomycin and Cefepime. He has been persistently hypotensive 83/38, 79/37, 89/36 despite 3L IVF given today. EKG: NSR 1st deg AV block, occasional ectopy, no ischemia. Vitals now: 91/52 84 96 on 4L. Right upper lobe lung mass with SCLC diagnosed [**2116-6-21**] with uptake on PET in pulmonary nodules, mediastinal, hilar, and contralateral supraclavicular lymph nodes, liver metastases, deposits in the retroperitoneum and anterior abdominal wall, and evidence of osseous metastatic disease in the pelvis, spine, and ribs. He most recently received chemotherapy C2D3 Carboplatin/vp16 on [**2116-10-7**]. Past Medical History: Diabetes Dyslipidemia Hypertension CAD s/p MI x2 s/p RCA stent in [**2104**] h/o NSVT and inducible monomorphic VT s/p AICD placement in [**10/2107**] diastolic CHF (EF 55% in [**2108**]) CKD - baseline of 1.7 Stage small cell lung carcinoma - undergoing carboplatin and etoposide palliative chemo. FDG avidity in the right upper lobe mass, other pulmonary nodules, mediastinal, hilar, and contralateral supraclavicular lymph nodes; liver metastases, deposits in the retroperitoneum and anterior abdominal wall; and evidence of osseous metastatic disease in the pelvis, spine, and ribs h/o internal hemorrhoids (bleeding on anoscopy in [**2109**]) h/o hyperplastic polyp and diverticulosis in [**2109**] hypothyroidism h/o TIAs prostate CA s/p TURP ([**2085**]) and radiation proctitis irritable bowel syndrome BPH s/p cataract surgery R eye secondary hyperparathyroidism h/o spinal stenosis and radiculopathy h/o SBO s/p exploratory laparotomy and LOA [**2115-12-31**] Social History: Lives in [**Hospital3 **] alone, wife passed away recently, lives alone and has a visiting nurse. His grandson and granddaughter [**Name (NI) **] for him and nurse helps him shower. He is a retired businessman, former cigar smoker for 50 years, quit 30 years ago, denies EtOH. Family History: Father died of emphysema. Mother died of complications from hypertension. [**Name (NI) **] brother died of "heart disease" but he is unsure exactly what type. Physical Exam: Physical Exam on Arrival to [**Hospital Unit Name 8113**]: pleasant, comfortable, NAD, coherent, alert and oriented x3 HEENT: PERRL, EOMI, anicteric, conjunctiva pale, MMM, no oral lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits RESP: crackles at bases b/l, occasional rhonchi that move with cough CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: warm and dry, no c/c/e SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. no focal deficits . Physical exam on Discharge: VS T 98.8 BP 98/48 HR 84 RR 18 O2 sat 95% on RA Gen- NAD CV- RRR, no m/g/r Lungs- left basilar crcakles, diffuse exp rhonchi which improve with cough Abd- s/nd/nt, +bs Ext- 2+ pulses, no edema Genitals- superficial penile nodule at base of penis, nontender Pertinent Results: [**2116-10-12**] 10:30AM BLOOD WBC-6.2 RBC-2.87* Hgb-9.6* Hct-29.7* MCV-103* MCH-33.6* MCHC-32.5 RDW-15.3 Plt Ct-214 [**2116-10-12**] 10:30AM BLOOD Neuts-89.1* Lymphs-9.6* Monos-0.4* Eos-0.6 Baso-0.2 [**2116-10-11**] 06:30AM BLOOD Plt Ct-246 [**2116-10-11**] 06:30AM BLOOD Glucose-87 UreaN-37* Creat-1.5* Na-140 K-4.5 Cl-106 HCO3-27 AnGap-12 [**2116-10-12**] 10:30AM BLOOD cTropnT-0.02* proBNP-5659* [**2116-10-12**] 10:20PM BLOOD Calcium-8.0* Phos-2.6* Mg-2.0 [**2116-10-13**] 03:59AM BLOOD Cortsol-26.6* [**2116-10-12**] 12:08PM BLOOD Type-ART pO2-74* pCO2-48* pH-7.36 calTCO2-28 Base XS-0 Intubat-NOT INTUBA [**2116-10-12**] 10:36AM BLOOD Lactate-1.0 [**2116-10-12**] 11:11PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015 [**2116-10-12**] 11:11PM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [**2116-10-12**] 11:11PM URINE RBC-1 WBC-12* Bacteri-FEW Yeast-NONE Epi-0 [**2116-10-12**] 11:11PM URINE CastHy-3* [**2116-10-12**] 11:11PM URINE Mucous-RARE [**2116-10-12**] 11:11PM URINE Hours-RANDOM UreaN-1029 Creat-102 Na-34 K-40 Cl-32 [**2116-10-12**] 11:11PM URINE Osmolal-587 ============= MICROBIOLOGY ============= [**2116-10-12**] - Blood cx [**12-24**]: neg - Urine cx: neg ============= IMAGING ============= [**2116-10-12**] - CXR: Upright portable AP view of the chest is obtained. Dual-lead AICD device is again noted with lead tips extending into the right atrium and right ventricle. There is slight elevation of the right hemidiaphragm with lucency below the right hemidiaphragm, which could reflect air-filled bowel below the right hemidiaphragm, though pneumoperitoneum cannot be excluded. There is relative increased opacity at the left lung base, which could reflect atelectasis versus pneumonia. The known masses in the right perihilar and upper lobe are suboptimally assessed. No pneumothorax is present. Heart size appears grossly stable. Atherosclerotic calcifications along the thoracic aorta are noted. Bony structures appear demineralized. IMPRESSION: 1. Lucency below the right hemidiaphragm could reflect air-filled large bowel, though pneumoperitoneum cannot be excluded. Please correlate clinically and with left lateral decubitus views of the abdomen to further assess as indicated. 2. Increased opacity at the left lung base could represent atelectasis versus pneumonia. Known right-sided lung masses are poorly visualized. - CXR (lateral decubitus): Single left lateral decubitus view of the chest was provided. There is no definite sign of free air below the right hemidiaphragm. Right lung remains clear. IMPRESSION: No definite signs of free air below the right hemidiaphragm. - CT Head: There is no hemorrhage or major acute vascular territorial infarction. There is no edema, mass effect or shift of normally midline structures. The ventricles and sulci are prominent in size and configuration, likely due to age-related global atrophy. Extensive periventricular white matter hypodensities are likely due to chronic small vessel ischemic disease. Bilateral calcified atherosclerosis are noted in the carotid siphons. The paranasal sinuses and mastoid air cells are clear. BONE WINDOWS: There is no concerning lesion for metastatic disease. IMPRESSION: No intracranial abnormality. In the setting of continued clinical concern, MRI is more sensitive for metastatic disease evaluation. [**2116-10-13**] - Echo: The left atrium is moderately dilated. Left ventricular wall thicknesses and cavity size are normal. There is moderate global left ventricular hypokinesis (LVEF = 35-40 %). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened. There is mild aortic valve stenosis (valve area 1.2-1.9cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is a very small pericardial effusion. IMPRESSION: Moderate left ventricular global hypokinesis. Mild aortic stenosis. Mild aortic regurgitation. Mild mitral regurgitation. Moderate estimated pulmonary artery systolic hypertension. - CT CHEST WITHOUT CONTRAST: Extensive vascular calcification noted in the thoracic aorta and coronary arteries. Pacemaker in situ, unchanged in position compared with the previous study. There are new small bilateral pleural effusions with associated compressive atelectasis. The right upper lobe mass has decreased in size from 2 x 1.7 cm to 1.9 x 0.8 cm. The bulky right paratracheal and right hilar lymphadenopathy has decreased in size, this previously measured approximately 2.3 x 4.1 cm but now measures 2.2 x 1.7 cm cyst. The right paratracheal lymphadenopathy is no longer appreciated. - CT ABDOMEN WITHOUT IV CONTRAST: There is interposition of a large bowel loop between the liver and the diaphragm, known as Chilaiditi's syndrome. This may account for the appearance of a pneumoperitoneum on the chest x-ray. No pneumoperitoneum is demonstrated on today's study. Non-contrast examination of the liver, spleen, adrenal glands, and pancreas is unremarkable. Both kidneys are somewhat small although cortical thickness is difficult to assess on this non-contrast study. No retroperitoneal or mesenteric lymphadenopathy is seen. No free fluid. Calcification of the abdominal aorta noted with a 3.3 x 3.6 cm infrarenal aortic aneurysm seen. There is a second aneurysm of the right common iliac artery near its bifurcation, which measures 3.5 x 3.3 cm. These have both increased slightly in the interval since the previous study. - CT PELVIS WITHOUT IV CONTRAST: There are numerous surgical clips seen along both pelvic sidewalls and the patient's prostate gland cannot be identified, presumed to be resected. The urinary bladder and rectum are unremarkable in appearance. Sigmoid diverticulosis without evidence of diverticulitis. No pelvic lymphadenopathy is seen. No free fluid. A fat-filled left inguinal hernia. Extensive calcification of the proximal femoral vessels noted. - OSSEOUS STRUCTURES: Degenerative joint disease is noted throughout the lumbar spine with anterolisthesis of L5 on S1 and mild scoliosis convex to the left. No concerning lytic or sclerotic bony lesions seen. IMPRESSION: 1. Extensive vascular calcifications throughout the visualized aorta, common iliac and femoral vessels as well as the coronary vessels. 2. Interval decrease in size of the right upper lobe pulmonary mass. Interval decrease in size of the right suprahilar and mediastinal lymphadenopathy. 3. No pneumoperitoneum, large bowel loop extending anteriorly between the dome of the diaphragm and the liver, known as Chilaiditi's syndrome and a normal variant. 4. Infrarenal abdominal aortic aneurysm measuring 3.6 cm, right common iliac artery aneurysm measures 3.5 cm. 5. Sigmoid diverticulosis without evidence of diverticulitis. [**2116-10-14**] - Bilater LENIS: IMPRESSION: No deep venous thrombosis involving the right or left lower extremity. [**2116-10-20**] - Penile u/s (prelim): hypoechoic 1.7x0.9x0.8 superficial penile lesion at base of penis, likely post-radiation effect though penile mets cannot be formallly excluded. Brief Hospital Course: 87 year old male with a CAD, CHF, and metastatic small cell lung cancer presents with hypotension, cough with thick sputum production as well as reported hemoptysis. # Hypotension: Initially admitted to [**Hospital Unit Name 153**] for hypotension likely secondary to volume depletion in the setting of poor PO intake. Upon transfer to the floor after 1 day in the [**Name (NI) 153**], pt did well, but did trigger twice for hypotension on the floor the evening of [**10-16**] and [**10-17**] which was fluid responsive. We felt this was unlikely to be septic shock, and PE was considered but given clincal stability and stable O2 sats this was not felt to be likely. Furthermore, CTA was not pursued [**12-24**] to increased Cr, and VQ scan was thought to be inaccurate in the setting of his lung cancer. Echo did not show right heart strain but did note some pHTN. LENIs were negative. PO intake was encouraged. Pt's BPs stabilized in SBP 90s-100s. Pt's home Carvedilol and Lasix were dosed with holding parameters. # Cough/sputum production: Likely pneumonia vs viral URI in the setting of his small cell lung cancer. We treated with PO levofloxacin for a 7 day course and patient clinically improved. Cultures were negative. He was continued with Mucinex, albuterol and ipratropium nebs. He was noted to have a choking episode on [**10-17**] while eating with associated coughing. His O2 sats remained normal, and his cough subsequently resolved. # Metastatic small cell lung cancer. Possibly contributing to recent chest pain and SOB with possibly hemoptysis. Chemotherapy was held, he is scheduled for oncology f/u on [**10-26**]. Pt is being discharged to rehab where he can get the chemotherapy. Pt's outpatient oncologist Dr. [**Last Name (STitle) 4149**] will be in contact with the rehab physicians in [**Last Name (un) 8114**] regard. Pt will likely need a follow-up appointment with Dr. [**Last Name (STitle) 4149**] in [**12-25**] weeks. . # Respiratory acidosis with metabolic compensation: Has underlying restrictive lung disease. [**Month (only) 116**] have increased dead space secondary to atelectasis, possible PE, or possible hypoventilation. # Chronic systolic CHF. Persantine MIBI in [**2109**] showed global hypokinesis with LVEF 40%. Echo was repeated to evaluate for the heart function, which showed persistent poor function of 35-40%. Clinically stable from this standpoint over admission. # Acute on chronic renal failure, most likely pre-renal azotemia due to poor PO intake and insensible losses through vomiting as suggested by urine lytes. [**Month (only) 116**] also have a small component of obstructive process given urinary retention and prostate cancer s/p TURP and radiation proctitis. His Cr improved, but noted to have urinary retention of 600cc on [**10-18**]. Foley was difficult to place likely [**12-24**] to his history of prostate surgery, so this was not done. Condom cath remained on and pt subsequently able pass urine. Pt's urine outpt has been lowish, with bladder scan up to 400cc. Urology was consulted who recommended not placing a Foley, unless pt is uncomfortable. Pt remains comfortable and voiding intermittently at time of discharge. # DM2. Home piaglitazone was held. He was switched to an insulin sliding scale with diabetic diet. Pt was discharged back on his home medication. # CAD. Patient was recently ruled out for MI. He continued with aspirin and rosuvastatin. His anti-hypertensives were initially held given hypotension on presentation. However, pt was restarted on them, with holding parameters. # HLD. He continued with rosuvastatin. # Anemia. Likely from anemia of chronic inflammation. There was history of GI bleeding, but while in the [**Hospital Unit Name 153**], he did not have any active signs of bleeding. He continued with ferrous sulfate and B12 supplementation. # Penile lesion: Pt was noted to have a 1cm nodal lesion at the penile base. Unclear how long he has had it. Clinical apperance most consistent with a sbaceous cyst. Urology was consulted who were unconcerned by its appearance however recommended a penile ultrasound. The study was performed, which showed a superficial lesion, likely a post-radiation effect, however penile metastatic disease cannot be formally ruled out. The final read was pending at time of discharge. Medications on Admission: 1. dipyridamole-aspirin 200-25 mg Cap, Multiphasic Release 12 hr (2) Cap PO DAILY (Daily). 2. rosuvastatin 5 mg Tablet Sig: (2) Tablet PO QHS (once a day (at bedtime)). 3. carvedilol 12.5 mg Tablet Sig: (1) Tablet PO BID (2 times a day). 4. levothyroxine 112 mcg Tablet Sig: (1) Tablet PO DAILY (Daily). 5. calcitriol 0.25 mcg Capsule Sig: (1) Capsule PO QTUES, FRI (). 6. furosemide 20 mg Tablet Sig: (1) Tablet PO QMWF (). 7. gabapentin 300 mg Capsule Sig: (1) Capsule PO Q12H (every 12 hours). 8. allopurinol 100 mg Tablet Sig: (1) Tablet PO DAILY (Daily). 9. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: (1) Tablet PO DAILY (Daily). 10. cyanocobalamin (vitamin B-12) 500 mcg Tablet Sig: (2) Tablet PO DAILY (Daily). 11. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: (1) Cap Inhalation DAILY (Daily). 12. hydrocortisone 2.5 % Cream Sig: (1) Appl Rectal [**Hospital1 **] (). 13. flunisolide 25 mcg (0.025 %) Spray, Non-Aerosol Sig: (2) Nasal twice a day. 14. albuterol sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: (1) Puff Inhalation q4hrs prn as needed for wheezing/sob. 15. docusate sodium 100 mg Capsule Sig: (1) Capsule PO BID (2 times a day). 16. senna 8.6 mg Tablet Sig: (1) Tablet PO BID prn as needed for constipation. 17. polyethylene glycol 3350 17 gram/dose Powder Sig: (1) PO daily prn as needed for constipation. 18. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: (1) Adhesive Patch, Medicated Topical DAILY (Daily): apply one patch daily to the affected area for pain relief. 19. lorazepam 0.5 mg Tablet Sig: (1) Tablet PO QHS prn as needed for insomnia. 20. ondansetron 4 mg Tablet, PO Q8H (every 8 hours) as needed for nausea. 21. morphine 15 mg Tablet Sustained Release Sig: (1) Tablet Sustained Release PO Q12H (every 12 hours). 22. morphine 15 mg Tablet Sig: one-half to one Tablet PO q4hrs prn as needed for breakthrough pain. 23. pioglitazone 15 mg Tablet Sig: (1) Tablet PO once a day. Tablet(s) 24. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: (1) Capsule PO twice per month. 25. Lomotil 2.5-0.025 mg Tablet Sig: (1) Tablet PO q6hrs prn as needed for diarrhea. Discharge Medications: 1. pioglitazone 15 mg Tablet Sig: One (1) Tablet PO once a day. 2. Spiriva with HandiHaler 18 mcg Capsule, w/Inhalation Device Sig: One (1) Inhalation once a day. 3. Vitamin D 50,000 unit Capsule Sig: One (1) Capsule PO TWICE MONTHLY. 4. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB/wheezing. 5. ipratropium bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for SOB/Wheezing. 6. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO 2X/WEEK (TU,FR). 7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 9. allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. rosuvastatin 10 mg Tablet Sig: One (1) Tablet PO once a day. 11. furosemide 20 mg Tablet Sig: One (1) Tablet PO 3X/WEEK (MO,WE,FR): hold for SBP<100. 12. benzonatate 100 mg Capsule Sig: One (1) Capsule PO TID (3 times a day) as needed for cough. 13. dipyridamole-aspirin 200-25 mg Cap, Multiphasic Release 12 hr Sig: One (1) Cap PO BID (2 times a day). 14. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 15. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours). 16. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. cyanocobalamin (vitamin B-12) 1,000 mcg Tablet Sig: One (1) Tablet PO once a day. 18. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily) as needed for constipation. 19. fluticasone 50 mcg/Actuation Spray, Suspension Sig: One (1) Spray Nasal [**Hospital1 **] (2 times a day). 20. carvedilol 6.25 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): hold for SBP<100. 21. hydrocortisone 2.5 % Cream Sig: One (1) Appl Rectal [**Hospital1 **] (2 times a day). 22. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. 23. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for apply to left chest wall. 24. oxycodone 5 mg Capsule Sig: One (1) Capsule PO every six (6) hours as needed for fever or pain. 25. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 26. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for nausea. Discharge Disposition: Extended Care Facility: [**Hospital **] Hospital for Continued Medical Care [**Hospital1 8**] Discharge Diagnosis: Primary diagnosis: Pneumonia Hypotension Urinary retention Secondary diagnosis: Metastatic small cell lung cancer Chronic systolic CHF DMII CAD/HL Dysphagia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname **], You were admitted to the hospital for low blood pressure and breathing difficulty. You came to the ICU and your blood pressure improved, and you were subsequently transferred to the regular floor and continued to do well. You did, however, have a couple of episodes of low pressure on the floor which improved with fluids. We believe your low blood pressure may have been from low blood volume from decrased fluid intake. We believe your cough may be from a pneumonia which we treated with antibiotics. You were noted to have some low urine output. Urology team was consulted and they recommended that you do not need a urinary catheter placed, unless you become uncomforable. We have made the following changes to your medications: STARTED: Benzonatate 100mg by mouth 3 times a day as needed for couth STOPPED: MS Contin, Morphine IR STARTED: Oxycodone as needed for pain Please continue all other home medications as before. Followup Instructions: You oncologist Dr. [**Last Name (STitle) 4149**] will be in contact with your physicians at the rehab facility regarding the plans for chemotherapy next week. You will likely need a follow up appointment with Dr. [**Last Name (STitle) 4149**] in [**12-25**] weeks. Completed by:[**2116-10-22**]

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

20586, 20683

11606, 15982

249, 256

20885, 20885

4215, 6905

22023, 22321

3160, 3321

18163, 20563

20704, 20704

16008, 18140

21036, 21775

3336, 3905

3933, 4196

21804, 22000

189, 211

284, 1851

6914, 11583

20785, 20864

20723, 20764

20900, 21012

1873, 2849

2865, 3144

51,755

173,010

37306

Discharge summary

report

Admission Date: [**2185-12-11**] Discharge Date: [**2185-12-16**] Date of Birth: [**2133-2-23**] Sex: F Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1481**] Chief Complaint: right wrist pain and chest pain Major Surgical or Invasive Procedure: 1. Open reduction, internal fixation, right intra-articular distal radius fracture, 2 or more fragments. 2. Open reduction, internal fixation, right distal ulnar fracture. History of Present Illness: [**Known firstname **] [**Known lastname **] is a 52 year old woman who was transferred to [**Hospital1 18**] from [**Hospital1 **] after being involved in a motor vehicle collision (car vs. tree). She was unrestrained, her vehicle's air bag was not deployed, there was no reported loss of consciousness, and her car speed at the time of the accident was unknown. Upon arrival, the patient was afebrile with stable vital signs. Her GCS was 15, ABCs intact. Secondary survey revealed ecchymoses and contusions over her chest wall and a bruise over her left buttock. More ecchymoses were noted in her right hand, which was in a splint. She arrived with her c-spine stabilized within a collar. She complained of chest wall pain, some difficulty breathing, and pain in her right upper extremity. Past Medical History: PMH: narcotic abuse, plantar fasciitis, pedal edema, urinary retention, hypertension PSH: c-section, abdominoplasty Social History: Married History of tobacco use, denies current use Denies EtOH History of narcotic abuse, Discontinued Suboxone about a week before this injury Family History: N/C Physical Exam: On arrival: T 98.3, HR 89, BP 159/42, RR 25, O2Sa 100% NRB GENERAL: NAD, A&Ox3, GCS 15 HEENT: NCAT, PERRL, no blood in nares or mouth, neck in c-collar PULM: CTAB; ecchymoses over anterior chest wall ABD: S/NT/ND, abdominoplasty scar, no gross blood on DRE VASC: 2+ distal pulses in all 4 extremities NEURO: good rectal tone; spine non-tender to palpation, no stepoffs MUSCULOSKELETAL: RUE in splint, ecchymoses over R hand, lac over right knee On discharge: Afebrile, VSS GENERAL: NAD, A&Ox3 HEENT: NCAT, PERRL, EOMI, MMM PULM: CTAB ABD: S/NT/ND MSK: RUE in cast Pertinent Results: [**2185-12-11**] 10:00PM BLOOD WBC-9.0 RBC-4.27 Hgb-12.7 Hct-37.5 MCV-88 MCH-29.8 MCHC-33.9 RDW-13.9 Plt Ct-237 [**2185-12-11**] 10:00PM BLOOD PT-12.3 PTT-19.3* INR(PT)-1.0 [**2185-12-11**] 10:00PM BLOOD Fibrino-370 [**2185-12-11**] 10:00PM BLOOD UreaN-19 Creat-1.1 [**2185-12-11**] 10:00PM BLOOD estGFR-Using this [**2185-12-11**] 10:00PM BLOOD Lipase-36 [**2185-12-11**] 10:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2185-12-11**] 10:12PM BLOOD Glucose-114* Lactate-2.0 Na-139 K-5.2 Cl-101 calHCO3-26 [**2185-12-11**] 10:12PM BLOOD Hgb-13.4 calcHCT-40 [**2185-12-15**] 05:50AM BLOOD Hct-33.2* [**2185-12-14**] 05:55AM BLOOD Plt Ct-174 [**2185-12-15**] 05:50AM BLOOD K-4.2 [**2185-12-15**] 05:50AM BLOOD Phos-2.5* Mg-1.9 IMAGING: CXR [**2185-12-11**]: Low lung volumes, but no definite cardiopulmonary abnormalities CT Head [**2185-12-11**]: No acute intracranial abnormality. CT C-spine [**2185-12-11**]: No fracture or malalignment of the cervical spine. Moderate degenerative changes in the lower cervical spine, with mild canal narrowing at C6-7. The left paracentral bony density contacting the thecal sac at [**Name (NI) 3569**] likely represents a calcified disk but recommend correlation with MRI on a non urgent basis. CT Torso [**2185-12-11**]: Multiple anterolateral rib fractures bilaterally, three through eight on the right and two through eight on the left. Posterior margin of manubrium fracture with small amount of hemorrhage in the anterior mediastinum abutting the manubrium. Moderate bilateral dependent atelectasis in the lungs. Likely small region of contusion in the posteromedial right lobe. Scattered ground glass opacities in the anterior lungs may be due to low lung volumes, or could reflect mild contusion. No pneumothorax or hemothorax. No solid organ injury. Focal discontinuity of the posterior left hemidiaphragm suggests congenital Bochdalek hernia, although traumatic diaphragm rupture cannot be definitively excluded. Relatively atrophic left kidney, although with symmetric contrast enhancement and excretion. X-ray Right Wrist (3 views) [**2185-12-11**]: Comminuted, impacted, dorsally angulated distal radius fracture. Distal ulna fracture with dorsal and proximal displacement of distal component. X-ray Right Wrist (3 views) [**2185-12-12**]: Comminuted intra-articular distal radius fracture with dorsal displacement and angulation. Distal ulnar fracture with dorsal displacement and radial angulation CXR [**2185-12-13**]: Worsened bibasilar atelectasis Brief Hospital Course: The patient was transferred out of the trauma bay and underwent multiple imaging studies ultimately revealing the following injuries: Right radius and ulnar fractures Right 2nd-8th rib fractures Left 3rd-8th rib fractures Posterior margin of manubrium fracture She was admitted to the trauma surgery service. Her pain was adequately controlled with an epidural that was managed by the acute pain service. Aggressive use of incentive spirometer was encouraged. She was given nebulizers as needed for dyspnea and wheezing. On [**2185-12-13**], she was taken to the OR by the orthopedics team for ORIF of her right wrist. The procedure was uncomplicated and the patient tolerated it well. Post-op, she was put on a regular diet, which she tolerated without nausea/vomiting. She was put on an aggressive bowel regimen. DVT prophylaxis was achieved with subcutaneous heparin. She was seen by both physical therapy and occupational therapy. Physical therapy believed she had no acute physical therapy needs. Occupational therapy recommended that the patient be discharged home with VNA services and occupational therapy. Her Foley catheter was removed [**2185-12-14**]. She did initiially have problems with urinary retention and was bladder scanned with a post-void residual of around 300cc. She was therefore straight-cathed and underwent another void trial. The epidural was discontinued [**2185-12-15**] and she was successfully transitioned to PO pain medications. At the time of discharge, the patient was afebrile with stable vital signs. Her pain was adequately controlled with oral pain meds. She was able to take deep slow breaths in with the aid of her incentive spirometer. She was able to void adequate amounts of urine. She was out of bed working and ambulating with her RUE in a splint and instructions from ortho to have the RUE non-weight bearing. She was tolerating a regular diet. Medications on Admission: Cymbalta 90mg daily Lisinopril 10mg daily Ambien 10mg qHS prn insomnia Trazodone 200mg qHS prn Suboxone was discontinued just prior to her accident Discharge Medications: 1. Duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: Three (3) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Capsule, Delayed Release(E.C.)(s) 2. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*2* 4. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. Trazodone 100 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime). 7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q3H (every 3 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) 1110**] VNA Discharge Diagnosis: Primary diagnosis S/P MVC 1.Right radius and ulnar fractures 2. Right 2nd-8th rib fractures 3. Left 3rd-8th rib fractures 4. Posterior margin of manubrium fracture Secondary diagnoses 1. narcotic abuse 2. plantar fasciitis 3. urinary retention 4. S/P C section 5. S/P abdominoplasty 6. Hypertension Discharge Condition: Alert and oriented x3 Out of bed and ambulating. Will be discharged home with VNA and occupational therapy. Discharge Instructions: Please call your doctor or nurse practitioner or return to the Emergency Department for any of the following: *You experience new chest pain, pressure, squeezing or tightness. *New or worsening cough, shortness of breath, or wheeze. *If you are vomiting and cannot keep down fluids or your medications. *You are getting dehydrated due to continued vomiting, diarrhea, or other reasons. Signs of dehydration include dry mouth, rapid heartbeat, or feeling dizzy or faint when standing. *You see blood or dark/black material when you vomit or have a bowel movement. *You experience burning when you urinate, have blood in your urine, or experience a discharge. *Your pain in not improving within 8-12 hours or is not gone within 24 hours. Call or return immediately if your pain is getting worse or changes location or moving to your chest or back. *You have shaking chills, or fever greater than 101.5 degrees Fahrenheit or 38 degrees Celsius. *Any change in your symptoms, or any new symptoms that concern you. Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid driving or operating heavy machinery while taking pain medications. Incision Care: *Please call your doctor or nurse practitioner if you have increased pain, swelling, redness, or drainage from the incision site. *Avoid swimming and baths until your follow-up appointment. *You may shower but protect your cast and keep it dry. *The stitches on your incision will dissolve on their own. Followup Instructions: Please follow up in the orthopedic clinic on [**2185-12-22**]. Call [**Telephone/Fax (1) **] to make an appointment. Call Dr. [**Last Name (STitle) **] at [**Telephone/Fax (1) 18052**] for a follow up appointment in 2 weeks Completed by:[**2185-12-16**]

[ "723.1", "807.08", "788.20", "E823.0", "338.11", "305.91", "891.0", "813.44", "345.10", "401.9", "807.2" ]

icd9cm

[ [ [] ] ]

[ "79.32", "86.59", "93.54", "03.90" ]

icd9pcs

[ [ [] ] ]

7632, 7691

4836, 6737

348, 522

8034, 8144

2266, 4813

9885, 10143

1661, 1666

6936, 7609

7712, 8013

6763, 6913

8168, 9537

9553, 9862

1681, 2127

2141, 2247

277, 310

550, 1344

1366, 1483

1499, 1645

66,557

197,531

51324

Discharge summary

report

Admission Date: [**2172-2-19**] Discharge Date: [**2172-3-7**] Date of Birth: [**2111-9-4**] Sex: M Service: MEDICINE Allergies: Heparin Agents Attending:[**First Name3 (LF) 2297**] Chief Complaint: rectal bleeding Major Surgical or Invasive Procedure: Intubation and mechanical ventilation Continuous [**Last Name (un) **]-venous hemofiltration Multiple paracenteses History of Present Illness: Mr. [**Known lastname **] is a 60M with recent admit for pancreatitis and urosepsis, s/p gastric bypass presents with BRBPR. He states that the bowel movements were red/cranberry colored. He had several bloody BM's at rehab, 2 in the ED, and 3 here on the floor since admit. Per patient, he denies fevers, chills, or abdominal pain except when he took the PO contrast for CT today. He denies nausea, vomiting, dysuria, or cough. He has had a very poor appetite x 3-4 days. He has not had blood in his stool before. He complains of severe thirst. . In the ED, vitals were afebrile 98 105/54 100% on RA. He had BRBPR x2 in the ED. Hct 27.8, baseline is 28-29. Labs notable for Hct of 26, Cr of 5, INR of 2 (not on anticoagulation). CXR showed RLL infiltrate vs atelectasis. Given levofloxacin for ?pna and IV flagyl for ?C difficile colitis. FFP given for coagulopathy. 40 of K given for K of 2.7. . GI saw him in ED recommended workup for C diff, thought no need for emergent scope as Hct at baseline. Remained hemodynamically stable. Foley was placed in the ED with about 50 cc urine. Stool now + for C diff . On the Floor (as mentioned) he had 2 bloody bowel movements. This morning he complained of severe thirst and of abdominal distensin, no N/V or abdominal pain. CT abdomen revealed: Fluid filled structure posterior to the excluded stomach, with suture line running through the posterior wall, raising the possibility of a dilated proximal efferent limb, ? obstruction due to adhesions. The anatomy is suboptimally evaluated due to lack of oral contrast in the bypass. Predominantly the oral contrast is in the colon. More free fluid, with diffuse colnic wall thickening and pericolonic fat stranding, mostly in the left colon, raising the possibility of c diff colitis. Continued peripancreatic stranding, however the previously seen pseudocyst is np longer seen. . Past Medical History: 1. Chronic pancreatitis - multiple episodes, most recently [**4-/2171**] w/ negative w/u for gallstone pancreatitis and thought [**1-6**] alcohol 2. Alcohol abuse - long-standing alcohol abuse, has denied AAA and other interventions in past 3. Hepatitis B and C - diagnosed during admission for BLE edema [**2171-2-5**], with markedly elevated hepatitis C viral load. Did not pursue follow-up. Discharge summary from admission notes multiple risk factors, including h/o IVDU, recent tatto, and multiple sexual partners (although had been in monogamous relationship > 20 yrs by then) 5. DMII - reportedly took insulin at home until gastric bypass, now only taking metformin 6. HTN 7. Cholelithiasis 8. s/p Gastric bypass - [**2169**], endoscopic, weight loss from ~350 lbs to ~250 lbs, has missed follow-up appts 9. Osteoarthritis - hip and knees 10. OSA requiring CPAP 11. s/p L hip surgeries including prosthesis placement w/ subsequent removal due to infection 12. s/p gunshot wound to L thigh in [**2134**] Social History: Living in [**Hospital1 1501**] since last hospitalization. Son [**Name (NI) 93401**] visits. Occupation: Retired firefighter EtOH: Drinks 3-6 tequila shots daily, has drank significantly for unclear number of years Drugs: Remote h/o IVDU per note from [**4-/2171**] admission, none recently Tobacco: Smokes 1ppd x several years Family History: mother who died at age 40 with multiple myeloma. Physical Exam: Vitals: T: 100.6 axillary BP: 94/68 P:98 R: 18 O2: 99% on AC General: Alert, oriented, no acute distress HEENT: Sclera icteric, MM dry, oropharynx w/ oral airway in place, poor dentition Neck: supple, JVP not elevated, no LAD Lungs: Coarse breath sounds bilaterally with loud upper airway sounds, no appreciable wheezes or rales CV: tachycardic, normal S1 + S2, no murmurs, rubs, gallops Abdomen: obese, distended but soft, bowel sounds present, unable to assess for tenderness to palpation Ext: 1+ RLE edema, trace LLE edema Pertinent Results: CT ABDOMEN W/O CONTRAST [**2172-2-20**]: IMPRESSION: 1. New fluid distention of the gastric remnant and afferent limb. This finding may represent ileus or possibly obstruction as can be seen in afferent limb syndrome. 2. Punctate foci of air are seen adjacent to the tail of the pancreas and are of unknown etiology. It is unclear if they are related to a collapsed loop of bowel or possibly the patient has developed a fistula in the region as there was previously a pancreatic pseudocyst in this region on the prior CT scan dated [**2172-1-26**]. Close followup with CT is recommended. 3. New ascites. 4. Fatty infiltration of the liver. 5. New diffuse colonic wall thickening, consistent with colitis. CT ABDOMEN W/O CONTRAST [**2172-2-26**]: IMPRESSION: 1. Unchanged dense ascites with slight worsening of extensive soft tissue anasarca and fluid tracking along the right abdominal wall fascial planes. 2. Slight interval improvement in colitis with residual colonic thickening involving the ascending, descending and sigmoid colon consistent with underlying C. diff colitis. 3. Unchanged dilation of the gastric remnant with worsening dilation of the Roux limb and remainder of the small bowel up to an apparent transition in the region of distal colon. 4. Hepatic steatosis. HEMATOLOGY: [**2172-2-19**] 03:45PM BLOOD WBC-26.6*# RBC-2.98* Hgb-8.9* Hct-27.8* MCV-93 MCH-29.7 MCHC-31.9 RDW-15.0 Plt Ct-336 [**2172-2-23**] 06:14PM BLOOD WBC-15.3* RBC-3.37* Hgb-10.1* Hct-31.2* MCV-92 MCH-29.9 MCHC-32.4 RDW-15.8* Plt Ct-213 [**2172-2-28**] 02:53AM BLOOD WBC-13.9* RBC-2.83* Hgb-8.6* Hct-26.8* MCV-95 MCH-30.3 MCHC-32.0 RDW-17.9* Plt Ct-76* [**2172-3-1**] 05:56PM BLOOD WBC-23.1* RBC-2.97* Hgb-9.4* Hct-29.5* MCV-99* MCH-31.6 MCHC-31.9 RDW-22.7* Plt Ct-88* [**2172-3-6**] 05:33AM BLOOD WBC-16.2* RBC-2.97* Hgb-9.7* Hct-30.3* MCV-102* MCH-32.7* MCHC-32.0 RDW-26.8* Plt Ct-122* PARACENTESIS FLUID: [**2172-2-26**] 11:40AM ASCITES WBC-[**Numeric Identifier **]* RBC-3500* Polys-86* Lymphs-4* Monos-10* [**2172-2-26**] 11:40AM ASCITES TotPro-3.3 LD(LDH)-679 Amylase-4 Albumin-1.3 Triglyc-20 [**2172-2-28**] 06:25PM ASCITES WBC-2885* RBC-1175* Polys-77* Lymphs-10* Monos-9* Mesothe-1* Macroph-3* [**2172-2-28**] 06:25PM ASCITES TotPro-3.5 Glucose-172 LD(LDH)-516 Albumin-1.9 [**2172-2-26**] 11:40 am PERITONEAL FLUID GRAM STAIN (Final [**2172-2-26**]): 4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). URINALYSIS: [**2172-3-4**] 11:39PM URINE RBC-901* WBC-52* Bacteri-MANY Yeast-MANY Epi-1 [**2172-3-4**] 11:39PM URINE Blood-LG Nitrite-NEG Protein->300 Glucose-NEG Ketone-NEG Bilirub-SM Urobiln-0.2 pH-5.5 Leuks-SM LACTATE TREND: [**2172-2-19**] 04:43PM BLOOD Lactate-1.7 K-2.7* [**2172-2-26**] 10:55AM BLOOD Lactate-2.9* [**2172-2-29**] 08:11PM BLOOD Lactate-5.2* [**2172-3-1**] 06:25PM BLOOD Lactate-3.8* [**2172-3-3**] 04:29PM BLOOD Lactate-2.4* [**2172-3-5**] 05:53AM BLOOD Lactate-1.8 [**2172-3-6**] 05:01PM BLOOD Lactate-2.4* Brief Hospital Course: Mr [**Known lastname **] had a long and complicated hospital course and eventually his care goals were changed to be Comfort Measures Only (CMO) on night of [**2172-3-6**] after a discussion with his son, [**Name (NI) 93401**]. At 0100 on [**2172-3-7**], Mr. [**Known lastname **] was pronounced to be dead. The following is a brief summary of hospital events. # Peritonitis: Upon admission Mr [**Known lastname **] had a CT scan which showed extraluminal air concerning for potential pancreatico-colonic fistula (in area of prior pseudocyst) or possible microperf/abscess. He was non-tender on exam initially; surgery evaluated and felt abscess was unlikely. On [**2-26**] he had a change in mental status and new abdominal tenderness concerning for peritonitis. Paracentesis showed 11K WBC with high protein, low glucose concerning for complicated (or secondary) peritonitis. Surgery again evaluated and felt this was unlikely due to colonic perforation. he was begun on broad spectrum antibiotics; cultures showed e coli. Repeat paracentesis 48-hours later showed improving wbc count; however, his course in the MICU was one in which he required accelerating pain control and sedation given that he appeared to have an extremely tender abdomen. He also required increasing vasoactive agents to maintain his blood pressure in a normal range. On night of [**2172-3-6**], vasoactive agents were discontinued when patient was made CMO and a morphine drip was started. Patient died at 0100 on [**2172-3-7**]. # C diff: Mr. [**Known lastname **] had numerous bloody bowel movements in the hosptial; CT scan showed colitis. Given his h/o recent antibiotics there was a high suspicion for c diff. He had course of IV, PO, and PR Vancomycin; however, he did not stool in the last week of hospitalization. He received 4U pRBCs for hematochezia. Surgery was consulted and recommended against colectomy. # Acute renal failure: pre-renal azotemia, nonresponsive to approximately 20L of fluid + albumin + midodrine & octreotide. By definition, hepatorenal syndrome given his cirrhosis. He was started on CVVH in the MICU; however, at his son's request, this was discontinued on night of [**2172-3-6**]. # ileus: Upon admission Mr. [**Known lastname **] had a distended afferent loop which was fairly asymptomatic. Surgery consulted and recommended against intervention, as did gastroenterology (due to the complication of placing a venting g-tube in a patient with ascites). NG tube placement was also recommended against by Dr. [**Last Name (STitle) **] of bariatric surgery due to the risk of placing a NGT in a patient with a small surgical stomach. In the final week of hospitalization, the patient did not stool and his lactate and bladder pressures steadily rose in his last few days of hospitalization. #Thrombocytopenia: steady trend down since admission. [**2-28**] all heparin products d/c'd and HIT ab sent. HIT antibody was negative; however, given high clinical suspicion for HIT, heparin products were avoided and a serotonin releasing assay was sent and was pending at time of death. # Dyspnea: Acute onset [**2-25**] during a plasma transfusion. thought to be either from transfusion reaction (TRALI) vs fluid overload (CXR clear). on [**2-28**] he had another acute episode of dyspnea with desats and was transferred to the MICU where he was intubated. He remained intubated throughout the remainder of his course until his death. Medications on Admission: MVI with minerals Methadone 90 mg [**Hospital1 **] Morphine 10 mg po q8H PRN pain Lactulose 30 ml daily titrate to [**2-5**] BMs Clonidine 0.1 mg daily Lisinopril 5 mg daily on [**2172-2-10**] completed course of Ciprofloxacin Discharge Medications: Patient expired. Discharge Disposition: Expired Discharge Diagnosis: Primary: Bacterial Peritonitis Aspiration Pneumonia Septic Shock Secondary: Clostridium difficile colitis Acute Kidney Injury Hypertension Diabetes Mellitus type 2 Obstructive Sleep Apnea Hepatitis B Hepatitis C Discharge Condition: Patient expired. Discharge Instructions: Patient expired. Followup Instructions: Patient expired. Completed by:[**2172-3-8**]

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icd9cm

[ [ [] ] ]

[ "99.15", "96.72", "54.91", "39.95", "38.93", "96.04", "38.95" ]

icd9pcs

[ [ [] ] ]

11112, 11121

7337, 10794

289, 406

11376, 11394

4316, 7314

11459, 11505

3705, 3755

11071, 11089

11142, 11355

10820, 11048

11418, 11436

3770, 4297

234, 251

434, 2309

2331, 3343

3359, 3689

27,251

109,677

45442

Discharge summary

report

Admission Date: [**2153-9-2**] Discharge Date: [**2153-9-6**] Service: MEDICINE Allergies: Penicillins / Codeine / Sulfonamides / Aspirin / Valium / Erythromycin Base / Ciprofloxacin / Biaxin / Acyclovir / Zestril / Egg / Oxycontin Attending:[**First Name3 (LF) 3151**] Chief Complaint: Garbled speech, Weakness Major Surgical or Invasive Procedure: none History of Present Illness: Ms. [**Known lastname 87838**] is a [**Age over 90 **] year old woman with history of several strokes, DM, CAD, and possible pAFib not on coumadin who developed garbled speech and right sided weakness at her [**Hospital3 **] facility. . She was in her usual state of health until she rang the call button at her [**Hospital3 **] stating she was feeling poorly. When help arrived, she was confused and unable to speak. . Upon arrival to the ED, initial VS were 102.4 97 176/95 23 100% BS 147. Code stroke was called. She was noted to have right sided weakness. Although she was initially aphasic, she was later described as dysarthric during her time in the ED. Stat MRI showed no diffusion abnormalities, so no tPA was given. The stroke team felt that her symptoms were most likely due to recrudescence in the setting of infection vs seizure activity at her old stroke site. Of note, she received a dose of ativan while the ED team was attempting to obtain an LP but they were unable to get the LP because of intense rigors. . She received vancomycin and ceftriaxone. She had an episode of brown bilious emesis for which she was given 4mg zofran; there was concern for aspiration during the MRI ([**Name8 (MD) **] RN report, the MRI was stopped early as she became cyanotic and was vomiting). A total of 1300cc of IV fluids were given. . These symptoms were identical to her stroke in 5/[**2152**]. As described in the excellent Neuro consult note: "Of note, she also presented as a CODE STROKE to [**Hospital1 18**] on [**2153-4-19**] with similar symptoms of garbled speech, right sided weakness, and left gaze preference. Her NIHSS was 17. Temp was 102 on admission, but blood and urine culture showed no growth. CTP showed area of abnormal perfusion in the left posterior cerebral artery distribution with no definite vascular stenosis identified and no CT evidence of completed infarction. MRI/MRA showed no evidence of acute ischemia or infarction in the left MCA territory, major intracranial vessels including left MCA appear patent on MRA. EEG showed intermittent brief bursts of moderate amplitude mixed theta and delta frequency slowing in a generalized distribution, no epileptiform features. She was seen by Dr. [**First Name8 (NamePattern2) 2530**] [**Name (STitle) **] in follow up on [**2153-6-26**], and was found to have no residual limb weakness or numbness, but minor residual language impairments." Past Medical History: Stroke--several in past, most recently [**4-12**] as described above CAD s/p MI, has Cypher stent to RCA [**2148**] TTE [**4-12**]: EF > 55%, [**12-6**]+MR, 3+TR DM--diet controlled HTN ? Paroxysmal AFib not on coumadin Pancreatic cyst -- benign, appears to be enlarging. Followed by Dr. [**First Name4 (NamePattern1) 2127**] [**Last Name (NamePattern1) 10113**] at [**Hospital1 18**]. R hydronephrosis [**1-6**] [**Month/Day (2) 96980**] obstruction (70% obstructed) - Asymptomatic, urology following, recommend no intervention at this time. Systemic sclerosis -- diagnosed at young age. Has associated Raynaud's, esophageal and intestinal dysmotility, interstitial lung disease. Sjogren's syndrome-- uses NS eyedrops Squamous cell carcinoma of skin Basal cell carcinoma -- 2 lesions removed Interstitial lung disease Osteoporosis GERD/peptic ulcer disease Macular degeneration -- legally blind, some sight in L eye Cataracts -h/o LE DVT but no known PE . PSH: -Colectomy in her 40s d/t SBO, likely [**1-6**] dysmotility from scleroderma -TAH/RSO for menorrhagia at age 39 -appendectomy (age 20s) -femoral hernia repair Social History: Lives at [**Location **] Place/[**Location (un) 55**] [**Telephone/Fax (1) 96982**] Patient was a [**Hospital1 18**] employee x 36 years, widowed. She has 2 children, one in [**State **] and [**State 4565**]. She has 5 grandchildren and 11 great-grandchildren. She lives in [**Location **] Place [**Hospital3 **] facility and is very satisfied with her care there. She is able to dress herself and go to the BR without assistance. She has meals delivered. She walks with a cane during the day and with a walker at night. She is legally blind [**1-6**] macular degeneration, and therefore cannot drive. Tobacco: 15 pk-yr, quit 65 yrs ago No EtOH or drug use. Family History: Father died at 52 of MI Mother died at 96 from stroke One died at age 60 from cancer She has two living sons, 69yo with macular degeneration and a younger son (can't remember age) with DM, MD, and h/o MI One grandchild died at young age from melanoma Physical Exam: 103.6 98 183/97 20 100% RA Very thin and wasted, able to orient to person's voice but makes poor eye contact. Awake but not alert, not oriented to time, place, or self. Unable to follow commands or answer questions appropriately. Speech garbled. Pupils equal, round, reactive, intact consensual response. Unable to track or to follow command to do so. Minimal extraocular movements while observing room. No blink to threat b/l. Unable to count fingers. Face symmetric. Kernig's and Brudzinski's negative, neck supple. Heart is tachy but regular without any murmur. Lungs clear b/l without wheeze. Abd: +BS, soft and not tender. Not distended. Neuro: 4/5 strength in LE b/l (unable to assess if [**4-9**]); at least [**2-7**] in UE b/l but unable to assess if greater. DTRs: +3 throughout, symmetric. Tremor of hands with voluntary movement b/l. Toes equivocal b/l. Pertinent Results: ADMISSION LABS: [**2153-9-2**] 07:30PM PT-12.6 PTT-22.9 INR(PT)-1.1 PLT COUNT-215 WBC-7.4 RBC-4.20 HGB-12.1 HCT-37.1 MCV-88 MCH-28.9 MCHC-32.7 RDW-16.8* proBNP-5849* LIPASE-51 ALT(SGPT)-24 AST(SGOT)-46* LD(LDH)-536* ALK PHOS-89 TOT BILI-0.7 GLUCOSE-141* UREA N-23* CREAT-1.6* SODIUM-136 POTASSIUM-5.6* CHLORIDE-100 TOTAL CO2-27 URINE: [**2153-9-2**] 07:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.0 LEUK-NEG [**2153-9-2**] 07:50PM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.006 LACTATE [**2153-9-2**] 11:22PM LACTATE-5.3* [**2153-9-3**] 01:25PM BLOOD Lactate-2.8* ARTERIAL: [**2153-9-2**] 11:22PM ART TEMP-38.2 PO2-122* PCO2-31* PH-7.44 TOTAL CO2-22 DISCHARGE LABS: [**2153-9-6**] 07:00AM BLOOD WBC-8.6 RBC-4.19* Hgb-12.1 Hct-37.7 MCV-90 MCH-28.9 MCHC-32.1 RDW-16.1* Plt Ct-185 [**2153-9-6**] 07:00AM BLOOD Glucose-94 UreaN-16 Creat-1.0 Na-142 K-3.9 Cl-103 HCO3-29 [**2153-9-6**] 07:00AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.9 WORK UP: [**2153-9-3**] 01:38AM BLOOD %HbA1c-6.1* [**2153-9-3**] 01:29AM BLOOD Triglyc-78 HDL-51 CHOL/HD-2.4 LDLcalc-53 CARDIAC ENZYMES: [**2153-9-3**] 01:29AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2153-9-3**] 09:53AM BLOOD CK-MB-5 cTropnT-0.06* [**2153-9-3**] 05:42PM BLOOD CK-MB-5 cTropnT-0.06* [**2153-9-4**] 04:57AM BLOOD cTropnT-0.07* [**2153-9-4**] 05:52PM BLOOD CK-MB-NotDone cTropnT-0.06* [**2153-9-4**] 08:14PM BLOOD CK-MB-4 cTropnT-0.05* [**2153-9-5**] 06:50AM BLOOD CK-MB-4 cTropnT-0.04* [**9-4**] MRA NECK W/CONTRAST: 1. Carotid arteries appear normal. 2. The vertebral artery origins are not visualized on the right and poorly visualized on the left, which may be related to technical limitations. The remainder of the vertebral arteries are patent. However, a high-grade stenosis at the right vertebral artery origin and a mild stenosis at the left vertebral artery origin cannot be excluded. [**9-3**] CXR: In comparison with the study of [**9-2**], there is little overall change. Again there is enlargement of the cardiac silhouette with diffuse interstitial pattern that could reflect vascular congestion, congestive failure, or both. The interstitial changes would be consistent with the apparent patient history of scleroderma. Specifically, no acute focal pneumonia. [**9-3**] ECHO: The left atrium is moderately dilated. The right atrium is markedly dilated. No atrial septal defect is seen by 2D or color Doppler. The right atrial pressure is indeterminate. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50-55%) (the conduction defect, irregular rhythm, and RV pressure /volume overload make ventricular septal systolic function difficult to assess). There is no ventricular septal defect. The right ventricular cavity is markedly dilated with moderate global free wall hypokinesis. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. 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. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate pulmonary artery systolic hypertension. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [**2153-4-20**], the overall LVEF is probably less vigorous. EEG: This EEG gives evidence for a moderate to moderately severe and diffuse encephalopathy with background slowing and relative invariance to the rhythm itself. There does appear to be, on occasion, some isolated localization with relative suppression of electrical activity over the left lateral temporal and dorsilateral prefrontal region suggesting either diffuse cortical injury in that region or the possibility of interposed materials, for example, subdural hematoma fluid collection. No epileptiform activity was identified and there is a markedly abnormal cardiac rhythm present. [**9-2**] MRI BRAIN w/o CONTRAST: The sagittal T1 and axial T2 images are somewhat limited by patient motion. Within the limits of this study, there is no evidence for hemorrhage, edema, mass effect, masses, or infarction. The ventricles and sulci are mildly enlarged, consistent with mild atrophy. Mild periventricular white matter FLAIR hyperintensities are likely secondary to small vessel ischemic disease. There is no diffusion abnormality detected to suggest acute ischemia. There are no abnormal susceptibility artifacts suggesting history of hemorrhage. An isolated diffusion artifact (4. 10) is likely secondary to air in the nearby sphenoid sinus. The major vascular flow voids are unremarkable. IMPRESSION: No evidence for acute ischemia. Mild parenchymal atrophy and sequelae of small vessel ischemic disease. [**9-2**]: SKULL AP&LAT/C-SP/CXR/ABD SLG VIEWS MR SCREENING PORT Dentures are seen in situ. There is no radiopaque foreign body within the soft tissues of the head, neck, chest or abdomen. Extensive degenerative change is present throughout the spine. There is cardiomegaly with background interstitial pulmonary fibrosis and bilateral hilar prominence, which may represent pulmonary artery enlargement versus hilar lymphadenopathy. ECGs: [**9-2**]: Rate PR QRS QT/QTc P QRS T 86 148 88 382/427 57 -76 60 Sinus rhythm with atrial premature depolarizations. Left axis deviation. Left anterior fascicular block. Inferior myocardial infarction. Leftward percordial R wave transition point. Diffuse non-diagnostic repolarization abnormalities. Compared to the previous tracing of [**2153-7-27**] heart rate has increased. Multiple other abnormalities as noted persist without major change. TRACING #1 [**9-3**]: Rate PR QRS QT/QTc P QRS T 71 140 94 460/479 21 -67 -38 Sinus rhythm with atrial premature beats. Left axis deviation. Left anterior fascicular block. Slight ST segment elevation in leads V1-V3 with T wave inversions in leads III, aVF and V1-V4 raising the question of ischemia. However, given the patient's prior intraventricular conduction delay, T wave memory could also explain the T wave inversions. Compared to the previous tracing of [**2153-9-3**] a run of atrial tachycardia is no longer seen and the intraventricular conduction delay has resolved. [**9-4**]: Rate PR QRS QT/QTc P QRS T 56 132 90 514/507 45 -70 -93 Sinus bradycardia. Inferior myocardial infarction. Anteroseptal myocardial infarction. Compared to the previous tracing of [**2153-9-3**] precordial T wave inversion is more pronounced. Otherwise, multiple abnormalities persist without major change. TRACING #1 [**9-5**]: Rate PR QRS QT/QTc P QRS T 59 134 92 496/494 32 -72 -70 Sinus bradycardia. Compared to the previous tracing multiple abnormalities as previously noted persist without major change. TRACING #2 Brief Hospital Course: [**Age over 90 **] year old female with a history of cerebral vascular accident who presented with expressive aphasia, right sided weakness and fevers. 1) Aphasia/R sided weakness/Altered Mental Status: Patient had no new changes on MRI. Neurology evaluated the patient in detail and felt that the symptoms were consistent with seizure. EEG showed evidence of patient's prior stroke and activity that could indicate a predisposition to seizure. Neurology recommended and the patient was initiated on Keppra 250 mg [**Hospital1 **] liquid. It is also possible that her symptoms were related to her fevers, discussed below, which resolved for > 48 hours prior to discharge. Speech, weakness, and mental status have improved to near baseline at time of discharge. Patient's gait was slightly off balance, as noted by physical therapy at time of discharge, though on examination her cerebellar function was intact and there were no findings on head MRI suggestive of cerebellar insult. Likely gait can be attributed to patient being deconditioned. Patient's antihypertensives were intially held due to concern for stroke, but were restarted prior to discharge as the patient did not have evidence of a new stroke. Patient was continued on her aspirin and plavix throughout her hospitalization. 2) Fever/Leukocytosis: Patient with fever to 102 and leukocytosis to 16 on presentation that resolved within 24 hours of admission. Patient had a witnessed aspiration event in the Emergency Department and it was unclear if the patient had aspirated at home. As mentioned above, neurology felt her neurological symptoms may have been due to a seizure. Abdominal and pelvic CT on [**9-4**] did not indicate an sources of infection. Fever at presentation initially treated with doses of cefepime, ceftriaxone and vancomycin over first 48 hours. Chest x-ray no pneumonia, urine culture negative. Given patient's rapidly recovery in mental status, and lack on menigismal signs at presentation patient was not felt to have had an infectious central process. Given no source for infection, the patient's antibiotics were stopped and the patient remained afebrile with no leukocytosis. Blood cultures all negative to date at time of discharge. Fever and leukocytosis have been attributed to event either viral infection or seizure. 3) Cardiac Enzymes: Patient troponins checked out of concern for cardiac event in the setting of presentation with altered mental status patient endorsed intermittent complaints of chest pain. Patient with troponin trend of [**9-3**] <0.01--> 0.06. [**9-4**] 0.07-->0.06-->0.05. CK-MB normal. Unlikely to represent ongoing ischemia since enzymes trending down. Patient did have T wave inversions on ECG [**9-4**] of unclear significance. Patient without hypertension, tachycardia, hypoxia. Patient continued to improve in terms of mental status. Patient's cardiac troponins with mild elevation that trended downward. Patient EKG remained stable from [**9-4**] onward. 4) Coronary Artery Disease status post PCI: patient was maintained on her aspirin, plavix, metoprolol and lipitor. Patient was restarted on imdur as discharge due to no evidence for stroke. 5) Paroxysmal Atrial Fibrillation: Patient currently not on anticoagulation due to her multiple falls. Patient was maintained on metoprolol for rate control. Patient to discuss with her primary care provider [**Name Initial (PRE) 19824**]/benefits of coumadin. Patient on aspirin 81mg and plavix currently. 6) Anxiety/Depression: Patient continued on her lexapro and lorasepam prn. 7) Diabetes: Patient was maintained on an insulin sliding scale for glucose control. Patient is a diet controlled diabetic at home and sliding scale was not continued upon discharge. 8) Sjogren's Syndrome: Cont normal saline eye drops 9) Gastroesophageal reflux disease continued lansoprazole 10) Asthma continued albuterol nebs q6h:PRN wheezing Patient was seen by speech and swallow and recommened for regular solids, nectar/thickened liquids, medications/pills with nectar/thickened liquids Patient was DNR/DNI during this hospitalization. Disposition to acute care rehabilitation per physical therapy recommendations. Medications on Admission: ASA 81mg daily Metoprolol 25mg [**Hospital1 **] Imdur 180mg daily Plavix 75mg daily Lipitor 10mg daily NTG SL PRN Ativan 0.5mg prn Clonazepam 0.25mg [**Hospital1 **] Lexapro 10mg daily Prilosec 20mg daily Fosamax 70mg weekly Tums 300mg [**Hospital1 **] Tylenol 500mg [**Hospital1 **] PRN Vitamin D 1000 units daily Colace 100mg prn Albuterol Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. Imdur 60 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO once a day. 4. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual ASDIR (AS DIRECTED). 7. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO four times a day as needed. 8. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 10. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week. 11. Tums 300 mg (750 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO twice a day: take twice a day with food. 12. Acetaminophen 500 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for headache. 13. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed. 14. Levetiracetam 100 mg/mL Solution Sig: 250 mg PO BID (2 times a day). 15. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette Sig: [**12-6**] Drops Ophthalmic PRN (as needed) as needed for dryness. 16. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. 17. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed for wheezing. 18. Vitamin D 1,000 unit Capsule Sig: One (1) Capsule PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital1 599**] of [**Location (un) 55**] Discharge Diagnosis: Primary: Altered mental status Secondary: Atrial Fibrillation, Hypertension, Coronary Artery Disease Discharge Condition: good Discharge Instructions: You were admitted to the hospital becuase you had right sided weakness and were having difficulty speaking. In the emergency department you were found to have a fever and given IV antibiotics. Your mental status improved while in the emergency department and during your time in the intensive care unit. Your fever also resolved during the rest of your admission. You were seen by the neurology team who felt that given your symtpoms on presentation combined with results of a brain test called an EEG you may have had a seizure. The neurologists did not feel that you had a stroke. We have added a new medication to your regimen called Keppra to prevent seizures. This medication should be taken twice per day. Neurology would like to follow up with you in one month. If you experience chest pain, shortness of breath, significant weakness of any part of your body or difficulty speaking please come to the emergency department for further evaluation. Followup Instructions: PROVIDER (PCP): [**Name6 (MD) 251**] [**Last Name (NamePattern4) 1114**], M.D. Date/Time:[**2153-9-19**] 8:40 Provider (Neurology): [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**], MD Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2153-10-8**] 1:00 Completed by:[**2153-9-8**]

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icd9cm

[ [ [] ] ]

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icd9pcs

[ [ [] ] ]

19178, 19250

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371, 378

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406, 2832

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3993, 4660

25,708

113,095

52305+52315

Discharge summary

report+report

Admission Date: [**2179-3-10**] Discharge Date: [**2179-3-14**] Date of Birth: [**2120-6-4**] Sex: M Service: MEDICINE HISTORY OF PRESENT ILLNESS: This is a 58 year old male with a very complicated previous medical history who was transferred to the [**Hospital1 69**] on [**2179-3-10**], from [**Hospital **] Rehabilitation for increasing lethargy, low grade temperatures and hypoxia. He had been in prior to admission. He was noted to have increasing lethargy over the few days and then on the day of admission his oxygen saturation decreased to the low 80% on his baseline four liters of oxygen. He had a low grade temperature. Notably he had had a PICC line placed recently. Arterial blood gases at [**Hospital1 **] showed pH 7.05, pCO2 76 and FIO2 95. The FIO2 is unknown on the sample. He was transferred to the [**Hospital3 **] only of feeling weak and of feeling very tired. He was disoriented. PAST MEDICAL HISTORY: 1. AIDS diagnosed in [**2169**]. Only opportunistic infection is apparently Candidal esophagitis. He also has severe cardiomyopathy secondary to HIV. His ejection fractions have been variously recorded at 30 to 40% and then 70% on a most recent echocardiogram. He has severe right ventricular dilation and hypokinesis. 2. End stage renal disease on hemodialysis. 3. Chronic obstructive pulmonary disease on four liters home oxygen. 4. Pulmonary embolus and deep vein thrombosis in [**2168**]. 5. Hepatitis B. 6. Hepatitis C. 7. Sustained ventricular tachycardia, status post ablation in [**2178-11-24**]. 8. Pneumonia, some with Methicillin resistant Staphylococcus aureus, one requiring intubation 9. Pancreatitis. 10. PPD positive. 11. VRE positive. 12. Methicillin resistant Staphylococcus aureus positive. 13. History of intravenous drug use, on Methadone. 14. Question of history of obstructive sleep apnea. MEDICATIONS ON ADMISSION: 1. Amiodarone 200 mg q.d. 2. Vitamin C 500 mg b.i.d. 3. Folate 1 mg q.d. 4. Epivir 25 mg q.d. 5. Prevacid 30 mg p.o. q.d. 6. Megace 400 mg q.d. 7. Multivitamin one q.d. 8. Senokot two at night. 9. Zoloft 50 mg q.d. 10. Bactrim double strength one p.o. q.Tuesday, Thursday and Saturday. 11. Zerit 20 mg q.d. 12. Coumadin 2.5 mg q.d. with a goal INR 2.0 to 3.0. 13. Zinc Sulfate 220 mg q.d. 14. Albuterol and Atrovent nebulizers. 15. Methadone 50 mg q.a.m. 16. Valium 5 mg a day. 17. Lactulose q.p.m. 18. Colace 100 mg b.i.d. 19. Percocet one p.o. q4hours prn 20. Vancomycin one gram and 80 mg Gentamicin on [**2179-3-9**]. ALLERGIES: Thorazine causes anaphylaxis, H2 blockers cause thrombocytopenia. Haldol, Clindamycin, Codeine and Stelazine all cause rashes. PHYSICAL EXAMINATION: At the time of admission to the Medicine Intensive Care Unit, the patient is comfortable, sleeping, but arousible, cachectic man. Temperature was 97.4, blood pressure 112/48, pulse 99, respiratory rate 12, oxygen saturation 96% on 50% face mask. The pupils were 4.0 millimeters bilaterally and reactive. There is no jugular venous distention. He had crackles at his lung bases. His heart was regular. He had a II/VI systolic ejection murmur at the left upper sternal border. His abdomen was soft, nontender, nondistended, normoactive bowel sounds. Liver edge was one to two centimeters below the costal margin. There was no cyanosis, clubbing or edema. He did not cooperate with neurologic examination but moved all four extremities. LABORATORY DATA: At the time of admission, laboratories were notable for a white count 4.4 without a left shift, hematocrit 43.9 and platelets 87,000. His Chem7 was 135, potassium 7.8, chloride 102, bicarbonate 15, blood urea nitrogen 64, creatinine 7.2 with a glucose of 95. Arterial blood gases on two liters showed pH 7.09, pCO2 57 and pO2 60. Electrocardiogram had slightly peaked T waves in the lateral leads which was unchanged from baseline. Chest x-ray showed mild pulmonary edema but no infiltrates. HOSPITAL COURSE: The impression at the time of arrival to the Emergency Department was that this was a 58 year old man with complicated medical history presenting with acidosis, hyperkalemia, and lethargy. He was treated with insulin, glucose, Kayexalate and taken to emergent hemodialysis. At that time, he complained only of dyspnea and fatigue with a question of increase in his sputum production. He was then admitted to the Medical Intensive Care Unit and was also placed on bilevel positive airway pressure and he should receive Vancomycin, Gentamicin and Levofloxacin, but these were discontinued after only one dose. Cultures are negative to date. He improved rapidly with dialysis and BiPAP and his antibiotics were discontinued. The pulmonary critical care team's overall impression was fluid overload versus bronchitis and felt that a possible left lower lobe process noted on chest x-ray was not pneumonia. His temperature maximum during this hospitalization was 99.9. On [**2179-3-13**], he was felt ready for transfer back to [**Hospital1 **], however, a bed was not available and he was transferred to the floor. He complained only of feeling very weak (diffusely) but said that his breathing was improved about 50 to 60% of the way back to baseline. A repeat chest x-ray showed improvement in the pulmonary edema. It showed no infiltrate. At this time, his date of discharge is not clear. An induced sputum for pneumocystis will be sent prior to discharge. However, it is felt clinically low probability that pneumocystis is involved in this presentation. DISCHARGE DIAGNOSES: 1. Profound metabolic acidosis, etiology unclear. 2. Concurrent respiratory acidosis. 3. Hyperkalemia secondary to acidosis. 4. Mental status changes secondary to multiple metabolic abnormalities, improved. 5. Severe chronic obstructive pulmonary disease. 6. End stage renal disease, on hemodialysis. 7. HIV/AIDS. 8. Cardiomyopathy. MEDICATIONS ON DISCHARGE: 1. Amiodarone 200 mg p.o. q.d. 2. Vitamin C 500 mg p.o. b.i.d. 3. Epivir 25 mg p.o. q.d. 4. Protonix 40 mg p.o. q.d. 5. Megace 400 mg p.o. q.d. 6. Multivitamin one tablet p.o. q.d. 7. Senokot two tablets p.o. q.h.s. 8. Zoloft 50 mg p.o. q.d. 9. Zerit 20 mg p.o. q.d. 10. Coumadin 2.5 mg p.o. q.d. with a goal INR of 2.0 to 3.0. 11. Zinc Sulfate 220 mg p.o. q.d. 12. Albuterol and Atrovent nebulizers q.i.d. and q2hours p.r.n. 13. Methadone 50 mg p.o. q.a.m. 14. Lactulose 30 ccs p.o. b.i.d. 15. Colace 100 mg p.o. b.i.d. 16. Percocet one tablet p.o. q6hours p.r.n. 17. Bactrim double strength one tablet p.o. q.Tuesday, Thursday, and Saturday. He will continue to be followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]. [**First Name11 (Name Pattern1) 4283**] [**Last Name (NamePattern4) 4284**], M.D. [**MD Number(1) 7551**] Dictated By:[**Last Name (NamePattern1) 108133**] MEDQUIST36 D: [**2179-3-14**] 15:51 T: [**2179-3-14**] 16:07 JOB#: [**Job Number 108134**] Admission Date: [**2179-3-10**] Discharge Date: [**2179-3-21**] Date of Birth: [**2120-6-4**] Sex: M Service: MEDICINE HISTORY OF PRESENT ILLNESS: The patient is a 58 year old man with multiple medical problems including HIV infection, deep vein thrombosis, pulmonary embolism, chronic obstructive pulmonary disease, history of pancreatitis, and venous thrombosis status post ablation, who was at hemodialysis for his end-stage renal disease the day prior to admission. He felt sluggish and was referred to the Emergency Room where he was found to have a potassium of 7.8. He was treated with Kayexalate, calcium, glucose, and insulin. He had been treated as well at dialysis with Vancomycin and Gentomycin for an infection. He was admitted initially to the Medical Intensive Care Unit for management of his hyperkalemia. He had been at rehabilitation where the lethargy and confusion was noted. He was noted that morning to have an arterial blood gas of 7.05 with PCO2 76 and PO2 of 95 and a low-grade temperature which was why the antibiotics were started. Question of a line infection was raised as well. He was hypotensive, which was baseline, but concern about sepsis was raised. MEDICATIONS ON ADMISSION: 1. Amiodarone 200 mg once daily. 2. Vitamin C 500 mg twice a day. 3. Folate 1 mg once daily. 4. Epivir 25 mg once daily. 5. Prevacid 30 mg once daily. 6. Megace 400 mg once daily. 7. Multivitamin 1 daily. 8. Senokot 2 at bedtime. 9. Vancomycin 1 gram given for 16 02. 10. Gentamycin 180 mg given intravenous for 16 02. 11. Valium 5 mg daily. 12. Lactulose taken in the evening. 13. Percocet 1 tablet q4 hours as needed. 14. Sertraline 50 mg once daily. 15. Bactrim DS once daily. 16. Zerit 20 mg once daily. 17. Coumadin 2.5 mg once daily. 18. Zinc sulfate 220 mg once daily. 19. Albuterol and Atrovent inhalers as needed. 20. Methadone 50 mg daily. 21. Erythropoietin 10,000 units once a week. 22. Albumin was given at hemodialysis for hypotension. 23. Colace. ALLERGIES: Haldol, Thorazine, Clindamycin, and an intolerance of H2 blockers which caused thrombocytopenia. FAMILY HISTORY: Thought to be non-contributory. SOCIAL HISTORY: Former intravenous drug user, married with children, no alcohol, former heavy tobacco. REVIEW OF SYSTEMS: Patient was not terribly cooperative, unable to give a detailed report. PHYSICAL EXAMINATION ON DAY OF ADMISSION: Blood pressure 112/48; temperature 97.4; pulse 99; respirations 12; oxygen saturation rate 96% on 50% face mask. General: He was sleeping but arousable, seen in hemodialysis. Head, eyes, ears, nose and throat: Pupils are equal, round, and reactive to light. Neck: No jugular venous distention. Lung examination: Significant for rales at the bases. Cardiovascular examination: Regular rate and rhythm, S1 S2 normal, 2/6 systolic murmur was noted at the left sternal border. Abdomen: Soft, non-tender, liver edge was palpable 1 to 2 cm below the right costal margin. Extremities without edema. Neurological examination: Moved all four, was not cooperative with detailed examination. LABORATORY DATA: White blood cell count 4.4; hematocrit 43; platelet 87; admission electrolytes were significant for potassium 8.3, then 7.8; creatinine 7.2; glucose 135; chloride 102; bicarbonate 15; blood gas 7.09/57/60 on 2 liters; electrocardiogram showed normal sinus rhythm at 96 with prominent T-waves in the lateral leaves with an indeterminate axis; chest x-ray showed mild pulmonary edema without infiltrates. HOSPITAL COURSE: The initial impression was of a profound metabolic acidosis and hyperkalemia. The metabolic acidosis was thought to be superimposed on his baseline, pH thought to be about 7.2. Little respiratory compensation was thought to be evident. Uremia was not thought to be the problem and perhaps that just was implicated. The hyperkalemia was treated as noted above and with hemodialysis. Hypoxemia was stable in the 90's and was monitored. His mental status changes were thought to be related to CO2 retention, sedating medications were minimized. His thrombocytopenia was thought to be relatively close to baseline and related to either renal disease, hepatitis, or more likely a chronic autoimmune thrombocytopenia. He was continued on antibiotics and followed in the Intensive Care Unit. The Nephrology team was closely involved as was the Intensive Care Unit team. It was thought that his shortness of breath might be related to his underlying chronic obstructive pulmonary disease, possible pulmonary edema, but also his inability to compensate for acidosis. He remained in the Intensive Care Unit until [**2179-3-13**]. He was given [**Hospital1 **]-level positive airway pressure to help with his respiratory illness. Fever remained low-grade and there was no evidence of any acute infection. On transfer, he had several episodes of desaturation, but none terribly symptomatic. Hemodialysis was continued. He was weak and deconditioned. Question was raised about aspiration versus mucous plugging versus V/Q mismatch. On discharge, he was evaluated by Physical Therapy and his medications were adjusted including calcium binders. He was ultimately discharged to home with services as there were delays in obtaining approval or placement for a skilled nursing facility. DISCHARGE CONDITION: Fair. [**Hospital6 407**] services were provided. DISCHARGE MEDICATIONS: 1. Amiodarone. 2. Vitamin C. 3. Epivir. 4. Protonix. 5. Megace. 6. Senna. 7. Zoloft. 8. Bactrim. 9. Zinc sulfate. 10. Albuterol and Atrovent nebulizers. 11. Methadone. 12. Lactulose. 13. Colace. 14. Zerit. 15. Renagel. 16. Tums. 17. Nephrocaps. 18. Coumadin. 19. Percocet. FOLLOW-UP: He was to call his primary care physician's office to arrange for follow-up and to continue with hemodialysis. [**First Name11 (Name Pattern1) 4283**] [**Last Name (NamePattern4) 4284**], M.D. [**MD Number(1) 7551**] Dictated By:[**Last Name (NamePattern4) **] MEDQUIST36 D: [**2180-11-15**] 14:02 T: [**2180-11-20**] 17:44 JOB#: [**Job Number 108157**]

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icd9cm

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[ "39.95", "38.93" ]

icd9pcs

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12342, 12394

9120, 9153

5566, 5908

12417, 13104

5934, 7120

8221, 9103

10530, 12320

2702, 3959

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