ChanBeDu/relevant_section_length · Datasets at Hugging Face

83,421

172,322

7796

Discharge summary

report

Admission Date: [**2147-11-17**] Discharge Date: [**2147-11-22**] Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 7299**] Chief Complaint: hyperkalemia Major Surgical or Invasive Procedure: None History of Present Illness: 86 yo M with h/o htn, IDDM presents after a fall. Pt reports that today he was walking on front steps, one step felt off balance and he fell on his buttock. He did not have any prodrome or LH or LOC. He called his son from his cell phone as he could not get off the ground. His son and dtr in law came and helped him get inside, and he had a cup of tea. Then he had two episodes while he was sitting at the table where "everything went [**Doctor Last Name 352**]" and he felt like he was about to pass out. Pt was taken by EMS to [**Location (un) **] ED where insulin pump was noted to be dislodged with FS >500. There, pt had bradycardia and LBBB pattern, TW peaked with K of 7.3, given insulin, bicarb, calcium with improvement in EKG and elevation of heart rate. Lactate was 8.7, serum glucose was 469 and Cr was 2.4. On blood gas pH was 7.24. Placed on insulin gtt for anion gap/dka. . Pt was transfered to [**Hospital1 18**] ED for trauma eval. In ED, triage VS were: 96.8 60 113/51 26 100% 2L. CT head concerning for frontal contusion with ? orbital air concerning for facial fracture and lumbar films showed compression fractures of unclear age. Potassium was treated with calcium, insulin (10 units) and [**12-17**] amp D50, bicarb and renal was consulted and recommended 2L IVF followed by 80mg IV Lasix, may repeat 30mg kayexelate in [**3-21**] hours, repeat electrolytes. In the ED a foley was attempted, but unable to be placed d/t large prostate. Past Medical History: IDDM on insulin pump, BG have been BPH S/p gallstone pancreatitis and ultimate removal of pancreas d/t cysts s/p ccy from gangrenous gallbladder recent LLE cellulitis completed keflex course x2 Social History: Lives with wife. Used to work for electric comp. No tobacco or EtOH or drug use. Family History: Non contributory. Physical Exam: Physical Exam: VS: Temp: 98.7/98.0 BP: 136/50 (128-138/55-62) HR: 58 (58-67) RR: 18 sat 98% on RA GEN: Elderly man, pleasant, comfortable, NAD HEENT: PERRL, EOMI, anicteric, MMM, op without lesions, no LAD, JVP flat RESP: CTA b/l with good air movement throughout CV: RR, S1 and S2 wnl, holosystolic murmur throughout precordium most audible RUSB, + radiation to carotids ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: No edema, 2+ pulses, fused right knee with abundant scar tissue, right leg apprx. 2 inches shorter than the left SKIN: ecchymoses on upper and lower extremities, lac on lower extremity (left), also with erythema, warmth over LLE which is much improved, RLE has small lesion on shin covered with gauze, not actively bleeding NEURO: AAOx3. Pertinent Results: Admission Labs: [**2147-11-16**] 08:20PM BLOOD WBC-14.1* RBC-3.05* Hgb-9.4* Hct-27.8* MCV-91 MCH-30.9 MCHC-33.8 RDW-13.2 Plt Ct-208 [**2147-11-16**] 08:20PM BLOOD Neuts-87.7* Lymphs-6.2* Monos-5.7 Eos-0.2 Baso-0.2 [**2147-11-16**] 10:30PM BLOOD PT-14.9* PTT-25.3 INR(PT)-1.3* [**2147-11-16**] 08:20PM BLOOD Glucose-144* UreaN-45* Creat-2.2* Na-136 K-6.1* Cl-109* HCO3-17* AnGap-16 [**2147-11-16**] 10:34PM BLOOD pH-7.28* [**2147-11-16**] 08:28PM BLOOD Lactate-3.1* K-5.1 Discharge Labs: [**2147-11-22**] 06:30AM BLOOD WBC-6.7 RBC-2.96* Hgb-8.9* Hct-26.9* MCV-91 MCH-30.0 MCHC-33.0 RDW-13.4 Plt Ct-217 [**2147-11-22**] 06:30AM BLOOD PT-12.7 PTT-24.8 INR(PT)-1.1 [**2147-11-22**] 06:30AM BLOOD Glucose-167* UreaN-29* Creat-1.3* Na-136 K-4.6 Cl-102 HCO3-25 AnGap-14 [**2147-11-22**] 06:30AM BLOOD Calcium-8.9 Phos-3.4 Mg-1.8 Cardiac: [**2147-11-16**] 08:20PM BLOOD CK-MB-7 cTropnT-0.05* [**2147-11-17**] 04:35AM BLOOD CK-MB-7 cTropnT-0.06* [**2147-11-17**] 11:32AM BLOOD CK-MB-8 cTropnT-0.08* Hematology: [**2147-11-16**] 10:34PM BLOOD Glucose-145* Lactate-2.5* Na-135 K-6.7* Cl-109 calHCO3-18* Studies: ECG Study Date of [**2147-11-16**] 8:24:40 PM Probable ectopic atrial rhythm. There is a late transition which is probably normal. Low voltage in the precordial leads. No previous tracing available for comparison. CT HEAD W/O CONTRAST Study Date of [**2147-11-16**] 11:37 PM IMPRESSION: 1. Hyperdense focus at the left frontal region may represent a small hemorrhagic focus versus hemorrhagic mass versus infectious process. Correlate clinically. 2. No acute fractures identified. 3. Periventricular and subcortical white matter low-attenuating lesions, likely sequelae of chronic small vessel ischemic disease. Final Attending Comment: A cavernoma is also in the differential given lack of significant surrounding edema, consider MRI for further evaluation. CT HEAD W/O CONTRAST Study Date of [**2147-11-18**] 3:08 AM IMPRESSION: 1. Hyperdense focus at the left frontal region may represent a small hemorrhagic focus versus hemorrhagic mass versus cavernoma given the lack of significant surrounding edema. An MRI should be considered for further evaluation. 2. No acute fractures are identified. 3. Periventricular and subcortical white matter low-attenuating regions likely sequelae of chronic small vessel ischemic disease. MR HEAD W & W/O CONTRAST Study Date of [**2147-11-21**] 11:39 AM IMPRESSION: 1. 7-mm left frontal periventricular lesion, with characteristics consistent with a cavernous malformation. 2. Moderate chronic small vessel ischemic disease. The study and the report were reviewed by the staff radiologist. CT C-SPINE W/O CONTRAST Study Date of [**2147-11-16**] 9:56 PM IMPRESSION: Extensive degenerative changes predominantly involving the facet joints, which slightly limit the evaluation for fracture. Ossification of posterior longitudinal ligament at C4-C5 level. Mild anterolisthesis of C6 on C7 secondary to degenerative change. If continued concern, MRI can be obtained for further assessment to exclude ligamentous injury. CT T-SPINE W/O CONTRAST Study Date of [**2147-11-16**] 9:58 PM IMPRESSION: 1. No acute fracture identified. Ossification of the anterior longitudinal ligaments. 2. Hiatal hernia. 3. Bibasilar atelectasis. UNILAT LOWER EXT VEINS LEFT Study Date of [**2147-11-17**] 3:19 PM IMPRESSION: No evidence of deep vein thrombosis in the left leg. Edematous superficial tissues are noted. RENAL U.S. Study Date of [**2147-11-17**] 3:20 PM IMPRESSION: Mild right hydronephrosis, which could possibly be related to the very distended urinary bladder. Simple left renal cyst. Brief Hospital Course: 86 yo M with IDDM, afib, htn presenting after a mechanical fall, with dislodgement of his insulin pump, hyperkalemia, metabolic acidosis and ARF. # Presyncope: He presented with a mechanical fall entering his son's house. He fell down three stairs and hit his head. He had multiple reasons for the fall. He has a fused right knee, and his leg is 2 inches shorter than his left. He had presyncopal symptoms and was likely dehydrated in the setting of his hyperglycemia and poor po intake, as well as having bradycardia. After correction of his metabolic abnormalities his symptoms resolved and PT recommend rehab. # Hyperkalemia: Mr. [**Known lastname 28205**] was admitted to the MICU with a metabolic acidosis, hyperglycemia and hyperkalemia, with EKG changes on admission. He was treated with insulin, dextrose, kayexalate, bicarbonate, and calcium. With correction of his acidosis and hyperglycemia his hyperkalemia resolved and his EKG returned to his baseline. He was discharged with a potassium of 4.6. Initially, his HCTZ, lisinopril, and spironolactone were held. His HCTZ was added back and the lisinopril and spironolactone were held. To Do: - Please restart spironolactone and lisinopril when appropriate # Hyperglycemia: He has had 2 episodes in the past month in which his insulin pump has failed and he has had resulting sugars of approximately 500. The first of which the needle was bent and was not delivering the medication properly. The most recent time, the concern is that his pump became dislodged during his mechanical fall. He fell at home due to presyncope and mechanical instability. He had subsequent issues of presyncope. During admission his hyperglycemia was reversed, [**Last Name (un) **] was consulted and felt comfortable with Mr. [**Known lastname 28206**] ability to use his pump. He was covered with Glargine and insulin sliding scale while in house. It will have to be determined at rehab whether or not to restart his insulin pump. To Do: -Please follow glargine and sliding scale insulin in accordance with his sliding scale # Acute Renal Failure: His baseline creatinine is 1.3. His acute renal failure was likely secondary to a combination of dehydration and hypotension due to poor forward flow with presyncope/syncope. Over the course of the hospitalization, with fluid resuscitation and diuresis, his creatinine returned to baseline. A foley catheter was not needed. His urine culture was negative with GNR's <3000. # Fe defic Anemia: Baseline hct is 35. His HCT was 29 on admission and was stable at 26 throughout his stay. He was guaiac positive, and his iron studies were consistent with iron deficiency anemia. His MCV is 91. He has a history of gastritis and [**Last Name (un) 865**] esophagus. Both pt and his PCP were notified about this issue and we recommended outpt EGD and Colonoscopy for evaluation of the anemia. He was hemodynamically stable throughout his stay and his HCT remained stable while in house. -Please arrange for outpatient EGD and Colonoscopy # Frontal lesion: Originally thought to be a traumatic ICH on CT head, but further evaluation with MRI was recommended which revealed a benign cavernous malformation. There was no evidence of acute trauma from the fall. # LLE edema: He has lower extremity stasis dermatitis changes. His left lower extremity was erythematous on admission. He also had a leuocytosis and low grade fever. He was started on Keflex, and changed to Vancomycin for a day. On transfer to the floor, his leg did not appear to have active cellulitis, his leukocytosis resolved, he was afebrile, and his ABx were discontinued. His erythema improved and at the time of discharge it had resolved. # Transfer of care: Mr. [**Known lastname 28205**] was discharged to [**Location (un) 25576**] Center rehab facility where Dr. [**Last Name (STitle) 1159**] is the Medical Director and will oversee his care. At the time of discharge he had no studies pending. Issues to follow-up on: Insulin pump restarting vs. sliding scale and glargine Investigation of anemia and guaiac positive stools with EGD and colonoscopy Medications on Admission: Sanctura 20 mg daily Verapamil 240mg daily Omeprazole 20mg daily HCTZ 25 daily Lisinopril 20 [**Hospital1 **] Simva 40 daily Aspirin 81 daily Spironolactone 25 daily Discharge Medications: 1. hydrochlorothiazide 12.5 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 3. ferrous sulfate 300 mg (60 mg Iron) Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 5. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 6. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Sanctura 20 mg Tablet Sig: One (1) Tablet PO once a day. 8. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day. 9. Insulin Sliding Scale Glargine 26 units at bedtime Sliding Scale insulin QACHS according to attached sliding scale Discharge Disposition: Extended Care Facility: [**Hospital6 25759**] & Rehab Center - [**Location (un) **] Discharge Diagnosis: Primary: Hyperkalemia Metabolic Acidosis Hyperglycemia Stasis dermatitis Secondary: Hypertension Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital due to a fall and fainting. You were found to have your insulin pump disloged. You also had kidney dysfunction and elevatated potassium. You required a stay in the ICU. Your kidney function returned to its baseline. Your sugars were well controlled and your electrolytes were all back to normal. Your blood count was low during admission, and you should have an endoscopy as an outpatient. You are now improving, but will need to gain back your strength in rehab. The following changes were made you your medications: -Your insulin pump is being stopped while you are in rehab -You are now on lantus and a sliding scale of humalog insulin -STOPPED lisinopril -STOPPED spironolactone -STOPPED verapamil -INCREASED omeprazole to 40mg daily -STARTED iron tabs Please keep your follow up appointments. Followup Instructions: PLEASE FOLLOW-UP WITH DR. [**Last Name (STitle) **] [**Telephone/Fax (1) 20587**] TO DISCUSS SCHEDULING AN OUTPATIENT ENDOSCOPY Completed by:[**2147-11-25**]

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icd9cm

[ [ [] ] ]

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icd9pcs

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116,778

44819

Discharge summary

report

Admission Date: [**2146-2-4**] Discharge Date: [**2146-2-16**] Date of Birth: [**2084-5-25**] Sex: M Service: NEUROSURGERY Allergies: IV Dye, Iodine Containing Attending:[**First Name3 (LF) 2724**] Chief Complaint: Bilateral lower extremity numbness, abdominal wound drainage Major Surgical or Invasive Procedure: [**2146-2-4**]: Bedside incision and drainage of abdominal wound [**2146-2-10**]: T1-6 posterior laminectomy/fusion with vertebrectomy/reconstruction T4 History of Present Illness: Mr. [**Known lastname 95891**] is a 61 year old man s/p left hepatic lobectomy with Dr. [**Last Name (STitle) **] on [**2146-1-3**] for a large L HCC. Prior to this on [**2145-12-17**] Dr. [**Last Name (STitle) **] performed VATS left upper lobe and left lower lobe nodules: one node positive for metastatic disease with clear margins and the other was negative. He had an uneventful post-op course from both surgeries. He has seen oncology for possible sorafenib treatment. However he complained of new back pain to his pcp, [**Name10 (NameIs) **] [**Last Name (STitle) 1407**]. At that time he had no neurologic symptoms. An MRI obtained [**2-1**] showed a new pathologic fx of T4 and an epidural lesion at that level compressing the cord. Plans were to stabilize the spine and radiate the lesion.However yesterday he developed b/l LE weakness and numbness. He has been brought in to the hospital for more immediate management.He has had some drainage from his incision and this was opened at the bedside. Past Medical History: PMH: hyperuricemia (no gout) dyspepsia hyperlipidemia diverticulosis osteoarthritis lumbar disc displacement basal cell CA face PSH: L knee arthroscopy [**2116**] L VATS wedge resection x 2 [**11/2145**] [**2146-1-3**] Left hepatic lobectomy, cholecystectomy, intraoperative ultrasound. Social History: Scottish. Educational administrator teacher/coach in HS. Married with 2 adult kids. No IVDU. Drinks 15/week, never smoker. No tattoos. Family History: Father: Coronary artery disease (died at age 47). Mother: Breast cancer Physical Exam: EXAM: PE: AFVSS A&Ox4 Hent: anicteric, mmm CV: RRR Resp: clear Abd: middle of incision opened, fascia intact, 5 cc's of turbid fluid evacuated Back: no mid-line spinal ttp Ext: no edema, able to lift legs against gravity, able to stand with assistance, sensation intact to b/l LE but feels a heavy, leaden feeling to mid thigh. 2+ pulses Physical Exam at Discharge: Pertinent Results: LABORATORIES: IMAGING: Abdominal Wall U/S: [**2146-2-4**]: Localized peri-incisional collection compatible with subcutaneous peri-incisional infection. CT A/P: [**2146-2-4**]: 1. Fluid collection along the hepatic resection margin with thin wall and without adjacent inflammatory. This most likely represents a post-operative seroma. 2. Midline open wound just inferior to the xiphoid with small amount of fluid. This may have been opened since the ultrasound from earlier in the day and may be nfected. 3. Marked interval increase in bilateral pulmonary metastases in the visualized lung bases, up to 1.2 cm. MRI T/L Spine: [**2146-2-4**]: Pathologic fracture T4 w associated cord compression; Extension of T4 epidural tumor to posterior vertebral body. CT C/A/P: [**2146-2-6**]: 1. Interval development of multiple bilateral pulmonary metastases involving all lobes. Enlarged metastatic left gastric lymph node. Interval progression of the lytic T4 lesion with increased epidural extension and anterior vertebral body compression fracture. 2. Slight decrease in the perihepatic fluid collection, which now contains some air consistent with the recent aspiration. 3. Thrombus in the anterior right portal vein and its segment V branch, bland thrombus is favored but this is uncertain. MICROBIOLOGY: Abdominal wound swab [**2146-2-4**]: MSSA BCx: [**2146-2-4**]: No growth - FINAL Urine Cx: [**2146-2-5**]: ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S LEVOFLOXACIN---------- 0.5 S NITROFURANTOIN-------- <=16 S TETRACYCLINE---------- =>16 R VANCOMYCIN------------ 2 S Peritoneal Fluid: [**2146-2-5**]: No growth - FINAL Urine Cx: [**2146-2-8**]: No growth - FINAL Brief Hospital Course: 1. Metastatic Hepatocellular Carcinoma: Patient is s/p L VATS wedge resection x 2 [**11/2145**], L hepatic lobectomy [**2146-1-1**]. Onset of radicular pain prompted MRI spine prior to this admission which showed a T4 epidural metastasis. CT of the chest, abdoment and pelvis [**2-6**] was performed to further stage possible recurrent HCC. He was found to have diffuse pulmonary metastases bilaterally in addition to previously seen spinal metastasis. Medical oncology, who sees patient as an outpatient, was consulted to discuss chemotherapeutic options with patient. They would like to start serafinib four to six weeks following neurosurgical intervention and will follow patient accordingly. - Spinal Metastasis: Patient admitted [**2146-2-4**] with complaint of worsening B/L lower extremity weakness in setting of T4 epidural mestatic lesion seen on MRI [**1-31**]. Neurosurgery was consulted on admission. Patient was placed on bed rest and given high dose IV steroids. Repeat MRI of thoracic and lumbar spine was performed [**2-4**] which showed pathologic fracture of T4 vertebral body and persistence of T4 epidural lesion. Patient was taken to the operating room on [**2-10**] for T1-6 posterior decompression and fusion with T4 vertebrectomy/reconstruction. He tolerated this well, was extubated and transferred to ICU overnight for close monitoring. His neuro exam remained stable. JP drain that was placed intra-op was recorded and was removed on [**2-13**] without difficulty. His foley was removed on [**2-12**] and he was able to void on his on without trouble. He was mobilized with PT and they recommended a rehab facility. He will be discharged to rehab facility in stable condition on [**2146-2-16**]. - Pain Control: Patient on oxycontin/oxycodone as an outpatient and these were continued in hospital. [**2-7**] patient noted increased pain and patient's medications were titrated with good effect pre and post-op. He is currently on oxycontin 30mg TID as well as oxycodone 15-20mg q1 per palliative care rec's and his pain is well controlled. 2. Fever: Patient was found to be febrile on day of admission. Cultures were drawn from all possible sources of infection and patient was started on vancomycin, unasyn [**2-5**]. Blood cultures [**2-4**] were shown to be negative. - Wound Infection: At time of admission, patient was complaining of drainage from medial aspect of abdominal incision related to hepatic resection [**1-7**]. Limited abdominal wall U/S [**2-4**] showed small fluid collection at medial aspect of incision. This was incised and drained at the bedside and contents was sent for culture. Cultures revealed MSSA and patient was treated with vancomycin x 4 days and nafcillin x 1 day. Wound packing was changed [**Hospital1 **] and monitored for any further signs of infection. - UTI: UA on admission was positive and subsequent urine culture drawn [**2-5**] showed enterococcus > 100k colonies. Patient completed unasyn x 4 days and one additional day of ampicillin. Repeat UA and urine culture [**2-8**] was negative and antibiotics were discontinued. - Fluid Collection: CT abdomen [**2-4**] without contrast showed a perihepatic fluid collection. This was aspirated by IR [**2-5**] and fluid was sent for culture. Cultures were negative and fluid analysis showed this to be a seroma/biloma. No further management was indicated. 3. Disposition: Given the patient's prognsosis, palliative care was consulted. Patient participated in Reiki sessions and will follow with palliative care for future services. Medications on Admission: ALLOPURINOL - (Prescribed by Other Provider) - 300 mg Tablet - 1 Tablet(s) by mouth DAILY (Daily) LORAZEPAM [ATIVAN] - (Prescribed by Other Provider) - 1 mg Tablet - 1 Tablet(s) by mouth at bedtime OXYCODONE - 5 mg Tablet - [**1-30**] Tablet(s) by mouth prn: every [**5-4**] as needed for pain oxycontin - 20'' Medications - OTC BISACODYL - (Prescribed by Other Provider) - 5 mg Tablet, Delayed Release (E.C.) - 1 PR by mouth once a day as needed for constipation DIPHENHYDRAMINE HCL [SLEEP AID (DIPHENHYDRAMINE)] - (Prescribed by Other Provider) - Dosage uncertain DOCUSATE SODIUM [COLACE] - (Prescribed by Other Provider) - 100 mg Capsule - 1 Capsule(s) by mouth twice a day as needed for constipation SENNA - (Prescribed by Other Provider) - 8.6 mg Tablet - 1 Tablet(s) by mouth twice a day Discharge Medications: 1. allopurinol 100 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 2. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 4. oxycodone 30 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release PO every eight (8) hours. Disp:*90 tablets* Refills:*0* 5. lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 6. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. 7. oxycodone 10 mg Tablet Sustained Release 12 hr Sig: Three (3) Tablet Sustained Release 12 hr PO Q8H (every 8 hours). 8. oxycodone 5 mg Tablet Sig: 3-4 Tablets PO Q1H (every hour) as needed for pain. 9. dexamethasone 2 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 1 days. 10. dexamethasone 2 mg Tablet Sig: 0.5 Tablet PO Q12H (every 12 hours) for 1 days. Discharge Disposition: Extended Care Facility: [**Hospital **] [**Hospital 8**] Rehab Center Discharge Diagnosis: Metastatic Hepatocellular Carcinoma Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: ?????? Do not smoke. ?????? Keep your wound clean/shower daily including incision but do not immerse in water for 6 weeks from your date of surgery. ?????? No pulling up, lifting more than 10 lbs., or excessive bending or twisting for 2 weeks then increase as tolerated. ?????? Limit your use of stairs to 2-3 times per day. ?????? Have your incision checked daily for signs of infection. ?????? Take your pain medication as instructed. ?????? Increase your intake of fluids and fiber, as pain medicine (narcotics) can cause constipation. We recommend taking an over the counter stool softener, such as Docusate (Colace) while taking narcotic pain medication. Followup Instructions: Follow Up Instructions/Appointments ??????Please return to the office for removal of your staples/suture or have this done at rehab or by visiting nurse [**First Name8 (NamePattern2) **] [**2-24**]. ??????Please call ([**Telephone/Fax (1) 2726**] to schedule an appointment with Dr. [**Name (NI) 548**]_to be seen in 6 weeks. ??????You will need AP and lateral x-rays of the thoracic spine prior to your appointment. Dr. [**Last Name (STitle) **] on [**2-23**] @ 940am. [**Hospital1 18**], [**Last Name (NamePattern1) **], [**Location (un) 436**] [**Telephone/Fax (1) 673**] Completed by:[**2146-2-16**]

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icd9cm

[ [ [] ] ]

[ "84.51", "86.04", "81.63", "80.99", "81.04", "81.05", "54.91" ]

icd9pcs

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18518

Discharge summary

report

Admission Date: [**2129-3-15**] Discharge Date: [**2129-3-24**] Date of Birth: [**2068-1-9**] Sex: F Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1283**] Chief Complaint: Asymptomatic Major Surgical or Invasive Procedure: [**2129-3-15**] Aortic Valve Replacement(21mm On-X mechanical valve) and Replacement of Ascending Aorta(26mm Gelweave Graft) History of Present Illness: Mrs. [**Known lastname 12143**] is a 61 year old female with hypertension. During evaluation for lymphadenopathy, she underwent CT scan which revealed dilated ascending aorta. Further workup included an echocardiogram which showed a bicuspid aortic valve with 1-2+ aortic insufficiency. Ascending aorta measured 4.7cm, aortic root measured 3.9 cm. The LVEF was 60-70%. Subsequent cardiac catheterization was notable for normal coronary arteries and normal left ventricular function. Given the above findings, she was admitted for surgical intervention. Of note, she recently underwent hematology evaluation for low white blood cell count. Etiology is unclear at this time but there was no contraindication to surgery. Past Medical History: Biscupid Aortic Valve; Aortic Insufficiency; Ascending Aortic Aneurysm; Hypertension; Epilepsy; History of Rheumatic Fever; Thyroid Nodules; Reactive Axillary Lymph Nodes; Pulmonary Nodules Social History: Quit tobacco over 30 years ago. Denies excessive ETOH. Works as a teacher. She is married. Family History: Denies premature CAD. Physical Exam: Vitals: BP 132/64, HR 70, RR 14 General: well developed female in no acute distress HEENT: oropharynx benign, Neck: supple, no JVD, Heart: regular rate, normal s1s2, soft diastolic murmur Lungs: clear bilaterally Abdomen: soft, nontender, normoactive bowel sounds Ext: warm, no edema, no varicosities Pulses: 2+ distally Neuro: nonfocal Pertinent Results: Echo [**3-15**]: PRE-BYPASS: Overall left ventricular systolic function is normal (LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. The aortic valve is bicuspid. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. The sinotubular junction of the ascending aorta is preserved. The ascending aorta is moderately dilated. The mitral valve appears structurally normal with trivial mitral regurgitation. No atrial septal defect is seen by 2D or color Doppler. There are simple atheroma in the aortic arch and n the descending thoracic aorta. There is no pericardial effusion. POST-BYPASS: Preserved [**Hospital1 **]-ventricular systolic function. A well seated mechanical prosthetic valve is seen in the aortic position. Trivial aortic regurgitation. No perivalvular leak. Mean trans aortic valvular gradient is 8 mm Hg. A tubegraft is seen in the ascending aorta position with a diameter of 2.6 cm. Thoracic aortic contour is preserved. Trace TR and MR. CXR [**3-23**]: Interval decrease in pulmonary edema and vascular congestion, as well as cardiac size. Interval improvement in bibasilar atelectasis as well. Stable bibasilar pleural effusions. No major residual pneumothorax and stable appearance of the lung apices as compared to two days ago. [**2129-3-15**] 10:46AM BLOOD WBC-4.6 RBC-2.20*# Hgb-7.4*# Hct-20.4*# MCV-92 MCH-33.6* MCHC-36.4* RDW-13.6 Plt Ct-139*# [**2129-3-22**] 02:16AM BLOOD WBC-7.0 RBC-2.65* Hgb-9.0* Hct-26.0* MCV-98 MCH-33.8* MCHC-34.5 RDW-14.0 Plt Ct-447* [**2129-3-15**] 10:46AM BLOOD PT-16.1* PTT-75.8* INR(PT)-1.4* [**2129-3-23**] 07:25AM BLOOD PT-18.6* PTT-68.5* INR(PT)-1.8* [**2129-3-23**] 09:15PM BLOOD PT-22.0* PTT-150* INR(PT)-2.2* [**2129-3-24**] 12:48AM BLOOD PT-22.0* PTT-132.0* INR(PT)-2.2* [**2129-3-15**] 12:09PM BLOOD UreaN-13 Creat-0.5 Cl-109* HCO3-23 [**2129-3-22**] 02:16AM BLOOD Glucose-93 UreaN-11 Creat-0.6 Na-133 K-4.2 Cl-99 HCO3-26 AnGap-12 Brief Hospital Course: Mrs. [**Known lastname 12143**] was admitted and underwent aortic valve replacement with replacement of her ascending aorta. For surgical details, please see separate dictated operative note. Following the operation, she was brought to the CSRU for invasive monitoring. Within 24 hours, she awoke neurologically intact and was extubated without incident. She maintained stable hemodynamics and weaned from intravenous therapy without difficulty. Her CSRU course was uneventful and she transferred to the SDU on postoperative day one. On postoperative day two, chest tubes and epicardial wires were removed without complication. Warfarin anticoagulation was initiated. Prothrombin times were monitored daily and Warfarin was dosed for a goal INR between 2.0 - 3.0. Over several days, she continued to make clinical improvements with diuresis. On post-op day five she was treated for some atrial fibrillation and converted back to sinus rhythm. Heparin was restarted until INR was increased while receiving Coumadin. Over next couple of days her INR trended upward over 2. She appeared to be doing well and worked with physical therapy for strength and mobility. On post-operative day nine she was discharged home with VNA services and the appropriate follow-up appointments. Dr.[**Last Name (STitle) 2472**] will be following her INR and adjusting her Coumadin as needed. Medications on Admission: Tegretol XL 800 qam, 400 qlunch, 800 qhs Lisinopril 10 qd Labetolol 100 [**Hospital1 **] Evista 60 qd Caltrate-D 1200 qd Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 2. Carbamazepine 200 mg Tablet Sustained Release 12 hr Sig: Ten (10) Tablet Sustained Release 12 hr PO once a day: 4 tabs [**Hospital1 **] (morning & night)and 2 tabs once daily (midday)as before your surgery. Disp:*300 Tablet Sustained Release 12 hr(s)* Refills:*0* 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. 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* 5. Ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 6. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 6 days: then daily until D/C'd by . Disp:*45 Tablet(s)* Refills:*0* 7. Metoprolol Tartrate 50 mg Tablet Sig: 1.5 Tablets PO three times a day. Disp:*135 Tablet(s)* Refills:*0* 8. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 7 days. Disp:*14 Tablet(s)* Refills:*0* 10. Ascorbic Acid 500 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 11. Ferrous Gluconate 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 12. Outpatient [**Name (NI) **] Work PT/INR PT/INR as needed goal 2.5-3.5 for Aortic Valve (On-x) first check [**2129-3-25**] with results to Dr [**Last Name (STitle) 2472**] office # [**Telephone/Fax (1) 133**] Fax: [**Telephone/Fax (1) 445**] 13. Warfarin 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime): Dose to be titrated per Dr.[**Name (NI) 5049**] instruction. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Biscupid Aortic Valve, Aortic Insufficiency, Ascending Aortic Aneurysm s/p Aortic Valve Replacement and Replacement of Ascending Aorta PMH: Hypertension, Epilepsy, History of Rheumatic Fever, Thyroid Nodules, Reactive Axillary Lymph Nodes, Pulmonary Nodules 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. [**Last Name (STitle) 1290**] in [**3-3**] weeks, call for appt [**Telephone/Fax (1) 170**] Dr. [**First Name (STitle) **] in [**1-1**] weeks, call for appt Dr. [**Last Name (STitle) 2472**] in [**1-1**] weeks, call for appt [**Telephone/Fax (1) 133**] PT/INR goal 2.5-3.5 for Aortic Valve (On-x) first check [**2129-3-25**] with results to Dr [**Last Name (STitle) 2472**] office # [**Telephone/Fax (1) 133**] Fax: [**Telephone/Fax (1) 445**] Completed by:[**2129-4-4**]

[ "395.1", "427.31", "401.9", "241.9", "746.4", "345.90", "441.2" ]

icd9cm

[ [ [] ] ]

[ "88.72", "35.22", "39.61", "38.45" ]

icd9pcs

[ [ [] ] ]

7388, 7446

3949, 5321

333, 459

7748, 7754

1938, 3926

8219, 8696

1543, 1566

5492, 7365

7467, 7727

5347, 5469

7778, 8196

1581, 1919

281, 295

487, 1206

1228, 1419

1435, 1527

12,954

149,516

1518

Discharge summary

report

Admission Date: [**2139-3-22**] Discharge Date: [**2139-4-2**] Date of Birth: [**2077-7-8**] Sex: M Service: MEDICINE Allergies: Penicillins / Zestril / Heparin Agents / Heparin,Beef / Diovan / Prevacid / Amiodarone Attending:[**First Name3 (LF) 5301**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: 61 yo M with severe COPD ([**3-11**] FEV1 14% FVC 39%) on 4L NC at home, [**Month/Year (2) 1291**], trachomalacia, HTN, h/o HIT, who now presents with worsening shortness of breath. Patient reports many weeks of difficulty breathing and productive cough. Also has been coughing up flecks of blood 2-3 times a day x weeks. . Last saw Dr [**Last Name (STitle) **] (pulmonologist) 2 weeks ago who placed him on increased prednisone 10mg qday + Z-pak. Patient did not improve and refused to come into the hospital. Dr. [**Last Name (STitle) **] increased his prednisone to 40mg qday with good effect. He began a steroid taper [**2139-3-19**] and a course of biaxin. . In the ED the patient was found to have a sat of 99% on neb. He was given methylpred 125mg x 1 and nebs with temporary releif of symptoms. Switched to BiPAP with good effect and transferred to MICU. . On arrival to the floor the patient was satting 95 % on neb. However he quickly became air hungry with sats dropping to the high 80's. BiPAP was initiated. . The patient denied fevers, chills, BP, abd pain, N/V, diarrhea, HA, change in vision/hearing, confusion, dysuria, hematuria. . Past Medical History: [**2136**]- Aortic stenosis -> [**Year (4 digits) 1291**] [**1-5**] [**Company **] porcine valve, post op course c/b delerium, ARF, afib, shock liver, repiratory failure (re-intubated X 2 after surgery) trach and PEG, PNA (Staph, tx with Vanco), PAF was initially treated with Procainamide due to transaminitis and then discharged on Amiodarone and Digoxin. Dig d/c'd in [**2-6**]. Amio d/c'd 3 mos later secondary to rash. HTN Severe COPD (FEV1 0.67) - 6 min walk test with drop in sat to 80s, pt refuses home O2, has been in pulm rehab h/o Trachomalacia - s/p flex bronch [**12-7**] - 50% collapse indistal trachea and left mainstem, 80% right bronchus intermedius - no surgical intervention H/o HIT H/o GIB secondary to ulcer [**2-6**] (Hct 21) [**2135**]- duodenitis, UGIB [**2132**]- hx L hip osteomyelitis, s/p hip replacement [**2133**]- L wrist septic arthritis s/p vasectomy s/p rhinoplasty as a child because of fx h/o adrenal mass s/p removal of skin cancers s/p ulnar aneurysm resection Social History: Married, retired fire fighter. Cigs: smoked [**2-3**] ppd x 30-40 years and quit in [**8-5**] ETOH: socially drinks beer on weekends Family History: + CAD Physical Exam: VS - 96.8 (ax) 140/83 112 20 95% @ neb Gen - a+ox3, dyspneic HEENT - OP clear, EOMI Neck - supple, no LAD Cor - RRR, [**3-10**] sys murmur LUSB Chest - extremely poor air movement, almost no breath sounds Abd - s/nt/nd +BS Ext - w/wp, no c/c/e Pertinent Results: [**3-24**] CT chest: IMPRESSION: Peribronchial multifocal interstitial abnormality progressing since [**2138-12-3**], was not present in [**2138-5-3**], is consistent with developing interstitial lung disease/interstitial pneumonitis . Moderate to severe emphysema. . Enlarging left adrenal mass, concerning for neoplasm. . Simple left renal cyst. . [**3-27**] Echo: Conclusions: The left atrium is mildly dilated. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thicknesses and cavity size are normal. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is mildly depressed. There is no ventricular septal defect. There is mild global right ventricular free wall hypokinesis. A bioprosthetic aortic valve prosthesis is present. The prosthetic aortic valve leaflets are thickened. The transaortic gradient is higher than expected for this type of prosthesis. Trace aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([**2-3**]+) mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. . Compared with the prior study (images reviewed) of [**2138-12-30**], the patient is now in rapid atrial fibrillation. The LVEF now appears depressed and the severity of aortic valve prosthesis stenosis has slightly increased. A repeat study after HR control or cardioversion is suggested to better quantify LVEF. A TEE may better characterize intrinsic aortic prosthetic valve stenosis. . Brief Hospital Course: A/P 61 yo M with severe COPD ([**3-11**] FEV1 14% FVC 39%) on 4L NC at home, [**Month/Year (2) 1291**], trachomalacia, HTN, h/o HIT, who now presents with worsening shortness of breath. . # Dyspnea In the [**Hospital Unit Name 153**], patient with exacerbation of already severe emphysema. Trigger of exacerbation thought most likely secondary to a URI or tapering of steroids. Patient was initially maintained on BiPap and was eventually weaned from that. Patient was then transferred to the floor where he remained stable on 4.5L with scheduled nebs and PO steroids. Patient also maintained on spiriva, advair, [**Last Name (LF) 8895**], [**First Name3 (LF) 130**]. Patient also completed doxycycline (avoid macrolide [**3-6**] QT; PCN allergic). . # Leukocytosis Patient with elevated WBC, most likely secondary to steroids. Patient was without signs of infection. Patient also had 3 induced sputums which demonstrated negative PCP and acid fast staining. Patient was maintained on doxycycline for treatment of possible pneumonia. . # Elevated Troponin Chronically elevated trop for unclear reasons. No symptoms of ischemia. EKG only with mild ST dep II/III. CK/MB flat. . # Afib - Patient was initially in sinus rhythym being maintained on procainamide. However, while in the [**Hospital Unit Name 153**], patient was in atrial fibrillation with RVR and was initially transferred from the [**Hospital Unit Name 153**] to [**Hospital Ward Name 121**] 3 for starting dofetilide with cardioversion with the last procainamide dose 2/23 at 10am. However, after discussion with attending, family and EP fellow, decided against initiation of dofetilide [**3-6**] risk of Torsades, need to reverse DNR status and low success rate. Goal now is to achieve rate control with diltiazem and digoxin. With consultation with Electrophysiology, patient was then started on norpace. He was monitored for 48 hours for evaluation of QT prolongation, which demonstrated no significant QT prolongation. Patient was not maintained on anticoagulation given GI bleed. . # HTN - Patient was maintained on PO diltiazem with good control of hypertension. . # h/o HIT - avoid all heparin products during the admission . # BPH: Patient was maintained on detrol. DNR/DNI Medications on Admission: Albuterol/Ipratropium Nebs Procainamide 1000 mg PO 5X/day Aspirin 81 mg qtues/thurs protonix 40 mg qday Diltiazem HCl 240 mg qday Lorazepam 0.5 mg Q4-6H prn valium 5mg qhsprn [**Doctor First Name 130**] 180 mg qday Fluticasone-Salmeterol 500-50 mcg [**Hospital1 **] Montelukast 10 mg qday Tolterodine 2 mg qday Ferrous Sulfate 325 mg qday Spiriva Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed. 3. Fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 4. Fluticasone-Salmeterol 500-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 5. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Multivitamin,Tx-Minerals Tablet Sig: One (1) Cap PO DAILY (Daily). 8. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for PCP [**Name Initial (PRE) 1102**]. 9. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day). 10. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**2-3**] Sprays Nasal QID (4 times a day) as needed. 12. Prednisone 20 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 13. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 14. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily). 15. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO HS (at bedtime). 16. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 17. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. Diltiazem HCl 90 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 19. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QTUESSAT (). 20. Disopyramide 150 mg Capsule Sig: One (1) Capsule PO Q8H (every 8 hours). Discharge Disposition: Extended Care Facility: [**Hospital3 105**] - [**Location (un) 86**] Discharge Diagnosis: - Severe COPD ([**3-11**] FEV1 14% FVC 39%) on 4L NC: Recently admitted [**1-7**] for COPD exacerbation. Followed previously by Dr. [**Last Name (STitle) 496**] and now Dr. [**Last Name (STitle) **] from pulmonary. Has been through pulmonary rehab. Has considered and decided against, both lung transplant and lung reduction surgery. No evidence of alpha-1 antitrypsin deficiency. - Atrial Fibrillation and Atrial flutter, now controlled with rate control with digoxin and diltiazem and with rhythm control with norpace. - h/o Trachomalacia - s/p flex bronch [**12-7**] - 50% collapse in distal trachea and left mainstem, 80% right bronchus intermedius - no surgical intervention - [**Month/Year (2) 1291**] [**1-5**] for aortic stenosis [**Company **] porcine valve, post-op course c/b: --- ARF --- shock liver --- repiratory failure (re-intubated X 2 after surgery) --- trach and PEG --- PNA (Staph, tx with Vanco) --- PAF: initially treated with Procainamide due to transaminitis and then discharged on Amiodarone and Digoxin. Dig d/c'd in [**2-6**]. Amio d/c'd 3 mos later secondary to rash. Required admission for Ibutilide cardioversion in past. - HTN - HIT positive - GIB secondary to ulcer [**2-6**] (Hct 21) - L hip osteomyelitis ([**2132**]), s/p hip replacement - L wrist septic arthritis ([**2133**]) - vasectomy - rhinoplasty as a child because of fx - h/o adrenal mass - ulnar aneurysm resection Discharge Condition: Stable - Patient is eating and ambulating with assistance. Patient with shortness of breath with exertional activity. Physical therapy recommended. Discharge Instructions: Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Please take all your medications as prescribed. Please seek medical attention if you have worsening shortness of breath, chest pain, abdominal pain, nausea, vomiting, fevers, chills, or night sweats. Followup Instructions: Provider: [**Name10 (NameIs) 1571**] BREATHING TESTS Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2139-5-15**] 11:40 Provider: [**Name10 (NameIs) 1570**],[**Name11 (NameIs) 2162**] [**Name12 (NameIs) 1570**] INTEPRETATION BILLING Date/Time:[**2139-5-15**] 12:00 Provider: [**Name10 (NameIs) **] [**Name8 (MD) 611**], M.D. Phone:[**Telephone/Fax (1) 612**] Date/Time:[**2139-5-15**] 12:00 - After leaving rehab, patient should have follow-up appointments with his primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 8896**] ([**Telephone/Fax (1) 8897**] and his cardiologist Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 73**] ([**Telephone/Fax (1) 8898**]. - Patient recommended to follow-up with his outpatient primary care physician regarding his MGUS and his adrenal mass.

[ "600.00", "V42.2", "427.31", "491.22", "427.32", "486", "518.83", "515", "255.9" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9092, 9163

4697, 6948

354, 361

10617, 10767

3031, 4674

11116, 11943

2740, 2747

7346, 9069

9184, 10596

6974, 7323

10791, 11093

2762, 3012

306, 316

389, 1549

1571, 2573

2589, 2724

30,681

123,435

31411

Discharge summary

report

Admission Date: [**2172-7-27**] Discharge Date: [**2172-8-21**] Date of Birth: [**2106-8-15**] Sex: M Service: NEUROSURGERY Allergies: Doxycycline Attending:[**First Name3 (LF) 2724**] Chief Complaint: ICH due to fall Major Surgical or Invasive Procedure: trach PEG IVC filter History of Present Illness: Pt is a 65 yo male w/ PMHx sig for CAD s/p stent who presents after fall. The patient is currently intubated and the history was obtained from the chart and family members at the bed side. The patient works as a security guard [**Hospital1 14628**]. This afternoon he was in his USOH when he complained to a co-worker that he felt warm. He went outside and was witnessed to tilt his head back to take a drink of water. Once his head tilted back, the patient fell backwards hitting his head. It is unclear if he lost consciousness. The patient was then taken via ambulance to [**Hospital1 18**]. In the ED, the patient was noted to have some agonal breathing. As a result, he was intubated. CT scan shows a 7-mm left frontotemporal subdural hematoma, diffuse bilateral subarachnoid hemorrhage is noted within the frontal, parietal and temporal lobes., and L frontal hemorrhagic contusions. Pt wife states that the patient was bitten by a tick this summer. There was some concern for Lyme disease though there was apparently no confirmatory testing. He was placed on doxycycline but had a rash to the medication. Past Medical History: CAD s/p stent '[**64**], Osgood Schlatter disease as a child, carpal tunnel release, ear surgery w/ copper insertion (wife does not think this is MRi compatible). Social History: Retired police officer, works security at [**Hospital1 778**] part time. Lives with wife. 20 pack years, quit 25 years ago. Drinks 2 beers & 2 glasses wine per night. Family History: father - CAD. mother - [**Name (NI) 2481**], CAD. 2 brother deceased from HIV associated lymphoma, sister - stroke. Physical Exam: Vitals: T 98.4; BP 110/pap; P 74; RR 16; O2 sat 98% General: intubated, agitated HEENT: NCAT, moist mucous membranes Neck: supple, no carotid bruit Pulmonary: CTA b/l Cardiac: regular rate and rhythm, with no m/r/g Carotids: no blood flow murmur Abdomen: soft, nontender, non distended, normal bowel sounds Extremities: no c/c/e. Neurological Exam: Mental status: does not open eyes to voice, does not follow simple or complex commands. Cranial Nerves: I: Not tested II: PERRL, 3-->2mm with light. + corneal reflex. + VOR. face symmetric. Motor: Normal bulk. Normal tone. Moves all 4 ext without asymmetry. Sensation: withdraws purposefully to nail bed pressure in all four ext. Reflexes: Bic T Br Pa Ac Right 2 2 2 2 2 Left 2 2 2 2 2 Coordination: FNF intact. Pertinent Results: CT C-SPINE W/O CONTRAST [**2172-7-27**] 8:18 PM 1. No cervical pathology is identified including no fracture. However, there is a prevertebral soft tissue swelling in front of C2 and C3 cervical vertebra. Although this might be related to the recent intubation, possible ligamentous injury cannot be excluded. If further assessment of the cervical spine is required, MRI is recommended. 2. Remainder of the study appears unremarkable except for multilevel degenerative changes. CT HEAD W/O CONTRAST [**2172-7-27**] 8:17 PM 1. A 7-mm left frontotemporal subdural hematoma with parafalcine extension and associated 6 mm subfalcine herniation. Diffuse bilateral subarachnoid hemorrhage is noted within the frontal, parietal and temporal lobes. 2. Possible foci of hemorrhagic contusion are noted within the superior portion of the left frontal lobe measuring 5 mm and the supraorbital portion of the right frontal lobe measuring 10 mm. CT HEAD W/O CONTRAST [**2172-7-29**] 10:12 AM IMPRESSION: There is a slightly increased mass effect on the frontal [**Doctor Last Name 534**] of the left lateral ventricle compared to prior study. Otherwise, there is little interval change in the extensive hemorrhagic contusions, SAH, SDH, and intraventricular hemorrhage. CT OF THE NECK WITH CONTRAST 8/6/7 1. There is a small focus of air seen within the soft tissues adjacent to the tracheostomy site, with surrounding fluid. This may represent a sinus tract. 2. There is no evidence of discrete abscess formation. 3. There is no evidence of pathologically enlarged lymph nodes within the neck. Brief Hospital Course: Patient was admitted on [**2172-7-28**] for ICH (left acute on chronic SDH, left frontal contusion and diffuse SAH) s/p fall from standing. Patient was intubated in ED due to agonal breathing/asystole x 8sec. Seizure prophylaxis with Dilantin is started. Repeat head CT on the same day showed blossoming of contusion. Cardiac enzyme was negative x 3. Cardiology was consulted re asystole. Echo was WNL and cardiology recommend no further intervention needed. He had fevers and was treated with antibiotics for aspiration pneumonia. On [**7-29**] patient presented rhythmic movement of left arm. EEG was performed and no epileptiform waves seen. CT of cervical spine was negative and hard collar was removed. The pt continued to have decreased mental status and right sided weakness.On [**8-4**] he underwent tracheostomy, PEG and IVC filter. Stroke Neurology was consulted at familiy's request for decreased mental status; transcranial dopplers were done and showed possible vasospasm. Nimodipine was started and his was given fluids and pressors to keep systolic blood pressure greater than 140. His mental status improved - opening his eyes and moving right side. Head CT done [**8-6**] showed resolving hemorrhage. On [**8-9**] he was able to write his name, follow intermittent commands better with the family then staff and ambulate a few feet. On [**8-10**] he was transferred to the stepdown then to regular floor; Between [**8-10**] and [**8-15**], he had developed a significant painful torticollis to the R, thought to be reactive from the prolonged ICU stay. Clinical evaluation did not demonstrate spasms other than in the posterior neck region, and a CT of the neck did not reveal previous obscure fractures. With painmedications and benzodiazepines for muscle relaxation this slowly resolved. on [**8-13**] patient developed hyponatremia (serum Na 125), with a marked increased urine osmolality and Na, and a urine:serum osmolality ratio of >2-2.5, all consistent with prominent SIADH. He was treated with NaCl tabs PO, fluid restriction currently at 1L/day (tubefeeds 30 cc/hour (containing 500 cc H2), and half a liter with his IV medications. He was eventually also started on Lasix 20 mg [**Hospital1 **], which should be discontinued after normalization of his Na. His serum sodium level fluctuated between 125 and 130, currently at 127. His fluid balance has been appropriately negative about 500 - 800 cc for the last 5 days. on [**8-16**] purulent discharge was noted on trach site, culture showed positive MRSA infection, patient was started on Vancomycin IV and ID recommend Vanco for total of 14days. A PICC line was place on [**2172-8-20**]. CT of trach site showed no abscess or infectious tract. Surgery was consulted and a superficial debridement was performed. Neurologically he has been stable, and slowly improving. Physical therapy was consulted and recommended patient to be discharged to rehab. Upon discharge, the patient was in NAD, had supple neck, a chest that was CTA bilaterally, heart showing RRR, with a soft, nontender nondistended abdomen, extremities warm w/o clubbing, cyanosis, eryhtema. Neurologically, he follows simple commands (when yelled in ears), and indicates his needs to some extend (gesticulates with L hand). CN PERRL, EOMI with grossly symmetric facial musculature. Motor examination shows normal tone in all 4 extremities, with symmetric strenght at least [**4-16**] UE, but unable to assess full strenght given limited cooperation, the same applies for the legs, which are at least [**4-16**]. Sensory exam was deferred, but he withdraws to stimulation with all 4's. Reflexes are 2+ symmetric, with ankles 1+, toes mute bilaterally. Coordination unable to asses formally, but no nystagmus, with reaching and grasping w/o evident dysmetria. A follow-up CT scan prior to discharge revealed resolution of the blood. Medications on Admission: Atenolol, Lipitor, ASA. Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 2. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 3. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 6. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours). 7. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 8. Sodium Chloride 1 g Tablet Sig: Two (2) Tablet PO TID (3 times a day) as needed for hyponatremia: Discontinue when sodium normalizes!. 9. Lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 10. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day). 11. Cyclobenzaprine 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) as needed. 12. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 14. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous Q 12H (Every 12 Hours). 15. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: One (1) ML Intravenous DAILY (Daily) as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 1107**] [**Hospital **] Hospital - [**Location (un) 38**] Discharge Diagnosis: Diffuse traumatic subarachnoid hemorrhage Left frontal intraparenchymal hemorrhage Left frontotemporal acute on chronic subdural hemorrhage Aspiration pneumonia Hyponatremia Peritracheal MRSA infection Discharge Condition: Stable Discharge Instructions: *** CONTINUE VANCOMYCINE IV UNTIL [**2172-8-31**] *** CONTINUE DAILY FLUID RESTRICTION TO NO MORE THAN ONE (1) LITER AND PO NaCL; CONTINUE DAILY SERUM SODIUM CHECK UNTIL IT IS NORMALIZED; PLEASE ADJUST YOUR FLUID RESTRICTION AND PO NaCL ACCORDIINGLY. DO NOT FORGET TO DISCONTIUE THE LASIX AFTER NORMALIZATION OF SODIUM. ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an anti-seizure medicine, take it as prescribed and follow up with laboratory blood drawing as ordered 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: PLEASE CALL [**Telephone/Fax (1) **] TO SCHEDULE AN APPOINTMENT WITH DR. [**Last Name (STitle) **] TO BE SEEN IN 4 WEEKS. YOU WILL NEED A CAT SCAN OF THE BRAIN WITHOUT CONTRAST Completed by:[**2172-8-21**]

[ "041.11", "519.01", "V45.82", "998.2", "E885.9", "V09.0", "414.01", "507.0", "253.6", "851.80", "723.5" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.6", "38.7", "96.04", "96.72", "43.11", "31.1" ]

icd9pcs

[ [ [] ] ]

9773, 9870

4423, 8311

292, 314

10115, 10124

2799, 4400

11299, 11507

1857, 1977

8386, 9750

9891, 10094

8337, 8363

10148, 11276

1992, 2324

2343, 2343

237, 254

342, 1467

2448, 2780

2358, 2432

1489, 1654

1670, 1841

72,146

196,849

39209+58269

Discharge summary

report+addendum

Admission Date: [**2174-3-30**] Discharge Date: [**2174-4-20**] Date of Birth: [**2120-9-10**] Sex: M Service: SURGERY Allergies: Prochlorperazine / Fenofibrate Attending:[**First Name3 (LF) 1556**] Chief Complaint: Epigastric pain with nausea and vomiting Major Surgical or Invasive Procedure: [**2174-3-31**]: ERCP with sphincterotomy and sludge removal. History of Present Illness: 53 year old male with HIV infection, HTN with history of symptomatic cholelithiasis presenting with acute onset of abdominal pain approximately 6 hours prior to presentation. Pain is (R)UQ/epigastric, sharp, radiating to the back, moderate to severe intensity, associated with nausea/vomiting, no exacerbating or relieving factors. No fevers/chills, no change in bowel habits, no change in urinary habits, no chest pain/shortness of breath. Admitted for further evaluation and treatment. Past Medical History: PMHx: HIV (most recent viral load undetectable, CD4 count 530), vertigo, gout, Mild Parkinsons, HTN, hypertriglyceridemia. PSHx: Bilateral inguinal hernias, septorhinoplasty. Social History: No tobacco, rare ETOH, no illicit drug use. Family History: Non-contributory. Physical Exam: On Admission: Temp:97.9 HR:87 BP:131/75 Resp:20 O(2)Sat:98 GEN: In NAD HEENT: no cervical adenopathy, trachea midline, neck supple RESP: no distress CV: regular rhythm ABD: soft non-distended, RUQ/epigastric tenderness to palpation, no rebound, no guarding EXTREM: no c/c/e NEURO: CN II-XII grossly intact, slight tremor. Pertinent Results: [**2174-3-30**] 02:30PM WBC-17.1* RBC-5.18 HGB-18.2* HCT-51.0 MCV-99* MCH-35.1* MCHC-35.7* RDW-13.2 [**2174-3-30**] 02:30PM NEUTS-73.7* LYMPHS-19.1 MONOS-4.4 EOS-1.8 BASOS-0.9 [**2174-3-30**] 02:30PM PLT COUNT-270 [**2174-3-30**] 02:30PM UREA N-14 CREAT-1.5* SODIUM-138 POTASSIUM-4.0 CHLORIDE-97 TOTAL CO2-24 ANION GAP-21* [**2174-3-30**] 02:30PM ALT(SGPT)-74* AST(SGOT)-77* ALK PHOS-88 TOT BILI-2.5* [**2174-3-30**] 02:30PM LIPASE-9845* [**2174-3-30**] Gallbladder US : 1. Cholelithiasis, with distended gallbladder and tender right upper quadrant. This could be a manifestation of early cholecystitis, in the appropriate clinical setting, although no evidence of gallbladder wall thickening or pericholecystic fluid. If clinical concer persists, one could consider a HIDA scan. 2. Fatty infiltration of the liver, though more advanced forms of liver disease, including fibrosis and/or cirrhosis, can have this appearance. 3. Right renal cyst. [**2174-3-31**] ERCP : Stones at the galbladder Normal biliary tree without any evidence of biliary obstruction. Given high suspicion for cholangitis, a biliary sphincteromy was performed. Sludge was extracted from the bile duct.(sphincterotomy, stone extraction) Otherwise normal ercp to third part of the duodenum [**2174-4-1**] Abdominal CT : 1. Peripancreatic inflammation and stranding of the mesenteric fat, consistent with acute pancreatitis. Ill-defined enhancement of the pancreatic parenchyma at the neck is suggestive of necrosis in this area. No other focal fluid collection is seen within the abdomen. 2. Extensive atelectasis and consolidation in the lower lobes of both lungs may represent pneumonia [**2174-4-10**] Abdominal CT : 1. Significant worsening of acute pancreatitis with areas of pancreatic necrosis especially within the head, neck and proximal body of the pancreas. A large amount of multiloculated fluid collections in the peripancreatic region extending to bilateral pericolic gutters, left more than right with peripheral enhancement are consistent with pancreatic pseudocysts. Overlying infection-abscess formation cannot be excluded. 2. Significant cholelithiasis; air in the gallbladder is new since prior exam 9 days ago. 3. Thickening of the stomach and duodenal wall as well as mild thickening of the wall of the ascending colon and transverse colon likely secondary to inflammatory process within the abdomen. 4. Splenomegaly, mildly increased since prior exam, likely reactive. Splenic vein remains patent. 5. Bilateral pleural effusions, left more than right with left lower lobe collapse. Underlying pneumonia cannot be excluded. [**2174-4-11**] CXR for PICC line placement : Tip of the new right PIC catheter ends approximately a centimeter below the superior cavoatrial junction, it was reported to the IV nurse. As discussed with the care team physician, [**Name10 (NameIs) **] lower lobe is still collapsed and there is small-to-moderate left pleural effusion and small right pleural effusion, overall unchanged. Upper lungs are clear. No pneumothorax. Heart size normal. . MICROBIOLOGY: [**2174-4-10**] STOOL CLOSTRIDIUM DIFFICILE TOXIN A & B TEST: Negative. [**2174-4-9**] BLOOD CULTURE-FINAL: NO GROWTH. [**2174-4-9**] BLOOD CULTURE-FINAL: NO GROWTH. [**2174-4-9**] URINE CULTURE-FINAL: MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION. [**2174-4-6**] BLOOD CULTURE-FINAL: NO GROWTH. [**2174-4-6**] BLOOD CULTURE-FINAL: NO GROWTH. [**2174-4-6**] URINE CULTURE-FINAL: NO GROWTH. [**2174-4-3**] URINE CULTURE-FINAL: NO GROWTH. [**2174-4-3**] BLOOD CULTURE-FINAL: NO GROWTH. [**2174-4-1**] BLOOD CULTURE-FINAL: NO GROWTH. [**2174-3-31**] BLOOD CULTURE-FINAL: NO GROWTH. [**2174-3-31**] MRSA SCREEN-FINAL: NEGATIVE. Brief Hospital Course: Mr. [**Known lastname 86800**] was admitted to the hospital, made NPO and hydrated with IV fluids. His HAART medications were held together. His LFT's were elevated and his lipase was 9800. His abdomen was distended and he was a bit more comfortable with a Dilaudid PCA. He underwent an ERCP on [**2174-3-31**] and a sphincterotomy was performed along with removal of sludge. Following this procedure he was sent to the ICU for more vigorous fluid resuscitation. He was placed on IV Unasyn for 48 hours and his LFT's were slowly declining from a high TBili of 6.1 to normal 5 days later. . He continued to have temperature spikes almost daily. His abdominal pain was gradually decreasing along with his WBC although he remained distended. Once he resumed clear liquids, the pain recurred along with nausea. He subsequently had a feeding tube placed for tube feedings, however, due to discomfort, he removed it on 2 different occasions. Once afebrile, a PICC line was placed on [**2174-4-11**], and TPN started. While on TPN, the patient's blood sugars were routinely monitored, and he received sliding scale insulin when indicated. . Due to persistent temperature spikes, he had a repeat Abdominal/Pelvic CT done on [**2174-4-10**], which showed worsening of his pancreatitis with necrosis around the head and neck and pancreatic pseudocysts. Imipenem-Cilastatin IV was started on [**2174-4-10**]. His pain remained well controlled on a Dilaudid PCA. As his symptoms improved, he was started on sips of clears on [**2174-4-12**]. His diet was slowly advanced to clears on [**2174-4-15**], and to a low fat regular by discharge. Some of his home medications were re-introduced. As recommended by Infectious Disease, his HAART medications were held until the patient was ready to restart them all together. The patient will consult [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD, his Infectious Disease provider, [**Name10 (NameIs) 3**] an outpatient as to when he should re-initiate HAART. On [**2174-4-15**], the Dilaudid PCA was discontinued, and he was started on Dilaudid PO PRN for pain with continued good effect. Imipenem-Cilastatin was discontinued on [**2174-4-18**]. He retained normal function of his bowels and bladder. . During this hospitalization, the patient ambulated early and frequently, was adherent with respiratory toilet and incentive spirrometry, and actively participated in the plan of care. The patient initially received subcutaneous heparin, which was later placed in the TPN, and venodyne boots were used during this stay. Labwork was routinely followed; electrolytes were repleted when indicated. . At the time of discharge, the patient was doing well, afebrile with stable vital signs. The patient was tolerating a low fat regular diet and cycled TPN, ambulating, voiding without assistance, and pain was well controlled. The (R) PICC line was patent and intact. He was discharged home with nursing and home infusion services, as he was sent home on cycled TPN. The patient received discharge teaching and follow-up instructions with understanding verbalized and agreement with the discharge plan. Medications on Admission: 1. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Nefazodone 100 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 3. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for SOB. 8. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 9. Norvir 100 mg Capsule Sig: One (1) Capsule PO once a day. 10. Reyataz 150 mg Capsule Sig: One (1) Capsule PO twice a day. 11. Viread 300 mg Tablet Sig: One (1) Tablet PO every Mon-Wed-Fri. 12. Epivir 300 mg Tablet Sig: One (1) Tablet PO once a day. 13. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. Enalapril Maleate 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Nefazodone 100 mg Tablet Sig: Two (2) Tablet PO QHS (once a day (at bedtime)). 3. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Cyanocobalamin 100 mcg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 5. Trazodone 50 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 7. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler Sig: Two (2) Puff Inhalation Q6H (every 6 hours) as needed for SOB. 8. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 9. Norvir 100 mg Capsule Sig: One (1) Capsule PO once a day: Please restart after consulting Dr. [**Last Name (STitle) **] (ID). 10. Reyataz 150 mg Capsule Sig: One (1) Capsule PO twice a day: Please restart after consulting Dr. [**Last Name (STitle) **] (ID). . 11. Viread 300 mg Tablet Sig: One (1) Tablet PO every Mon-Wed_Fri: Please restart after consulting Dr. [**Last Name (STitle) **] (ID). . 12. Epivir 300 mg Tablet Sig: One (1) Tablet PO once a day: Please restart after consulting Dr. [**Last Name (STitle) **] (ID). . 13. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day. 14. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**3-29**] hours as needed for fever or pain. 15. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*40 Tablet(s)* Refills:*0* 16. Heparin Flush (10 units/ml) 2 mL IV PRN line flush PICC, heparin dependent: Flush with 10mL Normal Saline followed by Heparin as above daily and PRN per lumen. 17. Ondansetron 4 mg IV Q8H:PRN nausea 18. Ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q8H (every 8 hours) as needed for fever or pain. Disp:*90 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: CareGroup [**Month/Day (3) 269**] Discharge Diagnosis: 1. Acute gallstone pancreatitis. 2. Necrotizing pancreatitis. 3. Pancreatic pseudocysts. 4. HIV 5. HTN Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please resume all regular home medications , unless specifically advised not to take a particular medication. Also, please take any new medications as prescribed. Please get plenty of rest, continue to ambulate several times per day, and drink adequate amounts of fluids. Avoid lifting weights greater than [**5-2**] lbs until you follow-up with your surgeon, who will instruct you further regarding activity restrictions. Avoid driving or operating heavy machinery while taking pain medications. Please follow-up with your surgeon and Primary Care Provider (PCP) as advised. . 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: CT SCAN: Abdominal/Pelvic CT Scan with and without contrast. Phone:[**Telephone/Fax (1) 327**] Date/Time: Tuesday, [**2174-4-26**] at 1:30PM. Location: RA [**Hospital Unit Name **] ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX), [**Location (un) **], [**Hospital Ward Name 516**]. . Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD (Surgery). Phone: ([**Telephone/Fax (1) 11501**]. Date/Time: Friday, [**2174-4-29**] at 2:00PM. Location: [**Hospital Ward Name 23**] 3, [**Hospital Ward Name 516**]. . Please call ([**Telephone/Fax (1) 86801**] to arrange a follow-up appointment with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] (PCP) in [**1-26**] weeks. . Please schedule a follow-up appointment with [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD (Infectious Disease) in [**1-26**] weeks. You should consult Dr. [**Last Name (STitle) **] regarding re-initiation of anti-retroviral therapy (HAART). Completed by:[**2174-4-20**] Name: [**Known lastname 12113**],[**Known firstname **] Unit No: [**Numeric Identifier 13737**] Admission Date: [**2174-3-30**] Discharge Date: [**2174-4-20**] Date of Birth: [**2120-9-10**] Sex: M Service: SURGERY Allergies: Prochlorperazine / Fenofibrate Attending:[**First Name3 (LF) 3524**] Addendum: Error Note: Zofran IV order not prescribed and deleted from final discharge. Discharge Disposition: Home With Service Facility: CareGroup VNA [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 2207**] MD [**MD Number(1) 3525**] Completed by:[**2174-4-20**]

[ "576.8", "577.2", "274.9", "574.20", "332.0", "401.9", "577.0", "780.60", "272.1", "V08" ]

icd9cm

[ [ [] ] ]

[ "38.93", "99.15", "51.85", "96.6" ]

icd9pcs

[ [ [] ] ]

14579, 14780

5363, 8520

331, 395

11664, 11664

1568, 5340

13090, 14556

1191, 1210

9580, 11430

11538, 11643

8546, 9557

11815, 13067

1225, 1225

251, 293

423, 913

1239, 1549

11679, 11791

935, 1114

1130, 1175

67,041

188,739

34703

Discharge summary

report

Admission Date: [**2113-8-18**] Discharge Date: [**2113-8-25**] Date of Birth: [**2030-12-30**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Known firstname 8790**] Chief Complaint: Bright red blood per rectum Major Surgical or Invasive Procedure: Sigmoidoscopy [**2113-8-19**], Colonoscopy [**2113-8-21**] History of Present Illness: 82 year old female with a history of stage [**Doctor First Name 690**] squamous cell carcinoma of the vulva in diagnosed in [**6-/2112**] and recent admission from [**2113-8-7**] to [**2113-8-11**] for diagnosis of extensive left sided DVT for which she was started on heparin and bridged to coumadin. She was discharged to rehab on [**2113-8-11**] on a heparin drip. She was doing well until the morning of presentation when she noticed that she felt wet in her underwear and noticed that she was bleeding. She assumed that the bleeding was coming from her vagina but was not certain. Her last bowel movement was earlier in the morning and was normal. She only had one episode of bleeding but per notes she had a large amount of brigh red blood per rectum with clots. It was not associated with lightheadedness, dizziness, chest pain, shortness of breath, nausea, vomiting, abdominal pain, diarrhea or decreased urine ouput per the patient, but her rehab noted that she was complaining of crampy abdominal pain. Her heparin drip was discontinued and she was transferred to the emergency room for further management. . In the ED, initial vs were: T: 98 P: 106 BP: 122/62 R: 14 O2 sat: 97% on RA. Her blood pressure ranged from the 120s to 140s systolic and her heart rate was in the 90s. She received one liter of normal saline and one unit of FFP. Initial hematocrit was 26.7 (from baseline (27-29) and [**Date Range 263**] was 3.1. She received vitamin K 10 mg IV x 1, morphine 2 mg IV x 1 and zofran 4 mg IV x 1. She was noted to have bright red blood on rectal exam with no vaginal bleeding. NG lavage was negative. She was admitted to the MICU for further management. . On arrival to the MICU she has no specific complaints. Specifically no fevers, chills, nausea, vomiting, chest pain, shortness of breath, abdominal pain, lightheadedness or dizziness. She has extensive left lower extremity swelling with slight tingling in her left foot. She feels that her bleeding is from her vaginal tract. She has never had bleeding like this before. All other review of systems is negative in detail. Past Medical History: PAST ONCOLOGIC HISTORY: ====================== . This is an 81 year-old G6P6 female who was recently diagnosed with Stage [**Doctor First Name 690**] squamous cell carcinoma of the vulva in [**6-/2112**] based on a vulvar biopsy and imaging. She was presented at Tumor Board on [**2112-8-24**] at which point chemotherapy and radiation were recommended. She underwent chemoradiation therapy with weekly Cisplatin therapy. Her radiation treatment was discontinued early due to skin toxicity. . She presented for follow-up evaluation on [**2112-11-9**] at which point the primary vulvar lesion was noted to have decreased in size from 5 cm to 1 cm. There was no palpable inguinal lymphadenopathy on exam. A follow-up CT scan of the abdomen and pelvis on [**2112-10-31**] revealed interval increased thickening of the left vulva. There was interval increase in the size of the right pelvic wall soft tissue density that had been seen on prior imaging. Bilateral inguinal lymphadenopathy was noted but was decreased in size from prior imaging. . Surgical excision of the vulvar lesion and surgical evaluation of the right pelvic wall soft tissue density was pursued. On [**2112-12-1**] the patient underwent bilateral radical vulvectomy, exploratory laparotomy, bilateral salpingo-oophorectomy, bilateral pelvic lymphadenectomy, paraaortic lymph node sampling. Intra-operatively, the left vulvar mass was 2 cm with a depth of 0.5 cm which extended to the right labium. The exploratory laparotomy revealed a normal uterus. The left tube and ovary were normal and the right ovary had a 2 cm cyst. The pelvic and paraaortic lymph nodes appeared normal. . Pathology revealed invasive squamous cell carcinoma, moderately differentiated in the vulvar specimen. The pathology revealed a grade 2 lesion with a greatest dimension of 2.1 cm and 4 mm invasion. Margins were not involved. Lichen sclerosus et atrophicus was also present. Bilateral tubes and ovaries were normal. Paraaortic and pelvic nodes were negative. . The patient has Stage [**Doctor First Name 690**] squamous cell carcinoma of the vulva. In [**Month (only) 547**], she reported having some back pain and had CT abd/pelvis. This revealed a mass that is approximately 9 cm in size on the left pelvic side wall with hydronephrosis noted on the left side. A biopsy of this mass was obtained on [**2113-6-24**] revealed squamous cell carcinoma. . PAST MEDICAL HISTORY: ==================== . Past Medical History: -Arthritis -GERD -h/o bleeding ulcer surgically managed in [**2109**] -DVT in the [**2063**]'s . Past Surgical History: -Surgical management of bleeding ulcer in [**2109**] -Left varicose vein stripping -Right inguinal hernia repair Social History: Now coming from [**Hospital **] rehab facility. She lives in [**Location 14663**], [**State 350**] in an apartment. Son lives upstairs. No history of smoking and only occassional alcohol. She has six children. Previously was working as a receptionist. Family History: Her mother had gastric cancer. Her father died of emphysema. Her older son had kidney cancer at age 52. There is no other family history of malignancy to her knowledge. Physical Exam: Physical Exam on admission [**2113-8-18**]: Vitals: T: 98.9 BP: 127/60 P: 81 R: 21 O2: 97% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MM dry, 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, 3+ edema of left lower extremity, trace edema of right lower extremity, 2+ pulses, no clubbing or cyanosis Rectal/Vaginal: Gross red blood in rectal vault, erythema of remaining vaginal tissues with evidence of vulvectomy, no blood in vaginal region . Physical exam on transfer from [**Hospital Unit Name 153**] to OMED [**2113-8-20**]: General: Alert, oriented, no acute distress Lungs: Clear to auscultation bilaterally, no wheezes, rales, rhonchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 3+ edema of left lower extremity, trace edema of right lower extremity, 2+ pulses, no clubbing or cyanosis . Physical exam on discharge [**2113-8-25**] Vitals: 99.3, 118/60, 86, 16, 94RA, UOP: 1625 General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Ext: warm, well perfused, 3+ edema of left lower extremity wrapped in ace bandage, 2+ pulses b/l , no clubbing or cyanosis Pertinent Results: Labs on admission [**2113-8-18**]: WBC-9.6 RBC-3.07* Hgb-8.6* Hct-26.9* MCV-88 MCH-27.9 MCHC-31.9 RDW-14.1 Plt Ct-522* Neuts-91.3* Lymphs-4.3* Monos-3.7 Eos-0.5 Baso-0.1 PT-30.8* PTT-43.5* [**Month/Day/Year 263**](PT)-3.1* Glucose-104 UreaN-16 Creat-1.1 Na-135 K-3.5 Cl-97 HCO3-27 AnGap-15 . Labs on transfer [**2113-8-20**]: WBC 8.0 RBC-2.87* Hgb-8.5* Hct-25.5* MCV-89 MCH-29.7 MCHC-33.3 RDW-14.6 Plt Ct-371 Repeat Hct-26.6* PTT-87.2* Glucose-138* UreaN-18 Creat-0.9 Na-137 K-3.3 Cl-101 HCO3-25 AnGap-14 Calcium-8.5 Phos-2.7 Mg-2.1 . Micro: [**2113-8-24**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2113-8-18**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [**8-18**] URINE CULTURE STAPHYLOCOCCUS, COAGULASE NEGATIVE; >100,000 ORGANISMS/ML. YEAST: 10,000-100,000 ORGANISMS/ML. STAPHYLOCOCCUS, COAGULASE NEGATIVE, PRESUMPTIVELY | GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R NITROFURANTOIN-------- <=16 S OXACILLIN-------------<=0.25 S TETRACYCLINE---------- <=1 S VANCOMYCIN------------ 2 S . **Sensitivity for bactrim added on on [**2113-8-26**] . Imaging: [**2113-8-18**]: IVC filter - not placed as pt IVC too wide . EKG: normal sinus rhythm, normal axis, normal intervals, no ST [**Street Address(2) 13234**] depression in V4, otherwise no acute ST segment changes. Compared with prior dated [**2113-8-7**] ST depression in new. R-wave progression is earlier. . Sigmoidoscopy [**2113-8-19**]: -Grade 1 internal hemorrhoids -Diverticulosis of the distal sigmoid colon, proximal sigmoid colon and distal descending colon -Blood in the rectum, sigmoid colon and distal descending colon -We did not find mass lesion during our procedure. -Otherwise normal sigmoidoscopy to distal descending colon -Recommendations: Pt's bleeding is most likely secondary to her diverticulum. However, the right side colon mass lesion can not be r/o now. . Colonoscopy [**2113-8-22**]: Grade 1 internal hemorrhoids Diverticulosis of the mid-descending colon, distal descending colon and sigmoid colon Blood in the descending colon and sigmoid colon Polyp in the mid-ascending colon Otherwise normal colonoscopy to cecum Brief Hospital Course: 82 year old female with a history of stage [**Doctor First Name 690**] squamous cell carcinoma of the vulva and recent diagnosis of DVT on anticoagulation who presented from rehab with bright red blood per rectum. . Lower Gastrointestinal Bleeding: Differential diagnosis for lower gastrointestinal bleeding included diverticulosis, polyps, gastrointestinal malignancies, AVM, hemorrhoids, versus malignant invasion of known gynecologic tumor into rectum. Pt remained hemodynamically stable throughout hospital course, but with hematocrit drop to 23 at lowest point. Pt was transfused PRBC as needed for Hct<25. Sigmoidoscopy and subsequent colonoscopy showed no source of bleed, just multiple diverticuli, which were thought to be the source. Heparin drip was restarted in ICU, but upon transfer to the floors on [**2113-8-21**], she had additional BRBPR. Even after heparin drip had been d/c'ed, she continued to have BRBPR, which excluded her as a candidate for future anticoagulation. She did not have any brisk bleeding during her course, so tagged bleeding scan was not done and source of bleed was never identified. Surgery was consulted, but the patient and her family found that surgical resection was not in line with goals of care (as explained below). . Left Lower Extremity DVT: Patient recently diagnosed and started on heparin and coumadin for DVT. IVC filter was indicated to allow anticoagulation to safely be held in the setting gastrointestinal bleeding and large DVT with potential for pulmonary embolism. However, it could not be placed as her IVC was too wide. Pneumoboot was kept on right leg throughout hospitalization. . Vulvar Cancer: Patient is s/p radical vulvectomy and chemoradiation but recently with new pelvic mass and associated hydronephrosis and urinary tract infection. Renal function remained stable during hospitalization. She was maintained on her home dose of morphine PRN with good effect. Goals of care discussed as below. Patient will follow up with Dr. [**Last Name (STitle) 4149**] as an outpatient. . UTI: Urine culture grew coag negative staph, with S. saphrophyticus excluded. Pt started on Bactrim [**2113-8-20**] and to complete a ten day course for complicated UTI. Sensitivities are as above. Bactrim was added to sensitivities on [**2113-8-26**] and should be followed up as an outpatient. Blood cultures from [**2113-8-24**] are still pending. She had had a temperature of 100.3 on [**2113-8-24**] and fever workup had been initiated. She never had a true fever during her hospitalization. . GERD: Stable. Pt continued on home protonix. . Goals of Care: Since anticoagulation could not be administered for DVT in the setting of GI bleed, goals of care were readdressed during this admission. After multiple family meetings and the involvement of the palliative care team, the patient and her family decided to go home with hospice. She also remained DNR/DNI throughout her hospitalization. Medications on Admission: Colace Senna Morphine 7.5 mg PO Q4H:PRN Protonix 40 mg daily Ensure TID Heparin Coumadin Discharge Medications: 1. Morphine 15 mg Tablet Sig: 0.5 Tablet PO Q4H (every 4 hours) as needed for pain. 2. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) for 5 days: continue until [**2113-8-30**]. [**Month/Day/Year **]:*10 Tablet(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). 4. Compazine 10 mg Tablet Sig: One (1) Tablet PO every six (6) hours as needed for nausea. [**Month/Day/Year **]:*30 Tablet(s)* Refills:*0* 5. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day as needed for constipation. Discharge Disposition: Home With Service Facility: Hospice of the [**Location (un) 1121**] Discharge Diagnosis: PRIMARY DIAGNOSIS: 1. Lower GI bleed 2. Deep Vein Thrombosis SECONDARY DIAGNOSIS: 1. Vulvar Squamous Cell Carcinoma Discharge Condition: Stable, afebrile Discharge Instructions: You were admitted to the hospital on [**2113-8-18**] with bleeding in your GI tract. Your heparin was then stopped, but you cannot have anticoagulation for your leg clot because of your GI bleeding. A colonoscopy was done, and there was no clear source of bleeding in your GI tract. This likely means that you have diverticulosis or a bleeding blood vessel that could not be seen with the colonoscopy. STOP taking coumadin (a blood thinner). As we discussed, there is no further treatment for your clot. You are also at risk for a clot to your lungs because the clot is not being treated. A filter could not be placed your blood vessel to prevent a clot from going to your lungs. You are going home with hospice care. If you have any concerns, you can call your hospice nurse at any time. Your hospice team will also be in touch with Dr. [**Last Name (STitle) 4149**] and you will have an appointment with Dr. [**Last Name (STitle) 4149**] as well in two weeks. You are on pain medication called morphine. Do not drive or do anything that requires fast reaction time on this medication. Do not drink alcohol with this medication. You should take colace and senna with this medication to help with constipation. You also had a urinary tract infection. You must continue bactrim until [**2113-8-30**]. Please notify your hospice nurse/Dr. [**Last Name (STitle) 4149**] or go to the ER if you have bleeding from your rectum or vagina, fevers>100.4, severe nausea/vomiting, abdominal pain, chest pain, shortness of breath, diarrhea, or any symptoms that are concerning to you. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 4149**] in two weeks. Her office has been notified that you need an appointment. They will be scheduling it later today. You will be called with the date of the appointment, or you can call her office at ([**Telephone/Fax (1) 77797**].

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icd9cm

[ [ [] ] ]

[ "88.51", "45.24", "45.23" ]

icd9pcs

[ [ [] ] ]

13720, 13790

9921, 12874

343, 403

13951, 13970

7687, 9898

15596, 15883

5572, 5744

13013, 13697

13811, 13811

12900, 12990

13994, 15573

5168, 5283

5759, 7668

276, 305

431, 2546

13894, 13930

13830, 13873

5048, 5145

5299, 5556

23,028

124,346

19031

Discharge summary

report

Admission Date: [**2140-12-19**] Discharge Date: [**2140-12-22**] Date of Birth: [**2101-11-13**] Sex: F Service: MEDICINE Allergies: Codeine / Doxycycline Attending:[**First Name3 (LF) 1162**] Chief Complaint: Fever Major Surgical or Invasive Procedure: None History of Present Illness: 39 yo F w/ HIV/AIDS (CD4 331), HCV, DMII, HTN, bipolar disorder, presents from [**Hospital **] clinic with fever to 100.4 and LE cellulitis. Pt. reports she was at [**Hospital **] hospital for cellulitis where she was started on vancomycin. She had initially presented with bilateral burning leg pain and erythema. She reported dry-cracked, bleeding skin over the past 1 month. She received 4 days of vancomycin prior to discharge and reported improvement in her legs. She was d/c'd from [**Hospital1 **] on Sunday night w/o abx, to attend her [**Hospital **] clinic appointment at [**Hospital1 18**]. At the [**Hospital **] clinic she had a fever of 100.4. Her legs were noted to be warm and edematous. She was sent to the ED for further workup of fever and cellulitis. In the ED her initial vitals were: 99.4, 85, 96/54, 20, 86RA. For her hypoxia, she was placed on 4L NC with improvement of 02 sats to only 90%. Her ABG was 7.42/55/46. Blood cx. were drawn and she was given 1g of IV vanco, tylenol 1gm, bactrim 600mg iv (PCP [**Name Initial (PRE) **]), morphine 4mg x1, prednisone 40mg po x1 (for ?PCP w/ Pa02<70). She was admitted to the [**Hospital Unit Name 153**] for hypoxia and cellulitis. Past Medical History: HIV/AIDS dx in [**2130**] CD4 331 h/o PCP [**Last Name (NamePattern4) **] [**2132**] HCV liver bx in [**5-22**] shows grade-2 inflammation, stage 3 fibrosis diverticulitis c/b colovaginal fistula [**2136**] GERD bipolar anxiety TAH/BSO HTN genital HSV Social History: Lives alone, +tobacco (6cig/day), h/o IVDU (last in [**2133**]) Family History: Non-contributory Physical Exam: VS: Temp: 98.5 BP: 115/65 HR: 7876 RR: 20 O2sat 90% ABG 7.42/57/68 GEN: overweight F, laying in bed, complaining of generalized, non-focal pain HEENT: MMM, NC in place NECK: no carotid bruits. could not assess JVP 2/2 body habitus RESP: CTA b/l with good air movement throughout CV: RRR, no murmurs ABD: obese, Nt/ND, ecchymosis from subq heparin injections, midline surgical scar- well healed, normoactive BS, non-tender, soft. EXT: painful to touch bilaterally. legs are slightly erythematous, trace edema. NEURO: AAOx3. Pertinent Results: Admission Labs [**2140-12-19**] 01:20PM WBC-5.1 RBC-4.45 HGB-12.5 HCT-38.5 MCV-87 MCH-28.0 MCHC-32.3 RDW-17.4* [**2140-12-19**] 01:20PM GLUCOSE-114* UREA N-9 CREAT-0.9 SODIUM-133 POTASSIUM-7.4* CHLORIDE-91* TOTAL CO2-31 ANION GAP-18 [**2140-12-19**] 01:20PM PLT SMR-NORMAL PLT COUNT-322 LPLT-2+ [**2140-12-19**] 03:35PM O2 SAT-63 MET HGB-0 [**2140-12-19**] 01:55PM LACTATE-3.3* [**2140-12-19**] 06:38PM TYPE-ART PO2-68* PCO2-57* PH-7.42 TOTAL CO2-38* BASE XS-9 CXR [**11-19**] - No evidence of acute intrathoracic process; specifically, no evidence of focal pneumonia or congestive heart failure. CTA [**11-20**] - Markedly limited and poor inspiration No saddle PE. Cardiomegaly. Enlarged pulmonary artery suggestive of pulmonary artery hypertension. 6 mm RUL nodule Old rib fractures Echo: The left atrium is mildly dilated. There is right-to-left passage of microbubbles across the interatrial septum at rest c/w a secundum type atrial septal defect. Left ventricular wall thicknesses and cavity size are normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is low normal (LVEF 50-55%). The estimated cardiac index is borderline low (2.0-2.5L/min/m2). The right ventricular cavity 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 mildly thickened. There is no mitral valve prolapse. Trivial mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Suboptimal image quality. Right-to-left passage of microbubbles after intravenous injection c/w atrial septal defect. Low normal left ventricular systolic function. Right ventricular cavity enlargement. Brief Hospital Course: 39 yo F w h/o HIV/AIDS, HCV, DMII, HTN, chronic pain, h/o IVDU on methadone, presents with fever, hypoxia, cellulitis. 1. Hypoxia: Pt. stateed on admission that she chronically has poor 02 sats and has refused oxygen supplementation and Bipap for OSA in the past. Her CXR showed no acute process. Her initial ABG indicated hypercarbia and hypoxemia. Her ABG on presentation to the ICU was still significant for hypercarbia, but with a improvement in hypoxemia. She remained asymptomatic throughout. Due to the pts. HIV hx, there was a suspicion of PCP (tachypnea, hypoxia, fevers). She did have a h/o PCP, [**Name10 (NameIs) **] her latest CD4 count was >300 and she maintained compliance with her PCP [**Name9 (PRE) **], which made that diagnosis less likely. She was given a dose of bactrim for empiric therapy and steroids in the ED. Diff. for hypoxia also included pneumonia (CAP), narcotic- induced, obesity hypoventilation. Pt had an A-a gradient of >30 so it was felt that this could not [**Last Name (un) 7245**] be attributed to hypoventilation alone. A PE was ruled out by CT-PA. An TTE with bubble study was obtained which did show evidence of an atrial septal defect. This was discussed with the cardiology consult team and it was felt that this was most likely a congenital defect and not solely responsible for the patient's hypoxia. The patient adamantly requested discharge, refused to wear oxygen while in house and refused bipap for her OSA. An appointment was made for her to follow up with cardiology in the future to evalutate for her newly diagnosed ASD. 2. chronic pain: the patient is on a significant amt of methadone and oxycodone. She has been seen by pain service and is on a home regimen as above. She was continued on her prior regimen and given scripts that would cover her until her follow up in [**Hospital **] clinic with Dr. [**Last Name (STitle) **]. 3. HIV: pt is followed here by ID. Her last CD4 count on [**2140-11-14**] was 331. Her viral load on [**2140-11-14**] was undetectable. Current CD4 count 245. She was continued on her home regimen. 4. Cellulitis: pt. was treated at [**Hospital **] hosp with vanc x 4days for presumed cellulitis, however, she was left to attend her [**Hospital **] clinic appt. and was not d/c'd on abx. She had a slight fever and no leukocytosis and the patient's regular ID attending came to evaluate her and stateed that she felt the LE's looked the same or better than baseline and that further antibiotics were not warranted. Her coverage was stopped and the patient remained afebrile for the rest of the hospitalization. 5. DMII- continued home meds however metformin was held for 48 hours following contrast for CT and restarted on discharge. . 6. lower extremity edema: patient was continued on lasix 20mg qday. 7. UTI--A UA was obtained upon transfer to the floor and the patient was found to have a UTI. She was placed on cipro for 3 days. The urine culture showed only fecal contaminant. . Medications on Admission: ASPIRIN 325 mg qdaily BACTRIM DS 160-800 mg po qdaily EPZICOM 600-300 mg po qdaily Methadone 80 mg TID Methadone 40 mg [**Hospital1 **] prn lyrica 150mg [**Hospital1 **] NEURONTIN 600 tid NYSTATIN 100,000 unit/g--apply as directed twice a day NYSTATIN 100,000 unit/gram--apply to affected areas twice a day PROZAC 30 mg qdaily oxycontin 20mg po bid REYATAZ 400mg qdaily albuterol prn glucophage 1000 [**Hospital1 **] lantus 40mg qAM SSI xanax 2mg TID lasix 20mg qday pyridium phenergen prn Discharge Medications: 1. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed. Disp:*60 Tablet(s)* Refills:*3* 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 3. Oxycodone 20 mg Tablet Sustained Release 12 hr Sig: One (1) Tablet Sustained Release 12 hr PO Q12H (every 12 hours). Disp:*30 Tablet Sustained Release 12 hr(s)* Refills:*0* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 5. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Pregabalin 75 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 7. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 8. Atazanavir 200 mg Capsule Sig: Two (2) Capsule PO DAILY (Daily). 9. Abacavir 300 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. Lamivudine 150 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 11. Methadone 40 mg Tablet, Soluble Sig: Two (2) Tablet, Soluble PO TID (3 times a day) for 15 days. Disp:*90 Tablet, Soluble(s)* Refills:*0* 12. Trimethoprim-Sulfamethoxazole 160-800 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Fluoxetine 10 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 14. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. 15. Miconazole Nitrate 2 % Cream Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 16. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 17. Cipro 500 mg Tablet Sig: One (1) Tablet PO twice a day for 3 days. Disp:*6 Tablet(s)* Refills:*0* 18. Xanax 2 mg Tablet Sig: One (1) Tablet PO three times a day as needed. 19. Glucophage 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. 20. Insulin Glargine 100 unit/mL Solution Sig: One (1) 40 units Subcutaneous qAM. 21. med Please see attached sliding scale, check BG 4x daily Discharge Disposition: Home With Service Facility: [**Last Name (LF) 486**], [**First Name3 (LF) 487**] Discharge Diagnosis: hypoxemia atrial septal defect UTI HIV chronic pain Discharge Condition: stable Discharge Instructions: You were admitted with hypoxia and a question of cellulitis in your legs. You had a CT scan of your lungs which showed no evidence of a PNA or a pulmonary embolus. You were also found to have a UTI and will be treated with 3 days of antibiotics. Your oxygen saturation is persistently low but you are refusing oxygen treatment. You should return to the ER if you develop fevers, chills, nausea, or worsening shortness of breath. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 22367**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2141-1-2**] 11:30 Provider: [**Name10 (NameIs) **] PSYCHOLOGY Phone:[**Telephone/Fax (1) 1091**] Date/Time:[**2141-1-18**] 10:00 Provider: [**Name10 (NameIs) 13368**] [**Last Name (NamePattern4) 13369**], MD Phone:[**Telephone/Fax (1) 1091**] Date/Time:[**2141-1-18**] 1:40 We are in the process of making an appointment with the cardiology department for you to follow up regarding your new diagnosis of ASD. Since you are requesting to leave the hospital immediately you will need to follow up by calling [**Telephone/Fax (1) 62**] to confirm the date and time of your appointment. The cardiology clinic is located on the [**Hospital Ward Name **] of [**Hospital1 **] center on the [**Location (un) 436**] of the [**Hospital Ward Name 23**] clinical center.

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

9891, 9974

4410, 7400

291, 297

10070, 10079

2477, 4387

10559, 11458

1900, 1918

7942, 9868

9995, 10049

7426, 7919

10103, 10536

1933, 2458

246, 253

325, 1527

1549, 1803

1819, 1884

29,989

130,274

43907

Discharge summary

report

Admission Date: [**2169-3-15**] Discharge Date: [**2169-3-20**] Date of Birth: [**2115-1-26**] Sex: M Service: CARDIOTHORACIC Allergies: Aspirin / Nsaids / Aleve / Apricot Attending:[**First Name3 (LF) 1505**] Chief Complaint: Chest pain Major Surgical or Invasive Procedure: [**2169-3-15**] - CABGx1 (Vein->Right coronary artery) History of Present Illness: Mr. [**Known lastname **] is a 54-year-old male with anginal symptoms with exertion who underwent a stress test that was positive. Cardiac catheterization showed an anomalous right coronary artery coming off the left coronary cusp and traveling between the pulmonary artery and the aorta with a hint of compression. CT scan and MRI evaluation of the anatomy confirmed the above anatomy. He did not have any suggestion of an intramural portion of the coronary within the wall of the aorta that would lend itself to unroofing. He is presenting for bypass to his right coronary artery. Past Medical History: HTN Epistaxis s/p laser surgery Systemic mastocytosis Hereditary Hemorrhagic Telangiectasias (Osler-Rendu-[**Doctor Last Name 11586**]) s/p inguinal hernia repair on [**2166-6-20**] Social History: Married with children, occ ETOH, < 1 pack year history of smoking Family History: sister- hereditary hemorrhagic telangiectasias, mild stroke daughter- hemoptysis uncles- MI Physical Exam: PE: Vitals: 102 - 17 - 117/62 - 95%RA - Afebrile GENERAL: The patient is a well-appearing male lying in hospital bed, NAD, drowsy but easily arousable. Oriented x3. HEENT: Extraocular movements intact. Pupils equal round and reactive to light. Sclerae anicteric. Mucous membranes moist. Pharynx is clear without erythema or exudate. NODES: There is no appreciable cervical, supraclavicular, axillary lymphadenopathy. NECK: Supple. There is no evidence of thyromegaly or thyroid nodules. HEART: Regular rate and rhythm, normal S1, S2. No murmurs, rubs, or gallops. Surgical wound in central chest, bandaged. LUNGS: Clear to auscultation bilaterally. ABDOMEN: Normal bowel sounds. Soft, nontender, nondistended. There is no hepatosplenomegaly or masses noted. EXTREMITIES: RLE wrapped in bandages. LLE no e/c/c Pertinent Results: [**2169-3-15**] ECHO PRE-BYPASS: 1. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. Overall left ventricular systolic function is normal (LVEF>55%). 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the descending thoracic aorta. 5. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. Trace aortic regurgitation is seen. 6. The L main coronary artery is noted off the L aortic coronary cusp, and there is another noted arterial vessel flow off the L coronary cusp that is presumably the RCA. 7. The mitral valve appears structurally normal with trivial mitral regurgitation. 8. There is no pericardial effusion. POST-BYPASS: For the post-bypass study, the patient was receiving vasoactive infusions including nitroglycerine infusion and was in normal sinus rhythm. 1. The noted arterial vessel, RCA, is no longer off the left coronary cusp. The left main coronary artery is patent. 2. Regional and global biventricular systolic function are normal. 3. Aortic contours are intact post-cannulation. [**2169-3-19**] 07:11AM BLOOD WBC-7.7 RBC-4.02* Hgb-12.5* Hct-35.3* MCV-88 MCH-31.1 MCHC-35.4* RDW-12.3 Plt Ct-190 [**2169-3-19**] 07:11AM BLOOD Plt Ct-190 [**2169-3-15**] 12:27PM BLOOD PT-13.6* PTT-39.1* INR(PT)-1.2* [**2169-3-19**] 07:11AM BLOOD Glucose-114* UreaN-15 Creat-1.1 Na-139 K-4.2 Cl-102 HCO3-26 AnGap-15 CHEST (PA & LAT) [**2169-3-19**] 11:27 AM CHEST (PA & LAT) Reason: ? infiltrate [**Hospital 93**] MEDICAL CONDITION: 54 year old man with s/p cabg REASON FOR THIS EXAMINATION: ? infiltrate STUDY: PA and lateral chest [**2169-3-19**]. HISTORY: 54-year-old man status post CABG. FINDINGS: Comparison is made to previous study from [**2169-3-17**]. Mediastinotomy wires are again seen. Cardiac silhouette was within normal limits. There are small pleural effusions and atelectasis at the lung bases. No overt pulmonary edema or focal consolidation is seen. The previously described pneumomediastinum is not well seen. Brief Hospital Course: Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2169-3-15**] for surgical management of his anomalous right coronary artery. He was taken directly to the operating room where he underwent coronary artery bypass grafting to one vessel. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. He later awoke neurologically intact and was extubated. The hematology service was consulted regarding anticoagulation given his history of Osler-[**Doctor Last Name 11586**]-Rendu syndrome. It was recommended to use a baby aspirin at least in the short term given the possibility of developing furture AV malformations. On postoperative day one, Mr. [**Known lastname **] 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. He had some rapid atrial fibrillation for which he was started on amiodarone. He developed a L arm phlebitis and was started on keflex. U/S of the phlebitis on [**3-20**] showed superficial thrombosis. The pt. will return to [**Hospital Ward Name 121**] 6 on [**3-22**] to monitor L arm. He was discharged to home in stable condition on POD#5. Medications on Admission: HCTZ 25 mg PO daily Protonix 40 mg PO daily Zantac 150 mg PO TID Zyrtec 10 mg PO daily PRN Omega 3 CoQ Vitamin D Glucosamine Chondroitin 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:*0* 2. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 3. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 4. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*0* 5. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 5 days: then 400 mg daily x 7 days, then 200 daily ongoing until dc'd by cardiologist. Disp:*60 Tablet(s)* Refills:*0* 6. Zantac 150 mg Tablet Sig: One (1) Tablet PO three times a day. Disp:*90 Tablet(s)* Refills:*2* 7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 9. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) for 10 days. Disp:*40 Capsule(s)* Refills:*0* 10. Furosemide 20 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 5 days. Disp:*10 Tablet(s)* Refills:*0* 11. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours) for 5 days. Disp:*10 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Anomalous RCA HTN Hyperlipidemia GERD Hereditary hemorrhaging telangiectasia Discharge Condition: Stable 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. 7) Call with any questions or concerns. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] in 1 month. ([**Telephone/Fax (1) 1504**] Please follow-up with Dr. [**Last Name (STitle) **] in 2 weeks. Please follow-up with Dr. [**Last Name (STitle) 2472**] in [**2-12**] weeks. [**Telephone/Fax (1) 133**] Please call all providers for appointments. Please return to [**Hospital Ward Name 121**] 6 on Wed. [**3-22**] to check L arm Completed by:[**2169-3-20**]

[ "401.9", "746.85", "448.0", "997.1", "451.82", "272.0", "998.89", "427.31", "780.6", "530.81" ]

icd9cm

[ [ [] ] ]

[ "39.61", "89.60", "36.11" ]

icd9pcs

[ [ [] ] ]

7343, 7401

4392, 5679

312, 369

7522, 7531

2244, 3829

8273, 8693

1288, 1382

5866, 7320

3866, 3896

7422, 7501

5705, 5843

7555, 8250

1397, 2225

262, 274

3925, 4369

397, 982

1004, 1188

1204, 1272

8,542

176,267

26057+57477

Discharge summary

report+addendum

Admission Date: [**2159-12-26**] Discharge Date: [**2160-1-9**] Date of Birth: [**2082-8-17**] Sex: F Service: SURGERY Allergies: Iodine / Penicillins / Morphine Sulfate Attending:[**First Name3 (LF) 1481**] Chief Complaint: Transferred from rehabilitation facility for decreased hematocrit Major Surgical or Invasive Procedure: [**12-28**] Colonoscopy [**12-28**] EGD [**1-2**] Octreotide scan History of Present Illness: 77 yo F with h/o hypertension, tachy-brady syndrome s/p pacer, CAD s/p NSTEMI in [**2157**], s/p recent admission for cholecystitis s/p percutaneous biliary drain placement and recent dx of mesenteric mass (?carcinoid tumor) who presents from rehab with maroon stool. Pt was admitted in [**11/2159**] with cholecystitis. She had a perc drain placed which ultimately fell out, and plan was to follow up with Dr. [**Last Name (STitle) **] for CCY. She was also recently diagnosed with mesenteric mass on CT, which was felt to possibly be carcinoid tumor. She was discharged to rehab on [**2159-12-19**] and on [**2159-12-26**] per nursing notes, she had a small amount of BRBPR and hct drop to 22.7 (bl 33). She had a negative lavage in ED. She was hemodynamically stable, with SBP 100-110's, with maroon stool on ED rectal exam. A sublclavian line was placed for access and she was transfused 2 units of PRBC. She complains of some abdominal pain, in RUQ, RLQ and epigastrium. She did not notice the color of her stools. She denies CP, SOB, dysuria, diarrhea, history of GIB, dizzyness. She does note DOE, night sweats, fatigue, and zoster rash on buttocks. Past Medical History: Past Medical History; HTN Tachy-brady syndrome '[**57**] NSTEMI CAD GERD '[**41**] [**First Name9 (NamePattern2) 8751**] [**Last Name (un) 8061**] Shingles Past Surgical History: [**12-22**] Coronary catheterization '[**51**] Pacemaker Colectomy Left lumpectomy Umbilical hernia repair Social History: Married, came in from rehab after recetn admission, prior to that lived with husband, they were functional and still working for a used car facility, delivering cars, She quit smoking 40+ years ago, about 15 pack yr history, no alcohol use Family History: Father and mother both deceased from CAD Physical Exam: 98.8, 134/61, 104, 20, 95%2L NC GENL: pleasant female in NAD HEENT: OP dry, no LAD, no elev JVP, EOMI, PERL CV: RRR no MRG Lungs: CTAB Abd: soft, tender to palp in RLQ, mild tenderness to palp in RUQ and epigastrium, brown stool guaiac pos, no rebound, slight guarding Ext: no edema, 2+ pedal pulses Neuro: EOMI, PERL Pertinent Results: Cardiology Report ECG Study Date of [**2159-12-26**] 5:45:28 PM Technically difficult study Sinus tachycardia Marked left axis deviation Intraventricular conduction delay Lateral ST-T wave changes V2-3 R wave reversal Since previous tracing, no significant change Intervals Axes Rate PR QRS QT/QTc P QRS T 102 0 138 374/[**Telephone/Fax (2) 64699**] Chest X-Ray [**12-30**]: IMPRESSION: No change in size and appearance of moderate left pleural effusion with adjacent atelectasis/consolidation and small right pleural effusion, given difference in techniques. Operative note: Carcinoid tumor of the small bowel and cholecystitis. PROCEDURE: Laparotomy, lysis of adhesions, small bowel resection, cholecystectomy. Octreotide scan [**1-2**]: IMPRESSION: 1. No abnormal focus of tracer uptake to indicate somatostatin receptor avid tumor. 2. Markedly distended gallbladder with mild wall thickening. Correlate clinically and with ultrasound if indicated. Admission labs: [**2159-12-26**] 04:25PM BLOOD WBC-14.6* RBC-2.47* Hgb-7.8* Hct-23.2* MCV-94 MCH-31.7 MCHC-33.7 RDW-15.1 Plt Ct-782* [**2159-12-26**] 04:25PM BLOOD Neuts-85.1* Bands-0 Lymphs-7.7* Monos-5.5 Eos-1.4 Baso-0.1 [**2159-12-26**] 04:25PM BLOOD Plt Smr-VERY HIGH Plt Ct-782* [**2159-12-26**] 07:32PM BLOOD PT-14.6* PTT-28.5 INR(PT)-1.3* [**2159-12-26**] 04:25PM BLOOD Glucose-118* UreaN-24* Creat-0.9 Na-130* K-4.7 Cl-95* HCO3-26 AnGap-14 [**2159-12-26**] 04:25PM BLOOD ALT-11 AST-19 AlkPhos-63 Amylase-44 TotBili-0.3 [**2159-12-26**] 04:25PM BLOOD Lipase-23 [**2159-12-26**] 04:25PM BLOOD Albumin-2.8* Phos-3.2 Mg-2.3 [**2159-12-26**] 06:10PM BLOOD Lactate-2.3* Discharge labs: [**2160-1-7**] 04:33AM BLOOD WBC-8.3# RBC-2.85* Hgb-8.8* Hct-26.5* MCV-93 MCH-30.9 MCHC-33.3 RDW-15.2 Plt Ct-287 [**2160-1-7**] 04:33AM BLOOD Plt Ct-287 [**2160-1-7**] 10:03AM BLOOD Glucose-90 UreaN-13 Creat-0.5 Na-139 K-3.5 Cl-105 HCO3-25 AnGap-13 [**2160-1-7**] 10:03AM BLOOD Calcium-7.6* Phos-2.7 Mg-1.7 Brief Hospital Course: 77 yo F with h/o htn, CAD, recent hosp for cholecystitis s/p percutaneous drain that has since fallen out, mesenteric mass felt to be carcinoid who presents from rehab with BRBPR/maroon stool. . #) GIB: Likley lower source given BRBPR. She was transfused a total of 4U prbcs for a goal of >28 and her hct has since remained. She had no evidence of continued bleeding while in the [**Hospital Unit Name 153**]. GI was consulted and upon preparation for EGD/colonoscopy there was no evidence of bright blood/active bleed, rather just old blood. Although poorly prepped, colonoscopy was normal and her EGD showed atrophic gastritis in the antrum. H. Pylori studies were sent and should be followed up as an outpatient. She will need a repeat colonoscopy in 6 months which can be set up by her PCP. [**Name10 (NameIs) **] she to have recurrent bleeding, small bowel follow through and capsule endoscopy would be the next steps per GI. . #) Cholecystitis: She was continued on her course of levofloxacin/Flagyl which she is to complete on [**2159-12-29**]. She had no abdominal pain during her stay. She should follow up with surgery upon discharge regarding cholecystectomy. . #) Mesenteric mass: Radiographically was c/w carcinoid. She has had some flushing that would be consistent with dx, but denies diarrhea. Chromogranin A was found to be elevated while 5HIAA was normal. This will need further evaluation as well for octreotide scan. . #) CAD: No signs of ischemia on EKG but paced rhythm. She was restarted on her home dose metoprolol. ASA was held in the setting of her bleed. Restarting this will need to be readdressed upon outpatient follow up given her known h/o of CAD. Her ACEI was held on admission in the setting of her GI bleed and was restarted as her blood pressure tolerated. . #) Hypertension: Antihypertensives were held originally in the setting of GIB. Metoprolol was added back for persistent tachycardia (h/o tachy-brady). ACEI and Lasix can be added back as blood pressure and fluid status tolerates. On HD 6, she was transferred to the surgical service for planned surgical intervention of her known mesenteric mass; she was afebrile, hemodynamically stable with a hematocrit of 34, ambulating with a walker, tolerating Ensure supplementation, and had moderate right upper quadrant pain controlled with Vicodin. On HD 7 and 8, she underwent an Octreotide scan, which demonstrated no abnormal focus of tracer uptake to indicate somatostatin receptor avid tumor. On HD 10 she underwent an exploratory laparotomy, lysis of adhesions, small bowel resection, and cholecystectomy; intra-operatively she was found to have large bulky disease, consistent with carcinoid with nodules which had a tremendous sclerotic reaction which basically enveloped substantial portions of the small intestine, she had no complications. Post-operatively she was NPO with intravenous hydration, Morphine PCA, nasogastric tube, foley catheter, and was continued on telemetry monitoring while receiving intravenous beta-blockade. On POD 4, she had +flatus and a bowel movement, her diet was advanced, her pain was well controlled with Vicodin, her oral medications were resumed, she remained afebrile, and was voiding without difficulty. She had been followed by physical therapy during her hospitalization course with recommendations of transfer to a rehab facility for continued therapy. She was discharged on [**1-9**] to Life Care Center of the [**Hospital3 **] rehabilitation facility in good condition. She was to follow-up with Dr. [**Last Name (STitle) **] in [**12-18**] weeks. Medications on Admission: Ezetimibe 10 mg Daily Buspirone 15 mg PO BID Nortriptyline 75 mg HS Alprazolam 1 mg TID Pantoprazole 40 mg Q24H Metoprolol Tartrate 50 mg PO BID Fexofenadine 60 mg [**Hospital1 **] Aspirin 325 mg Daily Hydrocodone-Acetaminophen 5-500 mg 1-2 Tablets PO Q4-6H PRN Levofloxacin 250 mg PO Q24H Last Dose 1/13 Metronidazole 500 mg PO TID Last dose pm [**12-29**]. Ipratropium Inhalation Q6H as needed for wheezing. Albuterol Inhalation Q6H as needed for wheezing. Docusate Sodium 100 mg PO BID Lactulose 30 ML PO DAILY Lasix 20 mg PO BID Quinapril 10 mg daily Zovirax apply to affected area [**Hospital1 **] Discharge Medications: 1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 2. Acyclovir 5 % Ointment Sig: One (1) Appl Topical 5X/D (5 times a day). 3. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. 4. Alprazolam 1 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 5. BusPIRone 15 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for fever or pain. 7. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day): Hold for HR < 60 Hold for SBP < 100. 8. Furosemide 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Nortriptyline 25 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). 10. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed for pain. 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 12. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. 13. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Two (2) Capsule, Sustained Release PO once a day: While on Lasix. 14. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO once a day. 15. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO twice a day. 16. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. 17. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day as needed for constipation. Discharge Disposition: Extended Care Facility: Life Care Center of the [**Hospital3 **] - [**Location (un) 3493**] Discharge Diagnosis: Lower gastrointestinal bleed Cholecystitis Carcinoid tumor of small bowel Discharge Condition: Stable Discharge Instructions: Notify MD or return to the emergency department if you experience: *Increased or persistent pain not relieved by pain medication *Fever > 101.5 *Nausea, vomiting, diarrhea, or abdominal distention *Inability to pass gas, stool, or urine *If incision appears red or if there is drainage *Bleeding from any part of the body *Shortness of breath or chest pain *Any other symptoms concerning to you You may shower and wash incision with soap and water, pat dry No swimming or tub baths for 2 weeks Followup Instructions: Follow-up with Dr. [**Last Name (STitle) **] in [**12-18**] weeks, call [**Telephone/Fax (1) 2981**] for an appointment Completed by:[**2160-1-9**] Name: [**Known lastname 887**],[**Known firstname 11416**] Unit No: [**Numeric Identifier 11417**] Admission Date: [**2159-12-26**] Discharge Date: [**2160-1-9**] Date of Birth: [**2082-8-17**] Sex: F Service: SURGERY Allergies: Iodine / Penicillins / Morphine Sulfate Attending:[**First Name3 (LF) 203**] Addendum: Invasive procedure: [**1-4**] Exploratory laparotomy, lysis of adhesions, small bowel resection, and cholecystectomy Discharge Disposition: Extended Care Facility: Life Care Center of the [**Hospital3 413**] - [**Location (un) 414**] [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 206**] MD [**MD Number(1) 207**] Completed by:[**2160-1-9**]

[ "414.01", "567.82", "285.9", "553.3", "443.0", "401.9", "053.9", "568.0", "511.9", "235.2", "578.9", "535.40", "530.81", "V45.01", "574.10", "412" ]

icd9cm

[ [ [] ] ]

[ "45.62", "51.22", "99.04", "45.16", "45.23", "54.59" ]

icd9pcs

[ [ [] ] ]

11892, 12142

4584, 8189

365, 432

10678, 10687

2602, 3562

11231, 11869

2206, 2248

8843, 10443

10581, 10657

8215, 8820

10711, 11208

4253, 4561

1823, 1932

2263, 2583

260, 327

460, 1619

3579, 4236

1641, 1799

1948, 2190

1,559

147,179

8761

Discharge summary

report

Admission Date: [**2179-6-15**] Discharge Date: [**2179-6-25**] Date of Birth: [**2109-8-16**] Sex: M Service: CARDIOTHORACIC SURGERY CHIEF COMPLAINT: This is a 69-year-old male with a past medical history significant for hypertension, coronary artery disease, hypercholesterolemia, benign prostatic hypertrophy, with allergies to Cipro. The patient is a nonsmoker. He denied alcohol use and abuse. MEDICATIONS ON ADMISSION: 1. Lopressor 50 mg p.o. t.i.d. which was held the morning of admission. 2. Lovenox 80 mg subcutaneously q. 12. 3. Levaquin 500 mg q.d. 4. Toprol XL 100 mg p.o. q.d. 5. Digoxin 0.25 mg p.o. q.d. 6. Aspirin 325 mg p.o. q.d. HISTORY OF THE PRESENT ILLNESS: This is a 69-year-old male with a history of fever and chills one week prior to admission who was brought to the Emergency Room and diagnosed with an upper respiratory infection for which he was administered Levaquin. He remained afebrile for five days and then was reevaluated the following Monday and admitted to [**Hospital6 2910**] for a cardioversion due to the patient's atrial fibrillation which was diagnosed by an EKG in the Emergency Room. The patient was successfully converted with digoxin. Cardiac catheterization was performed at [**Hospital6 2910**] which revealed 80% stenosis of the LAD and 90% stenosis of the LAD after the diagonal, 80% stenosis of the ramus, 70% stenosis of the first OM, 80-90% stenosis of the right coronary artery proximal with an EF of 45%. The patient underwent coronary artery bypass grafting times four on [**2179-6-16**] with a left internal artery mammary to the left anterior descending artery, saphenous vein graft to the ramus intermedius, saphenous vein graft to the diagonal, saphenous vein graft to the posterior descending artery. The total cardiopulmonary bypass time was 96 minutes, total cross clamp time 85 minutes. The patient was discharged to the Cardiac Surgery Recovery Unit in stable condition on propofol. On postoperative day number one, 24 hour events including the patient being extubated without difficulty, currently with a low-grade fever at 99, alert and oriented. The physical examination revealed that the patient had coarse breath sounds bilaterally on Neo-Synephrine 0.2 with a cardiac index of 3.71 and an SVR of 634. The plan was to wean the Neo-Synephrine and to hold off on the diuresis until the Neo-Synephrine is off and to continue vancomycin with possible transfer to the floor. On postoperative day number two, 24-hour events included an episode of atrial fibrillation as well as delirium overnight. The atrial fibrillation resolved spontaneously. The delirium was treated with IV Haldol with good effect. The patient was subsequently placed on IV amiodarone for the atrial fibrillation. On postoperative day number three, 24 hour events included continued episodes of atrial fibrillation for which the patient was placed on heparin. The plan was to continue the IV amiodarone. The patient was complaining of a persistent cough for which he was administered Robitussin with codeine. On postoperative day number three, the patient continued to have atrial fibrillation over the last 24 hours; however, with an improving cough. The patient was afebrile. The vital signs were stable in atrial fibrillation. On physical examination, the patient was with decreased breath sounds at the left base and improved wheezing bilaterally. The plan was to increase the patient's Lopressor and to encourage ambulation. On postoperative day number five, the patient converted to sinus rhythm overnight. However, still with occasional PVCs, afebrile. The vital signs were stable. However, on physical examination, the breath sounds were still decreased at the left base. The plan was to begin Coumadin and to stop the heparin. The patient's laboratories had a white count of 10.1, hematocrit 26.7. Sodium 145, potassium 3.7, BUN 19, creatinine 1.2 with a glucose of 114. The patient's delirium which had occurred over the last three to four days appears to be resolved. Geriatrics came back to look at the patient and recommended to discontinue the Benadryl and Darvocet due to the resolution of the delirium. Psychiatry came by and saw the patient on postoperative day number five, at which time they recommended to reinstate the Zyprexa 2.5 mg b.i.d. or Haldol 0.5 mg b.i.d. and hold for sedation to administer Haldol 0.5 mg p.o. p.r.n. q. 12 for agitation, to consider head imaging given that the patient was still delirious occasionally five days postoperatively even though improving and due to the fact that the patient was in atrial fibrillation for several days prior to admission. They also recommended to consider a blood transfusion as the hematocrit trailed from 40 to 26.7. They also recommended to add a TSH, folate, and B12 to the next blood draw. They did not recommend a one-to-one sitter because the patient has not been behaviorly inappropriate or dangerous to himself or others as of yet. However, they did recommend to discontinue the Benadryl, Darvocet, and any other anticholinergics, narcotics, or benzodiazepines, and treat the pain control with NSAIDs. The EP Service also came by to see the patient on postoperative day number five for the patient's episodes of nonsustained ventricular tachycardia and paroxysmal atrial fibrillation. They recommended a TEE in the morning to reassess the patient's LV function. They also recommended to continue amiodarone and hold further Coumadin doses until the LVEF is known and to continue heparin as well as a formal postoperative EKG in the morning. On postoperative day number five, the patient had no acute events overnight as well as no further bouts of atrial fibrillation, afebrile. The vital signs were stable. The patient is saturating at 97% on room air. TEE was performed revealing a normal EF. The plan was to restart the Coumadin. On postoperative day number seven, 24 events included an asymptomatic five beat run of ventricular tachycardia, spontaneously converted back to sinus. The patient was afebrile. The vital signs were otherwise stable. The physical examination remained benign. The plan was to check the patient's folate and B12 levels. The patient had a white count of 6.8, hematocrit 24.9, platelet count 307,000. Sodium 142, potassium 3.9, BUN 22, creatinine 1.2 with a glucose of 87. The patient's delirium was resolving. The patient was appearing to be almost back to baseline. On postoperative day number eight, the patient had no acute events overnight, still in sinus rhythm at 71, afebrile. On physical examination, he had improved. The lung examination was with mild rhonchi on the left side. Because the patient had not had any more episodes of atrial fibrillation, the plan was to discontinue the heparin and Coumadin and to possibly be discharged to home if the patient could complete level V with Physical Therapy. The patient was discharged on postoperative day number nine to home with Visiting Nurse services. The physical examination on discharge revealed that the patient's vital signs were stable, saturating at 93% on room air in sinus rhythm at 71 beats per minute. He had coarse breath sounds slightly at the left base. DISCHARGE STATUS: The patient was discharged in stable condition on the following medications. DISCHARGE MEDICATIONS: 1. Metoprolol 50 mg p.o. b.i.d. 2. Amiodarone 400 mg p.o. b.i.d., then 400 mg p.o. q.d. 3. Aspirin 325 mg p.o. q.d. 4. Colace 100 mg p.o. b.i.d. p.r.n. 5. Potassium chloride 20 mEq q.d. times ten days. 6. Lasix 20 mg p.o. q.d. times ten days. 7. Acetaminophen 650 mg p.o. q. 4-6 hours p.r.n. pain. 8. Ibuprofen 400 mg p.o. q. six hours p.r.n. pain. DISCHARGE DIAGNOSIS: Coronary artery disease, status post coronary artery bypass grafting times four. DISCHARGE INSTRUCTIONS: Follow-up with Dr. [**First Name (STitle) **] in three to four weeks and follow-up with Dr. [**Last Name (STitle) 1537**] in four weeks. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Last Name (NamePattern4) 30647**] MEDQUIST36 D: [**2179-11-11**] 10:19 T: [**2179-11-14**] 19:16 JOB#: [**Job Number **]

[ "427.31", "465.9", "272.4", "401.9", "997.1", "600.0", "427.1", "293.0", "414.01" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

7386, 7744

7766, 7848

445, 7363

7873, 8289

168, 419

28,042

187,429

44444

Discharge summary

report

Admission Date: [**2134-2-2**] Discharge Date: [**2134-2-9**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1674**] Chief Complaint: BRBPR, LLQ pain Major Surgical or Invasive Procedure: . History of Present Illness: This is a 88 yo F with h/o PAF on coumadin who presents with BRBPR and LLQ pain X 3 days. Her symptoms began Friday night when she began to experience BRBPR with minimal amounts of loose stools. This was associated with crampy LLQ > RLQ pain. Denies n/v, melena, fevers. + chills. These symptoms continued until Monday when the blood became less brisk with an increase in the amount of loose stools. She attempted to keep well hydrated over the weekend but began to feel increasingly lightheaded to the point that she felt she may pass out if she stood up too quickly. The pt has had BRBPR in the past [**2-20**] hemorrhoids but reports those past episodes were not nearly as significant and not accompanied by abdominal pain. She was recently started on a baby ASA 1 week ago and also reports that her lasix dose was increased 2 weeks ago. No recent antibiotics. Denies recent change in diet, including increased ingestion of leafy, green vegetables. She went to see her PCP today who noted her SBP to be in the 90s (usual baseline 140s) and referred her to the ED for further evaluation. . In the [**Name (NI) **], pt AF, BP 97/49, HR 61. Rectal exam significant only for small amounts of dried blood in the vault, NGL was negative. Labs were significant for WBC 15.2, Hct 43.5, BUN 31, Cr 2.0, lactate 1.4, and INR 17.1. A CT abd/pelvis was significant for pancolitis. She was given 2 units FFP, 10 mg IV vitamin K, protonix 40 IV X 1, levaquin 750 mg IV X 1, flagyl 500 mg IV X 1, and a total of 3 L IVFs. Repeat INR 2.6. She remained hemodynamically stable and did not have any episodes of BRBPR in the ED in spite of having several BMs. She was then admitted to the [**Hospital Unit Name 153**] for further management. . ROS otherwise only positive for stable DOE. She is unable to walk up a flight of stairs without becoming signicantly winded. ROS otherwise negative. . Past Medical History: PAF on coumadin HTN (baseline BP 140/70s) h/o CHF (EF 20% in [**2126**], TTE in [**2-25**] with nl EF) mod MR [**First Name (Titles) **] [**Last Name (Titles) **] s/p PPM [**2-20**] syncope in [**2117**], s/p dual chamber PPM replacement in [**10-26**] Melanoma s/p resection Asthma Depression Breast cancer 5 years ago, s/p R lumpectomy and XRT, s/p L lumpectomy in early 90's 4 yrs ago that was negative Pancreatic lesion, reportedly extensively worked up 4 yrs ago that was negative, stable lesion on serial CTs Post granulomatous infection of liver and spleen Seasonal allergies Gout Social History: Lives at home with son. [**Name (NI) **] smoking, alcohol, no drug use. Family History: father with [**Name2 (NI) 499**] CA Physical Exam: VS: Temp: 98.9 BP: 145/45 HR: 64 RR: 22 O2sat 100% on 2L NC GEN: pleasant, comfortable, NAD HEENT: PERRL, EOMI, anicteric, dry MM, op without lesions NECK: supple, no LAD, jvd flat RESP: + bibasilar rales that clear with deeper breaths CV: RR, II/VI holosystolic murmur radiating to apex ABD: Soft, diffusely TTP especially over LLQ, + guarding, + rebound, normoactive BS, no HSM EXT: no c/c/e, warm, good pulses SKIN: no rashes/no jaundice NEURO: AAOx3 RECTAL: guaiac positive, dried blood in vault Pertinent Results: [**2134-2-2**] 04:35PM GLUCOSE-95 UREA N-31* CREAT-2.0* SODIUM-136 POTASSIUM-3.9 CHLORIDE-100 TOTAL CO2-26 ANION GAP-14 [**2134-2-2**] 04:35PM CALCIUM-8.4 PHOSPHATE-3.8 MAGNESIUM-2.4 [**2134-2-2**] 04:35PM ALT(SGPT)-21 AST(SGOT)-35 LD(LDH)-370* AMYLASE-71 TOT BILI-0.4 LIPASE-88* . [**2134-2-2**] 11:57PM LACTATE-1.0 [**2134-2-2**] 07:00PM LACTATE-1.4 . Brief Hospital Course: # Bright red blood per rectum- Evidence of pancolitis on initial CT, stool studies significant for c diff colitis. Bleeding stopped once INR was corrected. GI was consulted and suggest a colonoscopy in about 4 weeks, after colitis has had time to improve. Follow up scheduled with GI, VNA to check INR and hct 3 times per week. . # C Difficile colitis: Diarrhea improved on Flagyl, planned 14 day course. . # Supratherapeutic INR: Coumadin restarted prior to discharge without GI bleed. She was discharged on approx [**1-20**] the dose of coumadin she was on prior to admission. VNA to check INR 3 times per week. Nutritionist saw pt to eduated re: food restrictions while on coumadin. . # Falls/imbalance- Patient had a fall while in the [**Hospital Ward Name 332**] ICU overnight, and hit her head (likely on an open cabinet door adjacent to the toilet), requiring 3 stitches for a laceration. A CT head was obtained immediately after and showed no acute hemorrhage. There had been no significant events on telemetry and no indication of pacemaker malfunction. A CT spine was obtained and the read showed no fracture, and her C-spine was cleared. Approximately 12 hours later, a nurse observed the patient to be extremely unsteady on her feet, somewhat tremulous, and not as easily conversant as prior. A second CT head was obtained and was negative for edema or new subdural. The patient was observed overnight on fall precautions and there were no further events, and her mental status was at baseline. The attending radiologist later re-read the C-spine study and notified the team that there was possible cervical cord compression. . # Cervical Cord compression w/o radiculopathy: Possible C6-C7 cord compression based on CT cervical spine. No associated neurologic deficits. Neurosurgery was consulted and recommended myelogram for further assessment. The family and patient chose not to have the CT myelogram done. They stated that they would never opt for surgery, and if that was the only recommendation to come out of CT myelogram, they felt there was no use for the study. Neurosurgery team confirmed this was in fact the case. Family is aware that if symptoms develop, falls increase from weakness, or any other concerns for symptomatic cord compression, and they should see PCP immediately to discuss CT myelogram and possible decompressive surgery. . #CKD, stage III: Pt in ARF at admission, resolved to baseline creatinine of 1.3 . #Chronic systolic heart failure: Past EF 20% per family, however recent echo in [**2133**] with EF > 60%. Pt was continued on isosorbide, metoprolol, lasix. Lisinopril was held as pt noticed that she had a chronic cough that had resolved during the hospitalization while off of Lisinopril. Plan is to hold off on restarting, note any cough symptoms at home, and follow up with PCP [**Last Name (NamePattern4) **] 2 weeks to discuss whether Lisinopril could in fact be cause of cough. Also will need to discuss whether alternative [**Last Name (un) **] needed. Digoxin was held at request of family. No recent CHF exacerbations, most recent EF >60%, and pacer interrogations show atrial fibrillation despite therapuetic digoxin levels. They asked to stop this because they were concerned that it may be the cause of the patients chronic diarrhea. They are aware that they will need to follow up with cardiologist Dr. [**Last Name (STitle) **] regarding need to restart digoxin. Medications on Admission: ASA 81 mg daily Coumadin 4 mg daily Zestril 10 mg daily Lopressor 25 mg [**Hospital1 **] Digoxin 125 mcg daily Isosorbide dinitrate 20 mg [**Hospital1 **] Lasix 40 mg qod, 20 mg qod Singulair 10 mg daily Prednisone 10 mg prn (for gout flares) [**Doctor First Name **] 60 mg [**Hospital1 **] Advair 250/50 1 puff [**Hospital1 **] Allopurinol 150 mg daily Celexa 20 mg daily Omeprazole 20 mg daily Caltrate daily . Discharge Medications: 1. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 9 days. Disp:*27 Tablet(s)* Refills:*0* 2. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 3. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 4. Warfarin 2 mg Tablet Sig: One (1) Tablet PO DAILY16 (Once Daily at 16). Disp:*30 Tablet(s)* Refills:*0* 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Isosorbide Dinitrate 20 mg Tablet Sig: One (1) Tablet PO twice a day. 7. Lasix 40 mg Tablet Sig: One (1) Tablet PO every other day. 8. Lasix 20 mg Tablet Sig: One (1) Tablet PO every other day. 9. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. Fexofenadine 60 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 11. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 12. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 13. Omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 14. DISCONTINUED MEDICATIONS STOP TAKING DIGOXIN AND LISINOPRIL UNTIL YOU SEE DR. [**Last Name (STitle) **]. 15. INR checks Please check INR and Hct 3 times per week for the next 2 weeks. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: c difficile colitis acute renal failure (now resolved) Discharge Condition: stable Discharge Instructions: Please call your PCP with shortness of breath, weight gain of more than 2 pounds in one day, dizziness, blood in stool, or other concerning symptoms. Followup Instructions: Please be sure to go to the appointment scheduled [**3-2**] at 1:50 Dr. [**Last Name (STitle) 6680**]. Call the day before to confirm time. Your next check of the pacer has been re-scheduled for [**Month (only) 205**]. Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2134-8-12**] 8:30 An appointment has been made for you to see Dr. [**Name (NI) 9890**] of gastroenterology on [**2-19**] at 9:30 am in [**Hospital Unit Name 1825**] rm 101, [**Hospital Ward Name **] (same builcing as during hospitalization). At that time, the doctor will determine when the colonoscopy can be done. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 1677**] Completed by:[**2134-2-9**]

[ "V45.01", "403.90", "873.8", "276.51", "585.9", "V10.3", "280.0", "008.45", "427.31", "428.22", "578.9", "584.9", "V10.82", "274.9", "428.0", "E888.9" ]

icd9cm

[ [ [] ] ]

[ "86.59" ]

icd9pcs

[ [ [] ] ]

9085, 9142

3866, 7307

276, 279

9241, 9250

3477, 3843

9448, 10230

2904, 2941

7771, 9062

9163, 9220

7333, 7748

9274, 9425

2956, 3458

221, 238

307, 2187

2209, 2799

2815, 2888

63,311

180,102

34749

Discharge summary

report

Admission Date: [**2151-8-6**] Discharge Date: [**2151-8-9**] Date of Birth: [**2102-6-4**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2745**] Chief Complaint: Transfer from [**Hospital3 417**] with GI bleed Major Surgical or Invasive Procedure: Ileoscopy History of Present Illness: Mr. [**Known firstname **] [**Known lastname **] is a 49 year old male with a longstanding history of Crohn's disease s/p total colectomy and ileostomy who presented to [**Hospital3 417**] hospital on [**8-5**] after noting watery maroon stool with clots in ileostomy bag. He did not have any associated abdominal pain, nausea, vomiting, diarrhea, fever, chills or dysuria. He presented to the Emergency Department after discussing his symptoms with his gastroenterologist. Hemoglobin at the time of admission was 15.1, hematocrit 43.5. Remainder of labs were within normal limits. A CT scan of the abdomen was done which showed no acute pathology. He continued to pass large amounts of dark blood from his ileostomy bag. He was admitted to a general medical floor however shortly after arrival he was noted to be pale and tachycardic. Orthostatics were positive - SBP 112 to 90, HR 112 to 130. He was transferred to the ICU. He had negative NG lavage. He was seen by GI and underwent EGD/ileoscopy which was negative for bleeding source. Ileoscopy noted old erosions in the distal ileum however no bleeding source. He is being transferred to [**Hospital1 18**] for angiography and possible embolization which is unavailable at OSH. He had been treated with stress dose steroids. Of note the patient is reportedly a difficult type and cross, + antibodies on screen. s/p 1U PRBC at OSH. . On arrival to the [**Hospital Unit Name 153**] the patient is feeling well. He has no complaints and says that he has not been symptomatic at any point during this episode. He denies lightheadedness or dizziness both at rest and with change of position. He has no abdominal pain, shortness of breath, chest pain, palpitations. Past Medical History: Crohn's disease diagnosed as teenager. s/p total colectomy and ileostomy. Hypertension Osteoporosis secondary to steroid use History of DVT during a hospitalization. Social History: The patient works as an accountant. He does not smoke cigarettes. He does not drink alcohol. He lives alone. He walks and rides a bike for exercise. Family History: The patient's mother died of metastatic colon cancer (did not have Crohn's disease). There is a strong history of colon cancer in his mother's side of the family. Father lived into his 80s with Alzheimer's disease. Physical Exam: Vitals: T 98.4, BP 126/97, HR 96-98, RR 13-18, O2sat 100% on 2L NC Gen: Pale male in no acute distress HEENT: Normocephalic, atraumatic. PERRL. OP clear. dry MM. Neck: Supple. No JVD CV: Regular rate and rhythm, nl s1 s2, no m/r/g appreciated. Pulm: Clear bilaterally. Abd: Soft, NT, ND, +BS. Ileostomy in place. Multiple abdominal scars. Ext: No edema. 2+ DP pulses. Neuro: A&Ox3. Pertinent Results: [**2151-8-6**] 07:35PM PT-14.6* PTT-33.3 INR(PT)-1.3* [**2151-8-6**] 07:35PM PLT COUNT-141* [**2151-8-6**] 07:35PM NEUTS-85.0* LYMPHS-9.6* MONOS-4.8 EOS-0.3 BASOS-0.2 [**2151-8-6**] 07:35PM WBC-5.2 RBC-2.31* HGB-7.2* HCT-20.9* MCV-91 MCH-31.3 MCHC-34.6 RDW-14.2 [**2151-8-6**] 07:35PM ALBUMIN-2.5* CALCIUM-6.0* PHOSPHATE-2.6* MAGNESIUM-1.4* [**2151-8-6**] 07:35PM estGFR-Using this [**2151-8-6**] 07:35PM GLUCOSE-92 UREA N-7 CREAT-0.5 SODIUM-141 POTASSIUM-3.2* CHLORIDE-116* TOTAL CO2-20* ANION GAP-8 Brief Hospital Course: The patient was transferred to the [**Hospital Unit Name 153**] from an outside hospital due to an occult GI bleed from his ileostomy. His Hct was at 21 upon arrival and subsequently received 4 units of PRBC's, bumping his Hct up to 29 (he was a difficult type and cross). He then underwent an ileoscopy, where a bleeding distal ileal ulcer was found 40 cm proximal to the ileostomy. The ulcer was administered epinephrine and was clipped. His Hct's have subsequently been stable between 29 and 34, he was placed on home medications, is eating a regular cardiac diet. Patient had no further bleeding with a stable hct while on the medical service. Patient discharged on protonix 40 mg po bid, his prior Crohns disease regimen and instructed to stop taking his fosamax until discussion with his appt with outpt GI. Medications on Admission: Encort 6mg PO daily Pentasa 500mg (ten tabs daily) Atenolol 50mg daily Fosamax q week. Multivitamin with iron supplementation Calcium supplementation Discharge Medications: 1. Mesalamine 250 mg Capsule, Sustained Release Sig: Three (3) Capsule, Sustained Release PO BID (2 times a day). 2. Mesalamine 250 mg Capsule, Sustained Release Sig: Four (4) Capsule, Sustained Release PO HS (at bedtime). 3. Atenolol 50 mg Tablet Sig: One (1) Tablet PO once a day. 4. Budesonide 3 mg Capsule, Sust. Release 24 hr Sig: Two (2) Capsule, Sust. Release 24 hr PO once a day. 5. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 6. Clonazepam 0.5 mg Tablet Sig: unknown Tablet PO twice a day as needed: Patient to take outpt clonazepam dose. Pt did not know dose. Dose above is not correct. 7. Potassium & Sodium Phosphates [**Telephone/Fax (3) 4228**] mg Powder in Packet Sig: Two (2) Powder in Packet PO TID (3 times a day) for 3 days. Disp:*18 Powder in Packet(s)* Refills:*0* 8. Multivitamin Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 9. immodium Sig: One (1) three times a day as needed. 10. Citracal + D 250-200 mg-unit Tablet Sig: One (1) Tablet PO twice a day. 11. Tylenol 325 mg Tablet Sig: Two (2) Tablet PO four times a day as needed for pain. Discharge Disposition: Home Discharge Diagnosis: Upper GI Bleed Small Bowel Anastomosis Ulcer with Visible Vessel s/p cautery and clippingx2 Crohns Disease Anxiety HTN DVT Discharge Condition: Vital Signs Stable Discharge Instructions: Return if having red blood or dark black blood in ostomy output, light-headness, significant fatigue, shortness of breath. Followup Instructions: Patient to schedule GI f/u appt with outpatient gastroenterologist in 2 weeks. Patient to schedule f/u with PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 487**] [**Last Name (NamePattern1) 1603**] in 2 weeks.

[ "V58.65", "401.9", "V12.51", "V44.2", "E932.0", "733.09", "E849.0", "555.0", "300.00", "427.89", "V16.0" ]

icd9cm

[ [ [] ] ]

[ "45.13", "39.98", "00.17", "99.04" ]

icd9pcs

[ [ [] ] ]

5924, 5930

3661, 4479

360, 371

6096, 6116

3122, 3638

6287, 6520

2488, 2704

4680, 5901

5951, 6075

4505, 4657

6140, 6264

2719, 3103

273, 322

399, 2116

2138, 2306

2322, 2472

16,656

157,031

12171

Discharge summary

report

Admission Date: [**2195-1-6**] Discharge Date: [**2195-1-8**] Date of Birth: [**2135-4-18**] Sex: M HISTORY OF PRESENT ILLNESS: This is a 59-year-old right-handed man who presented to the Emergency Room after having an episode were essentially after driving in his car he had the acute onset of left arm weakness which over the course of approximately half an hour. He was brought to the Emergency Room for further evaluation. At that time he was admitted to Neurology for further evaluation. In the Emergency Department he was felt to have an acute was treated with intravenous t-PA. Afterwards, the patient's deficits appeared to improve slowly during the course of the following few hours. THe patient also received intravenous magnesium for 24 hours. PAST MEDICAL HISTORY: Past medical history is significant for pulmonary fibrosis with a current workup in progress and hypertension. PAST SURGICAL HISTORY: None known. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: None. HOSPITAL COURSE: The patient was admitted to Neurology for further workup. A carotid ultrasound was done which showed normal flow in both internal and external carotids. He also had an echocardiogram performed which was normal. Initial imaging of his magnetic resonance imaging and magnetic resonance angiography showed no lesion, and DWI was negative on his follow-up study magnetic resonance imaging performed on [**2195-1-8**]. He had no lesions on DWI or T2. The patient's examination continued to improve, and his deficits resolved during the course of his stay; largely within the first few hours following his presentation in the Emergency Department. PHYSICAL EXAMINATION ON DISCHARGE: The patient was awake, alert and oriented, and in no acute distress. Lungs were clear to auscultation bilaterally. Cardiac examination revealed a regular rate and rhythm. The abdomen was soft, nontender, and nondistended. Extremities were warm and well perfused. On neurologic examination, the patient was alert and oriented times three. He had normal speech that was fluent without any paraphasic errors and with normal pronunciation in Spanish. He performed months of the year backwards easily and was able to recount a coherent history. On cranial nerve examination, his pupils were equally round and reactive to light. Extraocular movements were intact. Visual fields were full to confrontation. Facial movements were symmetric. Tongue and palate were midline. Trapezius and sternocleidomastoid strength were full. On motor examination, he had 5/5 strength throughout all upper extremity musculatures as well as lower extremities. There was no evidence of any drift. The sensory examination was normal; with regard to pinprick, light touch, vibratory, and position sense. There was no extinction present. Deep tendon reflexes were slightly brisker in his left compared to his right arm; otherwise, symmetric. He had a normal gait and normal coordination with finger-nose-finger and rapid finger movements. MEDICATIONS ON DISCHARGE: Aspirin 325 mg p.o. q.d. DISCHARGE FOLLOWUP: The patient was to follow up in the [**Hospital 4038**] Clinic with Dr. [**First Name (STitle) 36006**] [**Name (STitle) 35880**] on [**2195-1-18**] at 1 p.m (that is a wrong date). The patient also had a referral made for a primary care physician in order to follow him for other medical issues. CONDITION AT DISCHARGE: The patient was discharged in good condition on [**2195-1-8**]. DISCHARGE STATUS: To home. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 13-279 Dictated By:[**Last Name (NamePattern1) 38109**] MEDQUIST36 D: [**2195-1-8**] 17:13 T: [**2195-1-8**] 18:13 JOB#: [**Job Number **]

[ "342.90", "434.91", "515" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

3083, 3109

1018, 1025

1044, 1712

940, 991

3454, 3777

1727, 3055

3131, 3439

149, 780

804, 916

8,324

168,931

52231

Discharge summary

report

Admission Date: [**2101-7-17**] Discharge Date: [**2101-8-5**] Date of Birth: [**2021-2-6**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1572**] Chief Complaint: unresponsiveness Major Surgical or Invasive Procedure: Left thoracentesis History of Present Illness: 80 y.o. male with hx CAD, s/p CABG, ischemic CM EF 20%, ICD & pacemaker discharged 1 month ago after undergoing VT ablation. . His wife states she looked at him tonight while he was sleeping and noted he had a gasping, labored breathing. She tried to wake him up but he was unresponsive. There were no signs of t-c seizures or fecal incontinece. She called EMS who arrived 20 minutes later. Patient was alert but somnolent and diaphoretic at that time. Patient is unsure whether pacemaker went off. . Found to be hypokalemic and started repletion in ED. ICD fired once night of admission and once later that morning (in ED) for VTach -> NSR. Past Medical History: 1. CAD status post CABG and IMI. Catheterization in '[**88**] with 3 VD, 2+ MR, moderate systolic and diastolic dysfunction. PTCA of SVG to PDA, MIBI in '[**91**], severe fixed defect infero, post, and apical. Partial reversible inferolateral defects. 2. Esophageal stricture x2. 3. Increased cholesterol. 4. Colonic polyps. 5. Abdominal aortic aneurysm s/p repair at [**Hospital1 2025**] in [**2099**]. 6. Hypertension. 7. Pacemaker placed prior to AAA repair - being checked monthly by Dr.[**Name (NI) 15419**] office. 8. Status post bilateral cataract surgery. 9. Ischemic CMY (echo [**2098**] EF 20% 1-2+ MR) 10. Gout 11. Chronic renal insufficiency (recent baseline unknown - no labs since [**2098**]) Social History: Retired shipyard inspector. He quit smoking over 50 years ago. Denies alcohol or drugs. Lives with his wife and son. Family History: Non-Contributory Physical Exam: T 96.7 BP 104/64 HR 70 RR 18 Sat 97% on 2L Gen: comfortable, elderly cachectic man in NAD Neck: JVP at clavicles while sitting at 30 degrees CV: reg rate, II/VI systolic murmur at apex Chest: faint crackles at both lung bases; clear in middle and at apices Abd: soft, ntnd, no organomegaly Extr: cool, no edema, 2+ DP and PT pulses Pertinent Results: [**2101-7-17**] 12:45AM BLOOD WBC-13.3* RBC-3.17* Hgb-9.9* Hct-29.0* MCV-91 MCH-31.1 MCHC-34.1 RDW-14.4 Plt Ct-321# [**2101-8-4**] 06:35AM BLOOD WBC-20.2* RBC-3.99* Hgb-11.6* Hct-37.0* MCV-93 MCH-29.0 MCHC-31.2 RDW-16.0* Plt Ct-240 [**2101-7-17**] 12:45AM BLOOD Neuts-75.8* Lymphs-18.7 Monos-3.4 Eos-1.9 Baso-0.2 [**2101-7-28**] 06:25AM BLOOD Neuts-89.7* Lymphs-6.1* Monos-3.5 Eos-0.5 Baso-0.2 [**2101-7-17**] 12:45AM BLOOD PT-26.8* PTT-31.9 INR(PT)-2.7* [**2101-7-20**] 04:58PM BLOOD PT-38.4* PTT-50.9* INR(PT)-6.0* [**2101-8-4**] 06:35AM BLOOD PT-21.4* PTT-35.7* INR(PT)-2.1* [**2101-7-17**] 12:45AM BLOOD Glucose-186* UreaN-35* Creat-2.5* Na-139 K-2.7* Cl-100 HCO3-23 AnGap-19 [**2101-8-4**] 12:35PM BLOOD Glucose-119* UreaN-97* Creat-3.6* Na-145 K-4.4 Cl-109* HCO3-21* AnGap-19 [**2101-7-17**] 12:45AM BLOOD ALT-37 AST-63* CK(CPK)-26* AlkPhos-288* Amylase-50 TotBili-1.0 [**2101-8-4**] 06:35AM BLOOD ALT-30 AST-55* AlkPhos-273* TotBili-4.7* [**2101-7-17**] 12:45AM BLOOD CK-MB-NotDone cTropnT-0.05* [**2101-7-17**] 07:40AM BLOOD CK-MB-2 cTropnT-.11* [**2101-7-17**] 03:24PM BLOOD CK-MB-NotDone cTropnT-0.08* [**2101-8-3**] 05:25AM BLOOD proBNP-[**Numeric Identifier 108040**]* . Radiology CT Abdomen: FINDINGS: The evaluation of the great vessels and mediastinum is somewhat limited due to lack of intravenous contrast [**Doctor Last Name 360**]. No significant mediastinal lymphadenopathy is noted. Coronary arteries are calcified. The heart is enlarged in size. The patient is status post CABG with median sternotomy. Note is made of bilateral pleural effusion, somewhat larger on the left, partially loculated. There is interlobar effusion on the left as well. In the lung window, note is made of diffuse ground-glass opacity with interlobular septal thickening predominantly in central distribution involving upper lobes, as well as lower lobes and middle lobes. There is somewhat focal patchy opacity in right middle lobe and lower lobes. Mucous secretion in the trachea is seen, however, no central obstructing lesion is noted. NG tube is noted, with the tip terminating in the stomach. There is no suspicious lytic or blastic lesion. Small bone islands are seen in lower thoracic vertebra. IMPRESSION: 1. Moderate amount of pleural effusion, larger on the left and somewhat loculated on the left, associated with basilar atelectasis. Interlobar effusion on the left. 2. Diffuse ground-glass opacity predominantly in central distribution, associated with smooth interlobular septal thickening bilaterally involving upper and lower lobes. The finding may represent pulmonary edema as mentioned in the report of prior chest radiograph, however, in the appropriate clinical setting, superimposed infection cannot be excluded. Other possibility includes alveolar hemorrhage if the patient has hemoptysis. Please correlate clinically. 3. Patchy opacities in the right middle and lower lobes, which may be part of diffuse process mentioned in #2, however, please perform followup study after effusion and ground-glass opacities have resolved. 4. Cardiomegaly, status post CABG and coronary artery calcification. . Echocardiogram: Conclusions: The left atrium is moderately dilated. The right atrium is moderately dilated. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. There is severe global left ventricular hypokinesis (ejection fraction 20-30 percent). No masses or thrombi are seen in the left ventricle. There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The aortic 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. Moderate to severe (3+) mitral regurgitation is seen. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2101-2-16**], no major change is evident. Brief Hospital Course: The patient expired on [**2101-8-5**] after a prolonged hospitalization. I will briefly outline his medical problems leading up to his death. . # Syncope: Patient came in to the hospital secondary to being found unresponsive by his wife. A head CT on admission ruled out an intracranial bleed and his potassium was closely monitored. In the emergency department they noted 15-20 beats of VTach and also a potassium of 2.7. It was thought that his VTach was the cause of his syncopal episode and his hypokalemia was the cause of his VTach. His potassium was repleted and he no longer experienced problems with pacing. . # CHF: EF 20% - patient came in appearing euvolemic or even slightly dry. He was kept off his spironolactone, his lasix was initially held and his [**Last Name (un) **] and BB were continued. His fluid status was monitored daily with serial exams and he had multiple chest xrays to monitor for fluid overload. He subsequently became fluid overload which prompted a visit to the medical ICU. While in the ICU, they tapped a pleural effusion on his left side which yielded 1.5L of transudative fluid. They also gave him gentle diuresis with lasix 10 mg IV. The patient subsequently became euvolemic and was transferred back to the floor. A day later, he became hypovolemic with a free water deficit of 3L. We replaced his fluid deficit appropriately but struggled with deteriorating respiratory status. . # CRI: patient has had a baseline creatinine of 2.0 and had been increasing over the last month. His creatinine on admission was 2.5 and it climbed to 3.5 by the end of his stay. We initially held his [**Last Name (un) **] and ACE inhibitor and involved renal in his care. It was thought that his renal impairment was secondary to both ATN from ischemic injury during his VTach but also from prerenal azotemia. We balanced his fluid status with his CHF and attempted unsuccessfully to preserve his renal function. . # Nutrition: Patient had poor PO intake during the admission so an NGT was placed for tube feeds. He tolerated the procedure well and was given low volume tube feeds with minimal flushing. Once his sodium began to rise, we increased the flushing volumes in an attempt to correct his volume status. . # Odynophagia: The etiology behind this wasn't clear. The patient developed throat pain in the middle of his admission. We sent multiple cultures and even had a biopsy performed of his posterior oropharynx. The cultures only yielded MSSA and GNR which we treated with antibiotics. We had suspected HSV, [**Female First Name (un) **], viral, bacterial and involved ID, GI, and ENT. The pain was resolving when patient expired. . # Leukocytosis: present at admission without any fever or identifying source. Initially thought to be secondary to inflammatory state. However, the differential showed 88% PMNs. We began antibiotic treatment for coverage of the MSSA and GNR described above yet his leukocytosis persisted. On the day of death, the patient had an even higher WBC. . # Coagulopathy: patient had been taking coumadin at home and his INR rose during the beginning of his admission. Initially it was 2.7 but gradually it rose to 6.4. We continued to hold his coumadin and encouraged patient to eat leafy vegetables. We believe that the significant rise of his INR was secondary to the increasing dosages of amiodarone the patient had received. It had returned to below 1.5 prior to thoracentesis but again climbed prior to his death. . # Cardiovascular- Coronaries: We continued the patient on BB, statin, aspirin and monitored for any signs or sx of chest pain. The patient had a workup for ACS upon arrival which was negative. . ### Events leading up to death: Patient returned from the medical ICU and was doing well on 60% O2. This was weaned over the next day and a half and the patient was oriented to person, place, situation, time. However, the patient gradually became more disoriented and his mental status was waxing and waining. We had considered infectious, medications, hypoxia, renal failure, hypercarbia, and hypernatremia in our differential. The patient was weaned from O2 so we thought hypoxia unlikely. Additionally, we obtained a VBG which suggested he was not hypercarbic. We broadened his abx coverage for anaerobes with flagyl as he had developed abdominal pain the day prior to death. As he was clearly deteriorating, we had a family meeting the day prior to his death to discuss code status. At that time the family decided to change his code to DNR/DNI with thoughts of CMO if he worsened. That night, he became hypotensive to the 60s systolic. Aggressive fluid boluses were delivered (4 liters) without much improvement. The family was called and were present as the patient was undergoing fluid resuscitation. After attempts were seemingly unsuccessful, they decided to stop providing fluid and the patient expired shortly thereafter. No autopsy was requested. Medications on Admission: simvastatin 20mg daily allopurinol 100mg QOD digoxin 0.125mg QOD valsartan 40mg daily metoprolol 50mg [**Hospital1 **] warfarin 2.5mg daily niacin 500mg [**Hospital1 **] lasix 10mg QOD amiodarone 200mg daily kayexelate [**Hospital1 **] Discharge Medications: none Discharge Disposition: Home Discharge Diagnosis: CHF Respiratory failure acute renal failure delirium hypotension Discharge Condition: expired Discharge Instructions: none Followup Instructions: none

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icd9cm

[ [ [] ] ]

[ "29.12", "34.91", "93.90", "96.6" ]

icd9pcs

[ [ [] ] ]

11604, 11610

6315, 11289

338, 358

11718, 11727

2302, 6292

11780, 11787

1913, 1931

11575, 11581

11631, 11697

11315, 11552

11751, 11757

1946, 2283

282, 300

386, 1031

1053, 1762

1778, 1897

15,347

134,311

46172

Discharge summary

report

Admission Date: [**2119-2-28**] Discharge Date: [**2119-3-3**] Service: MEDICINE Allergies: Erythromycin Base / Metoprolol Tartrate / Keflex Attending:[**First Name3 (LF) 1974**] Chief Complaint: Shortness of breath Major Surgical or Invasive Procedure: none. History of Present Illness: 89 year old female with history CHF(EF 40%), MI([**12-18**]- medically managed), chronic hyponatremia who presents from nursing home with hypotension, hypoxia, and progressive cough x 2 weeks. No clear history of aspiration, but pt eats pureed food. No fever/chills, 88% on RA at nursing home, 89% on RA on arrival to ED, 99% on 3L NC. In ED afebrile, BP initially 99/60, dropped to 79/50, improved to 106/70 with 2L NS bolus. Patient CXR was consitent with pulmonary edema. She was given dose of levofloxacin, cefepime, and clinda for possible aspiration PNA. She uderwent CTA chest in the ED which showed multiple segmental and subsegmental pulmonary emboli in the bilateral lower lobes and patient was started on IV heparin and admitted to the ICU. Also in the ED patient was noted to be hyponatremic with Na of 122, her Na on previous admission has been ranged from 122-128. Cortisol was sent in the ED. . ROS: Denies any HA, chest pain, currently no SOB, denies any abdominal pain. Patient states she feels weak. Admits to recent weight loss. States her heels hurt her. Past Medical History: Hypertension S/P hysterectomy Iron deficiency anemia Basal cell carcinomas (largest on scalp; patient refuses to have treated per PCP) Recent MI [**12-18**] medically managed CHF most recent echo with LVEF 40% Critical AS: Peak velocity 4.0 and valve area of 0.5 Rectal mass (no workup) Social History: Pt previously lived alone but most recently from rehab. Nephew is HCP. She does not smoke or drink alcohol. She previously [**First Name8 (NamePattern2) 98190**] [**Last Name (NamePattern1) 23081**]. The patient does not have any family; her nephew does not see her often. She has no children. Family History: Noncontributory Physical Exam: Docusate Sodium 100 mg PO BID Aspirin 325 mg PO DAILY Lisinopril 5 mg PO DAILY Senna 8.6 mg PO BID Bisacodyl 5 mg PO DAILY prn Furosemide 40 mg PO DAILY Atenolol 25 mg PO DAILY Omeprazole 20mg daily MVI Zinc sulfate Vit C KCL 20meq daily Pertinent Results: [**2119-2-28**] 04:15PM WBC-10.9# RBC-4.03* HGB-11.4* HCT-35.0* MCV-87 MCH-28.2 MCHC-32.5 RDW-14.3 [**2119-2-28**] 04:15PM NEUTS-94.3* BANDS-0 LYMPHS-3.3* MONOS-1.9* EOS-0.2 BASOS-0.3 [**2119-2-28**] 04:15PM PLT SMR-NORMAL PLT COUNT-355# [**2119-2-28**] 10:27PM CK-MB-3 cTropnT-0.03* [**2119-2-28**] 04:15PM GLUCOSE-134* UREA N-24* CREAT-0.9 SODIUM-122* POTASSIUM-6.6* CHLORIDE-91* TOTAL CO2-27 ANION GAP-11 . CHEST CT: 1. Multiple segmental and subsegmental pulmonary emboli in the lower lobes bilaterally. 2. Diffuse small pulmonary nodules, most conspicuous in the lower lobes. Some are relatively ill defined, but others are well circumscribed. Differential considerations include neoplastic, infectious, and inflammatory etiologies. Followup with chest CT in [**2-20**] months time after acute symptoms resolve would be standard. Index of suspicion for underlying malignancy should guide the decision on the time interval to rescan. 3. More organized areas of consolidation, particularly in the right lower lobe could represent focal areas of infection, but peripheral consolidations in the left lower lobe could also represent infarction associated with pulmonary emboli. 4. Small bilateral pleural effusions. 5. Extensive vascular calcifications in the coronary arteries and mitral and aortic valves. 6. Moderate hiatal hernia. 7. Left kidney cysts, one of which appears hyperdense. These are incompletely imaged on this study. Furhter evaluation with ultrasound may be pursued if indicated. . ECG: Sinus rhythm Atrial premature complex Left anterior fascicular block Probable left ventricular hypertrophy Delayed R wave progression - may be left ventricular hypertrophy or possible prior anterior myocardial infarction ST-T wave abnormalities - could be left ventricular hypertrophy Clinical correlation is suggested Since previous tracing of [**2119-1-15**], no significant change Brief Hospital Course: 1) Hypoxia: The patient has multiple subsegmental PEs seen on CTA last night. However, as she improved so much in only 18 hours (did receive heparin drip), it is unlikely that PEs were causing symptoms. After discussion between ICU team and HCP, it was decided not to continue anticoagulation given risks (ie known rectal mass). Aspiration PNA was also likely contributing to her hypoxia as there was some evidence of consolidation on chest CT. She was initially on abx, then stopped, but restarted with levaquin upon review of this CT. Though CHF may have been a small part of her hypoxia, given that her hypoxia resolved without diuresis, this is less likely. . In addition, chest CT showed multiple pulmonary nodules which had a broad ddx. Although malignancy is possible, since pt does not want any further workup, this can be followed with serial imaging in [**2-14**] months. . 2) Hypotension: Patient noted to be hypotensive in nursing home and ED, she responded well to IVF. Hypotension likely from volume depletion as she responded well to IVF overnight. Other etiology of hypotension could be from PE but this is unlikely given patient does not appear to have large central PE on CT scan. Cortisol levels normal so unlikely to be adrenally insufficient. Her anti HTN will need to be slowly restarted. . 3) Hyponatremia: Patient with chronic hyponatremia. On previous admission her Na was 122 and improved to 128 after diuresis, felt hyponatremia secondary to volume overload. On this admission, sodium improved with IVF so likely hypovolemic component. Stabilized around 127 to 128 which is her baseline. . 4) Cardiac; Patient with recent STEMI in [**12-18**] that was medically managed. Also patient with CHF and LVEF of 40%. Continued aspirin 325mg. Once hypotension resolved, restarted beta blocker at low dose atenolol 12.5 mg daily. As BP held stable, furosemide also restarted. She did not have any significant clinical volume overload though BNP was elevated. ACE-I held as was hyperkalemic but will need to be restarted in next several days if BP remains stable and hyperkalemia resovles. . 4) Pressure Ulcers: Wound care for ulcer on RLE, waffle boots for heels sores. . 5) FEN: Patient evaluated in past by speech and swallow, Pureed diet, pills whole with thin liquids. Fluid restrict given CHF. Hyperkalemic to 5.4--this will decrease as lasix is restarted. K should be checked every 1-2 days for next several days. . 6) Code: DNI/DNR, has been confirmed by patient Medications on Admission: Docusate Sodium 100 mg PO BID Aspirin 325 mg PO DAILY Lisinopril 5 mg PO DAILY Senna 8.6 mg PO BID Bisacodyl 5 mg PO DAILY prn Furosemide 40 mg PO DAILY Atenolol 25 mg PO DAILY Omeprazole 20mg MVI Zinc sulfate Vit C KCL 20meq daily Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid [**Date Range **]: One Hundred (100) mg PO BID (2 times a day). 2. Senna 8.6 mg Tablet [**Date Range **]: One (1) Tablet PO BID (2 times a day) as needed. 3. Aspirin 325 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily). 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Date Range **]: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 5. Atenolol 25 mg Tablet [**Date Range **]: 0.5 Tablet PO DAILY (Daily). 6. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 7. Levofloxacin 500 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q24H (every 24 hours) for 3 days. 8. Atorvastatin 10 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 9. Furosemide 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 10. Multi-Vitamin Tablet [**Last Name (STitle) **]: One (1) Tablet PO once a day. 11. Zinc Sulfate Oral Discharge Disposition: Extended Care Facility: On [**Location (un) **] - [**Location (un) **] Discharge Diagnosis: PRIMARY: 1) Chronic PEs 2) Pneumonia 3) CHF SECONDARY: 1) Aortic stenosis 2) CAD 3) Chronic hyponatremia Discharge Condition: Good. Discharge Instructions: 1. Take medications as prescribed. 2. Follow up as below. 3. Please call Dr. [**Last Name (STitle) 1683**] if you have fevers, chills, worsening breathing, or any other symptoms that concern you. Followup Instructions: Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) 2352**] [**Last Name (NamePattern1) 2352**] - ADULT MEDICINE (SB) Date/Time:[**2119-4-5**] 10:30

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

8079, 8152

4245, 6748

275, 283

8302, 8310

2320, 4222

8557, 8720

2028, 2045

7031, 8056

8173, 8281

6774, 7008

8334, 8534

2060, 2301

216, 237

311, 1388

1410, 1699

1715, 2012

48,885

167,609

37440

Discharge summary

report

Admission Date: [**2113-2-7**] Discharge Date: [**2113-2-17**] Date of Birth: [**2056-11-26**] Sex: F Service: MEDICINE Allergies: Morphine / Sulfa (Sulfonamide Antibiotics) Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: neutropenic fever Major Surgical or Invasive Procedure: mechanical ventilation pleurex drainage History of Present Illness: 56 y/o female with stage IV SCC lung presents from NH with neutropenic fever to 104 and concern for PNA. She is status post 1 full cycle of carboplatin 5 AUC D1 and gemcitabine D1, D8, last dose [**2113-2-2**]. Per report she was having non-bloody, non-bilious vomiting all day, and 4 days of diarrhea with inability to tolerate TF [**1-10**] high residuals. . On arrival to the ED, initial vs were: HR 140 BP 152/76 RR 18 POx 94 O2 sat. Initial labs confirmed pancytopenia. She then became hypotensive and received total 7L IVF and was started on levophed. A right groin central line was placed [**1-10**] SVC syndrome, with left femoral aline. She 1u PRBCs, 1u platelets, and was placed back on ventilator (trache at baseline) and sedated with fentanyl and versed. A CT ab/pelvis was performed concerning for possible SBO and ischemia and surgery was consulted who feel patient is not a surgical candidate. Patient was given zofran, oxycodone, Acetaminophen 500mg, Lorazepam 2mg/mL, Levofloxacin 750mg, Levophed gtt at 0.3 mcg, Albuterol, Midazolam gtt, Fentanyl gtt, Flagyl, Hydrocortisone Na Succ 100mg, Magnesium Sulfate 2 g. She required etomidate for line places. At the NH prior to transfer she received zosyn. VS prior to transfer T 98.2 HR 104 BP 132/64 RR 18 100% on FIO2, on trache AC. . On the floor, she was intubated and sedated. . Review of sytems: Unable to obtain [**1-10**] sedation. . Past Medical History: Non-small cell lung cancer diagnosed [**10-17**] SVC syndrome Scoliosis chronic back pain s/p cholecystectomy s/p hysterectomy Anxiety Social History: She has been living at rehab since d/c from [**Hospital Unit Name 153**] [**11-16**]. She has smoked a pack of cigarettes per day since she was 18 years old (37 pack year history). Denies alcohol or illicit drug use. Family History: NC, no known lung cancer Physical Exam: General: intubated and sedated HEENT: pupils pinpoint and minimally reactive, Sclera anicteric but edematous, MMD, oropharynx clear Neck: supple, JVP unable to assess [**1-10**] body habitus, no LAD Lungs: Coarse throughout, rhonorus at right base, no wheezes, right pleurex catheter w/out drainage CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: distended, tympanitic, not tense,no bowel sounds present, unable to assess for tenderness [**1-10**] sedation G-tube to suction GU: foley - 170 cc urine made in ED, yellow Ext: warm, well perfused, 1+ pulses, anasarcic, no mottling Pertinent Results: [**2-6**] CXR: IMPRESSION: Interval increase in large bilateral pleural effusions with overlying atelectasis. Underlying consolidation cannot be excluded. [**2-7**] CT abd/pelvis: IMPRESSION: 1. Focal dilatation of the second portion of the duodenum, which tapers as it crosses the midline concerning for partial obstruction, particularly given the lack of transit of oral contrast out of the stomach at the time of the study. However, given the fluid-filled loops of jejunum distal to the duodenal dilatation, a motility disorder such as ileus is also possible. There may be minimal wall thickening of some of the loops of small bowel, but no definite evidence of ischemia. 2. Interval increase in loculated right pleural effusion and small left effusion with associated opacity at the left base which may represent infection. [**2-7**] CXR: IMPRESSION: Moderate bilateral pleural effusions have increased. Mediastinal vasculature is engorged suggesting increased intravascular volume or pressure. There is no pulmonary edema, but bibasilar atelectasis has worsened. Heart size is obscured but not appreciably enlarged. No pneumothorax. Tracheostomy tube in standard placement. [**2113-2-6**] 09:30PM BLOOD WBC-0.1*# RBC-2.56* Hgb-7.1* Hct-21.8* MCV-85 MCH-27.8 MCHC-32.7 RDW-13.6 Plt Ct-15*# [**2113-2-7**] 01:00AM BLOOD WBC-0.1* RBC-2.01* Hgb-5.8* Hct-17.2* MCV-86 MCH-28.8 MCHC-33.7 RDW-13.9 Plt Ct-11* [**2113-2-7**] 12:47PM BLOOD WBC-0.1* RBC-3.13* Hgb-9.0* Hct-26.2* MCV-84 MCH-28.9 MCHC-34.5 RDW-14.0 Plt Ct-60* [**2113-2-8**] 03:10AM BLOOD WBC-0.1* RBC-3.01* Hgb-8.8* Hct-25.0* MCV-83 MCH-29.2 MCHC-35.2* RDW-14.6 Plt Ct-16*# [**2113-2-6**] 09:30PM BLOOD Neuts-34* Bands-0 Lymphs-64* Monos-0 Eos-2 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2113-2-6**] 09:30PM BLOOD Plt Smr-RARE Plt Ct-15*# [**2113-2-7**] 10:32AM BLOOD Plt Ct-63*# [**2113-2-8**] 03:10AM BLOOD Plt Smr-RARE Plt Ct-16*# [**2113-2-6**] 09:30PM BLOOD Glucose-164* UreaN-18 Creat-0.4 Na-138 K-3.0* Cl-101 HCO3-31 AnGap-9 [**2113-2-8**] 03:10AM BLOOD Glucose-162* UreaN-21* Creat-0.4 Na-140 K-2.8* Cl-109* HCO3-26 AnGap-8 [**2113-2-6**] 09:30PM BLOOD ALT-398* AST-151* LD(LDH)-172 CK(CPK)-41 AlkPhos-246* TotBili-0.8 [**2113-2-8**] 03:10AM BLOOD ALT-297* AST-75* LD(LDH)-168 AlkPhos-146* TotBili-0.8 [**2113-2-6**] 09:30PM BLOOD cTropnT-<0.01 [**2113-2-6**] 09:30PM BLOOD Calcium-6.9* Phos-4.0 Mg-1.1* [**2113-2-8**] 03:10AM BLOOD Calcium-7.8* Phos-3.4 Mg-2.2 [**2113-2-7**] 05:02AM BLOOD Type-ART Temp-36.6 pO2-158* pCO2-35 pH-7.49* calTCO2-27 Base XS-4 [**2113-2-8**] 06:26AM BLOOD Type-ART Temp-36.1 pO2-78* pCO2-57* pH-7.32* calTCO2-31* Base XS-0 [**2113-2-6**] 10:05PM BLOOD Lactate-0.8 [**2113-2-7**] 05:02AM BLOOD freeCa-1.00* [**2113-2-8**] 06:26AM BLOOD freeCa-1.27 Brief Hospital Course: 56 yo F with stage IV NSCLC, on palliative chemotherapy s/p [**Doctor Last Name **]/gemcitabine last dose 2/25 presents from NH with nausea/vomiting/diarrhea and febrile neutropenia admitted to [**Hospital Unit Name 153**] with septic shock. . # Septic Shock - Source likely pulmonary vs. GI. Unable to trend SvO2 or CVP 2/2 SVC syndrome and inability to place upper extremity central line. S/P 7L IVF resuscitation in ED. She was covered broadly with vanc/cefepime/cipro/flagyl. Blood cultures and urine cultures showed no growth, so her antibiotics were streamlined to cefepime/cipro/flagyl. Stool was negative for cdiff. All antibiotics were stopped on [**2113-2-13**]. Her condition was noted to improve with a resolution of her sepsis. . # Anasarca: ***PRIOR TO ADMISSION TO THE ICU Mrs. [**Known lastname **] was aggressively resuscitated with IVFs and was more than 10L positive at the beginning of her ICU stay. She was diuresed successfully on a lasix drip with resolution of her anasarca. She will require monitoring of her fluid status at rehab and may require po lasix prn. On [**2113-2-17**], prior to discharge, the patient was given 20 mg IV lasix with good effect. . # Febrile Neutropenia - s/p [**Doctor Last Name **]/gemcitabine treatment [**2-2**]. She was started on GCSF per oncology recommendations and her CBC was monitored daily with transfusion goals of HCT>21, plts >10. As mentioned above, the patient was covered broadly with antibiotics; blood, stool, urine, and sputum cultures were all unrevealing. She was started on GCSF per BMT recommendations. Her WBC blood count remained at 0.1 until [**2-12**] and on [**2-13**] her WBC count improved to 8.8. All antibiotics were stopped. Her WBC was elevated at 41.8 on [**2113-2-16**], and this was felt to be secondary to GCSF treatment, last given on [**2-13**]. She had no other signs concerning for infection. **OF NOTE, patient was also admitted to ICU on steroids, and these were tapered during her hospitalization. She will need further tapering off her steroids at rehab.** . # ? SBO vs. ileus - thought to to be infection associated ileus, as pt was putting out stool, had bowel sounds, and admission CT abdomen not convincing of SBO. Surgery was consulted in ED and felt that patient was not a surgical candidate. Lactate remained normal. She was monitored with serial abdominal exams and her tube feeds were initially held then restarted at a low rate on [**2113-2-8**]. On [**2-12**] she had leaking around her G-tube site, and she had excess residuals and tube feeds were held, and gradually restarted without difficulty. . # Loculated Right Pleural Effusion - IP drained 400cc of fluid from the pleurix catheter which when analyzed was found to be consistent with an exudative process, most likely her underlying NSCLC. The pleurix was drained 2-3 times weekly by IP. Cultures of pleural fluid were negative. . # Oliguria - Persisted despite adeqate IVF resuscitation and stabilization of her renal function. IVF boluses of NaHCO3 transiently improved UOP but patient remained oliguric and was ~14 liters positive. She did require pressure support with Levophed initially, but this was weaned quickly and she was placed on a Lasix gtt with excellent diuresis. . # Pancytopenia - Patient with low blood counts secondary to chemotherapy on admission. She required numerous transfusions of platelets and pRBC's during her hospital stay to maintain a hematocrit above 21 and platelets above 10K. This resolved on [**2-13**] with recovery of her cell lines. . Code: reversed to Full on presentation, given grave prognosis, it was re-addressed with her daughter and she was made DNR, then reversed again to full code on [**2113-2-14**]. On [**2113-2-13**], patient became more interactive and expressed that she would like to be discharged home with hospice. Palliative care was consulted and recommended restarting many of the patient's home medications; all of their recommendations have been incorporated into the discharge medications and planning. The patient's fentanyl and midazolam were discontinued on [**2-15**] and she was switched to treatment with diazepam and ativan with good effect. . Communication: Husband, HCP [**Name (NI) **] [**Name (NI) **] [**0-0-**], [**First Name4 (NamePattern1) 2270**] [**Known lastname **] (daughter) [**Telephone/Fax (1) 84137**], [**Telephone/Fax (1) 84138**] . Medications on Admission: Fragmin Mirtazapine 7.5 mg PO QHS Zofran prn nausea Nexium 40 mg PO BID Senna MVI Lorazepam 0.5 mg PO QHS Metoclopramide 5 mg PO TID Pro Air Dexamethasone Prochlorpemazine Amoxicillin-Pot Clavulanate Colace Oxycodone Glenique 10% transdermal Patch Sucralfate Fluticasone Discharge Medications: 1. Chlorhexidine Gluconate 0.12 % Mouthwash [**Telephone/Fax (1) **]: One (1) ML Mucous membrane [**Hospital1 **] (2 times a day). 2. Docusate Sodium 50 mg/5 mL Liquid [**Hospital1 **]: Two (2) PO BID (2 times a day) as needed for constipation. 3. Senna 8.6 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day) as needed for constipation. 4. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for constipation. 5. Ipratropium Bromide 17 mcg/Actuation HFA Aerosol Inhaler [**Hospital1 **]: [**3-14**] Inhalation Q6H (every 6 hours). 6. Albuterol Sulfate 90 mcg/Actuation HFA Aerosol Inhaler [**Month/Day (3) **]: 8-10 puffs Inhalation Q6H (every 6 hours). 7. Polyvinyl Alcohol-Povidone 1.4-0.6 % Dropperette [**Month/Day (3) **]: [**12-10**] Drops Ophthalmic PRN (as needed) as needed for dry eyes. 8. Acetaminophen 325 mg Tablet [**Month/Day (2) **]: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever. 9. Diazepam 5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO TID (3 times a day). 10. Lorazepam 0.5 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO Q4H (every 4 hours) as needed for anxiety. 11. Sucralfate 1 gram Tablet [**Month/Day (2) **]: One (1) Tablet PO QID (4 times a day). 12. Polyethylene Glycol 3350 17 gram/dose Powder [**Month/Day (2) **]: One (1) PO DAILY (Daily) as needed for constipation. 13. Heparin (Porcine) 5,000 unit/mL Solution [**Month/Day (2) **]: 5000 (5000) units Injection TID (3 times a day). 14. Mirtazapine 15 mg Tablet [**Month/Day (2) **]: 0.5 Tablet PO HS (at bedtime). 15. Dronabinol 2.5 mg Capsule [**Month/Day (2) **]: One (1) Capsule PO BID (2 times a day). 16. Pantoprazole 40 mg IV Q12H 17. Ondansetron 4 mg IV Q8H:PRN nausea/vomiting 18. Heparin Flush (10 units/ml) 2 mL IV PRN line flush Tunneled Access Line (e.g. Hickman), heparin dependent: Flush with 10 mL Normal saline followed by Heparin as above daily and PRN per lumen. 19. Fentanyl 100 mcg/hr Patch 72 hr [**Month/Day (2) **]: One (1) Patch 72 hr Transdermal Q72H (every 72 hours). 20. Prochlorperazine Maleate 10 mg Tablet [**Month/Day (2) **]: One (1) Tablet PO Q8H (every 8 hours) as needed for nausea. 21. Metoclopramide 10 mg Tablet [**Month/Day (2) **]: 0.5 Tablet PO TID (3 times a day). 22. Oxycodone 5 mg/5 mL Solution [**Month/Day (2) **]: Twenty (20) mg PO Q3H (every 3 hours) as needed for pain. 23. Methylprednisolone Sodium Succ 40 mg/mL Recon Soln [**Month/Day (2) **]: Twenty Five (25) mg Injection Q24H (every 24 hours). Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Febrile neutropenia Septic Shock Discharge Condition: Stable. Patient is alert, able to follow verbal commands, moves all four extremities. Verbal communication limited by trach. Activity has been limited to bedrest, though patient was ambulatory at baseline. Discharge Instructions: Mrs. [**Known lastname **], you were admitted to the ICU at [**Hospital1 18**] because of neutropenic fever and septic shock. You were treated with antibiotics and a medication to increase your white blood cell count, called GCSF, and your condition was noted to improve. You were placed on mechanical ventilation to help your breathing. In addition, you were treated with a diuretic medication to help resolve swelling that you initially had in order to help your breathing. You are now deemed medically stable for transfer to an rehabilitation facility for further care. Followup Instructions: You should follow-up with your oncologist and primary care provider [**Name Initial (PRE) 176**] 2 weeks of discharge from rehabilitation facility. [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2113-2-17**]

[ "V44.1", "276.6", "995.92", "E933.1", "560.1", "518.81", "780.61", "038.9", "511.81", "162.9", "459.2", "785.52", "511.9", "288.00", "V44.0", "V58.65", "737.30", "284.89", "V15.82", "788.5" ]

icd9cm

[ [ [] ] ]

[ "96.72", "38.91", "38.93", "34.91", "96.6" ]

icd9pcs

[ [ [] ] ]

12950, 13022

5653, 10057

328, 369

13099, 13307

2886, 5630

13929, 14244

2213, 2239

10379, 12927

13043, 13078

10083, 10356

13331, 13906

2254, 2867

271, 290

1762, 1804

397, 1744

1826, 1963

1979, 2197

3,796

101,683

52647

Discharge summary

report

Admission Date: [**2148-6-25**] Discharge Date: [**2148-6-29**] Date of Birth: [**2088-11-25**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Last Name (NamePattern1) 1171**] Chief Complaint: Dyspnea Major Surgical or Invasive Procedure: Intubation for hypoxia History of Present Illness: 59F with recent left foot surgery and osteomyelitis, s/p ant-inf MI s/p stent to pLAD, hx EtOH abuse with CHF and EF 20-25% (? mixed myopathy) admitted to [**Hospital Unit Name 153**] [**6-25**] with acute pulmonary edema. She denied dietary indiscretion and did not have any chest pain PTA. Intubated and diuresed, then extubated. Initially required nitro gtt for HTN, then 1 day of dopamine for hypoTN (weaned [**6-26**]). Patient had 1 run of irregular short-lived (3 to 9 beats) WCT which resolved without treatment and was called out from [**Hospital Unit Name 153**] to [**Hospital1 1516**] service for ?ICD placement. Per EP consult note on [**6-26**], no emergent reason for ICD placement. . Prior to call out patient noted to have 6 point HCT drop (28-> 21)and drop in WBC (9 -> 2) of unclear etiology. Guiac negative. Got two units PRBC and transferred to floor. Past Medical History: s/p ant-inf MI with stent to pLAD ([**2142**]) CHF with EF 20-25% s/p Left foot HAV repair & 2nd digit PIPJ arthroplasty HTN Hypercholesterolemia Hx. of substance Abuse Hx. of EtOH Abuse Depression Anxiety Social History: (+) EtOH (+) Recreational Drug usage including Marijuana, but denies IVDU Family History: Father died of heart disease Physical Exam: Vitals: T: 98.9 P:76 BP:109/71 R: 18 General: Awake, alert, NAD. HEENT: NC/AT, EOMI without nystagmus, no scleral icterus noted Neck: supple, no JVD or carotid bruits appreciated Pulmonary: faint crackles BL Cardiac: RRR, nl. S1S2. II/VI SEM. No S3, no S4. Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses b/l. Neurologic: alert, oriented, CN grossly intact, movess all extremities, no abnormal movements noted. Psych: Full affect, somewhat dramatic Pertinent Results: [**2148-6-24**] 10:47PM WBC-9.3# RBC-2.54* HGB-8.7* HCT-24.2* MCV-95 MCH-34.3* MCHC-36.0* RDW-14.7 [**2148-6-24**] 10:47PM MACROCYT-1+ [**2148-6-26**] 03:50AM BLOOD calTIBC-229* VitB12-811 Folate-16.3 Hapto-130 Ferritn-1177* TRF-176* [**2148-6-24**] 10:47PM NEUTS-41.8* LYMPHS-50.6* MONOS-5.3 EOS-2.0 BASOS-0.3 [**2148-6-24**] 10:47PM PLT COUNT-474*# . [**2148-6-24**] 10:47PM PT-13.4* PTT-26.4 INR(PT)-1.2* . [**2148-6-24**] 10:47PM GLUCOSE-302* UREA N-26* CREAT-1.4* SODIUM-125* POTASSIUM-4.3 CHLORIDE-89* TOTAL CO2-18* ANION GAP-22* . [**2148-6-24**] 11:15PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-250 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5 LEUK-NEG . [**2148-6-25**] 03:06AM D-DIMER-2368* . [**2148-6-25**] 03:06AM CORTISOL-21.6* [**2148-6-25**] 03:06AM TSH-3.9 . [**2148-6-24**] 10:47PM BLOOD CK(CPK)-160* [**2148-6-24**] 10:45PM BLOOD cTropnT-<0.01 [**2148-6-25**] 03:06AM BLOOD ALT-11 AST-55* LD(LDH)-511* CK(CPK)-253* AlkPhos-97 Amylase-117* TotBili-0.6 [**2148-6-24**] 10:47PM BLOOD CK-MB-4 [**2148-6-25**] 02:59PM BLOOD CK(CPK)-208* [**2148-6-25**] 03:06AM BLOOD CK-MB-6 cTropnT-0.05* proBNP-7406* [**2148-6-25**] 02:59PM BLOOD CK-MB-7 cTropnT-0.02* . [**2148-6-29**] 05:30AM BLOOD WBC-4.8 RBC-3.47* Hgb-11.2* Hct-32.2* MCV-93 MCH-32.4* MCHC-34.9 RDW-16.6* Plt Ct-405 [**2148-6-29**] 05:30AM BLOOD Plt Ct-405 [**2148-6-29**] 05:30AM BLOOD PT-13.8* PTT-40.8* INR(PT)-1.2* [**2148-6-29**] 05:30AM BLOOD Glucose-96 UreaN-19 Creat-1.2* Na-133 K-4.7 Cl-99 HCO3-26 AnGap-13 [**2148-6-29**] 05:30AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.7 . Tox Screen on admission: [**2148-6-24**] 10:47PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . AP ERECT PORTABLE RADIOGRAPH OF THE CHEST (on admission): A PICC is seen with the tip in the superior vena cava. Interval development of interstitial pulmonary edema. There is discoid atelectasis at the right lung base. No pleural effusions are apparent. The heart size is within normal limits. IMPRESSION: Interval development of pulmonary edema. Discoid atelectasis at the right lung base. . CHEST CT to R/O PE: IMPRESSION: 1. Bilateral patchy opacities represent asymmetric pulmonary edema versus multifocal pneumonia. Clinical correlation recommended. No evidence for PE. 2. Bibasilar atelectasis and very small bilateral pleural effusions. . EKG on admission: Sinus rhythm, Probable old anteroseptal infarct. Since previous tracing, no significant change Brief Hospital Course: 59F with osteomyelitis, s/p ant-inf MI s/p stent to pLAD, CHF with EF 20-25%, was admitted intially to the [**Hospital Unit Name 153**] with CHF exacerbation and then called out from [**Hospital Unit Name 153**] [**6-25**] to [**Hospital1 **] service for further work-up and treatment. . # CHF exacerbation: Patient was hypoxic on admission with pulmonary edema on CXR, so was intubated and diuresed in ICU; given her known EF = 20-25%, CHF was the most likely cause of her dyspnea. No apparent cause for the acute exacerbation could be identified; patient denies any dietary indiscretion, cardiac enzymes were negative and EKG was unchanged from prior. PE was also considered as a cause of her dyspnea, and given an elevated D dimer, CTA of the chest was performed which did not identify any PE. After 24 hours of ventilatory support and aggressive diuresis, she was able to be extubated and transferred to the [**Hospital Ward Name 121**] 3 telemetry [**Hospital1 **]. . At the time of transfer to the [**Hospital1 **], patient appeared clinically normovolemic. She was gently diuresed to slightly below her home dry weight of 95lbs. She was started on metoprolol and lisinopril was added once her creatinine had stabilized. . # Hct drop: From 28-21 with no evidence of active bleeding - guiac negative. Patient received 2 units of PRBC in [**Hospital Unit Name 153**] prior to transfer with appropriate response, Hct stable thereafter. Heme consult reviewed peripheral smear with no concerning findings. Does not appear to be a consumptive process--no signs of hemolysis on lab work. Iron studies c/w anemia of inflammation. Acute change in Hct during acute pulmonary edema appears to have resulted from fluid volume shifts. . # WBC drop: 9.1 to 2.3 on [**6-26**], gradually increased to 4.8 on [**6-29**] without intervention. Unclear etiology; lymphocyte predominant with a monocytosis suggestive of toxin-mediated bone marrow suppression. Heme consult suspects drug reaction, possibly levafloxacin, which was given in [**Hospital Unit Name 153**] and has been reported to cause agranulocytosis. HIV infection can also cause leukopenia, although patient denies high-risk behaviors such as unprotected sex with anyone other than husband or IVDA, she consented to be tested for HIV and test results pending. . # Short runs of WCT, asymptomatic: EP consulted and felt that emergent ICD placement was not indicated given current comorbidities. Had a negative V-Stim at [**Hospital1 112**] [**2145-12-17**] with Dr. [**Last Name (STitle) **] (EF 20-25% at that time). Pt. wants to avoid ICD if possible. Continued beta blocker therapy should decrease the incidence of the NSVT/WCT. . # Anxiety/depression: Patient says she has had a psychiatrist for many years and used to take valium with good effect. Her new doctor, Dr [**First Name4 (NamePattern1) 47716**] [**Last Name (NamePattern1) **] [**Telephone/Fax (1) 108658**], stopped benzos b/c she had a history of abusing the valium and started prozac plus neurontin. [**6-27**] patient expressed SI and was seen by in-house psychiatry consult, who felt patient was not at risk to self and did not need 1:1 sitter but recommended treating her significant anxiety with resperidone and uptitrating neurontin. However, patient had symptomatic hypotension after first dose risperidone 1mg, but patient said she slept well and felt much better the morning after the risperidone, so restarted risperidone at 0.25mg hs prn. Continued home dose of fluoxetine 60 mg po and gabapentin 300mg tid as recommended per psych. Patient will see Dr [**Last Name (STitle) **] to adjust outpatient anti-anxiety and anti-depressant regimen next week. . # Substance abuse: Pt admits to smoking marijuana daily and has history of abusing diazepam. Social work consulted to discuss coping mechanisms with patient. They recommended, as did psychiatry consult, that patient go to day treatment center such as [**Doctor First Name 1191**] Day Center for ongoing substance, which psychiatry recommended is best arranged through her outpatient psychiatrist for continuity. . # Osteomyelitis - Receiving cefazolin via home pump. Per podiatry notes, still needs 3 more weeks, so D/C'd with prescription to continue through [**7-19**] to completely treat osteomyelitis of L great toe. Pt has home IV nursing who maintains PICC line and helps her with Abx infusions; will contact the agency before discharge to reinitiate their services. . # Hyponatremia - serum osms low, so hypoosmolar, hypervolemic hyponatremia upon presentation to ER, likely CHF as etiology. Resolved steadily with diuresis and sodium normal at 133 on the morning of discharge. Medications on Admission: Cefazolin 1gm IV Q8H for infection Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily). Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Gabapentin 300mg tid (patient has not been taking) Discharge Medications: 1. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): for heart disease. 2. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO at bedtime: for cholesterol. [**Month (only) **]:*30 Tablet(s)* Refills:*2* 3. Fluoxetine 20 mg Capsule Sig: Three (3) Capsule PO DAILY (Daily): for depression. [**Month (only) **]:*90 Capsule(s)* Refills:*2* 4. Gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day): for anxiety. [**Month (only) **]:*90 Capsule(s)* Refills:*2* 5. Risperidone 0.5 mg Tablet Sig: one-half Tablet PO at bedtime as needed for insomnia for 4 days. [**Month (only) **]:*2 Tablet(s)* Refills:*0* 6. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily): for blood pressure and heart failure. [**Month (only) **]:*15 Tablet(s)* Refills:*2* 7. Metoprolol Succinate 25 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily): for blood pressure and heart failure. [**Month (only) **]:*30 Tablet Sustained Release 24HR(s)* Refills:*2* 8. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): for heart failure. [**Month (only) **]:*30 Tablet(s)* Refills:*2* 9. Cefazolin 1 g Piggyback Sig: One (1) Piggyback Intravenous Q8H (every 8 hours) for 3 weeks: for osteomyelitis, to be administered by IV nurse. [**Last Name (Titles) **]:*3 weeks' supply* Refills:*0* 10. Heparin Lock Flush (Porcine) 100 unit/mL Syringe Sig: Two (2) ML Intravenous DAILY (Daily) as needed for 3 weeks: instill in PICC line. [**Last Name (Titles) **]:*qs for one month* Refills:*0* 11. Normal Saline Flush 0.9 % Syringe Sig: Ten (10) mL Injection once a day for 3 weeks: to flush PICC line. [**Last Name (Titles) **]:*qs one month* Refills:*0* Discharge Disposition: Home With Service Facility: Crititcal Care Services Discharge Diagnosis: Primary: excerbation of congestive heart failure . Secondary: osteomyelitis of left great toe, hypertension, substance abuse, depression, hyperlipidemia Discharge Condition: At the time of discharge, patient is afebrile, tolerating po diet and meds, and ambulatory. Additionally, she does not have any suicidal or homicidal ideation. Discharge Instructions: Weigh yourself daily and call your cardiologist if you gain more than 2 pounds in one day. . Follow a low-sodium diet to prevent heart failure exacerbations. . Continue taking all medicines as prescribed. . Call 911 if you have chest pain or shortness of breath. Call your doctor if you have chills, fevers, nausea, vomiting, or diarrhea. Followup Instructions: On Monday, call Dr. [**Last Name (STitle) 4628**] [**Name (STitle) **] ([**Telephone/Fax (1) 108658**]), your psychiatrist, for first available appointment. . When you get home, call Dr. [**First Name4 (NamePattern1) 449**] [**Last Name (NamePattern1) 32963**] ([**Telephone/Fax (1) 34119**]), your cardiologist, for an appointment in [**1-12**] weeks. . Provider: [**First Name8 (NamePattern2) 7618**] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2148-7-9**] 9:30

[ "412", "305.21", "427.1", "401.9", "518.81", "V45.82", "285.29", "730.17", "425.4", "414.01", "276.1", "428.0", "272.0" ]

icd9cm

[ [ [] ] ]

[ "96.04", "96.71", "00.17", "99.04" ]

icd9pcs

[ [ [] ] ]

11672, 11726

4693, 9362

332, 357

11923, 12085

2208, 3792

12473, 12970

1598, 1628

9957, 11649

11747, 11902

9389, 9934

12109, 12450

1643, 2189

285, 294

385, 1260

4574, 4670

1282, 1490

1506, 1582

68,221

117,308

47220

Discharge summary

report

Admission Date: [**2167-10-7**] Discharge Date: [**2167-10-16**] Date of Birth: [**2107-7-5**] Sex: F Service: MEDICINE Allergies: Penicillins / Sulfa (Sulfonamide Antibiotics) / Aspirin Attending:[**First Name3 (LF) 398**] Chief Complaint: Right hip fracture Major Surgical or Invasive Procedure: Endotracheal intubation [**2167-10-9**] Central venous catheter placement [**2167-10-8**] Intramedullary rod fixation of right peritrochanteric hip fracture [**2167-10-8**] History of Present Illness: Ms. [**Known lastname 41330**] is a 60yo F w/hx of CAD s/p IMI PCI to LCx [**2164**], CHF w/EF 20% s/p AICD, COPD on 2L home O2, SLE, scleroderma, recurrent C. Diff who presents as a transfer from [**Hospital1 5109**] for hip fracture. She was previously admitted [**2167-10-1**] for C. Diff pancolitis, discharged on [**2167-10-6**] on PO vancomycin. During that stay she had a CT scan showing pancolitis. While walking into the house on [**2167-10-6**], she tripped and fell off of 2 stairs. No LOC. She was taken to [**Hospital3 **] were she was found to have a R intertrochanteric hip fracture which was displaced. She was evaluated by orthopedics and cardiology who recommended transfer to [**Hospital 86**] hospital for more sophisticated intraoperative cardiac monitoring and higher level postoperative surgical ICU. . On arrival, she is somnolent and complaining of pain in the R hip. She denies chest pain, shortness of breath, fever. She has mild abdominal pain. Per her husband and daughter, she has been having several ([**7-8**]) BMs per day with some blood in the stool. Otherwise, no complaints. . Review of systems: (+) 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. No recent change in bowel or bladder habits. No dysuria. Denied arthralgias or myalgias. Past Medical History: - CAD s/p IMI, cardiac cath [**2164**] with PCI to LCx, minor irregularities in LAD and RCA territories - CHF, EF in [**2164**] was 55%, EF [**5-8**] was 30%, EF [**10-8**] 20%, thought to be due to systemic sclerosis - s/p AICD for low EF - Severe Pulmonary Hypertension - Systemic Sclerosis with ischemia to L index finger with osteomyelitis - Multiple episodes of C. Diff diarrhea while on antibiotics - Stress Test [**10-8**] without active ischemia - Severe Raynaud's syndome - SLE/CREST - COPD on 2L oxygen, ? scleroderma lung disease - s/p RHC [**12-7**] to evaluate response to vasodilator therapy, no response, PAP 100mm Hg, Cardiac Index 2L/min - GERD - Occipital Neuralgia - SBO/lysis of adhesions - Meningitis [**3-9**], treated with braod-spectrum abx and developed C. Diff Social History: 25 pack year smoking history, quite smoking 11 years ago, no prior alcohol use. Family History: NC, no history of autoimmune disease. Physical Exam: VS: 98.4 BP131/73 HR 97 94%on 4L GENERAL: appears older than stated age, lying in bed in NAD HEENT: No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No LAD. CARDIAC: RR. Normal S1, S2. No m/r/g. LUNGS: Limited to due patient positioning and body habitus but clear anteriorly. ABDOMEN: +BS. tender to palpation diffusely without rebound or guarding. Non-distended. Well-healed surgical scar in lower right abdomen. EXTREMITIES: R hip rotated. 2+ peripheral pulses bilaterally in DP and PT. No edema. Fingers demonstrate scleroderma changes. Acrocyanosis of fingers and toes. NEURO: Alertness waxes and wanes through intervies. CN 2-12 grossly intact. Pt unable to follow commands to squeeze fingers but able to move legs. Unable to assess sensation as pt does not follow commands. Pertinent Results: Discharge labs: [**2167-10-16**] 03:05AM BLOOD WBC-12.3* RBC-3.44* Hgb-9.7* Hct-30.7* MCV-89 MCH-28.3 MCHC-31.8 RDW-17.8* Plt Ct-352 [**2167-10-16**] 03:05AM BLOOD Glucose-101 UreaN-27* Creat-0.9 Na-146* K-3.8 Cl-114* HCO3-25 AnGap-11 [**2167-10-11**] 04:06AM BLOOD ALT-25 AST-39 LD(LDH)-254* AlkPhos-34* TotBili-0.3 [**2167-10-16**] 03:05AM BLOOD Calcium-7.5* Phos-1.8* Mg-2.1 . MICRO: [**2167-10-9**] 3:08 am URINE Source: Catheter. **FINAL REPORT [**2167-10-12**]** URINE CULTURE (Final [**2167-10-12**]): KLEBSIELLA PNEUMONIAE. >100,000 ORGANISMS/ML.. ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA PNEUMONIAE | ESCHERICHIA COLI | | AMPICILLIN------------ <=2 S AMPICILLIN/SULBACTAM-- <=2 S <=2 S CEFAZOLIN------------- <=4 S <=4 S CEFEPIME-------------- <=1 S <=1 S CEFTAZIDIME----------- <=1 S <=1 S CEFTRIAXONE----------- <=1 S <=1 S CEFUROXIME------------ <=1 S <=1 S CIPROFLOXACIN---------<=0.25 S <=0.25 S GENTAMICIN------------ <=1 S <=1 S MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- 64 I <=16 S PIPERACILLIN---------- <=4 S PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ <=1 S <=1 S TRIMETHOPRIM/SULFA---- <=1 S <=1 S . RADIOLOGY: AXR [**10-15**]: ABDOMEN, SINGLE VIEW: Bowel gas pattern is non-obstructive. There is interval improvement of small bowel dilatation as compared to [**2167-10-13**]. There is no evidence of pneumoperitoneum. Air is visualized in the rectum. An NG tube is coiled in the stomach. Scattered phleboliths are seen in the right hemipelvis. A gamma nail in the right femoral head is partially visualized. IMPRESSION: No evidence of bowel obstruction. . CXR [**10-15**]: FINDINGS: The support lines and tubes are unchanged. The evaluation is limited by motion. Moderate cardiomegaly is unchanged. The lung volumes remain low, with right infrahilar and left retrocardiac atelectasis. Small left effusion may be present. There is no pulmonary edema. . CT head [**10-11**]: FINDINGS: There is no intracranial hemorrhage, edema, mass effect or vascular territorial infarction. Ventricles and sulci are large bilaterally, consistent with global parenchymal volume loss. Periventricular white matter hypodensities are also bilateral, the sequela of chronic microvascular ischemia. Extracranial soft tissue structures are unremarkable. The included mastoid air cells are notable for partial opacification of the mastoid air cells on the right/underpneumatization. The visualized paranasal sinuses are clear. IMPRESSION: 1. No acute intracranial hemorrhage. 2. Partial opacification of the right mastoid air cells . ECHO [**10-9**]: The left atrium is dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is small and underfilled. Regional left ventricular wall motion is normal. There is mild global left ventricular hypokinesis (LVEF = 50-55%), although in the context of a small cavity size, this may be slightly underestimated. The right ventricular free wall is hypertrophied. The right ventricular cavity is markedly dilated with severe global free wall hypokinesis. There is abnormal systolic septal motion/position consistent with right ventricular pressure overload. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. Moderate [2+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Dilated, hypertrophied and markedly hypokinetic right ventricle. Small left ventricle with mild systolic dysfunction. Moderate tricuspid regurgitation. Severe pulmonary hypertension. . [**10-8**] Femur X-ray Six fluoroscopic images of the right femur demonstrate interval placement of an intramedullary rod with proximal gamma nail. This is fixating an intertrochanteric fracture of the right femur. There is good anatomic alignment and no hardware-related complications. The total intraservice time was 99 seconds. Brief Hospital Course: ASSESSMENT AND PLAN: 60F with CAD s/p IMI, severe pulmonary HTN c/b R heart failure, chronic LV diastolic dysfunction, SLE, scleroderma, COPD on home O2 admitted after R hip fracture now s/p ORIF, admitted to MICU for respiratory failure and multifactorial distributive shock. #Distributive shock: This was felt to by multifactorial including volume depletion and sepsis from UTI, C. diff. She briefly required pressors. She was treated initially with vanc/cefepime and flagyl/po vanc for C. diff. When urine culture results returned, patient was changed to cipro according to sensitivity data to complete 7 day course [**10-19**]. #Respiratory failure: She was difficult to extubate due to severe pulmonary hypertension, COPD, and volume overload with SVT. She was treated for her pulmonary hypertension with her home regimen of sildenafil and bosentan when her BP stabilized. She was finally successfully extubated on [**10-13**]. She is now satting 97% on 2L NC. She has a home O2 requirement of 2L. #MAT vs sinus arrhythmia: Metoprolol was uptitrated to 100 mg [**Hospital1 **] with good effect. There is no indication for therapeutic anticoagulation as unlikely to be fib/flutter. #Pulmonary HTN c/b R heart failure: TEE showed dilated, hypertrophied, hypokinetic RV on TTE. She was diuresis with IV Lasix 20-40 mg prn to decrease burden on RV. She was continued on her outpt regimen of sildenafil and bosentan. #R Hip Fracture: She underwent R ORIF on [**2167-10-8**]. She was started on lovenox. #C. difficile infection: She was started on PO vanco. She will continue for another 2 weeks after last dose of abx (through [**2167-11-2**]) and THEN taper to 125mg PO QID X 14 days, 125mg PO BID X 1, 125mg daily x 1 week, 125mg QOD x 1 week, 125mg q3 days x 2 weeks; no evidence of megacolon #CAD s/p PCI to LCx: She was continued on ASA, statin, and BB. Her plavix was discontinued given her post-op and since her PCI was in [**2164**]. #SLE: She was continued on hydroxychloroquine. Fingers and toes demonstrate chronic acrocyanosis. Medications on Admission: MEDICATIONS ON TRANSFER: Dilaudid PRN pain Revatio 20mg PO TID Spiriva 1 inhalation daily Advair 500/50 1 puff [**Hospital1 **] Metoprolol 75mg PO BID Plavix 75mg PO qday Gabapentin 600mg PO TID Lipitor 40mg PO qday Omeprazole 20mg PO qday Aspirin 81mg PO qday Lisinopril 2.5mg PO qday Tracleer 125mg PO qday Lasix 20mg PO TID KCl 20meq PO qday Plaquenil 200mg PO BID Elavil 50mg PO qday Vancomycin PO 125mg QID . HOME MEDICATIONS (per admission H&P at [**Hospital1 2436**]) same as discharge meds Discharge Medications: 1. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated [**Hospital1 **]: One (1) Adhesive Patch, Medicated Topical QDAY () as needed for r hip. 2. Ciprofloxacin 250 mg Tablet [**Hospital1 **]: One (1) Tablet PO Q12H (every 12 hours) for 4 days. 3. Enoxaparin 40 mg/0.4 mL Syringe [**Hospital1 **]: One (1) injection Subcutaneous DAILY (Daily). 4. Metoprolol Tartrate 50 mg Tablet [**Hospital1 **]: Two (2) Tablet PO BID (2 times a day). 5. Oxycodone 5 mg/5 mL Solution [**Hospital1 **]: Five (5) mg PO Q6H (every 6 hours) as needed for right hip pain: hold for rr<12, oversedation. 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) [**Hospital1 **]: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed for Constipation. 7. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization [**Hospital1 **]: One (1) INH Inhalation Q6H (every 6 hours) as needed for wheezing/sob. 8. Ipratropium Bromide 0.02 % Solution [**Hospital1 **]: One (1) INH Inhalation Q6H (every 6 hours). 9. Bosentan 125 mg Tablet [**Hospital1 **]: One (1) Tablet PO BID (2 times a day). 10. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 11. Senna 8.8 mg/5 mL Syrup [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day) as needed for Constipation. 12. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One Hundred (100) mg PO BID (2 times a day). 13. Sildenafil 20 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO TID (3 times a day). 14. Aspirin 81 mg Tablet, Chewable [**Last Name (STitle) **]: One (1) Tablet, Chewable PO DAILY (Daily). 15. Atorvastatin 40 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 16. Hydroxychloroquine 200 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 17. Vancomycin 125 mg Capsule [**Last Name (STitle) **]: One (1) Capsule PO Q6H (every 6 hours): Please continue vancomycin orally (by mouth) 125 mg twice daily through Monday, [**11-2**], followed by 125 mg daily x 1 week, then 125 mg every other day x 1 week, then 125 mg every 3 days for 2 weeks. 18. Acetaminophen 160 mg/5 mL Solution [**Month (only) **]: 325-650 mg PO Q6H (every 6 hours) as needed for fever. Discharge Disposition: Extended Care Facility: Shaugnessy-[**Hospital1 656**] Discharge Diagnosis: Primary 1) Hypoxemic respiratory failure 2) Septic shock 3) Acute complicated cystitis 4) Clostridium dificile colitis 5) Right peritrochanteric hip fracture Secondary 1) Pulmonary hypertension 2) Supraventricular tachycardia 3) Chronic obstructive pulmonary disease 4) Systemic lupus erythematosus 5) Raynaud's phenomenon Discharge Condition: Clinically improved with stable vital signs on supplemental oxygen (2L via NC) Discharge Instructions: You were admitted to the hospital with a right hip fracture which was surgically repaired. There was difficulty getting you off of the ventilator probably because of your history of pulmonary hypertension and chronic obstructive pulmonary disease. You also had low blood pressures that were likely from C. dificile colitis and urinary tract infections. You were also noted to have an irregular heart rhythm, that was likely exacerbated by your infections, and your home metoprolol dose was increased (100 mg twice daily) Please continue taking the antibiotic ciprofloxacin through [**10-19**]. Please continue vancomycin orally (by mouth) 125 mg twice daily through Monday, [**11-2**], followed by 125 mg daily x 1 week, then 125 mg every other day x 1 week, then 125 mg every 3 days for 2 weeks. Followup Instructions: Please ensure that a follow-up appointment is arranged with your primary care physician [**Name Initial (PRE) 176**] 1 week of discharge from the rehab facility. Completed by:[**2167-10-16**]

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icd9cm

[ [ [] ] ]

[ "96.04", "88.72", "79.15", "96.72", "38.93" ]

icd9pcs

[ [ [] ] ]

13166, 13223

8256, 10325

334, 509

13591, 13672

3796, 3796

14521, 14715

2930, 2969

10873, 13143

13244, 13570

10351, 10351

13696, 14498

3812, 8233

2984, 3777

1669, 2006

276, 296

537, 1650

10376, 10850

2028, 2817

2833, 2914

75,488

125,168

41671

Discharge summary

report

Admission Date: [**2128-10-4**] Discharge Date: [**2128-10-12**] Date of Birth: [**2068-2-18**] Sex: F Service: MEDICINE Allergies: Acetylcysteine Attending:[**First Name3 (LF) 602**] Chief Complaint: tylenol overdose Major Surgical or Invasive Procedure: PICC placement and removal History of Present Illness: 60F history of frontotemporal dementia, complains of ingestion of ~ 70 tablets of extra strength Tylenol on Saturday 2 days ago at 1 pm, denies any other ingestions. Reported SI with superficial cutting of both wrists. She is a markedly poor historian, and is unable to provide much history. Her husband states that she is significantly more confused than usual. She went to outside hospital ([**Hospital3 3583**]), received one dose of N-acetylcysteine. Developed mild facial flushing for which she received Benedryl. Tylenol level was negative, but AST was 16,000, INR was 1.8. . Per husband, patient was in her baseline (child like, longterm memory intact, short term impaired). Her husband brought the tylenol 3 days prior and put it in the medicine cabin. She found it on Saturday and took it. . In the ED initial vital signs were 99.5 86 122/68 18 100% 2L NC. Exam was notable for icteric sclera, soft diffusely tender belly, mumbles. Labs were notable for elevated AST, ALT, INR was elevated to 2.7, lipase to 105, large blood in the UA. Patient underwent EKG which showed NSR. Patient was given N-acetylcysteine. Patient was seen by toxicology: N-acetylcysteine after 1st loading dose 50 mg/kg over 4 hrs, then 100 mg/kg over 16 hrs. Benadryl and/or ranitidine as needed for reaction to NAC, admit to MICU. Patient was admitted for tylenol OD. Vital signs prior to transfer 99.5 90 94/44 23 97% RA. . On floor, she recognizes her husband, follows command. . Review of systems: (+) Per HPI Past Medical History: FTD HLD depression gerd Social History: - Tobacco: none - Alcohol: occassional - Illicits: none Family History: No family history of dementia or depression. Physical Exam: Admission Physical Vitals: T:100 BP:114/62 P:90 R: 18 O2:95% General: mild distress, A&Ox1, flushed red in the face HEENT: slight sclera icteric, dMM, oropharynx clear, poor dentition Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: tachy, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, diffusely tender, mildly-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Discharge PE: VS: 99.1 160/90 66 18 96RA Gen: calm, cooperative, AAO x3 HEENT: anicteric sclera Card: RRR, S1, S2 heard, no murmurs, rubs or gallops. Pulm: lungs CTAB, no crackles or wheezes appreciated Abdomen: soft, nontender, nondistended, obese, normoactive bowel sounds, no HSM detected extremities: warm, well perfused, 2+ DP pulses Neuro: no asterixis noted Pertinent Results: At admission: [**2128-10-4**] 08:03PM BLOOD WBC-6.6 RBC-4.20 Hgb-13.5 Hct-38.5 MCV-92 MCH-32.1* MCHC-35.0 RDW-13.2 Plt Ct-49* [**2128-10-4**] 08:03PM BLOOD Neuts-91.4* Lymphs-6.4* Monos-1.3* Eos-0.7 Baso-0.2 [**2128-10-4**] 08:03PM BLOOD PT-28.2* PTT-39.1* INR(PT)-2.7* [**2128-10-4**] 08:03PM BLOOD Glucose-120* UreaN-27* Creat-1.1 Na-140 K-4.0 Cl-111* HCO3-17* AnGap-16 [**2128-10-4**] 08:03PM BLOOD Glucose-120* UreaN-27* Creat-1.1 Na-140 K-4.0 Cl-111* HCO3-17* AnGap-16 [**2128-10-4**] 08:03PM BLOOD ALT-[**Numeric Identifier 48748**]* AST-[**Numeric Identifier **]* AlkPhos-90 TotBili-1.0 [**2128-10-5**] 01:00AM BLOOD ALT-[**Numeric Identifier **]* AST-[**Numeric Identifier 38529**]* LD(LDH)-[**Numeric Identifier 90589**]* AlkPhos-90 TotBili-1.0 [**2128-10-4**] 08:03PM BLOOD Lipase-105* [**2128-10-5**] 01:00AM BLOOD Albumin-3.6 Calcium-9.2 Phos-1.5* Mg-2.3 Iron-169* [**2128-10-4**] 08:03PM BLOOD Ammonia-90* [**2128-10-5**] 12:56AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE IgM HAV-NEGATIVE [**2128-10-5**] 01:00AM BLOOD AFP-2.0 [**2128-10-5**] 02:55PM BLOOD Type-ART pO2-74* pCO2-36 pH-7.37 calTCO2-22 Base XS--3 Intubat-NOT INTUBA Imaging: CT head [**10-5**] FINDINGS: No hemorrhage, large territorial infarction, edema, mass, or shift of normally midline structures is present. The ventricles and sulci are prominent consistent with cortical atrophy. The basal cisterns are widely patent. The visualized paranasal sinuses and mastoid air cells are well aerated. IMPRESSION: No acute intracranial process; bilateral frontal more than temporal lobar atrophy, consistent with the given history. COMMENT: Findings were discussed with Dr. [**Last Name (STitle) **] via phone at 11 p.m. on [**2128-10-5**]. The study and the report were reviewed by the staff radiologist. CXR [**10-5**] FINDINGS: Upright AP and lateral views of the chest show new small bilateral pleural effusions. Otherwise, the exam is unchanged. The cardiamediastinal and pulmonary structures are unremarkable. No pneumothorax. IMPRESSION: New small bilateral pleural effusions. [**10-5**] U/S INDICATION: Tylenol overdose, evaluate liver with Doppler. LIVER AND GALLBLADDER ULTRASOUND. COMPARISON: None. FINDINGS: The liver appears slightly coarse in echotexture. Within the left lobe of the liver is a septated cyst measuring 2 x 1.4 x 1.6 cm. In the right lobe is a simple-appearing cyst measuring 1.5 x 1 x 1 cm. No solid lesions are identified within the liver. There is normal hepatopetal flow within the main portal vein. Hepatic vasculature including the portal veins, and the hepatic veins are patent. The hepatic arteries are patent. Direction of flow is normal. The IVC is patent. The splenic vein is patent and the superior mesenteric vein is patent. There is trace abdominal ascites. The spleen is normal in size measuring 10 cm. The right and left kidneys are normal in echotexture measuring 12.2 and 12.1 cm, left and right respectively. There is marked gallbladder wall thickening, particularly along the contour of the liver with the thickness of the gallbladder wall measuring up to 1.1 cm. However, there is no son[**Name (NI) 493**] [**Name2 (NI) 515**] elicited and no stones within the gallbladder. IMPRESSION: 1. Patent hepatic vasculature. 2. Marked gallbladder wall thickening likely related to hepatic dysfunction in the setting of Tylenol overdose. 3. Trace abdominal ascites. 4. Liver cysts. [**10-5**] TTE The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size and regional/global systolic function are normal (LVEF >55%). There is no ventricular septal defect. Right ventricular chamber size and free wall motion are normal. The diameters of aorta at the sinus, ascending and arch levels are normal. The aortic valve leaflets (3) are mildly thickened 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. [**10-4**] ECG Sinus rhythm. Normal tracing. No previous tracing available for comparison. TRACING #1 Micro: [**2128-10-6**] URINE URINE CULTURE-PENDING INPATIENT [**2128-10-6**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2128-10-6**] BLOOD CULTURE Blood Culture, Routine-PENDING INPATIENT [**2128-10-5**] Blood (Toxo) TOXOPLASMA IgG ANTIBODY-FINAL; TOXOPLASMA IgM ANTIBODY-FINAL INPATIENT [**2128-10-5**] Blood (EBV) [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgG AB-PENDING; [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS EBNA IgG AB-PENDING; [**Doctor Last Name **]-[**Doctor Last Name **] VIRUS VCA-IgM AB-PENDING INPATIENT [**2128-10-5**] Blood (CMV AB) CMV IgG ANTIBODY-FINAL; CMV IgM ANTIBODY-FINAL INPATIENT [**2128-10-5**] SEROLOGY/BLOOD VARICELLA-ZOSTER IgG SEROLOGY-FINAL INPATIENT [**2128-10-5**] SEROLOGY/BLOOD Rubella IgG/IgM Antibody-FINAL INPATIENT [**2128-10-5**] SEROLOGY/BLOOD RAPID PLASMA REAGIN TEST-FINAL INPATIENT [**2128-10-4**] MRSA SCREEN MRSA SCREEN-PENDING INPATIENT [**2128-10-4**] URINE URINE CULTURE-FINAL EMERGENCY [**Hospital1 **] [**2128-10-4**] BLOOD CULTURE Blood Culture, Routine-PRELIMINARY {STAPHYLOCOCCUS, COAGULASE NEGATIVE}; Anaerobic Bottle Gram Stain-FINAL EMERGENCY [**Hospital1 **] [**2128-10-4**] BLOOD CULTURE Blood Culture, Routine-PENDING EMERGENCY [**Hospital1 **] Discharge: [**2128-10-12**] 05:58AM BLOOD WBC-7.0 RBC-3.20* Hgb-10.6* Hct-30.0* MCV-94 MCH-33.1* MCHC-35.4* RDW-13.8 Plt Ct-254 [**2128-10-5**] 01:00AM BLOOD Neuts-91.8* Lymphs-6.8* Monos-0.8* Eos-0.4 Baso-0.2 [**2128-10-12**] 05:58AM BLOOD PT-11.8 PTT-24.1 INR(PT)-1.0 [**2128-10-12**] 05:58AM BLOOD Glucose-90 UreaN-9 Creat-1.0 Na-143 K-3.5 Cl-113* HCO3-20* AnGap-14 [**2128-10-12**] 05:58AM BLOOD ALT-934* AST-135* AlkPhos-93 [**2128-10-12**] 05:58AM BLOOD Calcium-9.1 Phos-2.7 Mg-2.0 [**2128-10-5**] 12:56AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE IgM HAV-NEGATIVE [**2128-10-5**] 12:56AM BLOOD AMA-NEGATIVE Smooth-NEGATIVE Brief Hospital Course: 60F with frontotemporal dementia admitted after Tylenol overdose from suicide attempt. complains of ingestion of 70 tablets of extra strength Tylenol on Saturday at 1 pm, now with AMS, worsening LFTs, concerning for fulminent liver failure. . . #Tylenol overdose/Acute liver failure: Patient admitted to ingesting 70 tablets of extra strength Tylenol. She was admitted to the ICU with evidence of hepatic necrosis and synthetic liver dysfunction with encephalopathy and coagulopathy but without hyperbilirubinemia. She was treated with NAC protocol with improvement in mental status and coagulopathy. To rule out other causes of acute liver failure a RUQ US was obtained which showed normal hepatic vasculature and an AFP was wnl. Serologic workup for viral hepatitis and autoimmune liver diseases were negative. Her antipsychotic and anxiolytic medications were held in the setting of ALF but were restarted at low doses when liver chemistries, INR, and mental status improved. Her chemistries were not normal on discharge, but had been downtrending for a number of days and PCP was [**Name (NI) 653**] to recheck at follow up visit. # Coag negative staph bacteremia: This was felt to be a contaminant as it grew from only [**2-10**] bottles and patient did not have clinical evidence of infection. She was started on antibiotics during transplant evaluation but this was discontinued when liver function normalized. #Frontotemporal dementia: The patient's home medications were held and then restarted at lower dose (including Seroquel) when liver function normalized. #+UA: Patient was initially started on CTX but this was discontinued when UCx grew mixed flora and felt not to have true UTI. #Depression: Given severe depression with suicide attempt the patient was kept on suicide precautions. She was evaluated by inpatient Psychiatry who felt that patient would benefit from inpatient psychiatry admission. Given acute liver failure, home medications were held and were not restarted when liver function normalized as these would be managed by the patient's inpatient psychiatry facility to which the patient was discharged. Transitional Issues: # HTN: While hospitalized on the medical floor, the patient had SBPs 150s-170s. Before hospitalization, the patient was not on any anti-hypertensives medications. She was started on Metoprolol tartrate 25 mg [**Hospital1 **] with fair control of BPs and discharged on metoprolol succinate 50mg daily. Please follow her blood pressures and discontinue them if not necessary. It is possible some of her hypertension is related to anxiety and taking less than her home dose of Ativan. #Liver injury: The patient should have LFTs checked weekly until normal. Medications on Admission: ativan 1mg five times a day omeprazole 40mg [**Hospital1 **] citalopram 40mg QD premarin 0.3 QOD simvastatin 40mg QD Gabapentin 800mg TID Rivastigmine 3mg TID Seroquel 100mg TID Discharge Medications: 1. quetiapine 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 2. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 3. lorazepam 1 mg Tablet Sig: One (1) Tablet PO at bedtime as needed for insomnia. 4. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig: One (1) Tablet Extended Release 24 hr PO once a day. 5. Outpatient Lab Work please get liver function test including: AST, ALT, alkaline phosphatase, total bilirubin, albumin, and INR weekly Discharge Disposition: Extended Care Discharge Diagnosis: primary diagnosis: tylenol toxicity depression secondary diagnosis: frontotemporal dementia Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname **], It was a pleasure taking care of you while you were hospitalized at [**Hospital1 18**]. You were admitted to the hospital with tylenol toxicity. You were initially admitted to the intensive care unit and given a medication that helps treat the effects of tylenol toxicity. Your liver function tests were continually improving and will continue to be followed as an outpatient. Our transplant surgery evaluated you and felt that you did NOT need to have a liver transplant because your liver was improving on its own. Because of your improvement, you were transferred out of the intensive care unit and came to the medicine floor. While on the medicine floor, your mental status continued to improve and your liver function also started to get better. We also noted that your blood pressures were a little high while you were here and we started you on a blood pressure lowering medicine. We also started giving you some ativan at night before bed to help you sleep. You will be transferred to a psychiatric rehabilitation facility where you will continue to receive care. The psychiatry team there will assess you and restart the rest of your medications when it is safe to do so depending on your liver enzymes. The following changes were made to your medications: 1) START metoprolol succinate 50mg daily 2) DECREASE seroquel to 25mg three times daily 3) DECREASE ativan to 1mg at night as needed for sleep 4) STOP citalopram 5) STOP premarin 6) STOP simvastatin 7) STOP gabapentin 8) STOP rivastigmine Followup Instructions: Please make sure patient follows up with her outpatient Dr. [**Last Name (STitle) 28322**] [**Telephone/Fax (1) 90590**]. Completed by:[**2128-10-14**]

[ "401.9", "965.4", "287.5", "296.20", "300.02", "530.81", "348.30", "276.2", "E849.0", "787.91", "272.4", "E950.0", "570", "294.8" ]

icd9cm

[ [ [] ] ]

[ "38.97" ]

icd9pcs

[ [ [] ] ]

12648, 12663

9154, 11293

292, 320

12800, 12800

2988, 9131

14523, 14677

1993, 2039

12103, 12625

12684, 12684

11900, 12080

12951, 14500

2054, 2602

11314, 11874

1838, 1852

2616, 2969

236, 254

348, 1819

12753, 12779

12703, 12732

12815, 12927

1874, 1900

1916, 1977

58,551

185,208

37744

Discharge summary

report

Admission Date: [**2193-8-23**] Discharge Date: [**2193-9-7**] Date of Birth: [**2121-7-7**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 3326**] Chief Complaint: Respiratory Failure Major Surgical or Invasive Procedure: Bronchoscopies Pulmonary Stent placement, Right Bronchus Intermedius History of Present Illness: 72 y/o male with COPD, CAD s/p angioplasty in [**2180**], afib and small cell lung CA who started [**First Name9 (NamePattern2) 3454**] [**8-19**] with carboplatin/VP-16 in [**State 1727**]. He initially presented to SMMC on [**8-23**] with hypotension after accidental overdose on diltiazem. There, a CXR showed R lung white out and was transferred to [**Hospital1 18**] for bronch given concern for mass compression of the bronchus. Chest CT at [**Hospital1 18**] showed large centrally obstructing mass with right apical pneumothorax, right middle and lower lobe opacity, pigtail was placed. Patient was then bronched on [**8-24**] with purulent drainage, stent was placed and started on Vanco/Zosyn for presumed post-obstructive pneumonia. Patient continued to be intubated after the bronch and developed hypotension requiring pressors. Patient also noted to be neutropenic thought likely [**1-7**] [**Month/Day (2) 3454**] and sepsis and patient with afib with RVR on a dilt gtt. Patient self-extubated on [**8-26**] and was subsequently re-intubated for hypoxia and respiratory distress. A repeat bronch was performed to open collapse. He was also started on radiation chemotherapy to shrink the tumor in his chest. Past Medical History: Extensive Small Cell Lung Cancer COPD CAD Social History: From [**State 1727**]. Son lives with him in [**Hospital3 400**] Facility. Daughter [**Name (NI) 803**] in [**State 2690**] is Health Care Proxy. [**Name (NI) **] has also been close with step-son [**Name (NI) **]. Family History: Non-contributory Pertinent Results: [**2193-8-23**] 08:45PM BLOOD WBC-10.9 RBC-4.10* Hgb-12.1* Hct-38.0* MCV-93 MCH-29.6 MCHC-31.9 RDW-15.0 Plt Ct-150 [**2193-9-7**] 06:04AM BLOOD WBC-24.9* RBC-2.73* Hgb-8.4* Hct-25.2* MCV-92 MCH-30.8 MCHC-33.3 RDW-15.9* Plt Ct-116* [**2193-8-24**] 06:36PM BLOOD Neuts-93.4* Lymphs-4.5* Monos-0.9* Eos-1.1 Baso-0.2 [**2193-9-6**] 03:12AM BLOOD Neuts-71* Bands-18* Lymphs-2* Monos-2 Eos-0 Baso-0 Atyps-2* Metas-2* Myelos-3* [**2193-9-6**] 03:12AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-2+ Macrocy-1+ Microcy-1+ Polychr-1+ Spheroc-1+ Schisto-1+ Burr-OCCASIONAL Bite-1+ Acantho-OCCASIONAL [**2193-8-23**] 08:45PM BLOOD PT-12.0 PTT-26.6 INR(PT)-1.0 [**2193-9-2**] 03:27AM BLOOD PT-13.2 PTT-31.0 INR(PT)-1.1 [**2193-9-7**] 06:04AM BLOOD PT-16.1* PTT-150* INR(PT)-1.4* [**2193-8-29**] 03:33AM BLOOD Gran Ct-50* [**2193-9-1**] 04:43AM BLOOD Gran Ct-1770* [**2193-8-23**] 08:45PM BLOOD Glucose-88 UreaN-57* Creat-1.1 Na-138 K-5.2* Cl-107 HCO3-22 AnGap-14 [**2193-9-6**] 03:12AM BLOOD Glucose-131* UreaN-39* Creat-1.1 Na-137 K-4.1 Cl-102 HCO3-28 AnGap-11 [**2193-9-7**] 06:04AM BLOOD Glucose-240* UreaN-47* Creat-1.3* Na-134 K-4.7 Cl-98 HCO3-25 AnGap-16 [**2193-8-23**] 08:45PM BLOOD ALT-399* AST-464* AlkPhos-778* TotBili-1.3 [**2193-8-28**] 01:47PM BLOOD ALT-129* AST-118* AlkPhos-440* TotBili-1.5 [**2193-9-1**] 04:43AM BLOOD ALT-60* AST-63* AlkPhos-400* TotBili-0.9 [**2193-9-6**] 03:12AM BLOOD ALT-39 AST-72* LD(LDH)-530* AlkPhos-763* TotBili-0.9 [**2193-8-23**] 08:45PM BLOOD proBNP-1870* [**2193-8-24**] 01:26PM BLOOD cTropnT-<0.01 [**2193-8-28**] 01:47PM BLOOD proBNP-1157* [**2193-8-23**] 08:45PM BLOOD Calcium-7.7* Phos-4.0 Mg-2.5 [**2193-9-7**] 06:04AM BLOOD Calcium-7.3* Phos-4.0 Mg-1.9 [**2193-8-25**] 02:05AM BLOOD Osmolal-291 [**2193-8-24**] 04:41AM BLOOD TSH-0.53 [**2193-8-25**] 01:00PM BLOOD Cortsol-52.0* [**2193-8-25**] 02:05AM BLOOD Cortsol-16.5 [**2193-8-24**] 06:00AM BLOOD Type-ART pO2-74* pCO2-46* pH-7.33* calTCO2-25 Base XS--1 [**2193-8-28**] 05:57PM BLOOD Type-ART Temp-36.7 Rates-18/5 Tidal V-450 PEEP-10 FiO2-40 pO2-120* pCO2-36 pH-7.47* calTCO2-27 Base XS-3 Intubat-INTUBATED [**2193-9-6**] 02:35PM BLOOD Type-ART Temp-37.0 Rates-24/0 Tidal V-460 PEEP-15 FiO2-100 pO2-67* pCO2-49* pH-7.37 calTCO2-29 Base XS-1 AADO2-597 REQ O2-98 -ASSIST/CON Intubat-INTUBATED [**2193-9-7**] 10:08AM BLOOD Type-ART Temp-36.3 Rates-26/ Tidal V-600 PEEP-15 FiO2-100 pO2-52* pCO2-50* pH-7.33* calTCO2-28 Base XS-0 AADO2-630 REQ O2-100 Intubat-INTUBATED Vent-CONTROLLED [**2193-8-24**] 03:06PM BLOOD Glucose-83 Lactate-2.4* Na-133* K-4.9 Cl-105 [**2193-8-28**] 02:19PM BLOOD Lactate-1.6 [**2193-8-31**] 05:22AM BLOOD Lactate-2.6* [**2193-9-1**] 09:33AM BLOOD Lactate-3.4* [**2193-9-6**] 11:58AM BLOOD Lactate-2.3* Radiology Report CT CHEST W/CONTRAST Study Date of [**2193-8-24**] 12:49 AM IMPRESSION: 1. Occlusion of the right main bronchus from the surrounding nodular conglomerate mass, in keeping with diagnosis of lung cancer with complete collapse of the right lung and surrounding pleural effusion with pleural enhancing lesions probably metastases. Minimal left pleural effusion with associated airspace opacities at the left lung base, could be interstital lung disease, basilar atelectasis, mild aspiration, however, superinfection cannot be excluded. 2. Innumerous enlarged lymph nodes in the mediastinum and hila bilaterally concerning for metastatic deposits. 3. No PE or dissection of the thoracic aorta. 4. Innumerous liver lesions consistent with metastasis. Radiology Report CHEST (PORTABLE AP) Study Date of [**2193-8-24**] 9:50 AM IMPRESSION: 1. Moderate right apical pneumothorax, as communicated to Dr. [**Last Name (STitle) **] by telephone. 2. Large centrally obstructing mass with epicenter in right hilum. 3. Right mid and lower lung opacities, which may be due to post-obstructive atelectasis/pneumonitis, but reexpansion pulmonary edema is also possible in setting of recent thoracentesis. Radiology Report CT HEAD W/ & W/O CONTRAST Study Date of [**2193-8-25**] 8:45 AM IMPRESSION: No evidence of intracranial metastatic disease. MRI is more sensitive for small metastatic lesions. Aerosolized secretions in the left sphenoid sinus could indicate acute sinusitis. Radiology Report CT CHEST W/O CONTRAST Study Date of [**2193-8-25**] 8:45 AM IMPRESSION: 1. Patient status post right bronchus intermedius stent placement. Improved aeration of the right lung. Opacities in right upper lobe likely a combination of post-obstructive changes or metastatic disease. 2. Interval development of small-to-moderate right-sided pneumothorax. 3. No significant change in extensive metastatic disease including nodal conglomerate within the mediastinum and bilateral hilar regions, encasing the right main stem bronchus. 4. Extensive pleural plaques and pleural nodularity along with multiple lung nodules and liver lesions concerning for metastatic disease, unchanged. 5. Interval decrease in bilateral pleural effusions. No change in bilateral basilar airspace opacities. Radiology Report CHEST (PORTABLE AP) Study Date of [**2193-9-6**] 12:45 AM IMPRESSION: AP chest compared to [**9-4**]: Some of bibasilar opacification is due to persistent pulmonary edema, but the more severe abnormality on the left is pneumonia or pulmonary hemorrhage progressed since [**7-4**], accompanied by small to moderate left pleural effusion, has not appreciably changed. Although heart size is normal, mediastinal vascular engorgement suggests volume overload. Right bronchial stent noted. ET tube in standard placement. Nasogastric tube passes into the stomach and out of view. No pneumothorax. Brief Hospital Course: Mr. [**Name13 (STitle) 84549**] was a 72 year old male with COPD, CAD initially presented to an outside hospital on [**8-23**] with hypotension secondary to a diltiazem overdose, noted to have post-obstructive PNA and transferred to [**Hospital1 18**] on [**8-24**] for bronch and stent placement. He was then noted to have a pneumothorax requiring chest tube placement, then was transferred from the Surgical ICU to the Medical ICU for initiation of radiation therapy in the setting of continued hypoxic respiratory failure and hypotension requiring pressors. # Hypoxic Respiratory Failure: Patient was initially intubated for bronchoscopy and stent placement into his right bronchus intermedius/right mainstem to help alleviate obstruction from tumor burden. After the procedure, he was not able to be weaned due to complicated status of lungs. In addition to his underlying COPD and post-obstructive PNA secondary to lung tumor burden, his initial course was also complicated by a PNX. A chest tube was placed on the right side, which was to remain there for as long as patient would need mechanical ventilation. The patient had self-extubated once early during his hospitalization and required re-intubation for hypoxia and work of breathing. He had multiple bronchoscopies throughout hospitalization to evaluate for worsening respiratory status. He was started on empiric broad spectrum antibiotics for post-obstructive pneumonia and transferred to the MICU. He received Radiation Therapy to his chest to help shrink the pulmonary tumor and help prevent post-obstructive atelectasis. XRT has the potential to cause increased edema in the lungs, for which the team monitored. After re-intubation, the patient was maintained mostly on Assist Control ventilation. He was not able to tolerate trials of Pressure Support, which had resulted in increased agitation, exacerbation of his rapid Afib and subsequent hypotension. After two weeks of intubation, the patient's respiratory status began to acutely decline further. His children and step-children came to the decision to make him CMO and extubate. The patient was extubated and taken off pressors and expired very soon afterwards. . #Hypotension: Mr. [**Last Name (Titles) 84550**] hypotension was secondary to sepsis from his complicated pneumonia. Additionally, when he had Afib with rapid RVR, his blood pressure would drop further. His blood pressure was supported by norepinephrine for much of his ICU stay. . #Pancytopenia: His pancytopenia was secondary to the chemotherapy he had received for metastatic small cell lung cancer within a week before hospitalization. The patient was initially neutropenic but recovered his blood counts within a couple of weeks. His blood counts were briefly supported with neupogen in addition to pRBC and platelet transfusions. While neutropenic, he was especially susceptible to infection, which likely contributed to the severity of his pneumonia. . #Transaminitis: The patient's elevated LFTs were thought to be secondary to his chemotherapy regimen and trended down slowly with time. He likely had a baseline LFT elevation due to his known liver metastases. . #Afib: Patient had a history of Afib, for which he took sotalol and diltiazem at home. These medicines were continued for the majority of his ICU stay. When the patient became agitated, his ventricular rate would rapidly rise into the 140s and contribute to hemodynamic instability. Because the patient also had a pressor requirement to maintain his blood pressure, the sotalol was discontinued, while the diltiazem was continued at more frequent dosing. He was not anticoagulated during his stay due to his initial pancytopenia. . #Small Cell Lung CA: The patient had extensive small cell lung cancer with known lung metastases and was status post a recent round of chemotherapy. Head CT with and without contrast showed no metastases. Per Oncology team, the patient would have had a reasonable expectation for extending life by up to 5-6 months if he were able to continue chemotherapy, but he was very unlikely to be able to be ready for another round of chemotherapy (considering that his platelet count had not yet recovered, he was still intubated, and he was still requiring pressors). In addition, if this past round of chemotherapy had caused such significant complication for the patient, he would have been likely to develop further complications with another round even if he could have recovered this time. He received 5 doses of palliative radiation therapy to his chest to try to reduce the size of the tumor during his hospitalization. Medications on Admission: Sotalol 80BID Cardizem 108 q day Flovent Proventil Pravastatin Dilt SR 100 daily Lisinopril 30 daily Metoprolol 50 daily Aspirin 81 daily Discharge Medications: None. Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: None. Followup Instructions: None.

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icd9cm

[ [ [] ] ]

[ "33.91", "38.91", "34.09", "96.72", "33.23", "96.04", "99.05", "34.91", "99.25", "99.04", "92.29", "96.71", "96.05", "38.93" ]

icd9pcs

[ [ [] ] ]

12510, 12519

7643, 12292

333, 403

12570, 12579

2012, 7620

12633, 12641

1975, 1993

12480, 12487

12540, 12549

12318, 12457

12603, 12610

274, 295

431, 1661

1683, 1726

1742, 1959

17,000

154,104

30859

Discharge summary

report

Admission Date: [**2171-3-18**] Discharge Date: [**2171-3-29**] Date of Birth: [**2089-4-21**] Sex: F Service: NEUROSURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1835**] Chief Complaint: Transfer with cerebellar hemorrhage Major Surgical or Invasive Procedure: Placement External ventricular drain History of Present Illness: HPI: 8 1 y/o female with past medical history of afib on coumadin, Breast CA, Depression, Back pain and falls. Pt reports falling at home today while getting dressed for bed. She was taken to an outside hospital and found to have a left cerebellar bleed with an INR of 4.0 Past Medical History: PMHx: AFib, Breast CA, Depression/Aniexty, falls All: NKDA Social History: Social Hx:Widowed, lives alone, non smoker no alcohol Family History: Family Hx: Unknown Physical Exam: PHYSICAL EXAM: O: T:97.8 BP:184/109 HR:66 R27 O2Sats 90% Gen: WD/WN, comfortable on stretcher complaing about collar HEENT: Pupils: 3.5-3.0 EOMs full Neck: in collar. Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Ecchymosis left shoulder left knee Neuro: Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: [**1-19**] objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light,3.5 to 3.0 mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**3-23**] throughout. No pronator drift Sensation: Intact to light touch, Toes downgoing bilaterally Coordination: normal on finger-nose-finger, CT/MRI: 3X2.7cm hemorrhage in left cerbellar hemisphere with mild comprression of 4th ventricle with no sign of hydrocephlus Pertinent Results: CT/MRI: 3X2.7cm hemorrhage in left cerbellar hemisphere with mild compression of 4th ventricle with no sign of hydrocephlus. CTA chest with contrast 1. Right lower lobe mass measuring 2.2 x 2.2 cm and smaller left upper lobe 3 mm nodule. 2. No pulmonary embolism. 3. Prominent caliber of pulmonary artery raising question of pulmonary hypertension. [**2171-3-18**] 03:25AM GLUCOSE-193* UREA N-12 CREAT-0.6 SODIUM-134 POTASSIUM-3.7 CHLORIDE-93* TOTAL CO2-29 ANION GAP-16 [**2171-3-18**] 03:25AM WBC-12.0* RBC-4.37 HGB-15.2 HCT-44.6 MCV-102* MCH-34.9* MCHC-34.2 RDW-14.9 [**2171-3-18**] 03:25AM PLT COUNT-229 [**2171-3-18**] 03:25AM PT-24.9* PTT-31.1 INR(PT)-2.5* [**2171-3-28**] 135 96 15 118 AGap=17 4.6 27 0.7 Ca: 9.4 Mg: 1.8 P: 3.3 106 10.3 13.2 291 38.7 Brief Hospital Course: The patient is an 81 year old woman with a history of AF (on coumadin), breast cancer, back pain, depression and anxiety and previous falls who presented with headache following a fall. CT showed a left cerebellar hemorrhage. Her INR was supratherapeutic on admission at 4. Coagulopathy was reversed with proplex, FFP and vitamin K. She was also treated with dexamethasone. External ventricular drain was placed on [**2171-3-18**]. Blood pressure was carefully monitored. She had some fluctuation in level of consciousness but overall gradual improvement. Serial CT scans have been stable. The EVD was clamped on [**2171-3-25**]. CT remained stable and the drain was removed on [**2171-3-26**]. She was transferred to the floor on [**2171-3-27**]. Sutures from the main scar were removed on [**2171-3-28**]. There is one remaining suture over the EVD drain site which should be removed on [**2171-4-2**]. At the time of discharge she was oriented x2 (person and time, not place), following commands, with EOMI, left facial droop and good bilateral strength. Sensation and proprioception were intact and the wound was in good condition. CTA and MRI of the head with contrast did not clearly show underlying mass. Repeat MRI/MRS [**Last Name (STitle) **] attempted to further assess possibility of underlying mass lesion and studies were limited, showing evolving hemorrhage stable in size. It was not possible to be definitive regarding presence/absence of mass. Repeat CT head in 6 weeks has been arranged and follow up with Dr [**Last Name (STitle) **]. Her respiratory status declined on [**2171-3-22**] and there was concern for PE. CTA was negative for PE but did reveal a right lower lobe mass measuring 2.2 x 2.2 cm and smaller left upper lobe 3 mm nodule with mediastinal lymphadenopathy. She was seen by the thoracic surgery team who recommended outpatient management to include PET scan and core needle biopsy. The need for follow up was discussed with Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (PCP) who will arrange follow up Pulmonology consultation. CD of chest CT will be forwarded to her office as discussed with patient and family. AF and blood pressure were managed with metoprolol. There was no AF with RVR. Coumadin could be restarted at low dose on Monday [**2171-4-1**] (14 days after admission) with careful monitoring of INR to avoid supratherapeutic INR range (goal 2.0-2.5). Mrs [**Known lastname 73021**] has fragile skin and wounds including right forearm (overlying skin intact) and left biceps (unroofed skin), small dry scabs on heels and several on knees were reviewed by wound care service. No evidence of infection. She needs pressure cares for heels, daily irrigation, pat dry with gauze, dressing with adaptic to L bicep and right heel secured with Kerlix. Diet: soft solids with nectar thick liquids. The patient was seen by PT and OT. She will be discharged to [**Hospital **], Wobern for ongoing recovery. Medications on Admission: Medications prior to admission: Coumadin, Lopressor, Ativan, Serroquel, Reglan, Paxil Discharge Medications: 1. Docusate Sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 2. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 3. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation every 4-6 hours as needed. 4. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 7. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 8. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Quetiapine 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 10. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO every [**2-22**] hours as needed for pain. 11. Restart medication Restart coumadin on Monday [**4-1**] at low dose with careful INR monitoring to avoid supratherapeutic range. Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: Left cerebellar hemorrhage Right lung mass AF Discharge Condition: Neurologically stable Discharge Instructions: DISCHARGE INSTRUCTIONS FOR CRANIOTOMY/HEAD INJURY ?????? Have a family member check your incision daily for signs of infection ?????? Take your pain medicine as prescribed ?????? Exercise should be limited to walking; no lifting, straining, excessive bending ?????? You may wash your hair only after sutures and/or staples have been removed ?????? You may shower before this time with assistance and use of a shower cap ?????? Increase your intake of fluids and fiber as pain medicine (narcotics) can cause constipation ?????? Unless directed by your doctor, do not take any anti-inflammatory medicines such as Motrin, aspirin, Advil, Ibuprofen etc. ?????? If you have been prescribed an 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 Restart coumadin on Monday [**2171-4-1**]. Followup Instructions: PCP Dr [**Last Name (STitle) **] (replacing Dr [**Last Name (STitle) 55474**] for general check and follow up of nodule seen in the right lung. Follow up with Dr [**Last Name (STitle) **] Neurosurgery afterv head CT [**2171-4-30**] Nothing to eat or drink from 10am, then 1.45pm for CT on West Clinical Centre Radiology Dept, followed by Dr [**Last Name (STitle) **] at 2.45pm [**Hospital Unit Name **] [**Last Name (NamePattern1) **]. ph [**Telephone/Fax (1) 2731**] with questions. Restart coumadin on Monday [**4-1**] at low dose and monitor INR carefully to avoid supratherapeutic dose (goal 2-2.5). Remove x1 suture from scal wound on [**2171-4-2**].

[ "799.02", "V10.3", "E888.9", "786.6", "853.00", "427.31", "787.2", "293.0", "V45.61", "401.9", "790.92", "311" ]

icd9cm

[ [ [] ] ]

[ "96.6", "02.2", "99.07" ]

icd9pcs

[ [ [] ] ]

7306, 7378

3139, 6127

356, 395

7468, 7492

2334, 3116

8922, 9585

872, 892

6264, 7283

7399, 7447

6153, 6153

7516, 8899

922, 1195

6185, 6241

280, 318

423, 700

1488, 2315

1210, 1472

722, 784

800, 856

81,295

118,987

42162

Discharge summary

report

Admission Date: [**2199-9-2**] Discharge Date: [**2199-10-1**] Date of Birth: [**2118-9-1**] Sex: M Service: CARDIOTHORACIC Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 922**] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: [**2199-9-16**] - Redo Sternotomy, Aortic Valve Replacement (27mm [**Company 1543**] Mosaic Ultra Porcine) History of Present Illness: Mr. [**Known lastname **] is an 81 year old man with a diabetes, squamous cell carcinoma of the neck s/p resection, hypertension, coronary artery disease, severe aortic stenosis, and anemia who presented to [**Hospital6 3105**] with a syncopal episode on [**2199-8-27**]. Prior to this event, he had been complaining of worsening lower extremity edema, dyspnea on exertion and orthopnea for two months. On [**2199-8-27**], he was bending forward when he fell over and hit the floor with his head. At [**Hospital6 3105**], CT head without contrast [**Hospital6 3780**] stable volume loss and microvascular ischemic changes but no acute changes. An echocardiogram performed at [**Hospital6 3105**] on [**2199-8-28**], which [**Date Range 3780**] mild concentric left ventricular hypertrophy with an ejectino fraction of 55%, severe aortic stenosis 0.64 cm2, and mean gradient 57 mmHg. Cardiac catheterization was performed on [**2199-8-30**] with visualization of clean grafts. Upon presentation to [**Hospital6 3105**], he was found to have acute on chronic kidney injury with a creatinine of 2.2. Lisinopril and lasix were held, and the creatinine downtrended to 1.4 upon discharge. Upon presentation, he was also found to be anemic with iron deficiency anemia (ferritin of 7). Fecal occult blood was positive, and he was scheduled for a colonoscopy. Febrile to 101 degrees on [**9-1**], and was started on vancomycin and levaquin for pneumonia as a chest film [**Month/Year (2) 3780**] a right basilar infiltrate. Also of note, on [**9-1**] he went into atrial fibrillation and metoprolol 12.5mg [**Hospital1 **] was restarted. Upon arrival to the floor at [**Hospital1 18**], Mr. [**Known lastname **] was tachycardic to 130's in atrial fibrillation. He was also borderline febrile to 100. Otherwise, he was oxygenating well and was hemodynamically stable. He complained of pleuritic right sided chest pain, but was otherwise without complaint. Past Medical History: Aortic Stenosis Diabetes Hypertension hyperlipidemia CABG: in [**2182**] CKD -baseline Cr 1.4 Skin cancer to his R neck SCC s/p resection in [**2193**] Pneumonias in past Glaucoma BPH Social History: Mr. [**Known lastname **] has lived in [**Location 86**] since [**2155**]. He lives with his wife, his daughter and son. [**Name (NI) **] emigrated from [**Country 6257**]. He quit smoking 24 years ago, and reports having smoked 40 pack years. He denies alcohol or ellicit drug use. Family History: non-contributory. Physical Exam: ADMISSION EXAM:64" 80kg ( pre-op) VS: T=100.5.BP=137/75.HR=110.RR=20-30.O2 sat=98% on 3L GENERAL: elderly frail man in NAD. Oriented x3. Portuguese speaking only. Mood, affect appropriate. HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: JVD unable to determine given altered neck anatomy CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. II/VI systolic ejection murmur. No thrills, lifts. No S3 or S4. LUNGS: Resp were labored, bibasilar crackles were present, no accessory muscle use. ABDOMEN: Soft, obese and distended No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominial bruits. EXTREMITIES: 2+ peripheral edema. No femoral bruits. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ . DISCHARGE EXAM: Same as above except for the following: VS: T= BP=.HR=.RR=.O2 sat=% Pertinent Results: [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname 831**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 91441**] (Complete) Done [**2199-9-16**] at 3:23:48 PM PRELIMINARY Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) 177**] C. [**Hospital Unit Name 927**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2118-9-1**] Age (years): 81 M Hgt (in): 64 BP (mm Hg): 135/55 Wgt (lb): 176 HR (bpm): 62 BSA (m2): 1.85 m2 Indication: Atrial fibrillation. Chest pain. Coronary artery disease. Hypertension. Left ventricular function. Preoperative assessment. Shortness of breath. Valvular heart disease. Intraoperative TEE for AVR. Aortic valve disease. ICD-9 Codes: 402.90, 427.31, 786.05, 424.1 Test Information Date/Time: [**2199-9-16**] at 15:23 Interpret MD: [**Name6 (MD) 1509**] [**Name8 (MD) 1510**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2011AW-:1 Machine: us3 Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Septal Wall Thickness: *1.4 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.5 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 5.4 cm <= 5.6 cm Left Ventricle - Ejection Fraction: 50% >= 55% Left Ventricle - Stroke Volume: 62 ml/beat Left Ventricle - Cardiac Output: 3.87 L/min Left Ventricle - Cardiac Index: 2.09 >= 2.0 L/min/M2 Left Ventricle - Lateral Peak E': *0.05 m/s > 0.08 m/s Left Ventricle - Septal Peak E': *0.00 m/s > 0.08 m/s Left Ventricle - Ratio E/E': *32 < 15 Aorta - Annulus: 2.5 cm <= 3.0 cm Aorta - Sinus Level: 3.2 cm <= 3.6 cm Aorta - Sinotubular Ridge: 2.5 cm <= 3.0 cm Aorta - Ascending: 3.2 cm <= 3.4 cm Aorta - Arch: 2.7 cm <= 3.0 cm Aorta - Descending Thoracic: 2.3 cm <= 2.5 cm Aortic Valve - Peak Velocity: *5.0 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: *100 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 49 mm Hg Aortic Valve - LVOT VTI: 18 Aortic Valve - LVOT diam: 2.1 cm Aortic Valve - Valve Area: *0.6 cm2 >= 3.0 cm2 Mitral Valve - E Wave: 0.8 m/sec Mitral Valve - A Wave: 0.3 m/sec Mitral Valve - E/A ratio: 2.67 Findings LEFT ATRIUM: Mild spontaneous echo contrast in the body of the LA. Mild spontaneous echo contrast in the LAA. Good (>20 cm/s) LAA ejection velocity. RIGHT ATRIUM/INTERATRIAL SEPTUM: A catheter or pacing wire is seen in the RA and extending into the RV. Left-to-right shunt across the interatrial septum at rest. Small secundum ASD. LEFT VENTRICLE: Moderate symmetric LVH. Normal LV cavity size. Mild regional LV systolic dysfunction. Low normal LVEF. TDI E/e' >15, suggesting PCWP>18mmHg. Doppler parameters are most consistent with c/w Grade II (moderate) LV diastolic dysfunction. RIGHT VENTRICLE: Mildly dilated RV cavity. Borderline normal RV systolic function. TASPE normal (>=1.6cm) AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. Complex (mobile) atheroma in the aortic arch. Normal descending aorta diameter. Complex (>4mm) atheroma in the descending thoracic aorta. AORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Critical AS (area <0.8cm2). Moderate (2+) AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Moderate mitral annular calcification. No MS. Mild to moderate ([**12-16**]+) MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Mild [1+] TR. PULMONIC VALVE/PULMONARY ARTERY: Physiologic (normal) PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: A TEE was performed in the location listed above. I certify I was present in compliance with HCFA regulations. The patient was under general anesthesia throughout the procedure. No TEE related complications. The rhythm appears to be atrial fibrillation. Results were personally reviewed with the MD caring for the patient. See Conclusions for post-bypass data REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-BYPASS: Mild spontaneous echo contrast is seen in the body of the left atrium. Mild spontaneous echo contrast is present in the left atrial appendage. A left-to-right shunt across the interatrial septum is seen at rest. A small secundum atrial septal defect is present. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with hypokinesia of the apex.. Overall left ventricular systolic function is low normal (LVEF 50%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Doppler parameters are most consistent with Grade II (moderate) left ventricular diastolic dysfunction. The right ventricular cavity is mildly dilated with borderline normal free wall function. There are complex (mobile) atheroma in the aortic arch. There are complex (>4mm) atheroma in the descending thoracic aorta. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Mild to moderate ([**12-16**]+) mitral regurgitation is seen. There is no pericardial effusion. Dr. [**Last Name (STitle) 914**] was notified in person of the results on [**2199-9-16**] at 1345. POST-BYPASS: Patient is AV paced and receiving an infusion of phenylephrine and epinephrine. LVEF= 55%. RV function much improved. Bioprosthetic valve seen in the aortic position. It appears well seated and leaflets move well. No aortic insufficiency seen. Mean gradient across the aortic valve is 9 mm Hg. [**12-16**]+ mitral regurgitation present. Aorta is intact post decannulation. Brief Hospital Course: Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] on [**2199-9-2**] for further management of his aortic stenosis. He initially presented to an outside hospital after a syncopal episode as well as several months of lower extremity edema and exertional chest pain. Mr. [**Known lastname **] [**Last Name (Titles) 3780**] severe symptomatic AS (valve area < 0.8 cm2 with associated chronic congestive heart failure (EF 35-40%). While on the cardiology floor, Mr. [**Known lastname **] was initially gently diuresed with subsequent improvement in his dyspnea and edema; he continued to self-diurese and had no dyspnea prior to his surgery. Cardiothoracic surgery was consulted and recommended surgical aortic valve replacement. He was worked-up in the usual preoperative manner. On [**2199-9-16**], He was taken to the operating room where he underwent a redo sternotomy with replacement of his aortic valve using a 27mm [**Company 1543**] Mosaic ultra porcine valve. Please see operative note for details. Postoperatively he was taken to the intensive care unit for monitoring. Over the next svereal hours, he awoke neurologically intact and was extubated. He was transfused to maintain a hematocit of 25% or better. On postoperative day 2, 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. On POD#4 he developed abd pain, nausea and hypoactive bowel sounds. KUB revealed retained barium in colon from a study done on [**2199-9-13**]. He was placed on an aggressive bowel regimen and made NPO with slow improvement. General surgery was consulted and agreed with management plan. After days of aggressive bowel regimen he began passing barium. His diet was resumed and was well toelrated. During this time he also developed afib and given his pre-op bradycardia, the cardiology service was consulted and recommended amiodarone and betablockers. He became bradycardic to the 30's and was transferred back to the ICU for monitoring. The cardiology service was again consulted and his betablocker and amiodarone were held and once his heart rate recovered, the amiodarone was resumed without further bradycardia. He was started on coumadin for afib. Hypertension was treated with amlodipine and hydralazine. . # Anemia: In light of Mr. [**Known lastname **] iron deficiency anemia and positive fecal occult blood at the OSH, colon cancer was entertained as a potential cause. Iron deficiency anemia with positive occult blood. Colonoscopy and EGD could not be obtained due to high anesthesia risk. CT abdomen/pelvis, Liver MRI, and barium swallow were performed instead as per GI recs. He was cleared by GI for the AVR, which was performed on [**2199-9-16**]. Iron was not started post-op due to ileus. Mr. [**Known lastname **] was transfused with PRBC for post-op anemia. . # Acute on Chronic CKD: Mr. [**Known lastname **] Creat was elevated at 1.9 on admission from a baseline of 1.4. During this admission, his Creat ranged from 1.6 to 2.0. In light of his poor renal function, lisinopril was held and lasix was stopped. # Pulmonary nodules discovered on CT chest w/o contrast, this will require follow up in [**2-17**] months. Possible exophytic renal mass also seen on CT chest, but further evaluated with renal US and was found to be simple renal cyst which will not require follow up. will need daily labs for the next 3 days until creat stable. . # Dyspnea/Pneumonia: Upon presentation, Mr. [**Known lastname **] was treated with vanc/cefepime for a presumptive pneumonia given leukocytosis, fever, and possible infiltrate on OSH CXR. On the second day of admission, however, a pre-operative CT did not demonstrate any infiltrates suggestive of pneumonia. Antibiotics were then discontinued. Continued to make good progress and was cleared for discharge to [**Hospital3 **]- [**Location (un) 8957**] on POD # 15. All f/u appts were advised. Target INR 2.0-2.5 for A Fib. First INR check day after discharge. Medications on Admission: Confirmed with family: Lisinopril 10mg daily metoprolol 50mg [**Hospital1 **] oxybutinin 5mg daily ASA 81mg Simvastatin 20mg daily finasteride 5mg daily furosemide 20mg TID Insulin levemir 45 units at night latananoprost 0.005% qhs brimonidine 0.15% [**Hospital1 **] Xopenex [**Hospital1 **] Combivent PRN. Discharge Medications: 1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. polyethylene glycol 3350 17 gram/dose Powder Sig: Seventeen (17) gm PO DAILY (Daily). 4. oxybutynin chloride 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 5. brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q8H (every 8 hours): both eyes OU. 6. latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime): both eyes OU. 7. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. ipratropium-albuterol 18-103 mcg/Actuation Aerosol Sig: [**12-16**] Puffs Inhalation Q6H (every 6 hours) as needed for wheezing. 9. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 10. amiodarone 200 mg Tablet Sig: One (1) Tablet PO once a day for 1 months. 11. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain. 13. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 14. bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal DAILY (Daily). 15. erythromycin 250 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q6H (every 6 hours) for 5 days. 16. acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. 17. simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 18. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: goal INR 2-2.5, plan for INR check [**10-2**] for further dosing . 19. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 20. Norvasc 10 mg Tablet Sig: One (1) Tablet PO once a day. 21. Lantus 100 unit/mL Solution Sig: Thirty (30) units Subcutaneous once a day: continue to titrate up - home dose is 45 units . 22. insulin Sliding scale Humalog Breakfast Lunch Dinner Bedtime Humalog Humalog Humalog Humalog 71-100 mg/dL 0 Units 0 Units 0 Units 0 Units 101-140 mg/dL 3 Units 3 Units 3 Units 0 Units 141-180 mg/dL 5 Units 5 Units 5 Units 1 Units 181-220 mg/dL 7 Units 7 Units 7 Units 3 Units 221-280 mg/dL 9 Units 9 Units 9 Units 6 Units 23. Norvasc 10 mg Tablet (see above) 24. folate Sig: One (1) once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) 8957**] Discharge Diagnosis: Severe Aortic Stenosis Coronary Artery Disease (prior bypass in [**2183**]) postop ileus postop A Fib /intermittent bradycardia L renal cyst Hypertension Hyperlipidemia (high cholesterol) Chronic Kidney Disease History of Skin Cancer Glaucoma Benign Prostatic Hypertrophy pulmonary nodule Discharge Condition: Alert and oriented x3 nonfocal speaks primarily Portugese Ambulating with one assist Incisional pain managed with ultram prn Incisions: Sternal - healing well, no erythema or drainage Left groin with mild erythema small amount serous drainage - continue with [**Hospital1 **] drsg [**Name5 (PTitle) 4245**] with [**Name5 (PTitle) **] Edema +1 bilateral lower extremities Discharge Instructions: 1) Please shower daily including washing incisions gently with mild soap, no baths or swimming until cleared by surgeon. Look at your incisions daily for redness or drainage. 2) Please NO lotions, cream, powder, or ointments to incisions. 3) Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart provided. 4) No driving for approximately one month and while taking narcotics. Driving will be discussed at follow up appointment with surgeon when you will likely be cleared to drive. 5) No lifting more than 10 pounds for 10 weeks 6) Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments Surgeon: Dr.[**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 914**] ([**Telephone/Fax (1) 1504**] on [**10-22**] at 3:30pm in the [**Hospital **] medical office building [**Hospital Unit Name **]. [**Doctor First Name **],[**Hospital Unit Name **],[**Location (un) 86**] Dr. [**Last Name (STitle) **] (Electrophysiology) [**Location (un) **] 417 in one month. ([**Telephone/Fax (1) 3942**]. Please schedule an appointment. Cardiologist Dr. [**Last Name (STitle) 67247**] [**Telephone/Fax (1) 37284**] on [**10-16**] at 12:15pm in the [**Location (un) 7661**] office. Please call to schedule appointments with your Primary Care Dr. [**Last Name (STitle) 29065**] in 4 weeks Labs: PT/INR for Coumadin ?????? indication Atrial Fibrillation Goal INR 2.0-2.5 First draw [**10-2**] wednesday Coumadin to be managed by rehab physician Please check INR monday, wednesday and friday for the first two weeks and then as directed by physician ***please arrange for coumadin/INR f/u prior to discharge from rehab ** You will need a iron panel with Dr. [**Last Name (STitle) 29065**] as an outpatient for further evaluation of your iron deficiency anemia, ***as well as a chest CT in [**2-17**] months to follow the pulmonary nodule **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2199-10-1**]

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11106

Discharge summary

report

Admission Date: [**2180-12-30**] Discharge Date: [**2181-3-7**] Date of Birth: [**2110-12-26**] Sex: M Service: SURGERY Allergies: Morphine Attending:[**First Name3 (LF) 473**] Chief Complaint: Hypotension Major Surgical or Invasive Procedure: None History of Present Illness: 70 yo male with recent pancreatitis from pancreatic CA on TPN sent in for fever and hypotension SBP70s concerning for sepsis. Mr. [**Known lastname 35831**] was discharged from [**Hospital1 18**] to [**Hospital3 105**] in [**Location (un) 38**] on [**2180-12-20**]. he has been admitted to the [**Hospital1 **] for sork-up for a newly identified pancreatic mass found during a recent episode of gallstone pancreatitis. ERCP was unable to perform sphincerotomy or obtain brush sample secondary to significant inflammation and edema. The patient was sent to [**Location (un) **] NPO on TPN for bowel rest in the hope that there would be a redcution in the edema so that a Whipple procedure might be possible. He states that he was in his usual state of health at [**Location (un) 38**] until his TPN was switched from a 12 hour cycle to a 16 hour cycle. He states that he then began to have severe, non-bloody diarrhea - up to 20 bowel movements a day. Patient states that he has been unable to sleep at all for the last several days. Per report from the OSH, TPN was switched on [**12-28**] and diarrhea began. On [**12-29**], mental status changed were noted and the patient refused all medications. WBC count rose to 14.2 but the patient remained afebrile. Stools were sent for c.diff and are pending. This am temp was 102, BP 85/50, HR 105, RR 20 and )2 97%. Fever work-up was initiaited with UA, CXR, KUB, BCx2, and repeat CBC. NS was started and the patient was transferred with a BP of 100/60, HR 105 and T 102.8. In the ED, T 100.3, BP 97/57 HR 103 and RR 16. Patient given IV Vanc, Levo, and Flagyl. he also received 2 liters of fluid, a CXR was performed in addition to blood cultures. LIJ was placed. Patient was transferred to the ICU for further management fo sepsis Past Medical History: Pancreatitis s/p ERCP. Details above. CAD , history of MI [**2174**], CABG s/p AICD (followed by Dr [**Last Name (STitle) **] at [**Hospital1 18**]) Asthma Hyperlipidemia s/p TURP Diverticulitis Hypertension, benign Hard of hearing, mild Small unbilical hernia Social History: Smoking: 40 pack year (quit in [**2158**]). H/o social alcohol use. Quit in [**2160**]. One time use thereafter 2 yrs back. None since then. No illicit drug use. Retired mechanic. Lives in his home. Grandson who is 26 lives with him. Has a fiance' who lives across the street. Wants fiance, Ms [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5239**] to be his health care proxy. Family History: MI (father), ovarian cancer (mother) Wife - smoker, dementia. Deceased many years back. Physical Exam: Gen: VS: T98.1F P 89 RR 28 BP 98/56 O2 sats: 96% RA. No acute distress. Obese man lying in bed. Eyes: PERRL, no pallor or icterus ENT: Moist oral mucosae. No ulcers or thrush. No exudates or erythema. Wears dentures CV: S1,2 regular. No murmurs, rubs or gallops. Peripheral vascular access. RS: No crackles or wheezes. Abd: Soft, obese. Bowel sounds heard and normal. Mild tenderness to palpation in RUQ. No rebound tenderness or guarding. No masses palpable but limited exam given obesity. Umbilical hernia seen. MSK- Extremeties: No cyanosis, clubbing, No joint swelling. No peripheral LE edema. Neuro: Alert and oriented. Normal attention. Fluent speech. Skin: no rashes or ulcers noted. Psychiatric: Appropriate, pleasant. Pertinent Results: [**2180-12-30**] 01:30PM HYPOCHROM-NORMAL ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL [**2180-12-30**] 01:30PM NEUTS-93.2* BANDS-0 LYMPHS-4.2* MONOS-1.9* EOS-0.7 BASOS-0.1 [**2180-12-30**] 01:30PM WBC-14.8*# RBC-3.89* HGB-11.4* HCT-32.2* MCV-83 MCH-29.2 MCHC-35.3* RDW-15.4 [**2180-12-30**] 01:30PM ACETONE-NEGATIVE [**2180-12-30**] 01:30PM ALBUMIN-2.6* CALCIUM-8.0* PHOSPHATE-4.0 MAGNESIUM-1.9 URIC ACID-1.8* [**2180-12-30**] 01:30PM cTropnT-0.02* [**2180-12-30**] 01:30PM LIPASE-54 [**2180-12-30**] 01:30PM ALT(SGPT)-34 AST(SGOT)-29 LD(LDH)-199 CK(CPK)-21* ALK PHOS-68 AMYLASE-62 TOT BILI-0.4 [**2180-12-30**] 01:30PM GLUCOSE-152* UREA N-45* CREAT-1.4* SODIUM-134 POTASSIUM-4.1 CHLORIDE-101 TOTAL CO2-20* ANION GAP-17 [**2181-3-7**] 03:44AM BLOOD WBC-9.6 RBC-3.26* Hgb-10.1* Hct-30.5* MCV-94 MCH-31.1 MCHC-33.2 RDW-17.6* Plt Ct-196# [**2181-3-7**] 03:44AM BLOOD Glucose-91 UreaN-15 Creat-0.7 Na-139 K-3.7 Cl-101 HCO3-33* AnGap-9 [**2181-2-27**] 07:04PM BLOOD ALT-36 AST-32 AlkPhos-720* Amylase-68 TotBili-1.9* [**2181-2-27**] 07:04PM BLOOD Lipase-68* [**2181-2-27**] 06:43PM BLOOD CK-MB-NotDone cTropnT-0.05* [**2181-3-4**] 02:12PM BLOOD Albumin-2.3* Calcium-7.3* Phos-1.8* Mg-2.0 [**2181-1-21**] 03:26AM BLOOD calTIBC-77* Ferritn-476* TRF-59* [**2181-1-21**] 03:26AM BLOOD Triglyc-111 [**2181-2-20**] 03:08AM BLOOD TSH-2.5 [**2181-2-20**] 03:08AM BLOOD T4-4.8 T3-50* [**2181-2-28**] 02:13AM BLOOD Digoxin-2.0 . CHEST PORT. LINE PLACEMENT [**2181-3-5**] 3:14 PM FINDINGS: In comparison with the study of [**2-28**], there is little change in the appearance of the heart and lungs. Low lung volumes persist with some opacification at the left base that could represent some combination of pleural effusion and atelectasis. The right subclavian PICC line extends to the lower portion of the SVC. . ECHO Conclusions No spontaneous echo contrast or clotis seen in the body of the left atrium. . There are simple atheroma in the descending thoracic aorta. There are three mildly thickened aortic valve leaflet with trace aortic regurgitation. There is no vegetation on the aortic valve. The mitral valve leaflets are mildly thickened with mild (1+) mitral regurgitation but no vegetation. No clear vegetation or regurgitation is seen on the tricuspid or pulmonic valve. The atrial and ventricular ICD leads are visualized and there are no massess or vegetations on the leads. The atrial lead terminates in the right atrial appendage. IMPRESSION: no evidence of endocarditis or myocardial abscess on TEE. . CTA CHEST W&W/O C&RECONS, NON-CORONARY [**2181-2-27**] 8:59 PM IMPRESSIONS: 1. No evidence of pulmonary embolus. 2. Post-surgical changes of Whipple, with moderate fat stranding in the surgical bed, but no evidence of discrete fluid collection to suggest abscess. 3. Enlarged lymph nodes in the chest are nonspecific. 4. Improving hepatic retractor injury. 5. Stable right adrenal nodule. . LIVER OR GALLBLADDER US (SINGLE ORGAN) [**2181-2-22**] 9:03 PM IMPRESSION: Evolution of left hepatic lobe lesion which is now more ill- defined with mixed echogenicity suggests that this was related to acute injury as previously described. No other focal hepatic lesions. No biliary ductal dilatation. Small amount of fluid around the liver edge. Right pleural effusion incompletely imaged. . CT ABDOMEN W/CONTRAST [**2181-2-15**] 9:22 AM IMPRESSION: 1. Status post Whipple procedure and removal of surgical bed drains. A couple of foci of gas are consistent with removal of the drainage catheters, but no new fluid collections identified. 2. Decrease in size of a left lobe hepatic lesion likely reflecting retractor injury. 3. Increased bilateral pleural effusions and atelectasis. 4. Right adrenal nodule, unchanged. . CT ABDOMEN W/O CONTRAST [**2181-2-10**] 12:29 PM IMPRESSION: 1. Overall decrease in size of the previously noted several small intraabdominal fluid collections. No new fluid collections are identified. 2. No significant change in position of the surgical drains as above. 3. Nonspecific filling defect seen in several loops of small bowel that may be related to enteric feeds. Differential diagnosis also includes blood clots. . CT ABDOMEN W/CONTRAST [**2181-1-15**] 2:02 PM IMPRESSION: 1. Findings concerning for anastomotic leak at the hepaticojejunostomy, within the lesser sac. There is no discrete abscess formation at this time, however there is more gas than expected at six days postoperatively. Close continued followup is advised. 2. Likely retraction injury within the left lobe of the liver, although a developing abscess would be difficult to exclude and clinical assessment as well as close interval followup is advised. Markedly distended stomach with relatively decompressed small-bowel loops. Distended, fluid-filled esophagus. . SPECIMEN SUBMITTED: gallbladder, Whipple Specimen. Procedure date Tissue received Report Date Diagnosed by [**2181-1-9**] [**2181-1-9**] [**2181-1-13**] DR. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]/vf Previous biopsies: [**-8/4347**] DUODENUM BIOPSY (1 JAR). DIAGNOSIS: 1. Pancreatic duodenectomy: 1. Unlined, inflammatory and hemorrhagic cyst with giant cell reaction. 2. Segment of unremarkable small bowel. 3. No carcinoma seen. 2. Gallbladder, cholecystectomy: Chronic cholecystitis. . CTA ABD W&W/O C & RECONS [**2181-1-1**] 3:40 PM IMPRESSION: 1. Compared to prior exam, the inflammatory change surrouding the head of the pancreas is improved and there is slight decrease in the size of the enlarged uncinate process containing tubular cystic structures. Additionally, the relative contribution of the cystic portion of the mass appears subjectively decreased in size. Diagnostic consideration for this lesion include intraductal papillary mucinous neoplasm versus pseudocyst related to prior pancreatitis. 2. Stable right adrenal adenoma. 3. Cholelithiasis without evidence of cholecystitis. 4. Stable pneumopericardium. 5. Small bilateral pleural effusions and adjacent atelectasis. . Brief Hospital Course: 70 yo male with recent pancreatitis from pancreatic CA on TPN sent in for fever and hypotension SBP 70s concerning for sepsis. . Sepsis - currently stable - normotensive, afebrile s/p 2L IVFs, IV vanc, levo and flagyl. WBC 14.2, CXR negative for PNA, blood cultures pending. Differential includes pancreatitis, pancreatic pseudocyst, line infection from TPN picc, and infectious diarrhea. Blood cultures grew out gram positive cocci both here and OSH - send stool studies, inc c.diff toxins A and B - f/u cx from ED - gram pos cocci - f/u cx from OSH - gram pos cocci - continue to monitor for s/sx of sepsis including hypotension, change in mental status and fever. - CT scan ABD - cont vanc, and flagyl - can now d/c levo as has not grown any gram neg's in 48 hours - surveillance cultures to make sure is clearing infection - consider Echo to r/o endocarditis - goal to keep fluids even, can give IVFs is patient dry or febrile - catheter tip - coag negative staph . Diarrhea - patient reports 15-50 bowel movements while on 16h TPN cycle. Reports that BM's have slowed to about 5 BM's a day. Dnies blood, states that stools are liquid and wake him from his sleep. - multiple cdiff negative, have good reason for diarrhea with bacteremia, will d/c flagyl . #Pancreatic Mass/Pancreatitis: Patient had CTA which confirmed mass. Possible diagnosis of IPMN. Pt underwent ERCP. Due to significant inflammation around pancreas, ampulla could not be visualized and brushings could not be obtained. Duodenal biopsy negative. Pt had been transferred to [**Hospital1 **] in [**Hospital1 1474**] so that he could remain on TPN in an effort to reduce this inflammation and possibly move forward with a Whipple. - General Surgery consult appreciated - CT ABD - Pain well controlled with dilaudid. . Adrenal Adenoma: Seen on imaging as above. Will need follow up imaging with PCP. [**Name10 (NameIs) **] was sent to PCP. . # Hypertension: holding current regimen of amlodipine, lopressor and losartan for now until blood pressures stable. will continue amiodarone # h/o VT s/p ICD - patient states that his defbrillator has gone off several times recently and possibly once since admission - cards consult to interrogate ICD - parameters reset as patient shocked for afib with RVR # chronic systolic heart failure - no evidence of pulmonary edema on CXR, cardiomegaly stable in appearance # Coronary artery disease s/p CABG/ . #Hyperlipidemia: restarted Simvastatin. . # Acute renal failure: likely [**3-10**] recent diarrhea, baseline 1.0, now back to baseline - gentle rehydration - change meds back to regular dosing . # Code status: full code as discussed with patient. HCP per patient preference - [**Name (NI) **] [**Last Name (NamePattern1) 5239**] (fiance). No information to be given out to patient daughter or other family members. . Precautions: MRSA . # PPx: Heparin SC, pneumoboots, PPI # FEN: NPO, nutrition consult needed to restart TPN, replete lytes as needed = = = = = = = = = = = = = ================================================================ He was then transferred to the surgical service. He went to the OR on [**2181-1-9**] for a Whipple. Pain: APS was following along and managing his epidural. He had borderline hypotension and so his epidural dose was decreased. Once tolerating a diet, he was started on PO pain meds and was comfortable. Post-op Hypotension: He received several fluid boluses on POD 1 and received albumin on the evening on POD 1. POD #5, transferred to TICU for new onset afib with HR 150's and initial SBP's in 80's. No CP or palpitations. Brought back to OR for dehisced PJ anastomosis with intrab sepsis. . Events: [**1-14**]: Transferred to TSICU team, new rapid afib attempted electrical cardioversion, started on amiodarone drip [**1-15**]: dilt gtt, PO amio, TPN continued, EP c/s - ICD working appropriately, febrile, cultures sent [**1-16**]: Pt was put on vanc/cipro/flagyl, NGT and Reglan. OR - reexploration, repair dehisced pancreaticjejunostomy with stenting, feeding jejunostomy, drains x2 [**1-22**] 4 abd staples removed, serous fluid apprec. amio gtt for afib [**1-29**] Pt extubated [**1-30**] reintubated for respiratory distress; [**1-31**] lines removed for VRE in blood, 2 episodes melena; [**2-6**] amio restarted, extubated, 2 units blood; [**2-6**]: Incr dilt to attempt wean levo [**2-8**]: Continued failure to wean pressors. TSH/cosyntrop normal. Apneic episodes with 25mcg fent. [**2-11**] changed levophed to neo [**2-12**] pancreatic drain d/c'ed, lateral JP d/c'ed [**2-13**] more confused, transfused 2 units for Hct 23, fever 101.2 [**2-14**] intubated electively, EGD showed no active UGI bleed [**2-15**] self-extubated, began precedex for agitation [**2-17**] - replaced RIJ w/ Rsubcl CVL, 2U PRBCs [**2-21**] Wound vac removed w/ some purulent material, wet-->dry dressings placed, Go-lytely for C-scope in AM [**2-22**] lateral portion of wound opened and moist to dry packing done. [**2-22**]- Colonoscopy - Diverticulosis of the sigmoid colon Polyp in the hepatic flexure (polypectomy) Polyp at 50cm in the mid-descending colon (polypectomy) Polyp at 30cm in the mid-sigmoid colon (polypectomy) Polyp at 20cm in the distal sigmoid colon (polypectomy) Otherwise normal colonoscopy to cecum [**2-27**] - Septic, bradycardic, hypertensive, transferred to ICU. Restarted on broad spectrum ABX. [**2-27**] - Positive Blood cultures {PSEUDOMONAS [**Last Name (LF) 35836**], [**First Name3 (LF) **] ALBICANS}. [**2-28**] - still having bloody stools, transfused 2uRBC, prep'd for C-scope in AM (potential bleed from polypectomy sites) [**3-1**] - repeat colonoscopy for GI bleed. Transfused 4 Units PRBC. [**2181-3-6**] - Wound VAC'd [**2181-3-6**] - Continue IV Lasix for aggressive diuresis to goal weight of less that 225 lbs. Needs PT! . RADS: [**2-1**]: CT Abd - Interval resolution of previous lesser sac collection. Sm fluid collection lat to stomach on L: 2.2x3.7 cm. Fluid collection abutting splenic hilum : 2.6 x 3.8 cm. 3rd focal fluid collection R mid-abdomen: 3.6x2.6 cm; slightly decr since prior + anterior intra-abdominal fat stranding [**2-15**]: CT Abd - foci of gas are consistent with removal of the drainage catheters, but no new fluid collections. Decrease in size of L lobe hepatic lesion likely reflecting retractor injury. [**2-17**] TTE: EF 40-45%. Mild LVH. No AS,trace AR. 1+MR. [**First Name (Titles) **] [**Last Name (Titles) 35837**]s. [**2-22**] Liver US: Evolution of left hepatic lobe lesion related to acute injury. [**2-28**] TEE: no evidence of endocarditis or myocardial abscess on TEE . Micro: [**2-27**]: Urine cx: Pseudomonas 10-100K [**2-27**]: Blood cx: [**Female First Name (un) **] (prelim)and pseudamonas (cipro, ceftaz resist) [**2-21**]: Swab: Gram stain shows 1+ PMN, no orgs [**2-21**]: Blood cx: P [**2-19**]: VRE Swab: Enterococcus (mod growth) [**2-18**]: Blood cx x2: P [**2-15**]: Sputum cx: pseudomonas (R ceftaz, cipro, pip, zosyn), no fungus [**2-15**]: Urine cx: pseudomonas >100K [**2-15**]: Blood cx: Enterococcus (R to amp, PCN, vanco, S to linezolid) [**2-13**]: Urine cx - Pseudomonas 10-100K [**2-13**]: BCx - GPC, chains [**2-12**]: C-diff - negative [**2-11**]: BCx: Enterococcus (R to amp, levo, vanco) [**2-6**]: Sputum - pseudomonas [**2-6**]: UCx - pseudomonas (pan sensitive) [**1-25**]: BCx: ENTEROCOCCUS FAECIUM (PCN, amp, vanc res, linezolid [**Last Name (un) 36**]) [**1-25**]: Sputum - 2+ GNRs pseudomonas aerug, pan-sensitive, yeast [**1-23**]: + VRE [**1-17**]: Abdomen - 3+ GNRs, 2+ GPCs, 2+ yeast -->moderate Pseud aerug [**1-3**]: C-diff - Positive [**12-31**]: Cath Tip - MRSA . VRE: Most recently persistent VRE bacteremia. Original source may have been in the abdomen given presence of GPC in pairs from swab, although current CT is not suggestive for worsening or enhancing fluid collection. Patient is at risk for endocarditis. He completed a course of Linezolid that ended on [**2181-3-1**]. A TEE showed no evidence of endocarditis or myocardial abscess on TEE Additional blood cultures on [**2-27**] were positive and grew PSEUDOMONAS [**Month/Year (2) 35836**] and [**Female First Name (un) **] ALBICANS. He was started on Meropenem, Fluconazole and should continue thru [**2181-3-16**]. . Post-op Hyperglycemia: He was followed by [**Last Name (un) **] for blood glucose control and his insulin was adjusted accordingly. . GI: He was receiving cycled tubefeedings and tolerating a regular diet. He was having occasional loose stool, and C.diff's were checked on several occasions, and all were negative. His incision was opened at the bedside and drained. He had serial debridements and the wound bed was clean and pink. He continued with moist to dry gauze dressing changes. The wound was VAC'd and can be VAC'd at rehab. . Renal: He continued to receive IV Lasix for diuresis as needed. His input and ouput was watched closely and he was kept negative ~[**Telephone/Fax (1) 1999**] mL each day. His goal weight is 225 lbs. and most recent weight was 240lbs. . PT: [**Name (NI) **] was deconditioned and unsteady. PT recommended rehab. Medications on Admission: Amiodarone 200mg daily Amlodipine 5mg daily Metoprolol 50mg [**Hospital1 **] Heparin 5000units sc tid ASA 81mg daily Pantoprazole 40mg daily Simethicone 80mg tid Losartan 50mg daily Prochloperazine 5mg q6h Hydromorphone 1mg q6h Ondansetron 4mg q6h Questran 1 gm daily Metoclopramide 5mg q6h TPN Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection [**Hospital1 **] (2 times a day). 2. Polyvinyl Alcohol 1.4 % Drops Sig: 1-2 Drops Ophthalmic PRN (as needed). 3. Nystatin 100,000 unit/mL Suspension Sig: Five (5) ML PO QID (4 times a day) as needed. 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for fever. 5. Trazodone 50 mg Tablet Sig: 0.5 Tablet PO HS (at bedtime) as needed for Insomnia. 6. Digoxin 250 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Quetiapine 25 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed. 8. Oxycodone 5 mg/5 mL Solution Sig: [**2-7**] PO Q6H (every 6 hours) as needed for pain. 9. Papain-Urea 830,000-10 unit/g-% Ointment Sig: One (1) Appl Topical DAILY (Daily): apply to affected area on back . 10. Ursodiol 300 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 12. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 13. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Five (5) Units Subcutaneous once a day. 14. Insulin NPH Human Recomb 100 unit/mL Suspension Sig: Twelve (12) Subcutaneous at bedtime. 15. Insulin Lispro 100 unit/mL Solution Sig: SS Subcutaneous every four (4) hours: See sliding scale. 16. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: [**3-12**] Capsule, Sustained Releases PO BID (2 times a day) for 1 weeks: HOLD for K>4.5. continue while aggressive diuresis. 17. Meropenem 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q6H (every 6 hours) for 9 days: thru [**2181-3-16**]. 18. Fluconazole in Saline(Iso-osm) 400 mg/200 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours) for 9 days: thru [**2181-3-16**]. 19. Acetazolamide Sodium 500 mg Recon Soln Sig: Two Hundred Fifty (250) mg Injection Q6H (every 6 hours) for 2 doses. 20. Furosemide 10 mg/mL Solution Sig: Two (2) Injection twice a day: Continue with diuresis until at dry weight of 225 lbs (most recently 240 lbs). . Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 38**] Discharge Diagnosis: Pancreatic Mass Pancreatico-jejunostomy anastomosis Dehisced with intra-abdominal sepsis/leak Hypotension, Arrythmia VRE bacteremia Post-op blood loss anemia GI Bleed Diverticulosis Multiple Colon Polyp with polypectomies. Wound infection Positive Blood cultures (PSEUDOMONAS [**Last Name (LF) 35836**], [**First Name3 (LF) **] ALBICANS Discharge Condition: Good Tolerating tubefeeding and regular diet Wound bed clean with good granulation tissue. Continue to VAC 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 amubulate several times per day. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) 468**] in 2 weeks. You will have a CT at 9:00am on [**2181-3-19**] in the [**Hospital Ward Name 23**] building. Nothing to eat or drink 4 hours prior to you appointment. Then follow-up with Dr. [**Last Name (STitle) 468**] at 11:00am on [**2181-3-19**]. Call [**Telephone/Fax (1) 2835**] with questions or concerns. Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2181-3-30**] 11:30 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1008**], M.D. Phone:[**Telephone/Fax (1) 285**] Date/Time:[**2181-3-30**] 12:00 Completed by:[**2181-3-7**]

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icd9cm

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icd9pcs

[ [ [] ] ]

21320, 21401

9740, 18856

280, 286

21782, 21891

3660, 9717

22981, 23638

2808, 2897

19202, 21297

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21915, 22958

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315, 2096

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2396, 2792

2,378

162,768

1635

Discharge summary

report

Admission Date: [**2141-6-8**] Discharge Date: [**2141-6-21**] Date of Birth: [**2060-5-11**] Sex: F Service: MEDICINE Allergies: Losartan / Lisinopril / Penicillins / Flagyl / Ultram Attending:[**First Name3 (LF) 1990**] Chief Complaint: Shortness of Breath Major Surgical or Invasive Procedure: Left IJ complicated by pneumothorax Left-sided chest tube placement Endotracheal intubation PICC line placement History of Present Illness: Mrs. [**Known lastname 9483**] is an 81 yoF with a h/o [**Known lastname 9215**], COPD (FEV1 48%P; FEV1/FVC 72%P), eosinophilic lung disease, AT and recent C. Diff colitis x 2 who presented to the ED from home today for evaluation of shortness of breath. The patient reports that she has had a sense of head congestion with rhinorrea for the last three days, associated with some progressive dyspnea. She has also had a chronic cough for the last six months, but it has become productive of yellowish sputum. Today, the patient had a mechanical fall while ambulating with her walker and hit her left chest. EMS was called to the patient's home, however she felt well at the time of their evaluation and did not go to the ED. Later in the day, with increasing dyspnea, she did decided to come to the ED. In the ED, initial vitals were 96.1, 79, 106/57, 20, 98% on RA. She was treated with nebs and PO prednisone and apparently appeared well. She was offered the opportunity for discharge with PCP f/u, however indicated she would feel more comfortable with admission. On arrival to 11 [**Hospital Ward Name 1827**], the patient was quickly noted to be in severe respiratory distress. Additional nebs were administered along with methylprednisolone. The patient was urgently transferred to the [**Hospital Unit Name 153**] where she was initially unable to provide much history secondary to her respiratory distress. Emperic BPAP was initiated, which the patient tolerated well. Within 15 minutes, she had improved markedly and was able to begin answering some questions. During this period, she was intermittently noted to be tachycardiac as high as the 140s and hypotensive with SBPs in the 70s-80s; this all improved as her respiratory status stabalized. On ROS, the pt endorses pleuritic chest pain just above the right breast where she fell earlier today. She also notes that her LE may be slightly swollen as compared to baseline; she does not believe she has had significant weight gain. No other chest discomfort or palpitations. No fevers or chills. No abdominal pain. No change in bowel or bladder function. Past Medical History: -h/o C. diff colitis -h/o MSSA PNA -AF/AT -COPD -[**Last Name (LF) 9215**], [**First Name3 (LF) **] 55% -Osteoarthritis -H/o myocarditis in [**2137**] with EF 20-25% at that time, cath negative -Hyperlipidemia -Peripheral artery disease -HTN -Migraine HA -Chronic eosinophilic lung disease (chronic eosinophilic pneumonia or Churg-[**Doctor Last Name 3532**] syndrome) -Hypoalbuminemia -History of angioneurotic edema on [**Last Name (un) **] thera Social History: Pt. has a previous 40 pack-year history of smoking (stopped 25 yrs ago). She does not drink alcohol and denies other drug use. She lives with her husband and has three grown children. Family History: [**Name (NI) 1094**] mother's side notable for "extensive" heart disease (several of her family members died from this); pt's father died of "cancer of the spleen." No history of diabetes or stroke. Physical Exam: Physical Exam at Admission Gen: Acutely ill appearing adult female, agitated, in respiratory distress. HEENT: PERRL, EOMI. MMM. Conjunctiva well pigmented. Neck: Supple, without adenopathy or JVD. No tenderness with palpation. Chest: Diffusely wheezy and rhoncherous with poor air movement throughout. Cor: Normal S1, S2. Regular, tachycardic. No murmurs appreciated. Abdomen: Soft, non-tender and non-distended. +BS, no HSM. Extremity: Warm, without edema. 2+ DP pulses bilat. Trace LE to mid-calves bilaterally. Diffuse ecchymotic patches. Neuro: Alert and oriented. CN 2-12 intact. Motor strength intact in all extremities. Sensation intact grossly. Pertinent Results: Labs at Admission: [**2141-6-8**] 05:35PM BLOOD WBC-7.8 RBC-4.18* Hgb-11.0* Hct-35.6* MCV-85 MCH-26.4* MCHC-31.0 RDW-17.5* Plt Ct-268 [**2141-6-8**] 05:35PM BLOOD Neuts-58.3 Lymphs-26.9 Monos-5.0 Eos-9.3* Baso-0.5 [**2141-6-8**] 11:27PM BLOOD PT-14.8* PTT-150* INR(PT)-1.3* [**2141-6-8**] 05:35PM BLOOD Glucose-115* UreaN-23* Creat-1.0 Na-141 K-4.1 Cl-103 HCO3-29 AnGap-13 [**2141-6-9**] 04:05AM BLOOD ALT-22 AST-30 LD(LDH)-268* CK(CPK)-216* AlkPhos-83 TotBili-0.2 [**2141-6-9**] 04:05AM BLOOD Albumin-3.5 Calcium-7.5* Phos-5.3*# Mg-2.0 [**2141-6-8**] 05:35PM BLOOD D-Dimer-576* Imaging Studies: CT angiogram chest ([**6-9**]): 1. No evidence of pulmonary embolism. 2. Partial right lower lobe collapse secondary to obstruction of the basal segments of the right lower lobe bronchi secondary to secretions. Near complete obstruction of the left main stem bronchus secondary to secretions with only minimal left lower lobe atelectasis identified. 3. Ground-glass opacities within the right middle lobe, lingula and left lower lobe, which may represent the sequelae of aspiration. Multiple borderline enlarged probable reactive mediastinal lymph nodes. 4. Multiple bilateral calcified granuloma with several noncalcified nodules measuring less than 3 mm as described above, which could represent noncalcified granulomas. 5. Stable emphysema. Brief Hospital Course: An 81 yo woman with history of [**Month/Year (2) 9215**], COPD and eosinophilic lung disease who presents with acute onset of respiratory distress in setting of several days of worsening dyspnea. # Acute respiratory failure The most likely etiology for her symptoms was pneumonia in the setting of chronic obstructive lung disease. She also has a history of poorly differentiated eosinophilic pneumonitis based on mucosal biopsy from [**2138**]. CTA was negative for PE but did show a right lower lobe infiltrate. She was started on vancomycin and levofloxacin for pneumonia (gram + cocci in sputum) in addition to Flagyl for history of C dif. Levo was later changed to ciprofloxacin when pseudomonas was isolated in her sputum; similarly vancomycin was switched to nafcillin when the GPC isolated was speciated as MSSA. Albuterol, ipratropium, and steroids were given for COPD exacerbation. Her worsening respiratory acidosis required intubation on the second hospital day. She remained intubated for approx three days, at which time she was extubated to BiPAP without complication. She was transferred to the floor with stable oxygen saturations and respiratory status on oxygen by nasal cannula ... # Atrial fibrillation / supraventricular tachycardia She was noted to have irregular rate tachycardia to 160s two days after extubation. EKG was consistent with atrial fibrillation. She was started on IV Lopressor and converted back into sinus. This was switched back to her home metoprolol when tolerating pos. Due to hypotension, metoprolol was stopped ... # Pneumothorax This was a complication of placing a left IJ as the patient abruptly sat partway up during procedure. A pigtail catheter was placed by interventional pulmonary service with good decompression. This was placed to wall suction after extubation. When CXR showed resolution of pneumothorax, the chest tube was placed to water seal. # History of C dificile While she was treated with cipro and nafcillin as above, she was also treated with IV Flagyl for history of C dif. The Flagyl should be continued for two weeks after stopping cipro/nafcillin (on [**6-19**]). # Sepsis She was started on levophed for dropping systolic blood pressure. This was tapered quickly as her infection was treated. # ECG changes Most likely secondary to demand ischemia in setting of respiratory distress. We continued her home aspirin and statin. # History of congestive heart failure As above, her home statin and aspirin were continued. Metoprolol and Lasix held due to low blood pressure. These can be added back when her blood pressure tolerates. # Anemia Her hematocrit was stable and at baseline. A work-up in [**1-23**] was consistent with anemia of chronic disease and possible iron deficiency. This may need further work-up as an oupatient. # Abdominal distension KUB was done to ensure no small bowel obstruction. After extubation, she was evaluated by speech and swallow who recommended pureed solids and thin liquids and eventually soft solids/thin liquids. Above course as written by ICU team: Summary of course on medical [**Hospital1 **] (Dr. [**Last Name (STitle) **]: Chest tube removed after repeat CXR revealed resolution of pneumothorax. PICC line removed Rectal tube removed Foley catheter removed C Difficile - empiric treatment with oral vancomycin (as has documented metronidazole allergy). Two toxin assays negative at time of discharge. Third pending (see instruction to rehab hospital staff below) Predisone taper prescribed, and PPI prescribed for protection of gastric mucosae Home Beta Blocker and diuretic resumed PT worked with pt. and pt. able to ambulate with assistance of two persons. Sent to [**Hospital 9502**] hospital for ongoing rehabilitation. Medications on Admission: ALBUTEROL SULFATE - 2.5 mg/3 mL (0.083 %) Solution for Nebulization - 1 (One) vial(s) inhaled via nebulizaiton up to 4 times daily as needed for shortness of breath or wheezing ALENDRONATE [FOSAMAX] - (Prescribed by Other Provider) - 70 mg Tablet - 1 Tablet(s) by mouth qwk ATORVASTATIN [LIPITOR] - (Prescribed by Other Provider) - 40 mg Tablet - 1 Tablet(s) by mouth once a day FEXOFENADINE - (Prescribed by Other Provider) - 60 mg Tablet - 1 Tablet(s) by mouth twice daily FLUTICASONE - 50 mcg Spray, Suspension - 2 squirts(s) nasally once daily FLUTICASONE-SALMETEROL [ADVAIR DISKUS] - 500 mcg-50 mcg/Dose Disk with Device - one inhalation twice daily - No Substitution FUROSEMIDE - (update) - 40 mg Tablet - 2 Tablet(s) by mouth once a day extra 40mg in the pm as needed METOPROLOL TARTRATE - 25 mg Tablet - 0.5 (One half) Tablet(s) by mouth twice a day PANTOPRAZOLE - (Prescribed by Other Provider) - 20 mg Tablet, Delayed Release (E.C.) - 1 (One) Tablet(s) by mouth once a day POTASSIUM CHLORIDE [KLOR-CON 10] - (update) - 10 mEq Tablet Sustained Release - 1 (One) Tablet(s) by mouth twice a day PREDNISONE - 5 mg Tablet - 1 (One) Tablet(s) by mouth once a day unless otherwise directed TEST HEARING - - Test hearing, audiology test. TIOTROPIUM BROMIDE [SPIRIVA WITH HANDIHALER] - (Prescribed by Other Provider) - 18 mcg Capsule, w/Inhalation Device - 1 puff inhaled once daily TRAZODONE - (Prescribed by Other Provider) - 50 mg Tablet - 0.5 (One half) Tablet(s) by mouth once a day as needed ASPIRIN - (OTC) - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth DAILY (Daily) GUAIFENESIN [MUCINEX] - (Prescribed by Other Provider) - 600 mg Tablet Sustained Release - 1 Tablet(s) by mouth twice daily NEBULIZER ACCESSORIES [NEBULIZER] - Kit - use albuterol solution in nebulizer up to every 4 hours as needed for shortness of breath or wheezing SACCHAROMYCES BOULARDII [FLORASTOR] - (Prescribed by Other Provider) - Dosage uncertain Discharge Medications: 1. Atorvastatin 40 mg Tablet [**Hospital **]: One (1) Tablet PO DAILY (Daily). 2. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital **]: One (1) mL Injection TID (3 times a day). 3. Levalbuterol HCl 0.63 mg/3 mL Solution for Nebulization [**Hospital **]: One (1) inh Inhalation q4h () as needed for shortness of breath. 4. Ipratropium Bromide 0.02 % Solution [**Hospital **]: One (1) neb Inhalation Q4H (every 4 hours) as needed. 5. Aspirin 81 mg Tablet, Chewable [**Hospital **]: One (1) Tablet, Chewable PO DAILY (Daily). 6. Trazodone 50 mg Tablet [**Hospital **]: 0.5 Tablet PO HS (at bedtime) as needed for insomnia. 7. Lorazepam 0.5 mg Tablet [**Hospital **]: One (1) Tablet PO Q8H (every 8 hours) as needed for anxiety. 8. Benzonatate 100 mg Capsule [**Hospital **]: One (1) Capsule PO TID (3 times a day). 9. Vancomycin 125 mg Capsule [**Hospital **]: One (1) Capsule PO Q6H (every 6 hours) for 2 weeks: this can be discontinued if third C Difficile Toxin Assay final report is negative. It is pending at the microbiology laboratory at [**Hospital1 18**] as of the day of discharge. Call [**Telephone/Fax (1) 4645**] for the final result please. Result should be available as of [**2141-6-22**]. 10. Codeine-Guaifenesin 10-100 mg/5 mL Syrup [**Date Range **]: 5-10 MLs PO Q6H (every 6 hours) as needed for cough. 11. Metoprolol Tartrate 25 mg Tablet [**Date Range **]: One (1) Tablet PO BID (2 times a day). 12. Furosemide 40 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily). 13. Prednisone 20 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily) for 3 days. 14. Prednisone 5 mg Tablet [**Date Range **]: Three (3) Tablet PO DAILY (Daily) for 3 days: following 20 mg tapered dose. 15. Prednisone 10 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily) for 3 days: following 15 mg tapered dose. 16. Prednisone 5 mg Tablet [**Date Range **]: One (1) Tablet PO DAILY (Daily): following 10 mg tapered dose (this is pt.s baseline dose). 17. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Date Range **]: One (1) Tablet, Delayed Release (E.C.) PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Pneumonia, COPD exacerbation, with course complicated by iatrogenic pneumothorax left Discharge Condition: Stable Discharge Instructions: Return to the [**Hospital1 18**] Emergency Department for: chest pain, severe shortness of breath, fevers. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 8718**], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2141-7-11**] 1:00 Provider: [**Name10 (NameIs) **] [**Name8 (MD) 9501**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2141-7-24**] 9:00 Provider: [**Name10 (NameIs) **] STUDY Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2141-7-24**] 10:30

[ "427.89", "428.0", "995.92", "401.9", "584.9", "512.1", "008.45", "518.84", "E879.8", "482.1", "482.41", "785.52", "272.4", "491.21", "276.0", "427.31", "038.9", "428.32" ]

icd9cm

[ [ [] ] ]

[ "96.04", "34.09", "96.71", "38.93" ]

icd9pcs

[ [ [] ] ]

13417, 13489

5539, 9295

333, 446

13619, 13628

4172, 4753

13783, 14166

3283, 3483

11292, 13394

13510, 13598

9321, 11269

13652, 13760

3498, 4153

274, 295

474, 2592

2614, 3065

3081, 3267

4771, 5516

46,034

186,098

37605

Discharge summary

report

Admission Date: [**2171-3-22**] Discharge Date: [**2171-4-11**] Date of Birth: [**2126-12-25**] Sex: M Service: MEDICINE Allergies: Penicillins / Vancomycin / daptomycin Attending:[**First Name3 (LF) 13256**] Chief Complaint: elevated creatinine on labs Major Surgical or Invasive Procedure: Expired History of Present Illness: 44yoM with ETOH cirrhosis c/b portal HTN, hepatic encephalopathy and diuretic-resistent ascites admitted with an elevated creatinine concerning for HRS. . The patient has a history of diuretic-resistent ascites requiring large volume paracentesis weekly. His last paracentesis was [**3-15**] and he had 12L removed. He came to the clinic today for his next weekly paracentesis and was found on to have hyponatremia (126 basline 130) and acute renal failure (Cr 2.2 up from baseline of 1.0-1.3 on [**3-15**]). The procedure was performed and 4L removed. He was given albumin for a fluid challenge to evaluate for potential HRS. He received 100 gm of 25% albumin, 3 units FFP, Oxycodone 10mg q 4-6 hrs per radiology paracentesis note. . He endorses feeling unwell with upset stomach and dyspnea for over one week. He denies taking NSAIDS, change in diet, GI bleed, fever/chills/dysuria. Reports stable urine output. Denies increased PO fluid intake. . He has a long history of refractory hypervolemic hyponatremia and was initiated on tolvaptan in [**2170-1-23**]. He has been maintained on this therapy since, but has been found to be hyponatremic during prior admissions. In mid-[**Month (only) 1096**] he was treated with fluid restriction with some success, but on readmission in late [**Month (only) 1096**] again was found to be hyponatremic. Per report his mental status was normal despite Na < 130, and his baseline may be in the high 120s. In the past he has not been compliant with fluid restriction at home (up to 5L daily). Past Medical History: 1. ETOH cirrhosis c/b portal HTN - hepatic encephalopathy - diuretic resistent ascites - hyponatremia 2. rectus sheath hematoma [**12-27**] paracentesis on [**11-10**] 3. HTN 4. cholelithiasis 5. gout 6. depression 7. C. diff colitis 8. mild pulmonary artery systolic hypertension-mean PA pressure 28 9. incarcerated umbilical hernia s/p repair [**2-/2170**] c/b subcutaneous hematoma and wound dehiscence 10. L femur comminuted fx s/p rod ([**2144**]) Social History: Lives alone, divorced x2, has three children. - tobacco: denies - ETOH: prior use, last drink [**2168-7-28**] - IVDA: denies Family History: mother's family with liver disease/ cirrhosis Physical Exam: 44yoM with ETOH cirrhosis c/b portal HTN and diuretic-resistent ascites presenting with an elevated creatinine concerning for HRS also with SBP. . # HEPATORENAL SYNDROME: The patient presented with an elevated creatinine of 2.2 up from a baseline of 1.0-1.2. He was given 1gm/kg albumin for three days as well as blood products but his creatinine continued to worsen and his urine output declined. He was started on midodrine/octreotide. His diuretics were held... . #SPONTANEOUS BACTERIAL PERITONITIS: Patient with diuretic refractory ascites requiring weekly paractensis with abdominal pain and tense ascites, underwent paractensis on [**3-25**] and found to have 3050WBC with 87%PMN c/w SBP. He was started on daptomycin (hx of VRE) and ceftriaxone. Peritoneal cultures grew... -hold ciprofloxacin prophylaxis for now,restart after ABX course -albumin on day 3 (tuesday) . #PORTAL VEIN THROMBOSIS: RUQ U/S showed focal thrombus in the right posterior portal vein new compared to prior. No plans for anticoagulation. -consider verify w/ cross section imaging . #DECOMPENSATED LIVER FAILURE: The patient has advanced liver failure secondary to alcoholic cirrhosis, now decompensated in the setting of SBP and HRS. Transplant surgery was consulted. . . . . #Hyperkalemia: Patient with acute renal failure and limited urine output with potassium up to 5.6 this AM -obtain EKG now, if ekg changes give calcium -give kayexcelate now -give 10 IV regular insulin and 25gmdextrose -recheck potassium early afternoon -renal consult -hold spironolactone -check PM potassium . # Hyponatremia: The patient has chronic hyponatremia in the 120's-130's, likely secondary to increased renin-angiontensin axis response due to advanced liver failure. Tolvaptan was held. . # Thrombocytopenia: Platelets of 33 currently without evidence of active bleed. Chronic, likely secondary to advanced liver failure and decreased platelet production. - Trend daily - Type and screen . #low back pain: chronic -continue lidocaine patch -continue oxycodone Pertinent Results: Expired Brief Hospital Course: Hospital Course: The patient had a complicated hospital course. His renal function continued to deteriorate despite aggressive medical therapy with midodrine and octreotide. He became anuric and required initiation of hemodialysis for volume and electrolyte control. Hypotension limited the efficacy of dialysis and, eventually, the patient required transfer to the ICU for CVVH after aggressive resuscitation with blood products. The patient's course was further complicated by C diff colitis, daptomycin-induced eosinophilic pneumonia, encephalopathy, and coagulopathy. The patient's coagulopathy was difficult to reverse with PRBCs, platelets, FFP, and cryo. The patient had functional DIC from severe liver disease. No systemic infection was localized including negative cell counts for SBP, however, the patient was still placed on broad spectrum antibiotics due to his significant illness. The patient had episodes of hematemesis as well, prompting transfer to the ICU. In the ICU in spite of aggressive resuscitative measures, his severe coagulopathy and thrombocytopenia continued with frequent bleeding. Due to extremely poor outlook, he was made comfort measures only and transferred back to the floor on [**2171-4-9**]. He died on [**2171-4-11**] at 19:00. Medications on Admission: - Alendronate 70 mg 1X/WEEK - Rifaximin 550 mg [**Hospital1 **] - Lidocaine 5 % (700 mg/patch) Adhesive Patch DAILY - Cipro 250 mg daily - Ergocalciferol (vitamin D2) 50,000 unit: 1X/WEEK - Folic acid 1 mg DAILY - Calcium carbonate 200 mg (500 mg) TID - Magnesium oxide 400 mg TID PRN constipation - Multivitamin Daily - Simethicone 80 mg: 0.5-1 Tablet, PO QID PRN for gas. - Tolvaptan 30 mg Daily - Omeprazole 20 mg Delayed Release Daily - Oxycodone 5 mg/5 mL Solution: 10-15 mg PO Q4H PRN pain - Polyethylene glycol Daily PRN constipation - Lactulose (patient not taking for several months) - Furosemide 20 mg in AM and 10mg in evening - Spironolactone 75 mg Daily Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired

[ "567.23", "584.9", "518.3", "V15.51", "276.7", "452", "286.6", "784.7", "253.6", "287.5", "724.2", "038.9", "571.2", "518.82", "572.8", "041.83", "008.45", "276.69", "274.9", "456.21", "995.92", "572.4", "V49.87", "V49.83", "276.2", "416.8", "401.9", "789.59", "572.2", "E930.8", "458.21", "288.60", "415.12", "560.1" ]

icd9cm

[ [ [] ] ]

[ "00.14", "54.91", "39.95", "38.91", "38.95" ]

icd9pcs

[ [ [] ] ]

6711, 6720

4689, 4689

328, 337

6771, 6780

4657, 4666

6836, 6846

2541, 2588

6679, 6688

6741, 6750

5987, 6656

4706, 5961

6804, 6813

2603, 4638

261, 290

365, 1906

1928, 2382

2398, 2525

3,122

161,583

497

Discharge summary

report

Admission Date: [**2122-5-30**] Discharge Date: [**2122-6-8**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 710**] Chief Complaint: Respiratory failure/sepsis Major Surgical or Invasive Procedure: MICU stay [**2122-5-30**]->[**2122-6-6**] Endotrachael tube intubation on [**2122-5-30**] (extubated on [**2122-6-4**]) Right IJ placement on [**2122-5-30**] (removed [**2122-6-8**]) NG tube placement (removed) PICC line placement [**2122-6-8**] History of Present Illness: Pt is a [**Age over 90 **] yo male with a history of Alzheimer's dementia, HTN, hypercholesterolemia, who presents to the MICU with respiratory failure. Per daughter, pt had a cough for the last two weeks as a virus was going around the NH. He was started on levaquin on [**5-24**]. Per NH notes, on [**2122-5-26**] chest was clear and pt was satting 97RA but there were complaints of congestion. Assessment was that pt had a upper respiratory tract infection. On [**2122-5-27**] notes to still not be eating or drinking and to be restlest. He was taking sips for food only. Sats were noted to be 96% RA and HR 110 and regular. Labs were revealing for a sodium of 163, BUN/cr of 40/1.7 which were new. Notes state that daughter wanted pt to be Full code. On [**2122-5-29**] notes shows that discussions still had with daughter and despite advanced dementia and poor prognosis want pt to be full code. He was noted to be non-verbal. . In the ED, VS on arrival: T 102.6, HR: 120, BP: 62/50, RR: 26. P2: O2--> 98% NRB. He was intubated for respiratory distress and give 5 mg IV versed. Lactate was 4.1. He was also started on norepinephrine, given 1 gram of ceftazadine, 1 gram of vancomycin and started on a versed gtt. He was also started on the sepsis protocol. Past Medical History: 1. Alzheimers dementia 2. HTN 3. Hypercholesterolemia 4. Nephrolithiasis 5. s/p appy 6. Depression/psychosis Social History: lives at [**Hospital **] rehab about 2 years. No smoking or ETOH. Family History: Non-contributory Physical Exam: VS: T: 96.5; BP: 112/60; HR: 71; AC 600/16/100/5 RR: 16, Tv pulling: 574. Gen: Intubated, sedated. Neck: No LAD. CV: RRR S1S2. No M/R/G Lungs: Anteriorly with scattered rales course. Abd: soft, nt, nd Ext: no edema. DP 2+ Neuro: pupils reactive, left slightly greater ? surgical pupil. Skin: No rashes. Back examined and no warmth or cellulitis Pertinent Results: Admission labs: . [**2122-5-30**] 04:20AM BLOOD WBC-20.9*# RBC-4.52*# Hgb-13.1*# Hct-40.8# MCV-90 MCH-28.9 MCHC-32.0 RDW-13.5 Plt Ct-171 [**2122-5-30**] 08:12AM BLOOD Neuts-77* Bands-15* Lymphs-5* Monos-3 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2122-5-30**] 04:20AM BLOOD PT-18.2* PTT-33.7 INR(PT)-1.7* [**2122-5-30**] 04:20AM BLOOD Fibrino-928* [**2122-5-30**] 04:20AM BLOOD UreaN-75* Creat-4.6*# [**2122-5-30**] 08:12AM BLOOD Glucose-254* UreaN-66* Creat-3.3*# Na-158* K-3.5 Cl-130* HCO3-16* AnGap-16 [**2122-5-30**] 04:20AM BLOOD CK(CPK)-389* Amylase-85 [**2122-5-30**] 08:12AM BLOOD ALT-14 AST-26 CK(CPK)-415* AlkPhos-104 TotBili-0.6 [**2122-5-30**] 04:20AM BLOOD CK-MB-3 cTropnT-0.04* [**2122-6-2**] 04:19AM BLOOD Lipase-96* [**2122-5-30**] 03:44PM BLOOD Albumin-2.3* Calcium-6.4* Phos-2.2* Mg-3.2* [**2122-5-30**] 04:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-8.3 Bnzodzp-NEG Barbitr-NEG Tricycl-NEG . Other Labs: [**2122-6-3**] 08:04AM BLOOD FDP-0-10 [**2122-6-3**] 08:04AM BLOOD Fibrino-793* D-Dimer-[**2125**]* [**2122-5-30**] 03:44PM BLOOD FDP-40-80 [**2122-5-30**] 03:44PM BLOOD Fibrino-800* [**2122-6-2**] 04:19AM BLOOD calTIBC-116* VitB12-618 Folate-12.4 Ferritn-429* TRF-89* [**2122-6-2**] 04:19AM BLOOD Albumin-2.3* Calcium-7.1* Phos-2.4* Mg-2.1 Iron-20* [**2122-5-30**] 03:44PM BLOOD Osmolal-339* [**2122-5-30**] 09:15AM BLOOD Cortsol-39.2* [**2122-5-30**] 04:33AM BLOOD Type-ART pO2-125* pCO2-25* pH-7.43 calTCO2-17* Base XS--5 [**2122-5-30**] 04:39AM BLOOD Comment-GREEN TOP [**2122-5-30**] 09:59AM BLOOD Type-ART pO2-147* pCO2-25* pH-7.38 calTCO2-15* Base XS--8 Intubat-INTUBATED [**2122-5-30**] 04:56PM BLOOD Type-ART Temp-35.3 Rates-/20 Tidal V-500 PEEP-5 FiO2-80 pO2-107* pCO2-24* pH-7.38 calTCO2-15* Base XS--8 AADO2-455 REQ O2-76 -ASSIST/CON Intubat-INTUBATED [**2122-5-31**] 04:19AM BLOOD Type-ART pO2-137* pCO2-26* pH-7.39 calTCO2-16* Base XS--7 [**2122-5-31**] 11:46AM BLOOD Type-ART Temp-37.0 Rates-/26 Tidal V-450 PEEP-5 pO2-109* pCO2-28* pH-7.36 calTCO2-16* Base XS--7 Intubat-INTUBATED Vent-SPONTANEOU [**2122-5-31**] 11:48AM BLOOD Type-MIX [**2122-5-31**] 04:25PM BLOOD Type-ART Temp-36.5 Rates-/22 Tidal V-450 PEEP-5 pO2-101 pCO2-27* pH-7.43 calTCO2-19* Base XS--4 Intubat-INTUBATED Vent-SPONTANEOU [**2122-6-1**] 05:54AM BLOOD Type-ART Temp-36.2 Rates-/28 Tidal V-542 PEEP-5 FiO2-50 pO2-86 pCO2-26* pH-7.47* calTCO2-19* Base XS--2 Intubat-INTUBATED Vent-CONTROLLED [**2122-6-1**] 01:04PM BLOOD Type-ART Temp-37.7 pO2-103 pCO2-28* pH-7.41 calTCO2-18* Base XS--4 [**2122-6-2**] 04:32AM BLOOD Type-ART Temp-37.4 pO2-98 pCO2-38 pH-7.35 calTCO2-22 Base XS--3 [**2122-6-3**] 11:48AM BLOOD Type-ART Temp-37.0 Rates-/24 PEEP-5 pO2-82* pCO2-27* pH-7.47* calTCO2-20* Base XS--1 Intubat-INTUBATED [**2122-6-3**] 10:12PM BLOOD Type-ART Temp-36.8 Rates-/32 Tidal V-321 PEEP-5 FiO2-50 pO2-81* pCO2-29* pH-7.45 calTCO2-21 Base XS--1 Intubat-INTUBATED [**2122-6-4**] 03:11AM BLOOD Type-ART Temp-36.8 Tidal V-400 PEEP-5 FiO2-50 pO2-139* pCO2-34* pH-7.45 calTCO2-24 Base XS-0 Intubat-INTUBATED [**2122-6-4**] 10:32AM BLOOD Type-ART Temp-37.6 Rates-/20 FiO2-50 pO2-91 pCO2-33* pH-7.45 calTCO2-24 Base XS-0 Intubat-INTUBATED Vent-CONTROLLED Comment-AXILLARY T [**2122-6-2**] 04:19AM BLOOD Lipase-96* [**2122-5-30**] 04:20AM BLOOD CK-MB-3 cTropnT-0.04* [**2122-5-30**] 08:12AM BLOOD CK-MB-4 cTropnT-0.02* [**2122-5-30**] 04:20AM BLOOD CK(CPK)-389* Amylase-85 [**2122-5-30**] 08:12AM BLOOD ALT-14 AST-26 CK(CPK)-415* AlkPhos-104 TotBili-0.6 [**2122-6-2**] 04:19AM BLOOD ALT-26 AST-45* LD(LDH)-216 AlkPhos-263* Amylase-107* TotBili-0.4 [**2122-6-3**] 04:27AM BLOOD LD(LDH)-206 TotBili-0.2 [**2122-6-1**] 10:32AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.020 [**2122-6-1**] 10:32AM URINE Blood-LG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2122-5-31**] 03:52AM URINE Hours-RANDOM Creat-79 Na-70 [**2122-5-31**] 03:52AM URINE Osmolal-618 [**2122-5-30**] 04:20AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.023 [**2122-5-30**] 04:20AM URINE Blood-NEG Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG . EKG [**5-30**]: Sinus tachycardia, Ant/septal and lateral ST-T changes are nonspecific. Since previous tracing of [**2120-5-26**], heart rate is faster, and ectopic atrial rhythm not seen . . CT Abd/Pelvis [**5-30**]: 1. Bilateral lower lobe consolidation, most consistent with pneumonia or aspiration. 2. Left flank soft tissue stranding surrounding the left external oblique muscle with a sliver of fluid collection that has the appearance of hematoma secondary to trauma in the appropriate clinical setting, differential diagnosis includes cellulitis. Clinical correlation is recommended. 3. No evidence of small-bowel obstruction or ascites. . CXR [**6-1**]: Endotracheal tube has been withdrawn slightly now terminating about 5 cm above the carina. Central venous catheter and nasogastric tube remain in place, with side port of nasogastric tube remaining proximal to expected location of GE junction. Cardiac and mediastinal contours are stable. There has been improvement in the degree of vascular engorgement. Pulmonary edema has shifted in response to positional differences of the patient, now more basilar in distribution. Overall, degree of edema has slightly decreased. Small pleural effusions are more apparent on the current than on the prior study, but may not have been readily detectable due to supine positioning previously. . multiple CXR in between CXR ([**2122-6-6**]) IMPRESSION: Slight improved aeration at both lung bases consistent with improving airspace disease. Small right pleural effusion. Interval extubation and removal of the NG tube. . Microbiology: [**2122-5-30**] 4:45 am SPUTUM Site: ENDOTRACHEAL **FINAL REPORT [**2122-6-2**]** GRAM STAIN (Final [**2122-5-30**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): BUDDING YEAST WITH PSEUDOHYPHAE. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S). RESPIRATORY CULTURE (Final [**2122-6-2**]): MODERATE GROWTH OROPHARYNGEAL FLORA. STAPH AUREUS COAG +. MODERATE GROWTH. PENICILLIN SENSITIVITY AVAILABLE ON REQUEST. Please contact the Microbiology Laboratory ([**7-/2421**]) immediately if sensitivity to clindamycin is required on this patient's isolate. YEAST. MODERATE GROWTH OF TWO COLONIAL MORPHOLOGIES. GRAM NEGATIVE ROD(S). RARE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | ERYTHROMYCIN---------- 1 I GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- 0.5 S [**2122-6-1**] 12:34 pm SPUTUM Source: Endotracheal. **FINAL REPORT [**2122-6-4**]** GRAM STAIN (Final [**2122-6-1**]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): BUDDING YEAST. RESPIRATORY CULTURE (Final [**2122-6-4**]): Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. OROPHARYNGEAL FLORA ABSENT. STAPH AUREUS COAG +. RARE GROWTH. Please contact the Microbiology Laboratory ([**7-/2421**]) immediately if sensitivity to clindamycin is required on this patient's isolate. YEAST. SPARSE GROWTH OF TWO COLONIAL MORPHOLOGIES. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPH AUREUS COAG + | ERYTHROMYCIN---------- 1 I GENTAMICIN------------ <=0.5 S LEVOFLOXACIN---------- =>8 R OXACILLIN------------- 0.5 S [**2122-6-2**] 10:22 am SPUTUM Source: Endotracheal. GRAM STAIN (Final [**2122-6-2**]): >25 PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): BUDDING YEAST. RESPIRATORY CULTURE (Final [**2122-6-4**]): Due to mixed bacterial types ( >= 3 colony types) an abbreviated workup will be performed appropriate to the isolates recovered from this site. RARE GROWTH OROPHARYNGEAL FLORA. YEAST. SPARSE GROWTH OF TWO COLONIAL MORPHOLOGIES. STAPH AUREUS COAG +. RARE GROWTH. LEGIONELLA CULTURE (Preliminary): NO LEGIONELLA ISOLATED. FUNGAL CULTURE (Preliminary): YEAST. Blood cx and urine cx - negative to date Discharge Labs: [**2122-6-8**] 05:44AM BLOOD WBC-9.3 RBC-3.31* Hgb-9.6* Hct-28.3* MCV-85 MCH-28.9 MCHC-33.8 RDW-15.1 Plt Ct-191 [**2122-6-8**] 05:44AM BLOOD Calcium-7.3* Phos-3.2 Mg-1.9 [**2122-6-8**] 05:44AM BLOOD Glucose-86 UreaN-15 Creat-0.8 Na-141 K-3.0* Cl-109* HCO3-23 AnGap-12 Brief Hospital Course: [**Age over 90 **] M with Alzheimer's dementia, presented in septic shock from bilateral pneumonia with APACHE 38 on pressors, extubated on [**6-4**]; off all pressors since [**6-4**]; He was gradually wean off the NC and called out to the regular medicine floor on [**2122-6-6**]. His hospital course during this admission is as follows: 1 Septic shock: Likely secondary to bilateral pneumonia. Sputum cultures show MSSA, blood and urine cx negative NGTD. Antibiotics had been received in the ED, then was transferred to the MICU. Cortisol stimulation test initial value was 39, so no further steroid support was given. Xigris was initiated on [**5-30**] x 96 hrs. Apache score was 38 with predicted mortality of >85% (however, he did well). Patient was started on vanco, zosyn, doxycycline to cover respiratory sources (hospitalized, gram negatives, atypicals), vanc was d/ced on [**6-3**] due to MSSA in sputum, zosyn was d/ced on [**6-5**], and is currently on doxycycline and nafcillin (will continue until [**2122-6-12**]). On MICU admission, patient presented with polymorphic VT with prolonged QT (so fluoroquinolones and macrolides were avoided). Legionella antibody was negative on [**5-31**]. Stopped levophed on [**6-2**] and started vasopressin, off vasopressin since [**6-4**]. His blood pressure remained stable off pressors and once on the floor. He had a PICC line placed on [**2122-6-8**] to complete his course of IV antibiotics. 2 Respiratory failure: secondary to bilateral pneumonia requiring intubation on [**2122-5-30**] and extubated on [**6-4**]; Respitory cx grew MSSA and yeast; blood cx and urine cx - ngtd; he was gradually weaned off the NC and was on RA at the time of the discharge; CXR on [**2122-6-6**] showed improving airspace disease w/ small R pleural effusion; He was to continue nafcillin (MSSA) and doxycycline (atypicals) until [**2122-6-12**]. He had a PICC line placed on [**2122-6-8**] to complete his course of IV antibiotics. 3 Hypernatremia- Na on admission 158 w/ free water deficit of >5 L on admission. After fluid resuscitation, received free water via OGT. resolved on [**6-3**]; slightly elevated again on [**2122-6-6**] to 148 from 134 yesterday; received 2L of D5W, and hypernatremia resolved. 4 Anemia and Thrombocytopenia: worsened acutely on [**6-3**] with Hct 28->22; plt 121->77; DIC and hemolysis labs negative on [**6-3**] s/p transfuse 1 unit pRBCs; guaiac stool negative; Hct stable and trending up after transfusion; plt also started trending up and stable >100 5 Renal Failure: initially Cr 4.6 on admission, w/ aggressive IVF; resolved by [**6-2**] back to his baseline to 0.8-1.0. 6 Dementia: remained at baseline 7 F/E/N- initially NPO, then tube feeds w/ NGT; NGT removed on [**2122-6-5**] and started soft and thin liquids (needs daughters to feed him) tolerated well; 8 Access- R IJ (removed on [**2122-6-8**]); PICC line placed on [**2122-6-8**] to complete IV antibiotics 9 Contact- [**Name (NI) 4136**] [**Name2 (NI) **] [**Telephone/Fax (1) 4137**] daughter and [**Name (NI) 4138**] [**Name (NI) 4139**] wife [**Telephone/Fax (1) 4140**] (co-HCP). [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 4141**] [**Telephone/Fax (1) 4142**] (H) daughter (co-HCP). 10 ppx- heparin sc, PPI, bowel regimen 11 Code- discussed with family and team. He is DNR but will be aggressive otherwise. They feel as if he is extremely happy person walking around normally but do not want to harm him or cause him pain. - rediscussed on [**6-4**], will reintubate in needed. - rediscussed on [**6-6**], no reintubation per daughter; DNR/DNI Medications on Admission: Ceftriaxone 500 mg q24 (D1 [**6-18**]) Morphine sulfate 4 mg po q2 hr prn (5 pm and 1:45 am today) Tylenol 650 mg prn Dulcolax 10 mg prn Calcium/vitamin D Albuterol q2 hr prn Tylenol prn Levaquin 250 mg qday po (start [**5-24**]) Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Doxycycline Hyclate 100 mg Recon Soln Sig: One (1) Intravenous twice a day for 4 days: last day [**2122-6-12**]. 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 4. Nafcillin 2 g Piggyback Sig: One (1) Intravenous every six (6) hours for 4 days: last day [**2122-6-12**]. 5. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 6. Prevacid 30 mg Susp,Delayed Release for Recon Sig: One (1) PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged Discharge Diagnosis: Primary diagnosis: Pneumonia (treated) respitory failure from bilateral pneumonia (resolved) sepsis (resolved) hypernatremia (resolved) thrombocytopenia (resolved) anemia (stable) Secondary diagnosis: Alzheimers dementia (diagnosed [**5-31**] yrs ago) Discharge Condition: afebrile, vital sign stable, tolerating PO Discharge Instructions: You were admitted for respitory failure and sepsis requiring 7 day of intensive unit care. You clinically improved and was transferred to the floor on [**2122-6-6**] and has been doing well clinically. You need to continue IV nafcillin and doxycycline until [**2122-6-12**] to complete the 14 day course of antibiotics for your pneumonia. . Please take all of your medications as prescribed. . Please follow up with your PCP [**Last Name (NamePattern4) **] [**1-27**] weeks. . Please call 911 or go to the nearest emergency room if fever>101, chills, chest pain, shortness of breath, severe nausea, vomiting, or diarrhea or any other sytmpoms that are concerning to you. Followup Instructions: please follow up with your PCP [**Last Name (NamePattern4) **]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4143**] [**Social Security Number 4144**] within 1-2 weeks after discharge. Completed by:[**2122-6-8**]

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icd9cm

[ [ [] ] ]

[ "96.72", "00.11", "38.93", "99.04", "96.04" ]

icd9pcs

[ [ [] ] ]

16072, 16131

11593, 15219

287, 535

16428, 16473

2461, 2461

17194, 17426

2063, 2081

15499, 16049

16152, 16152

15245, 15476

16497, 17171

11301, 11570

2096, 2442

11235, 11285

221, 249

563, 1830

16354, 16407

2477, 3366

16171, 16333

1852, 1962

1978, 2046

3378, 11199

10,206

165,403

47396

Discharge summary

report

Admission Date: [**2150-12-2**] Discharge Date: [**2150-12-29**] Date of Birth: [**2091-9-27**] Sex: F Service: CTS HISTORY OF PRESENT ILLNESS: This 59 year old female was referred in by her primary care physician to the hospital and admitted to the medical service on [**2150-12-2**], presenting with increasing dyspnea on exertion and lower extremity edema. She had a known history of breast cancer with moderate severe aortic stenosis. She was feeling fine until she developed symptoms approximately two weeks prior to admission after a trip to New [**Country 6679**]. She felt she had some unusual chest sensations and no dyspnea at that time but she went to her son again three weeks ago and had noticed increasing dyspnea, as well as palpitations with walking but no lower extremity edema. Then in the prior two weeks to admission, she developed some orthopnea and paroxysmal nocturnal dyspnea over one week. She also noticed she had a ten pound weight gain in one week and decreased urine output times one week with dark urine and increased thirst. Her primary care physician noted her increasing lower extremity edema. She had no chest pain at that time and was admitted into the hospital on the medical service. PAST MEDICAL HISTORY: Breast cancer, stage II hormone positive, status post lumpectomy, chemotherapy and radiation therapy with chemotherapy in [**2149-1-1**], to [**2149-6-1**], with Adriamycin, Cytoxan and Taxol, and radiation therapy [**2149-7-1**], to [**2149-8-1**], thirty-three visits. Bicuspid aortic valve. Prior echocardiogram at [**Hospital1 346**] in [**2150-12-2**], revealed mild to moderate aortic stenosis with two plus aortic insufficiency and one plus mitral and tricuspid regurgitation. At the time, she had a peak aortic valve gradient of 43 mmHg and a mean of 28 mmHg. Benign positional labyrinthitis. Diverticulosis. Hypothyroidism. Hiatal hernia with gastroesophageal reflux disease. PAST SURGICAL HISTORY: In addition to her lumpectomy includes a tonsillectomy, appendectomy and removal of a benign nevus. ALLERGIES: She has no known medical allergies although she says she is sensitive to adhesive tape. MEDICATIONS ON ADMISSION: 1. Levoxyl 50 mcg p.o. one daily. 2. Trazodone as needed. 3. Tamoxifen 10 mg p.o. twice a day. 4. Hydrochlorothiazide 25 mg p.o. daily. 5. Desipramine 50 mg p.o. twice a day. 6. Lipitor 10 mg p.o. every other day. 7. Zoloft 100 mg p.o. twice a day. 8. Ativan 1 mg p.o. daily. 9. Prilosec 20 mg p.o. twice a day. 10. Aspirin 81 mg p.o. daily. 11. Clonidine 0.1 mg p.o. twice a day. 12. Sudafed and Rhinocort as needed. 13. She also stated that she periodically took Sulfamethoxazole as well as vitamins, calcium, Vitamin E, multivitamin, Fibercon and a stool softener. She additionally uses Vioxx p.r.n. and Flexeril p.r.n. SOCIAL HISTORY: She quit smoking 24 years ago, having started at the age of 16 and smoking up to two packs per day. HO[**Last Name (STitle) **] COURSE: The patient was treated by the medical service and cardiology for her congestive heart failure that she presented with in preparation for cardiac catheterization and repeat echocardiogram. She was followed by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], her primary care physician. [**Name10 (NameIs) **] patient was diuresed and ultimately received echocardiogram on [**2150-12-8**], which showed global left ventricular hypokinesis, bilateral atrial enlargement, moderate aortic stenosis with two plus aortic insufficiency, one to two plus mitral regurgitation, and depressed right ventricular function. Cardiac catheterization was performed on [**2150-12-4**], which showed 30 percent left main lesion, two plus mitral regurgitation, left ventricular ejection fraction of 20 percent with severe diffuse hypokinesis and severe aortic stenosis with a valve area of 0.5 centimeter squared, a peak gradient of 45 mmHg. The patient additionally had low cardiac output in the catheterization laboratory. The patient was referred to Dr. [**Last Name (Prefixes) **] of cardiothoracic surgery for aortic valve replacement with a question of mitral valve replacement versus repair. She was seen by Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7625**] of cardiothoracic surgery who noted her prior history of bicuspid aortic valve, mitral valve prolapse and her history of left breast cancer, status post chemotherapy, radiation therapy and surgery with Adriamycin. Of note, the patient also had left upper extremity lymphedema from her prior lumpectomy and axillary node dissection. The patient was seen by Dr. [**Last Name (STitle) 7625**] who noted her prior medical history. On examination, she was in no apparent distress but slightly short of breath in bed. She had mild jugular venous distention. The heart was regular rate and rhythm with a grade II/VI systolic ejection murmur heard best at the left upper sternal border and apex. Her lungs were clear bilaterally without any wheezes, rhonchi or rales. She had a soft, nontender, nondistended abdomen. Her extremities were without any cyanosis, clubbing or edema but her hands bilaterally were slightly cyanotic. Her neurological examination was nonfocal. She had two plus bilateral carotid pulses, no palpable radial pulses, and one plus bilateral femoral, popliteal, dorsalis pedis and posterior tibial pulses. Preoperative laboratories were as follows: White blood cell count 8.1, hematocrit 30.4, platelet count 403,000. Prothrombin time 14.9, partial thromboplastin time 24.8, INR 1.4. Sodium 138, potassium 4.6, chloride 103, creatinine 1.0, blood sugar 119. Prothrombin time 33.9, partial thromboplastin time 57, INR 0.9. CK 141, troponin less than 0.01. Hepatitis antibody was negative. Chest x-ray showed cardiomegaly. Additional laboratories were as follows: ALT 339, AST 173, alkaline phosphatase 67, total bilirubin 0.9. Preoperative electrocardiogram showed atrial fibrillation. Preoperative gallbladder ultrasound showed a right pleural effusion and just minimal fluid around the gallbladder attributed to her congestive heart failure. Th[**Last Name (STitle) 1050**] was referred to Dr. [**Last Name (Prefixes) **] for evaluation of double valve surgery with additional studies to be done including the completion of her echocardiogram which was done on [**2150-12-8**]. Please refer to the above results. The elevated AST and ALT were again noted the following morning to be elevated as well as INR of 1.4. Hepatology consultation was called to evaluate the patient. It was recommended that the patient have some Vitamin K subcutaneously and repeat liver function tests and INR check in the morning. Carotid ultrasound was also ordered. The patient remained on the medical service and was seen by the hepatology fellow. Please refer to the official consultation note dated [**2150-12-6**], which was completed preoperatively. Additional studies were recommended by hepatology service. Preoperatively on [**2150-12-6**], the patient had an episode of left sided chest pain and was given intravenous Morphine and a bolus of normal saline. This was then stopped after the patient complained of worsening dyspnea. The patient was evaluated again. INR the next day rose to 2.2. The patient was appropriate at that time with no asterixis and continued to be followed on the medical service in preparation for her surgery. The patient was also seen by Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 2031**] of the heart failure service and cardiology for the patient's worsening congestive heart failure. The patient was loaded with Digoxin per Dr. [**First Name (STitle) 2031**]. Swan-Ganz catheter was placed and the patient was then intubated on [**2150-12-7**], by anesthesia given her aortic stenosis and increasing respiratory distress with respiratory rate over 30 and an unobtainable peripheral oxygen saturation. At the time, her potassium was 5.8. The patient was intubated successfully and transferred to the Coronary Care Unit from [**Hospital Ward Name 121**] Six. Central venous line and Swan-Ganz was placed as mentioned previously. Given the patient's worsening hemodynamic status and worsening transaminases, as well as recent intubation, the plan was discussed to possibly have the patient have a valvuloplasty the following morning and manage her volume. At the time of cardiac catheterization on [**2150-12-8**], the patient underwent aortic valve balloon valvuloplasty in the catheterization laboratory. The resulting mean gradient was 25 and the aortic valve area was increased from 0.5 to 0.65 centimeter squared. Liver function tests continued to trend upward with ALT of 1450, AST 1406, LDH 1380. This was discussed with Dr. [**Last Name (Prefixes) **] and cardiothoracic surgery service continued to follow from a distance preoperatively for potential aortic valve surgery. A postprocedure echocardiogram also noted by the congestive heart failure fellow was that the patient's echocardiogram showed some worsening of her aortic insufficiency which was now moderate. SN NP was started by the cardiology heart failure service. The patient was also evaluated by clinical nutrition given her abnormal liver function. Her creatinine rose slightly with sodium nitroprusside but the goal was to get her to an index of 2.6. She continued to run slightly negative for her diuresis. She was transfused two units of packed red blood cells. The patient was also evaluated by the case manager for cardiothoracic surgery in preparation for her hospitalization and potential surgery. Dr. [**Last Name (Prefixes) **] evaluated the patient on [**2150-12-10**], and noted that her situation was improving but was planned for surgery only once her liver function tests recovered. He also encouraged aggressive attention to nutrition and general condition as the patient is preoperative for high risk surgery. Preoperative stroke risk was also evaluated by the stroke attending who recommended carotid ultrasound and MRI/MRA of the brain as well as tight glucose control. The patient had some slight disorientation after her extubation on [**2150-12-10**], and some right sided weakness was also noted. Stroke service was immediately called. The patient was also evaluated by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] of the heart failure service covering for Dr. [**First Name (STitle) 2031**] and was seen by Dr. [**Last Name (STitle) 9673**] of the heart failure service also. Hepatology service also continued to follow the patient daily. KUB was negative for obstruction. Blood cultures on [**2150-12-7**], showed no growth to date. Fungal and acid fast bacilli also showed no growth to date. Sputum had some polymorphonuclear cells with four plus gram positive cocci in pairs, chains and clusters, as well as sputum culture showing moderate oropharyngeal growth. Please refer to the official report dated [**2150-12-7**]. Electrocardiogram showed occasional premature ventricular contractions with short runs of trigeminy. The head CT with contrast showed a small hypodense focus seen adjacent to the left side of the left angle commissure consistent with a Virchow-[**Doctor First Name **] space. This was noted on prior MRA examination of 06/[**2145**]. No mass effect, midline deviation or hemorrhage was seen. Chest x-ray [**2150-12-10**], showed left hemidiaphragm opacity likely a combination of small pleural effusion, atelectasis and consolidation. Ativan was discontinued and neurologic examination was followed daily. Magnetic resonance imaging was also ordered to help better determine possible cerebrovascular accident. Preoperatively also the patient had some supraventricular tachycardia versus atrial fibrillation which was relieved by Lopressor. She also had her magnetic resonance imaging done with an improved examination. Her congestive heart failure became better compensated. Head MR showed no evidence of a cerebrovascular accident. The patient did have some chest pressure briefly with tachycardia that resulted from the atrial fibrillation and was given Diltiazem and beta blocker with relief. At this time, though, on [**2150-12-13**], the patient did have some persistent right sided weakness despite any evidence that she had had a cerebrovascular accident. On additional review by neurology, it was determined that the patient probably did have an abnormality that seemed like motion artifact. Please refer to the final MRA report. The patient did continue to have some right arm weakness but was then referred on to cardiothoracic surgery, was also seen and evaluated by physical therapy. Nitropride was stopped on [**2150-12-14**]. Captopril was started with a goal systolic arterial blood pressure of greater than 110. The patient also had several more visits by the clinical nutrition team. Urine culture showed E. coli with Bactrim resistance. The patient's antibiotics were changed to Ciprofloxacin with a four to seven day course and was given Miconazole cream. The patient was reevaluated by cardiac surgery on [**2150-12-15**], who noted her decreasing liver function tests and the fact that she had been cleared by neurology for cardiac surgery and heparinization. The patient was also increasing her activity level and was doing much better. The plan was discussed with Dr. [**Last Name (Prefixes) **]. The patient's preference was for mechanical valve and the plan was to schedule the patient for aortic valve replacement and mitral valve replacement on the following Friday. The patient was seen again by the stroke service on [**2150-12-16**], and was evaluated again by the congestive heart failure service to make sure her diuresis and volume status had been optimized. Additional preoperative laboratories on [**2150-12-17**], prior to surgery were as follows: White blood cell count 11.6, hematocrit 35.8, platelet count 348,000. Prothrombin time 13.7, INR 1.2. Potassium 4.3, blood urea nitrogen 21, creatinine 0.5, ALT 194, AST 34, alkaline phosphatase 72, total bilirubin 1.2. Urinalysis showed some leukocytes with 6-10 white blood cells and no bacteria. Repeat urinalysis and culture was ordered. Antibiotics were given empirically prior to her valve replacement. Preoperative carotid ultrasound showed no significant disease. Please refer to the official report. The patient remained on Ciprofloxacin also in addition to her usual medications prior to surgery. On[**2150-12-18**], the patient underwent aortic valve replacement with a 23 millimeter pericardial valve and mitral valve replacement with a 29 millimeter pericardial valve by Dr. [**Last Name (Prefixes) 2545**] and was transferred to the Cardiothoracic Intensive Care Unit in stable condition on an Epinephrine drip of 0.03 mcg/kg/minute, Nitroglycerin drip at 1.0 mcg/kg/minute and Propofol drip at 20 mcg/kg/minute. On postoperative day number one, the patient was in sinus tachycardia in the 120s and blood pressure was 126/66. Cardiac index 2.9 on an Esmolol drip. Other drips had been weaned off. The patient was given Aspirin and Toradol for pain. Lungs were clear bilaterally. The abdomen was soft, nontender, nondistended. Extremities were warm and well perfused. Carvedilol was started. Swan was discontinued. Her chest tubes remained in place and Lasix diuresis was begun. On postoperative day number two, the patient had spiked a temperature, continued with diuresis, had a run of atrial fibrillation and was converted. The patient in the morning was in atrial fibrillation again at 106 on p.o. Carvedilol and Amiodarone was started. The patient also continued with perioperative Vancomycin and was otherwise alert and oriented in no apparent distress and doing well with an unremarkable examination. Lisinopril was also started low dose at 2.5 mg. Chest tubes were discontinued. Foley remained in place. The plan was to increase Carvedilol, double the dose, the following day. Pacer wires remained in place with a plan for the patient to be transferred out to the floor the following day on postoperative day three. The patient continued to do very well and was alert and oriented and continued with Lisinopril and Carvedilol. Pacing wires were discontinued. Heparin and Coumadin were both given. Amiodarone was switched over to p.o. The patient's Foley was discontinued and the patient was transferred out to the floor. Creatinine was stable at 0.4, potassium 3.8 and INR 1.2. White blood cell count 12, hematocrit 32. On [**2150-12-21**], the patient was transferred out to the floor where she could be evaluated by physical therapy and start her cardiopulmonary rehabilitation. The patient continued to be anticoagulated with Heparin while her Coumadin dose continued to raise her INR. The patient had some incisional pain which was medicated with Tylenol number three. The patient was voiding well after Foley. Sternal incision was dry and clean and intact. The patient was ambulating with assistance, continued to make very good progress, did a level three on postoperative day four, was restarted on her preoperative medications with the addition of Carvedilol and the Amiodarone. The patient's creatinine was stable at 0.7. Her postoperative atrial fibrillation had converted to sinus rhythm on Amiodarone and Lopressor. The patient also received Milk of Magnesia and an evening dose of Coumadin 3 mg that day. Amiodarone was decreased to 400 mg twice a day from three times a day. The patient remained on a Heparin drip. Lipitor was discontinued given her recent elevated liver function tests without any evidence of coronary disease. She continued to work with physical therapy, had some incisional pain, a little bit of ankle edema as well as right arm edema and weakness which was known to the team from preoperative workup. The patient continued to stay on the floor and work with physical therapy and the nurses to improve her activity level and tolerance while we waited for her INR to rise. On postoperative day number five, her INR was 4.4, partial thromboplastin time was pending. As the partial thromboplastin time was drawn from the same arm as the intravenous Heparin, so it was repeated. Coagulation studies were rechecked. The patient continued to progress well. Carvedilol was increased to 6.25 mg p.o. twice a day on postoperative day number five. The patient was moving all extremities and was increasing her activity level slowly. INR rose to 1.6 on postoperative day number six. On postoperative day number seven, her INR rose to 1.9 and her liver function tests approached normal range. The patient also had a small amount of back pain which was also medicated with Tylenol number three. When her INR hit 2.1, her Heparin drip was discontinued. The patient had one episode of hypotension after doing stairs. The blood pressure was 74/47 and she was completely asymptomatic. A liter of saline bolus was given and the patient was placed back in bed. She continued to do well on postoperative day number eight. On postoperative day number nine, the patient did a level five on the stairs and felt well doing that. A cortisol level was checked which was normal. She continued to drop her blood pressure every time she did the stairs but was retested. Her Lasix diuresis was discontinued. The patient was restarted on her home dose of Hydrochlorothiazide 25 mg p.o. daily. The patient was seen again by case management on [**2150-12-28**], in preparation for discharge, hopefully with VNA services. The patient was also doing well on postoperative day number ten. She did continue to have this hypotension when she was doing stairs but otherwise asymptomatic. Carvedilol was continued. The patient continued with Lisinopril. On [**2150-12-29**], the patient discharged to home with services. On the evening after discharge, teaching was done. DI[**Last Name (STitle) 408**]E INSTRUCTIONS: The patient was instructed to follow- up with Dr. [**First Name8 (NamePattern2) 449**] [**Last Name (NamePattern1) 2031**], her cardiologist, approximately two to three weeks postdischarge, to see Dr. [**Last Name (Prefixes) **] in the office in four weeks for her postoperative surgical visit, follow-up with Dr. [**Last Name (STitle) **] by telephone when she had her INR checked by the VNA. Dr. [**Last Name (STitle) **] is to follow her INR and Coumadin dosing, area code [**Telephone/Fax (1) 100298**]. MEDICATIONS ON DISCHARGE: 1. Colace 100 mg p.o. twice a day. 2. Enteric Coated Aspirin 81 mg p.o. daily. 3. Levothyroxine Sodium 50 mcg one tablet p.o. daily. 4. Zoloft 100 mg p.o. once daily. 5. Tamoxifen Citrate 10 mg p.o. twice a day. 6. Lisinopril 5 mg p.o. daily. 7. Tylenol number three with Codeine one to two tablets p.o. q4-6hours p.r.n. 8. Desipramine Hydrochloride 50 mg p.o. twice a day. 9. Amiodarone Hydrochloride 400 mg twice a day for one week, then 400 mg once a day for one week, then 200 mg per day. 10. Coumadin 2 mg per day until she spoke to her physician after her blood draw when she got home. The patient was to check with Dr. [**Last Name (STitle) **] for Coumadin dosing. 1. Hydrochlorothiazide 25 mg p.o. daily. 2. Lipitor 10 mg p.o. daily. 3. Prilosec enteric coated 20 mg p.o. twice a day. DISCHARGE STATUS: The patient was discharged home with VNA services in stable condition on [**2150-12-29**]. DISCHARGE DIAGNOSES: Status post aortic valve replacement and mitral valve replacement. Breast cancer, status post chemotherapy with Adriamycin and radiation therapy and lumpectomy. Left upper extremity lymphedema. Diverticulosis. Hypothyroidism. History of migraines. Congestive heart failure. Atrial fibrillation. Question cerebrovascular accident. CONDITION ON DISCHARGE: The patient was discharged home in stable condition on [**2150-12-29**]. [**Doctor Last Name **] [**Last Name (Prefixes) **], M.D. [**MD Number(1) 1288**] Dictated By:[**Last Name (NamePattern1) **] MEDQUIST36 D: [**2151-2-23**] 16:19:12 T: [**2151-2-23**] 19:35:14 Job#: [**Job Number 100299**]

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icd9cm

[ [ [] ] ]

[ "35.23", "96.71", "35.21", "39.61", "96.04", "89.64", "37.78", "88.56", "88.53", "99.04", "37.23", "89.68", "35.96", "88.72", "38.93" ]

icd9pcs

[ [ [] ] ]

21566, 21897

20623, 21544

2214, 2869

1986, 2188

166, 1251

1274, 1962

2886, 20597

21922, 22249

29,665

175,645

2745

Discharge summary

report

Admission Date: [**2129-3-30**] Discharge Date: [**2129-4-6**] Date of Birth: [**2093-1-14**] Sex: F Service: NEUROLOGY Allergies: Demerol / Dilaudid / Ciprofloxacin / Bacitracin / Neosporin / Adhesive Tape / Latex / Optiray 300 Attending:[**Last Name (NamePattern1) 13561**] Chief Complaint: Worsening of generalized dystonia after PEG replacement Major Surgical or Invasive Procedure: PEG replacement History of Present Illness: 36 F with 12-year hx of dystonia with some autonomic features, followed by [**Last Name (NamePattern1) **]. [**Last Name (STitle) **] and [**Name5 (PTitle) 951**], [**Name5 (PTitle) 1834**] IR-guided replacement of her G-tube on [**2129-3-29**]. Per a prior note from Dr. [**First Name (STitle) 951**], she was to be pre-treated with 20 mg valium, followed by 10 mg Q3hrs for up to 3 doses after the procedure. This protocol was deviated from somewhat. She received 30 mg valium during the procedure, then recived 20 mg valium on admission to the PACU at about noon on [**3-29**]. Over the course of the next 12 hours, she remained in the PACU and received an additional 32.5 mg valium plus 3 mg morphine. Although the plan was for her to go home the same day, she took a long time to rouse, and when she did, she continued to have worsened dystonia from her baseline. This has improved over time, but she states she is still not at her baseline. She will continue to be observed in the PACU overnight. Past Medical History: #. generalized dystonia - involving mainly her lower extremities and intermittently her arms, right more than left, occasionally her neck and voice; provoked exacerbations of the symptoms without a clear direct inducer[seen by Dr. [**Last Name (STitle) 13551**] at [**Hospital1 2025**] and Dr. [**Last Name (STitle) 13552**] at [**Hospital1 1774**]] #. dysautonomia with orthostasis, baseline SBP 80s-90s - followed by Dr. [**First Name (STitle) **] #. neuro-cardiogenic syncope s/p pacer in [**12/2120**] #. Parkinsonism- occasional adventitious choreiform movements in both upper extremities induced by action #. gastric dysmotility s/p g-tube placement #. bladder areflexia s/p bladder stimulator implant and urostomy [**2126**] #. depression with h/o suicide attempt #. peripheral neuropathy #. h/o chronic pupillary dilation #. s/p lap CCY # gastric dysmotility- with g-tube # bladder areflexia requiring ileostomy # Chronic anemia- EGD in '[**27**] with gastritis, colonoscopy in '[**22**] with firability Social History: Married and lives with husband. Not working and on disability. Currently at [**Hospital1 **] for rehab. Family History: GF w/ h/o frequent sycnope; 3 deceased paternal uncles with [**Name (NI) 5895**] Disease Physical Exam: T- 98.4 F BP- 97/48 HR- 80 RR- 12 O2Sat 98%RA Gen: Lying in bed, NAD HEENT: NC/AT, moist oral mucosa Neck: contracted to the right CV: RRR, Nl S1 and S2, no murmurs/gallops/rubs Lung: Clear to auscultation bilaterally Abd: +BS, soft, nontender; (+) G-tube and ostomy Ext: no c/c/e; (+) small, red, nickel-sized circles on her LE B/L, which she states is a staph infection. Neurologic examination: Mental status: sleeping but rousable, cooperative with exam, but unable to open eyes (eyelid apraxia?) and actively opposes forced opening. Voice very hypophonic. Oriented to person, place, and date. Attentive, says DOW backwards. Speech is fluent with normal comprehension and repetition; naming intact. No dysarthria. No evidence of apraxia or neglect. Cranial Nerves: Pupils equally round and reactive to light, 7 to 4 mm bilaterally. Non-cooperative with extraocular movement testing. Sensation intact V1-V3. Facial movement symmetric. Hearing intact to finger rub bilaterally. Palate elevation symmetrical. Tongue midline, movements intact Motor: Normal bulk bilaterally. Significantly increased tone throughout. Neck contracted to the right, RUE flexor contracted and ADducted (unable to break) LUE with some spontaneous mvmt at the delt (at least a [**3-17**]) with flexor contracted wrist and fingers in contracted pincer-grasp LE (B/L): able to flex at the hip with full strength. Non-voluntary, slow, low amplitude movements at the knees. Feet are dorsi-flexor contracted and toes are flexor contracted Sensation: decreased to PP and temp in the LE B/L to the mid-thigh. Otherwise intact to light touch, pinprick throughout. Proprioception unable to be tested properly. Reflexes: +2 and symmetric at the biceps, otherwise, unable to elicit reflexes. Toes unresponsive bilaterally Coordination/Gait: unable to properly assess Brief Hospital Course: Patient is a 36-year-old woman with a 12-year history of generalized dystonia without clear etiology, with a history of autonomic dysfunction, which seems to be less of a problem lately, was admitted [**2129-3-29**] for elective replacement of her G-tube by IR. Neuro - Although she was meant to go home following the procedure, she required a long time to rouse post procedure and had worsened dystonia from her baseline, particularly in her RUE. Due to concern after receiving total 97.5mg og valium within 24 hr period including during the procedure and need for frequent monitoring, patient was admitted to ICU overnight after spending the night in PACU post-operatively. She remained stable but fluctuations in muscle tone. Tone primarily increased in RUE, adducted with elbow, wrist and fingers flexed. Also plantarflexion and inversion of feet and at times flexion at knees. Intermittent torticollis with head to L. Intermittent spasm on R eyelid. Voice remained a wisper though varied in volume. Overall she gradually improved with some intermittent fluctuations. She is not yet able to do transfers to her wheelchair, will need to continue intensive inpatient physical therapy. Patient's home med regimen including baclofen was continued in addition to Valium that was slowly titrated down and morphine for pain as needed. She also received benadryl prn to help with discomfort related to increased tone. On discharge getting valium 5mg PG [**Hospital1 **] prn for dystonia. Home regimen is 5mg up to 3x/week prn for increased tone. FEN/GI - Continued TPN, nutrition consulted and helped with TPN formulation. TPN x5 days, [**4-5**] IVFs only. Speech and swallow evaluated her for concerns regarding cough/gag with feeding. She was having some difficulty, they recommended ground solids and thin liquids. ID - Patient spiked to 100.7 x1 but not persistently febrile. UA showed mixed flora as expected with her ostomy. Urology recommended if persistently febrile could do sterile urine sample from ostomy via catheter but she did not have further fevers.. CXR was also obtained and LFTs were normal. She does have chronic, intermittent staph infections of skin and she did have papules seen on lower extremities bilaterally. Discussed with dermatology re staph skin infection. They recommended swabs from wound site and nasal swab for MRSA, if positive would treat with oral antibiotics. MRSA nasal swab was negative, wound culture with mixed skin flora. Heme - Patient also has pancytopenia - she does have hx of anemia that has been thoroughly worked up without clear etiology. Hematology consulted. Anemia consistent with iron deficiency anemia. Iron 29, TIBC 316, ferritin 20, transferrin 243, haptolgobin 152. B12 and folate normal. Retics 1.7. Transfused 1 unit pRBCs. Low hct 23.4, post transfusion 27. Attempted IV iron dextran infusion, but stopped during test dose as patient had a change in heart rythm. After review with EP, this is an expected paced rhythm that results when she becomes bradycardic and thus not likely a complication from the iron dextran infusion. Nonetheless, iron infusion was discontinued and can be reconsidered as an outpatient. WBCs initially 2.8 improved to 4.6 on [**4-3**] with 63N 30L. Platelets initially 74 improved to 113. Blood smear not consistent with primary bone marrow process. Valium can cause neutropenia and thrombocytopenia. They recommended outpatient hematology f/u in 1 month, which was arranged. CV - Patient has a pacemaker. On 2 occassions during admission, patient had a noted asymptomatic wide complex cardiac rythm. Cardiology/EP consulted on [**4-5**]. Her pacemaker, dual chamber, is programed to increase HR above set rate of 80 temporarily in resonse to bradycardia in order to increase blood pressure and avoid syncopal episodes. They felt that the rhythm was consistent with her dual chamber paced rhythm. Psychiatry - Noted worsening of dystonia symptoms related to increase in anxiety. Patient recognizes anxiety esp when difficulty speaking. Arranged for outpatient psychiatry appointment in behavioral neurology as outpatient. Medications on Admission: 1. Baclofen 20 mg three times a day. 2. Nadolol 80 mg daily. 3. Prilosec 20 mg twice a day. 4. Zoloft 50 mg daily. 5. Valium 5 mg at night three times a week. 6. Midodrine which she takes only on p.r.n. basis and hardly any at all, although she had been prescribed to take it had 5-10 mg three times a day. Discharge Medications: 1. Baclofen 10 mg Tablet [**Month/Year (2) **]: Two (2) Tablet PO TID (3 times a day). 2. Nadolol 80 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). 3. Sertraline 50 mg Tablet [**Month/Year (2) **]: One (1) Tablet PO DAILY (Daily). 4. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR PO BID (2 times a day). 5. Trihexyphenidyl 2 mg Tablet [**Last Name (STitle) **]: 1.5 Tablets PO BID (2 times a day). 6. Trihexyphenidyl 2 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO DINNER (Dinner). 7. Heparin (Porcine) 5,000 unit/mL Solution [**Last Name (STitle) **]: 5000 (5000) units Injection TID (3 times a day). 8. Senna 8.6 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO BID (2 times a day). 9. Docusate Sodium 50 mg/5 mL Liquid [**Last Name (STitle) **]: One Hundred (100) mg PO BID (2 times a day). 10. Bisacodyl 10 mg Suppository [**Last Name (STitle) **]: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 11. Ferrous Sulfate 325 mg (65 mg Iron) Tablet [**Last Name (STitle) **]: One (1) Tablet PO DAILY (Daily). 12. Diazepam 5 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q12H (every 12 hours) as needed. 13. Mupirocin Calcium 2 % Cream [**Last Name (STitle) **]: One (1) Appl Topical [**Hospital1 **] (2 times a day) for 7 days. Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: primary: generalized dystonia, acute exacerbation secondary: anemia leukopenia and thrombocytopenia, improved folliculitis autonomic dysfunction Discharge Condition: stable Discharge Instructions: You were admitted to this hospital for GTube placement and because of your medical condition you needed close observation. Your valium was slowly weaned down then transitioned to enteral valium. You received a blood transfusion and were started on iron supplementation. Initially your white blood cell and platelet counts were low but they improved prior to discharge. You will need to continue to follow with hematology. Your skin infection improved with topical antibiotics. Followup Instructions: F/u with hematology at [**Hospital3 **] Hospital - Provider: [**Name10 (NameIs) 2295**] [**Name8 (MD) 13562**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2129-6-8**] 4:00 F/u with Neurology at [**Hospital3 **] Hopsital. Provider: [**Name Initial (NameIs) 1220**]. [**Name5 (PTitle) **] & VADERHORST Phone:[**Telephone/Fax (1) 44**] Date/Time:[**2129-6-14**] 4:00 Call to set up communication device consult with [**First Name5 (NamePattern1) 714**] [**Last Name (NamePattern1) 13563**]. [**Telephone/Fax (1) 3731**]. Follow up with your primary care phsyician within 1-2 weeks of discharge from rehab. Psychiatry appointment in the behavioral neurology department. [**Hospital3 **] Hospital [**Last Name (un) 13564**] building [**Location (un) **].Provider: [**First Name11 (Name Pattern1) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 1682**] Date/Time:[**2129-4-22**] 11:00

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Discharge summary

report

Admission Date: [**2147-5-16**] Discharge Date: [**2147-5-23**] Date of Birth: [**2088-8-30**] Sex: F Service: MEDICINE Allergies: Sulfa (Sulfonamides) / Nsaids Attending:[**First Name3 (LF) 6021**] Chief Complaint: hemoptysis Major Surgical or Invasive Procedure: bronchoscopy R mainstem bronchus intubation EGD History of Present Illness: 58 F with history of metastatic breast CA to bone, liver, and lungs, malignant pleural effusions s/p pleurodesis, s/p R mastectomy and multiple chemotherapeutic regimens and hormone therapy now on taxotere (17 cycles) salvage therapy who was in USOH until 9 pm [**2147-5-15**]. She noted acute onset of hemoptysis with shortness of breath. Per family pt was aggitated and taken to ED. In ED hemodynamically stable but O2 sat 88% RA. Per report, she had about 6 tablespoons of bright red hemoptysis. CXR showed left sided white out and she was intubated in right mainstem. OGT lavage noted 150 cc of dark blood. Incidently, she had torso CT on [**5-8**] showing new subcentimeter right sided pulm nodules and increase in hilar lymphadenopathy. Per family report has not had bleeding, hemoptysis, fevers/chills, lower ext swelling/trauma, or recent shortness of breath. Has been taking NSAIDS on prn basis. . She was admitted to the MICU, with right mainstem intubation. A CT was performed demonstrating diffuse metastatic disease. She a flexible bronchoscopy in the OR performed on [**5-16**] which showed ischemic changes of R mainstem ([**2-2**] ETT cuff) and no obvious source of bleeding. The left bronchial tree was narrowed distally with billious secretions noted. She was extubated in OR prior to returning to the MICU. In the MICU she also had an EGD demonstrating an ulcer in the body of the stomach without evidence of active bleeding or adherent clot. As her Hct and O2 sats were stable for 12 hours, she was [**Hospital 11428**] [**Hospital 11429**] medical floor. Past Medical History: 1. Metastatic breast CA with mets to lung, pleura, bone. Admitted to [**Hospital1 **] in [**2136**] with an anterior mediastinal mass. She was diagnosed as having adenocarcinoma via mediastinoscopy and immunoperoxidase studies of this tumor showed it to be both estrogen receptor positive and gross cystic disease fluid protein positive clinching the diagnosis of breast carcinoma. She received while in hospital chemotherapy with CAF (cytoxan, adriamycin, 5-fluorouracil) given the presence of a significant left pleural effusion. She has been on 17 cycles of taxatore and arimidex. CEA CA-27.29 [**2147-4-25**] 60 [**2068**] [**2147-3-14**] 95 2848 [**2147-2-7**] 99 2631 [**2146-12-6**] 69 1669 [**2146-10-11**] 59 1180 [**2146-8-16**] 46 1414 [**2146-7-5**] 51 1821 [**2146-6-14**] 52 1579 . . 2. Malignant effusion s/p talc pleurodesis in [**8-3**] complicated by metastasis at the site of thoracentesis . 3. HTN . 4. Anxiety . 5. s/p appy . 6. disc herniation L4-5, no cord compression Social History: Former engineer from [**Country 532**] who lived near Chernobyl during the incident. She is originally from [**Location (un) 3155**]. The patient currently lives in [**Location **] by herself. She has a daughter. [**Name (NI) **] tobacco, alcohol or illicit drug use. Family History: 1. Mother - MS, HTN 2. Father - Glaucoma, CAD s/p CABG, 1st MI in 60s 3. No family history of CA Physical Exam: 99.6, 100, 24, 124/08, 96 2L N.C. Gen: Speaks in full sentences w/o accessory mm use. A/O x 3. NAD. Coughing small amounts of blood streaked sputum into tissue. HEENT: PEARLA. EOMI. Nares without evidence of blood. No blood seen in posterior oropharyx. Has extensive dental hardware which appears clean dry and intact. Neck supple w/o appreciable LAD. CV: RR. No murmurs. Pulm: Bronchial breath sounds on right with diffuse wheezes. Diminished b.s. at left base with coarse rhonchi at apex. Abd: Soft/NT/ND Ext: no edema, warm, well perfused Neuro: Motor [**5-5**] at all flex/ex b/l. Sensation GI to LT. CN II-XII GI. Pertinent Results: ADMISSION LABS: . [**2147-5-15**] 10:25p 137 99 13 AGap=16 ------------< 179 4.3 26 0.8 Ca: 9.6 Mg: 1.8 P: 5.0 ALT: 21 AP: 80 Tbili: 0.4 Alb: 4.2 AST: 41 LDH: 275 Dbili: TProt: [**Doctor First Name **]: 122 Lip: 34 79 16.8 \ 12.7 / 654 / 39.6 \ N:83.6 L:14.7 M:0.9 E:0.2 Bas:0.7 PT: 12.0 PTT: 27.0 INR: 1.0 . ADDITIONAL LABS: . [**2147-5-23**] 06:45AM BLOOD WBC-14.6* RBC-4.64 Hgb-11.3* Hct-35.4* MCV-76* MCH-24.4* MCHC-32.0 RDW-17.3* Plt Ct-567* [**2147-5-22**] 07:40PM BLOOD WBC-15.1* RBC-4.18* Hgb-10.6* Hct-32.3* MCV-77* MCH-25.4* MCHC-32.8 RDW-17.1* Plt Ct-566* [**2147-5-22**] 06:50AM BLOOD WBC-14.8* RBC-3.86* Hgb-9.5* Hct-29.6* MCV-77* MCH-24.8* MCHC-32.2 RDW-17.5* Plt Ct-569* [**2147-5-21**] 05:10PM BLOOD Hct-33.8* [**2147-5-21**] 07:20AM BLOOD WBC-15.6* RBC-3.92* Hgb-9.7* Hct-30.4* MCV-78* MCH-24.8* MCHC-32.0 RDW-17.3* Plt Ct-548* [**2147-5-20**] 07:30PM BLOOD WBC-19.8* RBC-4.21 Hgb-10.7* Hct-32.6* MCV-78* MCH-25.4* MCHC-32.7 RDW-17.3* Plt Ct-591* [**2147-5-20**] 06:50AM BLOOD WBC-17.9* RBC-4.04* Hgb-10.2* Hct-31.7* MCV-78* MCH-25.2* MCHC-32.1 RDW-17.3* Plt Ct-579* [**2147-5-19**] 07:30PM BLOOD WBC-20.0* RBC-4.17* Hgb-10.5* Hct-32.9* MCV-79* MCH-25.2* MCHC-32.0 RDW-17.1* Plt Ct-638* [**2147-5-19**] 07:10AM BLOOD WBC-17.8* RBC-4.29 Hgb-11.0* Hct-33.4* MCV-78* MCH-25.7* MCHC-33.0 RDW-17.1* Plt Ct-625* [**2147-5-18**] 07:20PM BLOOD WBC-20.2* RBC-4.38 Hgb-11.1* Hct-33.8* MCV-77* MCH-25.3* MCHC-32.9 RDW-17.0* Plt Ct-559* [**2147-5-18**] 10:40AM BLOOD WBC-21.4* RBC-4.11* Hgb-10.4* Hct-31.3* MCV-76* MCH-25.3* MCHC-33.2 RDW-16.9* Plt Ct-548* [**2147-5-18**] 07:00AM BLOOD WBC-19.7* RBC-4.16* Hgb-10.2* Hct-31.6* MCV-76* MCH-24.6* MCHC-32.4 RDW-16.9* Plt Ct-625* [**2147-5-17**] 09:50PM BLOOD WBC-24.4* RBC-4.30 Hgb-11.2* Hct-33.4* MCV-78* MCH-26.2* MCHC-33.7 RDW-17.0* Plt Ct-575* [**2147-5-17**] 06:09AM BLOOD WBC-25.3* RBC-4.22 Hgb-10.7* Hct-33.1* MCV-79* MCH-25.3* MCHC-32.2 RDW-17.4* Plt Ct-582* [**2147-5-16**] 06:52PM BLOOD Hct-34.2* [**2147-5-16**] 03:08AM BLOOD WBC-17.6* RBC-4.65 Hgb-12.0 Hct-36.3 MCV-78* MCH-25.9* MCHC-33.2 RDW-17.0* Plt Ct-624* [**2147-5-15**] 10:25PM BLOOD WBC-16.8*# RBC-4.99 Hgb-12.7 Hct-39.6 MCV-79* MCH-25.5* MCHC-32.2 RDW-17.0* Plt Ct-654* [**2147-5-15**] 10:25PM BLOOD Neuts-83.6* Lymphs-14.7* Monos-0.9* Eos-0.2 Baso-0.7 [**2147-5-23**] 06:45AM BLOOD Plt Ct-567* [**2147-5-23**] 06:45AM BLOOD PT-11.7 PTT-28.5 INR(PT)-1.0 [**2147-5-22**] 07:40PM BLOOD Plt Ct-566* [**2147-5-22**] 06:50AM BLOOD Plt Ct-569* [**2147-5-22**] 06:50AM BLOOD PT-12.2 PTT-30.4 INR(PT)-1.0 [**2147-5-23**] 06:45AM BLOOD Glucose-98 UreaN-13 Creat-0.7 Na-136 K-4.4 Cl-103 HCO3-25 AnGap-12 [**2147-5-22**] 06:50AM BLOOD Glucose-108* UreaN-14 Creat-0.7 Na-138 K-3.8 Cl-105 HCO3-25 AnGap-12 [**2147-5-21**] 07:20AM BLOOD Glucose-86 UreaN-14 Creat-0.6 Na-136 K-4.1 Cl-103 HCO3-25 AnGap-12 [**2147-5-16**] 03:08AM BLOOD LD(LDH)-432* [**2147-5-15**] 10:25PM BLOOD ALT-21 AST-41* LD(LDH)-275* AlkPhos-80 Amylase-122* TotBili-0.4 [**2147-5-15**] 10:25PM BLOOD Lipase-34 [**2147-5-23**] 06:45AM BLOOD Calcium-9.5 Phos-4.4 Mg-2.0 [**2147-5-22**] 06:50AM BLOOD Calcium-9.0 Phos-4.1 Mg-1.8 [**2147-5-21**] 07:20AM BLOOD Calcium-9.1 Phos-3.7 Mg-1.8 [**2147-5-18**] 07:00AM BLOOD Calcium-9.0 Phos-3.4 Mg-1.9 Iron-23* [**2147-5-15**] 10:25PM BLOOD Albumin-4.2 Calcium-9.6 Phos-5.0* Mg-1.8 [**2147-5-18**] 07:00AM BLOOD calTIBC-242* Ferritn-118 TRF-186* . REPORTS: . CT Chest: CT CHEST W/CONTRAST [**2147-5-15**] 10:51 PM IMPRESSION: 1. Intubation of the right mainstem bronchus with collapse of the left mainstem bronchus. 2. Diffuse metastatic disease similiar in appearance to the prior examination. 3. Sclerotic lesion in T1, not significantly changed. 4. Left subcutaneous mass unchanged. . Flexible bronch [**2147-5-16**] right mainstem bronchus with mild ischemic injury. Left bronchial tree narrowed and with bilious secretions. No bleeding seen. . EGD [**2147-5-17**] Findings: Esophagus: Lumen: A small size hiatal hernia was seen, displacing the Z-line to 36cm from the incisors, with hiatal narrowing at 38cm from the incisors. Stomach: Mucosa: Erosions of the mucosa was noted in the stomach body. Excavated Lesions A single cratered non-bleeding 11mm ulcer was found in the stomach body. Duodenum: Normal duodenum. Impression: Small hiatal hernia Ulcer in the stomach body Erosions in the stomach body . CHEST (PORTABLE AP) [**2147-5-15**] 10:28 PM IMPRESSION: Multiple pleural-based masses and loculated fluid collections with decreased aeration of the left upper lung. . CHEST (PORTABLE AP) [**2147-5-17**] 9:33 PM IMPRESSION: No change in the large left pleural effusion and left pleural metastases. . MICRO: . Time Taken Not Noted Log-In Date/Time: [**2147-5-17**] 6:49 pm SEROLOGY/BLOOD CHEM S# [**Serial Number 11430**]R. **FINAL REPORT [**2147-5-19**]** HELICOBACTER PYLORI ANTIBODY TEST (Final [**2147-5-19**]): POSITIVE BY EIA. Reference Range: Negative. . [**2147-5-16**] 10:02 pm BLOOD CULTURE **FINAL REPORT [**2147-5-22**]** AEROBIC BOTTLE (Final [**2147-5-22**]): NO GROWTH. ANAEROBIC BOTTLE (Final [**2147-5-22**]): NO GROWTH. . [**2147-5-16**] 10:02 pm URINE **FINAL REPORT [**2147-5-18**]** URINE CULTURE (Final [**2147-5-18**]): NO GROWTH. Brief Hospital Course: #) Hematemesis vs hemoptysis - The patient was admitted for hemoptysis vs hematemesis. She was intubated in the ED initially in the right mainstem bronchus, as there was concern for her left lung to bleed into her right lung. Flexible bronch was performed which showed ischemia of the area with the cuff on the right, and bilious fluid but no bleeding on the left. She was put on antibiotics empirically to prevent pneumonia/pneumonitis. She was extubated uneventfully. pt continued to have stable, low-volume hemoptysis during the remainder of the admission. The source was thought most likely to be pulmondary, given diffuse metastatic disease seen on CT, although bronch was without definite endobronchial lesion. ENT was consulted, and scope did not show ENT source of bleeding. Pt required 1 U PRBC's during this admission to maintain hct>30. NSAIDS were d/c'd, and this was listed as an allergy on pt's med list given non-bleeding ulcer seen on EGD. Pt was continued on high-dose PPI during the admission and on discharge. Pt only had one episode of desaturation during the admission to the high 80's on room air. She was given O2 for comfort, and was set up for home O2 on discharge. If pt developed more significant hemoptysis, she may need embolectomy by interventional radiology in the future. . #) Gastric ulcer - GI was consulted given the concern for coffee grounds by lavage, and EGD revealed an ulcer in the stomach body, nonbleeding. H pylori was sent and she should follow up with Dr. [**First Name (STitle) 679**] and continue PPI twice daily for the next several weeks. She will need a repeat endoscopy in 2 months. . #) Breast CA - The patient has stage IV metaststic breast cancer. She will follow-up with Dr. [**Last Name (STitle) **] as an outpatient. . #) [**Name (NI) 11431**] Fever - Pt had low-grade temps during the admission. Thought to be due to infection vs. tumor vs. post-bronch. Pt also had leukocytosis, which was chronic. - Pt was placed on ceftriaxone and azithromycin on admission to prevent infection, given significant blood/effusion was seen on chest CT. CTX was then d/c'd, and azithromycin was continued for 10 day course. Blood and urine cultures were negative. . #) R forearm swelling: Pt had episode of mild R forearm swelling, possibly due to A-line while pt was in ICU. - did not pursue u/s, given result would not change mangement (not a candidate for anticoagulation in setting of hemoptysis) . #) HTN - held anti-hypertensive meds in setting of bleeding, also held on discharge . #) FEN - NPO initially, then advanced to regular diet prior to d/c. . #) Proph: PPI [**Hospital1 **], pneumoboots, down on left side in case of hemoptysis, suction at bedside . #) Code - pt remained FULL CODE during the admission . #) Communication: [**First Name5 (NamePattern1) **] [**Known lastname 11432**] (daughter) cell# [**Telephone/Fax (1) 11433**] . #) Dispo: home Medications on Admission: 1. elavil 2. ibuprofen 800 mg TID prn 3. lorazepam 4. MS Contin 15 [**Hospital1 **] 5. Zantac 150 [**Hospital1 **] 6. Zestril 20 mg Qday Discharge Medications: 1. home oxygen 2 L/min continuous. Dx: breast CA metastatic to lung Room air sat down to 87% pt leaves 4-6 hours daily for appointments 2. Outpatient Lab Work check CBC on [**2147-5-25**] and have the results faxed to your PCP and your oncologist 3. Azithromycin 250 mg Capsule Sig: One (1) Capsule PO Q24H (every 24 hours) for 3 days. Disp:*3 Capsule(s)* Refills:*0* 4. Amitriptyline 25 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*0* 5. Morphine 15 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO BID (2 times a day). Disp:*60 Tablet Sustained Release(s)* Refills:*0* 6. Albuterol 90 mcg/Actuation Aerosol Sig: Six (6) Puff Inhalation Q6H (every 6 hours) as needed. Disp:*30 days* Refills:*2* 7. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO Q8H (every 8 hours) as needed for constipation. Disp:*30 days* Refills:*0* 8. Ativan 0.5 mg Tablet Sig: 1-2 Tablets PO every 4-6 hours as needed for anxiety. Disp:*60 Tablet(s)* Refills:*0* 9. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 10. 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* 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 12. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4-6H (every 4 to 6 hours) as needed. Disp:*60 Tablet(s)* Refills:*0* 13. Codeine-Guaifenesin 10-100 mg/5 mL Syrup Sig: 5-10 MLs PO Q6H (every 6 hours) as needed. Disp:*60 days* Refills:*0* 14. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 15. Sodium Chloride 0.65 % Aerosol, Spray Sig: [**1-2**] Sprays Nasal TID (3 times a day) as needed. Disp:*30 days* Refills:*2* 16. Atrovent 18 mcg/Actuation Aerosol Sig: 1-2 puffs Inhalation every six (6) hours as needed for shortness of breath or wheezing. Disp:*30 days* Refills:*2* Discharge Disposition: Home With Service Facility: [**Hospital 6549**] Medical Discharge Diagnosis: metastatic breast CA hemoptysis gastric ulcer Discharge Condition: Continues to have chronic, small-volume hemoptysis. Hct stable. Vitals stable. Discharge Instructions: Please seek medical attention immediately if you experience more bleeding with coughing, or if you have chest pain, shortness of breath, nausea, vomiting, diarrhea, fevers, chills, or dizziness. Please take all medications as prescribed. Please attend all follow-up appointments. Followup Instructions: Please follow-up with Dr. [**Last Name (STitle) **] on Tuesday, [**5-30**] at 2:30 PM on [**Hospital Ward Name 23**] 9. Provider: [**First Name11 (Name Pattern1) 569**] [**Last Name (NamePattern4) 570**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2147-5-30**] 2:30 Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) **] HEMATOLOGY/ONCOLOGY-CC9 Date/Time:[**2147-5-30**] 2:30 Provider: [**Name10 (NameIs) 26**] [**Name8 (MD) 28**], RN Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2147-5-30**] 3:00 Have a CBC checked on [**2147-5-25**], and have the results faxed to your PCP and oncologist. Please follow up with Dr. [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**] in two months for repeat endoscopy. Please call [**Telephone/Fax (1) 682**] to schedule this appointment. Please make an appointment with Dr. [**Name (NI) **] in the next 3-4 months. Please call [**Telephone/Fax (1) 612**] to schedule this appointment. Completed by:[**2147-6-3**]

[ "197.2", "V10.3", "197.7", "531.90", "198.5", "197.0", "786.3" ]

icd9cm

[ [ [] ] ]

[ "96.05", "96.04", "45.13" ]

icd9pcs

[ [ [] ] ]

14575, 14633

9426, 12337

301, 351

14723, 14805

4034, 4034

15135, 16124

3277, 3379

12525, 14552

14654, 14702

12363, 12502

14829, 15112

3394, 4015

251, 263

379, 1957

4050, 9403

1979, 2974

2990, 3261

25,702

175,085

22159

Discharge summary

report

Admission Date: [**2170-8-4**] Discharge Date: [**2170-8-10**] Service: MED Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2181**] Chief Complaint: 1) Upper GI bleed Major Surgical or Invasive Procedure: EGD History of Present Illness: Pt is a [**Age over 90 **] yo female who was transferred to the [**Hospital1 18**] for treatment of a upper GI bleed from a mass like lesion in her stomach. On [**7-25**] she was admitted to [**Hospital3 8544**] with a right lower quadrant pneumonia. Five days before that, she was seen at the [**First Name4 (NamePattern1) 5871**] [**Last Name (NamePattern1) **] for asthmatic bronchitis, and she was treated with prednisone. The [**Hospital 228**] hospital course apparently proceeded without complication until the day prior to when she was supposed to be discharged [**7-31**] when she vomited bright red blood and melena (INR 3.1). An EGD was done on [**8-1**] which revealed a large clot on the fundus. Cardiac enzymes were negative. CT was negative for splenic vein thrombosis, or liver disease, but was positive for a 3 cm round lesion in the pancreatic head. Repeat EGD on [**2170-8-3**] showed a lobulated mass in the fundus that was quite soft. EGD on [**8-4**] showed a submucosal vascular appearing mass overlying the cardiac border with feeding vessels but no active bleeding. The patient subsequently received 6 units of RBC and 3 units of FFP and 3 mg Vit K which raised the Hct to 30.4 before transfer from the OSH to [**Hospital1 18**] for further evaluation. Just before transfer, however, the patient had another episode of hematemesis (200mL BRB) along with grossly melanotic stools and tachycardia/afib. Her HCT decreased from 32.7 to 28.4 and increased to 29.7 with 2 units PRBCs. She was intubated for airway protection. On admission to the [**Hospital1 18**], the patient received 1 unit of RBC. Her Hct was 30.9. Hct on [**8-4**] was 28.4 from 32 and then increased to 29.7 with 1 unit of PRBCs. No bleeding was seen at the [**Hospital1 18**]. She did not have any GI complaints, h/o HIV, chest pain, liver disease, or a history of GI bleeds. Past Medical History: 1) AF on coumadin 2) hypothyroid 3) constipation 4) THR 5) TAH/BSO Social History: 1) lives with her daughter Family History: NC Physical Exam: On admission to the [**Hospital1 18**] ICU: Vitals - 97.4 96/36 70-85 97%RA GEN: no acute distress HEENT: anicteric COR: S1/S2 nl, irregular, no murmurs THORAX: R lung base coarse rales. L few basilar crackles ABD: no tenderness, distended, bowel sounds normal EXT: chronic venous stasis with edema NEURO: alert and oriented x 3. MAE x 4 Pertinent Results: [**2170-8-9**] 07:15AM BLOOD WBC-8.4 RBC-3.97* Hgb-12.6 Hct-36.0 MCV-91 MCH-31.6 MCHC-34.9 RDW-15.1 Plt Ct-152 [**2170-8-6**] 12:12AM BLOOD Neuts-84.5* Lymphs-12.2* Monos-2.6 Eos-0.4 Baso-0.3 [**2170-8-9**] 07:15AM BLOOD Plt Ct-152 [**2170-8-9**] 07:15AM BLOOD Glucose-101 UreaN-12 Creat-0.8 Na-143 K-3.5 Cl-109* HCO3-25 AnGap-13 [**2170-8-9**] 07:15AM BLOOD Calcium-7.5* Phos-2.5* Mg-1.8 Brief Hospital Course: 1) Upper GI bleed: In the ICU, the patient's soft vascular mass was considered to be gastroesophageal varices. Other possibilities in the differential were leiomyoma, lipoma, or malignancy. It was generally felt that whatever the precise character, the mass was still oozing blood insofar as the three units that she received at the outside hospital did not significantly increase her Hct. The ICU team set a goal of Hct > 30 given her age and potential rapidity of rebleeding. On ICU day 2, the patient was transfused 1 unit PRBC to reach a Hct of 32.1, but she continued to have no episodes of hematemesis or melena. RUQ ultrasound was negative for signs of liver disease. A repeat EGD was also performed which revealed 1. a normal celiac axis. 2. pancreatic body and the PD within it were normal. 3. in the proximal stomach, the protruding mass was identified and endosonographically was both hypoechoic and vascularly consistent with gastric varices. Unfortunately, it remained difficult to determine the cause of the most latter finding. On [**8-8**], the patient was transferred from the ICU to the floor for further care under the medicine service. At this point, the GI team saw her and recommended nadolol to help decrease portal pressures. Anticoagulation remained discontinued, and the patient's femoral line was discontinued. A PPI was started to decrease gastric distress and the patient's diet was advanced to a soft, low salt diet. Potassium was repleted as necessary. The patient did not experience any repeat episodes of hematemesis or melena. All stools were guaiac negative. At discharge, the patient's Hct was 36.0. Throughout the hospital course within the ICU and on the floor, the patient's family was kept well-informed of all medical decisions. Some clarification will be required regarding her code status as it is relatively unclear. At the moment, she is full code, but her son has expressed a desire not to have "my mother on any machines." The patient's daughter, her health care proxy wishes to have "aggressive but not extraordinary" routes of treatment pursued. 2) Cardiac: With respect to atrial fibrillation, The patient was rate controlled on digoxin and discontinued from anticoagulation in light of her upper GI bleed. Heart rate remained stable at <100. Cardiac ECHO was performed on [**8-8**] which showed the following: 1. Overall left ventricular systolic function is normal (LVEF>55%). 2. no free wall motion abnormalities. 3. Moderate (2+) mitral regurgitation is seen. 4. Moderate [2+] tricuspid regurgitation is seen. 5. Significant pulmonic regurgitation is seen. 3) Activity: Physical therapy was consulted and the patient was found to demonstrate safe and independent functional mobility with a cane. It was recommended that she be discharged home with home safety evaluation and home PT. The patient's family, however, refused to take the patient home and the patient was screened for transfer to a lower level rehab facility. 4) Hypothyroid: the patient was continued on levothyroxine 5)Code Status: The patient was admitted with a code status of DNR but full intubation. However, upon further discussion, her code status changed to full code. This topic will need to be discussed in more detail at a later date. Medications on Admission: 1) digoxin .125 once a day 2) coumadin 3 once a day 3) levoxyl 50 once a day 4) protonix iv 40 once a day 5) digoxin .125 once a day 6) ceftriaxone 1 once a day Discharge Disposition: Extended Care Facility: Maples Nursing & Retirement Center - [**Location (un) 6151**] Discharge Diagnosis: 1) upper GI bleed 2) gastroesophageal varices 3) atrial fibrillation 4) hypothyroidism 5) pneumonia 6) GERD Discharge Condition: good Discharge Instructions: 1) Please follow up with your PCP regarding this hospital admission. She has been contact[**Name (NI) **] via phone and mail. 2) Please discuss your advanced directives with your family so that your doctors [**Name5 (PTitle) **] help [**Name5 (PTitle) **] most accordingly to your wishes. 3) Please seek medical attention if you experience any or all of the following: vomiting blood, blood in your stool, blood from your rectum, lightheadedness, chest pain, palpitations, shortness of breath, swelling in your extremities, sudden weakness 4) You have slight thrombocytopenia at discharge. Please follow up on your Platelet count and Hematocrit in a few days. 5) Please have a repeat CBC and Electrolytes analysis in a few days. Followup Instructions: 1) Please follow up with your PCP regarding this hospital admission. She has been contact[**Name (NI) **] via phone and mail. 2) Please discuss your advanced directives with your family so that your doctors [**Name5 (PTitle) **] help [**Name5 (PTitle) **] most accordingly to your wishes. 3) Please seek medical attention if you experience any or all of the following: vomiting blood, blood in your stool, blood from your rectum, lightheadedness, chest pain, palpitations, shortness of breath, swelling in your extremities, sudden weakness

[ "456.8", "V58.61", "424.0", "397.0", "428.0", "427.31", "578.9", "456.1", "486" ]

icd9cm

[ [ [] ] ]

[ "45.13", "99.04" ]

icd9pcs

[ [ [] ] ]

6654, 6742

3142, 6442

274, 279

6903, 6909

2729, 3119

7688, 8232

2344, 2348

6763, 6882

6468, 6631

6933, 7665

2363, 2710

217, 236

307, 2194

2216, 2284

2300, 2328

22,165

108,233

1269

Discharge summary

report

Admission Date: [**2168-12-28**] Discharge Date: [**2169-1-3**] Service: HISTORY OF PRESENT ILLNESS: This is an 80-year-old Russian- speaking male with a history of coronary artery disease (status post coronary artery bypass graft), type 2 diabetes, and chronic renal failure who presents with two days of extreme shortness of breath at rest and dull 7/10 chest pain with radiation to the left shoulder. Positive paroxysmal nocturnal dyspnea, two-pillow orthopnea, and positive peripheral edema. The patient has not had any change in his medications or diet. The patient saw his primary care physician this morning and was noted to be hypoxic and was sent to the Emergency Department. In the Emergency Department, found to have evidence of congestive heart failure and acute renal failure with a creatinine of 3.2 (baseline of 2) and ST depressions in V2 to V4 on electrocardiogram. The patient was given aspirin and started on a heparin drip. He was given Plavix, nitroglycerin, and morphine and is now pain free. The patient was also given one dose of Lasix with minimal response. PAST MEDICAL HISTORY: 1. Coronary artery disease; status post coronary artery bypass graft in [**2157**]; status post cardiac catheterization in [**2168-3-22**] at an outside hospital (no stents placed). 2. Type 2 diabetes with nephropathy; baseline creatinine of 2. 3. Chronic renal failure. 4. Peripheral vascular disease with right leg revascularization. 5. Hyperlipidemia. 6. Back pain secondary to spinal stenosis. ALLERGIES: No known drug allergies. MEDICATIONS ON ADMISSION: 1. Lasix 20 mg once per day. 2. Atenolol 100 mg once per day. 3. Lisinopril 20 mg once per day. 4. Cardia 30 mg twice per day. 5. Lipitor 40 mg once per day. 6. Aspirin 81 mg. 7. Avandia 8 mg once per day. 8. Acarbose 25 three times per day. 9. Neurontin 300 three times per day. 10. Glyburide 5 mg twice per day. 11. Nitroglycerin as needed. SOCIAL HISTORY: Healthcare proxy is son. [**Name (NI) **] alcohol, tobacco, or drug use. PHYSICAL EXAMINATION ON PRESENTATION: Temperature was 97, heart rate was 54, blood pressure was 118/91, breathing at 15, and 90 percent on a nonrebreather. Generally, in no acute distress. No accessory muscle use. Head, eyes, ears, nose, and throat examination revealed jugular venous pressure elevated to the angle of the jaw. The mucous membranes were moist. Cardiovascular examination revealed a regular rate first heart sounds and second heart sounds. Positive third heart sound. No murmurs. The lungs with crackles two thirds of the way up with diffuse wheezing. Abdomen with positive bowel sounds and nontender. Mild distention, tympanitic to percussion. Lower extremities with 2 plus lower extremity edema bilaterally. Distal pulses were intact bilaterally. Neurologically, alert. Cranial nerves II through XII were intact. PERTINENT LABORATORY VALUES ON PRESENTATION: Notable for white count of 10.2, hematocrit was 32.5, and platelets were 161. INR was 1.1. Potassium elevated at 5.8, blood urea nitrogen was 95, creatinine was 3.2, glucose was 352. Creatine kinase elevated at 1030, MB was 15, and troponin was 0.85. Urinalysis was negative. PERTINENT RADIOLOGY-IMAGING: A chest x-ray showed evidence of congestive heart failure with pulmonary edema. An electrocardiogram showed sinus bradycardia, normal intervals, T wave inversions in V2 through V4, and ST depressions in V2 through V4. These were new changes compared to prior examination. IMPRESSION: This is an 80-year-old male with coronary artery disease (status post coronary artery bypass grafting in [**2157**]) here with a non-ST-elevation myocardial infarction and acute congestive heart failure with hypoxia requiring supplemental oxygen. SUMMARY OF HOSPITAL COURSE: 1. CARDIOVASCULAR ISSUES: (a) Coronary artery disease: The patient was continued on aspirin, Plavix, and statin. The patient was started on a heparin drip and nitroglycerin drip. Currently chest pain free. The patient was ultimately weaned from the nitroglycerin drip. Cardiac catheterization was considered. The patient continued to be a good candidate cardiac catheterization; however, limited by poor renal function. The patient was continued on aspirin, Plavix, statin, beta blocker, and ACE inhibitor. His treatments were optimized during hospital course. Ultimately, the patient did not receive a cardiac catheterization and will follow up as an outpatient. (b) Pump: The patient demonstrated an ejection fraction of 30 percent with multiple wall motion abnormalities. ACE inhibitor was restarted. The patient was initially managed on a Lasix drip for diuresis; however, was diuresing adequately off the Lasix drip. Current presentation thought to be due to decompensated heart failure. The patient was started on spironolactone. Medications were titrated to optimize congestive heart failure. (c) Rhythm: Remained stable on telemetry. 1. PULMONARY ISSUES: The patient with significant diuresis during the course of hospitalization but still required oxygen. The patient was given nebulizers and incentive spirometry. Upon optimization of cardiac regimen, the patient's oxygen requirement decreased, and oxygen saturations were stable on room air. 1. ACUTE RENAL FAILURE ISSUES: Thought to be likely due to congestive heart failure. Initially, diabetic medications and ACE inhibitor were held; however, creatinine began to decrease with good diuresis, and ACE inhibitors and diabetic medications were reinitiated. Creatinine had improved to better than baseline at the time of discharge. 1. TYPE 2 DIABETES ISSUES: Initially started on a regular insulin sliding scale. His sugars were elevated. The patient was ultimately restarted on his home diabetic medications. 1. MENTAL STATUS ISSUES: The patient demonstrated multiple onsets of agitation and confusion thought to be secondary to a communication barrier. The patient was initially given Haldol and placed in restraints for fear of harm to self. Per primary care physician assistant, the patient was started on low-dose Zyprexa and given frequent reorientation. Family members were present to help calm and orient the patient. With initiation of his medication, the patient's mental status improved. The patient remained calm. 1. FLUIDS/ELECTROLYTES/NUTRITION ISSUES: The patient was placed on a cardiac and diabetic diet. His electrolytes were repleted as needed. 1. PROPHYLAXIS ISSUES: Prophylaxis was with proton pump inhibitor and bowel regimen. 1. CODE STATUS ISSUES: The patient remained a full code. CONDITION ON DISCHARGE: Stable. DISCHARGE STATUS: Discharged to home with services. DISCHARGE DIAGNOSES: 1. Non-ST-elevation myocardial infarction. 2. Congestive heart failure with acute exacerbation. 3. Hypoxia secondary to pulmonary edema from congestive heart failure. 4. Anemia. 5. Diabetes. 6. Acute hyperglycemia. 7. Chronic renal insufficiency. 8. Peripheral vascular disease. 9. Delirium. MEDICATIONS ON DISCHARGE: 1. Aspirin 325 mg one once per day. 2. Plavix 75 mg one once per day. 3. Lipitor 40 mg by mouth at hour of sleep. 4. Gabapentin 100 mg by mouth at hour of sleep. 5. Lisinopril 20 mg by mouth once per day. 6. Lasix 40 mg by mouth once per day. 7. Glyburide one tablet by mouth twice per day. 8. Spironolactone 25 mg by mouth once per day. 9. Acarbose 25 mg by mouth three times per day. 10. Toprol-XL 50 mg by mouth once per day. DISCHARGE INSTRUCTIONS-FOLLOWUP: 1. Followup is with Dr. [**First Name8 (NamePattern2) 714**] [**Last Name (NamePattern1) 1603**] on [**2169-1-11**]. 2. The patient was to call the [**Hospital **] Clinic for further management of diabetes. 3. The patient was to follow up with Cardiology within one to two weeks. DR.[**Last Name (STitle) **],[**First Name3 (LF) **] 12-426 Dictated By:[**Last Name (NamePattern1) 7898**] MEDQUIST36 D: [**2169-5-5**] 12:12:48 T: [**2169-5-6**] 12:13:52 Job#: [**Job Number 7899**]

[ "250.40", "414.01", "410.71", "V45.81", "285.9", "585", "584.9", "440.20", "428.0" ]

icd9cm

[ [ [] ] ]

[ "99.04" ]

icd9pcs

[ [ [] ] ]

6853, 7150

7176, 8162

1604, 1961

3819, 6744

113, 1103

1125, 1578

1978, 3791

6769, 6832

28,094

126,597

17222

Discharge summary

report

Admission Date: [**2185-3-14**] Discharge Date: [**2185-3-23**] Date of Birth: [**2126-8-22**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2090**] Chief Complaint: Generalized Seizure and Confusion Major Surgical or Invasive Procedure: Lumbar Puncture on [**2185-3-15**] PICC line placement [**2185-3-22**] (43 cm) History of Present Illness: Mr. [**Known firstname **] [**Known lastname 10083**] is a 58-year-old man with a h/o oligoastrocytoma s/p resection in [**2169**] and radiation that has been complicated by radiation necrosis and infection with bacteroides/citrabacter who presents with confusion after having a seizure. According to his wife, she received a call from the rehab her husband was at indicating that RS had had a "gran mal seizure". He was transfered to [**Hospital3 7571**]Hopsital where he underwent a CT scan and was given 2 Percocets. His wife noticed that there has been a significant drop in his left-sided motor function from the day before and that he appeared confused and disoriented. He was, therefore, transfered to [**Hospital1 18**] ED, where he was given 1gm of Keppra and blood cultures were sent. Mrs. [**Known lastname 10083**] notes that RS's cognitive and motor function had been steadily decreasing since his tumor resection in [**2169**]. She notes that RS gradually lost memory, balance, and dexterity, but was able to take care of himself. However, in [**12-23**], RS was hospitalized after driving his car out of the garage without opening the door and afterwards suffered a notable drop in his functionality. Although he was still able to take care of himself, he was no longer able to drive and needed closer supervision. He was again hospitalized in [**10-23**] after being found confused and trying to change the channel with the remote backwards in his hand. He was taken to Southern [**Hospital **] Medical Center, but was later transfered to [**Hospital1 18**] where MRI showed changes from prior imaging. A biopsy demonstrated radiation necrosis. He developed wound breakdown, which was treated with a rotational flap. He then developed a wound infection with bacteroides and citrobacter, which required debridement. He was hospitalized from [**2185-1-20**] - [**2185-3-1**] and was sent to rehab where he spent the last two weeks. This morning, he had a witnessed generalized seizure for 30 seconds and was afterwards very confused. His wife reports that he is now less confused but still not back to baseline. She notes that his LUE is postured so that the hand is fisted and held close to his chest. She notes that he has had this same type of posturing twice in the past ([**12-23**] and [**10-23**]), at which time he also had confusion. Those episodes lasted 30-45 minutes and were suspected to be complex partial seizures. A routine EEG done near or on the date of one of those events showed slowing but no epileptiform discharges. He has never had a generalized seizure. ROS: He denies any pain, headache, neck stiffness, fevers, chills, vision changes, weakness. Past Medical History: Oligoastrocytoma, right frontal lobe, s/p craniotomy and resection, s/p XRT [**2169**] Anxiety Panic Attacks Alcohol Abuse Shoulder Dislocation HTN Macular Edema Retinopathy Keloids Social History: Patient is a retired military officer. He has 3 chlildren - 2 from his current marriage (19, 21) and one from a previous marriage (30's). He married his current wife in [**2159**]. His wife notes that he abused alcohol and could drink a six pack and several shots of liquor in one sitting. His last drink was in [**10-23**]. He quit smoking 28 years ago, but smoked 2-3 packs/day prior to that for [**8-31**] yrs. Family History: Father, 80s, had a benign brain tumor in his 70s. Mother still alive in mid 80's. Sister died in [**12-23**] from MS complications. Physical Exam: Physical Exam: Vitals: T: 99.8 P: 80 R: 18 BP: 140/64 SaO2: 99%RA General: Sleeping, arousable to voice, but continuously dozing off, in NAD. HEENT: Wound clean, dry, with sutures in place. No erythema, edema or discharge. Drain in place. Rest of HEENT exam limited because patient not awake to cooperate Neck: Supple, no carotid bruits appreciated PULM: CTABL no wheezing, rales, rhonchi CV: RRR, nl S1, S2, no M/R/G appreciated Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly Extremities: No clubbing, pitting edema, pulses palpable bilaterally. Skin: scar on chest and on right thigh Neurologic examination: Mental status: Awake and alert, cooperative with exam, flat affect. Oriented to person, place, and date. Attentive with MOYB quick and without errors. Speech is fluent with normal comprehension and repetition; naming intact [**12-19**]. No dysarthria. [**Location (un) **] intact. Registers 0/3 then [**1-17**]. recalls [**1-17**] at 2 minutes, but 0 at 5. Significant right/left confusion on vision and sensory testing. no neglect. Cranial Nerves: Pupils equally round and reactive to light, 4 to 2 mm bilaterally. Difficult to formaly test VF with his L/R confusion, but blinks to threat bilaterally. Disc margins intact. Extraocular movements intact bilaterally but poor effort/attention, no nystagmus. Sensation intact V1-V3. Facial movement symmetric. Hearing intact to finger rub bilaterally. Palate elevation symmetrical. Sternocleidomastoid and trapezius normal bilaterally. Tongue midline, movements intact Motor: Normal bulk bilaterally. Tone increasd in LUE and LLE. Motor exam limited because patient not awake and not terribly responsive. Sensation: When pain stimuli provided, patient was able to localize the pain with his hands. His response on the left side was considerably slower. Sensation to pain on the left was notably decreased. Other tests could nt be performed. Reflexes: +1 and symmetric throughout both upper extremities. 2+ knees. Absent ankles. Babinski: Up in left, down in right. Gait/Coordination: Could not be assessed. Pertinent Results: [**2185-3-15**] 06:10AM BLOOD WBC-11.0 RBC-4.39* Hgb-13.2* Hct-38.4* MCV-88 MCH-30.0 MCHC-34.2 RDW-12.6 Plt Ct-254 [**2185-3-22**] 06:37AM BLOOD WBC-6.2 RBC-3.66* Hgb-11.0* Hct-32.3* MCV-88 MCH-29.9 MCHC-33.9 RDW-12.9 Plt Ct-311 [**2185-3-14**] 10:08AM BLOOD Neuts-76.5* Lymphs-16.0* Monos-6.3 Eos-0.9 Baso-0.4 [**2185-3-17**] 06:25AM BLOOD Neuts-68.4 Lymphs-20.2 Monos-8.9 Eos-2.1 Baso-0.3 [**2185-3-14**] 10:08AM BLOOD PT-12.3 PTT-27.2 INR(PT)-1.0 [**2185-3-14**] 10:08AM BLOOD Glucose-95 UreaN-13 Creat-0.9 Na-137 K-4.2 Cl-97 HCO3-31 AnGap-13 [**2185-3-22**] 06:37AM BLOOD Glucose-125* UreaN-5* Creat-0.7 Na-139 K-3.9 Cl-103 HCO3-28 AnGap-12 [**2185-3-18**] 12:39PM BLOOD ALT-14 AST-16 LD(LDH)-152 AlkPhos-70 TotBili-0.5 [**2185-3-18**] 12:39PM BLOOD Albumin-3.4 Calcium-8.6 Phos-2.8 Mg-1.9 [**2185-3-22**] 06:37AM BLOOD Albumin-PND Calcium-8.5 Phos-3.3 Mg-1.8 [**2185-3-15**] 06:10AM BLOOD TSH-0.35 [**2185-3-22**] 06:37AM BLOOD Vanco-17.8 [**2185-3-22**] 06:37AM BLOOD Phenyto-18.4 [**2185-3-14**] 10:08AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG EEG ([**2185-3-14**]): Please refer to MRI report from one day prior for full evaluation of the brain. On this post-contrast study, there is mild enhancement adjacent to the frontal [**Doctor Last Name 534**] of the right lateral ventricle adjacent to the surgical site, however, this has decreased since [**2184-12-28**] and likely reflects radiation changes, or less likely residual tumor. No diffusion abnormality to suggest abscess. Extensive periventricular FLAIR hyperintensity consistent with vasogenic edema, is not significantly changed. The extra- axial fluid collection overlying the resection site is unchanged measuring 11 mm in greatest diameter. No new areas of enhancement are identified. MR [**Name13 (STitle) 430**] ([**2185-3-15**]) Please refer to MRI report from one day prior for full evaluation of the brain. On this post-contrast study, there is mild enhancement adjacent to the frontal [**Doctor Last Name 534**] of the right lateral ventricle adjacent to the surgical site, however, this has decreased since [**2184-12-28**] and likely reflects radiation changes, or less likely residual tumor. No diffusion abnormality to suggest abscess. Extensive periventricular FLAIR hyperintensity consistent with vasogenic edema, is not significantly changed. The extra- axial fluid collection overlying the resection site is unchanged measuring 11 mm in greatest diameter. No new areas of enhancement are identified. CT ([**2185-3-18**]): Small right-sided subdural hemorrhage, right frontal encephalomalacia, cerebral white matter periventricular hypodensities are unchanged. Similarly, unchanged hyperdense foci in the pons likely representing calcifications are noted. There is no evidence of acute interval hemorrhage in the brain. The ventricles and extra-axial CSF spaces are prominent but unchanged. Patient is status post right frontal craniotomy. PICC line placement ([**2185-3-22**]): Uncomplicated ultrasound and fluoroscopically guided double lumen PICC line placement via the right brachial venous approach. Final internal length is 43 cm, with the tip positioned in SVC. The line is ready to use. X-ray Left Foot ([**2185-3-23**]): No signs of osteomyelitis Brief Hospital Course: Patient is a 58 yo man with PMh of oligoastrocytoma s/p craniotomy and XRT in [**2169**], s/p repeat Bx several months ago with finding of necrosis complicated by chronic citrabacter/bacteroides infection and poor wound healing, now presenting with confusion and first generalized seizure. . Based on his posturing of his left hand noted on physical examination along with confusion, there was concern for seizure activity. Therefore he was given an extra 1g of Keppra and his home dose was increased. An EEG did not show any continued non-convulsive status. An MRI showed decreased enhancement in the surgical site and unchanged vasogenic edema likely reflective of post-treatment changes and less likely residual tumor. There was also no suggestion for an abscess formation. . Given his history of citrabacter/bacteroides infection, a lumbar puncture was performed with CSF results as follows: 88 protein, 64 glucose, 22 WBC (96 polys/2 lymphs) and 0 RBC. His ertapenem was changed to meropenem at admission. A blood culture from his PICC line on [**3-14**] grew coagulase negative staph. His antibiotics were changed to vancomycin, ceftriaxone and flagyl per ID recommendations. . A CTV was obtained on [**2185-3-16**] for evaluation of venous thrombus given his worsened left hemiplegia and left neglect and was negative. . He received swallow tests on both [**3-16**], [**3-17**], and [**3-21**], which he failed, passed and passed respectively. The recommendation was for him to remain on soft solids and advance as tolerated. . Fevers resolved on [**2185-3-16**] and he remained stable until [**2185-3-18**] when the patient went into status epilepticus for about 30 minutes. Ativan (10mg total) was administered with little improvement. He was then loaded with Dilantin 1g with seizure resolution after ~10 minutes and then transfered to the Neurological ICU. . In the ICU, he was loaded again with Dilantin 1g based on a level of 5.9 on [**3-19**] and with another 300mg on [**3-20**] for a level of 11.7. His Dilantin was also increased to 200mg [**Hospital1 **]. On [**3-20**], he was noted to have spontaneous movements of his left extremities, was able to speak and with mild residual left visual neglect. On [**3-22**], his mental status appeared improved from admission. Patient able to state months of the year backwards and follow basic commands, though some memory and cognitive dysfunction still evident. His Dilantin level on [**2185-3-22**] was 18.4 and his dosing was changed to 300mg q HS. . PICC line placed on [**2185-3-22**]. PICC is 43 cm long. Patient left foot appeared erythematous, warm and swollen. Given his bacteremia, there was concern for osteomyelitis. Plain foot films were obtained and showed no signs of infection or osteomyeltis. His blood culture from [**2185-3-17**] showed no growth. Prior to discharge follow up labs were obtained (ESR and CRP) discussed with the infectious disease team. Final plan with respect to his antibiotics regimen and follow up was determined at that point as outlined below. Medications on Admission: Ertapenem 1gm Q24 hours Keppra 500 [**Hospital1 **] Pepcid Lisinopril 20 daily Dulcolax ASA 81 HCTZ 25 Discharge Medications: 1. Levetiracetam 500 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). 2. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 3. Phenytoin Sodium Extended 100 mg Capsule Sig: Three (3) Capsule PO QHS (once a day (at bedtime)). 4. Ceftriaxone 2 gram Piggyback Sig: One (1) piggyback Intravenous twice a day for 7 days: last day should be [**2185-3-30**]. 5. Ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 14 days: Please start after the course of ceftriaxone has been completed ([**3-31**]), and continue through [**2185-4-13**]. 6. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 21 days: please continue through [**2185-4-13**]. 7. Vancomycin 1,000 mg Recon Soln Sig: One (1) dose Intravenous twice a day for 13 days: please continue through [**2185-4-5**]. Please check trough [**3-25**]. 8. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Discharge Disposition: Extended Care Facility: [**Hospital6 25759**] & Rehab Center - [**Location (un) **] Discharge Diagnosis: Primary Diagnosis: Seizure, status epilepticus Line bacteremia Parameningeal infection Resolving wound infection Secondary Diagnosis 1. Oligoastrocytoma, right frontal lobe, as per above 2. HTN 3. Anxiety 4. Retinopathy 5. Macular Edema Discharge Condition: Stable Residual frontal behavioral deficit, at baseline Improving weakness of the L arm and leg Mild residual neglect to the L. Discharge Instructions: You were admitted with seizures and fever. Please: 1. Continue Ceftriaxone 2g IV BID through [**2185-3-30**], then change to Ciprofloxacin 500mg po BID through [**2185-4-13**]. 2. Continue Flagyl 500mg po q 8hrs through [**2185-4-13**]. 3. Continue Vancomycin 1000mg IV BID through [**2185-4-5**]. 4. Please check weekly CBC with differential and LFTs. Have results faxed to Infectious Disease at [**Telephone/Fax (1) 1419**]. 5. Please check Dilantin & Vancomycin trough level on [**2185-3-25**]. Please follow up with your primary medical doctor. Please go to the nearest emergency department if you experience severe headache, seizures, or new neurological symptoms such as weakness or numbness. Followup Instructions: 1. Provider: [**Name10 (NameIs) **] [**Name8 (MD) **], MD, PHD[**MD Number(3) 708**]:[**Telephone/Fax (1) 1690**] Date/Time:[**2185-3-30**] 1:30 2. Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 7447**], MD Phone:[**Telephone/Fax (1) 457**] Date/Time:[**2185-4-18**] 12:00 3. Patient will be followed up by Dr. [**Last Name (STitle) 32255**] at [**Hospital 48275**]. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**] MD [**MD Number(1) 2107**]

[ "995.91", "322.9", "401.9", "999.31", "998.59", "345.3", "038.19", "V10.85" ]

icd9cm

[ [ [] ] ]

[ "03.31", "38.93" ]

icd9pcs

[ [ [] ] ]

13763, 13849

9438, 12504

350, 432

14131, 14261

6134, 9415

15018, 15541

3837, 3973

12658, 13740

13870, 13870

12530, 12635

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4003, 4612

277, 312

460, 3171

5093, 6115

13889, 14110

4651, 5077

4636, 4636

3193, 3385

3401, 3821

24,995

133,263

46135

Discharge summary

report

Admission Date: [**2171-7-1**] Discharge Date: [**2171-7-6**] Date of Birth: [**2107-9-11**] Sex: F Service: MEDICINE Allergies: Gantrisin Attending:[**First Name3 (LF) 613**] Chief Complaint: Found unresponsive at home Major Surgical or Invasive Procedure: Endotracheal intubation [**2171-7-1**] Central venous line placement [**2171-7-1**] History of Present Illness: Ms. [**Known lastname **] is a 63 yo female with a history of DM type 1 X 35 years complicated by neuropathy, nephropathy and retinopathy with prior admissions for DKA and hypoglycemia, who was found unresponsive at home. The patient's son (mentally retarded) called EMS. She was down for an unknown period of time. Per the patient's sister, she was last seen well on Saturday. Per EMS, Ms. [**Known lastname **] was unresponsive, sugar 500, BP 90/50, HR 110, regular and RR 24, Sat 100% on NRB. On arrival to ED, she was responsive to pain, saying "no". She was intubated for airway protection (ABG 7.02/23/69), sugar >1000, SBP 100/83, HR 87. Post-intubation, her BP dropped to 72/33. A femoral line was attempted but resulted in a femoral stick. A right IJ was placed, and Levophed was started. In the ED, she was also given calcium gluconate, Levofloxacin, Flagyl, Vancomycin, Ceftriaxone. Past Medical History: 1. DM type 1 x 35 years. Previous admissions for DKA and hypoglycemic episodes. Her DM is complicated by peripheral neuropathy, proliferative retinopathy (left eye blindness), and nephropathy. Followed at [**Last Name (un) **]. 2. Hypertension 3. History of osteomyelitis, status post left transmetatarsal amputation. 4. History of herpes zoster of left chest in [**2163**]. 5. Bezoar, disclosed on UGI series [**7-/2166**]. 6. No documented CAD. Nuclear stress test [**4-21**]: P-MIBI, without fixed or reversible defects, normal wall motion. EF 61%. Social History: She lives at home with her son, who is mentally retarded. Past history of EtOH use. Ex-smoker, quit in [**2154**]. No history of illicit drug use. Family History: Per OMR records, mother with DM. Father with AD. Sister with DM and breast cancer. Physical Exam: Physical examination per admission note: VITALS: T 97.3, BP 75/33 --> 118/60. HR 80-100. GEN: Sedated, intubated, on Levophed. HEENT: MM dry, ET in place. NECK: Supple, right IJ in place. CHEST: CTAB anteriorly CVS: Tachy, regular. No murmur, or rub. GI: Soft, no grimacing. EXT: No edema. Left stump, well-healed. NEURO: Sedated, arousable to pain. Right pupil reactive. Surgical eye. Physical examination on transfer to floor: VITALS: Tm 99.1, HR 70-90, BP 100-149/60/100 off Levophed, RR 20s, Sat 98-100% on room air. GEN: In NAD. Conversant. HEENT: Right pupil reactive, left surgical eye. NECK: Supple, right IJ still in place. RESP: Early fine bibasilar crackles, no bronchial breathing. CVS: RRR. Normal S1, S2. No S3, S4. No murmur or rub. GI: BS NA. Abdomen soft and non-tender. EXT: Without edema. No ulcer. Let foot stump well-healed. NEURO: Oriented to time, place and name. Moves all 4 extremities. Pertinent Results: Relevant laboratory data on arrival: CBC: WBC-12.9* RBC-4.16* HGB-10.8* HCT-39.9 MCV-96# MCH-26.0* MCHC-27.1*# RDW-14.2 PLT COUNT-324 NEUTS-89.1* BANDS-0 LYMPHS-8.9* MONOS-1.4* EOS-0.4 BASOS-0.1 Chemistry: GLUCOSE-1240* UREA N-70* CREAT-4.5*# SODIUM-134 POTASSIUM-8.7* (repeat 4.5) CHLORIDE-85* TOTAL CO2-<5.0* PHOSPHATE-9.2*# MAGNESIUM-3.1* ALT(SGPT)-8 AST(SGOT)-11 ALK PHOS-126* AMYLASE-1730* LIPASE-93* LACTATE-4.9* TOT BILI-0.1 Cardiac enzymes: [**2171-7-1**] 11:30AM BLOOD CK(CPK)-191* [**2171-7-1**] 06:18PM BLOOD CK(CPK)-156* [**2171-7-2**] 02:14PM BLOOD CK(CPK)-426* [**2171-7-1**] 11:30AM BLOOD CK-MB-3 cTropnT-0.03* [**2171-7-1**] 12:28PM BLOOD cTropnT-0.03* [**2171-7-1**] 06:18PM BLOOD CK-MB-7 cTropnT-0.15* [**2171-7-2**] 02:14PM BLOOD CK-MB-10 MB Indx-2.3 cTropnT-0.19* Urinalysis: COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.019 BLOOD-NEG NITRITE-NEG PROTEIN-30 GLUCOSE-1000 KETONE-50 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG Urine and serum tox negative Relevant imaging data: [**2171-7-1**] CXR: An endotracheal tube is seen, a few centimeters above the carina, which should be repositioned. A [**Last Name (un) **]/orogastric tube is seen coursing below the diaphragm. Cardiac, mediastinal, and hilar contours are unremarkable. The lungs themselves are clear; a nodular density over the right mid/lower lung field is probably a nipple shadow. Osseous structures are unremarkable. IMPRESSION: Successful placement of endotracheal tube, which should be retracted a few centimeters. [**2171-7-1**] CT HEAD: There is no intracranial hemorrhage, mass lesion, hydrocephalus, shift of normally midline structures, minor or major vascular territorial infarct. The density values of the brain parenchyma are within normal limits. Note is made of dystrophic calcifications in the lentiform nuclei. There are extensive atherosclerotic calcifications of the carotid arteries. Note is made of a left phthsis bulbi. Surrounding osseous and soft tissue structures are otherwise unremarkable. IMPRESSION: No acute intracranial pathology, including no sign of intracranial hemorrhage. See above report. [**2171-7-1**] V/Q scan: Low likelihood ratio for recent pulmonary embolism. Matched asymmetry as described likely due to differences in airflow with decrease on the right relative to the left. It may be secondary to mucous plugging versus effects from mechanical ventilation. /nkg ******** Micro: Blood cultures X 4 NGTD Urine cultures X 2 negative Brief Hospital Course: 63 yo female with long-standing DM type 1 with triopathy, admitted with DKA of unclear precipitant and profound metabolic dissaray. 1) DKA: As noted above, her initial gap on admission was 44 with profound metabolic dissaray. She was started on a regular insulin drip (required as much as 20 units per hour), and aggressively hydrated with close monitoring of her electrolytes, with eventual closure of the gap. She was transitionned to subcutaneous insulin on [**7-2**] with NPH, then Lantus at out-patient dose with Novolog sliding scale. Of note, Lantus was recently decreased to 12 units QHS on [**6-20**], resumed at 14 units QHS in hospital with Novolog sliding scale as above, with good glycemic control. Lantus decreased to 12 units QHS [**First Name8 (NamePattern2) **] [**Last Name (un) **] on [**7-5**]. The precipitant remains unclear. She has little recollection of the events that pre-dated her admission, but remembers feeling slightly unwell 3 days PTA with some dizziness. No clear dietary indiscretions or medication non-compliance. She did have an elevated WBC on admission without left shift, and an infectious work-up was negative, including U/A, urine culture, blood cultures, and CXR. She was given Levo/Vanco and Flagyl in the ED, not continued in the MICU. A CT head was negative. She did have a mild troponin leak, but with flat MB, and this was not felt to be an acute coronary syndrome. It was ultimately felt that a viral syndrome may have been the precipitant. 2) Hypotension: As noted above, her blood pressure dropped in the ED following intubation, and she was started on Levophed for hemodynamic support. She was weaned off on the day of admission, and remained hemodynamically stable. Her hypotension was most likely [**2-20**] hypovolemia, exacerbated by sedative medications peri-intubation. As noted, she had a mild troponin leak on admission, not felt to be an acute coronary syndrome. PE was ruled out. Infectious work-up on admission negative. 3) CAD: EKG on admission showed lateral ST depressions in the setting of tachycardia. Cardiac enzymes also revealed a mild troponin leak with peak troponin 0.19 but flat MB, in the setting of acute renal failure and tachycardia. Review of her records indicated that she had a P-MIBI in [**2169**] without reversible defects, normal EF. A repeat EKG on hospital day #2 showed resolution of the changes. She remained asymptomatic throughout her course. She was restarted on ASA, Metoprolol and statin, then Nifedipine. Diovan was reintroduced last given her renal insufficiency. No other acute issues in the hospital. 4) Respiratory: She was intubated in the ED for airway protection. ABG was initially concerning for an A-a gradient, and a V/Q scan was obtained and returned as low probability for PE. She was succesfully extubated on hospital day #2, and remained stable on room air. 5) ARF on CRI: Baseline creatinine in 2s. Her creatinine peaked at 4.5 on admission, and came down with hydration. Sediment was unremarkable on U/A. Urine lytes were sent on [**7-3**], and were suggestive of superimposed ATN with FeNa 5.2%. Her creatinine continued to improve with hydration, down to baseline at the time of discharge. 6) Anemia: Her hematocrit dropped to 28 while in the MICU, felt [**2-20**] aggressive fluid rescuscitation. She was transfused 1 unit of PRBCs, with appropriate response, and was placed on Protonix [**Hospital1 **]. Review of her records indicated a baseline hematocrit in the high 20s. Her hematocrit subsequently remained stable, and further work-up was deferred. She was changed back to daily Protonix. 7) Elevated amylase: Her amylase peaked at 1730, with only mildly elevated lipase with peak at 92. Her abdominal examination was benign throughout, and amylase trended down with hydration. Amylasemia is not infrequent in the setting of DKA. 8) Hypernatremia: Patient with corrected sodium >150 in the setting of DKA and volume depletion. She was aggressively hydrated, with normalization of her sodium. 9) ID: As noted above, an initial infectious work-up was unremarkable. However, she developed a new fever in the hospital on hospital day #3 to 101.2. A repeat infectious work-up was performed, with negative CXR, U/A with few WBC but + epithelial cells (foley removed), and cultures all negative to date. Her central line was kept in place given inability to obtain alternative peripheral access, finally removed on [**7-5**]. She did have diarrhea on [**7-5**] after drinking a coffee with cream despite her known lactose intolerance. Nonetheless, C. difficile sent, and result pending at the time of discharge. Dr. [**Last Name (STitle) 3029**] [**Name (NI) 653**] and to follow-up on result. She had no recurrence of fever in the hospital without antibiotics. Medications on Admission: Atenolol 12.5 mg PO QD ASA 325 mg Po QD Nifedipine 60 mg PO QD Protonix 40 mg PO QD Diovan 80 mg PO BID Lumigan 0.03% 1 drop OD QD Timolol 0.5% 1 drop OD QD Lantus 12 units QHS with Novolog sliding scale. Discharge Medications: 1. Atenolol 25 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Nifedipine 60 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO DAILY (Daily). 4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Valsartan 80 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Atorvastatin Calcium 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 8. Lumigan 0.03 % Drops Sig: One (1) drop OD Ophthalmic once a day. 9. Lantus 12 units SC QHS 10. Novolog insulin sliding scale Please continue your sliding scale as you were prior to admission. Please see enclosed sheet. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Primary diagnosis: Diabetic ketoacidosis Probable viral syndrome Diabetes mellitus type 1 Secondary diagnoses: Hypertension Discharge Condition: Patient discharged home in stable condition. Discharge Instructions: Please call your PCP or return to the ED if your blood sugars are greater than 400 or less than 50. Please take all medications as prescribed. Followup Instructions: 1) You have a scheduled appointment with your PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) 3029**] on Friday [**7-12**]. See below for time. It is important that you go to this appointment. - Provider: [**First Name11 (Name Pattern1) 674**] [**Initial (NamePattern1) **] [**Last Name (NamePattern1) **], M.D. Where: [**Hospital6 29**] [**Hospital **] Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2171-7-12**] 11:50 2) You also have a scheduled appointment with Dr. [**Last Name (STitle) **] at the [**Last Name (un) **] Diabetes Center on Tuesday [**7-16**] at 1500. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 617**] Completed by:[**2171-7-7**]

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

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3091, 3525

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23,084

149,010

51377

Discharge summary

report

Admission Date: [**2129-1-28**] Discharge Date: [**2129-2-15**] Date of Birth: [**2082-10-16**] Sex: F Service: MEDICINE Allergies: Bactrim Attending:[**First Name3 (LF) 3984**] Chief Complaint: Dyspnea on Exertion Major Surgical or Invasive Procedure: Right and Left Heart Catheterization ICU Care with arterial cannulation, central venous cannulation Mechanical Ventilation History of Present Illness: 46F s/p autologous BMT for NHL in [**2111**] with course complicated by radiation-induced pulmonary fibrosis and chemo-induced cardiomyopathy now on transtracheal O2 who presents with increasing dyspnea on exertion, tachycardia, and cough. Although OMR notes reveal prior complaints of DOE, patient reports worsening over the past 2-3 weeks. Denies pleuritic chest pain but does report some back pain with coughing. No exertional chest pain (but she feels unable to exert herself enough to know - no history of exertional CP). She was previously on 2L TTO at rest and increased to 4L with activity. She has now increased to 3L at rest with >4L with activity (she reports she turns it up as high as she can and is still unable to exercise - she even gets short of breath brushing her teeth). She has previously had volume overload but not in a long while and denies pedal edema or orthopnea. She had pneumonia in [**3-7**] which presented with neck stiffness and wheezing - she denies these symptoms at present. Reports seasonal allergies without asthma. She has a dog at home and has lived in the same place with that dog for years. Previously worked as a field officer for NSTAR where she may have been exposed to hazardous fumes, but since [**3-7**] she has been on disability. Denies fevers. She reports tachycardia seems to have started with this worsening dyspnea as well. Saw pulmonologist in beginning of [**Month (only) **] who felt she was doing well. Seen by PT in early [**Month (only) **] as well - report states that she gets out of breath with exertion on treadmill but at that point she did not feel this was worse than previous and O2 sat actually was better than previously. Of note patient is on hormone replacement therapy (Premarin/Provers) since it was decided that she should not have children post-chemo. She does not smoke. She has not had personal or family history of blood clots. Past Medical History: 1. Non-hodgkin's lymphocytic lymphoma: Diagnosed in [**2109**], treated with radiation and adriamycin, autologous bone marrow transplantation in [**2111**], one episode of congesive heart failure in the first one to two months after her transplantation, good recovery after that and cancer free since then. 2. IPF: Developed SOB 2 years ago, likely related to full body irradiation, found to have bilateral pulmonary fibrosis and apical blebs. Has been treated with prednisone and supplemental oxygen. PFTs from [**2128-2-4**] demonstrated no change in restrictive pattern since [**2127-8-18**]. 3. Systolic Heart Failure: Diagnosed in [**2125**] at same time of IPF, likely due to Adriamycin treatment for NHL. Echo from [**2128-1-26**] demonstrated mild to moderate global left ventricular hypokinesis (ejection fraction 40 percent) and moderate pulmonary artery systolic hypertension without R-ventricular abnormalities. This was no change from a [**2-3**] echo. 4. Pulm HTN: Echo from [**2128-1-26**] demonstrated moderate pulmonary artery systolic hypertension without R-ventricular abnormalities in size, structure, and contractile function. 5. Chronic anemia: Thought to be related to her BMT in [**2111**]. Labs in OMR since [**3-/2125**] demonstrate Hct ranging from 28.7 to 34.3. . PSH: -None but currently being evaluated for lung vs heart/lung transplant at [**Hospital1 112**] Social History: General: Is single, lives with family. No children. Works as field rep for NStar. Tobacco: Quit smoking approximately four to five years ago. Smoked 10 cigs per day for 15 years, quit after hospitalization in [**2122**]. EtOH: Denies use Recreational drugs: Denies use Family History: -Hypertension on her mother's side -Maternal grandmother: heart disease as well as diabetes Physical Exam: T 97.0 BP 145/124(?) HR 104 RR 18 Sat 98% on 2 L/min TTO Weight: 63 kg General: well-appearing HEENT: no scleral icterus; (+) transtracheal catheter Neck: JVP 7 cm, supple Chest: scatterred rales throughout left lung field; left-sided breath sounds also diminished; right lung field clear to auscultation CV: mildly tachycardic, regular; nl s1s2, no m/r/g Abdomen: soft, NTND, no HSM Extremities: warm, no edema, 2+ PT pulses Skin: no rashes/jaundice Neuro: alert, appropriate, CN 2-12 intact Pertinent Results: [**2129-1-28**] 01:30AM BLOOD WBC-9.2 RBC-3.57* Hgb-10.5* Hct-31.4* MCV-88 MCH-29.4 MCHC-33.4 RDW-13.5 Plt Ct-274 [**2129-1-28**] 10:45AM BLOOD WBC-7.5 RBC-3.38* Hgb-9.6* Hct-29.0* MCV-86 MCH-28.3 MCHC-33.0 RDW-13.3 Plt Ct-233 [**2129-2-12**] 02:13AM BLOOD WBC-33.1*# RBC-3.45* Hgb-10.4* Hct-31.0* MCV-90 MCH-30.0 MCHC-33.4 RDW-16.6* Plt Ct-70* [**2129-2-13**] 02:21AM BLOOD WBC-20.9* RBC-3.34* Hgb-10.2* Hct-30.0* MCV-90 MCH-30.5 MCHC-34.0 RDW-16.5* Plt Ct-77* [**2129-2-14**] 03:47AM BLOOD WBC-25.9* RBC-3.22* Hgb-9.8* Hct-29.8* MCV-93 MCH-30.5 MCHC-32.8 RDW-17.7* Plt Ct-83* [**2129-2-15**] 03:34AM BLOOD WBC-34.8* RBC-3.47* Hgb-10.5* Hct-32.8* MCV-95 MCH-30.4 MCHC-32.1 RDW-18.0* Plt Ct-88* [**2129-2-10**] 03:00AM BLOOD Neuts-71* Bands-10* Lymphs-12* Monos-4 Eos-0 Baso-0 Atyps-2* Metas-1* Myelos-0 NRBC-17* [**2129-2-13**] 02:21AM BLOOD Neuts-79* Bands-1 Lymphs-7* Monos-7 Eos-0 Baso-0 Atyps-0 Metas-5* Myelos-1* NRBC-63* [**2129-1-28**] 01:30AM BLOOD Plt Ct-274 [**2129-1-28**] 02:30AM BLOOD PT-12.6 PTT-26.6 INR(PT)-1.1 [**2129-2-15**] 03:34AM BLOOD PT-19.8* PTT-31.7 INR(PT)-1.8* [**2129-2-6**] 02:51PM BLOOD Fibrino-357 [**2129-2-8**] 04:50PM BLOOD FDP-80-160* [**2129-2-15**] 06:06AM BLOOD FDP-40-80 [**2129-1-28**] 01:30AM BLOOD Glucose-115* UreaN-23* Creat-1.1 Na-141 K-4.2 Cl-99 HCO3-34* AnGap-12 [**2129-1-28**] 10:45AM BLOOD Glucose-146* UreaN-20 Creat-0.9 Na-139 K-3.8 Cl-102 HCO3-29 AnGap-12 [**2129-1-29**] 07:40AM BLOOD Glucose-110* UreaN-15 Creat-0.9 Na-139 K-4.4 Cl-100 HCO3-26 AnGap-17 [**2129-2-14**] 03:47AM BLOOD Glucose-144* UreaN-88* Creat-3.2* Na-140 K-4.4 Cl-113* HCO3-20* AnGap-11 [**2129-2-15**] 03:34AM BLOOD Glucose-99 UreaN-99* Creat-4.4*# Na-135 K-6.7* Cl-106 HCO3-16* AnGap-20 [**2129-2-10**] 03:00AM BLOOD ALT-1855* AST-828* LD(LDH)-925* AlkPhos-74 TotBili-1.4 [**2129-2-13**] 02:21AM BLOOD ALT-891* AST-243* LD(LDH)-1099* AlkPhos-182* TotBili-1.3 [**2129-2-15**] 03:34AM BLOOD ALT-613* AST-533* LD(LDH)-2235* AlkPhos-243* TotBili-4.2* [**2129-1-28**] 01:30AM BLOOD CK-MB-NotDone cTropnT-0.02* [**2129-1-28**] 10:45AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2129-1-28**] 05:38PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2129-1-30**] 07:20AM BLOOD proBNP-5249* [**2129-2-6**] 02:51PM BLOOD CK-MB-NotDone cTropnT-0.03* [**2129-2-6**] 02:51PM BLOOD Hapto-161 [**2129-2-7**] 09:06AM BLOOD Hapto-161 [**2129-1-31**] 07:10AM BLOOD TSH-1.1 [**2129-2-7**] 05:10AM BLOOD Cortsol-24.2* [**2129-2-7**] 05:22AM BLOOD Cortsol-30.1* [**2129-2-6**] 10:51AM BLOOD Glucose-126* Lactate-1.6 [**2129-2-6**] 02:59PM BLOOD Lactate-6.5* [**2129-2-6**] 06:42PM BLOOD Glucose-235* Lactate-6.3* [**2129-2-7**] 01:45AM BLOOD Lactate-4.0* [**2129-2-12**] 12:30PM BLOOD Lactate-1.7 [**2129-2-14**] 01:26PM BLOOD Lactate-2.5* [**2129-2-14**] 06:11PM BLOOD Lactate-2.4* [**2129-2-8**] 04:50PM BLOOD ASPERGILLUS GALACTOMANNAN ANTIGEN- TEST [**2129-1-31**] 08:47PM URINE RBC->1000 WBC-[**2-2**] Bacteri-FEW Yeast-NONE Epi-0 [**2129-2-2**] 10:58PM URINE RBC->1000* WBC-59* Bacteri-NONE Yeast-NONE Epi-0 [**2129-2-6**] 08:49AM URINE RBC-[**10-20**]* WBC-0-2 Bacteri-FEW Yeast-NONE Epi-0-2 [**2129-1-31**] 08:47PM URINE Blood-LG Nitrite-NEG Protein-30 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR [**2129-2-2**] 10:58PM URINE Blood-LG Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR MICROBIOLOGY [**2129-2-5**] 10:19 am SPUTUM Source: Expectorated. **FINAL REPORT [**2129-2-11**]** GRAM STAIN (Final [**2129-2-5**]): >25 PMNs and <10 epithelial cells/100X field. 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. RESPIRATORY CULTURE (Final [**2129-2-11**]): RARE GROWTH OROPHARYNGEAL FLORA. ASPERGILLUS SPECIES. RARE GROWTH. NOT FLAVUS OR [**Country **]. [**2129-2-13**] 1:10 pm SPUTUM Source: Endotracheal. GRAM STAIN (Final [**2129-2-13**]): >25 PMNs and <10 epithelial cells/100X field. NO MICROORGANISMS SEEN. RESPIRATORY CULTURE (Preliminary): OROPHARYNGEAL FLORA ABSENT. YEAST. SPARSE GROWTH. MOLD. RARE GROWTH. SENT TO MYCOLOGY. REPORTS AND STUDIES [**2129-1-28**] 1. No pulmonary embolism or aortic dissection. The coronary arteries arise from the normal expected anatomical location. 2. Chronic pulmonary fibrosis as described above in predominately subpleural location, unchanged. ECHO [**2129-2-1**] The left atrium is normal in size. Left ventricular wall thicknesses and cavity size are normal. There is mild regional left ventricular systolic dysfunction with mild hypokinesis of the anteroseptum and inferior walls. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular cavity is moderately dilated with mild hypokinesis of the free wall. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. The tricuspid valve leaflets are mildly thickened. Moderate [2+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. The pulmonic valve is abnormal. The end-diastolic pulmonic regurgitation velocity is increased suggesting pulmonary artery diastolic hypertension. There is a trivial/physiologic pericardial effusion. Compared with the prior study (images reviewed) of [**2128-11-22**], subtle left ventricular regional wall hypokinesis was present, however, the right ventricle has increased in size with signs of pressure volume overload. Severe estimated pulmonary systolic hypertension is now present. ECHO [**2129-2-12**] The left atrium and right atrium are normal in cavity size. Left ventricular wall thicknesses is normal with wmall cavity size. There is mild regional left ventricular systolic dysfunction with hypokinesis of the distal anterior wall and apex. The remaining segments contract normally (LVEF = 45%). The right ventricular cavity is markedly dilated with severe global free wall hypokinesis. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis. Trace aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the prior study (images reviewed) of [**2129-2-1**], the right ventricle is larger with more prominent free wall hypokinesis. An apical left ventricular wall motion abnormality is now present. The severity of tricuspid regurgitation is similar. C CATH [**2129-2-4**] 1. Coronary arteries are normal. 2. Hypovolemia. 3. No significant change in cardiac output with volume challenge. 3. Significant increase in cardiac output with little change in pulmonary artery pressures during 100% O2 (therefore, PVR decreased). 4. Compared to baseline, significant increase in cardiac output and decrease in pulmonary artery pressures with nitric oxide therapy. 5. Given low cardiac index would use caution if considering calcium channel blocker therapy. Brief Hospital Course: PULMONARY HYPERTENSION / BACTERIAL PNEUMONIA The patient was admitted with dyspnea on exertion. She underwent cardiac catheterization which revealed elevated pulmonary vascular resistance that did not significantly improve after vasodilator trial. She was trialed on sildenifil without benefit, and this was discontinued. After catheterization, she developed sepsis, meeting SIRS criteria with positive sputum gram stain with gram positive cocci. That culture ultimately grew aspergillus, discussed below. She developed respiratory distress with while septic, and was electively intubated without immediate complication. Her pulmonary disease was quite severe, and she was difficult to ventilate, requiring high pressures in a pressure control ventilation mode. CARDIAC ARREST / CARDIOGENIC SHOCK Unfortunately 3-4 hours after intubation, the patient became bradycardic and became pulseless in PEA arrest, and a code was called. She was given CPR and epinephrine x3 and atropine. A femoral code line was placed. She was briefly in what appeared to be VT and was shocked x1, and regained spontaneous circulation. She was initially hypertensive in the next few minutes but then became quite hypotensive, requiring vasopressor support, ultimately being maxed on 3 pressors. Over the next 72 hours, pressors were slowly weaned, with the exception of severe hypotensive episode at 72h likely from hypoxia [**1-1**] cuff leak, from which she recoved. Echocardiogram showed severe pulmonary hypertension and right heart failure. RESPIRATORY FAILURE The patient remained intubated, and was on pressure control ventillation, with a PIP set initially at 45. This was attempted to be decreased, ended at PIP of 41, but still with elevated PEEPs. SEPSIS The presumption at time of first meeting SIRS criteria was that she had pneunomia. She was treated broadly with vancomycin and Zosyn, and caspofungin added later for aspergillus. One week after her arrest, she again became hypotensive and febrile, with presumption of infection. Sources included VAP, line infection, urine, or progression of aspergillus. SHe remained on her broad spectrum antibiotics, and her femoral line was promptly discontinued, but the patient rapidly before she became febrile, hypotensive requiring multiple vasopressor support, high FiO2, sedation and paralysis again. With her underlying severe pulmonary disease and recurrent severe septic episode, a family meeting was held, and the family via HCP decided to make the patient [**Name (NI) 3225**]. ASPERGILLUS INFECTION The patient grew aspergillus from expectorated sputum prior to intubation, and was started on caspofungin. ACUTE RENAL FAILURE The patient went into renal failure after her cardiac arrest, likely ATN. She still maintained some concentrating capacity. EXPIRATION Within hours of the [**Name (NI) 3225**] decision, the patient died peacefully and quietly in the presence of her friends and family. Medications on Admission: Toprol 50 mg daily Mucinex 1200 mg [**Hospital1 **] aspirin 325 mg daily Premarin 0.625 mg daily Provera 2.5 mg daily Calcarb with D 600/200 mg 2 tabs daily MVI Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: PRIMARY Pulmonary Hypertension Pulmonary Fibrosis Cardiogenic Shock Acute Systolic Congestive Heart Failure Septic Shock Severe Sepsis Aspergillus pulmonary infection Cardiac Arrest SECONDARY History of: Non-Hodgkin's Lymphoma Anemia Discharge Condition: Expired [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2437**] MD [**MD Number(1) 2438**]

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icd9cm

[ [ [] ] ]

[ "88.56", "96.6", "96.72", "37.23", "99.60", "99.15", "38.93", "96.04" ]

icd9pcs

[ [ [] ] ]

15316, 15325

12124, 15075

289, 413

15603, 15739

4707, 8731

4085, 4178

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230, 251

441, 2350

2372, 3776

3792, 4069

50,895

136,047

38849

Discharge summary

report

Admission Date: [**2106-6-7**] Discharge Date: [**2106-6-17**] Date of Birth: [**2022-12-19**] Sex: M Service: CARDIOTHORACIC Allergies: IV Dye, Iodine Containing Attending:[**First Name3 (LF) 1505**] Chief Complaint: dyspnea on exertion Major Surgical or Invasive Procedure: Aortic valve replacement with a [**Street Address(2) 86239**]. [**Hospital 923**] Medical Biocor tissue valve. [**2106-6-10**] History of Present Illness: 83 year old male with a known history of aortic stenosis, renal insufficiency, diabetes mellitus, and HTN who is presenting with chronic symptoms of shortness of breath previously attributed to his aortic stenosis. Over the past five years, Mr [**Name13 (STitle) **] has experienced dyspnea on exertion for which he declined surgery. Over the last three months, he has experienced worsening shortness of breath, dyspnea, cough, and pallor which resolves with rest. Cardiac workup revealed Aortic valve area <0.8cm2. Dr.[**Last Name (STitle) **] was consulted for surgical correction. Past Medical History: aortic stenosis PMH: hypertension Diabetes mellitus Aortic stenosis Renal insufficiency Duodenal ulcers/GI bleeding (rectal and esophageal) Gout deep vein thrombosis 3 years ago benign prostatic hyperplasia Social History: Lives with: : Moved from [**Country **] to the US in [**2080**]; currently retired and lives in [**Hospital3 28354**] in [**Location (un) 86**] with his wife. [**Name (NI) **] two sons, both of whom are in medicine. Occupation:Ran a factory in [**Location (un) **] that produced electrical pumps. Tobacco:denies ETOH: occasional Family History: Father died of MI at age 77, sister had aortic valve replacement. Physical Exam: Pulse:88 Resp:21 O2 sat: 96%RA B/P Right: Left: Height:5'5" Weight:165 lbs General: Skin: Dry [x] intact [x] HEENT: PERRLA [x] EOMI [x]anicteric sclera;OP unremarkable Neck: Supple [x] Full ROM []no JVD Chest: Lungs clear right; faint basilar rales left Heart: RRR [x] Irregular [] Murmur: 3/6 SEM radiates throughout precordium to carotids Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x]; no HSM/CVA tenderness Extremities: Warm [x], well-perfused [x] Edema-trace bil. Varicosities: None [x] Neuro: Grossly intact Pulses: Femoral Right: 1+ Left:2+ DP Right: NP Left:NP PT [**Name (NI) 167**]: 1+ Left:1+ Radial Right: NP Left:2+ Carotid Bruit murmur radiates bil. Pertinent Results: [**2106-6-15**] 04:00AM BLOOD WBC-7.6 RBC-3.92* Hgb-9.2* Hct-29.2* MCV-75* MCH-23.6* MCHC-31.6 RDW-17.3* Plt Ct-189 [**2106-6-15**] 04:00AM BLOOD Glucose-85 UreaN-50* Creat-2.6* Na-139 K-3.8 Cl-100 HCO3-30 AnGap-13 [**2106-6-12**] 02:54AM BLOOD Glucose-111* UreaN-33* Creat-2.7* Na-139 K-4.3 Cl-102 HCO3-25 AnGap-16 [**2106-6-16**] 10:52AM BLOOD WBC-8.0 RBC-3.97* Hgb-9.5* Hct-30.3* MCV-76* MCH-23.9* MCHC-31.4 RDW-17.2* Plt Ct-227 [**Hospital1 18**] ECHOCARDIOGRAPHY REPORT [**Known lastname **], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 86240**]TTE (Complete) Done [**2106-6-8**] at 9:22:07 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) 18**] - Cardiology Division [**Location (un) 830**], SL 423C [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2022-12-19**] Age (years): 83 M Hgt (in): 64 BP (mm Hg): 148/87 Wgt (lb): 165 HR (bpm): 78 BSA (m2): 1.80 m2 Indication: Aortic valve disease. Shortness of breath. Left ventricular function. Congestive heart failure ICD-9 Codes: 786.05, 424.1, 428.0, 394.0, 424.2, Test Information Date/Time: [**2106-6-8**] at 09:22 Interpret MD: [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **], MD Test Type: TTE (Complete) Son[**Name (NI) 930**]: Doppler: Full Doppler and color Doppler Test Location: West Echo Lab Contrast: None Tech Quality: Adequate Tape #: 2010W006-0:46 Machine: Vivid [**8-18**] Echocardiographic Measurements Results Measurements Normal Range Left Atrium - Long Axis Dimension: *5.3 cm <= 4.0 cm Left Atrium - Four Chamber Length: *6.7 cm <= 5.2 cm Right Atrium - Four Chamber Length: *5.1 cm <= 5.0 cm Left Ventricle - Septal Wall Thickness: *1.3 cm 0.6 - 1.1 cm Left Ventricle - Inferolateral Thickness: *1.3 cm 0.6 - 1.1 cm Left Ventricle - Diastolic Dimension: 4.6 cm <= 5.6 cm Left Ventricle - Systolic Dimension: 3.3 cm Left Ventricle - Fractional Shortening: *0.28 >= 0.29 Left Ventricle - Ejection Fraction: 40% >= 55% Left Ventricle - Stroke Volume: 41 ml/beat Left Ventricle - Cardiac Output: 3.19 L/min Left Ventricle - Cardiac Index: *1.77 >= 2.0 L/min/M2 Left Ventricle - Lateral Peak E': *0.07 m/s > 0.08 m/s Left Ventricle - Septal Peak E': *0.03 m/s > 0.08 m/s Left Ventricle - Ratio E/E': *34 < 15 Aorta - Sinus Level: 3.0 cm <= 3.6 cm Aorta - Ascending: *3.5 cm <= 3.4 cm Aortic Valve - Peak Velocity: *4.7 m/sec <= 2.0 m/sec Aortic Valve - Peak Gradient: *88 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 58 mm Hg Aortic Valve - LVOT VTI: 18 Aortic Valve - LVOT diam: 1.7 cm Aortic Valve - Valve Area: *0.4 cm2 >= 3.0 cm2 Mitral Valve - Peak Velocity: 1.8 m/sec Mitral Valve - Mean Gradient: 4 mm Hg Mitral Valve - MVA (P [**2-13**] T): 4.7 cm2 Mitral Valve - E Wave: 1.7 m/sec Mitral Valve - A Wave: 1.0 m/sec Mitral Valve - E/A ratio: 1.70 TR Gradient (+ RA = PASP): *60 to 66 mm Hg <= 25 mm Hg Findings LEFT ATRIUM: Moderate LA enlargement. RIGHT ATRIUM/INTERATRIAL SEPTUM: Mildly dilated RA. Normal IVC diameter (<2.1cm) with 35-50% decrease during respiration (estimated RA pressure (0-10mmHg). LEFT VENTRICLE: Mild symmetric LVH. Normal LV cavity size. Mildly depressed LVEF. TDI E/e' >15, suggesting PCWP>18mmHg. No resting LVOT gradient. No VSD. RIGHT VENTRICLE: RV hypertrophy. Normal RV chamber size. Normal RV systolic function. AORTA: Normal ascending aorta diameter. Focal calcifications in ascending aorta. Mildly dilated aortic arch. Focal calcifications in aortic arch. AORTIC VALVE: Severely thickened/deformed aortic valve leaflets. Critical AS (area <0.8cm2). Mild (1+) AR. MITRAL VALVE: Severely thickened/deformed mitral valve leaflets. No MVP. Severe mitral annular calcification. Mild thickening of mitral valve chordae. Calcified tips of papillary muscles. Mild functional MS due to MAC. Mild (1+) MR. [Due to acoustic shadowing, the severity of MR may be significantly UNDERestimated.] TRICUSPID VALVE: Mildly thickened tricuspid valve leaflets. Mild to moderate [[**2-13**]+] TR. Severe PA systolic hypertension. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflet. No PS. Physiologic PR. PERICARDIUM: No pericardial effusion. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions The left atrium is moderately dilated. The estimated right atrial pressure is 0-10mmHg. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is mildly depressed (LVEF= 45 %). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. The right ventricular free wall is hypertrophied. Right ventricular chamber size is normal. with normal free wall contractility. The aortic arch is mildly dilated. There are focal calcifications in the aortic arch. The aortic valve leaflets are severely thickened/deformed. There is critical aortic valve stenosis (valve area <0.8cm2). Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are severely thickened/deformed. There is no mitral valve prolapse. There is severe mitral annular calcification. There is mild functional mitral stenosis (mean gradient 4 mmHg) due to mitral annular calcification. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is severe pulmonary artery systolic hypertension. There is no pericardial effusion. Electronically signed by [**First Name11 (Name Pattern1) 449**] [**Last Name (NamePattern4) **], MD, Interpreting physician [**Last Name (NamePattern4) **] [**2106-6-8**] 14:09 ?????? [**2099**] CareGroup IS. All rights reserved. Brief Hospital Course: During the preoperative workup, an abdominal MRI was performed to evaluate the abdominal aorta for plaque/calcifications, and evaluate renal arteries for plaques/calcifications. Based on the MRI results, a future MRCP was recommended by Radiology. The MRI results per Radiology are as follows: # Pancreatic cysts: This was found on MRI of the abdomen as part of the pre-op work-up. Diagnostic considerations include multiple side branch IPMNs versus sequela of pancreatitis. Radiology recommended a MRCP in six months. # Multiple hemorrhagic cysts within the kidneys: This was found on MRI of the abdomen. This should also be evaluated by MRCP. The patient was brought to the operating room on [**2106-6-10**] where he underwent aortic valve replacement. Please see Dr[**Last Name (STitle) **] operative report for further details. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. Vancomycin was used for surgical antibiotic prophylaxis given the preoperative stay of longer than 24 hours. Mr/[**Last Name (STitle) **] awoke neurologically intact and was weaned and extubated without difficulty. The patient was neurologically intact and hemodynamically stable, weaned from inotropic or vasopressor support by POD 2. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. He was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued in a timely fashion, without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. He continued to progress and was cleared by Dr.[**Last Name (STitle) **] for discharge to home on POD ******** All follow up appointments were advised. ****stopped [**2106-6-17**] Medications on Admission: 1. aspirin 81 mg daily 2. lipitor 10 mg every other day 3. Coreg 6.25 mg [**Hospital1 **] 4. lasix 40 mg daily 5. allopurinol 100 mg daily 6. glipizide 5 mg daily 7. aciphex 20 mg daily 8. folate daily 9. Coenzyme Q10 100 mg daily Discharge Medications: 1. Outpatient Physical Therapy please evaluate and treat for deconditioning s/p aortic valve replacement 2. Outpatient Lab Work BUN, Creatinine on [**2106-6-23**] Results to Dr. [**Known lastname 32668**] phone: [**Telephone/Fax (1) 12551**] 3. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). Disp:*30 Tablet(s)* Refills:*0* 5. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 6. Furosemide 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 7. Potassium Chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO once a day. Disp:*30 Tab Sust.Rel. Particle/Crystal(s)* Refills:*0* 8. Tramadol 50 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 9. Glipizide 5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO DAILY (Daily). Disp:*30 Tablet Extended Rel 24 hr(s)* Refills:*0* 10. Allopurinol 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. Rabeprazole 20 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 12. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 13. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6hrs prn pain. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: s/p Aortic Valve Replacement (#19mm St.[**Male First Name (un) 923**] tissue valve) PMH: aortic stenosis hypertension Diabetes mellitus Aortic stenosis Renal insufficiency Duodenal ulcers/GI bleeding (rectal and esophageal) Gout deep vein thrombosis 3 years ago benign prostatic hyperplasia Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage 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**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Females: Please wear bra to reduce pulling on incision, avoid rubbing on lower edge Followup Instructions: Provider: [**Name10 (NameIs) **] [**Name8 (MD) 6144**], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2106-7-15**] 1:45 Please call to schedule appointments Primary Care Dr. [**Known lastname **],VARTAN [**Telephone/Fax (1) 12551**] in [**2-13**] weeks *VNA to draw BUN, creatinine in 1 week with results to PCP* Cardiologist Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 10548**] in [**2-13**] weeks **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Completed by:[**2106-6-17**]

[ "276.6", "428.0", "250.42", "424.1", "583.81", "600.00", "585.4", "788.5", "274.9", "403.90", "416.8" ]

icd9cm

[ [ [] ] ]

[ "39.61", "88.56", "35.21", "38.93", "37.22" ]

icd9pcs

[ [ [] ] ]

12172, 12230

8505, 10376

312, 441

12570, 12726

2495, 6830

13512, 14143

1648, 1716

10658, 12149

12251, 12549

10402, 10635

12750, 13489

6879, 8482

1731, 2476

253, 274

469, 1054

1076, 1285

1301, 1632

29,115

110,347

50360

Discharge summary

report

Admission Date: [**2119-5-21**] Discharge Date: [**2119-6-1**] Date of Birth: [**2063-11-21**] Sex: F Service: SURGERY Allergies: Morphine / Azithromycin / Erythromycin Attending:[**First Name3 (LF) 371**] Chief Complaint: abdominal pain, nausea, vomiting, and inability to pass flatus Major Surgical or Invasive Procedure: total abdominal colectomy with end ileostomy & mucous fistula History of Present Illness: 55 y.o. woman with PMH of several bowel operations presents with abdominal pain, nausea, vomiting and no flatus or bowel movements x 1 day. Past Medical History: 1. depression 2. bipolar disease 3. CHF Past Surgical History 1. emergent sigmoidectomy for perforated diverticuli 4 years ago 2. reversal of ostomy 3 months later 3. emergent ostomy for SBO 4. reversal of ostomy 5. appendectomy 6. lumpectomy right breast Social History: 1 PPD tob x 40 years, occasional EtOH Family History: noncontributory Physical Exam: T: 98.8 HR: 94 BP: 105/59 RR: 20 96%RA Gen: awake, alert, NAD HEENT: neck supple, no masses CV: regular rate and rhythm, no m/r/g Pulm: clear to auscultation bilaterally, no w/r/r Abd: nondistended, nontender, ostomy intact on R side of abdomen, mucous fistula intact on L Ext: warm, well-perfused Pertinent Results: [**2119-5-21**] 04:20AM WBC-13.8* RBC-5.22 HGB-17.3* HCT-48.2* MCV-92 MCH-33.0* MCHC-35.8* RDW-14.4 [**2119-5-21**] 04:20AM ALT(SGPT)-56* AST(SGOT)-38 ALK PHOS-138* AMYLASE-141* TOT BILI-0.6 CT abdomen [**5-21**]: Dilated large bowel proximal to the anastomosis extending to the cecum measuring up to 9 cm in maximal diameter without small bowel dilation. Abd XRay [**5-21**]: Gas filled loops of dilated colon & minimally distended loops of small bowel. Multiple air-fluid levels seen within the large bowel. [**2119-5-30**] 03:00AM BLOOD WBC-10.3 RBC-2.99* Hgb-9.6* Hct-27.7* MCV-93 MCH-32.1* MCHC-34.7 RDW-15.0 Plt Ct-412 Brief Hospital Course: Pt presented to the ED where abdominal CT and Xray demonstrated dilated large bowel and she was found to have a WBC of 13.8. Pt was admitted to the SICU. On HD1 endoscopy demonstrated no obstruction and normal mucosa. On HD3 she was brought to the OR for an ex-lap. Pt was found to have a gangrenous right colon which was treated with a partial colectomy, ileostomy, and mucous fistula with placement of a rectal tube. Pt returned to the SICU postoperatively. On HD3 she was intubated and was started on pressors. She was extubated on HD 10. Shortly thereafter the pt's bowel function returned and her diet was advanced. She was discharged home with VNA on HD12. Medications on Admission: 1. Buspar 60 [**Hospital1 **] 2. Abilify 30 daily 3. Nexium 20 daily 4. Lasix 20 daily 5. Advair daily Discharge Medications: 1. Aripiprazole 15 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). Disp:*60 Tablet(s)* Refills:*0* 2. Buspirone 5 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*0* 3. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO every four (4) hours as needed for pain. Disp:*50 Tablet(s)* Refills:*0* 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:*30 Patch 24 hr(s)* Refills:*2* 7. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day: take while using narcotics to prevent constipation. Disp:*60 Capsule(s)* Refills:*2* 8. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*1 inhaler* Refills:*5* 9. Lorazepam 1 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Disp:*20 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: gangrenous right colon bipolar disease depression asthma Discharge Condition: good Discharge Instructions: Diet as tolerated. Resume your prehospitalization medications. No bathing (showers are OK - pat wounds dry), no strenuous activity, no driving while using narcotics. No lifting objects heavier than a gallon of milk. Contact your MD if you develop fevers>101, increasing redness or drainage from your wounds, inability to tolerated oral diet, or if you have any other questions or concerns. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) **] in approximately 2 weeks. Please call ([**Telephone/Fax (1) 2300**] to schedule an appointment.

[ "560.1", "296.80", "557.0", "933.1", "995.92", "493.90", "038.9", "428.0", "518.82" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.04", "45.79", "46.21", "96.72", "96.6", "96.05", "99.15", "45.23" ]

icd9pcs

[ [ [] ] ]

3919, 3977

1955, 2625

360, 424

4078, 4085

1299, 1932

4524, 4675

944, 961

2778, 3896

3998, 4057

2651, 2755

4109, 4501

976, 1280

258, 322

452, 593

615, 873

889, 928

75,171

143,627

49049

Discharge summary

report

Admission Date: [**2153-8-30**] Discharge Date: [**2153-9-4**] Date of Birth: [**2084-7-18**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5141**] Chief Complaint: presyncope and anemia Major Surgical or Invasive Procedure: none History of Present Illness: 69 yo F with breast and lung CA on chemo, last dose within the past week, who presents with orthostatic symptoms in the setting of 12 point drop in HCT to 14 and BRBPR. Pt had been having orthostatic presycope for over a month, becoming dizzy and weak when getting up from bed with resolution when lying down. She has continued to take her antihypertensives though advised not to by PCP. [**Name10 (NameIs) **] is currently being treated for both SCLC and breast carcinoma. She has required transfusion in the past, receiving 1 unit [**Unit Number **] weeks prior during her cycle of chemotherapy. . In oncologist's office on day of admission, had orthostatic presyncope. BP 77/56, HR 116. Her CBC revealed HCT of 14, down from 26 two weeks prior. In addition, her platelet count was 37. There was no evidence of hemolysis and anemia was felt to be chemotherapy induced. . Over the past 2 weeks, her stools have been getting progressively darker. She has a been having problems with constipation in the setting of opiate analgesics. Her last stool was two days prior to admission. She reports it being black and hard. She has not had any diarrhea or BRBPR. Additionally, she received PO contrast yesterday for CT. After her CT, she vomited contrast, and there was no blood seen. . Today, her oncologist advised her to go to the ED after the abnormal HCT [**Location (un) 1131**]. In the ED, initial vs were: T98.4 P122 BP89/34 R18 O298% sat. She was found to have BRBPR on rectal exam, but not passing any stool. NG lavage showed no blood but no bile either. She was given protonix IV and 1 unit PRBCs (O+), 1 unit plasma (AB+), and 2 units of platelets (B+ and O+). The pt is [**Name (NI) **] and has Anti-D antibody. She was also seen by GI in the ED. . On the floor, the patient was feeling slightly better and reporting no new symptoms. She was transfused with 4 units of crossmatched O- blood and continued on protonix. . Review of systems: (+) Per HPI (-) Denies fever, chills. Denies headache, rhinorrhea or congestion. Denies cough, shortness of breath, or wheezing. Denies chest pain, chest pressure, palpitations, PND. Denies dysuria, frequency, or urgency. Denies arthralgias or myalgias. Denies rashes or skin changes. Past Medical History: Oncologic History: -- [**4-/2153**] CT with evidence of metastatic disease with multiple right pleural metastases and moderate-to-large right pleural effusion; solitary lung metastases, multiple liver metastases, right adrenal metastases, and several pancreatic metastases. -- [**2153-5-4**] Biopsy of pleural implants was performed and showed tumor that displayed a high mitotic rate, necrosis and involvement of skeletal muscle. Immunohistochemical studies showed positive staining of the tumor cells with cytokeratin, TTF-1, synaptophysin and chromogranin. An ER stain was negative. These findings support the diagnosis of small cell lung cancer. The patient's prior breast resection was also reviewed (S05-[**Numeric Identifier **], slide G), displaying a tumor with low grade morphologic features.Based on the above mentioned findings, the patient has evidence of extensive stage small cell lung cancer. The cells of origin are neuroendocrine cells within the lung parenchyma, and this is a very aggressive neoplasm. -- [**2153-5-11**] received cycle 1 of carboplatin 5 AUC D1 and etoposide 80 mg/m2 D1, D2, D3 of a 21-28 day cycle. Her course was complicated by neutropenia and thrombocytopenia. -- Additionally, the patient has a history of breat CA. ER/PR positive, HER-2/neu negative, stage T1b, N0, M0, infiltrating right breast carcinoma. She is s/p right partial mastectomy, XRT, and (continued)arimidex therapy -- cycle 3 Carboplatin/Etoposide [**2153-7-10**] -- cycle 4 Carboplatin/Etoposide [**2153-8-14**], transfused 1U PRBC . Other Past Medical History: -Anti-D Ab: Should receive D-antigen negative products for all red cell transfusions. -Hypertension -Hypercholesterolemia -Osteoporosis -Depression -COPD/Emphysema -S/P open cholecystectomy -S/P bilateral tubal ligation Social History: Lives alone at home, separated from her husband who remains supportive, past smoker (1ppd x40yrs), quit 5yrs ago, was taking care of her disbaled daughter who is now in a nursing home because the patient is no longer able to care for her daughter. 4 sons, 3 of whom are in the [**Location (un) **] fire dept. [**1-24**] Glasses of wine per night. Retired housekeeper. No pets. Family History: Non-contributory. No history of cancer, GI bleed, or coagulopathy. Physical Exam: Vitals: T: afeb BP:115/64 P:87 R: 12 O2:98% General: Alert, oriented, no acute distress, pale HEENT: Sclera anicteric, dry MM, oropharynx clear, pale conjunctiva Neck: supple, no LAD Lungs: Poor air movement. Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, systolic murmur heard best at base. Abdomen: mild epigastric and RUQ tenderness. soft, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Pertinent Results: Admission Labs: [**2153-8-30**] 10:08AM PLT COUNT-37*# [**2153-8-30**] 10:08AM WBC-9.8# RBC-1.53*# HGB-5.0*# HCT-14.2*# MCV-93 MCH-32.6* MCHC-35.2* RDW-16.3* [**2153-8-30**] 03:00PM PLT COUNT-37* [**2153-8-30**] 03:00PM WBC-7.3 RBC-1.47* HGB-4.9* HCT-13.7* MCV-94 MCH-33.4* MCHC-35.7* RDW-17.8* [**2153-8-30**] 09:25PM freeCa-1.00* [**2153-8-30**] 03:00PM BLOOD PT-11.9 PTT-22.0 INR(PT)-1.0 [**2153-8-30**] 10:08AM BLOOD Gran Ct-7470 [**2153-8-30**] 09:10AM BLOOD UreaN-18 Creat-0.9 Na-139 K-4.1 Cl-105 HCO3-25 AnGap-13 [**2153-8-30**] 09:10AM BLOOD ALT-8 AST-14 AlkPhos-63 TotBili-0.2 [**2153-8-30**] 03:00PM BLOOD Lipase-73* [**2153-8-30**] 03:00PM BLOOD Albumin-3.6 Calcium-8.4 Phos-2.5* Mg-1.6 [**2153-8-30**] 04:16PM BLOOD Glucose-113* Lactate-2.6* K-3.4* [**2153-8-30**] 04:16PM BLOOD Hgb-4.7* calcHCT-14 . Other Pertinent Labs: [**2153-8-31**] 12:40AM BLOOD Fibrino-269 [**2153-8-31**] 11:42AM BLOOD CK(CPK)-55 [**2153-8-31**] 11:42AM BLOOD CK-MB-3 cTropnT-<0.01 [**2153-9-1**] 08:15AM BLOOD CK(CPK)-25* [**2153-9-1**] 08:15AM BLOOD CK-MB-2 cTropnT-<0.01 . Discharge Labs: [**2153-9-4**] 09:22AM BLOOD WBC-5.0 RBC-3.63* Hgb-11.2* Hct-32.5* MCV-90 MCH-30.9 MCHC-34.4 RDW-15.8* Plt Ct-232 [**2153-9-4**] 09:22AM BLOOD Neuts-65.1 Lymphs-19.4 Monos-14.4* Eos-0.6 Baso-0.6 [**2153-9-4**] 09:22AM BLOOD PT-15.4* PTT-37.2* INR(PT)-1.3* [**2153-9-4**] 09:22AM BLOOD Glucose-93 UreaN-7 Creat-0.7 Na-142 K-4.3 Cl-107 HCO3-29 AnGap-10 [**2153-9-4**] 09:22AM BLOOD Calcium-8.9 Phos-2.7 Mg-1.8 . [**2153-8-30**] EKG: sinus tachycardia [**2153-8-31**] EKG: sinus rhythm with sinus arrhythmia . [**2153-8-31**] CXR: The opacity at the right base is improved. There remains bilateral pleural effusions, right side greater than left with some loculation of the pleural fluid on the right base. The cardiac silhouette and mediastinum are within normal limits. There is calcification of the thoracic aorta. There are no overt consolidations or signs for pulmonary edema. Brief Hospital Course: 69yo female with breast and lung cancer on active treatment, who presented with orthostatic symptoms in the setting of 12 point drop in HCT to 14 and BRBPR noted on rectal exam. # BRBPR: The patient had no history of passing blood per rectum, but was noted to have bright red blood on rectal exam in ED. An NG lavage was negative. The patient was initially admitted to the ICU for further evaluation and treatment. She received a total of 4 units PRBC (1 in ED), 2 units platelets, and 1 unit plasma (all in ED), with rise in HCT to 33.4 from a nadir of 13.7. Platelets rose from 37 to 152, and were >200 at time of discharge. She was started on IV PPI therapy. It was thought that her bleeding was due to a combination of marrow suppression from chemotherapy and a slow GI bleed. She was to have an endoscopy performed by GI, but this was initially deferred when the patient developed chest pain. An EKG was checked and showed no evidence of ischemia, and cardiac enzymes were negative. Serial HCTs were stable so the patient was called out to medical oncology floor. She had one guiac positive bowel movement after transfer, but did not have any additional bloody bowel movements or BRBPR prior to discharge. She was followed by GI, who decided to defer EGD/colonoscopy given patient's co-morbidities and stabilization of her HCT. HCT peaked at 38.0 on [**2153-9-1**], but was slowly trending down again prior to discharge (32.5 on day of discharge [**2153-9-4**]). The patient was hemodynamically stable. She will have VNA services at home, and her HCT will continue to be closely monitored. She will follow-up in hematology/oncology clinic next week on [**2153-9-10**]. . # Hypoxia: The patient developed a new oxygen requirement during this admission. There was initially some concern for pulmonary edema in setting of transfusion, however CXR did not show evidence of overt edema or consolidation. Of note, CXR did show bilateral pleural effusions. The patient's O2 was gradually weaned, and she was satting well on room air at time of discharge. She also maintained sats in the mid-90s on room air following ambulation. She will be discharged home with VNA services and physical therapy. . # Small cell lung cancer: The patient has been on recent treatment, with carboplatin and etoposide, and was scheduled to begin her next cycle of chemotherapy on [**2153-9-3**]. This cycle was delayed, and the patient will follow up with oncology one week following discharge. Her counts were closely monitored in setting of recent chemo, and as above she was transfused with both PRBCs and platelets during this admission. For her pain, she was continued on oxycodone and acetominophen as needed. She was ordered for ondansetron and prochlorperazine for nausea, but did not have significant symptoms of N/V during this hospital admission. . # Breast Cancer: She was continued on anastrazole. . #. HTN: The patient has a h/o HTN, and her home regimen included quinapril, HCTZ, and nifedipine. The patient's anti-hypertensives were held during the admission, especially given hypotension and acute bleeding on presentation. After transfer from the ICU to the floor, the patient's BP was stable. She was becoming hypertensive again prior to discharge, and her quinapril and HCTZ were resumed on discharge. The patient was asked to continue holding her nifedipine. She should have her blood pressure monitored in the outpatient setting, with her anti-hypertensive regimen adjusted accordingly. . # Depression: She was continued on zyprexa. Medications on Admission: 4th cycle of Carboplatin/Etoposide finished on [**8-14**] with 5th cycle scheduled for [**9-3**]. ANASTROZOLE [ARIMIDEX] - 1 mg Tablet - 1 Tablet(s) by mouth once a day OLANZAPINE [ZYPREXA] - 5 mg Tablet - 1 Tablet(s) by mouth once a day ONDANSETRON HCL - 8 mg Tablet - 1 Tablet(s) by mouth Q8H prn nausea OXYCODONE - 5 mg Tablet - [**12-23**] Tablet(s) by mouth q 4 hrs prn pain PROCHLORPERAZINE MALEATE - 10 mg Tablet - 1 Tablet(s) by mouth Q8H prn nausea SIMVASTATIN - 20 mg Tablet - 1 Tablet(s) by mouth once a day Quinipril 10mg PO QD - (has not been taking for past 2 days) HCTZ 25mg PO QD (has not been taking for past 2 days) Nifedipine XL 30mg PO QD (has not been taking for past 2 days) ASPIRIN - 81 mg Tablet, Delayed Release (E.C.) - One Tablet(s) by mouth daily CALCIUM - Dosage uncertain MULTIVITAMIN - Tablet - One Tablet(s) by mouth daily Discharge Medications: 1. Anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily (). 2. Olanzapine 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 4. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q6H (every 6 hours) as needed for pain or fever. 5. Simvastatin 20 mg Tablet Sig: One (1) Tablet PO once a day. 6. Quinapril 10 mg Tablet Sig: One (1) Tablet PO once a day. 7. Hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once a day. 8. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. 10. Senna 8.6 mg Capsule Sig: [**12-23**] Capsules PO once a day as needed for constipation. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: Gastrointestinal bleed requiring blood transfusion Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to the hospital with anemia. This was felt to be due to blood loss from your GI tract and from bone marrow supression from your chemotherapy. You required 4 units of blood and 2 bags of platelets. Your blood counts stabalized and you are being discharged with physical therapy and visiting nurse. We held your blood pressure medications while you were here. We ask that you hold your Nifedipine. You may restart your quinapril and hydrochlorathiazide. Followup Instructions: Department: HEMATOLOGY/ONCOLOGY When: MONDAY [**2153-9-10**] at 9:00 AM With: [**First Name4 (NamePattern1) 2747**] [**Last Name (NamePattern1) 5780**], RN [**Telephone/Fax (1) 22**] Building: [**Hospital6 29**] [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: TUESDAY [**2153-9-11**] at 9:00 AM With: [**First Name4 (NamePattern1) 539**] [**Last Name (NamePattern1) 10603**], RN [**Telephone/Fax (1) 22**] Building: [**Hospital6 29**] [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: HEMATOLOGY/ONCOLOGY When: WEDNESDAY [**2153-9-12**] at 9:00 AM With: [**First Name4 (NamePattern1) 2747**] [**Last Name (NamePattern1) 5780**], RN [**Telephone/Fax (1) 22**] Building: [**Hospital6 29**] [**Location (un) 24**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage

[ "E933.1", "174.8", "197.7", "733.00", "401.9", "V45.71", "511.81", "285.3", "799.02", "198.7", "311", "496", "285.1", "272.0", "197.0", "162.8", "578.9", "197.8", "197.2" ]

icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

12747, 12804

7502, 11051

336, 343

12899, 12899

5507, 5507

13577, 14489

4832, 4900

11956, 12724

12825, 12878

11077, 11933

13082, 13554

6597, 7479

4915, 5488

2317, 2603

275, 298

371, 2298

5523, 6330

6352, 6581

12914, 13058

4200, 4421

4437, 4816

11,844

104,294

5455

Discharge summary

report

Admission Date: [**2193-1-1**] Discharge Date: [**2193-3-27**] Date of Birth: [**2113-8-9**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 16983**] Chief Complaint: 79 yo m with aplastic anemia, Fournier's gangrene and history of possible old TB exposure admitted [**1-1**] for a 5 day course of ATG and initition of CSA Major Surgical or Invasive Procedure: Transverse colectomy with creation of Hartmann's pouch and proximal revision of colostomy to an end colostomy. History of Present Illness: 79 year old male with untreated aplastic anemia is being admitted for ATG + cyclosporine treatment. Pt was found to have a hematopoietic disorder in [**4-19**] when he went to his PCP for [**Name Initial (PRE) **] follow up after experiencing lethargy. Patient's marrow was initially aplastic on [**2192-6-28**]. Since then, he has been tried on IVIG and prednisone without significant effect. His medical course has been complicated by line infection, perianal abscess, retinal bleed and the findings of pulmonary nodules and granulomatous disease. Hence, at this time he is finishing a 9 month course of INH. His CT Chest shows improved nodules allowing him to undergo ATG + Cyclosporine at this time. At home, he denies any fevers, chest pain, SOB or bodily pain. Denies any rashes, bleeding. Past Medical History: 1) Aplastic anemia dx [**4-19**] by bone marrow biopsy. Given some questions about a history of TB, he was treated with INH for one month and then started on prednisone 60mg daily on [**2192-7-5**]. He requires platelet transfusions weekly, and blood transfusions every several weeks or so. Complicated by retinal hemorrhage. 2) Pt remembers living in a sanitorium from age [**2-24**]. This prompted an investigation for TB, with subsequent sputum and bone marrow negative for acid fast bacilli. However, given a concern for this in face of starting steroids, pt is being treated with Isoniazid and Pyridoxine since [**2192-5-29**]. Chest CT showed evidence of granulomatous disease in the past, but no active disease. 3) kyphoscoliosis 4) L inguinal hernia, reducible present for long time, not painful Social History: Lives with wife in [**Name (NI) **]. Has two grown daughters nearby. [**Name2 (NI) **] tobacco, quit 40 years ago Rare alcohol when he goes out Family History: There is no history of blood disorders. Physical Exam: Gen: Thin elderly male in NAD HEENT: Oropharynx clear CV: +s1+s2 RRR No murmurs Resp: CTA B/L No crackles or wheezing Abd: R ostomy bag. GU: No perianal signs of abscess or skin degradation. Inguinal hernia present. Neuro: AAO x 3. CN 2-12 grossly intact. Pertinent Results: [**2193-1-1**] 06:35PM BLOOD WBC-2.4* RBC-2.97* Hgb-8.5* Hct-24.7* MCV-83 MCH-28.7 MCHC-34.4 RDW-13.9 Plt Ct-15*# [**2193-1-3**] 12:10AM BLOOD WBC-0.3*# RBC-2.60* Hgb-7.5* Hct-21.5* MCV-83 MCH-28.9 MCHC-34.8 RDW-14.2 Plt Ct-20*# [**2193-1-6**] 01:15AM BLOOD WBC-0.3* RBC-3.77* Hgb-10.7* Hct-30.4* MCV-81* MCH-28.4 MCHC-35.2* RDW-14.2 Plt Ct-46* [**2193-1-9**] 06:13PM BLOOD WBC-1.2* RBC-3.72* Hgb-10.8* Hct-29.3* MCV-79* MCH-29.0 MCHC-36.8* RDW-14.3 Plt Ct-80*# [**2193-1-19**] 12:42AM BLOOD WBC-0.3* RBC-2.99* Hgb-8.5* Hct-24.0* MCV-80* MCH-28.4 MCHC-35.3* RDW-13.4 Plt Ct-28* [**2193-2-1**] 07:08AM BLOOD WBC-1.1* RBC-2.95* Hgb-8.5* Hct-23.5* MCV-80* MCH-28.9 MCHC-36.3* RDW-13.5 Plt Ct-13* [**2193-2-4**] 06:50AM BLOOD WBC-0.9* RBC-2.67* Hgb-7.7* Hct-20.9* MCV-78* MCH-28.8 MCHC-36.8* RDW-13.3 Plt Ct-85* [**2193-2-7**] 06:30AM BLOOD WBC-1.1* RBC-3.28* Hgb-9.5* Hct-25.6* MCV-78* MCH-28.8 MCHC-36.9* RDW-13.9 Plt Ct-20* [**2193-1-1**] 06:35PM BLOOD Hypochr-NORMAL Anisocy-NORMAL Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL [**2193-1-1**] 06:35PM BLOOD Plt Smr-RARE Plt Ct-15*# [**2193-1-3**] 11:55AM BLOOD Plt Ct-49*# [**2193-1-8**] 08:09AM BLOOD Plt Ct-11* [**2193-1-24**] 07:20AM BLOOD Plt Ct-7* [**2193-2-1**] 02:54PM BLOOD Plt Ct-51*# [**2193-2-2**] 06:55AM BLOOD Plt Ct-208 [**2193-2-7**] 06:30AM BLOOD Plt Ct-20* [**2193-1-1**] 06:35PM BLOOD Gran Ct-560* [**2193-1-31**] 06:45AM BLOOD Gran Ct-280* [**2193-1-1**] 06:35PM BLOOD Glucose-101 UreaN-27* Creat-1.2 Na-142 K-3.9 Cl-102 HCO3-25 AnGap-19 [**2193-1-8**] 01:08AM BLOOD Glucose-196* UreaN-25* Creat-0.8 Na-136 K-3.2* Cl-105 HCO3-24 AnGap-10 [**2193-1-16**] 01:31AM BLOOD Glucose-135* UreaN-37* Creat-0.9 Na-135 K-5.9* Cl-101 HCO3-31 AnGap-9 [**2193-2-1**] 07:08AM BLOOD Glucose-89 UreaN-16 Creat-0.9 Na-141 K-3.4 Cl-101 HCO3-33* AnGap-10 [**2193-2-7**] 06:30AM BLOOD Glucose-PND UreaN-PND Creat-PND Na-PND K-PND Cl-PND HCO3-PND [**2193-1-1**] 06:35PM BLOOD ALT-20 AST-28 AlkPhos-142* TotBili-0.5 [**2193-1-9**] 06:08AM BLOOD ALT-87* AST-66* AlkPhos-147* TotBili-3.0* [**2193-1-30**] 12:10AM BLOOD ALT-35 AST-20 LD(LDH)-101 AlkPhos-130* TotBili-0.6 [**2193-2-4**] 06:50AM BLOOD Albumin-2.7* Iron-127 [**2193-2-4**] 06:50AM BLOOD calTIBC-139* TRF-107* [**2193-1-3**] 07:30PM BLOOD Hapto-221* [**2193-1-18**] 12:00AM BLOOD Cortsol-9.5 [**2193-1-7**] 08:50AM BLOOD Cyclspr-357 [**2193-2-1**] 07:08AM BLOOD Cyclspr-107 [**2193-2-6**] 06:10AM BLOOD Cyclspr-155 [**2193-1-4**] 09:40AM URINE Blood-TR Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2193-1-4**] 09:40AM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-0 . URINE CULTURE (Final [**2193-1-8**]): PSEUDOMONAS AERUGINOSA. >100,000 ORGANISMS/ML.. IMIPENEM RESISTANT sensitivity testing performed by [**First Name8 (NamePattern2) 3077**] [**Last Name (NamePattern1) 3060**]. STAPHYLOCOCCUS, COAGULASE NEGATIVE. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA | CEFEPIME-------------- 16 I CEFTAZIDIME----------- 8 S CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ =>16 R IMIPENEM-------------- R MEROPENEM------------- =>16 R PIPERACILLIN---------- 32 S PIPERACILLIN/TAZO----- 64 S TOBRAMYCIN------------ =>16 R [**2193-1-21**] 1:07 am URINE Site: CLEAN CATCH **FINAL REPORT [**2193-1-23**]** URINE CULTURE (Final [**2193-1-23**]): MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT WITH FECAL CONTAMINATION. WORK-UP PER DR [**First Name (STitle) **] ([**Numeric Identifier 21495**]). Culture workup discontinued. Further incubation showed contamination with mixed fecal flora. Clinical significance of isolate(s) uncertain. Interpret with caution. GRAM NEGATIVE ROD(S). >100,000 ORGANISMS/ML.. SUGGESTING PSEUDOMONAS. GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML.. ORGANISM. 10,000-100,000 ORGANISMS/ML.. URINE CULTURE (Final [**2193-1-20**]): ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML.. YEAST. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ =>32 R CHLORAMPHENICOL------- <=4 S LEVOFLOXACIN---------- =>8 R LINEZOLID------------- 1 S NITROFURANTOIN-------- 256 R VANCOMYCIN------------ =>32 R AEROBIC BOTTLE (Final [**2193-1-23**]): REPORTED BY PHONE TO [**Last Name (LF) **],[**First Name3 (LF) **] -7F- @ 14:45 [**2193-1-21**]. ENTEROCOCCUS FAECALIS. FINAL SENSITIVITIES. HIGH LEVEL GENTAMICIN SCREEN: Susceptible to 500 mcg/ml of gentamicin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details. HIGH LEVEL STREPTOMYCIN SCREEN: Susceptible to 1000mcg/ml of streptomycin. Screen predicts possible synergy with selected penicillins or vancomycin. Consult ID for details.. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS FAECALIS | AMPICILLIN------------ <=2 S LEVOFLOXACIN---------- 0.5 S PENICILLIN------------ 2 S VANCOMYCIN------------ <=1 S ANAEROBIC BOTTLE (Final [**2193-1-23**]): ENTEROCOCCUS FAECALIS. IDENTIFICATION AND SENSITIVITIES PERFORMED FROM AEROBIC BOTTLE. AEROBIC BOTTLE (Final [**2193-1-25**]): ENTEROCOCCUS FAECALIS. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 202-6864S [**2193-1-21**]. ANAEROBIC BOTTLE (Final [**2193-1-25**]): ENTEROCOCCUS FAECALIS. IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE # 202-6864S [**2193-1-21**]. WOUND CULTURE (Final [**2193-1-25**]): ENTEROCOCCUS SP.. <15 colonies. Isolate(s) identified and susceptibility testing performed because of concomitant positive blood culture(s) Comparison of the susceptibility patterns may be helpful to assess clinical significance. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ENTEROCOCCUS SP. | AMPICILLIN------------ <=2 S LEVOFLOXACIN---------- 0.5 S PENICILLIN------------ 2 S VANCOMYCIN------------ <=1 S URINE CULTURE (Final [**2193-1-27**]): PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML.. SENSITIVITIES PERFORMED ON CULTURE # [**Numeric Identifier 22095**] [**2193-1-24**]. . ABDOMEN (SUPINE & ERECT) [**2193-1-8**] 7:16 PM Large soft tissue density overlying right lower quadrant secondary to the prolapsed bowel. A few gas-filled minimally dilated loops of small bowel are present with small air-fluid levels, no definite evidence for intestinal obstruction. Calcific densities in the known calcified atrophic left kidney and left mid abdomen. No free intraperitoneal gas. . [**1-9**] Abd U/S: Normal appearing liver less scattered granulomas, no findings to explain the patient's rising LFTs. Incidental note of an adherent cholesterol stone versus gallbladder polyps. . [**1-24**] TTE: The left atrium is normal in size. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF 60%). 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 ascending aorta is mildly dilated. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. No vegetation/mass is seen on the pulmonic valve. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2192-11-19**], no major change is evident. The absence of a vegetation by 2D echocardiography does not exclude endocarditis if clinically suggested. . [**2-1**] Pathology: TRANSVERSE COLON AND PROXIMAL LIMB OF COLON (2). DIAGNOSIS: I. Transverse colon (A-G): 1. Focal area of submucosal fibrosis. 2. Peritoneal fibrous adhesions. 3. Intact mucosa. II. Proximal limb of colon (H-K): 1. Stoma with focal ulcer and granulation tissue. 2. Peritoneal fibrous adhesions. . [**2-4**] TTE: The left atrium is normal in size. No spontaneous echo contrast is seen in the left atrial appendage. No thrombus is seen in the left atrial appendage. No atrial septal defect is seen by 2D or color Doppler. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Right ventricular chamber size and free wall motion are normal. The ascending aorta is mildly dilated. There are simple atheroma in the ascending aorta. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. There are three aortic valve leaflets. No masses or vegetations are seen on the aortic valve. Mild (1+) aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. No mass or vegetation is seen on the mitral valve. There is a small pericardial effusion. IMPRESSION: No evidence of endocarditis. . [**2-9**] CT abdomen/pelvis: 1. Dilatation of cecum and terminal ileum between two fixed points, i.e., new stoma and patulous left inguinal orifice. The possibility of a closed-loop obstruction is considered given the extent of the cecal distension.No proximal small bowel distension is seen however 2. Prior granulomatous disease affecting multiple visceral organs. . [**2-12**] CXR: 1. Cardiomegaly. 2. Improvement of congestive heart failure. 3. Slightly dilated loops of small bowel with air-fluid level within it and may represent SBO- a clinical correlation is suggested. . [**2-13**] Chest CT: 1. Interval development of bilateral pleural effusions. 2. Calcified right upper lobe granuloma, calcified mediastinal and hilar lymph nodes, calcified intra-abdominal lymph nodes, as well as punctate calcifications in the spleen and liver and atrophic calcified left kidney are all consistent with previous granulomatous infection including tuberculosis infection. 3. Vague opacity in the right upper lobe is unchanged. . [**2-13**] Head CT: No evidence of hemorrhage or acute infarction. . [**2-15**] CT abdomen/pelvis: 1. Distal right colon at ostomy concerning in appearance for ischemia vs inflammation, with markedly abnormal heterogeneous, thickened bowel wall; infection is less likely. Small amount of air concerning for bowel perforation at the distal ostomy site. 2. Similar appearance to prior dilated loops of bowel in left lower quadrant concerning in appearance for closed-loop obstruction. After discussion with Dr. [**Last Name (STitle) **], this is apparently a reducible hernia. 3. Unchanged appearance of evidence of prior granulomatous infection including multiple calcified granulomata in liver, spleen, and left "putty" kidney. 4. Otherwise stable examination since [**2193-2-9**]. . [**2-16**] CT abdomen/pelvis: 1. Markedly abnormal appearance of the large bowel leading into the patient's diverting colostomy with edematous-appearing wall again demonstrated. Differential diagnosis includes ischemia, infectious or inflammatory process. 2. Free fluid and sigmoid colon containing right inguinal hernia. 3. Small bowel and free fluid in a left inguinal hernia. 4. Bilateral pleural effusions with associated atelectasis. 5. Bilateral hydroceles. . [**2-21**] CT abdomen/pelvis: Continued but slightly improved distal colitis. Otherwise stable appearance of the abdomen and pelvis compared to [**2193-2-16**]. . [**2-28**] CT abdomen/pelvis: 1. Peripherally enhancing cystic structures in the seminal vesicles are new since the study of [**11-15**], and raise the possibility of seminal vesiculitis and/or prostatitis with abscesses. Consider Urology consult. Transrectal aspiration can be performed under ultrasound guidance if clinically indicated. 2. Slight improvement in the bilateral pleural effusions since the study of [**2193-2-21**]. 3. Calcified granulomas in the lung, calcified mediastinal and mesenteric lymph nodes, punctate calcifications in the liver and spleen, as well as the atrophic and calcified appearance of the right kidney are all consistent with prior granulomatous infection. 4. Bilateral bowel-containing inguinal hernias without evidence of incarceration. 5. Improving appearance of the colitis adjacent to the right upper quadrant ostomy with persistent fat stranding in this region. . [**3-8**] Prostate U/S: No evidence of prostatic or seminal vesicle abscesses. The presumed small infected collection demonstrated on prior CT (and diminishing in size on followup CT) has completely resolved. Consequently, the planned TRUS guided aspiration was canceled. Brief Hospital Course: Initial BMT Course: Patient with known history of aplastic anemia was admitted for ATG + cyclosporine therapy. The patient was educated that it would take a few months to see any effects of the therapy. He was also advised of the potential risks and mortality of this regimen. . COURSE PRIOR TO SURGERY: . *Aplastic anemia: The patient has aplastic anemia of unknown etiology. He was admitted for ATG and cyclosporine therapy. He finished a 5 day course of ATG ([**Date range (1) 22096**]) @ 3.5mg/kg/day. His cyclosporine was started at 300 mg PO BID. His dose was changed initially to 200 mg PO q12 because of hypertension, tachycardia and developement of spasms, that were thought to be secondary to cylosporin. Patient also developed rigors. The rigors resolved with demerol and for the fevers, he was given tylenol. For the hypertension, he was started on nifedipine with good control. He was also started on prednisone during his course and this was slowly tapered down. His hct was maintained above 25 and plts above 10 with transfusions, though he remained neutropenic, requiring products approximately every 3-4 days. He was started on GCSF 480 mcg qd b/c of this. He was started on Atovaquone for PCP [**Name Initial (PRE) 1102**]. . * H/o of granulomatous disease The patient had a h/o of old granulomatous disease. At the time of admission, patient did not appear to have active infection by CT scan, but known old granulomatous lesions were seen in the lungs, LN, spleen and liver. He was continued on isoniazide and pyridoxine for empiric treatment of TB and was to follow-up with ID after discharge regarding when to stop these medications. His O2 sats remained stable throughout BMT course. . * Enterococcus bacteremia: Patient spiked a temperature and was found to have growth of enterococcus sensitive to ampicillan from PICC line on [**1-21**]. The PICC line was removed and the patient was treated with ampicillan and gentamicin. Surveillance cultures showed no growth and patient remained afebrile throughout the rest of his BMT stay. . *Hyperkalemia: Patient became hyperkalemic for several days during his admission. Was thought to be secondary to cyclosporine. She was treated with fluids, lasix and lactulose to help decrease her potassium levels. Her potassium levels normalized after addition of florinef and remained stable throughout the rest of her admission. . * Pseudomonas UTI: Patient developed pseudomonas UTI for which he was treated with Ceftazidime for 7 days. Repeat cultures were negative. . *Oral lesions: Patient had lesions on his upper lip that appeared to be HSV and his HSV 1 serology was positive. He was treated for this with acyclovir and the lip lesions resolved. The patient then developed some white spotes in the back of his throat. It was thought this was possibly [**Female First Name (un) **] growing over oral HSV lesions. These regions were swabbed and showed no growth. Nystatin was started and the lesions disappeared over the course of the admission. . * HTN: His hypertension was well controlled with Nifedepine TID. . *Bowel edema: Patient had [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] pouch secondary to necrotic bowel resection from several months prior. On [**12-8**] pt had increased edema (the thought was that somehow the bowel edema was exacerbated by his treatment) in his prolapsed bowel. We were unable to support the bowel with a truss because of fear of strangulating the blood supply to the bowel and making the small areas of necrosis even worse. He received sugar on bowel to try to osmotically shrink the edema; this was tried 3 times with small improvement. Surgery was consulted regarding the management of this bowel issue. We felt that it would be advantageous for him to have surgical intervention while in house, in a situation where his medical issues were better controlled rather than to send him to rehab, where potential worsening of his bowel edema would constitute a surgical emergency. . . Surgery Course: Patient was taken to the OR on HD31 after all blood and urine infections were resolved as well as abnormal electrolytes issues were under control. Patient received stress dose steroids, platelets on call to the OR as well as dapsone, gent, and flagyl for 72 hours. Surgery was uneventful and successful in revision of his colostomy. Patient was extubated in the OR, taken to the PACU, and then transferred to the floor when met criteria. Platelets were initially transfused to maintain a level above 100 in the immediate post-op period. Steroid taper was also initiated. Cyclosporine levels were monitored and increased accordingly. Stoma looked healthy throughout the post-operative course. Flatus was first noted on POD4 at which time clears were started, then advanced to fulls and regular as tolerated. Patient had a TEE per ID recs to rule out endocarditis which was negative. PT worked with the patient throughout and recommended rehab for the patient. BP control was done with lopressor and hydralazine. On [**2-5**] he was advanced to clears and PO meds, then fulls on POD4. PT saw him and helped him ambulate. [**Last Name (un) **] was consulted for Glucose control. POD7 CT scan showed dilated R colon and he was febrile to 102.5. C.Diff x 3 was sent - all of which were negative and pt was started on Zosyn along with flagyl and linezolid, and made NPO. Tx to TSICU on POD9 after started on ambisome and had BP drop. BP responded to 2U of PRBCs. Urine Cx from [**2-9**] came back pos for pseudomonas. ID and Heme closely followed pt and pt was stable on floor. occassionally had high BP to 180s controlled by PRN hydralazine. On [**2-13**] he had a CT of his head for suspected change in MS that was negative. CT on [**2-15**] showed increased inflammatory changes in R colon, and pt. was started on TPN. Decision was made to cont to watch him. [**2-16**] CT also showed similar results. On [**2-19**] he was tx to Heme/Onc and Surgery will cont to closely follow. . . Subseqent BMT Course: # Aplastic anemia: Danazol and epogen ([**2-27**]) were started in addition to prior neupogen to try and aid hematopoiesis. Neupogen was stopped on [**3-18**] as his ANC did not seem to improve on this therapy. He was tapered off of cyclosporin, stopping on [**2-26**]. He was transfused to maintain his hct>25 and plt>10. He was also continued on atovaquone for PCP prophylaxis and fluconazole was added for ppx. He will follow up with hem/onc ([**Doctor Last Name 410**]) as an outpatient for repeated transfusions and decision regarding need for further epogen and danazol. . # Bradycardia: pt was put on telemetry after having a brief episode of disorientation, red face, ?dyspnea (witnessed by nurse) - recovered quickly. On tele, pt noted to become bradycardic with coughing episodes (likely vagal). Otherwise asymptomatic. He ruled out for MI by cardiac enzymes. metoprolol was lowered to 12.5 tid as of [**3-22**]. . # H/o of granulomatous disease: As above. The patient had completed a 9-month course of INH/pyridoxine, so this was discontinued on [**2193-2-26**]. . # HTN: As above, hypertension was exacerbated by cyclosporine. The patient was treated with nifedipine, metoprolol, and hydralazine at the time of transfer from SICU. Lisinopril was added and hydralazine discontinued to simplify the regimen. Later, HCTZ was added with the hope of discontinuing metoprolol, as the patient was noted to have episodes of asymptomatic bradycardia. HCTZ was d/c as it caused his creatine to rise, and he was discharged on nifedipine, lisinopril, and metoprolol. . # Colostomy revision: Surgery continued to follow the patient when he was transferred back to the BMT service. Serial CT scans showed gradual improvement of distal colitis. The patient's diet was advanced and he was weaned off TPN. He was tolerating a regular diet at the time of discharge and learned self ostomy care. . # Fever: At the time of transfer the patient was afebrile, and he was soon switched to PO antibiotics. He then had an isolated fever spike. At that time a CT of the abdomen and pelvis revealed a possible seminal vesiculitis vs. prostatitis. Urology evaluated the patient and recommended ultrasound guided aspiration of this area. Ultrasound revealed no abnormality, so the aspiration procedure was cancelled. The patient remained afebrile thereafter except for one elevated [**Location (un) 1131**] which revealed nothing on culture or exam. . # Mild Renal Insufficiency: Patient had poor PO intake and was maintained on gentle IVF's for much of his hospital admission. However, he was encouraged to increase intake and florinef was added to aid in retention of intravascular volume, and Cr was stable at ~1.1. # Confusion: The patient developed mental status changes while on the surgery service. CT head was negative. Sedating medications were held. The patient's mental status improved prior to transfer to the BMT service, and he remained at his baseline throughout the remainder of the hospital course. Medications on Admission: Medications: 1. G-CSF 300 mcg/mL Q24H 2. Colace 100mg [**Hospital1 **] 3. Isoniazid 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Acetaminophen 325 mg PRN 5. Folic Acid 1 mg PO DAILY 6. Pyridoxine 50 mg PO DAILY 7. Pantoprazole 40 mg delayed release Q24. Discharge Medications: 1. Atovaquone 750 mg/5 mL Suspension Sig: Ten (10) ml PO DAILY (Daily). Disp:*300 ml* Refills:*2* 2. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 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. Peppermint Oil Oil Sig: One (1) Miscell. ONGOING () as needed for colostomy. 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. Danazol 200 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 7. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). Disp:*30 Cap(s)* Refills:*2* 8. Prednisone 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. Amoxicillin-Pot Clavulanate 875-125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 10. Clotrimazole 10 mg Troche Sig: One (1) Troche Mucous membrane QID (4 times a day) as needed for thrush. Disp:*30 Troche(s)* Refills:*0* 11. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 12. Nifedipine 60 mg Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO DAILY (Daily). Disp:*60 Tablet Sustained Release(s)* Refills:*2* 13. Epoetin Alfa 10,000 unit/mL Solution Sig: [**Numeric Identifier 961**] ([**Numeric Identifier 961**]) units Injection QMOWEFR (Monday -Wednesday-Friday). Disp:*QS units* Refills:*2* 14. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO TID (3 times a day). Disp:*45 Tablet(s)* Refills:*2* 15. Fludrocortisone 0.1 mg Tablet Sig: One (1) Tablet PO QD (). Disp:*30 Tablet(s)* Refills:*2* 16. Fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home With Service Facility: Physician [**Name9 (PRE) **] [**Name9 (PRE) **] Discharge Diagnosis: Primary Diagnosis: transfusion dependent aplastic anemia prolapsed stoma pseudomonas urinary tract infection enterococcus bacteremia Discharge Condition: good Discharge Instructions: If you experience fever, chills, severe nausea, vomiting, or abdominal pain, shortness of breath, or any other new or concerning symptoms, please call your doctor or return to the emergency room for evaluation. . Please take all medications as prescribed. . Please attend all follow up appointments. Followup Instructions: 1. Please follow up with Dr. [**Last Name (STitle) 410**]. 10:30Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 5026**], MD Phone:[**Telephone/Fax (1) 3237**] Date/Time:[**2193-3-28**] 9:30 Provider: [**Name10 (NameIs) **] [**Name11 (NameIs) **], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2193-3-28**] 9:30 . 2. Please follow up with Dr. [**Last Name (STitle) **] on [**4-19**] at 8:00 a.m. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 16984**] MD, [**MD Number(3) 16985**]

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icd9cm

[ [ [] ] ]

[ "99.15", "38.93", "46.13", "88.72", "99.04", "99.28", "45.71", "99.05" ]

icd9pcs

[ [ [] ] ]

27581, 27659

16292, 25362

470, 583

27836, 27843

2754, 13688

28191, 28749

2420, 2462

25678, 27558

27680, 27680

25389, 25655

27867, 28168

2477, 2735

275, 432

611, 1408

13697, 16269

27699, 27815

1430, 2241

2257, 2404

10,780

160,565

30031

Discharge summary

report

Admission Date: [**2181-3-20**] Discharge Date: [**2181-3-25**] Date of Birth: [**2162-12-31**] Sex: M Service: ORTHOPAEDICS Allergies: Ampicillin / Cephalexin / Penicillins / Latex Attending:[**First Name3 (LF) 3645**] Chief Complaint: Mr. [**Known lastname 11622**] is a 18 year old male who was involved as an unrestrained high speed driver that collided into house. Major Surgical or Invasive Procedure: 1. Posterior cervical arthrodesis C4 to C7. 2. Posterior cervical instrumentation C4 to C7. 3. Left iliac crest bone graft. History of Present Illness: Mr. [**Known lastname 11622**] is an 18 year old male that was involved in a motor vehicle accident where the car crahed into a house. He was the unrestrained, intoxicated driver of the vehicle. The vehicle demolished the [**Location (un) 453**] with the [**Location (un) **] collapsed onto the vehicle. There was a prolonged extrication. The passenger, who was his best friend, dead at the scene. Past Medical History: ADHD Social History: ETOH Drug Use Family History: N/C Physical Exam: O: T: BP:127 /70 HR:68 R20 O2Sats 100% Gen: WD/WN, comfortable, NAD. HEENT: Pupils: [**2-2**] EOMs full no obvious head injuries, scrapes no hemotympan Neck: In collar not examined Lungs: CTA bilaterally. Cardiac: RRR. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Neuro: Mental status: Awake slow to answer cooperative with exam, normal affect. Orientation: Oriented to person, place, and date -[**4-9**]. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light, to mm bilaterally. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Facial strength and sensation intact and symmetric. VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. [**Doctor First Name 81**]: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. No abnormal movements, tremors. Strength full power [**4-7**] throughout. No pronator drift Sensation: Intact to light touch, Reflexes: B T Br Pa Ac Right decreased to absent Left decreased to absent Toes downgoing mute Pertinent Results: [**2181-3-20**] 01:35AM ASA-NEG ETHANOL-163* ACETMNPHN-NEG bnzodzpn-NEG barbitrt-NEG tricyclic-NEG [**2181-3-20**] 04:09AM PHENYTOIN-<0.6* [**2181-3-20**] 12:52PM WBC-13.9* RBC-4.92 HGB-15.0 HCT-41.3 MCV-84 MCH-30.6 MCHC-36.5* RDW-13.2 [**2181-3-20**] CT C-Spine: compression fx C6. fx C5 w/o loss of height. C5 R pedicle and laminar fractures = unstable fracture. grade 1 retrolisthesis C6 on c7. high density material indenting right thecal sac at C5 - can represent extradural hematoma. mild prevertebral soft tissue swelling [**2181-3-20**] MRI C-S: Disruption interspinous ligament C5-6 w/ at least ligamentous sprain throughout the remaining interspinous ligament. Prevertebral edema C3-C6, with possible anterior longtitudinal ligament injury. Posterior soft tissue hematoma overlying the spinous processes. C5 and C6 edema due to the previously described fractures. fluid in facet joints b/tw C4-5 & C5-6 R indicating injury. Brief Hospital Course: Mr. [**Known lastname 11622**] is an 18 year old male that was involved in a motor vehicle accident where the car crahed into a house. He was the unrestrained, intoxicated driver of the vehicle. The vehicle demolished the [**Location (un) 453**] with the [**Location (un) **] collapsed onto the vehicle. There was a prolonged extrication. The passenger, who was his best friend, dead at the scene. 1. C5-C6 fractures: After quite a bit of discussion with his family of conservative treatment versus operative intervention, we decided to proceed with surgery. We discussed using the halo and the problems with using the halo with his head injury as well as small skull fracture. We talked about treating him just in a collar and the risk of him being noncompliant with his collar. Based on all these things, we decided to proceed with surgical stabilization. Medications on Admission: Adderall Discharge Medications: 1. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. Disp:*168 Tablet(s)* Refills:*0* 2. Clindamycin HCl 150 mg Capsule Sig: Two (2) Capsule PO Q6H (every 6 hours) for 10 days: Please finish all of this medication. Disp:*80 Capsule(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: 1. C5 fracture. 2. C6 fracture. 3. Disruption of the posterior C5-C6 ligamentous complex. 4. Skull fracture. Discharge Condition: Stable to home with parents Discharge Instructions: Please keep incisions clean and dry. You may resume any home medication. Your staples will be removed in approximately 14 days during your 2 week follow up with Dr. [**Last Name (STitle) 1352**]. You may clean yourself using a cloth. Please do not shower or take a bath at this time. If you have redness, swelling or drainage from your wound or if you have a fever greater than 100.5, please call the office at [**Telephone/Fax (1) **] Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 1352**] on Wednesday [**2181-3-28**]. We will have other follow up appointmes and will discuss them at that time. Completed by:[**2181-3-28**]

[ "801.21", "805.06", "305.00", "314.01", "805.05", "861.21", "307.9", "930.8", "E823.0" ]

icd9cm

[ [ [] ] ]

[ "81.03", "77.79", "98.21", "81.62", "03.53" ]

icd9pcs

[ [ [] ] ]

4603, 4609

3363, 4223

444, 573

4766, 4796

2397, 3340

5285, 5479

1079, 1084

4282, 4580

4630, 4745

4249, 4259

4820, 5262

1099, 1393

272, 406

601, 1004

1661, 2378

1408, 1645

1026, 1032

1048, 1063

23,651

103,416

48720+59115

Discharge summary

report+addendum

Admission Date: [**2144-2-27**] Discharge Date: [**2144-3-6**] Date of Birth: [**2076-4-27**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 618**] Chief Complaint: less interactive and independent after a fall at home Major Surgical or Invasive Procedure: none History of Present Illness: 67 year old man with history of bilateral frontal strokes and hypertension who presents with left intracranial hemorrhage. Two days ago, his son was helping him dress while standing. patient then started to fall backwards, hitting his head without loss of consciousness. The next day, patient began to have decreased verbal output but appeared understand his son. [**Name (NI) **] complained of headache and started having increasing general weakness to the point that he could not even stand with assistance (he normally walks with a walker). His swallowing requires thickened food but it now appeared to be unable to hold this food. Son took him to [**Hospital **] hospital around 11 am where NCHCT showed 1 x 1 x 1 cm left frontal hemorrahge. His sbp was running 157-186. He was then given 1 gm dilatin and caused him to be more sedated. Patient was then transferred for further management ALL: ?statin Past Medical History: 1. Hypertension. 2. Hyperlipidemia. 3. Type 2 diabetes mellitus. 4. Coronary artery disease with a myocardial infarction 20 years ago. The patient is status post coronary artery bypass graft in [**2140-2-11**], for five-vessel disease. 5. History of gastrointestinal bleed. 6. Bifrontal stroke s/p right CEA when Left ICA was totally occluded [**2141**] 7. Chronic renal insufficiency 1.8-2 Social History: The patient lives with son and was a part time at a court house as a security guard. He quit smoking in [**2124**] and use to drink heavy etoh but quit months ago. no ivdu Family History: no seizure or stroke Physical Exam: PE: 98 59 137/59 20 100% room air Gen: sleeping Neck: no carotid bruit CV: RRR Chest: CTA Abd: soft, nontender ext: no edema Neuro: sleeping but easily opens eyes to voice and stay awake for exam decreased verbal output with maximum of 2 words for spontaneous speech. intact comprehension and repetition. Pupil 3 to 2 mm bilaterally. unable to see fundi. visual fields grossly full to finger counting. no facial assymetry. tongue midline and palate elevates symmetrically. Motor: increased tone throughout. raises arms antigravity without drift. strong left grasp but weak right grasp. right leg externally rotates but both legs move symmetrically at 2/5 spontaneously and to stimuli Sensory: localizes pain in four extremities. has more brisk withdrawal on left than right arm. Reflex: brisk DTRs with [**Name2 (NI) 11849**] toes bilaterally Coordination/Gait: unable to test 2nd to cooperation Pertinent Results: Admission Labs: [**2144-2-27**] 07:22PM BLOOD WBC-7.9 RBC-3.66* Hgb-9.8* Hct-29.1* MCV-79*# MCH-26.8*# MCHC-33.8 RDW-17.6* Plt Ct-351 [**2144-2-27**] 07:22PM BLOOD Neuts-65.9 Lymphs-24.8 Monos-2.6 Eos-5.6* Baso-1.1 [**2144-2-27**] 07:22PM BLOOD PT-13.7* PTT-26.3 INR(PT)-1.2 [**2144-2-27**] 07:22PM BLOOD Glucose-142* UreaN-43* Creat-1.8* Na-142 K-4.5 Cl-107 HCO3-24 AnGap-16 [**2144-2-27**] 07:22PM BLOOD Calcium-10.2 Mg-2.0 Other lab results: [**2144-2-27**] 07:22PM BLOOD CK(CPK)-35* [**2144-2-28**] 04:00AM BLOOD ALT-12 AST-12 CK(CPK)-44 [**2144-2-29**] 03:48AM BLOOD CK(CPK)-43 [**2144-2-28**] 04:00AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2144-2-29**] 03:48AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2144-2-29**] 03:48AM BLOOD VitB12-622 Folate-GREATER THAN 20 [**2144-2-28**] 04:00AM BLOOD calTIBC-333 Ferritn-532* TRF-256 [**2144-2-29**] 03:48AM BLOOD TSH-1.4 [**2144-2-29**] 03:48AM BLOOD Phenyto-2.8* [**2144-3-3**] 04:55AM BLOOD Phenyto-11.8 [**2144-2-28**] 10:00AM URINE Color-Straw Appear-Hazy Sp [**Last Name (un) **]-1.015 [**2144-2-28**] 10:00AM URINE Blood-NEG Nitrite-POS Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM [**2144-2-28**] 10:00AM URINE RBC-0-2 WBC-21-50* Bacteri-MANY Yeast-NONE Epi-0 MIcro: BLOOD CULTURE [**2-28**] negative URINE CULTURE (Final [**2144-3-3**]): KLEBSIELLA OXYTOCA. >100,000 ORGANISMS/ML.. Trimethoprim/sulfa sensitivity confirmed by [**Doctor Last Name 3077**]-[**Doctor Last Name 3060**]. ESCHERICHIA COLI. >100,000 ORGANISMS/ML.. PRESUMPTIVE IDENTIFICATION. Trimethoprim/sulfa sensitivity confirmed by [**Doctor Last Name 3077**]-[**Doctor Last Name 3060**]. WARNING! This isolate is an extended-spectrum beta-lactamase (ESBL) producer and should be considered resistant to all penicillins, cephalosporins, and aztreonam. Consider Infectious Disease consultation for serious infections caused by ESBL-producing E. coli and Klebsiella species. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ KLEBSIELLA OXYTOCA | ESCHERICHIA COLI | | AMPICILLIN------------ =>32 R AMPICILLIN/SULBACTAM-- 8 S =>32 R CEFAZOLIN------------- 16 I =>64 R CEFEPIME-------------- <=1 S R CEFTAZIDIME----------- <=1 S R CEFTRIAXONE----------- <=1 S R CEFUROXIME------------ 4 S R CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ <=1 S =>16 R IMIPENEM-------------- <=1 S <=1 S LEVOFLOXACIN----------<=0.25 S =>8 R MEROPENEM-------------<=0.25 S <=0.25 S NITROFURANTOIN-------- <=16 S 32 S PIPERACILLIN---------- =>128 R PIPERACILLIN/TAZO----- <=4 S <=4 S TOBRAMYCIN------------ <=1 S 8 I TRIMETHOPRIM/SULFA---- <=1 S =>16 R ECG: no st-t changes NCHCT [**2-27**]: left frontal hemorrhage 1 x 1 x 1.2 cm anterior to left lateral ventricle and located parasagitally. (scan at OSH at noon shows 1x1x1 cm bleed) MR brain [**2-27**]: Area of hemorrhage in the left corona radiata unchanged in size since the prior CT obtained on the same day. There is questionable rim enhancement in postcontrast studies around the area is not certain if these are related to the patient's motion. There is evidence of multiple prior infarctions. Echo [**2-28**]: 1.The left atrium is normal in size. The left atrium is elongated. 2.There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is mild depressed. Resting regional wall motion abnormalities include basal septal hypokinesis, inferobasal akinesis, with inferior and basal septal hypokinesis. 3.Right ventricular chamber size is normal. Right ventricular systolic function is normal. 4.The aortic root is moderately dilated. The ascending aorta is moderately dilated. 5.The aortic valve leaflets (3) are mildly thickened. 6.The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. 7.The estimated pulmonary artery systolic pressure is normal. 8.There is no pericardial effusion. Brief Hospital Course: 1. Parasagittal hemorrhage. 67 year old man with history of bilateral ischemic strokes, vascular risk factors, and hypertension who presented with worsening weakness, dysphagia, and speech 2 days after a fall. The patient was admitted to the neurology service. Head CT was done and showed small left parasagittal hemorrhage. MR of the brain was done but did not visualize the area of the hemorrhage because the bleeding was located above where the cuts were taken. The differential diagnoses included hypertensive bleed, bleeding secondary to AVM, aneurysm, mass, or amyloid. The patient's blood pressure control was optimized with goal to keep SBP between 120-140. He was also started on insulin sliding scale for glycemic cont tol. The patient underwent CT Angio on [**3-4**] which was negative for aneurysm. The patient was loaded with dilantin on [**2-28**] for seizure prophylaxis. Dilantin was tapered and discontinued prior to discharge. His symptoms improved prior to the discharge. He became more alert, demonstrated improved spontaneous movement and was able to speak in full sentences although his voice remained soft. The patient was evaluated by PT and OT and felt to be a candidate for rehab. 2. UTI. The patient had urinalysis on admission that was c/w UTI. He was initially started empirically on Levofloxacin which on [**3-2**] was changed to Zosyn after his urine culture grew resistant E coli and sensitive Klebsiella. He spiked fevers up to 100.7. On [**3-3**] CXR showed new LLL infiltrated and Clindamycin was added to cover aspiration pneumonia. The patient has been afebrile since [**3-4**]. He should complete 7 days course of antibiotics. 3. Parkinsonism. Sinemet was resumed on [**3-4**]. 4. Apnoea. Initially, the patient had episodes of central and obstructive apnea with >20 sec frequent apneic pauses. Per family he has a history of not breathing followed by loud snoring at home. It was thought that he would benefit from being initiated on CPAP given obstructive component of apnea. The patient went to ICU but did well in the ICU and did not require CPAP. 5. Chronic renal insufficiency. Baseline Cr 1.4-1.8. Patient received Mucomyst and hydration with bicarb IV fluids for renal protection pre- and post- contract administration for CT Angio on [**3-4**]. His medications were renally dosed. His renal function, urine output will need to be monitored closely given risk of nephrotoxicity. On the day of discharge, his creatinine was stable at 1.4. 5. Anemia. Patient received one unit pRBC for HCT 28 given h/o CAD on [**2-28**]. His HCT has been stable close to 30. Fe studies (pre-transfusion) were checked and showed normal serum iron, high ferritin and normal TIBC. He was not restarted on Fe supplements. 6. Hypernatremia - hypovolemic hypernatremia due to NPO and being on IV NS. This was corrected slowly with free water boluses. 7. Hypertension. The patient's goal SBP 120-140 in the acute period after the hemorrhage and then can be lowered to goal SBP <130. He was restarted on an ACE inhibitor. HCTZ was added to his medications for BP control. His SBP was in 130-150 range on these medications. His medications will need to be adjusted to achieve goal BP gradually. 8. Nutrition. The patient initially failed speech and swallow eval. He received several days of NG tube feedings. He underwent video swallowing study on [**3-5**] and did well. He was resumed on a cardiac/diabetic/low sodium diet prior to discharge and tolerated it well. He requires assistance with feeding at all times and should be maintained on aspiration precautions. Medications on Admission: Meds: isordil 60 mg po qd lisinopril 2.5 mg po qd gemfibrozil 600 mg po bid insulin NPH 10 units qam regular insulin sliding scale glyburide 7.2 mg o qam and 5 mg po qhs sinemet 25/100 po tid asa 81 mg po qd atenolol 12.5 mg po qhs folate thiamine effexor 75 mg po qd feso4 prevacid 30 mg po bid colace actos 30 mg po qd Discharge Disposition: Extended Care Facility: [**Doctor Last Name **]Nursing Home Discharge Diagnosis: 1. Intracranial bleed, parasagital 2. Parkinsonism 3. Urinary tract infection 4. Hypertension 5. History of alcohol dependence 6. Diabetes 7. Hypernatremia 8. Pneumonia, aspiration Discharge Condition: Improved, slightly bradykinetic, able to move all four extremities, eat with assistance and supervision, and answer simple questions. Discharge Instructions: Please keep all follow- up appointments. Please take all medications as prescribed. Please do not take aspirin or other blood thinners/anti-platelet agents for 3 weeks after discharge. Please return to care if you develop new weakness, numbness, difficulty speaking, or other concerning sympomts. Followup Instructions: Please follow up with Dr. [**Last Name (STitle) 656**] ([**Telephone/Fax (1) 102424**]) in [**1-12**] weeks after discharge. Please follow up with your neurologist in [**1-12**] months. [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 632**] Completed by:[**2144-3-6**] Name: [**Known lastname 4727**],[**Known firstname **] Unit No: [**Numeric Identifier 16549**] Admission Date: [**2144-2-27**] Discharge Date: [**2144-3-6**] Date of Birth: [**2076-4-27**] Sex: M Service: NEUROLOGY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 608**] Addendum: Prior to discharge, it was noticed that the patient's glans penis was erythematous, edematous, and tender. Urology was consulted and felt that the swelling was consistent with dependent edema. They recommended that the patient be seen by a urologist in the next 1-2 weeks if the symptoms do not impove over the next week. He should return to care immediately if he is not able to urinate. The patient was able to void without difficulty prior to discharge. Discharge Disposition: Extended Care Facility: [**Doctor Last Name 13448**]Nursing Home [**Name6 (MD) **] [**Name8 (MD) **] MD, [**MD Number(3) 610**] Completed by:[**2144-3-6**]

[ "276.0", "250.00", "V45.81", "401.9", "599.0", "412", "507.0", "332.0", "276.5", "285.9", "431" ]

icd9cm

[ [ [] ] ]

[ "99.04" ]

icd9pcs

[ [ [] ] ]

13144, 13331

7231, 10829

368, 374

11487, 11622

2889, 2889

11968, 13121

1930, 1952

11283, 11466

10855, 11177

11646, 11945

1967, 2870

275, 330

402, 1311

2905, 7208

1333, 1725

1741, 1914

11,702

117,269

49701

Discharge summary

report

Admission Date: [**2153-8-28**] Discharge Date: [**2153-9-1**] Date of Birth: [**2079-7-7**] Sex: M Service: MEDICINE Allergies: Nsaids Attending:[**First Name3 (LF) 905**] Chief Complaint: weakness, vomiting Major Surgical or Invasive Procedure: None History of Present Illness: 73 M hx of MDS, pancreatic adenocarcinoma s/p surgery in [**2-19**] and XRT last in [**5-19**], and previous GI bleed [**2-15**] ulcers presents to the ED with weakness and vomiting. Since his discharge for ulcers, he has been feeling well. His energy level has improved. He denies any abdominal pain, nausea, vomiting, diarrhea. States that he has been eating well. Denies any recent weight loss and actually says he has gained about a few pounds since his recent admission. He does however report 2 wk hx of fatigue. Day before admission, in afternoon vomited, accompanied by transient nausea. Nonbilous, nonbloody. Awoke from sleep b/c nausea, vomited, nonbilous, nonbloody,non mucous. denied coffee grounds or frank blood. Denies any dizziness, abdominal pain, CP, SOB, fever, headache, cough, or cold symptoms. He also denies any recent changes in his bowel habits. No BRBPR, hematochezia, or malanotic stools. . Of note, patient had an admission from [**Date range (1) 103929**] of this year for GI bleeding with a very similar presentation. At that time, EGD showed bleeding gastric, pyloric and duodenal ulcers. An endo clip was put around duodenal ulcer, others were injected with epi and cauterized with good hemostasis. Admission Hct=16, transfused 6U. . In the [**Name (NI) **] pt was guiac + but had a NG lavage which was negative for any frank blood or coffee grounds. He was given 1 L NS followed by 1 unit PRBC and 40 mg IV protonix. He was also treated with 2 grams cefapime for a WBC which was felt to be elevated above his usual abnormally high baseline. Pt was transfered to MICU for decrease in Hct despite transfusion, Hct=17. EGD was done, showed changed c/w gastritis. Transfused X 6U, Hct=29.1 stable. Transferred to floor. . Yesterday, the patient has had 1 melonotic BM, Hct=27.1 at that time. 1U blood was transfused and we are currently awaiting his post-transfusion Hct. If post transfusion Hct <28, he will be sent for another EGD to assess for active bleeding. . Past Medical History: # ONC HISTORY: Pt has had MDS x 15 years/ Ring sideroblastic anemia diagnosed in the early [**2137**] by bone marrow biopsy: - managed by Dr. [**Last Name (STitle) 2539**], his PCP. [**Name10 (NameIs) 2772**], almost 1 yr PTA he visited Dr. [**Last Name (STitle) 410**] for further management. In [**Month (only) 462**] he began getting Procrit 60,000 qo-week with good response. Vit b-6. In [**Month (only) **] he developed DM and treated with oral antihyperglycemics. CT scan in early [**2152**] that demonstrated a mass in the pancreas - f/u MRI redemonstrated this. On [**2153-3-13**], he was taken to the OR for a partial pancreatectomy and splenectomy; path revealed pancreatic adenocarcinoma Grade I with 2 out of 27 lymph nodes positive and positive margins. The surgery was uncomplicated and the pt did well therafter. Given high risk dz with pos nodes and margine, He has been treated with a 6 week course of Xeloda (antimetabolite) and externak beam XRT. Last dose of xeloda was [**2153-6-8**]. Last XRT is [**5-19**]. Repeat CT neg. 4 cycles of Genmcitbine started in [**6-19**] to consolidate adjuvant tx, however, because of the underlying MDS and subsequent GI bleed he was unable to tolerate Gemcitabine adjuvant chemotherapy and it was put on hold. #. Dm dx'd [**11/2152**] #. benign prostatic hypertrophy. #. Gout: The patient had one flare in [**2147-4-15**] to the right ankle, which was his only episode and he was then on allopurinol for quite some time. #. Scarlet fever as a child. #. diverticulosis Social History: The patient was married, had three children and quit tobacco in [**2122**]. Prior to that, he had a 30 pack year history. He used alcohol rarely. He worked as a tax attorney in [**Location (un) 86**]. He lived in [**Location (un) 745**]. Family History: His sister died of congestive heart failure. Physical Exam: Vitals: Tm97.7 Tc97.7 BP152/68 HR72 RR22 02sat 95% Gen: lying flat in bed in NAD HEENT: PERRLA, EOMI, neck supple, OP clear, MMM CV: RRR, nl S1S2, [**2-19**] holosystolic murmur best heard @ upper sternal border Lung: CTAB Abd: Soft, NT, ND, +BS, no hepatomegaly Ext: no cyanosis, or edema. Neuro: normal strength and sensation throughout Pertinent Results: [**2153-8-28**] 11:46PM HCT-24.6* [**2153-8-28**] 09:50AM ALT(SGPT)-157* AST(SGOT)-128* [**2153-8-28**] 09:50AM WBC-53.4* RBC-2.39*# HGB-7.6*# HCT-21.8* MCV-91 MCH-31.9 MCHC-34.9 RDW-23.0* [**2153-8-28**] 09:50AM PLT COUNT-494* [**2153-8-28**] 09:50AM PT-13.7* PTT-26.8 INR(PT)-1.2* [**2153-8-28**] 06:00AM URINE HOURS-RANDOM [**2153-8-28**] 06:00AM URINE GR HOLD-HOLD [**2153-8-28**] 06:00AM URINE COLOR-Straw APPEAR-Clear SP [**Last Name (un) 155**]-1.013 [**2153-8-28**] 06:00AM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2153-8-28**] 06:00AM URINE RBC-0-2 WBC-0 BACTERIA-NONE YEAST-NONE EPI-0 [**2153-8-28**] 05:43AM COMMENTS-GREEN TOP [**2153-8-28**] 05:43AM LACTATE-1.9 [**2153-8-28**] 02:09AM HGB-5.9* calcHCT-18 [**2153-8-28**] 01:50AM GLUCOSE-146* UREA N-61* CREAT-1.2 SODIUM-137 POTASSIUM-5.0 CHLORIDE-102 TOTAL CO2-22 ANION GAP-18 [**2153-8-28**] 01:50AM ALT(SGPT)-183* AST(SGOT)-153* ALK PHOS-458* AMYLASE-27 TOT BILI-1.0 [**2153-8-28**] 01:50AM LIPASE-23 [**2153-8-28**] 01:50AM CALCIUM-9.8 PHOSPHATE-3.3 MAGNESIUM-2.2 [**2153-8-28**] 01:50AM WBC-68.0*# RBC-1.86*# HGB-5.9*# HCT-17.7*# MCV-95 MCH-31.7 MCHC-33.4 RDW-28.2* [**2153-8-28**] 01:50AM NEUTS-49* BANDS-15* LYMPHS-5* MONOS-5 EOS-2 BASOS-0 ATYPS-0 METAS-15* MYELOS-6* PROMYELO-2* NUC RBCS-76* OTHER-1* [**2153-8-28**] 01:50AM HYPOCHROM-3+ ANISOCYT-2+ POIKILOCY-2+ MACROCYT-2+ MICROCYT-1+ POLYCHROM-1+ OVALOCYT-1+ TARGET-OCCASIONAL SCHISTOCY-OCCASIONAL STIPPLED-OCCASIONAL HOW-JOL-OCCASIONAL ENVELOP-OCCASIONAL [**2153-8-28**] 01:50AM PT-13.8* PTT-27.5 INR(PT)-1.2* [**2153-8-28**] 01:50AM PLT COUNT-571* LPLT-1+ PLTCLM-1+ . Studies: EKG- Sinus rhythm Left axis deviation Intraventricular conduction defect Since previous tracing, no significant change . CXR- Lungs are clear. Heart size is normal. No pleural effusion or pneumoperitoneum. . EGD-[**2153-8-28**]: c/w gastritis, single chronic cratered non-bleeding 20mm ulcer in duodenal bulb. Brief Hospital Course: 73 man history of MDS, pancreatic adenocarcinoma s/p surgery and XRT, previous GI bleed [**5-19**] presents to the ED with nausea and vomiting. Found to have guiac + stool and acutely decreased HCT. . #GI Bleeding: Patient has history of GI bleeding secondary to gastric ulcers ([**5-19**]). Patient presented to ED guaic postive stool with Hct=17. Gastric Lavage was done in ED, which did not reveal frank blood or blood clots. Hct did not increase despite transfusion and patient was admitted to the MICU for GI bleed. EGD was done which revealed gastric changes consistent with gastritis and a well-healed, nonbleeding duodenal ulcer was seen. At that time patient was transfused a total of 6U pRBC with increase and stabilization of Hct to 29.1. Patient was subsequently transferred to medical floor. PPI drip was discontinued and he was placed on PPI 80mg [**Hospital1 **] IVI and sucralfate. While in hospital patient had a total of [**2-16**] episodes of melena, no vomiting, however vital signs were stable. It was questionable if melena was from active bleed or old blood. Hct continued to decrease to as low as 26 with continued requirements for blood transfusion, however patient's vital signs remained relatively stable. Hct remained between 26-28 and as per GI, patient was scheduled for outpatient repeat EGD. H. pylori was negative. . . #Leukocytosis: Patient's baseline widely variable but appears to be 20-30's. Upon admission, WBC was 68 with highest WBC being 80. Patient also had a left shift of 15% bands, but usually has some bandemia [**2-15**] his underlying MDS. Still, given the acute rise, may want to screen for possible infection. Patient was afebrile during entire hospital course and denied any symptoms of infection. In the ED he received 2 grams empiric cefapime. Heme-Onc was consulted, who came to see patient and indicated this transient increase in WBC above baseline was likely secondary to stress reaction. Peripheral blood smear was evaluated and was negative for blasts, making blastic transformation of MDS less likely. Urineanalysis was negative, chest x-ray was within normal limits. Patient has follow up appointment with Heme-Onc as outpatient. . #DM: Patient's finger sticks ranged between 150-220's while in hospital. His home oral medications were held and patient was maintained on regular insulin sliding scale. He ws discharged back on home regimine. . #Pancreatic Cancer: S/P surgery and XRT for Grade I, T3 N1b adenocarcinoma Recently on clinical trial, followed by Dr. [**Last Name (STitle) 410**], who was contact[**Name (NI) **] via email in regard to patient's admission. . #MDS: Pt has had MDS x at least 15 years Vitamin B6, folic acid was continued while inpatient and iron was stopped secondary to blood transfusions. As per heme/onc from peripheral blood smear, patient did not appear to have transformation to blastic crisis and remained stable throughout hospital course. . #Gout: Remained stable. Allopurinol was continued. . Medications on Admission: 1. Procrit 60,000U qo week 2. Glipizide 10mg [**Hospital1 **] 3. Protonix 40mg 4. Metformin 500mg [**Hospital1 **] Discharge Medications: 1. Sucralfate 1 g Tablet Sig: One (1) Tablet PO QID (4 times a day): Please make into a slurry (crush pill and mix with water). Disp:*120 Tablet(s)* Refills:*0* 2. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO twice a day: Please take two tablets two times a day. Disp:*120 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 4. Glipizide 10 mg Tablet Sig: One (1) Tablet PO twice a day. 5. Metformin 500 mg Tablet Sig: One (1) Tablet PO twice a day. 6. Nulytely 420 g Recon Soln Sig: One (1) PO once a day for 1 days. Disp:*1 * Refills:*0* Discharge Disposition: Home Discharge Diagnosis: Primary: Gastritis and nonbleeding duondenal ulcer . Secondary : 1. Pancreatic adenocarcinoma 2. Blood loss anemia 3. Myelodysplastic syndrome 4. Diabetes, type II 5. Gout Discharge Condition: Stable Discharge Instructions: Complete the colonoscopy prep and attend your scheduled GI appointments on Monday. . Please return to your PCP or emergency department if you experience increase in vomiting, increase in bloody or dark colored stools, lightheadedness, chest pain or shortness of breath. Followup Instructions: 1. You are scheduled for endoscopy with Gastroenterologist, [**Name6 (MD) **] [**Name8 (MD) **], MD (Phone:[**Telephone/Fax (1) 2799**]) on Monday [**2153-9-3**] 10:00AM. PLEASE ARRIVE AT 9:00AM. SUITE GI ROOMS . 2.Provider: [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern1) 4961**], MD Phone:[**Telephone/Fax (1) 2309**] on Monday, [**2153-9-3**] 3:30 with Dermatology . 3.Please go to appointment with Heme/Onc. Dr.[**Last Name (STitle) 13145**], [**First Name3 (LF) **] on Wednesday, [**2153-9-5**]. Please call ([**Telephone/Fax (1) 5562**] to find out what time. [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**]

[ "238.7", "600.00", "274.9", "535.51", "285.1", "288.8", "V10.09", "532.90", "250.00" ]

icd9cm

[ [ [] ] ]

[ "45.13", "99.04" ]

icd9pcs

[ [ [] ] ]

10457, 10463

6602, 9611

283, 290

10679, 10688

4556, 6579

11006, 11688

4135, 4181

9777, 10434

10484, 10658

9637, 9754

10712, 10983

4196, 4537

225, 245

318, 2314

2336, 3863

3879, 4119

2,784

167,082

26725

Discharge summary

report

Admission Date: [**2173-5-21**] Discharge Date: [**2173-6-1**] Date of Birth: [**2104-4-12**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 25342**] Chief Complaint: fever and respiratory distress Major Surgical or Invasive Procedure: bedside bronchoscopy [**2173-5-21**] Laryngoscopy Tracheal exchange Tracheal intubation Bronchoscopy Central Line insertion History of Present Illness: This is 69 yo Cambodian woman with a PMH significant for thyroid goiter s/p thyroidectomy in [**4-12**], s/p trach in [**4-12**], s/p PEG in [**4-12**], with newly diagnosed DM, treated for acinetobacter and enterobacter PNA in [**4-12**], who now presents s/p episode of respiratory distress. Per Dr. [**Last Name (STitle) 65845**], the pt was doing well since her last discharge from [**Hospital1 **] on [**5-5**] until last night when she developed respiratory stridor. He states the pts sats decreased, she was gasping for air, her RR increased to the 30s, and suctioning her trach was difficult. Per tDr. [**Month/Year (2) 65845**], the pt has been doing well at rehab, weaned off O2 except for at night. Of note, the pt has been treated for a C diff infection diagnosed [**5-13**] which, per report, has been improving. . In the ED, . Pt was suctioned with improvement in hypoxia but did spike a temp to 101.1. She was satting well s/p suctioning on 5% FM at 99%. She was pan cultured and given CTX and vancomycin. She also received Tylenol, Albuterol, and ASA given that she complained to the interpreter of some chest pain. While in the ED her HR rose up to 136, although also in the setting of having received combivent. She was started on 1 LNS . Admitted for fever/respiratory distress. Past Medical History: 1. thyroid cancer dx in [**3-/2173**]- Papillary cancer with positive nodes status post sternotomy and partial right and total left thyroidectomy on [**2173-4-12**]. She was found unresponsive at home on [**2173-4-6**]. Prior to this, the patient had neck swelling for 2 days which occurred in conjunction with administration of Actos for newly diagnosed diabetes. Laryngoscopy was performed revealing airway edema. A CT scan of the chest and neck revealed a goiter with airway compression. TSH was elevated at 7.13. Path showed the patient to have papillary carcinoma of the thyroid with extrathyroidal invasion and nodal involvement, status post rigid bronchoscopy and tumor debridement on [**2173-4-14**], status post open tracheostomy on [**2173-4-16**], status post bronchoscopy and percutaneous endoscopic gastrostomy tube placement on [**2173-5-3**]. 2. s/p trach for tracheal stenosis 3. Acinetobacter in sputum [**4-18**], MDR 4. Pansensitive enterococcus in urine [**4-12**] 5. Diastolic dysfcn, echo [**4-12**], EF >75% 6. Nosocomial PNA [**4-12**]: nosocomial pneumonia with sputum cultures positive for Acinetobacter, pan-resistant, as well as Enterobacter cloacae, pansensitive, treated with imipenem and tobra 7. atrial flutter during last hospitalization 8. newly diagnosed DM 9. HTN 10.sinusitis diagnosed during last admission 11. h/o R PTX last hospitalization requiring CT placement (d/c'd) 12. ?hypoxic brain injury with paresis and cognitive deficit 13. PICC line placement [**2173-4-26**] Social History: Social: The pt has six children living in the area, 2 children living in [**Country 5737**]. She is from [**Country **] and speaks Catnonese. She understands some English. Apparently she was independent with mobility and basic ADL prior to her last hospitalization. Her functional capacity recently has been the need for maximal assistance to total dependency in most areas Family History: NC Physical Exam: Tm 101.1 Tc 100.7 P 98-136 BP 119-154/56-62 R 22-26 Sat 94-100% on 5%trach mask Gen: Cambodian female, laying on stretcher, NAD, appearing slightly tachypneic HEENT: NCAT, PERRL, conjunctivae noninjected, MMM Neck: trach site c/d/i, no JVP CV: tachy, nl S1/S2, no m/r/g Lungs: coarse breath sounds at the bases but otherwise CTA Ab: soft, NTND, NABS, PEG site is c/d/i Extrem: wwp, no c/c/e, full dp/pt pulses Neuro: [**Name (NI) 65846**], pt awake, tracks examiner, able to move her extremities on command Pertinent Results: [**2173-5-21**] 07:18AM LACTATE-1.6 [**2173-5-21**] 07:05AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.014 [**2173-5-21**] 07:05AM URINE RBC-[**4-11**]* WBC-[**4-11**] BACTERIA-FEW YEAST-NONE EPI-[**4-11**] [**2173-5-21**] 05:25AM TSH-13* [**2173-5-21**] 05:25AM FREE T4-0.2* [**2173-5-21**] 05:25AM PT-12.0 PTT-22.1 INR(PT)-1.0 [**2173-5-21**] 04:40AM GLUCOSE-173* UREA N-18 CREAT-0.8 SODIUM-135 POTASSIUM-4.4 CHLORIDE-98 TOTAL CO2-22 ANION GAP-19 [**2173-5-21**] 04:40AM CK(CPK)-51 [**2173-5-21**] 04:40AM CK-MB-2 cTropnT-0.01 [**2173-5-21**] 04:40AM WBC-14.8*# RBC-3.62* HGB-10.3* HCT-30.5* MCV-84 MCH-28.3 MCHC-33.7 RDW-15.2 [**2173-5-21**] 04:40AM PLT COUNT-323 . CXR: IMPRESSION: 1. No focal opacities. 2. Thorocostomy tube tip lower than usual. . EKG: sinus, tachy, no ST changes . CT CHest / ABD from MICU: . CT OF THE CHEST: A left-sided central venous catheter is seen with the tip terminating in the superior vena cava. There is a moderate-sized left pneumothorax. There are foci of air within the mediastinum as well as air within the pericardium. The lungs demonstrate bibasilar consolidative opacities posteriorly. Tracheostomy is seen. The lumen of the trachea is quite narrow. The patient is status post median sternotomy. Coronary artery calcifications are identified. Multiple small calcified lymph nodes are seen within the right hilum and mediastinum. No clearly pathologically enlarged lymph nodes are seen in the axillary, mediastinal, or hilar regions. Foci of air are also seen in the subcutaneous soft tissues on the left. CT OF THE ABDOMEN: There is no evidence of intraperitoneal air. There is air seen tracking along the musculature of the anterior and lateral abdominal wall as well as air tracking in the retroperitoneum bilaterally. The liver, adrenal glands, spleen, and pancreas appear unremarkable on this non-contrast study. The gallbladder appears distended without evidence of pericholecystic fluid or gallbladder wall edema. A rounded density is seen within its lumen consistent with gallstone. The kidneys appear unremarkable on this non- contrast study and do not demonstrate any evidence of hydronephrosis. The opacified loops of small and large bowel appear normal in caliber and contour. Note is made of a PEG tube entering the stomach. No pathologic lymphadenopathy is identified in the mediastinum or retroperitoneum, although assessment is limited by lack of intravenous contrast. No ascites is seen. CT OF THE PELVIS: A Foley catheter is seen within a non-distended bladder. The uterus and rectum are unremarkable. Pelvic loops of small and large bowel appear normal in caliber and contour. No enlarged pelvic or inguinal lymphadenopathy is identified. Note is made of air within the bladder lumen. There is no free fluid within the pelvis. The osseous structures do not demonstrate any concerning lytic or sclerotic lesions. IMPRESSION: 1. Moderate-sized left-sided pneumothorax, as well as pneumomediastinum, pneumopericardium, and pneumoretroperitoneum. There is also air tracking in the subcutaneous tissues of the chest and abdomen. There is no free intraperitoneal air. 2. Bibasilar consolidative opacities are concerning for aspiration pneumonia. 3. Small lumen of the trachea. 4. Cholelithiasis without cholecystitis. . CXR . Tip of the tracheostomy tube is less than a cm from the carina, lower than standard placement. There is a new opacity at the lateral base of the left lung, which could be overlying soft tissue; I would recommend routine radiographs if feasible to exclude a focal lung infection or infarction. Lungs are otherwise clear. The heart is normal size and there is no appreciable pleural effusion or indication of pneumothorax. Dr. [**Last Name (STitle) **] was paged to report these findings at the time of dictation . ECG: . Atrial fibrillation with a rapid ventricular response. Low limb lead voltage. Non-specific ST-T wave abnormalities. Compared to the previous tracing of [**2173-5-21**] atrial fibrillation is new. . CXR . The lung volume is small. The tracheostomy tube and left subclavian IV catheter in place. No pneumothorax is identified. There is slight elevation of right hemidiaphragm with patchy atelectasis at the right lung base. The heart is normal in size. There is mild tortuosity of the thoracic aorta. No pneumothorax is identified. There is evidence of G-tube overlying the stomach. Brief Hospital Course: Briefly, this is a 69 yo Cambodian woman with a PMH significant for thyroid goiter s/p thyroidectomy in [**4-12**], s/p trach in [**4-12**], s/p PEG in [**4-12**], with newly diagnosed DM, treated for acinetobacter and enterobacter PNA in [**4-12**], who presented to our ED following an episode of respiratory distress/stridor. The pt was subsequently found in the ED to be febrile and tachycardic. . She was suctioned in the ED, and had dramatic improvement in her hypoxia and symptoms. While getting admitted, she had a temp of 101.1, and was started empirically on CTX adn vancomycin. There was no obvious source identified; the antibiotics were stopped. She was doing well, awaiting availability of bed at rehab and ongoing speech and swallow evaluations, until [**2173-5-26**]. . [**5-26**]: Pt became acutely hypoxic to O2 sat 30s and tachypneic to 40s. Code blue called. Pts existing trach did not allow ventilation. Suction cath could not be passed. No breath sounds bilaterally. Intubation attempted and failed [**3-11**] glottic stenosis. Intubation stylet passed into trach to 10 cm which allowed some ventilation. Bronch showed ~ 90% occlusion with hard stuck on debris. Multiple trials of suctioning through fiberoptic scope improved opening to 50%. Initial ABG 6.90/117/368. Lactate 8.8. R femoral line placed. Pt ventilated on AC 20X 300 P 10 FiO2 80% and repeat ABG 7.26/59/253. Noted by RT that regular suction cath could not be passed. She was trasferred to the intensive care unit. . MICU COURSE: She was transferred to MICU team, intubated and ventilated with low VT and moderate RR. She was started on vanco and zosyn for fever and leukocytosis that were stopped after two days as it was felt that the respiratory cultures were colonization. There was a bronch done on [**2173-5-26**] which showed gummy secretions lining trach; tube significantly narrowed. She was taken to the operating room later that day for another bronch, and had airway patency achieved with cryoprobe. She had her trach tube exchanged. Her post-op CT showed pneumothorax, pneumopericardium and pneumomediastinum, which was felt to have occured during her respiratory failure and forced oxygenation. Her ventilatory support was changed to pressure support 10 / PEEP 5 on [**5-27**]. She had a central line placed on [**5-27**] for IV access. She was taken back for another bronch on [**5-28**], where the tip of the trach tube was advanced to 110mm with patent airway distally (2cm above carina). She had another short episode of resp distress which was felt to be due to leak around tracheostomy. She also had one isolated episode in the intensive care unit where she developed a rapid atrial fibrillation; this was slowed with beta blockers and she converted back to NSR. The pneumothorax continued to improve during her intensive care unit stay; it have resolved by the time she was transferred back to the floor. She was started on iron supplements for her anemia. She was weaned off the vent on [**5-28**]; on 30%TM or room air, with continued suctioning (every 4 hours), inhalers. She was transferred back to the floor in stable condition. . On the medical floor she had no further episodes of respiratory distress. She was maintianed on nebulizers, and has had suctioning done every four hours. She had a repeat speech and swallow evaluation, which demonstrated that she was not safe to eat anything by mouth, with severe aspiration felt likely to be due to increased secretions. They suggested a re-trial of oral food once the secretions have lessened. She was kept NPO, with promote with fiber as tube feeds. . Other issues that were addressed during the hospitalization are outlined as follows: . #Respiratory distress: The patient's respiratory status improved after suctioning. She was also given combivent nebs in the ED. Her lung exam was fairly benign, and CXR was not notable for any infiltrates. Interventional Pulmonary was consulted and performed bronchoscopy in the ED. They noted the patient's tach was in the correct position (contrary to the read on CXR). The likely etiology of the patient's symptoms were felt to be a mucus plug. . # Fever/Elevated WBC: The pt had an elevated WBC on admission, which rose to 17 on [**5-22**]. She was also noted to have low grade fevers. The source of her fevers was unclear given that her UA/urine culture was negative for signs of infection, her CXR was fairly clear, and all blood cultures were negative for growth. The pts midline was pulled in the ED in the case it was the source of her infection. She was given a one time dose of Vancomycin and Ceftriaxone in the ED, however she was not maintained on antibiotics given she had no clear source of infection. The pt did seem to indicate that she had some mild LUQ abdominal pain, so abdominal Xray was obtained to rule out dilated bowel or bowel wall thickening (which it was negative for these things). The pt was continued on treatment for her C diff with flagyl, and she did not have any diarrhea either. She completed a two week course of flagyl. She developed several loose stools after the MICU, and c.diif toxin was sent three times and returned negative each time. . #Tachycardia: The pt was tachycardic in the ED up to the 130s (which was sinus tachycardia). This was after receiving combivent and in the setting of a fever. Her heart rate decreased after receiving 3 liters of fluids. She had a transient episode of atrial fibrillation in the intensive care unit, which was treated effectively with beta blockade. . #C. Diff infection: This was iagnosed on [**5-13**] at the pts rehab. She was continued on flagyl started on [**5-13**] for a two week course. . #Hypothyroidism s/p thyroidectomy: The pts TSH was 13 with low Free T4 at 0.2 Her liothyronine was increased from 12.5 to 25 mcg [**Hospital1 **]. . #Anemia: Her hematocrit was stable during this admission without any need for transfusions. It was felt to be an anemia of chronic disease; she was started on iron supplementation. . #HTN: The pt was continued on lopressor 37.5 mg po tid . #DM: The pt was continued on NPH 24 U [**Hospital1 **] and humalog sliding scale. She made need some titration of her NPH insulin dosing. Medications on Admission: colace Promote with fiber at 50cc/hr Flagyl 500 mg TID satrt [**5-13**] Liothyronine 12.5 mg [**Hospital1 **] Ca carbonate 500 cctid Lansoprazole 30 cc qd Metoprolol 37.5 mg po tid NPH 20 [**Hospital1 **] SSI Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) **] Discharge Diagnosis: PRIMARY respiratory distress likely due to mucus plug respiratory distress due to acute tracheal obstruction s/p trach exchange fever papillary thyroid cancer s/p resection c.dif colitis pneumothorax diabetes mellitus type 2, well controlled atrial fibrillation SECONDARY: hypertension anemia Discharge Condition: stable, ambulating, tolerating tube feeds, afebrile Discharge Instructions: 1) Please take all medications as directed. Your liothyronine dose has been increased 2) Call your doctor or return to the ER for worsening shortness of breath or stridor, fever, chest pain, or any other concerning symptoms 3) Please keep all follow up appointments as scheduled 4) You will need to have a repeat speech and swallow evaluation to determine if you can have your trach capped to speak or eat once your secretions are less. Followup Instructions: Provider: [**Last Name (NamePattern4) **]. [**Last Name (STitle) 12647**] [**Name (STitle) **] Phone:[**Telephone/Fax (1) 1803**] [**2173-7-9**] at 2:00pm. Please call [**Telephone/Fax (1) 1803**] to update your current insurance information.

[ "V10.87", "998.81", "519.02", "196.0", "008.45", "197.3", "780.6", "420.90", "478.74", "401.9", "599.7", "518.82", "V55.0", "280.9", "244.1", "427.31", "518.81", "E912", "250.00", "512.1", "934.0" ]

icd9cm

[ [ [] ] ]

[ "96.72", "31.5", "38.93", "33.21", "97.23", "96.6" ]

icd9pcs

[ [ [] ] ]

15252, 15322

8753, 14992

346, 472

15659, 15713

4300, 8730

16199, 16445

3753, 3757

15343, 15638

15018, 15229

15737, 16176

3772, 4281

276, 308

500, 1806

1828, 3343

3359, 3737

23,325

130,021

23929

Discharge summary

report

Admission Date: [**2135-10-14**] Discharge Date: [**2135-10-26**] Service: MEDICINE Allergies: Penicillins Attending:[**First Name3 (LF) 5827**] Chief Complaint: dyspnea, productive cough Major Surgical or Invasive Procedure: intubation R IJ central line placement History of Present Illness: 82 YO F with hx of PE, COPD, with hx of FTT for past few months, coming in from home with a week hx of respiratory distress, with associated productive green sputum cough and hemoptysis x1 four days ago, presented with respiratory distress complaining of SOB and wheezing. She otherwise denies f/c, cp In ED, VS 98 74 148/56 22 98RA, was satting 92RA while sleeping and 97RA when awake, otherwise a CXR was taken which suggested mild failure although clinically appears hypovolemic. She was otherwise give azithromycin, also 60mg prednisone, and nebulizers. Past Medical History: 1. COPD on 2L home O2 (no PFTs available) 2. RUL lung nodule, followed by Dr. [**Last Name (STitle) 60991**] at [**Location (un) 5700**] (pulmonary) 3. h/o CHF - ?takatsubo's cardiomyopathy, [**3-13**] TTE w/ EF=25-30%, most recent TTE with EF>55% ([**3-14**]) 4. DM- type II, on repaglinide 5. History of DVT/PE on coumadin 6. Breast ca s/p left mastectomy [**2127**] 7. PUD 8. Borderline pulmonary HTN 10. Clean cath [**3-13**] Social History: lives at [**Location (un) 45045**], previous tobacco use from her teenage years until age 60, ?ppd, no EtOH or illicits. Family History: non-contributory Physical Exam: Vitals- T 99.5, HR 144, BP 140/78, RR 30s, 93-95% BiPAP 18/5/40% General- cachectic elderly woman, tachypneic, using accessory muscles, A&Ox3 HEENT- PERRL, sclerae anicteric, CPAP mask in place Neck- accessory muscle use, no JVD Pulm- fair air movement, +crackles over R mid lung field and R base CV- tachycardic but regular, no murmur/rub/gallop Abd- + epigastric tenderness with no rebound/guarding Extrem- no LE edema, diminished peripheral pulses Skin- thin, papery, multiple scattered ecchymoses Pertinent Results: [**2135-10-13**] 06:30PM WBC-6.3 RBC-3.44* HGB-10.8* HCT-31.7* MCV-92# MCH-31.3 MCHC-33.9 RDW-13.7 [**2135-10-13**] 06:30PM NEUTS-76.6* LYMPHS-17.5* MONOS-3.5 EOS-2.1 BASOS-0.3 [**2135-10-13**] 06:30PM PLT COUNT-194 [**2135-10-13**] 06:30PM PT-47.4* PTT-30.5 INR(PT)-5.5* [**2135-10-13**] 06:30PM GLUCOSE-122* UREA N-24* CREAT-1.0 SODIUM-137 POTASSIUM-5.0 CHLORIDE-98 TOTAL CO2-33* ANION GAP-11 . ECG- sinus tachycardia at 144bpm, RBBB with LAFB, TWI in aVL but otherwise no significant change from prior study on [**10-14**] . CXR ([**10-17**])- Accounting for technical differences, I do not see any significant interval change. Slight blunting of the costophrenic sulci could be fibrosis or fluid. Continued followup is recommended. . CXR ([**10-15**])- Less prominent interstitial markings versus prior with no evidence for CHF. No new consolidations. . CXR ([**10-13**])- Comparison is made to [**2135-4-11**]. Comparison is also made to [**2135-4-9**]. Right middle lobe opacity has mostly resolved, but there is persistent opacity in the right upper lobe, perhaps due to traction bronchiectasis in part, but also likely due to an atypical appearance of mild congestive heart failure. There is a diffuse hazy opacity seen on the lateral view, probably also due to mild congestive heart failure. . Echo [**10-18**]: Cardiology Report ECHO Study Date of [**2135-10-18**] PATIENT/TEST INFORMATION: Indication: Left ventricular function. Weight (lb): 101 BP (mm Hg): 127/55 HR (bpm): 81 Status: Inpatient Date/Time: [**2135-10-18**] at 14:20 Test: Portable TTE (Complete) Doppler: Full Doppler and color Doppler Contrast: None Tape Number: 2006W048-1:06 Test Location: West CCU Technical Quality: Suboptimal REFERRING DOCTOR: DR. [**First Name (STitle) **] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] MEASUREMENTS: Left Ventricle - Ejection Fraction: >= 55% (nl >=55%) Aortic Valve - Peak Velocity: 0.9 m/sec (nl <= 2.0 m/sec) Mitral Valve - E Wave: 0.7 m/sec Mitral Valve - A Wave: 1.0 m/sec Mitral Valve - E/A Ratio: 0.70 Mitral Valve - E Wave Deceleration Time: 227 msec TR Gradient (+ RA = PASP): 20 mm Hg (nl <= 25 mm Hg) INTERPRETATION: Findings: This study was compared to the prior study of [**2135-4-5**]. LEFT VENTRICLE: Normal LV wall thickness, cavity size, and systolic function (LVEF>55%). Normal regional LV systolic function. No resting LVOT gradient. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTIC VALVE: No AR. MITRAL VALVE: Normal mitral valve leaflets with trivial MR. TRICUSPID VALVE: Normal tricuspid valve leaflets with trivial TR. Normal PA systolic pressure. PULMONIC VALVE/PULMONARY ARTERY: Normal pulmonic valve leaflets with physiologic PR. PERICARDIUM: No pericardial effusion. GENERAL COMMENTS: Suboptimal image quality - poor parasternal views. Conclusions: Limited study. Left ventricular wall thickness, cavity size, and systolic function are normal (LVEF>55%). Regional left ventricular wall motion is normal. Right ventricular chamber size and free wall motion are normal. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The estimated pulmonary artery systolic pressure is normal. There is no pericardial effusion. IMPRESSION: Normal global and regional biventricular systolic function. Compared with the prior study (images reviewed) of [**2135-4-5**], the findings appear similar. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 171**], MD on [**2135-10-18**] 16:08. [**Location (un) **] PHYSICIAN: [**Name10 (NameIs) **],[**Name11 (NameIs) **] [**Name Initial (NameIs) **]. Brief Hospital Course: A/P: 82F with COPD on home O2, h/o DVT/PE on Coumadin, DM, presenting with respiratory distress. . 1. COPD exacerbation: The patient was treated on admission for respiratory distress/COPD exacerbation. She was maintained on nasal cannula O2, nebulizers, and began a oral steroid taper. She was also started on azithromycin. On [**10-15**], one day after admission, she was found to have tachypnea (RR 44) with stable O2sats at 94% 2L NC. She had bibasilar crackles on exam and no wheezes. She was given nebs and 1mg morphine. On [**10-17**], she was again tachypneic, complaining of SOB, RR 30s-40s and was admitted to the MICU where she was initially placed on BiPAP but then required intubation. Sputum culture from [**10-17**] grew MRSA, and sparse GNR. She was started on vancomycin on [**10-17**], as well as merepenem for gram negative coverage. She was successfully extubated on [**2135-8-22**]. She was transferred to the floor [**2135-8-23**]. Since transition to the floor, she has had no pain, been conversant, breathing comfortably, had good apetite. She was maintained on O2 nasal cannula, her nebulizers and oral steroid inhaler, and a prednisone taper. Her blood cultures were negative and no other organisms other than MRSA were isolated from her sputum. She was maintained on vancomycin as well as ceftriaxone for presumed multibacterial pneumonia. In addtion, influenza DFA was negative. A PICC line was placed on [**10-25**] for ease of access and completion of a course of IV antibiotics. She was discharged with expectation of receiving 5 more days of IV vancomycin and ceftriaxone. She was also discharged on nasal cannula oxygen, inhaled steroids as she took prior to admit, steroid taper, and inhalers as she had taken previously. . History of PE/DVT: By report, she has a history of PE and DVT and is on Coumadin as an outpatient. She has been on Coumadin as early as her admission in [**3-13**]. Her INR was supratherapeutic on admission on her regimen on 3 mg qd. She was discharged on 2mg coumadin qd, to be adjusted as determined by her physician. . Diabetes: The patient's repaglinide was held when she was admitted and she was covered with sliding scale insulin but had some high blood sugars recorded. She was discharged on her normal oral dose, but on day before discharge still had some high blood sugars which were covered with sliding scale insulin. She may need to have an increase in her oral glucose control medications in the future. . Hypertension: The patient has high blood pressure and her metoprolol was increased from 50 [**Hospital1 **] to 50 TID. She should continue to have her blood pressure checked regularly and may need to increase her hypertension regimen as determined by her physician. Medications on Admission: Pantoprazole 40 mg QD Tiotropium Bromide 18 mcg Capsule QD Fluticasone-Salmeterol 250-50 mcg/Dose [**Hospital1 **] Betaxolol 0.25 % Drops, [**Hospital1 **] Metoprolol Tartrate 50 mg [**Hospital1 **] Tobramycin-Dexamethasone 0.3-0.1 % Drops QHS Latanoprost 0.005 % QHS Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Repaglinide 2 mg Tablet Sig: One (1) Tablet PO TIDAC Cefazolin 10 g Recon Soln Sig: Two (2) grams Injection Q12H (every 12 hours) for 4 weeks: Patient will have infectious disease follow up. Oxycodone 5 mg Tablet PRN Oxycodone 10 mg Tablet Sustained Release 12HR Warfarin 3 mg QHS Discharge Medications: 1. Tobramycin-Dexamethasone 0.3-0.1 % Drops, Suspension Sig: One (1) Drop Ophthalmic QHS (once a day (at bedtime)). 2. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain/fever. 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Artificial Tear with Lanolin 0.1-0.1 % Ointment Sig: One (1) Appl Ophthalmic PRN (as needed). 7. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 8. Insulin Regular Human 100 unit/mL Solution Sig: [**1-10**] u Injection ASDIR (AS DIRECTED). 9. Prednisone 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 days: Part of prednisone taper. Dose should be swiched to 10 mg on [**2135-10-28**]. 10. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 3 days: Please start three days at this dose on [**2135-10-28**]. 11. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). 12. Betaxolol 0.25 % Drops, Suspension Sig: One (1) Drop Ophthalmic DAILY (Daily). 13. Repaglinide 2 mg Tablet Sig: One (1) Tablet PO TIDAC (3 times a day (before meals)). 14. Vancomycin in Dextrose 1 g/200 mL Piggyback Sig: One (1) Intravenous Q 24H (Every 24 Hours) for 5 days: Administer through PICC line and continue for 5 days. 15. Ceftriaxone-Dextrose (Iso-osm) 1 g/50 mL Piggyback Sig: One (1) Intravenous Q24H (every 24 hours) for 5 days: Administer through PICC for 5 days. 16. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. 17. Coumadin 2 mg Tablet Sig: One (1) Tablet PO once a day: Have your INR checked every three days and adjust your coumadin as needed. . 18. Outpatient Lab Work INR check 19. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) capsule Inhalation once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 537**]- [**Location (un) 538**] Discharge Diagnosis: Primary: Pneumonia COPD . Secondary: HTN Diabetes Previous history of DVT/PE Discharge Condition: Good Ambulating Normal diet Discharge Instructions: You were admitted with a serious pneumonia that required intubation and IV antibiotics. You should continue to receive IV Vancomycin and IV Ceftriaxone intravenously for at least another 5 days. You currently have a PICC line in your right arm in order to deliver these medications. Provided you are feeling well, this PICC line should be removed after you complete the 5 day course of antibiotics. . In addition, because you have COPD, you needed steroids to help in your recovery. You are currently completing a steroid taper regimen, which should be complete in four days. You should continue your other routine COPD medications, including inhaled steroids, nebulizer treatments, and nasal cannula oxygen as you were prior to your admission. . You should be vigilant for any signs of a residual pneumonia. If you have fevers, chills, cough, difficulty breathing, loss of apetite or fatigue you should consult with your physician. . Your blood sugars were found to be elevated while you were in the hospital. This may have been in response to your added steroids or it may be because you current medication with oral antiglycemics is not sufficient. You should have your blood sugar checked regularly at your nursing home. . Your blood pressure was elevated while you were staying in the hospital. To help with this your metoprolol dose was increased from 50 mg twice a day to 50 mg three times a day. You should have your blood pressure checked regularly and you may need to add another medication, such as an ACE inhibitor, in order to control your blood pressure. . Also, you are currently taking anticoagulation medicine because of your past medical history of a DVT. When you came into the hospital your INR was supratherapeutic. You have been discharged on a lower dose of coumadin (2 mg every day). You should have your INR checked every 3 days for the next two weeks and your coumadin level adjusted as necessary by your doctor. After your INR is steady in the 2.0-3.0 range, you can have your INR checked less frequently. Followup Instructions: Follow up with your primary care physician with [**Name9 (PRE) **] [**Name9 (PRE) **] ([**Telephone/Fax (1) 8417**]. Completed by:[**2135-10-26**]

[ "788.20", "V58.61", "285.29", "250.00", "V10.3", "425.4", "518.81", "428.0", "482.41", "401.9", "416.8", "V12.51", "792.1", "491.21", "V09.0" ]

icd9cm

[ [ [] ] ]

[ "96.6", "38.91", "93.90", "38.93", "99.04", "96.72", "96.04" ]

icd9pcs

[ [ [] ] ]

11212, 11283

5763, 8507

247, 288

11404, 11434

2038, 3431

13515, 13664

1484, 1502

9168, 11189

11304, 11383

8533, 9145

11458, 13492

3457, 5628

1517, 2019

182, 209

316, 876

5660, 5740

898, 1330

1346, 1468

21,273

107,846

52100

Discharge summary

report

Admission Date: [**2114-6-21**] Discharge Date: [**2114-6-27**] Date of Birth: [**2056-10-31**] Sex: M Service: NEUROLOGY Allergies: Dilantin Attending:[**First Name3 (LF) 2090**] Chief Complaint: Status epilepticus Major Surgical or Invasive Procedure: Mechanical ventilation Arterial line History of Present Illness: 57 year-old right-handed gentleman with a history of frontotemporal dementia and epilepsy (with prior episode of status epilepticus) who presented with seizure. The pt is nonverbal at baseline, therefore the following history is er the medical record and the primary team. . Per the record, the pt was at in the dining room at his nursing facility the day of admission and was seen to abruptly begin convulse. The activity was described as "grand mal." Exactly how long he was convulsing prior to EMS arrival is unknown, however he was seizing for at least 25 minutes after they did arrive. He was given 20mg of intravenous valium without effect and multiple attempts were made at intubation but ultimately failed. He was taken to [**Hospital1 **] [**Location (un) 620**] where he was noted to have rhythmic movements of his head and neck. He was given paralytic agents (etomidate and succinylcholine) at 11:15am and was intubated. He was also given ativan, total amount unknown. His seizure activity was noted to cease after about 60 minutes total. He was then started on a proprofol gtt, however he became hypotensive to the 70's systolic. The rate was decreased, and his pressure stabilized. He was also given 1g of IV phenytoin. He was transferred to [**Hospital1 18**] for further care. En route, EMS administered an additional 2mg of intravenous lorazepam for prophylaxis. . On arrival to the [**Hospital1 18**] ED, he was intubated. No abnormal movements were noted on arrival. . The pt was unable to offer complaints nor a review of symptoms. Past Medical History: -frontotemporal dementia, followed by Dr. [**Last Name (STitle) **] [**Last Name (NamePattern4) **]. He is now nonverbal and fully dependent on his caretakers in all of his ADLs. -Seizure disorder. Pt was admitted to [**Hospital1 18**] in [**2113-7-6**], presenting after episode of generalized status epilepticus lasting 70 minutes. Seizure was thought to occur in setting of pneumonia and fever, and standing Tylenol was given to prevent recurrent fever. Initially his Keppra dose was increased, and he was monitored on continuous EEG, which demonstrated no additional seizure activity. He had a head CT that showed no acute changes, persistent ventriculomegaly and cortical atrophy. Trileptal was also added to his antiepileptic regimen after another seizure on day 3 of hospitalization. Of note, hospital course was also notable for treatment of RUL pneumonia, C. difficile enterocolitis, NSTEMI, and rhabdomyolysis. -coronary artery disease, with history of myocardial infarction, angioplasty and stent placement -anxiety -depression -hyperlipidemia -status-post prostate resection -obstructive sleep apnea, on CPAP -admitted to [**Hospital **] Hospital in [**2-10**] with pyelonephritis -clostridium difficile enterocolitis Social History: The pt is currently living in a nursing home. He has a distant history of cigarette use. No history of alcohol or illicit drug abuse. He previously worked in real estate. He is fully dependent on his caretakers for all of his ADLs. Family History: Remarkable for mother with frontotemporal dementia. No history of seizure in other family members. Physical Exam: Vitals: T: 99.8F P: 81 R: 14 BP: 108/74 SaO2: 100% ventilated General: Lying in bed with eyes closed, intubated. HEENT: NC/AT, no scleral icterus noted, MMM, laceration and dried blood on lips Neck: No carotid bruits appreciated. Pulmonary: Lungs with transmitted sounds bilaterally Cardiac: RRR, S4 gallop noted, no murmur noted Abdomen: soft, NT/ND, normoactive bowel sounds Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses bilaterally. Skin: no rashes or lesions noted. . Neurologic: -mental status: Lying in bed with eyes closed. Spontaneously opens eyes, but not to command. He follows no commands. . -cranial nerves: PERRL 3.5 to 2mm and brisk. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. EOM full to oculocephalic maneuver. There is horizontal nystagmus with possible torsional component bilaterally. Facial musculature appears symmetric. Corneal reflex intact bilaterally. Gag reflex intact. . -motor: Normal bulk throughout. Tone slightly increased on the left. No adventitious movements noted. The pt withdrew right upper and lower extremity more briskly than left upper and lower extremity to noxious stimuli. . -sensory: Pt grimaced to noxious stimuli bilaterally. . -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 2 2 2 3 4 R 2 2 2 3 2 . Plantar response was extensor bilaterally. Pertinent Results: Laboratory Data ([**Hospital1 **] [**Location (un) 620**]): WBC 10.6 Plt 194 Hct 48.7 INR 1.1 PTT 25.9 148| [**Age over 90 **]|17 /175 4.7|14.5|1.5\ Ca 8.3 Mg 2.1 ALT 68 AST 24 AP 99 Tbili 0.34 Tprot 7.2 Alb 3.9 Dilantin <0.5 Urine and serum tox negative. . Other pertinent values: [**2114-6-21**] 02:40PM BLOOD CK(CPK)-884* [**2114-6-21**] 07:51PM BLOOD CK(CPK)-2599* [**2114-6-22**] 02:17AM BLOOD CK(CPK)-3921* [**2114-6-22**] 01:22PM BLOOD CK(CPK)-4107* CXR [**6-21**]: Endotracheal tube terminates 5 cm above the carina, and nasogastric tube terminates below the diaphragm. Cardiac and mediastinal contours are within normal limits. Patchy and linear opacities have developed at both bases, most likely due to atelectasis, although coexisting aspiration is also possible in this patient with history of seizure. CXR [**6-22**]: The [**6-21**] film may show a large cavity in the left perihilar lung. On today's examination, lung volumes are lower and mild interstitial pulmonary edema has developed creating a region of heterogeneous consolidation in the same area. Findings are suggestive of pneumonia, perhaps due to aspiration. CT scanning is recommended for clarification once the cardiovascular situation improves. Heart size top normal, increased since [**6-21**]. Tip of the ET tube is at the upper margin of the clavicles, at least 5 cm from the carina and the nasogastric tube passes below the diaphragm and out of view. . Chest CT: FINDINGS: Lung volumes are low. Heterogeneous opacification in the dependent portions of the lung could be either atelectasis or, less like, mild aspiration, but there is no consolidation to suggest pneumonia or any bronchiectasis to suggest chronic aspiration. Lungs are otherwise clear. . A 15 x 29 mm central cyst expands the right lobe of the thyroid gland at the expense of the subglottic trachea for a length of 2 cm, deforming the trachea and narrowing the coronal diameter from 20 to 14 mm while elongating the sagittal diameter. . There is no pathologic enlargement of central lymph nodes by size criteria. LAD coronary stent is noted. Small pericardial effusion is physiologic, and there is only a miniscule amount of left pleural effusion, clinically insignificant. Feeding tube passes into the second portion of the duodenum and beyond the field of view. . IMPRESSION: 1. No evidence of pneumonia. Dependent atelectasis, less likely mild aspiration. 2. Stented, atherosclerotic LAD coronary artery. 3. Moderate right goiter deforms and mildly narrows the trachea. . Head CT: FINDINGS: The study is compared with most recent examination dated [**2113-7-18**]; the overall appearance is unchanged. Again demonstrated is moderately severe and relatively uniform ventriculomegaly, which appears disproportionate to the moderate degree of cerebral atrophy. This is unchanged and likely represents either underlying communicating hydrocephalus or relatively selective central atrophy. A cavum septum pellucidum et vergae is redemonstrated. There is confluent low-attenuation in bihemispheric periventricular white matter, likely representing chronic microvascular infarction. There is no intra- or extra-axial hemorrhage, the midline structures are in the midline, and there is no evidence of acute cerebral edema. No space-occupying lesion is seen. Incidentally noted are relatively minor inflammatory changes involving the right maxillary and bilateral sphenoid sinuses and bilateral ethmoidal air cells. . IMPRESSION: 1. No acute intracranial abnormality. 2. Disproportionate ventriculomegaly suggestive of either underlying communicating hydrocephalus or selective central atrophy. 3. Moderate chronic microvascular infarction in periventricular white matter. . EEG: ABNORMALITY #1: As the recording began, the background was very slow and of very low voltage. About 10 minutes after the beginning of the record, there was a more widespread faster background rhythm, still of relatively lower voltage. This appeared symmetric and without focal findings. Clinically noted movements of the limbs did not have an EEG correlate. Later in the recording, along with the widespread low voltage fast activity, there were some bursts of generalized slowing. HYPERVENTILATION: Could not be performed. INTERMITTENT PHOTIC STIMULATION: Could not be performed. SLEEP: No normal waking or sleeping morphologies were seen. CARDIAC MONITOR: Showed a generally regular rhythm. IMPRESSION: Markedly abnormal portable EEG due to the very low voltage and generally slow background throughout. This finding suggests a widespread encephalopathy. Medications, metabolic disturbances, and infection are among the most common causes. The widespread faster rhythms raise concern for medication effect. No prominent focal abnormalities were evident, but encephalopathies may obscure focal findings. There were no epileptiform features. . Admission Labs: [**2114-6-21**] 08:04PM TYPE-ART PO2-262* PCO2-33* PH-7.45 TOTAL CO2-24 [**2114-6-21**] 07:51PM GLUCOSE-108* UREA N-12 CREAT-0.8 SODIUM-146* POTASSIUM-3.2* CHLORIDE-113* TOTAL CO2-24 ANION GAP-12 [**2114-6-21**] 07:51PM CK(CPK)-2599* [**2114-6-21**] 07:51PM CALCIUM-8.3* PHOSPHATE-1.4*# MAGNESIUM-2.2 [**2114-6-21**] 07:51PM WBC-11.0# RBC-4.46* HGB-14.4 HCT-40.2 MCV-90 MCH-32.4* MCHC-35.9* RDW-13.5 PLT COUNT-124* [**2114-6-21**] 07:51PM PT-13.6* PTT-28.6 INR(PT)-1.2* [**2114-6-21**] 05:53PM URINE COLOR-LtAmb APPEAR-SlCloudy SP [**Last Name (un) 155**]-1.018 [**2114-6-21**] 05:53PM URINE BLOOD-LGE NITRITE-NEG PROTEIN-30 GLUCOSE-NEG KETONE-15 BILIRUBIN-NEG UROBILNGN-NEG PH-5.0 LEUK-NEG [**2114-6-21**] 02:40PM CK(CPK)-884* Brief Hospital Course: Mr. [**Known lastname 107818**] is a 57yo man with frontotemporal dementia and seizure disorder admitted from an OSH after status epilepticus. He was admitted to the neurology ICU. Hospital course is detailed below by problem. . 1. seizures: On arrival, Mr. [**Known lastname 107818**] did not appear clinically to be seizing, and he had no further seizures in house. EEG was performed the night of admission and showed no evidence of seizure activity (see report above). He had a head CT, which was negative. Urinalysis was borderline positive and was thought to have been a possible trigger for his seizures. He also had evidence of an aspiration PNA on initial CXR which was treated which was another possible trigger of seizures. He was given an extra 500mg dilantin and started on dilantin 100mg tid as well as continued on his home dose of keppra. He was given additional dilantin for goal level 15 given subtherapeutic levels on 100 TID and his dose was increased to 100/100/130. He should have a Dilantin trough drawn on Friday [**6-29**] then once a week, and the dose should be adjusted as needed for goal level 15-20. LP was attempted to definitely r/o meningitis, but was unsuccessful. Given low suspicion for meningitis (afebrile, no meningismus, UTI or PNA more likely triggers for seizures) LP under flouro was not pursued. 2. elevated CK: He was noted to have elevated CK on arrival, which initially continued to rise. He was started on IVF with goal UOP 100-200cc/hr to prevent rhabdomyolysis. It trended down over the next few days with the IV fluids. 3. pneumonia: The patient was extubated the day after admission, but was noted on a follow up CXR to have a blossoming pneumonia, thought to be secondary to aspiration. He was started on flagyl in addition to the ceftriaxone for UTI (see below). Chest CT was later performed (see report above) and showed atelectasis but no evidence of pneumonia. Given that Chest CT was negative for pneumonia, Ceftriaxone and Flagyl were stopped on [**6-27**], and it was felt that CXR finding were more c/w a chemical pneumonitis from aspiration. . 4. UTI: He was noted to have a borderline urinalysis and was started on ceftriaxone for treatment. Urine culture ultimately came back negative, so Ceftriaxone was stopped after a 5 day course. Medications on Admission: -prevacid 30mg po daily -lisinopril 5mg po daily -keppra 1000mg po bid (no recent missed doses per NH [**Month (only) 16**]) -metoprolol 37.5mg po tid -acetaminophen prn -MVI 1 tab daily -folate 1mg po daily -zetia 10mg po daily -lipitor 10mg po daily -zoloft 25mg po daily -MOM prn Discharge Medications: 1. Phenytoin 50 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO Q 8H (Every 8 Hours). 2. Phenytoin Sodium Extended 30 mg Capsule Sig: One (1) Capsule PO DAILY (Daily): with PM dose to make total PM dose 130 mg. 3. Levetiracetam 100 mg/mL Solution Sig: 1000 (1000) mg PO BID (2 times a day). 4. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Sertraline 50 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 6. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 9. Multi-Vitamin Tablet Sig: One (1) Tablet PO once a day. 10. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Extended Care Facility: [**Location (un) 1036**] - [**Location (un) 620**] Discharge Diagnosis: Status Epilepticus Discharge Condition: Improved Discharge Instructions: Please call your doctor if you fevelop any fevers, chills, cough, chest pain, shortness of breath, seizures, or any other symptoms that concern you. Followup Instructions: Neurology: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 11771**], M.D. Phone:[**Telephone/Fax (1) 26488**] Date/Time:[**2114-9-4**] 11:30 [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 43**] MD [**MD Number(1) 2107**] Completed by:[**2114-6-27**]

[ "272.4", "241.9", "414.01", "331.19", "518.0", "327.23", "345.3", "507.0", "599.0" ]

icd9cm

[ [ [] ] ]

[ "38.93", "96.71" ]

icd9pcs

[ [ [] ] ]

14058, 14135

10607, 12915

290, 328

14198, 14209

4935, 7469

14406, 14728

3431, 3531

13248, 14035

14156, 14177

12941, 13225

14233, 14383

4183, 4916

3546, 4048

232, 252

356, 1909

7478, 9823

9839, 10584

4063, 4166

1931, 3165

3181, 3415

76,780

180,212

41390

Discharge summary

report

Admission Date: [**2122-5-16**] Discharge Date: [**2122-5-20**] Date of Birth: [**2047-9-21**] Sex: M Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 1384**] Chief Complaint: fever 103, hypotension, back and abdominal pain Major Surgical or Invasive Procedure: [**2122-5-16**]: Abdominal CT [**2122-5-17**]: Cervical Spine MRI [**2122-5-20**]: PICC Line placment History of Present Illness: 74 yoM s/p OLT for cryptogenic cirrhosis on [**2122-4-29**] who was discharged yesterday to [**Hospital3 **], now presents from rehab after running a fever to 103 F. He was transiently hypotensive to 90's systolic which responded to IVF bolus. He now presents in ED stating he is in pain and localizes to his back and his abdomen. It is diffuclt to assess, however, because he states the pain has been there since before his transplant. He then counters that this pain is much worse. He complains of abdominal pain only with palpation and he complains of difficulty breathing when palpating his abdomen. According to his family, his mental status has not declined. ROS: Overall this is a difficult history to extract. He does not endorse nausea or vomiting. He denies diarrhea and denies any dysuria. He has no headache or vision changes. No gait abnormalities but he says he is too weak to walk. Past Medical History: Hiatal Hernia, GERD, Esophageal dysmotility, Prostate Cancer Depression, ? Elevated Glucose, Insomnia, ESLD (cryptogenic) . Past Surgical History: Radical Prostatectomy, Penile Prosthesis, Liver transplant [**2122-4-29**] with takeback for closure [**2122-4-28**] Social History: He lives with his wife in [**Name (NI) 90084**] and moved from [**Name (NI) 6257**] >25 years ago. No tobacco use or current alcohol. No current drug use. Family History: No family history of liver disease, diabetes, or premature CAD. Physical Exam: Tmax: 103 Tcur: 100.1 HR 114 BP 124/58 16 100% 2L AAOx3, NAD, confused at times Tachycardic, No MRG Clear at apices, poor inspiratory effort, rales at bases soft, tender diffusely to palpation, scar healing well, ND rectal weakly hemoccult positive B/L edema 2+, palpable pulses B/L Pertinent Results: On Admission: [**2122-5-16**] WBC-13.9* RBC-3.49* Hgb-10.7* Hct-31.3* MCV-90 MCH-30.7 MCHC-34.3 RDW-16.2* Plt Ct-352 PT-15.0* PTT-23.4 INR(PT)-1.3* Glucose-53* UreaN-59* Creat-2.0* Na-136 K-4.4 Cl-99 HCO3-25 AnGap-16 ALT-50* AST-35 AlkPhos-206* TotBili-0.8 Lipase-21 Albumin-3.3* Calcium-8.7 Phos-3.8 Mg-1.3* Iron-25* calTIBC-183* TRF-141* Lactate-1.9 At Discharge: [**2122-5-20**] WBC-8.9 RBC-2.95* Hgb-9.5* Hct-27.1* MCV-92 MCH-32.0 MCHC-34.9 RDW-16.3* Plt Ct-391 Glucose-228* UreaN-48* Creat-1.6* Na-132* K-4.7 Cl-101 HCO3-21* AnGap-15 ALT-24 AST-14 AlkPhos-133* TotBili-0.7 Calcium-8.7 Phos-2.2* Mg-1.7 [**2122-5-19**] Vanco-17.9 [**2122-5-20**] tacroFK-13.4 Brief Hospital Course: 74 y/o male readmitted from Rehab with fever. Patient was sent on arrival to ED for a CT scan which showed Left upper lobe ground-glass opacities likely representing early pneumonia and post-surgical changes with edema in the porta hepatis and a large simple subphrenic fluid collection measuring about 10 x 5 cm. Blood and urine cultures were sent. From the previous hospitalization he had grown E faecalis and so was started on Vancomycin and Cefepime. An ID consult was obtained, and they recommended 8 days of Cefepime, 14 days of Vancomycin. PICC line was placed. Additionally an MRI of the neck was done showing no evidence of a prevertebral or paravertebral soft tissue collection. No evidence of an infective process in this unenhanced study. There were degenerative changes with mild to moderate canal narrowing. The patient continued tube feeds via dobhoff and was tolerating. PT evaluated patient and recommended he discharge back to rehab. He is ambulating with minimal assist, but needs assistance with tube feeds and antibiotics. Medications on Admission: Mycophenolate Mofetil 1000 mg PO BID CefePIME 2 g IV Q24H OxycoDONE (Immediate Release) 5-10 mg PO/NG Q4H:PRN pain Pantoprazole 40 mg IV Q24H Fluconazole 200 mg PO/NG Q24H PredniSONE 20 mg PO/NG DAILY Sulfameth/Trimethoprim SS 1 TAB PO/NG DAILY Heparin 5000 UNIT SC TID Tacrolimus 2 mg PO Q12H Insulin SC (per Insulin Flowsheet) Vancomycin 1000 mg IV Q 24H Levofloxacin 750 mg PO/NG Q48H ValGANCIclovir 450 mg PO EVERY OTHER DAY MetRONIDAZOLE (FLagyl) 500 mg IV Q8H Discharge Medications: 1. sulfamethoxazole-trimethoprim 400-80 mg Tablet [**Year/Month/Day **]: One (1) Tablet PO DAILY (Daily). 2. mycophenolate mofetil 500 mg Tablet [**Year/Month/Day **]: Two (2) Tablet PO BID (2 times a day). 3. fluconazole 200 mg Tablet [**Year/Month/Day **]: One (1) Tablet PO Q24H (every 24 hours). 4. valganciclovir 450 mg Tablet [**Year/Month/Day **]: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 5. oxycodone 5 mg Tablet [**Year/Month/Day **]: One (1) Tablet PO Q4H (every 4 hours) as needed for pain. 6. pantoprazole 40 mg Tablet, Delayed Release (E.C.) [**Year/Month/Day **]: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. prednisone 5 mg Tablet [**Year/Month/Day **]: 3 1/2 Tablets PO once a day: Follow transplant clinic taper. 8. insulin glargine 100 unit/mL Solution [**Year/Month/Day **]: Twenty Five (25) units Subcutaneous once a day: AM dose. 9. insulin glargine 100 unit/mL Solution [**Year/Month/Day **]: Fifteen (15) units Subcutaneous at bedtime: PM dose. 10. Humalog 100 unit/mL Solution [**Year/Month/Day **]: per sliding scale Subcutaneous four times a day: See scale. 11. cefepime 2 gram Recon Soln [**Year/Month/Day **]: Two (2) grams Injection Q12H (every 12 hours) for 5 days: Through [**5-24**]. 12. vancomycin 500 mg Recon Soln [**Month (only) **]: Five Hundred (500) mg Intravenous Q 12H (Every 12 Hours) for 6 days: Through [**2122-5-26**]. 13. heparin, porcine (PF) 10 unit/mL Syringe [**Year (4 digits) **]: Two (2) ML Intravenous PRN (as needed) as needed for line flush: Per facility protocol. Discharge Disposition: Extended Care Facility: [**Hospital1 **] [**Hospital1 8**] Discharge Diagnosis: Fever/Bacteremia Hyperglycemia Back/Neck Pain POD 21 from liver transplant Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Please call the transplant clinic at [**Telephone/Fax (1) 673**] for fevers > 101, chills, increased abdominal pain, nausea, vomiting, diarrhea, inability to tolerate medications, increased yellowing of skin or eyes, feeding tube dislodging, intolerance of tube feeds or any other concerning symptoms. No heavy lifting Please have labs drawn every Monday and Thursday, CBC, Chem 10, AST, ALT, ALk Phos, T bili, Albumin and trough Prograf levels with results to the transplant clinic. (Fax [**Telephone/Fax (1) 697**]) Please do not change medication dosing without prior discussion/approval of the transplant clinic. Continue IV antibiotics via PICC line, Cefepimeend date [**5-24**] and Vancomycin end date [**5-26**]. PICC line was placed [**5-20**] and is okay to use. Continue tube feeds via Dobhoff. Patient may have regular diet and calorie counts would be helpful to assess continued need for Followup Instructions: [**Hospital **] Medical Building [**Last Name (NamePattern1) **], [**Location (un) **], [**Location (un) 86**] MA Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2122-5-28**] 3:20 Provider: [**First Name11 (Name Pattern1) 674**] [**Last Name (NamePattern4) 675**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2122-6-4**] 1:20 Completed by:[**2122-5-20**]

[ "V42.7", "997.39", "486", "530.81", "V10.46", "553.3" ]

icd9cm

[ [ [] ] ]

[ "96.6", "38.93" ]

icd9pcs

[ [ [] ] ]

6093, 6154

2946, 3993

320, 424

6273, 6273

2257, 2257

7350, 7800

1838, 1903

4512, 6070

6175, 6252

4019, 4489

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1531, 1649

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2624, 2923

232, 282

452, 1362

2271, 2610

6288, 6400

1384, 1508

1665, 1822

59,387

179,164

41762

Discharge summary

report

Admission Date: [**2124-10-9**] Discharge Date: [**2124-10-20**] Date of Birth: [**2043-8-8**] Sex: F Service: SURGERY Allergies: Bactrim / Cipro / Lactose Attending:[**First Name3 (LF) 668**] Chief Complaint: Right upper quadrant and epigastric pain without fever or nausea/vomiting Major Surgical or Invasive Procedure: [**2124-10-10**]: ERCP with common bile duct stent placement [**2124-10-13**]: ERCP with removal of common bile duct stent, removal of gallstones, and sphincterotomy History of Present Illness: The patient is an 81 year old female who was transferred from an outside hospital after presenting with complaint of persistent, dull, severe abdominal pain x10 hours. The pain was primarily loacalized to the right upper quadrant and epigastric region, and radiating to the back. The patient denied any nausea or vomiting, and denied fevers or chills. She was noted to have an elevated bilirubin at the OSH and with RUQ ultrasound demonstrating stones in the gallbaldder, a dilated common bile duct, and pericholecystic fluid. She was transfered to [**Hospital1 18**] for likely cholecystitis/choledocolithiasis and for further care. Past Medical History: Past medical history: End-stage renal disease on hemodialysis (T/Th/Sa) secondary to Good Pasture's Syndrome Hypothyroidism Coronary artery disease s/p stent placement x1 CHF Atrial fibrillation on Coumadin and with pacemaker in place HTN Hyperlipidemia Past surgical history: s/p bilateral knee surgeries Pacemaker placement Left thigh AV graft Social History: The patient lives with her husband. She denies any alcohol, cigarette, or recreational drug use Family History: Denies family history of cancer or hepatobiliary disease Physical Exam: GENERAL: No acute distress; alert and oriented; responsive and cooperative HEENT: Mucous membranes moist and pink; sclera anicteric; MMM, no ocular or nasal discharge NECK: No thyroid enlargement or masses; JVP not elevated; no carotid bruit CARDIAC: Regular rate and rhythm; normal S1 + S2; no murmurs, rubs, or gallops LUNGS: Clear to auscultation bilaterally; no wheezes, rales, or ronchi ABDOMEN: Soft, non-distended, non-tender; +bowel sounds; no rebound or guarding; liver and spleen not palpable EXTREMITIES: Warm and well perfused; 2+ dorsalis pedis pulses bilaterally; no swelling/edema bilaterally; left thigh AV graft with thrill and bruit Pertinent Results: ADMISSION LABS: [**2124-10-9**] 03:20AM PT-81.9* PTT-44.5* INR(PT)-9.5* [**2124-10-9**] 03:20AM WBC-16.3* RBC-4.14* HGB-12.4 HCT-37.5 MCV-91 MCH-29.9 MCHC-33.0 RDW-14.2 [**2124-10-9**] 03:20AM NEUTS-91.6* LYMPHS-5.7* MONOS-2.0 EOS-0.4 BASOS-0.2 [**2124-10-9**] 03:20AM PLT COUNT-155 [**2124-10-9**] 03:20AM DIGOXIN-3.1* [**2124-10-9**] 03:20AM ALT(SGPT)-36 AST(SGOT)-39 ALK PHOS-248* TOT BILI-5.0* DIR BILI-3.7* INDIR BIL-1.3 [**2124-10-9**] 03:20AM GLUCOSE-112* UREA N-23* CREAT-6.0* SODIUM-136 POTASSIUM-4.5 CHLORIDE-94* TOTAL CO2-30 ANION GAP-17 IMAGING/STUDIES: GALLBLADDER/LIVER ULTRASOUND [**2124-10-9**]: Impression: 1. Dilated CBD to 1 cm with multiple stones within it, consistent with choledocolithiasis. Mild intrahepatic biliary prominence. 2. Distended gallbladder with wall thickening, pericholecystic fluid and non-shadowing stones/sludge, concerning of cholecystitis. ERCP [**2124-10-10**]: Impression: The exam of major papilla was normal. A 5Fx5cm pancreatic stent was placed to facilitate the cannulation of CBD. Cannulation of the biliary duct was successful and deep. Given cholangitis, small amount of contrast was injected with opacification of CBD only. There were some filling defects at the distal CBD suggesting stones and sludge. CBD measured 7-8 mm. The proximal PD was normal. Given the elevated INR, sphincterotomy was deferred. A 7cm by 10FR Cotton [**Doctor Last Name **] pancreatic stent was placed successfully in the CBD. Some pus and sludge came out. The PD stent was removed with a snare. Otherwise normal ERCP to third part of the duodenum. ERCP [**2124-10-13**]: Impression: A plastic stent was noted in the biliary tree - This stent appeared to be blocked with stones/sludge. A guidewire was placed into the biliary duct through the stent. A snare was then passed to remove the stent while maintaining access. Sphincterotome was then advanced over the guidewire into the biliary tree and contrast medium was injected resulting in complete opacification. Several small stones and one 1 cm stone were seen at the common bile duct. The CBD measured 11 mm. A sphincterotomy was performed in the 12 o'clock position using a sphincterotome over an existing guidewire. Two stones and debris were extracted successfully using a balloon. Final cholangiogram did not reveal any filling defects. Brief Hospital Course: The patient was admitted to the West-1 surgery service with suspected cholelithiasis and cholecystitis. Given her extensive medical history/co-morbidities which included end stage renal disease in conjunction with congestive heart failure, she was admitted to the SICU for close monitoring of her fluid status and further management of her biliary disease. She was begun on IV Vancomycin and Zosyn prophylactically - dosed for dialysis - and kept NPO. She was immediately transfused 2 units of FFP and given 5 of Vitamin K+ in an attempt to normalize her elevated INR (9.5 on admission). Her Coumadin was held, and she underwent a R. upper quadrant ultrasound which demonstrated findings consistent with both choledocolithiasis and cholecystitis. The patient was stabilized on antibiotics overnight, and was scheduled for ERCP the following morning. However at that time her INR remained elevated at 5.6 and she required another 4 units of FFP while on dialysis, in addition to 10 of Vitamin K+ in order to normalize her to an INR of 1.6. During the ERCP a pancreatic stent was required to facilitate access to the biliary system (removed at the end of the procedure), and a common bile duct stent was placed to allow drainage of the biliary obstruction caused by stones and sludge. However, due to the patient's elevated INR, no sphincterotomy or stone removal was performed. Frank pus was noted to be draining from the common bile duct, and post-ERCP it was recommended that the patient remain on IV Zosyn for at least a week. The Vancomycin was discontinued. Initially the patient did well post-procedure and the following morning was transferred out of the SICU to the floors - during which time she was tolerating PO and with improved abdominal pain. However, later in the afternoon her bilirubin levels were noted to be elevated (to 9.9 from 6.5 and the following morning this was further increased to 12.0 - leading to concern for obstruction of the biliary stent. As the patient was noted to be clinically stable, afebrile with a normal WBC count, pain-free, and in all other respects with a non-septic clinical picture, it was recommended by gastroenterology that the patient's LFTs/serum bilirubin be trended and the patient be observed for another day on antibiotics. On hospital day 4 (post-procedure day 3) the patient returned to ERCP for re-evaluation of her biliary stent as her LFTs and bilirubin continued an upward trend. On ERCP the previous biliary stent was noted to be acutely obstructed by biliary sludge and stones. As the patient's INR was normalized to 1.2, a sphincterotomy was safely performed, with removal of several biliary stones in addition to the common bile duct stent. At the conclusion of the procedure, retrograde cholangiogram was negative for filling defects. The patient again tolerated the procedure well, and without complications. However, post-procedure her serum bilirubin levels remained elevated for several days, with a slow down-trend despite negative hemolysis work-up, and no complaint of further abdomina pain, nausea, or vomiting. A R. upper quadrant ultrasound was obtained on hospital day 7 (post-procedure day 2 following second ERCP) to rule out liver abscess as a possible cause of persistently elevated bilirubin. This was negative for abscess and the gallbladder was noted to be non-distended although the gallbladder wall remained thickened. Hepatitis serologies were negative for infection. The ERCP team was again consulted, and did not believe a repeat procedure to be warranted as they believed the elevated bilirubin levels to be secondary to accumulation from prior biliary obstruction and slow clearance due to the patient's severe renal dysfunction. Additionally, beginning on hospital day 6 the patient had multiple bouts of diarrhea and stool samples returned positive for C. diff colitis. As WBC count was not elevated, the patient was initially treated with oral Flagyl alone. However following two days of increasing numbers of bowel movements despite antibiotics, treatment was upgraded to oral Vancomycin and IV Flagyl. The patient was stabilized on this regimen with a gradual down-trend in her serum bilirubin levels and a decrease in her diarrhea. By hospital day 12 it was deemed appropriate to discharge the patient home. At the time of discharge she was tolerating PO, had been afebrile since initial admission, was ambulating independently with a cane, had no pain issues, and was otherwise stable. The patient was discharged on PO Augmentin 500mg q24hrs (replaced IV Zosyn) to complete a total of 14 days antibiotics. As her diarrhea had demonstrated significant improvement and her WBC count remained within normal limits, IV Flagyl and PO Vancomycin were discontinued and she was discharged with PO Flagyl 500mg q8hrs. She will follow-up with her PCP for titration of her Coumadin which had been held for the entirety of her hospital stay. INR prior to discharge was 1.5 The patient will follow-up with Dr. [**Known lastname **] in clinic during the week following discharge and re-evaluation of liver enzymes and bilirubin levels. Medications on Admission: Coreg 3.12mg [**Hospital1 **] Synthroid 0.112mg daily Coumadin 2.5mg daily Lipitor 40mg daily Digoxin 0.125mg every other day Nephrocaps 40mg daily PhsLo Prilosec 20mg [**Hospital1 **] Cardizem 360mg daily Amiodarone 200mg daily Discharge Medications: 1. levothyroxine 112 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. amiodarone 200 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. atorvastatin 40 mg 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 BID (2 times a day). 5. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 7. digoxin 125 mcg Tablet Sig: One (1) Tablet PO EVERY OTHER DAY (Every Other Day). 8. amoxicillin-pot clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours). Disp:*4 Tablet(s)* Refills:*0* 9. Flagyl 500 mg Tablet Sig: One (1) Tablet PO three times a day for 11 days. Disp:*33 Tablet(s)* Refills:*0* 10. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO once a day: INR monitored by your nephrologist. 11. PhosLo 667 mg Capsule Sig: One (1) Capsule PO three times a day: with meals. 12. Cardizem CD 360 mg Capsule, Ext Release 24 hr Sig: One (1) Capsule, Ext Release 24 hr PO once a day. Discharge Disposition: Home Discharge Diagnosis: Cholangitis, Common Bile duct stones 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: Please Call Dr [**Known lastname 9411**] office at [**Telephone/Fax (1) 673**] for fever, chills, nausea, vomiting, worsening diarrhea, increased abdominal pain, inability to tolerate food, fluids or medications, increased yellowing of your skin or eyes, worsening itch or other concerning symptoms. Continue the antibiotics as ordered Return to Dr [**Known lastname 9411**] office on Monday [**10-23**] for labwork and to see Dr [**Known lastname **] Continue your outpatient dialysis regimen of Tues-Thurs-Sat, they are expecting you at your outpatient clinic on Saturday [**10-21**]. Dr [**Last Name (STitle) 5970**] will be seeing you and will be responsible for monitoring your coumadin dosing No heavy lifting greater than 10 pounds Followup Instructions: Outpatient Dialysis: Tues/Thurs/Sat. Start Saturday [**10-21**] [**First Name11 (Name Pattern1) **] [**Known lastname 1330**], MD Phone:[**Telephone/Fax (1) 673**] Date/Time:[**2124-10-23**] 10:40 [**Last Name (NamePattern1) **], [**Hospital Unit Name **] [**Location (un) **], [**Location (un) 86**], MA Completed by:[**2124-10-20**]

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icd9cm

[ [ [] ] ]

[ "39.95", "51.88", "51.87", "51.85", "97.55" ]

icd9pcs

[ [ [] ] ]

11331, 11337

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358, 526

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2434, 2434

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11433, 11577

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13207+13208+56440

Discharge summary

report+report+addendum

Admission Date: [**2101-3-3**] Discharge Date: [**2101-3-31**] Date of Birth: [**2066-10-31**] Sex: F HISTORY OF PRESENT ILLNESS: The patient is a 34-year-old woman with a history of [**Doctor Last Name 73**] encephalitis at age 8, status post left hemisphere resective surgery at the age of 19 with residual right hemiparesis and language deficit with at the age of 8. She has been wheelchair bound since the resective surgery. She lives in a group home, and at baseline can communicate somewhat with gestures and limited language. She was admitted to [**Doctor Last Name 40277**] Hospital two times in [**2101-2-4**] for recurrent pneumonia, the first time requiring an the outside hospital her seizure frequency increased. Her medications were adjusted at that time, and she became supratherapeutic on Dilantin. Her seizure medications were then held, and she subsequently presented to the [**Hospital1 **] [**First Name (Titles) 875**] [**Last Name (Titles) **] on [**3-3**] with very frequent partial seizures, witnessed to be up to five per hour. Her seizures consisted of head and eye deviation to the right, eyelid blinking bilaterally, eye movement to the right, and left arm elevating tonically. These episodes lasted between 30 seconds and 60 seconds. Also, at the time of her presentation to the [**Month (only) **], she was found to be tachypneic with decreased responsiveness. She was sent to the Emergency Department at that time. PAST MEDICAL HISTORY: 1. [**Doctor Last Name 73**] encephalitis at the age of 8; status post left hemisphere resective surgery at the age of 19 with residual right hemiparesis and language deficits, wheelchair bound since the time of the resective surgery. 2. Seizure disorder since the [**Doctor Last Name 73**] encephalitis. 3. She is status post vagal nerve stimulator implantation in [**2099-12-7**] with fairly good response. 4. Recurrent pneumonia including methicillin-resistant Staphylococcus aureus pneumonia in the past. 5. Multiple urinary tract infections. 6. Adenoidectomy. MEDICATIONS ON ADMISSION: ALLERGIES: An allergy to PENICILLIN has been recorded, but her mother has stated that she thinks this is a mistake. FAMILY HISTORY: There is no history of seizures or febrile seizures in the family. There is no history of mental retardation or other developmental problems in the family. Her father died of brain cancer. SOCIAL HISTORY: She lives in a group home, which she moved to in [**2100-9-6**]. She graduated from high school before the resective surgery was done, and went to a special school after that. She has been wheelchair bound since the resective brain surgery. She enjoys watching television and doing crafts in her day program. She is able to move herself. At baseline, prior to admission, she was able to use utensils to feed herself. She required help to transfer to a toilet and was able to move herself slowly in her wheelchair. PHYSICAL EXAMINATION ON PRESENTATION: Physical examination on initial admission on [**3-3**] revealed the patient's temperature was 99, blood pressure of 103/60, heart rate was in the 90s, respiratory rate was 24. The patient was initially unresponsiveness with labored breathing. Heart was regular in rate and rhythm. Lungs with diffuse upper airway noises. The abdomen was benign. Extremities were without edema. On neurologic examination, the patient had intermittent right facial, eye, and mouth twitching but was still able to follow some commands on the left. Pupils were 5 mm and reactive. Extraocular movements were full. Formal visual fields could not be tested, but the patient seemed to acknowledge all fields. There was a right facial droop. On motor examination, there was no spontaneous movement on the right. Arm was held in flexed position with fingers flexed. The right lower extremity was externally rotated with flexion response to pain. The left upper extremity was without asterixis and had full strength. There was some difficulty maneuvering the left lower extremity, and strength was about 4+/5 throughout. Reflexes could not be elicited. The left toes were downgoing. The right toes were upgoing. Sensation was intact to light touch on the left. RADIOLOGY/IMAGING: A chest x-ray on admission showed no infiltrate. PERTINENT LABORATORY DATA ON PRESENTATION: Dilantin level was 9. Phenobarbital level was 25. White blood cell count was 4 (with 42% neutrophils), hematocrit was 33, platelets were 203. Electrolytes, blood urea nitrogen, and creatinine were within normal limits. HOSPITAL COURSE: After receiving 1 mg of Ativan in the Emergency Department, her responsiveness and respiratory status improved. She was admitted to the Neurology Service and treated with Ativan, Topamax, Dilantin, and phenobarbital for seizure control. On [**3-7**], she was transferred to the Neurology Intensive Care Unit for decreased responsiveness, fever, and increasing respiratory distress. On [**3-9**], she was intubated for airway protection. She continued to have frequent seizure activity intermittently with clinical episodes and by electroencephalogram. Over the next several days her seizure frequency improved, and her respiratory status improved as well. A tracheostomy was placed on [**3-16**]. The patient was found to have tracheomalacia, and a percutaneous endoscopic gastrostomy tube was placed on [**3-21**]. Her respiratory status continued to improve, and she was weaned off the ventilator. She did continue to have right eye blinking and facial twitching episodes intermittently which did not seem to have electroencephalogram correlation. She was transferred to the Neurology floor out of the Intensive Care Unit on [**3-25**]. By that time, her seizures were well controlled with only the intermittent facial twitching and eye blinking, and she had completed a full antibiotic course for aspiration pneumonia. Her respiratory status remained stable while on the floor. She did begin to complain of abdominal pain on the floor and also developed a low-grade temperature. She was found to have a urinary tract infection and started on antibiotics for this. A CT of the abdomen was done which found no evidence of abscess, a small hematoma around the site of the percutaneous endoscopic gastrostomy tube insertion, and significant constipation. The percutaneous endoscopic gastrostomy tube was checked by Interventional Radiology and found to be placed correctly and functioning correctly. She received laxatives, and her constipation resolved after an enema. She does continue to gesture and show some discomfort around the site of the percutaneous endoscopic gastrostomy tube; however, there remained no sign of infection or dysfunction of the percutaneous endoscopic gastrostomy tube, and a KUB done on [**3-30**] showed no obstruction or impaction. Neurologically, she had remained stable with an unchanged right hemiparesis that is longstanding secondary to her left hemisphere resective surgery. Her level of arousal and responsiveness has been normal over the last several days. She remained nonverbal, but followed commands, and gestures appropriately. The remainder of the hospital course by system: 1. NEUROLOGY: As stated above, the patient was initially admitted and started on an increased dose of Dilantin, continued on her phenobarbital, and started on Topamax, as well as Ativan for seizure control. She continued to have right facial and eye twitching intermittently throughout her entire hospital course. She had multiple electroencephalograms which showed widespread background slowing focally on the left but also on the right and with frequent sharp wave discharges in the left parasagittal region. There were occasional electrographic seizures seen by electroencephalogram, but the eye twitching and facial movements did not seem to have electroencephalogram correlation. She remained on phenobarbital, Dilantin, and Topamax throughout her hospital course; and the seizures were relatively well controlled on these medications. Her goal levels for the phenobarbital was around 26 and for the Dilantin around 18 with a free Dilantin around 3. She was on olanzapine and Zoloft on admission. These medications were discontinued as they were thought to be contributing to her decreased level of responsiveness. 2. PULMONARY: The patient has a history of recurrent pneumonias, for which she was admitted to [**Doctor Last Name 40277**] Hospital in [**2101-2-4**]; including methicillin-resistant Staphylococcus aureus, which was found in her sputum. During this admission, she was treated for aspiration pneumonia and methicillin-resistant Staphylococcus aureus. She is status post methicillin-resistant Staphylococcus aureus which required intubation. She is status post tracheostomy on [**3-16**] and has been doing well. She has been off the ventilator since [**3-24**], and respiratory status has been stable. She was seen by Speech and Swallow on [**3-30**] for placement of a Passy-Muir valve to enable her to speak; however, she was unable to tolerate this secondary to coughing when the tracheostomy cuff was deflated and continued coughing with the Passy-Muir valve in place. She was found to have tracheomalacia, and therefore any placement of the Passy Muir valve must be done under bedside supervision. She should have the cuff deflated prior to Passy-Muir valve placement, and it should not be placed while she is asleep. She will follow up for management of the tracheostomy with Dr. [**Last Name (STitle) **] in four to six weeks. 3. INFECTIOUS DISEASE: The patient is status post an antibiotic course for pneumonia, as above. She is currently receiving ceftriaxone for treatment of Morganella urinary tract infection that is resistant to Levaquin. She will complete a 10-day course of the ceftriaxone. She has been afebrile for over 48 hours. 4. GASTROINTESTINAL: The patient is status post percutaneous endoscopic gastrostomy tube placement on [**3-21**]. She has been tolerating tube feeds without complications. She does motion discomfort around the percutaneous endoscopic gastrostomy tube site. This was worked including an abdominal CT which showed a small hematoma around the site of the percutaneous endoscopic gastrostomy tube and constipation. The patient constipation was relieved after enema. She does still complain of some abdominal pain, but the percutaneous endoscopic gastrostomy tube is functioning well and has been checked by Interventional Radiology, and a Gastrointestinal consultation was obtained who had no further recommendations at this time. MEDICATIONS ON DISCHARGE: 1. Topamax 125 mg per G-tube b.i.d. 2. Phenobarbital 40 mg per G-tube at 8 a.m. and 60 mg per G-tube at 4 p.m. and 12 a.m. 3. Ceftriaxone 1 g intravenously q.24h. (for a 7-day course; this was started on [**3-29**]). 4. Dilantin 150 mg intravenously t.i.d. 5. Colace 100 mg per G-tube t.i.d. 6. Epogen 40,000 units subcutaneous every week. 7. Miconazole powder p.r.n. 8. Zinc sulfate 220 mg per G-tube q.d. 9. Vitamin C 500 mg per G-tube b.i.d. 10. Iron sulfate 325 mg per G-tube t.i.d. (in elixir form). 11. Heparin 5000 units subcutaneous b.i.d. 12. Dulcolax 10 mg p.o./p.r. p.r.n. 13. Fleet enema p.r. p.r.n. 14. Prevacid 30 mg per G-tube q.d. DISCHARGE DIAGNOSES: 1. Increased seizure frequency. 2. Aspiration pneumonia. 3. Status post tracheostomy. 4. Status post percutaneous endoscopic gastrostomy tube. 5. Old right hemiparesis secondary to left hemisphere resective surgery. 6. Seizure disorder and mental retardation secondary to [**Doctor Last Name 73**] encephalitis. She will see Drs. [**First Name (STitle) 437**] and [**Name5 (PTitle) **] in follow-up for management of her [**Name5 (PTitle) **]. [**First Name8 (NamePattern2) 7495**] [**Name8 (MD) **], M.D. [**MD Number(1) 7496**] Dictated By:[**Last Name (NamePattern1) 19315**] MEDQUIST36 D: [**2101-3-31**] 10:40 T: [**2101-3-31**] 11:06 JOB#: [**Job Number 40278**] Admission Date: [**2075-2-4**] Discharge Date: [**2101-3-31**] Date of Birth: [**2066-10-31**] Sex: F Service: ADDENDUM: The patient's follow up appointments are: 1. Neurology with Dr. [**First Name (STitle) 437**] and Dr. [**Last Name (STitle) **] on Thursday, [**4-14**] at 4 p.m. in the neurology department at [**Hospital1 **] in the [**Last Name (un) 469**] Building. 2. Pulmonary with Dr. [**First Name (STitle) **] [**Name (STitle) **] on [**4-29**] at 10 a.m. on [**Hospital1 **] Two on the [**Hospital Ward Name 517**] of [**Hospital1 **]. 3. The patient should have phenobarbital and Dilantin both total and free levels drawn every three days and with these results faxed to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 437**] at [**Telephone/Fax (1) 40279**]. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3351**], M.D. [**MD Number(1) 3352**] Dictated By:[**Last Name (NamePattern4) 40280**] MEDQUIST36 D: [**2101-3-31**] 14:27 T: [**2101-3-31**] 15:12 JOB#: [**Job Number 40281**] Name: [**Known lastname **], [**Known firstname 1884**] Unit No: [**Numeric Identifier 7269**] Admission Date: [**2101-3-3**] Discharge Date: [**2101-4-7**] Date of Birth: [**2066-10-31**] Sex: F Service: NEUROLOGY ADDENDUM BY SYSTEM: 1. Neurologic: The updated medications for Miss [**Known lastname **] are as follows: She is now on Dilantin 200 mg via PEG three times a day and Topamax 150 mg via PEG twice a day and continued on phenobarbital 40/60/60. Her levels on the day of discharge are phenobarbital 24.5 and Dilantin 13.8. She should have her Dilantin level checked every three days and faxed to Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], as previously instructed. 2. Gastrointestinal: The PEG tube is in place with tube feeds and she is tolerating tube feeds without any difficulty. She occasionally gestures that she has abdominal discomfort when medications are put in the PEG tube. She is on a bowel regimen and has not been constipated. Her liver function tests, amylase and lipase, are all within normal limits and abdominal CT scan and KUB have been negative. 3. Pulmonary: She remains with a tracheostomy. She has been unable to tolerate Passe-Muir valve placement by Speech and Swallow. This is likely secondary to a tracheal stenosis. She remains on PEG tube feeds but her swallow function should be tried further as her tracheal stenosis should not interfere with her swallow functioning. [**First Name8 (NamePattern2) **] [**Name8 (MD) **], M.D. [**MD Number(1) 3827**] Dictated By:[**First Name3 (LF) 7270**] MEDQUIST36 D: [**2101-4-7**] 13:40 T: [**2101-4-7**] 13:55 JOB#: [**Job Number 7271**]

[ "519.1", "507.0", "780.39", "482.41", "326", "319", "599.0" ]

icd9cm

[ [ [] ] ]

[ "43.11", "33.22", "96.04", "96.72", "96.6", "31.1" ]

icd9pcs

[ [ [] ] ]

2234, 2425

11392, 14950

10701, 11371

2098, 2216

4609, 10674

151, 1477

1499, 2071

2442, 4591

27,666

100,915

4022

Discharge summary

report

Admission Date: [**2205-8-7**] Discharge Date: [**2205-8-13**] Date of Birth: [**2130-12-20**] Sex: F Service: SURGERY Allergies: Penicillins / Codeine Attending:[**First Name3 (LF) 2777**] Chief Complaint: Occluded aorto-bifemoral bypass graft. Major Surgical or Invasive Procedure: 1. Bilateral groin exploration. 2. Thrombectomy of aorto-bifem graft, bilateral SFA, bilateral profunda, bilateral common iliac arteries. 3. Patch closure of arteriotomies. 4. Endovascular stents of aorto-[**Hospital1 **] fem limbs. 5. Bilateral fasciotomies. History of Present Illness: This is a 74-year-old female who is status post aorto-bifemoral graft in [**2201**] who presented with acute onset of left leg pain starting at 8:30 this morning. The patient had previously been ambulatory without claudication or rest pain. The patient was brought to [**Hospital3 4527**] and was started on heparin and emergently transferred to [**Hospital1 **] for further care. Upon examination, the patient had no palpable femoral pulses. The patient had poor motor function of her left leg below the knee as well as decreased sensation of the left leg compared to the right leg. The patient was taken urgently to the operating room. Her preoperative creatinine was elevated at 1.2. Her bicarbonate was 15. Her CK was 40. Past Medical History: Lung cancer, Emphysema, s/p Lt CEA [**2-21**], Rt carotid 100% occluded, h/o TIAs post-CEA, HTN, Chol, Arthritis PSH- Right middle and lower lobectomies in [**1-22**], Left CEA [**2-21**], Hysterectomy remote, Tonsillectomy remote, aortobifem in [**2201**] Social History: x smoker non drinker Family History: n/c Physical Exam: Vitals: 98.6, HR 74 BP 142/80 RR18 96%RASat Gen: NAD Neuro: A&OX3 RESP: CTA ABD: soft, NT B/L DP/PT doppler Pertinent Results: [**2205-8-12**] 03:06AM BLOOD WBC-9.9 RBC-3.22* Hgb-9.9* Hct-29.2* MCV-91 MCH-30.6 MCHC-33.8 RDW-15.9* Plt Ct-201 [**2205-8-12**] 03:06AM BLOOD PT-11.6 PTT-34.9 INR(PT)-1.0 [**2205-8-12**] 03:06AM BLOOD Glucose-131* UreaN-13 Creat-0.9 Na-138 K-4.4 Cl-109* HCO3-18* AnGap-15 [**2205-8-12**] 03:06AM BLOOD Calcium-7.9* Phos-1.5* Mg-2.0 CT ABDOMEN W/CONTRAST [**2205-8-12**] 7:57 PM CT OF THE ABDOMEN WITH IV CONTRAST: The visualized portion of the lung bases demonstrates severe centrilobular emphysematous changes of the lung. No parenchymal opacification or pulmonary nodule is seen. The left atrium is mildly enlarged. The liver, gallbladder, intra and extrahepatic bile ducts, spleen, pancreas, stomach, duodenum and loops of small bowel are unremarkable. Colonic pandiverticulosis is noted. Both kidneys contain multiple hypodense lesions which are too small to characterize. No free air or fluid is noted within the abdomen. The patient is status post mesh placement of anterior abdominal wall. No pathologically enlarged retroperitoneal or mesenteric nodes are noted. The thoracic aorta demonstrates mural thrombus and aneurysmal dilatation measuring 3.9 x 4.4 cm which extends for 7.1 cm and extends into the suprarenal aorta. The patient is status post aorto- biliac bypass grafting. Complete opacification of the both external iliac arteries are noted. Severe stenosis is noted at the origin of the right common iliac artery. The abdominal aorta demonstrates severe calcification with calcification noted at the origin of celiac artery, superior mesenteric artery and both renal arteries. CT OF THE PELVIS WITH IV CONTRAST: The urinary bladder contains small locules of air most likely related to the prior Foley catheter placement. The rectum contains impacted stool. The sigmoid colon contains multiple diverticula. No evidence of diverticulitis is seen. Left-sided rectus sheath hematoma is noted which measure 4.3 x 5.9 in transverse diameter and measures 10.9 cm in craniocaudal diameter. In the right inguinal region a fluid density material is surrounding the right common femoral artery consistent with the patient history of recent thrombectomy on the right inguinal region. Right indirect inguinal hernia is noted which contains fluid. No evidence of bowel obstruction or incarceration is noted. No free air or fluid is noted within the pelvis. No pathologically enlarged pelvic or inguinal nodes are detected. BONE WINDOWS: No concerning lytic or sclerotic lesions are noted. Degenerative changes of lower lumbar spine are identified. IMPRESSION: 1. Relatively large rectus sheath hematoma which extends into the left inguinal region measuring 4.3 x 5.9 x 10.9 cm. No evidence of bowel entrapment within the inguinal canals were noted. 2. Small fluid containing right-sided inguinal hernia was noted. 3. Status post aorto-biiliac bypass garfting. 4. Abdominal aortic aneurysm measuring 3.9 x 4.4 cm in transverse diameter which extends 7.2 cm in craniocaudal diameter. 5. Status post thrombectomy at the right inguinal region with a small amount of fluid tracking along the common femoral artery. 6. Stool impaction is noted within the rectum. 7. Small right-sided pleural effusion is seen. Emphysematous changes of lung bases are noted. 8. Colonic pandiverticulosis. Brief Hospital Course: [**2205-8-7**] The patient was brought to [**Hospital3 4527**] and was started on heparin and emergentlytransferred to [**Hospital1 **] for further care. On arrival to [**Hospital1 18**], patient with B/L cold feet and pain L>R. Acutely ischemic, taken to OR for Bilateral groin exploration, Thrombectomy of aorto-bifem graft, bilateral SFA, bilateral profunda, bilateral common iliac arteries, Patch closure of arteriotomies, Endovascular stents of aorto-[**Hospital1 **] fem limbs, Bilateral fasciotomies. Pulses at end of case: palpable RT DP, doppler PT. LT dop PT/DP. pt did well post opeative with out complications. She progressed with PT / PT recommended reah. To note pt did have abdominial pain. Thi sprompted a US of abdomen. This showed fluid collection vs strangulated bowel, A CT scan was done. Negative for bowel entrapment. There was a small hematoma. Pt stable for DC Medications on Admission: asa, [**Hospital1 17339**], zestril 20 Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours). 4. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 8. Famotidine 20 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours). 9. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection twice a day: Discontinue when fully ambulatory. 10. Regular Insulin Sliding Scale Insulin SC Sliding Scale Breakfast Lunch Dinner Bedtime Regular Glucose Insulin Dose 0-60 mg/dL [**1-22**] amp D50 61-120 mg/dL 0 Units 0 Units 0 Units 0 Units 121-140 mg/dL 2 Units 2 Units 2 Units 2 Units 141-160 mg/dL 4 Units 4 Units 4 Units 4 Units 161-180 mg/dL 6 Units 6 Units 6 Units 6 Units 181-200 mg/dL 8 Units 8 Units 8 Units 8 Units 201-220 mg/dL 10 Units 10 Units 10 Units 10 Units 221-240 mg/dL 12 Units 12 Units 12 Units 12 Units 241-260 mg/dL 14 Units 14 Units 14 Units 14 Units 261-280 mg/dL 16 Units 16 Units 16 Units 16 Units 281-300 mg/dL 18 Units 18 Units 18 Units 18 Units 301-320 mg/dL 20 Units 20 Units 20 Units 20 Units 321-340 mg/dL 22 Units 22 Units 22 Units 22 Units 341-360 mg/dL 24 Units 24 Units 24 Units 24 Units > 360 mg/dL Notify M.D. 11. Bisacodyl 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as needed for constipation. 12. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 13. Dulcolax 10 mg Suppository Sig: One (1) Rectal at bedtime as needed for constipation. Discharge Disposition: Extended Care Facility: [**Location (un) 582**] Of [**Location (un) 620**] Discharge Diagnosis: 74F s/p Thrombectomy b/l aorto-bifem limbs, SFA, profundas; patch closure of arteriotomies, stents to aorto-bifem, b/l fasciotomies [**8-7**] for occlued ABF . PMH:Lung cancer, Emphysema, s/p Lt CEA [**2-21**], Rt carotid 100% occluded, h/o TIAs post-CEA, HTN, Chol, Arthritis. Discharge Condition: Stable Discharge Instructions: Division of [**Month/Year (2) **] and Endovascular Surgery Lower Extremity Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel tired, this will last for 4-6 weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? Unless you were told not to bear any weight on operative foot: you may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have swelling of the leg you were operated on: ?????? Elevate your leg above the level of your heart (use [**2-23**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? Unless you were told not to bear any weight on operative foot: ?????? You should get up every day, get dressed and walk ?????? You should gradually increase your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (unless you have stitches or foot incisions) no direct spray on incision, let the soapy water run over incision, rinse and pat dry ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 100.5F for 24 hours ?????? Bleeding, new or increased drainage from incision or white, yellow or green drainage from incisions Followup Instructions: Follow up with Dr. [**Last Name (STitle) 17751**] in the office in one week. Call for an appointment [**Telephone/Fax (1) 3121**] Previously scheduled: Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2205-9-2**] 8:00 Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2205-9-2**] 9:00 Provider: [**Name10 (NameIs) **] LAB Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2205-9-2**] 9:30 Completed by:[**2205-8-13**]

[ "401.9", "272.0", "996.74", "998.12", "E878.2", "V10.11", "492.8", "441.4" ]

icd9cm

[ [ [] ] ]

[ "83.14", "99.04", "38.16", "38.18", "00.46", "39.49", "39.90", "00.43", "88.42", "39.50" ]

icd9pcs

[ [ [] ] ]

8062, 8139

5171, 6061

321, 592

8461, 8470

1836, 5148

11320, 11810

1683, 1688

6150, 8039

8160, 8440

6087, 6127

8494, 10887

10913, 11297

1703, 1817

242, 283

620, 1348

1370, 1629

1645, 1667

9,710

186,917

47754

Discharge summary

report

Admission Date: [**2170-5-3**] Discharge Date: [**2170-5-7**] Date of Birth: [**2105-10-26**] Sex: F Service: MEDICINE Allergies: Aspirin / Reglan / Quinine Sulfate / Codeine / Augmentin / Clindamycin / Dilaudid (PF) / Iodine Attending:[**First Name3 (LF) 2291**] Chief Complaint: dyspnea Major Surgical or Invasive Procedure: None History of Present Illness: 64yo F h/o ?COPD not on home O2, asthma (never intubated or admitted to ICU), CAD (s/p RCA stents [**12-19**]), PVD s/p BKA, MS, chronic paraplegia [**3-15**] spinal cord compression, IDDM, multiple DVTs (on warfarin) who p/w increasing dyspnea, productive cough (green sputum), and wheezing over past few days. Had sore throat and ear pain last week; was started on azithromycin for presumed COPD flare 3 days ago. Breathing worsened acutely over last 24 hrs. Pt states she feels worse than "usual COPD flares." Baseline O2 sat ~95% on RA. No fevers, chest pain, headache, n/v, abd pain. Never been intubated or in the ICU for COPD flares, but has been admitted. In the ED inital vitals were 97.6, 103, 166/80, 22, 99% 6L NRB. Pt appeared uncomfortable, with diffuse rhonchi/wheezing. Received combivent nebs x4 (improved clinical exam post-neb), solumedrol, levofloxacin, vancomycin, and cefepime. Also changed Foley (pt has indwelling Foley; it was last changed 2 wks ago). Received 500cc IVF. VS on transfer: 98.2 ??????F, 109, 95/78, 18, 96% on 10L NRB 10L, satting low 80s on RA. On arrival to the ICU, pt has labored breathing, speaking in short phrases. Alert and oriented, interactive and answering questions appropriately. Past Medical History: -?COPD, not on home O2; satting 95% on RA; never admitted to ICU or intubated; spirometry [**2168-6-17**]: FVC 58% of predicted, FEV1 62% of predicted, FEV1/FVC = 78%; FEV1/FVC unchanged at 78% post-drug -Asthma, never intubated -CAD s/p BMS to mid-RCA in [**12-19**] (repeat cath [**9-19**] showed <30% in-stent restenosis), LVEF>55% per TTE [**6-21**] -PVD s/p left BKA -multiple DVTs, previously off Coumadin [**3-15**] GI bleeding, back on Coumadin as of [**2170-4-5**] for recurrent R leg DVT -stroke in [**2152**], p/w speech difficulty and L-sided weakness and no residual deficit -HLD -HTN -Type II IDDM -uterine CA s/p radical hysterectomy -sarcoidosis -MS diagnosed in [**2150**], MRI in [**2155**] with innumerable T2 [**Male First Name (un) 4746**] lesions -spinal cord compression s/p C3-7 and T7-11 laminectomies and fusion with residual paraparesis and absent sensation in legs -seizure disorder -OSA -Obesity -?Cardiac arrest? -recurrent UTIs, with indwelling foley catheter -h/o GI bleed while on coumadin Social History: Per OMR, lives with her daughter (very close relationship) and has three home health aids. Uses a wheelchair for mobility, and [**Doctor Last Name **] lift. H/o significant alcohol but quit nearly 30 years ago. No smoking in 30 years. Family History: Per OMR, multiple individuals w/DM and CAD. Mother died of brain tumor at 50 and father died of MI at 48. Brother lived to 53 and had a CABG. Physical Exam: ON ADMISSION: Vitals: 98, 118/72, 105, 22, 94% on 6L NC General: Alert, oriented x3, NAD [**Doctor Last Name 4459**]: Sclera anicteric, dry MM, oropharynx clear, visual acuity low bilaterally; PERRL Neck: supple, JVP not elevated, no LAD Lungs: Expiratory wheezing bilaterally, rhonchi diffusely CV: RRR, no murmurs, rubs, gallops Abdomen: obese, soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly GU: foley Ext: warm, well perfused; 2+ pulses, no clubbing, cyanosis or edema; below-knee amputation left leg; healing foot ulcers on R foot Pertinent Results: ON ADMISSION: [**2170-5-3**] 05:02PM TYPE-ART PO2-75* PCO2-43 PH-7.39 TOTAL CO2-27 BASE XS-0 INTUBATED-NOT INTUBA [**2170-5-3**] 12:00PM WBC-9.8 RBC-4.21 HGB-12.8 HCT-38.8 MCV-92 MCH-30.4 MCHC-33.0 RDW-14.8 [**2170-5-3**] 12:00PM NEUTS-72.6* LYMPHS-21.3 MONOS-3.3 EOS-2.0 BASOS-0.8 [**2170-5-3**] 12:00PM CK(CPK)-180 [**2170-5-3**] 12:00PM CK-MB-3 [**2170-5-3**] 12:00PM cTropnT-0.01 [**2170-5-3**] 12:20PM URINE BLOOD-SM NITRITE-NEG PROTEIN-300 GLUCOSE-TR KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5 LEUK-MOD [**2170-5-3**] 12:20PM URINE RBC-5* WBC-38* BACTERIA-NONE YEAST-NONE EPI-1 TRANS EPI-<1 IMAGING: CXR [**2170-5-3**] at 11:31AM (wet read): Bibasilar opacities probably atelectasis, but somewhat nodular at the right base; suggest short-term follow-up PA and lateral films to show resolution. . CXR [**2170-5-4**]: The positioning of the patient is suboptimal. Within those limitations, there is no substantial change in the right lower lung and left basal opacities that might reflect areas of atelectasis but infectious process cannot be excluded. Repeated radiograph is indicated. . EKG: sinus tachycardia @ 101, left axis deviation, no ST changes; unchanged from prior [**2170-4-17**] . Microbiology: Blood, urine and sputum cx's ([**5-3**]): no growth Respiratory Viral cx ([**5-3**]): no growth . Discharge Labs: [**2170-5-7**] 07:00AM BLOOD WBC-9.4 RBC-3.91* Hgb-11.6* Hct-36.2 MCV-93 MCH-29.5 MCHC-31.9 RDW-15.2 Plt Ct-317 [**2170-5-7**] 07:00AM BLOOD Glucose-75 UreaN-23* Creat-0.9 Na-142 K-3.3 Cl-104 HCO3-29 AnGap-12 [**2170-5-7**] 07:00AM BLOOD Calcium-8.5 Phos-3.1 Mg-2.2 [**2170-5-7**] 07:00AM BLOOD PT-17.4* PTT-49.7* INR(PT)-1.6* Brief Hospital Course: Patient is a 64yo female with a history of asthma, question COPD not on home O2, CAD (s/p RCA stents [**12-19**]), PVD s/p BKA, IDDM, and multiple DVTs (on warfarin) who presented to the hospital with acute respiratory distress requiring ICU admission. . #Hypoxia/Respiratory distress: She was initially admitted to the ICU for respiratoy distress. She was treated for acute exacerbation of her underlying asthma with aggressive bronchodilator therapy, steroid burst, and she was also started on empiric antibiotics for possible HCAP, given some haziness on chest x-ray. All her culture data returned negative. Her repeat chest x-ray remained stable, and her respiratory status returned to baseline. She was transferred to the General Medical floor given her stability. Given the absence of growth from her respiratory culture, she was tailored to single [**Doctor Last Name 360**] antibiotic therapy with Levaquin, and will complete a course of antibiotics. She will also complete a quick steroid taper. She will need a repeat CXR to assess for resolution of the basilar opacities seen bilaterally, should be repeated in [**5-18**] weeks, assuming clinical stability. . #Pyuria without evidence of UTI: Pt had indwelling Foley for recurrent UTIs. UA on admission showed 38 WBC, mod leukocyte esterase, neg nitrites, no bacteria, 1 epi; no urinary symptoms to suggest infection. Urine cx was negative. . #H/o DVTs, on warfarin: INR 1.7 on admission; no missed home doses per pt. Given h/o multiple DVTs and CVA, pt was put on lovenox bridge until INR in therapeutic range. INR on discharge on day of discharge is 1.6 . #CAD s/p BMS to mid-RCA in [**12-19**] (repeat cath [**9-19**] showed <30% in-stent restenosis), LVEF>55% per TTE [**6-21**]. Continued home clopidogrel (pt allergic to ASA) and metoprolol. . #HLD: continued home atorvastatin. . #HTN: continued home nitrate. Furosemide restarted after pt gently volume-resuscitated. . #Type II IDDM: on insulin SS; continued home NPH. . #Seizure disorder: carbamazepine was in therapeutic range (8.2) on admission. Continued home carbamazepine. . #PVD s/p BKA: continued home baclofen for spasm. . #OSA: pt declined CPAP. . Medications on Admission: albuterol sulfate 90 mcg/actuation, 1 puff q6hrs PRN SOB/wheezing fluticasone 110 mcg/actuation, 2 puffs [**Hospital1 **] warfarin 7.5 mg PO DAILY clopidogrel 75 mg PO DAILY isosorbide mononitrate 120 mg Tablet Extended Release 24 hr PO DAILY metoprolol tartrate 75 mg PO BID furosemide 40 mg PO DAILY atorvastatin 40 mg PO DAILY carbamazepine 400 mg PO BID baclofen 10 mg PO QID NPH insulin 90 units Subcutaneous QAM NPH insulin 35 units Subcutaneous at bedtime Humalog 6 units Subcutaneous QAM Discharge Medications: 1. warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO Once Daily at 4 PM: start [**2170-5-8**]. 2. isosorbide mononitrate 60 mg Tablet Extended Release 24 hr Sig: Two (2) Tablet Extended Release 24 hr PO DAILY (Daily). 3. enoxaparin 120 mg/0.8 mL Syringe Sig: One [**Age over 90 **]y (120) mg Subcutaneous Q12H (every 12 hours): till INR >1.8 or instructed otherwise by [**Hospital 191**] [**Hospital3 **]. Disp:*20 syringes* Refills:*1* 4. furosemide 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. fluticasone 110 mcg/actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 6. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. carbamazepine 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). 8. baclofen 10 mg Tablet Sig: One (1) Tablet PO QID (4 times a day). 9. atorvastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 10. metoprolol tartrate 25 mg Tablet Sig: Three (3) Tablet PO twice a day. 11. levofloxacin 750 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 3 days. Disp:*3 Tablet(s)* Refills:*0* 12. prednisone 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily) for 2 days: take for 2 days ([**5-8**], [**5-9**]). Disp:*4 Tablet(s)* Refills:*0* 13. prednisone 20 mg Tablet Sig: One (1) Tablet PO once a day for 3 days: take on [**5-1**], [**5-12**]. . Disp:*3 Tablet(s)* Refills:*0* 14. prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for 3 days: take on [**5-12**], [**5-15**]. Disp:*3 Tablet(s)* Refills:*0* 15. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) neb Inhalation Q6H (every 6 hours). 16. ipratropium bromide 0.02 % Solution Sig: One (1) neb Inhalation Q6H (every 6 hours). 17. NPH insulin human recomb 100 unit/mL Suspension Sig: Ninety (90) units Subcutaneous QAM. 18. NPH insulin human recomb 100 unit/mL Suspension Sig: Thirty Five (35) units Subcutaneous at bedtime. 19. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig: 1-2 puffs Inhalation every four (4) hours as needed for shortness of breath or wheezing. Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: astham/COPD exacerbation pneumonia, likely bacterial Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Out of Bed with assistance to chair or wheelchair. Discharge Instructions: You were admitted to the hospital after presenting with cough, shortness of breath, and low oxygen levels. You were initially admitted to the ICU, and you were treated with oxygen, as well as antibiotics and nebulizers/steroids for both pneumonia and asthma/COPD flare. You were subsequently transferred to the General Medical floor and had your oxygen weaned off and your antibiotics tapered. You are being discharged to home and will complete a course of oral steroids and antibiotics. Your INR was subtherapeutic on admission, and you will need to cont on Lovenox until your INR is approrpiate. Your INR will continue to be followed by the anticoagulation nurses at the [**Hospital 191**] [**Hospital3 **]. . Please take your medications as prescribed below. Please follow-up with your doctors as listed below. . Followup Instructions: Department: [**Hospital3 249**] When: FRIDAY [**2170-5-11**] at 10:50 AM With: DR [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **]/[**Company 191**] POST [**Hospital 894**] CLINIC [**Telephone/Fax (1) 2010**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage **This appointment is with a hospital-based doctor as part of your transition from the hospital back to your primary care provider. [**Name10 (NameIs) 616**] this visit, you will see your regular primary care doctor in follow up.** . Dr. [**Last Name (STitle) **] does not have any available appointments till mid-[**Month (only) 547**]. You can call his office to try to book an earlier appointment. His number is [**Telephone/Fax (1) 250**]. Otherwise, you should follow-up in the [**Hospital 1944**] clinic. .

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icd9cm

[ [ [] ] ]

[]

icd9pcs

[ [ [] ] ]

10243, 10300

5428, 7620

363, 370

10397, 10397

3732, 3732

11418, 12307

2959, 3102

8166, 10220

10321, 10376

7646, 8143

10573, 11395

5077, 5405

3117, 3117

316, 325

398, 1644

3746, 5061

10412, 10549

1666, 2691

2707, 2943

17,238

102,487

15963

Discharge summary

report

Admission Date: [**2153-6-29**] Discharge Date: [**2153-7-8**] Service: MEDICINE Allergies: Sulfur / Zestril / Zithromax Attending:[**First Name3 (LF) 2160**] Chief Complaint: sepsis Major Surgical or Invasive Procedure: none History of Present Illness: This is a [**Age over 90 **]M with h/o CAD, CHF, CKD, hyperlipidemia, HTN, anemia presenting with rigors, fever, hypotension consistent with septic shock, likely from pneumonia. Pt admitted to ICU for pressors, fluid support, and antibiotics. BP improved and antibiotics narrowed to levaquin only. Denies CP, SOB, HA, fevers, chills, rigors, abd pain, N/V. States he has been eating well though not so much today. Has had some diarrhea but can't quantify it. Started on flagyl in ICU empirically for possible Cdiff. Past Medical History: PVD CAD s/p MI [**2105**], 4vCABG [**2137**] CRI (baseline Cr 1.5-2.0) HTN Anemia of chronic disease GERD BPH BCC L ear Paget's dz s/p cholecystectomy s/p cataract surgery Social History: lives independently, son in the area, occasional alcohol, denies tobacco use Family History: non-contributory Physical Exam: VS: Temp: 102/98 BP:90/60 HR:78 RR:16 96%4liters O2sat . general: pleasant, mentating well, NAD HEENT: PERLLA, EOMI, anicteric, MMM, op without lesions, no supraclavicular or cervical lymphadenopathy, RIJ in place lungs: CTA b/l with good air movement throughout heart: RR, S1 and S2 wnl, 3/6 Systolic murmur, LUSB abdomen: nd, +b/s, soft, nt, no masses or hepatosplenomegaly extremities: [**2-6**]+edema edema skin/nails: no rashes/no jaundice/no splinters neuro: AAOx3. Cn II-XII intact. 5/5 strength throughout. rectal:guiac negative Pertinent Results: [**2153-6-29**] 09:30AM BLOOD WBC-6.4 RBC-2.68* Hgb-9.5* Hct-26.6* MCV-100* MCH-35.4* MCHC-35.5* RDW-12.9 Plt Ct-113* [**2153-6-29**] 09:30AM BLOOD Neuts-87.8* Bands-0 Lymphs-7.1* Monos-3.9 Eos-1.1 Baso-0 [**2153-7-1**] 04:42AM BLOOD PT-14.7* PTT-28.9 INR(PT)-1.3* [**2153-7-7**] 07:00AM BLOOD UreaN-34* Creat-2.0* Na-135 K-3.4 Cl-105 HCO3-22 AnGap-11 [**2153-6-29**] 09:30AM BLOOD Glucose-151* UreaN-58* Creat-2.6* Na-142 K-5.0 Cl-107 HCO3-25 AnGap-15 [**2153-7-2**] 04:40AM BLOOD CK(CPK)-337* [**2153-6-29**] 07:24PM BLOOD LD(LDH)-258* CK(CPK)-351* [**2153-6-29**] 09:30AM BLOOD ALT-21 AST-31 LD(LDH)-214 CK(CPK)-539* AlkPhos-81 Amylase-134* TotBili-0.3 [**2153-6-29**] 09:30AM BLOOD Lipase-57 [**2153-7-2**] 04:40AM BLOOD CK-MB-9 cTropnT-0.16* [**2153-6-29**] 09:30AM BLOOD CK-MB-3 [**2153-6-30**] 03:42PM BLOOD CK-MB-10 MB Indx-2.0 cTropnT-0.17* [**2153-6-30**] 04:07AM BLOOD CK-MB-9 cTropnT-0.15* [**2153-6-29**] 07:24PM BLOOD CK-MB-6 cTropnT-0.05* [**2153-7-5**] 06:35AM BLOOD Calcium-8.2* Mg-2.0 [**2153-6-29**] 07:24PM BLOOD Calcium-6.6* Phos-2.8 Mg-1.6 [**2153-6-29**] 07:24PM BLOOD VitB12-638 Folate-17.7 [**2153-6-30**] 04:49AM BLOOD Cortsol-30.4* [**2153-6-30**] 04:07AM BLOOD Cortsol-27.5* [**2153-6-29**] 07:24PM BLOOD Cortsol-17.6 [**2153-6-29**] 08:51PM BLOOD Type-MIX pO2-33* pCO2-39 pH-7.34* calTCO2-22 Base XS--5 [**2153-6-29**] 06:52PM BLOOD Lactate-1.4 [**2153-6-29**] 02:10PM BLOOD Lactate-2.8* [**2153-6-29**] 06:52PM BLOOD Hgb-8.2* calcHCT-25 O2 Sat-60 [**2153-7-1**] 09:01AM BLOOD freeCa-1.01* [**2153-7-6**] 10:25PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.015 [**2153-7-6**] 10:25PM URINE Blood-SM Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG [**2153-6-29**] 03:00PM URINE RBC-0-2 WBC-1 Bacteri-NONE Yeast-NONE Epi-0 [**2153-7-6**] URINE URINE CULTURE-PENDING INPATIENT [**2153-7-6**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC BOTTLE-PENDING INPATIENT [**2153-7-5**] BLOOD CULTURE AEROBIC BOTTLE-PENDING; ANAEROBIC BOTTLE-PENDING INPATIENT [**2153-7-3**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL INPATIENT [**2153-7-2**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL INPATIENT [**2153-7-1**] STOOL CLOSTRIDIUM DIFFICILE TOXIN ASSAY-FINAL INPATIENT [**2153-6-30**] URINE Legionella Urinary Antigen -FINAL INPATIENT [**2153-6-29**] URINE URINE CULTURE-FINAL INPATIENT [**2153-6-29**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL INPATIENT [**2153-6-29**] BLOOD CULTURE AEROBIC BOTTLE-FINAL; ANAEROBIC BOTTLE-FINAL INPATIENT UNILAT LOWER EXT VEINS LEFT Reason: r/o DVT [**Hospital 93**] MEDICAL CONDITION: [**Age over 90 **] year old man with swollen, tender left leg REASON FOR THIS EXAMINATION: r/o DVT INDICATION: [**Age over 90 **]-year-old man with swollen tender left leg. No comparison is available. No comparison is a vailable. [**Doctor Last Name **] scale, color flow and Doppler images of left lower extremity were obtained. The common femoral vein, superficial femoral vein, popliteal vein demonstrate normal compressibility, respiratory variation in venous flow and venous augmentation. IMPRESSION: No evidence of DVT in left lower extremity LEFT TIBIA AND FIBULA CLINICAL HISTORY: Pain and trauma. AP and lateral views were obtained. No fracture is seen. Vascular calcifications and surgical clips are noted. IMPRESSION: No bony abnormality is seen. CT, LEFT LEG WITHOUT CONTRAST: There is no fracture. No erosive changes, lucent or sclerotic lesions, or periosteal reaction is evident. An enthesophyte is seen along the quadriceps insertion on to the patella. There is non-specific diffuse circumferential subcutaneous edema surrounding the lower leg. No loculated fluid collection or muscle atrophy is evident. Only a minimal amount of the right leg was imaged, but on the portion imaged, similar subcutaneous edema findings are noted. Extensive atherosclerotic vascular calcifications are present. Scattered surgical clips are present within the medial soft tissues. There is a small knee joint effusion. Within the limits of technique, the tendons about the ankle are unremarkable. IMPRESSION: Non-specific subcutaneous edema, probably similar to that partially imaged on the right side without focal fluid collection or underlying osseous abnormality. Conclusions: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size. There is moderate regional left ventricular systolic dysfunction with focal akinesis of the inferior wall and hypokinesis of the inferolateral wall. The remaining segments contract well. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). Right ventricular chamber size and free wall motion are normal. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No masses or vegetations are seen on the aortic valve. Moderate (2+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. No mass or vegetation is seen on the mitral valve. Moderate (2+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the report of the prior study (images unavailable for review) of [**2152-1-28**], moderate pulmonary artery hypertension is now identified (not measured on prior study). No obvious vegetations are identified on the current study. The severity of mitral and aortic regurgitation are probably similar. Elevated left ventricular filling pressures are present. AP chest compared to [**6-29**] through 27: Small bilateral pleural effusions have decreased substantially and pulmonary edema is no longer present. Heart is normal size. Right jugular line ends at the superior cavoatrial junction. No pneumothorax. Non-contrast CT of the head was performed. FINDINGS: The posterior fossa structures are unremarkable. The cerebral parenchyma is normal in [**Doctor Last Name 352**] and white matter differentiation. There is no acute intracranial hemorrhage, mass effect, shift of normally midline structures or hydrocephalus. Prominent ventricles and extra-axial CSF spaces, consistent with age appropriate involution of the brain parenchyma was noted. Bilateral maxillary retention cysts are noted, incompletely evaluated on the present study. IMPRESSION: No acute intracranial hemorrhage. Brief Hospital Course: SEPSIS: Resolved in the ICU with aggressive Rx. Likely source is pneuminia. To complete a 14 days course of levofloxacin. NSTEMI, CAD, CABG - likely from the stress of septic shock. He was continued on ASA, beta blocker, statin, [**Last Name (un) **]. This was discussed with his out-patient cardiologist - Dr [**Last Name (STitle) **] who recommended no further testing at this time. CHF, systolic: Secondary to known systolic dysfunction, after vigourous fluids in ICU Improved with diuresis, however diuresis stopped give rising creat. ARF/CKD: Cr was high initially from the prerenal state. stabilized at discharge. Anemia: Hct stable s/p transfusion in ICU. he will require follow up CBC with PCP. Diarrhea: resolved with empiric flagyl. Cdiff x 3 = negative. The patient had a non-gap acidosis from the diarrhea which also was resolving at discharge. Leg edema - asymmetric L>R - LENI neg for DVT, No fracture on XR and CT revealed subcut edema. Given that the left leg had the saph vein removed during CABG, this was likely venous stasis. Vascular was consulted who did not feel ABI were needed. 2 pillow elevation of leg and teds were recommended and the edema was markedly improved prior to dc. Dr [**Last Name (STitle) 3407**] from vascular to follow up. Medications on Admission: 1. Aspirin 81mg daily 2. diovan 40mg daily 3. toprol 12.5 mg daily 4. zocor 20mg daily 5. flomax 0.4 mg daily 6. Protonix 40mg 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). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily). 4. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 7 days. Disp:*21 Tablet(s)* Refills:*0* 8. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 6 days. Disp:*3 Tablet(s)* Refills:*0* 9. Zocor 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 10. Tamsulosin Oral 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: 0.5 Tablet Sustained Release 24 hr PO DAILY (Daily). 4. Valsartan 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 6. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 7. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO TID (3 times a day) for 7 days. Disp:*21 Tablet(s)* Refills:*0* 8. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 6 days. Disp:*3 Tablet(s)* Refills:*0* 9. Zocor 20 mg Tablet Sig: One (1) Tablet PO at bedtime. 10. Tamsulosin Oral Discharge Disposition: Home With Service Facility: All Care VNA of Greater [**Location (un) **] Discharge Diagnosis: Septic shock from community acquired pneumonia NSTEMI Venous stasis, likely (Left leg > rt leg) Anemia Acute renal failure Chronic kidney disease CAD, CABG Diarrhea - resolved Non anion gap metabolic acidosis Discharge Condition: stable Discharge Instructions: Return to the hospital if you have fevers, chils, chest pain, trouble breathing or any other symptoms of concern to you. Keep your appointments as below. Please call Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 410**] at [**Telephone/Fax (1) 1144**] and reschedule an earlier appointment in the next 1-2 weeks. Complete the course of antibiotics as prescribed. Your should wear the [**Male First Name (un) **] hoses on both legs in the day and maintain an elevated position for legs when you are sitting down. This should help the swelling in the legs get better. Followup Instructions: Please call Dr [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 410**] at [**Telephone/Fax (1) 1144**] and reschedule an earlier appointment in the next 1-2 weeks. Provider: [**Name10 (NameIs) **],[**First Name8 (NamePattern2) 2352**] [**Last Name (NamePattern1) 2352**] - ADULT MEDICINE (SB) Date/Time:[**2153-10-5**] 11:15 Also make a follow up appointment with Dr [**Last Name (STitle) **] - your cardiologist in the next 2 weeks. ([**Telephone/Fax (1) 7236**]. Provider: [**Name10 (NameIs) **],[**Name11 (NameIs) 7721**] VASCULAR LMOB (NHB) Date/Time:[**2153-10-16**] 1:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1244**], MD Phone:[**Telephone/Fax (1) 1237**] Date/Time:[**2153-10-16**] 1:30

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icd9cm

[ [ [] ] ]

[ "38.93" ]

icd9pcs

[ [ [] ] ]

11443, 11518

8246, 9519

242, 248

11770, 11778

1690, 4274

12414, 13163

1099, 1117

9703, 11420

4311, 4373

11539, 11749

9545, 9680

11802, 12391

1132, 1671

196, 204

4402, 8223

276, 793

815, 988

1004, 1083

76,594

150,990

52590

Discharge summary

report

Admission Date: [**2148-7-2**] Discharge Date: [**2148-7-7**] Date of Birth: [**2080-10-31**] Sex: F Service: MEDICINE Allergies: IV Dye, Iodine Containing / Keflex / Codeine / Isoniazid / Indocin / Percocet / Vicodin Attending:[**First Name3 (LF) 2763**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: EGD History of Present Illness: 67 yo F with a PMH of SLE, DMI, HTN, ESRD on HD T, Th, Sat, paroxysmal afib s/p PV isolation x2, tachy-brady syndrome s/p pacer and PVD with SFA stent placement, NSTEMI with DES to LAD and BMS to OM1 on [**6-21**] presenting with lightheadedness and bright red blood per rectum. She stated that last night, she noted large red "clots" in her stool, along with BRB with wiping. Of note, she has hemorhoids. She had more bowel movemets with clots this AM and felt lightheaded. Of note, she is on aspirin, plavix, and coumadin, [**Last Name (un) **] took none of her meds this AM. . On arrival to the ED, initial vitals were 97.9 70 85/47 22 96% RA. By the time she got to her room, her SBPs had come up tot he 90s/100s without any fluids. Labs were notable for a Hct of 23.7 down from 32.7 one week ago on discharge. K+ was 7.2, she was given insulin, D50, calcium gluconate. ECG was V paced without any T wave changes. 10 mg IV Vitamin K given, 1 unit FFP and PRBCs ordered (and given in ED). CTA done in the ED. GI and renal aware. On transfer, vitals were 70s paced 106/59 no fluids RR 15 98% RA. A left groin cordis was placed. . On arrival to the MICU, patient had large melanotic bowel movement, otherwise HD stable. . Of note, patient states that she had an EGD at [**Hospital1 112**] showing gastritis and healed ulcers, as well as [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] which showed polyps that were removed. Past Medical History: Diabetes Hypertension CAD s/p DES to midLAD and BMS to OM1 [**2148-6-20**] Tachy-brady syndrome s/p [**Company 1543**] pacemaker implanted [**2143**] for offset pauses Symptomatic paroxysmal atrial fibrillation s/p afib ablation x2 last one [**9-/2147**] by Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at [**Hospital1 112**]. Does not tolerate 1C agents due to lightheadedness. PVD, recent left SFA stent placement on plavix Mohs procedure for SQC carcinoma of leg SLE Type 1 diabetes mellitus ESRD (end stage renal disease) on dialysis x~2yr (T,TH,Sat) Calcification/fibroadenoma of left breast h/o squamous cell carcinoma, leg and face DJD of knee and hip Anemia in chronic kidney disease Hyperphosphatemia Hyperparathyroidism due to renal insufficiency Cataract Moderate Nonproliferative Diabetic Retinopathy Colonic Adenoma Neuritis/Radiculitis due to Herniated Lumbar Disc OBESITY - MORBID SPINAL STENOSIS - LUMBAR GLOMERULONEPHRITIS - MEMBRANOUS THROMBOCYTOPENIA - IMMUNE ESOPHAGEAL REFLUX ANTICARDIOLIPIN ANTIBODY SYNDROME GLAUCOMA SUSPECT W OPEN ANGLE VARICOSE VEINS ESOTROPIA HISTORY BASAL CELL CARCINOMA POSITIVE PPD PERICARDITIS S/p cholecystectomy, hysterectomy Social History: Used to work as a nurse. [**First Name (Titles) 1817**] [**Last Name (Titles) 1818**], quit 40yrs ago. Denies ETOH and other drugs. Family History: brother who died of esophageal CA Father - DM, [**Name (NI) **] Cancer (70s), Mother -DM, CAD/PVD, Sister - Lupus, Sister - Breast [**Name2 (NI) 3730**] (age 43), Sister - Bladder [**Name (NI) 3730**]. Paternal GF - CRC Physical Exam: ADMISSION EXAM: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact . DISCHARGE EXAM: General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL Neck: supple, JVP not elevated, no LAD CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: no foley Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, 2+ reflexes bilaterally, gait deferred, finger-to-nose intact, She was able to get out of bed with a two person assist and was able to shuffle herself to a wheelchair. Pertinent Results: ADMISSION LABS: [**2148-7-2**] 07:35AM BLOOD WBC-12.5*# RBC-2.43*# Hgb-7.5*# Hct-23.7*# MCV-98 MCH-31.0 MCHC-31.6 RDW-18.8* Plt Ct-182 [**2148-7-2**] 07:35AM BLOOD Neuts-90.6* Lymphs-5.2* Monos-2.3 Eos-1.5 Baso-0.4 [**2148-7-2**] 07:35AM BLOOD PT-55.3* PTT-75.5* INR(PT)-5.5* [**2148-7-2**] 07:35AM BLOOD Glucose-194* UreaN-57* Creat-7.5*# Na-138 K-7.2* Cl-100 HCO3-23 AnGap-22* [**2148-7-2**] 07:35AM BLOOD Calcium-7.8* Phos-6.8* Mg-2.0 [**2148-7-2**] 07:45AM BLOOD Lactate-1.6 . PERTINENT LABS: . DISCHARGE LABS: . MICRO: none . IMAGING: [**2148-7-2**] CT abdomen/pelvis w/o con: 1. Left femoral venous catheter has an unusually short intra-vascular course. 2. 4.6-cm rounded structure in the gallbladder fossa contains a dependent calcification and demonstrates no inflammatory change. This potentially represents a post-operative collection without surrounding inflammation or a retained portion of the gallbladder. Correlation with detailed surgical history is suggested. 3. Sigmoid diverticulosis without evidence of diverticulitis 4. Focus of air within bladder. Please correlate with history for recent instrumentation. 5. Severe vascular calcifications. . [**2148-7-2**] GI Bleeding Study: Blood flow images show normal tracer flow through the large vessels of the abdominal and pelvic vasculature. Dynamic images of the abdomen show tracer extravasation in the right upper quadrant likely in the hepatic flexure of the [**Month/Day/Year 499**] at the onset of the study. Over 72 minutes, there is relatively little transit of isotope reaching only the region of the mid-transverse [**Month/Day/Year 499**]; slow transit is typical of bleeding in the large bowel. IMPRESSION: GI bleed likely in the region of the hepatic flexure of the [**Month/Day/Year 499**]. . [**2148-7-2**] CXR: Exam is limited as the bilateral bases are excluded from the field of view. Where seen the lungs appear clear. Cardiac silhouette is slightly enlarged likely accentuated by positioning however is unchanged. Dense atherosclerotic calcifications noted at the arch. Osseous and soft tissue structures are unchanged. . [**2148-7-2**] Mesenteric angiogram by IR: 1. Extensive atherosclerotic disease, with calcification of multiple vessels seen on fluoroscopic images without contrast. 2. Right common femoral artery access was obtained. Atherosclerotic disease but patent right common femoral artery with contrast flowing through and around the sheath. 3. SMA angiography demonstrated no evidence of active extravasation, specifically within the right [**Month/Day/Year 499**] or hepatic flexure. Additional selective angiography of the middle colic and right colic arteries demonstrated no active extravasation within the [**Month/Day/Year 499**] or visualized portions of small bowel branches. 4. Celiac artery angiography demonstrated no active extravasation within the right upper quadrant. Specifically, no active extravasation is seen within the GDA. 5. Angiography of the hepatic artery demonstrated a 5-6 mm pseudoaneurysm arising off the right hepatic artery. This is likely an incidental finding. No active extravasation was seen from this into any biliary ducts or outside of the vessel lumen. IMPRESSION: No evidence of active extravasation on this mesenteric angiogram. . [**2148-7-3**] CTA abdomen/pelvis: 1. Suboptimal bolus limits evaluation for active GI bleeding, although existing high-density intraluminal contents suggests extravasation from prior angiogram. 2. Mild bladder wall thickening and surrounding fat stranding is suggestive of cystitis, correlate with urinalysis. Further, air seen within the bladder wall may relate to prior Foley placement but emphysematous cystitis is not excluded. 3. Extensive atherosclerosis, without aneurysm. 4. Sigmoid diverticulosis without diverticulitis and cholelithiasis in a gallbladder remnant without cholecystitis. 5. Left adnexal cystic lesion is not fully characterized on this study. If warranted, a non-urgent pelvic ultrasound may be performed. Brief Hospital Course: 67 year old female with SLE, DMI, HTN, ESRD on HD, paroxysmal afib s/p PV isolation x2, tachy-brady syndrome s/p pacer, PVD with SFA stent placement, and NSTEMI s/p DES to LAD and BMS to OM1 on [**2148-6-21**] on aspirin, plavix, and coumadin who presented with melena and BRBPR. . # GIB: Patient presented with melena and BRBPR, suspicious for either an upper or lower GI source. The EGD showed mild gastritis but no active bleeding. The flex sig was also negative for active bleeding. The tagged RBC scan was positive in the hepatic flexure, however when she was taken to IR for a mesenteric angiogram, there was no active bleeding. She continued to have melena so underwent an abdominal CTA (after prep for her iodine allergy), which was also negative for active bleeding. She was scheduled for a colonoscopy which was then cancelled due to her Afib with RVR (see below). Overall she received 8 units of PRBCs, 3 units of FFP, and 1 unit of platelets while in the ICU. It was determined by the team that the colonoscopy can be deferred to the outpatient setting given her relative stability. . # Atrial fibrillation: S/p two ablations in the past, now with pacemaker. We continued her amiodarone but initially held her home metoprolol and diltizem in the setting of the GIB. She went into AFib with RVR on MICU day #3 so she was given IV diltiazem and metoprolol and her home metoprolol and diltiazem were restarted. However, she continued to have RVR and required a diltiazem gtt. She was eventually transitioned to her home doses. . # ESRD: On Tues/Thurs/Sat dialysis schedule, which was continued in the MICU. . # CAD: Patient with NSTEMI one week ago s/p DES to LAD and BMS to OM1. We continued aspirin/plavix despite the GIB given risk for in-stent thrombosis one week out. This was discussed with her [**Date Range **] outpatient cardiologist. . # PVD s/p SFA stenting recently: Recent peripheral angiogram by Dr. [**Last Name (STitle) 3407**] with angioplasty/stenting of the left SFA and angioplasty of the left tibial artery; had been on plavix prior to NSTEMI. She has 2 gangrenous toes, which appear similar to prior. Continued aspirin/Plavix. . # Chronic pain: Continued home gabapentin and dilaudid. . # Depression: Continued sertraline. # Goals of Care: Patient expressing interest in rethinking her goals of care. She is considering a do not hospitalize, but would like to talk things over with her family before making these decisions. She will speak to her primary care doctor, Dr. [**Last Name (STitle) 1057**], about these issues. She had declined rehab while in the MICU and was very insistent on going home. Because she had good family support and very good insight into her condition, she was discharged home with close follow up by the MICU team. She felt weak at home and was not able to navigate her home as well as she would have liked. The [**Last Name (STitle) 2287**] case managers arranged for her to go to [**Hospital 1785**] Rehab from home the day after admission. The MICU team was in communication with the case manager and primary care doctor during the post-discharge period in order to faciliatate a proper disposition. There is a separate note in OMR detailing this. Medications on Admission: 1. diltiazem HCl 120 mg Capsule, Extended Release Sig: Three (3) Capsule, Extended Release PO BID (2 times a day): Take 360mg in morning and night and 240mg in afternoon. 2. diltiazem HCl 240 mg Capsule, Extended Release Sig: One (1) Capsule, Extended Release PO DAILY (Daily): Take 360mg in morning and night and 240mg in afternoon. 3. metoprolol succinate 100 mg Tablet Extended Release 24 hr Sig: Two (2) Tablet Extended Release 24 hr PO BID (2 times a day). 4. warfarin 1 mg Tablet Sig: 4.5 Tablets PO once a day: Take 4.5mg daily. 5. amiodarone 200 mg Tablet Sig: One (1) Tablet PO TUES,THURS,SAT (). 6. fluorouracil 0.5 % Cream Sig: One (1) application Topical once a day for 2 weeks: apply to face with bactroban. 7. Bactroban 2 % Cream Sig: One (1) application Topical once a day for 2 weeks: Apply to face with Fluorouracil. 8. gabapentin 300 mg Capsule Sig: One (1) Capsule PO TID (3 times a day). 9. sertraline 50 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). 10. Ferrlecit 62.5 mg/5 mL Solution Intravenous 11. lorazepam 1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 12. tramadol 50 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed for pain. 13. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 14. Voltaren 1 % Gel Sig: One (1) application Topical four times a day: Apply to affected area up to 4times daily. 15. Epogen Injection 16. insulin aspart 100 unit/mL Solution Sig: One (1) injection Subcutaneous four times a day: Take as directed according to home sliding scale. 17. hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q3H (every 3 hours) as needed for Pain. 18. sevelamer carbonate 800 mg Tablet Sig: 1.5 Tablets PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 19. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 20. acetaminophen 650 mg Tablet Sig: Two (2) Tablet PO twice a day as needed for Pain. 21. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*0* 22. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for Chest pain: Place 1 tablet under the tongue for chest pressure. Take 1 every 5 minutes, up to three times in a row. Disp:*30 Tablet, Sublingual(s)* Refills:*0* 23. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*0* 24. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 25. doxercalciferol Intravenous Discharge Medications: 1. Amiodarone 200 mg PO QTUTHSA (TU,TH,SA) 2. Aspirin 81 mg PO DAILY 3. Atorvastatin 80 mg PO DAILY 4. Clopidogrel 75 mg PO DAILY 5. Gabapentin 300 mg PO TID 6. HYDROmorphone (Dilaudid) 2 mg PO Q3H:PRN pain 7. Insulin SC Sliding Scale Fingerstick QACHS Insulin SC Sliding Scale using HUM Insulin 8. Lorazepam 1 mg PO BID: PRN anxiety Hold for sedation or RR<12. 9. Mupirocin Cream 2% 1 Appl TP QD 10. Nephrocaps 1 CAP PO DAILY 11. sevelamer CARBONATE 1200 mg PO TID W/MEALS 12. Pantoprazole 40 mg PO Q12H RX *pantoprazole 40 mg 1 Tablet(s) by mouth twice a day Disp #*60 Capsule Refills:*0 13. Diltiazem Extended-Release 360 mg PO QAM 14. Diltiazem Extended-Release 240 mg PO QPM 15. Diltiazem Extended-Release 360 mg PO QHS hold for sbp<100, hr<55 16. Sertraline 150 mg PO DAILY 17. TraMADOL (Ultram) 50 mg PO BID: PRN pain 18. Metoprolol Succinate XL 200 mg PO BID 19. Nitroglycerin SL 0.3 mg SL PRN chest pain take one tab under your tongue if you have chest pain. [**Month (only) 116**] repeat up to three times, five minutes apart. Please call 9-1-1 if your chest pain persists. Discharge Disposition: Home With Service Facility: [**Hospital 2255**] [**Name (NI) 2256**] Discharge Diagnosis: Lower GI Bleed Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Dear Ms. [**Known lastname 21056**]: It was a pleasure to take care of you at [**Hospital1 18**]. You were seen in the hospital because of a gastrointestinal bleed, likely secondary to a high INR. Your coumadin was held and you were transfused with multiple units of blood. Your blood counts then remained stable. You will likely need to follow up with an outpatient gastroenterologist for a colonosocpy at some point in the next several months. We made the following changes to your medications: STOP Coumadin - You should have a conversation with your primary care doctor about when you should restart this medication given your bleed DECREASE aspirin to 81 mg daily START pantoprazole 40 mg PO twice a day STOP Omeprazole Followup Instructions: You need to make an appointment to see your primary care doctor within the next week. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 2764**] Completed by:[**2148-7-9**]

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Discharge summary

report

Admission Date: [**2200-4-1**] Discharge Date: [**2200-4-25**] Date of Birth: [**2159-10-27**] Sex: F Service: [**Hospital1 **] MEDICINE HISTORY OF PRESENT ILLNESS: This 40-year-old woman is transferred from the [**Hospital Ward Name 516**] to the [**Hospital Ward Name 517**] on [**2200-4-15**] for further management of liver failure. She has a past medical history significant for HIV and hepatitis C seropositivity. A liver biopsy in [**2196-2-1**] revealed the presence of grade 2 inflammation and Stage II-III fibrosis. Prior to admission, the patient had been receiving a course of PEG-interferon and ribavirin for her hepatitis C. She was also taking Trizivir antiretroviral therapy for HIV. She initially presented to the ED on [**4-1**] with a three week history of sore throat, pain with swallowing, nasal congestion, cough productive of white sputum, nausea, vomiting, and painful swelling of the left lower extremity. She reports taking [**1-6**] Extra Strength Tylenol every four hours for several weeks for management of her painful symptoms. On admission, she was found to be in acute liver failure with AST of 2,158, ALT 948, total bilirubin 6.0, and alkaline phosphatase of 142. She was additionally found to have pancreatitis with amylase in the 400's and lipase in the 300's. She was admitted to the [**Hospital Unit Name 153**] and stayed there for seven days and before being transferred to the floor on the [**Hospital Ward Name 516**]. A summary of her medical problems up until time of transfer to the [**Hospital Ward Name 517**] is as follows: 1. Liver disease/pancreatitis: The patient's acute liver failure was attributed to Tylenol toxicity in the setting of chronic liver disease secondary to hepatitis C. She was treated with intravenous N-acetylcysteine and her antiretroviral therapy was held. With treatment her liver function tests improved. The pancreatitis was also attributed to acetaminophen toxicity by the Toxicology consult service. Her amylase and lipase also improved with treatment. Complications of her liver failure included thrombocytopenia, impaired synthetic function with coagulopathy and hypoalbuminemia, and portal hypertension with ascites and splenomegaly. The patient's peak INR was 4.6 on [**4-2**] and her peak PTT was 80 on [**4-16**]. She developed epistaxis as well as grossly bloody stools in the course of her hospital stay. She received several units of fresh-frozen plasma and was transfused a unit of packed red cells for a drop in her hematocrit to 24.2 on [**4-8**]. A MRCP was performed to evaluate for additional causes of pancreatitis and/or obstructive biliary disease. This study was negative for obstruction of the bile ducts, but did show evidence of acute liver inflammation as well as portal hypertension. The pancreas appeared normal. Patient had a brief period of hepatic encephalopathy with confusion and asterixis. She was placed on lactulose with an appropriate increase in stool output and resolution of her confusion and asterixis. 2. Cellulitis: The patient received an ultrasound evaluation of the left lower extremity for her pain, erythema, and swelling on [**2200-4-3**]. This study revealed an area of tracking subcutaneous edema, but no deep vein thrombosis. The clinical picture was felt to be most consistent with cellulitis, and the patient was started on cefazolin. This antibiotic was changed to Unasyn when the patient did not appear to respond. As of time of transfer to the [**Hospital Ward Name 12053**], the patient was on day 10 of IV Unasyn. 3. Pharyngitis: The patient was initially felt to most likely have a viral supraglottitis. The ENT service was consulted and after an evaluation with laryngoscopy, they recommended administration of a proton-pump inhibitor for potential laryngeal reflux. They also recommended starting nystatin for empiric treatment of [**Female First Name (un) **] esophagitis. Swabs for viral culture were obtained and at time of transfer to the [**Hospital Ward Name 517**], had not revealed the presence of a viral infection. 4. Skin changes: The patient had two bullous skin lesions on her back on admission. She was evaluated by the Dermatology service. A biopsy revealed changes consistent with bullous impetigo. The consult recommended initiating topical mupirocin in addition to sterile dressings. 5. HIV: Patient's HAART was held on admission because of her liver failure. A CD4 count was drawn on [**4-2**] and returned at 574. In summary, the patient's main issues at time of transfer to the [**Hospital Ward Name 517**] were her continued liver failure, GI bleed of unknown source, persistent left lower extremity cellulitis, and persistent sore throat. She was transferred to be followed more closely by the Hepatology service. PAST MEDICAL HISTORY: 1. HIV diagnosed in [**2194**] when the patient requested in-[**Last Name (un) 5153**] fertilization. The infection is most likely secondary to heterosexual contact as the patient had a previous significant other who is deceased from HIV. 2. Hepatitis C diagnosed in [**2194**] and treated with ribavirin and PEG-interferon. 3. Anemia. 4. Depression. 5. Hypercholesterolemia. MEDICATIONS ON TRANSFER: 1. Lidocaine 2% 20 mL po tid prn. 2. Citalopram 20 mg po q day. 3. Nystatin oral suspension 5 mL po qid. 4. Mupirocin cream 2% one application [**Hospital1 **]. 5. Unasyn 3 grams IV q8h day #10. 6. Lidocaine jelly 2% one application topically q12h. 7. Protonix 40 mg po q12h. 8. Zofran 2 mg IV q6h prn. 9. Oxycodone 5 mg po q6h prn. 10. Lasix 40 mg IV q day. 11. Kaopectate/Benadryl/viscus lidocaine 30 mL po tid prn. 12. Vitamin K 10 mg po q day. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient previously smoked [**6-10**] cigarettes per day prior to admission. She denies the use of recreational drugs. She drinks alcohol occasionally. She formally worked as a salesperson until [**2194**]. PHYSICAL EXAMINATION AT TIME OF TRANSFER: Temperature 98.0, heart rate 78-112, blood pressure 101-120/60-76, oxygen saturation 97% on room air. In's/out's: 1,[**Telephone/Fax (1) 22653**]. Weight 75.1 kg. General: Pleasant, in no acute distress. HEENT: Icteric sclerae, pupils equal, round, and light responsive, extraocular motility intact, oropharynx icteric and moist. Skin: Bandage over biopsy site on upper back, generalized jaundice throughout. Neck: Normal jugular venous pressure, no palpable lymphadenopathy. Heart: Tachycardic, regular rhythm, grade 2/6 systolic murmur at the left lower sternal border, no rubs or gallops. Lungs: Decreased breath sounds at the right base, few crackles bilaterally, otherwise clear to auscultation and without egophony. Abdomen: Slightly distended, diffuse tenderness with maximum tenderness in the lower abdomen, no rebound or guarding, bowel sounds normoactive. Extremities: No cyanosis; 3+ pitting edema to the knees bilaterally, left calf with a bright red area, warm and tender to palpation (28 x 10 cm in extent). Neurologic: Alert and oriented times three, speech fluent, thought content appropriate, no asterixis. LABORATORIES AT TIME OF TRANSFER: White blood cell count 8.2, hematocrit 32.5, platelets 44. INR 2.5, PTT 50.9. Sodium 136, potassium 3.0, chloride 105, bicarbonate 25, BUN 12, creatinine 1.1, glucose 122, calcium 8.6, magnesium 1.5, phosphorus 4.1. ALT 31, AST 58, alkaline phosphatase 149, amylase 217, total bilirubin 10.7, albumin 2.1. Respiratory culture pending, throat culture for beta Streptococcus and GC pending. Throat culture from [**4-5**] with 2+ budding yeast, Clostridium difficile toxin assay negative x3, CMV-DNA not available, HSV antigen negative, VZV antigen negative, CMV IgM negative, EBV IgM negative, viral culture negative for adenovirus, enterovirus, herpes simplex virus, RSV, influenza, parainfluenza. Bacterial wound culture with gram-positive cocci in pairs, coagulase negative Staph sparse. Blood cultures negative x3. Abdominal ultrasound revealing patent hepatic vasculature, appropriate flow directionality, small fluid around and in the left lower quadrant, edematous gallbladder. MRCP with pathological enhancement of the liver in the arterial phase consistent with vasospasm due to acute inflammation, portal hypertension, Morgagni hernia with the liver in it, no gallbladder stones, intra or extrahepatic bile duct dilatation, normal evaluation of the pancreas. HOSPITAL COURSE BY PROBLEM: 1. Liver failure complicated by hypoalbuminemia with third spacing of fluids, coagulopathy, portal hypertension with mild ascites, splenomegaly with thrombocytopenia, and macrocytic anemia: The patient continued to be treated supportively for her liver failure. She was diuresed and with Lasix 40 mg IV bid and spironolactone 100 mg po q day. She was consistently negative in her fluid balance and her anasarca improved. On [**4-19**], Lasix dose was changed from 40 mg IV bid to 40 mg po bid. The patient received 10 mg of vitamin K q day for treatment of her coagulopathy, but continued to have INR's in a range between 2 and 3. Likewise, her PTT's were consistently elevated in the 40's and 50's. By time of discharge, liver function tests had trended down to following levels: ALT 16, AST 42, alkaline phosphatase 130, and total bilirubin 7.1; direct fraction 3.4. 2. GI bleed: On [**4-16**], the patient had hematemesis in the setting of drinking GoLYTELY for colonoscopy prep. The vomited fluid was clear with blood clots. The patient received 2 units of fresh-frozen plasma, one bag of cryoprecipitate, and 1 unit of packed red cells. She received an EGD on [**4-17**], which revealed a single oozing 5 mm ulcer in the lower third of the esophagus, normal stomach, and normal duodenum. No esophageal varices were seen. A colonoscopy performed on [**4-17**] revealed nonbleeding grade 1 internal hemorrhoids, and otherwise normal colonoscopy exam to the cecum. The patient was continued on her proton-pump inhibitor dose to [**Hospital1 **]. An esophageal swab from the ulcer was tested for HSV-I and II. The patient was placed on empiric acyclovir followed by valaciclovir. At time of discharge, she was planned to complete an additional two weeks of valaciclovir. 3. Left lower extremity cellulitis: The Infectious Disease service was consulted regarding management of the patient's cellulitis, which appeared to be refractory to antibiotic therapy. They recommended continuing the Unasyn and obtaining a MRI of the left lower extremity to evaluate for presence of osteomyelitis. The MRI revealed a large fluid collection tracking down into the calf, potentially representing a ruptured [**Known lastname 4675**] cyst versus an independent infectious process. A possible aspiration of this fluid to evaluate for infection was considered, but it was decided that a procedure would potentially cause more harm than benefit as the patient had a persistent coagulopathy and could potentially bleed into the space. It was therefore decided that the patient would continue on antibiotics for the cellulitis. She was converted to oral antibiotics (Augmentin) with plans to complete an additional two weeks after discharge. 4. Sore throat: Patient described persistent sore throat. The ENT service was reconsulted regarding further workup and management. In their impression, the patient's odynophagia was likely related to candidiasis with overlying reflux. The patient was subsequently placed on nocturnal humidification and fluconazole was added to her antifungal regimen. By time of discharge the patient was symptomatically improved with less of a sore throat. 5. Bullous impetigo: The Dermatology service was reconsulted in regarding the lesions on the patient's back. At the time ([**2200-4-23**]), patient had ulceration with minimal crusting and a pink epithelialized rim of her major back lesion. She had a lesion on her neck that was ulcerated and oozing brown material. In the impression of the Dermatology service, the back lesion was healing well and the ulcerated left neck lesion continued to have an element of impetigo. They recommended continuing Bactroban with sterile gauze dressing changes made q day to [**Hospital1 **]. 6. Persistent coagulopathy: As aforementioned, the patient had a persistent coagulopathy despite resolution of her elevated transaminases and the administration of vitamin K. The Hematology service was consulted, and the impression was that the differential diagnosis for the patient's persistent coagulopathy included decreased synthetic function by the liver, DIC, and inhibitor to clotting factors. An inhibitor screen was sent, and was pending at time of discharge. The patient was scheduled to followup in Hematology/[**Hospital **] Clinic for further evaluation of her coagulopathy. DISCHARGE DIAGNOSES: 1. Acute on chronic liver failure secondary to acetaminophen ingestion. 2. Hepatitis C virus infection. 3. Human immunodeficiency virus infection. 4. Left lower extremity cellulitis. 5. Left lower extremity cystic structure in calf, ruptured [**Known lastname **]s cyst. 6. Esophageal ulcer. 7. Internal hemorrhoids. 8. Laryngeal candidiasis. 9. Anemia secondary to blood loss with hypoproliferative bone marrow response. 10. Thrombocytopenia secondary to liver failure and splenic sequestration. 11. Coagulopathy of undetermined etiology. 12. Bullous impetigo. DISCHARGE CONDITION: Fair. DISCHARGE STATUS: Home with services. FOLLOW-UP INSTRUCTIONS: 1. The patient has followup with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 497**] in two weeks. 2. To follow-up with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] in two weeks. 3. Follow-up in [**Hospital **] Clinic to be determined. DISCHARGE MEDICATIONS: 1. Lasix 40 mg po q day. 2. Potassium 40 mEq po q day. 3. Fluconazole 100 mg q day for two weeks. 4. Augmentin 875-125 one tablet [**Hospital1 **] for two weeks. 5. Valaciclovir 100 mg [**Hospital1 **] for two weeks. 6. Protonix 40 mg po q12h. 7. Spironolactone 100 mg po q day. 8. Oxycodone 5 mg q6h prn. 9. Celexa 20 mg q day. 10. Lidocaine 30 mL po tid prn. 11. Lactulose 30 mL po tid prn to achieve three or more stools per day. 12. Mupirocin cream one application topically [**Hospital1 **]. 13. Vitamin K 10 mg po q day. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 8507**], M.D. [**MD Number(2) 22654**] Dictated By: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD MEDQUIST36 D: [**2200-5-26**] 15:57 T: [**2200-6-3**] 09:05 JOB#: [**Job Number 22655**]

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icd9cm

[ [ [] ] ]

[ "38.93", "86.11" ]

icd9pcs

[ [ [] ] ]

13483, 13530

12898, 13461

13863, 14708

8502, 12877

183, 4834

13554, 13840

5259, 5746

4856, 5234

5763, 8474

65,341

122,777

22848

Discharge summary

report

Admission Date: [**2162-1-16**] Discharge Date: [**2162-1-26**] Date of Birth: [**2101-6-19**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**Known firstname 922**] Chief Complaint: non ST elevation mycardial infarction, acute. Major Surgical or Invasive Procedure: Aortic Valve replacement (27mm Tissue) [**2162-1-22**] left heart catheterization, coronary angiography History of Present Illness: This 60 year old male with ESRD on HD (MWF), and known bicuspid aortic valve with AS (1.0 [**Location (un) 109**]) presented to [**Location (un) **] with paroxysmal nocturnal dyspnea. The patient reports that 1 week prior, after "skidooing", he became acutely short of breath and feeling his heart pounding. EMS was called and they gave him O2 and monitored his VS. with resolution of his symptoms. The day prior to admission, after dialysis, the patient reports that prior to dinner he had substernal burning sensation with some radiation into the right shoulder. The pain was [**10-2**] and lasted 4 hours. It was not associated with excertion and simialar to his prior heart-burn. The patient had run out of his PPI. The pain resolved on its own and he was able to eat dinner. He then went to sleep and awoke several hours later acutely SOB and again gasping for air. He also felt his "heart beating out of his chest." EMS was called and he went to [**Hospital3 7569**]. He was tachycardiac in the ED and thought to either be in sinus tach vs V-tach. He was given 10mg IV dilt, 40mg IV lasix and carotid massage. BNP:3120, CPK:152, Trop:1.04. He was transferred here for further management. It was thought he most likely has sinus tachycardia with a left bundle branch. . In the ED VS: 97.9 104 129/77 18 97%RA. The patient was in NAD. CK: 355 MB: 53 MBI: 14.9 Trop-T: 0.44. He was started on a heparin infusion and ordered for plavix which was not given. He was also given levofloxacin 250mg IV x1 for possible RLL pneumonia. On the floor he was chest pain free, breathing comfortably without any complaints. He reports SOB with walking short distances (down the [**Doctor Last Name **]). No orthopnea, lower extremety edema. Past Medical History: hepatitis C hypertension end stage renal disease on HD hypercholesterolemia secondary hyperparathyroidism congenital bicuspid aortic valve aortic stenosis chronic, systolic heart failure aortic insufficiency homocysteinemia anemia of chronic disease Social History: married, 1 ppd x 45 years, no alcohol, no drugs Family History: Brother MI at age 62 Mother had some type of cancer Physical Exam: VS: 98.8, 120/69, 94SR, 18, 93%RA General: NAD, WG, chronically ill appearing [**First Name5 (NamePattern1) 4746**] [**Last Name (NamePattern1) 4459**]: unremarkable Lungs: CTAB CV: RRR, no murmur or rub Abd: +BS, soft, non-tender, non-distended Ext: warm, no edema Sternal Incision: c/d/i without erythema or drainage Neuro: grossly intact Pertinent Results: [**2162-1-25**] 11:53AM BLOOD WBC-6.5 RBC-2.61* Hgb-8.5* Hct-24.0* MCV-92 MCH-32.6* MCHC-35.4* RDW-15.6* Plt Ct-129* [**2162-1-26**] 08:50AM BLOOD Hct-27.5* [**2162-1-25**] 11:53AM BLOOD Glucose-196* UreaN-36* Creat-6.0* Na-136 K-5.0 Cl-99 HCO3-25 AnGap-17 [**2162-1-26**] 08:50AM BLOOD K-4.4 Cardiology Report ECG Study Date of [**2162-1-16**] 5:25:08 AM Sinus rhythm. Left bundle-branch block. Compared to the previous tracing of [**2158-1-24**] left bundle-branch block is new. CXR [**1-16**] IMPRESSION: 1. Hyperinflation consistent with chronic lung disease. 2. Small bilateral pleural effusions. 3. Interstitial pulmonary edema. 4. Probable right lower lobe pneumonia. RUQ U/S [**1-17**] IMPRESSION: 1. Slightly coarsened echotexture of the liver. 2. Patent portal venous and hepatic veins with normal flow in terms of directions and velocity. 3. Main hepatic artery normal in terms of waveform. 4. Bilaterally small kidneys consistent with chronic renal disease Cath [**1-18**] COMMENTS: 1. Coronary angiography of this right dominant system revealed single vessel branch CAD with diffuse atherosclerosis. The LMCA had mild distal tapering. The LAD was heavily calcified with a tubular 35% stenosis in the mid vessel; the D1 origin had a 70% stenosis. The LCx had a 40% proximal taper. The RCA had a 30% mid vessel stenosis. 2. Resting hemodynamics revealed mildly elevated right sided filling pressures with RVEDP of 10 mm Hg. Left sided filling pressures were severely elevated with LVEDP of 37 mm Hg. Moderate to severe pulmonary arterial hypertension was present; mean PCWP was elevated at 30 mm Hg. Systemic arterial pressures were elevated with aortic systolic pressure of 155 mm Hg. Cardiac index was preserved at 3.1 l/min/m2. 3. Peak to peak gradient across the aortic valve was 46 mm Hg. Mean aortic valve area was calculated to be 0.5 cm2. 4. Left ventriculography was not performed. 5. The right common femoral and right common iliac arteries were heavily calcified, causing some initial difficulty in advancing the J wire into the abdominal aorta. 6. 20-30 mm pulsus alternans was present after crossing with a double lumen pigtail catheter in to the left ventricle. FINAL DIAGNOSIS: 1. Single vessel branch CAD with diffuse atherosclerosis. 2. Moderate-severe pulmonary arterial hypertension. 3. Severe LV diastolic dysfunction. 4. Moderate to severe aortic stenosis; calculated [**Location (un) 109**] underestimated in setting of know 3+ AI and cannot be accurately computed using estimated O2 consumption due to need for supplemental O2. 5. Calcified peripheral arterial atherosclerosis. 6. Pulsus alternans consistent with aortic regurgitation and/or LV systolic dysfunction. 7. No evidence of intracardiac shunting. TTE [**1-19**] The left atrium is moderately dilated. The left atrium is elongated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. Regional left ventricular wall motion is normal. Overall left ventricular systolic function is low normal (LVEF 50 %). Right ventricular chamber size and free wall motion are normal. The aortic root is moderately dilated at the sinus level. The number of aortic valve leaflets cannot be determined. The aortic valve leaflets are severely thickened/deformed. There is severe aortic valve stenosis (area <0.8cm2). Mild to moderate ([**12-25**]+) aortic regurgitation is seen. The aortic regurgitation jet is eccentric, directed toward the anterior mitral leaflet. [Due to acoustic shadowing, the severity of aortic regurgitation may be significantly UNDERestimated.] The mitral valve leaflets are severely thickened/deformed. There is moderate thickening of the mitral valve chordae. Mild (1+) mitral regurgitation is seen. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Severe aortic stenosis. Mild to moderate aortic regurgitation. Low-normal left ventricular systolic function. Moderate pulmonary hypertension. Moderate aortic root dilation. Compared with the prior study (images reviewed) of [**2158-1-23**], left ventricular systolic function is mildly reduced, the left ventricular cavity size is larger and the severity of aortic stenosis has progressed. Brief Hospital Course: The patient has a history of hepatitis C and therefore was evaluated and cleared by hepatology prior to surgery. He was brought to the operating room on [**2162-1-22**] where he underwent aortic valve replacement (27mm [**Company 1543**] mosaic tissue). Overall he tolerated the procedure well and postoperatively was transferred to the CVICU on epi, vasopressin, and levo. He was extubated within 24 hours and all drips were weaned. Chest tubes and pacing wires were discontinued without complication. He was transferred to the telemetry floor for further recovery. The patient was dialyzed according to the recommendations of the renal service. Postoperative course was uneventful. The patient made excellent progress with physical therapy, showing good strength and balance prior to discharge. By the time of discharge on POD 4 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. He was discharged home with VNA services. Medications on Admission: Epo @ dialysis ASA 81mg daily Sensipar 120mg Docusate 100mg [**Hospital1 **] Flomax 0.8mg daily Lisinopril 20mg [**Hospital1 **] Methadone 10mg TID Protonix 40mg [**Hospital1 **] Renagel 800mg QC Dialyvite 800 Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*100 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 3. Acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q4H (every 4 hours) as needed. Disp:*100 Tablet(s)* Refills:*0* 4. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain for 4 weeks. Disp:*50 Tablet(s)* Refills:*0* 5. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: Two (2) Capsule, Sust. Release 24 hr PO HS (at bedtime). 6. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Cinacalcet 30 mg Tablet Sig: Four (4) Tablet PO QPM (once a day (in the evening)). 9. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 10. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 11. Nicotine 21 mg/24 hr Patch 24 hr Sig: One (1) Patch 24 hr Transdermal DAILY (Daily). Disp:*30 Patch 24 hr(s)* Refills:*2* 12. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day). Disp:*30 Tablet(s)* Refills:*2* 13. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO twice a day: 200mg twice daily for 2 weeks, then 200mg daily until further instructed. Disp:*56 Tablet(s)* Refills:*0* 14. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. Disp:*60 Capsule(s)* Refills:*0* 15. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Location (un) **] Nursing Service Discharge Diagnosis: acute myocardial infarction (NSTEMI) Bicuspid aortic valve chronic systolic heart failure aortic stenosis aortic insufficiency s/p aortic valve replacement end stage renal disease on hemodialysis hypertension hypercholesterolemia secondary hyperparathyroidism Hepatitis C homocysteinemia anemia of chronic disease Discharge Condition: good Discharge Instructions: shower daily, no baths or swimming no lotions, creams or powders to incisions no driving for 4 weeks and off all narcotics no lifting more than 10 pounds for 10 weeks report any weight gain greater than 2 pounds a day or 5 pounds a week report any fever greater than 100.5 report any redness of, or drainage from incisions take all medications as directed Followup Instructions: Dr. [**Last Name (STitle) 914**] in 4 weeks ([**Telephone/Fax (1) 170**]) Dr.[**Known firstname **] [**Last Name (NamePattern1) 19334**] in [**12-25**] weeks ([**Telephone/Fax (1) 41354**]) Dr. [**First Name (STitle) 3459**] at VAH in 2 weeks [**Wardname 5010**] wound clinic in 2 weeks Please call for appointments Completed by:[**2162-1-26**]

[ "585.6", "285.9", "414.01", "410.71", "746.4", "416.0", "486", "428.22", "428.0", "588.81", "403.91", "571.5", "424.1" ]

icd9cm

[ [ [] ] ]

[ "35.21", "39.61", "39.95", "88.56", "37.23" ]

icd9pcs

[ [ [] ] ]

10337, 10404

7304, 8288

365, 471

10762, 10769

3019, 5219

11173, 11520

2589, 2643

8549, 10314

10425, 10741

8314, 8526

5236, 7281

10793, 11150

2658, 3000

280, 327

499, 2235

2257, 2508

2524, 2573

4,383

124,650

17561+17562+56873

Discharge summary

report+report+addendum

Admission Date: [**2120-11-1**] Discharge Date: [**2120-11-16**] Date of Birth: [**2049-1-17**] Sex: M Service: HISTORY OF THE PRESENT ILLNESS: Mr. [**Known lastname **] is a 71-year-old gentleman referred by his cardiologist for a cardiac catheterization at [**Hospital6 2018**] due to complaints of lower chest burning for the past eight months that has woken him up from sleep. He had a recent GI workup which was negative and the pain did not resolve with a trial of proton pump inhibitors. His exercise treadmill test was significant for inferolateral ST changes and reversible inferolateral defect on imaging. PAST MEDICAL HISTORY: 1. Tobacco 55 pack year, current smoker. 2. Osteoarthritis. 3. GERD. 4. Multiple hand surgeries for finger contractures. ALLERGIES: The patient has no known drug allergies. PREOPERATIVE MEDICATIONS: 1. Celebrex 200 mg p.o. q.d. 2. Nitroglycerin p.r.n. HOSPITAL COURSE: The patient was taken to the Cardiac Catheterization Laboratory on [**2120-11-1**]. Cardiac catheterization at that time showed a left ventricular ejection fraction of 35-40%, 80% distal left main coronary artery disease, 50% left circumflex, 60% OM1 and 90% OM2 lesions and a 90% mid RCA lesion. The patient was referred to Dr. [**Last Name (STitle) **] for operative consideration. It was decided by Dr. [**Last Name (STitle) **], due to the patient's severe coronary artery disease, that the patient would be taken to the Operating Room that same day. The patient was taken to the Operating Room by Dr. [**Last Name (STitle) **] for a CABG times four with LIMA to LAD, SVG to OM1, SVG to OM2, and SVG to RCA. The total bypass time was 87 minutes, cross clamp time was 72 minutes. Transesophageal echocardiogram showed an ejection fraction of 40% with mildly depressed LV systolic function, improved postoperatively in light of inotropes. Normal RV systolic function, trace MR, no AI, and the aorta was intact. The patient was transferred to the Intensive Care Unit in stable condition. Shortly after arriving to the Intensive Care Unit, the patient became profoundly hypotensive and was unable to sustain an adequate blood pressure in spite of being given boluses of fluid and calcium. The patient subsequently became pulseless and was administered boluses of epinephrine, bicarbonate, and fluids. Dr. [**Last Name (STitle) **] was at the bedside. A transesophageal echocardiogram was performed which showed cardiac standstill. The chest was opened at the bedside and internal cardiac massage was begun. The patient's rhythm during this time deteriorated into ventricular fibrillation and was not responsive to internal defibrillation. During open cardiac massage it was noted that there was no blood in the chest cavity when it was initially opened. There subsequently was a large amount of dark blood coming from the region of the right atrium from a presumed tear. The patient was taken emergently back to the Operating Room with Dr. [**Last Name (STitle) **] and Dr. [**Last Name (STitle) 70**], and placed back on bypass. The tear in the right atrium was repaired and the patient was resuscitated. The patient was weaned from bypass with the assistance of an intra-aortic balloon pump, low-dose inotropic support, and the patient was separated from bypass without difficulty. The patient was transferred to the Intensive Care Unit in stable condition where he remained on low-dose [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Last Name (NamePattern1) 3870**] MEDQUIST36 D: [**2120-11-15**] 05:07 T: [**2120-11-15**] 18:52 JOB#: [**Job Number 48974**] Admission Date: [**2120-11-1**] Discharge Date: [**2120-11-16**] Date of Birth: [**2049-1-17**] Sex: M Service: ADDENDUM: On about postoperative day number seven, it was noted that the patient had increasing bilateral patchy infiltrates on his chest x-ray. There was concern that the patient had the beginnings of Amiodarone toxicity. The patient's Amiodarone was discontinued. The patient was also noted to be volume overloaded. The patient's diuresis was increased and the patient was also noted to have an MRSA pneumonia. With the treatment of all of these things, by postoperative day number 14, it was noted that the patient had interval resolution of pulmonary edema with some residual interstitial pulmonary edema present and presence of small bilateral effusions. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Last Name (NamePattern1) 3870**] MEDQUIST36 D: [**2120-11-15**] 05:29 T: [**2120-11-15**] 19:04 JOB#: [**Job Number 48974**] Name: [**Known lastname 3205**], [**Known firstname 33**] Unit No: [**Numeric Identifier 9099**] Admission Date: [**2120-11-1**] Discharge Date: [**2120-11-16**] Date of Birth: [**2049-1-17**] Sex: M Service: . ADDENDUM: This is a continuation of the previous Discharge Summary which was interrupted. HOSPITAL COURSE: The patient was transported from the Operating Room to the Intensive Care Unit with a labile blood pressure on low dose inotropic support with an intra-aortic balloon pump, Levophed and requiring large amounts of volume resuscitation. Vascular Surgery was consulted as the patient's pedal pulses were variable. At that time, the patient had sheaths in bilateral femoral arteries and as the patient had Doppler-able pedal pulses, they were just continued to observe patient. On that first postoperative night, the patient required large amounts of volume resuscitation, continued to remain acidotic, however, the patient progressively stabilized. On the morning of postoperative day number one, the patient's sedation was lightened and he was found to be arousable and moving all extremities and following simple commands. The patient was re-sedated due to his hemodynamic instability. The Vascular Surgical Team continued to follow the patient and felt that the patient's variable pedal pulse examination was due to the bilateral femoral artery cannulation and his lower extremities were not significantly ischemic. The patient was given doses of Lasix for attempt of diuresis due to the large amount of volume resuscitation that the patient had required. By postoperative day number three, the patient was weaned off of epinephrine. The patient continued to require Levophed for maintaining adequate blood pressure. On the morning of postoperative day number three, the patient had been having runs of nonsustained ventricular tachycardia on an amiodarone infusion. The patient developed atrial fibrillation and was given boluses of amiodarone and electrolytes were corrected. The patient initially became hypotensive and the patient required DC-cardioversion and was subsequently converted into sinus rhythm. The patient was subsequently paced with good return of his blood pressure. On postoperative day number four, the patient's intra-aortic balloon pump was weaned and removed without complication. The patient's pedal pulses were improved with the removal of the arterial sheaths. The patient, over the course of postoperative day number four, was weaned off of his pressors and continued to be hemodynamically stable with an adequate cardiac index. On postoperative day number five, the patient was weaned and extubated from mechanical ventilation and required significant pulmonary toilet to maintain oxygenation. By chest x-ray the patient was with increasing pulmonary edema with diffuse patchy infiltrates. On postoperative day number six, the patient underwent a bedside speech and swallow examination. It was recommended that the patient undergo a videoscopic swallowing evaluation which subsequently showed that the patient had functional oropharyngeal swallowing ability for pureed foods and nectar thick liquids. The patient was cleared to eat. The patient had periods of confusion during this time and re-oriented easily. The patient was started on Haldol for episodes of confusion and agitation with good effect. The patient began working with Physical Therapy on postoperative day number seven and was very weak but was able to ambulate about 100 feet with the assist of pushing a wheelchair. The patient continued to require large amounts of pulmonary toilet with occasional nasotracheal suctioning. It was noted on postoperative day number seven that the patient had an elevated white blood cell count. The patient was pan-cultured and subsequent sputum cultures showed that he was growing Methicillin resistant Staphylococcus aureus for which he was placed on Vancomycin. The patient also had a positive urinalysis with subsequent negative urine cultures. The patient was empirically started on ceftriaxone as he had developed a urinary tract infection while on Levofloxacin. As the patient's white blood cell count on postoperative day number 12 had risen to 21,000, the patient was started on Vancomycin and white blood cell count subsequently dropped to 12,000. The patient had been ambulating with Physical Therapy and was able to be transferred to the floor where he continued to work with Physical Therapy and increase his diet. During this time he remained hemodynamically stable. On postoperative day number 14, the patient was cleared for discharge to rehabilitation. CONDITION ON DISCHARGE: Temperature maximum 98.1 F.; pulse 75 and in sinus rhythm; blood pressure 133/68; respiratory rate 17; room air oxygen saturation 92 to 96%. The patient's weight today is 74.3 kilograms. Preoperatively, the patient weighed 72 kilograms. Neurologically, the patient is awake and alert, oriented times three, occasionally forgetful of current situation, however, reoriented easily. The patient is ambulating in the halls without difficulty and is neurologically non-focal. Cranial nerves II through XII are grossly intact. Heart is regular rate and rhythm without rub or murmur. Lungs with bilateral rhonchi, positive sputum production with cough, without wheezes. Abdomen has positive bowel sounds, soft, nontender, nondistended, tolerating regular diet, having normal bowel movement. Bilateral lower extremities with three plus pitting edema, bilateral vein harvest incisions draining small to moderate amounts of serosanguinous fluids, which are covered with a dry sterile dressing. There is no erythema. The sternal incision has staples which were intact. The sternum is stable. White blood cell count is 12.2, hematocrit 30.7, platelet count 410. Potassium 3.5, BUN 19, creatinine 1.0. DISCHARGE DIAGNOSES: 1. Coronary artery disease. 2. Status post urgent coronary artery bypass graft. 3. Postoperative cardiac arrest and re-operation. 4. Postoperative Methicillin resistant Staphylococcus aureus pneumonia. DISCHARGE MEDICATIONS: 1. Lopressor 75 mg p.o. twice a day. 2. Potassium chloride 20 mEq p.o. three times a day. 3. Colace 100 mg p.o. twice a day. 4. Enteric-coated aspirin 325 mg p.o. q. day. 5. Tylenol 350 mg p.o. q. four hours p.r.n. 6. Dulcolax 10 mg p.r. q. day p.r.n. 7. Milk of Magnesia 30 cc p.o. q. day p.r.n. 8. Captopril 25 mg p.o. q. Three times a day. 9. Haldol 1 mg p.o. q. a.m. and 2 mg p.o. q. p.m. 10. Lasix 40 mg intravenously three times a day until lower extremity edema is decreased, and then should be changed to p.o. Lasix. 11. Miconazole nitrate powder applied to bilateral groin three times a day. 12. Nystatin swish and swallow, 5 cc p.o. four times a day. 13. Vancomycin 1 gram intravenously q. 12 hours for two weeks. The patient should have a Vancomycin peak and trough drawn on [**11-17**] and the dose should be adjusted accordingly. 14. Combivent MDI two puffs twice a day. DISCHARGE STATUS: The patient is to be discharged to rehabilitation in stable condition. DISCHARGE INSTRUCTIONS: 1. The patient should follow-up with Dr. [**Last Name (STitle) 9100**] in two weeks. 2. The patient should follow-up with his primary care physician, [**Last Name (NamePattern4) **]. [**Doctor Last Name 9101**] in one to two weeks. 3. The patient should follow-up with Dr. [**Last Name (STitle) 256**] upon discharge from rehabilitation. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 358**], M.D. [**MD Number(1) 359**] Dictated By:[**Last Name (NamePattern1) 5788**] MEDQUIST36 D: [**2120-11-15**] 17:26 T: [**2120-11-15**] 19:08 JOB#: [**Job Number 9102**]

[ "482.41", "427.41", "427.31", "427.1", "599.0", "414.01", "998.2", "427.5", "411.1" ]

icd9cm

[ [ [] ] ]

[ "34.03", "36.15", "39.61", "88.55", "37.61", "37.4", "37.22", "37.91", "88.53", "36.13" ]

icd9pcs

[ [ [] ] ]

10756, 10963

10986, 11973

5173, 9505

11997, 12614

868, 924

662, 842

9531, 10735

782

163,679

13844

Discharge summary

report

Admission Date: [**2176-3-4**] Discharge Date: [**2176-3-7**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5644**] Chief Complaint: chest discomfort, dizziness, blask stool Major Surgical or Invasive Procedure: EGD History of Present Illness: 80 yo M with CAD s/p CABG [**2176-2-12**] on coumadin for Afib (post-surgical)presents with to ED from rehab with evidence of UGIB. * Pt was discharged from [**Hospital1 18**] [**2-23**] to rehab and was doing well. It appears that he was treated for ? of incisional infection with diclox. On the evening of [**3-3**], Pt c/o diaphoresis, nausous and a chest discomfort that felt different than his anginal equivalent and transferred to [**Hospital1 18**] for further eval. On arrival Pt reports black stools for 2-3 days. He denied hematemsis, however in the ED witnessed coffee-ground emesis. NGT was place and hematemsis did not clear to 500cc NG lavage. * In ED VS 96.2, HR 84, BP 118/60. Initial hct 24.1 and INR 2.7. Two 16-ga ivs placed in right arm. Given anzimet, protonix, 2UPRBC, 3UFFP, Vitamin K 5mgsubq. After 2uPRBC, hct remained 23.5, so Pt admitted to MICU for further ebvaluation. * Of note during recent admission for CABG, his admission hct was 44.8 to 25 post-op on [**2-12**]. Was transfused 3 units on [**2-13**] and hct went from 24 to 30.6 but then trended down to mid20s and was 27 on the day of discharge to rehab. Past Medical History: 1. CAD: s/p CABGx 4 on [**2-12**]. Normal EF. 2. Breast Cancer s/p right mastectomy 3. Afib on coumadin 4. OA 5. Hiatal hernnia 6. Glaucoma 7. Hyperlipidemia 8. HTN 9. myelodysplastic syndrome w/ leukocytosis recently Social History: The patient lives with his wife in [**Name (NI) 3494**], but currently in rehab post CABG. A positive history of tobacco (60-pack-year); quit 30 years prior and denies alcohol use or abuse. Family History: NC Physical Exam: VS: 96.2, 84, 118/60, 22 99%2L PE: gen-obese, pale man in NAD heent-PERRl, EOMI, OP wnl, dry MM neck-supple, no JVD cvs-RRR, nl s1/s2, no M/R/G chest-CTAB; sternotomy wound C/D/I abd-soft, NT, ND, NABS, no HSM ext-1+ pedal edema neuro-A&O3, CNs intact, strength 5/5 Pertinent Results: [**2176-3-4**] 02:00AM BLOOD WBC-14.9* RBC-2.53* Hgb-7.3* Hct-24.1* MCV-95 MCH-29.0 MCHC-30.4* RDW-17.8* Plt Ct-207 [**2176-3-4**] 06:30PM BLOOD WBC-21.8* RBC-2.57* Hgb-7.5* Hct-22.9* MCV-89 MCH-29.4 MCHC-32.9 RDW-19.8* Plt Ct-167 [**2176-3-5**] 02:11AM BLOOD WBC-16.6* RBC-3.06* Hgb-9.0* Hct-26.6* MCV-87 MCH-29.4 MCHC-33.9 RDW-18.9* Plt Ct-155 [**2176-3-5**] 06:17AM BLOOD Hct-26.3* [**2176-3-6**] 12:45PM BLOOD WBC-15.0* RBC-3.38* Hgb-10.3* Hct-31.0* MCV-92 MCH-30.4 MCHC-33.1 RDW-19.0* Plt Ct-129* [**2176-3-7**] 10:50AM BLOOD WBC-16.0* RBC-3.65* Hgb-11.4* Hct-33.0* MCV-90 MCH-31.1 MCHC-34.4 RDW-18.7* Plt Ct-119* [**2176-3-4**] 02:00AM BLOOD Neuts-70 Bands-0 Lymphs-7* Monos-14* Eos-2 Baso-2 Atyps-1* Metas-3* Myelos-1* [**2176-3-4**] 11:40AM BLOOD Neuts-70 Bands-3 Lymphs-8* Monos-18* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-1* [**2176-3-4**] 02:00AM BLOOD PT-20.5* PTT-30.5 INR(PT)-2.7 [**2176-3-4**] 06:30PM BLOOD PT-17.2* PTT-27.2 INR(PT)-1.9 [**2176-3-7**] 10:50AM BLOOD PT-14.5* PTT-26.4 INR(PT)-1.3 [**2176-3-4**] 02:00AM BLOOD Glucose-132* UreaN-52* Creat-1.0 Na-139 K-4.6 Cl-105 HCO3-28 AnGap-11 [**2176-3-6**] 12:45PM BLOOD Glucose-215* UreaN-23* Creat-1.0 Na-138 K-3.5 Cl-107 HCO3-25 AnGap-10 [**2176-3-7**] 10:50AM BLOOD UreaN-17 Creat-0.9 K-3.4 [**2176-3-4**] 02:00AM BLOOD CK(CPK)-22* [**2176-3-4**] 11:40AM BLOOD CK(CPK)-23* [**2176-3-4**] 06:30PM BLOOD CK(CPK)-27* [**2176-3-5**] 02:11AM BLOOD CK(CPK)-20* [**2176-3-4**] 02:00AM BLOOD cTropnT-<0.01 [**2176-3-4**] 11:40AM BLOOD cTropnT-<0.01 [**2176-3-4**] 06:30PM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2176-3-5**] 02:11AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2176-3-5**] 02:11AM BLOOD Calcium-8.7 Phos-3.4 Mg-1.8 CXR: 1) Stable cardiomegaly without evidence of congestive heart failure. 2) Small right pleural effusion. Left costophrenic angle excluded from the study. 3) No focal consolidations Left base atelectasis without definite pneumonia. No CHF. EGD: 8mm bleeding ulcer in body of stomach. Hemostasis achieved with Epi and BICAP Brief Hospital Course: 80 yo M with CAD s/p CABG ([**2-10**]), AF on coumadin, MDS with recent leukocytosis p/w melena, UGIB. 1) UGIB: Pt presents to ED with melena and hematesis in setting of coumadin use. In [**Name (NI) **], Pt given IVF along with 2 u PRBCs. INR was reversed with 5mg Vit K SQ and FFP given since Pt was actively bleeding. Pt with minimal response to 3 total units of PRBCs. Gastroenterology service consulted who proceeded with EGD that evening in the MICU. A 8 mm bleeding ulcer in the body of the stomach was found. After application of epinephrine and BICAP, hemostasis was acheived. Pt remained HD stable throughout. Pt recieved a total of 5 units of PRBC in first 24 hours and Hct stabilized. Pt placed on bowel rest, Protonix IV started and cardiac medications held. Serial Hct checked and on HD#2 Pt stable for transfer from MICU to general medicine floor. Diet advanced slowly and diet advanced as tolerated. Hct responded to previous transfusions and Hct maintained above 28. Upon discharge, EGD Bx returned being positive for H.pylori. Pt to be discharged home on Protonix, tetracycline and flagy (times 2 weeks); did not choose Biaxin due to interactions with amiodarone. Pt to follow up with Dr [**First Name (STitle) 679**] on [**4-15**] for repeat EGD. 2) AFib: Pt with hisory of AF post CABG for which he was placed on amio and coumadin with proper anticoagulation. On presentation, INR 2.5 and reversed with a total of 10mg VitK SQ and at discharge was 1.2. Pt to not continue taking coumadin upon discharge. Pt as outpatient on amiodarone, and will continue after discharge. Unsure as to plan for total length of treatment for post-CABG AF with amio. Pt to follow up with Dr [**Last Name (STitle) **] at which time, it should be addressed. 3) CAD: Pt with CAD s/p CABG ([**2176-2-12**]) who presents from rehab with UGIB. As above ASA and BB held. Once Pt stabilized lopressor was restarted and Pt tolerated it well. Pt to stop taking ASA, until decision is made to restart post follow-up EGD. Because of chest discomfort pain, Pt was ruled out for MI by cardiac enzymes. Pt maintained on tele without event. Pt to follow up with CT-[**Doctor First Name **] Dr [**Last Name (STitle) **] on Wed [**3-13**], to asses sternotomy wound and post CABG f/u. Pt to be discharged home on atenolol 25 mg daily. Pt should benefit from ACEi, and will be s/c home on low dose Lisinopril. Pt will need repeat chemistry checked as outpatient. 4) Htn: Pt with h/o HTn for which he was on amlodopine. CCB held during stay because of UGIB. Pt remained relatively normotensive. Decision made for Pt to discontinue CCB until evaluated by PCP or cardiologist. Pt to follow up with Dr [**Last Name (STitle) **] on Tuesday [**3-12**]. At which point, home medical regimen should be reviewed. 5) CHF: No documented of CHF by cath results (EF60%). However Pt has not had an echo. Pt maintened on home regimen of Lasix 20 mg daily, for which he will be discharged on. Pt without evidence of decompensated CHF during stay. Pt should benefit from ACEi, and will be s/c home on low dose Lisinopril. 6) Dipso: Pt seen by PT while in hospital. They felt he was no longer in need for acute rehab. He is being discharged home with services, including PT and cardiac rehab. Medications on Admission: ASA 81 Coumadin 3 Amio 400 [**Hospital1 **] amlodopine 5 lopressor 25 [**Hospital1 **] lasix 20 qd doxazosin 2 qd lipitor 29 colace percocet prn neurontin 600 [**Hospital1 **] allopurinol timolol Discharge Medications: 1. Gabapentin 300 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). [**Hospital1 **]:*120 Capsule(s)* Refills:*2* 2. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 3. Amiodarone HCl 200 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). [**Hospital1 **]:*30 Tablet(s)* Refills:*0* 4. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day: take until told otherwise by doctor. [**Last Name (Titles) **]:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 6. Brimonidine Tartrate 0.15 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 7. Atenolol 25 mg Tablet Sig: One (1) Tablet PO once a day. [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 8. Lisinopril 2.5 mg Tablet Sig: One (1) Tablet PO once a day. [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 9. Doxazosin Mesylate 2 mg Tablet Sig: One (1) Tablet PO once a day. [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 10. Colace 100 mg Capsule Sig: One (1) Capsule PO twice a day. [**Hospital1 **]:*60 Capsule(s)* Refills:*2* 11. Lasix 20 mg Tablet Sig: One (1) Tablet PO once a day. [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 12. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day. [**Hospital1 **]:*30 Tablet(s)* Refills:*2* 13. Flagyl 250 mg Tablet Sig: One (1) Tablet PO four times a day for 2 weeks. [**Hospital1 **]:*56 Tablet(s)* Refills:*0* 14. Tetracycline HCl 500 mg Capsule Sig: One (1) Capsule PO four times a day for 2 weeks. [**Hospital1 **]:*56 Capsule(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: upper GI bleed peptic ulcer disease H. pylori coronary artery disease Discharge Condition: good Discharge Instructions: please take all medications as prescribed. You will no longer take aspirin, coumadin or amlodopine. You may restart taking aspirin after you've had a follow up EGD to look at your ulcer and tald you may restart it. please attend all follow-up appointments, if unable rechedule as soon as possible. please call your PCP or go to ED if: fever >101.4, chest pain, shortness of breath, dizziness, persistent vomitting or diarrhea, black stool, vomit with "coffe grounds" (black particles), or blood in stool or vomit. Followup Instructions: 1) please follow up with your PCP, [**Name10 (NameIs) **] [**Last Name (STitle) **] ([**Telephone/Fax (1) 41556**]), on Tuesday [**3-12**] at 11:00 AM. 2) Please follow up with your cardiothoracic surgeon, Dr. [**First Name11 (Name Pattern1) **] [**Initial (NamePattern1) **]. [**Last Name (NamePattern1) **] ([**Telephone/Fax (1) 170**]) Wednesday [**3-13**] at 1:30 at [**Last Name (NamePattern1) 10357**]. [**Hospital Unit Name **]. Call with questions. 3) Please follow up with Dr [**First Name8 (NamePattern2) 1158**] [**Last Name (NamePattern1) 679**] to have a repeat EGD to evaluate your stomach ulcer, on [**4-15**] at 9:00 AM. Provider: [**Name10 (NameIs) **] WEST,ROOM FOUR GI ROOMS Where: GI ROOMS Date/Time:[**2176-4-15**] 9:00 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **],[**First Name3 (LF) **] PROCEDURES ENDOSCOPY SUITES Where: [**First Name8 (NamePattern2) **] [**Hospital Ward Name **] BUILDING ([**Hospital Ward Name **]/[**Hospital Ward Name **] COMPLEX) ENDOSCOPY SUITE Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2176-4-15**] 9:00

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2736

Discharge summary

report

Admission Date: [**2196-5-10**] Discharge Date: [**2196-7-1**] Date of Birth: [**2134-10-28**] Sex: F Service: MEDICINE Allergies: Codeine / Sulfa (Sulfonamides) / Pineapple Attending:[**First Name3 (LF) 2485**] Chief Complaint: Large B Cell Non-Hodgkin's Lymphoma Major Surgical or Invasive Procedure: none History of Present Illness: 61 y/o F w/ diffuse B cell lymphoma, s/p high-dose chemotherapy with autologous stem cell rescue in [**2195-4-4**] with relapse of disease. Here for MUD Nonmyeloblative Allogeneic Stem Cell Transplantation. .. **Patient was noted to become more hypoxic and required increased O2 requirement during the day. She was noted to be hypersomnolent during the day. BMT moonlighter was notified of status around 8pm, (VS p 90s SBP 90s O2 low 90s on [**5-10**] L o2) who felt she was wet on exam and she was given 40 IV lasix with some effect in terms of urine outpt, but her respiratory status continued to deteriorate and ABG was hypoxic 7/43/40s/60s, CXR w/ diffuse pulmonary infiltrate. lasix 80 x 1 was given around 11pm for concern of pulmonary edema and ?frothy pink production. ICU evaluation was called at 2am. Pt was found to have P 90s SBP 80s, R 30s (chronic all day), low 90s on NRB. She was non-responsive. Patient family was informed of impending need for intubation. Pt family consented for intubation. Intubation was started and she became hypotensive to 60s/30s and acute became asystolic. COde was called. She was started on CPR and 1 mg epi was given. Asytole changed to PEA. . 1 mg epi was given. SHe was also given 1 amp Ca gluc for low ca from lab before. Then, it changed to V Fib, she was shocked once and her pulse returned to 160s BP 90-100. Her BP was drifting down and was started on levophed. Her EKG was notable for sinus tachycardia. Her VS stabilized at P 130s SBP 110-120s and then she was transferred to [**Hospital Unit Name 153**]. SHe received A-line, 1L fluid bolus, started on propofol for agitation and continued on levophed and her antibiotics was changed to linezolid/zosyn/foscarnet/caspofungin to optimize possible VRE infection. Her CXR at [**Hospital Unit Name 153**] s/p intubation showed nl heart size and diffuse, somethwat improved opacitiy but no focal infiltrate. .. She was diagnosed in [**2194-11-3**] after routine CBC. A CT scan of the abdomen and pelvis showed a large mass in the left upper quadrant with numerous enlarged celiac, porta hepatis, splenic and hilar lymph nodes. A fine needle aspirate of the retroperitoneal lymph node unfortunately was nondiagnostic and she underwent a bone marrow biopsy and retroperitoneal lymph node biopsy which did prove positive for diffuse large B-cell non-Hodgkin's lymphoma. She was treated with 6 cycles of R-CHOP resulting in a CR, followed by high-dose chemotherapy and autologous stem cell rescue in [**2195-4-4**]. She relapsed with disease in her spleen and underwent a splenectomy in [**Month (only) 359**] [**2194**]. She received [**Hospital1 **] with rituximab x 6 cycles, and one cycle of Zevalin. [**2196-3-4**] PET scan showed an interval increase in the size of the left upper quadrant mass measuring 2.3 x 5 cm when compared to 1.1 x 2.8 cm. There was also an increase in the size of the left diaphragmatic lymph nodes. She received a combination of gemcitabine and cisplatin x1 and then underwent radiation therapy, completed on [**2196-5-6**]. [**2196-5-9**] underwent a CT scan on a which showed no evidence for adenopathy, particularly in the retroperitoneum at sites of her prior disease. A new right upper lobe opacity was noted. Her chemotherapies have been fairly well tolerated -- she has not had febrile neutropenia, line infections or nausea/vomiting/ diarrhea. She denies fevers, chills, night sweats, sinsus congestion, cough, chest pain, abdominal pain, nausea, vomiting, urinary sx, gyn sx, neurologic changes. Past Medical History: Diffuse large B-cell lymphoma: The pt. was initially diagnosed with diffuse large B-cell lymphoma in [**2194-11-3**] and was treated with R-CHOP for a total of six cycles, which resulted in complete remission. This was followed by an autologous bone marrow transplant as consolidation treatment in [**2195-4-4**]. She relapsed in the spleen in [**2195-9-4**] and underwent plenectomy. Patien then had three cycles of [**Hospital1 **]-R, one cycle of ESHAP-R, and Zevalin. She was planned to undergo a non- ablative matched unrelated donor stem cell transplant. The PET CT that she had [**3-28**] showed an interval increase in the size of the left upper quadrant mass which now measures 2.3 x 5 cm compared to 1.1 x 2.8 cm. There was also an increase in the size of the left diaphragmatic lymph node which now measures nine millimeters. Therefore it was decided that the patient would undergo more chemo with combination of gemcitabine at 1.5 grams per meters squared on day one and eight every three weeks with cisplatin at 50 mg per meters squared on day one and eight. Has now finished cycle 1 of Gemzar/Cisplatin (last chemo was [**4-6**]) . -interstitial pneumonitis -hypothyroidism -migraine headaches -h/o hyperglycemia on steroid tx. -hyperlipidemia -s/p CCY -s/p splenectomy -s/p portacath placement in R subclavian vein -TTE on [**2195-12-28**] with preserved LVEF (>70%) -h/o WPW pattern on ECG Social History: She lives with her husband. She does not have children. She currently works as speech writer and editor. She has never used tobacco. She uses ETOH rarely (few times per month). Family History: Sister dx. with leukemia at age 18. Parents with MI: father at age 59; mother at age 88. Brother with stroke at age 50 and ENT cancer (had h/o tobacco and EtOH use). Physical Exam: TGEN: acute respiratory distress HEENT: mmm, no lad, rosacea on cheeks CV: tachycardic, nl s1/s2, no m/r/g PULMO: coarse BS bilaterally ABD: bs+, nt, nd, no masses EXT: warm, slight LE edema b/l, 2+ DP/PT NEURO: moves all extremities and withdraw to pain Pertinent Results: XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX CT chest/abd/pelvis/bone. IMPRESSION: 1. The patient is status post splenectomy, with no evidence of recurrent, or residual disease within the abdomen or pelvis. 2. New 1.6 x 0.8 cm focal opacity within the right upper lobe. Continued attenuation to this area should be paid on continued follow up scans. 3. Focal area of opacity within the left lobe anteriorly, is unchanged from prior exam, and most likely represents a parenchymal scar. XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX ECG: Sinus tachycardia with ventricular pre-excitation/ [**Doctor Last Name 13534**]-Parkinson-White pattern Since previous tracing of [**2196-4-14**], ventricular pre-excitation/[**Doctor Last Name 13534**]-Parkinson-White pattern now present XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX MRI Head: FINDINGS: Comparison is made with prior study from [**2196-6-10**]. Overall, there has been no change. There are small areas of increased T2 signal within the periventricular white matter, within the deep white matter of both frontal lobes. These are most consistent with chronic microvascular ischemic changes. However, there is no evidence of acute infarct. There is no mass effect. There is no midline shift. The lateral ventricles are normal in size and configuration. The visualized vascular flow voids are normal and present. There is increased T2 hyperintensity within both mastoid sinuses. This is more significant than on the prior examination. These findings could be consistent with inflammatory/infectious etiologies, including opportunistic infection. IMPRESSION: 1.Increased fluid within both mastoid sinuses, could secondary to inflammatory or infectious processes, including an opportunistic infection. 2.Chronic small vessel infarction. X X XXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXXX Liver Bx: 1. No significant portal inflammation. 2.Very rare small cluster of neutrophils in lobule. 3.Occasional necrotic hepatocyte. 4.No evidence of lymphoma. 5.No evidence of graft vs host disease. 6.No evidence of [**Last Name (un) **]-occlusive disease. 7.No fibrosis on trichrome stain. 8.Increased iron predominantly in Kupffer cells and focally in hepatocytes on iron stain. 9.Immunostains for Herpes, CMV, and hepatitis B are negative with appropriate control. 10.Special stains for Fungi, AFB, and pneumonitis are negative with appropriate control. 11.Immunostain for adenovirus was sent to [**Hospital1 **] and will be reported in an addendum. .............................................................. 61 y/o F w/ diffuse B cell lymphoma,MUD Nonmyeloblative Allogeneic Stem Cell Transplantation #hypoxic respiratory distress-CXR concerning for ARDS, less c/w pulmonary edema -Pt had new onset SOB. CxR found large effusions, L>R on Chest CxR ([**6-4**]). Attempting Lasix Drip for diuresis. -improved s/p thoarcentesis, diuresis. -TTE nl - small pericardial effusion, no tamponade, EF >55% -resolved, off o2 on [**6-14**] -Worsened on [**6-18**]. Thoracentesis on [**6-19**], but unremarkable. -off O2 for now -CXR with increasing fluid, gave Lasix x1 on [**6-24**]. -continue coverage w/ linezolid, zosyn, foscarnet, caspofungin -will send additional bld and sputum cx (consider bronch in AM) -will consult w/ ID again in AM for optimal abx coverage (? need for anaerobic coverage) -will cycle enzyme (elevated trop s/p arrest likely [**1-6**] to CPR) -will get ECHO to assess for pericardial effusion (though CXR w/ nl heart size, last ECHO WNL EF) -maintain vent support on AC for now- -TV 6 mg/kg range , plateua pressure 30 -check ABG and adjust vent settings -will ask neurology if seizure ppt #Hypotension and diffuse pulm infiltrate concerning for sepsis, though elevated WBC -aggressive IVF -levophed titrate to stable BP control -will get ECHO to assess for -check CVP (will check off port) -will reassess if aspiration #lactic acidosis -likely sepsis vs CPR -related -will check AM lactate again #. Diffuse B Cell Lymphoma: -MUD Nonmyeloblative Allogeneic Stem Cell Transplantation ([**5-17**]). Tolerated therapy well. -Was off and on CSA, but d/ced on [**6-20**] d/t ?altered MS [**Name13 (STitle) **] prednisone 10bid, then Decadron 2mg IV qD, now SoluMedrol 20 [**Hospital1 **] -? about CSA leading to altered MS, ?LFT abnormalities. Being held. #. Altered Mental Status -waxing and [**Doctor Last Name 688**] -Pt with declining MS over past 2 days. Likely toxic metabolic. -Noncontrast CT normal. MRI with chronic microvascular ischemia - no acute findings on [**6-13**]. -Began to resolve on [**6-13**] - likely toxic-metabolic -[**6-20**] began worsening MS once again. ?CSA toxicity. d/ced CSA. Sent cultures. Did LP - nml, cx negative. Noncontrast CT nml on [**6-20**]. nml TSH. MRI nml. ***EEG from [**6-20**] showed seizure activity. Started IV Dilantin load on [**6-22**]. Will change to Keppra PO once awake, swallowing*** -Dilantin level 2.3 on [**6-23**], re-bolused on [**6-23**], dilantin 7.9 on [**6-24**], re-bolused [**6-24**], dilantin 17.9 on [**6-25**]. - Cont Dilantin 100mg IV tid. Neuro following. -(+) HHV-6 on [**6-25**]. Started Foscarnet 8g q12. -EEG from [**6-28**] still c occasional spikes per Neuro #.Fever -Pt had been spiking low grade fevers, started on empiric cefepime ([**6-6**]). Also started on Caspofungin [**6-5**] for spiking fevers. Flagyl ([**6-5**]) added because of diarrhea, possibiliy of C.Dif, cultures x2 have been negative. - thoracentesis for [**6-7**] --> non-infectious exudate. - Flagyl d/ced on [**6-11**] d/t confusion, possible cause. -thoracentesis on [**6-19**] for reaccumulation of fluid, fevers to 103 -+VRE urine on [**6-15**] --> tx'ed with Linezolid x6 days. D/ced on [**6-22**] -ID consult on [**6-22**], no new recs. Sent for urine/stool adenovirus -Cont'd fevers to 101. Added vanco [**6-26**] -changed to lizezolid/zosyn on top of caspofungin and foscarnet on [**6-29**] #. Increased [**Month/Year (2) 9026**] -Unknown etiology - started [**6-10**]. s/p cholecystectomy -RUQ U/S nml, CT abd/pelvis nml. -Hepatology consulted. -U/S guided liver bx on [**6-20**] - ?CMV. Started gancyclovir [**6-21**]. -Final report showed no CMV, HSV, hepatitis, GVHD, or VOD on liver bx. -Await ID recs when can dc IV Ganciclovir d/ced [**6-25**] #. HTN: h/o and now hypotensive on IV pressors. -Off po meds. Has trended up, but has not required IV antihypertensives -Give Lopressor IV as needed to control BP off po meds. #. Thrombocytopenia -?dilantin vs. ?ganciclovir medication effect. Ganciclovir d/ced on [**6-25**]. Plts remain low. FC COmmunication with husband [**Name (NI) **] [**Name (NI) **] (H) [**Telephone/Fax (1) 13535**], (c) [**Telephone/Fax (1) 13536**] Dispo: ICU for now #FEN-continue TPN for now Brief Hospital Course: +61 y/o WF with a PMHx of B cell lymphoma treated with 6 cycles of R-CHOP, followed by high-dose chemotherapy and autologous stem cell rescue in [**2195-4-4**], relapse and splenectomy in [**9-/2195**], [**Hospital1 **] with rituximab x 6 cycles, and one cycle of Zevalin, continued disease and treatment with gemcitabine and cisplatin x1 and then underwent radiation therapy who presents to [**Hospital1 18**] for MUD nonmyeloablative allogenic SCT. 1. MUD NONMYELOABLATIVE ALLOGENIC SCT: Pt was not given Bactrim PPX secondary to sulfa allergy. She was given Campath seven days before transplant. After the first administration of Campath she experienced fever, tachycardia, rigors, nausea, vomiting, diarrhea. She was given demerol x2, tylenol, and ativan. In addition she was given lopressor for rate control. She tolerated the subsequent doses of Campath well. Fludarabine was started five days and Cytoxan/Mesna four days pre-transplant. Cyclosporine was started day -1. MUD nonmyeloblative allogeneic stem cell transplantation was performed on [**2196-5-19**]. GM-CSF was started day three. She had no significant signs of hematuria or tamponade/pericarditis. Tolerated therapy well. Patient engrafted well, with her counts improving appropriately 9 days post-transplant. Her counts rose to a level of 22,000 due to ?GVHD vs. infection, but trended down to normal range. Two weeks into her post-tx course, Cyclosporine was held due to possible toxicity and altered MS. It was evenutally restarted 3 weeks in due to resolution of MS changes, although when MS worsened once again, it was held and not restarted. During the entire course, her CSA was at times supratherapeutic and thus it was believed may have been causing her symptoms. However symptoms of altered MS persisted once CSA was stopped. Patient was placed on SoluMedrol 20mg IV bid for immunosuppression to prevent graft rejection. 2. FEVER/NEUTROPENIA: Pt had no further fever until day +1, at which time she was started on Cefepime in addition to the acyclovir and fluconazole PPX that had been started on day -1. Vancomycin was started day +2. Caspofungin was started day +5. She spike a fever and flagyl was added for possible C.Dif, cultures were negative x2 for C.Dif. As patient continued into her second week, her counts improved, fevers remitted, and patient was d/ced from Flagyl and vancomycin. As her [**Date Range 9026**] began rising on [**6-10**], patient was d/ced from Caspofungin due to increased [**Month/Day (4) 9026**]. 3. DIARRHEA: Pt had continual diarrhea from days -2 to +3. C. Diff cultures x5 were negative. Pt was given metronidazole empirically with resolution of the diarrhea. 4. ALTERED MS: Approximately 2 weeks post-tx, patient began to have altered MS, difficulty with attention/communicating. Neurology was consulted, patient had a noncontrast head CT that was normal, MRI negative except for chronic microvascular ischemia, and an LP that was cx negative, and was cytology negative. HSV, CMV, EBV, Toxo negative. At the time, patient had an elevated white count, was in acute renal failure with elevated BUN, and with fevers, who was thought to be encephalopathic. Pt had an acute change in MS on [**6-20**], with nonresponsiveness to sternal rub, touch or command, but had spontaneous eye opening and arm movements. Neuro ordered an EEG which showed 3 Hz electrical spikes consistant with ?seizures. Pt was loaded with Dilantin and followed clinically over the last 5 days. Pt has continued to be unresponsive. Repeat EEG [**6-23**] EEG concerning for post-ictal seizure activity, and a repeat EEG on [**6-28**] continued to show spikes possibly c/w seizures. We have continued to titrate up her Dilantin per Neuro recs until spikes disappear on routine EEG. On [**6-27**], pt was found to have (+) HHV-6 from her CSF from LP on [**6-20**]. She was started on Foscarnet per ID recs for treatment of HHV-6, although it is unclear whether all of MS changes are due to HHV-6, or ?seizures d/t HHV-6 infection. 5. WPW PATTERN: Pt's admission ECG was significant for WPW pattern and LBB pattern. She had exhibited this pattern in the past and was asymptomatic. Her tachycardia (both regular WPW pattern and sinus tachycardia) was managed with metoprolol. Per cardiology recommendations, she was monitored on tele for wide qrs patterns, but was recommended to load 100mg procainamide if she became tachycardic with afib, and a wide qrs pattern. PT continued to have sinus tachycardia while occasionally switching into a ventricular pre-excitation rhythmn, but never developed a-fib. 6. +VRE BACTIURIA -Pt was found to have +VRE bactiuria on [**6-17**], her catheter was replaced, and pt was placed on Linezolid 600mg qD. Pt never had positive blood cultures, and her vitals remained stable. Because pt began to have altered MS, and increase in her [**Month/Year (2) 9026**], patient's Linezolid was d/ced after 5 days of therapy due to ?interactions with MS [**First Name (Titles) **] [**Last Name (Titles) 9026**]. 7. ACUTE RENAL FAILURE -Pt was placed on CSA post-tx and developed increasing Creatinine levels, decreased UOP, and worsening pleural effusions. Pt was placed on a Lasix drip and the CSA was held. Pt's Cr peaked at 1.8, and gradually returned to baseline with good UOP. Pt diuresed effectively and was taken off of the Lasix drip. 8. Hypoxia: The patient developed new onset shortness of breath. A CxR found large effusions, L>R on Chest CxR ([**6-4**]). A Lasix Drip for diuresis was started with good urine output. She then had a thoracentesis x2 which removed the left sided effusion. She remained stable on RA - 2L O2 with an oxygen saturation at 95%. 8. FEN: Patient was started on TPN [**5-19**]. It was continued to replete her albumin level, which may have contributed to her fluid overload. D/ced when tolerating PO, and restarted recently when pt's MS [**First Name (Titles) **] [**Last Name (Titles) **] and pt was not tolerating PO diet. More recently on [**6-27**], pt began to have worsening tachypnia, although was still satting 94-95% on 2L. 9. HYPOTHYROID: continued synthroid 100 mcg QD, and switched to Synthroid 50mg IV qD when not tolerating PO meds. 10. MIGRAINE: discontinued verapamil 120 mg QD, no symptoms throughout hospitalization. Continued Hospital Course: O/N on [**6-29**], pt was noted to have increased work of breathing with hypoxia up on bone marrow transplant floor. At this time it was decided that she would be intubated on the floor and then be transported to the ICU for further care, as she was too unstable to be transported prior to intubation. During intubation, pt became asystolic and ACLS protocol was followed. She then transferred to PEA and ACLS protocol was changed accordingly. She then transferred to V-fib and ACLS protocol was again changed accordingly and she regained sinus rhythm with pulse after initial defibrillation. Pt was transported to ICU and her care continued there. Initially pt was kept on caspofungin and foscarnet and other abx were changed to zosyn and linezolid to ensure broad coverage as etiology of her worsening medical condition was not known. She also required transient pressure support with neosynephrine when initially transferred but was subsequently weaned off. During ICU stay, pt was evaluated and consulted by ID, who recommended changing Imipenem to daptomycin for less Bone marrow suppression, so that was performed. Neurology was also seeing pt as she had been in ?status during stay on bone marrow transplant wards. During this time, dilantin dose was adjusted and bedside EEG monitoring was performed which demonstrated decreased amplitude, decreased spike activity. Approximately 48 hours after presentation to ICU, pt became increasingly difficult to ventilate, with PaO2 dropping to below 60 on ABG, requiring increasingly elevated FiO2 and PEEP. On her 3rd day in the ICU, pt became increasingly acidemic and hypotensive, requiring pt to be placed back on neosynephrine pressure support. When pt's pH dropped < 2, pt was placed on Tham x 500mL for non-HCO3 buffer, which transiently raised her pH to 7.2, but it subsequently dropped again below 7.2. During this time, family was informed of the critical nature of the [**Hospital 228**] medical problems and they decided to make the patient DNR and also to not escalate the current amount of intervention, specifically they did not want to dialize the patient and they did not want to add another pressor if her blood pressure required. Throughout the day on pt's 3rd day in ICU, she became increasingly acidemic, with increasing Neosynephrine requirement until the maximum dose of the pressor was reached. At approximately 8:40pm on [**7-1**] pt's heart stopped after BP dropping and HR dropping over previous hours. Pt's family was at bedside. They agreed to full autopsy of pt, as they believed she would want people to learn from her case. Medications on Admission: Vanco/cefipime 2 q 8/caspofungin/foscarnet ursodial [**Hospital1 **] methylprednisone 20 q 12 levothyroxine ISS miconazole powder dilantin 200 q 12 Discharge Medications: None Discharge Disposition: Expired Discharge Diagnosis: Cardiac Failure Respiratory Failure Discharge Condition: Death Discharge Instructions: None Followup Instructions: None

[ "E933.1", "276.8", "787.91", "V16.6", "V17.3", "275.2", "287.5", "518.81", "995.92", "401.9", "599.0", "041.04", "346.90", "518.82", "V45.79", "038.9", "584.9", "244.9", "794.8", "426.3", "200.02", "426.7", "518.0", "428.0", "780.39", "054.3" ]

icd9cm

[ [ [] ] ]

[ "00.92", "99.05", "41.05", "99.23", "00.14", "99.60", "99.04", "96.04", "38.93", "96.71", "99.28", "50.11", "99.15", "33.24", "89.19", "38.91", "03.31", "34.91", "99.29", "99.25" ]

icd9pcs

[ [ [] ] ]

22144, 22153

12929, 19270

339, 345

22232, 22239

6026, 12906

22292, 22299

5564, 5732

22115, 22121

22174, 22211

21942, 22092

19288, 21916

22263, 22269

5747, 6007

264, 301

373, 3919

3941, 5352

5368, 5548

2,513

117,823

25326

Discharge summary

report

Admission Date: [**2148-12-7**] Discharge Date: [**2148-12-16**] Date of Birth: [**2110-2-12**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 348**] Chief Complaint: Infected AICD Major Surgical or Invasive Procedure: AICD removal PICC Central line History of Present Illness: 38 year old male with h/o CAD s/p 2 vessel CABG, biventricular pacemaker placement, dilated cardiomyopathy, and CHF with EF 20-25% who presents with erythema and swelling over AICD site. It was difficult to obtain history as patient was very sleepy, and information is gathered from chart and from limited patient interaction. Patient states that approximately one week ago he noticed swelling around AICD site, and over past week site has become warm and painful. Pain occasionally radiates across chest to the right, but no jaw pain, arm pain, SOB, palps. Does relate fever, but unclear of onset. He presented to [**Hospital3 417**] today and was found to have a fever to 104, o/w HD stable, with erythema and warmth around AICD site. Given Invanz (Carbapenem) 1G IV, Vanc 1 g IV, and dilaudid and then developed runs of NSVT (monomorphic, 16-20 beats per ED verbal, 10-15 per ED notes, [**3-30**] per tele sent over from [**Hospital3 417**]) that broke on its own. Patient was given lidocaine 100 mg IV, amiodarone 150 mg PO x 1 and started on amiodarone gtt. Transferred to [**Hospital1 18**] for further management. . In ED patient was febrile to 101.9, HR 100, BP 110/70. His site was noted to be erythematous and painful and was given gentamycin loading dose of 430mg x 1 as well as dilaudid, tylenol, and amiodarone gtt. 2 large bore IV's were placed and patient sent to floor. Past Medical History: # 2VD CABG (LIMA --> LAD, SVG --> PDA) in [**5-/2146**] # Last CATH [**2147-9-14**] - 3VD, occluded SVG-RPDA, patent LIMA-LAD, no intervention. # Last ECHO [**2148-8-12**] - Apical LV aneurysm, 1+MR, 1+TR. No EP report on when BiV pacer was placed. # Has had LAD and RCA stents placed in past, but in North [**Doctor First Name **] # H/O NSVT # AICD placed [**2148-10-13**] - leads in RA and RV (old pacer leads abandoned on CXR [**10-2**]) # Dental extraction [**10-17**] (7 teeth removed) # CHF/Ischemic cardiomyopathy - EF 20-25%, admissions in past for CHF # Previous wedge P 30s in [**8-31**] cath # HTN # Hyperlipidemia # H/O Biventricular pacemaker, now removed # MRSA abscess on abdomen Social History: He is divorced and has one daughter. [**Name (NI) **] spent two months in prison secondary to domestic abuse charges. He quit smoking after his CABG. He does not use alcohol or illicit drugs. He does not work and is on disability. His mother is very ill and has hospice services. She is his main source of support. Family History: CAD - mother Physical Exam: Vitals: 104.8, 98/60 (MAP 70), 110, 98% on 4L, 26 HEENT: PERRL, EOMI, anicteric sclera, MMM, no teeth Neck: supple, no LAD, no thyromegaly Cardiac: tachycardic, regular, NL S1 and S2, no MRGs Lungs: CTAB, no wheezes, rhonchi, crackles anteriorly Abd: soft, mildly TTP in lower quadrant, NABS, no HSM, no rebound or guarding Ext: cool (on cooling blanket), 2+ DP pulses, no C/C/E Neuro: CN III-XII intact, MAE Skin: psoriatic plaques with silvery scale on abdomen around umbilicus, right knee, left LE Skin: . Pertinent Results: [**2148-12-7**] 09:30PM WBC-13.9*# RBC-4.92 HGB-16.3 HCT-48.3 MCV-98 MCH-33.0* MCHC-33.7 RDW-14.1 [**2148-12-7**] 09:30PM NEUTS-87* BANDS-1 LYMPHS-9* MONOS-2 EOS-0 BASOS-0 ATYPS-1* METAS-0 MYELOS-0 [**2148-12-7**] 08:42PM LACTATE-1.5 K+-6.6* [**2148-12-7**] 09:30PM DIGOXIN-<0.2* [**2148-12-7**] 09:30PM CALCIUM-9.0 PHOSPHATE-3.5 MAGNESIUM-1.7 [**2148-12-7**] 09:30PM CK-MB-NotDone cTropnT-<0.01 [**2148-12-7**] 09:30PM CK(CPK)-55 Brief Hospital Course: A/P: 38 year old male with CAD s/p CABG, pacer, AICD, CHF, who presents with infection over AICD site. . # AICD INFECTION: His AICD was placed in [**2148-9-27**] for non-ischemic cardiomyopathy. He presented from OSH on [**12-7**] with high grade MRSA bacteremia and infected AICD pocket. ID consult was called and he was put on vancomycin and gentamycin. On [**12-9**], he had the AICD and all the wires removed. His blood cultures drawn from [**12-9**] to [**12-12**] were persistently positive for MRSA. While in the ICU, he remained hemodynamically stable. A temporary subclavian central catheter was placed for access and was later discontinued. A left PICC was placed on [**12-12**] while still presumably bacteremic but he needed access. Surveillance cultures from [**12-13**] onward finally became negative. His PICC was left in since he became afebrile and MRSA was no longer growing in his blood. Gentamycin was discontinued after blood cultures remained negative x 72 hours. He had a TTE on admission that was negative for endocarditis or abcess but he needed a TEE for a more definitely rule out. However, he persistently refused to have the TEE despite encouragement from the primary team and the ID consult team. . On [**12-16**], he left the hospital against medical advice. He was being set up for VNA service and will get long term vancomycin treatment (6 weeks) since he refused the TEE. However, he decided not to stay until the VNA was set up. Eventually VNA was scheduled and they will follow up at home. He still had his PICC when he left. . For followup, he needs to be seen at infectious disease clinic, appointment made for him at discharge. He also needs to follow up at [**Hospital **] clinic since his AICD was removed. For the pocket wound, plastics surgery was consulted and they recommended wet to dry dressings x 4 weeks with help from VNA. Then he will need primary closure. Orthopaedic consult was called to assess for possibly bone infection in the pocket area but this was deemed unlikely. . # NSVT: He has had runs of NSVT on telemetry but is asymptomatic. He was started on amiodarone, loaded with 400mg [**Hospital1 **] x 1 week and then 100mg daily therafter. PFTs were done to assess lung function pre-amiodarone: FVC 59%, FEV1 56%, FEV1/FVC 94%, suggesting baseline restrictive disease. His TSH and LFTs were normal. He will follow up with Dr. [**Last Name (STitle) **] at [**Hospital **] clinic. . # CAD: s/p CABG. PMIBI in [**Month (only) **] showed no definite areas of ischemia although there is global perfusion abnormalities. EKG did not suggest active ischemia and troponins were negative x 3. He continued asa + metoprolol + lisinopril + plavix + lipitor + ezetimibe. . # CHF: echo on this admission shows EF of 15-20%. He had signs of overload on admission and was diursed in his MICU course. He continued metoprolol and lisinopril but lasix and spirinolactone were held because he seemed euvolemic after adequate diureses and his blood pressure was low-normal. Medications on Admission: Digoxin 125 mcg PO QD Atorvastatin 80 mg PO QD Spironolactone 25 mg PO QD Lasix 80 mg PO QAM ASA 81 mg PO QD Plavix 75 mg PO QD Metoprolol 25 mg PO BID Ezetimibe 10 mg PO QD Gemfibrozil 600 mg PO QD Fluticasone 110 mcg 2 puffs [**Hospital1 **] Lisinopril 5 mg PO QD Folic acid Discharge Medications: 1. Atorvastatin 40 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 3. Ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 5. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 7. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day) for 5 days: then 400mg (2 tablets) daily thereafter. Disp:*120 Tablet(s)* Refills:*0* 9. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 11. 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* 12. Vancomycin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q 8H (Every 8 Hours) for 6 weeks. Disp:*90 Recon Soln(s)* Refills:*1* Discharge Disposition: Home with Service Discharge Diagnosis: PRIMARY DIAGNOSIS: Infected AICD (defibrillator) Bacteremia SECONDARY DIAGNOSIS: CAD CHF Non-sustained Vtach Htn Hyperlipidemia Discharge Condition: hemodynamically stable, afebrile, ambulating Discharge Instructions: Please take all medication as prescribed. Keep all appointments listed below. If you have fever or chills or worsening pain where your defibrillator site was, please seek medical attention immediately. Also seek attention if you have chest pain or shortness of breath. If you have any general medical questions or concerns, please call your doctor or go to the emergency room. ------------------ You need to do wet-to-dry dressings on your wound twice a day for 4 weeks. After 4 weeks, you need to go back to your cardiologist for futher care of your wound, possibly including primary closure of the wound. ------------------ You will be on vancomycin three times daily x 6 weeks. ------------------ HEART FAILURE INSTRUCTIONS Weigh yourself every morning, [**Name8 (MD) 138**] MD if weight > 3 lbs. Adhere to 2 gm sodium diet Fluid Restriction: 1500mL Followup Instructions: Please follow up with your PCP in two weeks: [**Last Name (LF) **],[**First Name3 (LF) **] H. [**Telephone/Fax (1) 63353**] -------------------- Please follow up with Dr. [**Last Name (STitle) 11382**] from Infectious Disease: [**Telephone/Fax (1) 457**]. Appointment is set [**1-1**] @ 11am. Call for their location. She will monitor you antibiotics level and lab work. -------------------- You need to follow up with Cardiology in four weeks with Dr. [**Last Name (STitle) **]. ([**Telephone/Fax (1) 5862**]. Please call for an appointment. They will check on your wound to see if anything needs to be done. Completed by:[**2149-6-11**]

[ "995.91", "425.4", "V45.81", "719.41", "401.9", "V09.0", "V17.3", "038.11", "428.0", "427.1", "996.61" ]

icd9cm

[ [ [] ] ]

[ "37.77", "38.93", "37.79" ]

icd9pcs

[ [ [] ] ]

8392, 8411

3874, 6916

329, 362

8584, 8631

3405, 3851

9537, 10183

2846, 2860

7244, 8369

8432, 8432

6942, 7221

8655, 9514

2875, 3386

276, 291

390, 1778

8514, 8563

8451, 8493

1800, 2497

2513, 2830

14,716

125,692

15390

Discharge summary

report

Admission Date: [**2168-1-13**] Discharge Date: [**2168-1-24**] Date of Birth: [**2105-7-23**] Sex: M Service: MEDICINE Allergies: Heparin Agents Attending:[**First Name3 (LF) 1493**] Chief Complaint: Cc:[**CC Contact Info 44681**] Major Surgical or Invasive Procedure: Paracentesis with removal of ~2L on [**2168-1-13**] Diagnostic paracentesis [**2168-1-15**] History of Present Illness: HPI: Mr. [**Known lastname 16189**] is a 62 yo male with h/o cirrhosis secondary to sclerosing cholangitis, UC and recent h/o of SBP. Presents after being transferred from clinic by Dr. [**Last Name (STitle) 497**] for PNA, ascites, hepatic encephalopathy and FTT. He had, per the ER notes, been started on levaquin for PNA 5 days prior to this admission. He also had a recent admission from [**Date range (1) 44682**] for lethargy and was found to have hyponatremia, hepatic encephalopathy and a PNA that was treated with a 10 day course of levaquin. At that time there was no evidence for SBP. Currently the patient is confused on examination and denies recent fevers, chills, abdominal pain (though it appears he was c/o this earlier in the day), nausea, vomiting or diarrhea. On arrival to the ED he was afebrile with BP 137/52 HR 95 and O2 sat 94% on RA. His abdomen was distended and he had a diagnostic/therapeutic tap with removal of ~2.5 L of fluid. He was given once dose of ceftriaxone for possible SBP. CXR showed findings consistent with CHF. Past Medical History: Past Medical History (from prior notes as patient was confused): 1. Recurrent hepatic encephalopathy. 2. End stage liver disease secondary to sclerosing cholangitis. 3. Hepatitis C. 4. Status post banding for varices. 5. Ulcerative colitis. 6. Duodenal ulcers. 7. E-coli sepsis. 8. Restrictive lung disease. 9. Asthma. 10. Anemia. 11. Status post cholecystectomy. Social History: He is currently in a rehab facility following a left shoulder dislocation. He denies any alcohol, tobacco or illegal drug usage. Family History: Unknown. Physical Exam: PE: Gen: appears jaundiced, ill and confused, though responding to questions HEENT: pupils equal and round, has scleral icterus and yellow discharge in both eyes. Mucous membranes are moist. Cardio: RRR, nl S1 S2, no m/r/g Pulm: CTA B anteriorly Abd: distended but soft with drainage of ~ 2 L straw colored fluid from abdomen, +BS Ext: trace peripheral edema Neuro: confused and oriented to place but not month or time of year No asterixis in right hand, but unable to move left arm or grasp fingers with left hand (states [**2-4**] to dislocation of shoulder). Sensation intact in left fingers, and they are well perfused. Moves lower extremities well Pertinent Results: [**2168-1-13**] 01:45PM BLOOD WBC-5.1 RBC-2.74* Hgb-10.2* Hct-29.6* MCV-108* MCH-37.3* MCHC-34.5 RDW-18.8* Plt Ct-101*# [**2168-1-14**] 05:58AM BLOOD WBC-5.1 RBC-2.62* Hgb-10.0* Hct-28.4* MCV-108* MCH-38.0* MCHC-35.1* RDW-18.7* Plt Ct-107* [**2168-1-13**] 01:45PM BLOOD Neuts-79.7* Lymphs-9.6* Monos-6.2 Eos-3.9 Baso-0.6 [**2168-1-15**] 05:45AM BLOOD PT-20.8* PTT-42.1* INR(PT)-3.1 [**2168-1-13**] 01:45PM BLOOD PT-21.2* PTT-41.6* INR(PT)-3.2 [**2168-1-15**] 05:45AM BLOOD Glucose-95 UreaN-8 Creat-0.6 Na-134 K-3.5 Cl-99 HCO3-27 AnGap-12 [**2168-1-13**] 01:45PM BLOOD ALT-37 AST-62* AlkPhos-127* Amylase-12 TotBili-11.6* [**2168-1-13**] 01:45PM BLOOD Lipase-25 [**2168-1-15**] 05:45AM BLOOD Calcium-8.5 Phos-2.1* Mg-1.5* [**2168-1-14**] 05:58AM BLOOD calTIBC-81* VitB12-1425* Folate-4.6 Ferritn-875* TRF-62* [**2168-1-13**] 02:59PM BLOOD Ammonia-22 [**2168-1-13**] 01:45PM BLOOD Acetone-NEGATIVE [**2168-1-13**] 03:11PM BLOOD Lactate-1.7 . [**1-13**]: LIMITED ABDOMINAL ULTRASOUND: Targeted examination of all four quadrants of the abdomen was performed. There is a moderate to large volume of ascites. The largest collection is present within the right lower quadrant, and skin overlying the site was marked for paracentesis as requested. . [**1-13**] cxr:IMPRESSION: Findings most consistent with CHF. . [**1-14**] cxr:Left lateral decubitus radiograph demonstrates a layering moderate sized left pleural effusion, and the right lateral decubitus view demonstrates a small layering right pleural effusion. Allowing for decubitus positioning, there has overall been no significant change in the appearance of the chest since the recent study of one day earlier. . [**1-14**] abd ultrasound:IMPRESSION: 1. Cirrhotic liver with large amount of ascites and right pleural effusion. 2. Patent portal venous system with reversed (hepatofugal) flow that is unchanged compared to [**2167-12-23**]. . CXR [**1-15**]: CONCLUSION: 1. Interval progression of pulmonary oedema. Moderate left effusion, small right effusion. . Pleural fluid [**1-15**]:NEGATIVE FOR MALIGNANT CELLS . CTA chest [**1-16**]: IMPRESSION: 1. Bilateral pleural effusions, greater on the left than the right. 2. Multifocal patchy opacities within the lungs bilaterally, consistent with a multifocal pneumonic process. 3. Cirrhotic liver and ascites are again noted. . CXR [**1-17**]: IMPRESSION: 1. Improving pulmonary edema and slight decrease in right pleural effusion. 2. Enlarging left pleural effusion. . CXR [**1-18**]: IMPRESSION: Nasogastric tube in satisfactory placement. Worsening left-sided pleural effusion. . CXR [**1-19**]: IMPRESSION: 1. Large left and small right effusion. 2. Asymmetric pulmonary edema, more on the left. 3. Right basilar consolidation/atelectasis. . CXR [**1-20**]: interval slight increase in left pleural effusion . CXR [**1-22**]:PICC line is in region of cavoatrial junction. Heart size is borderline for technique. There is a left pleural effusion as previously demonstrated. There are diffuse bilateral predominantly air space opacities increased since the prior study of [**2168-1-20**] consistent with pulmonary edema/massive aspiration. No pneumothorax. . [**1-13**] bcx:STAPHYLOCOCCUS, COAGULASE NEGATIVE. ISOLATED FROM ONE SET ONLY. . [**1-13**] peritoneal fluid: no growth . [**1-15**] pleural fluid: no growth . [**1-17**] ucx: yeast [**Numeric Identifier 961**]-[**Numeric Identifier 4856**] organisms . [**1-16**], [**1-17**] bcx: no growth . [**1-19**]: sputum cx: MRSA Brief Hospital Course: The patient is a 62 yo male with h/o cirrhosis secondary to sclerosing cholangitis, UC and recent h/o of SBP who presented with PNA, hepatic encephalopathy and FTT. He had a therapeutic/diagnostic paracentesis at admission with drainage of ~2.5 L of fluid. No evidence of SBP was seen in the ascitic fluid, but he was treated empirically with ceftriaxone. A CXR at admission showed a left pleural effusion and findings consistent with CHF. He had a thoracentesis of the pleural effusion and a chest CT to visualize whether anything was hidden behind the effusion. He was found to have bilateral patchy opacities on CXR and pleural fluid was transudative and c/w with parapneumonic effusion. He developed fevers during his stay and repeat paracentesis was done on [**1-17**] and did not demonstrate SBP. He was started on flagyl to cover for possible aspiration PNA, since he was spiking temps on ceftriaxone. The patient was encephalopathic throughout his stay and treated with lactulose and rifamaxin for this. He had decreased PO intake, so an NGT was placed and tube feeds were started. He had an aspiration event the next day with desat to 70s on RA and ABG that revealed pH 7.46/46/115 on NRB. He was transferred to the MICU for furthur monitoring and care. He had been stable on O2 (2L with sats ranging from 92-97%) prior to this event. . In the MICU the patient was suctioned frequently and was not started on bipap for fear of pushing the aspirated contents further into the lungs. It was confirmed with the patient's family that he was DNR/DNI. The patient wanted to continue eating knowing that he would likely aspirate but was convinced to try TPN for a short while until he got a little stronger and his PNA was treated. He was started on TPN on [**2168-1-21**]. Additionally he had sputum samples that grew out MRSA and he was started on vancomycin. The patient was transferred back to the floor on [**2168-1-21**] and was stable on a face mask and requiring less suctioning. On [**2168-1-23**] the patient became markedly hypoxic, tachypneic and possibly had another aspiration event. After discussion with the patient's brother, who was his health care proxy, and the team, the patient was made CMO. He expired in the early morning of [**2168-1-24**]. Medications on Admission: .Lansoprazole 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). Capsule, Delayed Release(E.C.)( 2. Mesalamine 400 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO TID 3. Sucralfate 1 g Tablet Sig: One (1) Tablet PO BID 4. Cholecalciferol (Vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO DAILY 5. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO QD 6. Vitamin E 400 unit Capsule Sig: One (1) Capsule PO DAILY 7. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QD 8. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H as needed. 9. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical TID as needed. 10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H for 3 days. 11. Cholestyramine-Sucrose 4 g Packet Sig: One (1) Packet PO QID 12. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q6H PRN 13. Rifaximin 200 mg Tablet Sig: One (1) Tablet PO TID 14. Dextroamphetamine 5 mg Tablet Sig: One (1) Tablet PO Q AM 15. Spironolactone 100 mg Tablet Sig: One (1) Tablet PO DAILY Discharge Medications: Patient expired Discharge Disposition: Extended Care Discharge Diagnosis: Primary Diagnosis Multifocal MRSA pneumonia Aspiration pneumonia Bilateral pleural effusions Ascites secondary to cirrhosis Failure to thrive Hepatic encephalopathy . Secondary Diagnosis 1.End stage liver disease 2. Sclerosing cholangitis 3. Hepatitis C 4. Ulcerative colitis 5. h/o duodenal ulcrs 6. Asthma 7. Anemia Discharge Condition: patient expired Discharge Instructions: patient expired Followup Instructions: patient expired

[ "556.9", "511.9", "789.5", "493.90", "571.5", "482.41", "070.54", "428.0", "507.0", "572.2" ]

icd9cm

[ [ [] ] ]

[ "96.6", "99.07", "34.91", "54.91", "99.15" ]

icd9pcs

[ [ [] ] ]

9725, 9740

6250, 8526

305, 399

10102, 10119

2737, 6227

10183, 10201

2038, 2048

9685, 9702

9761, 10081

8552, 9662

10143, 10160

2063, 2718

236, 267

427, 1485

1507, 1875

1891, 2022

19,631

185,175

235

Discharge summary

report

Admission Date: [**2198-4-23**] Discharge Date: [**2198-5-8**] Date of Birth: [**2122-10-14**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 148**] Chief Complaint: fever Major Surgical or Invasive Procedure: 1. Exploratory laparotomy. 2. Pancreatic debridement with wide drainage. 3. Open cholecystectomy. 4. Placement of a combined G/J tube (MIC tube). 5. PICC line placement 6. ERCP with stent History of Present Illness: This is a 75 year old man who is a retired anethesiologist with h/o CAD s/p CABG and ischemic cardiomyopathy with EF of 25% who was recently discharged from [**Hospital1 18**] following a hospital course for gallstone pancreatitis and now re-presents from rehab for fevers. During last admission, he was transferred from OSH with with fever and pancreatitis which was thought to be from gallstones although there were no gallstones in the bile ducts, just in the gallbladder itself. CT scan done on admissionw as consistent with severe pancreatitis. ERCP was done on [**2198-4-6**], with sphinceterotomy and CBD stent placed. His post procedure course was complicated by fevers and repeat CT abd shows progression of severe pancreatitis with extensive peripancreatitis fluid collection. This was thought to be either from PNA or from inflammation from his pancreatitis. He finished a course of azithro/ctx and a course of flagyl/cipro and eventually he devefesced. All cultures were negative. He was discharged to rehab. . At rehab, he reports having fevers since Friday [**2198-4-21**], with highest at 102.0. He has no localizing pain. Denies cough, dysuria, abd pain or nausea and vomit. . ROS: Negative for headache, chest pain, shortness of breath or change in bowel habits. Past Medical History: # Coronary artery disease status post CABG x4 in [**2183**]. # Status post MI in [**2182**]. # Ischemic cardiomyopathy, EF 20-25%, echo [**2194**]. # Atrial flutter, currently A-paced. # Ventricular irritability. # ICD placement [**2193**], changed in [**2195**] ([**Company 1543**] dual- chamber system.) # CRI with a baseline creatinine of 1.2-1.5. # Gout. # Gallstones. # Kidney stones. # h/o Syncope. Social History: A retired anesthesiologist, worked in pain management. Denies tobacco, drugs. Bottle of wine per week. Family History: Father had a MI at age 70. Physical Exam: VITALS: 102.2 112/P 68 16 93%-RA GEN: A+Ox3, NAD HEENT: MMM, OP clear NECK: no LAD, no JVD CV: RRR, II/VI holosystolic murmur at LLSB PULM: crackles at bases with decreased sounds on right base, no wheeze, rhonchi ABD: soft, NT, ND, +BS EXT: [**Male First Name (un) **] stockings on both legs; 1+ pitting edema to knees bilaterally Pertinent Results: 137 101 19 --------------< 105 4.3 28 1.2 Ca: 9.4 Mg: 1.9 P: 3.1 ALT: 23 AP: 135 Tbili: 0.6 Alb: 3.0 AST: 22 LDH: 169 [**Doctor First Name **]: 25 Lip: 38 95 13.1 > 9.5 < 176 28.9 N:90.0 Band:0 L:5.2 M:4.5 E:0.1 Bas:0.2 Hypochr: 2+ Anisocy: 1+ Macrocy: 1+ Ovalocy: 1+ PT: 15.8 PTT: 28.3 INR: 1.4 EKG: Regular 68 PBM, apaced, low voltage in limb leads, no ST/T changes compared to [**2198-4-5**] CT ABD WITH IV AND ORAL CONTRAST: 1. All visualized peripancreatic collections appear slightly smaller. 2. New air bubbles within multiple collections. Correlate with history of marsupialization or attempts at drainage in the interval since [**2198-4-10**]. Superimposed infection in the collections cannot be excluded given the new air bubbles, although the collections are infected, they would not expect to get smaller. 3. Biliary stent in position. No evidence of worsening biliary dilatation. 4. Cholelithiasis and Phrygian cap in gallbladder. 5. Bilateral pleural effusions, right greater than left with associated bilateral lower lobe atelectasis. Effusions slightly larger than on [**2198-2-8**]. CXR: Small bilateral pleural effusions have increased. Moderate enlargement of the cardiac silhouette is stable. Upper lungs grossly clear. Atelectasis at the lung bases is slightly more severe today. No pneumothorax. Transvenous right atrial pacer and right ventricular pacer defibrillator leads are unchanged in their respective positions. The patient is status post median sternotomy and coronary bypass grafting. . [**2198-4-30**] 05:17AM BLOOD WBC-8.1 RBC-2.98* Hgb-9.3* Hct-27.9* MCV-94 MCH-31.2 MCHC-33.2 RDW-16.2* Plt Ct-197 [**2198-5-3**] 04:35AM BLOOD WBC-10.4 RBC-3.03* Hgb-9.0* Hct-28.2* MCV-93 MCH-29.5 MCHC-31.7 RDW-16.2* Plt Ct-277 [**2198-4-23**] 12:50PM BLOOD Neuts-90.0* Bands-0 Lymphs-5.2* Monos-4.5 Eos-0.1 Baso-0.2 [**2198-5-3**] 04:35AM BLOOD Glucose-145* UreaN-21* Creat-0.7 Na-136 K-4.2 Cl-100 HCO3-30 AnGap-10 [**2198-5-5**] 05:31AM BLOOD Glucose-145* UreaN-22* Creat-0.8 Na-138 K-4.1 Cl-101 HCO3-28 AnGap-13 [**2198-5-1**] 04:07AM BLOOD ALT-31 AST-39 AlkPhos-160* Amylase-23 TotBili-0.7 DirBili-0.4* IndBili-0.3 [**2198-5-1**] 04:07AM BLOOD Lipase-41 [**2198-5-5**] 05:31AM BLOOD Calcium-9.0 Phos-3.1 Mg-2.0 [**2198-4-30**] 05:17AM BLOOD Albumin-2.4* Iron-12* [**2198-4-30**] 05:17AM BLOOD calTIBC-140* Ferritn-589* TRF-108* . SPECIMEN SUBMITTED: GALLBLADDER AND CONTENTS. Gallbladder, cholecystectomy (A): Acute and chronic cholecystitis. Cholelithiasis. . REPEAT, (REQUEST BY RADIOLOGIST) [**2198-5-5**] 6:47 PM FINDINGS: X-ray of the three surgical drains revealed no evidence of any contrast which is radiopaque within these drains. . CT PELVIS W/CONTRAST [**2198-5-5**] 12:07 PM IMPRESSION: 1. Heterogeneity in the region of the pancreas consistent with the patient's previous necrotizing pancreatitis. 2. Three surgical drains in situ with some high attenuation in the region of the lesser sac which may represent fistulization from the small bowel into this residual collection. 3. Loculated fluid under the anterior abdominal wall measuring 16 cm. 4. Gastrojejunostomy in situ. 5. Renal cysts. 6. Bilateral pleural effusions. 7. Enlarged prostate at 8 cm. . Brief Hospital Course: 75 year old man with CAD s/p CABD and ischemic cardiomyopathy EF 25% who was recently admitted for gallstone pancreatitis, now re-admitted from rehab for fevers. . # FEVERS: Likely source is from his pancreas. On last admission, he was febrile without an identified infectious source and was thought to be from inflammatory response to pancreatitis and peri-pancreatic fluid. Currently with leukocytosis and left shift although no localizing signs of infection. The differential at this time includes (infected) pancreatic pseudocyst, necrotizing pancreatitis and an obstructed bile duct stent. -- appreciate GI following -- keep NPO for now until CT scan and labs return -- CT scan of abdomen with oral and IV contrast -- culture blood and urine -- CXR to r/o PNA . # CAD: currenty stable without chest pain. -- continue asa + captopril + carvedilol . # CHF: currently euvolemic, and stable. -- admitted and dry weight: -- continue asa + captopril + carvedilol . # Aflutter: currently apaced -- continue to hold coumadin in case he needs surgery -- continue carvedilol . # CRI: Baseline creatinine 1.2-1.5 -- hydration and bicarb prior to contrast study -- continue to monitor creatinine . # ANEMIA: iron studies from last admission suggest iron deficiency and chronic disease -- continue iron supplements -- continue to monitor hct . # GOUT: continue allopurinol . # BPH: continue flomax [**Hospital1 **] . # FEN: -- IV hydration prior to CT scan . # PPX: -- ambulating -- protonix . # CODE: full . # DISPO: pending . . = = = = = = = = = = = = = = = = = = ================================================================ Surgery was then consulted and he went to the OR on [**4-24**] for his Infected pancreatic necrosis, status post gallstone pancreatitis. He had 1. Exploratory laparotomy. 2. Pancreatic debridement with wide drainage. 3. Open cholecystectomy. 4. Placement of a combined G/J tube (MIC tube). Post-op he stayed in the ICU for 2 nights and was trasnfered to the floor on POD 3. GI/Abd: He was NPO with a NGT and IVF. The NGT was removed on POD 2. His G-tube was left to gravity drainage. His J-tube was capped and then trophic tubefeedings were started on POD 2. His tubefeedings were advanced to a goal of Replete with Fiber 3/4 strength at 80cc/hr. He had 3 JP drains in place and these were draining thick, dark fluid. He continued to have high output from these drains. He was started on sips on POD 5, he was advanced to clears on POD 6. JP amylase was checked on POD 7, once on a full liquid diet. His JP Amylase was 27K, 34K, and 14K. He was made NPO due to his JP amylase reported as high. He continued on the tubefeedings. A grape juice test was positive for a leak from around the JP drains. He had one small spot with minimal drainage that could be expressed from his incision. His is now having drainage around all his drains and g/j tube with mild skin irritation. He has irritation around the tube extending out from ~0.5 - 3 cm and appears at [**Doctor First Name **] to develop yeast. His midline incision is c/i but has a small amount of serous drainage on the gauze. Have suggested using Criticaid anti fungal moisture barrier to protect his skin from the drainage and to prevent the formation of yeast. Continue to apply a thin layer of dressing around the drains and change as needed do not allow the gauze to become saturated with drainage. Apply the antifungal Criticaid two to three times/day. A CT was obtained on [**5-5**] and showed: 1. Heterogeneity in the region of the pancreas consistent with the patient's previous necrotizing pancreatitis. 2. Three surgical drains in situ with some high attenuation in the region of the lesser sac which may represent fistulization from the small bowel into this residual collection. 3. Loculated fluid under the anterior abdominal wall measuring 16 cm. 4. Gastrojejunostomy in situ. 5. Renal cysts. 6. Bilateral pleural effusions. 7. Enlarged prostate at 8 cm. . He will remain NPO with TF for 2 weeks and then return for a repeat CT. His drains will remain and the drainage will be monitored. Pain: He had good pain control with a PCA. He continued on a PCA thru POD 6. Once back on a diet, he was ordered for PO pain meds with good control. Labs: We monitored his labs and his Tbili decreased from a high of 2.6 on POD 2 to WNL by [**2198-4-28**]. Cards: He was being followed by his PCP/Cardiologist. He was put back on his home meds on POD5, including Lasix IV for gentle diuresis and his heart meds. Renal: He was diuresing well and continued to have negative fluid balance and losing weight appropriately. Medications on Admission: # Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). # Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). # Captopril 25 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day). # Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). # Digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). # Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY # Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. # Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day as needed for shortness of breath, edema. # Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO DAILY (Daily). # Phenazopyridine 100 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). # Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed for shortness of breath or wheezing. # Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO BID (2 times a day). # Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed for insomnia. # Multivitamin,Tx-Minerals Tablet Sig: One (1) Tablet PO DAILY (Daily). # Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO once a day. # Albuterol 90 mcg/Actuation Aerosol Sig: One (1) Inhalation every 4-6 hours as needed for shortness of breath or wheezing. # Colace, senna PRN # Protein powder, 2 scoops [**Hospital1 **] # Demerol PRN Discharge Medications: 1. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 2. Albuterol Sulfate 0.083 % (0.83 mg/mL) Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 3. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 4. Insulin Regular Human 100 unit/mL Solution Sig: Sliding Scale Injection ASDIR (AS DIRECTED). 5. Tylenol 325 mg Tablet Sig: 1-2 Tablets PO every 6-8 hours as needed for fever or pain. 6. Digoxin 125 mcg Tablet Sig: One (1) Tablet PO once a day. 7. Tamsulosin 0.4 mg Capsule, Sust. Release 24 hr Sig: One (1) Capsule, Sust. Release 24 hr PO BID (2 times a day). 8. Captopril 25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Carvedilol 12.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 10. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 11. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed. 12. Allopurinol 100 mg Tablet Sig: 1.5 Tablets PO DAILY (Daily). 13. Calcium Carbonate 500 mg Tablet, Chewable Sig: Two (2) Tablet, Chewable PO QID (4 times a day) as needed. 14. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 15. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 16. Percocet 5-325 mg Tablet Sig: 1-2 Tablets PO every [**3-2**] hours. 17. Octreotide Acetate 100 mcg/mL Solution Sig: One (1) Injection Q8H (every 8 hours). 18. Amiodarone 200 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 19. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 20. Imipenem-Cilastatin 500 mg Recon Soln Sig: One (1) Recon Soln Intravenous Q8H (every 8 hours) for 2 doses: D/C on [**5-9**]. Disp:*2 Recon Soln(s)* Refills:*0* Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: PRIMARY: Infected pancreatic necrosis, status post gallstone pancreatitis. Post-op Pancreatic leak SECONDARY: # Coronary artery disease status post CABG x4 in [**2183**]. # Ischemic cardiomyopathy, EF 20-25%, echo [**2194**]. # Atrial flutter, currently A-paced. # Ventricular irritability. # ICD placement [**2193**], changed in [**2195**] ([**Company 1543**] dual- chamber system.) # CRI with a baseline creatinine of 1.2-1.5. # Gout # Gallstones Discharge Condition: hemodynamically stable, afebrile, ambulating Discharge Instructions: Please take all medication as prescribed. Keep appointments listed below. If you have chest pain or shortness of breath, get medical attention immediately. If you have fevers or any discomfort, please call your doctor or go to the emergency department. . Continue with tubefeedings. Continue with drain care and with tubefeeding care. Followup Instructions: Provider: [**Name10 (NameIs) **] SCAN Phone:[**Telephone/Fax (1) 327**] Date/Time:[**2198-5-25**] 9:00 Please follow-up with Dr. [**Last Name (STitle) **] on [**2198-5-25**] at 10:15. Call ([**Telephone/Fax (1) 2363**] with questions. Please follow up with your PCP [**Name Initial (PRE) 176**] 2 weeks: PCP: [**Name10 (NameIs) **],[**Name11 (NameIs) 1730**] [**0-0-**] OTHER APPOINTMENTS: Provider: [**First Name4 (NamePattern1) 1386**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 463**] Date/Time:[**2198-4-30**] 10:20 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) **], MD Phone:[**Telephone/Fax (1) 2359**] Date/Time:[**2198-4-30**] 3:30 Completed by:[**2198-5-8**]

[ "V45.81", "427.32", "V45.02", "574.10", "274.9", "414.00", "997.4", "577.0", "585.9", "414.8", "574.00" ]

icd9cm

[ [ [] ] ]

[ "51.22", "46.39", "52.22", "38.93", "96.6" ]

icd9pcs

[ [ [] ] ]

13969, 14048

6054, 10670

319, 515

14542, 14589

2797, 6031

14975, 15696

2398, 2426

12128, 13946

14069, 14521

10696, 12105

14613, 14952

2441, 2778

274, 281

543, 1834

1856, 2262

2278, 2382

58,163

107,057

38291

Discharge summary

report

Admission Date: [**2185-11-29**] Discharge Date: [**2185-12-2**] Date of Birth: [**2151-1-15**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 7299**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: None History of Present Illness: 34M with hx of IDDM complicated by gastroparesis/retinopathy, chronic kidney disease stage III, HTN, 2 recent admissions last two months for DKA presents with nausea/vomiting and abdominal pain and found to have an Anion Gap Acidosis. . Patient was in his usual state of health until this afternoon when he developed nausea, vomiting, mild diffuse abdominal pain. He feels this is consistent with his normal gastroparesis flair. He does note that emesis was darker in color and reminded him of coffee. He noted no obvious blood. He states he hasn't otherwise been unwell recently. No fevers, chills, diarrhea, sick contacts, travel. [**Name2 (NI) **] exotic foods. Denies chest pain, productive cough. No urinary frequency, burning with urination. No new sexual contact. . In the ED initial vitals 97.6 123 161/115 14 100%. Physical exam was unrevealing. Lab data revealed Hyperglycemia and Anion Gap 19. EKG with sinus tachycardia. Patient was given four liters of fluid. Insulin Bolus 10 units regular and gtt. 8mg IV zofran. 4mg IV morphine. 1mg IV dilaudid. 1 mg IV ativan. Two peripheral IVs in place. Vitals prior to transfer: 113 156/93, 18, 98% RA. . In the ICU the patient appears somewhat sedated though is able to communicate clearly. He notes feeling much better and hoped to try to drink some water. Past Medical History: -DM1 x 15 years; Complicated by gastroparesis, retinopathy, chronic renal disease stage III -HTN -HLD -Asthma as a child -[**Doctor Last Name 9376**] Syndrome Social History: Lives [**Location 6409**] with his girlfriend and 2 children - ages 3 and 14. No sexual exposures. No tobacco or ETOH. No drugs. Pt is currently unemployed. Family History: Father with CAD/MI. Mother Thyroid [**Name (NI) 3730**] Physical Exam: Admission exam: VS: Temp: AFebrile BP:167/96 HR: 111 RR:16 O2sat: 100% GEN: pleasant, comfortable, NAD HEENT: PERRL, EOMI, anicteric, Dry Mucous Membranes, op without lesions, no supraclavicular or cervical lymphadenopathy, no jvd, no carotid bruits, no thyromegaly or thyroid nodules RESP: CTA b/l with good air movement throughout CV: RR, S1 and S2 wnl, no m/r/g ABD: nd, +b/s, soft, nt, no masses or hepatosplenomegaly EXT: no c/c/e SKIN: no rashes/no jaundice/no splinters NEURO: AAOx3. Cn II-XII intact. 5/5 strength throughout. No sensory deficits to light touch appreciated. No pass-pointing on finger to nose. 2+DTR's-patellar and biceps NG Lavage: Tea colored fluid and specs of clotted blood, Gastrocult positive, Cleared after 500cc. Pertinent Results: Admission Results: [**2185-11-29**] 01:25AM BLOOD WBC-8.9 RBC-3.94*# Hgb-11.6*# Hct-33.8*# MCV-86 MCH-29.3 MCHC-34.2 RDW-14.1 Plt Ct-233 [**2185-11-30**] 03:01AM BLOOD WBC-7.9 RBC-3.23* Hgb-9.2* Hct-27.4* MCV-85 MCH-28.5 MCHC-33.6 RDW-14.1 Plt Ct-182 [**2185-11-29**] 01:25AM BLOOD Glucose-417* UreaN-37* Creat-3.3* Na-139 K-4.2 Cl-101 HCO3-19* AnGap-23* [**2185-11-30**] 04:41PM BLOOD Glucose-95 UreaN-20 Creat-2.5* Na-137 K-4.2 Cl-107 HCO3-24 AnGap-10 Imaging: CXR [**2185-11-29**]: FINDINGS: As compared to the previous radiograph, there is no relevant change. No evidence of mediastinal air. No pneumothorax. Normal size of the cardiac silhouette. No pleural effusions, no focal parenchymal opacities. ECG [**2185-11-29**]: Sinus tachycardia, rate 117. Moderate baseline artifact. Non-diagnostic Q waves in leads II, III, aVF and V3-V6. Compared to the previous tracing of [**2185-11-8**] the rate has increased from 75 to 117. The J point elevation seems somewhat more prominent. No other diagnostic interval change. Read by: [**Last Name (LF) **],[**First Name3 (LF) 125**] M. Intervals Axes Rate PR QRS QT/QTc P QRS T 117 128 76 354/453 64 66 73 Discharge Results: [**2185-12-2**] 06:40AM BLOOD WBC-5.6 RBC-3.41* Hgb-9.8* Hct-29.0* MCV-85 MCH-28.9 MCHC-34.0 RDW-14.2 Plt Ct-179 [**2185-11-29**] 01:25AM BLOOD Neuts-86.6* Lymphs-10.9* Monos-1.5* Eos-0.2 Baso-0.8 [**2185-12-2**] 06:40AM BLOOD Plt Ct-179 [**2185-12-2**] 06:40AM BLOOD [**2185-12-2**] 06:40AM BLOOD Glucose-153* UreaN-20 Creat-2.9* Na-140 K-4.1 Cl-105 HCO3-26 AnGap-13 [**2185-11-29**] 06:56AM BLOOD CK(CPK)-38* [**2185-12-2**] 06:40AM BLOOD Calcium-8.5 Phos-4.6* Mg-1.8 . Microbiology [**2185-11-30**] 7:33 pm URINE Source: CVS. URINE CULTURE (Preliminary): STAPHYLOCOCCUS, COAGULASE NEGATIVE. >100,000 ORGANISMS/ML.. SENSITIVITIES REQUESTED PER DR. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] ON [**2185-12-2**] AT 12:56PM. . [**2185-12-1**] 5:59 pm URINE Source: CVS. Chlamydia trachomatis, Nucleic Acid Probe, with Amplification (Pending): NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH AMPLIFICATION (Pending): Brief Hospital Course: 34M with hx of IDDM complicated by gastroparesis/retinopathy, chronic kidney disease stage III, HTN, 2 recent admissions last two months for DKA presents with nausea/vomiting and abdominal pain and found to be in DKA. . 1. Diabetic Ketoacidosis: Presentation similar in character to prior episodes of DKA. Likely related to flair in gastroparesis N/V/Abdominal Pain. No clear source of infection and cardiac biomarkers were cycled and were negative. Pt was initially on an insulin gtt for 24 hrs and his anion gap resolved. Once the pt was able to tolerate PO's the pt was started on his home lantus dose. . 2. Nausea/Vomiting/Abdominal Pain: Severe gastroparesis on recent gastric emptying study which is the most likely contributor. LFTS, Lipase are not elevated. EKG without evidence of ischemia/infarct. Of note, the pt's metoclopramide was recently discontinued due to concerns that it might be worsening gastroparesis symptoms. The pt was not able to take PO's initially, but after the first 24 hours of the hospitalization he was able to tolerate clears. He was continued on anti-emetics, erythromycin, and metoclopramide. He was able to tolerate POs prior to discharge. . 3. Coffee Ground Emesis: Initial HCT elevated compared to recent baseline though undoubtedly hemoconcentrated. NG lavage without evidence of active bleed and cleared with only 500cc fluid. There was no further evidence of GIB, and CXR did not show any signs of mediastinal air to suggest [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] tear, and pt was restarted on home antihypertensive meds. . 4. Acute on Chronic Kidney Injury: Creatinine 3.3 which is up from baseline of approx 2.5. Chronic kidney disease secondary to diabetes. Acute kidney injury likely secondary to dehydration in the setting of DKA. Creatinine returned to baseline of 2.5 with IV fluids. He had a mild elevation of his creatinine to 2.9 and was given 1L of IVF's prior to discharge. . 5. Hypertension: The patient's medications were held on admission because of acute kidney injury. After fluid repletion, he was hypertensive, so a clonidine patch was placed and his home lisinopril dose was restarted. He remained hypertensive, so nifedipine 10mg PO TID was started. His pressures became normotensive, and his nifedipine dose was changed to 10 mg Q12H. He was discharged home with instructions to measure his blood pressure at home and if his SBP was > than 170 or his DBP > 100, he should take nifedipine and recheck is blood pressure later in the day. Pt was scheduled for close follow up with his PCP and nephrologist. . 6. UTI: The patient had coag negative staph in his urine on admission. He has been asymptomatic, and was not treated as a repeat UA was entirely normal. He was also given instructions to call Urology to get evaluated for any potential anatomical abnormalities predisposing him to UTIs. . 7. Social: PCP was concerned about patients compliance and reliability to follow with providers. SW was consulted and pt was educated about the importance of keeping in contact with his PCP to help prevent progression of DM related damage. Medications on Admission: 1. Lantus 10 Units once daily 2. Lantus 7 Units at bedtime 3. Humalog Sliding Scale 4. Lisinopril 10 mg Daily 5. Clonidine 0.1 mg Tablet Sig: One (1) Tablet PO TID 6. Erythromycin 250 mg Tablet TID 7. Omeprazole 40mg Daily 8. Cholecalciferol (vitamin D3) 400 unit one tablet daily 9. Procrit 10,000 unit/mL one injection weekly Discharge Medications: 1. erythromycin 250 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. clonidine 0.3 mg/24 hr Patch Weekly Sig: One (1) Patch Weekly Transdermal QTHUR (every Thursday). Disp:*30 Patch Weekly(s)* Refills:*0* 4. metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). Disp:*40 Tablet(s)* Refills:*2* 5. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 4 days. Disp:*3 Tablet(s)* Refills:*0* 6. Lantus 100 unit/mL Solution Sig: One (1) units Subcutaneous qAM, qPM: Please take 10 units at breakfast. Please take 7 units at bedtime. Disp:*3 100 units* Refills:*5* 7. Humalog 100 unit/mL Cartridge Sig: One (1) units Subcutaneous four times a day: Please take Humalog based upon your insulin sliding scale. 8. clonidine 0.1 mg Tablet Sig: One (1) Tablet PO three times a day: Please take if you can not fill your prescription for the clonidine patch. Disp:*90 Tablet(s)* Refills:*2* 9. omeprazole 40 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO once a day. 10. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1) Tablet PO once a day. 11. Procrit 10,000 unit/mL Solution Sig: One (1) Injection once a week. 12. lorazepam 0.5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for nausea, anxiety. Disp:*28 Tablet(s)* Refills:*0* 13. ondansetron 4 mg Tablet, Rapid Dissolve Sig: One (1) Tablet, Rapid Dissolve PO Q8H (every 8 hours) as needed for nausea. Disp:*30 Tablet, Rapid Dissolve(s)* Refills:*2* 14. prochlorperazine maleate 5 mg Tablet Sig: Two (2) Tablet PO Q6H (every 6 hours) as needed for nausea. Disp:*40 Tablet(s)* Refills:*2* 15. nifedipine 10 mg Capsule Sig: One (1) Capsule PO Q 12H (Every 12 Hours): Please measure your blood pressure at home. If your blood pressure is greater than 170. Please take one pill and recheck in 5 hours. Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Primary Diagnosis Diabetic ketoacidosis Secondary Diagnosis gastroparesis Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: It was a pleasure treating you at [**Hospital1 18**] during your hospitalization. You were admitted for nausea, vomiting, and worsening abdominal pain. When you arrived, you were found to be hyperglycemic and to be in diabetic ketoacidosis. You were admitted to the MICU and started on a continuous insulin drip. Your DKA resolved within two days, and you were restarted on your home insulin dose. Your nausea, vomiting, and abdominal pain were thought to be related to a flare of your gastroparesis. You were treated with erythromycin and antiemetics. Your symptoms improved over the next few days and you were able to eat on [**12-1**]. When you were admitted, you were found to have acute kidney injury over your underlying chronic kidney disease. This resolved with IV fluids. You were also hypertensive. We added nifedipine to your antihypertensive medications and were able to get better control of your blood pressure. We made the following changes to your medications: # ADD nifedepine 10 mg SR. Please take your blood pressure prior to taking this medication. If your systolic blood pressure (the top number) is greater than 170 or your diastolic blood pressure (the bottom number) is greater than 100, please take one pill. Please recheck your blood pressure several hours afterwards. If you blood pressure is still high, then you may take another pill at the regularly scheuled interval. Please continue to take the rest of your medications as prescribed. The following medications were added to your regiment: Reglan, thiamine, zofran, compazine, loarazepam, nifedipine Please attend the follow-up appointments listed below. Followup Instructions: Name: [**Last Name (LF) **],[**First Name3 (LF) **] Location: [**Hospital1 641**] Address: [**Street Address(2) 642**], [**Location (un) **],[**Numeric Identifier 643**] Phone: [**Telephone/Fax (1) 644**] When: Tuesday, [**12-6**], 10AM Name: [**Last Name (LF) 85321**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Hospital1 641**] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2296**] *Someone from Dr. [**Last Name (STitle) 85321**] office will call you to schedule an appointment. If you dont hear back in 2 business days, call the number above. Name: [**Last Name (LF) 76274**], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Hospital1 641**] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2296**] When: Tuesday, [**12-13**], 9:10AM Name: ZANDI-NEJAD,[**Name8 (MD) 40716**] MD Location: [**Location (un) 2274**] [**Location (un) 2277**] Address: [**Location (un) **], [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2263**] When: Tuesday, [**12-27**], 9:30 Completed by:[**2185-12-2**]

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Discharge summary

report

Admission Date: [**2166-3-26**] Discharge Date: [**2166-3-29**] Date of Birth: [**2116-10-17**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 106**] Chief Complaint: CHIEF COMPLAINT: chest pain REASON FOR CCU ADMISSION: STEMI Major Surgical or Invasive Procedure: Cardiac catheterizaztion [**2166-3-26**] History of Present Illness: Mr. [**Known lastname 6164**] is a 49y/o gentleman with HTN, HLD, hiatal hernia/GERD and gout who presented to the ED with chest pain and is admitted to the CCU s/p cardiac catheterization after being found to have a STEMI. . He is a software programmer and is not very active at baseline, though he walks at work and says he can climb 5 flights of stairs without ever having chest pain but might have mild shortness of breath. He has a hiatal hernia & GERD which causes frequent heartburn. . He was in this usual state of health until 2 days ago when he felt the gradual onset of heartburn/reflux, not associated with exertion or with food. It was persistent and he was surprised that it was not relieved with his PPI or by chewing gum as his usual heartburn is; the pain kept him awake that night. Then yesterday around dinnertime the discomfort changed and he began experiencing dull substernal chest pain that was worse with breathing, causing a feeling of shortness of breath because he has been trying to take very shallow breaths. The pain only came on with breathing, and with deep breaths extended to include his [**Last Name (un) 23228**]/jaw/shoulders. No diaphoresis. The discomfort seemed to be worse when lying down so he slept in a chair. When the pain was still there in the morning he decided to come to the ED. . In the ED, initial vitals were T97.8, HR 88, BP 131/98, RR 16, POx 97% RA. EKG showed I + aVL, as well as V2-V6, and Q waves in II, III, aVF and V3-V6. Labs were notable for troponin 2.53, Cr 1.2, WBC 23.3. He received ASA 325mg, Plavix 600mg, Metoprolol 15mg IV, received a Heparin bolus, and was started on an Integrillin drip. Due to evidence of anterior STEMI, he was taken to the cath lab. Was found to have LAD with diffuse proximal and mid irregularities, distal totally occluded; no collaterals. No intervention was pursued. . On arrival to the floor, patient feels fine but does have [**5-4**] chest pain with inspiration, exactly the same as last night and this morning. The pain was not present during the procedure today but is there now. Otherwise feels fine. . REVIEW OF SYSTEMS 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 pertinent for intermittent ankle swelling (which he says started after starting Norvasc, and happens at the end of the day). No dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea, palpitations, syncope or presyncope. Past Medical History: HTN HLD gout (resolved after stopping diuretics) s/p L4-L5 discectomy [**2141**] S1 radiculopathy Social History: -Home: Lives alone, has no family in the area. Close with his brother, who does not live here. Friends are his main support. -Occupation: Software programmer. -Tobacco history: Never. -ETOH: No history of heavy use, and now no EtOH due to reflux. -Illicit drugs: Never. Family History: Paternal GF died of MI, paternal uncle died of MI in his 50's. Brother had an MI last year at age 50. No family history of arrhythmia, cardiomyopathies, or sudden cardiac death; otherwise non-contributory. Physical Exam: ADMISSION EXAM VS: T 99.5, HR 84, BP 141/97, RR 30, POx 92% 2L NC GENERAL: overweight gentleman in NAD, lying in bed with 2 pillows, breathing comfortably, alert & oriented x3 HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were pink, no pallor or cyanosis of the oral mucosa. No xanthalesma. NECK: Supple with no JVD. CARDIAC: PMI non-displaced, S1 and S2, no murmur, no rub, no chest wall tenderness LUNGS: CTA throughout all fields bilaterally ABDOMEN: obese, nondistended, no masses EXTREMITIES: no edema SKIN: no stasis dermatitis, ulcers, scars, or xanthomas PULSES: Right: Carotid 2+ DP 2+ PT 2+ Left: Carotid 2+ DP 2+ PT 2+ DISCHARGE EXAM GENERAL: 49 yo male in no acute distress HEENT: PERRLA, no pharyngeal erythemia, mucous membs moist, no lymphadenopathy, JVP non elevated CHEST: CTABL no wheezes, no rales, no rhonchi CV: S1 S2 Normal in quality and intensity RRR no murmurs rubs or gallops ABD: soft, non-tender, non-distended, BS normoactive. no rebound/guarding, neg HSM. neg [**Doctor Last Name 515**] sign. EXT: Right radial cath approach, soft, no bleeding/ hematoma/ ecchymosis noted. 2+ radial and ulnar pulses, + CSM right hand. No pedal edema, 2+ DP/PTs. NEURO: CNs II-XII intact. 5/5 strength in U/L extremities. DTRs 2+ BL (biceps, achilles, patellar). sensation intact to LT, pain, temperature, vibration, proprioception. cerebellar fxn intact (FTN, HTS). gait normal. SKIN: no rash, skin intact PSYCH: appropriate Pertinent Results: ADMISSION LABS: [**2166-3-26**] 11:50AM BLOOD WBC-23.3*# RBC-5.17 Hgb-15.5 Hct-44.5 MCV-86 MCH-29.9 MCHC-34.8 RDW-12.9 Plt Ct-311 [**2166-3-26**] 11:50AM BLOOD Neuts-87* Bands-0 Lymphs-5* Monos-8 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2166-3-26**] 11:50AM BLOOD Glucose-119* UreaN-15 Creat-1.2 Na-140 K-3.5 Cl-94* HCO3-32 AnGap-18 CARDIAC ENZYME TREND: [**2166-3-26**] 11:50AM BLOOD CK-MB-66* MB Indx-3.2 [**2166-3-26**] 11:50AM BLOOD cTropnT-2.53* [**2166-3-26**] 11:50AM BLOOD CK(CPK)-2048* [**2166-3-26**] 09:57PM BLOOD CK-MB-27* MB Indx-2.1 cTropnT-2.08* [**2166-3-26**] 09:57PM BLOOD CK(CPK)-1314* DISCHARGE LABS: [**2166-3-29**] 08:20AM BLOOD WBC-9.7 RBC-4.06* Hgb-11.9* Hct-36.4* MCV-90 MCH-29.3 MCHC-32.8 RDW-12.9 Plt Ct-235 [**2166-3-29**] 08:20AM BLOOD PT-16.5* PTT-56.5* INR(PT)-1.6* [**2166-3-29**] 08:20AM BLOOD Glucose-95 UreaN-21* Creat-1.2 Na-142 K-3.5 Cl-102 HCO3-34* AnGap-10 [**2166-3-29**] 08:20AM BLOOD Calcium-8.6 Phos-3.5 Mg-2.3 CARDIAC RISK FACTOR LABS: [**2166-3-26**] 11:50AM BLOOD %HbA1c-5.5 eAG-111 [**2166-3-26**] 11:50AM BLOOD Triglyc-84 HDL-55 CHOL/HD-3.0 LDLcalc-92 EKG [**2166-3-26**]: Sinus rhythm. Diffuse ST segment elevation in the context of evidence of recent or ongoing inferoposterolateral myocardial infarction and probable acute anterior ischemic process as well. Clinical correlation is suggested. CXR [**2166-3-26**]: As compared to the previous radiograph, there is a substantial decrease in lung volumes. Moderate cardiomegaly with signs of mild fluid overload. The presence of a small left pleural effusion cannot be excluded. Relatively extensive retrocardiac and left basal atelectasis but no indication for pneumonia. CARDIAC CATHETERIZATION [**2166-3-26**]: [final report pending] LAD with diffuse proximal and mid irregularities, distal totally occluded; no collaterals. No intervention was pursued. TTE [**2166-3-26**]: The left atrium is mildly dilated. The left atrium is elongated. The estimated right atrial pressure is 0-5 mmHg. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is mildly dilated. Overall left ventricular systolic function is moderately depressed (LVEF= 35-40 %) secondary to akinesis of the apex and distal segments of all LV walls. The remaining segments contract normally. 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 at the sinus level. The ascending aorta is mildly dilated. The aortic arch is mildly dilated. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic stenosis or aortic regurgitation. The mitral valve appears structurally normal with trivial mitral regurgitation. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with moderate regional and global systolic dysfunction c/w CAD or takotsubo cardiomyopathy. No significant valvular disease. CXR [**2166-3-27**]: 1. Improved aeration in the lungs. 2. Left basilar atelectasis and small pleural effusion. EKG [**2166-3-28**]: Sinus rhythm. Q waves in leads II, III and aVF indicating an old inferior myocardial infarction. Q waves in leads V4-V6 with ST segment elevation in leads V3-V6 and biphasic T waves in lead V2 and that inverted T wave in lead V1 indicating an acute anterior myocardial infarction. However, there are also ST segment elevations in leads I, II, and ST segment depressions in lead aVR which may indicate a pericarditis process. Clinical correlation is suggested. Brief Hospital Course: Mr. [**Known lastname 6164**] is a 49y/o gentleman with coronary risk factors of HTN, HLD, and family history of early CAD who presented with STEMI. During this admission, his MI was treated medically (no intervention), and he was treated for pericarditis as well as apical aneurysm/akinesis with no complications and he was discharged home. . #. Anterior/lateral/inferior STEMI: totally occluded distal LAD. His "heartburn" 2 days prior to admission that was different from his usual GERD likely represented ACS. Presented 48 hours out from that event, with no more heartburn (though had pleuritic pain - please see below). Q waves already present, no hemodynamic instability or dynamic changes to suggest that intervention at this point would be beneficial (and besides, lesion was 100% occluded) so his STEMI was managed medically. His pleuritic pain likely represents post-MI pericarditis (see below). Other complications of his MI included apical aneurysm/akinesis (see below). He was monitored in the CCU for more serious complications of STEMI, but he had none. Note that persistent ST elevations could reflect his recent ACS, his pericarditis (there are some PR depressions), and/or LV aneurysm. He was discharged on ASA (will take anti-inflammatory dose for 1 week then continue with 81mg indefinitely); statin was changed from Crestor 5mg to Atorvastatin 80mg; his beta blocker (Carvedilol) was uptitrated; his RAAS blocker (Losartan) was continued at lower dose. He was Plavix-loaded but no indication to continue Plavix. He will follow-up with his Cardiologist after discharge. . #. Peri-infarct pericarditis: still has mild pleuritic chest pain. He has pleuritic chest pain that is somewhat positional, and EKG could be consistent. No rub. No effusion on TTE. He is being treated with high-dose ASA (650mg PO TOD x1 week). Colchicine was not started; his pain was reasonably controlled on aspirin. . #. Apical akinesis, ?LV aneurysm: started on Warfarin. TTE showed symmetric akinesis of the apex, mild aneurysm as well. He was started on Heparin gtt and was transitioned to Warfarin (note, was discharged before fully anticoagulated as no clear evidence for bridge). He was discharged on Warfarin and will follow up at his Cardiologist's office for INR check and management of anticoagulation. . #. LV EF 25-30%: euvolemic on discharge. No intervention was pursued for his lesion but it is possible that his EF will improve somewhat. He is already on a beta blocker and a RAAS blocker. He will follow up with his Cardiologist and will likely have a follow-up TTE in the future. . #. Mild hypoxia: resolved. He was 88%RA on the morning after presentation. Differential included pulmonary edema (mildly depressed EF, but CXR was not very convincing for edema, and he seemed otherwise euvolemic). PE was considered but did not fit with clinical picture and ABG was not concerning. With deep breaths his O2 rose to 91%RA; the most likely etiology for his hypoxia was splinting from pericarditis pain, along with likely underlying obesity hypoventilation. His pain was controlled and by the time of discharge his O2 sat was >90%RA. He might benefit from outpatient sleep study. #. Leukocytosis: resolved, likely related to MI. No localizing signs/symptoms to suggest infection. Leukocytosis likely from MI or pericarditis. CXR was not concerning and his WBC normalized by discharge. #. HTN: BP reasonably controlled. He was continued on Carvedilol, which was uptitrated for better HR control. As a result, he was able to be discharged off Amlodipine. His Losartan dose was decreased. He will follow up with his PCP and Cardiologist. . #. HLD: stable. His statin was chaned from Crestor 5mg to Atorvastatin 80mg daily. . TRANSITIONAL ISSUES: -PCP [**Name Initial (PRE) **]/or Cardiologist to follow up lipid control (changed from Crestor 5mg to Atorvaststin 80mg) -Cardiologist might wish to repeat TTE in the future -[**Month (only) 116**] benefit from outpatient sleep study -Code status this admission: Full Code -Emergency contact: [**Name (NI) 5279**] [**Name (NI) 6164**] (brother) [**Telephone/Fax (1) 109971**] Medications on Admission: ASA 81mg daily Losartan 50mg daily Crestor 5mg daily Carvedilol 18.75mg [**Hospital1 **] Norvasc 10mg daily Pantoprazole 40mg [**Hospital1 **] Fish oil 1200mg daily Centrum 1 tab daily Glucosamine sulfate 1200mg daily Coenzyme Q-10 100mg daily Ibuprofen 800mg PRN Discharge Medications: 1. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 2. omega-3 fatty acids Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. aspirin 325 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day) for 3 days: UNTIL [**2166-4-1**]. Disp:*18 Tablet(s)* Refills:*0* 5. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO once a day: START ON [**2166-4-1**] AND CONTINUE INDEFINITELY. Disp:*30 Tablet, Chewable(s)* Refills:*2* 6. carvedilol 25 mg Tablet Sig: Two (2) Tablet PO twice a day. Disp:*120 Tablet(s)* Refills:*2* 7. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4 PM. Disp:*30 Tablet(s)* Refills:*2* 8. nitroglycerin 0.4 mg Tablet, Sublingual Sig: One (1) Tablet, Sublingual Sublingual PRN (as needed) as needed for chest pain. Disp:*30 Tablet, Sublingual(s)* Refills:*0* 9. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours). 10. losartan 25 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: Coronary artery disease (s/p ST elevation myocardial infarction) Peri-infarct pericarditis LV apical aneurysm/akinesis Hypertension Dyslipidemia GERD Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Mr. [**Known lastname 6164**], It was a pleasure treating you during your hospitalization. You were admitted to [**Hospital1 69**] after having a heart attack. You have a complete blockage in your left anterior descending artery (LAD) which we are treating with medications at this time. As a result of the heart attack you have some apical wall motion abnormalities in your heart which will have to be monitored. Because your heart is not pumping normally after the heart attack you need to be cautious about fluid build up. You should weigh yourself every morning and call your doctor if weight goes up more than 3 lbs in 3 days or 5 lbs in 2 days. Follow a low salt diet and try to restrict your fluid intake to [**2153**] ml per day. In addition, due to the abnormal movement/shape of the bottom of the heart (apical aneurysm, apical akinesis), you are at risk for blood clot formation in the heart so you are being discharged home on a blood thinner (Warfarin). You will need to have the blood level of this medication checked frequently (INR, goal is between 2 and 3). Please follow up at Dr.[**Name (NI) 5765**] office on Tuesday to have the blood level checked. The chest pain you are experiencing that is worse with breathing is likely due to "pericarditis," or inflammation of the tissue layer around the heart, which can happen after a heart attack. For this, you are being treated with high-dose aspirin for 1 week (and then you will be decreased to the lower-dose Aspirin, which you will continue indefinitely for your coronary artery disease. If you experience chest pressure of atypical heartburn again, take Nitroglycerin under your tongue as directed. If the pain does not go away, call 911. Medication changes: - STOP your Norvasc (Amlodipine) - STOP your Crestor - STOP taking Ibuprofen - DECREASE your Losartan to 25mg daily - INCREASE your Carvedilol to 50mg twice daily - INCREASE your Aspirin to 650mg three times a day until [**2166-4-1**] - After [**2166-4-1**] resume Aspirin 81mg daily (baby aspirin) - START Atorvastatin 80mg Daily - START Coumadin (Warfarin) at 5mg daily: Followup Instructions: ANTICOAGULATION - DR.[**Last Name (STitle) **] OFFICE ***You will need to have blood work on Tuesday [**4-1**] to check the INR (measure of blood thinning), electrolytes and kidney function. These should be followed up by Dr. [**Last Name (STitle) **]. PRIMARY CARE Name: [**Last Name (LF) 903**],[**First Name3 (LF) 251**] J. Location: [**Hospital6 9657**] MEDICAL GROUP Address: [**Location (un) **], [**Apartment Address(1) 25389**], [**Location (un) **],[**Numeric Identifier 1700**] Phone: [**Telephone/Fax (1) 24396**] When: Thursday, [**2165-4-2**]:00 AM ***In 6 weeks you will need to have your cholesterol and liver function tests repeated (to make sure the Lipitor is working). CARDIOLOGY Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **]/CARDIOLOGY Address: [**Street Address(2) 2687**],STE 7C, [**Location (un) **],[**Numeric Identifier 822**] Phone: [**Telephone/Fax (1) 5768**] When: Wednesday, [**4-23**], 1:00 PM

[ "274.9", "799.02", "414.10", "530.81", "724.4", "278.03", "411.0", "553.3", "V17.3", "272.4", "410.11", "414.01", "786.52" ]

icd9cm

[ [ [] ] ]

[ "37.22", "88.56" ]

icd9pcs

[ [ [] ] ]

14521, 14527

8895, 12653

365, 408

14721, 14721

5308, 5308

17007, 18017

3614, 3821

13366, 14498

14548, 14700

13078, 13343

14872, 16590

5931, 8872

3836, 5289

12674, 13052

16610, 16984

283, 327

436, 3185

5324, 5915

14736, 14848

3207, 3306

3322, 3598

57,593

154,015

39598

Discharge summary

report

Admission Date: [**2144-1-13**] Discharge Date: [**2144-1-21**] Date of Birth: [**2085-4-4**] Sex: M Service: CARDIOTHORACIC Allergies: Sulfa (Sulfonamide Antibiotics) Attending:[**First Name3 (LF) 165**] Chief Complaint: preop CABG Major Surgical or Invasive Procedure: [**2144-1-15**] 1. Coronary artery bypass graft x4, left internal mammary artery to left anterior descending artery and saphenous vein graft to diagonal, obtuse marginal and posterior left ventricular branch. 2. Endoscopic harvesting of the long saphenous vein. History of Present Illness: This is a 58 year old male with known coronary artery disease who ruled in for an MI in [**2142-10-9**]. He was offered a CABG at [**Hospital1 2025**] at that time but the patient refused because he was told "his heart was too weak". He was recently had exertional angina, associated with palpitations, SOB, and chest tightness. Patient saw Dr. [**Last Name (STitle) 11493**] who referred patient to Dr. [**First Name (STitle) **] to evaluate for CABG. Past Medical History: Coronary Artery Disease, s/p CABG PMH: - Ischemic Cardiomyopathy, severe 3VD - Hypertension - Dyslipidemia - History of PAF - Type II Diabetes - GERD - CVA [**2133**] (Left side weakness initially- no current deficits-on coumadin) - CHF - squamous cell CA on nose s/p biopsy (needs excision) - MI [**2142**] Social History: Lives with:alone, [**Location (un) 448**]. Divorced. 1 Daughter died in a MVA, second daughter lives in [**Name (NI) **] with her 2 children, patient has not seen in >5 years. No support systems Occupation: unemployed/ former Army Tobacco: Remote tobacco, quit in [**2103**]'s ETOH: none since [**2103**]'s Family History: +FH, father suffered multiple [**Name (NI) 5290**] between ages 50 and 55, died at 56 Physical Exam: Temp 97.7 Pulse: 73 Resp: 20 O2 sat: 97%-RA B/P Right: 149/99 Left: Height: 5'5" Weight: 240 lbs General: Skin: Warm[x] Dry [x] intact [x] HEENT: NCAT[x] PERRLA [x] EOMI [x] biopsy site under bandage on bridge of nose Neck: Supple [x] Full ROM [x] Chest: Lungs clear bilaterally [x] Heart: RRR [x] Irregular [] Murmur Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds + [x] obese Extremities: Warm [x], well-perfused [x] Edema none Varicosities: None [x] Neuro: A&Ox3, non focal exam Pulses: Femoral Right: 2+ Left: 2+ DP Right: 2+ Left: 2+ PT [**Name (NI) 167**]: 2+ Left: 2+ Radial Right: cath Left: 2+ Carotid Bruit Right:no Left:no Pertinent Results: [**2144-1-20**] 04:10AM BLOOD WBC-9.9 RBC-3.74* Hgb-11.1* Hct-33.0* MCV-88 MCH-29.8 MCHC-33.8 RDW-15.0 Plt Ct-293 [**2144-1-19**] 05:04AM BLOOD WBC-10.3 RBC-3.75* Hgb-11.7* Hct-33.7* MCV-90 MCH-31.3 MCHC-34.7 RDW-14.6 Plt Ct-239 [**2144-1-20**] 04:10AM BLOOD PT-24.5* INR(PT)-2.3* [**2144-1-19**] 10:02AM BLOOD PT-20.3* INR(PT)-1.9* [**2144-1-18**] 05:50AM BLOOD PT-15.2* INR(PT)-1.3* [**2144-1-17**] 03:58AM BLOOD PT-15.2* PTT-28.1 INR(PT)-1.3* [**2144-1-15**] 03:23PM BLOOD PT-14.3* PTT-39.2* INR(PT)-1.2* [**2144-1-15**] 02:10PM BLOOD PT-16.1* PTT-31.3 INR(PT)-1.4* [**2144-1-20**] 04:10AM BLOOD Glucose-131* UreaN-29* Creat-1.4* Na-139 K-4.2 Cl-101 HCO3-31 AnGap-11 [**2144-1-19**] 05:04AM BLOOD Glucose-127* UreaN-28* Creat-1.5* Na-139 K-4.1 Cl-100 HCO3-32 AnGap-11 [**2144-1-18**] 05:50AM BLOOD Glucose-126* UreaN-21* Creat-1.4* Na-137 K-3.8 Cl-99 HCO3-31 AnGap-11 [**2144-1-21**] 04:57AM BLOOD PT-24.8* INR(PT)-2.4* Brief Hospital Course: The patient was admitted preoperatively for a heparin bridge, as he is on coumadin for atrial fibrillation. Pre-op workup included carotid ultrasound which did not reveal significant carotid disease. The patient was brought to the operating room on [**2144-1-15**] where the patient underwent CABG x 3 with Dr. [**First Name (STitle) **]. Overall the patient tolerated the procedure well and post-operatively was transferred to the CVICU in stable condition for recovery and invasive monitoring. POD 1 found the patient extubated, alert and oriented and breathing comfortably. The patient was neurologically intact and hemodynamically stable, weaned from inotropic and vasopressor support. Beta blocker was initiated and the patient was gently diuresed toward the preoperative weight. The patient was transferred to the telemetry floor for further recovery. Chest tubes and pacing wires were discontinued without complication. The patient was evaluated by the physical therapy service for assistance with strength and mobility. Coumadin was resumed for atrial fibrillation. By the time of discharge on POD #6 the patient was ambulating freely, the wound was healing and pain was controlled with oral analgesics. The patient was discharged to [**Hospital 70637**] Rehab in [**Location (un) 32944**] in good condition with appropriate follow up instructions. Medications on Admission: Albuterol MDI PRN Amlodipine 5mg PO daily Digoxin 250 mcg po daily Lasix 20mg po daily Glipizide 5mg po daily Insulin Detemir 110 units SC twice a day Isosorbide Mononitrate SR 30mg po once a day Lisinopril 40 mg po daily Metformin 1000mg po daily Metoprolol XL 100mg po once a day Nitroglycerin 0.4 mg SL prn Rosuvastatin 20mg po once a day Serevent Diskus 50 mcg disk 1 puff IH daily Trimethroprim 100mg po daily Warfarin 2mg tab alternating 3mg tab po once a day ASA 81 mg po once a day Discharge Medications: 1. metoprolol tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 2. oxycodone-acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*60 Tablet(s)* Refills:*0* 3. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 4. metformin 500 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 5. rosuvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 6. amiodarone 200 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day): 400mg [**Hospital1 **] x 2 weeks, then 400mg daily x 1 week, then 200mg daily until further instructed. Disp:*120 Tablet(s)* Refills:*2* 7. salmeterol 50 mcg/dose Disk with Device Sig: One (1) Disk with Device Inhalation DAILY (Daily). Disp:*qs Disk with Device(s)* Refills:*2* 8. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 9. warfarin 1 mg Tablet Sig: One (1) Tablet PO once a day: dose today [**1-21**] only 2.5 mg;MD to dose daily for goal INR [**3-13**], dx: a-fib. Disp:*30 Tablet(s)* Refills:*1* 10. Outpatient Lab Work Labs: PT/INR Coumadin for atrial fibrillation Goal INR [**3-13**] First draw day after discharge, [**2144-1-22**] Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by [**Location (un) **] VA coumadin clinic Results to phone [**Telephone/Fax (1) 87386**] 11. furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day for 1 weeks. Disp:*14 Tablet(s)* Refills:*0* 12. furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day: begin 20mg daily when 40mg [**Hospital1 **] is complete, [**2144-1-27**]. Disp:*30 Tablet(s)* Refills:*2* 13. potassium chloride 20 mEq Tab Sust.Rel. Particle/Crystal Sig: One (1) Tab Sust.Rel. Particle/Crystal PO Q12H (every 12 hours): 20mEq [**Hospital1 **] x 1 week, then 20mEq daily. Disp:*60 Tab Sust.Rel. Particle/Crystal(s)* Refills:*2* 14. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 15. glipizide 5 mg Tablet Extended Rel 24 hr Sig: One (1) Tablet Extended Rel 24 hr PO once a day. Disp:*30 Tablet Extended Rel 24 hr(s)* Refills:*2* 16. insulin detemir 100 unit/mL Solution Sig: Fifty Five (55) units Subcutaneous twice a day: 55 Units Detemir Subcutaneous [**Hospital1 **]. Disp:*qs * Refills:*2* Discharge Disposition: Extended Care Facility: Maplewood Care & Rehabilitation Center - [**Location (un) 32944**] Discharge Diagnosis: Coronary Artery Disease, s/p CABG PMH: - Ischemic Cardiomyopathy, severe 3VD - Hypertension - Dyslipidemia - History of PAF - Type II Diabetes - GERD - CVA [**2133**] (Left side weakness initially- no current deficits-on coumadin) - CHF - squamous cell CA on nose s/p biopsy (needs excision) - MI [**2142**] Discharge Condition: Alert and oriented x3 nonfocal Ambulating, gait steady Sternal pain managed with oral analgesics Sternal Incision - healing well, no erythema or drainage Discharge Instructions: Please shower daily including washing incisions gently with mild soap, no baths or swimming, and look at your incisions Please NO lotions, cream, powder, or ointments to incisions Each morning you should weigh yourself and then in the evening take your temperature, these should be written down on the chart No driving for approximately one month and while taking narcotics, will be discussed at follow up appointment with surgeon when you will be able to drive No lifting more than 10 pounds for 10 weeks Please call with any questions or concerns [**Telephone/Fax (1) 170**] **Please call cardiac surgery office with any questions or concerns [**Telephone/Fax (1) 170**]. Answering service will contact on call person during off hours** Followup Instructions: You are scheduled for the following appointments: Surgeon [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 170**] Date/Time:[**2144-2-10**] 1:45 Cardiologist Dr. [**Last Name (STitle) 11493**] on [**2-11**] at 9:45am Please call to schedule the following: Primary Care Dr. [**Last Name (STitle) **],[**First Name3 (LF) **] J. [**Telephone/Fax (1) 57401**] in [**5-13**] weeks Labs: PT/INR Coumadin for atrial fibrillation Goal INR [**3-13**] First draw day after discharge, [**2144-1-22**] Then please do INR checks Monday, Wednesday, and Friday for 2 weeks then decrease as directed by [**Location (un) **] VA coumadin clinic Results to phone [**Telephone/Fax (1) 87386**] Plan confirmed with Candy [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2144-1-21**]

[ "414.8", "413.9", "530.81", "414.01", "V12.54", "412", "514", "401.9", "V58.83", "799.02", "V10.83", "250.00", "V58.61", "272.4", "427.31" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

7895, 7988

3521, 4889

308, 584

8340, 8496

2573, 3498

9284, 10143

1743, 1830

5430, 7872

8009, 8319

4915, 5407

8520, 9261

1845, 2554

257, 270

612, 1068

1090, 1400

1416, 1727

12,666

192,675

12532

Discharge summary

report

Admission Date: [**2200-4-15**] Discharge Date: [**2200-4-22**] Date of Birth: [**2144-1-11**] Sex: M Service: CARDIOTHORACIC CHIEF COMPLAINT: Increaesed fatigue. HISTORY OF PRESENT ILLNESS: The patient is a 56 year-old gentleman with a history of coronary artery disease and congestive heart failure. In [**2196**] the patient underwent cardiac catheterization, which revealed a 90% stenosis in the RPL and a sequential 80% lesion in distal left anterior descending coronary artery. There was also disease of first and second diagonals. Subsequently he underwent stenting of the distal right coronary artery on [**2197-9-28**]. On [**2198-5-14**] he was catheterized at [**First Name8 (NamePattern2) 38829**] [**Last Name (NamePattern1) 805**] Medical Center due to congestive heart failure, although by report there were no interventions at that time. Since then the patient has been in his usual state of health, but more recently the daughter reports her father has been very fatigued. There is no complaint of chest pain, chest discomfort or shortness of breath. Due to the increase in fatigue and loss of exercise tolerance the patient was referred to a cardiologist and underwent further testing. On [**2200-1-31**] the patient underwent echocardiogram, which demonstrated moderate concentric left ventricular hypertrophy, mild aortic stenosis, moderate aortic insufficiency and a mildly dilated aortic root. There was also moderate MR and mild tricuspid regurgitation. He underwent an exercise stress tolerance test at the same time with Myoview, which was significant for symptomatic exercise test, which was stopped due to diaphoresis and pallor. Imaging revealed a partially reversible inferolateral defect. An EF was 45%. The patient denies currently any orthopnea, paroxysmal nocturnal dyspnea, lightheadedness or peripheral edema. The patient presents to [**Hospital1 69**] for catheterization and likely AVR coronary artery bypass graft procedure by Dr. [**Last Name (STitle) **] and the Cardiothoracic team. PAST MEDICAL HISTORY: 1. Hypertension. 2. Hypercholesterolemia. 3. Diabetes mellitus. 4. Coronary artery disease status post stenting of right coronary artery. PAST SURGICAL HISTORY: Significant for status post recent laser eye surgery and status post tooth extractions. MEDICATIONS ON ADMISSION: Aspirin 375 mg po q.d., Mavic 4 mg po t.i.d., Glucovance 5/500 mg po b.i.d., Lipitor 10 mg po q.d., Lasix 20 mg o q.o.d., Toprol 200 mg po q.d. ALLERGIES: No known drug allergies. SOCIAL HISTORY: The patient has a supportive daughter. [**Name (NI) **] owns and works at a family grocery store. Tobacco, the patient smoked since the age of 14, but quit four years ago and occasional ETOH use. PHYSICAL EXAMINATION: The patient's temperature is 98.2. Heart rate 76. Blood pressure 162/68. Sating 98% on room air. The patient has a supple neck with no bruits. Lungs are clear to auscultation bilaterally. Heart is regular rate and rhythm with a 2/6 systolic ejection murmur. Abdomen is soft, nontender, with no masses. Distal extremity examination is negative for edema. Warm bilaterally. Electrocardiogram significant for normal sinus rhythm with a rate of 70. There is inverted T waves in V4 through V6, left shift of the axis and widened QRS and no evidence of active ischemia. LABORATORIES ON ADMISSION: White blood cell count 6.9, hematocrit 34.8, platelets 146, sodium 138, potassium 4.4, chloride 105, bicarbonate 21, BUN 24, creatinine 1.5, which is baseline. INR of 1.3. Chest x-ray is significant for slight cardiomegaly with left ventricular predominance, tortuosity of the thoracic aorta. No congestive heart failure. No infiltrate. Urinalysis negative. HOSPITAL COURSE: The patient on the day of admission was admitted to the Cardiothoracic Service. The patient underwent a cardiac catheterization. This was significant for an ejection fraction of 50% with normal wall motion. Mitral valve showed 1+ regurgitation. There was 3+ aortic regurgitation. Right coronary artery showed 60% stenosis. Left anterior descending coronary artery showed 80% stenosis. Proximal circumflex showed 50% stenosis. Obtuse marginal one was 60% stenotic. On hospital day number two the patient was taken to the Operating Room with Dr. [**Last Name (STitle) **] and the Cardiothoracic team where he underwent a coronary artery bypass graft times three and AVR. The patient received a #23 CarboMedics mechanical valve and the grafts were left internal mammary coronary artery to left anterior descending coronary artery, saphenous vein graft to diagonal and saphenous vein graft to posterior descending coronary artery. The patient tolerated this procedure well. He underwent an EVJ on the right thigh with hyper skip. The patient also underwent a Dermabond study. Postoperatively, the patient was transferred to the Cardiothoracic Intensive Care Unit in stable condition. The patient was extubated without incident with good O2 saturation. The patient was weaned off of all drips. The patient received 4 units of packed red blood cells for a hematocrit of 22. The chest tubes had a total drainage of 600 cc over 24 hours. The patient's intravascular was augmented with 500 cc of Hespan. The patient remained hemodynamically stable and in no acute distress. On postoperative day number one the patient remained stable and was transferred to the floor. On the night of postoperative day number one the patient developed atrial fibrillation with rapid ventricular response. The patient was managed with intravenous Lopressor. Rate and blood pressure remained stable in the 130s. The patient was started on po Amiodarone and rate became controlled. The patient spontaneously converted to sinus rhythm on the morning of postoperative day number two. The patient's chest tubes and lines were discontinued on postoperative number two without incident. The patient's hematocrit remained stable at 26. The patient has occasionally reverted back to atrial fibrillation. He has been anticoagulated for his valve and his atrial fibrillation for a goal of 2.5 to 3.5 on Coumadin. The patient is continued on Amiodarone and will be on 400 mg po t.i.d. times one week and then will switched to 400 b.i.d. times one week and then 400 q.d. for several months. The patient's creatinine had been elevated on postoperative day number two to a high of 2.0. The patient's Lasix and potassium had been stopped and the patient's creatinine has now drifted down to a baseline of 1.3. The patient's urine output has remained adequate. The patient's diet has been advanced to a diabetic [**Doctor First Name **] 1800 diet. The patient is ambulating and is now stable for discharge to home. DISCHARGE DIAGNOSES: 1. Coronary artery disease coronary artery bypass graft times three. 2. Aortic insufficiency status post AVR, #23 CarboMedics mechanical valve. 3. Hypertension. 4. Diabetes mellitus. 5. Hypercholesterolemia. 6. Postoperative atrial fibrillation. MEDICATIONS ON DISCHARGE: Amiodarone 400 mg po b.i.d. stop [**2200-5-2**], Amiodarone 400 mg po t.i.d. start [**2200-5-3**], Glucovance 5/500 po b.i.d., Lopressor 75 mg po b.i.d., Lipitor 10 mg po q.d., Lasix 20 mg po q.o.d., Percocet 5/325 one to two po q 4 hours prn, Colace 100 mg po b.i.d., ASA 81 mg po q.d., Coumadin po b.i.d. dosed per primary care physician. CONDITION ON DISCHARGE: Stable. The patient will follow up with Dr. [**Last Name (STitle) **] in four weeks and follow up with Dr. [**Last Name (STitle) 38839**] [**Name (STitle) 38840**] in two weeks. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Last Name (NamePattern1) 3835**] MEDQUIST36 D: [**2200-4-21**] 10:57 T: [**2200-4-22**] 10:14 JOB#: [**Job Number 38841**]

[ "401.9", "272.0", "428.0", "424.1", "427.31", "V45.82", "414.01" ]

icd9cm

[ [ [] ] ]

[ "37.23", "35.22", "39.61", "36.15", "36.12", "88.53", "88.56" ]

icd9pcs

[ [ [] ] ]

6794, 7047

7074, 7416

2365, 2548

3771, 6773

2249, 2338

2787, 3375

161, 182

211, 2057

3390, 3753

2080, 2225

2565, 2764

7441, 7901

3,884

133,921

7656

Discharge summary

report

Admission Date: [**2188-1-18**] Discharge Date: [**2188-2-1**] Date of Birth: [**2130-4-19**] Sex: F Service: Cardiothoracic Surgery HISTORY OF PRESENT ILLNESS: The patient is a 57-year-old woman with multiple medical problems including coronary artery disease, status post inferior Q wave MI in [**2184**], COPD, CHF/MR who presented to outside hospital with progressive shortness of breath and chest pain. The patient was noted to be hypoxic and was intubated. She had a severe respiratory acidosis with a PH of 6.99 shortly after intubation. EKG showed old inferior Q waves and [**Street Address(2) 4793**] depressions in the anterior leads. She was initially started on Heparin and Nitroglycerin for ischemia. A TTE was performed emergently on [**1-16**] and showed hyperdynamic LV function with an EF of 75%. Small amount of inferobasilar wall hypokinesis, trace TR, normal aortic valve, [**1-28**]+ MR and normal RV function. The patient ruled out for MI with negative enzymes. The patient was extubated on [**1-17**] although she was still requiring 50% FIO2 and ventilating well with normal PH. She was fatigued but not retaining CO2 and tolerated extubation early in a.m. on [**1-18**] when she was noted to be in severe respiratory distress, tachycardic to 150 and hypertensive to 160/112, O2 sat on 100% non rebreather. The patient was given 100 mg IV Lasix. Chest x-ray showed flash pulmonary edema. The patient was also having long runs of V tach and given Lidocaine 100 mg IV bolus. She had a seizure for which she was given Ativan. The patient was intubated. A repeat TTE was performed and she was transferred to [**Hospital1 346**] for further management. PAST MEDICAL HISTORY: 1) Coronary artery disease, status post inferior wall MI in [**2184**]. 2) Congestive heart failure times one episode. 3) Severe chronic obstructive pulmonary disease. 4) Lumbar laminectomy. 5) Right humeral fracture. 6) Sciatica. 7) Shingles. 8) Left hydronephrosis. 9) Severe diverticulosis. 10) Appendectomy. 11) Cardiogenic shock due to severe MR [**First Name (Titles) **] [**Last Name (Titles) **]. MEDICATIONS: Xanax 0.5 mg po tid, Imdur 90 mg po q d, Accolate 20 mg po bid, [**Last Name (un) **]-Dur 300 mg tid, Univasc 15 mg po q d, Prevacid 15 mg po q d, Atenolol 50 mg po q d, Lipitor 10 mg po q d, Albuterol and Atrovent inhalers prn, Percocet 1-2 tabs po q 6 hours prn. On transfer she was also on a Heparin drip, Reglan 6 mg IV q 6 hours, Levaquin 500 mg IV q d, Ativan drip, Lidocaine, Amiodarone bolus, Fentanyl drip, Nitroglycerin drip. ALLERGIES: Penicillin which causes anaphylaxis. SOCIAL HISTORY: She is a heavy smoker with 2-3 pack per day history times 30 years and moderate alcohol use. PHYSICAL EXAMINATION: She was intubated, sedated, with dysconjugate gaze, her vital signs were temperature 100.6, heart rate 100, blood pressure 100/57 and O2 saturation of 97%. Vent settings on transfer were assist control of 500/16, PEEP of 5, FIO2 50%. HEENT: Pupils are equal, round, and reactive to light. Neck, no jugulovenous distension. Chest clear to auscultation bilaterally and anteriorly. Heart regular, normal S1 and S2 with 3/6 systolic ejection murmur at the apex radiating to the axilla and carotids. Abdomen soft, diffusely tender but mostly in the right upper quadrant, non distended, positive bowel sounds, bruit vs transmitted heart murmur, no clubbing, cyanosis or edema on extremities. LABORATORY DATA: On admission white count was 26.1, hematocrit 43.8, platelet count 264,000. Chem 7, 140, 3.0, 104, 27, 32, 1.0 and 138. PT 10.9, INR 0.8, PTT 87.4. HOSPITAL COURSE: The patient was admitted and remained intubated on the coronary care unit service. Repeat TTE at [**Hospital1 69**] showed severe MR and a hypodynamic left ventricular function. The patient was requiring Levophed for blood pressure support. The patient was started empirically on Vancomycin, Flagyl and Levaquin for presumed sepsis. The patient was aggressively diuresed in the CCU. Cardiac catheterization demonstrated severe MR. [**First Name (Titles) 6**] [**Last Name (Titles) **]-aortic balloon pump was placed. Cardiothoracic surgery was contact[**Name (NI) **] for mitral valve replacement and one vessel CABG. The patient underwent mitral valve repair with a mechanical valve and saphenous vein graft to the PDA CABG on [**2188-1-24**]. Postoperatively the patient did well and was transferred to the unit. The patient was noted to have a pneumothorax on chest x-ray on postoperative day #1 so right chest tube was placed. The patient continued to do well and on postoperative day #4 the patient's chest tubes were removed. The patient was restarted on her Coumadin post-operatively. On postoperative day #5 the patient was transferred to the floor. On the first night on the floor the patient required a sitter due to some confusion but on postoperative day #6 the patient no longer required a sitter and was somewhat more oriented. On postoperative day #6 the patient's INR was noted to be 5.8. The previous day the patient's Coumadin had been held and was held again on postoperative day #6. The patient's Foley was removed on postoperative day #6 and patient was transferred to rehab in stable condition on postoperative day #7, [**2188-1-31**]. DISCHARGE MEDICATIONS: Metoprolol 25 mg po bid, Lasix 20 mg po bid times 7 days, KCL 20 mEq po bid times 7 days, Colace 100 mg po bid, Zantac 150 mg po bid, Aspirin 81 mg po q d, Percocet 1-2 tabs po q 4-6 hours prn, Albuterol and Atrovent nebs q 4 hours prn, Combivent 2 puffs q 4 hours, Accolate 20 mg po bid, Lipitor 20 mg po q d, OxyContin 10 mg po bid, [**Last Name (un) **]-Dur 300 mg po tid and Haldol 0.5 mg IV q 6 hours prn. DISCHARGE DIAGNOSIS: 1. Status post MVR with mechanical valve and CABG times one vessel. DISCHARGE STATUS: To rehab in stable condition. Dr. [**Last Name (STitle) 9346**] will regulate anticoagulation. [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern1) **], M.D. [**MD Number(1) 3113**] Dictated By:[**Last Name (NamePattern1) 6067**] MEDQUIST36 D: [**2188-1-30**] 13:37 T: [**2188-1-30**] 13:46 JOB#: [**Job Number **]

[ "512.1", "511.9", "038.9", "428.1", "424.0", "305.1", "518.81", "429.5", "414.01" ]

icd9cm

[ [ [] ] ]

[ "37.23", "39.61", "37.61", "35.24", "34.04", "39.64", "96.72", "36.11", "88.56" ]

icd9pcs

[ [ [] ] ]

5360, 5772

5793, 6251

3661, 5336

2781, 3643

181, 1708

1731, 2647

2664, 2758

30,457

104,032

1535

Discharge summary

report

Admission Date: [**2149-5-27**] Discharge Date: [**2149-6-3**] Date of Birth: [**2085-5-14**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 458**] Chief Complaint: bradycardia Major Surgical or Invasive Procedure: Cardioversion History of Present Illness: Mr [**Known lastname **] is a 63 year old gentleman with recent CABG x 2 and MVR (OnX mechanical valve)/ MAZE/PFO closure admitted for hypotension and bradycardia s/p DC cardioversion for aflutter/atach. Per [**Name (NI) **], pt was recently admitted in [**2149-4-5**] for subtherapeutic INR. During that admission, he was found to be in aflutter. At that time he was on Toprol Xl and amiodarone. Per the patient, amiodarone was then discontinued. Given his multiple recent surgeries, DC cardioversion was thought to be the best option for rhythm control. The patient himself has not had symptoms of tachycardia, no CP, no SOB. . The patient underwent DC cardioversion with sedation. He then became hypotensive and was bradycardic in a junctional rythm. He was placed on dopamine and recovered his blood pressure. He was subsequently admitted to the ICU for observation. Currently he states that he felt dizzy after cardioversion, but now feels well. Past Medical History: [**1-14**] complex cardiac surgery: -- artifical MV placed -- Coronary Artery Bypass Graft x 2 (LIMA to LAD, SVG to Diag) -- Patent Foramen Ovale closure -- [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1916**] ligation -- MAZE procedure Atrial Fibrillation Endocarditis - source thought to be dental abscesses Chronic Obstructive Pulmonary Disease Asthma Gout Anxiety s/p cataract surgery Social History: Quit smoking in [**10/2148**] after 2ppd x 50yrs. Denies ETOH use. Family History: Non-contributory Physical Exam: Vitals: afebrile BP 114/89 HR 83 R 14 Sao2 97% RA GEN: well appearing in NAD HEENT: no JVD CVS: well healed, midline chest scar RRR, mechanical S2, [**3-12**] diastolic murmur Resp: CTAB, no labored breathing EXT: no edema Neuro: Aox3 Pertinent Results: [**2149-5-27**] 09:54PM BLOOD WBC-10.4 RBC-4.83 Hgb-13.6* Hct-40.5 MCV-84 MCH-28.1 MCHC-33.6 RDW-16.8* Plt Ct-254 [**2149-5-29**] 04:10AM BLOOD WBC-8.7 RBC-4.15* Hgb-11.9*# Hct-34.7* MCV-84 MCH-28.8# MCHC-34.4# RDW-16.7* Plt Ct-225# [**2149-5-27**] 09:54PM BLOOD Neuts-68.3 Lymphs-24.1 Monos-6.1 Eos-1.1 Baso-0.4 [**2149-5-27**] 12:10PM BLOOD INR(PT)-2.0* [**2149-5-28**] 06:00AM BLOOD PT-13.7* PTT-21.6* INR(PT)-1.2* [**2149-5-29**] 04:10AM BLOOD PT-22.6* PTT-63.7* INR(PT)-2.2* [**2149-5-27**] 09:54PM BLOOD Glucose-133* UreaN-21* Creat-1.1 Na-141 K-3.8 Cl-104 HCO3-30 AnGap-11 [**2149-5-29**] 04:10AM BLOOD Glucose-95 UreaN-17 Creat-0.8 Na-142 K-4.2 Cl-107 HCO3-26 AnGap-13 [**2149-5-28**] 06:00AM BLOOD CK(CPK)-54 [**2149-5-28**] 06:00AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2149-5-27**] 09:54PM BLOOD Calcium-9.0 Phos-3.7 Mg-2.0 [**2149-5-29**] 04:10AM BLOOD Calcium-8.9 Phos-2.8 Mg-2.1 Brief Hospital Course: This 69 year old gentleman with a history of afib, COPD and endocarditis underwent CABG x 2, mechanical MVR, closure of patent foramen ovale, [**Name Prefix (Prefixes) **] [**Last Name (Prefixes) 1916**] ligation and MAZE procedure on [**2149-1-13**] s/p DC cardioversion with subsequent hypotension and bradycardia. . # Rhythm: The patient was admitted with afib/flutter for DC cardioversion. After cardioversion the patient was hypotensive to SBp 80's and bradycardic with a junctional rhythm of 40's. He was placed on dopamine. Just after cardioversion, he felt dizzy but was assymptomatic from then on. He was weaned off the dopamine. Intially, he remained in a junctional rythm but he sinus node then recovered to a sinus bradycardia with occaisonal pauses. He was able to increase his HR to 60's with walking and did not feel lightheaded or weak with excercise. Pacemaker implantation was discussed with the pt who declined and strongly desired to avoid device implantation. His beta blocker was stopped. . # Valves: Prosthetic Mitral Valve, no acute issues. His goal INR is 2.5-3.5. Heparin gtt was started with a low INR and coumadin held in setting of possible pacemaker placement. Coumadin was restarted when it was decided not to place a pacemaker. He was kept in hospital on heparin until his INR reached 2.5; it reached 2.6 on the day of discharge. . # CAD/Ischemia: no acute issues. He was maintained on ASA and statin. BB was discontinued. . # Pump: Mild chronic systolic heart failure at baseline w/o exacerbation. No signs of fluid overload on exam. Intially lasix was held in the setting of hypotesion. It was restarted when his blood pressure recovered. - holding lasix and BB in setting of hypotension . # COPD: No excerbation. The patient was maintained on home regimen. . #Contact: [**Name (NI) 553**] [**Last Name (NamePattern1) 174**] (Friend) [**Telephone/Fax (1) 9003**] Medications on Admission: Aspirin 81mg daily Ranitidine 150mg [**Hospital1 **] Toprol xl 75mg daily Lasix 40mg daily Multivitamin daily Singulair 10mg daily Coumadin as per the [**Hospital 18**] [**Hospital 197**] clinic Lipitor 20mg daily Colace 100mg PRN [**Doctor First Name **] 180mg daily Ambien 10mg PRN for sleep Albuterol inhaler Advair disc 250-50 1 disc twice a day Colchicine prn for gout flares Spiriva inhaler daily Discharge Medications: 1. Atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*0* 2. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*90 Tablet, Chewable(s)* Refills:*2* 3. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 4. Furosemide 40 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*90 Tablet(s)* Refills:*2* 5. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*90 Tablet(s)* Refills:*2* 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day) as needed for constipation. Disp:*180 Capsule(s)* Refills:*0* 7. Fexofenadine 60 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily). Disp:*270 Tablet(s)* Refills:*2* 8. Zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime) as needed. Tablet(s) 9. Albuterol 90 mcg/Actuation Aerosol Sig: 1-2 Puffs Inhalation Q6H (every 6 hours) as needed. Disp:*3 inhalers* Refills:*0* 10. Fluticasone-Salmeterol 250-50 mcg/Dose Disk with Device Sig: One (1) Disk with Device Inhalation [**Hospital1 **] (2 times a day). Disp:*3 Disk with Device(s)* Refills:*2* 11. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:*90 caps* Refills:*2* 12. Lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). Disp:*15 Tablet(s)* Refills:*2* 13. Warfarin 2.5 mg Tablet Sig: Three (3) Tablet PO DAILY16 (Once Daily at 16). Disp:*90 Tablet(s)* Refills:*2* 14. Multivitamin Tablet Sig: One (1) Tablet PO once a day. Disp:*90 Tablet(s)* Refills:*0* 15. Colchicine 0.6 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*90 Tablet(s)* Refills:*2* 16. Outpatient Lab Work Please check INR and notify the [**Company 191**] coumadin clinic of results. Discharge Disposition: Home Discharge Diagnosis: atrial fibrillation/Atrial Flutter Junctional Rhythm Bradycardia Hypotension Hypertension anticoagulation for mechanical valve Discharge Condition: Good. Ambulating, afebrile, tolerating PO. Discharge Instructions: You were admitted to the hospital to undergo a procedure which would eliminate your atrial fibrillation. After the procedure, your heart rate was extremely low and you needed to be transferred to the CCU for closer monitoring. Over 48 hours, your heart rate gradually increased. . Please take your medications as prescribed. Please do not take your metoprolol XL (toprol XL) because this will slow your heart rate even further. Your doctors [**Name5 (PTitle) **] [**Name5 (PTitle) 9004**] to restart this medication at some point later. You were started on a new blood pressure medication called lisinopril. . You should have your INR checked on Thursday [**2149-6-5**] and sent to your coumadin clinic/PCP [**Name Initial (PRE) 3726**]. . Please follow-up as described below. Please see your PCP or go to the emergency room if you have fevers over 102, chills, chest pain, trouble breathing, lightheadedness or any other symptoms which are concerning to you. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 9001**], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2149-6-10**] 2:40 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], [**Name Initial (NameIs) **].D. Phone:[**Telephone/Fax (1) 5003**] Date/Time:[**2149-6-17**] 1:40 PM Provider: [**Name10 (NameIs) 6821**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 1971**] Date/Time:[**2149-9-23**] 9:45 . Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], cardiology: make an appointment in six months by calling [**Telephone/Fax (1) 285**].

[ "V43.3", "427.31", "493.20", "458.9", "414.00", "428.20", "428.0", "427.89", "427.32", "V45.81", "401.9", "300.4" ]

icd9cm

[ [ [] ] ]

[ "99.61" ]

icd9pcs

[ [ [] ] ]

7206, 7212

3049, 4949

325, 341

7383, 7428

2133, 3026

8438, 9060

1844, 1862

5403, 7183

7233, 7362

4975, 5380

7452, 8415

1877, 2114

274, 287

369, 1322

1344, 1743

1759, 1828

65,559

178,786

31503

Discharge summary

report

Admission Date: [**2123-3-18**] Discharge Date: [**2123-3-22**] Date of Birth: [**2094-11-19**] Sex: F Service: OBSTETRICS/GYNECOLOGY Allergies: Penicillins / Aspirin / Latex / shrimp Attending:[**Doctor First Name 6716**] Chief Complaint: menorrhagia, endometriosis, chronic pelvic pain Major Surgical or Invasive Procedure: 1. total laparascopic hysterectomy 2. cystoscopy History of Present Illness: 28 year old G5P1041 with a history of severe pelvic pain with laparoscopy-proven endometriosis, metromenorrhagia, and severe constipation who presents for preoperative visit. This patient has failed medical treatments: depo-provera, COCPs, progestin-only OCPs, Mirena, with moderate-severe side effects with each. She did get some relief from laparoscopy with excision of endo x4, for 2-6 months each time. Previous operative reports from the [**Country 13622**] republic classified her endometriosis as Stage 2. The patient has severe pain when menstruating but always has some pain at baseline. She has never had normal menses and has required narcotic medications for pain relief. She has need excessive amounts of tylenol for pain relief. SHe is currently also using Vicodin at bedtime as well as Gabapentin. She also has chronic constipation with some discomfort in bowel movements. She uses a bowel prep twice a week as well as an enema, fiber supplements and stool softeners. There are also plans for bio feedback. Past Medical History: GynHx: Long history of endometriosis and pelvic pain. Currently on OCPs. On continuous hormones for many years with irregular menses. Menarche age 11. Reports no "normal menses"; LMP H/o abnormal paps, s/p colposcopy. Last Pap negative [**2122-12-3**]. Endometrial biopsy negative [**2122-12-10**] Denies STIs, PID, or [**Last Name (un) **]. Currently sexually active with one male partner although infrequent intercourse due to pain. ObHx: G5P1041 (in previous notes, had reported G6P1) SAB x4, some requiring D&C SVD x1, term, c/b short cvx, pt declined cerclage PMH: - Endometriosis - Constipation - Hx DVT, s/p several months anticoagulation (per pt both injected and po) PSH: Dx LSC x4, with LOA and ?fulguration/excision endometriosis, most recent [**3-/2122**] LSC appy Social History: Originally from [**Country 13622**] Republic. Has worked as hairdresser for several years. No t/e/d. Family History: non-contributory Pertinent Results: [**2123-3-18**] 07:02PM WBC-10.5# RBC-4.02* HGB-11.6* HCT-34.8* MCV-87 MCH-28.8 MCHC-33.3 RDW-15.3 [**2123-3-18**] 07:02PM PLT COUNT-233 Radiology: MR HEAD W/O CONTRAST Study Date of [**2123-3-20**] 2:41 AM There is no focus of decreased diffusion to suggest an acute infarct. On the FLAIR sequence, there is very subtle increased signal intensity scattered adjacent to the cortex in the frontal and the parietal lobes, for example, series 6, image 15. The significance of this finding is uncertain. It is unclear if these are artifactual or related to recent anesthesia or other abnormality. A close followup evaluation can be considered on a different MRI scanner to assess stability/progression/resolution. No focus of negative susceptibility is noted to suggest hemorrhage. Ventricles and extra-axial CSF spaces otherwise are unremarkable. Small cavum septum pellucidum is noted along with a prominent cavum velum interpositum. The major intracranial arterial flow voids are noted on the T2-weighted images. Mild mucosal thickening is noted in the ethmoid air cells. There is a retention cyst measuring approximately 2.2 x 1.6 cm in the left maxillary sinus/polyp. MRV HEAD WITHOUT CONTRAST: The major venous sinuses are patent. IMPRESSION: 1. No focus of acute infarction. 2. Scattered subtle FLAIR hyperintense signal foci adjacent to the sulci as described above are of equivocal significance. Unclear if these are artifactual or related to an abnormality. Interval close followup evaluation can be considered on a different MRI scanner from the present one to evaluate for any interval change. 3. Retention cyst/polyp in the left maxillary sinus. CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2123-3-19**] 8:28 AM FINDINGS: Moderate respiratory motion artifacts that limit the quality of the CT examination. There are filling heterogeneities in the intermediate right pulmonary artery, towards the medial part of the vessel (3, 48) and in a left lower lobe segmental artery (3, 45). In addition, smaller hypodense attenuation heterogeneities are seen in both the right and left lower lobes, at the level of segmental arteries. Bilaterally, relatively extensive areas of dependent atelectasis, but on the left, an additional peripheral wedge-shaped opacity is seen (3, 65). A second right-sided wedge-shaped opacity is seen at the level of the right lower lobe apex (3, 43). The heart is of overall borderline size, but the right heart is not enlarged, and there is no bulging of the septum. No evidence of pleural effusions. Because of the high likelihood of acute pulmonary embolism, the referring physician, [**Last Name (NamePattern4) **]. [**Last Name (STitle) 34602**], was paged for notification at the time of dictation, 9:22 a.m., on [**2123-3-19**]. IMPRESSION: High likelihood of right rather central and left lower lobe peripheral pulmonary embolism. There are bilateral wedge-shaped parenchymal opacities that support this diagnosis. Moderate bilateral dependent atelectasis. No right heart enlargement, no bulging of the intraventricular septum. Free air in the right upper quadrant after abdominal surgery. Brief Hospital Course: 28 year old F G5P1041 with h/o severe pelvic pain with laparoscopy-proven endometriosis, metromenorrhagia, and severe constipation, h/o DVT s/p short course of anticoagulation and spontaneous abortion x 5 (details unclear, negative hypercoagulable workup per report) transferred to ICU for unresponsiveness, now resolved, and new dx of PE, all on POD 1. She was transferred back to the floor on POD 2 and discharged on POD 4. Her hospital course is organized by systems below. # unresponsiveness/ sedating medication overdose on POD 1: likely secondary to multiple sedating medications, including high doses of opiates received overnight prior to transfer. Improved with one dose of IV Narcan 0.5mg, although transient. Patient transferred to unit and with time improved without further intervention. We initially held sedating medications for now, including Ativan. We attempted pain control with Toradol and PO Tylenol, but this was inadequate so low dose IV Dilaudid was started (after a trial of oxycodone without sedition). Toradol was discontinued due to questionable allergic reaction including vasculitic lesion on the right lower extremity. After transfer to the floor on POD 2, her pain was well-controlled with vicodin and she had no further somnolence. # PE: on POD 1 she complained of chest pain and had persistent tachycardia to 130s-140s. bilateral PE noted on CTA chest [**3-19**], likely was contributing to tachycardia and new O2 requirement. Pt with h/o DVT and multiple spontaneous abortions, it is possible she has an underlying clotting disorder however testing in the past has been unremarkable and is unlikely to be helpful now. Patient was started on Lovenox 60 mg sc BID, will need lifelong anticoagulation with Coumadin. discharged to home with VNA and lovenox, to make appiontment with [**Hospital 3052**]. # tachycardia: likely [**3-4**] PE and hypovolemia, as tachycardia improved with IV fluids # Vasculitic lesion: question temporal relationship to Toradol administration. Derm was consulted due to concern of the lesions, question vasculitis given history of abortions and PE. Biopsy is pending, no further interventions. # s/p lap hysterectomy: pt complaining of pain, but tolerated surgery. pain controlled with vicodin prior to discharge. # lower extremity weakness/numbness: likely [**3-4**] epidural catheter, which persisted a day into the ICU course. Neurology was consulted and expressed concern about the possibility of a venous sinus thrombosis given that the patient also has left-sided headache. MRI/MRV was unremarkable. Neurology also recommended MRI t and l spine to r/o epidural bleed, but unlikely, weakness likely functional. L-spine MRI and weakness/numbness spontaneously improved. She was seen by PT and by POD 4 (day of discharge) was ambulating independantly with no ongoing deficit. The patient was discharged to home in good condition on POD 4. Medications on Admission: Epinephrine, medroxyprogesterone, omeprazole, polyethylene glycol, bisacodyl, cetirizine, colace, percocet Discharge Medications: 1. Vicodin 5-500 mg Tablet Sig: 1-2 Tablets PO every six (6) hours as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 2. Lovenox 60 mg/0.6 mL Syringe Sig: One (1) syringe Subcutaneous twice a day. 3. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: endometriosis/pelvic pain, menorrhagia pulmonary emboli Discharge Condition: Activity Status: Ambulatory - Independent. Level of Consciousness: Alert and interactive. Mental Status: Clear and coherent. Discharge Instructions: Dear Ms. [**Known lastname 74133**], You were admitted for laparoscopic hysterectomy for heavy bleeding and pelvic pain. Your post-operative course was complicated by bilateral pulmonary emboli (lung clots), and a stay in the ICU. For this, you will need lifelong anticoagulation (blood thinners). For now, you will inject lovenox twice daily and will be transitioned to oral coumadin. You will need to call the [**Hospital 18**] [**Hospital3 **] on Tuesday do set up an appointment ([**Telephone/Fax (1) 10413**]). They will help you start the coumadin and arrange for blood draws to monitor your dose. Also, you had leg numbness and weakess that was possibly related to the epidural and slowly resolved. You were seen by neurology and physical therapy both of which thought you were improving and safe to be discharged on your own. General instructions: * Take your medications as prescribed. * Do not drive while taking narcotics. * Do not combine narcotic and sedative medications or alcohol * Do not take more than 4000mg acetaminophen (APAP) in 24 hrs * No strenuous activity until your post-op appointment * Nothing in the vagina (no tampons, no douching, no sex) for 3 months * no heavy lifting of objects >10lbs for 6 weeks. * You may eat a regular diet Incision care: * You may shower and allow soapy water to run over incision; no scrubbing of incision. No bath tubs for 6 weeks. * If you have steri-strips, leave them on. They will fall off on their own or be removed during your followup visit. To reach medical records to get the records from this hospitalization sent to your doctor at home, call [**Telephone/Fax (1) 2806**]. Call your doctor for: * fever > 100.4 * severe abdominal pain * difficulty urinating * vaginal bleeding requiring >1 pad/hr * abnormal vaginal discharge * redness or drainage from incision * nausea/vomiting where you are unable to keep down fluids/food or your medication Followup Instructions: ob/gyn 1) call the [**Hospital 18**] [**Hospital3 **] first thing on Tuesday at [**Telephone/Fax (1) 10413**]. Tell them that you had bilateral pulmonary emboli and were discharged on lovenox and need lifetime anticoagulation. They can call [**Telephone/Fax (1) 2664**] with any questions but you need an appointment as soon as possible. 2) Follow-up with Dr. [**First Name4 (NamePattern1) 11320**] [**Last Name (NamePattern1) 34602**] on [**2123-4-7**] at 4pm. 3) Follow-up with your primary care provider within one week of discharge. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(1) 6721**]

[ "287.0", "617.0", "780.09", "729.89", "625.9", "E935.7", "415.11", "626.2", "346.90", "564.00" ]

icd9cm

[ [ [] ] ]

[ "03.90", "68.41", "57.32", "86.11" ]

icd9pcs

[ [ [] ] ]

9038, 9044

5621, 8545

362, 412

9144, 9234

2448, 5598

11244, 11909

2410, 2429

8703, 9015

9065, 9123

8571, 8680

9295, 10565

10580, 11221

275, 324

440, 1470

9249, 9271

1492, 2275

2291, 2394

25,038

144,446

22875

Discharge summary

report

Admission Date: [**2198-6-23**] Discharge Date: [**2198-7-9**] Date of Birth: [**2147-8-22**] Sex: F Service: MEDICINE Allergies: Codeine / Iodine; Iodine Containing / Soybean / Lecithin Attending:[**First Name3 (LF) 1055**] Chief Complaint: CC:[**CC Contact Info 59136**] Major Surgical or Invasive Procedure: Radial Artery Cannulation Intubation for respiratory failure PICC line placement and removale Chest tube placement and removal History of Present Illness: HPI: 50F w/ HIV (last CD4 408 [**10-31**]), Hep C, COPD, asthma, prior aspiration PNA presents from [**Hospital3 672**] Rehab after recent ICU admission to [**Hospital3 **] for COPD flare. Was being treated for COPD flare c steroids, abx, nebs at rehab until yesterday when patient noted to have some dyspnea night prior to [**Hospital1 18**] presentation; otherwise ROS negative from rehab. Evening of admission, pt. found unconscious in bathtub with O2 sat 55% RA. Placed on O2 6L NC c O2 sat 88%. Then started BiPap 6L, [**10-31**] c O2 sat 96%, BP 125/66, 115. ABG done at Rehab showing 7.30/85/71. . In ED, vitals: 75% NRB, 10, 98.0, 101/68, 96. Intubated for GCS 5, hypoxic respiratory failure. Head and C-spine CT done to look for fracture/bleed - negative. CXR done showing diffuse L lung opacity. Given ceftriaxone / flagyl / vancomycin for aspiration PNA and nosocomial PNA. Sputum sent, including samples for PCP. [**Name10 (NameIs) 59137**] to [**Hospital Unit Name 153**]. . In [**Name (NI) 153**], pt. intubated, sedated and no history available. Past Medical History: PMH: 1. COPD/asthma - recent admission for COPD flare. Was taking levofloxacin, nebs, theophylline, advair and solumedrol 80 q8 hrs. 2. Aspiration PNA - recurrent but unknown # hosp. 3. DMII - on NPH 52 qAM, 30 qPM + sliding scale 4. HTN 5. R Breast CA s/p lumpectomy/radiation therapy in [**2195**]. 6. HIV - CD4 408, [**10-31**] 7. Hep C 8. OSA 9. Diverticulitis 10. Schizoaffective Disorder 11. Psoriasis Social History: SH: Lives in group home, continues to smoke [**1-29**] ppd > 25 yrs, drinks socially. Family History: FH: Mother with emphysema. Physical Exam: VS - 97.3, 136/76, 87 - On vent A/C FiO2 0.5, PEEP 5, Vt 500, RR 20 HEENT - MMM, ETT in place, EOMI LUNGS - coarse rhonchi b/l at apices/axillae HEART - RRR, S1, S2, no rmg ABD - soft, NT, ND, BS+ EXT - wwp, no peripheral edema, 2+ DP pulse, denuded, chronic venous stasis changes over legs b/l NEURO - intubated, sedated. Upgoing toe R, no response L Babinski Pertinent Results: labs - see below; notable for LDH 480, WBC 18.7 imaging - CXR: diffuse, interstitial pattern over L lung field. diffuse pattern over R middle lobe CT head: There is no evidence of intracranial hemorrhage, shift of normally midline structures, hydrocephalus, major vascular territorial infarction, or fracture. The ventricles and sulci are symmetric. There is preservation of the normal [**Doctor Last Name 352**]/white matter differentiation. The paranasal sinuses are clear and the orbits are unremarkable. Regional soft tissues demonstrate no significant abnormality. CT C-spine: No acute fracture. Minimal grade 1 anterolisthesis of T1 over T2. Large left upper lobe consolidation concerning for aspiration or pneumonia. . CHEST CT: 1. Elevation of left hemidiaphragm. If there is clinical concern for diaphragmatic paralysis, fluoroscopic assessment may be helpful. No mass is identified in the expected course of the phrenic nerve. 2. Centrilobular opacities in right lower lobe, which may be due to infectious small airways disease or aspiration. 3. Trace left pleural effusion. No evidence of subpulmonic pleural effusion. 4. Small low-attenuation lesion in upper pole portion of left kidney and low attenuation lesion in the thyroid gland left lobe, both incompletely evaluated on this study. If warranted clinically, dedicated ultrasound could be considered to evaluate these areas. . CHEST FLUOROSCOPY: There is normal motion of the right hemidiaphragm. The motion of the left hemidiaphragm is sluggish. There is no evidence of paradoxical motion. IMPRESSION: Sluggish left hemidiaphragm but no evidence for diaphragmatic paralysis. . ECHO [**2198-6-26**]: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The right ventricular cavity is moderately dilated. Right ventricular systolic function is borderline normal. The aortic valve leaflets (3) appear structurally normal with good leaflet excursion and no aortic regurgitation. There is no aortic valve stenosis. The mitral valve appears structurally normal with trivial mitral regurgitation. There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Dilated RV cavity with moderate pulmonary hypertension (? Chronic). LVEF appears preserved. . SPUTUM GRAM STAIN (Final [**2198-6-23**]): [**11-21**] PMNs and <10 epithelial cells/100X field. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S). 1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND SINGLY. RESPIRATORY CULTURE (Final [**2198-6-25**]): MODERATE GROWTH OROPHARYNGEAL FLORA. ACINETOBACTER BAUMANNII. MODERATE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ ACINETOBACTER BAUMANNII | CEFEPIME-------------- 32 R CEFTAZIDIME----------- 16 I CIPROFLOXACIN--------- =>4 R GENTAMICIN------------ 4 S IMIPENEM-------------- <=1 S LEVOFLOXACIN---------- =>8 R TOBRAMYCIN------------ <=1 S TRIMETHOPRIM/SULFA---- <=1 S Brief Hospital Course: 1. Hypoxic Resp. Failure - Differential included PNA (CAP vs. nosocomial vs. PCP [**Last Name (NamePattern4) **]. aspiration), likely concurrent with or exacerbating a COPD flare. Less likely possibilities included PE and CHF. A CXR in the ED showed diffuse L lung opacity. Patient was started on Ceftriaxone, Flagyl, Vancomycin, Bactrim, and prednisone. Blood and sputum was sent for culture and patient was transferred to the [**Hospital Unit Name 153**] for further management. In the [**Hospital Unit Name 153**], patient was underwent a bronchoscopy which showed: no inflammation, minimal secretions, and a partially obstructing lesion, likely a foreign body, which looked exactly like a piece of [**Last Name (LF) 59138**], [**First Name3 (LF) **] report. Of note, patient was admitted to [**Hospital 8**] hospital ~ 3 months prior to this admission after aspirating [**Hospital 59138**]. Urine was sent to check for legionella antigen and was negative. Sputum was sent to assess for PCP and was negative. Patient was ruled out for ACS with negative cardiac enzymes x 3. An arterial line was placed. A BAL was performed and the initial read showed gram-positive cocci and gram-negative rods. Patient was maintained on theophylline, albuterol/atrovent INH, fluticasone, montelukast, and prednisone. Sputum culture returned positive for acinitobacter baumanni which was sensitive to bactrim and imipenum. A repeat bronchoscopy was performed on [**6-26**] which showed continuing obstruction. A central line was attempted, with resulting R pneumothorax. CT surgery was consulted and a chest tube was placed with good resolution of pneumothorax. A femoral line was placed, then removed once patient had a L PICC line placed. The bronchopscopy was repeated on [**6-27**] with [**Month/Day (4) 59138**] removed. A repeat bronchoscopy performed on [**6-28**] - no findings were documented. Patient was extubated on [**6-29**] without difficulty. The chest tube was also removed on [**6-29**]. Shortly after extubation, the patient became somewhat agitated, crying out and moving around restlessly in bed. She was treated with haldol and zyprexa with good effect and her agitation had entirely resolved by the next day. Speech and swallow evaluation was ordered and is discussed below in FEN in more detail. Imipenum was discontinued on [**6-30**] and the a-line was discontinued secondary to concerns of infection. Patient appeared somewhat tremulous on [**7-1**] and although she says that she is normally shaky at baseline, Albuterol was changed to PRN and patient was started on serovent. Seroquel was restarted with aplan to uptitrate to home dose as tolerated, which was done. Imipenim was restarted and Bactrim and imipenem were continued for a 14 day course and prednisone was started for possible COPD exacerbation and tapered. . #Altered MS - Differential diagnosis included hypoxia insetting fo respiratory distress, infection (given HIV status, unknown CD4 count, not on HAART or prophylaxis), seizure (possibly secondary to infection), toxic/metabolic, and less likely, CVA. A CT scan was obtained in the ED which was negative for masses or bleeding with preserved grey-white matter differentiation. Toxicology screen was negative. Seroquel was discontinued for it's sedating effects and possible contribution to her mental status. There was some concern that depakote may also be contributing so that was discontinued on [**6-27**]. Mental status improved as patient stabilized and she is now back to her baseline. . #Neck pain: Patient had plain films of the cervical spine to rule-out possible fracture, but while in the [**Hospital Unit Name 153**] complained of diffuse posterior cervical neck pain on palpation. Patient was placed back into a rigid neck collar, which she tolerated very poorly. The neck collar was removed and patient denied any further neck pain. Given her somewhat questionable mental status, repeat flexion and extension films were obtained and showed some minimal instability at at C2/3 and C3/4, of indeterminate acuity. A formal spine/ortho consult was obtained and patient was cleared of possible cervical spinal trauma. . #Cardiac - Patient had some chest pain on [**6-30**]. ECG was negative. Pain was not relieved with nitroglycerin SL, but did entirely resolve with 2 mg IV morphine. Patient had been ruled out for ACS with three sets of negative cardiac enzymes on admission. Another set was set and again was negative. Her chest pain was attributed to anxiety. Patient also became somewhat intermittently tachycardiac during her stay in the ICU. There was no obvious etiology and patient was comfortable, making good urine so not further action was taken. . #DM II - Patient was initially maintained on an insulin gtt per [**Hospital Unit Name 153**] protocol. Currently she is being covered with an insulin sliding scale and glargine. She was started on NPH in the a.m. and dose increased to help with high afternoon sugars, and we continue to adjust this regimen. . #HTN - Nifedipine was held in the acute setting of infection. Once patient was more stable, it was restarted at her usual outpatient dose. Patient remained hypertensive with SBP in the 160-170's. Nifedipine was changed to diltiazem, which was uptitrated, and Captopril was added with good control. . #HIV - Patient is not on HAART or any prophylaxis. Her most recent CD4 count on [**6-23**] was 296. . #Hyperlipidemia - Atorvastatin was continued at outpatient dose. . #Schizoaffective D/O - Depakote Sprinkles and seroquel were both discontinued secondary to concerns they may be contributing to patient altered mental status. Citalopram was continued. After patient's mental status improved, her seroquel was restarted and is being tapered up to her previous dose. . FEN - Maintained on tube feeds without problem while intubated, then transitioned over to a diabetic diet. A Speech and swallow evaluation was ordered and after bedside eval, a videoswallow study was ordered. Patient was cleared for a ground solid diet with nectar-thick liquids. Meds should be crushed and given with purees. Lytes were repleted as necessary. On the day of discharge she was tolerating a regular diabetic diet without any signs or symptoms of aspiration. . Ppx - PPI, SC hep, Pneumoboots . Access - PIV and PICC . Code - Full; confirmed verbally with patient on [**2198-7-1**]. . Communication: Problem[**Name (NI) 115**]. [**Name2 (NI) **] report patient has HCP: Aunt [**Name (NI) 1123**] [**Name (NI) 59139**] [**Telephone/Fax (1) 59140**] who has not been able to be contact[**Name (NI) **] for the duration of this admission. Patient verbalized that she would like [**First Name4 (NamePattern1) 1258**] [**Last Name (NamePattern1) **] to speak for her if she is unable to speak for herself. She works at [**Company 59141**] house, phone number [**Telephone/Fax (1) 59142**], a group housing facility which the patient has lived at for more than 5 years. Need to clarify if [**First Name4 (NamePattern1) 1258**] [**Last Name (NamePattern1) **] or another Ruah House employee (Nurit Adem) will be the new HCP or if this is a temporary arrangement until the aunt can be contact[**Name (NI) **]; PCP is [**First Name4 (NamePattern1) 8513**] [**Last Name (NamePattern1) **] at [**Hospital 59143**] Clinic at [**Hospital 8**] Hospital, phone #[**Telephone/Fax (1) 59144**] I, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], attending of record, assumed care on the day of discharge. I spoke directly with patient's nurse practioner about the kidney lesion and thyroid lesion and recommended follow up with urology and endocrine for further evaluation. She understood and will discuss follow up with patient's PCP This d/c summary was faxed to the NP. Medications on Admission: Meds: NPH 52 AM, 30 PM Protonix 40 [**Hospital1 **] Theophylline 200 qd Albuterol nebs Solumedrol 80 IV q8 Diamox 250 PO bid Moxifloxacin 400 IV qd Singulair 10 qd Advair 500/50 1 puff [**Hospital1 **] Spiriva 1 puff QD Nifedipine XL 60 PO qd ECASA 81 qd Atorvastatin 40 qd Quetiapine 75 tid Depakote 750 [**Hospital1 **] Celexa 20 qd Nicotine patch Tylenol 650 q8 Arimidex 1 mg daily Potassium chlride 40 meq PO daily prn K<4.0 Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Atorvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Quetiapine 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day). 4. Divalproex 250 mg Tablet, Delayed Release (E.C.) Sig: Three (3) Tablet, Delayed Release (E.C.) PO BID (2 times a day). 5. Citalopram 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Nicotine 21 mg/24 hr Patch 24HR Sig: One (1) Patch 24HR Transdermal DAILY (Daily). Disp:*30 Patch 24HR(s)* Refills:*2* 7. Acetaminophen 650 mg Tablet Sig: One (1) Tablet PO every eight (8) hours as needed for pain. 8. Anastrozole 1 mg Tablet Sig: One (1) Tablet PO daily (). 9. Diltiazem HCl 180 mg Capsule, Sustained Release Sig: One (1) Capsule, Sustained Release PO DAILY (Daily). Disp:*30 Capsule, Sustained Release(s)* Refills:*2* 10. Tiotropium Bromide 18 mcg Capsule, w/Inhalation Device Sig: One (1) Cap Inhalation DAILY (Daily). Disp:*QS QS* Refills:*2* 11. Fluticasone 110 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). Disp:*QS QS* Refills:*2* 12. Montelukast 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 13. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**1-29**] Puffs Inhalation Q6H (every 6 hours) as needed for SOB/wheezing. Disp:*QS QS* Refills:*0* 14. Albuterol Sulfate 0.083 % Solution Sig: One (1) Inhalation Q2H (every 2 hours) as needed. Disp:*QS QS* Refills:*0* 15. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 16. Docusate Sodium 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 17. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 18. Prednisone 10 mg Tablet Sig: One (1) Tablet PO once a day for 1 days. Disp:*1 Tablet(s)* Refills:*0* 19. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Thirty Five (35) units Subcutaneous QAM. 20. Insulin NPH Human Recomb 100 unit/mL Cartridge Sig: Twenty (20) units SC Subcutaneous at bedtime. 21. Regular Insulin Sliding Scale Please use a regular insulin sliding scale four times a day - before meals and QHS. 22. Home Oxygen Home oxygen at 3L/min via nasal cannula to keep oxygen sats >92%. Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Aspiration pneumonia Chronic Obstructive Pulmonary Disease Asthma H/o breast cancer Type II Diabetes Mellitus Hypertension Hepatitis C Obstructive Sleep Apnea Schizoaffective Disorder Psoriasis HIV Discharge Condition: Stable. Patient oxygenating at 97% on 3L, which is her baseline. Discharge Instructions: # Please take all of your medications as prescribed # Please call your PCP or return to the ED if you have difficutly breathing, chest pain, worsening cough, fevers, chills, nausea, vomiting, or any other symptom that is of concern to you. # Do not smoke. # Please follow-up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] a thyroid ultrasound to evaluate a thyroid lesion that was seen on CT scan. This may need to be biopsied. # Please follow-up with a urologist regarding a small kidney cyst on your CT scan. Followup Instructions: # Please follow up with your NP, [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] (attending physician is [**Last Name (NamePattern4) **]. [**Last Name (STitle) **], at [**Numeric Identifier 59145**], on Friday [**2198-7-13**] at 9:30 a.m. Her pager is pager [**Numeric Identifier 59146**], fax [**Numeric Identifier 59147**]. Please follow-up with your primary care doctor [**First Name (Titles) **] [**Last Name (Titles) **] a thyroid ultrasound to evaluate a thyroid lesion that was seen on CT scan. This may need to be biopsied. # Please follow up with Dr. [**Last Name (STitle) 952**] on [**2198-7-17**] at 3:00 to have your stitches removed. Provider: [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **], MD Phone:[**0-0-**] Date/Time:[**2198-7-17**] 3:00 # Please follow-up with a urologist (kidney doctor) regarding a small kidney cyst on your CT scan.

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Discharge summary

report

Admission Date: [**2194-11-8**] Discharge Date: [**2194-11-23**] Date of Birth: [**2117-4-13**] Sex: M Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**Last Name (NamePattern1) 1167**] Chief Complaint: chest pain Major Surgical or Invasive Procedure: [**2194-11-11**] cystoscopy procedure: bladder neck contracture was able to be dilated up to 25-French. Calcifications, using the cystoscope knocked the calcification off into the bladder. Then using stone crushers through a 20-French cystoscope, the stones were crushed into small pieces. These were then Ellik evacuated free. mechanical ventilation History of Present Illness: Mr. [**Known lastname 101110**] is a 77M with a history of known proximal descending aortic arch penetrating ulcer (found in [**2189**] medically treated) also with history of CAD s/p CABG, who intially presented to [**Hospital 4199**] hospital on [**2194-11-8**] with 9/10 chest pain radiating to the back x 1 day. CTA at this time showed worsening ulcer and he was transferred to [**Hospital1 18**] for surgical intervention. On arrival to ED, EKG showed new LBBB and Cardiology thought this was [**2-27**] chronic ischemic cardiac disease. While on vascular surgical service hypertension was attempted to be controlled with labetolol drip and IV Labetalol pushes with goal BP<120. He was then found to have acute renal failure which was thought most likely secondary to contrast infuced nephropathy from CTA. Aggressive IVFs for treatment of CIN caused respiratory distress and pulmonary edema. TTE showed LVEF40% stable, moderate MR, moderate to severe TR. Patient was transferred to the unit where he was intubated for a short term and started on a Lasix drip. While in the MICU, patient was agressively diuresed with lasix drip while understanding kidneys needed protection. Hypertension was difficult to control requiring Nicardipine drip to maintain SBPs <120. Nicardipine has since been discontinued on Tuesday (day before transfer) and oral regimen of Amlodipine 10mg, Imdur 90mg daily, Carvedilol 25 [**Hospital1 **] and Hydralazine 50mg PO TID have been able to maintain BP at goal. Renal function improved slightly to 2.4 (baseline of 1) and Lasix drip discontinued >24 hours ago. Patient has now been autodiuresing -500 today without medical diuresis. Of note, also patient received 4 transfusions during admission [**2194-11-9**] x2, [**2194-11-12**] and 10/18/12m. No clear source of bleeding and patient was guiac negative. On arrival to the floor, patient overall appears well though with pain in his legs which is a chronic issue. He is upset that pain is not being adequately treated and he is only receiving half his normal home dose. He is breathing comfortably on 4L NC. Past Medical History: - Proximal descending aortic arch ulcer diagnosed [**2189**] on CTA done for chest pain (managed medically by cards/PMD) - HTN - HLD - CAD s/p CABGx3 ([**2174**]), stent ([**2186**]) - B/L lower extremity calf pain of unknown etiology (ABIs WNL [**12/2193**]) - CKD (baseline Cr: 1.1) - History of prostate CA s/p brachytherapy ([**2188**]) - BPH - History of nephrolithiasis s/p lithotripsy - Bladder calculus - History of PUD ([**2162**]) - [**Initials (NamePattern4) 9376**] [**Last Name (NamePattern4) **] - History of GIB (hemorrhoids, no bleeding source on c-scope [**3-/2192**]) - Chronic anemia (baseline hct: 24-32) PSH: - CABGx3 LIMA-LAD, SVG-OM, SVG-D1 ([**2174**]) - LCx stent ([**2186**]) - Open cystolithotomy ([**2188**]) Social History: Patient was born in Poland, lived there for 20 years then moved to [**Country 2784**] and lived there for 6 years. Currently retired. Has 2 daughters, in [**Name (NI) **] and [**Name (NI) **] port, and one son. Currently living with his wife. His wife recently had a hip surgery, now recovering at rehab facility. Patient is a former smoker, used to smoke about 4 cigarettes/day for 10-15 years but quit 30-40 years ago. No history of alcohol or drug abuse. Primarily Polish-speaking. Independent in ADLs at baseline. Family History: Heart disease on Father's side of the family. No history of sudden cardiac death. No family history of colon cancer or other cancers. No reported history of kidney disease in family. Father: CAD Mother: anemia Physical Exam: Exam on Trasnfer from CVICU: Vitals: 98.6, 127/43, 63, 14, 97% 6L NC General: Alert, oriented, no acute distress interactive and moving around. Occassionally appears uncomfortable. HEENT: Sclera anicteric, MMM, oropharynx clear w/ dentures, EOMI, PERRL Neck: supple, JVP elevated to 11cm, no LAD CV: Regular rate and rhythm, normal S1/S2, +S3, no murmurs, rubs Lungs: rales 2/3 up lungs posteriorly, no wheezes or rales Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly GU: foley Ext: warm, well perfused, 1+ pulses, no clubbing, cyanosis, trace edema bilaterally Neuro: CNII-XII intact, 5/5 strength upper/lower extremities, grossly normal sensation, gait deferred Discharge Exam: Vitals- T 98.5 BP 147/69 HR 62 RR 18 O2 96% RA, maintained when ambulating GENERAL: WDWN 77 yo male in NAD. Oriented x3. Mood, affect appropriate. HEENT: NCAT. NECK: Supple with flat JVP. CARDIAC: PMI located in 5th intercostal space, midclavicular line. RR, normal S1, S2. Soft [**3-3**] diastolic murmur heard best at LSB. No thrills, lifts. No S3 or S4. LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp were unlabored, no accessory muscle use. No crackles ABDOMEN: Soft, NTND. No HSM or tenderness. Abd aorta not enlarged by palpation. No abdominal bruits. EXTREMITIES: No c/c/e. SKIN: No stasis dermatitis, ulcers, scars, or xanthomas. PULSES: Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ PT 2+ Neuro: no focal deficits Pertinent Results: Admission Labs: [**2194-11-8**] 01:25PM BLOOD WBC-3.1* RBC-2.76* Hgb-8.2* Hct-24.5* MCV-89 MCH-29.6 MCHC-33.4 RDW-16.8* Plt Ct-235# [**2194-11-8**] 01:25PM BLOOD Neuts-59.4 Lymphs-33.9 Monos-6.2 Eos-0.4 Baso-0.1 [**2194-11-8**] 01:25PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-2+ Macrocy-NORMAL Microcy-1+ Polychr-NORMAL Ovalocy-2+ Tear Dr[**Last Name (STitle) **]1+ Ellipto-2+ [**2194-11-8**] 01:25PM BLOOD PT-12.8* PTT-36.9* INR(PT)-1.2* [**2194-11-8**] 01:25PM BLOOD Glucose-110* UreaN-13 Creat-1.1 Na-143 K-4.2 Cl-105 HCO3-25 AnGap-17 [**2194-11-8**] 10:43PM BLOOD CK(CPK)-25* [**2194-11-8**] 01:25PM BLOOD CK-MB-2 [**2194-11-8**] 01:25PM BLOOD cTropnT-<0.01 [**2194-11-8**] 10:43PM BLOOD CK-MB-2 cTropnT-<0.01 [**2194-11-12**] 08:00PM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-6913* [**2194-11-8**] 01:25PM BLOOD Calcium-9.0 Phos-3.0 Mg-1.7 [**2194-11-8**] 12:50PM URINE Color-Straw Appear-Clear Sp [**Last Name (un) **]-1.028 [**2194-11-8**] 12:50PM URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG [**2194-11-12**] 10:01AM URINE RBC-101* WBC-37* Bacteri-FEW Yeast-NONE Epi-0 TransE-<1 BNP: [**2194-11-12**] 08:00PM proBNP-6913* [**2194-11-22**] 08:10AM BLOOD WBC-8.3 RBC-3.65* Hgb-10.9* Hct-31.1* MCV-85 MCH-29.9 MCHC-35.1* RDW-16.5* Plt Ct-227 [**2194-11-18**] 04:29AM BLOOD Glucose-125* UreaN-45* Creat-3.0* Na-137 K-4.4 Cl-93* HCO3-34* AnGap-14 [**2194-11-20**] 06:10AM BLOOD Glucose-95 UreaN-36* Creat-1.9* Na-134 K-4.1 Cl-93* HCO3-39* AnGap-6* [**2194-11-21**] 08:10AM BLOOD Glucose-117* UreaN-32* Creat-1.7* Na-137 K-4.3 Cl-93* HCO3-33* AnGap-15 [**2194-11-23**] 08:40AM BLOOD Glucose-125* UreaN-40* Creat-1.7* Na-137 K-3.8 Cl-92* HCO3-33* AnGap-16 [**2194-11-23**] 08:40AM BLOOD Calcium-9.4 Phos-4.0 Mg-2.1 [**2194-11-20**] 08:08PM BLOOD PEP-NO SPECIFI Micro: All negative [**2194-11-12**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2194-11-12**] BLOOD CULTURE Blood Culture, Routine-FINAL INPATIENT [**2194-11-12**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [**2194-11-12**] URINE URINE CULTURE-FINAL INPATIENT [**2194-11-9**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [**2194-11-8**] MRSA SCREEN MRSA SCREEN-FINAL INPATIENT [**2194-11-8**] BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY [**Hospital1 **] [**2194-11-8**] BLOOD CULTURE Blood Culture, Routine-FINAL EMERGENCY [**Hospital1 **] [**2194-11-8**] URINE URINE CULTURE-FINAL EMERGENCY [**Hospital1 **] Imaging: [**2194-11-10**] Carotid US: Less than 40% stenosis of the bilateral extracranial internal carotid arteries. [**2194-11-10**] CT Torso: 1. Increase in size of previously seen thoracic aortic ulceration. 2. Multiple smaller ulcerations of the descending thoracic aorta and abdominal aorta. 3. Stenosis of the celiac artery origin and the bilateral renal artery origins. 4. Small bilateral pleural effusions. 5. Air within the bladder, recommend clinical correlation. [**2194-11-12**] Echo: The left atrium is moderately dilated. The left atrium is elongated. The right atrium is markedly dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity is moderately dilated. Overall left ventricular systolic function is mildly depressed (LVEF= 40 %) secondary to mild global hypokinesis. Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). The right ventricular cavity is mildly dilated There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Moderate (2+) mitral regurgitation is seen. Moderate to severe [3+] tricuspid regurgitation is seen. There is moderate-severe 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.] The main pulmonary artery is dilated. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Moderately dilated left ventricular cavity with mild global systolic dysfunction. Moderate mitral regurgitation. Moderate-severe tricuspid regurgitation with moderate-severe pulmonary artery systolic hypertension. [**2194-11-12**] MRI CHEST W&W/O CONTRAS 1. Stable size and appearance of distal aortic arch penetrating ulcer. 2. New, moderate bilateral pleural effusions with simple fluid. 3. Supra-renal 3.2cm aortic aneurysm with small dissection is unchanged. [**2194-11-18**] CXR: In comparison with study of [**11-16**], there are lower lung volumes in this patient who has undergone a prior CABG procedure. Continued cardiomegaly with increased pulmonary vascular congestion, the appearance of which may be enhanced by the low lung volumes. Mild bibasilar atelectasis persists. [**2194-11-22**] EKG: Sinus or ectopic atrial rhythm. Left bundle-branch block. Since the previous tracing of [**2194-11-15**] the rate is now faster. Q-T interval is shorter. Otherwise, probably no change. Brief Hospital Course: Mr. [**Known lastname 101110**] is a 77M with a history of known proximal descending aortic arch penetrating ulcer (found in [**2189**], treated medically with antihypertensives), CAD s/p CABG, who was transferred to [**Hospital1 18**] initally for surgical intervention however course was complicated by hypoxia, [**Last Name (un) **] and decompensated CHF. # Hypoxemic Respiratory failure/acute congestive heart failure: Most likely secondary to pulmonary edema [**2-27**] acute CHF, but also suspect a component of atelectesis decreased tidal volume from constipation, and decreased respiratory drive from frequent opiod use for chest pain. No evidence of PNA and suspicion for PE not high at this time. JVP, rales, CXR and BNP consistent with fluid overload. Additionally, prior to tranfer from surgery service, patient received aggressive IVFs and blood transfusions (6L positive currently) for acute kindey injury and contrast administration. Patient briefly required ventilatory support. Patient was managed on a lasix ggt, and began to autodiurese prior to transfer from ICU. Electrolytes were monitored frequently and repleted as needed. At time of transfer to the medical floor, patient was 3L positive for hospital stay still. Supplemental O2 was weaned down to 4L NC satting 91-92% upon transfer. On the cardiology floor, pt. was started on torsemide 20mg PO daily for 3 more days, and diuresed approximately 3L. His respiratory status greatly improved and by time of discharge his SpO2 was 96% on RA while ambulating. # Aortic ulcer: Initial appearance on CTA was concerning for enlargement of descending aortic arch ulcer and initial vascular surgery's initial plan was for urgent operative management. Patient subsequently developed contrast-induced nephorpathy and congestive heart failure exacerbation as outlined above. At this point patient not medically stable for major vascular surgery. MRI showed that aortic ulceration was actually stable in size and vascular surgery decided that it could be managed medically until his acute medical issues of acute congestive heart failure and acute kidney injury had resolved. Goal BPs for managment of aortic ulceration were set at SBPs in the 120s. This was initially difficult to achieve in the ICU, requiring multiple antihypertensive drips. Upon transfer to cardiology floor, patient was stabilized on PO regimen of Amlodipine 10mg DAILY, Carvedilol 25 mg PO/NG [**Hospital1 **], HydrALAzine to 75 mg PO/NG TID, and Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY. With this regimen, patient's systolic BPs were consistently in the 110s to low 120s. Vascular surgery wanted to allow for patient's renal function to return toward baseline before operating, as the procedure would require a significant contrast load, so patient was discharged on this antihypertensive regimen with plan to follow-up with Dr. [**Last Name (STitle) **] of vascular surgery in 2 weeks for planning of surgical repair of aortic arch ulceration. #[**Last Name (un) **]: Patient developed acute kidney injury with Cr peaking at 3.0 from a baseline of 1.2-1.5. [**Last Name (un) **] was felt to be multifactorial with contrast induced nephropathy (patient received 2 contrast CTs in a short period of time), ATN (muddy brown casts seen on UA), and post-obstuctive nephropathy from bladder constriction causing bilateral kidney injury. Additionally, patient was aggressively diuresed with evidence of contraction alkalosis and Cr rise to 3.0. With break from lasix ggt, Cr improved to 2.4. Prior to transfer from the unit, patient began autodiuresing. On cardiology floor, urine output improved and Cr trended down to 1.7 on discharge. # Anemia: Patient remained within baseline range (high 20s), however given cardiac issues, hct was trended closely and patient was transfused to a goal hct of >25. He was given 4 units pf PRBCs prior to transfer from the vascular surgery service, where hct goal was >30. #CAD: Pt has known CAD and is s/p CABG and PCI in the mid-90s. ECG has shown IVCD to LBBB in the past, which is consistent with the current ECG. Patient was started on aspirin 81mg daily and continued on home statin. Blood pressures were managed as above. # Bladder neck contracture: On [**11-11**], patient was taken by urology for cystoscopy and a bladder neck contracture was identified and dilated up to 25-French. Calcifications, using the cystoscope knocked the calcification off into the bladder. Then using stone crushers through a 20-French cystoscope, the stones were crushed into small pieces. These were then Ellik evacuated free. A 20-French 3 way catheter was then placed into the bladder. Foley remained in place over the course of the admission and patient was discharged with urology follow up in 1 week with Dr. [**Last Name (STitle) 770**]. Medications on Admission: Home Medications: - Amlodipine 10 mg PO daily - Dilaudid 4 Q6H prn - Losartan 100 PO daily - Metoprolol tartrate 50 PO BID - Nitroglycerin 0.4 SL prn - Omeprazole 20 mg PO daily - Pravastatin 80 mg PO daily Discharge Medications: 1. Amlodipine 10 mg PO DAILY 2. HYDROmorphone (Dilaudid) 4 mg PO Q6H:PRN pain 3. Omeprazole 20 mg PO DAILY 4. Aspirin 81 mg PO DAILY RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*3 5. Atorvastatin 80 mg PO DAILY RX *atorvastatin 80 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*3 6. Carvedilol 25 mg PO BID RX *carvedilol 25 mg 1 tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*3 7. HydrALAzine 50 mg PO TID RX *hydralazine 50 mg 1 tablet(s) by mouth three times a day Disp #*90 Tablet Refills:*3 8. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY RX *isosorbide mononitrate [Imdur] 60 mg 1.5 tablet(s) by mouth daily Disp #*45 Tablet Refills:*30 9. Torsemide 20 mg PO DAILY RX *torsemide [Demadex] 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet Refills:*3 10. Nitroglycerin SL 0.4 mg SL PRN chest pain Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Aortic arch ulceration acute on chronic systolic congestive heart failure contrast induced nephropathy acute renal failure urethral calculus urinary obstruction Discharge Condition: mental status: clear, coherent ambulatory status: ambulates independently Discharge Instructions: Dear Mr. [**Known lastname 101110**], It was a pleasure taking part in your care here at [**Hospital1 771**]. You were admitted for severe chest pain. Your initial CT scan looked like the ulceration of your aorta was expanding. Repeat MRI, which is a more sensitive test, showed that the ulceration was actually relatively stable. You developed kidney failure likely caused by a combination of the contrast from the CAT scan and obstruction from a stone in your urethra. You were given fluids to help improve your kidney function. This resulted in worsening of your heart failure, ultimately requiring you to be on a breathing machine. With IV diuretics, your breathing improved significantly and you were able to come off the breathing machine. We continued to remove fluid using an oral diuretic and you no longer required extra oxygen. Your chest pain resolved during the course of your hospitalization. You were evaluated by vascular surgery. Given the results of your MRI, which showed a stable ulcer, you do not require surgery during this hospitalization. Instead your aortic ulceration was managed medically with strict blood pressure control. Extra blood pressure medications were added to keep your blood pressure low to prevent worsening of your aortic ulcer. Also, during your hospitalization you had a stone removed from your urethra and have had a Foley catheter in place since then. You should follow-up with your urologist, Dr. [**Last Name (STitle) 770**] in 1 week for removal of the catheter. Your kidney function has been steadily improving and your urine output has been good suggesting that your kidney function should return to normal. You will follow-up with the kidney doctors to ensure that your kidney function has returned to [**Location 213**]. The vascular surgery team has decided that it would be safest to send you home with strict blood pressure control and allow your kidneys and heart to recover from this hospitalization before performing the operation to repair your aorta. You will follow-up with Dr. [**Last Name (STitle) **] as an outpatient for further discussion of this surgery. Again it was a pleasure taking part in your care and I wish you all the best in the future. Followup Instructions: Department: VASCULAR SURGERY When: [**Last Name (STitle) **] [**2194-12-22**] at 10:30 AM With: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 20205**], MD [**Telephone/Fax (1) 20206**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) **] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: CARDIAC SERVICES When: THURSDAY [**2194-11-27**] at 9:00 AM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], MD [**Telephone/Fax (1) 62**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: WEST [**Hospital 2002**] CLINIC When: [**Hospital **] [**2194-12-1**] at 2:30 PM With: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 2540**], RN [**Telephone/Fax (1) 721**] Building: De [**Hospital1 **] Building ([**Hospital Ward Name 121**] Complex) [**Location (un) **] Campus: WEST Best Parking: [**Street Address(1) 592**] Garage Department: [**Hospital1 18**] [**Location (un) 2352**] When: PENDING With: [**First Name4 (NamePattern1) 1575**] [**Last Name (NamePattern1) 1576**], MD [**Telephone/Fax (1) 6662**] Building: [**Location (un) 2355**] ([**Location (un) **], MA) [**Location (un) 551**] Campus: OFF CAMPUS Best Parking: Free Parking on Site **We are working on a follow up appointment with DR.[**Last Name (STitle) 1576**]. You will be called at home with the appointment. If you have not heard within 2 business days or have questions, please call the number above.** Please follow-up with Dr. [**Last Name (STitle) 770**] of urology in 1 week for removal of Foley catheter.

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icd9cm

[ [ [] ] ]

[ "96.71", "57.32", "57.0", "96.04", "57.92" ]

icd9pcs

[ [ [] ] ]

17084, 17142

11089, 15918

324, 680

17346, 17346

5872, 5872

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4118, 4330

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17163, 17325

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3583, 4102

68,964

139,161

5928

Discharge summary

report

Admission Date: [**2163-5-13**] Discharge Date: [**2163-5-24**] Date of Birth: [**2082-9-15**] Sex: M Service: ORTHOPAEDICS Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3190**] Chief Complaint: Back pain and kyphosis Major Surgical or Invasive Procedure: L1 corpectomy with cage and T12-L2 fusion (lateral approach) [**2163-5-15**] Posterior T9-L4 fusion with instrumentation [**2163-5-16**] History of Present Illness: 80M s/p L2-L4 fusion with laminectomy [**2162-12-27**] and L1-L4 fusion [**2163-1-23**] for chronic back pain with failure of hardware presents for elective revision of fusion. Past Medical History: PMHx: -HTN/HLD -DM PSHx: -hernia repair Social History: denies tobacco Family History: N/C Physical Exam: A&O X 3; NAD RRR CTA B Abd soft NT/ND Kyphosis [**Company 5249**]/L junction BUE- good strength at deltoid, biceps, triceps, wrist flexion/extension, finger flexion/extension and intrinics; sensation intact C5-T1 dermatomes; - [**Doctor Last Name 937**], reflexes symmetric at biceps, triceps and brachioradialis BLE- good strength at hip flexion/extension, knee flexion/extension, ankle dorsiflexion and plantar flexion, [**Last Name (un) 938**]/FHL; sensation intact L1-S1 dermatomes; - clonus, reflexes symmetric at quads and Achilles Pertinent Results: [**2163-5-23**] 05:25AM BLOOD WBC-10.8 RBC-3.19* Hgb-9.6* Hct-29.4* MCV-92 MCH-30.1 MCHC-32.7 RDW-13.5 Plt Ct-372 [**2163-5-21**] 06:40AM BLOOD WBC-13.0* RBC-3.95* Hgb-11.6* Hct-37.9*# MCV-96 MCH-29.3 MCHC-30.6* RDW-13.7 Plt Ct-349 [**2163-5-20**] 05:35AM BLOOD WBC-10.1 RBC-3.19* Hgb-9.5* Hct-29.6* MCV-93 MCH-29.7 MCHC-32.0 RDW-13.7 Plt Ct-291 [**2163-5-19**] 02:11PM BLOOD WBC-10.8 RBC-3.11* Hgb-9.2* Hct-29.1* MCV-94 MCH-29.4 MCHC-31.5 RDW-13.9 Plt Ct-296 [**2163-5-16**] 06:45PM BLOOD WBC-16.7* RBC-4.05* Hgb-12.3* Hct-37.3* MCV-92 MCH-30.3 MCHC-32.8 RDW-14.0 Plt Ct-224 [**2163-5-15**] 01:16PM BLOOD WBC-14.1*# RBC-3.91* Hgb-11.7* Hct-36.0* MCV-92 MCH-29.9 MCHC-32.5 RDW-13.2 Plt Ct-286 [**2163-5-23**] 05:25AM BLOOD Glucose-216* UreaN-32* Creat-1.2 Na-140 K-4.1 Cl-112* HCO3-20* AnGap-12 [**2163-5-21**] 06:40AM BLOOD Glucose-173* UreaN-43* Creat-1.4* Na-141 K-4.3 Cl-111* HCO3-18* AnGap-16 [**2163-5-20**] 05:35AM BLOOD Glucose-164* UreaN-53* Creat-1.5* Na-139 K-4.4 Cl-111* HCO3-19* AnGap-13 [**2163-5-23**] 05:25AM BLOOD Calcium-7.3* Phos-2.6* Mg-2.2 [**2163-5-20**] 05:35AM BLOOD Calcium-8.0* Phos-2.9 Mg-2.3 [**2163-5-19**] 01:54AM BLOOD Albumin-2.7* Calcium-8.4 Phos-3.3 Mg-2.3 Brief Hospital Course: Mr. [**Known lastname **] was admitted to the [**Hospital1 18**] Spine Surgery Service on [**2163-5-13**] and taken to the Operating Room for L1 vertebrectomy through a lateral approach with a T12-L2 fusion. Please refer to the dictated operative note for further details. The surgery was without complication and the patient was transferred to the T/SICU in a stable condition. TEDs/pnemoboots were used for postoperative DVT prophylaxis. Intravenous antibiotics were given per standard protocol. Initial postop pain was controlled with a IV pain medication. On HD#2 he returned to the operating room for a scheduled T9-L4 decompression with PSIF as part of a staged 2-part procedure. Please refer to the dictated operative note for further details. The second surgery was also without complication and the patient was transferred to the T/SICU in a stable condition. Postoperative HCT was low and he was transfused PRBCs with good effect. A bupivicaine epidural pain catheter placed at the time of the posterior surgery remained in place until postop check when it was removed. He developed post-op confusion and his narcotics were decreased. He was kept NPO until bowel function returned then diet was advanced as tolerated. The patient was transitioned to oral pain medication when tolerating PO diet. Foley was removed on POD#4 from the second procedure. He was fitted with a TLSO brace for comfort. Physical therapy was consulted for mobilization OOB to ambulate. Hospital course was otherwise unremarkable. On the day of discharge the patient was afebrile with stable vital signs, comfortable on oral pain control and tolerating a regular diet. Medications on Admission: olanzapine oxycodone ketoprolol insulin ativan Discharge Medications: 1. olanzapine 5 mg Tablet, Rapid Dissolve Sig: 0.5 Tablet, Rapid Dissolve PO Q4H (every 4 hours) as needed for agitation . 2. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. 3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed for constipation. 5. docusate sodium 50 mg/5 mL Liquid Sig: One (1) PO BID (2 times a day). 6. metoprolol tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. insulin regular human 100 unit/mL Solution Sig: One (1) syringe Injection ASDIR (AS DIRECTED). 8. tramadol 50 mg Tablet Sig: 0.5 Tablet PO Q6H (every 6 hours) as needed for pain. 9. lorazepam 0.5 mg Tablet Sig: One (1) Tablet PO Q12 () as needed for anxiety. Discharge Disposition: Extended Care Facility: Life Care Center of [**Location 15289**] Discharge Diagnosis: L1 fracture Post-op confusion Discharge Condition: Good Discharge Instructions: You have undergone the following operation: ANTERIOR/POSTERIOR Thoracolumbar Decompression With Fusion Immediately after the operation: -Activity: You should not lift anything greater than 10 lbs for 2 weeks. You will be more comfortable if you do not sit or stand more than ~45 minutes without getting up and walking around. -Rehabilitation/ Physical Therapy: o2-3 times a day you should go for a walk for 15-30 minutes as part of your recovery. You can walk as much as you can tolerate. oLimit any kind of lifting. -Diet: Eat a normal healthy diet. You may have some constipation after surgery. You have been given medication to help with this issue. -Brace: You have been given a brace. This brace is to be worn when you are out of bed. You may take it off when lying in bed. -Wound Care: Remove the dressing in 2 days. If the incision is draining cover it with a new sterile dressing. If it is dry then you can leave the incision open to the air. Once the incision is completely dry (usually 2-3 days after the operation) you may take a shower. Do not soak the incision in a bath or pool. If the incision starts draining at anytime after surgery, do not get the incision wet. Cover it with a sterile dressing. Call the office. -You should resume taking your normal home medications. No NSAIDs. -You have also been given Additional Medications to control your pain. Please allow 72 hours for refill of narcotic prescriptions, so please plan ahead. You can either have them mailed to your home or pick them up at the clinic located on [**Hospital Ward Name 23**] 2. We are not allowed to call in or fax narcotic prescriptions (oxycontin, oxycodone, percocet) to your pharmacy. In addition, we are only allowed to write for pain medications for 90 days from the date of surgery. Please call the office if you have a fever>101.5 degrees Fahrenheit and/or drainage from your wound. Physical Therapy: Activity: Activity: Out of bed w/ assist Thoracic lumbar spine: when OOB Treatments Frequency: Please continue to change the dressing daily with dry sterile gauze Followup Instructions: With Dr. [**Last Name (STitle) 363**] in 10 days Completed by:[**2163-5-23**]

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icd9cm

[ [ [] ] ]

[ "81.05", "84.52", "81.63", "81.37", "03.90", "81.62", "81.04", "80.99", "84.51" ]

icd9pcs

[ [ [] ] ]

5145, 5212

2584, 4238

331, 471

5286, 5293

1369, 2561

7443, 7523

790, 795

4335, 5122

5233, 5265

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269, 293

5688, 6118

6130, 7230

499, 677

699, 741

757, 774

58,451

161,476

36352

Discharge summary

report

Admission Date: [**2177-4-20**] Discharge Date: [**2177-4-22**] Date of Birth: [**2110-4-28**] Sex: M Service: MEDICINE Allergies: Penicillins Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: hemoptysis Major Surgical or Invasive Procedure: Right Inferior Thyroid Embolization History of Present Illness: 66 y.o with PMH of HTN, COPD, gout, s/p CVA, and a recently dx SCC of the larynx ca ([**2177-3-31**]) after presenting to [**Hospital1 34**] with respiratory distress and stridor. Ptis s/p planned trach and peg on [**2177-4-1**]. After initial diagnosis at [**Hospital6 33**], pt was sent to [**Hospital **] [**Hospital **] Rehab with plans for further procedures prior to starting chemo/radiation as well as tx for LLL PNA. However, pt reports that he began to experience bleeding from his trach/mouth/nose yesterday, but more substantially today. Therefore, pt was sent to [**Hospital3 417**] Hospital where he was evaluated by GI and thoracics that suggested ENT evaluation. Pt received 3 units of FFP for an INR of 1 and 1 unit of RBCs for HCT of 25. Trach was replaced with a size 7 with a cuff. . Upon arrival to the MICU, pt had no complaints including SOB, CP, LH/dizziness/cough/URI symptoms, fever/chills, headache, abdominal pain/n/v/d/c/dysuria, joint pains. However, he had profuse epistaxis and hemoptysis (nose, mouth, trach). Urgent PIVs were placed, ENT was at the bedside to perform examination and pharyngeal packing. Pt consented for blood products, ICU care, code status, as well as informed of possible IR procedure. Pt was given fentanyl and versed for sedation and placed on ventilation, however he was uncomfortable and uncooperative with the ENT procedures so he was bolused with propofol. Packing successfully in place. Past Medical History: SCC of the larynx dx. [**2177-3-31**] s/p trach and peg [**2177-4-1**] ETOH abuse Social History: Former smoker quit at day of dx, ETOH 14 beers daily up until ~2 wks ago. Family History: per report-lymphoma and lung ca. Physical Exam: gen-awake, alert, answering questions, sitting upright, red blood seen in nares, mouth, at trach site, thin. vitals-T. 97.5, BP 119/75, HR 66, RR 17, sat 100% on RA HEENT-perrla, EOMI, anicteric, +blood at nares dried and fresh, +dried blood/clot draining from mouth. neck-+trach in place with clot at trach site, dried blood at collar, supple, no LAD chest-b/l AE no w/c/r heart-s1s2 rrr no m/r/g abd-+bs, soft, NT, +Gtube in place, no erythema. No guarding/rebound ext-no c/c/e 2+pulses neuro-awake, alert, oriented. Pertinent Results: [**2177-4-20**] 10:46PM TYPE-ART TEMP-36.8 RATES-15/ TIDAL VOL-600 PEEP-5 O2-100 PO2-307* PCO2-44 PH-7.40 TOTAL CO2-28 BASE XS-2 AADO2-388 REQ O2-66 -ASSIST/CON INTUBATED-INTUBATED [**2177-4-20**] 10:07PM PLT COUNT-373 [**2177-4-20**] 02:42PM PT-12.6 PTT-27.1 INR(PT)-1.1 [**2177-4-20**] 02:42PM PLT COUNT-545* [**2177-4-20**] 02:42PM NEUTS-75.8* LYMPHS-13.8* MONOS-7.3 EOS-2.8 BASOS-0.4 [**2177-4-20**] 02:42PM WBC-10.8 RBC-2.77* HGB-8.5* HCT-25.8* MCV-93 MCH-30.8 MCHC-33.0 RDW-14.4 [**2177-4-20**] 02:42PM GLUCOSE-100 UREA N-22* CREAT-0.6 SODIUM-131* POTASSIUM-4.6 CHLORIDE-95* TOTAL CO2-30 ANION GAP-11 CTA NECK W&W/OC & RECONS Study Date of [**2177-4-20**] 6:16 PM: 1. Arterial vasculature is patent including the carotids,carotid siphons, right vertebral, visualized basilar. Left vertebral artery is not visualized throughout course, proximal occlusion cannot be excluded. No active extravasation. 2. Large heterogeneous transglottic mass, arising predominantly from the left side and may reflect residual known squamous cell cancer. 3. Possible hyperdense packing material seen throughout the pharynx, clinical correlation recommended. Brief Hospital Course: Pt is a 66 y.o with h.o HTN, COPD, gout, s/p CVA, s/p newly dx laryngeal CA who presents with bleeding from mass. #[**Name (NI) 48445**] Pt presented with profuse bleeding from hypopharyngeal mass. No bleeding seen below the mass. Suspected bleeding was from the mass and above into the mouth/nares. ENT packed tumor, pt to IR for coil embolization of inferior thyroidal artery and repacked. Given 4 u pRBC total, crits stable since. Oropharyngeal packing removed by ENT [**4-21**]. Pt. to follow up with outpatient ENT and outpatient oncologist after being discharged to LTAC facility #Respiratory failure-secondary to sedation with fentanyl/versed/propofol. On presentation was sating 100% RA. Weaned off of sedation after various procedures completed. Chest x-ray showed ? left lower lobe collapse. GPCs and GNRs on sputum gram [**Month/Year (2) 2733**]. Pt. started on vanc/cefepime given sputum gram [**Last Name (LF) 2733**], [**First Name3 (LF) **] end 10 day course on [**2177-4-30**]. #S/p hypotension-pt transiently hypotensive during initial sedation with fetanyl and versed bolus. Transiently on neosyn during sedation/ENT evaluation. Currently off neosyn. S/p 4 units of PRBCs, and IVF. HD stable. #SCC of the larynx-recently dx. S/p trach and G-tube. Plan per report was for dental procedure then chemo/radiation. #HTN-held home meds (lisinopril) initially for hypotension, restarted at end of stay due to hypertension #COPD-will monitor resp status/sats. #Gout-hold allopurinol #ETOH abuse-family states 14 beers daily, but none in ~2weeks. Had been getting ativan per family. Gave thiamine and folate during stay. No other issues. #FEN-NPO for procedure initially, nutrition consulted for tube feeds after poor PO intake. Medications on Admission: Prior to admission per records allopurinol 300 per G-tube, lisinopril 50mg, colace 100mg [**Hospital1 **], nexium 20mg, asa 81mg, senna, MVI, lovenox 40mg SC daily, lorazepam, levalbuterol, acetaminophen, fleet enema, oxycodone 5mg Q4h pRN, G tube feeds-isosource 1.5cal 55ML per hour, ativan 0.5mg QID prn. Discharge Medications: 1. Oxymetazoline 0.05 % Aerosol, Spray Sig: One (1) Spray Nasal [**Hospital1 **] (2 times a day) as needed for 3 days. 2. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. 3. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day) as needed. 4. Docusate Sodium 50 mg/5 mL Liquid Sig: Two (2) PO BID (2 times a day). 5. Famotidine 20 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 6. Thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 8. Lisinopril 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Vancomycin in Dextrose 1 gram/200 mL Piggyback Sig: One (1) Intravenous Q 12H (Every 12 Hours): Please continue until [**2177-4-30**]. 10. Cefepime 2 gram Recon Soln Sig: One (1) Recon Soln Injection Q12H (every 12 hours): Please continue until [**2177-4-30**]. Discharge Disposition: Extended Care Facility: [**Hospital1 700**] - [**Location (un) 701**] Discharge Diagnosis: Primary: Hemoptysis and Epistaxis Secondary: Squamous Cell Carcinoma of the larynx Alcoholism Discharge Condition: Stable, trach in place, patient cooperative and responsive to commands. Discharge Instructions: You were admitted to the Intensive Care Unit with bleeding from your nose and your tracheostomy site. Upon arrival, you were seen by our otolaryngology specialists and, given that it was difficult to perform the packing that was required, you were placed under sedation and on mechanical ventilation. The otolaryngology specialists were successful in packing your wound. In addition, your had a procedure done to stop your bleeding which required artificial blocking of one of the small blood vessels in your neck. You were also found to possibly have a pneumonia, so you have been placed on antibiotics. If you have any subsequent excessive bleeding, or difficulties breathing, please return to the hospital immediately. Followup Instructions: 1.) Please schedule a follow up with your primary care physician [**Last Name (NamePattern4) **] 1 to 2 weeks 2.) ENT: Please follow up with your outpatient otorlaryngologist 2 weeks after discharge [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**] Completed by:[**2177-4-22**]

[ "458.29", "784.7", "518.81", "496", "E937.8", "V44.1", "V12.54", "401.9", "161.9", "V44.0", "786.3", "274.9", "V15.82", "303.93" ]

icd9cm

[ [ [] ] ]

[ "94.62", "38.93", "21.01", "88.41", "39.72", "96.71" ]

icd9pcs

[ [ [] ] ]

6860, 6932

3794, 5549

290, 328

7071, 7145

2607, 3771

7920, 8287

2018, 2052

5908, 6837

6953, 7050

5575, 5885

7169, 7897

2067, 2588

240, 252

356, 1805

1827, 1911

1927, 2002

32,276

182,043

45790

Discharge summary

report

Admission Date: [**2186-11-6**] Discharge Date: [**2186-11-12**] Date of Birth: [**2131-4-18**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1505**] Chief Complaint: Dyspnea on exertion Major Surgical or Invasive Procedure: CABGx5 (LIMA-LAD,SVG-Diag,SVG-OM1-OM2,SVG-PDA)[**11-6**] History of Present Illness: Reported dypnea on exertion while being evaluated for shoulder surgery and was referred for ETT which showed ischemia. A subsequent cardiac catheterization revealed 3 vessel coronary disease and he was referred for cardiac surgery. He was accepted as a surgical candidate and returns now for surgery. Past Medical History: HTN ^chol DM2 Obesity Gout Restless leg syndrom OSA Rt elbow surgery Rt carpal tunnel release Rt bicep repair Piloneal cyst removal Social History: Lives w/wife Denies tobacco Rare ETOH Family History: Father died at 53yo of MI Sister has heart murmur Physical Exam: Admission: HR 80 BP 154/86 RR 14 Gen: NAD Neuro: A&Ox3, nonfocal exam Pulm: CTA-bilat CV: RRR, S1-S2 Abdm: soft, NT/ND-obese Ext: warm, well perfused, no pedal edema, no varicosities Pertinent Results: [**2186-11-6**] 11:52AM BLOOD WBC-10.5# RBC-2.46*# Hgb-8.0*# Hct-22.7*# MCV-92 MCH-32.3* MCHC-35.0 RDW-14.7 [**2186-11-6**] 07:48PM BLOOD Plt Ct-175 [**2186-11-6**] 11:52AM BLOOD PT-14.0* PTT-25.2 INR(PT)-1.2* [**2186-11-6**] 12:06PM BLOOD UreaN-30* Creat-1.4* Cl-114* HCO3-21* [**2186-11-10**] 06:22AM BLOOD WBC-7.8 RBC-3.00* Hgb-9.6* Hct-27.4* MCV-91 MCH-31.9 MCHC-35.0 RDW-14.9 Plt Ct-191 [**2186-11-10**] 06:22AM BLOOD Plt Ct-191 [**2186-11-9**] 02:54AM BLOOD PT-12.6 PTT-32.5 INR(PT)-1.1 [**2186-11-10**] 06:22AM BLOOD Glucose-104 UreaN-52* Creat-1.7* Na-137 K-4.4 Cl-99 HCO3-25 AnGap-17 RADIOLOGY Preliminary Report CHEST (PORTABLE AP) [**2186-11-9**] 8:52 AM CHEST (PORTABLE AP) Reason: evalaute [**Hospital **] [**Hospital 93**] MEDICAL CONDITION: 55 year old man with CABG and REASON FOR THIS EXAMINATION: evalaute lll SINGLE AP PORTABLE VIEW OF THE CHEST REASON FOR EXAM: CABG. Comparison is made with multiple prior studies including most recent one performed a day earlier. Mild cardiomegaly is unchanged and the right lung remains clear with lower lobe retrocardiac atelectasis is unchanged from prior study [**11-8**] at 14:00 hours but has improved from [**11-8**] at 8:00 hours. There is a probable small left pleural effusion. Right IJ line remains in place. Patient is post median sternotomy and CAGB. DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 97552**], [**Known firstname **] [**Hospital1 18**] [**Numeric Identifier 97553**] (Complete) Done [**2186-11-6**] at 10:09:58 AM FINAL Referring Physician [**Name9 (PRE) **] Information [**Name9 (PRE) **], [**First Name3 (LF) **] R. Division of Cardiothoracic [**Doctor First Name **] [**Hospital Unit Name 4081**] [**Location (un) 86**], [**Numeric Identifier 718**] Status: Inpatient DOB: [**2131-4-18**] Age (years): 55 M Hgt (in): BP (mm Hg): / Wgt (lb): HR (bpm): BSA (m2): Indication: Abnormal ECG. Hypertension. ICD-9 Codes: 402.90, 440.0 Test Information Date/Time: [**2186-11-6**] at 10:09 Interpret MD: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD Test Type: TEE (Complete) Son[**Name (NI) 930**]: [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 5209**], MD Doppler: Full Doppler and color Doppler Test Location: Anesthesia West OR cardiac Contrast: None Tech Quality: Adequate Tape #: 2007AW1-: Machine: Echocardiographic Measurements Results Measurements Normal Range Left Ventricle - Ejection Fraction: 50% to 55% >= 55% Aorta - Annulus: 2.0 cm <= 3.0 cm Aorta - Sinus Level: *3.9 cm <= 3.6 cm Aorta - Sinotubular Ridge: *3.2 cm <= 3.0 cm Aorta - Ascending: 3.2 cm <= 3.4 cm Aortic Valve - Peak Gradient: 4 mm Hg < 20 mm Hg Aortic Valve - Mean Gradient: 2 mm Hg Findings RIGHT ATRIUM/INTERATRIAL SEPTUM: Normal RA size. A catheter or pacing wire is seen in the RA and extending into the RV. No ASD by 2D or color Doppler. LEFT VENTRICLE: Wall thickness and cavity dimensions were obtained from 2D images. Normal LV wall thickness. Normal LV cavity size. Mild regional LV systolic dysfunction. Low normal LVEF. LV WALL MOTION: Regional left ventricular wall motion findings as shown below; remaining LV segments contract normally. RIGHT VENTRICLE: Normal RV chamber size and free wall motion. AORTA: Normal aortic diameter at the sinus level. Normal ascending aorta diameter. Normal aortic arch diameter. Simple atheroma in aortic arch. Normal descending aorta diameter. Simple atheroma in descending aorta. AORTIC VALVE: Three aortic valve leaflets. Mildly thickened aortic valve leaflets. No masses or vegetations on aortic valve. No AS. No AR. MITRAL VALVE: Mildly thickened mitral valve leaflets. Mild mitral annular calcification. Calcified tips of papillary muscles. Trivial 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. The patient was under general anesthesia throughout the procedure. The patient received antibiotic prophylaxis. The TEE probe was passed with assistance from the anesthesioology staff using a laryngoscope. No TEE related complications. REGIONAL LEFT VENTRICULAR WALL MOTION: N = Normal, H = Hypokinetic, A = Akinetic, D = Dyskinetic Conclusions PRE-CPB:1. No atrial septal defect is seen by 2D or color Doppler. 2. Left ventricular wall thicknesses are normal. The left ventricular cavity size is normal. There is mild regional left ventricular systolic dysfunction with anterior apical and anteroseptal apical hypokinesis. Overall left ventricular systolic function is low normal (LVEF 50-55%). The remaining left ventricular segments contract normally. 3. Right ventricular chamber size and free wall motion are normal. 4. There are simple atheroma in the aortic arch. There are simple atheroma in the descending thoracic aorta. 5. There are three aortic valve leaflets. The aortic valve leaflets are mildly thickened. No masses or vegetations are seen on the aortic valve. There is no aortic valve stenosis. No aortic regurgitation is seen. 6. The mitral valve leaflets are mildly thickened. Trivial mitral regurgitation is seen. POST-CPB: On infusion of phenylephrine.l Preserved LV systolic function post bypass. Anteroseptal wall is improved. MR is trivial. Aortic contour is normal post decannulation. I certify that I was present for this procedure in compliance with HCFA regulations. Electronically signed by [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 5209**], MD, Interpreting physician Brief Hospital Course: Mr [**Known lastname **] was a direct admission to the operating room for coronary bypass grafting on [**2186-11-6**]. At that time he had CABGx5 withLIMA-LAD,SVG-Diag, SVG-OM!, SVG-OM2, SVG-PDA. His bypass time was 102 minutes with a crossclam time of 80 minutes. Please see OR report for details. He was transferred to the cardiac surgery ICU in stable condition. He was hemodynamically stable in the immediate post-op period, his anesthesia was reversed, he was weaned from the ventilator and extubated. On POD1 he continued to require Neosynephrine for BP support and stayed in the ICU, by POD2 the Neosynephrine had been weaned off and he was discharged to the post-op floors. Over the next several days his activity level improved with the assistance of nursing and physical therapy. ON POD#3 the pt was noted to have developed a left pleural effusion and it was drained. The pt continued to work with advancing his activity level and on POD 6 it was decided he was ready for discharge home w/VNA. Post CT [**Name (NI) 1788**] pt had small apical pneumo / repeat cxr showed stable appearence Medications on Admission: Benicar/HCTZ 40/12.5' Norvasc 10' Allopurinol 300' Metformin 1000" Glyburide 5' Vytorin 10/40' Gemfibrozil 600" ASA 81' Ambien-HS Plavix 75' Metoprolol 25' Discharge Medications: 1. Glyburide 2.5 mg Tablet Sig: Two (2) Tablet PO BID (2 times a day). Disp:*120 Tablet(s)* Refills:*2* 2. Vytorin 10-40 10-40 mg Tablet Sig: One (1) Tablet PO once a day: resume preop regime. 3. Gemfibrozil 600 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). Disp:*30 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 5. Potassium Chloride 10 mEq Tablet Sustained Release Sig: Two (2) Tablet Sustained Release PO twice a day for 20 days: 20 mEq [**Hospital1 **] x 10 days then 20 mEq QD x 10 days. Disp:*60 Tablet Sustained Release(s)* Refills:*0* 6. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 7. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Disp:*50 Tablet(s)* Refills:*0* 8. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO BID (2 times a day). Disp:*180 Tablet(s)* Refills:*2* 9. Furosemide 40 mg Tablet Sig: One (1) Tablet PO twice a day: 40mg [**Hospital1 **] x 10 days then 40mg QD x 10 days. Disp:*30 Tablet(s)* Refills:*2* 10. Amiodarone 200 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): please take 1 tablet PO bid x 7 days / Then take one tablet po qd. Disp:*60 Tablet(s)* Refills:*2* 11. Metformin 1,000 mg Tablet Sig: One (1) Tablet PO twice a day. Disp:*60 Tablet(s)* Refills:*2* 12. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO once a day. 13. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Discharge Disposition: Home With Service Facility: [**Hospital3 **] VNA Discharge Diagnosis: CAD s/p CABG x5(LIMA-LAD,SVG-Diag,SVG-OM1-OM2,SVG-PDA)[**11-6**] PMH: ^chol, DM2, Obesity, Gout, OSA, rest leg syndrome PSH: Rt elbow [**Doctor First Name **], R carpal tunnel release, R bicep repair, Piloneal cyst removal Discharge Condition: good Discharge Instructions: Keep wounds clean and dry. OK to shower, no bathing or swimming. Take all medications as prescribed. Call for any fever, redness or drainage from woun Followup Instructions: [**Hospital 409**] clinic in 2 weeks Dr [**Last Name (STitle) **] in [**2-25**] weeks Dr [**Last Name (STitle) 14522**] in [**2-25**] weeks Dr [**Last Name (STitle) **] in 4 weeks Completed by:[**2186-11-12**]

[ "250.00", "333.94", "511.9", "278.00", "413.9", "427.31", "327.23", "458.29", "401.9", "414.01" ]

icd9cm

[ [ [] ] ]

[ "39.61", "36.15", "99.04", "93.90", "36.14", "34.91" ]

icd9pcs

[ [ [] ] ]

9843, 9894

6948, 8049

342, 401

10161, 10168

1229, 1952

10367, 10579

957, 1008

8255, 9820

1989, 2019

9915, 10140

8075, 8232

10192, 10344

5579, 6925

1023, 1210

283, 304

2048, 5535

429, 731

753, 886

902, 941

31,062

160,550

33379

Discharge summary

report

Admission Date: [**2148-4-8**] Discharge Date: [**2148-5-6**] Date of Birth: [**2096-4-4**] Sex: M Service: CARDIOTHORACIC Allergies: Nafcillin Sodium Attending:[**First Name3 (LF) 1267**] Chief Complaint: Direct transfer from [**Hospital1 18**] [**Location (un) 620**] for epidural abscess. Major Surgical or Invasive Procedure: [**2148-4-9**] 1. Cervical laminectomy and medial facetectomy, C5 and C6. 2. Hemilaminectomy, left side, C7, for extradural epidural abscess. 3. T9 and T10 laminectomy and medial facetectomy for extradural epidural abscess. 4. Lumbar laminectomy, L1, L2, L3, L4, and L5, for extradural epidural abscess and decompression. 5. Incision and debridement, paraspinal abscess in the right and left paraspinal muscles tracking down to the L5-S1 facets versus sacroiliac joints. [**2148-4-10**] 1. Incision and drainage of right first metatarsophalangeal joint. [**2148-4-11**] Irrigation and debridement of right septic elbow. [**2148-4-15**] 1. Soft tissue debridement. 2. Resection of bone. 3. Incision and drainage right foot. [**2148-4-19**] Right first metaphalangeal joint debridement, soft tissue debridement, closure of dorsal incision, packed open plantar incision. [**2148-4-23**] Placement of Tunneled Dialysis Catheter [**2148-4-29**] Mitral Valve Repair(32mm [**Doctor Last Name 405**] Annuloplasty Band) with Resection of P3 [**2148-5-2**] Removal of a Right Tunneled Hemodialysis Catheter. History of Present Illness: Mr. [**Known lastname 41304**] is a 52 year old male with newly diagnosed Type II diabetes, recent gum surgery, neck and back pain. He presented to [**Location (un) 620**] [**2148-4-7**], with 4/4 bottles gram positive cocci, and subsequently started on Oxacillin, and Vancomycin. He was noted to have epidural abscess on L spine MR scout images, and found to have a new heartmurmur. Due to MSSA bacteremia with seeding to multiple sites, he was transferred for further treatment and evaluation. Past Medical History: Type II Diabetes Mellitus(recently diagnosed) Hypertension Hyperlipidemia GERD Cervical spondylosis with chronic neck pain Obesity Osteoarthritis Prior Rotator cuff surgery Prior Right great toe surgery Social History: Denies tobacco. Social ETOH. No history of ETOH abuse. Married with two children. He is a marketing director. Family History: Mother with [**Name2 (NI) **] and gout. No family history of premature CAD. Physical Exam: Vitals: on admission: T 97.6, BP 163/93, HR 107, O2 sat 99% 2L General: overweight, lying in bed, intubated and sedated with OG tube in place HEENT:faint erythema on forehead CV: Regular rate, normal S1 and S2, systolic murmur heard best over mitral area Pulm: CTA bilaterally Abd: distended, high pitched bowel sounds, firm Ext: bilateral feet with erythema, edema, purple in areas, demarcated, PT 2+, DP 1+ by doppler -- no osler nodes or [**Last Name (un) **] lesions noted Neuro: pupils pinpoint, patient not currently responsive to voice or stimulation Pertinent Results: Admit Labs: [**2148-4-8**] WBC-26.4* RBC-4.10* Hgb-11.4* Hct-34.4* MCV-84 MCH-27.7 MCHC-33.1 RDW-14.5 Plt Ct-101* [**2148-4-8**] Neuts-84* Bands-4 Lymphs-8* Monos-3 Eos-0 [**2148-4-8**] PT-13.8* PTT-26.9 INR(PT)-1.2* [**2148-4-9**] Fibrino-671* [**2148-4-8**] ESR-101*, CRP-200.0* [**2148-4-8**] Glucose-178* UreaN-31* Creat-1.0 Na-128* K-3.9 Cl-91* HCO3-25 AnGap-16 [**2148-4-8**] ALT-67* AST-76* LD(LDH)-689* AlkPhos-272* TotBili-3.8* [**2148-4-8**] Calcium-7.3* Phos-3.4 Mg-3.4* [**2148-4-8**] Spine MRI: Findings of concern for multiple sites of epidural infection as well as cervical-thoracic prevertebral soft tissue swelling and possible C6- C7 disc infection. [**2148-4-9**] TEE: No spontaneous echo contrast or thrombus is seen in the body of the left atrium/left atrial appendage or the body of the right atrium/right atrial appendage. Overall left ventricular systolic function is normal (LVEF>55%). The aortic valve leaflets (3) are mildly thickened but aortic stenosis is not present. No aortic regurgitation is seen. No mass is definitively seen associated with the aortic valve. The mitral valve leaflets are very mildly thickened. There is partial mitral leaflet flail that involves the P3 scallop. Torn mitral chordae appear present at the tip of this segment. An endocarditic lesion associated with this can not be completely ruled out. There is an eccentric, anteriorly directed jet of at least mild to moderate ([**12-27**]+) mitral regurgitation. [**2148-4-10**] RUQ Ultrasound: 1. Echogenic liver consistent with fatty infiltration. Other forms of liver disease including cirrhosis/fibrosis cannot be excluded on this study. 2. Cholelithiasis. Minimal gallbladder wall thickening. 3. Splenomegaly with several apparent hypoechoic raising concern for micro- or macro-abscess, in this clinical setting. [**2148-4-20**] Abdominal CT Scan: 1. Hypodense splenic lesions suggestive of splenic infarcts. No splenic abscesses or collections noted in the spleen. 2. Stones within a contracted gallbladder with no signs of acute cholecystitis. 3. Mild ascites is seen in the pelvis. 4. Status post extensive lower thoracic and lumbar laminectomy with post- surgical changes involving the posterior muscles of the back. A catheter is introduced through the back from the sacral level and is embedded with tip embedded in the T11 thoracic vertebral body posteriorly. No adjacent pockets of air or fluid suspicious for inflammation is noted. 5. Abnormal swelling and thickening of the left piriform muscle and medial portion of the gluteus minimus/medius. This appearance is nonspecific. Focal area of myositis cannot be excluded. [**2148-4-23**] Ultrasound Guided PICC Placement: Uncomplicated ultrasound and fluoroscopically guided placement of a double-lumen hemodialysis catheter measuring 27 cm from tip to cuff through the right common jugular venous approach. The tip of the catheter is located within the right atrium. [**2148-4-25**] TEE: The aortic valve leaflets (3) appear structurally normal with good leaflet excursion. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is partial flail of the posterior mitral leaflet. There is a small (3-mm) echodensity of the posterior mitral leaflet, which is likely a flail portion of the valve, but a small vegetation cannot be excluded. An eccentric, anteriorly directed jet of moderate to severe (3+) mitral regurgitation is seen. There is a trivial/physiologic pericardial effusion. [**2148-4-26**] Cardiac Cath: 1. Selective coronary angiography of this right-dominant system demonstrated no angiographically-apparent coronary artery disease. 2. Resting hemodynamic assessment revealed normal systemic arterial blood pressure (135/76 mmHg) and moderately elevated pulmonary arterial pressure (50/9 mmHg). The left and right-sided filling pressures were markedly elevated with LVEDP 24 mmHg, PCWP 26 mmHg and RVEDP 19 mmHg. The cardiac index and cardiac output were in the upper normal range (8.6 l/min and 3.6 l/mi/m2 sons[**Name (NI) 77463**]). 3. [**Name2 (NI) 2325**] ventriculography deferred. [**2148-4-29**] Intraop TEE: PREBYPASS - Overall left ventricular systolic function is normal (LVEF>55%). The mitral valve leaflets are mildly thickened. There is partial mitral poster (P3)leaflet flail. Severe (4+) mitral regurgitation is seen. The MR jet is eccentric and directed anteriorly. POSTBYPASS - LV systolic function appears normal. RV systolic function now appears normal. There is ring prosthesis in the mitral annular position. Trace valvular MR [**First Name (Titles) **] [**Last Name (Titles) 48613**]. The study is otherwise unchanged from prebypass. Discharge Labs: [**2148-5-3**] WBC-Hgb-Hct-Plt: 12.0- 9.4- 27.5-436 [**2148-5-3**] Na-K-Cl-HCO3-Bun-Cr: 134-4.3-[**Medical Record Number 77464**]-1.6 [**2148-4-28**] Alt-Ast-AlkPhos-Tbili: 4-17-201-1.0 Brief Hospital Course: Infectious Disease: Followed closely throughout his hospital stay by the ID service for his Methicillin sensitive Staphylococcus aureus bactermia/sepsis which was complicated by epidural abcesses of the cervical, lumbar and thoracic spine(Staph aureus) along with infection of his right elbow(Staph aureus) and foot(Staph aureus and Pseudomonas). He was also treated for a urinary tract infection(Staph aureus). He required multiple operative interventions by the orthopedic and podiatry services for incision and drainage along with debridement procedures. Intravenous antibiotics were changed according to culture/sensitivies while doses were titrated according to renal function. At discharge, ID recommendations were to continue Cefepime 2g IV Q24 hours until [**2148-6-25**]. Weekly CBC, chem panel, LFTs, ESR and CRP should be monitored with results faxed to the [**Hospital **] clinic. Cardiac: Serial TEE and TTEs demonstrated no clear vegetations but did show a flail mitral cusp and worsening mitral regurgitation. Given worsening mitral regurgitation along with congesitve heart failure symptoms, CT surgery was consulted. Work up included cardiac catheterization which showed clean coronaries. Mitral valve repair was eventually performed by Dr. [**Last Name (STitle) **] on [**4-29**]. Postoperative TEE revealed only trace mitral regurgitation. Following mitral valve repair, he remained in a normal sinus rhythm. The remainder of his postoperative course was uneventful. Renal: In the setting of his MSSA bacteremia, the patient experienced acute renal failure. He initially required CVVH to help with both his electrolytes and fluid status. He was eventually transitioned to hemodialysis. His creatinine peaked to 7.7 on [**4-23**]. The patient was continued on hemodialysis until [**4-26**]. Throughout his hospital stay, he was followed closely by the renal service. By discharge, his creatinine improved to 1.6. It is expected his renal function will continue to improve and normalize. GI: Initially had elevated LFTs. RUQ ultrasound was obtained which demonstrated gallstones but no evidece of acute cholecystitis. A splenic US was originally concerning for abscess. CT scan of his abdomen later in his hospitalization was more consistent with splenic infarct. By discharge, LFTs normalized without intervention. Heme: Initially noted to have low platelet counts. Dropped as low as 101K. Unclear etiology but by discharge, platelet count normalized. Following mitral valve repair, he was intermittently transfused with PRBC to maintain hematocrit near 30%. Staples were removed from back incision, and he was medically cleared for discharge to rehab on postoperative day 7. Medications on Admission: Home meds: Vicodin, Indocin, Omeprazole 20 qd, Afrin Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Capsule(s) 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Paroxetine HCl 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Cefepime 2 gram Recon Soln Sig: 2 grams Recon Solns Injection Q24H (every 24 hours): Complete 8 week course - last dose on [**2148-6-25**]. Please titrate according to renal function. 6. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 7. Heparin, Porcine (PF) 10 unit/mL Syringe Sig: One (1) ML Intravenous PRN (as needed) as needed for line flush. Disp:*30 ML(s)* Refills:*0* 8. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Miconazole Nitrate 2 % Powder Sig: [**12-27**] Appls Topical TID (3 times a day) as needed. 10. Acetic Acid 0.25 % Solution Sig: One (1) Appl Irrigation DAILY (Daily). 11. Calcium Carbonate 500 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed. Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Hospital1 **] Discharge Diagnosis: Mitral Valve Endocarditis with Mitral Regurgitation - s/p MV Repair Sepsis/MSSA bactermia Urinary Tract Infection Epidural Abscess - s/p Drainage Right Foot Abscess with Osteomylelitis - s/p Drainage & Debridement Right Elbow Infection - s/p Drainage Acute Renal Insufficiency requiring Hemodialysis Pulmonary Edema/Congestive Heart Failure Shock Liver Hypertension Type II Diabetes Anemia Anxiety Discharge Condition: Stable. 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 sternal 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)Continue Cefepime through [**2148-6-25**] - titrate according to renal function 7)Please check weekly CBC, chem panel, LFTs, ESR and CRP. Results should be faxed to Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 7443**] @ [**Telephone/Fax (1) 432**]. All questions regarding outpatient antibiotics should be directed to the infectious disease R.Ns. at ([**Telephone/Fax (1) 14199**]. 8)Local wound care to right foot. Continue NWB and RLE elevation. Followup Instructions: Cardiac Surgeon, Dr. [**Last Name (STitle) **] in [**3-30**] weeks, call for appt [**Telephone/Fax (1) 170**] Dr. [**Last Name (STitle) **] (cardiology) in [**2-27**] weeks call for appt.[**Telephone/Fax (1) 5003**] PCP, [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in [**1-28**] weeks, call for appt ID, Dr. [**Last Name (STitle) 7443**] on [**2148-6-3**] @ 9AM, office [**Telephone/Fax (1) 457**] Podiatry, Dr. [**Last Name (STitle) **] - next week, call office [**Telephone/Fax (1) 543**] for appt Ortho, Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 1352**] in 2 weeks - call for appt [**Telephone/Fax (1) 1228**] Followup with Dr [**Last Name (STitle) **] (podiatry clinic) a week after DC. Call [**Telephone/Fax (1) 77465**]. Completed by:[**2148-5-6**]

[ "E879.8", "518.81", "428.0", "785.4", "998.32", "038.11", "324.1", "429.5", "785.52", "999.31", "995.92", "421.0", "728.89", "041.7", "444.89", "711.09", "250.00", "599.0", "570", "682.7", "584.5", "730.09" ]

icd9cm

[ [ [] ] ]

[ "38.93", "86.05", "83.39", "35.32", "80.12", "39.95", "88.56", "81.91", "39.61", "96.72", "35.12", "03.09", "83.82", "77.69", "86.04", "80.88", "38.95", "37.23", "88.72" ]

icd9pcs

[ [ [] ] ]

11981, 12056

7932, 10635

366, 1466

12498, 12508

3034, 7705

13323, 14125

2362, 2439

10739, 11958

12077, 12477

10661, 10716

12532, 13300

7721, 7909

2454, 2462

241, 328

1494, 1992

2476, 3015

2014, 2219

2235, 2346

28,544

156,602

6768

Discharge summary

report

Admission Date: [**2114-6-19**] Discharge Date: [**2114-7-5**] Date of Birth: [**2043-3-23**] Sex: M Service: SURGERY Allergies: Sulfa (Sulfonamides) / Iodine Containing Agents Classifier / Bee Sting Kit Attending:[**First Name3 (LF) 1234**] Chief Complaint: gangreneous ulcer of LLE Major Surgical or Invasive Procedure: s/p L femoral/sfa thrombectomy, sfa stenting, popliteal stenting, angioplasty of below knee [**Doctor Last Name **], peroneal [**6-25**] History of Present Illness: 71 y.o M patient who has CKD on HD (MWF)with a baseline creatinine of 3.0-3.2 now with gangreneous ulcer of LLE. He was seen at Dr.[**Name (NI) 1720**] clinic [**2114-6-19**], he was recommeded to be admitted for angiogram with possible intervention for revascularization in am. The ulcers started in [**Month (only) **]/08, patient had been on Augmentin for 2 weeks, that improved the looks of his L foot. Patient had R fem-[**Doctor Last Name **] bypass graft '[**04**], CABG x 5 '[**08**]. Patient is legally blind. Patient denies any fever, chills, or generalized body malaise. Past Medical History: PMH: PVD, claudication, CHF, MI [**07**], CRI (baseline 3.0-3.2), DM2, ^chol, Gastroparesis, HTN, Depression, Glaucoma, legally blind PSH: R fem-[**Doctor Last Name **] bypass graft '[**04**], CABG x 5 '[**08**], Cholecystectomy, R 1st and 2nd toe amputation Social History: Lives with wife, HD 3x per week (MWF) Family History: N/C Physical Exam: Physical Exam: VS TM 98.4 TC 98.4 HR 76 BP 132/70 RR 16 Sats 100% RA General: Patient is AAOx3, NAD HENT: no carotid bruits Lungs: diminished bases, breathing with ease, tolerates being flat in bed. Heart: RRR Abd: Protruberant, distended, but non-tender. There is some bruising over the L side of the abdomen. Positive bowel sounds in all quadrants. Extremities: UE's Right warm no focal lesion, L AVF with palpable shrill. LE's, R 1st and 2nd toe amputee, no erythema, no swelling, no edema. L dark discoloration from ankle to toe tips. The R big toe has an ulceration on the medial side aspect now has black dry eschar. There is a small ulcer in the web of 5th and 4th toe that appears dry. Pulses: Rad Fem [**Doctor Last Name **] DP PT R palp 2+ palp dop [**Hospital1 **] [**Hospital1 **] L palp 2+ palp dop mono mono Pertinent Results: [**2114-7-2**] 05:00AM BLOOD WBC-7.8 RBC-2.83* Hgb-8.6* Hct-25.9* MCV-91 MCH-30.4 MCHC-33.3 RDW-16.2* Plt Ct-120* [**2114-6-30**] 03:06PM BLOOD Neuts-65.2 Lymphs-22.3 Monos-8.0 Eos-4.1* Baso-0.4 [**2114-7-2**] 05:00AM BLOOD Plt Ct-120* [**2114-7-2**] 05:00AM BLOOD PT-14.7* PTT-38.5* INR(PT)-1.3* [**2114-7-1**] 04:57AM BLOOD Glucose-123* UreaN-39* Creat-7.3*# Na-136 K-4.8 Cl-98 HCO3-30 AnGap-13 CK(CPK)-67 [**2114-7-2**] 05:00AM BLOOD Calcium-7.6* Phos-4.6* Mg-1.9 ECG Study Date of [**2114-6-26**] 1:50:42 AM Sinus rhythm. First degree A-V block. Possible left atrial abnormality. Q-T interval may be prolonged. Early transition. Downsloping anterolateral ST segments with T wave inversions - cannot exclude ischemia. Compared to the previous tracing of [**2114-6-23**] the QRS complexes and ST-T wave changes in leads V2-V3 could be positional. Voltage criteria for left ventricular hypertrophy are no longer present. CHEST (PRE-OP PA & LAT) [**2114-6-19**] 11:49 AM COMPARISON: No comparison available at the time of dictation. Status post CABG, the two apical sternotomy wires are ruptured. Post-surgical clips in standard position. There is slight enlargement of the cardiac silhouette without signs of overhydration or cardiac insufficiency, there is no evidence of pleural effusions. Dense costosternal cartilages. In the lung parenchyma, subtle interstitial thickening suggests minimal airways disease. There are no focal parenchymal opacities suggestive of pneumonia. No evidence of pneumothorax. Brief Hospital Course: 71 y.o M with L foot gangrene, was directly admitted to Vascular Surgery/Dr. [**Last Name (STitle) **] service on [**2114-6-19**] Pre-oped, consented, for angio and possible intervention for revascularization the same day. Taken to angio suite and had a successful contralateral second order arteriography with abdominal aortogram and unilateral extremity runoff by Dr. [**Last Name (STitle) **]. He was kept after his arteriography for a femoral endarterctomy. His post operative course after the femoral endarterectomy was complicated by hypertension to the 70s systolic. The patient was extubated from his second surgery on [**6-26**]. The patient was transferred to the VICU on POD 4 after being weaned off her nitrogycerin drip. The patient's arterial line was removed on POD 5. Pt stabalized. A PT consult was obtained. Recommended rehab. Pt trnsfered to rehab in stable condition. Neuro: The patient had excellent pain control during his hospitalization. CV: The patient had a cardiac catheterization on [**6-22**]. The patient had postoperative hypotension after his femoral endarterectomy on [**6-25**]. He was started on a pressor in the ICU for blood pressure support. RESP: The patient remained in good respiratory status throughout his stay. He was briefly intubated and in the ICU for hypotension postoperatively. His sats have remained stable on the floor. GI: The patient was started on a cardiac diet in the ICU. He was tolerating a diet prior to discharge. FEN/GU: The patient has a history of ESRD, and does not void. The patient underwent regular hemodialysis three times a week. He was followed by the renal team while he was here. HEME: The patient was transfused 1 unit of blood on [**7-1**] for a hematocrit of 25.5. This was not due to acute blood loss. He remained hemodynamically stable afterwards. ID: The patient was started on Augmentin for the dry gangrene on his left first toe. The course was completed and the patient was restarted on Augmentin on [**7-5**] for possible infection around his wound. He will stay on this for a 7 day course. Medications on Admission: Sensipar 30 mg 1 po QHS Lisinopril 10 mg 1 po QAM Reglan 5 mg 1 PO tid prn nausea Compazine 10 mg 1 po QD prn nausea Coumadin 5 mg 1 po QHS Klonipin 1 mg 1 po QHS Lantus 10 units SC Q evening Humalog SS Cosopt 1 drop OU twice daily Alphagan 1 drop OU twice daily Xalatan .005% 1 drop OU QHS Amoxicillin w/ Clavulanate 500-125mg 1 po BID Nephrocaps 1 po QD Mirapex 0.25 mg 1 po TID Lyrica 50 mg 1 po TID Phoslo 667 mg Celexa 20 mg 1 po QD Coreg 20 mg 1 po QD Discharge Medications: 1. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) Injection TID (3 times a day). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Brimonidine 0.15 % Drops Sig: One (1) Drop Ophthalmic Q 12H (Every 12 Hours). 5. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 6. Dorzolamide-Timolol 2-0.5 % Drops Sig: One (1) Drop Ophthalmic [**Hospital1 **] (2 times a day). 7. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 8. Pregabalin 25 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 9. Pramipexole 0.25 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 10. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 11. Simvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 12. Metoclopramide 10 mg Tablet Sig: 0.5 Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 13. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 14. Clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO QHS (once a day (at bedtime)) as needed. 15. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 16. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical PRN (as needed). 17. Hydrocodone-Acetaminophen 5-500 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. 18. Regular Insulin SC Sliding Scale Glucose Insulin Dose 0-65 mg/dL [**1-17**] amp D50 66-120 mg/dL 0 Units 121-160 mg/dL 3 Units 161-200 mg/dL 6 Units 201-240 mg/dL 9 Units 241-280 mg/dL 12 Units 281-320 mg/dL 15 Units > 320 mg/dL Notify M.D. 19. Outpatient Lab Work INR QD for Coumadin management desired INR [**2-18**] 20. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed. Tablet(s) 21. Warfarin 5 mg Tablet Sig: One (1) Tablet PO ONCE (Once) for 1 doses: Monitor INR to determine daily dose of coumadin. 22. Amoxicillin-Pot Clavulanate 500-125 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 7 days. Tablet(s) 23. Midodrine 2.5 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Tablet(s) Discharge Disposition: Extended Care Facility: [**Hospital6 1293**] - [**Location (un) **] Discharge Diagnosis: L heel gangrene PVD claudication CHF CAD MI'[**07**] CRI (baseline 3.0-3.2) DM2 Hypercholesterolemia Gastroparesis HTN Depression Glaucoma legally blind PSH: R fem-[**Doctor Last Name **] bypass graft '[**04**], CABG x 5 '[**08**], Cholecystectomy Discharge Condition: Good Discharge Instructions: Division of Vascular and Endovascular Surgery Lower Extremity Angioplasty/Stent Discharge Instructions Medications: ?????? Take Aspirin 325mg (enteric coated) once daily ?????? If instructed, take Plavix (Clopidogrel) 75mg once daily ?????? Continue all other medications you were taking before surgery, unless otherwise directed ?????? You make take Tylenol or prescribed pain medications for any post procedure pain or discomfort What to expect when you go home: It is normal to have slight swelling of the legs: ?????? Elevate your leg above the level of your heart (use [**2-18**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated ?????? It is normal to feel tired and have a decreased appetite, your appetite will return with time ?????? Drink plenty of fluids and eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? When you go home, you may walk and go up and down stairs ?????? You may shower (let the soapy water run over groin incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing or band aid over the area that is draining, as needed ?????? No heavy lifting, pushing or pulling (greater than 5 lbs) for 1 week (to allow groin puncture to heal) ?????? After 1 week, you may resume sexual activity ?????? After 1 week, gradually increase your activities and distance walked as you can tolerate ?????? No driving until you are no longer taking pain medications ?????? Call and schedule an appointment to be seen in [**3-20**] weeks for post procedure check and ultrasound What to report to office: ?????? 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 vascular office [**Telephone/Fax (1) 1237**]. If bleeding does not stop, call 911 for transfer to closest Emergency Room. Followup Instructions: You have a follow up appointment scheduled with Dr. [**Last Name (STitle) **] on [**2114-7-17**] at 11:15 AM. Please call [**Telephone/Fax (1) 1237**]. Completed by:[**2114-7-10**]

[ "707.15", "440.24", "V45.81", "727.41", "585.6", "414.01", "369.4", "428.0", "311", "536.3" ]

icd9cm

[ [ [] ] ]

[ "38.18", "39.50", "88.48", "00.48", "37.22", "39.95", "88.56", "38.91", "99.04", "88.42", "39.90", "88.47", "00.42" ]

icd9pcs

[ [ [] ] ]

8735, 8805

3901, 5989

358, 497

9097, 9104

2348, 3878

11715, 11898

1464, 1469

6498, 8712

8826, 9076

6015, 6475

9128, 11118

11144, 11692

1499, 2329

294, 320

525, 1109

1131, 1392

1408, 1448

4,574

142,085

23713

Discharge summary

report

Admission Date: [**2181-3-22**] Discharge Date: [**2181-4-3**] Date of Birth: [**2131-2-1**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 148**] Chief Complaint: Abd pain Major Surgical or Invasive Procedure: None History of Present Illness: 50M admitted to [**Hospital3 35813**] Center with EtOH pancreatitis that required ventilatory support and ultimately a Trach and PEG wh was transferred to [**Hospital1 18**] for elevated tempuratures while on antibiotics and for the concern of necrotizing pancreatitis. Past Medical History: EtOH abuse Pancreatitis MRSA bacteremia MRSA pneumonia Alcoholic hepatitis C diff ARF DT PSVT Respiratory failure s/p trach and PEG DMII High triglyceridemia Social History: + EtOH Lives alone 2 pack per day Family History: None Physical Exam: Temp 100, HR 110 ST, BP 105/61 Sedated and ventilated Follows commands when aroused Tachy with no murmurs CTA (b) Soft, Non-tender, Non-distended mild edema, no clubbing Pertinent Results: [**2181-3-23**] 12:50PM BLOOD WBC-16.3* RBC-2.88* Hgb-8.4* Hct-25.5* MCV-88 MCH-29.0 MCHC-32.8 RDW-15.5 Plt Ct-684* [**2181-3-23**] 12:50PM BLOOD Plt Ct-684* [**2181-3-23**] 12:50PM BLOOD Glucose-106* UreaN-19 Creat-0.4* Na-137 K-4.1 Cl-97 HCO3-36* AnGap-8 [**2181-3-23**] 07:31PM BLOOD ALT-17 AST-95* LD(LDH)-996* AlkPhos-136* Amylase-54 TotBili-0.3 [**2181-3-23**] 07:31PM BLOOD Lipase-97* [**2181-3-23**] 12:50PM BLOOD Calcium-8.2* Phos-5.1* Mg-1.9 [**2181-3-27**] 04:11AM BLOOD Triglyc-249* [**2181-4-1**] 01:00AM BLOOD Vanco-13.3* [**2181-4-3**] 03:07AM BLOOD WBC-9.7 RBC-3.06* Hgb-8.8* Hct-27.3* MCV-89 MCH-28.8 MCHC-32.3 RDW-15.2 Plt Ct-523* [**2181-4-3**] 03:07AM BLOOD Plt Ct-523* [**2181-4-3**] 03:07AM BLOOD PT-12.7 PTT-24.0 INR(PT)-1.0 [**2181-4-3**] 03:07AM BLOOD Glucose-107* UreaN-11 Creat-0.3* Na-135 K-4.0 Cl-100 HCO3-31* AnGap-8 [**2181-4-3**] 03:07AM BLOOD Amylase-42 [**2181-3-30**] 02:05AM BLOOD ALT-24 AST-35 LD(LDH)-237 AlkPhos-159* Amylase-50 TotBili-0.4 [**2181-4-3**] 03:07AM BLOOD Lipase-90* [**2181-4-3**] 03:07AM BLOOD Albumin-2.6* Calcium-8.9 Phos-5.4* Mg-1.7 Brief Hospital Course: Pt was admitted to the SICU on [**3-22**]. He was placed on the ventilator on arrival. A CT scan was done which showed an inflammatory phlegmon with no secondary signs of infection. He was slowly weaned from the ventilator however this required bronchoscopic clearance of his lungs and aggressive pulmonary toilet. He was maintained on TPN while his pancreatitis resloved. Ultimately, he was transitioned to TF and he tolerated this well. He was maintained on ativan for treatment of his DT and antibiotics for his pancreatitis. After completing his course of abx. they were stopped however he began to have elevated tempuratures and was found to have a recurrent MRSA pneumonia. He was started on Vancomycin and he is to complete a 14day course for his pneumonia. He achieved his goal of TF and his TPN was D/C. He began having high stool output. Multiple samples were sent for C. diff and they were all negative. He was successfully weaned from the ventilator and tolerated trach mask. Speech and swallow evaluated him for a Passe-Muir valve. He was started on lasix for diureses and his sedatives were stopped. Pt was awake, comfortable, and following commands at time of discharge. A R PICC was placed on [**4-3**] for continued antibiotics. He is currently tolerating TF at goal, on trach mask, and working with PT Medications on Admission: None Discharge Medications: Ascorbic Acid (Liquid) 500 mg PO DAILY Ferrous Sulfate 325 mg PO DAILY Lorazepam 3 mg PO TID Metoprolol 100 mg PO/NG TID hold for hr<60, sbp <100 Vancomycin HCl 1500 mg IV Q12H X 7 days Insulin SC (per Insulin Flowsheet) Sliding Scale Clonidine HCl 0.2 mg PO TID hold for SBP<110 Morphine Sulfate 2-5 mg IV Q3-4H:PRN pain Lansoprazole 30 mg PO DAILY Heparin 5000 UNIT SC TID Lorazepam 2 mg IV Q2H:PRN Discharge Disposition: Extended Care Facility: Rehab Hospital Of [**Doctor Last Name **] Discharge Diagnosis: Necrotizing pancreatitis EtOH DT MRSA pneumonia MRSA bacteremia EtOH hepatitis C diff ARF PSVT Respiratory failure s/p Trach and PEG DMII High triglycerides s/p bronchoscopy s/p PICC Discharge Condition: Stable Discharge Instructions: Continue TF at goal. Aggressive pulmonary toilet OOB and PT consult Followup Instructions: F/U with Dr. [**Last Name (STitle) **] in [**3-1**] wks Completed by:[**0-0-0**]

[ "250.00", "303.91", "577.0", "V55.1", "482.41", "V55.0", "V09.0", "305.1" ]

icd9cm

[ [ [] ] ]

[ "96.72", "54.91", "33.24", "38.93", "96.6", "99.15" ]

icd9pcs

[ [ [] ] ]

4003, 4071

2199, 3520

320, 326

4297, 4305

1085, 2176

4421, 4503

874, 880

3575, 3980

4092, 4276

3546, 3552

4329, 4398

895, 1066

272, 282

354, 625

647, 806

822, 858

4,713

183,508

15001

Discharge summary

report

Admission Date: [**2122-9-29**] Discharge Date: [**2122-10-3**] Date of Birth: [**2060-4-1**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 1145**] Chief Complaint: Non Sustained Ventricular Tachycaredia on Holter, lightheadedness, dyspnea on exertion Major Surgical or Invasive Procedure: 1. Endotracheal intubation 2. Placement of ICD. History of Present Illness: Mr. [**Known lastname 12041**] is a 62 man w/ hx of CAD, HTN, hypercholesterolemia, who presented to his cardiologist (Dr. [**Last Name (STitle) 11493**] yesterday with c/o lightheadedness. He has not been feeling his usual self for the past few months, but cannot completely pinpoint why. For the past month, he has felt intermittent episodes of lightheadedness not particularly associated with any movements or positional changes. He denies vertigo, blurry vision, LOC, dimming vision. He reports orthopnea, possible PND, DOE, and worsening fatigue over past few months. He reports occasionally feeling palpitations. He has never had chest pain or syncope. . He had a holter monitor a few weeks ago, which revealed runs of [**Last Name (STitle) 6059**]. Recent Echo report revealed inferior and posterior wall motion abnormalities. EF 40%. He was sent to [**Location (un) **] ER for further management and for transfer to [**Hospital1 18**] for EP study. . In the ED, he was seen by EP, and was admitted with plans for EP study and possible ICD placement. Past Medical History: - CAD s/p 5 vessel CABG in [**10-3**] with LIMA->LAD, SVG->OM1->OM2, SVG-> ramus, SVG->RCA; s/p PTCA [**8-4**] s/p VT to ramus PCI, s/p LM/Cx PCI [**10-5**] Cath [**2122-5-6**]: 1. Severe native vessel coronary artery disease. 2. SVG --> OM1 --> OM2 is occluded. 3. SVG --> Ramus with serial stenoses. 4. SVG --> RCA patent. 5. LIMA --> LAD patent. 6. Successful stenting of the SVG-Ramus Cath [**2122-5-15**]: occlusion of SVG-Ramus stent - COPD, on intermittent home O2 - Leg cramps - Chronic back pain s/p MVA many yrs ago, s/p many back surgeries including steel rod placement - NIDDM - Hypertension - Hyperlipidemia - TIA (remote, 15-20 years ago) - GERD - s/p hernia repair Social History: Retired truck driver, now lives with wife and son. Smoking: 1ppd, down from [**3-6**] ppd, 30-40 pack-year history. EtOH: has not consumed EtOH for 15 years although drank a substantial amount before that. No illicit substance use. Family History: Mother died of MI at 73. Father had lung cancer, no known coronary dz. Older sister has diabetes. Has a daughter and son who are healthy. No known additional fam hx of stroke, MI Physical Exam: VS: 97.7, 94-126/57-76, 69, 20, 100% RA Gen: NAD, lying comfortably in bed HEENT: EOMI, MMM, OP clear Neck: think diameter, JVP and LAD no able to assess Lungs: diffuse rales and coarse breath sounds bilaterally CV: RRR, nl S1S2, no m/r/g Abd: obese, +BS, S/NT/ND Ext: + pedal pulses, no edema Skin: numerous tatoos and scars from car accident Pertinent Results: Labs on admission: [**2122-9-30**] WBC-9.0 RBC-4.46* Hgb-14.0 Hct-41.2 MCV-92 RDW-15.9* Plt Ct-291 Glucose-333* UreaN-25* Creat-1.2 Na-131* K-5.4* Cl-93* HCO3-29 ALT-24 AST-13 CK(CPK)-50 AlkPhos-80 TotBili-0.3 TSH-1.1 . . Labs on discharge: [**2122-10-2**] 04:28AM BLOOD WBC-15.4* RBC-4.09* Hgb-13.2* Hct-37.4* MCV-92 MCH-32.3* MCHC-35.3* RDW-15.8* Plt Ct-173 [**2122-10-2**] 04:28AM BLOOD Neuts-77* Bands-8* Lymphs-8* Monos-6 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 [**2122-10-2**] 04:28AM BLOOD Plt Ct-173 [**2122-10-2**] 04:28AM BLOOD Glucose-205* UreaN-27* Creat-1.0 Na-135 K-4.4 Cl-99 HCO3-26 AnGap-14 [**2122-10-2**] 04:28AM BLOOD Calcium-8.7 Phos-3.0# Mg-1.5* [**2122-10-2**] 02:20PM BLOOD Type-ART Temp-37.2 Rates-/16 Tidal V-580 PEEP-5 FiO2-40 pO2-121* pCO2-45 pH-7.38 calTCO2-28 Base XS-1 Intubat-INTUBATED Vent-SPONTANEOU [**2122-10-2**] 06:11AM BLOOD O2 Sat-95 . . Other pertinent data: EKG: NSR at 69 bpm, nl axis, nl intervals, no ST-T changes, no peaked T waves . CXR: Mild cephalization present without overt failure on the current examination. . CT Chest [**2122-10-1**]: 1. No evidence of pleural effusion. 2. Left lower lobe consolidation likely representing atelectasis. Patchy left lower lobe opacities could represent a component of airspace disease or aspiration. 3. No hematoma observed at the pacemaker placement site. . CXR [**2122-10-3**]: There is no evidence for an orogastric line. ICD device is present, unchanged in position. No infiltrates are present. Some atelectasis of the left base is seen. . TTE [**2122-5-16**]: Moderately dilated LA, moderate symmetric LVH, EF 40% 2/2 severe hypokinesis of posterior and lateral walls, moderately dilated aortic root and ascending aorta, trace AR, moderate to severe MR, moderate TR, severe pulmonary artery systolic hypertension. . Micro: URINE CULTURE (Final [**2122-10-3**]): NO GROWTH. . [**2122-10-1**] 11:29 pm SPUTUM Source: Endotracheal. GRAM STAIN (Final [**2122-10-2**]): >25 PMNs and <10 epithelial cells/100X field. 4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S). 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS. RESPIRATORY CULTURE (Preliminary): ? OROPHARYNGEAL FLORA. PSEUDOMONAS AERUGINOSA. MODERATE GROWTH. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ PSEUDOMONAS AERUGINOSA Brief Hospital Course: Cardiac: Rhythm: [**Month/Day/Year 6059**] on Holter: It was unclear whether [**Name (NI) 6059**] was contributing to his SOB and lightheadedness. On admission, he was in NSR without any complaints. His TSH was normal. EP study was obtained to further evaluate his lightheadedness as well as risk for sudden cardiac arrest. During the study, they were able to induce VT/VF. Post study, it was felt that ICD placement was necessary. A dual lead ICD was implanted. He was given prophylactic cephalexin. During the hospital course, he was continued on his metoprolol for rate control, and was monitored on telemetry without any events once his BP was stable. He did not complain of any other symptoms post-procedure. Pump: Based on Echo in [**5-7**], EF 40%. CXR on admission revealed cephalization, but no signs of overt CHF. Follow up CXR did not demonstrate any CHF. He remained stable throughout admission. Ischemia: no evidence of ischemia on EKG; He had no evidence of ischemia on EKG and had two sets of negative cardiac enzymes. He continued his home doses of ASA, metoprolol, Lipitor, lisinopril, and plavix. . Respiratory: The patient was intubated during ICD placement. Post procedure, they had difficulty weaning him from the ventilator. A CT of the chest did not show any acute processes other than atelectasis. It was thought likely due to poor reserve secondary to COPD vs. atelectasis/plugging. He was sent to the CCU for post-procedure management due to intubation. The patient was usccessfully extubated in the CCU. He did spike a fever to 101 and was pan cultured on [**10-2**] prior to extubation. He also had an elevated WBC to 15. However, fearing aspiration and ? pneumonia, He was started on Levaquin and Clindamycin. Sputum/blood/ urine cultures were sent. His prednisone was continued and he was given Solumedrol. He did not have any fevers or localizing signs once extubated. On discharge, he was did not have any symptoms. On discharge, he was given Levaquin to complete a 7 day course for possible pneumonia pending return of cultures. . HTN: During the procedure he briefly required neosynephrine, but was able to be weaned successfully off pressors. His BP then remained stable for the duration of admission and he was restarted on his outpatient regimen. . COPD: He had no active issues; however, the house staff did try to encourage smoking cessation. He was treated with a nicotine patch, and continued Advair, nebs, and prednisone. Once he was extubated, he was put on prednisone 30mg for a 6 day taper to return him to his outpatient dose of Prednisone 10mg PO qDay. . Fatigue: unclear etiology, and were thought to be most likely related to cardiac problems. [**Name (NI) **] may benefit from further work-up for possible sleep apnea. . Chronic back pain: no active issues and continue Fentanyl patch, Percocet prn . DM: Sugars in high 270's-300's during hospital course. His HA1C was found to be 9. He continued his home oral hypoglycemics of glipizide and Actos, and was put on a sliding scale. His sugars leveled at 200. Metformin was held given risk for CHF. . FEN: cardiac diabetic diet, electrolytes repleted as needed until Mg>2 and K>4. . PPx: He was put on heparin SC, PPI (on pantoprazole at home), and a bowel regimen as needed. . Code: He was FULL CODE during this admission. . Outstanding Issues: 1. ? Pneumonia: He was discharged on Levaquin for a total 7 day course. The medical team thought pneumonia was unlikely given his clinical picture. However, after discharge his sputum cx grew pseudomonas. On writing this note, susceptabilities were pending. If the pseudomonas is not sensitive to Levaquin, then the patient will have to be switched accordingly. His blood/urine cultures will also have to be followed up. The patient will be called if a change in his antibiotic is necessary. . 2. ICD: The patient has an appointment in the device clinic on [**10-9**]. He was instructed to follow up with his cardiologist and PCP [**Name Initial (PRE) 176**] 1-2 weeks. . 3. Diabetes: His blood sugars were elevated during admission, and his A1C was 9. He will need follow up with his PCP for management. This was stressed to the patient and the patient understood and agreed to follow up. Medications on Admission: ASA 325 qd Percocet prn Sliding scale insulin Protonix 40mg qd Metoprolol 50mg [**Hospital1 **] Nicotine patch glipizide 5mg qd Plavix nebs Lipitor 80mg qd Lisinopril 5mg qd Metformin 750mg [**Hospital1 **] fentanyl patch prednisone 10mg qd Actos 30mg qd Lexapro 10mg qd Advair 100/50 q puff [**Hospital1 **] Quinine sulfate 260mg qhs 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. Atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Fentanyl 75 mcg/hr Patch 72HR Sig: One (1) Patch 72HR Transdermal Q72H (every 72 hours). 5. Escitalopram 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Albuterol-Ipratropium 103-18 mcg/Actuation Aerosol Sig: [**2-2**] Puffs Inhalation Q6H (every 6 hours) as needed for SOB/Wheeze. 7. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: One (1) Tablet PO Q4-6H (every 4 to 6 hours) as needed for pain. 8. Lisinopril 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 9. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*0* 10. Levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every 24 hours) for 4 days. Disp:*6 Tablet(s)* Refills:*0* 11. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 12. Prednisone 10 mg Tablet Sig: Three (3) Tablet PO DAILY (Daily) for 2 days: [**Date range (1) 27592**]. 13. Prednisone 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily): START [**10-8**]. 14. Prednisone 10 mg Tablet Sig: Two (2) Tablet PO once a day for 2 days: [**Date range (1) 43904**]. Discharge Disposition: Home Discharge Diagnosis: Primary: 1. Non-sustained ventricular tachycardia inducible on electrophysiology study. . Secondary: 2. Hypertension 3. Diabetes Mellitus 4. Acid reflux 5. Possible Pneumonia Discharge Condition: Good. Afebrile. Hemodynamically stable Discharge Instructions: Please keep all follow up appointments. Please take all medications as prescribed. No weight bearing or heavy use with left arm. Please do not lift left arm overhead until seen and cleared by cardiologist. Please return to the hospital with fevers/chills, chest pain, worsening shortness of breath, palpitations, worsening pain/swelling over insertion site, or any other symptoms that concern you. Followup Instructions: * Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2122-10-9**] 2:30 * Please call ([**Telephone/Fax (1) 22764**] to make appointment with Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 11493**] within a week. * Please follow up with your PCP [**Name Initial (PRE) 176**] 1-2 weeks

[ "250.00", "305.1", "428.0", "780.79", "V45.82", "482.1", "780.2", "414.8", "530.81", "496", "427.1", "458.29", "V58.65", "401.9", "V45.89", "V45.81", "724.5" ]

icd9cm

[ [ [] ] ]

[ "37.94", "37.26", "96.71" ]

icd9pcs

[ [ [] ] ]

11612, 11618

5575, 9840

401, 451

11837, 11880

3070, 3075

12330, 12675

2510, 2690

10226, 11589

11639, 11816

9866, 10203

11904, 12307

2705, 3051

5296, 5552

275, 363

3311, 5255

479, 1541

3089, 3292

1563, 2245

2261, 2494

28,997

198,957

32313

Discharge summary

report

Admission Date: [**2182-11-26**] Discharge Date: [**2182-12-5**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 5552**] Chief Complaint: transfer from [**Hospital1 **] [**Location (un) 620**] for large mediastinal mass Major Surgical or Invasive Procedure: None History of Present Illness: Patient is an 83F with hx of DM, several abdominal surgeries tx from [**Hospital1 **] [**Location (un) 620**] with new mediastinal mass. Pt presented earlier today at [**Hospital1 **] [**Location (un) 620**] with 2 weeks wheezing, unresponsive to neb treatments at home. She went to [**Hospital1 **]-[**Location (un) 620**] and CXR revealed large mass in her R lung as well as a possible post-obstructive PNA. CTA at [**Location (un) 620**] with large R mediastinal mass, invading into R lung, wraps around R PA, and compresses R mainstem bronchus down to diameter of 3 cm at points. No PE. She was then transferred to [**Hospital1 18**] for onc w/u and possible IP stenting. She received 1X levaquin for post obstructive pna. . During transfer at 6PM, she became tachycardic to 140's, but in sinus rhythm. In [**Hospital1 **] ED, 97.5 102/56 146 93% 4LNC. Notably, HR decreased to 100s after foley placed w/copious UOP. BP initially 90's w/one [**Location (un) 1131**] in 70's. Pt given 2.5 liters IVF and BP stablized in 110s. Baseline BP 120's. . Although her vitals signs were stable in the ED, she was admitted to the ICU for close monitoring given the potential risk for airway compromise as well as erosion of mass into her pulmonary artery. . Upon arrival to MICU, patient reports feeling better, but tired. She reporst a 12 poound weight loss since [**8-6**] as well as increasing fatigue. Her SOB has gradually increased over the past 2 weeks with worsening wheezing and DOE to less than a block. Also, over past few days, she has developed numerous enlarged lymph nodes as well as a large mass under right axilla. She denies any night sweats, fever, chest pain, N/V, LE edema, abd pain, diarhea/constipation. She denies any hx of childhood irradiation Past Medical History: Type 2 DM HTN hx of DVT s/p appy/chole osteoporosis glaucoma Social History: Pt lives alone. Daughter lives in [**State 8780**] and is visiting Family History: Father: good health; Mother died heart disease Sister: breast cancer dx age 68 No other family hx of malignancy Physical Exam: Vitals: 98.6 118/52 106 95%4L NC Gen: NAD, pleasant, breathing comfortably HEENT: MM dry, PERRL, EOM intact NECK: no thyromegaly, LYMPH nodes: +R 2 cm firm, tender LN; numerous Pulm: coarse BS more on right than left, occ wheezes CHEST: 3 inch large mass on right midaxillary line, slightly tender Heart: tachycardic, [**2-12**] sysolic ejection murmur, no rubs Abd: soft, NT,ND Ext: no edema Neuro: strength 5/5 in UE and LE, face symmetric Pertinent Results: CXR: FINDINGS: There is a dense right hilar mass with narrowing of the right main stem bronchus and inferior trachea. There is minimal mediastinal shift to the right. The left lung is clear. There is no pleural effusion. IMPRESSION: Right hilar mass with associated compression of the right mainstem bronchus and inferior trachea, better visualized on the concurrent CTA chest examination ([**Hospital1 18**]-[**Location (un) 620**]). No significant interval change. . CT CHEST: There is a large mass centrally in the mediastinum mainly located cranially of the left atrium in the midline and expanding towards the right side where it completely encircles the right main bronchus which is for a stretch narrowed only 3 cm in diameter. It also encircles the proximal portion of the right middle lobe branch and the right lower lobe branch. The maximum diameter of the mass is about 8 cm. It encircles the right main pulmonary artery which is slightly narrowed. In addition there are two separate large rounded masses in the right upper lobe with a diameter each of about 3 cm. There is also a smaller mass with a diameter of 2 cm implanted on the dome of the right hemidiaphragm. There are no suspicious lesions in the left lung. There is also a large hiatal hernia present. IMPRESSION: AN 8 CM LARGE [**Location (un) **] ENCIRCLING THE RIGHT MAIN BRONCHUS AND ITS MAJOR BRANCHES AS WELL AS THE RIGHT MAIN PULMONARY ARTERY. THE RIGHT MAIN BRONCHUS HAS ONLY A 3 MM DIAMETER FOR SEVERAL CMS. IN ADDITION THERE ARE SEVERAL SATELLITE LESIONS MAINLY IN THE RIGHT UPPER LOBE BUT ALSO IN THE RIGHT LOWER LOBE WITH PLEURAL ATTACHMENTS. THERE ARE NO PLEURAL EFFUSIONS. IN THE LOWER AXILLARY PORTION OF THE RIGHT BREAST THERE IS A 3 CM LARGE MASS. . Lymph node, biopsy: Small cell carcinoma; Tumor cells are positive for cytokeratin cocktail, CK7, TTF-1, synaptophysin, and chromogranin; tumor cells are negative for CK20. Immunophenotyping: Non-specific T cell dominant lymphoid profile; diagnostic immunophenotypic features of involvement by leukemia or lymphoma are not seen in specimen. However, majority of the analyzed events were in the CD45-negative, variable side-scatter region area are of uncertain lineage. Brief Hospital Course: ASSESSMENT AND PLAN: . # Mediastinal mass: Mass encircles the right main bronchus as well as the pulm artery indicating that it is a middle mediastinal mass. Biopsy of supraclavicular node revealed small cell carcinoma. Patient underwent treatment with carboplatin. As small cell carcinoma highly chemosensitive, will complete treatment with chemotherapy and evaluate response. Plan is to avoid stenting of bronchus if possible. Patient tolerated chemotherapy without complication. On day of discharge patient reported difficulty hearing. It was unclear if this was new onset hearing loss or age-related. On exam excessive cerumen in b/l ear canals. Thought unlikely to be related to chemotherapy. Attending was informed in order to follow up. . # ? PNA: Pt reported noted to have a possible post-ostructive PNA at OSH and started on levaquin. CXR here without evidence of PNA. Pt remained afebrile. Therefore further antibiotics were held and patient remained stable. Cultures remained negative. . # Anemia: Hct 29 today, and only other lab data from [**2175**] with Hct 40's. MCV low as well. Iron was low on iron studies. Ferritin low normal. Started on iron supplements. . # DM: type 2 on oral hypoglycemics. Home meds continued. Covered with insulin sliding scale. , # HTN: Had transient hypotensive episode in ED, but now BP in low 110's. As blood pressure was then stable, patient was restarted on her antihypertensives with holding parameters. . # CODE: DNR but OK to intubate discussed with pt and daughter . # Communication: HCP: [**Name (NI) **] [**Name (NI) 75512**] [**Telephone/Fax (1) 75513**] Medications on Admission: Actos 15 mg daily Glyburide 5 mg [**Hospital1 **] Metformin 1000 mg [**Hospital1 **] Lipitor 20 mg daily Lisinopril/HCTZ 10/12.5 daily Fosamax 70 mg weekly Xalatan 0.005% eye drops each eye daily Timolol 0.5% daily each eye Discharge Medications: 1. Home O2 Please provide patient with home oxygen therapy. Please evaluate for conserving device. Flow rate 2L-6L by nasal cannula as needed. O2 sat on room air is 87%. 2. Senna 8.6 mg Tablet Sig: 1-2 Tablets PO BID (2 times a day) as needed. Disp:*60 Tablet(s)* Refills:*0* 3. Atorvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Latanoprost 0.005 % Drops Sig: One (1) Drop Ophthalmic HS (at bedtime). 5. Timolol Maleate 0.5 % Drops Sig: One (1) Drop Ophthalmic DAILY (Daily). 6. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Ferrous Sulfate 325 (65) mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 8. Bisacodyl 5 mg Tablet, Delayed Release (E.C.) Sig: Two (2) Tablet, Delayed Release (E.C.) PO DAILY (Daily) as needed. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*2* 9. Actos 15 mg Tablet Sig: One (1) Tablet PO once a day. 10. Glyburide 5 mg Tablet Sig: One (1) Tablet PO twice a day. 11. Lipitor 20 mg Tablet Sig: One (1) Tablet PO once a day. 12. Fosamax 70 mg Tablet Sig: One (1) Tablet PO once a week. 13. Lisinopril-Hydrochlorothiazide 10-12.5 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home With Service Facility: [**Hospital 5065**] Healthcare Discharge Diagnosis: Primary: Small Cell Lung Cancer Secondary: Anemia, Diabetes Mellitus, Hypertension Discharge Condition: Good, with improvement in shortness of breath, requiring 02 with baseline 02sat of 87% Discharge Instructions: You were admitted to the hospital for shortness of breath. This was secondary to your lung cancer. You were started on chemotherapy. . You should follow up with Dr. [**Last Name (STitle) **] and Dr [**Last Name (STitle) 877**] on [**12-12**] at 11:30AM. . Please return to the emergency room for any worrisome symptoms such as shortness of breath, chest pain, palpitations. . Followup Instructions: Please follow up Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] at the [**Last Name (un) **] in [**1-8**] weeks. Call ([**Telephone/Fax (1) 55238**] . You should follow up with Dr. [**Last Name (STitle) **] and Dr [**Last Name (STitle) 877**] on [**12-12**] at 11:30AM.

[ "401.9", "733.00", "162.8", "250.00", "198.89", "788.20", "197.1", "196.0", "196.1", "280.9" ]

icd9cm

[ [ [] ] ]

[ "99.25", "40.11" ]

icd9pcs

[ [ [] ] ]

8279, 8340

5179, 6791

345, 352

8467, 8556

2932, 5156

8981, 9277

2334, 2448

7066, 8256

8361, 8446

6817, 7043

8580, 8958

2463, 2913

224, 307

380, 2148

2170, 2233

2250, 2318

59,637

171,676

543

Discharge summary

report

Admission Date: [**2129-7-7**] Discharge Date: [**2129-7-12**] Date of Birth: [**2086-10-2**] Sex: M Service: MEDICINE Allergies: Ibuprofen / Ace Inhibitors / Bupropion / Zoloft / Aspirin Attending:[**First Name3 (LF) 2195**] Chief Complaint: GI bleed Major Surgical or Invasive Procedure: Sigmoidoscopy History of Present Illness: Patient is a 42yo male with history of CAD s/p stents x 3 admitted with acute GI bleed. . Patient reports being in his normal state of health until this evening when he developed sudden onset of BRBPR. It occurred around 9pm. He was taken to the ED by his parents where he continued to have lower GI bleed. He has never had a GI bleed before. Pt denied abd pain and n/v, no hematemesis, coffee-ground emesis or melena. Patient states he has on and off suprapubic pain for the past year and that he has frequent constipation with straining and painn with bowel movements. Of note, he is on aspirin and plavix for coronary stent placement. . In the ED, initial vs were: T- 98.0, HR- 118, BP- 184/157, RR- 18, SaO2- 98% on RA. Patient was initially given 250cc NS but had persistent tachycardia and developed lightheadedness. He was then give 3U PRBC and 2L NS with resolution of the tachycardia. He never became hypotensive or had a fever. Abdominal exam was benign. Rectal exam showed bright red [**First Name3 (LF) **]. NG lavage was negative. EKG was unchanged from prior. Hct on admission to ED- 45.8 (with normal coags). Patient lost about 1L of [**First Name3 (LF) **] from GI tract. . GI was consulted and recommended angiogram with embolization as they were concerned for diverticulosis vs AVM. General surgery was also made aware of the patient and are available if needed. IR-team notified and will be coming in tonight to perform embolization if needed. . On the floor, he remained hemodynamically stable. Vitals on transfer: BP- 126/87, HR- 88, SaO2- 98% on RA, RR- 12, and afebrile. Patient lost another 100cc of [**First Name3 (LF) **] on arrival to the floor but remained hemodynamically stable. He denied any nausea/vomiting, chest pain, shortness of breath, dizziness, lightheadedness. He did report some lower abdominal tenderness to palpation (L>R) but was not in any distress and did not demonstrate any signs of acute abdomen. Past Medical History: 1. Inferior MI in [**3-13**], treated with BMSx3 at [**Hospital3 2358**] 2. LV systolic dysfunction, EF 40-45% 3. Diabetes type 2 last A1C in [**2125**] 8.6% 4. Hypertension 5. Depression 6. Hyperlipidemia 7. past h/o cocaine use 8. R knee surgery 9. MRSA leg abscess in the past 10. fracture left tibia in [**2123**] 11. IBS history Social History: He lives with his parents and was unemployed. He worked yesterday as in HPI. Smoked 2ppd for 25 years and quit in [**3-13**]. No alcohol in 3 weeks because he was pulled over for a DUI. +marijuana. Cocaine use in teh past. Pt reports that he was doign cocaine when he has his MI in [**2128**]. Reports he did cocaine last week. Family History: has several relative with MI in their 40's. Maternal grandmother with stroke. Physical Exam: Vitals: T: 97.9 BP: 183/98 P: 87 R: 13 O2: 96% on RA General: Alert, oriented, no acute distress HEENT: Sclera anicteric, MMM, oropharynx clear Neck: supple, JVP not elevated, no LAD Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs, gallops Abdomen: soft, non-tender, non-distended. +bowel sounds. Slightly TTP in lower abdomen (L > R)- no rebound tenderness or guarding, no organomegaly GU: Foley in place Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema. LUE- fluctuance consistent with cellulitis, TTP. Pertinent Results: Sigmoidoscopy on [**2129-7-8**]: [**Date Range **] in the sigmoid colon and rectum Diverticulosis of the rectum and sigmoid colon Otherwise normal sigmoidoscopy to splenic flexure Recommendations: Diverticular bleed likely with adjacent clot visible. Scope reached mid sigmoid colon. Monitor hematocrit. Surgical consultation for potential hemi-colectomy if continued severe bleeding. Monitor in ICU. Outpatient colonoscopy is indicated. Additional notes: The attending was present for the entire procedure. ADMISSION LABS: [**2129-7-7**] 10:10PM [**Month/Day/Year 3143**] WBC-8.2 RBC-5.63 Hgb-15.9 Hct-45.9 MCV-82 MCH-28.2 MCHC-34.7 RDW-14.4 Plt Ct-290 [**2129-7-7**] 11:09PM [**Month/Day/Year 3143**] PT-12.6 PTT-24.1 INR(PT)-1.1 [**2129-7-7**] 10:10PM [**Month/Day/Year 3143**] Glucose-199* UreaN-23* Creat-1.3* Na-133 K-4.0 Cl-100 HCO3-20* AnGap-17 DISCHARGE LABS: [**2129-7-12**] 09:35AM [**Month/Day/Year 3143**] WBC-6.0 RBC-5.61 Hgb-15.6 Hct-45.7 MCV-81* MCH-27.8 MCHC-34.2 RDW-14.3 Plt Ct-332 [**2129-7-12**] 09:35AM [**Month/Day/Year 3143**] Plt Ct-332 [**2129-7-12**] 09:35AM [**Month/Day/Year 3143**] Glucose-146* UreaN-15 Creat-1.1 Na-138 K-4.0 Cl-103 HCO3-22 AnGap-17 Brief Hospital Course: 42M with CAD s/p stent (most recent [**Month/Day/Year **] in [**11-15**]) on clopidogrel and ASA, CHF w/EF=40-45%, h/o of MRSA leg abscess, and diet-controlled diabetes (A1C 6.2%) who presented with severe GI bleed [**2-8**] diverticulosis of sigmoid colon. The patient was given 4 units of pRBC's and stabilized in the ICU, and was discharged in stable condition, with no active bleeding back on his ASA and plavix, and tolerating regular diet and having small, formed, dark brown to black stools. He was also treated with antibiotics for cellulitis in his left arm due to an insect bite. Course summarized by problem below: # GI bleed secondary to diverticulosis of the sigmoid colon: Followed by surery and GI. Tagged red [**Month/Day (2) **] cell scan revealed [**Month/Day (2) **] in rectal area. GI performed sigmoidoscopy and found diverticuli with [**Month/Day (2) **] clots explaining source of the bleed. Admitted to ICU for careful observation in setting of acute GI bleed with significant [**Month/Day (2) **] loss. He received 4u of pRBC's, and did not require further transfusions after leaving the ICU. He remained hemodynamically stable throughout his course, with Hcts in the 43-45 range, and was tolerating a regular diet prior to discharge. On the day of discharge he was having small, formed, dark brown to black stools, with no further bright red [**Month/Day (2) **]. His aspirin and Plavix were initially held in the setting of his acute bleed, but were re-started during this hospitalization and he had no BRBPR, Hct remained stable. He did have dark BMs during his hospital stay, consistent with old [**Month/Day (2) **]. The importance of a high-fiber, high-vegetable content diet with ample hydration was emphasized to the patient and his family. Also, it was emphasized to patient that he MUST NOT stop the ASA or plavix and take both of these medications daily and not stop these without talking to his cardiologist. The patient was scheduled for outpatient follow-up with GI for full colonoscopy. # Coronary artery disease: patient has history of MI s/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Last Name (Prefixes) **] in RCA on 11/[**2128**]. While inpatient, his ASA and plavix were held during acute GI bleed. His aspirin was carefully restarted (ASA desensitization done in ICU) and plavix restarted after patient stabilized. Given the recent placement of a [**Year (4 digits) **] in [**11-15**], as well as his allergy to aspirin and need for desensitization, the importance of strict adherence to this daily regimen was emphasized with both the patient and the family. His home metoprolol was also re-started during admission, after initial stabilization. # Acute renal failure: Cr was slightly elevated at 1.3 on admission, likely secondary to GI losses and pre-renal state. Cr returned to [**Location 213**] during hospitalization. Cr on discharge was 1.1. # Left arm lesion and cellulitis: Patient reported a "horse fly bite" and was started on Bactrim (1DS [**Hospital1 **])for cellulitis one day prior to admission. While inpatient he was given 3 doses (1.5 days) of Vancomycin and then restarted on Doxycycline for a total of 5 days antibiotic treatment, which he finished during his hospital stay. The cellulitis subsided, and the patient remained afebrile throughout. The patient did report 2 year history of myalgias in bilateral calves and shoulders which may suggest possible tick bite and underlying lyme disease. Lyme serologies were pending at time of discharge. Medications on Admission: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Epinephrine Base 0.3 mg/0.3 mL (1:1,000) Syringe Sig: One (1) Injection anaphylaxis. 5. Fenofibrate Micronized 67 mg Capsule Sig: One (1) Capsule PO once a day. 6. Losartan 50 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Medications: 1. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 2. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 4. Epinephrine Base 0.3 mg/0.3 mL (1:1,000) Syringe Sig: One (1) Injection anaphylaxis. 5. Fenofibrate Micronized 67 mg Capsule Sig: One (1) Capsule PO once a day. 6. Losartan 50 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: PRIMARY DIAGNOSIS: 1. Diverticulosis of the sigmoid colon SECONDARY DIAGNOSES: 1. Cellulitis 2. Hypertension 3. Coronary artery disease Discharge Condition: Stable, eating regular diet. With some bowel movements with old dark [**Hospital1 **] but no bright red [**Hospital1 **] in stool. [**Hospital1 **] levels have been stable during whole hospital stay. Discharge Instructions: Dear Mr. [**Known lastname 4467**], Thank you for allowing us to participate in your care. You were admitted to the hospital for bleeding from your intestines. You were diagnosed with diverticulosis of the sigmoid colon. Diverticulosis is a condition in which there are small outpouchings in the wall of the intestine; in your case, these small outpouchings eroded into a neighboring [**Name2 (NI) **] vessel, causing significant bleeding. The sigmoid colon is the lowermost portion of the large intestine before connecting to the rectum and anus. Due to the extensive [**Name2 (NI) **] loss from your intestine, you were given a [**Name2 (NI) **] transfusion. You were cared for first in the Intensive Care Unit (ICU), then after your condition stabilized, you were transferred to the regular medical floor. Over the course of your stay, you did not have recurrence of bleeding, and you were able to tolerate eating normal food once again. When you were admitted, a test called Sigmoidoscopy was done to look inside the sigmoid colon. Due to the bleeding and inflammation, it was not possible to look inside the rest of the colon, further up, to evaluate for any problems there. It will be very important for you to follow up with a gastroenterologist to be further evaluated and have a full colonoscopy done. Please see below for information on the appointment that has been arranged with Dr. [**Last Name (STitle) 1256**]. While in the hospital, you were also treated with antibiotics for a skin infection in your left arm due to an apparent insect bite. You finished the course of antibiotics in the hospital. Since the possibility exists that this was a tick bite, a test for Lyme disease was done, but the results of this test were not ready before you left the hospital. You will need to discuss the results of this test with your primary care doctor. Finally, an important note about your medications: during the bleeding from your intestine, your aspirin and Plavix were temporarily stopped. This was done because although these medications did not cause the bleeding, their effect is to worsen any bleeding that may occur for another reason, such as diverticulosis, as in your case. These medications are extremely important to prevent clots from forming at the sites where stents were placed in the [**Last Name (STitle) **] vessels in your heart, so they were both re-started once your bleeding stopped. Since you were de-sensitized to aspirin, it is EXTREMELY IMPORTANT that you take aspirin EVERY DAY, since if you skip doses, this may cause you to have a bad reaction to the medication. MEDICATION CHANGES: There were no changes made to your medications. Please continue taking your regular home medications. Followup Instructions: You have a follow up appointment with your primary care doctor: Department: [**Hospital3 249**] When: FRIDAY [**2129-7-22**] at 11:30 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**] Building: [**Hospital6 29**] [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage You also have an important follow up appointment with Dr. [**Last Name (STitle) 1256**], of gastroenterology: Department: GASTROENTEROLOGY When: TUESDAY [**2129-7-26**] at 9:00 AM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1983**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: [**Hospital3 249**] When: FRIDAY [**2129-7-22**] at 11:30 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**] Building: [**Hospital6 29**] [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: GASTROENTEROLOGY When: TUESDAY [**2129-7-26**] at 9:00 AM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1983**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: [**Hospital3 249**] When: FRIDAY [**2129-7-22**] at 11:30 AM With: [**Name6 (MD) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 250**] Building: [**Hospital6 29**] [**Location (un) 895**] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: GASTROENTEROLOGY When: TUESDAY [**2129-7-26**] at 9:00 AM With: [**First Name8 (NamePattern2) **] [**Name8 (MD) **], MD [**Telephone/Fax (1) 1983**] Building: LM [**Hospital Ward Name **] Bldg ([**Last Name (NamePattern1) **]) [**Location (un) 858**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage

[ "562.12", "305.60", "311", "E906.4", "272.4", "412", "564.1", "414.01", "530.10", "285.1", "V12.04", "250.00", "428.20", "401.9", "912.5", "428.0", "682.3", "584.9", "V45.82" ]

icd9cm

[ [ [] ] ]

[ "48.23" ]

icd9pcs

[ [ [] ] ]

9495, 9501

4966, 8513

326, 341

9682, 9885

3757, 4266

12675, 14631

3036, 3115

9017, 9472

9522, 9522

8539, 8994

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4630, 4943

3130, 3738

9602, 9661

12548, 12652

278, 288

369, 2317

4283, 4613

9541, 9581

2339, 2674

2690, 3020

15,357

102,981

25222

Discharge summary

report

Admission Date: [**2187-9-5**] Discharge Date: [**2187-9-13**] Date of Birth: [**2112-9-3**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2074**] Chief Complaint: Ongoing chest pain and positive cardiac enzymes transfer for cardiac catheterization Major Surgical or Invasive Procedure: Cardiac catheterization History of Present Illness: Pt is a 75 yo male with DM, ESRD, on HD for 18 months , HTN, high cholesterol, PAF, with dual chamber pacer for heart block, transferred to [**Hospital1 18**] for urgent cath due to ongoing CP and + cardiac enzymes. Patient was admitted to [**Hospital3 **] yesterday with N/V/D. He notes that he had bilateral upper chest pain 2 weeks ago that was attributed to pleuritic CP secondary to pneumonia. He did have a hacking cough with minimal sputum for the past 2 weeks. He was treated for CAP. On day of transfer to [**Hospital1 **], he c/o SOB, sats 83-84% which resp to nonrebreather ->high 90's and upon further questioning said that he had been having chest and shoulder pain for several days at home. Cardiac enzymes were drawn 1st trop I was 18.32, given plavix, lopressor, nitro drip. Cardiac catheterization showed CO 4.09, CI 1.95, PCWP 21, RA 12, PA 51/22 LMCA normal LAD: midsegment 80% lesion with modest calcium LCX: non-domninant vessel with mid-segment 90% lesion after OM1. OM 1 TO with bridging and retrograde L-L collaterals RCA: dominant vessel with occlusion proximally. Distal flow from L-R collaterals. Transferred to CCU for observation and treatment of ? pneumonia. He denies CP, SOB, abd pain, palpitations. Past Medical History: PMH: 1. A fib during dialysis 2.? wenkebach to complete heart block, 2:1 AV block; pacer placed 3/12/043.DM 4. neuropathy 5. ESRD on dialysis for past 18 months 6. Retinopathy 7. Anemia 8. Hypercholesterolemia 9. Hypertension Social History: Social history: Lives with wife. HAs 3 children. Never smoked. occasionally drinks Family History: non-contributory Physical Exam: Vitals: General: HEENT: CV: Pulmonary: Abd: Ext: Neuro: Pertinent Results: Labs from OSH: OSH cultures: bl cultures +micrococcus (contaminant) CK 392 MB 52.9 index 13.5 TropI 18.32- [**2187-9-6**] 02:15AM BLOOD WBC-10.6 RBC-3.52* Hgb-11.1* Hct-33.3* MCV-95 MCH-31.7 MCHC-33.4 RDW-16.7* Plt Ct-218 [**2187-9-8**] 08:27PM BLOOD Hct-26.5* [**2187-9-9**] 11:11PM BLOOD Hct-30.4* [**2187-9-12**] 04:00PM BLOOD Hct-35.8* [**2187-9-13**] 08:25AM BLOOD WBC-8.3 RBC-3.73* Hgb-11.7* Hct-35.0* MCV-94 MCH-31.5 MCHC-33.6 RDW-16.6* Plt Ct-318 [**2187-9-6**] 02:15AM BLOOD PT-16.7* PTT-30.4 INR(PT)-1.9 [**2187-9-7**] 03:30AM BLOOD PT-21.0* PTT-118.7* INR(PT)-2.9 [**2187-9-8**] 05:59AM BLOOD PT-16.6* PTT-34.9 INR(PT)-1.8 [**2187-9-12**] 07:20AM BLOOD PT-17.2* PTT-78.1* INR(PT)-2.0 [**2187-9-6**] 02:15AM BLOOD Glucose-132* UreaN-48* Creat-6.9* Na-135 K-5.8* Cl-97 HCO3-24 AnGap-20 [**2187-9-9**] 09:13AM BLOOD Glucose-188* UreaN-44* Creat-5.1*# Na-136 K-5.7* Cl-96 HCO3-27 AnGap-19 [**2187-9-13**] 08:25AM BLOOD Glucose-271* UreaN-63* Creat-6.6*# Na-136 K-3.8 Cl-96 HCO3-25 AnGap-19 [**2187-9-6**] 02:15AM BLOOD CK-MB-79* MB Indx-12.4* cTropnT-4.84* [**2187-9-6**] 09:43AM BLOOD CK-MB-47* MB Indx-9.2* [**2187-9-6**] 06:22PM BLOOD CK-MB-23* MB Indx-6.0 [**2187-9-6**] 08:49PM BLOOD CK-MB-16* MB Indx-4.4 [**2187-9-8**] 08:27PM BLOOD CK-MB-11* cTropnT-9.13* [**2187-9-6**] 02:15AM BLOOD Phos-4.6* Mg-2.3 [**2187-9-13**] 08:25AM BLOOD Albumin-3.4 Calcium-9.0 Phos-4.2 Mg-1.9 [**2187-9-7**] 03:30AM BLOOD Ferritn-1163* [**2187-9-8**] 05:59AM BLOOD calTIBC-157* VitB12-789 Folate-10.5 Hapto-170 Ferritn-1512* TRF-121* [**2187-9-8**] 05:59AM BLOOD TSH-2.5 [**2187-9-7**] 03:30AM BLOOD Vanco-13.5* [**2187-9-5**] 09:33PM BLOOD Type-ART O2 Flow-15 pO2-89 pCO2-43 pH-7.38 calHCO3-26 Base XS-0 Intubat-NOT INTUBA Comment-NRB [**2187-9-5**] Cardiac catheterization: Final report pending. preliminary report indicates severe 3 VD. [**2187-9-6**] CXR: 1. Moderate congestive heart failure. 2. Patchy opacities in the right lung and left upper lobe. This could be due to alveolar pulmonary edema or superimposed infection. Echocardiogram: EF 20-25% 1. The left atrium is moderately dilated. 2. The left ventricular cavity size is normal. There is severe global left ventricular hypokinesis. Overall left ventricular systolic function is severely depressed. 3. The aortic valve leaflets are moderately thickened. 4. The mitral valve leaflets are mildly thickened. Mild (1+) mitral regurgitation is seen. [**2187-9-7**] Carotid U/S: Globular, partially shadowing plaque in both proximal internal carotid arteries with less than 40% hemodynamic effect on the right and around 40% hemodynamic effect on the left. Brief Hospital Course: 75 yo male with multiple medical problems admitted to [**Hospital **] hospital with temp. 101.5 and N/V/D found to have NSTEMI with CHF/PNA. Tranferred emergently for cath and found to have severe 3VD with no obvious culprit artery. + enzymes thought to be due to demand ischemia 1. CAD: Patient was found to have severe 3VD on cardiac catheterization and intervention was not thought to be of benefit as there was no real culprit lesion. CT surgery was consulted and patient had pre-op work-up but they concluded that he was not a good candidate for surgery. He was medically managed with aspirin, statin, [**Last Name (un) **] and beta blocker and plavix was added once surgery was no longer an option. He will follow up with Dr. [**Last Name (STitle) **] for further medical management and consideration of possible intervention in the future. 2. Rhythm: On admission the patient was V paced. His pacer was adjusted during his admission and be was a and V paces. He had a long QT interval on catheterization so the azithromycin he was on upon admission was discontinued and all other QT prolonging medications were avoided. He did have one episode of torsades during dialysis which quickly resolved. He had history of PAF and was continued on coumadin. His INR was 2 on discharge and he was continued on coumadin 5 mg QHS. His levels will be monitored at dialysis as they have been in the past. 3. Pump: EF 20-25% on echocardiogram with significant akinesis of the apex. He was continued on coumadin as stated above. 4. Infection: Culture results from OSH showed micrococcus in blood whoch wa sthought to be a contaminant. He reecieved 3 days of vancomycin at the OSH. Blood and urine performed during this admission were negative. It was thought that this was most likely a pneumonia as indicated by chest x-ray and symptoms. He was originally treated with ceftriaxone and azithromycin x 2 days but decided to discontinue the azithromycin out of concern for prolonged QT. He was continued on ceftriaxone and then switched to cefpodoxime to complete a 10 day course. At discharge he was afebrile for >5 days with resolving cough. He will follow up with his PCP [**Last Name (NamePattern4) **]. [**Last Name (STitle) **] in 2 weeks. 3. Diabetes: His fingersticke were well controlled on Lantus and insulin sliding scale during this admission. He was discharged on his home lantus and sliding scale and will follow up with his PCP [**Last Name (NamePattern4) **] 2 weeks. 4. ESRD: Patient received dialysis as regularly scheduled (Tuesday, Thursday, Saturday). He ahd a brief episode of torsades during dialysis most likley secondary to his prolonged QT. Otherwise he tolerated dialysis well and will continue on his regular schedule as an outpatinet at the [**Hospital1 1474**] Kidney Center. 5. Anemia: Most likely anemia of chronic disease. He recievd 1 unit of packed RBCs during this admission as his HCT dropped as low as 26.5. He had an appropriate increase in hematocrit and it remained stable thereafter. On discharge his HCT was 35. He will continue to recieve epogen with dialysis and should have a colonoscopy as an outpatient. 6.Mental statusus changes: Patient had 1 episode of sundowning with visual hallucinations and combativeness at the beginnning of his admission. He received haldol with good response and had no further episodes. It was thought that this was secondary to his infection. Medications on Admission: 1. Sertraline 50 mg po qd 2. ASA 325 mg po qd 3. Losartan 100 mg po qd 4. Insulin Glargine 21 U QHS, aspart 5 units afternoon dose, aspart 13 units Sun, M,W,F 5.Famotidine 20 mg po qd 6. Calcium acetate 1334 mg po TID with meals 7. Norvasc 8. Vancomycin Discharge Medications: 1. Calcium Acetate 667 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 2. Aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Acetaminophen 325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 4. Losartan Potassium 50 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Warfarin Sodium 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). Disp:*30 Tablet(s)* Refills:*0* 6. Clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 7. Sertraline 50 mg Tablet Sig: One (1) Tablet PO once a day. 8. Insulin Glargine 100 unit/mL Solution Sig: Twenty One (21) units Subcutaneous at bedtime. 9. Insulin Aspart 100 unit/mL Solution Sig: Five (5) units Subcutaneous every 6-8 hours: afternoon dose. 10. Insulin Aspart 100 unit/mL Solution Sig: Thirteen (13) units Subcutaneous Sun, mon, wed, fri: Take as you do usually. 11. Simvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*2* 12. Famotidine 20 mg Tablet Sig: One (1) Tablet PO once a day. 13. Dextromethorphan-Guaifenesin 10-100 mg/5 mL Syrup Sig: Five (5) ML PO Q6H (every 6 hours) as needed. 14. Cefpodoxime Proxetil 200 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 3 days: To complete a 10 day course. Disp:*8 Tablet(s)* Refills:*0* 15. Metoprolol Succinate 50 mg Tablet Sustained Release 24HR Sig: One (1) Tablet Sustained Release 24HR PO DAILY (Daily). Disp:*30 Tablet Sustained Release 24HR(s)* Refills:*1* Discharge Disposition: Home Discharge Diagnosis: 1. Aspiration pneumonia 2. Demand cardiac ischemia Discharge Condition: afebrile, chest pain free, no shortness of breath Discharge Instructions: If you have any chest pain, shortness of breath, palpitations or any other concerning symptoms call your doctor or go to the emergency room. The following changes have been made to you medications: 1. You are now on metoprolol XL 50 mg once daily 2. Do not take you Norvasc, you can discuss restarting it with Dr. [**Last Name (STitle) **] at your next appointment 3. You are also on cefpodoxime 200 mg twice daily for 3 more days to complete your 10 day course. You can continue all the rest of your usual medications including your insulin regimen. Followup Instructions: You have a follow up appointment with Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 3183**] on Wednesday, [**9-26**] at 11am to discuss options for further treatment you your heart disease. You also have a follow up appointment with your primary doctor Dr. [**Last Name (STitle) **] [**Telephone/Fax (1) 3183**] Wednesday, [**9-26**] at 11:45 am. You should also discuss getting a sleep study as you were observed having episodes when you were not breathing during sleep. Since you are on coumadin, you should have your INR checked when you have dialysis on Sat [**2187-9-15**].

[ "333.99", "599.0", "486", "250.40", "428.0", "427.31", "V45.01", "250.60", "790.7", "250.50", "272.0", "403.91", "427.1", "293.0", "410.71", "285.9", "414.01", "V10.46" ]

icd9cm

[ [ [] ] ]

[ "99.04", "88.56", "37.23", "39.95", "88.53" ]

icd9pcs

[ [ [] ] ]

10065, 10071

4805, 8235

398, 424

10166, 10218

2165, 4782

10820, 11409

2056, 2074

8539, 10042

10092, 10145

8261, 8516

10242, 10797

2089, 2146

274, 360

452, 1691

1713, 1940

1972, 2040

252

190,159

23644

Discharge summary

report

Admission Date: [**2133-3-31**] Discharge Date: [**2133-4-23**] Date of Birth: [**2078-3-6**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 783**] Chief Complaint: Esophageal Variceal Hemorrhage Major Surgical or Invasive Procedure: Intubation, Mechanical Ventilation, EGD Without Intervention, IVC Filter Placement. History of Present Illness: 55 yo man with hx of alcoholism, admitted with GI bleed to OSH, with gelatinous bright red blood emesis, and weakness, found to be unresponsive, BP 68/38, HR 130s, HCT 19 at [**Hospital3 7569**]. He was then was intubated for airway protection, given 2uPRBC and 2-3L NS, SBP came up to 100. Pt transferred here to [**Hospital1 18**] for further evaluation. In the MICU, he received 9 units pRBC, 4 units FFP (for coagulopathy that has since resolved). He was seen by GI who did multiple EGDs; these showed no active bleeding, grade 2 esophageal varices, and portal gastropathy. No intevention was performed. He was also seen by neuro for some ?myoclonic jerks that were thought to be [**2-25**] etoh withdrawal vs. anoxic brain injury vs. hepatic encephalopathy. His hct stabilized and he had no more episodes of active bleeding. He was extubated on [**4-9**], but his MS continues to wax and wane. He is currently completing a 10 day course of Vancomycin for ?GPC in sputum. He also completed an 8 day course of Levo/flagyl for SBP ppx given his ascites. Also during the MICU course, abdominal US showed diffusely coarsened and heterogeneous hepatic echotexture, consistent with cirrhosis. No focal lesions identified. Small amount of perihepatic ascites. Patent portal veins, with flow in the appropriate direction. He had a TTE that showed only mild MR. [**Name13 (STitle) **] jad a swam placed; numbers did not implicate a primary cardiac cause for his initial hypotension. Abd CT showed showed mesenteric edema, some diverticuli. MRI of head showed mild to mod age-inappropriate brain atrophy. He was transferred to the floor when hct was stable; MS is still waxing and [**Doctor Last Name 688**], and he is still not able to adequately take PO's. Past Medical History: Alcoholism, Kidney Stones, ETOH Cirrhosis. Social History: 1 ppd smoking hx and known alcoholic- unclear when last drink, lives alone with no known family Family History: NC Physical Exam: VS: 99.5 110/78 75 20 104 Gen: not completely clear speech, A&O x 2 (knows year, knows in hospital, ?knows president), mild distress, tearful at times HEENT: PERRL, some yellow saliva/exudate on roof of mouth Neck: with right IJ, no lad, no JVD appreciated Lungs: CTA from anterior exam CV: distant heart sounds, nl s1/s2, no m/r/g Abd: soft, distended, ?fluid wave, no HSM, nt, no reb/guard Extr: 2+ pitting edema in LE (with pneumoboots), DP 1+ bilaterally Neuro: MS as above, [**5-28**] grip, can lift legs off bed, 3-4/5 strength LE Pertinent Results: ABD U/S ([**2133-3-31**]): IMPRESSION: 1) Diffusely coarsened and heterogeneous hepatic echotexture, consistent with cirrhosis. No focal lesions identified. Small amount of perihepatic ascites. 2) Patent portal veins, with flow in the appropriate direction. EGD ([**2133-3-31**]): Impression: Grade II varices were noted in the lower esophagus but last 4 cm of esophagus appeared fibrotic with no varices, consistent with possible prior endoscopic therapy. No bleeding noted from the esophagus. Mostly old, and some fresh blood in the stomach - ?bleeding from proximal stomach. Erythema and congestion in the whole stomach compatible with portal gastropathy and hypoalbuminemia. Otherwise normal egd to second part of the duodenum. L LE U/S ([**2133-4-19**]): IMPRESSION: There is a crescenteric-shaped thrombus within the left common femoral vein, which is only partially occlusive. Acuity of this can not be determined, and this may be an acute thrombus. These correspond to the findings on recent CT scan. CT TORSO/PELVIS ([**2133-4-18**]): IMPRESSION: 1) 3.4-cm aneurysm arising from the proximal left common iliac artery. 2) Apparent peripheral filling defect within the left superficial femoral vein. While this could represent artifact, an ultrasound could be performed to evaluate for the presence of thrombus in this patient with history of left femoral vein catheterization. 3) Diverticulosis with no CT evidence of diverticulitis. 4) Sludge and stones within a nondistended gallbladder. 5) Moderate amount of intra-abdominal ascites with a nodular liver contour, findings suggestive of cirrhosis. 6) Small bilateral pleural effusions with associated atelectasis. 7) Emphysema. 8) Bilateral low-attenuation lesions within both kidneys, likely representative of simple cysts. A focal area of dense calcification is also present adjacent to a cystic area of low attenuatiuon within the posterior right kidney. [**2133-3-31**] 04:38AM BLOOD freeCa-1.03* [**2133-4-2**] 05:36AM BLOOD freeCa-1.19 [**2133-3-31**] 04:38AM BLOOD Glucose-127* Lactate-9.0* Na-144 K-4.9 Cl-115* calHCO3-17* [**2133-3-31**] 09:48AM BLOOD Lactate-3.0* [**2133-3-31**] 04:05PM BLOOD Lactate-1.8 [**2133-4-5**] 08:11AM BLOOD Lactate-1.3 [**2133-3-31**] 07:37AM BLOOD Type-ART Temp-35.3 Rates-12/ PEEP-5 FiO2-100 pO2-303* pCO2-45 pH-7.23* calHCO3-20* Base XS--8 AADO2-364 REQ O2-65 Intubat-INTUBATED [**2133-3-31**] 09:48AM BLOOD Type-ART Temp-36.4 pO2-107* pCO2-37 pH-7.35 calHCO3-21 Base XS--4 Intubat-INTUBATED [**2133-3-31**] 04:05PM BLOOD Type-[**Last Name (un) **] Temp-38.2 Tidal V-50 PEEP-5 pO2-104 pCO2-36 pH-7.35 calHCO3-21 Base XS--4 Intubat-INTUBATED Vent-CONTROLLED [**2133-4-1**] 04:45PM BLOOD Type-ART Temp-36.4 Rates-18/2 Tidal V-500 PEEP-5 FiO2-50 pO2-82* pCO2-35 pH-7.34* calHCO3-20* Base XS--5 -ASSIST/CON Intubat-INTUBATED [**2133-4-8**] 08:03AM BLOOD Type-ART Temp-36.7 Rates-14/3 Tidal V-500 PEEP-5 FiO2-50 pO2-89 pCO2-38 pH-7.48* calHCO3-29 Base XS-4 -ASSIST/CON Intubat-INTUBATED [**2133-4-8**] 02:30PM BLOOD Type-ART Temp-35.8 Rates-0/9 Tidal V-500 PEEP-5 FiO2-50 pO2-93 pCO2-36 pH-7.47* calHCO3-27 Base XS-2 Intubat-INTUBATED [**2133-4-1**] 03:17AM BLOOD HCV Ab-NEGATIVE [**2133-3-31**] 04:10AM BLOOD ASA-NEG Ethanol-19* Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2133-3-31**] 04:33AM BLOOD ASA-NEG Ethanol-10 Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2133-4-1**] 03:17AM BLOOD AFP-6.2 [**2133-4-12**] 05:36AM BLOOD [**Doctor First Name **]-POSITIVE Titer-1:40 [**Last Name (un) **] [**2133-4-1**] 03:17AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE HBcAb-NEGATIVE HAV Ab-POSITIVE [**2133-3-31**] 07:21PM BLOOD Cortsol-14.0 [**2133-3-31**] 09:38PM BLOOD Cortsol-13.5 [**2133-3-31**] 10:01PM BLOOD Cortsol-14.2 [**2133-3-31**] 07:21PM BLOOD TSH-0.85 [**2133-4-11**] 05:09AM BLOOD calTIBC-130* Ferritn-816* TRF-100* [**2133-3-31**] 06:33AM BLOOD Albumin-3.0* Calcium-7.0* Phos-5.2* Mg-1.2* [**2133-3-31**] 02:02PM BLOOD Calcium-8.1* Phos-3.1# Mg-1.8 [**2133-3-31**] 07:21PM BLOOD Calcium-7.5* Phos-2.6* Mg-1.6 [**2133-4-10**] 05:26AM BLOOD Calcium-7.9* Phos-2.6* Mg-1.7 [**2133-4-16**] 05:48AM BLOOD Calcium-7.9* Phos-3.0 Mg-1.7 [**2133-4-23**] 05:46AM BLOOD Calcium-7.7* Phos-4.5 Mg-1.9 [**2133-4-1**] 03:17AM BLOOD Lipase-12 [**2133-4-17**] 06:04AM BLOOD Lipase-224* [**2133-4-18**] 05:55AM BLOOD Lipase-219* [**2133-4-19**] 06:24AM BLOOD Lipase-235* [**2133-4-20**] 05:50AM BLOOD Lipase-191* [**2133-4-21**] 05:50AM BLOOD Lipase-147* [**2133-3-31**] 04:10AM BLOOD Amylase-23 [**2133-3-31**] 04:33AM BLOOD Amylase-21 [**2133-3-31**] 06:33AM BLOOD ALT-16 AST-47* AlkPhos-93 TotBili-2.2* [**2133-3-31**] 07:21PM BLOOD ALT-15 AST-46* AlkPhos-62 TotBili-1.9* [**2133-4-1**] 03:17AM BLOOD ALT-16 AST-61* AlkPhos-68 Amylase-14 TotBili-1.4 DirBili-0.8* IndBili-0.6 [**2133-4-21**] 05:50AM BLOOD ALT-22 AST-47* AlkPhos-128* Amylase-115* TotBili-1.5 [**2133-4-22**] 06:19AM BLOOD ALT-20 AST-41* LD(LDH)-266* AlkPhos-120* TotBili-1.6* [**2133-3-31**] 04:10AM BLOOD UreaN-25* Creat-1.2 Na-145 K-4.2 Cl-115* HCO3-14* AnGap-20 [**2133-3-31**] 04:33AM BLOOD UreaN-26* Creat-1.2 [**2133-3-31**] 06:33AM BLOOD Glucose-127* UreaN-24* Creat-1.1 Na-143 K-5.3* Cl-111* HCO3-18* AnGap-19 [**2133-3-31**] 09:03AM BLOOD Glucose-124* UreaN-27* Creat-1.1 Na-144 K-4.4 Cl-114* HCO3-21* AnGap-13 [**2133-3-31**] 02:02PM BLOOD Glucose-109* UreaN-34* Creat-1.3* Na-146* K-4.2 Cl-117* HCO3-20* AnGap-13 [**2133-4-4**] 04:10AM BLOOD Glucose-127* UreaN-28* Creat-1.0 Na-146* K-3.6 Cl-119* HCO3-24 AnGap-7* [**2133-4-5**] 05:06AM BLOOD Glucose-131* UreaN-28* Creat-1.0 Na-146* K-3.7 Cl-119* HCO3-24 AnGap-7* [**2133-4-6**] 06:21PM BLOOD Glucose-107* UreaN-28* Creat-1.1 Na-146* K-3.4 Cl-113* HCO3-26 AnGap-10 [**2133-4-7**] 04:14AM BLOOD Glucose-131* UreaN-29* Creat-1.1 Na-145 K-2.9* Cl-115* HCO3-25 AnGap-8 [**2133-4-13**] 05:00AM BLOOD Glucose-92 UreaN-15 Creat-1.2 Na-143 K-2.3* Cl-109* HCO3-29 AnGap-7* [**2133-4-14**] 05:18AM BLOOD Glucose-110* UreaN-16 Creat-1.4* Na-144 K-3.4 Cl-111* HCO3-28 AnGap-8 [**2133-4-15**] 06:02AM BLOOD Glucose-104 UreaN-15 Creat-1.5* Na-144 K-4.0 Cl-111* HCO3-26 AnGap-11 [**2133-4-21**] 05:50AM BLOOD Glucose-85 UreaN-22* Creat-1.9* Na-138 K-4.3 Cl-106 HCO3-27 AnGap-9 [**2133-4-22**] 06:19AM BLOOD Glucose-89 UreaN-20 Creat-1.8* Na-138 K-3.8 Cl-106 HCO3-25 AnGap-11 [**2133-4-23**] 05:46AM BLOOD UreaN-15 Creat-1.7* K-3.9 [**2133-3-31**] 04:10AM BLOOD Fibrino-150 [**2133-3-31**] 04:33AM BLOOD Fibrino-140* [**2133-3-31**] 06:33AM BLOOD Fibrino-213# [**2133-4-2**] 05:26AM BLOOD Fibrino-304 [**2133-3-31**] 04:10AM BLOOD PT-19.0* PTT-36.7* INR(PT)-2.3 [**2133-3-31**] 04:10AM BLOOD Plt Ct-113* [**2133-3-31**] 04:33AM BLOOD PT-19.3* PTT-46.2* INR(PT)-2.4 [**2133-3-31**] 04:33AM BLOOD Plt Ct-110* [**2133-4-4**] 04:10AM BLOOD PT-14.8* PTT-31.4 INR(PT)-1.4 [**2133-4-4**] 04:10AM BLOOD Plt Ct-92* [**2133-4-5**] 05:06AM BLOOD PT-15.4* PTT-30.6 INR(PT)-1.5 [**2133-4-22**] 06:19AM BLOOD PT-14.8* INR(PT)-1.4 [**2133-4-22**] 06:19AM BLOOD Plt Ct-180 [**2133-4-14**] 05:18AM BLOOD Neuts-79.8* Lymphs-12.1* Monos-6.0 Eos-1.8 Baso-0.3 [**2133-4-15**] 06:02AM BLOOD Neuts-78.2* Bands-0 Lymphs-12.6* Monos-6.7 Eos-2.1 Baso-0.3 [**2133-4-16**] 05:48AM BLOOD Neuts-75.6* Lymphs-15.5* Monos-6.3 Eos-2.4 Baso-0.2 [**2133-4-20**] 05:50AM BLOOD Neuts-66.6 Lymphs-22.4 Monos-5.6 Eos-4.6* Baso-0.7 [**2133-3-31**] 04:10AM BLOOD WBC-28.5* RBC-2.51* Hgb-8.1* Hct-25.6* MCV-102* MCH-32.2* MCHC-31.5 RDW-21.2* Plt Ct-113* [**2133-3-31**] 04:33AM BLOOD WBC-27.1* RBC-2.54* Hgb-8.3* Hct-25.7* MCV-101* MCH-32.7* MCHC-32.4 RDW-20.8* Plt Ct-110* [**2133-3-31**] 06:33AM BLOOD WBC-20.5* RBC-4.42*# Hgb-13.4*# Hct-40.4# MCV-92# MCH-30.3 MCHC-33.1 RDW-18.6* Plt Ct-76* [**2133-4-1**] 06:00PM BLOOD WBC-9.4 RBC-3.77* Hgb-11.4* Hct-32.9* MCV-87 MCH-30.3 MCHC-34.7 RDW-19.5* Plt Ct-95* [**2133-4-1**] 11:31PM BLOOD WBC-9.7 RBC-3.73* Hgb-11.5* Hct-32.9* MCV-88 MCH-30.7 MCHC-34.9 RDW-19.3* Plt Ct-104* [**2133-4-2**] 05:26AM BLOOD WBC-9.1 RBC-3.76* Hgb-11.2* Hct-33.6* MCV-89 MCH-29.7 MCHC-33.3 RDW-19.3* Plt Ct-106* [**2133-4-6**] 08:12PM BLOOD Hct-35.7* [**2133-4-11**] 07:14PM BLOOD Hct-36.2* [**2133-4-14**] 05:18AM BLOOD WBC-16.2* RBC-3.40* Hgb-10.7* Hct-31.3* MCV-92 MCH-31.5 MCHC-34.2 RDW-19.0* Plt Ct-93* [**2133-4-15**] 06:02AM BLOOD WBC-14.1* RBC-3.44* Hgb-10.9* Hct-32.2* MCV-94 MCH-31.8 MCHC-34.0 RDW-19.2* Plt Ct-99* [**2133-4-20**] 05:50AM BLOOD WBC-8.6 RBC-3.10* Hgb-9.5* Hct-29.0* MCV-94 MCH-30.7 MCHC-32.8 RDW-19.1* Plt Ct-138* [**2133-4-21**] 05:50AM BLOOD WBC-8.0 RBC-3.07* Hgb-9.6* Hct-29.3* MCV-95 MCH-31.2 MCHC-32.8 RDW-18.7* Plt Ct-148* [**2133-4-22**] 06:19AM BLOOD WBC-8.3 RBC-2.99* Hgb-9.5* Hct-28.2* MCV-94 MCH-31.7 MCHC-33.6 RDW-19.0* Plt Ct-180 [**2133-4-23**] 05:46AM BLOOD Hct-28.7* Brief Hospital Course: 1. UGIB/Cirrhosis: The patient presented from and an outside hospital after suffering a severe upper GI bleed, hypotension, and hypovolemia. He was resuscitated with PRBC and IVF, and sent to the [**Hospital1 18**] MICU. The etiology was considered likely variceal in nature, given the briskness of his bleed, and history of heavy ETOH use. He had had multiple EGD's at [**Hospital1 18**] showing varices, portal gastropathy, but required no EGD-interventions (ie. cautery or clipping). Of note, Hepatitis A titers were positive. He was started on Lactulose, PPI, Nadolol, Spironolactone and Lasix. The latter two were discontinued given declining renal function. His HCT remained stable on the floor thereafter, with levels in the high 20's to low 30's. He was completd on a course of Levofloxain and Flagyl for SBP PPx in the setting of an UGIB. He was discharged with [**Hospital1 18**] Liver follow-up. 2. Confusion: He was seen by neurology while in the MICU who felt that the differential diagnosis for this patient included, alcoholic encephalopathy, anoxic brain injury, or hepatic encephalopathy. His EEG, Head MRI and Head CT were negative. His mental status improved, with sedation avoidal and treatment of his liver disease, as noted above. 4. Fevers (UTI and LE DVT): While in the MICU, he was treated with a course of vancomycin for gram positive cocci in his sputum, and he received a course of levo/flagyl for SBP prophylaxis. Once on the floor, he continued to have persistent low grade fevers. Multiple urine/blood/peritoneal fluid cultures were negative. A CT of the torso did not show any source. However, a clot in the left common femoral vein, which was confirmed by ultrasound, was seen. Further, his urine cultures later grew out VRE. Regrading the clot, an IVC filter was placed (given the fact he was not a anticoagulate candidate and the high probability of the acuity of the clot because of recent femoral line placement). He was started on a short course of Linezolid for the UTI. It was unclear if the clot or the UTI were the cause of his fevers. 5. ARF: The patient had normal renal function at baseline. He evidenced an acute decline in his GFR after a CT contrast dye exposure and his creatinine peaked in the low 2.0's. It improved thereafter. He had a possible ATN (with FENa at 6%) and was managed with gentle hydration. 6. Alcoholism: He had nos signs of withdrawal over his course. He was seen by the Addiction service, social work and was advised to enter a detoxification center upon discharge from his rehab facility. Medications on Admission: Meds on Transfer: Nadolol 20 Vanco 1 [**Hospital1 **] Haldol Protonix Ativan Dulcolax SSI Meds on Admission: Ativan 0.5 PRN, Lasix 40 QDay, Remeron 15 QDay, Aldactone 25 QDay, Naprosyn PRN Discharge Medications: 1. Nadolol 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 2. Miconazole Nitrate 2 % Powder Sig: One (1) Appl Topical [**Hospital1 **] (2 times a day). 3. Lactulose 10 g/15 mL Syrup Sig: Thirty (30) ML PO TID (3 times a day). 4. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Multivitamin Capsule Sig: One (1) Cap PO DAILY (Daily). 6. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 7. Linezolid 600 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 4 days. Discharge Disposition: Extended Care Facility: [**Hospital6 979**] - [**Location (un) 246**] Discharge Diagnosis: Primary Diagnosis: 1) Variceal Hemorrhage. 2) Alcoholic Cirrhosis. Secondary Diagnosis: 3) Vancomycin-Resistant Enterococcal Urinary Tract Infection. 4) Common Femoral Vein Thrombosis. Discharge Condition: Fair/Stable. Discharge Instructions: 1) Please call your doctor or return to the ER if you have any nausea, vomiting, fevers, chills, dizziness, dark stools, diarrhea, bleeding, or any other concerning symptoms. 2) Take your medications as instructed. Followup Instructions: 1) Please arrive on the following date to see your new liver doctor. Your liver doctor will restart your Aldactone and Lasix when your kidney function returns to normal: Provider [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] Where: LM [**Hospital Unit Name 7129**] CENTER Phone:[**Telephone/Fax (1) 2422**] Date/Time:[**2133-6-3**] 9:00 2) Please see your primary doctor (MAURUKAS,RIMAS J. [**Telephone/Fax (1) 28582**]) in the next 2-3 weeks. Your hematocrit (blood level) should be checked at least weekly for a month after you leave your rehab, to ensure it is stable. 3) We recommend you enter an alchohol detoxification center once you leave the physical rehab facility. The social workers at the rehab facility can help you with this. [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**]

[ "453.41", "305.1", "571.2", "785.59", "E879.6", "348.31", "518.81", "286.7", "789.5", "867.0", "070.1", "276.1", "305.00", "486", "456.20", "578.0", "584.9", "572.3", "572.2", "285.1", "599.0", "273.8", "579.8", "V13.01", "263.9", "599.7", "287.5" ]

icd9cm

[ [ [] ] ]

[ "96.07", "38.7", "96.6", "38.93", "99.07", "45.13", "96.72", "54.91", "99.05", "99.04" ]

icd9pcs

[ [ [] ] ]

15137, 15209

11732, 14299

344, 430

15439, 15453

3001, 11709

15717, 16647

2416, 2420

14539, 15114

15230, 15230

14325, 14325

15477, 15694

2435, 2982

274, 306

458, 2220

15319, 15418

15249, 15298

14435, 14516

2242, 2286

2302, 2400

14343, 14421

5,003

142,073

46073

Discharge summary

report

Admission Date: [**2196-5-19**] Discharge Date: [**2196-5-23**] Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 134**] Chief Complaint: fatigue, abdominal pain Major Surgical or Invasive Procedure: pacemaker placement History of Present Illness: 86M with hx of HTN, DM who presented to the ER today with malaise, fatigue and found to be in complete heart block. Patient initially presented to a physician in [**Name9 (PRE) 108**] two days prior to admission with complaints of 3 days of lightheadedness and presyncopal symptoms. The physician checked his heart rate and found it to be low along with a low BP but told him he was dehydrated and was OK to go on a plane to [**Location (un) 86**] the next day. This morning, he continued to feel very bad, complained of fatigue and malaise and his family brought him to the [**Hospital1 18**] ER. On arrival to the ER, pt was found to have a heart rate in the 20s with high degree AV block, conducting 4:1. His BP remained stable. He was also found to be in congestive heart failure and renal failure. He was given 20mg IV lasix along with ASA 325mg. For his heart rate, he was given glucagon and atropine with no effect. Electrophysiology was consulted and pt was taken the cath lab for emergent pacemaker placement. . En route to cath lab, pt increasingly tachypneic and on arrival, was intubated. A temporary pacer was placed via the right femoral vein followed by a permanent PCM. . Of note, pt has been complaining of abdominal pain for one week associated with "gagging". Also with decreased po and poor appetite. Unclear what workup has been to this point. Past Medical History: * Diabetes * HTN * asthma * hearing loss * s/p lap chole * s/p TURP * chronic headaches s/p negative temporal artery biopsy * chronically elevated alk phos . Cardiac Risk Factors: Diabetes, Hypertension Social History: Social history is significant for the absence of current tobacco use. There is no history of alcohol abuse. Family History: There is no family history of premature coronary artery disease or sudden death. Physical Exam: Blood pressure was 138/68mm Hg while seated. Pulse was 80 beats/min and regular, respiratory rate was 16 breaths/min, satting 97% on the vent. Generally the patient was well developed, well nourished and well groomed. The patient was oriented to person, place and time. The patient's mood and affect were not inappropriate. . There was no xanthalesma and conjunctiva were pink with no pallor or cyanosis of the oral mucosa. The neck was supple with JVP of 10cm. Pt breathing on vent; decreased breath sounds at bases but esp at right base; no discernible crackles. . Palpation of the heart revealed the PMI to be located in the 5th intercostal space, mid clavicular line. There were no thrills, lifts or palpable S3 or S4. The heart sounds revealed a normal S1 and the S2 was normal. There were no rubs, murmurs, clicks or gallops. . The abdominal aorta was not enlarged by palpation. There was no hepatosplenomegaly or tenderness. The abdomen was soft nontender but mildly distended. The extremities had no pallor, cyanosis, clubbing. There was trace bilateral edema, warm. There were no abdominal, femoral or carotid bruits. Inspection and/or palpation of skin and subcutaneous tissue showed no stasis dermatitis, ulcers, scars, or xanthomas. . Pulses: Right: Femoral 2+ DP 2+ PT 2+ Left: Femoral 2+ DP 2+ PT 2+ Pertinent Results: [**2196-5-19**] 10:30AM WBC-12.9* RBC-4.26* HGB-12.0* HCT-34.1* MCV-80* MCH-28.1 MCHC-35.1* RDW-17.3* [**2196-5-19**] 10:30AM NEUTS-88.9* BANDS-0 LYMPHS-7.7* MONOS-2.9 EOS-0.2 BASOS-0.3 [**2196-5-19**] 10:30AM ALBUMIN-4.3 CALCIUM-8.5 PHOSPHATE-4.8* MAGNESIUM-2.7* [**2196-5-19**] 10:30AM ALT(SGPT)-67* AST(SGOT)-44* LD(LDH)-238 CK(CPK)-124 ALK PHOS-414* AMYLASE-56 TOT BILI-1.0 [**2196-5-19**] 10:30AM LIPASE-42 [**2196-5-19**] 10:30AM GLUCOSE-138* UREA N-55* CREAT-2.4* SODIUM-139 POTASSIUM-4.8 CHLORIDE-104 TOTAL CO2-19* ANION GAP-21* [**2196-5-19**] 12:12PM LACTATE-2.3* [**2196-5-19**] 10:30AM CK-MB-5 [**2196-5-19**] 10:30AM cTropnT-0.06* . EKG: 4:1 conduction, narrow complex QRS, Q wave in V1 . CXR: Left perihilar patchy opacity worrisome for pneumonia. Markedly elevated right hemidiaphragm of unknown acuity. . Echo [**2196-5-20**]: The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and systolic function (LVEF>55%). Regional left ventricular wall motion is normal. 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. Mild (1+) aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. Physiologic mitral regurgitation is seen (within normal limits). There is moderate pulmonary artery systolic hypertension. There is no pericardial effusion. IMPRESSION: Mild symmetric left ventricular hypertrophy with preserved global and regional biventricular systolic function. . CXR [**2196-5-22**]: Single portable radiograph of the chest demonstrates persistent elevation of the right hemidiaphragm, similar to that seen on [**2196-5-21**]. Cardiomediastinal contours are unchanged. No effusion is detected. Lung volumes are low but the lungs are clear. The trachea is midline. The aorta is tortuous. Dual-lead pacemaker is unchanged in position. No consolidation. No evidence of pulmonary edema. . CT abdomen [**5-19**]: There are bibasilar consolidative opacities with air bronchograms, which may reflect pneumonia or aspiration. A lingular opacity in particular is patchy without volume loss and suggests pneumonia versus aspiration. There are small pleural effusions. . The patient is status post cholecystectomy. There is no intra- or extra- hepatic biliary ductal dilatation. The liver appears normal. The spleen, adrenal glands, and kidneys are unremarkable. There are scattered vascular calcifications. A simple cyst of 14 mm in diameter in the left kidney is noted. There is distal calcification in the right main renal artery. The pancreas is atrophic but has a normal contour. . There is bilateral stranding in the pararenal fascia and paracolic gutters bilaterally, with a small amount of ascites. . There is also a small amount of low- density ascites tracking into the pelvis. The appendix appears normal. There is diverticulosis throughout the colon. Because there is no specific segments of the colon along which there is more stranding than elsewhere, diverticulitis is unlikely. Brief Hospital Course: 86M with hx of HTN, DM who presents with fatigue and abdominal pain found to be in high degree AV block, heart failure, acute renal failure now s/p pacemaker. . 1. Rhythm: Initial EKG on presentation showed high degree AV block with 4:1 conduction. EP was consulted and he was taken to the cath lab for dual lead pacemaker placement. Possible etiologies included acute anterior MI, drugs, increased vagal tone, and endocarditis. CK-MB negative x 2. If this were ischemia, would have expected markedly elevated CKs. An Echo showed mild LVH but conserved global heart function. He received keflex x 3 days for prophylaxis and CXR confirmed proper lead placement. He will follow up in device clinic. . # Pump/CHF: Found to be in heart failure in setting of complete heart block. Worsening resp distress lead to intubation. Following pacemaker placement an echo was performed and showed a normal EF of >55% and no significant valvular disease. He was diuresed with IV lasix prn and continued on BB and ACEI. His atenolol was changed to metoprolol for better titration and then changed to long acting Toprol XL prior to discharge. Prior to discharge he was also restarted on his home dose of lasix of 10mg. . # Ischemia: TTE showed no focal wall motion abnormalities to suggest an ischemic event. He was continued on ASA and BB. . # HTN: Patient was continued on his outpatient dose of felodipine and his lisinopril was initially held in the setting of renal failure. His SBP ranged from 130s-170s at times so his BP medications were uptitrated. His lisinopril was increased to 20mg daily and his Toprol XL was titrated up to 75mg daily. He continued to have some elevated BP in the setting of activity which should be monitored and medications adjusted as needed. . # Abd Pain: Patient initially complained of abdominal pain of one week duration, possibly worsened by eating leading to decreased appetite. Ddx is large, esp since the abd exam is benign and our history is limited. Includes mesenteric ischemia, hepatic congestion/ascites from right sided heart failure, diverticulitis, mass, pancreatitis, constipation. LFTs unremarkable except for alk phos elevation though this has been chronic according to daughter. CT abdomen was performed that showed no acute process to explain his abdominal pain. Following extubation his pain had resolved and his exam was benign. . # Leukocytosis: Patient initially had an elevated WBC with left shift. He was afebrile with no clear infectious source. Blood and urine cultures were sent. His urine culture returned negative x2 and blood cultures showed no growth at the time of discharge. His WBC normalized on HD 2 and he remained afebrile. . # Acute on chronic renal failure: Cr from FL showed creatinine of 1.8 and values from [**Hospital1 **] [**Location (un) 620**] over past 2 years range between 1.6 and 2.3. On admission his Cr was elevated to 2.4, likely in setting of his acute heart failure and poor forward flow. His ACEI was held and medications were renally dosed. His Cr trended back to below baseline and his ACEI was restarted. It was 1.4 on the day of discharge. . # Resp failure: Likely [**2-12**] volume overload in setting of CHF. Patient was intubated for hypoxic respiratory failure. His pulmonary edema was treated with lasix and her was extubated the following day. With continued diuresis he was able to be weaned off oxygen. Given his h/o of asthma he was given prn nebs with good effect. . # Elevated right hemidiaphragm: chronic and stable. . # DM: Was placed on an insulin sliding scale. . # Anemia: on aranesp as outpatient. His hct remained stable throughout. . # Access: 2PIV, a-line . # Ppx: boots, sq heparin, bowel regimen . # code: full . # Comm: daughter ([**Name (NI) **] [**Name (NI) **]) (H) [**Telephone/Fax (1) 98053**]; (C) [**Telephone/Fax (1) 98054**] Medications on Admission: * atenolol 25 mg qd * lisinopril 10 mg qd * felodipine 10 mg qd * Glyburide 2.5mg qday * aspirin 81mg [**Hospital1 **] * gapabentin 300mg qd * Lasix 10mg qd * potassium * folate 1 mg qd * Aranesp injections Discharge Medications: 1. Felodipine 5 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 2. Furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily). 3. Metoprolol Succinate 25 mg Tablet Sustained Release 24 hr Sig: Three (3) Tablet Sustained Release 24 hr PO DAILY (Daily). 4. Lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 5. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 6. Glyburide 2.5 mg Tablet Sig: One (1) Tablet PO once a day. 7. Gabapentin 300 mg Tablet Sig: One (1) Tablet PO once a day. Tablet(s) 8. Folic Acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 9. Aranesp Discharge Disposition: Extended Care Facility: [**Hospital3 5277**] - [**Location (un) 745**] Discharge Diagnosis: Primary Diagnosis: 1. 1:4 Type II Mobitz Heart block, s/p biventricular pacemaker placement 2. Acute CHF due to heart block 3. Respiratory distress requiring intubation, due to acute CHF 3. Hypertension 4. Abdominal pain, unclear etiology . Secondary Diagnosis: 1. Diabetes mellitus 2. Chronic elevated right hemidiaphragm Discharge Condition: Afebrile. Hemodynamically stable. Tolerating PO. Discharge Instructions: You have been found to have a block in your conduction system of the heart. You have been intubated because of heart failure due to impaired conduction of your heart rhythm. You have been given medications to increase your urination. A permanent pacemaker has been placed. Your medications changes are: toprol xl 75mg qday, lisinopril 20mg qday. Please call your primary doctor or return to the ED with fever, chills, chest pain, shortness of breath, nausea/vomiting, spontaneous bleeding or any other concerning symptoms. . Please take all your medications as directed. . Please keep you follow up appointments as below. Followup Instructions: Please follow up with your primary care doctor ([**Last Name (LF) 21373**],[**First Name3 (LF) **] L. [**Telephone/Fax (1) 6163**]) in [**1-12**] weeks from now. . Please also follow up with: . Provider: [**Name10 (NameIs) 676**] CLINIC Phone:[**Telephone/Fax (1) 59**] Date/Time:[**2196-5-25**] 1:00 . Cardiologist [**First Name4 (NamePattern1) 122**] [**Last Name (NamePattern1) **] ([**Hospital1 **] at [**Last Name (un) 5869**]). Phone: [**Telephone/Fax (1) 98055**]. Address: [**Street Address(1) **], [**Location (un) 620**], [**Numeric Identifier 3002**]. Please schedule an appointment within one month after discharge in order to follow up with a heart doctor. Completed by:[**2196-5-23**]

[ "585.9", "426.12", "401.9", "493.90", "519.4", "428.0", "584.9", "518.81", "250.00" ]

icd9cm

[ [ [] ] ]

[ "96.71", "37.72", "38.91", "37.83", "96.04", "39.64" ]

icd9pcs

[ [ [] ] ]

11490, 11563

6689, 10554

285, 306

11931, 11982

3527, 6666

12657, 13359

2077, 2159

10812, 11467

11584, 11584

10580, 10789

12006, 12634

2174, 3508

222, 247

334, 1710

11847, 11910

11603, 11826

1732, 1936

1952, 2061

32,669

117,805

6230

Discharge summary

report

Admission Date: [**2189-3-29**] Discharge Date: [**2189-4-16**] Date of Birth: [**2121-5-9**] Sex: M Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 783**] Chief Complaint: headache Major Surgical or Invasive Procedure: none History of Present Illness: This is a 67 year old with a history of hypertension, type II diabetes mellitus, CRI who initially presented on [**2189-3-29**] with headache following mechanical falls at home 2 weeks ago. His wife notes that he has had three falls in the last 2 weeks. His first fall was two weeks ago while he was being weighed on a scale. He lost his balance, fell backwards and hit the back of his head on a shelf. His second fall was one week ago, he was on his way to the bathroom with his walker and fell on the left side of his head. His third fall was three days prior to admission, he was on his walker when his wife noted that his legs buckled. No head trauma was noted following this third fall. His wife reports witnessing these falls and denies LOC, associated chest pain, SOB, palpitations, and lightheadedness. He walks with a walker at baseline. His wife notes that in the last two weeks, she has noticed a deterioriation in his mental status. She has found him increasingly confused and tired. He has also been reporting headaches for the last two weeks. 3 days prior to admission, he also began to have nausea and vomitting along with the headache. His last INR at home was 4.3 five days prior to admisison. He was brought to the [**Hospital **] Hospital ED on [**2189-3-30**] where he was noted to have a SDH. . He received 5 mg vitamin K at the OSH prior to transfer to the [**Hospital1 18**]. At [**Hospital1 18**] ED, he [**Last Name (un) **] given FFP x 4 units. He also received Lasix IV and Dilantin. He was seen by the neurosurgury team who recommended NSICU and he was subsequently transferred to the ICU. He was deemed stable from a neurosurgical perspective on [**3-30**] and there were plans for his discharge. However early morning on [**3-31**], he began to have black guaiac positive stools and had atrial fibrillation with RVR to the 130s. His coumadin has been held and he received 10mg SC vitamin K on presentation ([**2189-3-29**]) and an additional 10mg SC vitamin K on [**3-31**]. Additionally, he received 1 unit FFP on [**2189-3-31**]. INR is currently 1.7. . Of note, he has been on home hospice for heart failure since 3 weeks ago. On review of systems, his wife denies fever, chills, cough, weight loss, abdominal pain, and diarrhea. Past Medical History: 1. Atrial fibrillation on anticoagulation 2. Congestive Heart Failure (per Med c/s note, diastolic with relatively preserved EF 50%, dry weight around 285 to 290 lbs, uses metolazone 2.5 mg when weight increase to 190 lbs. On standing K repletion). 3. Hypertension 4. Type II Diabetes Mellitus 5. Chronic renal insufficiency (most recent baseline Cr 3) 6. Gout Social History: Lives at home with wife, on hospice for CHF, No tobacco, alcohol, IVDU Family History: DM, CAD Physical Exam: T: 100.4 at 8 AM, T 99.6 BP: 150/60 HR: 88 (88-102) R: 16 O2Sats: 99% 4L Gen: Sleeping, somnolent but arousable, falling asleeping throughout the exam HEENT: Pupils: R 3-2 mm, L 2-1.5 EOMs intact Neck: Supple. Lungs: Clear to ascultation anteriorly Cardiac: irregular, irreg. S1/S2. Abd: Soft, NT, BS+, obese Extrem: LE venous stasis changes bilaterally. Neuro: CNII-XII grossly in tact. Moves all extremities freely. Neurological exam limited by somnolence. [**2189-3-29**] CT head: 1. Acute right-sided subdural hematoma, stable when compared to outside study. 2. Bilateral superior ophthalmic vein enlargement, left greater than right. These findings can be seen with carotid cavernous fistula and/or cavernous sinus thrombosis. Clinical correlation is suggested. . [**2189-3-31**] CT head: Stable appearance of right-sided acute subdural hematoma. Unchanged left greater than right superior ophthalmic vein enlargement. . [**2189-4-10**] CXR: In comparison with study of [**3-30**], the pulmonary vessels now appear to be essentially within normal limits. Enlargement of the cardiac silhouette persists. No evidence of acute focal pneumonia at this time. Pertinent Results: [**2189-3-29**] CT head: 1. Acute right-sided subdural hematoma, stable when compared to outside study. 2. Bilateral superior ophthalmic vein enlargement, left greater than right. These findings can be seen with carotid cavernous fistula and/or cavernous sinus thrombosis. Clinical correlation is suggested. . [**2189-3-31**] CT head: Stable appearance of right-sided acute subdural hematoma. Unchanged left greater than right superior ophthalmic vein enlargement. . [**2189-4-10**] CXR: In comparison with study of [**3-30**], the pulmonary vessels now appear to be essentially within normal limits. Enlargement of the cardiac silhouette persists. No evidence of acute focal pneumonia at this time. Brief Hospital Course: 67 y/o male with a history of type II DM, congestive heart failure (class IV), atrial fibrillation, hypertension, chronic renal insufficiency, who was admited with a supratherapeutic INR and SDH following fall, complicated by intermittent seizure activity. . SDH with opthal vein engorgement: His repeat CT scan was stable on [**3-31**]. However, he was found to have new seizures on [**4-3**], with focal motor activity of LUE, suggesting that SDH may be progressing. We attempted to reimage his head on [**4-3**], and onward, but due to his tenuous respiratory status and severe orthopnea, repeat CT was unfeasible. Per extensive discussion with his wife about pt's comfort, decision was made to provide supportive care with management of seizure activity and pain. He was continued on valproic acid for seizure prophylaxis. He was given ativan 0.5 prn for persistent seizure activity lasting for a prolonged period of time (>2-3 mins). . Pain: He had continued headaches and back pain throughout this hospitalization. As noted above, goals of care shifted towards focusing on pt's comfort, even if it meant that this would be at the cost of increased sedation. He was started on concentrated morphine. He has a peripheral IV if morphine gtt in case morphine gtt is required. . GIB: There were concerns of melanic stools during this hospitalization and likely UGIB on [**3-31**] on the neurosurgical service. He does have a long standing history of epistaxis, this may explain his guaiac positive stools. He remained hemodynamically stable otherwise. EGD could not be done on [**3-30**] due to desats when lying flat. On the evening of [**3-30**] with hct drop to 24 from baseline of 27-28. He received 1 unit pRBC on [**3-30**] with appropriate response. As above, with changes in goals of care, lab draws were discontinued on [**4-10**]. . CHF: Based on OSH echo results, mainly diastolic, with relatively preserved EF. Prior to admission, at home with hospice for class IV HF. At home on lasix 80 mg [**Hospital1 **] and metolazone. Diuretics were held in the setting of metabolic abnormalities (primarly hypernatremia) and GIB. He appeared fluid overloaded on [**4-4**] and in respiratory distress and his home regimen of lasix reintroduced. On [**4-14**], diuretics were discontinued following meetings with his wife who expressed her wishes to discontinue all medications that could potentially prolong his life. Diuretics and anti-hypertensives were discontinued at this time. . Atrial Fibrillation: On admission he was rate controlled on digoxin, CCB, and BB. However, due to change in goals of care, his rate control agents were discontinued. . Pt is DNR/DNI, with comfort measures only. His current medications include keppra for seizure prophylaxis, ativan for prolonged seizures, and morphine for comfort. Medications on Admission: Insulin SS Lantus 45U QPM Potassium 20 Meq [**Hospital1 **] Lasix 80 MG [**Hospital1 **] Metolazone 2.5 mg sliding scale Levothyroxine 175 mcg Daily Alopurinol 100 mg daily Colchicine 0.6 mg daily digoxin 0.125 mg QPM Renal Caps Daily Diltiazem SR 180 mg QAM Coreg 25 mg [**Hospital1 **] Coumadin 7.5 as directed Clarinex 5mg QPM Iron 300 mg [**Hospital1 **] Lyrica 100 mg TID Lidoderm patch 12 hrs QPM Klonopin 0.5-1 mg QID Celexa 10 mg QPM Percocet [**12-17**] Q4-6 hrs PRN Procrit 15,000 U QMonday Discharge Medications: 1. Morphine Concentrate 20 mg/mL Solution Sig: One (1) PO Q1H (every hour) as needed. 2. Morphine Concentrate 20 mg/mL Solution Sig: One (1) PO Q4H (every 4 hours). 3. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily). 4. Lorazepam 0.5 mg IV Q4H:PRN 5. Valproic Acid 250 mg Capsule Sig: Three (3) Capsule PO every six (6) hours. Discharge Disposition: Extended Care Discharge Diagnosis: Primary Subdural hemorrhage Gastroinstestinal bleeding Congestive heart failure Atrial fibrillation Focal motor seizure Secondary Chronic renal insufficiency Gout Hypothyroidism Discharge Condition: poor, tachycardic, 89-90% RA Discharge Instructions: You were admitted with a bleed in your head. You were evaluated by our neurosurgical staff. You also had bleeding in your gastrointestinal tract. You were seen by the gastrointestinal doctors and were [**Name5 (PTitle) **] blood transfusions. Your bleeding could not be further assessed on CT scan due to your respiratory status. It is possible that your bleed is progressing. You also had seizures during this admission. You are currently receiving comfort care. Your medications include keppra for seizure prophylaxis, ativan for prolonged seizures, lidocaine for pain and morphine for comfort. If you have any of the following symptoms, you should return to the emergency room: Worsening headache, blurry vision, worsening drowsiness/sleepiness, loss of consciosness, chest pain, shortness of breath or any other serious concerns. Followup Instructions: n/a [**First Name11 (Name Pattern1) 734**] [**Last Name (NamePattern1) 735**] MD, [**MD Number(3) 799**] Completed by:[**2189-4-16**]

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icd9cm

[ [ [] ] ]

[ "99.07", "99.04", "93.90" ]

icd9pcs

[ [ [] ] ]

8857, 8872

5041, 7884

322, 329

9094, 9125

4316, 4332

10016, 10181

3111, 3120

8436, 8834

8893, 9073

7910, 8413

9149, 9993

3135, 3611

274, 284

357, 2622

4651, 5018

2644, 3007

3023, 3095

66,399

171,024

51488

Discharge summary

report

Admission Date: [**2167-9-14**] Discharge Date: [**2167-9-20**] Date of Birth: [**2103-4-29**] Sex: F Service: CARDIOTHORACIC Allergies: Penicillins / Ibuprofen Attending:[**First Name3 (LF) 1505**] Chief Complaint: Coronary artery disease Major Surgical or Invasive Procedure: coronary artery bypass grafts x 4 (LIMA-LAD, SVG-PDA, SVG-PLAD, SVG-Dg) [**9-14**] History of Present Illness: Patient with known coronary disease, having undergone RCA intervention in [**Month (only) 956**]. On routine examination she was found to have new ECG changes and on questioning related minor exertional pain and dyspnea for a few months this summer. Stress MIBI revealed new fixed septal deficit and elective catheterization was done. This revealed progression of her disease and she was admitted now for surgical intervention. Past Medical History: hyperlipidemia hypertesnion fibromyalgia spinal stenosis s/p cataract extractions asthma Social History: Social history is significant for the absence of current or previous tobacco use. There is no history of alcohol abuse. Widowed, no children. Works as interior designer. Family History: There is a family history of premature coronary artery disease in the patient's father - died of MI at age 40. Mother died at 47 of uterine cancer. Physical Exam: VS: 97.6, 91/65, 90SR, 18, 98%ra Gen: NAD, appears stated age HEENT: unremarkable Lungs: CTAB CV: RRR, no murmur or rub Abd: NABS, soft, non-tender, non-distended Ext: trace edema Incisions: [**Doctor Last Name **]- c/d/i no erythema or drainage, sternum stable; EVH- c/d/i, no erythema or drainage Pertinent Results: [**2167-9-19**] 07:50AM BLOOD WBC-5.5 RBC-4.23 Hgb-13.1 Hct-37.9 MCV-90 MCH-31.0 MCHC-34.6 RDW-14.3 Plt Ct-269# [**2167-9-19**] 07:50AM BLOOD Glucose-98 UreaN-8 Creat-0.6 Na-134 K-4.3 Cl-96 HCO3-29 AnGap-13 [**2167-9-19**] 07:50AM BLOOD Mg-2.1 [**Known lastname **],[**Known firstname **] [**Medical Record Number 106756**] F 64 [**2103-4-29**] Radiology Report CHEST (PA & LAT) Study Date of [**2167-9-19**] 4:56 PM [**Last Name (LF) **],[**First Name3 (LF) **] R. CSURG FA6A [**2167-9-19**] SCHED CHEST (PA & LAT) Clip # [**Clip Number (Radiology) 106757**] Reason: f/u atx, effusion [**Hospital 93**] MEDICAL CONDITION: 64 year old woman with s/p cabg REASON FOR THIS EXAMINATION: f/u atx, effusion Provisional Findings Impression: JRld SUN [**2167-9-20**] 8:37 AM Small bilateral pleural effusions are larger in the left side and associated with atelectasis unchanged from prior. Preliminary Report !! PFI !! Small bilateral pleural effusions are larger in the left side and associated with atelectasis unchanged from prior. DR. [**First Name (STitle) 3901**] [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3902**] PFI entered: SUN [**2167-9-20**] 8:37 AM Imaging Lab Brief Hospital Course: On [**9-14**] she was admitted and went to the operating room where revascularization was performed. Grafting times 4 was done and she weaned form bypass easily on low dose neosynephrine. She remained stable and was extubated easily. Her neosysynephrine weaned slowly on POD 1 and she was transferred to the floor. Pain control was an issue due to her fibromyalgia. She resumed her preoperative regimen and was comfortable. While asleep her systolic BP fell into the 70s, although she remained asymptomatic. She transferred back to the CVICU for resumption of her neosynephrine. Blood pressure stabilized, and neo was weaned off. The patient was transferred back to the floor where she made excellent progress, showing good strength and balance with physical therapy. She did develop a bilateral superficial phlebitis and complained of night sweats. She remained afebrile and white count remained normal. She was started on Keflex for this. The patient did develop sinus tachycardia and her lopressor was titrated appropriately. ACE inhibitor was held due to hypotension. By the time of discharge on POD 6, the patient was ambulating freely, the wound was healing, and pain was controlled with oral analgesics. She was discharged to home with the usual post-op instructions and follow-up. Medications on Admission: Atenolol 25mg [**Hospital1 **],Buprion 150mg/D,Zyrtec 10mg/D, Lasix 20mg/D, Neurontin 400mg TID,Dilaudid 1-4mg/4-6hr prn, Levoxyl125mcg/D,Lidoderm TD 700/D, Ativan 0.5/D, Protonix 40mg/D,Pravastatin 80mg/D Discharge Medications: 1. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO every twelve (12) hours. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 2. Levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily). 3. Gabapentin 400 mg Capsule Sig: Two (2) Capsule PO TID (3 times a day). 4. Bupropion 150 mg Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO QAM (once a day (in the morning)). 5. Lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as needed for pain. 6. Plavix 75 mg Tablet Sig: One (1) Tablet PO once a day. 7. Pravachol 80 mg Tablet Sig: One (1) Tablet PO once a day. 8. Ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). Disp:*60 Capsule(s)* Refills:*2* 10. 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* 11. Albuterol 90 mcg/Actuation Aerosol Sig: Two (2) Puff Inhalation Q4H (every 4 hours) as needed. 12. Lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO BID (2 times a day). 13. Lorazepam 0.5 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day) as needed. 14. Hydromorphone 2 mg Tablet Sig: 1-2 Tablets PO every [**3-22**] hours as needed. Disp:*60 Tablet(s)* Refills:*0* 15. Metoprolol Tartrate 25 mg Tablet Sig: 1.5 Tablets PO TID (3 times a day). Disp:*135 Tablet(s)* Refills:*0* 16. Cephalexin 500 mg Capsule Sig: One (1) Capsule PO Q6H (every 6 hours) as needed for superficial phlebitis for 4 days. Disp:*16 Capsule(s)* Refills:*0* 17. Furosemide 20 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 18. Potassium Chloride 20 mEq Packet Sig: One (1) Packet PO once a day. Disp:*30 Packet(s)* Refills:*0* 19. Ambien 10 mg Tablet Sig: One (1) Tablet PO hs prn insomnia. Disp:*30 Tablet(s)* Refills:*0* 20. Evista 60 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* 21. Zyrtec 10 mg Tablet Sig: One (1) Tablet PO once a day. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: coronary artery disease s/p coronary revascularization fibromyalgia spinal stenosis hypercholesterolemia lacunar infarcts asthma s/p coronary angioplasty Discharge Condition: good Discharge Instructions: no lifting more than 10 pound for 10 weeks no driving for 4 weeks and off all narcotics report any drainage from or redness of incisions report any fever greater than 100.5 report any weight gain more than 5 pounds in aweek shower daily, no baths or swimming no lotions, creams or powders to incisions take all medications as directed. Followup Instructions: [**Hospital 409**] clinic in 1 week Dr. [**Last Name (STitle) **] in 3 weeks ([**Telephone/Fax (1) 170**]) Dr. [**Last Name (STitle) 1016**] in [**12-17**] weeks Dr. [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) 4251**] in 2 weeks Completed by:[**2167-9-20**]

[ "V12.54", "244.9", "414.01", "729.1", "999.2", "451.82", "511.9", "493.90", "E879.8", "458.29", "250.00", "V45.82", "518.0", "272.4", "411.1", "285.1", "V17.3", "401.9" ]

icd9cm

[ [ [] ] ]

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

icd9pcs

[ [ [] ] ]

6651, 6709

2895, 4198

314, 399

6907, 6914

1658, 2256

7298, 7576

1175, 1324

4454, 6628

2296, 2328

6730, 6886

4224, 4431

6938, 7275

1339, 1639

251, 276

2360, 2872

428, 858

880, 971

987, 1159

63,076

168,166

437

Discharge summary

report

Admission Date: [**2176-11-17**] Discharge Date: [**2176-11-24**] Date of Birth: [**2096-10-24**] Sex: M Service: SURGERY Allergies: E-Mycin Attending:[**First Name3 (LF) 371**] Chief Complaint: right sided abdominal pain Major Surgical or Invasive Procedure: laparoscopic cholecystectomy History of Present Illness: 80 year old male who is well-known to the surgical service who presented on [**11-13**] with abdominal pain and was found to have evidence of choledocholithiasis. He underwent ERCP on [**11-14**] for delivery of stone and sphincterotomy with stent placement. He was discharged yesterday and was pain free until 9pm this evening. He describes sudden onset of right sided abdominal burning that is identical in character to the pain that originally brought him to the hospital several days prior. He currently denies nausea/vomiting/fevers/chills. Past Medical History: Degenerative arthritis right knee gout prostate Ca s/p XRT and Lupron secondary gynecomastia (resolved) CAD s/p PTCA/2 stents glaucoma mild hearing impairment non-toxic goiter hypertension hypercholesterolemia hiatal hernia with GERD mild irritable bowel syndrome history of intestinal polyps (benign) hemorrhoids Past Surgical History: glaucoma surgery b/l cataract surgery Inginal hernia '[**70**] (Dr. [**Last Name (STitle) **] meniscus knee surgery Social History: lives with wife, runs a business prior tobacco ~30pk/yrs. quit 40yrs ago no etoh, no ilicits Family History: sister with lung cancer and sister with [**Name2 (NI) 499**] cancer Physical Exam: 98.7 60 165/68 16 98 General- well appearing elderly male in no acute distress CV- RRR Pulm- CTA b/l Abd- soft, protuberant, moderately tender on palpation in RUQ > epigastrium, no rebound or guarding, no palpable masses Ext- no edema Pertinent Results: [**2176-11-17**] 09:10PM PT-11.3 PTT-29.7 INR(PT)-0.9 [**2176-11-17**] 09:20AM ALT(SGPT)-139* AST(SGOT)-59* ALK PHOS-123* AMYLASE-48 TOT BILI-3.0* [**2176-11-17**] 09:20AM LIPASE-26 [**2176-11-17**] 09:20AM ALT(SGPT)-139* AST(SGOT)-59* ALK PHOS-123* AMYLASE-48 TOT BILI-3.0* [**2176-11-17**] 09:20AM CALCIUM-8.3* PHOSPHATE-2.6* MAGNESIUM-2.1 [**2176-11-17**] 09:20AM LIPASE-26 [**2176-11-17**] 09:20AM WBC-5.0 RBC-4.16* HGB-13.2* HCT-38.2* MCV-92 MCH-31.7 MCHC-34.5 RDW-13.5 [**2176-11-17**] 09:20AM WBC-5.0 RBC-4.16* HGB-13.2* HCT-38.2* MCV-92 MCH-31.7 MCHC-34.5 RDW-13.5 [**2176-11-17**] 09:20AM PLT COUNT-133* [**2176-11-17**] 12:30AM URINE COLOR-Yellow APPEAR-Clear SP [**Last Name (un) 155**]-1.010 [**2176-11-17**] 12:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG KETONE-TR BILIRUBIN-MOD UROBILNGN-2* PH-5.0 LEUK-NEG [**2176-11-16**] 11:24PM LACTATE-1.5 [**2176-11-16**] 11:00PM GLUCOSE-148* UREA N-18 CREAT-0.9 SODIUM-139 POTASSIUM-3.5 CHLORIDE-103 TOTAL CO2-26 ANION GAP-14 [**2176-11-16**] 11:00PM ALT(SGPT)-170* AST(SGOT)-71* ALK PHOS-131* TOT BILI-4.4* [**2176-11-16**] 11:00PM LIPASE-65* [**2176-11-16**] 11:00PM NEUTS-75.9* LYMPHS-13.2* MONOS-9.0 EOS-1.6 BASOS-0.4 [**2176-11-16**] 11:00PM PLT COUNT-125* [**2176-11-17**] CT Abdomen: no fluid collections. b/l renal cysts, gb distention, wall thickening and stones are unchanged with pneumobilia seen, likely secondary to instrumentation [**2176-11-18**] TTE (post op due to new onset a fib): There is symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. Overall left ventricular systolic function is normal (LVEF>55%). Doppler parameters are most consistent with normal left ventricular diastolic function. Right ventricular chamber size and free wall motion are normal. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is no aortic valve stenosis. Mild (1+) aortic regurgitation is seen. No mitral regurgitation is seen. The pulmonary artery systolic pressure could not be determined. There is no pericardial effusion. IMPRESSION: Preserved [**Hospital1 **]-ventricular systolic function. Mild aortic insufficiency. [**2176-11-18**] ECG: Probable atrial fibrillation with rapid ventricular response. Left axis deviation. Consider left ventricular hypertrophy. ST-T wave abnormalities. Since the previous tracing of [**2176-11-17**] atrial fibrillation is new. [**2176-11-19**] ECG: Sinus bradycardia. P-R interval prolongation. Left ventricular hypertrophy. ST-T wave abnormalities. Since the previous tracing sinus bradycardia is new. [**2176-11-19**] CXR: Stable chest findings, bilateral basal atelectasis and mild blunting of pleural sinuses. [**2176-11-20**] ECG:Atrial fibrillation with rapid ventricular response. Left axis deviation. Poor R wave progression. Left ventricular hypertrophy with lateral ST-T wave abnormalities. Compared to the previous tracing of [**2176-11-19**] rapid atrial fibrillation is new. Lateral ST-T wave abnormalities are new. Poor R wave progression is new. [**2176-11-21**] ECG: Atrial fibrillation with a rapid ventricular response. Left axis deviation. Left anterior fascicular block. There is an abnormal transition across the precordium most likely due to lead placement with additional evidence of possible prior anterior myocardial infarction. Left ventricular hypertrophy with associated ST-T wave changes, although ischemia or myocardial infarction cannot be excluded. Compared to the previous tracing atrial fibrillation is new. Brief Hospital Course: [**2176-11-17**] HD1 POD0: Patient admitted to surgery, Dr. [**Last Name (STitle) **]. He was made NPO and given IVF. He was taken to the OR for a laparoscopic cholecystectomy. His surgery was relatively uncomplicated with minimal blood loss, however the patient developed afib with RVR to 180 after extubation. He was initially given lopressor which improved his HR, and then was started on a dilt drip as per the primary team. He was also started on a nitro drip for HTN with good control over his BP. He has hx of MI and CAD s/p stents in [**2165**] and is admitted to the TSICU for ROMI and stabilization. He denied chest pain, nausea, or SOB at that time. [**2176-11-18**] HD2 POD1: A cariology consult was obtained. They stated that the atrial fibrillation likely secodnary to operative course and has now resolved. Pt has not had any recurrances of atrial fibrillation or atrial flutter since being on telemetry. Cardiac enzymes were negative and pt did not have any chest pain. Repeated short runs of SVT are likely the palpitatiosn the pt has been having for years. It appears to be a short RP tachycardia and possible etiologies include atrial tachycardia, AVNRT, or circus movement tachycardia. These are not dangeours arrhythmias and the pt has likely been having it for years as his symptoms suggest. Cardiology recommended no anticoagulation needed. Pt should be sent home with his beta blocker and his [**Doctor Last Name **] of hearts monitor. They continued to follow throughout the hospital course. The patient was tranferred from the ICU to the floor. He was placed on telemetry. [**2176-11-19**] HD3 POD2: 12 lead ECG's performed [**Hospital1 **]. Patient was given a clear liquid diet. [**2176-11-20**] HD4 POD3: Patient's diet was advanced to regular kosher diet, which the patient tolerated well. [**2176-11-21**] HD5 POD4: Patient was placed on a full bowel regiment. A holter monited was placed on the patient per cardiology recommendations. Lopressor, IV was used for rate control. [**2176-11-22**] HD6 POD5: Patient had a small bowel movement with the bowel regiment in place. Potassium was repleted. Labs were monitored daily. [**2176-11-23**] HD7 POD6: A 12 lead ECG was performed due to some ectopy seen on telemetry. The patient had a large bowel movement. Spoke to electrophysiology fellow who stated that despite the ectopy, the patient may go home with the [**Doctor Last Name **] of hearts monitor. [**2176-11-24**] HD8 POD7: The [**Doctor Last Name **] of hearts monitor was placed on the patient and he was given adequate instructions on its use as well as relevant follow up. The metoprolol controlled the patients heart rate and he did not have any episodes of atrial fibrillation since POD 1. Patient was discharged to home. Medications on Admission: Simvastatin 20', Allopurinol 300', Lisinopril 10', Isosorbide Mononitrate SR 120', Metoprolol 50", Acetaminophen PRN, HCTZ 12.5', Zantac 150', Prevacid 30", ASA 81' Discharge Medications: 1. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO DAILY (Daily). 2. Hydrochlorothiazide 12.5 mg Capsule Sig: One (1) Capsule PO DAILY (Daily). 3. Simvastatin 10 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). 5. Lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 6. Allopurinol 300 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 7. Magnesium Hydroxide 400 mg/5 mL Suspension Sig: Thirty (30) ML PO three times a day as needed for constipation for 2 weeks. Disp:*qs ML(s)* Refills:*0* 8. Dronedarone 400 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). Disp:*60 Tablet(s)* Refills:*2* 9. Simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO TID (3 times a day) as needed for gas. Disp:*12 Tablet, Chewable(s)* Refills:*2* 10. Zantac 150 mg Tablet Sig: One (1) Tablet PO once a day. 11. Prevacid 30 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO twice a day. 12. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: For pain not controlled by Acetaminophen . Disp:*40 Tablet(s)* Refills:*0* 13. Polyethylene Glycol 3350 17 gram/dose Powder Sig: One (1) PO DAILY (Daily). 14. Isosorbide Mononitrate 60 mg Tablet Sustained Release 24 hr Sig: Two (2) Tablet Sustained Release 24 hr PO BID (2 times a day). 15. Bisacodyl 10 mg Suppository Sig: One (1) Suppository Rectal HS (at bedtime) as needed for constipation. 16. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime). 17. Lopressor 50 mg Tablet Sig: 1.5 Tablets PO twice a day. Disp:*90 Tablet(s)* Refills:*2* Discharge Disposition: Home Discharge Diagnosis: s/p cholecystectomy A Fib with rapid ventricular response Discharge Condition: Ambulating, tolerating POs, pain controlled, afebrile and with stable vital signs Discharge Instructions: You are being discharged on medications to treat the pain from your operation. These medications will make you drowsy and impair your ability to drive a motor vehicle or operate machinery safely. You MUST refrain from such activities while taking these medications. These medications include but are not limited to: narcotics and benzodiazepines. Use extreme caution when combining these substances with each other, alcohol, or other central nervous system depressants. For your atrial fibrillation events, you have been fitted with a [**Doctor Last Name **] of Hearts monitor to wear at home. Dr. [**Last Name (STitle) **] will be following you for this. For post-operative pain, please take Tylenol (Acetaminophen) as prescribed. Note that Acetaminophen is also in many over-the-counter medications, so check labels -- do not exceed a daily dose of 4 grams (4,000 mgs) of Acetaminophen. For pain that breaks thru despite Tylenol, as discussed you should take Dilaudid as prescribed. Take all medications as directed. Please call your doctor or return to the emergency room if you have any of the following: * You experience new chest pain, pressure, squeezing or tightness. * New or worsening cough or wheezing. * If you are vomiting and cannot keep in fluids or your medications. * You are getting dehydrated due to continued vomiting, diarrhea or other reasons. Signs of dehydration include dry mouth, rapid heartbeat or feeling dizzy or faint when standing. * You see blood or dark/black material when you vomit or have a bowel movement. * You have shaking chills, or a fever greater than 101.5 (F) degrees or 38(C) degrees. * Any serious change in your symptoms, or any new symptoms that concern you. * Please resume all regular home medications and take any new meds as ordered. Activity: No heavy lifting of items [**10-10**] pounds for 6 weeks. You may resume moderate exercise at your discretion, no abdominal exercises. Wound Care: You may shower, no tub baths or swimming. If there is clear drainage from your incisions, cover with clean, dry gauze. Your steri-strips will fall off on their own. Please remove any remaining strips 7-10 days after surgery. 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) **] in [**12-29**] weeks. Call for an appointment at ([**Telephone/Fax (1) 2300**]. Please also follow up with Dr. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] from the electrophysiology cardiology department. ([**Telephone/Fax (1) 2037**] for an appointment. You will also want to follow up with your primary care doctor, Dr. [**First Name4 (NamePattern1) 140**] [**Last Name (NamePattern1) 141**]. Completed by:[**2176-11-25**]

[ "401.9", "V10.46", "574.00", "530.81", "427.31", "272.0", "V45.82", "553.3", "427.0", "412", "576.1", "715.96", "574.10", "414.01", "564.1", "997.1", "E878.8" ]

icd9cm

[ [ [] ] ]

[ "51.23" ]

icd9pcs

[ [ [] ] ]

10270, 10276

5540, 8317

296, 327

10378, 10462

1849, 5517

12814, 13317

1508, 1578

8533, 10247

10297, 10357

8343, 8510

10486, 12445

1262, 1380

1593, 1830

230, 258

12457, 12791

355, 902

924, 1239

1396, 1492

64,311

107,569

5167

Discharge summary

report

Admission Date: [**2170-6-26**] Discharge Date: [**2170-7-2**] Date of Birth: [**2096-8-22**] Sex: M Service: SURGERY Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2777**] Chief Complaint: abdominal and chest pain Major Surgical or Invasive Procedure: [**2170-6-28**] Repair of ruptured juxtarenal abdominal aortic aneurysm with a retroperitoneal approach and a 16 mm x 8 mm bifurcated Dacron graft. History of Present Illness: 73 previously healthy male presents from an OSH after being found to have a large, ~8cm AAA on U/S. The patient first noticed a pulsatile abdominal mass 1-2 months ago and feels it has gradually been growing. He denies any associated pain or other symptoms related to this. Today while working in his home he experienced 2 bouts of dull chest pain radiating to both armpits and his jaw. These episodes lasted approximately 20 minutes, were associated with dizziness and resolved after 10-15 minutes of rest. His wife called 911 and he was taken to St. [**Hospital 107**] Medical Center in [**Hospital1 189**], MA. After noticing the large pulsatile abdominal mass, an ultrasound was performed and he was immediately transferred to [**Hospital1 18**] for Managen of this AAA. He denies back pain/syncopal episodes/shortness of breath. He denies fevers/chills/nausea/vomiting. Past Medical History: PMH: none PSH: L total hip replacement, R lateral resection of clavicle Social History: +tobacco, 1PPD for over 50 years. EtOH socially. Retired FBI [**Doctor Last Name 360**] (26 years). Lives at home with his wife. Family History: NC, denies family history of CAD, vascular disease Physical Exam: Afebrile VSS Gen: WDWN, NAD, AOx3 Neck: supple, no JVD, trachea midline CVS: RRR no M/R/G Pulm: CTA bilat, no W/R/R Abd: Inicision clean/dry/intact without errythema or drainage; bs, soft no m/t/o LE: warm well perfused, no edema bilat Pulses: Rad Fem DP PT [**Name (NI) **] p p p p LLE p p p p Pertinent Results: [**2170-7-2**] 06:25AM BLOOD WBC-7.6 RBC-3.14* Hgb-9.9* Hct-29.1* MCV-93 MCH-31.6 MCHC-34.1 RDW-15.1 Plt Ct-217 [**2170-7-2**] 06:25AM BLOOD PT-12.7 PTT-25.7 INR(PT)-1.1 [**2170-7-2**] 06:25AM BLOOD Glucose-99 UreaN-16 Creat-1.0 Na-139 K-3.3 Cl-100 HCO3-31 AnGap-11 [**2170-7-2**] 06:25AM BLOOD Calcium-8.0* Phos-2.6* Mg-1.9 [**2170-6-27**] 12:47AM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.028 [**2170-6-27**] 12:47AM URINE Blood-NEG Nitrite-NEG Protein-150 Glucose-NEG Ketone-TR Bilirub-SM Urobiln-NEG pH-5.0 Leuks-NEG [**2170-6-27**] 12:47AM URINE CaOxalX-RARE [**2170-6-27**] 12:47 am URINE Source: Catheter. **FINAL REPORT [**2170-6-28**]** URINE CULTURE (Final [**2170-6-28**]): STAPHYLOCOCCUS SPECIES. ~1000/ML. [**2170-6-26**] 9:05 pm MRSA SCREEN Source: Nasal swab. **FINAL REPORT [**2170-6-29**]** MRSA SCREEN (Final [**2170-6-29**]): No MRSA isolated. Radiology Report CTA CHEST W&W/O C&RECONS, NON-CORONARY Study Date of [**2170-6-26**] 4:49 PM [**Last Name (LF) **],[**First Name3 (LF) **] A. EU [**2170-6-26**] 4:49 PM CTA CHEST W&W/O C&RECONS, NON-; CTA ABD W&W/O C & RECONS; CTA PELVIS W&W/O C & RECONS Clip # [**Clip Number (Radiology) 21133**] Reason: Eval AAA. Pt with Cr 1.5 at OSH. Pls proceed with scan. Plea Contrast: OPTIRAY Amt: 90 [**Hospital 93**] MEDICAL CONDITION: 73 year old man with AAA on u/s REASON FOR THIS EXAMINATION: Eval AAA. Pt with Cr 1.5 at OSH. Pls proceed with scan. Please evaluate from top of arch to Mid thigh CONTRAINDICATIONS FOR IV CONTRAST: None. Wet Read: WWM TUE [**2170-6-26**] 5:37 PM 8.2cm OD (4.3 cm ID) infrarenal AAA spanning from renal aa to bifurcation with fistula to L renal vein (3:144) [d/[**Initials (NamePattern4) **] [**Last Name (NamePattern4) 21134**] at 5:30p] incidentals: tiny layering gallstones, no cholescystsitis; emphysema; liver cysts; adrenal hyperplasia Final Report HISTORY: 73-year-old male with AAA. STUDY: CTA of the torso; MDCT images were generated through the chest, abdomen and pelvis after the administration of 90 cc of Optiray intravenous contrast. Coronal and sagittal reformatted images were also generated. FINDINGS: CHEST: There is no axillary, hilar or mediastinal lymphadenopathy. Diffuse emphysematous changes are noted throughout the lungs. Multiple pulmonary nodules are noted throughout the lungs, all of which measure less than 4 mm. They do have a spiculated appearance. A metallic density just inferior to the left main stem bronchus may represent prior surgical intervention. The aorta demonstrates no evidence of intramural hematoma or dissection. The pulmonary arteries opacify normally down to the subsegmental level. The heart appears unremarkable. There is no pleural or pericardial effusion. ABDOMEN: In the left lobe of the liver, there are three well-circumscribed hypodensities, the largest of which measures 25 x 24 mm (3; 95). These are most consistent with cysts. Multiple small hypodensities are seen in the right lobe of liver, many of which are too small to characterize but likely represent cysts. No intrahepatic biliary dilatation is seen. Densities layering within the gallbladder are most consistent with cholelithiasis, although no pericholecystic fluid or wall edema is seen. The spleen is normal in size and appearance. Pancreas appears unremarkable. The adrenal glands are hypertrophic-appearing bilaterally. The kidneys enhance with and excrete contrast symmetrically. In the mid pole of the left kidney is a well-circumscribed hypodensity that measures 25 mm in diameter and likely represents a simple cyst. The small and large intestine show no evidence of obstruction or wall thickening, enhances normally. No lymphadenopathy is seen. No free air or free fluid is noted. CTA: Just below the takeoff of the renal arteries, there is a fusiform abdominal aortic aneurysm that extends down to the iliac bifurcation, but does not extend into the iliac vessels. The aneurysm sac maximally measures 82 mm in diameter (401; 36). Intimal calcifications line the outer perimeter of the sac. The functional lumen of the aorta measures 43 mm in diameter (401; 36) and remainder of the sac is filled with nearly complete circumferential mural thrombus. The height of the aortic aneurysm is approximately 154 mm from the renal artery takeoff to the iliac bifurcation. In series 3, images 143 and 144, there is erosion of the aortic aneurysm into the left renal vein, signifying an arteriovenous fistula. Arterial contrast is then seen refluxing into the left renal vein and down the IVC in a retrograde manner to the level of the iliac veins. Arterial contrast is also seen flowing antegrade up the IVC and refluxing into the hepatic veins. This leak of the abdominal aortic aneurysm appears to be contained within the venous system and no retroperitoneal contrast collections are noted. The [**Female First Name (un) 899**] is occluded. The celiac, SMA, renal, and iliac arteries opacify normally, although with the diversion of flow from the high pressure aortic system to the low-pressure venous system, decreased flow to the mesenteric and lower extremity circulations resulting in underlying ischemia cannot be ruled out. PELVIS: The bladder, prostate and rectum appear unremarkable. BONES: There is a left total hip arthroplasty that shows no evidence of failure or loosening. Degenerative changes are seen in the right hip in the form of subchondral sclerosis and subchondral cysts. Degenerative changes are seen in the lumbar spine with grade 1 retrolisthesis of L5 on S1. Vacuum phenomenon is also noted at the L5-S1 intervertebral discs as well as at the L3-L4 and L2-L3 intervertebral discs. No suspicious lytic or sclerotic lesions are seen. IMPRESSION: 1. Fusiform abdominal aortic aneurysm extending from the renal artery takeoff to the iliac bifurcation; the aneurysm has eroded into the left renal vein creating arteriovenous fistula between the aorta and left renal vein. No extravascular contrast leak is seen. 2. Diffuse emphysematous changes with numerous spiculated 4-mm pulmonary nodules; while the number of nodules is reassuring, the possibility of malignancy cannot be excluded and so a 6- to 12-month followup chest CT is recommended. 3. Cholelithiasis without cholecystitis 4. Hepatic and renal cysts. These findings were discussed by Dr. [**Last Name (STitle) **] with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 21134**] at 17:30 on [**2170-6-26**] via phone. Further discussion with vascular surgery consult resident was also had. Brief Hospital Course: Mr. [**Known lastname 21135**] was admitted from an OSH on [**2170-6-26**] to the VICU. He was started on an esmolol gtt for BP control as well as mucomyst and sodium bicarb gtt for renal protection and preoped for emergent repair. Upon arival a CT scan was done showing fusiform abdominal aortic aneurysm extending from the renal artery takeoff to the iliac bifurcation; the aneurysm has eroded into the left renal vein creating arteriovenous fistula between the aorta and left renal vein. No extravascular contrast leak is seen. He was taken to the OR that afternoon where he underwent: Repair of ruptured juxtarenal abdominal aortic aneurysm with a retroperitoneal approach and a 16 mm x 8 mm bifurcated Dacron graft. He tolerated the procedure well, and was transfered to the CVICU. He received several blood transfusions throughout his stay, but did very well. His gttw were weaned off and he remained was hemodynamically stable. Mr. [**Known lastname **] was volume overloaded post operatively and was diuresed agressively with IV lasix. He was transfered to the VICU on [**6-28**]. While in the VICU he was on a free water restriction and continued with lasix therapy. He was able to void on his own, tolerated a regular diet and ambulated with physicial therapy who found him to be safe independently. On [**7-2**] he was deemed stable for discharge home. He will go on 1 week of diuresis w/ lasix. He should follow up with his pcp regarding BP control and initiation of a statin. Medications on Admission: none Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day): while on narcotics. 2. Oxycodone 5 mg Tablet Sig: 1-2 Tablets PO Q4H (every 4 hours) as needed for pain. Disp:*30 Tablet(s)* Refills:*0* 3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) for 1 weeks. Disp:*7 Tablet(s)* Refills:*0* 4. Potassium Chloride 10 mEq Tablet Sustained Release Sig: One (1) Tablet Sustained Release PO ONCE (Once) for 7 days. Disp:*7 Tablet Sustained Release(s)* Refills:*0* 5. Metoprolol Tartrate 25 mg Tablet Sig: 0.5 Tablet PO BID (2 times a day): hold for hr <55. Disp:*30 Tablet(s)* Refills:*2* 6. Aspirin 325 mg Tablet Sig: One (1) Tablet PO once a day. Discharge Disposition: Home Discharge Diagnosis: Ruptured juxtarenal abdominal aortic aneurysm and aortovenous fistula. Discharge Condition: Mental Status: Clear and coherent. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - Independent. Discharge Instructions: Division of Vascular and Endovascular Surgery Discharge Instructions What to expect when you go home: 1. It is normal to feel weak and tired, this will last for [**6-19**] weeks ?????? You should get up out of bed every day and gradually increase your activity each day ?????? You may walk and you may go up and down stairs ?????? Increase your activities as you can tolerate- do not do too much right away! 2. It is normal to have incisional and leg swelling: ?????? Wear loose fitting pants/clothing (this will be less irritating to incision) ?????? Elevate your legs above the level of your heart (use [**2-14**] pillows or a recliner) every 2-3 hours throughout the day and at night ?????? Avoid prolonged periods of standing or sitting without your legs elevated 3. It is normal to have a decreased appetite, your appetite will return with time ?????? You will probably lose your taste for food and lose some weight ?????? Eat small frequent meals ?????? It is important to eat nutritious food options (high fiber, lean meats, vegetables/fruits, low fat, low cholesterol) to maintain your strength and assist in wound healing ?????? To avoid constipation: eat a high fiber diet and use stool softener while taking pain medication What activities you can and cannot do: ?????? No driving until post-op visit and you are no longer taking pain medications ?????? You should get up every day, get dressed and walk, gradually increasing your activity ?????? You may up and down stairs, go outside and/or ride in a car ?????? Increase your activities as you can tolerate- do not do too much right away! ?????? No heavy lifting, pushing or pulling (greater than 5 pounds) until your post op visit ?????? You may shower (let the soapy water run over incision, rinse and pat dry) ?????? Your incision may be left uncovered, unless you have small amounts of drainage from the wound, then place a dry dressing over the area that is draining, as needed ?????? Take all the medications you were taking before surgery, unless otherwise directed ?????? Take one full strength (325mg) enteric coated aspirin daily, unless otherwise directed ?????? Call and schedule an appointment to be seen in 2 weeks for staple/suture removal What to report to office: ?????? Redness that extends away from your incision ?????? A sudden increase in pain that is not controlled with pain medication ?????? A sudden change in the ability to move or use your leg or the ability to feel your leg ?????? Temperature greater than 101.5F for 24 hours ?????? Bleeding from incision ?????? New or increased drainage from incision or white, yellow or green drainage from incisions MEDICATIONS: You have been started on aspirin and metoprolol (for blood pressure/ heart rate control. You will be on lasix and potassium for 1 week to help with fluid retention. You have been given a prescription for oxycodone, which is a narcotic pain medication. You should follow up with your primary care provider to have liver function tests done, and then start on a statin medication (simvastatin, atorvostatin, etc). The statin medication is beneficial in people with a history of aortic aneurysm, and should be started at a low dose, even if your cholesterol is normal. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 3469**], MD Phone:[**Telephone/Fax (1) 2625**] Date/Time:[**2170-7-11**] 1:45 call PCP for appt with in 2 weeks Completed by:[**2170-7-2**]

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icd9cm

[ [ [] ] ]

[ "38.44" ]

icd9pcs

[ [ [] ] ]

11019, 11025

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338, 489

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53231

Discharge summary

report

Admission Date: [**2167-3-11**] Discharge Date: [**2167-3-17**] Date of Birth: [**2084-10-24**] Sex: F Service: MEDICINE Allergies: Sulfonamides / Norvasc Attending:[**First Name3 (LF) 759**] Chief Complaint: Fall Major Surgical or Invasive Procedure: [**2167-3-12**]: S/P ORIF Left Hip History of Present Illness: Ms [**Known lastname 109588**] is an 82 y/o Female who fell on [**2167-3-11**] after her dialysis treatment and sustained a left intertrochanteric hip fracture. She was admitted to the Orthopedic service for surgical fixation via the emergency room after the fall. She was brought to the operating room on [**2167-3-12**] and underwent open reduction internal fixation with DHS device. The surgery was uncomplicated and the patient was transferred to the recovery room in stable condition. She did well in the recovery room and subsequently transferred to the floor in stable condition. On the night of surgery, she was triggered for asymptomatic hypotension in the 80's and bolused 500cc of IV fluids. On post-op day one, the patient became febrile(Tm 102.5), continued to by hypotensive with tachycardia to 110's. She also had mental status changes at which point the medical service was consulted. The recommendations was to due a delirium work-up which included an urine analysis showing moderate amount of bacteria. Her Foley catheter was discontinued and he patient was started on zosyn. In addition, the patient developed a new oxygen requirment. The patient's blood pressure continued to be labile from the 60's to 90's and her HCT was down to 23.1 from 36 on admission. The patient was pan-cultures and a chest x-ray was performed. The patient was ordered 2 units of pRBCs, at which point the MICU was consulted and the patient was transferred to the MICU on [**2167-3-13**] at 2300. Past Medical History: Hypertension Moderate LVOT obstruction Chronic Renal Failure Hyperlipidemia Osteoarthritis, s/p L total knee replacement Depression Dementia Urinary Incontinence Right internal capsular stroke in [**2158**]: no deficits reported h/o thyroid ablation Social History: Patient lives by herself and is visited by a physical therapist. She has two sons, [**Name (NI) **] and [**Name (NI) **], that are involved in her care. Her son, [**Name (NI) **], who lives nearby, is able to come help her take care of her dog and do shopping. However, she dispenses her own medications. She reports feeling extremely limited by urinary incontinence. Her husband passed away ~10 years ago, and she has been severely depressed (in the setting of suffering from chronic depression/anxiety throughout her life). She is retired from working as a shoe salesperson. She denies tobacco and admits to rare alcohol use. Family History: Father died s/p MI, mother died of "old age." Both sons and both daughters have no health problems. Physical Exam: Vitals: T:99 BP:150/75 P:80 R:14 98%ra General: Alert, oriented, no acute distress, pt able to respond to all questions appropriately, memory intact HEENT: Sclera anicteric, mildly dry membranes, oropharynx clear Neck: supple, JVP elevated in near supine, 3 cm above clavicle Lungs: Clear to auscultation bilaterally, no wheezes, rales, ronchi CV: Regular rate and rhythm, normal S1 + S2, [**3-23**] cres-decres murmur, faint diastolic murmur Abdomen: soft, non-tender, non-distended, bowel sounds present, no rebound tenderness or guarding, no organomegaly Extrem: Left leg externally rotated and shortened. Pain with internal and external rotation. DP/TP 2+. Right leg without sings of trauma, DP/TP 2+. Both upper extremities NVI without signs of trauma. Pertinent Results: ADMISSION LABS [**2167-3-11**] 05:00PM GLUCOSE-90 UREA N-17 CREAT-2.5*# SODIUM-143 POTASSIUM-3.4 CHLORIDE-99 TOTAL CO2-35* ANION GAP-12 [**2167-3-11**] 05:00PM CK(CPK)-63 [**2167-3-11**] 05:00PM cTropnT-0.03* [**2167-3-11**] 05:00PM CK-MB-NotDone [**2167-3-11**] 05:00PM WBC-5.3 RBC-3.79* HGB-12.9 HCT-36.6 MCV-97 MCH-34.0* MCHC-35.2* RDW-15.0 [**2167-3-11**] 05:00PM PLT COUNT-243 [**2167-3-11**] 05:00PM PT-13.1 PTT-27.4 INR(PT)-1.1 [**2167-3-11**] 05:00PM GRAN CT-2680 [**2167-3-11**] 05:00PM BLOOD WBC-5.3 RBC-3.79* Hgb-12.9 Hct-36.6 MCV-97 MCH-34.0* MCHC-35.2* RDW-15.0 Plt Ct-243 [**2167-3-11**] 05:00PM BLOOD Glucose-90 UreaN-17 Creat-2.5*# Na-143 K-3.4 Cl-99 HCO3-35* AnGap-12 CARDIAC ECHO: The left atrium is normal in size. There is moderate symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Left ventricular systolic function is hyperdynamic (EF 80%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is a mild resting left ventricular outflow tract obstruction. The gradient increased with the Valsalva manuever. Right ventricular chamber size and free wall motion are normal. The aortic arch is mildly dilated. There are focal calcifications in the aortic arch. The aortic valve leaflets (3) are mildly thickened. There is no valvular aortic stenosis. The increased transaortic velocity is likely related to high cardiac output. No aortic regurgitation is seen. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. Mild to moderate ([**12-19**]+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. There is mild pulmonary artery systolic hypertension. There is no pericardial effusion. Compared with the findings of the prior study (images reviewed) of [**2165-5-24**], the mitral regurgitation may be somewhat increased. CHEST X-RAY: Heterogeneous opacification in the right lung, predominantly in the mid lung region corresponds to consolidation seen on [**3-14**] chest CT, probably the result of aspiration. Mild pulmonary edema is worse. Mild cardiomegaly and mediastinal vascular engorgement also present. No pneumothorax. CT HEAD: No acute intracranial process. If concern for CVA continues, an MRI with DWI is recommended. CTA CHEST: 1. Small segmental and subsegmental pulmonary emboli within the right upper lobe pulmonary arteries. 2. Small bilateral pleural effusions with associated atelectasis. 3. Borderline enlarged mediastinal lymph nodes. HIP FILMS: Images from the operating suite show placement of a metallic plate with dynamic hip screw across a previously described intertrochanteric fracture. Brief Hospital Course: 82yoF ESRD-HD 3x/wk, htn, depression, p/w with hip fx was transfered to MICU for AMS, hypotension, fevers and found to have PE. Ms [**Known lastname 109588**] was admitted on [**2167-3-11**] for a left intertrochanteric hip fracture. She was brought to the operating room on [**2167-3-12**] and underwent open reduction internal fixation with DHS device. The surgery was uncomplicated and the patient was transferred to the recovery room in stable condition. She did well in the recovery room and subsequently transferred to the floor in stable condition. On the night of surgery, she was triggered for asymptomatic hypotension in the 80's and bolused 500cc of IV fluids. On post-op day one, the patient became febrile(Tm 102.5), continued to by hypotensive with tachycardia to 110's. She also had mental status changes at which point the medical service was consulted. The recommendations was to due a delirium work-up which included an urine analysis showing moderate amount of bacteria. The patient blood pressure continued to be labile from the 60's to 90's at which point the MICU was consulted and the patient was transferred to the MICU on [**2167-3-13**] at 2300. MICU Course: The patient had an epsiode of unresponsiveness with possible aspiration, from which she recovered with brief assist with BVM. She was started on empiric Levaquin/Vanco. All potentially sedating medications were discontinued as potential causes of her delirium. Her pain was controlled with Toradol and acetaminophen, and Oxycodone was disctoninued. A CT head was negative for acute pathology. A CTA chest revealed a subsegmental PE in the RUL; she was started on heparin without bolus given recent ORIF. Patient was seen by Renal, no need for urgent hemodialysis. PT evalauted the patient for early range of motion. A TTE was ordered but not performed prior to transfer to the floor. On the morning of transfer the patient was up in the chair, comfortable, and eating well. . PULMONARY EMBOLISM: Patient found to have subsegmental PE post op. Started on hepairn and bridged to coumadin. She recieved first dose of coumadin on [**2167-3-15**]. After 7.5 mg coumadin over 3 days, patient had INR of 9.5. Coumaden was held and atient was given 2.5 mg vitamin K. - Adjust coumadin dose for INR [**1-20**], would start with 1mg coumadin once INR < 9. - Given PE was provoked, will need anticoagulation for 3 months. - Consider hypercoagulability workup as outpatient . PNEUMONIA: Patient had hypoxia that was likely related to her PE. However, given her fevers and heterogeneous opacification in the right lung, there was concern for aspiration pneumonia. She was emperically started on Vanc and levoquin in the ICU and was started on levofloxacin and flagyl. She was seen by speech and swallow and found to have mild to moderate dysphagia with overt aspiration on thin liquids - Seven day course of levo/flagyl to end on [**3-19**] - Aspiration precautions per speech and swallow recs. . POSITIVE URINE ANALYSIS: Pt had a positive UA though it could be misleading in an oliguric patient. Started on zosyn on the floor and had been receiving cefazolin post-op. Urine culture was without growth and most UTI pathogens would be covered by levofloxacin. Would consider repeat culture if worseing. . DELERIUM. Patient appears to have baseline dementia per notes. She seems to have some additional delerium manifest by waxining and [**Doctor Last Name 688**] orientation. This is likely related to PE, infection, and hospital setting. - discontinued oxybutinin, oxycodone, gabapentin and quinine - Continue acetaminophen standing. . L-INTERTROCHANTERIC HIP FRACTURE S/P ORIF. Currently stable with well healing wound. See above. . ESRD on HD: Renal consult followed. Last HD on [**2167-3-16**]. - Continue to renally dose medications and continue calcium acetate and sevelamer and nephrocaps. . HYPERTENSION: Restarted home meds on discharge. . HYPERLIPIDEMIA: Continue statin. . FEN: Diabetic diet, replete lytes . PPX: Coumadin Medications on Admission: . Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 3. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Quinine Sulfate 324 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 6. Gabapentin 100 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). 7. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 8. Oxybutynin Chloride 5 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 9. Albuterol Sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 10. Ipratropium Bromide 0.02 % Solution Sig: One (1) Inhalation Q6H (every 6 hours) as needed. 11. Heparin (Porcine) 5,000 unit/mL Solution Sig: One (1) 5000 Injection TID (3 times a day) for 4 weeks. 12. Acetaminophen 325 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours). 13. Oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain. Discharge Medications: 1. Coumadin 1 mg Tablet Sig: One (1) Tablet PO once a day: Do not give unless INR < 3. Give at 4PM. 2. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO DAILY (Daily). 3. Calcium Acetate 667 mg Capsule Sig: One (1) Capsule PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 4. Citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 5. Ethyl Chloride 100 % Aerosol, Spray Sig: One (1) Topical PRN as needed for HD. 6. Lidocaine-Prilocaine 2.5-2.5 % Kit Sig: One (1) application Topical once a day as needed for HD. 7. Nifedical XL 30 mg Tab,Sust Rel Osmotic Push 24hr Sig: Three (3) Tab,Sust Rel Osmotic Push 24hr PO once a day. 8. Pravastatin 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily). 9. Sevelamer HCl 400 mg Tablet Sig: Two (2) Tablet PO TID W/MEALS (3 TIMES A DAY WITH MEALS). 10. Aspirin 81 mg Tablet Sig: One (1) Tablet PO once a day. 11. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 12. Senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 13. Levofloxacin 250 mg Tablet Sig: One (1) Tablet PO Q48H (every 48 hours) for 2 days: Last dose [**3-19**], give q48h. Give after HD on hemodialysis days . 14. Metronidazole 500 mg Tablet Sig: One (1) Tablet PO Q12H (every 12 hours) for 2 days: last dose [**3-19**] . 15. Acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q 8H (Every 8 Hours). Discharge Disposition: Extended Care Facility: [**Hospital3 7**] & Rehab Center - [**Hospital1 8**] Discharge Diagnosis: ## Pulmonary Embolism - acute, post-operative ## Delerium ## Aspiration Pneumonia ## Osteoporosis s/p fall with left hip fracture, s/p operative repair ## s/p fall - felt to be associated with orthostasis s/p hemodialysis ## Hypetension ## Depression ## incidentally noted borderline mediastinal lymphadenopathy Discharge Condition: Stable Discharge Instructions: You were admitted for a hip fracure. You developed a blood clot in your lungs and will need to take coumadin for this. You should discuss with your primary care doctor about how long to be on this medication and if any further studies are needed. You were also started on antibiotics for an infection in your lungs. For your fracture, please keep incision dry. Do not soak in tub. No showering until after your first follow up appointment. You cna continue to be full weight bearing on your Left leg. Continue to take Coumadin to prevent blood clots. Take all medications as instructed. Resume your home medications. If you have questions, concerns or experience fevers greater than 101.2, incisional drainage, bleeding or redness, calf pain, chest pain or shortness of breath, then call [**Telephone/Fax (1) 1228**] or go to your local emergency room. Followup Instructions: 2 weeks with [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], NP. Please call [**Telephone/Fax (1) 1228**] to make this appointment. Provider: [**Name10 (NameIs) 5536**] [**Name8 (MD) **], MD Phone:[**Telephone/Fax (1) 5537**] Date/Time:[**2167-3-26**] 10:30 Provider: [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) 26**] [**Last Name (NamePattern1) **], MD Phone:[**Telephone/Fax (1) 250**] Date/Time:[**2167-4-9**] 1:30 Completed by:[**2167-3-17**]

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icd9cm

[ [ [] ] ]

[ "79.35", "39.95" ]

icd9pcs

[ [ [] ] ]

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670

176,690

12242

Discharge summary

report

Admission Date: [**2161-2-6**] Discharge Date: [**2161-2-12**] Date of Birth: Sex: M Service: This discharge summary dictates the [**Hospital 228**] hospital cousre from the [**4-6**] to the [**4-12**] at approximately 10:00 a.m. HISTORY OF PRESENT ILLNESS: The patient is a 80 year-old male who is brought to [**Hospital6 3105**] by EMS after a neighbor had not seen the patient for two to three weeks. EMS found the patient slumped over the radiator unresponsive with a faint tachycardic pulse. He was intubated and supported on IMV. At the time his vital signs were reportedly temperature 93.3, heart rate 148, blood pressure 124/86, respiratory rate 16. The Emergency Room nurse [**First Name (Titles) **] [**Hospital6 3105**] noted a blood pressure of 50/palp and a respiratory rate 20. CT scan at the time was negative for intracranial hemorrhage. Fluid boluses were negative with amps of sodium bicarb. No arterial blood gases was performed prior to this treatment. The patient was started on broad spectrum antibiotics at [**Hospital3 **] for presumed aspiration pneumonia. The patient's skin was noted to be necrotic in different areas including his toes, feet, fingers and the tip of his penis. In addition the patient had an eschar over the sacrum reportedly over the skin that was intact with the radiator and an abrasion over the left scapular. These areas were treated with silver sulfadiazine DuoDerm dressings. He was transferred here for further treatment of his ischemic extremities and management of his ventilatory status. PAST MEDICAL HISTORY: None known. He has reportedly not seen a doctor in more then 20 years. ALLERGIES: No known drug allergies. MEDICATIONS ON TRANSFER: Digoxin .125 mg intravenous q.d., Ceftriaxone 1 gram intravenous q.d., Ciprofloxacin 400 mg intravenous q.d., Metronidazole 250 mg intravenous q 6 hours, ________________ 20 mg intravenous b.i.d., morphine sulfate 1 to 10 mg intravenous q one hour prn. The patient received two doses on the [**4-6**]. SOCIAL HISTORY: Unable to obtain. The patient lives alone. FAMILY HISTORY: Not obtainable. PHYSICAL EXAMINATION ON ADMISSION: Vital signs temperature 96.8. Heart rate 65 and regular. Blood pressure 140/45. Vent settings SIMV 700 by 8, pressure support 10, PEEP of 5, FIO2 .5, getting an O2 sat of 100%. He has a right subclavian and right art line in place. In general he is intubated and noted sedative drip is hanging. HEENT pupils are pin point bilaterally, mildly reactive, positive corneal reflex. Sclera are anicteric. Lungs decreased breath sounds at bases bilaterally. No wheezes, rhonchi or crackles. Heart regular rate and rhythm with S1 and S2. No S3 or S4. Abdomen positive abdominal bruit in abdomen, pulsatile aorta. Skin over the left scapula, there is an excoriation measuring 17 by 7 cm with black eschar covered with DuoDerm. On the coccyx there is a stripped sheet eschar 15 by 7 cm with surrounding skin breakdown. Toes and fingers are cold and cyanotic. There are open superficial sores on the tibia bilaterally. There is warm erythema proximal to the areas of necrosis. Ankles have blisters bilaterally. Neurologically, there is no response to sternal rub. He has positive corneal reflex. No gag. Toes are equivocal. Vascular, femoral pulses are palpable 2+ bilaterally. Popliteal pulses dopplerable bilaterally. Biphasic dorsalis pedis pulse and posterior tibial pulse are not dopplerable or palpable. Radials are 2+ bilaterally. LABORATORIES FROM [**Hospital3 **] [**2-5**]: White blood cell count 12.5, hematocrit 37, platelets 88. Differential is 56 neutrophils, 36 bands, 1 lymph. Electrolytes are 145, potassium 4.8, chloride 104, bicarb 30, BUN 188, creatinine 5.4, glucose 249, CK 6040, calcium 7.5. On the [**4-6**] his laboratories at [**Hospital3 **] white count 13.2, hematocrit 34, platelets 74. Differential 84 neutrophils, 13 bands, 1 lymphocytes, sodium 144, potassium 3.9, chloride 100, bicarb 35, BUN 140, creatinine 3.9, troponin is .37 and CK is 6767. On admission to [**Hospital3 **] white count 14.8, hematocrit 33.8, platelets 95, INR 1.5, PTT 26.5, sodium 148, potassium 3.9, chloride 105, bicarb 36, creatinine 3, glucose 103, calcium 8.1, magnesium 2.3, phosphate 4.9, albumin 1.8. CK 6322. Arterial blood gas is 7.50, 41 and 142. Microdata, sputum from [**2-4**] 4+ staph aureus. Chest x-ray here showed an ETT/OGT in place, subclavian on the right was advanced into the right atrium. This was subsequently pulled back. Right lower lobe infiltrate without effusions. No cephalization. No pneumothorax. Electrocardiogram from the 20th, atrial fibrillation with ventricular rate of 132, QRS duration of 149, QTC 536, left bundle branch block. On admission he was in sinus at 64, PR 162, QRS 120, QTC 473, normal axis, left bundle branch morphology, poor R wave progression, T wave inversions inferiorly. No prior comparison is made with an electrocardiogram before the [**4-4**]. HOSPITAL COURSE: The patient was admitted to the Medical Intensive Care Unit. 1. Ventilatory management: The patient was continued on SIMV for the first several days of his hospital admission. On the [**4-10**] he had an arterial blood gas of 7.49, 42 and 146. On the 27th it was 7.45, 41 and 162. He had a good rapid shallow breathing index of 35. His compliance was 60. The decision was made to extubate the patient on the [**4-11**]. He was extubated successfully and placed on 4 liters nasal canula and has been maintaining good oxygen saturation. He has not required reintubation. 2. Rhabdomyolysis: The patient's CKs were noted to be elevated greater then 6000 on admission. These trended down, but are not normal as of this dictation. The patient's renal failure was suspected to be secondary to this rhabdomyolysis. Urine sediment was examined on the night of admission and demonstrated muddy brown cast. The patient was hydrated first with normal saline and then with half normal saline and D5W. The patient's creatinine fell and at the time of this dictation it was .8. His BUN is 27. 3. Ischemic extremities: A vascular surgery consult was requested on the second hospital day. They did not see a need for acute intervention and felt that the ischemic areas would become gangrenous. Possibly requiring amputation. After consultation with the family amputation was determined to be inconsistent with the patient's premorbid wishes and the Vascular Surgery Service signed off. 4. Disseminated intravascular coagulopathy: The patient's platelets rose gradually reaching a level above 150 by hospital day five. His INR and PTT were also normal. DIC is not an active issue at present. 5. Infectious disease: The patient was initially started on Vancomycin and Ceftriaxone for coverage of sputum with staph aureus. Upon speciation of his sputum it was determined that it was sensitive to Oxacillin. He was changed to Oxacillin on hospital day number three and this was subsequently discontinued when the patient was made comfort measures only. The patient's family saw him on the [**4-9**] and were concerned about his prognosis. As the patient's mental status did not seem appropriate an electroencephalogram was ordered and this demonstrated encephalopathic changes. The patient's family made the decision to withdraw care and make the patient comfort measures only on [**2-11**]. His medications were changed at that time to a Fentanyl drip and an Ativan drip both titrated for his comfort and intravenous fluids to keep his vein open and prn Tylenol. The patient is currently comfort measures only. DISPOSITION: To be determined. [**Name6 (MD) 2467**] [**Last Name (NamePattern4) 10404**], M.D. Dictated By:[**Last Name (NamePattern1) 5476**] MEDQUIST36 D: [**2161-2-12**] 10:18 T: [**2161-2-12**] 10:36 JOB#: [**Job Number **]

[ "507.0", "286.6", "942.24", "785.4", "728.89", "584.9", "780.01", "E924.8", "348.3" ]

icd9cm

[ [ [] ] ]

[ "96.72", "96.6" ]

icd9pcs

[ [ [] ] ]

2130, 2168

5041, 7942

290, 1587

2183, 5023

1747, 2051

1610, 1721

2068, 2113

24,230

147,426

20529

Discharge summary

report

Admission Date: [**2141-3-14**] Discharge Date: [**2141-5-1**] Date of Birth: [**2095-3-8**] Sex: M Service: CARDIOTHORACIC Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 2969**] Chief Complaint: difficulty swallowing Major Surgical or Invasive Procedure: s/p 3-hole esophagectomy [**3-14**] for esophogeal cancer History of Present Illness: 46yo Chinese gentleman who presented with a two-month history of postprandial epigastric discomfort. Work-up included an esophagoscopy which noticed a lesion in the mid-to-distal esophagus, biopsy proven to be squamous cell carcinoma, mostly in-situ but with several foci indeterminate for invasion. EUS defined a T2N0 tumor, with a PET scan showing multiple radioactive lymph nodes, in the medistinum and bilateral cervical. ENT evaluation, including fine needle aspiration, demonstrated sinusitis with reactive lymph nodes. A staging procedure on [**2141-3-1**], consisting of bronchoscopy, mediastinoscopy, and EGD with gastric biopsy, was essentially negative. Accordingly, he now presents for elective resection of the primary tumor. Past Medical History: none Social History: Lives with 2 other adult men. Brother owns/operates Chinese Food Restaurant. Nephews visit regularly. Wife, son and daughter reside in [**Name (NI) 651**]; VISA/immigration process initiated for compassionate reasons Family History: no family history of cancer Physical Exam: In the Thoracic Surgery clinic: GENERAL: He is a thin gentleman weighing 129 pounds. VITAL SIGNS: He is afebrile, pulse is 61 and regular, blood pressure 123/75, respirations 16, room air saturation is 98%. HEENT: He has no scleral icterus or adenopathy that I could palpate in the neck or either supraclavicular fossa. LUNGS: Clear to auscultation and percussion. ABDOMEN: Soft and nontender with normal bowel sounds. HEART: Regular rhythm and rate. There is no murmur or gallop. Brief Hospital Course: 46yo M admitted to Thoracic surgery service after undergoing transthoracic near total esophagectomy with cervical esophagogastrostomy and feeding jejunostomy on [**2141-3-14**]; please see operative notes for details. Post-operatively the pt was brought to the ICU, hemodynamically stable, and extubated that evening. An epidural catheter was in place, as were #28 chest tubes bilaterally, 16F jejunostomy, and a #10 JP drain. He was transferred to the floor on POD 1. The chest tubes were initially placed to water seal, but developing pneumothorax prompted return to wall suction on POD 3. The chest tube output appeared chylous, with moderately high output and elevated triglycerides, and therefore enteral feedings were held as TPN was initiated with octreotide via a new PICC. In the meantime, the foley, epidural, and NGT were removed, a swallow study showed a tiny leak. A lymphangiogram on POD 13 was unsuccessful at prolonged lymphatic cannulization. The high chylous chest tube output prompted a return to the OR for thoracic duct ligation on [**2141-3-29**] via a R thoracotomy. Briefly on Neo, he was extubated the following day and returned to the floor. Nonetheless, the chest tube output remained high, (ie, 4 liters daily), electrolytes were corrected aggressively, and TPN continued. The patient returned to the OR on [**2141-4-4**] for accessory thoracic duct ligation via a L thoracotomy. At this point, there were 2 chest tubes on each side, with intermittent pneumothorax on the R. The L posterior tube was removed with little output. On POD 26, 11, 5 he spiked a fever with erythema noted at the epidural site; catheter tip culture revealed methicillin sensitive staph aureus and methicillin resistant staph epi; subsequent blood cultures revealed MSSA. Broad-coverage antibiotics were tailered down to just vancomycin and continued based on the first negative blood culture. The chest tube outputs had decreased from several liters to ~4-500cc daily each, and eventually both R chest tubes were removed. TF's via the J-tube were begun on POD 34, supplemented with PO full liquids, and TPN weaned off. However, the L chest tube then began having output of 1000-1500cc daily, became cloudier in appearance, and demonstrated intermittent air leak. Remainder of hospital course completed by [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 54929**] NP POD# 35-47 pt on soft solid diet. TPN d/c'd and tube feed to goal. Given medium chain fatty acids w/c/o diffuse abd pain w/ some focus in right upper quadrant. Made NPO. Abd ultrasound revealed "plump gall bladder but no acute process. LFT's elevated-presumably from TPN which had been d/c'd. Pt reminded NPO w/ resolution of symptoms - tube feed and po's resumed after 48hrs w/o further occurence of abd discomfort. LFT's continued to trend downward daily. Air leak in left chest tube resolved and output slowed and chest tube was removed w/o incident. transitioned from PCA to pain med via j-tube w/ good effect. Able to administer elixir medications and tube feed via j-tube w/ good technique. Sent home w/ VNA services for continued assessment and j-tube care and management. Medications on Admission: none Discharge Medications: 1. tube feeding vivonex C 93cc/hr 1600-1000 2. tube feeding supplies Kangaroo pump tube feeding supplies- syringes, tube feeding bags. 3. Oxycodone-Acetaminophen 5-325 mg/5 mL Solution Sig: 5-10 MLs PO Q4-6H (every 4 to 6 hours) as needed. Disp:*240 ML(s)* Refills:*0* 4. Gabapentin 250 mg/5 mL Solution Sig: Two (2) ml PO TID (3 times a day). Disp:*180 ml* Refills:*2* 5. Docusate Sodium 150 mg/15 mL Liquid Sig: Ten (10) ml PO BID (2 times a day). Disp:*600 ml* Refills:*2* 6. Lansoprazole 30 mg Susp,Delayed Release for Recon Sig: Thirty (30) mg PO DAILY (Daily). Disp:*30 mg* Refills:*2* 7. Ibuprofen 100 mg/5 mL Suspension Sig: Twenty (20) ml PO Q6H (every 6 hours). Disp:*2400 ml* Refills:*2* Discharge Disposition: Home With Service Facility: [**Location (un) 86**] VNA Discharge Diagnosis: esophageal cancer 3-hole esophagectomy [**3-14**] for cancer, return to OR [**3-29**] for right thorocotomy for thoracic duct ligation for chylothorax, return to OR [**4-4**] for Left thoracotomy and ligation of accessory thoracic duct. Discharge Condition: good Discharge Instructions: Call Dr.[**Doctor Last Name 4738**]/Thoracic Surgery office( [**Telephone/Fax (1) 170**]) for: fever, chest pain, shortness of breath, nausea, vomitting, clogged jejunostomy tube. Take medications as directed by mouth No medications to be crushed and given by j-tube as this may clog tube. Diet soft solids and Tubefeeding: Vivonex Full strength; Additives: Promod 35 gm/day @ 70 ml/hr continuous or 93cc/hr 1600-1000 Flush w/60ml water every 8hrs Tube feeding support by [**Hospital1 5065**] [**Telephone/Fax (1) 39931**] VNA services Followup Instructions: You have a follow-up with Dr. [**Last Name (STitle) **], [**First Name3 (LF) 1092**] Surgery on thursday [**2141-5-11**] at 11am in the [**Hospital Ward Name 23**] Clinical center [**Location (un) 8939**]. Arrive 45 minutes prior to your appointment and report to [**Hospital Ward Name 23**] clinical [**Location (un) **] radiology for a follow up CXR. Completed by:[**2141-5-2**]

[ "997.99", "512.1", "996.63", "790.7", "457.8", "041.11", "230.1", "511.8", "682.2" ]

icd9cm

[ [ [] ] ]

[ "42.41", "43.5", "99.10", "46.32", "40.3", "34.92", "34.04", "99.15", "96.6", "42.52", "40.64", "40.0" ]

icd9pcs

[ [ [] ] ]

5987, 6044

2008, 5206

341, 400

6327, 6334

6919, 7302

1454, 1483

5261, 5964

6065, 6306

5232, 5238

6358, 6896

1498, 1980

280, 303

428, 1173

1195, 1201

1217, 1438

12,727

169,047

42972+42984+58574

Discharge summary

report+report+addendum

Admission Date: [**2142-8-20**] Discharge Date: [**2142-9-11**] Date of Birth: [**2072-1-13**] Sex: M Service: ADDENDUM: His discharge laboratory studies include a white count of 5.7, hematocrit 32.1, platelet count 254,000, sodium 140, potassium 4.2, chloride 106, CO2 28, BUN 21, creatinine 1.6, glucose 106. He is also being discharged on 40 of NPH Insulin every morning and an insulin sliding scale, of which a copy will be attached to the discharge summary. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Last Name (NamePattern1) 31272**] MEDQUIST36 D: [**2142-9-11**] 09:05 T: [**2142-9-11**] 09:30 JOB#: [**Job Number 92755**] Admission Date: [**2142-8-20**] Discharge Date: [**2142-9-11**] Date of Birth: Sex: Service: HISTORY OF PRESENT ILLNESS: The patient is a 70-year-old male who presented to [**Hospital **] Hospital five days prior to admission at Byte [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **]. He stated he had several weeks of exertional and rest angina responsive to sublingual Nitroglycerin which he had been taking approximately every other day. On the day of admission to [**Hospital **] Hospital he awoke with 10/10 chest pain which initially was relieved with two sublingual Nitroglycerin but then returned and was unresponsive to a third Nitroglycerin. He was brought to the [**Hospital **] Hospital Emergency Room and was treated with Morphine, Heparin and Intactly and ruled out for an myocardial infarction. He underwent an Adenosine Myoview which was negative for chest pain but positive for dyspnea and lateral ST changes and showed a posterior lateral reversible defect and a fixed anterior defect. He also had an echocardiogram which showed an EF of 50% with mild mitral regurgitation and tricuspid regurgitation. He was then transferred to Byte [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] [**First Name (Titles) **] [**Last Name (Titles) **] for cardiac catheterization. PAST MEDICAL HISTORY: Coronary artery disease, status post coronary artery bypass grafting times five in [**2128**]. He has had a history of chronic renal failure, he has a history of AIBR, cellulitis in [**2136-3-27**], gout, essential tremor and status post cholecystectomy. He is also status post multiple PTCA's in the past five years. SOCIAL HISTORY: He is married, he does not drink alcohol. He smoked approximately 20 pack year smoking history and quit 25 years ago. ALLERGIES: Quinidine gives him gastrointestinal upset, shell fish and dye. MEDICATIONS: 1. Lopressor 75 mg p.o. twice a day. 2. Aspirin 325 mg p.o. q day. 3. Avapro 300 mg p.o. q day. 4. Lipitor 40 mg p.o. q day. 5. Lasix 20 mg to 80 mg p.o. q day depending on his edema. 6. NPH 48 units subcutaneously q PM. 7. Humalog sliding scale 70/30 insulin, 90 units q AM. 8. Allopurinol 150 mg p.o. q day. 9. Aldactone 25 mg p.o. q day. 10. Norvasc 5 mg p.o. q day. 11. Dyazide. 12. Xanax .5 mg p.o. q day. PHYSICAL EXAMINATION: Shows an elderly male lying on a stretcher in no acute distress. His skin is warm, dry and intact. Vital signs includes a heart rate of 78, blood pressure 124/65, respirations 20 with an O2 sat of 100% on two liters nasal cannula. His head, eyes, ears, nose and throat shows pupils are equal, round, and reactive to light and accommodation, extraocular movements intact. His pharynx is clear. Neck is supple with no jugular venous distention and no bruits. His lungs were clear to auscultation bilaterally. His heart is regular rate and rhythm with no murmur, rub or gallop. He has an old sternotomy scar which is well healed. His abdomen is obese, he has positive bowel sounds, he is nontender, nondistended with no hepatosplenomegaly. Extremities: No clubbing or cyanosis, he does have 3+ edema on the right and 4+ on the left. His dorsalis pedis and posterior tibial pulses are Dopplerable bilaterally and his right and left femoral arteries are without baseline bruits. LABORATORY: White count of 5.3, hematocrit 28.3, platelets 576,000. His Protime is 13.3, INR 1.2, his sodium 132, potassium 4.1, chloride 101, Co2 23, BUN 27, creatinine .8 and a blood glucose of 147. His LFTs include an ALT of 44, AST 16, LDH 43, alk phos 21, total bili .1 and albumin of .6. His chest x-ray on admission shows cardiomegaly with pulmonary vasculature is prominent suggesting failure. He does have bullous changes in his right lung apex. HOSPITAL COURSE: On the day of admission the patient underwent cardiac catheterization which showed elevated left filling pressures, capillary wedge pressure of 30, his left main was normal. His left anterior descending showed diffuse 60% disease proximally with 100% disease mid-vessel. His left circumflex shows a 100% stenosis proximally. Distal left circ to OM fills via the left to left collaterals. His right coronary artery has known occluded proximal distal vessels from his mammary artery, his saphenous vein graft to the first diagonal was occluded. The saphenous vein graft to the OM 1 is known to be occluded. The saphenous vein graft to the patent ductus arteriosus is occluded. Left internal mammary artery to the left anterior descending is widely patent. The left anterior descending has moderate diffuse disease distally and supplies collaterals to the right. Given this information he was considered to be a possible candidate for coronary artery bypass graft and Dr. [**Last Name (STitle) 1537**] was consulted. Also an intra-aortic pump was placed. Upon seeing the patient it was felt that he would be a candidate for surgery which was scheduled for the following morning. On [**2142-8-21**] the patient underwent coronary artery bypass grafting times three with a reduced sternotomy that included saphenous vein graft to the OM, saphenous vein graft to the diagonal and a saphenous vein graft to the posterior left ventricular branch. He had surgery performed under general endotracheal anesthesia. Cardiopulmonary bypass time was 166 minutes with a cross clamp time of 137 minutes. The patient tolerated the procedure well, was transferred to the Intensive Care Unit in normal sinus rhythm. Dobutamine, Levophed, Insulin and Propofol drips with two atrial and two ventricular pacing wires. Intra-aortic balloon pump and two mediastinal and one left pleural chest tube. Upon arrival in the Intensive Care Unit it was noted that he was acidotic and this was corrected through ventilatory changes. He was also noted to have minimal urine output and his Foley was changed and there was improvement in his urine output following. By the first postoperative day he had improved slightly and was somewhat more hemodynamically stable therefore, his intra-aortic pump was discontinued. Also on this date his Dobutamine was weaned to off and attempts at weaning off his Levophed drip. By the second postoperative day he continued to require Lasix to assist with his urine output and while trying to diurese him attempts were made to begin ventilatory wean. By postop day four, he was noted to be in atrial fibrillation and received bolus of Amiodarone and was eventually started on the Amiodarone drip. He did eventually convert to normal sinus rhythm and was continued on the Amiodarone drip while intubated. By postop day five he had tolerated multiple hours at CPAP and his pressure support was being weaned. He did undergo a bronchoscopy at the bedside which showed minimal secretions and no plugs. At this point he was receiving intermittent doses of diuretic with Lasix and continued in normal sinus rhythm. By postop day eight, he was ready for extubation and was extubated successfully. He had undergone a renal ultrasound because his creatinine had bumped to a peak of 1.9 despite the fact that he continued to make urine while on Lasix drip. A renal ultrasound showed a positive flow bilaterally with his left kidney being moderately greater in size than the right but it was otherwise normal. Also on this date was noted to have further episodes of A-fib and A-flutter and was started on Lopressor and started on Diltiazem drip and continued on the Amiodarone. He continued to receive aggressive diuresis and pulmonary toilet. On postop day nine he did have his cortise changed to a triple lumen and cortise was sent for culture. This eventually came back as staph coag negative and sputum he had sent off around that time was also positive for Methicillin resistant Staphylococcus aureus. He did have an ID consult because previous blood cultures were shown to be positive also including in addition to the staph coag negative, Serratia. Another blood culture from an A-line previously on [**8-25**] showed Klebsiella and Serratia all sensitive to Levaquin. He had been on Vancomycin up until this point and was started on Levaquin for further treatment. On postop day two he did receive a PICC line for intravenous access and also for his antibiotic treatment. By postop day 15 he had been stable in the Intensive Care Unit, required less pulmonary toilet and it was felt that he was ready to be transferred to the floor. Of note, he was started back on insulin regimen and to assist with this [**Initials (NamePattern4) **] [**Last Name (NamePattern4) 3408**] consult for endocrinology was placed. There have been multiple adjustments in his insulin regimen including NPH insulin and regular insulin sliding scale, all very much dependent on his p.o. intake. While he has been on the floor he has been receiving physical therapy and does ambulate some. He otherwise has progressed without incident and does remain in normal sinus rhythm at this time. It is felt that now he would be stable and ready to be discharged to a rehabilitation facility for further physical therapy work before returning to his home. DISCHARGE EXAM: Lungs clear to auscultation on the right with decreased breath sounds at the left base. Heart is regular rate and rhythm. Abdomen is soft, nontender, obese, nondistended. His extremities show no cyanosis, clubbing or edema. His right heel has an ulcer and also there is an ulceration of his decubitus. He is alert an oriented and his neurological status is grossly intact. His discharge labs will be put in an addendum tomorrow. His discharge chest x-ray shows a moderate left effusion with slightly decrease in the amount of atelectasis compared to previous films on the left side. DISCHARGE MEDICATIONS: 1. Lopressor 100 mg three times a day. 2. Tylenol 325 to 350 mg p.o. q 4 to 6 hours p.r.n. 3. Lasix 40 mg p.o. q day. 4. Entericoated aspirin 325 mg q day. 5. Percocet one to two tabs p.o. q 4 to 6 hours p.r.n. pain. 6. Lansoprazole 30 mg q day. 7. Amiodarone 400 mg q day. 8. KCL 25 mEq q day. 9. Colace 100 mg p.o. twice a day p.r.n. 10. Albuterol MDI one to two puffs q 6 hours. 11. Clonazepam .5 mg twice a day. 12. Lipitor 40 mg p.o. q day. He should follow-up with his primary care physician [**Last Name (NamePattern4) **]. [**Last Name (STitle) 92784**] in one to two weeks, with his cardiologist in 2 to 3 weeks and with Dr. [**Last Name (STitle) 1537**] in 4 weeks. He should keep his wounds clean and dry and he should be encouraged to ambulate and encouraged to cough and deep breath. He should have his cardiopulmonary status assessed daily and he should have his wound healing assessed. Also his sternal clips can be discontinued on [**2142-9-19**]. [**First Name11 (Name Pattern1) 275**] [**Last Name (NamePattern4) 1539**], M.D. [**MD Number(1) 1540**] Dictated By:[**Last Name (STitle) 92785**] MEDQUIST36 D: [**2142-9-10**] 18:21 T: [**2142-9-10**] 22:13 JOB#: [**Job Number 92786**] Name: [**Known lastname **], [**Known firstname 77**] Unit No: [**Numeric Identifier 14588**] Admission Date: [**2142-8-20**] Discharge Date: [**2142-9-12**] Date of Birth: [**2072-1-13**] Sex: M Service: ADDENDUM: This is an Addendum to the hospital course. The patient remained in the hospital secondary to lack of availability of a rehabilitation bed. He was discharged to rehabilitation on [**2142-9-12**] with no further complications. [**First Name11 (Name Pattern1) 63**] [**Last Name (NamePattern4) 1508**], M.D. [**MD Number(1) 1509**] Dictated By:[**Dictator Info 14589**] MEDQUIST36 D: [**2142-9-12**] 12:55 T: [**2142-9-12**] 12:59 JOB#: [**Job Number 14590**]

[ "707.0", "414.02", "790.7", "428.0", "427.31", "411.1", "996.62", "276.2", "414.01" ]

icd9cm

[ [ [] ] ]

[ "39.61", "37.22", "88.56", "97.44", "36.13", "38.93", "96.6", "37.61", "33.24", "99.20", "38.91" ]

icd9pcs

[ [ [] ] ]

10647, 12664

4656, 10016

10033, 10624

3189, 4638

921, 2175

2198, 2519

2536, 3166

57,987

190,061

36501

Discharge summary

report

Admission Date: [**2104-3-7**] Discharge Date: [**2104-3-7**] Date of Birth: [**2071-12-18**] Sex: M Service: MEDICINE Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 3561**] Chief Complaint: Respiratory Arrest Major Surgical or Invasive Procedure: Intubated at OSH Chest Tube at OSH Subclavian CVL at OSH History of Present Illness: Pt is a 32 yo M with anoxic brain injury, trachesostomy who presents from OSH after suffering a respiratory arrest. He presented to OSH in acute respiratory distress. He subsequently went into PEA arrest x25min receiving shocks, CPR, amio IV and gtt, epi, dopamine. He also received vanco/zosyn. WBC 69.4, Trop 2.72, ASA 300mg. Chest tube was placed and was [**Location (un) **] to [**Hospital1 18**]. At [**Hospital1 18**] patient had another bradycardic arrest. He was rescuscitated with epi/atropine and CPR. He was noted to have ? granulation tissue at tip of tracheostomy. He was also noted to have subcutaneous air near chest tube. He was taken to CT scan and had another bradycardic arrest secondary to tension pneumothorax. Needle thoracostomy was attempted and chest tube was re-inserted. Patient throughout was very difficult to ventilate. ABG with pH 6.88, WBC 80s, Cr 1.7, Trop 1.34. After discussion with the family patient was made DNR. . On arrival to the MICU patient was bronched and found to have large polypoid mass at trach entrance. Bronchi was found to have blood that did notc clear with saline flushes. . ROS: Unable to obtain as patient is intubated Past Medical History: Anoxi Brain injury at age 2, s/p head injury 9 yrs ago Tracheostomy Social History: trach dependent. Lives in [**Location **]. No EtOH, tobacco, recreational drugs Family History: Non-contributory Physical Exam: VS: 95.2, 87, 125/59, 20, 82% AC, Fi02 100%, PEEP 10, RR 28 Gen: Intubated, sedated HEENT: eyes closed, pupils dilated, slightly reactive on L Neck: Trach in place with oozing Heart: Regular, no m/r/g Lung: Coarse vented BS bilat Abd: distended Ext: cool, no pitting edema Neuro: Completely unresponsive with no CN reflexes Pertinent Results: Admission Labs: [**2104-3-7**] 04:44AM TYPE-MIX PO2-35* PCO2-145* PH-6.82* TOTAL CO2-27 BASE XS--17 [**2104-3-7**] 04:25AM GLUCOSE-185* UREA N-30* CREAT-2.2* SODIUM-144 POTASSIUM-5.6* CHLORIDE-112* TOTAL CO2-20* ANION GAP-18 [**2104-3-7**] 04:25AM ALT(SGPT)-150* AST(SGOT)-263* LD(LDH)-1810* CK(CPK)-851* ALK PHOS-284* TOT BILI-0.7 [**2104-3-7**] 04:25AM CK-MB-29* MB INDX-3.4 cTropnT-1.62* [**2104-3-7**] 04:25AM ALBUMIN-3.0* CALCIUM-8.6 PHOSPHATE-11.5* MAGNESIUM-3.3* [**2104-3-7**] 04:25AM WBC-80.1* RBC-4.69 HGB-11.7* HCT-38.8* MCV-83 MCH-24.9* MCHC-30.1* RDW-14.5 [**2104-3-7**] 04:25AM NEUTS-69 BANDS-12* LYMPHS-6* MONOS-6 EOS-0 BASOS-0 ATYPS-0 METAS-7* MYELOS-0 [**2104-3-7**] 04:25AM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-1+ [**2104-3-7**] 04:25AM PLT SMR-NORMAL PLT COUNT-418 [**2104-3-7**] 04:25AM PT-32.4* PTT-84.4* INR(PT)-3.4* [**2104-3-7**] 04:25AM FIBRINOGE-58* [**2104-3-7**] 02:28AM TYPE-ART RATES-/18 PO2-68* PCO2-145* PH-6.82* TOTAL CO2-27 BASE XS--16 INTUBATED-INTUBATED [**2104-3-7**] 12:41AM PO2-49* PCO2-136* PH-6.88* TOTAL CO2-28 BASE XS--13 [**2104-3-7**] 12:18AM URINE COLOR-Red APPEAR-Cloudy SP [**Last Name (un) 155**]-1.020 [**2104-3-7**] 12:18AM URINE BLOOD-LG NITRITE-POS PROTEIN->300 GLUCOSE-500 KETONE-NEG BILIRUBIN-SM UROBILNGN-0.2 PH-8.5* LEUK-TR [**2104-3-7**] 12:18AM URINE RBC->50 WBC-[**2-7**] BACTERIA-FEW YEAST-NONE EPI-0-2 [**2104-3-7**] 12:18AM URINE COMMENT-DUE TO ABNORMAL URINE COLOR INTREPRET DIPSTICK RESULTS WITH CAUTION [**2104-3-7**] 12:17AM COMMENTS-GREEN TOP [**2104-3-7**] 12:17AM LACTATE-2.8* [**2104-3-6**] 11:51PM COMMENTS-GREEN TOP [**2104-3-6**] 11:51PM GLUCOSE-243* NA+-148 K+-5.6* CL--108 TCO2-25 [**2104-3-6**] 11:15PM GLUCOSE-266* UREA N-25* CREAT-1.7* SODIUM-143 POTASSIUM-5.5* CHLORIDE-108 TOTAL CO2-25 ANION GAP-16 [**2104-3-6**] 11:15PM estGFR-Using this [**2104-3-6**] 11:15PM CK(CPK)-559* [**2104-3-6**] 11:15PM cTropnT-1.34* [**2104-3-6**] 11:15PM CK-MB-25* MB INDX-4.5 [**2104-3-6**] 11:15PM NEUTS-74* BANDS-6* LYMPHS-9* MONOS-4 EOS-1 BASOS-0 ATYPS-0 METAS-6* MYELOS-0 [**2104-3-6**] 11:15PM HYPOCHROM-1+ ANISOCYT-NORMAL POIKILOCY-1+ MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-1+ TEARDROP-1+ [**2104-3-6**] 11:15PM PLT SMR-HIGH PLT COUNT-549* [**2104-3-6**] 11:15PM PT-23.6* PTT-72.0* INR(PT)-2.3* . Imaging: CT Torso: IMPRESSION: 1. Large left tension pneumothorax, with rightward mediastinal shift and interval worsening of left lower lobe collapse. Left chest tube terminates at the left apex, in a region of atelectasis. 2. Dependent opacities in the right lung are likely atelectasis, but sequela of aspiration and infection remain a possibility. 3. Tracheostomy tube apparently abuts the posterior wall of the trachea, possibly partially occluding the lumen. 4. Extensive subcutaneous emphysema centered along the left chest wall, and tracking through the anterior abdominal and pelvic walls. Subcutaneous gas adjacent to the scrotum likely extends from the chest wall, but the scrotum is not imaged. Recommend clinical correlation to rule out scrotal infection. 5. Trace perihepatic ascites. 6. Scattered small retroperitoneal and mediastinal lymph nodes, not enlarged by size criteria. 7. Markedly distended urinary bladder with Foley catheter balloon inflated in the urethra. . CXR: Volume of the left pneumothorax, predominantly basal, has decreased substantially and rightward mediastinal shift is less severe, now due largely to right lower lobe collapse. Consolidation in the right upper lobe has improved, but severe consolidation throughout the left lung has not. Relative contributions of pulmonary hemorrhage, pneumonia, and large scale aspiration are difficult to determine. Heart size is normal. Tracheostomy tube is in standard placement, but the cuff remains severely overinflated, perhaps a necessity from chronic tracheostomy. Clinical examination advised. Left apical pleural tube and left subclavian line in standard placement, unchanged. Subcutaneous emphysema in the left chest wall and neck is receding, presumably a result of thoracostomy placement Brief Hospital Course: The patient was admitted from an OSH aftering suffering a respiratory arrest. At the OSH he went into PEA cardiac arrest complicated by pneumothorax. Chest tube was placed. On arrival to our hospital he had additional cardiac arrests, as well as a tension pneumothorax. After being stabilized, he was transferred to the MICU. In the MICU he underwent bronchoscopy which showed large amount of granulation tissue at the tracheostomy tube. There was also copious blood in the bronchi. He became hypotensive requiring 2 pressors (dopamine and norepinephrine). Exam was notable for complete unresponsiveness without any branstem reflexes. He was also very difficult to ventilate. Labs were remarkable for multiorgan system failure. An extensive family meeting took place explaining his very grave prognosis. When the morning came the family made the decision to make him comfort measures only. He was pronounced dead at 11AM on [**2104-3-7**]. Cause of death, respiratory arrest with subsequent cardiac arrest and tension pneumothorax. The family declined an autopsy. The case was accepted by the medical examiner. Medications on Admission: Fluticasone 50mcg 1 spray [**Hospital1 **] Glycopyrrolate 1mg q8 Metoclopramide 10mg q8 Protonix 40mg Daily Senna prn lactulose prn Tylenol 650mg q4 prn Albuterol 90mcg 6 puffs q2 prn Dulcolax prn lorazepam 2mg IM prn Milk of Mag Morphine 2-4mg q6 prn Discharge Medications: Expired Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired

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icd9cm

[ [ [] ] ]

[ "34.04", "96.71" ]

icd9pcs

[ [ [] ] ]

7802, 7811

6340, 7467

314, 372

7862, 7871

2160, 2160

7927, 7937

1782, 1800

7770, 7779

7832, 7841

7493, 7747

7895, 7904

1815, 2141

256, 276

400, 1577

2176, 6317

1599, 1669

1685, 1766

49,631

133,555

14067

Discharge summary

report

Admission Date: [**2169-10-15**] Discharge Date: [**2169-10-26**] Date of Birth: [**2090-4-22**] Sex: F Service: MEDICINE Allergies: No Known Allergies / Adverse Drug Reactions Attending:[**First Name3 (LF) 3326**] Chief Complaint: SOB Major Surgical or Invasive Procedure: None History of Present Illness: Ms. [**Known lastname 3761**] is a 79 year old woman with recurrent NSCLC IIIA adenocarcinoma of the left lung with metastatic disease of the lung, pleura and lymph nodes who presented today with dyspnea and found to have PE on CTA in the ED. The patient describes dyspnea x several weeks; worse with exertion. Was seen by her oncologist, Dr. [**Last Name (STitle) 9449**], on [**2169-10-11**] due to her dyspnea and was diagnosed with PNA based on exam and RLL infiltrate on CXR. Started on a 7-day azithro course. Since that visit, Ms. [**Known lastname 3761**] has noted significant worsening of her dyspnea and for that reason presented today. Notes cough x several weeks. . On the oncology floor the paitent was given Lovenox and antibiotics changed to levofloxacin. Initially on 2L O2 NC although was saturating in the 80% range. Oxygen supplementation increased to 6L NC and saturations reached the high 80s. Escalated to NRB and the patient was saturating a 100%. Appeared anxious but comfortable around 1700. Attempts were made to wean the patient off of the NRB although she had continuous desaturations on NC only. At 2200, the patient was noted to have increased WOB and was transferred to the MICU for further observation and possibly NIPPV. . On arrival to the MICU, patient's initial VS were 97.1 117/49 90 21 95% NRB. In mild discomfort due to resp distress with desats to high 80s with small movements. Past Medical History: POncH: NSCLC Stage IIIa . PMH: # CAD s/p stent x1 # Hypertension # Hyperlipidemia # Osteoarthritis # Osteoporosis # Irritable bowel syndrome # Diverticulosis # s/p appendectomy Social History: # Personal: Lives alone, 4 adult children # Tobacco: Somked from age 21 - 65, average 1ppd. # Alcohol: 1 glass wine nightly, social. # Recreational drugs: None Family History: Noncontributory Physical Exam: Vitals- 97.1 117/49 90 21 95% General- In mild distress due to dyspnea HEENT- PERRLA, EOMI, anicteric, MMM, OP clear, NRB mask in place Neck- Supple, mild JVD elevation CV- Tachycardic, S1 and S2, no m/r/g Lung- Crackles [**11-27**] way up lung field posteriorly on R, mild crackles at left base. Otherwise good air entry w/o wheezes. Abdomen- Soft, NT/ND, BSx4 Extremity- No gross deformity or edema Skin- No rashes appreciated Neuro- Awake, alert and oriented. Moving all extremities. Pertinent Results: On Admission: [**2169-10-15**] 11:00AM BLOOD WBC-8.9 RBC-3.04* Hgb-9.3* Hct-28.0* MCV-92 MCH-30.6 MCHC-33.2 RDW-16.2* Plt Ct-493*# [**2169-10-15**] 11:00AM BLOOD Neuts-88* Bands-0 Lymphs-5* Monos-7 Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2169-10-15**] 11:00AM BLOOD PT-16.5* PTT-27.0 INR(PT)-1.5* [**2169-10-15**] 11:00AM BLOOD Glucose-208* UreaN-16 Creat-1.0 Na-135 K-4.6 Cl-102 HCO3-18* AnGap-20 [**2169-10-16**] 04:15AM BLOOD ALT-16 AST-25 LD(LDH)-371* AlkPhos-93 TotBili-0.5 [**2169-10-16**] 04:15AM BLOOD Albumin-3.0* Calcium-8.6 Phos-3.4 Mg-1.9 [**2169-10-15**] 05:00PM BLOOD Type-ART Temp-37.6 pO2-59* pCO2-25* pH-7.49* calTCO2-20* Base XS--1 Intubat-NOT INTUBA Vent-SPONTANEOU Comment-NASAL [**Last Name (un) 154**] [**2169-10-15**] 11:11AM BLOOD Lactate-4.6* Brief Hospital Course: The patient is a 79 year old female with advanced NSCLC admitted with respiratory distress from newly diagnosed PE, pneumonia, and volume overload. . [**Hospital Unit Name 153**] Course: On the oncology floor the paitent was given Lovenox and her antibiotics were changed to levofloxacin. Initially on 2L O2 NC although was saturating in the 80% range. Oxygen supplementation increased to 6L NC and saturations reached the high 80s. Escalated to NRB and the patient was saturating a 100%. Appeared anxious but comfortable around 1700. Attempts were made to wean the patient off of the NRB although she had continuous desaturations on NC only. At 2200, the patient was noted to have increased WOB and was transferred to the MICU for further observation and possibly NIPPV. . In the MICU, the patient continued to saturate in the low 90s on facemask. Deep desaturation when moving. CXR appeared worse and abx broadened to cef/vanc. The patient did not require NIPPV although could not be weaned from the facemask initially. Diuresed well with net negative ~1L to 20mg IV lasix daily, and subsequent improvement in oxygenation. Respiratory issues thought to be secondary to pulmonary embolus, pulmonary edema, PNA, and lung cancer. She was anti-coagulated, diuresed, and treated with an 8 day course of vancomycin and cefepime. . OMED Course: # Dyspnea: She presented with several weeks of progressive dyspnea and developed a significant oxygen requirement shortly after arrival to the floor requiring ICU transfer. Her dyspnea is mulitfactorial including advanced NSCLC, new diagnosis of PE in the right upper, middle, and lower lobes, pneumonia, and volume overload. She was treated with Lovenox, antibiotics, and diuresis in the ICU with some improvement in her respiratory status. On floor transfer, she was on 6L NC with SpO2 in the low 90s, but desatting to the 80s with activity. She triggered [**2169-10-21**] for persistent SpO2<90% on facemask, and was diuresed overnight. Her respiratory status was more stable the next day. She was provided supplemental oxygen as needed and Albuterol and Ipratropium nebulizer treatments. The multiple conditions contributing to her dyspnea were managed as discussed below. . # Pulmonary Embolism: This was a new diagnosis found on admission CTA [**2169-10-15**] with emboli to right upper, middle, and lower lobes. Most likely related to underlying malignancy. She was treated with Enoxaparin Sodium 60 mg SC Q12H. . # Pneumonia: She was started on Azithromycin prior to admission by her oncologist due to concern for CAP after presenting with cough and dyspnea. Admission CTA on [**2169-10-15**] showed new (from [**2169-9-21**]) ground glass and interstitial opacities throughout the RLL and inferior RUL concerning for atypical pneumonia. She was started on Levofloxacin on admission and broadened to Vancomycin and Cefepime on [**2169-10-16**] for a worsening CXR. Azithromycin was continued, completing a 5 day course. Blood cultures from [**2169-10-15**] showed no growth. She was not febrile during her stay. Her cough improved after admission, but returned on [**2169-10-21**]. Portable CXR on [**2169-10-21**] showed a stable right sided infiltrate but increased left pulmonary edema. Her WBC count has steadily after floor transfer from 8.9 on [**2169-10-19**] to 16.6 on [**2169-10-22**] with neutrophil predominance on differential. Her Vancomycin trough on [**2169-10-22**] was 25.6, her AM dose was held, and her dose was adjusted. . # Volume Overload: Cardiomegaly and evidence of pulmonary edema was noted on recent CXRs. TTE on [**2169-7-14**] showed LVEF 55-60% without other significant abnormalities. Her left sided pulmonary edema may be due to elevated right heart pressures in the setting of her right sided PEs. Pulmonary edema is likely contributing to her dyspnea. She was diuresed in the ICU using Furosemide 20 mg IV doses with a daily fluid balance goal of negative 1000 ml. Some radiographic improvement was noted on ICU imaging, but recent CXR showed increased left sided pulmonary edema. Diuresis has continued on the floor with fair response, but her creatinine increased to 1.2 on [**2169-10-22**] AM from baseline 0.9 yesterday. It increased further to 1.4 on PM labs despite no further diuresis that morning. . # Anxiety: Moderate anxiety at baseline treated with Citalopram, exacerbated by recent illness. Likely contributing somewhat to her tachypnea and respiratory distress. She was continued on her home Citalopram 20 mg PO daily. . # Advanced NSCLC: Followed by Dr. [**Last Name (STitle) 9449**] here. Plan per recent Oncology note was to pursue three additional cycles of Pemetrexed prior to repeat imaging. She was scheduled for next treatment on Monday, which will be rescheduled. . # Anemia: She has developed a normocytic anemia since starting a new regimen of chemo in [**Month (only) **]. Most likely due to marrow suppressive properties of regimen. No signs of active bleeding. . # Hypertension: Her BP remained fairly stable in the 100s systolic. She was continued on her home Atenolol 50 mg PO daily. Her home Amlodipine 5 mg PO daily was held during her stay. . # Hyperlipidemia: She was continued on Simvastatin 10 mg PO daily. Her Aspirin 81 mg PO daily was held. . On [**2169-10-25**], the decision was made that the focus of care should be shifted to "comfort" only. The patient expired at 14:02 on [**2169-10-26**]. Medications on Admission: AMLODIPINE [NORVASC] - (Prescribed by Other Provider) - 5 mg Tablet - 1 Tablet(s) by mouth daily ATENOLOL - (Prescribed by Other Provider) - 50 mg Tablet - 1 Tablet(s) by mouth daily BENZONATATE - 200 mg Capsule - 1 Capsule(s) by mouth three times a day as needed for cough CITALOPRAM - 20 mg Tablet - 1 Tablet(s) by mouth daily DEXAMETHASONE - 4 mg Tablet - 1 Tablet(s) by mouth twice a day for 1 day before chemo, on the day of treatment, and 1 day after after chemo; take in morning and at 2pm FOLIC ACID - 1 mg Tablet - 1 Tablet(s) by mouth daily MEGESTROL - 400 mg/10 mL (40 mg/mL) Suspension - 10 ml by mouth daily PROCHLORPERAZINE MALEATE - 5 mg Tablet - [**11-27**] Tablet(s) by mouth every 8 hours as needed for nausea SIMVASTATIN - (Prescribed by Other Provider) - 20 mg Tablet - 1 Tablet(s) by mouth once a day ASPIRIN [ASPIRIN LOW DOSE] - (Prescribed by Other Provider) - 81 mg Tablet, Delayed Release (E.C.) - 1 Tablet(s) by mouth daily CALCIUM CARBONATE-VITAMIN D3 - (Prescribed by Other Provider) - 500 mg (1,250 mg)-200 unit Tablet - 1 Tablet(s) by mouth daily DOCUSATE SODIUM [COLACE] - (OTC) - 100 mg Capsule - 1 Capsule(s) by mouth QAM Discharge Disposition: Expired Discharge Diagnosis: Expired Discharge Condition: Expired Discharge Instructions: Expired Followup Instructions: Expired

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icd9cm

[ [ [] ] ]

[ "38.97" ]

icd9pcs

[ [ [] ] ]

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267, 272

344, 1766

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25,054

142,451

29601

Discharge summary

report

Admission Date: [**2165-1-16**] Discharge Date: [**2165-2-3**] Date of Birth: [**2140-4-10**] Sex: M Service: CARDIOTHORACIC Allergies: Azithromycin Attending:[**First Name3 (LF) 165**] Chief Complaint: Endocarditis Major Surgical or Invasive Procedure: [**2165-1-25**] - Bentall procedure with 23mm homograft aortic root and valve, Mitral Valve Replacement (31mm [**Company **] mosaic porcine valve), Tricuspid Valve Replacement (33mm [**Company **] mosaic porcine valve), Placement of AV pacer leads, pacer pericardial patch. [**2165-1-25**] - Re-Exploration for bleeding [**2165-1-24**] - Surgical extraction of all impacted teeth in preparation for cardiac surgery for patient with diagnosis of triple valve disease. Teeth 17, 18, 1, 32. [**2165-1-18**] - Esophagogastroduodenoscopy History of Present Illness: 24 y/o gentleman with history of IVDU with recurrent endocarditis, positive blood cultures for enterococcus fecalis who is transferred for possible mitral, aortic and tricuspid valve replacement. He originally presented to [**Hospital6 22197**] Center for cough and fevers. Blood cultures were poistive and a TEE showed severe AI, MR [**First Name (Titles) **] [**Last Name (Titles) **] with associated large vegetations. He was started on ampicillin and gentamycin and transferred to the [**Hospital1 18**] for further management. He was also noted to have guaiac positive stool on presentation. Past Medical History: Tuberculosis Endocarditis IVDU Hepatitis B and C Guaiac positive stool Depression and anxiety Social History: Working in construction field Pt is from Poland, came to USA 7 years ago IVDA Alcohol : 6~7 drinks/day Quit smoking after smoking 3-4 packs daily for 4 years. Lives with parents Family History: None Physical Exam: Preoperative/Admission: BT 95.6 BP 110/50 PR 67 RR 18 Sat 100 Gen : Looking very fatigued, irritated, short of breath HEENT : PERRL, No LAD, MMM Respiratory : Coarse breathing sound CV : increase S2, both systolic and diastolic murmur Abd : tenderness on right upper quadrant, normal bowel sound Ext : edema on both lower legs Neuro : no focal abnormality Discharge: Stable sternotomy. C/D/I. AVSS Pertinent Results: CT Scan of Chest/Abd/Pelvis 1. Hepatosplenomegaly and small amount of free intraperitoneal fluid with no focal findings suggestive of septic embolus. 2. Cardiomegaly and possible decreased cardiac output based on appearance of contrast (versus timing). Four small pulmonary parenchymal opacities more likely to represent atelectasis as no specific features of septic emboli. [**2165-1-17**] ECHO The left atrium is mildly dilated. The estimated right atrial pressure is 11-15mmHg. Left ventricular wall thicknesses are normal. The left ventricular cavity is moderately dilated. Overall left ventricular ejection fraction is normal (LVEF 70%). [Intrinsic left ventricular systolic function may be depressed given the severity of valvular regurgitation.] There is no ventricular septal defect. The right ventricular free wall is hypertrophied. The right ventricular cavity is dilated. Right ventricular systolic function appears depressed. There is abnormal septal motion/position consistent with right ventricular pressure/volume overload. There is a moderate-sized vegetation on the aortic valve (noncoronary cusp). There is no aortic valve stenosis. Severe (4+) aortic regurgitation is seen. There is a large vegetation on the mitral valve (anterior mitral leaflet), and a small vegetation on the posterior leaflet. There is a moderate vegetation on the tricuspid valve (posterior leaflet). Severe [4+] tricuspid regurgitation is seen. There is severe pulmonary artery systolic hypertension. No vegetation/mass is seen on the pulmonic valve. There is a trivial/physiologic pericardial effusion. Impression: 3 valve endocarditis with severe aortic, mitral, and tricuspid regurgitation; severe pulmonary hypertension; no obvious abscess [**2165-1-20**] Liver U/S No evidence of focal liver lesion. Small amount of ascites. Gallbladder sludge. The hepatic vessels are patent. [**2165-1-30**] CXR Tiny residual left pneumothorax, with new subcutaneous emphysema in the left axillary region. [**2165-1-31**] 05:52AM BLOOD WBC-9.4 RBC-3.64* Hgb-9.8* Hct-29.1* MCV-80* MCH-26.9* MCHC-33.6 RDW-17.9* Plt Ct-142* [**2165-1-31**] 05:52AM BLOOD Plt Ct-142* [**2165-1-28**] 02:30AM BLOOD PT-15.1* PTT-31.6 INR(PT)-1.4* [**2165-1-30**] 07:17AM BLOOD Glucose-97 UreaN-16 Creat-1.2 Na-130* K-3.3 Cl-91* HCO3-29 AnGap-13 Brief Hospital Course: Mr. [**Name14 (STitle) 70965**] was admitted to the [**Hospital1 18**] on [**2165-1-16**] for further management of his endocarditis. He was evaluated by the cardiac surgical service and preoperative workup was initiated. An echo revealed vegetations on his mitral, aortic and tricuspid valves. A dental consult was obtained given the plan for valve replacement surgery. After obtaining a dental panorex, it was suggested to extract 4 teeth prior to surgery. This was performed without complication when his INR was within an acceptable range on [**2165-1-24**]. The cardiology service was consulted and diuresis was continued. No cardiac catheterization was recommended. The infectious disease service was consulted given his history of a positive ppd. Further tests showed that there was no evidence of active or latent tuberculosis infections. Ampicillin and gentamicin were continued for his endocarditis. A left PICC line was placed for continued antibiotics. The gastrointestinal service was consulted for his history of guaiac positive stools although his current rectal exams were guaiac negative. An EGD was performed which was negative for any source of bleeding. The psychiatry service was consulted for assistance with his depression and anxiety. Prozac was stopped and remeron was started for depression. Seroquel was started for anxiety. The electrophysiology service was consulted given his long PR interval and continued to follow him given his risk of developing heart block and needing a pacemaker. The liver service was consulted for clearance for surgery. Vitamin K was used for his elevated INR. No evidence of cirrhosis was noted on ultrasound or laboratory workup however mild ascites and gallbladder sludge was noted. The renal service was consulted for acute renal failure and it was presumed to be realted to his diuresis, ace inhibitor use and possible gentamicin toxicity. As his creatinine stablized, he was cleared for surgery. On [**2165-1-25**], Mr. [**Known lastname 70966**] was taken to the operating room where he underwent a Bentall procedure, a mitral and tricuspid valve replacement, placement of AV pacer leads and a pacer pericardial patch. Postoperatively he was taken to the cardiac surgical intensive care unit for monitoring. He returned to the operating room later for a reexploration for bleeding with hemostasis acheived. He was then returned to the intensive care unit for monitoring. The electrophysiology service interoggated his dual chamber [**Company **] sigma pacemaker. On postoperative day one, Mr. [**Known lastname 70966**] [**Last Name (Titles) 5058**] neurologically intact and was extubated. He began gentle diuresis. His renal function remained stable. On postoperative day three, he was transferred to the step down unit for further recovery. The physical therapy service was consulted for assistance with his postoperative strength and mobility. His gentamicin levels were closely monitored and his dosage was appropriately adjusted. Mr. [**Known lastname 70966**] continued to make steady progress and was discharged to rehabilitation on psotoperative day 7. Medications on Admission: On Transfer: metoprolol 25 po bid pantoprazole 40 q12 guaifenisen-dextromethorphan 10 q6 prn fluoxetine 20 qd ASA 81 ampicillin 2mg IV q4 acetylcysteine 100 po bid x 4 bisacodyl 10 po qd prn codeine 15-30 prn q4-6h prn colace 100 [**Hospital1 **] ferrous sulfate 40 po bid lasix 40 po bid lisinopril 20 qd Discharge Medications: 1. Docusate Sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 2. Aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO DAILY (Daily). 3. Atorvastatin 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). 4. Pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 5. Oxycodone-Acetaminophen 5-325 mg Tablet Sig: 1-2 Tablets PO Q4-6H (every 4 to 6 hours) as needed. 6. Metoprolol Tartrate 25 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 7. Mirtazapine 15 mg Tablet Sig: 1.5 Tablets PO HS (at bedtime). 8. Gentamicin in Normal Saline 60 mg/50 mL Piggyback Sig: One (1) Intravenous Q8H (every 8 hours). 9. Ampicillin Sodium 2 g Recon Soln Sig: One (1) Recon Soln Injection Q4H (every 4 hours). 10. Hydromorphone 2 mg Tablet Sig: One (1) Tablet PO Q2H (every 2 hours) as needed. 11. Lasix 40 mg Tablet Sig: One (1) Tablet PO once a day. 12. Potassium Chloride 10 mEq Capsule, Sustained Release Sig: Four (4) Capsule, Sustained Release PO once a day. Discharge Disposition: Extended Care Facility: [**Hospital3 **] Discharge Diagnosis: Endocarditis Hepatitis B and C IV drug use Tuberculosis Anxiety/Depression Discharge Condition: good. Discharge Instructions: 1) Monitor wounds for signs of infection. These include redness, drainage or increased pain. 2) Report any fever greater then 100.5. 3) Report any weight gain of 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. 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. Followup Instructions: Follow-up with Dr. [**First Name (STitle) **] in 1 month. Follow-up with PCP [**Last Name (NamePattern4) **]. [**First Name (STitle) **] in 2 weeks. Follow-up with Infectious disease @[**Hospital6 16029**]. Follow-up with a cardiologist in 2 weeks. Follow-up with hepatologist @[**Hospital6 16029**]. Please call all providers for appointments. [**Name6 (MD) **] [**Name8 (MD) **] MD [**MD Number(2) 173**] Completed by:[**2165-2-1**]

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icd9cm

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icd9pcs

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290, 825

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104,041

30389

Discharge summary

report

Admission Date: [**2148-9-30**] [**Month/Day/Year **] Date: [**2148-10-13**] Date of Birth: [**2090-7-16**] Sex: M Service: MEDICINE Allergies: Cefepime / ciprofloxacin / Levofloxacin Attending:[**Last Name (NamePattern4) 290**] Chief Complaint: respiratory distress Major Surgical or Invasive Procedure: - removal of tunneled line History of Present Illness: Mr. [**Known lastname 47367**] is a 58-year-old man with a history of AML s/p allogeneic transplant [**2142**] complicated by graft-versus-host disease, multiple vertebral fractures and ultimately development of paraplegia in the setting of a vertebral fracture during a code situation. Admitted multiple times, most recently [**8-/2148**] for bacteremia and upper resp infection (cx: staph epi) and completed a course of vancomcyin, aztreonam. Discharged from rehab and home (wheelchair bound) with recent clinic followup [**9-26**] noting baseline health. Wife also states he was in his usual state of health until the morning of admission when she went to wake him he was more somnolent than usual and seemed to be having difficulty breathing taking rapid shallow breaths. His wife attributed his somnolence to recently starting Ambion and Valium 3 days prior to admission in addition to his home narcotic regimen of oxycontin and dilaudid. She also noted that he looked more pale than usual. She reports that he had a cough starting over the weekend productive of yellow sputum. No history of fevers, and outside of baseline pain, he had no complaints. Given his somnolence, EMS was called and administereed narcan in the field without improvement so he was admitted to Study hospital on [**9-30**] for acute respiratory failure. On arrival he was afebrile, tachycardic to 160s (sinus), hypotensive to 91/58 (though fell to 60s-70s per wife), RR of 8, and was satting 94% on BIPAP. He was bolused 500cc with improvement of HR to 130s. He was bolused more NS (unclear how much) and remained hypotensive so was started on norepinephrine 2mcg/min and given stress dose hydrocortisone. He does have a triple lumen port, but given poor peripheral access, an intraosseous was placed. He was given an additional dose of narcan given continued somnolence and transferred to the [**Hospital1 18**] at the family's request given that all of his care has been here. In the ED, initial VS were T 98.6 HR 128 BP 89/69 RR 17 99% on BIPAP and initial ABG was 7.27/61/83. Labs were notable for leukocytosis to 14.2, Trop-T: 0.18, Lactate:3.4, creatinine of 1.1 (baseline 0.6-0.8), and a grossly positive urinalysis with > 182 whites and moderate bacteria. He has an indwelling foley catheter that was changed this past Thursday. A chest x-ray was notable for LLL consolidation. He had received emperic vancomycin at the OSH and received a dose of Zosyn in the ED here. On arrival to the MICU, patient's VS were T: 99.5 HR: 115 BP 121/69 RR 20, O2 sat 93% 100% NRB and was receiving levo at 1mcg/min on arrival. He was somnolent but arousable and oriented x 3, but slow to answer questions. Complained of pain from the chest up, but otherwise no complaints. Review of systems: (+) Per HPI. His wife notes that he did a few episodes of loose stools. Morning headaches recently. (-) Denies fever, chills, chest pain, chest pressure, palpitations. Denies dark or bloody stools. Past Medical History: Past Medical History: - CKD (baseline Cr 0.6-0.7) - Hyperlipidemia - HTN - Type 2 DM (last A1c 6.8 [**2144**]) - Depression - Chronic pain - Pericardial effusion s/p [**3-23**] drainage. - Nephrolithiasis, lithotripsy and previous nephrostomy tube and emergent surgery to repair ureteral damage. - Left interpolar renal lesion, followed with MRs - Basal cell carcinoma, resected. - Squamous cell carcinoma left cheek, s/p Mohs' 6/[**2143**]. - Multiple back surgeries: Lumbar L5-S1 surgery x 3, and cervical spine fusion (bone graft, no hardware). - Anterior cervical diskectomy and instrument arthrodesis at C5-C6 and C6-C7 for degenerative cervical spondylitic disease with spinal cord compression and foraminal stenosis at C5-C6 and C6-C7 [**2-/2144**]- Dr. [**Last Name (STitle) 548**]. - Chronic numbness, neuropathic pain in left upper extremity. - Sleep Apnea, planned BIPAP, followed by Dr. [**Last Name (STitle) 4507**]. - Lower extremity wound, s/p debridement by plastics, grew [**Last Name (un) 2830**] resistent pseudomonas [**7-/2147**] ONCOLOGIC HISTORY: - diagnosed with AML in 04/[**2142**]. - [**2143-6-24**] underwent unrelated allogeneic stem cell transplant with busulfan and cyclophosphamide as his conditioning regimen. - continues bactrim, voriconazole, acyclovir ppx POST TRANSPLANT COMPLICATIONS: - GVHD of the liver and skin. Question of pulmonary cGVHD as often requires oxygen and steroids in the setting of respiratory infections (h/o RSV, parainfluenza) - paraplegia [**1-18**] vertebral fractures during code [**2147**] - Chronic lower extremity and abdominal edema, refractory to lasix, suspected to be GVHD - abdominal spasm - on valium (?etiology paraplegia) - COP/BOOP: home O2 1-2liters - Avascular necrosis (bilateral hips and left shoulder) - Multiple compression fractures of the spine with chronic pain - Pulmonary embolus in [**11/2144**] and [**5-/2146**], no with IVC [**Year (4 digits) 7448**] not on anticoagulation - s/p L5 vertebroplasty [**3-/2145**] - Ruptured left calf hematoma ([**9-/2146**]) complicated by MRSA wound infection - Influenza A [**1-/2147**] - bilateral Achilles tendon rupture [**2147-5-23**] ( attributed to levoflox). Social History: Discharged from rehab in [**2148-6-16**] and has now been living at home wiht VNA services and aid from his wife. [**Name (NI) **] is retired, worked as a [**Company 22957**] technician. He smoked for 40 pack years, now quit. He denies EtOH or drugs. Family History: Mother died suddenly in 70s. Father died of unknown cancer. One sister with thyroid cancer. One brother has diabetes. One sister has [**Name (NI) 5895**]. Physical Exam: ADMISSION PHYSICAL EXAM Vitals: T: 99.5 HR: 115 BP 121/69 RR 20, O2 sat 93% 100% NRB General: Somnolent, but arousable, oriented x 3, no acute distress, answers one question before falling asleep HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL, copious secretions Neck: supple, JVP not elevated, no LAD CV: Tachycardic regular rhythm, normal S1 + S2, no murmurs, rubs, gallops Lungs: Transmitted upper airway sounds bilaterally, good air movement Abdomen: soft, non-tender, non-distended, bowel sounds present, no organomegaly, no rebound or guarding GU: foley in place Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or edema Skin: Skin laceration on dorsum of left wrist Neuro: CN 2-12 intact, strength 5/5 in UE; paralyzed from the waist down. [**Name (NI) 894**] PHYSICAL EXAM Pertinent Results: Admission labs: [**2148-9-30**] 11:00AM BLOOD WBC-14.2* RBC-3.56* Hgb-12.5* Hct-39.2* MCV-110* MCH-35.1* MCHC-31.9 RDW-17.7* Plt Ct-334 [**2148-9-30**] 11:00AM BLOOD Neuts-78* Bands-7* Lymphs-6* Monos-8 Eos-0 Baso-0 Atyps-1* Metas-0 Myelos-0 [**2148-9-30**] 11:00AM BLOOD Hypochr-3+ Anisocy-1+ Poiklo-NORMAL Macrocy-3+ Microcy-NORMAL Polychr-1+ [**2148-9-30**] 11:00AM BLOOD PT-9.1* PTT-28.5 INR(PT)-0.8* [**2148-9-30**] 11:00AM BLOOD Glucose-174* UreaN-17 Creat-1.1 Na-140 K-4.0 Cl-103 HCO3-27 AnGap-14 [**2148-9-30**] 05:51PM BLOOD CK(CPK)-111 [**2148-10-1**] 02:30AM BLOOD ALT-46* AST-56* AlkPhos-106 TotBili-0.3 [**2148-9-30**] 11:00AM BLOOD cTropnT-0.18* [**2148-9-30**] 05:51PM BLOOD CK-MB-7 cTropnT-0.16* [**2148-10-1**] 02:30AM BLOOD Calcium-8.7 Phos-4.2 Mg-1.5* [**2148-9-30**] 06:29PM BLOOD Type-ART O2 Flow-15 pO2-91 pCO2-70* pH-7.23* calTCO2-31* Base XS-0 Intubat-NOT INTUBA [**2148-9-30**] 11:31AM BLOOD Glucose-167* Lactate-3.4* K-4.0 [**Month/Day/Year **] labs: Micro: [**2148-10-6**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE: PENDING [**2148-10-5**] CATHETER TIP-IV WOUND CULTURE- NO SIGNIFICANT GROWTH (PRELIMINARY) [**2148-10-5**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL CULTURE-PENDING; BLOOD/AFB CULTURE-PENDING [**2148-10-4**] URINE URINE CULTURE- NO GROWTH [**2148-10-4**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2148-10-4**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL CULTURE-PENDING; BLOOD/AFB CULTURE-PENDING [**2148-10-3**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2148-10-3**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL CULTURE-NO GROWTH; BLOOD/AFB CULTURE-NO GROWTH [**2148-10-2**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2148-10-1**] BLOOD CULTURE ( MYCO/F LYTIC BOTTLE) BLOOD/FUNGAL CULTURE-PRELIMINARY {[**Female First Name (un) **] (TORULOPSIS) GLABRATA}; BLOOD/AFB CULTURE-FINAL; Myco-F Bottle Gram Stain-FINAL BLOOD/FUNGAL CULTURE (Preliminary): [**Female First Name (un) **] (TORULOPSIS) GLABRATA. BLOOD/AFB CULTURE (Final [**2148-10-3**]): DUE TO OVERGROWTH OF YEAST, UNABLE TO CONTINUE MONITORING FOR AFB. Myco-F Bottle Gram Stain (Final [**2148-10-3**]): BUDDING YEAST. [**2148-10-1**] URINE URINE CULTURE-FINAL {YEAST} URINE CULTURE (Final [**2148-10-2**]): YEAST. 10,000-100,000 ORGANISMS/ML.. [**2148-10-1**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2148-10-1**] BLOOD CULTURE Blood Culture, Routine-PENDING [**2148-9-30**] URINE Legionella Urinary Antigen -FINAL - NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN. [**2148-9-30**] SPUTUM GRAM STAIN-FINAL; RESPIRATORY CULTURE-PRELIMINARY {YEAST} Source: Expectorated. GRAM STAIN (Final [**2148-9-30**]): >25 PMNs and <10 epithelial cells/100X field. 3+ (5-10 per 1000X FIELD): BUDDING YEAST. 3+ (5-10 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CHAINS. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE COCCI. IN PAIRS AND CLUSTERS. 2+ (1-5 per 1000X FIELD): GRAM POSITIVE ROD(S). RESPIRATORY CULTURE (Preliminary): MODERATE GROWTH Commensal Respiratory Flora. YEAST. MODERATE GROWTH. [**2148-9-30**] BLOOD CULTURE Blood Culture, Routine-PENDING Studies: [**2148-10-6**] CT CHEST W/O CONTRAST: [**2148-10-6**] CHEST (PORTABLE): Right pleural effusion has decreased in size with associated improvement in adjacent right basilar atelectasis. Multifocal areas of heterogeneous consolidation involving the left lung to a greater degree than the right, have slightly improved. A small hyperlucency is present in the periphery of the left upper lobe at the level of the second and third anterior ribs, but no discrete visceral pleural line is identified. This may represent an area of spared lung parenchyma from the presumed multifocal pneumonia, but attention to this area on short-term followup radiograph may be helpful to exclude an atypical presentation of pneumothorax, given clinical suspicion for this entity. [**2148-10-6**] CHEST (PORTABLE AP): Widespread combined alveolar and interstitial opacities affecting the left lung to a greater degree than the right have progressed in the interval, particularly in the right lower lung where there is also an increasing pleural effusion with adjacent consolidation and/or atelectasis. Small left pleural effusion also appears increased from prior radiograph. [**2148-10-5**] CHEST (PORTABLE AP): Status post removal of right subclavian vascular catheter. Widespread heterogeneous combined alveolar and interstitial opacities affecting the left lung to a greater degree than the right, have progressed in the interval, and may represent a multifocal pneumonia with or without coexisting pulmonary edema. Pulmonary hemorrhage is also possible in the appropriate clinical setting. [**2148-10-4**] CT ABD & PELVIS W & W/O 1. No evidence of IVC or iliac vein thrombosis. IVC [**Month/Day/Year 7448**] in place. 2. Stable lung base findings include, lingular pneumonia and bibasal peribronchovascular nodular opacities suggestive of aspiration. Bilateral small effusions and right lower lobe pulmonary emboli. 3. Hepatic steatosis. [**2148-10-2**] CTA CHEST W&W/O C&RECON 1. Right lower lobe lobar to subsegmental pulmonary acute embolism. The most proximal portion of the filling defect is peripheral in the artery raising the question if this could be chronic but new since [**2148-6-16**]. There is no dilatation of main pulmonary artery or right heart [**Doctor Last Name 1754**]. 2. Worsening of bilateral multifocal pneumonia. [**2148-10-2**] CT HEAD W/O CONTRAST 1. Limited study due to motion artifact, within this limitation, no acute intracranial pathology. 2. Multifocal paranasal sinus and bilateral mastoid air cell opacification. [**2148-10-2**] BILAT LOWER EXT VEINS No deep venous thrombosis in right or left lower extremity. Bilateral calf edema. [**2148-10-2**] ECHO The left atrium is mildly dilated. There is mild symmetric left ventricular hypertrophy with normal cavity size and global systolic function (LVEF>55%). Due to suboptimal technical quality, a focal wall motion abnormality cannot be fully excluded. The right ventricular cavity is mildly dilated with moderate global free wall hypokinesis. The aortic valve leaflets (?#) appear structurally normal with good leaflet excursion. There is no aortic valve stenosis. No aortic regurgitation is seen. The mitral valve appears structurally normal with trivial mitral regurgitation. The pulmonary artery systolic pressure could not be determined. There is an anterior space which most likely represents a prominent fat pad. IMPRESSION: Suboptimal image quality. Right ventricular cavity dilation with free wall hypokinesis. Mild symmetric left ventricular hypertrophy with preserved global biventricular systolic function. Compared with the prior study (images reviewed) of [**2147-5-24**], the right ventricular cavity is now dilated with free wall hypokinesis c/w an acute pulmonary process (e.g., pulmonary embolism, bronchospasm, etc.). [**2148-10-2**] ECG Sinus tachycardia with increase in rate as compared to the previous tracing of [**2148-6-27**]. Diffuse non-specific ST-T wave changes are more prominent in the context of wandering baseline and much baseline artifact. There appears to be more ST segment depression in leads V3-V6 without diagnostic interim change. [**2148-10-2**] EEG This is an abnormal EEG due to disorganized and slow background mostly consisting of mixed delta and theta suggestive of moderate encephalopathy but non-specific etiologically. There was no focal slowing or epileptiform discharges seen. Study limited by electrode artifact. Recommend repeat study if clinical concern for seizures persists. [**2148-10-1**] CHEST (PORTABLE AP) Previous pulmonary vascular congestion has improved, but there is still very extensive consolidation in the left lung due to pneumonia, without improvement, possibly worsened. Smaller region of consolidation in the right lower lung medially is either a second focus of pneumonia or atelectasis. Mild cardiomegaly is stable. Dual-channel right supraclavicular central venous set ends in the region of the superior cavoatrial junction. No pneumothorax. [**2148-10-1**] CHEST (PORTABLE AP) Progressive heterogeneous opacification in the left mid and lower lung zone is most likely pneumonia worsening since [**9-30**]. There could be a second focus of right infrahilar pneumonia, also advancing. Cardiomediastinal silhouette is essentially unchanged over several years. Dual-channel right supraclavicular central venous set ends close to the superior cavoatrial junction. No pneumothorax. [**2148-9-30**] CHEST (PORTABLE AP) 1. Worsening opacification in the left lung base with associated bronchial wall thickening concerning for infection. 2. Slight interval improvement in previously noted airspace disease within the right upper lobe. 3. No definite pulmonary edema. Brief Hospital Course: 57-year-old man with AML s/p matched unrelated allogeneic stem cell transplant in [**2142**], complicated by GVHD on chronic prednisone with multiple admission for infections now presents with somnolence in the setting if increased sedative medication use, hypercarbic respiratory distress, cough and CXR with LLL consolidation found to have segmental PE. # Goals of care: After frequent discussions with family and physicians involved in the pt's case and gradual reduction in number of interventions performed, it was decided to transition to comfort measures only on [**10-12**]. The below medical treaments, lab draws, and imaging procedures were held. The pt was kept in IV morphine, tylenol, and ativan to keep comfortable. He died peacefully on the morning of [**2148-10-13**]. # PE: Patient with tachycardia, hypoxemia, hypotensive on admission and history of PE not anticoaguated, with IVC [**Date Range 7448**] in place. TTE on [**10-2**] revealed large and hypokinetic RV and CTA showed segmental PE. Unclear if acute vs. subacute given appearance of clot on CTA. This was not present in [**Month (only) **], however. [**Month (only) **] is a potential source of clot as LENIs were negative. CTV showed no evidence of clot in IVC [**Month (only) 7448**]. Non contrast head CT was without hemorrhage, so started on heparin drip with intention to bridge to lovenox. Per discussion with inpatient heme attending and outpatient hematologist, it was decided that the pt's risk of hemorrhage was greater than his risk of clot given the negative LENIs and clean IVC [**Last Name (LF) 7448**], [**First Name3 (LF) **] heparin gtt was held. He was continued on prophylactic heparin subc. # Pneumonia: Productive cough followed by somnolence in the setting of starting Ambien and Valium in addition to his home oxycontin. CXR with LLL consolidation. Sputum gram stain with GPCs in clusters, GPCs in pairs and chains and GNRs and yeast. Started on vanco, [**Last Name (un) 2830**] (day 1: [**9-30**]), mica (day 1: [**10-3**]) in consultation with ID. Due to worsening CXR, vanco was changed to linezolid (day 1: [**10-6**]) per ID recs. Also question of possible pulmonary congestion, so pt was started on IV lasix. On [**10-8**], the pt appeared to have worsening WBC and respiratory distress. He was started on ambisome and given a dose of tobramycin. The tobramycin was thereafter uptitrated with little effect. Antibiotics were continued despite little improvement. # Fungemia: Yeast in urine, sputum and mycolytic blood cultures positive. Ophtho consulted and did not see evidence of fungal retinitis. Patient does have GVHD of conjunctiva, however. He was continued on micafungin (day 1 = [**10-3**]) and will need two week course following clearance of fungus. Mycolitic blood cultures were sent daily. CXR showed nodular areas, which was conserning for a mold pneumonia. Pt was started on ambisone for presumed fungal pneumonia. An MR head was performed which ruled out fungal brain extension. ENT was consulted for possible involvement of nasal sinuses, who recommended nasal irrigation as tolerated given sedation. # Hypotension: He was hypotensive to 60s-70s at OSH and required pressor support prior to transfer to the [**Hospital Unit Name 153**]. Possible sepsis as patient met SIRS criteria with tachycardia and leukocytosis with possible sources of infection including pulmonary given LLL opacity on CXR and productive cough. Urine source also possible given dirty urinalysis in the setting of indwelling catheter. Cardiogenic shock was considered given rising troponins, but they trended down and were likely elevated in the setting of tachycardia. ECG was without evidence of ischemia. Hypovolemic shock also possible given that his PO intake had been down prior to admission and his BP was fluid responsive on admission. He was started emperically on vancomycin and meropenem (day 1 = [**9-30**]) for pneumonia to complete an 8 day total course (through [**10-7**]). His urine, blood, and sputum cultures all returned positive for budding yeast (ID is [**Female First Name (un) **] (TORULOPSIS) GLABRATA), so he was initially started on IV fluconazole and was later transitioned to micafungin (day 1 = [**10-3**]). Ambisome was started and uptitrated as above. # Hypercarbic respiratory failure/somnolence: Patient difficult to arouse at home on AM of admission, and may have worsened since arriving to ICU. Likely multifactorial with hypercarbia from hypoventilation in the context of new sedating medications (ambien and valium, in addition to home narcotics), untreated OSA with likely CO2 retention at baseline, pneumonia, underlying GVHD of lung and PE. Pt has expressed wishes not to be intubated. His pneumonia and PE were treated as per above. His dyspnea was treated with either non-rebreather, venti mask, or bipap as tolerated in order to achieve sat > 90%. Ambien and valium were held. However, pt continued to complain of chest wall pain thought to be secondary to PNA and was continuously requesting more pain medication. After a goals of care discussion was held with pt, family, and specialists, it was decided to make the pt comfortable and give ativant and morphine despite hypercarbia. # Tachycardia: Continues to be in sinus tachycardia in the 130s. Initially in the 160s, but has improved with fluids. Likely multifactorial with PE, pain, hypovolemia, and withdrawal from opioids all contributing. He was given several doses of narcan at OSH and his home narcotics were initially held in the setting of hypotension. Morphine drip was started to relieve any pain without any improvement in tachycardia. # [**Last Name (un) **]: Cr 1.1 from baseline of 0.6-0.7. Unclear etiology, but likely prerenal in the setting of septic shock (above) with hypotension and tachycardia. Creatinine improved back to baseline with treatment of septic shock. # UTI: Patient has indwelling foley catheter, so would be considered complicated infection. Has grown E. coli most recently, though did have a negative urine culture on [**9-26**]. Continue with vancomycin and meropenem as per above. # Troponinemia: Patient with elevated troponin at OSH, which has risen on arrival to the [**Hospital1 18**] ED. He denies chest pain and ECG with sinus tachycardia without ischemic changes. Likely troponin leak in the setting of tachycardia to the 160s. # AML s/p MUD SCT in [**2142**]: Daily CBCs were checked and there was no evidence of reoccurance. He was continued on bactrim, acyclovir, and azithromycin. Dr. [**Last Name (STitle) **], outpatient oncologist following. # Chronic GVHD : In the past his chronic GVHC has primarily involved liver and lungs. His LFT's were mildly elevated at OSH, but has trended down while at [**Hospital1 18**]. He was continued on prednisone 10 mg PO daily, and ppx with with acyclovir, bactrim, and azithromycin. - IVIG monthly (last dose Thursday) # Type 2 DM on insulin: Most recent A1c is 6.8 from [**2144**]. His NPh was decreased to 10 units (from 15) due to low sugars. He was also placed on a sliding scale. # Hypertension: metoprolol was held given hypotension # Clot history: Prior PEs for which he was previously anticoagulated. Anticoagulation was discontinued in the setting of back surgery and an IVC [**Year (4 digits) 7448**] was placed. Now with segmental PE treated with heparin as per above. # Right axillary mass: Noticed by oncologist Dr. [**Last Name (STitle) **] and was planning on working up as outpatient with CT scan. # Paraplegia: Stable during this admission. A spine consult was called regarding further management. Per Spine, lumbar and thoracic spine x-rays were ordered -- these showed no significant interval change. # Transitional issues: deceased Medications on Admission: The Preadmission Medication list is accurate and complete. 1. Acyclovir 400 mg PO Q8H 2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H 3. Atorvastatin 10 mg PO DAILY 4. Azithromycin 250 mg PO Q24H 5. Bisacodyl 10 mg PO DAILY constipation 6. Bisacodyl 10 mg PR HS 7. Duloxetine 30 mg PO DAILY 8. Fluticasone Propionate NASAL 1 SPRY NU [**Hospital1 **] 9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH [**Hospital1 **] 10. FoLIC Acid 1 mg PO DAILY 11. Gabapentin 300 mg PO BID 12. Hydrocortisone Cream 1% 1 Appl TP QID apply to affected areas 13. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN pain 14. NPH 15 Units Breakfast NPH 15 Units Bedtime Insulin SC Sliding Scale using HUM Insulin 15. Ipratropium Bromide Neb 1 NEB IH Q6H 16. MethylPHENIDATE (Ritalin) 5 mg PO NOON 17. Metoprolol Tartrate 12.5 mg PO BID 18. Montelukast Sodium 10 mg PO DAILY 19. Multivitamins 1 TAB PO DAILY 20. MethylPHENIDATE (Ritalin) 5 mg PO QAM 21. Oxycodone SR (OxyconTIN) 40 mg PO BID 22. Pantoprazole 40 mg PO Q24H 23. PredniSONE 10 mg PO DAILY 24. Senna 2 TAB PO HS 25. Sodium Chloride Nasal [**12-18**] SPRY NU QID:PRN nasal congestion 26. Sulfameth/Trimethoprim SS 1 TAB PO DAILY 27. Zolpidem Tartrate 10 mg PO HS:PRN insomnia 28. Docusate Sodium 100 mg PO BID 29. Diazepam 5 mg PO Q8H:PRN anxiety, spasm [**Month/Day (2) **] Medications: deceased [**Month/Day (2) **] Disposition: Expired [**Month/Day (2) **] Diagnosis: pneumonia, fungemia [**Month/Day (2) **] Condition: deceased [**Month/Day (2) **] Instructions: deceased Followup Instructions: deceased [**Initials (NamePattern4) **] [**Last Name (NamePattern4) **] [**Name8 (MD) **] MD [**MD Number(1) 292**]

[ "518.89", "427.89", "344.1", "117.9", "415.19", "401.9", "V58.65", "995.92", "709.8", "E879.8", "250.00", "279.52", "996.59", "484.7", "V10.83", "996.74", "573.8", "V12.53", "V66.7", "V58.67", "996.88", "389.00", "786.6", "375.15", "V49.86", "518.81", "584.9", "785.52", "V10.62", "038.9", "348.30" ]

icd9cm

[ [ [] ] ]

[ "97.49", "88.72", "38.93" ]

icd9pcs

[ [ [] ] ]

15922, 23652

342, 370

6868, 6868

25243, 25390

5870, 6027

23711, 25220

6042, 6849

8812, 9965

10006, 15899

3169, 3369

281, 304

398, 3150

6884, 8776

23675, 23685

3413, 5584

5600, 5854

201

161,473

11987+56313

Discharge summary

report+addendum

Admission Date: [**2185-1-5**] Discharge Date: Date of Birth: [**2113-5-14**] Sex: M Service: HISTORY OF PRESENT ILLNESS: The patient is a 71 year old retired medical doctor who had percutaneous transluminal coronary angioplasty [**2184-11-24**], for coronary artery disease. On workup, it was discovered that he had advanced T2 NO distal esophageal gastric cancer, esophageal adenocarcinoma. PAST MEDICAL HISTORY: 1. Coronary artery disease, percutaneous transluminal coronary angioplasty times two, no history of myocardial infarction. 2. Chronic atrial fibrillation. 3. Hypertension. FAMILY HISTORY: Noncontributory. SOCIAL HISTORY: He is an ex-smoker of greater than twenty years. He denied ethanol abuse. ALLERGIES: Questionable allergy to Penicillin. PHYSICAL EXAMINATION: On admission, physical examination was unremarkable. HOSPITAL COURSE: He was taken to the operating room on [**2185-1-5**], for an esophagogastrectomy using [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **] approach by Dr. [**Last Name (STitle) 175**] and Dr. [**Last Name (STitle) **], assistants Dr. [**Last Name (STitle) 37699**] and Dr. [**Last Name (STitle) **], general endotracheal anesthesia. Please see the operative note for full details. Postoperatively, the patient was doing well. He had an epidural and we were using Lopressor for rate control and he was in the Intensive Care Unit at that time. He was on Vancomycin and Flagyl postoperatively. On postoperative day one, the patient was transferred from the Post Anesthesia Care Unit to the floor. Acute Pain Service was involved with reverse pain control. On [**2185-1-6**], at 4:00 p.m. the patient's blood pressure dropped to 70/40 with the heart rate in the 100s. Electrocardiogram showed atrial fibrillation. Urine output had dropped to 15 ccs per hour since 7:00 a.m. that morning. He was bolused. At 2:00 a.m. on [**2185-1-7**], the patient went to cardiac arrest and was resuscitated and was sent to the Intensive Care Unit. Central lines were placed and the patient was in grave condition. The patient's kidney function was slightly affected as he went into some degree of renal failure with a rising creatinine which resolved toward his discharge date. The patient was intubated and sedated in the unit. On the evening of [**2185-1-7**], the patient was extubated and was alert and confused and was again in atrial fibrillation. The patient remained in the unit anticoagulated on Heparin with chest tubes and nasogastric tube. The patient's creatinine at this point had decreased to 1.5 from a high of 2.2. The patient on postoperative day five, [**2185-1-10**], had recovered well and was transferred to the floor where rate control was an issue. The patient was getting tube feeds and was NPO. PCA was discontinued. Foley was discontinued and central line was discontinued on [**2185-1-12**]. On [**2185-1-12**], it was noted that the patient's white count had increased and his back wound was dehiscing. The middle third was opened and drainage came out. He was packed with gauze. The patient was continued on Vancomycin, Levofloxacin and Flagyl. The patient was confused and a Code Purple was declared on [**2185-1-13**], and psychiatry was involved. His Haldol was changed and adjusted. Heparin was discontinued on the patient on [**2185-1-13**], and Coumadin was begun since his INR was now therapeutic. For the rest of the stay and postoperative day number nine, we continued the antibiotics. His chest tube was put to water seal. The patient's chest tube was removed. On [**2185-1-15**], inferior aspect of the abdominal wound was showing some drainage and the patient's diet was being advanced and we continued wet to dry dressings at this point. However, the patient was then made NPO. The patient's tube feeds continued. CAT scan was done on the patient and showed question of a leak. On [**2185-1-18**], the CT scan questioned a leak, however, no direct leak was seen as some retromediastinal and supradiaphragmatic air and debris was seen. The patient had a nasogastric tube placed by fluoroscopy on 0/25/02, and nutrition was once again involved as he was made NPO as previously stated. Electrolytes were repleted. The patient's INR was continuously adjusted to be 2.0 to 2.5 and Lovenox was temporarily used for two days until for a moment when his INR dropped below 2.0. At the patient's behest, a medical consultation was called on [**2185-1-19**], with regard to controlling his atrial fibrillation. An echocardiogram was done to check his left ventricular function and right ventricular function which came back normal. We continued Vancomycin, Levofloxacin and Flagyl. Barium swallow CT was done on [**2185-1-21**], which showed the question of a leak as well. However, no direct leak was seen. The patient was transfused one unit of packed red blood cells to adjust for hematocrit which had fallen to 22.0 range and Lopressor was changed to 50 mg p.o. t.i.d. in an attempt to control his atrial fibrillation. During this time of admission on [**2185-1-22**], and onward, we were using Lasix to help diurese the patient. The patient was complaining of edema and was noted to be puffy and likely fluid overloaded. The patient had an episode of ventricular tachycardia on [**2185-1-25**], which was nonsustained and seven beats long and a cardiology electrophysiology consultation was called. They suggested increasing his Lopressor and discontinuing the Diltiazem which we did. They suggested a blood transfusion, discontinuing Diltiazem and Lopressor to be 100 mg t.i.d. which we did. The patient's nasogastric tube was discontinued on [**2185-1-26**], had a CT scan which showed unlikely to be a current leak since no communication was seen between the collections and esophageal and gastric anastomosis. The patient was allowed to have a clear liquid diet which he tolerated. Discharge summary addendum to follow. [**First Name11 (Name Pattern1) 177**] [**Last Name (NamePattern4) 178**], M.D. [**MD Number(1) 179**] Dictated By:[**Name8 (MD) 16758**] MEDQUIST36 D: [**2185-1-26**] 19:26 T: [**2185-1-26**] 19:40 JOB#: [**Job Number 37700**] Name: [**Known lastname 6800**], [**Known firstname 193**] Unit No: [**Numeric Identifier 6801**] Admission Date: [**2185-1-5**] Discharge Date: [**2185-1-27**] Date of Birth: [**2113-5-14**] Sex: M Service: ADDENDUM: The patient is being discharged on [**2185-1-27**], with the following medications. DISCHARGE MEDICATIONS: 1. Prevacid 30 mg per J-tube q. day. 2. Coumadin 3 mg per J-tube q. day, then as directed by the primary care physician for [**Name Initial (PRE) **] goal INR of 2.0 to 2.5. 3. Flomax 0.4 mg per J-tube q. day. 4. Aspirin 81 mg per J-tube q. day. 5. Reglan 10 mg p.o. J-tube three times a day. 6. [**First Name5 (NamePattern1) **] [**Last Name (NamePattern1) 3112**] 20 mEq, one tablet per J-tube q. day. 7. Lasix 40 mg, one tablet per J-tube twice a day times one week, then every day as a maintenance dose. 8. Calcium carbonate 500 mg, one tablet per J-tube three times a day. 9. Zocor 20 mg tablet per J-tube q. day. 10. Hytrin 5 mg tablet, one tablet per J-tube q. day. 11. Flagyl 500 mg tablet, one tablet per J-tube three times a day times five days. 12. Levaquin 500 mg per J-tube q. day times five days. 13. Lopressor 100 mg tablets, one tablet per J-tube three times a day. 14. Boost Plus, 110 cc per hour per J-tube 10 p.m. to 10 a.m. q. day. DISCHARGE INSTRUCTIONS: 1. The patient was going home with twice a day wet-to-dry normal dressing changes, pack the wound on the back and the abdomen. 2. He is to have a full liquid diet, less than 60 cc per hour. 3. His INR will be followed by Dr. [**First Name (STitle) **] and Dr. [**First Name (STitle) **] at his [**Location 6802**], telephone number [**Telephone/Fax (1) 6803**]. That office was contact[**Name (NI) **] and the medical staff was personally explained the disposition plan and understand his blood draws. A [**Hospital6 4262**] will forward the results of these draws to them. The nurse will draw such labs tomorrow and Monday. Today, he will receive 3 mg of Coumadin. His INR today is therapeutic. CONDITION AT DISCHARGE: The patient, upon discharge, is in fair condition and understands the plan. [**First Name11 (Name Pattern1) 33**] [**Last Name (NamePattern4) 2334**], M.D. [**MD Number(1) 2335**] Dictated By:[**Name8 (MD) 2965**] MEDQUIST36 D: [**2185-1-27**] 10:27 T: [**2185-1-27**] 12:20 JOB#: [**Job Number 6804**]

[ "401.9", "414.01", "998.3", "427.5", "V45.82", "427.1", "150.5", "427.31", "584.9" ]

icd9cm

[ [ [] ] ]

[ "46.39", "96.6", "96.04", "96.71", "42.42" ]

icd9pcs

[ [ [] ] ]

629, 647

6656, 7618

884, 6633

7642, 8356

812, 866

8372, 8713

142, 414

436, 612

664, 789

13,422

131,721

12493

Discharge summary

report

Admission Date: [**2154-11-9**] Discharge Date: [**2154-12-2**] Date of Birth: [**2072-3-30**] Sex: F Service: MEDICINE Allergies: Patient recorded as having No Known Allergies to Drugs Attending:[**First Name3 (LF) 398**] Chief Complaint: GIB, hypercarbic respiratory failure Major Surgical or Invasive Procedure: Intubation and extubation three times Central line placement and removal PEG placement Tracheostomy placement PICC placement Bone Marrow Biopsy History of Present Illness: Mrs. [**Known lastname **] is an 82 year old female with a history of coronary artery disease s/p CABG, aortic valve replacement, atrial fibrillation and COPD on home oxygen who presented to [**Hospital **] on [**2154-11-4**] after being found down in a shelter unresponsive. Per notes, she had been staying at a shelter because her power was out in her home. She was found unresponsive and was bradycardic to the 20s and hypotensive. She was taken to [**Hospital3 7569**] where she had an emergent temporary transvenous pacer placed. She also was intubated for hypercarbic respiratory failure. The initial cause of her bradycardiac was unclear but felt possibly to be related to digoxin toxicity for which she received digibind. She was subsequently treated for a COPD exacerbation with high dose solumedrol, zosyn and azithromycin. She also was noted to have acute renal failure thought by nephrology to be consistent with acute tubular necrosis in the setting of profound hypotension and was treated with lasix for decreased urine ouput. There was also concern for gastrointestinal bleeding as her hematocrit on presentation was 19.4 and she received two units of packed red blood cells. She was extubated on hospital day two without difficulty. She had an echocardiogram which showed preserved systolic function but pulmonary hypertension with a pulmonary artery pressure of 50 mm. The Zosyn was discontinued when the patient began to experience a drop in her platelet count to as low as 56k. On hospital day three she underwent a thoracentesis for a left sided pleural effusion which was consistent with a transudate with LDH 88, ratio 0.3, Prot 3.0. She continued to have loose black guaiac positive stools. She was started on IV flagyl and PO vancomycin out of concern for clostridium difficile although c. diff samples were negative x 1. Renal function has improved from a creatinine of 2.6 on admission to 1.7. She also suffered from a burn to her back from a heating pad used while she had the transvenous pacer placed and developed a stage II decubitous ulcer. The temporary pacer was removed prior to transfer. On arrival here the patient noted that she has been experiencing chest tightness since her endotracheal tube was removed. On arrival her heart rate was in the 140s in atrial fibrillation with blood pressures in the 160s systolic. She had a nitroglycerin patch on and it was unclear whether this was being used for chest pain or for blood pressure control. She received 5 mg IV metoprolol x 2 with good control of her heart rate. She currently denies lightheadedness or dizziness. She continues to experience chest tightness. Her breathing feels at baseline to her. She endorses mild nausea but no vomiting. She denies abdominal pain but endorses dark stools with diarrhea. She denies dysuria, hematuria or decreased urine output. She denies leg pain or swelling. She does note that she was admitted to [**Location (un) **] in [**Month (only) 547**] of this year with gastrointestinal bleeding and had a procedure but she does not recall what was found. All other review of systems negative in detail. Past Medical History: Coronary Artery Disease s/p CABG (LIMA to LAD and SVG to RCA) Aortic Valve Replacement (bioprosthetic) Atrial Fibrillation (not currently anticoagulated) Hypertension Hyperlipidemia COPD (FEV1 less than one liter) Diastolic Congestive Heart Failure Depression Left phrenic nerve paralysis Admission to [**Location (un) **] in [**2-26**] for gastrointestinal bleeding Social History: She does not actively drink or smoke, 100-pack-year history of smoking. Son in the area acts as health care proxy. Family History: Father had coronary artery disease, mother had [**Name (NI) 2481**] disease. Physical Exam: On Presentation: Vitals: T: 97.5 BP: 169/84 HR: 106 RR: 16 O2: 96% on 4L NC General: Awake, alert, oriented x 3, no distress HEENT: Sclera anicteric, MM dry, oropharynx clear Neck: JVP elevated at jaw, no LAD CV: irregularly irregular, s1 + s2, III/VI SEM at LLSB, HSM at apex, no rubs or gallops Lungs: Poor air movement throughout, scarce expiratory wheezes, no rales or ronchi GI: soft, non-tender, non-distended, +BS, no organomegaly appreciated GU: foley draining clear yellow urine Ext: WWP, 1+ pulses, no clubbing, cyanosis or edema Back: stage II decubitous ulcer on back, faint 3 mm erythematous lesions throughout buttocks and upper thighs, non raised Rectal: Flexiseal with dark guaiac positive stool Pertinent Results: IMAGING: CARDIAC ECHO [**2154-11-12**]: The left atrium is moderately dilated. There is mild symmetric left ventricular hypertrophy. The left ventricular cavity size is normal. Overall left ventricular systolic function is low normal (LVEF 50%). Tissue Doppler imaging suggests an increased left ventricular filling pressure (PCWP>18mmHg). There is no ventricular septal defect. The right ventricular cavity is dilated with depressed free wall contractility. There are focal calcifications in the aortic arch. There are three aortic valve leaflets. The aortic valve leaflets are moderately thickened. There is a minimally increased gradient consistent with minimal aortic valve stenosis. The mitral valve leaflets are mildly thickened. There is no mitral valve prolapse. There is severe mitral annular calcification. Mild (1+) mitral regurgitation is seen. [Due to acoustic shadowing, the severity of mitral regurgitation may be significantly UNDERestimated.] The tricuspid valve leaflets are mildly thickened. The supporting structures of the tricuspid valve are thickened/fibrotic. There is mild pulmonary artery systolic hypertension. The pulmonic valve leaflets are thickened. Significant pulmonic regurgitation is seen. There is no pericardial effusion. BONE MARROW BIOPSY: Results pending DISCHARGE LABS: -[**2154-12-2**] WBC-3.2* Hgb-8.8* Hct-27.3* Plt Ct-79* -[**2154-12-2**] Glucose-151* UreaN-33* Creat-1.1 Na-133 K-4.9 Cl-100 HCO3-32 -[**2154-11-19**] calTIBC-195* VitB12-343 Folate-11.1 Ferritn-238* TRF-150* Brief Hospital Course: 82 year old female with a history of coronary artery disease s/p CABG, aortic valve replacement, atrial fibrillation and COPD on home oxygen who presented to OSH on [**2154-11-4**] with hypotension, bradycardia and hypercarbic respiratory failure transferred for management of gastrointestinal bleeding which resolved; also with failure to extubate s/p trach and thrombocytopenia. Patient was discharged to a respiratory rehab facility in fair condition. # Hypercarbic Respiratory Failure: The patient was transiently intubated at the OSH prior to transfer for hypercarbic respiratory failure. She had been extubated since [**2154-11-5**] and doing well. She is on 3L nasal cannula at home. Here her ABG [**Last Name (un) **] worsening hypercarbia and she was felt to have pulmonary edema and possibly and aspiration event so was reintubated and started on vanc and meropenem. Reinitated solumedrol at 40mg [**Hospital1 **] which were eventually tapered (her last dose of steroids was [**11-20**]). Continued on atrovent q4h. She was extubated on [**11-10**] and placed on noninvasive ventilation for hypoxemia in setting of pulmonary edema, however she had to be reintubated. She was found to have a VAP and was treated with Vanc/[**Last Name (un) **] for an 8-day course (end date [**11-17**]). After failing multiple extubation attempts a trachestomy was placed and patient was discharged to a [**Hospital 38763**] rehab facility. # Gastrointestinal Bleeding: Patient had been having dark guaiac positive stools since admission to [**Location (un) **]. Her hematocrit on admission was 19.4 and per reports she received 2 units of packed red blood cells at the OSH. Her hematocrit on admission here was 26.0. She recieved 2 units of blood with minimal improvement in hct (23.7-->24.1-->25.5). She was started on an IV PPI [**Hospital1 **]. GI evaluated her, but felt she was too unstable from a cardiorespiratory status to scope. GI thought her guaiac positve stools may have been from stress gastritis. Her Hcts continued to be monitored, however they remained stable. She received one more unit of PRBC after she had PEG/trach placement and her Hct decreased to the 24's and bumped appropriately to the unit. After that time ([**11-21**]) she did not require further blood transfusions. Later on in the hospital course after her PEG was placed she had a little bit of blood from the PEG and vomit with blood in it, however this quickly resolved and as her Hct remained stable GI did not feel it was necessary to scope her. The PPI was changed to daily prior to discharge. During her hospital stay her vitamin B12 was found to be low and she was given a vitmain B12 shot x 1. Folate was WNL and Fe studies revealed anemia of chronic disease. # Thrombocytopenia: Unclear etiology. Thought at outside hospital to be secondary to Zosyn. Platelet count increasing from nadir of 56. She had anti-heparin antibiodies sent x 2 which were negative. Heparin products were held. She received one platlet transfusion with transient improvement in her platets, however they continued to trend downwards. Heme/onc was consulted and felt that her thrombocytopenia was chronic as there were labs from [**2147**] which showed a plt count int he 60's, although it did improve in [**Hospital3 **]. They recommended stopping her simvastatin (which was stopped), and also her PPI and dilt (these were continued given her strong indications for them including recent GI bleed and a.fib). SPEP and UPEP were negative. She underwent a bone marrow biopsy to rule out a production problem and the results of the biopsy are pending at the time of discharge. She has outpatient follow up scheduled with hematology. # Atrial Fibrillation: The patient was in a-fib with rapid ventricular response on admission and remained in atrial fibrillation throughout her hospital stay. Has been off digoxin and tykosyn since admission to outside hospital. She was initally treated with IV metoprolol with good response. Given her labile SBP's her home medications were stopped and medications were titrated throughout her stay. On discharge she was on carvedilol 25 mg po bid and diltiazem 15 mg po qid for rate control. Per her son, the patient had been taken off coumadin as an outpatient several months prior to admission by her PCP so anticoagulation was not restarted here even though she is at risk for stroke. # Coronary Artery Disease s/p CABG (LIMA to LAD and SVG to RCA). On admission she was complaining of chest tightness in the setting of rapid ventricular rates. Troponins were slightly elevated at 0.2. Trend not available from [**Location (un) **]. EKG without ischemic changes. She was initally continued on simvastatin (although this was later stopped due to thrombocytopenia, as above) and metoprolol (although this was changed to carvedilol, as above). # Acute Renal Failure: Her baseline creatinine 1.0. Was 1.5 on admission down from 2.6 on presentation to [**Location (un) **] on [**2154-11-4**]. Her Cr trended down to her baseline of 0.8 to 1.0 during the end of her hospital stay. # Aortic Valve Replacement (bioprosthetic): Not anticoagulated as an outpatient. Performed in [**2147**]. Echocardiogram with EF of 50% and a well placed valve. # Hypertension: The patient's antihypertensives were held initally given her hypotension. She very labile BP during her early hospital course and intermittently would become hypertensive requiring IV medication and then would have decreased mental status if her SBP was brought below 120. By discharge her BP medications consisted of carvedilol 25 mg po bid and lisinopril 5 mg po daily. Lisinopril can be up-titrated for blood pressure control. # Hyperlipidemia: The patient was initally continued on her outpatient simvastatin, however this was stopped per heme/onc recs as it could be a cause of her thrombocytopenia. # Diastolic Congestive Heart Failure: She had volume overload on her admission CXR with left sided effusion s/p thoracentesis with transudate. A TTE showed an EF 50%, severe Pulm regurg, mild pulm HTN. She was intermittently treated with IV lasix for diuresis, but given her labile SBP earlier in her hospital stay she ended up over 20 L positive for the hospital stay and will need continued diuresis as an outpatient. Her goal currently is 500 cc to 1 L negative daily. # Back Wound: Patient with stage II ulcer on back from burn injury at [**Location (un) **]. A wound care consult was obtained and she was treated with Silvadene 1% cream to coccyx [**Hospital1 **]. This treatment was completed by discharge. # FEN: She had a PEG placed as well as her tracheostomy and was started on tube feeds. Reglan qid was started as she was initally nausea with residuals when tube feeding was started. # Prophylaxis: pneumoboots # Code: DNR/DNI, this was discussed with the patient and her family, however they did wish to proceed with trach placement and PEG placement so this was done. # Communication: Son [**Name (NI) **] [**Name (NI) **] [**Telephone/Fax (1) 38764**] Medications on Admission: Simvastatin 20 mg daily Diltiazem 240 mg daily Tikosyn 62.5 mg [**Hospital1 **] Lasix 20 mg daily Digoxin 0.125 mg daily Hydralazine 25 mg PO BID Toprol XL 25 mg daily Enalapril 10 mg PO daily Discharge Medications: 1. Lisinopril 5 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 2. Metoclopramide 10 mg Tablet [**Hospital1 **]: One (1) Tablet PO QIDACHS (4 times a day (before meals and at bedtime)). 3. Lactulose 10 gram/15 mL Syrup [**Hospital1 **]: Thirty (30) ML PO Q8H (every 8 hours) as needed. 4. Furosemide 20 mg Tablet [**Hospital1 **]: One (1) Tablet PO DAILY (Daily). 5. Fluticasone 110 mcg/Actuation Aerosol [**Hospital1 **]: Two (2) Puff Inhalation [**Hospital1 **] (2 times a day). 6. Heparin (Porcine) 5,000 unit/mL Solution [**Hospital1 **]: One (1) Injection TID (3 times a day). 7. Trazodone 50 mg Tablet [**Hospital1 **]: 0.25 Tablet PO HS (at bedtime) as needed for insomnia. 8. Lansoprazole 30 mg Tablet,Rapid Dissolve, DR [**Last Name (STitle) **]: One (1) Tablet,Rapid Dissolve, DR [**Last Name (STitle) **] DAILY (Daily). 9. Carvedilol 12.5 mg Tablet [**Last Name (STitle) **]: Two (2) Tablet PO BID (2 times a day). 10. Ipratropium Bromide 17 mcg/Actuation Aerosol [**Last Name (STitle) **]: Six (6) Puff Inhalation Q4H (every 4 hours). 11. Simethicone 80 mg Tablet, Chewable [**Last Name (STitle) **]: 1.5 Tablet, Chewables PO QID (4 times a day) as needed for gaseous pain. 12. Ciprofloxacin 250 mg Tablet [**Last Name (STitle) **]: One (1) Tablet PO Q12H (every 12 hours) for 5 doses: Your last dose will be on [**2154-12-4**]. 13. Chlorhexidine Gluconate 0.12 % Mouthwash [**Date Range **]: Five (5) ML Mucous membrane [**Hospital1 **] (2 times a day). 14. Ondansetron HCl (PF) 4 mg/2 mL Solution [**Hospital1 **]: 4-8 mg Injection Q8H (every 8 hours) as needed for Nausea. 15. Prochlorperazine 10 mg IV Q6H:PRN Discharge Disposition: Extended Care Facility: [**Hospital3 105**] Northeast - [**Location (un) 1110**] Discharge Diagnosis: Respiratory Failure Urinary Tract Infection Low platelets (Thrombocytopenia) Discharge Condition: Stable, afebrile Discharge Instructions: You were admitted to the hospital after being found unconcious in the shelter. You were found to have a slow heart rate thought to be due to your digoxin medication. You were also intubated as you had difficulty breathing. Whilst in the hospital we tried several times to have you breath without the tube, unfortunately you were not able to breathe on your own so you underwent a tracheostomy. Prior to your transfer to the rehab facility you were breathing comfortably with minimal support from the ventilator. Your platelet levels were also found to be low so we performed a bone marrow biopsy. You have an appointment with the hematology/oncology doctors [**Last Name (NamePattern4) **] [**2154-12-18**] at 0900 to discuss the results. During your hospitalization we also noticed you had a urinary tract infection and we started you on an antibiotic called Ciprofloxacin. You will be taking 250mg twice a day your last dose of this medication will be on [**2154-12-4**]. Several other medication changes were made for your high blood pressure which may be changed at the rehab facility. Followup Instructions: Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern1) 3749**], MD Phone:[**Telephone/Fax (1) 3241**] Date/Time:[**2154-12-18**] 9:00 Provider: [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 10921**], MD Phone:[**Telephone/Fax (1) 22**] Date/Time:[**2154-12-18**] 9:00

[ "354.8", "997.31", "416.8", "707.22", "276.0", "V45.81", "428.33", "285.29", "707.02", "584.5", "V42.2", "287.5", "272.4", "427.31", "V46.2", "518.84", "578.9", "491.21", "401.9", "428.0", "599.0" ]

icd9cm

[ [ [] ] ]

[ "31.1", "96.04", "43.11", "96.72", "41.31", "96.6", "38.93" ]

icd9pcs

[ [ [] ] ]

15557, 15640

6566, 13647

351, 496

15761, 15780

5018, 6316

16922, 17230

4191, 4269

13891, 15534

15661, 15740

13673, 13868

15804, 16899

6332, 6543

4284, 4999

275, 313

524, 3652

3674, 4043

4059, 4175

17,864

117,159

48397

Discharge summary

report

Admission Date: [**2124-10-18**] Discharge Date:[**2124-10-12**] Service: HISTORY OF PRESENT ILLNESS: This is an 89 year-old white male with the history of coronary artery disease, status post PTCA times three, hypertension, spinal stenosis, osteoarthritis who presents with lower gastrointestinal bleed times three hours. Patient was in his usual state of health until approximately 9 P.M. last night when he noted the onset of diarrhea. He describes stool as bright red but with a formed element, i.e. not pure blood. He had five such episodes overnight. He says that he contact[**Name (NI) **] his granddaughter who recommended to try to get some rest. The diarrhea persisted and during the episode the patient go up to use the bathroom and felt faint. It is unclear whether he lost consciousness at this time. He had several more episodes of bloody diarrhea, the last of which was pure blood per the patient. He called 911 and was brought to the [**Hospital1 1444**] Emergency Room at 2 A.M. on the morning of admission. He denies abdominal pain although he describes some discomfort located in his suprapubic region. This discomfort is not new. He denies nausea, vomiting, melena, cramping, fevers, chills. He has not eaten anything unusual. He has had no sick contacts. [**Name (NI) **] has not had any fatigue and describes the weight loss as occurring during the last six months with wife's illness and death which was in [**2124-3-23**]. He presents for evaluation and work up of lower gastrointestinal bleeding. The patient does have a remote history of diverticulosis that improved when he stopped eating nuts and taking the skin off his apples. PAST MEDICAL HISTORY: Coronary artery disease. He is status post PTCA times three, hypertension, spinal stenosis, status post laminectomy, osteoarthritis, possible history of diverticulitis, hypothyroidism. MEDICATIONS: Lopressor 50 mg p.o. b.i.d., Lasix 50 mg p.o. q. day, Norvasc 10 mg p.o. q. day, Cardura 2 mg p.o. b.i.., Niacin 250 mg p.o. q. day, Levoxil 250 mcg p.o. q. day. He has allergy to benzodiazepines. SOCIAL HISTORY: Lives at Brick House in [**Location (un) **]. No alcohol use. He has a remote history of smoking less than ten pack years. FAMILY HISTORY: His father had cancer. PHYSICAL EXAMINATION: On admission vital signs temperature 98.1, blood pressure 138/44, pulse 76, respirations 12, oxygen saturation 99% on room air. In general this is a minimally obese elderly white male lying in bed in the Emergency Room in no acute distress. Head, eyes, ears, nose and throat normocephalic, atraumatic. Pupils equal, round and reactive to light and accomodation. Extraocular eye movements intact. Oropharynx was clear. Pulmonary clear to auscultation bilaterally, no wheezes, or rhonchi. Cardiology: distant heart sound, regular rate and rhythm, normal S1, S2, no murmurs or gallop. Abdomen soft and obese, nontender, no hepatosplenomegaly, no ecchymosis, no rebound or guarding, normal active bowel sounds. Extremities: 1+ pulses in lower extremities, no clubbing, cyanosis or edema, good capillary refill. Neurologic grossly intact. LABORATORY DATA: White blood cell count 9.4, hemoglobin 7.3, hematocrit 22.5, platelets 252, neutrophils 89%, lymphocytes 9%, monocytes 2%, no eosinophils or basophils. PT 12.9, INR 1.1. PTT 23.4. Sodium 140, potassium 4.8, chloride 106, bicarb 22, BUN 56, creatinine 1.8 and glucose 229. Electrocardiogram showed sinus rhythm with right bundle branch block, no acute changes compared with electrocardiogram from [**Month (only) 1096**] of 2,000. HOSPITAL COURSE: The patient was admitted for evaluation of lower gastrointestinal bleed, however, was noted to have a stool with bright red blood clots and was transferred to the Medical Intensive Care Unit the day after admission on the [**4-18**]. Gastrointestinal: Once the patient was transferred for evaluation to the Medical Intensive Care Unit he was given a bowel prep of Go-Lytely and sent for colonoscopy. On colonoscopy it was found that the patient had diverticulosis of the hepatic flexure, transverse colon and descending colon and sigmoid colon. Otherwise the colonoscopy was normal to the cecum. On the following day the patient had an esophagogastroduodenoscopy which only showed duodenitis and no other source for bleeding. The patient did not have any further episodes of diarrhea or bright red blood per rectum or melena throughout his course in the Medical Intensive Care Unit and once his hematocrit was stabilized with transfusions continued to do very well from gastrointestinal standpoint. The patient was started on Protonix 40 mg p.o. q. day on hospitalization to protect against further irritation of his stomach lining. This dose was increased to 40 mg p.o. b.i.d. during the hospital stay and was sent home with a prescription for Protonix 40 mg p.o. b.i.d. Hematology: The patient was transfused a total of eight units of packed red blood cells during his stay in the Medical Intensive Care Unit. His hematocrit responded initially inadequately to the transfusions, however, then responded adequately and was stable for 48 hours after his transfusions in the range of 33 to 37. The patient's coagulations were normal and his hematocrit was stable on discharge. Cardiology: The patient has a history of coronary artery disease, status post PTCA times [**2121**]. He had no episodes of chest pain during his hospital course. His hypertensive medication was held during his Medical Intensive Care Unit stay. On transfer to the floor he was restarted on his regular dose of Cardura and Norvasc and Lopressor was titrated back to his usual 58 mg b.i.d. dose. Endocrine: The patient has a history of hyperthyroidism and was maintained on Levoxil 250 mg p.o. q. day dosing. Pulmonary: The patient had no evidence for congestive heart failure after his transfusions. His O2 saturations were stable. Renal: The patient's creatinine was initially elevated on admission at 1.8. However, with hydration this dropped to a baseline of 1.2. Prophylaxis: The patient had pneumoboots while in the Medical Intensive Care Unit when he was not ambulating. These were discontinued once he started ambulating. He was also maintained on Protonix as described above. DISCHARGE DIAGNOSIS: Lower gastrointestinal bleed, likely secondary to bleeding diverticulosis. DISCHARGE CONDITION: Good and improving. Patient was evaluated by Physical Therapy and was able to ambulate very well before discharge. He was also tolerating p.o. without any nausea, vomiting or pain. Physical Therapy determined that the patient was functioning at a very high level and could return home with his cane. DISCHARGE MEDICATIONS: Protonix 40 mg p.o. b.i.d., Cardura 2 mg p.o. b.i.d., Lopressor 50 mg p.o. b.i.d. and Lasix 50 mg q. day, Norvasc 10 mg p.o. q. day, niacin 250 mg p.o. q. day, Levoxil 250 mg p.o. q. day, Levoxil 250 mcg p.o. q. day. [**First Name11 (Name Pattern1) **] [**Last Name (NamePattern4) 1207**], M.D. [**MD Number(1) 1208**] Dictated By:[**Last Name (NamePattern1) 7896**] MEDQUIST36 D: [**2124-10-22**] 13:03 T: [**2124-10-22**] 13:10 JOB#: [**Job Number **]

[ "562.12", "428.0", "401.9", "535.60", "593.9", "V45.82", "285.9", "244.9", "414.01" ]

icd9cm

[ [ [] ] ]

[ "45.13", "45.23" ]

icd9pcs

[ [ [] ] ]

6436, 6740

2268, 2292

6764, 7258

6338, 6414

3631, 6317

2315, 3613

113, 1685

1708, 2108

2125, 2251

78,891

150,707

20060

Discharge summary

report

Admission Date: [**2139-10-14**] Discharge Date: [**2139-10-20**] Date of Birth: [**2082-10-3**] Sex: M Service: SURGERY Allergies: Penicillins Attending:[**First Name3 (LF) 2836**] Chief Complaint: cholangitis with e.coli bacteremia Major Surgical or Invasive Procedure: * You underwent an ERCP to place a sent in your common bile duct on [**2139-10-14**]. This procedure helped to alleviate the obstruction in your duct. * You underwent a repeat ERCP on [**2139-10-16**] to remove multiple gallstones from your common bile duct. The stent that was placed on [**2139-10-14**] was removed during this procedure. History of Present Illness: 57M with HIV ([**7-25**]: CD4 977, viral load 50), HBV, HCV, HTN, polysubstance abuse, who presented to [**Hospital3 20284**] Center on [**2139-10-13**] in the evening with complaints of [**4-17**] days of abdominal pain, bloating, nausea, vomiting, and diarrhea. He reports fevers to 103.7 at home. The patient had a temperature of 100.2 in the ED and remained afebrile with stable vital signs and no further episodes of vomiting or diarrhea during his admission. His abdominal pain and bloating did progressively worsen and blood cultures grew gram negative rods, white count was 16, TBili 11.5. He was treated conservatively and made NPO, given IVF, and started on levaquin and flagyl. The patient denies any history of gallbladder disease or pancreatitis. The patient was transferred to [**Hospital1 18**] on the evening of [**2139-10-14**] for ERCP and further management. ERCP was performed and showed a large amount of thickened pus and stones in the CBD. A biliary stent was placed. Past Medical History: HIV diagnosed 22 years ago ([**7-25**]: CD4 977, viral load 50), HBV, HCV, HTN, reactive airway disease, chronic pain, MRSA, CKD baseline Cr 1.3-1.8 Social History: Social: 1 PPD x 10 years, IVDA - clean for 8 months, past cocaine use, past alcohol use, lives alone, unemployed, in a relationship Family History: non-contributory Physical Exam: VS: 98.8 97.5 70 154/90 18 94RA GEN: AAOx3, NAD HEENT: icteric CV: RRR, nml s1/s2 Resp: scattered wheezing, otherwise clear no ronchi, areas of consolidation, good air entry Abd: soft, obese, nontender, non tympanic, nondistended, no masses palpated Ext: no c/c/e Pertinent Results: [**2139-10-15**] 03:08AM BLOOD WBC-15.3*# RBC-3.43* Hgb-13.6*# Hct-36.9*# MCV-108* MCH-39.7* MCHC-36.9* RDW-14.8 Plt Ct-130* [**2139-10-19**] 04:20AM BLOOD WBC-8.6 RBC-3.10* Hgb-11.8* Hct-35.0* MCV-113* MCH-38.2* MCHC-33.8 RDW-14.5 Plt Ct-207 [**2139-10-19**] 04:20AM BLOOD Glucose-102* UreaN-20 Creat-0.7 Na-140 K-3.6 Cl-106 HCO3-28 AnGap-10 [**2139-10-15**] 03:08AM BLOOD ALT-54* AST-44* AlkPhos-209* Amylase-19 TotBili-10.7* DirBili-8.2* IndBili-2.5 [**2139-10-19**] 04:20AM BLOOD ALT-22 AST-31 AlkPhos-110 Amylase-67 TotBili-3.0* Brief Hospital Course: 57M with HIV ([**7-25**]: CD4 977, viral load 50), HBV, HCV, HTN, polysubstance abuse, who presented to [**Hospital3 20284**] Center on [**2139-10-13**] in the evening with complaints of [**4-17**] days of abdominal pain, bloating, nausea, vomiting, and diarrhea. He reports fevers to 103.7 at home. The patient had a temperature of 100.2 in the ED and remained afebrile with stable vital signs and no further episodes of vomiting or diarrhea during his admission. His abdominal pain and bloating did progressively worsen and blood cultures grew gram negative rods, white count was 16, TBili 11.5. He was treated conservatively and made NPO, given IVF, and started on levaquin and flagyl. The patient denies any history of gallbladder disease or pancreatitis. The patient was transferred to [**Hospital1 18**] on the evening of [**2139-10-14**] for ERCP and further management. ERCP was performed and showed a large amount of thickened pus and stones in the CBD. A biliary stent was placed on [**2139-10-14**] during initial ERCP. Pt was treated in SICU following procedure with IV antibiotics (Cipro -->Cefepime/Flagyl due to E.coli sensitivities) with good effect. Mr. [**Known lastname 6667**] remained stable while in the ICU, although his oxygen saturations remained low on RA thereby requiring 2-4L supplemental O2. He reported some mild improvement in pain, but was still tender on physical exam. There was improvement in his laboratory values immediately following the [**2139-10-14**] ERCP but had still not normalized. A second ERCP was scheduled on [**2139-10-16**] for removal of gallstones. The patient's second ERCP was notable for the removal of [**1-28**] stones from the CBD. There was no evidence of pus in the duct. The previously placed biliary stent was removed and a sphincterotomy was performed. Follwoing the [**2139-10-16**] ERCP, the patient was transferred to the floor on [**2139-10-18**]. His diet was slowly advanced from clears to regular, which he tolerated well. Pts vital signs remained stable since transfer from ICU, and on [**2139-10-20**] pt stated that he felt well to be discharged home. At the time of discharge, Mr. [**Name14 (STitle) 54005**] was stable, afebrile, ambulating and mentating at baseline, and tolerating a regular diet. His laboratory values have normalized and he feels ready to be discharged home. He was educated regarding his post-discharge plans to follow-up with Dr. [**First Name (STitle) **] in clinic to discuss removal of his gallbladder. He was educated regarding warning signs and symptoms and to seek medical evaluation for them if necessary. He was informed that he would require a two week treatment with oral antibiotics. Mr. [**Known lastname 6667**] [**Last Name (Titles) 54006**] expressed understanding of these plans and agreement with them. Medications on Admission: crixivan 800 q8, lactobacillus 2 pills daily, combivir'', methadone 10''', oxy IR 15'''', norvir 600'', retrovir 300'', spiriva 1 puff daily, albuterol prn Discharge Medications: 1. indinavir 400 mg Capsule Sig: Two (2) Capsule PO BID (2 times a day). 2. lamivudine-zidovudine 150-300 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours). 4. ritonavir 100 mg Capsule Sig: One (1) Capsule PO BID (2 times a day). 5. methadone 10 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). 6. tiotropium bromide 18 mcg Capsule, w/Inhalation Device Sig: [**2-15**] Caps Inhalation DAILY (Daily). 7. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for Nebulization Sig: [**2-15**] Inhalation Q6H (every 6 hours) as needed for wheezing. 8. cefpodoxime 200 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours for 14 days. Disp:*28 Tablet(s)* Refills:*0* Discharge Disposition: Home Discharge Diagnosis: * Cholangitis, with E. coli bacteremia Discharge Condition: Condition: Good Mental Status: AAOx3 Ambulatory status: ambulating w/o help, independent Discharge Instructions: * You were admitted to the hospital because of an infection in the ducts which drain bile from your gallbladder (cholangitis) as well as an infection in your blood. * You were treated with IV antibiotics and responded well to this treatment. * You underwent two procedures (ERCPs) to help clear the blockage in one of the ducts which drains bile from your gallbladder (the common bile duct). * During these procedures, the gastroenterologists removed many stones from your common bile duct and performed a procedure to enlarge the opening of this duct. * You responded well to this treatment and your laboratory values improved afterwards. * You should continue to take oral antibiotics (cefpodoxime) for 2 weeks. * You should call Dr.[**Name (NI) 5067**] office (number below) to schedule a follow-up appointment in 2 weeks to discuss having your gallbladder removed. * You may continue a low fat, regular diet. * You may continue to do your regular activities. * You may shower/bathe as normal. Followup Instructions: * You should follow-up with Dr. [**First Name (STitle) **] in the surgery office at [**Telephone/Fax (1) 476**] to discuss having your gallbladder removed. * You should follow-up with your primary care doctor (PCP) as needed following discharge. * You should follow-up with your infection disease (ID) doctor as needed following discharge. Completed by:[**2139-10-20**]

[ "V08", "574.50", "070.70", "041.4", "576.1", "790.7", "403.90", "070.30", "585.9", "305.93" ]

icd9cm

[ [ [] ] ]

[ "51.88", "97.55", "51.85", "51.87" ]

icd9pcs

[ [ [] ] ]

6736, 6742

2887, 5711

308, 650

6825, 6841

2329, 2864

7961, 8333

2011, 2029

5917, 6713

6763, 6804

5737, 5894

6940, 7938

2044, 2310

234, 270

678, 1672

6856, 6916

1694, 1845

1861, 1995

25,337

153,318

43141

Discharge summary

report

Admission Date: [**2119-11-16**] Discharge Date: [**2119-11-21**] Service: MED Allergies: Tape II Disposable Liner Adhes / Ciprofloxacin Attending:[**First Name3 (LF) 905**] Chief Complaint: Rectal Bleeding and AMS Major Surgical or Invasive Procedure: right IJ central line placed Fluid resuscitation. Flexible sigmoidoscopy. Gastic lavage. Fistula for HD. History of Present Illness: 81F [**First Name3 (LF) 595**]-Speaking H/O ESRD/HD, CHF, CAD/CABG, Stoke (Broca's Aphasia) with AMS and BRBPR. Had recent [**Hospital1 18**] Admission ([**Date range (1) 64574**]) for AMS + N/V --> found to have AF and started on Coumadin. On DOA, at NH, found down sitting in 150cc blood and initialy unresponsive. To [**Hospital1 18**] ED: SBPs 80s. Rec'd 500cc IVF -> SBPs to 130s with improved mentation. NGL showed no blood. RIJ placed. HCT 28.9 from baseline 38.9. Rec'd PRBC 2U. Then HCT to 21 and then to 19.4. Pt continued to have melena and BRBPR. Then had brown emesis, but heme negative. INR 4.2. Given VitK PO. Pt then rec'd 3rd PRBC as well as FFP x 2. Then had bloody vomitus (450cc). Given addn'l IVF + Protonix IV. ROS: Reports vomiting at home intermittently. Occ with blood. Pos hematochezia. Pos abd pain. Past Medical History: 1) CAD: s/p NSTEMI, CABG x 3v, [**10/2115**], course c/b by stroke with aphasia and right hemiparesis, with eventual regain of function. 2) ESRD: hemodialysis on T,Th,Sat, through left arm AV graft 3) H/o GI bleeding 4) Gout 5) Anemia 6) HTN 7) Hypercholesterolemia 8) DM2 9) Stoke in left posterior frontal area [**10/2115**] 10) CHF: EF 30-40% 11) Depression 12) Colon polyps 13) Hemorrhoids 14) Hyperhomocysteinemia Social History: [**Month/Year (2) 595**]-born. Moved to US in [**2104**]. Lives alone at [**Hospital 7137**]. No children. [**Location (un) **] is the health care proxy [**Name (NI) **] H/O ETOH or tobacco. [**Name (NI) **] (cousin) [**Numeric Identifier 92985**] [**Name (NI) **] ([**Name (NI) 802**]) [**Numeric Identifier 92986**] [**Name (NI) **] (son) [**Telephone/Fax (1) 92987**] Family History: Non-Contributory. Physical Exam: O: T: 98 BP: 178 / 75 HR: 100-118 RR: 20 O2Sat: 98 RA Gen: Pt. appears sick, opens eyes, follows some commands ([**Telephone/Fax (1) 595**] speaking), but appears disoriented, sluggish. Skin: Multiple skin ecchymoses, Jugular line in place. EENT: Oropharynx clear, 15 JVD, EOMI. Heart: Tachy Irreg irreg, S1 S2 possible ejection murmur, no rubs. Lungs: Clear to auscultation bilaterally. No wheezes, rhonchi or rubs. Abd: Soft, nontender, nondistended, normal bowel sounds. Extrem: Occas. Ecchymosis on legs b/l. No edema. DP PT 2+ bilaterally. Extremities warm. Squeezes L + R hand. Pertinent Results: [**2119-11-20**] 05:04AM BLOOD WBC-6.7 RBC-3.45* Hgb-10.9* Hct-32.2* MCV-94 MCH-31.5 MCHC-33.7 RDW-15.8* Plt Ct-199 [**2119-11-16**] 02:00PM BLOOD WBC-7.7 RBC-3.39* Hgb-10.8* Hct-31.2* MCV-92 MCH-31.9 MCHC-34.7 RDW-15.9* Plt Ct-157 [**2119-11-16**] 05:45AM BLOOD WBC-6.4 RBC-2.73*# Hgb-8.7* Hct-25.2*# MCV-92 MCH-31.7 MCHC-34.4 RDW-16.2* Plt Ct-158 [**2119-11-15**] 02:40PM BLOOD WBC-6.6 RBC-2.09* Hgb-7.0* Hct-19.4* MCV-93 MCH-33.4* MCHC-35.9* RDW-17.1* Plt Ct-201 [**2119-11-15**] 01:15PM BLOOD WBC-6.3 RBC-2.27* Hgb-7.1*# Hct-21.2*# MCV-94 MCH-31.5 MCHC-33.7 RDW-16.9* Plt Ct-211 [**2119-11-15**] 02:00AM BLOOD WBC-10.0 RBC-2.88*# Hgb-9.5*# Hct-28.9*# MCV-100* MCH-33.2* MCHC-33.1 RDW-15.5 Plt Ct-303 [**2119-11-20**] 05:04AM BLOOD Plt Ct-199 [**2119-11-20**] 05:04AM BLOOD PT-13.3 PTT-24.6 INR(PT)-1.1 [**2119-11-15**] 08:20AM BLOOD PT-25.7* INR(PT)-4.2 [**2119-11-15**] 02:00AM BLOOD Plt Ct-303 [**2119-11-20**] 05:04AM BLOOD Glucose-102 UreaN-27* Creat-3.9* Na-139 K-3.5 Cl-99 HCO3-25 AnGap-19 [**2119-11-17**] 05:17AM BLOOD Glucose-126* UreaN-41* Creat-2.7* Na-146* K-3.6 Cl-105 HCO3-31* AnGap-14 [**2119-11-15**] 02:00AM BLOOD Glucose-185* UreaN-58* Creat-3.6*# Na-139 K-4.9 Cl-94* HCO3-35* AnGap-15 [**2119-11-17**] 05:17AM BLOOD ALT-10 AST-21 LD(LDH)-217 CK(CPK)-48 AlkPhos-55 TotBili-0.4 [**2119-11-17**] 12:00AM BLOOD CK(CPK)-69 [**2119-11-16**] 02:00PM BLOOD CK(CPK)-106 [**2119-11-16**] 05:45AM BLOOD ALT-11 AST-23 LD(LDH)-193 CK(CPK)-110 AlkPhos-50 TotBili-0.3 [**2119-11-15**] 01:15PM BLOOD ALT-9 AST-17 LD(LDH)-170 CK(CPK)-54 AlkPhos-51 TotBili-0.3 [**2119-11-15**] 02:00AM BLOOD CK(CPK)-21* [**2119-11-17**] 05:17AM BLOOD CK-MB-NotDone cTropnT-1.11* [**2119-11-17**] 12:00AM BLOOD CK-MB-NotDone cTropnT-1.14* [**2119-11-16**] 02:00PM BLOOD CK-MB-18* MB Indx-17.0* cTropnT-1.06* [**2119-11-15**] 02:00AM BLOOD CK-MB-NotDone cTropnT-0.17* [**2119-11-20**] 05:04AM BLOOD Calcium-8.4 Phos-2.8 Mg-1.8 [**2119-11-15**] 01:15PM BLOOD Albumin-3.2* Calcium-7.4* Phos-4.2# Mg-1.4* [**2119-11-16**] 02:29AM BLOOD Hgb-8.9* calcHCT-27 [**2119-11-15**] 06:46AM BLOOD Hgb-10.5* calcHCT-32 [**2119-11-16**] 11:15AM URINE Blood-MOD Nitrite-NEG Protein-100 Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-0.2 pH-8.0 Leuks-LG [**2119-11-16**] 11:15AM URINE RBC-[**4-7**]* WBC->50 Bacteri-MANY Yeast-NONE Epi-[**4-7**] Brief Hospital Course: A/P: 81F [**Month/Day (1) 595**]-Speaking H/O ESRD/HD, CHF, CAD/CABG, Stoke (Broca's Aphasia) with AMS and BRBPR. 1) BRPRB: HCT unstable on admission (down to 20 from baseline of 40). Etiology unclear, but known hemorrhoids and villous rectal mass on sigmoidoscopy. HCT was kept > 30 given CAD and acute bleeding. Total PRBC Rec'd = 6Units. All vitals have been stable. Pt had gastric lavage in ED inconclusive, and flex sig once she was in MICU for volume resuscitation. Stabilized and transferred to floor. Following stable Hcrit >30 for >48 hr, had discussion re additional diagnostic and treatment procedures. Pt. was already consented for UGI and colonoscopy by GI 3 d prior even though Pt. prior to hospital admission had refused coloscopy for a 5year period ([**First Name8 (NamePattern2) **] [**Name (NI) **], [**Name (NI) 802**]) and was not ([**First Name8 (NamePattern2) **] [**Location (un) **]) interested in additional GI interventions. On [**11-20**], Ms. [**Known lastname 92981**] was assessed via interpreter to determine her decision making abilities, understanding of her condition, and her decision on further diagnostic/interventional scopes. She refused further endoscopy at this time understanding the risks of ongoing bleeding from an unidentified source. Ms. [**Known lastname 92981**] was found to be fully aware that she almost died during the last 5 days due to bleeding from her GI tract and expressed that she was not interested in additional scoping (either upper or lower) to determine where the source of bleeding was (GI states ?????? per [**Doctor Last Name 1255**] that their opinion is that her stable HCT is evidence that she is no longer bleeding and that UGI scope would have no therapeutic component, but would asses ulcer, tumor, etc). The patient understands that if she starts bleeding again she may die to which her response (through interpreter) was: ??????If that is how I go then that is how I will go.?????? She also expressed the view that she would refuse surgery given the observation of a tumor,etc responsible for the bleed. This conversation provides evidence that (1) Ms. [**Known lastname 92981**] is aware of her medical condition. (2) She is not interested in further GI studies or operations that are either diagnostic or therapeutic, (3) that this evidence is corroborated by [**Known lastname 802**] [**Name (NI) **], woho remarked that Ms. [**Known lastname 92981**]??????s discussions with her and pattern of behavior regarding her illnesses over the last 5 years are consistent with these remarks. 2) Coagulopathy: Recently started on Coumadin. Was held and reversed in ED. INR 4.0 on admission. Decr to <2 with FFP and Vit K (5). Coumadin held during admission - due to bleed it is recommended that pt. remain off of anticoags since risk of morbidity/mortality from bleeding is higher than embolic event. INR was 1.1 at discharge. 3) NSTEMI/CAD: MBI positive and TnT rose in MICU likely due to demand ischemia secondary to hypovolemia. ECG with NSSTT changes. Off anti-platelets given bleed. Continued low-dose short acting BB as long as SBPs stable. 4) ESRD: HD T/Th/Sat. Pt. continued HD in-house with same schedule. Electrolytes checked following HD, were normal. 5) HTN: Pt. had multiple SBP spikes to 200 and one to 230 on outpatient HTN regimen. We increased metoprolol 75 tid and also increased captopril to 100 TID. We added hydralazine for additional BP control. 6) Pt. had +U/A and was treated with ceftriax for 5 days inhouse. Was discharged on cefpodox 200 [**Hospital1 **] for 2 days to complete course. 7) Code: DNR/DNR. Medications on Admission: Remeron 30 QD Lipitor 10 QD Phoslo 667 TID ECASA 81 QD Colace Folate 1 QD Lisinopril 10 QD Isordil 40 [**Hospital1 **] Lopressor 75 TID Clonidine 0.1 TID Senna Amlodipine 10 QD Coumadin 5 QD Nephrocap 1 QD Discharge Medications: 1. Clonidine HCl 0.1 mg Tablet Sig: One (1) Tablet PO BID (2 times a day): Hold for SBP<10. 2. Isosorbide Dinitrate 20 mg Tablet Sig: Two (2) Tablet PO TID (3 times a day): Hold for SBP<100. 3. Metoprolol Tartrate 25 mg Tablet Sig: Three (3) Tablet PO TID (3 times a day): Hold for SBP<100, HR<60. Disp:*90 Tablet(s)* Refills:*2* 4. B Complex-Vitamin C-Folic Acid 1 mg Capsule Sig: One (1) Cap PO QD (once a day). 5. Pantoprazole Sodium 40 mg Tablet, Delayed Release (E.C.) Sig: One (1) Tablet, Delayed Release (E.C.) PO twice a day. Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0* 6. Hydralazine HCl 10 mg Tablet Sig: One (1) Tablet PO four times a day: For SPB>150 Hold for SBP<120. 7. Captopril 100 mg Tablet Sig: One (1) Tablet PO three times a day for 1 months. Disp:*90 Tablet(s)* Refills:*1* 8. Cefpodoxime Proxetil 200 mg Tablet Sig: One (1) Tablet PO every twelve (12) hours for 2 days: on [**11-22**] and [**11-23**] and then d/c. Discharge Disposition: Extended Care Facility: [**Hospital3 2558**] - [**Location (un) **] Discharge Diagnosis: GI bleed (refused EGD) myocardial infarction delerium ESRD Discharge Condition: Stable, Fair. Hemodynamically stable. Hematocrit stable. Patient has refused EGD/colonscopy and understands the risks in regard to continued bleeding. Discharge Instructions: Please take all medications as precribed. Please return to the ED if you experience any bleeding in stool or vomit, or chest pain, or other worrisome symptoms. Please take your medications as ordered and have dialysis per your 3 tiem per week schedule. Followup Instructions: Please continue to attend dialysis 3 times each week. Please schedule an appointment with Dr. [**Last Name (STitle) 3357**] [**Telephone/Fax (1) 4606**] in the next week to discuss your recent bleeding episode and to follow-up on the H. pylori test that is pending. Please follow up with your primary care doctor to discuss whether you are interested in any additional tests or endoscopy/colonoscopies. Please talk to your doctor about when it is safe to restart aspirin. Please keep the following appointment with your kidney doctor: Provider: [**First Name11 (Name Pattern1) 1877**] [**Last Name (NamePattern1) 1878**], M.D. Where: [**Hospital6 29**] MEDICAL SPECIALTIES Phone:[**Telephone/Fax (1) 435**] Date/Time:[**2119-12-21**] 4:00 [**Name6 (MD) 251**] [**Name8 (MD) **] MD [**MD Number(1) 910**] Completed by:[**2119-11-21**]

[ "427.31", "410.71", "285.9", "276.5", "578.9", "599.0", "414.00", "787.99", "250.40", "V45.81", "403.91" ]

icd9cm

[ [ [] ] ]

[ "96.34", "39.95", "48.23", "38.93", "99.04" ]

icd9pcs

[ [ [] ] ]

9949, 10019

5090, 8718

274, 381

10122, 10276

2754, 5067

10579, 11447

2086, 2105

8975, 9926

10040, 10101

8744, 8952

10300, 10556

2120, 2735

211, 236

409, 1239

1261, 1681

1697, 2070

4,908

106,923

13092

Discharge summary

report

Admission Date: [**2136-7-31**] Discharge Date: [**2136-8-4**] Service: NEUROLOGY Allergies: No Drug Allergy Information on File Attending:[**First Name3 (LF) 2569**] Chief Complaint: Found unresponsive Major Surgical or Invasive Procedure: None History of Present Illness: 88 year-old Cantonese-speaking woman who presented with unresponsiveness. The pt does not remember the events of yesterday, does not know why she is here. The following history is per EMS, the ED team, and her PCP. The pt was found next to her bed yesterday morning by a family friend. EMS was called shortly thereafter and she was brought to the [**Hospital1 18**] ED for further evaluation. Per the EMS note, v/s were 88 208/91 20 87%ra. She was given narcan with no response. She was moving her L arm/leg less than the R. On presentation to the ER, Code Stroke was called (at 12:23), but no time of onset was known. Therefore protocol was aborted. The pt was intubated shortly after directed neurologic examination over concern for airway protection. The pt was unable to offer a review of systems. She was admitted to the ICU. Her course in the ICU has been unremarkable. She was extubated without difficulty last evening [**7-31**] at 6pm. She has a UTI and was started on antibiotics (no cultures). She had one episode of nausea/vomiting today after she received cipro on an empty stomach. A central line was placed but the patient did not require a drip to sustain her blood pressure. Past Medical History: As [**First Name8 (NamePattern2) **] [**First Name8 (NamePattern2) 429**] [**Last Name (NamePattern1) **], PCP [**Telephone/Fax (1) 16171**]: Hx prior PNA DM2 LE edema (EF 50%, sestimibi stress [**5-11**] neg) HTN GERD Asthma Anxiety Dx of PD [**7-11**] (not on meds, gait difficulty) Stroke [**6-11**] Lung cancer [**2131**] Social History: Widowed, lives with son. Two other children. Walks with walker. Family History: Unable to obtain Physical Exam: Vitals: 100.1 Tm 135/62 83 18 100% on 2L General: sitting in chair, using the telephone HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in oropharynx Neck: supple Pulmonary: Lungs CTA bilaterally without R/R/W Cardiac: RRR, nl. S1S2, +murmur Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or organomegaly noted. Extremities: No C/C/E bilaterally, 2+ radial, DP and PT pulses bilaterally. Skin: no rashes or lesions noted. Neurologic: -mental status: awake and alert, language fluent without errors. Speaks at length on telephone to Cantonese translator. Follows simple commands. Oriented. No memory for yesterday. -cranial nerves: PERRL 2.5 to 2mm. Funduscopic exam revealed no papilledema, exudates, or hemorrhages. EOM full. Gag reflex intact. Slight L NLF flattening. -motor: Normal bulk throughout. No pronator drift. b/l asterixis present. Strength 5/5 throughout upper and lower extremities. No adventitious movements noted. Normal tone throughout. -sensory: withdraws legs and arms to noxious stimuli in all four extremities. Gait: stands, then retropulses and sits back down -DTRs: [**Name2 (NI) **] Tri [**Last Name (un) 1035**] Pat Ach L 2 2 2 2 2 R 1 1 1 3 2 Plantar response was extensor on both sides. Pertinent Results: [**2136-8-2**] 06:40AM BLOOD WBC-6.2 RBC-4.33 Hgb-9.6* Hct-30.7* MCV-71* MCH-22.1* MCHC-31.3 RDW-17.5* Plt Ct-168 [**2136-7-31**] 11:55AM BLOOD Neuts-67.6 Lymphs-26.8 Monos-3.0 Eos-1.7 Baso-0.9 [**2136-7-31**] 11:55AM BLOOD Hypochr-2+ Anisocy-1+ Poiklo-1+ Microcy-3+ [**2136-7-31**] 11:55AM BLOOD PT-11.8 PTT-23.2 INR(PT)-1.0 [**2136-8-2**] 06:40AM BLOOD Glucose-90 UreaN-14 Creat-0.8 Na-141 K-3.4 Cl-108 HCO3-24 AnGap-12 [**2136-8-2**] 06:40AM BLOOD ALT-13 AST-17 AlkPhos-42 Amylase-89 TotBili-0.5 [**2136-8-2**] 06:40AM BLOOD Lipase-23 [**2136-8-1**] 03:58AM BLOOD CK-MB-NotDone cTropnT-<0.01 [**2136-8-2**] 06:40AM BLOOD Albumin-3.6 Calcium-8.6 Phos-2.8 Mg-2.2 Iron-116 Cholest-152 [**2136-8-2**] 06:40AM BLOOD calTIBC-200* VitB12-337 Folate-10.3 Ferritn-212* TRF-154* [**2136-8-1**] 03:58AM BLOOD %HbA1c-6.0* [Hgb]-DONE [A1c]-DONE [**2136-8-2**] 06:40AM BLOOD Triglyc-51 HDL-86 CHOL/HD-1.8 LDLcalc-56 [**2136-7-31**] 11:55AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG [**2136-7-31**] 05:36PM BLOOD Type-ART pO2-292* pCO2-34* pH-7.45 calTCO2-24 Base XS-0 Study Findings: CT C-SPINE W/O CONTRAST: No fractures or dislocations. Normal alignment. Enlarged osteophytes with impingement upon the foramen transversarium at the C4 and C5 vertebral bodies in levels. CTA HEAD & NECK W&W/O CONTRAST & RECON: No evidence of an intracranial hemorrhage or mass effect. Chronic microvascular infarcts. The CTA does not demonstrate any vessel cut off/filling defect or aneurysm. There is diffuse dolichoectasia likely due to long standing hypertension. CHEST (PORTABLE AP): Satisfactory positioning of lines and tubes. No acute cardiopulmonary abnormality. CHEST PORT. LINE PLACEM: Right subclavian central venous catheter tip in the lower SVC. No pneumothorax. ECG: Sinus rhythm Atrial premature complex Possible left atrial abnormality Left ventricular hypertrophy Modest nonspecific lateral ST-T wave changes No previous tracing available for comparison EEG: Results pending CHEST (PA & LAT): Pulmonary nodule in the left upper lobe. CT is recommended for further characterization. Brief Hospital Course: Patient is a 88 year-old with multiple medical problems admitted to ICU on [**2136-6-29**] after being found unresponsive at bedside in her home. She was admitted to ICU and intubated for desats down to 87%. She was hypertensive with systolics in 220s and placed on labetelol drip. Head CT revealed chronic microvascular infarcts but was negative for an acute intracranial hemorrhage or mass effect. CTA was negative for vessel cut off/filling defect or aneurysm. These findings suggested toxic-metabolic or seizure etiology for unresponsiveness. She was started on dilantin for seizure prophylaxis. She was extubated the evening after admission and had stable sats on 2L oxygen. On admission to ICU, patient was arousable only to noxious stimuli by opening eyes but did not follow commands and unable to move left arm. Urinalysis was postive for UTI and ciprofloxacin was started. Patient became hemodynamically stable and remained afebrile with WBC count within normal limits. She was transferred to the Stroke service and her neurological exam had improved. Patient was awake and following commands. She had decreased strength 4/5 in upper and lower extremities with [**1-9**] reflexes. EEG showed generalized slowing without focal sharp waves/spikes consistent with encephalopathy. Dilantin was discontinued given low likelihood for seizure and her outpatient medications for hypertension and anxiety were re-started. Patient had lower extremity edema on exam and echocardiogram was done to evaluate for congestive heart failure. Echo was negative for ASD or thrombi, mild LVH, EF 70%, no valvular prolapse. Patient was started on B12 therapy for low levels. CXR revealed 7mm lung nodule in left upper lobe concerning for lung cancer given her history of cancer in [**2131**]. There was also faint opacity in the right lower lobe consistent with a developing pneumonia. She was started on broad antibiotic coverage with flagyl and ciprofloxacin. Brain MRI was done due to lack of concrete etiology for patient's unresponsiveness for this admission and past history of stroke. Patient's language barrier also made it difficult to collect more information. MRI showed: Chronic right basal ganglia subcortical infarct. Moderate-to- severe changes of small vessel disease. No definite evidence of acute infarct. No mass effect. It should be noted that the examination was performed without gadolinium which limits evaluation for metastasis or other enhancing mass lesions. If there is continued suspicion for metastasis, consider gadolinium-enhanced images. PT/OT evaluated the patient and was cleared to go home without rehab services. She was given a choice to receive PT services at home if she can get health insurance. Patient will followup with PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 429**] [**Last Name (NamePattern1) **] for medical management. She will continue on outpatient medications, in addition to B12. She will need a chest CT outpatient to evaluate lung nodule and PCP was notified about the finding. Medications on Admission: Protonix 40 Toprol xl 200 Lasix 20mg po daily (via VNA) KCl 8meq daily NTG PRN ASA 81 Colace [**Hospital1 **] Nortryptiline 25mg po qhs 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. Metoprolol Tartrate 50 mg Tablet Sig: One (1) Tablet PO TID (3 times a day). Disp:*90 Tablet(s)* Refills:*2* 3. Furosemide 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily). Disp:*30 Tablet(s)* Refills:*2* 4. Aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable PO DAILY (Daily). Disp:*30 Tablet, Chewable(s)* Refills:*2* 5. Nortriptyline 25 mg Capsule Sig: One (1) Capsule PO HS (at bedtime). Disp:*30 Capsule(s)* Refills:*2* 6. Zolpidem 5 mg Tablet Sig: One (1) Tablet PO HS (at bedtime) as needed. Disp:*30 Tablet(s)* Refills:*0* Discharge Disposition: Home With Service Facility: [**Hospital 119**] Homecare Discharge Diagnosis: Metabolic encephalopathy [**2-9**] UTI, hypoxia Hx prior PNA Diabetes mellitus II LE edema (EF 50%, sestimibi stress [**5-11**] neg) HTN GERD Asthma Anxiety ? Dx of PD [**7-11**] (not on meds, gait difficulty) Stroke [**6-11**] Lung Cancer [**2131**] Discharge Condition: Stable Discharge Instructions: Please take all medications. Followup Instructions: PCP [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) 429**] [**Last Name (NamePattern1) **] for medical management ([**Telephone/Fax (1) 16171**]). [**First Name8 (NamePattern2) **] [**Name8 (MD) 162**] MD [**MD Number(2) 2575**] Completed by:[**2136-8-7**]

[ "285.9", "486", "348.31", "518.89", "V10.11", "599.0", "250.00", "300.00", "401.9" ]

icd9cm

[ [ [] ] ]

[ "96.71", "96.04" ]

icd9pcs

[ [ [] ] ]

9391, 9449

5407, 8457

262, 268

9744, 9753

3266, 5384

9830, 10133

1942, 1960

8643, 9368

9470, 9723

8483, 8620

9777, 9807

2635, 3247

1975, 2437

204, 224

296, 1496

2452, 2617

1518, 1845

1861, 1926

20,969

123,200

54249

Discharge summary

report

Admission Date: [**2128-6-20**] Discharge Date: [**2128-7-4**] Date of Birth: [**2048-1-11**] Sex: F Service: MEDICINE Allergies: Morphine Attending:[**First Name3 (LF) 2279**] Chief Complaint: Abdominal pain Major Surgical or Invasive Procedure: Right sided IJ CVL placement Right sided chest tube placement Paracentesis PICC line placement History of Present Illness: 80yo F with PMH hepc C cirrohsis from blood transfusion, rectal CA s/p colectomy with ostomy who presented to the ED with a week of feeling poorly primarily increased fatigue and onset of abdominal pain this morning. Reports diarrhea up to 5BM in the last 24 hours and an episode of vomiting this morning. She notes that she has had c. diff in the past and feels like she has it again. Abdominal pain is all over her abdomen. In the ED, initial vs were:103.2 150 139/121 28 92% on RA. Exam was notable for diffuse abd pain, no rebound/guarding. Patient was given vancomycin, zosyn and flagyl and a R IJ CVL was placed. The pt was started on norepinephrine for pressures in the 80's. Lactate was 9 and came down to 3.3 after 2l IVF. CT abdomen and pelvis showed "moderate ascites with peritoneal enhancement, ? peritonitis" and transplant surgery was consulted. Transplant surgery reviewed images with attending and did not feel there was an infected fluid collection in her abdomen and were more concerned about SBP, but there was no safe tappable pocket. General sugery also was consulted and agreed with no surgically intervenable process. . On arrival to the floor, she reports she is feeling remarkably better. She denies abdominal pain currently. . Review of sytems: (+) 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: 1. Recurrent empyema (x3): [**4-7**] with a large right-sided empyema requiring chest tube and pigtail catheter drainage. Bacteria grew a pansensitive E. coli and a penicillin sensitive enterococcus. S/p vancomycin and ceftriaxone. Completed abx [**2127-5-15**]. - 2. HCV Cirrhosis obtained via blood transfusion during colon surgery in [**2097**]'s, h/o nodule with work-up underway by Dr. [**Last Name (STitle) 497**] 3. HTN 4. Remote history of rectal cancer s/p colectomy and ostomy in [**2103**] 5. h/o lacunar infarcts 6. Anxiety/Depression 7. GERD 8. h/o Multiple parastomal hernias with revisions and repositions from RLQ to LLQ to LUQ [**6-/2122**] 9. s/p CCY in [**2127-1-3**] 10. Clostridium Difficile Associated Diarrhea -- recurrent in [**7-/2127**] Social History: Lives alone in [**Location 1268**] with a nurse [**First Name (Titles) **] [**Last Name (Titles) 2176**] her daily. Independent in ADLs, and most IADLs. She is a lifelong non-smoker. No alcohol consumption since at least [**Month (only) 404**] and was never a heavy drinker. Worked in a bank for years, retired. Divorced. Son is HCP, involved in care. Of note, pt has daughter who wants to visit pt, but pt does not want to see daughter. Family History: Mother with uterine cancer. Sister with melanoma. Sister with lung cancer. Physical Exam: Exam on admission: VS - Temp 97.4F, BP 100/56 , HR 79 , R 20, O2-sat 95% 2L GENERAL - pleasant, alert, cachectic appearance HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear NECK - supple, no JVD LUNGS - resp unlabored, decreased breath sounds on L, bibasilar crackles, chest tube in place draining serosanguinous fluid to suction HEART - RRR, nl S1-S2 III/VI SEM ABDOMEN - NABS, soft/NT/ND, ostomy bag in place, no masses or HSM, no rebound/guarding EXTREMITIES - WWP, 2+ pitting pedal edema, 2+ peripheral pulses NEURO - awake, A&Ox3, CNs II-XII grossly intact, no focal neurologic deficits. On discharge, she continued to be afebrile with stable vitals (SBP consistently ranged 90s-100s, appears to be her baseline). On lung exam, she was breathing comfortably on room air, but with decreased air movement at the L lung base, no crackles/wheezes. She had mild intermittent tenderness to palpation on abdominal exam, and 2+ pitting pedal edema. She was awake and alert and oriented to person, place, and date, but at times showed evidence of delirium (unable to name months of year backward). Pertinent Results: Labs: CBC: [**2128-6-20**] 10:40AM BLOOD WBC-5.1 RBC-4.55 Hgb-14.9 Hct-45.6 MCV-100* MCH-32.9* MCHC-32.8 RDW-14.1 Plt Ct-152# [**2128-6-21**] 04:02AM BLOOD WBC-19.5*# RBC-3.76* Hgb-12.4 Hct-36.5 MCV-97 MCH-33.1* MCHC-34.1 RDW-14.2 Plt Ct-104* [**2128-6-22**] 03:46AM BLOOD WBC-15.5* RBC-3.22* Hgb-10.7* Hct-31.5* MCV-98 MCH-33.3* MCHC-34.1 RDW-14.1 Plt Ct-82* [**2128-6-22**] 10:17AM BLOOD WBC-18.8* RBC-3.43* Hgb-11.2* Hct-34.1* MCV-99* MCH-32.7* MCHC-32.9 RDW-14.5 Plt Ct-86* [**2128-6-23**] 03:53AM BLOOD WBC-17.4* RBC-3.60* Hgb-11.6* Hct-35.6* MCV-99* MCH-32.3* MCHC-32.6 RDW-14.3 Plt Ct-74* [**2128-6-24**] 06:18AM BLOOD WBC-11.5* RBC-3.43* Hgb-11.4* Hct-33.6* MCV-98 MCH-33.2* MCHC-33.9 RDW-14.3 Plt Ct-70* [**2128-6-25**] 04:26AM BLOOD WBC-13.8* RBC-3.51* Hgb-11.9* Hct-35.0* MCV-100* MCH-33.8* MCHC-34.0 RDW-14.3 Plt Ct-63* [**2128-6-26**] 03:04AM BLOOD WBC-16.5* RBC-3.65* Hgb-12.2 Hct-36.5 MCV-100* MCH-33.3* MCHC-33.3 RDW-14.3 Plt Ct-66* [**2128-6-27**] 03:58AM BLOOD WBC-13.0* RBC-3.31* Hgb-10.9* Hct-32.4* MCV-98 MCH-32.9* MCHC-33.6 RDW-14.6 Plt Ct-53* [**2128-6-28**] 02:34AM BLOOD WBC-11.3* RBC-3.30* Hgb-11.0* Hct-32.7* MCV-99* MCH-33.3* MCHC-33.6 RDW-14.2 Plt Ct-58* [**2128-6-29**] 04:20AM BLOOD WBC-12.9* RBC-3.46* Hgb-11.4* Hct-33.5* MCV-97 MCH-33.0* MCHC-34.0 RDW-14.9 Plt Ct-59* [**2128-6-30**] 05:01AM BLOOD WBC-11.1* RBC-3.24* Hgb-10.7* Hct-31.7* MCV-98 MCH-33.1* MCHC-33.8 RDW-15.1 Plt Ct-52* [**2128-7-1**] 05:25AM BLOOD WBC-11.6* RBC-3.15* Hgb-10.4* Hct-30.8* MCV-98 MCH-33.1* MCHC-33.9 RDW-15.2 Plt Ct-57* [**2128-7-2**] 06:07AM BLOOD WBC-11.1* RBC-3.22* Hgb-10.6* Hct-31.5* MCV-98 MCH-32.7* MCHC-33.5 RDW-15.7* Plt Ct-62* [**2128-7-4**] 06:09AM BLOOD WBC-7.7 RBC-2.85* Hgb-9.7* Hct-28.5* MCV-100* MCH-34.1* MCHC-34.1 RDW-15.4 Plt Ct-50* [**2128-7-4**] 06:09AM BLOOD Plt Ct-50* Diff: [**2128-6-20**] 10:40AM BLOOD Neuts-65 Bands-7* Lymphs-25 Monos-2 Eos-1 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2128-6-21**] 04:02AM BLOOD Neuts-67 Bands-29* Lymphs-1* Monos-2 Eos-0 Baso-0 Atyps-0 Metas-1* Myelos-0 [**2128-6-22**] 03:46AM BLOOD Neuts-99* Bands-0 Lymphs-0 Monos-1* Eos-0 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2128-6-22**] 10:17AM BLOOD Neuts-96.0* Lymphs-1.9* Monos-1.5* Eos-0.5 Baso-0.1 [**2128-6-23**] 03:53AM BLOOD Neuts-93.3* Lymphs-2.6* Monos-3.4 Eos-0.7 Baso-0.1 [**2128-6-25**] 04:26AM BLOOD Neuts-83.3* Lymphs-4.8* Monos-8.6 Eos-3.1 Baso-0.2 [**2128-6-29**] 04:20AM BLOOD Neuts-84* Bands-1 Lymphs-3* Monos-8 Eos-4 Baso-0 Atyps-0 Metas-0 Myelos-0 [**2128-7-2**] 06:07AM BLOOD Neuts-86.9* Lymphs-6.8* Monos-3.5 Eos-2.3 Baso-0.5 Coags: [**2128-6-20**] 10:40AM BLOOD PT-16.5* PTT-27.6 INR(PT)-1.5* [**2128-6-21**] 04:02AM BLOOD PT-19.3* PTT-34.3 INR(PT)-1.8* [**2128-6-26**] 04:54PM BLOOD PT-19.6* PTT-37.8* INR(PT)-1.8* [**2128-6-27**] 03:58AM BLOOD PT-18.9* PTT-38.4* INR(PT)-1.7* [**2128-6-28**] 02:34AM BLOOD PT-18.9* PTT-37.2* INR(PT)-1.7* [**2128-6-29**] 04:20AM BLOOD PT-18.4* PTT-36.1* INR(PT)-1.7* [**2128-6-30**] 05:01AM BLOOD PT-17.3* PTT-38.7* INR(PT)-1.5* [**2128-7-1**] 05:25AM BLOOD PT-18.0* PTT-37.8* INR(PT)-1.6* [**2128-7-2**] 06:07AM BLOOD PT-17.1* PTT-35.1* INR(PT)-1.5* Electrolytes: [**2128-6-20**] 10:40AM BLOOD Glucose-105* UreaN-20 Creat-1.0 Na-134 K-5.4* Cl-100 HCO3-17* AnGap-22* [**2128-6-21**] 04:02AM BLOOD Glucose-84 UreaN-21* Creat-0.9 Na-138 K-3.9 Cl-112* HCO3-16* AnGap-14 [**2128-6-22**] 03:46AM BLOOD Glucose-111* UreaN-19 Creat-0.8 Na-136 K-3.9 Cl-109* HCO3-21* AnGap-10 [**2128-6-23**] 03:53AM BLOOD Glucose-135* UreaN-19 Creat-0.7 Na-136 K-4.0 Cl-110* HCO3-20* AnGap-10 [**2128-6-24**] 06:18AM BLOOD Glucose-115* UreaN-20 Creat-0.8 Na-137 K-3.6 Cl-109* HCO3-21* AnGap-11 [**2128-6-25**] 04:26AM BLOOD Glucose-112* UreaN-24* Creat-0.7 Na-137 K-3.7 Cl-109* HCO3-20* AnGap-12 [**2128-6-26**] 03:04AM BLOOD Glucose-103* UreaN-26* Creat-0.8 Na-137 K-4.7 Cl-110* HCO3-19* AnGap-13 [**2128-6-27**] 03:58AM BLOOD Glucose-117* UreaN-23* Creat-0.7 Na-135 K-4.2 Cl-105 HCO3-22 AnGap-12 [**2128-6-28**] 02:34AM BLOOD Glucose-101* UreaN-23* Creat-0.7 Na-133 K-4.0 Cl-104 HCO3-22 AnGap-11 [**2128-6-29**] 04:20AM BLOOD Glucose-89 UreaN-19 Creat-0.7 Na-133 K-4.4 Cl-103 HCO3-22 AnGap-12 [**2128-6-30**] 05:01AM BLOOD Glucose-82 UreaN-19 Creat-0.7 Na-132* K-4.2 Cl-101 HCO3-26 AnGap-9 [**2128-7-1**] 05:25AM BLOOD Glucose-97 UreaN-21* Creat-0.8 Na-132* K-4.3 Cl-100 HCO3-24 AnGap-12 [**2128-7-2**] 06:07AM BLOOD Glucose-74 UreaN-24* Creat-0.9 Na-134 K-4.3 Cl-103 HCO3-25 AnGap-10 [**2128-7-4**] 06:09AM BLOOD Glucose-113* UreaN-27* Creat-0.8 Na-132* K-4.4 Cl-102 HCO3-25 AnGap-9 Lipase: [**2128-6-20**] 10:40AM BLOOD Lipase-35 Cardiac Enzymes: [**2128-6-28**] 11:24PM BLOOD CK-MB-2 cTropnT-<0.01 [**2128-6-29**] 10:09AM BLOOD CK-MB-2 cTropnT-<0.01 Elements: [**2128-6-21**] 04:02AM BLOOD Albumin-2.2* Calcium-7.5* Phos-4.2 Mg-1.2* [**2128-6-21**] 11:46AM BLOOD Calcium-7.4* Phos-3.5 Mg-2.1 [**2128-6-22**] 03:46AM BLOOD TotProt-5.0* Calcium-8.2* Phos-2.6* Mg-1.9 [**2128-6-23**] 03:53AM BLOOD Calcium-7.7* Phos-1.9* Mg-1.7 [**2128-6-24**] 06:18AM BLOOD Calcium-8.7 Phos-2.7 Mg-1.8 [**2128-6-25**] 04:26AM BLOOD Calcium-8.4 Phos-2.9 Mg-1.7 [**2128-6-26**] 03:04AM BLOOD Calcium-8.6 Phos-3.6 Mg-2.0 [**2128-6-28**] 02:34AM BLOOD Calcium-8.0* Phos-3.4 Mg-1.7 [**2128-6-29**] 04:20AM BLOOD Calcium-8.1* Phos-3.1 Mg-1.9 [**2128-6-30**] 05:01AM BLOOD Calcium-8.2* Phos-3.3 Mg-1.7 [**2128-7-1**] 05:25AM BLOOD Calcium-8.2* Phos-3.3 Mg-2.2 [**2128-7-4**] 06:09AM BLOOD Calcium-8.4 Phos-3.2 Mg-1.9 LFTs: [**2128-7-4**] 06:09AM BLOOD ALT-10 AST-18 AlkPhos-73 TotBili-1.6* Endocrine: [**2128-6-26**] 12:15PM BLOOD Cortsol-10.6 [**2128-6-26**] 01:00PM BLOOD Cortsol-20.5* [**2128-6-26**] 01:56PM BLOOD Cortsol-24.4* Lactate: [**2128-6-20**] 10:53AM BLOOD Lactate-7.9* [**2128-6-20**] 12:44PM BLOOD Lactate-3.3* K-3.8 [**2128-6-21**] 04:06AM BLOOD Lactate-2.8* Urine: [**2128-6-25**] 06:39PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.035 [**2128-6-20**] 02:35PM URINE Color-Yellow Appear-Clear Sp [**Last Name (un) **]-1.050* [**2128-6-25**] 06:39PM URINE Blood-MOD Nitrite-NEG Protein-30 Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM [**2128-6-20**] 02:35PM URINE Blood-NEG Nitrite-NEG Protein-TR Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG [**2128-6-25**] 06:39PM URINE RBC-55* WBC-8* Bacteri-NONE Yeast-FEW Epi-0 Pleural Analysis: [**2128-6-21**] 06:37PM PLEURAL WBC-[**Numeric Identifier **]* Polys-99* Bands-1* Lymphs-0 Monos-0 [**2128-6-21**] 06:37PM PLEURAL Hct,Fl-12.5* [**2128-6-29**] 04:00PM PLEURAL WBC-875* RBC-8575* Polys-43* Lymphs-8* Monos-47* Eos-2* [**2128-6-21**] 06:37PM PLEURAL TotProt-2.2 Glucose-102 LD(LDH)-798 Amylase-14 Albumin-1.1 [**2128-6-22**] 11:40AM ASCITES WBC-4750* RBC-8200* Polys-85* Bands-2* Lymphs-3* Monos-10* Micro: [**6-20**] BC Final negative [**2128-6-20**] 11:15 am BLOOD CULTURE #2. **FINAL REPORT [**2128-7-2**]** Blood Culture, Routine (Final [**2128-7-2**]): STAPHYLOCOCCUS, COAGULASE NEGATIVE. Isolated from only one set in the previous five days. SENSITIVITIES REQUESTED BY DR. [**Last Name (STitle) 5479**] ([**Numeric Identifier 11644**]). FINAL SENSITIVITIES. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. COAG NEG STAPH does NOT require contact precautions, regardless of resistance. STAPHYLOCOCCUS, COAGULASE NEGATIVE. SECOND MORPHOLOGY. Isolated from only one set in the previous five days. SENSITIVITIES REQUESTED BY DR. [**Last Name (STitle) 5479**] ([**Numeric Identifier 11644**]). FINAL SENSITIVITIES. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. COAG NEG STAPH does NOT require contact precautions, regardless of resistance. STAPHYLOCOCCUS, COAGULASE NEGATIVE. THIRD MORPHOLOGY. Isolated from only one set in the previous five days. SENSITIVITIES REQUESTED BY DR. [**Last Name (STitle) 5479**] ([**Numeric Identifier 11644**]). FINAL SENSITIVITIES. This isolate is presumed to be resistant to clindamycin based on the detection of inducible resistance . COAG NEG STAPH does NOT require contact precautions, regardless of resistance. Oxacillin RESISTANT Staphylococci MUST be reported as also RESISTANT to other penicillins, cephalosporins, carbacephems, carbapenems, and beta-lactamase inhibitor combinations. Rifampin should not be used alone for therapy. SENSITIVITIES: MIC expressed in MCG/ML _________________________________________________________ STAPHYLOCOCCUS, COAGULASE NEGATIVE | STAPHYLOCOCCUS, COAGULASE NEGATIVE | | STAPHYLOCOCCUS, COAGULASE N | | | CLINDAMYCIN----------- R R R ERYTHROMYCIN---------- =>8 R =>8 R =>8 R GENTAMICIN------------ <=0.5 S <=0.5 S <=0.5 S LEVOFLOXACIN---------- 4 R 4 R =>8 R OXACILLIN------------- =>4 R =>4 R =>4 R RIFAMPIN-------------- <=0.5 S <=0.5 S <=0.5 S TETRACYCLINE---------- <=1 S <=1 S 2 S VANCOMYCIN------------ 1 S 1 S 2 S [**6-20**] UCx URINE CULTURE (Final [**2128-6-21**]): <10,000 organisms/ml. [**2128-6-21**] C. Diff toxin negative [**2128-6-21**] 6:37 pm FLUID RECEIVED IN BLOOD CULTURE BOTTLES Fluid Culture in Bottles (Final [**2128-6-27**]): NO GROWTH. ACID FAST SMEAR (Final [**2128-6-22**]): NO ACID FAST BACILLI SEEN ON DIRECT SMEAR. ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED. [**2128-6-22**] Peritoneal Fluid **FINAL REPORT [**2128-6-28**]** GRAM STAIN (Final [**2128-6-22**]): 3+ (5-10 per 1000X FIELD): POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2128-6-25**]): NO GROWTH. ANAEROBIC CULTURE (Final [**2128-6-28**]): NO GROWTH. 6/23-24/11 Blood cultures Final negative [**2128-6-25**] C. Diff negative [**2128-6-25**] Urine Culture NO GROWTH [**2128-6-27**] Stool culture negative [**2128-6-29**] Pleural Fluid GRAM STAIN (Final [**2128-6-29**]): NO POLYMORPHONUCLEAR LEUKOCYTES SEEN. NO MICROORGANISMS SEEN. FLUID CULTURE (Final [**2128-7-2**]): NO GROWTH. ANAEROBIC CULTURE (Preliminary): NO GROWTH. - PLEURAL FLUID Procedure Date of [**2128-6-21**] NEGATIVE FOR MALIGNANT CELLS - ECG Study Date of [**2128-6-20**] 10:45:00 AM Moderate baseline artifact. Sinus tachycardia. Compared to the previous tracing of [**2128-2-27**] there is probably no diagnostic interval change. - CT ABD & PELVIS WITH CONTRAST Study Date of [**2128-6-20**] 12:39 PM FINDINGS: There is a significant interval increase in a large right basal loculated pleural fluid with mildly enhancing septations and pleura. These findings are concerning for infection within this collection. There has been interval removal of a right pleural drainage catheter. There is mild compressive atelectasis of the right lower lobe. The left lung is relatively clear. The airways are patent to subsegmental levels bilaterally. No significant mediastinal, hilar or axillary lymphadenopathy is detected. Extensive coronary arterial calcifications and mild aortic calcification is noted. There is no left pleural effusion or pericardial effusion. CT OF THE ABDOMEN WITH INTRAVENOUS CONTRAST: The liver has a nodular contour, consistent with known history of cirrhosis. The spleen is enlarged measuring 15.7 cm. The main portal vein, splenic vein are patent. The patient is status post cholecystectomy. Multiple perigastric and portosystemic varices are seen. There is a moderate amount of free intra-abdominal fluid, with mild enhancement of the peritoneum, which could be secondary to peritonitis. A loculated fluid collection tracking along the right paracolic [**Date Range 111147**] has enhancing walls, and an infection within this collection cannot be excluded. There is a left upper abdomen colostomy, with a small amount of mesenteric fat,blood vessels and fluid herniating through the ostomy defect. An additional ventral hernia containing ascitic fluid is seen in the left lower quadrant. The stomach, small and large bowel are unremarkable, without evidence of acute inflammation. There is diffuse stranding of the mesenteric fat which could be secondary to portal hypertension. No significant retroperitoneal or mesenteric lymphadenopathy is seen. Calcification of the abdominal aorta is seen without aneurysmal dilation. CT OF THE PELVIS: The urinary bladder is unremarkable. The uterus is surgically absent. The rectum and sigmoid colon are unremarkable. There is a moderate amount of pelvic free fluid. BONES AND SOFT TISSUES: No bone lesion suspicious for infection or malignancy is detected. Multilevel degenerative changes of the thoracolumbar spine are seen. IMPRESSION: 1. Large right basal loculated fluid collection with extensive septations and enhancing pleura, superimposed infection is not excluded. 2. Cirrhosis of the liver, with splenomegaly and portosystemic collaterals. 3. Moderate ascites with diffuse enhancement of the peritoneum, may sggest peritonitis. Additional focal rim enhancing fluid collection along the right paracolic [**Last Name (LF) 111147**], [**First Name3 (LF) **] infection in this collection is not excluded. 4. Uncomplicated ventral parastomal hernia containing mesenteric fat and blood vessels. Brief Hospital Course: Primary reason for hospitalization: 80yoF witih h/o HCV cirrhosis p/w abdominal pain, fever, hypotension. . Active conditions: # Sepsis: On initial eval in the [**Name (NI) **], pt had CT of chest and abdomen which revealed a R loculated pleural effusion and R paracolic [**Name (NI) 111147**] fluid, concerning for communicating SBP and R empyema. Her lactate was elevated at 9 and she was hypotensive, a RIJ central line was placed, she was started on pressors and admitted to the MICU due to concern for septic shock. Pressors were eventually weaned off after a couple days. R pleural fluid cultures did not grow organisms. General surgery was consulted to evaluate the R paracolic [**Name (NI) 111147**] fluid but did not feel that it was amenable to surgical intervention. A diagnostic paracentesis was performed and showed WBCs but no organisms. The infectious disease service was consulted and recommended broad spectrum antibiotics (IV Vanc/Zosyn). On HD#6 her IV Vancomycin was switched to IV Linezolid for VRE coverage. On HD#9 her IV Zosyn was stopped. On HD#10 she started Cipro 500mg [**Hospital1 **] for coverage of abdominal pathogens (and presumed SBP), and IV daptomycin 6mg/kg (350mg) daily for continued VRE coverage. ID recommended she continue both Cipro PO and IV daptomycin for a total of four weeks, with day 1 of Cipro = [**6-21**] (first day of Zosyn, transitioned to Cipro), and day 1 of IV daptomycin = [**6-26**] (first day of Linezolid, transitioned to daptomycin). . # R pleural effusion: Interventional pulmonary was consulted and a chest tube with pigtail catheter was placed in the R pleural space. The drain initially had good output (2L), but then drainage slowed and the pt received tPA via the chest tube for 3 days. The drainage then improved and continued to drain serosanguinous fluid. On HD#11 the drainage slowed to <10cc/24 hours and the chest tube was removed. . # L pleural effusion: Developed intervally during hospitalization, first noted on repeat CT torso on HD#6. IP service evaluated but did not feel that it was amenable to U/S-guided thoracentesis, suggested IR-guided drainage. However, at that time the patient expressed that she did not want to undergo any additional invasive procedures. On HD#10, she expressed that she may at some point want reconsider IR-guided drainage of the effusion. It was decided not to pursue further intervention during the hospitalization, but to re-address in the future at her follow up appointment with the Infectious Disease Service after repeat imaging. . # H/o recurrent c. diff infection: Pt started empiric tx with IV Flagyl for C diff due to her known h/o recurrent c diff infection (most recent in [**2-13**]). C diff toxin labs were negative and Flagyl was discontinued. ID recommended starting C diff prophylaxis with PO Vancoymycin in the setting of broad spectrum antibiotic treatment. They recommended that she continue PO Vancomycin until 1 week after completing her antibiotic regimen (projected date = [**7-31**]). . # Cirrhosis: The pt was evaluated by the hepatology service on admission. Based on her admission labs, her MELD score was 16 on admission, suggesting cirrhotic decompensation, likely due to infection. She was given 100g albumin on HD#1 and 65g on HD#2. Her transaminases and T bili improved during her hospitalization. She should follow up with her liver specialist, Dr. [**Last Name (STitle) **], as an outpatient after discharge. In addition, she should avoid use of NSAIDs and limit use of tylenol to no more than 2g/24 hours. . # Delirium: Pt exhibited waxing/[**Doctor Last Name 688**] orientation. She was evaluated by the psychiatry service, who felt that her delirium was likely multifactorial in the setting of acute illness, pain, and medications. Narcotic and other sedating medications were avoided when possible to prevent exacerbation of her delirium. . # Pain: Pain was controlled with standing tylenol (500mg q6hrs, total dose not to exceed 2g/24 due to cirrhosis) and standing tramadol (50mg [**Hospital1 **]). NSAIDs were avoided due to risk of hepatorenal syndrome with cirrhosis. . # Goals of care: Patient and family at times seemed ambivalent about how aggressively they wished to treat her medical conditions. Her family expressed concern about her nutritional status and reluctance to eat, and mirtazapine was started to stimulate appetite. Palliative care and social work were asked to offer guidance with discussions regarding goals of care. This was still an ongoing discussion at the time of hospital discharge, and palliative care will continue to follow. . Transitions: She should continue her antibiotic regimen as recommended by ID (see discharge instructions). She will need to have weekly labs drawn (CBC/diff, BUN/Cr, LFT's, CK) with results faxed to Infectious disease R.Ns. at ([**Telephone/Fax (1) 1353**]. She has follow up appointments scheduled at the [**Hospital **] [**Hospital 4898**] clinic on [**7-14**] and with the ID specialist on [**7-27**]. She will need repeat chest CT one week prior to her appointment on [**7-27**]; this should be scheduled by calling the [**Hospital **] clinic one week prior to the appointment. . She will also need to follow up with her liver specialist, Dr. [**Last Name (STitle) **], within 2 weeks of discharge. His office is aware and will be contacting her to schedule the appointment. . The palliative care service will continue to follow her while she is at rehab to provide assistance to her and her family with decisions regarding goals of care. . She should also have an appointment scheduled to follow up with her primary care doctor, Dr. [**First Name (STitle) **], within 1 week of hospital discharge. Medications on Admission: clotrimazole-betamethasone 1 %-0.05 % Topical Cream- apply to affected area on thigh twice a day as needed for itchy spot cyanocobalamin (vitamin B-12) 250 mcg Tab-one Tablet(s) by mouth once a day cholecalciferol (vitamin D3) 1,000 unit -one Tablet(s) by mouth once a day Calcium Carbonate 500 mg (1,250 mg) three times a day Omeprazole 20 mg Cap, Delayed Release once a day spironolactone 50 mg every other day docusate sodium 100 mg twice a day as needed for constipation Zeasorb AF 2 % Topical Powder-apply to affected areas in skinfolds twice a day as needed for rash folic acid 1 mg once a day Discharge Medications: 1. trazodone 50 mg Tablet Sig: 0.25 Tablet PO HS (at bedtime) as needed for insomnia. 2. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO three times a day. 3. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1) Capsule, Delayed Release(E.C.) PO DAILY (Daily). 4. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig: One (1) Adhesive Patch, Medicated Topical DAILY (Daily): Apply to affected area for 12 hours, remove for 12 hours before applying new patch. 5. acetaminophen 500 mg Capsule Sig: One (1) Tablet PO Q6H (every 6 hours) as needed for pain: Do not exceed 2g/24 hours. 6. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO twice a day for 4 weeks: Take every day until [**7-19**]. 7. vancomycin 125 mg Capsule Sig: One (1) Capsule PO every twelve (12) hours for 5 weeks: Continue to take every day until 1 week after stopping antibiotics (last day [**7-31**]). 8. tramadol 50 mg Tablet Sig: One (1) Tablet PO BID (2 times a day). 9. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable Sig: One (1) Tablet, Chewable PO QID (4 times a day) as needed for heartburn. 10. daptomycin 500 mg Recon Soln Sig: Three [**Age over 90 1230**]y (350) mg Intravenous Q24H (every 24 hours) for 4 weeks: Last day = [**7-24**]. 11. cyanocobalamin (vitamin B-12) 250 mcg Tablet Sig: One (1) Tablet PO once a day. 12. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1) Tablet PO once a day. 13. folic acid 1 mg Tablet Sig: One (1) Tablet PO once a day. 14. spironolactone 50 mg Tablet Sig: One (1) Tablet PO every other day. 15. clotrimazole-betamethasone 1-0.05 % Cream Sig: ASDIR Topical ASDIR: apply to affected area on thigh twice a day as needed for itchy spot . 16. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO twice a day. 17. Zeasorb AF 2 % Powder Sig: ASDIR Topical ASDIR: apply to affected areas in skinfolds twice a day as needed for rash. 18. mirtazapine 15 mg Tablet Sig: One (1) Tablet PO at bedtime. Discharge Disposition: Extended Care Facility: [**Hospital6 459**] for the Aged - [**Location (un) 550**] Discharge Diagnosis: Primary diagnoses: Pleural effusions Subacute bacterial peritonitis Sepsis Cirrhosis . Secondary diagnoses: Hypertension GERD Discharge Condition: Mental Status: Confused - sometimes. Level of Consciousness: Alert and interactive. Activity Status: Ambulatory - requires assistance or aid (walker or cane). Discharge Instructions: You were admitted to [**Hospital1 18**] because you were experiencing adominal pain and fever. You had a CT of your chest and abdomen which showed fluid collections in your right lung space and abdomen, which were concerning for infection. You were admitted to the Intensive Care Unit for blood pressure control and started on IV antibiotics. The interventional pulmonology service evaluated you and placed a chest tube in the right lung space to drain the fluid. The tube was removed on [**6-30**]. You also developed a fluid collection in the left lung space, however the pulmonary service did not feel that this could be tapped using ultrasound but would require a CT-guided procedure. Since you were not experiencing symptoms from this fluid collection, this procedure has been deferred for now. . We added the following medications to your [**Month/Year (2) 4085**] regimen: -Ciprofloxacin 500mg by mouth twice a day (take until [**7-19**]) -Daptomycin IV 350mg daily (take until [**7-24**]) -Vancomycin 125mg by mouth every 12 hours (take until [**7-31**]) -Trazadone 12.5 mg PO/NG HS:PRN insomnia -Acetaminophen 500 mg PO/NG Q6H -TraMADOL (Ultram) 50 mg PO BID -Lidocaine 5% Patch 1 PTCH TD DAILY -Mirtazapine 15 mg QHS . We made no other changes to your medications. You should continue to take your previous medications as prescribed by your physician. . It is important that you continue to follow up with the Infectious Disease clinic and Liver clinic. Please see below for your appointment times. . It has been a pleasure taking care of you at [**Hospital1 18**]. Followup Instructions: Please have your rehab facility schedule an appointment for you to follow up with your primary care provider, [**Last Name (NamePattern4) **]. [**First Name8 (NamePattern2) **] [**Last Name (NamePattern1) **], within 1 week of leaving the hospital. Please see below for your scheduled appointments at [**Hospital1 18**]: Name: [**Last Name (LF) **], [**First Name7 (NamePattern1) **] [**Initial (NamePattern1) **] [**Last Name (NamePattern4) **] Location: [**Hospital1 18**]-DEPT OF GASTROENTEROLOGY Address: [**Doctor First Name **], 8E, [**Location (un) **],[**Numeric Identifier 718**] Phone: [**Telephone/Fax (1) 2422**] *Dr. [**Last Name (STitle) 94816**] office is working on an appointment for you within 2 weeks. They will call you directly to schedule. If you dont hear from his office by Tuesday [**7-6**], please call the number above. Department: INFECTIOUS DISEASE When: WEDNESDAY [**2128-7-14**] at 1:30 PM With: URGENT CARE ID [**Telephone/Fax (1) 457**] Building: LM [**Hospital Unit Name **] [**Hospital 1422**] Campus: WEST Best Parking: [**Hospital Ward Name **] Garage Department: [**Hospital3 1935**] CENTER When: WEDNESDAY [**2128-7-21**] at 9:50 AM With: [**First Name11 (Name Pattern1) 1112**] [**Last Name (NamePattern4) 2334**], M.D. [**Telephone/Fax (1) 253**] Building: SC [**Hospital Ward Name 23**] Clinical Ctr [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage Department: [**Hospital3 1935**] CENTER When: WEDNESDAY [**2128-7-21**] at 9:50 AM With: LASER PROCEDURE [**Telephone/Fax (1) 253**] Building: [**Hospital6 29**] [**Location (un) **] Campus: EAST Best Parking: [**Hospital Ward Name 23**] Garage [**First Name4 (NamePattern1) **] [**Last Name (NamePattern1) **] MD [**MD Number(2) 2285**]

[ "510.9", "V66.7", "V49.86", "567.23", "287.5", "E928.8", "511.9", "785.52", "070.70", "789.59", "780.09", "V10.05", "995.92", "038.9", "E849.9", "401.9", "571.5" ]

icd9cm

[ [ [] ] ]

[ "00.14", "38.93", "38.97", "34.04", "99.10", "34.91", "54.91" ]

icd9pcs

[ [ [] ] ]

27182, 27267

18772, 24514

284, 380

27437, 27437

4550, 9129

29231, 31043

3329, 3406

25164, 27159

27288, 27375

24540, 25141

27622, 29208

3421, 3426

27396, 27416

14890, 15586

9146, 14854

229, 246

1687, 2067

408, 1669

3440, 4531

15622, 18749

27452, 27598

2089, 2855

2871, 3313